High-quality evidence is lacking for the impact on healthcare utilisation of short-stay alternatives to psychiatric inpatient services for people experiencing acute and/or complex mental health crises (known in England as psychiatric decision units [PDUs]). We assessed the extent to which changes in psychiatric hospital and emergency department (ED) activity were explained by implementation of PDUs in England using a quasi-experimental approach.

We conducted an interrupted time series (ITS) analysis of weekly aggregated data pre- and post-PDU implementation in one rural and two urban sites using segmented regression, adjusting for temporal and seasonal trends. Primary outcomes were changes in the number of voluntary inpatient admissions to (acute) adult psychiatric wards and number of ED adult mental health-related attendances in the 24 months post-PDU implementation compared to that in the 24 months pre-PDU implementation.

The two PDUs (one urban and one rural) with longer (average) stays and high staff-to-patient ratios observed post-PDU decreases in the pattern of weekly voluntary psychiatric admissions relative to pre-PDU trend (Rural: −0.45%/week, 95% confidence interval [CI] = −0.78%, −0.12%; Urban: −0.49%/week, 95% CI = −0.73%, −0.25%); PDU implementation in each was associated with an estimated 35–38% reduction in total voluntary admissions in the post-PDU period. The (urban) PDU with the highest throughput, lowest staff-to-patient ratio and shortest average stay observed a 20% (−20.4%, CI = −29.7%, −10.0%) level reduction in mental health-related ED attendances post-PDU, although there was little impact on long-term trend. Pooled analyses across sites indicated a significant reduction in the number of voluntary admissions following PDU implementation (−16.6%, 95% CI = −23.9%, −8.5%) but no significant (long-term) trend change (−0.20%/week, 95% CI = −0.74%, 0.34%) and no short- (−2.8%, 95% CI = −19.3%, 17.0%) or long-term (0.08%/week, 95% CI = −0.13, 0.28%) effects on mental health-related ED attendances. Findings were largely unchanged in secondary (ITS) analyses that considered the introduction of other service initiatives in the study period.

The introduction of PDUs was associated with an immediate reduction of voluntary psychiatric inpatient admissions. The extent to which PDUs change long-term trends of voluntary psychiatric admissions or impact on psychiatric presentations at ED may be linked to their configuration. PDUs with a large capacity, short length of stay and low staff-to-patient ratio can positively impact ED mental health presentations, while PDUs with longer length of stay and higher staff-to-patient ratios have potential to reduce voluntary psychiatric admissions over an extended period. Taken as a whole, our analyses suggest that when establishing a PDU, consideration of the primary crisis-care need that underlies the creation of the unit is key.

Objective – To discuss the difficulties encountered in providing rehabilitation to multi-problematic clients, and possible remedies. Method – The principles of psychiatric rehabilitation are outlined in the frame of the bio-psycho-social model and in the light of long-term follow-up studies. The limits of professional services and the importance of natural networks for successful rehabilitation and social adjustment are highlighted. Results – Worker cooperatives and consumer self-help associations seem to successfully complement health and social services in meeting the complex needs of this population. Conclusions – The integration of formal and informal networks of care is a major challenge and a relatively neglected, but important area of interest in contemporary psychiatric rehabilitation.

Declaration of Interest: no conflict of interests.

Achieving equitable healthcare access is a global challenge. Improving whole-population mental health and reducing the global burden of mental disorders is a key recommendation of the 2018 Lancet Global Mental Health Commission, which proposed monitoring national indicators, including the proportion of people with severe mental disorders who are service-users. This study aims to derive an equity indicator from national datasets integrating need, service utilisation and socioeconomic status, and demonstrate its utility in identifying gaps in mental health service use amongst those with the greatest need, thereby guiding equitable healthcare delivery.

We present a case study of a universal health insurance scheme (Medicare) in Australia. We developed the equity indicator using three national datasets. Geographic areas were linked to an area-based socioeconomic deprivation quintile (Census 2016). Per geographic area, we estimated the number with a mental healthcare need using scores ≥30 on the Kessler-10 (Australian National Health Surveys 2015 and 2018), and obtained the number of services used, defined as mental health-related contacts with general practitioners and mental health professionals (Medicare administrative data 2015–2019). We divided the number of services by the population with an estimated mental healthcare need and averaged these use-rates across each socioeconomic deprivation quintile. The equity indicator is the ratio of the use-rates in the least versus most deprived quintiles.

Those estimated to have the greatest need for mental healthcare in 2019 ranged between 8.2% in the most disadvantaged area quintile (Q1) and 2.4% in the least (Q5), corresponding to a proportional increase of 27.7% in Q1 and 19.5% in Q5 since 2015. Equity-indicator-adjusted service rates of 4.2 (3.8–4.6) and 23.9 (22.4–25.4) showed that individuals with the highest need for care residing in Q1 areas received a stark 6 times fewer services compared to their Q5 counterparts, producing an equity indicator of 6.

As the global prevalence of common mental disorders may be increasing, it is crucial to calculate robust indicators evaluating the equity of mental health service use. In this Australian case study, we developed an equity indicator enabling the direct comparison of geographic areas with different need profiles. The results revealed striking inequities that persisted despite publicly-funded universal healthcare, recent service reforms and being a high-income country. This study demonstrates the importance and feasibility of generating such an indicator to inform and empower communities, healthcare providers and policymakers to pursue equitable service provision.

We aimed to investigate child mortality, perinatal morbidities and congenital anomalies born by women with substance misuse during or before pregnancy (DP or BP).

Taiwan Birth Registration from 2004 to 2014 linking Integrated Illicit Drug Databases used to include substance misuse participates. Children born by mothers convicted of substance misuse DP or BP were the substance-exposed cohort. Two substance-unexposed comparison cohorts were established: one comparison cohort selected newborns from the rest of the population on a ratio of 1:1 and exact matched by the child’s gender, child’s birth year, mother’s birth year and child’s first use of the health insurance card; another comparison cohort matched newborns from exposed and unexposed mothers by their propensity scores calculated from logistic regression.

The exposure group included 1776 DP, 1776 BP and 3552 unexposed individuals in exact-matched cohorts. A fourfold increased risk of deaths in children born by mothers exposed to substance during pregnancy was found compared to unexposed group (hazard ratio [HR] = 4.54, 95% confidence interval (CI): 2.07–9.97]. Further multivariate Cox regression models with adjustments and propensity matching substantially attenuated HRs on mortality in the substance-exposed cohort (aHR = 1.62, 95% CI: 1.10–2.39). Raised risks of perinatal morbidities and congenital anomalies were also found.

Increased risks of child mortality, perinatal morbidities or congenital anomalies were found in women with substance use during pregnancy. From estimates before and after adjustments, our results showed that having outpatient visits or medical utilizations during pregnancy were associated with substantially attenuated HRs on mortality in the substance-exposed cohort. Therefore, the excess mortality risk might be partially explained by the lack of relevant antenatal clinical care. Our finding may suggest that the importance of early identification, specific abstinence program and access to appropriate antenatal care might be helpful in reducing newborn mortality. Adequate prevention policies may be formulated.

Psychosocial rehabilitation (PSR) is at the core of psychiatric recovery. There is a paucity of evidence regarding how the needs and characteristics of patients guide clinical decisions to refer to PSR interventions. Here, we used explainable machine learning methods to determine how socio-demographic and clinical characteristics contribute to initial referrals to PSR interventions in patients with serious mental illness.

Data were extracted from the French network of rehabilitation centres, REHABase, collected between years 2016 and 2022 and analysed between February and September 2022. Participants presented with serious mental illnesses, including schizophrenia spectrum disorders, bipolar disorders, autism spectrum disorders, depressive disorders, anxiety disorders and personality disorders. Information from 37 socio-demographic and clinical variables was extracted at baseline and used as potential predictors. Several machine learning models were tested to predict initial referrals to four PSR interventions: cognitive behavioural therapy (CBT), cognitive remediation (CR), psychoeducation (PE) and vocational training (VT). Explanatory power of predictors was determined using the artificial intelligence-based SHAP (SHapley Additive exPlanations) method from the best performing algorithm.

Data from a total of 1146 patients were included (mean age, 33.2 years [range, 16–72 years]; 366 [39.2%] women). A random forest algorithm demonstrated the best predictive performance, with a moderate or average predictive accuracy [micro-averaged area under the receiver operating curve from ‘external’ cross-validation: 0.672]. SHAP dependence plots demonstrated insightful associations between socio-demographic and clinical predictors and referrals to PSR programmes. For instance, patients with psychotic disorders were more likely to be referred to PE and CR, while those with non-psychotic disorders were more likely to be referred to CBT and VT. Likewise, patients with social dysfunctions and lack of educational attainment were more likely to be referred to CR and VT, while those with better functioning and education were more likely to be referred to CBT and PE.

A combination of socio-demographic and clinical features was not sufficient to accurately predict initial referrals to four PSR programmes among a French network of rehabilitation centres. Referrals to PSR interventions may also involve service- and clinician-level factors. Considering socio-demographic and clinical predictors revealed disparities in referrals with respect to diagnoses, current clinical and psychological issues, functioning and education.

Scopo - Analizzare l'attività del Servizio Psichiatrico di Diagnosi e Cura di Pavia nel periodo compreso tra il 1978 (anno dell'apertura del servizio) ed il 1990. Disegno - Analisi retrospettiva dei dati contenuti in un archivio computerizzato, nel quale, a partire dal 1978, sono state raccolte informazioni relative alle caratteristiche socio-demografiche e nosologiche dei pazienti ricoverati, nonché alia modalità ed all'andamento dei ricoveri. Setting - Il Servizio Psichiatrico di Diagnosi e Cura di Pavia, il cui bacino di utenza è costituito dall'ULSS 77, comprendente la città di Pavia e 61 comuni limitrofi. Principali indici utilizzati - Per ciascun anno considerato sono stati ricavati: indicatori d'uso (primi ricoveri, ricoveri complessivi, giornate di degenza, pazienti ricoverati); presenza media giornaliera e media annuale dei massimi mensili di pazienti ricoverati; indicatori d'intensita d'uso o di flusso (degenza media, indice di occupazione media dei posti-letto, indice di turnover, indice di rotazione dei posti-letto). La produttivita del servizio è stata indagata utilizzando il monogramma di Barber. Risultati - Tra il 1978 ed il 1983 si è verificato un progressivo incremento nel numero dei pazienti ricoverati, dei ricoveri complessivi e delle giornate di degenza; è seguito un periodo stazionario protrattosi fino al 1987; infine, durante gli ultimi tre anni il numero dei ricoveri complessivi e quello dei pazienti ricoverati sono leggermente diminuiti, mentre le giornate di degenza sono rimaste sostanzialmente stabili. Il numero annuale dei pazienti entrati in contatto per la prima volta con il servizio ha segnato due picchi negli anni 1979 e 1983 (N = 250), diminuendo poi progressivamente fino ai valori di 139 nel 1989 e di 152 nel 1990. Le frazione percentuali dei primi ricoveri rispetto ai ricoveri complessivi e rispetto ai pazienti ricoverati si sono ridotte nel corso del periodo considerato: nel 1990 esse erano pari a 30% e 50% rispettivamente. Presenza media giornaliera e media annuale dei massimi mensili di pazienti ricoverati sono aumentate tra il 1979 ed il 1983, passando da 12 a 21 pazienti/die, e da 14 a 25 pazienti/die, rispettivamente; negli ultimi otto anni i due parametri si sono stabilizzati su valori di 20-21 e 24-25 pazienti/die rispettivamente. II nomogramma di Barber, costruito sulla base dei valori assunti dagli indicatori d'intensita d'uso nel corso di ciascun anno considerato, ha mostrato che tutti gli anni in esame si sono distribuiti entro la zona di produttivita accettabile, ad eccezione del 1980 e del 1981. Conclusioni - Dopo una fase iniziale di progressiva espansione, il servizio sembra aver raggiunto una fase di equilibrio dinamico con il suo bacino di utenza, fornendo per la maggior parte del periodo considerato un livello di produttività accettabile.

servizi psichiatrici, utilizzazione, dei servizi, produttività.

Objective – To analyze the activity of a General Hospital Psychiatric Inpatient Service in Pavia between 1978 (when the service was set up) and 1990. Design - Retrospective analysis of data stored in a computerized database, in which, since 1978, information has been collected on sociodemographic and nosological characteristics of patients admitted to the service, as well as on clinical aspects of all admissions. Setting – A General Hospital Psychiatric Inpatient Service in Pavia, whose catchmentarea (ULSS 77) includes the town of Pavia and 61 close municipalities. Main outcome measures -For each yearover the period considered we reported on: the indices of service utilization (first admissions, total admissions, days of stay, number of admitted patients); the mean daily number of inpatients, and the mean of the largest daily numbers of inpatients by month; the indices of intensity of service utilization (mean lenght of stay, index of bed occupation, index of turnover, index of bed rotation). The service productivity was determined according to the Barber's nomogram. Results – Between 1978 and 1983 patients admitted to the service, total admissions, and days of stay gradually increased; a steady period then followed until 1987; over the last three years, total admissions and the number of admitted patients slightly decreased, while daysof stay remained substantially stable. The annual number of patients admitted for the first time to the service marked two peaks in 1979 and 1983 (N = 250), and then gradually decreased to 139 in 1989 and 152 in 1990. The percent ratio of first admissions by total admissions and that of first admissions by the number of admitted patients showed a reduction over the period considered: in 1990 they were 30% and 50% respectively. The mean daily number of inpatients and the mean of the largest daily numbers of inpatients by month increased between 1979 and 1983, from 12 to 21 and from 14 to 25 patients/day respectively; over the last eight years the values remained rather constant, around 20-21 and 24-25 patients/day respectively. The Barber's nomogram, obtained on the basis of the indices of intensity of service utilization over the period considered, showed that each year fell within the area of acceptable productivity, with the exception of 1980 and 1981. Conclusions – After an initial phase of gradual expansion, the service then reached asteadystate, providing an acceptable productivity over most of the period considered.