+44 3308188785Research Article, Int J Ment Health Psychiatry Vol: 3 Issue: 3
Correlates of Length of Hospitalisation in a Nigerian Psychiatric Hospital
Increase Ibukun Adeosun1,2*, Abosede Adekeji Adegbohun3 and Moyosore Ifeoluwa Maitanmi3
1Department of Medicine, Benjamin Carson Snr. School of Medicine, Babcock University, Ilishan-Remo, Nigeria
2Department of Psychiatry, Babcock University Teaching Hospital, Ilishan- Remo, Nigeria
3Federal Neuro-Psychiatric Hospital Yaba, Lagos
*Corresponding Author : Increase Ibukun Adeosun
Department of Medicine, Benjamin Carson Snr. School of Medicine, Babcock University, Ilishan-Remo, Nigeria
E-mail: [email protected]; [email protected]
Received: August 09, 2017 Accepted: August 25, 2017 Published: August 30, 2017
Citation: Adeosun II, Adegbohun AA, Maitanmi MF (2017) Correlates of Length of Hospitalisation in a Nigerian Psychiatric Hospital. Int J Ment Health Psychiatry 3:3. doi: 10.4172/2471-4372.1000148
Abstract
Introduction: Globally, current trend favors brief psychiatric hospitalisation and community based mental health care. However, in many sub-Saharan African settings, community based mental health services are non-existent, mental health professionals are scarce, and out-of pocket payment for services is the norm. The extent to which these differences in health systems and sociocultural contexts impact on length of psychiatric hospitalization in sub-Saharan Africa compared to western countries is largely unknown.
Aim: To determine the correlates of length of hospitalisation in a Nigerian psychiatric Hospital.
Method: Using a retrospective cohort study design, clinical records of patients (n=260) hospitalised at a public psychiatric hospital in south-west Nigeria were reviewed. Relevant socio-demographic and clinical characteristics of the patients were extracted, based on extant literature on the subject. The outcome variable was the length of hospitalisation. Data was analysed with SPSS 16.
Results: The mean and median length of hospitalisation was 14.3 (± 9.6) weeks and 12 weeks respectively. Male gender (p=0.012), unemployment (p<0.001), single marital status (p=0.013), schizophrenic illness (p=0.009), longer duration of illness before presentation (p=0.001), history of previous hospitalisation (p<0.001) and prescription of depot medications (p=0.005) correlated with longer hospitalisation. On linear regression analysis, male gender (p=0.03), employment status (p=0.03) and depot medication (p=0.001) were independently associated with prolonged psychiatric admission.
Conclusion: Though brief psychiatric hospitalisation is the current paradigm globally, longer periods of hospital stay may be inevitable or functional in low-resourced settings with dearth of after-care community based mental health services.
Keywords: Length of hospital stay; Psychiatric hospitalisation; Psychiatric admission; Nigeria
Introduction
The length of psychiatric hospitalisation is an issue of significant concern to clinicians, patients, caregivers, policy makers, and the community [1-3]. Hospitalisation is usually indicated when intervention on an out-patient basis is unlikely to be effective due to the severity or acuity of a patient’s clinical condition. Failure to hospitalise a patient with psychiatric disorder when indicated could lead to exacerbation of the clinical state with consequent risk of danger to the patient or the community, homicide or suicide [4]. However, prolonged psychiatric hospitalisation may isolate a patient, at the expense of vital, social and work-related engagements [5]. Prolonged admission has also been associated with disproportionately higher cost of health care, non-optimal use of scarce mental health resources, psychosocial poverty, stigmatization and poor quality of life [6].
Globally, current trend favours brief psychiatric hospitalisation and community based mental health care [2,7]. Length of hospitalisation has also been used as an index of effectiveness and efficiency of in-patient treatment program. However, it has been argued that limiting duration of admission could be at the risk of greater morbidity at discharge and need for aftercare [8]. In developed countries where brief hospitalisation is widely practised, after care support and mental health services are relatively easier to access in the community [9].
However, in many sub-Saharan African settings, community based mental health services are non-existent, mental health professionals are scarce, and out-of pocket payment for services is the norm [10,11]. In such resource-poor settings, brief hospitalisation may lead to early relapse, higher re-admission rates and poorer outcomes [12-15]. A study conducted in India found that 50% of patients with psychiatric hospitalisation lasting less than a week were re-admitted within six months of discharge, whereas patients admitted for at least two weeks were unlikely to be re-admitted until one to two years after discharge [15].
Previous studies have reported highly variable length of psychiatric hospitalisation [16-23]. Factors associated with length of hospitalisation also differ across studies. Commonly reported correlates of duration of hospitalisation include gender, age, marital status, employment status, illness severity, presence of psychosis or negative symptoms, level of functioning, history of previous hospitalisation, duration of illness and therapeutic modalities [8,16,19,22,24-35]. Health financing options, hospital structure, availability of alternative services and other health service policies may also determine the length of hospitalisation [19,22,29-30,33-34].
The extent to which the differences in health systems and sociocultural contexts impact on length of psychiatric hospitalisation in sub-Saharan Africa compared to western countries is not completely understood. The current study aimed to determine the correlates of length of hospitalisation in a psychiatric hospital in Lagos, Nigeria.
Method
The study was conducted at a public government funded psychiatric hospital in south west Nigeria, the Federal Neuro- Psychiatric Hospital Yaba, Lagos. The hospital is the largest mental health care facility in the country. It has an in-patient facility of 535 beds and an out-patient clinic attended by about 1,000 patients weekly. A retrospective cohort study design was used. The clinical records of patients hospitalised between January and March 2012 were retrieved from the Medical records department, after obtaining institutional approval from the Research and Ethical Committee. Patients who were admitted to the emergency department on observation (72 hours) and those referred to other hospitals on account of medical comorbidity were not included in the study. Case notes with incomplete data on the variables of interest, as well as the case notes of patients who absconded or discharged against medical advice were excluded from the sample.
A pro-forma was designed to document relevant clinical and socio-demographic data from the retrieved case notes, based on a literature search of the subject. Documented socio-demographic characteristics included age, gender, marital status, employment status, and level of education. Clinical variables included psychiatric diagnosis, co-morbid medical disorder, duration of illness, number of past episodes of psychiatric disorder, number of past psychiatric hospitalisation, prescription of depot medication (yes or no), date of admission and date of discharge. The outcome variable is the length of hospitalisation defined as the interval between the dates of admission and discharge. Case notes were reviewed by Resident doctors in Psychiatry under the supervision of a Consultant Psychiatrist and satisfactory inter-rater reliability ascertained during a pre-test. During the pre-test, it was observed that there could be discrepancies in the date a patient is discharged by the physician and the date the patient leaves the hospital due to caregivers’ refusal to take the patient home or failure to pay hospital bills. In such cases, the date the patient was discharged by the clinician was documented as the outcome variable of interest. Data was analysed using SPSS 16. The outcome variable was the length of hospitalisation in weeks entered as a continuous variable. Relationships between the outcome variable and categorical independent variables were determined using independent t-test, while correlation between continuous independent variables and the outcome variable was analysed using spearman correlation. Variables significantly associated with the outcome variable on bivariate analysis were entered into stepwise linear regression analysis.
Result
The case notes of 301 patients met the inclusion criteria for this study out of the 352 patients admitted at the study location during the period reviewed. A total of 267 case notes (88.7%) were available for review out of the 301 case notes. Table 1 highlights the sociodemographic and clinical characteristics of the cohort. The mean and median length of hospitalisation was 14.43 (± 9.6) weeks and 12 weeks respectively.
| Variable | n | (%) |
|---|---|---|
| Age: mean (±SD) | 39.2(±12.4) | |
| Gender | ||
| Male | 92 | 35.4 |
| Female | 168 | 64.6 |
| Marital status | ||
| Married | 74 | 28.5 |
| Single | 186 | 71.5 |
| Employment status | ||
| Employed | 105 | 40.4 |
| Unemployed | 155 | 59.6 |
| Educational Level | ||
| No formal education | 8 | 3.1 |
| Primary | 28 | 10.8 |
| Secondary | 98 | 37.7 |
| Tertiary | 126 | 48.5 |
| Diagnosis | ||
| Schizophrenia | 158 | 60.8 |
| Depression | 33 | 12.7 |
| Bipolar disorder | 56 | 21.5 |
| Others | 13 | 5.0 |
| Physical co-morbidity | ||
| Yes | 64 | 24.6 |
| No | 196 | 75.4 |
| Depot medication | ||
| Yes | 100 | 38.5 |
| No | 160 | 61.5 |
Table 1: Socio-demographic and clinical characteristics of the sample (N=260).
Factors associated with longer duration of hospitalisation include male gender (p=0.012), unemployment (p<0.001), single marital status (p=0.013), schizophrenic illness (p=0.009), longer duration of illness before presentation (p=0.001), history of previous hospitalization (p<0.001) and prescription of depot medications (p=0.005) (Table 2).
| Variable | Mean (SD) | t | p |
|---|---|---|---|
| Gender | |||
| Male | 16.76(12.2) | 2.538 | 0.012 |
| Female | 12.18(7.6) | ||
| Marital status | |||
| Married | 12.35(7.8) | -2.503 | 0.013 |
| Single | 15.29(10.1) | ||
| Employment status | |||
| Employed | 11.93(6.9) | -3.792 | <0.001 |
| Unemployed | 16.10(10.7) | ||
| Level of education | |||
| Tertiary | 13.38(8.8) | 1.674 | 0.093 |
| Below tertiary | 15.35(10.2) | ||
| Diagnosis | |||
| Schizophrenia | 15.42(10.1) | 2.616 | 0.009 |
| Others | 12.47(7.4) | ||
| Physical Co-morbidity | |||
| Yes | 12.93(9.4) | -1.465 | 0.146 |
| No | 14.93(9.6) | ||
| Depot medication | |||
| Yes | 16.75(11.9) | 2.821 | 0.005 |
| No | 12.98(7.4) | ||
| r* | p | ||
| Number of episodes | 0.087 | 0.169 | |
| Number of past admission | 0.132 | 0.036 | |
| Duration of illness | 0.222 | <0.001 |
Table 2: Association between length of hospitalisation and patient’s characteristics.
Length of hospitalisation was not significantly associated with physical co-morbidity (p=0.146) and number of past episodes (p=0.169). On linear regression analysis, male gender (p=0.03), employment status (p=0.03) and depot medication (p=0.001) predicted prolonged psychiatric admission (Table 3).
| Variable | Unstandardized Coefficient | Standardized Coefficient | ||||
|---|---|---|---|---|---|---|
| B | SE | B | t | p | 95%C.I | |
| Depot medication | -4.01 | 1.17 | -0.209 | -3.41 | 0.001 | -6.32 - -1.69 |
| Unemployment | 3.51 | 1.16 | 0.185 | 3.02 | 0.003 | 1.22 – 5.80 |
| Male gender | -3.56 | 1.2 | -0.182 | -2.98 | 0.003 | -5.91 - -1.20 |
Table 3: Logistic regression analysis of the correlates of length of hospitalisation.
Discussion
The current study determined the correlates of length of hospitalisation among patients admitted to a public psychiatric hospital in Lagos, Nigeria. Similar to previous research, the majority of patients admitted for in-patient psychiatric care had schizophrenia, followed by mood disorders (bipolar disorder and depression). This is consistent with the natural history of these disorders characterised by a chronic nature with intermittent episodes of relapse.
The duration of hospitalisation in the current sample is much more prolonged than that reported in most western countries and University teaching hospital settings in Africa. However, comparable lengths of hospitalisation have been documented in psychiatric hospital settings in sub-Saharan Africa and even developed countries [20,21,23]. Patients with psychiatric disorders admitted to University teaching Hospitals in south west Nigeria, stayed for about four weeks, on the average, before discharge [16,18]. Similarly the average length of psychiatric hospitalisation in a University teaching Hospital in Northern Nigeria was 15 days [37]. In Ethiopia, patients admitted to a psychiatric hospital stayed for an average of 63 days, while those hospitalised in a university hospital spent were discharged after 3 weeks on the average [19,20]. Longer average periods of psychiatric hospitalisation have even been reported in psychiatric hospitals in Asia and Africa. In a South African Psychiatric hospital, average length of hospitalisation was about seven months [21,23].
Apart from differences in hospital policies and service structure, variation in the length of hospital stay across studies could reflect disparities in social profile and clinical needs of the service users, bed availability, and mode of financing of in-patient care. The current study was conducted in a centennial psychiatric hospital with over 500 beds located in a metropolis, whereas the previous Nigerian studies were conducted in teaching hospitals with significantly fewer psychiatric beds. Furthermore, in a metropolitan city like Lagos, with scarce community social support, caregivers could be reluctant to take patients home until they attain symptom remission.
A study conducted in North America demonstrated that 80% of a cohort of hospitalised psychiatric patients still required acute care 30 days after admission on account of delusions, hallucinations, inability to take medications independently and poor impulse control [29]. Evidence has also shown that lack of community support, housing, and alternative treatment resources prevent discharge of non-acutely ill patients and prolong the duration of psychiatric hospitalisation [36,37]. A significant association was demonstrated between prolonged hospitalisation and lack of alternative after-care treatment resources in a recent study conducted in Europe [9].
A number of clinical factors correlated with longer duration of hospitalisation in the current study. This included diagnosis of schizophrenia, previous psychiatric hospitalisation and longer duration of illness before presentation. Patients who received depot medications while on admission also had significantly longer periods of hospitalization. The association between diagnoses of schizophrenia and length of admission converges with extant evidence on this subject [8,16,19,22], and reflects the chronic nature of the disorder. Similarly, history of previous psychiatric hospitalisation and longer duration of illness are possible proxy indicators of severity or chronicity of a disorder; both variables have also been shown to correlate with length of hospitalisation in previous studies [8,16,35]. The association between length of hospitalisation and use of depot medication could be attributed to the fact that patients perceived to be non-compliant or not responding to routine treatment are more likely to receive adjunct depot medications as in-patients.
In consonance with previous research, socio-demographic variables such as male gender [26,31-33], unemployment [8,27,29] and single marital status [8,22,27,29] were significantly associated with length of hospitalisation. Disparities in length of hospitalisation across socio-demographic gradient suggest that clinicians’ decision regarding discharge of patients could be influenced by these factors. Employed patients are more likely to have shorter periods of hospital admission because prolonged hospitalisation could jeopardise their career opportunities. It is also plausible that unemployment status may partly reflect the impact of the severity of morbidity and functional impairment of the patients. Similarly the marital status of the patient may be a reflection of the level of functional impairment of the patient. Patients with residual long term symptoms negatively impacting on their functioning are less likely to be engaged in lasting marital relationship or keep their jobs. Patients who are married could benefit from more intimate support from their spouses which may facilitate speedier transition to out-patient care.
Gender differences in length of psychiatric hospitalisation could be a reflection of the variation in the severity of morbidity of the patients. Since females are more likely to report distress or seek help earlier, they could be hospitalised at a lower morbidity threshold and consequently improve earlier. Furthermore, in a patriarchal society, where females are typically responsible for domestic chores and providing care for the household, family members may mount pressure to facilitate the discharge of female patients compared to their male counterparts.
In contrast with previous research, presence of co-morbid physical disorders was not associated with the length of hospitalisation [25]. This is not surprising as patients with significant co-morbid physical disorder are likely to be under-represented in the current study cohort. The study was conducted in a mono-specialist psychiatric hospital and patients requiring multi-specialist medical care are usually screened out before hospitalisation, and referred to teaching hospitals or multi-specialist centres.
The current study was limited by the manual mode of electronic medical record input and retrieval, a limitation common to many resource-poor settings. However, the process was painstakingly conducted and quality control measures put in place to minimise errors. The sample size was also relatively small. Finally, other variables which could influence length of hospitalisation such as health care financing, pattern of residual symptoms and level of functioning were not determined. However several important socio-demographic and clinical variables were investigated in the current study.
In conclusion, this study found that the mean length of hospitalisation in a public psychiatric hospital in a Nigerian metropolis was about 14 weeks. Patients with schizophrenia, past history of hospitalisation, longer duration of illness and those who received depot medications were admitted for longer periods. This suggests that length of hospitalisation was consistent with the clinical need of the patient However, socioeconomic profile also correlated with length of hospitalisation. Disparities in length of hospitalisation across socio-demographic gradient suggest that clinicians’ decision regarding discharge of patients could be influenced by these socio-demographic factors. Though the current paradigm is brief hospitalisation and subsequent after-care in the community, in the absence of effective community-based after-care mental health resources, pragmatically determined longer duration of hospital stay may be inevitable or even serve as a ‘safety net’.
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