Tuesday, 20 November 2018

Self-admission to Inpatient Treatment

Mattias Strand is Consultant Psychiatrist at the Stockholm Centre for Eating Disorders. He is also a PhD student at Karolinska Institutet in Stockholm, where his main research focus is on self‐admission as a potential tool in the treatment of severe eating disorders. 

In this post, he discusses the background to, and main claims of, a recent paper, co-authored with Manne Sj√∂strand, Senior Researcher at the Stockholm Centre for Healthcare Ethics at Karolinska Institutet, "Self‐admission in psychiatry: The ethics".

In recent years, self-admission to inpatient treatment has become an increasingly popular treatment tool in psychiatry in the Scandinavian countries as well as in the Netherlands. In self-admission, patients who are well known to a service and who have a history of high utilization of inpatient treatment are invited to decide for themselves when a brief admission episode – usually 3-7 days at a time – is warranted. Patients are also free to discharge at will.

Central to the concept is that the patients’ reasons for choosing to self-admit are not questioned. Participants are free to admit themselves because of deteriorating mental health, acute stress, lack of structure in everyday life, loneliness, or any other reason. In this way, the traditional inpatient admission model with a clinician serving as gatekeeper is bypassed, which means that potentially stressful repeated visits to an psychiatric emergency unit can be avoided.

The rationale behind self-admission is manifold. Proponents of the model argue that it can increase patient autonomy and agency, promote early help-seeking, reinforce the asylum function of the inpatient ward, reduce coercive interventions, and reduce total time spent in inpatient treatment.

Participants usually have a history of multiple and prolonged hospital admissions. Supposedly, encouraging self-monitoring of their mental health status and allowing swift help seeking can minimize the lag between first signs of deterioration and hospital admission, thus reducing the total time spent in hospital. Importantly, self-admission is an add-on tool rather than a replacement of other treatment options and admission through regular procedures is thus still available if needed.

For patients suffering from a psychotic or bipolar disorder, the aim of self-admission has primarily been to improve quality of life and everyday functioning, whereas for patients with borderline personality disorder or an eating disorder, the focus on promoting constructive coping strategies could have a directly symptom-modifying function. A distinction has been suggested between recovery from mental disorders and recovery in mental disorders.

Whereas the concept of recovery from a disorder reflects the traditional equating of recovery with full symptom remission, the idea of recovery in a disorder suggests that recovery does not necessarily require a “cure” and a “return to normal”. Instead, promoting such aspects of personhood and everyday functioning as self-mastery, self-regard, autonomy etc. could in itself be regarded as a form of recovery, even if the formal diagnosis noted in the patient records stays the same. For patients with schizophrenia or bipolar disorders it is hypothesized that self-admission can promote such recovery within an illness of a more or less chronic nature.

In a recent paper in Bioethics, Manne Sjöstrand and I examine the rationales behind self-admission from a bioethical perspective, present existing research on the different types of outcomes, and frame possible ethical issues. Self-admission could potentially transform health care from crisis-driven to pre-emptive and promote autonomy for severely ill patients.

Interview studies indicate a high degree of satisfaction with self-admission among participants, but this may not be very surprising given that the model implies a funneling of a scarce resource – i.e., hospital beds in psychiatry – towards this group and does not necessarily mean that it is efficient from a broader perspective. In fact, this may be at odds with the commonly accepted ‘principle of needs’ in allocation of public health care resources.

One main concern is whether the worse off patients are benefited by self-admission, or whether self-admission programs in practice rather means a regressive distribution of resources from worse off to less badly off patients. Commonly used inclusion criteria mean that some of the worst off patients are excluded from participation; e.g., patients with a high risk of suicide or violence or patients unable to independently assess their healthcare needs.

In sum, three scenarios could arise by the introduction of self-admission. As proponents of the model suggest, self-admission may turn out to be either a “zero-sum game” (i.e., benefits for participants and no negative consequences for non-participants) or a “win-win situation” (i.e., both participants and non-participants benefit) in terms of health care resources by removing patients with very high utilization of inpatient treatment from the larger pool of patient and providing them with a fast track for admission to earmarked hospital beds.

Thirdly, however, it may also be the case that worse off non-participants actually lose resources that have previously been available to them. Since no proper health economics evaluation of self-admission has yet been performed, it is currently not known which of these scenarios that is most plausible. In light of the current lack of consistent evidence of the usefulness and cost-effectiveness of self-admission, there are still many aspects that need to be further studied in order to guide any large-scale routine implementation of self-admission in psychiatry.

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