Inpatient treatment for mood disorders – A lost opportunity?

Mood disorders are one of the commonest causes of admissions to inpatient units in New Zealand, Australia and other developed countries. In these settings, inpatient admissions are generally reserved for times when community resources are overwhelmed. For episodes of depression, both unipolar and bipolar, the most common precipitant for admission is risk of suicide, whereas for episodes of mania, admissions are most commonly triggered by hazardous behaviour or major concerns about self care. Inpatient admission is initiated to treat mood disturbance and to manage risks which generally reduce as symptoms resolve during treatment.

Inpatient admissions may be extremely traumatic. They involve separation from usual supports and family and sometimes occur involuntarily, particularly for mania. For health services, they are expensive and often seen as an indicator of failed community care. Over a number of years, there has been a desire to reduce the duration of psychiatric admissions because of concerns regarding cost to health services and because of a genuine desire by researchers and clinicians to avoid the disconnection from family and community which may occur as a result of admission. This is a sensible aim but may have contributed to a situation in which there is a high rate of readmission, risking causing even more disruption to patients’ lives.

Over this period, what also appears to have been lost to inpatient psychiatric care is the sense that there may be positive aspects to inpatient admissions, including the opportunity for assessment and intensive treatment. Inpatient care for mood disorders represents an opportunity to deliver therapy in an effort to achieve full and early recovery. If successful, this will reduce the risk of relapse and likelihood of revolving door repeat admissions. In practice, it appears that often inpatient treatment offers little other than containment, monitoring and some addressing of psychosocial factors while waiting for pharmacological treatments to take effect or for risks to reduce. Patients are often not engaged in meaningful activities, and there is little administration of systematic behavioural or psychotherapeutic treatment (Mullen, 2009).

There are several barriers to the use of specific psychological therapies in inpatient units. First, patients usually present with severe symptoms and there can be the perception that engagement in useful psychological therapy is not possible in these circumstances. Second, in most health systems, admissions are very short, with the resultant perception that it is not worthwhile beginning psychological therapy. Third, diagnoses may not be clear early in the admission creating the impression that specific therapy may not be possible until this is clarified. Fourth, there is often the impression that such therapy, particularly in severely unwell patients, is only able to be undertaken by highly trained psychologists, whose time in inpatient units is usually limited. Fifth, nursing staff often have high caseloads and a high administrative responsibility, often related to the perceived need to document ‘risks’, rather than to engage in meaningful therapeutic activities to mitigate these risks.

A further issue related to non-pharmacological treatments in this unwell group is that of a relatively small evidence base for these treatments. Inpatient wards are difficult settings for clinical trials because of short stays, diagnostic uncertainty and difficulty in reliably performing assessments in a highly acute setting. In addition, it is difficult to avoid the use of active treatment elements in patients randomised to the non-active treatment, in a setting in which staff and patients from both arms of trials are in the same environment. Despite this, we have identified a number of potential treatments which we believe could practically be delivered to patients with episodes of depression in an inpatient setting. For example, our review of non-pharmacological treatments for inpatients with depression (Crowe et al., 2015) suggests some positive clinical trial evidence for behavioural activation (BA). BA focuses on activity scheduling to encourage patients to approach activities that they are avoiding, with the aim of increasing activities that provide positive reinforcement. Unlike cognitive behavioural therapy (CBT), BA does not involve the more complex skill of thought challenging and may therefore be more appropriate in an inpatient setting with more severely unwell patients. It may also translate more readily to usual care settings since the treatment can be undertaken by less specialised staff and training can be undertaken in only a few days.

Another, more experimental treatment at this stage is cognitive activation or cognitive rehabilitation. An example of a positive clinical trial is Trapp et al., (2016). While we note that patients were generally more mildly depressed than would be typical of inpatient units in New Zealand and Australia, this study still provides very useful preliminary evidence in an inpatient setting. There are other promising preliminary studies using similar techniques of cognitive activation or rehabilitation in patients with major depressive disorder including in more severely depressed patients (Porter et al., 2013).

In episodes of mania, while research is at an earlier stage, there is evidence that social rhythms therapy, focusing on the establishment of regular sleep wake times, meal times and socialisation at regular and appropriate times may be a promising adjunct to pharmacotherapy and could practically be undertaken by inpatient nursing staff (Crowe and Porter, 2014).

We propose that more intensive psychological treatment of patients with mood disorders in psychological therapies in the inpatient unit is feasible and important. The model of care in which this is conducted may vary from unit to unit, but in our opinion is most likely to work if the primary therapists are either inpatient nurses or community nurses who will be involved in care of patients following discharge. If inpatient nurses were involved, then this is also likely to improve morale in inpatient units by giving nurses the opportunity to engage in a more meaningful interaction than the current model of care that involves frequent observations and monitoring. While BA is an intensive systematic approach, the principles and task focus closely align with some of the roles of inpatient nurses. Alternatively, treatment could be delivered by outpatient staff with district nurses or case managers visiting the hospital to engage with patients and provide psychological therapy prior to the risky immediate post-discharge period. This has the further benefit of improving the link between the inpatient and outpatient services. Such interventions potentially require more training for staff and more dedicated time. However, they may be achieved with relatively few additional resources by optimising the organisation of wards, maximising patient staff interaction and adding therapeutic structure to current interactions.

The opportunity to provide non-pharmacological treatments with potentially long-term benefits for people with mood disorder during inpatient admissions may be lost if researchers fail to consider the opportunity this phase of treatment can provide. Further research is urgently needed into such models of care, including economic analysis to provide data for health authorities or other funders. It is likely that although the costs to services will increase in the short term, considerable savings might be achieved through reduced readmission rates, with financial benefits to services and a range of positive benefits for patients. Meanwhile, in our opinion, data are sufficient to suggest that nursing staff begin training in and use of BA techniques for patients with depression in inpatient units.