A PSYCHIATRIC DAY HOSPITAL

 

The emphasis of the mental health service is moving from the mental hospital into the community that it serves. The day hospital is one of the main components of the community psychiatry and it stands at the conflu­ence of the principal tributaries to the main stream of social psychiatry. USSR has had day centres as departments of its neuro-psychiatric dispensaries at least since 19421. The first day hospital in the English speaking world was started in Montreal2'3, as part of a psychiatric teaching hospital, the Allan Memorial Institute in 1946. Soon after this development two day hospitals were established in North America, one in a Montreal general hospital, a large general hospital with a psychiatric department4 and one in the Menninger Clinic, Kansas5'6. A day hospital operating successfully among primitive people in tropical Africa has also been described7. In England the first day hospital was started in London as an independent institution unconnected with any existing hospital8.

 

This paper describes a day hospital in the West of Scotland, an independent and detached unit, situated in the community to which it serves. It provides psychiatric services to a population of approximately 180,000  which has one of the worst problems of urban deprivation in Western Europe, with very high unemployment of around 35%.

 

The official opening was performed by a local com­munity leader on 23 August 1979. This was preceded by an open public meeting to discuss the proposed day hospi­tal in a local school on 14 December 1977, so that the community is aware of the psychiatric developments in their area. This meeting was addressed by two Consultant Psychiatrists and an administrator of the Health Board.

 

AIMS

 

1.                To provide care in the community setting familiar to its patients and the provision of treatment for those who would otherwise require psychiatric hospital care.

 

(a)               Patients who would otherwise need to be admitted to hospital thus maintaining links with family (spouse -children) friends and workmates.

 

(b)               Patients already in hospital, curtailing their stay and providing a stepping stone to satisfactory domestic and working life.

 

(c)               To provide concentrated out-patient treatment for certain patients for whom in-patient treatment is inadvisable, but for whom attendance at conventional out-patient departments is too brief and infrequent.

 

2.                To provide doctors, nurses and other care personnel with the opportunity of participating in a therapeutic community setting in contrast to the institutionalised setting where a high proportion of nurses must be deployed simply to give a 24 hour cover to patients.

 

3.                A teaching unit for students (medical, nursing, social work) and others who are seconded to the unit for variable periods, e.g. trainee clinical psychologists and voluntary agency personnel who intend to be involved in community care programmes in their own area.

 

DESCRIPTION

 

This detached psychiatric day hospital for up to 30 patients daily is a place in which patients spend a -substantial portion of their day under an active thera­peutic regime of multi-disciplinary nature and from which they return to their homes. The day hospital for -acute, short stay and some chronic psychiatric patients is an alternative to both in-patient and out-patient treatment of selected patients, giving most of the treat­ment normally available to in-patients, with an emphasis on social and therapeutic groups. It has been recognized by the General Nursing Council for student nurse training and is actively involved in the training and teaching of undergraduate medical students.

 

Time and Frequency of Attendance. The day hospital is open from 9.00 am to 5.00 pm Monday to Friday and Saturday mornings for the Solvent Abuse Clinic. It is not open Sundays or Bank Holidays.

 

Most patients attend 5 days weekly and receive active treatment, but after initial treatment some will attend 2 or 3 days per week. With the exception of a few who require to attend on a long-term basis, the patients are told that the length of stay will be short and that the maximum period will be 6 to 8 weeks, in usual circum­stances.

 

Type of Patients. Psychiatric patients who would other­wise have been in-patients - mainly acute and short-stay as well as some long-stay patients for rehabilitation. All age groups are represented - schizophrenic, housebound housewives with phobic anxiety, depressive and anxiety cases etc.

 

No seriously disturbed or alcoholic patients.

 

Source of Referral. Out-patient clinics at Duke Street (Carswell House) and Royal Infirmary, General Practition­ers, In-patient Units at Duke Street and Gartloch Hos­pitals. Patients will be selected and screened by the Consultants of the day hospital for their suitability to attend the day hospital before they are accepted.

 

Diagnosis. Psychiatric, physical and neurological examinations by the day hospital doctors. Investigations and x-rays.

 

Treatment. Physical treatment (drugs but no ECT at present) , occupational therapy, behaviour therapy, social therapy, family therapy, individual and group therapy. There is an organised programme of daily treatment and activities.

 

Staff. Medical: Two Consultant Psychiatrists, Assis­tant Psychiatrist and a full-time Clinical Assistant.

 

Nursing: One Charge Nurse, Five Trained Nursing Staff.

 

Others: One Art Therapist, One Psychologist, Two Occupational Therapists, One Social Worker, Literacy Teacher - 2 sessions.

 

Catchment Area. Eastern District (Psychiatric Catch­ment Area) of City of Glasgow.

     

When another day hospital is established in the Dis­trict, it will serve half of the District.

 

Transport. All patients come on their own initiative by public transport.

 

Meals. Morning coffee, midday meal and afternoon tea are provided free of charge. Coffee and tea are prepared by the patients themselves.

 

RESULTS

 

Two years after the day hospital's opening 228 patients have received treatment, 84 men and 144 women.

 

Ages ranged from 16 - 73 with a fairly even distri­bution between the third and sixth decades and a falling off in the seventh. The highest daily attendance has been 32, and the average 18. The daily attendances had to be reduced t~ 25 because during lunch time it is not physically possible to accommodate more than this number.

 

 

Table 1. Diagnoses.

                 Depressive Illness                                              98

                 Anxiety State                                                      51

                 Schizophrenic Illness                                        47

                 Personality Disorder                                          17

                 Bipolar Affective Disorder                                   6

                   (Manic Depressive Psychosis)

                 Mental Subnormality                                            4

                 Paranoid State                                                     4

                 Organic Brain Syndrome                                     1

                 (Head Injury)

                                                                        Total  =        228

 

DISCUSSION

 

The advantages of day hospital treatment are economic and social. It has been found that running costs of a 30 place day hospital are roughly one third of those of a 30 bedded ward. There is only one nursing shift and also kitchen and domestic staff are needed for a short time only. Day hospital treatment provides the patient with a greater chance of maintaining liberty and identifying as a person. Day treatment and hospital treatment may complement each other or may follow each other. The patient keeps his place in the family. The treatment tends to be shortened, for it is no longer necessary to test the patient's reaction to his normal environment by sending him home for 1/2 days and weekends. Our results show at least 50% of the patients who have attended would have required admission to the psychiatric units in our area.

 

COMMENT

 

This development of a psychiatric day hospital situ­ated in the community is in line with the feeling which is growing, not only in psychiatry, but in other branches of medicine also, that patients are sometimes isolated in hospital more often and for longer than is necessary. Social considerations and the possible harmful effect of a stay in hospital or receiving more attention. Thought needs to be given to capitalising on the advantages of day care while minimising the dangers of institutional­isation.

 

 

SUMMARY

 

The Day Hospital is one of the main components of the community psychiatry and it stands at the confluence of the principal tributaries to the mainstream of social psychiatry.

 

This paper describes the establishment of a day hospital with full cooperation from all agencies of local community and is sited in the community to which it serves. It provides psychiatric services to a popula­tion of approximately 180,000 which has one of the worst problems of urban deprivation in Europe.

 

A detailed account of the aims, staffing, criteria for admission, treatment programmes, etc., is given. Nurses are the core staff and their uniform is replaced by everyday clothes. The day hospital nursing is continuous and the patient is nursed by the same group of nurses. During the first year over 132 patients have attended the day hospital as day patients. At least 50 of these patients would have required admission to the area psychiatric hospital. An evaluation of this day hospital's functioning clearly shows that the advantages of day hospital treatment are two fold, the overall benefit is a less expensive service and a more efficient social rehabilitation programme. Emphasis is to be place on the expanding role of community psychiatry and day care in tackling what is still one of our major health problems.