The Case for Shared Medical and Psychiatric Units: Are They Needed and How They Could Run?
Duffy, R.M; Sadlier, M; Van Der Ploeg, A.H.; Sheehan, J
A diagnosis of major mental illness is associated with a 15-20 year reduction in life expectancy. Individuals with mental illness face many difficulties accessing and receiving healthcare, many of these barriers exist in secondary care. On medical and surgical wards, the majority of mental healthcare is delivered by consultation liaison services. Hospital based psychiatry is increasingly important; well designed services are often cost-effective and can reduce patient’s length of stay. Some individual’s care needs, however, exceed the capacity of such a service. There is a significant unmet need for individuals with severe co-morbid mental and physical illness, due to their increased lengths of stay, costs and readmission rate. In these cases ‘both medical and psychiatric safety features form a prerequisite for the physical settings’ 4. This paper examines the need for shared care units (SCU), with additional mental health input. A Vision for Change proposes one adult liaison mental health services for 300,000 people and a national 6-10 bed neuropsychiatry unit. While the proposed neuropsychiatry unit does not currently exist it would only address a small proportion of the individuals who could benefit from a SCU.
In Ireland there are currently just over 10,000 acute inpatient beds. Overall 52.5 people per 100,000 require inpatients mental health services. Based on these numbers there is a need for 5 inpatient beds nationally where medical and psychiatric needs can be addressed simultaneously. This calculation however falsely assumes no association between physical and mental health morbidity. In reality a bidirectional association is well established. Psychological morbidity is higher in medical inpatients. A study of general medical and trauma orthopedic admissions, showed that 64% of those over 70 had significant psychiatric morbidity including 8% with delusions and 6% with hallucinations. Patients with major mental illnesses have increased levels of mortality, even in highly income countries greatly reduced life expentancy Kishi and Kanthol suggest that one percent of patients admitted to general hospital would benefit from a SCU4. Compounding this association between physical and psychological illness is the fact that Ireland’s population is aging, older patients have higher rates of inpatient care for both physical and mental health reasons.
A review of four studies of such wards demonstrated that SCUs reduce psychiatric symptoms, shorten in length of stay, improve functional outcomes and a decrease the need for long-term care. A medical and mental health unit for older individuals with delirium and dementia has been trialed in the UK with initially favorable and cost effective results11.
We identify three cohorts of patients who may benefit from this service. The interventions such a ward could deliver are examined and some of the potential practical considerations are discussed. Key potential benefits that this shared model could provide are highlighted.
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