The period immediately following hospital admission for mania or bipolar depression is an important opportunity to optimise treatment and to prevent episode recurrence and readmission.Reference Kessing, Hansen, Hvenegaard, Christensen, Dam and Gluud1 Studies show that this period is one of high risk of readmission and episode recurrence.Reference Strakowski, Keck, McElroy, West, Sax and Hawkins2–Reference Keck, McElroy, Strakowski, West, Sax and Hawkins4 It is also a period of high suicide risk.Reference Appleby, Kapur, Shaw, Hunt, Flynn and Ibrahim5 The OPTIMA mood disorders service was established in 2015 in the South London and Maudsley (SLaM) NHS Foundation Trust.Reference Macritchie, Dewing, Mantingh and Young6 OPTIMA's core programme aims to consolidate recovery for people with bipolar disorder who have recently required a hospital admission or home treatment team (HTT) care for an episode of mania or depression. Importantly, the core programme focuses particularly on those who have required frequent hospital admissions. In a preparatory audit of admissions for bipolar disorder in the Trust, over a three-year period, there were approximately 500 admissions per year for bipolar disorder. Two-thirds of these were readmissions, emphasising the need for better preventive strategies. Approximately 150 people were admitted more than once a year: this group accounted for a quarter of the total number of admissions for patients in this diagnostic group.
The OPTIMA core programme offers an individually tailored treatment, comprising ongoing psychiatric assessment and review, the prescribing of psychotropic medication, specialist nursing, occupational therapy and individual psychoeducation.
This preliminary audit assessed the effect of this programme on readmission rates by comparing median admission rates before and after engagement with OPTIMA. A similar comparison was made with rates of HTT episodes.
Method
Approval for this audit was obtained from the SLaM Mood, Anxiety and Personality Clinical Academic Group Governance Committee. The audit focused on patients who had been admitted to the OPTIMA core programme between April 2015 and March 2017.
The core programme began with an assessment appointment with a consultant psychiatrist or senior trainee, and a key worker (a senior nurse or an occupational therapist). When the patient entered the programme, they were offered a period of engagement in which goals were agreed. Psychiatric review and medication changes were made to address ongoing affective episodes or subsyndromal symptoms. ‘Key working’ was offered: this was an individually tailored psychoeducation programme which aimed to reinforce prevention strategies. It included sensitive work, such as the identification of past episode triggers and early warning signs of mania and depression. Self-management skills, early intervention strategies and crisis planning were taught to prevent full episode recurrence.Reference Morriss, Faizal, Jones, Williamson, Bolton and McCarthy7
The programme also offered specialist nursing interventions and occupational therapy. Appointments were offered at times and at a frequency convenient to the patient to encourage attendance. Initially, it was planned that the core programme should last 12 weeks, followed by less frequent contacts prior to discharge to the patient's community team. However, in practice, a more flexible approach was used, and the duration of the core programme was adapted in each case to allow for individual variation in the time needed to engage patients and to address ongoing affective symptoms.
Basic demographic data were collected. The number of hospital admissions and HTT episodes in the three-year period before entering OPTIMA were extracted from electronic health records. Similarly, the number of hospital admissions and the number of HTT episodes in the (shorter) period following discharge were determined. Monthly rates of admission and HTT episodes in the 36 months before OPTIMA were calculated. For the period following discharge from OPTIMA, rates of admission and HTT contacts were calculated by dividing the number of admissions/HTT contacts by the number of months since discharge from the programme. Descriptive statistical analyses were used to characterise the audit sample. A Wilcoxon signed-rank test (Shapiro–Wilk, P = 0.001) was used to conduct comparisons of pre- and post-OPTIMA admission and HTT rates.
Results
At the time of this audit, 30 people had engaged with and had been discharged from the OPTIMA core programme; a further 22 patients remained in the programme. Of the group of 30 discharged patients, 20 were female and 10 were male. The median age was 40.5 years, with an interquartile range (IQR) of 25.
The median number of months since discharge from OPTIMA was 9.5 (IQR 8). Eighteen people did not complete the whole programme for the following reasons: recurrence of illness (n = 4), personal issues (n = 6) and lack of engagement (n = 8). For purposes of our analysis, these 18 patients were included in the analyses as they received at least one therapeutic intervention during their stay in the programme.
The median monthly rate of hospital admissions after OPTIMA was 0.00 (IQR 0.00), which was significantly different from the median monthly rate in the three years prior to OPTIMA (0.04; IQR 0.06; Wilcoxon signed-rank test Z = 3.1; P = 0.002). The post-OPTIMA median monthly rate of HTT episodes (0.00; IQR 0.02) was numerically reduced compared with the rate prior to OPTIMA (0.03; IQR 0.06), but this difference did not reach statistical significance (Wilcoxon signed-rank test Z = −1.5, P = 0.136).
Discussion
These results provide preliminary evidence of the effectiveness of the OPTIMA core programme in reducing hospital readmissions in a group of frequently admitted patients from an inner-city catchment area.
There was no statistical difference in HTT spells of care required before and after the programme. This may reflect the limited sample size and the short follow-up period of this early audit. However, it is possible that when OPTIMA ‘graduates’ do suffer recurrence, symptoms are recognised earlier, and patients are better able to use home treatment, and so hospital admissions are avoided.
The role of specialised programmes has been debated in recent years. Do the long-term benefits of specialised services justify the resources they require and their costsReference Vieta8? A growing body of evidence supports the need for and the effectiveness of specialist services, particularly in the case of complex and disabling illnesses, such as bipolar disorder.Reference Vieta9 In a recent study, Kessing et al Reference Kessing, Hansen, Hvenegaard, Christensen, Dam and Gluud1 randomised 158 recently discharged patients with bipolar disorder to the treatment arms of a specialised bipolar clinic or standard care. The specialised intervention consisted of a two-year comprehensive programme that combined individual and group treatments, including group-based psychoeducation, provided by psychiatrists, psychologists, nurses and social workers with relevant training and experience in the treatment of bipolar disorder. Over a period of almost six years, a significant reduction in the rates of readmission was found in the group receiving specialist care. Importantly, there was a significant associated reduction in the financial costs to the care provider, as well as higher patient satisfaction rates. The OPTIMA mood disorders programme used a similar approach, but there were several important differences. First, the OPTIMA mood disorders service provided intensive clinical care to recently discharged patients at any stage in their bipolar illness, but selected them on the frequency of their admissions; the Kessing study focused on those early in their bipolar course. Second, the OPTIMA programme was designed to recruit the Trust's most frequently admitted patients to our core programme. Third, patients on our core programme were often symptomatic and could not attend our structured group psychoeducation programme; in these cases, individual psychoeducation was provided instead.
Specialised programmes such as OPTIMA provide opportunities for education and research.Reference Vieta8, Reference Henry, Etain, Mathieu, Raust, Vibert and Scott10 The South London and Maudsley NHS Foundation Trust comprises a number of clinical academic groups which aim to facilitate the provision of evidence-based treatment, research and training in its clinical services. The OPTIMA programme hosts students, postgraduate students and trainees who wish to learn more about bipolar disorder.
Interpretation of the results of this early audit of a new service is subject to several limitations. The number of patients who completed the programme was small, and the period since discharge is short. Our results are based on an observational design with intra-individual comparisons: there was no control group to compare effects with standard treatment offered by the Trust. Despite these limitations, our initial findings support the importance of frequent specialist post-episode psychiatric review and maintenance phase interventions to stabilise bipolar disorder in frequently admitted patients. Future work will include the expansion of this model of care in the development of an OPTIMA ward liaison service to improve continuity of care from the in-patient to the community setting, and recruitment to the OPTIMA core programme.
Funding
This report represents work funded by the National Institute for Health Research (NIHR) Biomedical Research Centre at SLaM NHS Foundation Trust and King's College London. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health.
About the authors
Karine Macritchie is the lead consultant psychiatrist at OPTIMA mood disorders service, South London and NHS Foundation Trust (SLaM), London, UK. Tim Mantingh is a research assistant at SLaM and the Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, UK. Diego Hidalgo-Mazzei is a postdoctoral researcher at the Centre for Affective Disorders, IoPPN, King's College London, UK, and a psychiatrist with the bipolar disorders programme at the Hospital Clinic of Barcelona, Department of Psychiatry and Psychology, Barcelona, Spain. Sarah Bourne is the Clinical Team Leader at OPTIMA mood disorders service, SlaM, London, UK. Emma Borthwick is an occupational therapist at the Early Intervention Crisis Assessment Service in Lambeth, SLaM, London, UK. Allan H. Young is a professor of psychiatry at OPTIMA mood disorders service, SLaM, London, UK, and director of the Centre for Affective Disorders, IoPPN, King's College London, UK.
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