Factors linked with length of hospitalisation

The evaluated cohort had a balanced gender distribution (Table 1) and a mean age of ∼37 years, similar to the characteristics reported for patients with multiple hospital admissions in Romania. ^{Reference Crișan and Pop15} Most of the evaluated patients lived in a city (Table 1), which may reflect a tendency of rural patients to seek medical care closer to home, limiting access to a university hospital. Only a small proportion of participants were employed (Table 1), because chronic illness progression reduces work capacity and often leads to early retirement. Most patients were single but lived with others (Table 1), consistent with findings reported by Desalegn et al, ^{Reference Desalegn, Girma and Abdeta16} after accounting for cultural differences.

The length of hospitalisation in our cohort aligns with the findings reported by Gonçalves-Pinho et al. ^{Reference Gonçalves-Pinho, Ribeiro and Freitas17} Most of the patients in our cohort were users of tobacco, substances or drugs, a finding consistent with previous studies. ^{Reference Dervaux, Baylé, Laqueille, Bourdel, Le Borgne and Olie18–Reference Lähteenvuo, Batalla, Luykx, Mittendorfer-Rutz, Tanskanen and Tiihonen20}

Violence towards others, or suicidality (self-directed), was commonly observed in our cohort (Table 2). A third of the patients reported at least one adverse medication effect, with muscle stiffness being the most frequent, particularly among women, which is consistent with the adverse effects of antipsychotics reported in the literature. ^{Reference Khelfi, Azzouz, Abtroun, Reggabi and Alamir21,Reference Mathews, Gratz, Adetunji, George, Mathews and Basil22} A small proportion of patients had prolonged hospitalisation due to an acute infectious disease, resulting in outcomes similar to those reported by Lyketsos et al, who noted that somatic comorbidities can extend psychiatric in-patient stays. ^{Reference Lyketsos, Dunn, Kaminsky and Breakey23}

Within this clinical and sociodemographic context, multivariable analysis identified several factors associated with HLoS. Men had a hospital stay 39% longer than women after adjusting for other covariates, a finding consistent with some previous studies ^{Reference Ochoa, Usall, Cobo, Labad and Kulkarni24,Reference Abel, Drake and Goldstein25} but opposite to other studies which found that women experienced longer stays. ^{Reference Gonçalves-Pinho, Ribeiro and Freitas17,Reference Tseliou, Johnson, Major, Rahaman, Joyce and Lawrence26} Patients who were retired had an estimated 17% shorter expected HLoS than those employed (aIRR = 0.83, 95% CI [0.70; 0.98]). A similar pattern, with shorter HLoS, was also observed among unemployed patients, in line with findings reported by Ajnakina et al. ^{Reference Ajnakina, Stubbs, Francis, Gaughran, David and Murray27} This finding may reflect the financial burden placed on the healthcare system when patients lack insurance, leading to accelerated discharge.

Patients who experienced fear or those who were violent – both prevalent in our cohort – had significantly longer expected HLoS compared with patients without such manifestations, a result consistent with other evidence considering that the presence of such symptoms is associated with delayed stabilisation. Symptom reduction, as reflected in the percentage reduction score, was also linked to longer hospitalisation. This finding supports the clinical rationale that patients with higher severity at admission require more time to achieve significant improvement, a relationship well established in the literature. ^{Reference Velelekou, Papathanasiou, Alikari, Papagiannis, Tsaras and Fradelos8,Reference Goga and Marais9} The expected HLoS was 17% longer in patients treated with first-generation antipsychotic drugs compared with those administered adjuvant treatment, reflecting differences in treatment response and management complexity.

Taken together, our results indicate that both sociodemographic characteristics (gender, employment status) and clinical features (fear, violence, comorbidities, treatment type and baseline severity) directly influenced the length of hospitalisation in our cohort.

In line with the results reported for the whole cohort, although this subgroup comprised a small number of patients, more men than women had an extreme duration of hospitalisation (Supplementary Table 1). Our results are similar to others reported. ^{Reference Goga and Marais9,Reference Chung, Chang, Oh and Yoon28} Fear, suicidality and the presence of reasons for late discharge are reported more frequently in patients with XHLoS than in those with non-XHLoS (Supplementary Table 2), a finding consistent with results reported by Pompili et al. ^{Reference Pompili, Amador, Girardi, Harkavy-Friedman, Harrow and Kaplan29} and Chong et al. ^{Reference Chong, Wahab, Muthukrishnan, Tan, Ch’ng and Yoong30}

Limitations of the study

Although this study adhered to current scientific standards, several limitations should be considered. First, all patients were admitted to a single acute psychiatric ward focused on short-term stabilisation rather than prolonged hospitalisation. Discharge decisions depended not only on symptom improvement but also on the resolution of immediate risk and the feasibility of continued care within out-patient or social support services, thereby limiting hospitalisation duration and external validity.

Second, psychometric assessments were conducted by different psychiatrists without standardised instruments, introducing heterogeneity and subjectivity in symptom and severity evaluation, including negative, depressive and suicidal symptoms. A prospective design using standardised tools and a single examiner would have yielded more consistent assessments.

Third, many patients had multiple comorbidities requiring specialised treatment; however, potential pharmacokinetic interactions between psychotropic and somatic medications were not assessed due to incomplete medical records, despite their potential impact on length of stay.

Fourth, treatment with generic psychotropic medications approved based on bioavailability data, without further validation in controlled trials, may have influenced treatment response and hospitalisation duration.

Finally, reliance on routinely collected health data entails the risk of incomplete documentation and reporting bias, particularly for self-reported substance use. Given the small, geographically limited sample, findings should be interpreted cautiously and validated in larger external cohorts to establish generalisability and clinical relevance.

In conclusion, our results indicate that hospital length of stay in patients with schizophrenia is influenced by demographic, clinical and treatment-related factors. Unemployed or retired status was associated with shorter stays, whereas male gender, fear or violence during psychotic decompensation, reasons for late discharge, greater symptom reduction and first-generation antipsychotic treatment were linked with longer stays. Extreme hospitalisation (>47 days) was more likely in men with fear during decompensation, suicidal ideation and delayed discharge. These findings should be interpreted cautiously, and further studies with larger, standardised cohorts are needed.