BMJ  2004;328:867 (10 April), doi:10.1136/bmj.38058.605787.AE (published 5 April 2004)

Paper

Inappropriate admission of young people with mental disorder to adult psychiatric wards and paediatric wards: cross sectional study of six months' activity

¹ Royal College of Psychiatrists' Research Unit, 6th Floor, 83 Victoria Street, London SW1H 0HW, ² Health Services Research Department, Institute of Psychiatry, King's College London, De Crespigny Park, London, ³ Phoenix Centre, Fulbourn Hospital, Cambridge, ⁴ Department of Psychological Medicine, Great Ormond Street Hospital for Children, London

Introduction

Child and adolescent psychiatric inpatient wards were established because young people with mental illness are often poorly served by admission to general psychiatric wards owing to needs that differ from those adults, different skills needed by staff, and difficulty ensuring young people's safety.¹ The admission of young people with mental illness to paediatric wards also raises concerns about safety and the skills of staff. We estimated the number of inappropriate admissions of young people with mental disorder to adult psychiatric wards and paediatric wards.

Participants, methods, and results

We chose nine health authorities representative of England and Wales in terms of location, population size, deprivation, and provision of child and adolescent psychiatric wards (see table on bmj.com). These health authorities served 1.13 million people aged under 18, representing 9% of the population of England and Wales (1999 projections of 1991 census).

We identified all adult psychiatric wards and paediatric wards. Consultant general psychiatrists and paediatricians completed a questionnaire for each eligible patient (patients aged under 18 on general psychiatric wards and patients on paediatric wards for treatment of mental illness not solely for medical treatment of self harm) admitted between 1 July and 31 December 1999.

All 31 adult psychiatric wards replied, yielding 43 eligible admissions (23 male). Five were aged 15, and the remainder were 16 or 17. Sixteen of the 21 paediatric wards replied, with 11 eligible admissions (three male, one aged 3 and the others 8-16). The table presents estimates of the numbers and rates of admissions.

View this table: [in this window] [in a new window]   Estimates of numbers and rates of admissions of young people with mental disorder to general adult psychiatric wards and paediatric wards in England and Wales

 

The consultants rated whether each eligible admission was appropriate and, if not, why the patient had not been admitted to a more appropriate unit. Twenty six (60%) adult psychiatric admissions and six (55%) paediatric admissions were deemed "inappropriate." The main reasons for these admissions were non-provision of an appropriate facility (n = 25) or the appropriate facility being full or refusing the patient (n = 12).

Comment

Substantial numbers of young people with mental disorder are admitted to adult psychiatric wards (955, 95% confidence interval 666 to 1266, per year) and paediatric wards (244, 103 to 398). Over a half of these admissions were considered to be to an inappropriate ward.

Although our study population represents 9% of under 18s in England and Wales, the number of admissions was low, so extrapolations must be viewed cautiously. The validity of the estimates depends on the representativeness of the health authorities sampled, so we took care to attempt to ensure this. Five (24%) out of the 21 eligible paediatric units did not reply. We assumed no eligible admissions to non-responding wards; our data are thus a minimum estimate.

This study quantifies the use of non-specialist wards for young people with mental disorder. Around 2100 young people are admitted to specialist child and adolescent mental health units each year,² so more than a third of all young people admitted for a mental illness are admitted to general psychiatric wards and paediatric wards. Young people may have poor experiences in general psychiatric wards.¹ Levels of disturbance are high, assaults are common, and patients feel unsafe.^{3 4} On paediatric wards, adolescents with challenging behaviour raise concerns that staff are not trained to manage them safely; also specialist mental health skills are rare.

Our findings indicate an absolute lack of capacity in child and adolescent inpatient psychiatric units in England and Wales. This is consistent with the views of child and adolescent psychiatrists.⁵ Aggravating factors may include uneven geographical distribution and units that do not accept emergency admissions.² If these admissions to general psychiatric and paediatric wards are to continue, then skills need to be developed in units receiving these vulnerable young people. If the admissions are to be avoided, further investment in specialist inpatient care, the formulation of alternatives to admission, or both will be needed.

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An additional table is on bmj.com

We thank staff at the participating units, without whose assistance we could not have done this study. The views expressed are those of the authors and do not necessarily represent the views of the Royal College of Psychiatrists or the Department of Health.

Contributors: PL designed the original project, working with PH and TJ. All authors except AS and HB revised the protocol. AW and AO'H coordinated the research and collected data, along with AS and HB. The study was supervised by PL and SB. All authors participated in writing the paper, and all read and approved the final version. SB and PL are the guarantors.

Funding: This project was funded as part of the child and adolescent element of the Department of Health Policy Research Programme's Mental Health Research Initiative.

Competing interests: None declared.

Ethical approval: The study was approved by the London Multicentre Research Ethics Committee (MREC/99/2/36).

References

1. Scott D, McGilloway S, Donnelly M. Young people's experience of adult in-patient psychiatric care: a Northern Ireland case study. Mental Health and Learning Disabilities Care 2001;4: 305-8.
2. O'Herlihy A, Worrall A, Banerjee S, Jaffa T, Hill P, Mears A, et al. National in-patient child and adolescent psychiatry study (NICAPS). Report submitted to the Department of Health, 2001. www.rcpsych.ac.uk/cru/complete/nicaps.htm (accessed 18 Mar 2004).
3. Barker S. Environmentally unfriendly: patients' views of conditions on psychiatric wards. London: MIND, 2000.
4. MILMIS Project Group. Monitoring inner London mental illness services. Psychiatr Bull R Coll Psychiatr 1995;19: 276-80.
5. Worrall A, O'Herlihy A. Psychiatrists' views of in-patient child and adolescent mental health services: a survey of members of the child and adolescent faculty of the Royal College of Psychiatrists. Psychiatr Bull R Coll Psychiatr 2001;25: 219-22.

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