Rată de recădere redusă a bolii psihice severe datorită monitorizării în centrul de sănătate mintală

Introduction

The approach to caring for people with mental health problems has swept through history between two directions, biomedical and psychosocial. If the biomedical approach focused on establishing diagnostic accuracy and drug and possible psychological therapeutics, with the aim of regaining neurobiochemical and emotional balance, the focus on psychosocial aspects has proven to be a better perception of the quality of life on the part of the family, but also on the part of the beneficiaries of these approaches⁽¹⁾.

In a study in Helsinki on the promotion of mental health, the benefits for mental health were outlined as being divided into three categories related to civil values, common values, and the value of mental health. Social inclusion, personal meaning, stigma, paradigm shift, daily life environment, sustainability, which have been used in mental health promotion actions, are listed as important for mental health⁽²⁾.

Another study, conducted by a group of Italian researchers, evaluated the social and clinical determinants of involuntary admissions in a group of 30 people compared to a group of 134 people admitted voluntarily. If social functioning was affected at the time of admission in all those admitted involuntarily, at discharge, after seven days of hospitalization, the evolution was similar for both groups, which led to the conclusion that social determinants were the determinants of involuntary admissions in a large proportion⁽³⁾.

In Denmark, in 2017, the impact of the assertive community approach on involuntary and voluntary admissions was evaluated at national level, and a significant influence on the admission rate and relapse reduction because of the community approach was concluded compared to the “usual” approach in the outpatient psychiatric system⁽⁴⁾.

In South Africa, barriers and factors that facilitate recovery in cases of severe mental illness were evaluated from the perspective of service users, caregivers and service providers. The most relevant barriers were identified: family, environment, mental health policies, stigmatizing attitude, and behavior of those who provide rehabilitation services. Among the factors that help in rehabilitation-recovery actions, friends and family with their support, those who provide services, organizational structure and responsible investment of the people involved in the recovery process were identified. The need for support was the most important element identified as underlying these themes⁽⁵⁾.

Barriers and facilitators to recovery appear to have both interpersonal and external sources that sometimes intersect. Recovery needs to be supported at the individual level, particularly through a subtle resource such as peer support work, but also in conjunction with the development of recovery-friendly environments in services and communities in South Africa⁽⁵⁾.

In the case of unemployed people with mental health problems, a qualitative study identified subjective feelings of helplessness and weakness, low self-esteem, and avoidance of seeking help from those who could provide support in finding employment⁽⁶⁾.

Awareness and attitudes of health professionals regarding mental health issues should be improved. The stigma of people with mental illnesses should be reduced in health care settings. Training of employment agency staff on mental health issues and services is recommended^(6).

The study hypothesis was that, in the mental health center (MHC), bio-psycho-social rehabilitation servi­ces, organized in a structured, periodic and procedural manner, can lead to a reduction in the hospitalization rate for people with severe mental health problems.

Methodology

A retrospective study was conducted in 2024 at the “Dr. Gheorghe Preda” Clinical Hospital of Psychiatry in Sibiu, Romania, over a period of five years (2019-2023), to compare the impact of monitoring in the adult mental health center (MHC) with that in the specialty outpatient clinic.

The study included adult patients with the following diagnoses: psychotic disorders with ICD-10 codes 312, 314, 317, 312, 314, 317; affective disorders with ICD-10 codes 321, 320, 303; cognitive disorders with ICD-10 codes 368, 303 and 299.

The data sources were the hospital admission records, outpatient registers, and the involuntary admissions register. The variables analyzed were: overall hospitalization rate, involuntary hospitalization rate in the last 12 months, and diagnostic category.

Statistical tests were applied to compare the two care models, and results with p

Results

Following the evaluation of the admissions in the 60 months, a 30% admission rate was found for patients treated in the adult MHC Sibiu compared to the people monitored in the Specialized Outpatient Clinic of the “Dr. Gheorghe Preda” Clinical Hospital of Psychiatry in Sibiu, which was 45%. The cases evaluated were psychotic disorders with diagnostic codes 312, 314 and 317, affective disorders with codes 321, 320 and 303, and cognitive disorders with codes 368, 303 and 299.

The difference between the two organizational structures of the same institution is the approach to people with severe mental illness. If in the Specialized Outpatient Clinic, the monitoring is only psychiatric and sometimes psychological, these being conditioned by the payment per service per CNP by the County Health Insurance House, in the adult MHC, the monitoring is on several levels, with a complex therapeutic team, without there being any conditioning by the County Health Insurance House of the payment of the services. The first and most effective in terms of therapeutic compliance is the psychiatric home care service by psychiatric nurses whose main role is to monitor the therapeutic compliance and the family reinsertion two weeks after discharge, after drawing up the discharge management sheet, even during the hospitalization period. Another role of the field nurse is the administration of injectable treatment at the patient’s home, for those with prolonged-release injectable treatment (LAI), except for Zypadhera® which is administered only in the adult MHC, according to the protocol recommended in the summary of product characteristics (SPC).

The assessment of the living environment as well as intra-family relationships and daily skills are part of the purpose of the home visit by the field nurse. Their expertise in the early detection of prodromal signs of decompensation comes to the rescue of a relapse by notifying the attending physician and scheduling a consultation to review the drug treatment. All these aspects achieve a complex and preventive approach in terms of maintaining remissions for as long as possible and postponing decompensation and automatically rehospitalization. The solid “base” of the psychosocial rehabilitation therapeutic plan is achieved by this monitoring of treatment compliance and maintaining remission for as long as possible. On this “base” we can build a personalized psychosocial rehabilitation plan.

Among the psychosocial rehabilitation services, we mention with a primary role the psychoeducation sessions in therapeutic groups with the objectives of informing about mental illness, but also of training emotional and relationship skills. These goals represent the informational and emotional “base” for a good management of the disease but also of emotions and interpersonal relationships. Group therapy is a “model of good practice” that is taken as a reference for its replication in the family and social environment of which people with severe mental illness are part.

Socialization, social and community inclusion, anti-stigma and job placement actions represent the social “base” of the therapeutic plan.

Leisure activities represent one of the objectives of mental health centers to create a framework in which groups of people with severe mental illness can come together to carry out therapeutic activities such as melotherapy, chess club, literary club, movement therapy, excursions and outdoor walks.

Occupational therapy and occupational therapy are scientifically proven to be effective in increasing the quality of life of people with severe mental illness, which is why it is recommended to set up a workshop on these topics in every mental health center.

Within the “Dr. Gheorghe Preda” Clinical Hospital of Psychiatry, Sibiu, a mono-specialty hospital, in addition to five psychiatric departments, there is a specialized outpatient clinic and a mental health center, a day hospital and a day inpatient clinic, structures that articulate hospitalization services with services that ensure the continuity of the therapeutic act outside of hospitalization, which represents an important point in the quality of services offered to people with mental health problems.

We evaluated the 2019-2023 period the pathology coded with the following ICD-10 codes: 312, 314, 315, 317, 320, 321, 322, 338, 368, 299 and 303, following the rate of scheduled hospitalizations but also involuntary hospitalizations from the two outpatient structures, the adult MHC and the specialized outpatient clinic.

As we can easily see, the hospitalization rate in the specialized outpatient clinic is twice as high as in the adult MHC, which serves as a statistical argument for the efficiency of monitoring in the MHC to maintain remissions and the reduced readmission rate.

During the period 2019-2023, the pathology coded with the ICD-10 codes 312, 314, 315, 317, 320, 321, 322, 338, 368, 299 and 303 was analyzed according to the environment of origin and the referring structure, and the number of admissions were higher for ambulatory versus adult MHC.

We also evaluated the last 12 months of the involuntary hospitalization register, and we found that the percentage of people monitored in the adult MHC compared to that of people in the specialized outpatient clinic was 13.7% compared to 20.6% (p=0.0088), being statistically significant. Involuntary hospitalizations are carried out only for cases that represent a danger to those around them or to the persons themselves, therefore a severe decompensation of the chronic mental illness. The aforementioned data prove the superiority of monitoring in the adult MHC versus the specialized outpatient clinic, this fact being justified also by the significantly superior human resources and diverse expertise used in the therapeutic chain in the adult MHC versus the specialized outpatient clinic. Another argument for the superiority of the adult MHC model is the financing method, being financially supported by the Ministry of Health, the purpose being “nonprofitable” – an important aspect is to support the socio-professional reinsertion, and not financing per CNP or per service, compared to the specialized outpatient clinic.

Analyzing the register of involuntary admissions in the last 12 months, we found that the percentage of people monitored in the adult MHC is significantly lower (26.75%) than the percentage of those monitored in the specialized outpatient clinic (73.25%).

If the number of people hospitalized in the adult MHC did not exceed 300, the number of those from the specialized outpatient clinic was close to 800. The hospitalizations of people monitored in the adult MHC in five years did not exceed 350 cases.

Discussion

For the Nordic countries, social inclusion, personal meaning, stigma, paradigm shift, daily living environment and sustainability are important for mental health, and as an approach, the assertive community approach is considered the best, especially for involuntary hospitalizations.

Among the factors that help in rehabilitation-recovery actions, friends and family with their support, those who provide services, the organizational structure, and the responsible investment of the people involved in the recovery process were identified.

Regarding the attitude of mental health professionals, we consider the attitude free of stigma to be very important, as well as its awareness in the rehabilitation process.

For socio-professional rehabilitation, the involvement of professionals in mediating and facilitating the acquisition of a job is considered an important point of support. The social environment of origin, as an external factor, increases the risk of hospitalization, and feelings of devaluation, avoidance and fear of asking for help represent intrinsic factors considered barriers to psychosocial rehabilitation.

Conclusions

The community approach is the optimal option for people with severe mental health problems, having an impact both on reducing hospitalizations while maintaining long remissions and on the rate of involuntary hospitalization. External but also internal factors are recommended to be taken into account in drawing up the personalized psychosocial rehabilitation plan. Mental health professionals are of great importance for the success of rehabilitation through attitude, approach, prejudices and continuous information. The social environment of origin as well as the personal internal environment are important factors in psychosocial rehabilitation. National policies favorable to people with mental disabilities are an external factor that can greatly help the rehabilitation of people with severe mental illness.    

Corresponding author: Adriana Mihai E-mail: dradrianamihai@yahoo.com

Conflict of interest: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY licence.