Length of stay in hospital for people with severe mental illness

Since the 1960s, in North America and most of Europe, large psychiatric hospitals have been closed and small local hospital units established. Medical opinion as to whether people with mental illness should stay in hospital for months and years or just a few weeks has changed. Care in the community has been helped by the advent of medication for people with mental illness. Consequently, in the developed world, hospital stays are now relatively short and large psychiatric hospitals or asylums have almost disappeared. However, there is still some doubt about whether short admissions are good because the person does not get institutionalised, or harmful because the causes and symptoms of the illness are not completely addressed. This is further complicated because there are patients who have short but frequent admissions (‘revolving door patients’) in contrast to others who despite treatment stay in hospital for a long time (‘new long stay patients’).

The review aims to determine what length of stay in hospital is the most helpful and is now based on a 2012 search. Six randomised trials are included that compare short stay in hospital with either long stay in hospital or standard care. No differences were found between groups in readmission to hospital, mental state, leaving the study early, risk of death and people lost to follow-up. There was a significant difference favouring short-stay hospitalisation for social functioning. There was limited information that suggested that short-stay hospitalisation does not encourage a ‘revolving door’ pattern of admission to hospital and disjointed or poor care.

This should reassure people with mental illness coming into hospital that a short stay (of less than 28 days) means they are no more likely to be readmitted, to leave hospital abruptly, or to lose contact with services after leaving hospital than if they received long-stay care. Short-stay patients are also more likely to leave hospital on their planned discharge date and possibly have a greater chance of finding employment. For psychiatrists, policy makers and health professionals it is important to know that short-stay hospitalisation does not lead to a ‘revolving door’ pattern of admission to hospital and poor or fragmented care.

However, all evidence in this review was rated by the review authors to be low quality. More large, well-designed and well-reported trials are justified that focus on important outcomes such as death, self-harm, harm to others, employment, criminal behaviour, mental state, satisfaction with treatment and services, homelessness, social or family relationships and costs.

This plain language summary has been written by a consumer Benjamin Gray, Service User and Service User Expert, Rethink Mental Illness.

Authors' conclusions: 

The effects of hospital care and the length of stay is important for mental health policy. We found limited low and very low quality data which were all over 30 years old. Outcomes from these studies do suggest that a planned short-stay policy does not encourage a 'revolving door' pattern of admission and disjointed care for people with serious mental illness. More large, well-designed and reported trials are justified especially where a short-stay policy is not routine care.

Read the full abstract...
Background: 

In high-income countries, over the last three decades, the length of hospital stays for people with serious mental illness has reduced drastically although considerable variation remains. In lower-income countries this variation may be greater. Some argue that reduction in hospital stay leads to 'revolving door admissions' and worsening mental health outcomes despite apparent cost savings, whilst others suggest longer stays may be more harmful by institutionalising people to hospital care.

Objectives: 

To evaluate the effect of short stay/brief admission hospital care with long stay/standard in-patient care in people with serious mental illness.

Search strategy: 

We searched the Cochrane Schizophrenia Group's register of trials, July 2007 and updated this search in May 2012.

Selection criteria: 

We included all randomised controlled trials comparing planned short/brief with long/standard hospital stays for people with serious mental illnesses.

Data collection and analysis: 

We extracted data independently. For dichotomous data we calculated risk ratios (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based using a fixed-effect model. For continuous data, had we identified such data, we planned to calculate fixed-effect mean differences (MD). We assessed risk of bias for included studies and rated quality of evidence using GRADE.

Main results: 

We included six relevant trials undertaken between 1969 and 1980. We found no significant difference in death (n = 175, 1 RCT, RR in the longer term 0.42, CI 0.10 to 1.83, very low quality evidence). In the long term, there was no difference in improvement of mental state (n = 61, 1 RCT, RR 3.39, CI 0.76 to 15.02, very low quality evidence). There was no difference in readmission to hospital (n = 651, 4 RCTs, RR by the long term 1.26, CI 1.00 to 1.57, low quality evidence). Data for leaving the study prematurely by the longer term showed no difference (n = 229, 2 RCTs, (RR 0.77, CI 0.34 to 1.77, low quality evidence). There was a significant difference favouring short stay (P = 0.01) in numbers of participants with delayed discharge from hospital exceeding the time planned in study (n = 404, 3 RCTs, RR in the longer term 0.54, CI 0.33 to 0.88, low quality evidence). There was no difference in numbers of participants lost to follow-up (n = 404, 3 RCTs, RR by the longer term 1.07, CI 0.70 to 1.62, low quality evidence). Finally, there was a significant difference favouring short-stay hospitalisation for social functioning, including unemployment, unable to housekeep, or unknown employment status (n = 330, 2 RCTs, RR by longer term 0.61, CI 0.50 to 0.76, very low quality evidence).

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