Latest developments in psychiatry

Sandra Ryan reports on the College of Psychiatrists of Ireland Winter Conference, which was held in collaboration with its Northern counterpart

This year’s Winter Conference of the College of Psychiatrists of Ireland was held on November 14-15 in Belfast, a joint event held with the Royal College of Psychiatrists in Northern Ireland. Specialists in psychiatry from Ireland, Europe and the UK presented new research and discussed updates on topics including crisis management, physician burnout, and the opioid crisis. Below is a selection of highlights from the event.

‘If you build it, they will come’

A team of researchers from the RCSI and Beaumont Hospital in Dublin presented a new study they conducted, titled ‘If you build it, they will come — Beaumont Hospital Emergency Department as a mental health referral option for general practitioners’.

The group, including Dr Cornelia Carey and Dr Vincent Russell of the RCSI and Dr Helen Barry at Beaumont, sought to investigate the extent to which GPs directly refer patients who have no urgent medical need to the emergency department for mental health reasons.

The authors explained that — as stated in the 2012 National Emergency Medicine Programme report — the ED “must not be the pathway of access to mental health care for patients with mental ill-health who have no acute medical need”.

Previous work had determined that a high number of patients without physical needs present to EDs in Ireland, such as a 2017 review of the National Clinical Programme for the Assessment and Management of Patients Presenting to the ED following Self-Harm. This report found that 41 of such patients presented to ED “solely with suicidal ideation”.

The team studied referrals to psychiatry from Beaumont Hospital ED from 1 January to 1 July 2019. All psychiatric assessments in Beaumont are recorded electronically, and data are then anonymously collated within the NetDIVER programme.

According to the results, 588 patients were referred to Beaumont Hospital ED for mental health reasons during the study period, of which 359 presented during normal working hours. Of these 359 patients, 76 were referred by GPs — the majority of patients having self-presented.

The study findings revealed that:

12 (16 per cent) of ED patients referred by GPs were recorded as having self-harmed.

137 (38 per cent) of all patients referred during normal working hours were recorded as having self-harmed

59 per cent of daytime GP referrals cited suicidal ideation, similar to the total daytime figure of 54 per cent.

A minority of patients referred for psychiatric assessment with suicidal ideation have self-harmed.

“A substantial number of patients presenting to the ED for mental health reasons could potentially be catered for by community services,” the team concluded. “Our findings raise the question of whether the focus on the ED in the national clinical programme may have had the unintended consequence of normalising the ED as a locus of mental health care.”

They added that they plan to conduct a qualitative phase of this study, to explore the influences on GPs’ decisions surrounding urgent mental health referrals.

Homelessness and ED psychiatry referrals

A second study examining referrals to EDs was presented, titled ‘Dublin’s Homeless Crisis: Is This Reflected in Emergency Department Psychiatry Referrals?’

Conducted by Dr Aoibheann McLoughlin and Dr Anna Feeney from the Central Mental Hospital and Dr Jamie Danaher and Dr John Cooney from St James’s Hospital, Dublin, the study aimed to explore the prevalence and impact of homelessness in an adult sample of psychiatry referrals over a one-month period in 2019 via the emergency department at St James’s Hospital.

According to the authors: “Homelessness has now reached a crisis point in Ireland. The role of homelessness in amplifying mental distress and illness has been widely documented.”

In July 2019, there were 10,275 people documented as homeless nationwide, with the number of homeless families increasing by 178 per cent since June 2015.

For the study, all ED psychiatry referrals over a randomly allocated one-month period were analysed using electronic patient records and it was revealed that during the month of the study (March 2019), 4,315 adults accessed emergency homeless accommodation in Dublin. Of the 109 psychiatry referrals received through the St James’s ED during March, over a quarter (28 per cent) of those referred reported themselves to be homeless or living in temporary accommodation. An additional 5 per cent were documented as living in residential or sheltered care.

Additional findings revealed that:

The most frequently represented group were Irish unemployed males between the ages of 20-to-29.

50 per cent of homeless patients were referred to psychiatry following expressed thoughts or acts of self-harm.

Illicit drug abuse was associated with 73 per cent of homeless referrals. Alcohol abuse was associated with 47 per cent of referrals.

Of those who were referred to psychiatry, under a quarter (23 per cent) of homeless presenters were assessed as having a major mental illness, and in the majority of these cases, illicit drug and alcohol abuse were compounding factors in exacerbating symptomatology.

Personality-based difficulties and impaired coping mechanisms, in the setting of substance misuse, accounted for the majority of diagnoses (67 per cent).

Of those referred, 66 per cent of homeless presenters had been previously reviewed by psychiatry during prior ED presentations.

Over 67 per cent of homeless presenters had been previously admitted to an acute psychiatric inpatient unit (compared to 40.7 per cent of general presenters).

60 per cent of homeless presenters reported that they had previously been, or were currently linked in with, community mental health teams.

All of the referred homeless patients were unemployed and over 96 per cent reported that they were not in a current relationship.

“Our findings from this study strongly reflect Dublin city’s current ‘homeless crisis’, as evidenced by the high proportion of homeless people referred for psychiatric assessment via the emergency department. In this report, the majority of homeless presenters referred to psychiatry were assessed as having concomitant substance misuse and personality difficulties, and had been previously reviewed by psychiatry services at both an ED and community level,” the authors stated.

Poly-substance abuse, vulnerable personality traits, unemployment, social isolation and lack of continued engagement with planned healthcare services are factors leading to “significant mental distress” for homeless patients referred for psychiatric assessment in the study, the team added. They concluded that the high numbers of patients reporting to be homeless is a cause for concern, and suggests the need for “tailored and flexible multidisciplinary assessments and interventions at an emergency department and primary care level”. 

“Frequently, vulnerable patients most in need of integrated care, such as homeless people with addiction issues, are obscured from accessing continuing supports.  Mental healthcare delivery demands a different approach, which works with homeless stakeholders and primary care in enabling better utilisation of services.  More research is needed to explore what form this delivery will take.”

Inpatient referrals and the school calendar: is there a relationship?

Dr Conon Brady of the Central Mental Hospital and Prof Brendan Doody of Linn Dara HSE Child and Adolescent Mental Health Services, Cherry Orchard Hospital, Dublin, presented an interesting study that examined whether specific times of the academic year affected inpatient admission numbers. The study was titled ‘Inpatient Referrals and the School Calendar: Is There a Relationship? A Five-Year Analysis of 2,476 Referrals to a CAMHS Inpatient Unit’.

They found that there are significantly fewer referrals to the inpatient unit during school break times overall, at Christmas and at summer breaks, and at the beginning of semesters and in the lead time to examinations. They also noted a significant increase in the number of referrals to the inpatient unit in November and December.

Explaining the rationale for the study, the authors stated that, while community-based care “probably offers optimal treatment for adolescents with mental health problems”, inpatient admission can provide benefits in specific cases.

Such special cases include children who require diagnostic work that cannot be provided on an outpatient basis; those with severe psychiatric disorders requiring multidisciplinary treatment; and those who are being exposed to adverse environmental circumstances hindering the child’s improvement at home.

The Linn Dara Centre, an inpatient psychiatric unit for young people under the age of 18, receives referrals nationally, and the majority of referrals come from community CAMHS teams and paediatric consultation liaison psychiatry services.

“The removal of the child from the education system is considered a relative contraindication to admission but school is also recognised as being a dominant source of stress for adolescents,” the authors explained. “We hypothesised that the perceived need for inpatient admission could vary, depending on whether school was in session and whether specific times of the academic year — specific breaks or term periods and the beginning of the school year, when students return to school after a prolonged break — and the end of the Christmas and summer semesters, in the run-up to exam periods.”

The authors examined weekly referrals, categorising each week as either a “term” week or a “break” week. A term week was defined as a week in which there were three or more school days.

The data was then reviewed to answer three questions: Firstly, to see if there was a significant difference in the number of referrals received between term and break weeks; secondly, to see if there was a significant difference in referrals received between specific periods; and thirdly, to see if there was a significant difference in the referrals received at the beginning, middle or end of terms.

The results showed that:

There were 2,476 referrals over 261 weeks.

There was a significant difference in the number of referrals received during terms compared to during breaks. For every break week, 0.76 referrals were received compared to term weeks. The mean number of referrals received during break weeks was 7.8; the term time weekly mean was 10.3

With regards to specific periods, there were significantly fewer referrals during Christmas weeks (0.565 referrals for every week) and summer weeks (0.82 weekly referrals).

There was a significant increase in referrals in November and December, and there was no significant difference in the number of referrals for the remaining periods.

There were significantly fewer referrals after the summer break and before examinations.

Physician burnout

Another topic of interest at the Winter Conference was physician burnout. Dr Genevieve Crudden of the Department of Psychiatry, University Hospital Galway (UHG), presented a new study on the subject which she conducted at UHG with Dr Anne Doherty and colleagues.

Dr Crudden told the Medical Independent that significant research exists showing that burnout is prevalent among doctors, including in Ireland, and that it negatively affects the quality of patient care. She added that the team at UHG began their study as little research on burnout in consultant-level doctors has been done.

They decided to measure burnout in hospital consultants specifically in Ireland, and sent anonymous online surveys to hundreds of hospital consultants. They received 477 responses.

Some 42 per cent of this number reported high levels of burnout. The study also found that consultants with Type A contracts reported more burnout than those on older contracts.

“We found that face-to-face contact with patients, specialty, exercise, remuneration and type of contract influenced burnout levels,” said Dr Crudden. “Our finding raises concerns for patient safety and standard of care, as well as doctors’ wellbeing.”

The study, published in the Irish Journal of Medical Science, concludes that interventions to address and minimise burnout are important to guarantee good patient outcomes and retain medical staff.

Speaking about such interventions to manage and prevent burnout, Dr Crudden mentioned international examples of best practice, including cognitive behavioural therapy (CBT), stress-reducing activities such as mindfulness and group activities, and strict implementation of work-hour limitations.

The Milestone Project

Prof Fiona McNicholas of University College Dublin co-chaired a session at the meeting which focused on transitioning from children’s to adults’ mental health services.

Part of this session included an update on the EU-wide Milestone Project, which was presented by Dr Gwendolyn Dieleman of Erasmus MC-Sophia, Rotterdam, Netherlands.

Dr Dieleman explained that, despite the fact that the transition period from adolescence to adulthood is the period of onset of the most severe mental illnesses, the current service configuration with distinct child and adult mental health services is “weakest where it should be most robust”.

“Concern with regard to the group of youths who fall through the ‘care gap’ increases, yet no studies to date have investigated the transitional pathways in relation to mental health outcomes longitudinally,” she said.

The Milestone Project is an EU-wide study that began in 2014 and is investigating mental health transition across diverse healthcare systems. Dr Dieleman said that findings from the project will transform mental healthcare in the EU for young people.

“Our results will assist policy-makers in making informed and evidence-based decisions for improving health systems, enhancing patient outcomes, quality-of-life, service satisfaction, and improving health status at individual and population levels,” she said.

The study has not yet been completed but initial findings have revealed areas of concern related to CAMHS across the EU: Poor service planning; a lack of standardised outcome assessments for service provision or performance; scarce or variable involvement of service users or their families; or the scarcity of interdisciplinary CAMHS and adult mental health services.

Another notable project finding is how the majority of EU countries have no specialised transition planning and how only two countries — Denmark and the UK — have national or regional policies or guidelines in place for the management of individual service user transition.