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A Contact-Based Intervention for People Recently Discharged from Inpatient Psychiatric Care: A Pilot Study a
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Olive Bennewith , Jonathan Evans , Jenny Donovan , Sangeetha a
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Paramasivan , Amanda Owen-Smith , William Hollingworth , b
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Rosemary Davies , Susan O'Connor , Keith Hawton , Navneet e
Kapur & David Gunnell
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School of Social and Community Medicine, University of Bristol , Bristol , UK b
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Faculty of Health and Life Sciences , University of the West of England , Bristol , UK c
Somerset Partnership NHS Foundation Trust , Yeovil , UK
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Center for Suicide Research, University Department of Psychiatry, Warneford Hospital , Oxford , UK e
Center for Suicide Prevention , University of Manchester , Manchester , UK Accepted author version posted online: 27 Mar 2014.Published online: 08 May 2014.
To cite this article: Olive Bennewith , Jonathan Evans , Jenny Donovan , Sangeetha Paramasivan , Amanda Owen-Smith , William Hollingworth , Rosemary Davies , Susan O'Connor , Keith Hawton , Navneet Kapur & David Gunnell (2014) A Contact-Based Intervention for People Recently Discharged from Inpatient Psychiatric Care: A Pilot Study, Archives of Suicide Research, 18:2, 131-143, DOI: 10.1080/13811118.2013.838196 To link to this article: http://dx.doi.org/10.1080/13811118.2013.838196
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Archives of Suicide Research, 18:131–143, 2014 Copyright # International Academy for Suicide Research ISSN: 1381-1118 print=1543-6136 online DOI: 10.1080/13811118.2013.838196
A Contact-Based Intervention for People Recently Discharged from Inpatient Psychiatric Care: A Pilot Study Olive Bennewith, Jonathan Evans, Jenny Donovan, Sangeetha Paramasivan, Amanda Owen-Smith, William Hollingworth, Rosemary Davies, Susan O’Connor, Keith Hawton, Navneet Kapur, and David Gunnell People recently discharged from inpatient psychiatric care are at high risk of suicide and self-harm, with 6% of all suicides in England occurring in the 3 months after discharge. There is some evidence from a randomized trial carried out in the United States in the 1960s–70s that supportive letters sent by psychiatrists to high-risk patients in the period following hospital discharge resulted in a reduction in suicide. The aim of the current pilot study was to assess the feasibility of conducting a similar trial, but in a broader group of psychiatric discharges, in the context of present day UK clinical practice. The intervention was piloted on 3 psychiatric inpatient wards in southwest England. On 2 wards a series of 8 letters were sent to patients over the 12 months after discharge and 6 letters were sent from the third ward over a 6 month period. A total of 102 patients discharged from the wards received at least 1 letter, but only 45 (44.1%) received the full series of letters. The main reasons for drop-out were patient opt-out (n ¼ 24) or readmission (n ¼ 26). In the context of a policy of intensive follow-up post-discharge, qualitative interviews with service users showed that most already felt adequately supported and the intervention added little to this. Those interviewed felt that it was possible that the intervention might benefit people new to or with little follow-up from mental health services but that fewer letters should be mailed. Keywords
inpatient, intervention, psychiatric patients, self-harm, suicide
BACKGROUND
discharged from inpatient psychiatric care are a particularly high-risk group with about 250 deaths by suicide each year in the 3 months after discharge (Appleby, Shaw, Kapur et al., 2006; Meehan, Kapur, Hunt et al., 2006). Similarly there is an increased
Suicide is the most serious consequence of mental illness. Over 4,000 people take their lives every year in England (Office for National Statistics, 2012). People recently
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risk of non-fatal self-harm in the postdischarge period, with 6% of people discharged from psychiatric hospitals being admitted to a general hospital bed following self-harm within 12 months of psychiatric inpatient discharge and one–third of these episodes occurring within 1 month (Gunnell, Hawton, Ho et al., 2008; Gunnell, Metcalfe, While et al., 2012). A number of trials of follow-up contacts, by letter, postcard, or telephone, with people who have self-harmed have shown promising results in the prevention of repeat self-harm (Kapur, Cooper, Bennewith et al., 2010), though in recent studies effectiveness appears to have varied according to history of previous self-harm and the cultural setting (Beautrais, Gibb, Faulkner et al., 2010; Carter, Clover, Whyte et al., 2005; Hassanian-Moghaddam, Sarjami, Kolahi et al., 2011). In some studies, the contacts were made by emergency department staff, in others they were made by members of the mental health team. It is believed that the effectiveness of such interventions is likely to be related to the ‘‘social connectiveness’’ they engender—a sense of being joined to something meaningful outside oneself that acted as a stabilizing emotional influence (Kapur, Cooper, Bennewith et al., 2010). To the best of our knowledge only one such trial (N ¼ 843) has been carried out among people discharged from inpatient psychiatric care (Motto, 1976; Motto & Bostram, 2001). In that study, in the United States in the 1960s and 1970s, a series of letters were mailed over the 5 years following hospital discharge to people who had refused ongoing care and a lowered risk of suicide was observed in the intervention group during the first 2 years of the trial. The aim of the current pilot study was to assess the usefulness and feasibility of a contact-based intervention for people recently discharged from inpatient psychiatric care in the UK. The intervention was based on the earlier study that focused on this patient group (Motto, 1976;
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Motto & Bostram, 2001), and on information from qualitative interviews and a questionnaire survey with current and recent psychiatric inpatients carried out to inform intervention development. METHOD Participating Hospitals
The intervention was piloted on three wards drawn from three different psychiatric inpatient units in the southwest of England serving different catchment populations: ward A (a 23-bed unit) serving an inner city, ward B (a 19-bed unit) serving a suburban area and ward C (a 22-bed unit) serving a mixed urban=rural population. Subjects
Following approval from the Southmead Research Ethics Committee, consecutive patients discharged from two wards (wards A and B) over a 6-month period (ward A November 1, 2009–April 30, 2010; Ward B January 11, 2010–July 26, 2010) and over a 3-month period from ward C (February 24, 2011–May 23, 2011) were included in the intervention. Intervention
The intervention was broadly based on Motto and Bostrum’s study conducted in the USA (Motto, 1976; Motto & Bostram, 2001). During the development phase qualitative interviews were carried out with 10 people recently discharged from inpatient psychiatric units to assess their attitudes towards the intervention. In the 40 years since Motto and Bostrum’s study there have been major changes in communication technology, with increased access to telephones and use of e-mail and mobile phones, so these interviews also explored the best means of communicating with patients
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following discharge. Participants indicated that their preferred modes of contact were by letter or telephone rather than text or e-mail, although some indicated that they would find telephone calls intrusive. Respondents also thought that the letters should come from someone they knew and that they should be an integrated part of a follow-up care plan. A subsequent questionnaire survey of two-thirds (48=71, 67.6%) of inpatients on 4 psychiatric wards showed similar results, with telephone or letter the preferred modes of contact. A steering group comprising psychiatrists, researchers, and service users devised 8 letters to be mailed to people discharged from psychiatric hospital within 1 week of discharge and at 2 weeks, 4 weeks, and 2, 4, 6, 9, and 12 months following discharge. So that the wording of the letters reflected their care arrangements, some of the content of the letters differed for people discharged to different community settings, e.g., to a community psychiatric team, their primary care team (see Box A at end of article). The core wording on the letters was similar to that used in Motto and Bostrum’s study (1976, 2001), but in response to feedback from the qualitative interviews, reminders of follow-up arrangements and service contact details were included in the first three letters. A support and advice leaflet, with contact details for telephone helplines, local support groups, and mental health crisis services (for those still in receipt of mental health services), was included with each mailing. This meant that only those discharged within the catchment for local mental health services (127=162, 78.4%) could be included in the intervention. In contrast to Motto and Bostrum’s study (1976, 2001), recipients were not invited to make contact with the person signing the letters as this was felt to be inappropriate within the context of local mental health service care pathways where community services are responsible for post-discharge care.
The letters were mailed from the ward from which they had been discharged and were signed by the ward manager (or another member of staff known to the patient) on behalf of the ward team. This was administered by a member of ward staff or a Mental Health Research Network clinical studies officer. As the intervention among those discharged from one of the pilot wards (ward C) started over 1 year after the others, letters from that ward were mailed for only the first 6 months post-discharge, so those patients received only 6 letters. A study database was set up so that the person administering the letter had to respond to a series of questions at each time point that prevented the printing of a letter if the participant had moved out of the area, been readmitted, or died. If a participant was admitted then discharged again during the study period the mailings recommenced (with letter 1). A study information sheet was mailed with the first letter. An opt-out slip and a stamped addressed envelope were included in all mailings up to the penultimate mailing. The patient’s care coordinator (key worker) was mailed a copy of all the letters. Outcomes
To assess the feasibility of the intervention, data were recorded on patient inclusion and retention and staff hours worked on the study for all 3 intervention wards. To pilot the processes for obtaining outcome and economic evaluation data for a large-scale trial, for logistical reasons, information was collected only for participants from intervention wards A and B on the number of (1) psychiatric readmissions, and (2) emergency department attendances= general hospital admissions for self-harm, during the 12 months post-discharge. In addition, anonymized data were obtained on all admissions and readmissions to wards A and B and other general adult acute
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inpatient psychiatric wards (wards X, Y, and Z) at the same hospitals for the 12-month period prior to the pilot and for the period of the pilot study. Similar data on the incidence of self-harm in the pre-intervention period were not available. Data on the number of community mental health service contacts in the 12 months after discharge were collected for a subset of participants (six from each of wards A and B), to identify existing levels of community support=frequency of contact with services, to assess the role of the letter-based contacts in the context of the patients’ overall care. To assess participant views on the usefulness of the intervention, study participants were invited to take part in a qualitative interview 2.5–11 months following the index discharge. After obtaining informed consent, in-depth interviews were carried out using a topic guide which was amended in response to the interviews to facilitate the investigation of arising themes. Questions posed included asking respondents about their background and experience of mental illness; previous experiences of mental health care and contact with mental health services since discharge; usefulness of the intervention; and the format, frequency, duration, source and stopping of the letters. Extensive summaries were written for each interview for qualitative analysis. Data Analysis
Statistical analyses were carried out using Stata version 11.2 for Windows (Stata Corporation, 2009). Descriptive data and 95% CIs were used to report patient readmission, self-harm and community contacts during the intervention period. Thematic analysis of the interview transcripts was carried out using the technique of constant comparison, whereby emerging themes and codes were compared within and across transcripts (Donovan & Sanders, 2005, Miles & Huberman, 1994).
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Transcripts were scrutinized for ‘‘negative cases’’ to uncover examples of views and experiences different to the majority, to add further explanatory power to the analysis. Two descriptive accounts were produced at the mid and end points of the series of interviews. RESULTS Intervention
Across all 3 wards a total of 102 patients received the intervention and 577 letters were mailed. Two-thirds (67=102) of the patients were male and the mean age was 38 years (Table 1). The main diagnostic group was schizophrenia=psychosis— comprising 44% of the participants, though nearly two-thirds (27=43, 62.8%) of data on diagnosis were missing from the discharge summaries on one ward (ward B). Nearly two-thirds (102=162, 63.0%) of patients discharged from wards A, B, and C over the intervention period received at least one letter (Figure 1). The main reason for non-inclusion was that patients resided out of area. Of those who received at least one study letter, only 45 (44.1%) received all eight letters (Figure 1) with a mean of six letters. These comprised 27.8% (45= 162) of all discharges over the relevant periods. The main reasons for cessation of mailings were patient opt-out (24=102, 23.5%) or readmission (26=102, 25.5%). Some people who opted out, or were excluded from further mailings for other reasons, were also subsequently readmitted. The maximum time per week taken to administer the mailing of the letters ranged from 4 hours (ward B) to 7 hours (ward A). Self-Harm
For logistical reasons data on the incidence of self-harm were only obtained for participants discharged from wards A and
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TABLE 1. Number and Characteristics of Patients Recruited to the Study
No. patients Age, mean (range) Gender, n (%) Male Female Diagnosis , n(%) Affective disorders Schizophrenia & other psychoses Personality disorders Substance related disorders Other
Ward A
Ward B
Ward C
37 39.2 (18–70)
43 38.2 (20–67)
22 35.4 (18–57)
Total 102 37.8 (18–70)
26 (70.2) 11 (29.7)
23 (53.5) 20 (46.5)
18 (81.8) 4 (18.2)
67 (65.7) 35 (34.3)
15 (45.5) 10 (30.3) 3 (9.1) 3 (9.1) 2 (6.0)
3 (18.8) 12 (75.0) 0 0 1 (6.2)
6 (27.3) 9 (40.9) 5 (22.7) 1 (4.6) 1 (4.6)
24 (33.8) 31 (43.7) 8 (11.3) 4 (5.6) 4 (5.6)
Note. Based on data for 33 (89.2%) cases for ward A, 16 (37.2%) for ward B, 22 (100%) for ward C, data missing for 31 cases.
B. Twelve (15.0% 95% CI: 6% to 21%) of the 80 patients receiving the intervention on those wards attended a local emergency department for treatment following a selfharm episode in the 12 months postdischarge; 8 (10%, 95% CI 3% to 17%) of these were admitted to a general hospital bed. In addition, one person who had not attended the emergency department for self-harm, died by suicide. Two study participants self-harmed within 2 weeks of
discharge (one the same day), a further 8 within the first 6 months of discharge and two during the 6 to 12 months after discharge. Most (72.7%) of these participants were still receiving the letters at the time of self-harm. Readmission
Thirty-three (41.3%) of the 80 intervention patients discharged from wards
FIGURE 1. Participation and dropout in the CONTACT study.
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Community Mental Health Contacts
A and B were readmitted to a psychiatric ward within 12 months of the index discharge. The proportion of patients readmitted to participating (wards A and B) and non-participating (labelled wards X, Y, and Z) wards in the 12 months before the intervention began and for the period of the intervention is shown in Table 2. There was no clear evidence of a reduction in re-admissions to the pilot wards compared with other (non-pilot) wards. For example on the first hospital site (wards A, X, and Y) there was a 0.4% (95% CI 22%–17%) increase in readmissions in the intervention period for participating ward A whereas readmissions declined by 2.6% (95% CI 20%–15%) and 11.4% (95% CI 4%–28%) on the non-participating wards.
Policy changes within the trust providing mental health services to wards A and B meant that local crisis services were required to make face-to-face contact with at least 70% of patients discharged from inpatient psychiatric care within 48 hours of discharge and a total of 6 such contacts within the first 2 weeks post-discharge (personal communication, Avon and Wiltshire Mental Health Partnership NHS Trust). Eleven of the 12 individuals, for whom data on community mental health service contacts was recorded, had at least 2 follow-up contacts in the first week post-discharge. One person who had no contact during the first week after discharge had 3 face-to-face
TABLE 2. Discharges from Intervention Wards A and B a) Before and b) During the Intervention Period Wards Hospital A
X (non-intervention) Y (non-intervention) A (intervention)
Pre-intervention period (November 1, 2007 to April 30, 2008) Total number of discharges 62 Total readmitted within 12 months 21 (33.9) Intervention period November 1, 2009 to April 30, 2010 Total number of discharges 48 Total readmitted within 12 months (%) 15 (31.3) Difference (%) in readmissions across the 2 time points
89 36 (40.4)
51 18 (35.3)
69 20 (29.0)
56 20 (35.7)
11.4
0.4
2.6
Wards Hospital B Pre-intervention period (January 6, 2008 to July 30, 2008) Total number of discharges Total readmitted within 12 months Intervention period (January 6, 2010 to July 30, 2010) Total number of discharges Total readmitted within 12 months
B (intervention)
Z (non-intervention)
68 30 (44.1)
52 24 (46.2)
58 21 (36.2)
102 37 (36.3)
7.9
9.9
Difference (%) in readmissions across the 2 time points
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contacts during the second week. There was a mean number of 12 contacts (either faceto-face or by telephone) during the first month after discharge (Figure 2). This number of contacts fluctuated over the year after discharge and was lowest at about 4 months post-inpatient discharge, though there was still a mean of about one contact per week at this time. When we stratified our sample to take account of the possible effects of readmission, the peaks in the level of community contacts in the first month after discharge and (to a lesser degree) at 6 months post-discharge, remained. Qualitative Interviews
A total of 13 participants (12.7% of those in receipt of the intervention) were interviewed. The interviews took place on average 14 weeks (median 8 weeks, range 2 weeks–11 months) after the last study letter was received. Five respondents had received 4 intervention letters at the time of the interview, 6 had received 5–7 letters and 2 had received all 8 letters. Respondents broadly reflected the socio-demographic
characteristics of those recruited to the study with nearly two-thirds (61.5%) male and a mean age of 40.8 years. In general, participants appeared to be well-supported post discharge and mentioned a range of services and professionals who were helping them, with some recalling instances of the ward telephoning to check on their welfare. There were, however, instances of discontent with the mental health services and post-discharge support. These views and experiences, both positive and negative, tended to influence participants’ views of the intervention. As the sample comprised primarily long-term service users, most were aware of the services and numbers to call in a crisis situation (so use of the numbers=information provided in the letters=leaflets was minimal). Because if you do get into trouble, because you’ve already been in the ward, you know the people to ring up . . . because like once you’re admitted in, you work with the crisis team and also your CPN [Community psychiatric nurse] is, sort of, you know,
FIGURE 2. Mean number of face-to-face and telephone contacts by month over the 12 months post index inpatient discharge (N ¼ 12).
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they give you all the numbers and things anyway (P8; 41 yrs, Female).
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Such participants therefore felt that the intervention did not offer anything new to them, but would be of more use for those new to the system (none of whom consented to an interview) and those who did not have as much support as themselves. I think I’m quite lucky that the support I was getting from (team name) and I am still getting is, pretty much meets all of my needs and so I can imagine for somebody else, if they weren’t happy with what was going on, it might have been more helpful (P12; 31 years, Female). To the first timers, yeah, and, you know, they come out and they’ve got nowhere to turn, and obviously the information could be vital for them. So I’m not denigrating the information, I think the information was great (P13; 38 years, Male). Although some found the initial letters and support and advice leaflets positive and reassuring, a recurring theme was that after a while these felt too frequent, and could serve as a negative reminder of their hospitalization. I thought it was quite reassuring . . . if I needed contact with anybody, then, you know, the services were available. . . . (laughs) And after the first couple, I thought, ‘‘oh! not another one!’’ (P10; 42 years, Female). When I first got the letters, they were kind of a reassurance as such that there was . . . fall-back service after the crisis team, you know. But what I found, it was a repetition, it was the same letter, same numbers. . . . And then I found it was a reminder that I’d been into hospital (P9; 42 years, Male).
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For me, as somebody with a lot of support and a lot of experience of being unwell, it was more the psychological aspect of receiving a letter . . . and feeling that somebody out there actually does care of the fact that you were in hospital and eventually you’re alright now . . . there’s probably no need to send three or four, one is probably not enough because you’ve recently come out of hospital and there’s a chance it could just slip through the net and two to make sure that you definitely got it, and that you, do you know what I mean? Three and four is overkill (P13; 38 years, Male). The letters were also perceived by some to be impersonal. The letters were impersonal, like round robins. To me, they suggested that you’d written a draft, it was printed off on the computer, and sent to everyone. . . . If you’re looking for a way of reducing self-harm or suicide after a hospital admission you need to have a sense of love. Don’t you agree? You need to have this sense of actual human compassion instead of this computerized letter and a round robin of telephone numbers (P5; 36 years, Male). Reactions to the letters being sent from the ward were mixed, being viewed both positively and negatively. There was some confusion and questioning over not being able to contact the ward, despite the letters coming from there. I think the strange thing was though getting a letter from the hospital, kind of telling me about support, but nothing of it was to do with them and that felt a little bit strange . . . it was like reminding me that they were there but they weren’t going to do anything
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and they can’t help, they’re just giving me information (P12; 31 years, Female).
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One person (who had been asked to leave the ward) had found the letters upsetting and another explained that the salutation (use of their forename and surname) on the letters had triggered their psychotic symptoms. The salutation was subsequently personalized on letters by the members of ward staff who signed the letters. DISCUSSION
To the best of our knowledge this is the first evaluation of a UK contact-based intervention for people discharged from inpatient psychiatric care and only the third internationally (Luxton, Kinn, June et al., 2012; Motto, 1976; Motto & Bostrum, 2001). There are considerable differences between current psychiatric inpatient and post-discharge practices in the UK compared with those in the United States in the 1960s and 70s when the intervention was first evaluated (Department of Health, 2002). Furthermore, patients in Motto and Bostrum’s study (1976, 2001) had been hospitalized due to being in a depressed or suicidal state and had refused therapeutic follow-up on discharge from inpatient care. In contrast, we included in our study consecutively discharged patients with a range of diagnoses. The patients in our study were still in contact with mental health services after discharge from the ward and this is likely to have affected the impact of receiving the letters. Also, due to policy changes in the local mental health trust, the number of post-discharge contacts among people discharged from two of the three intervention wards may have been higher than that in other trusts in England. A recent paper has described the piloting of a contact-based intervention for United States military personnel discharged from inpatient psychiatric care. The post-discharge
mental health service context is likely to have been different to that for the general adult psychiatric patients in our study or Motto’s previous evaluation (Motto, 1976; Motto & Bostram, 2001). The use of a study database in our study meant that the intervention was relatively easy to operationalize, using a maximum of 4 to 7 hours per week of administrator or research staff time. However, interviews with service users showed that most already felt adequately supported after inpatient discharge. Though some found the initial letters reassuring, generally the intervention seemed to add little to the perception of post-discharge support. Clearly, the experience of those who did not respond to the invitation to participate in a qualitative interview and those who were new to mental health services may have been different. However, the high 12-month readmission rates and the fact that a quarter of patients who received at least one copy of the letter opted out, indicates that the intervention may be appropriate for less than a half of patients discharged from inpatient care. Though the intervention may have benefitted those who had little contact with services, the qualitative interviews showed that the relatively impersonal format of the letters—a consequence of piloting an intervention with the potential for implementation in mainstream practice—may have offset the benefit for some individuals. Any personalization of the intervention by staff, who may not have had any contact with the service user for nearly a year since discharge, and possibly only minimal contact on the ward, would be likely to be difficult. While in Motto and Bostrum’s study there was evidence of a decrease in suicide in those receiving post-discharge letters (Motto 1976; Motto & Bostrum, 2001), there was no evidence in our study of any impact on hospital admissions for self-harm, though our pilot study was not designed to have the statistical power to detect this. While 10% (95% CI 3% to 17%) of those
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in receipt of the intervention were admitted to a hospital bed following a self-harm episode, national data indicate that between April 1, 2004 and March 31, 2005 the comparable figure was similar (6.5%) (Gunnell, Hawton, Ho et al., 2008). Similarly, there was no apparent reduction in psychiatric readmissions—while 41% of participants discharged from the intervention wards A and B during the period of the intervention were readmitted within 12 months, nationally between 1 April 2004 and 31 March 2005, this figure was 24.7% (Gunnell, Hawton, Ho et al., 2008). Although differences in policies across trusts and over time will have influenced these figures, there was no evidence of lower readmission rates when intervention wards were compared with other wards in the same inpatient psychiatric units during comparable periods. Similarly, there was also no evidence of lower readmission rates among service personnel taking part in the recent contactbased pilot study in the United States (Luxton, Kinn, June et al., 2012). Those in receipt of the letters in the study of those discharged from inpatient care in the United States in the 1960s and 1970s had refused therapeutic follow-up and the mechanism by which that intervention was thought to be effective was through inducing a sense of social connectedness (Motto, 1976; Motto & Bostram, 2001). It is likely, therefore, that the amount and quality of existing mental health service contacts would have an impact on the effectiveness of a contact-based intervention, as suggested by the results of some other studies (Gunnell, Metcalfe, While et al., 2012; HassanianMoghaddam, Sarjami, Kolahi et al., 2011; Kapur, Cooper, Bennewith et al., 2010).
health policy in England. Participant accounts show that the letters add little to the experience of post-discharge support. There are also difficulties of trialing an intervention where such a high proportion (72.2%) of the study group are either ineligible or do not complete the intervention, due to opt-out or readmission. The relatively high proportion of psychiatric readmissions and general hospital admissions following self-harm, also raise doubts about the efficacy of the intervention, though power to detect this was limited. We cannot rule out a potential benefit in areas where postinpatient discharge follow-up by mental health services is less intensive. There is recent evidence of the possible benefit, through reduced self-harm admissions, of the 48 hour post-inpatient discharge telephone contact from wards provided by all mental health trusts in England (Gunnell, Metcalfe, While et al., 2012). It is also possible that the effectiveness of the intervention might be restricted to certain sub-groups, e.g., first time admissions, though targeting specific sub-groups could cause practical problems in running the intervention on a large-scale. Interviews with participants suggest an intervention with fewer mailings may be more acceptable. Though the results of this pilot study do not appear to justify a full RCT of this intervention specifically, while post-discharge selfharm remains high, other interventions need to be developed for this period of increased risk. More qualitative work, particularly to compare the post-discharge experiences of those who have experienced their first psychiatric admission with those who have had several admissions, would assist with an understanding of the post-discharge period and which interventions might be useful.
CONCLUSION AUTHOR NOTE
Based on the data provided by this pilot study, we have doubts about the usefulness of the letter-based intervention in its present format and in the setting of current mental
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Olive Bennewith, Jonathan Evans, Jenny Donovan, Sangeetha Paramasivan, Amanda Owen-Smith, William Hollingworth, and
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David Gunnell, School of Social and Community Medicine, University of Bristol, Bristol, UK. Rosemary Davies, Faculty of Health and Life Sciences, University of the West of England, Bristol, UK. Susan O’Connor, Somerset Partnership NHS Foundation Trust, Yeovil, UK. Keith Hawton, Center for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford, UK. Navneet Kapur, Center for Suicide Prevention, University of Manchester, Manchester, UK. Correspondence concerning this article should be addressed to David Gunnell, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. E-mail: [email protected] DG initiated the study, DG, OB, JE, RD, SO’C, WH, and NK contributed to the design of the study, OB collated and analyzed the quantitative data, DG, OB, and AOS carried out the qualitative interviews, SP and AOS analyzed and reported on the qualitative data, all authors contributed to the paper. ACKNOWLEDGMENTS
We thank Jerome Motto for information on the content of the letters sent to participants in his contact-based study that contributed to the development of our study and staff on the intervention wards and the Mental Health Research Network for their assistance in administering the mailing of the letters—in particular, Davina Chauhan, Nicola Cook, and Genevieve Riley who also collected data on patient participation and retention and outcome data on community contacts. We also thank Sarah Greef who carried out some of the qualitative interviews, Keith Hall and Stephen Hoddell who contributed to study design, and staff in the AWP Information
Department for providing anonymized outcome data on admissions and readmissions. FUNDING
This article presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0606-1247). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) host the research program. KH, DG, and JD are NIHR Senior Investigators. KH is also supported by Oxford Health NHS Foundation Trust and NK by the Manchester Mental Health and Social Care Trust. REFERENCES Appleby, L., Shaw, J., Kapur, N., Windfuhr, K., Ashton, A., Swinson, N., . . . Stones, P. (2006). Avoidable deaths: Five year report of the National Confidential Inquiry into suicide and homicide by people with mental illness. http://www.bbmh.manchester.ac.uk/ cmhr/research/centreforsuicideprevention/nci/ reports/ Beautrais, A. L., Gibb, S. J., Faulkner, A., Fergusson, D. M., & Mulder, R. T. (2010). Postcard intervention for repeat self-harm: Randomized controlled trial. British Journal of Psychiatry, 197, 55–60. Carter, G. L., Clover, K., Whyte, I. M., Dawson, A. H., & D’Este, C. (2005). Postcards from the EDge project: Randomized controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self-poisoning. British Medical Journal, 331, 805–807. Department of Health (2002). National suicide prevention strategy for England. London: Department of Health. Donovan, J., & Sanders, C. (2005). Key issues in the analysis of qualitative data in health services research. In A. Bowling, S. Ebrahim (Eds.), Handbook of health research methods (pp. 515–532). UK: Open University Press. Gunnell, D., Hawton, K., Ho, D., Evans, J., O’Connor, S., Potokar, J., . . . Kapur, N. (2008).
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Hospital admissions for self-harm after discharge from psychiatric inpatient care: Cohort study. British Medical Journal, 337, 2278. Gunnell, D., Metcalfe, C., While, D., Hawton, K., Ho, D., Appleby, L., & Kapur, N. (2012). The impact of national policy initiatives on fatal and non-fatal self-harm after psychiatric hospital discharge: A time series analysis. British Journal of Psychiatry, 201, 233–238. Hassanian-Moghaddam, H., Sarjami, S., Kolahi, A. A., & Carter, G. L. (2011). Postcards in Persia: Randomized controlled trial to reduce suicidal behaviors 12 months after hospital-treated selfpoisoning. The British Journal of Psychiatry, 198, 309–3168. Kapur, N., Cooper, J., Bennewith, O., Gunnell, D., & Hawton, K. (2010). Postcards, green cards, and telephone calls: Therapeutic contact with individuals following self-harm (editorial). British Journal of Psychiatry, 197, 55–60. Luxton, D. D., Kinn, J. T., June, J. D., Pierre, L. W., Reger, M. A., & Gahm, G. A. (2012). Caring
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letters project: A military suicide-prevention pilot program. Crisis, 33, 5–12. Meehan, J., Kapur, N., Hunt, I. M., Turnbull, P., Robinson, J., Bickley, H. . . . Appleby, L. (2006). Suicide in mental health in-patients and within 3 months of discharge. National clinical survey. British Journal of Psychiatry, 188, 129–134. Miles, M., & Huberman, M. (1994). Qualitative data analysis. London, UK: Sage. Motto, J. A. (1976). Suicide prevention for high-risk persons who refuse treatment. Suicide and Life Threatening Behaviour, 6, 223–230. Motto, J. A., & Bostrom, A. G. (2001). A randomized controlled trial of post crisis suicide prevention. Psychiatric Services, 52, 828–33. Office for National Statistics Suicide rates in the United Kingdom and in England and Wales, 1991 to 2010. Retrieved from: http://www.ons.gov.uk/ons/ publications/re-reference-tables.html?edition=tcm %3A77-245453 StataCorp. (2009). Stata statistical software: Release 11. College Station, TX: StataCorp LP.
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BOX A Examples of Intervention Letters
a) Letter mailed to service users one week after discharge from the ward where follow-up had been arranged with a community mental health team Dear
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It has been a short time since you were on [name of ward]. We know that the time after discharge can be difficult for people so wanted to drop you a line. We are writing to you to remind you that a member of your community mental health team [name of team] should be contacting or visiting you within the next 7 days and that if things get difficult you can contact them on [number]. You can talk to a member of the team about any areas of your life that are causing you concern (e.g., money or housing problems), not just mental health issues. If things get difficult outside 9 a.m. to 5 p.m. and at weekends you can contact the [team name] on [number]. Enclosed is a leaflet that we have put together to provide you with some information about other services that might be of interest to you. These include telephone support lines and support groups. With best wishes, [name of ward manager] On behalf of the ward team b) Letter mailed to service users at discharge from mental health services Dear It is now some time since you left the hospital and we hope that things are going well for you. As you have now been discharged from mental health services we thought you might find it useful to have another copy of the leaflet showing some of the services that are available to you. This is enclosed. If things become difficult for you we hope you will feel that you can contact your GP, [GP name] at [name of surgery] tel: [telephone number]. With best wishes, [name of ward manager] On behalf of the ward team
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A Contact-Based Intervention for People Recently Discharged from Inpatient Psychiatric Care: A Pilot Study a
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Olive Bennewith , Jonathan Evans , Jenny Donovan , Sangeetha a
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Rosemary Davies , Susan O'Connor , Keith Hawton , Navneet e
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Center for Suicide Prevention , University of Manchester , Manchester , UK Accepted author version posted online: 27 Mar 2014.Published online: 08 May 2014.
To cite this article: Olive Bennewith , Jonathan Evans , Jenny Donovan , Sangeetha Paramasivan , Amanda Owen-Smith , William Hollingworth , Rosemary Davies , Susan O'Connor , Keith Hawton , Navneet Kapur & David Gunnell (2014) A Contact-Based Intervention for People Recently Discharged from Inpatient Psychiatric Care: A Pilot Study, Archives of Suicide Research, 18:2, 131-143, DOI: 10.1080/13811118.2013.838196 To link to this article: http://dx.doi.org/10.1080/13811118.2013.838196
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Archives of Suicide Research, 18:131–143, 2014 Copyright # International Academy for Suicide Research ISSN: 1381-1118 print=1543-6136 online DOI: 10.1080/13811118.2013.838196
A Contact-Based Intervention for People Recently Discharged from Inpatient Psychiatric Care: A Pilot Study Olive Bennewith, Jonathan Evans, Jenny Donovan, Sangeetha Paramasivan, Amanda Owen-Smith, William Hollingworth, Rosemary Davies, Susan O’Connor, Keith Hawton, Navneet Kapur, and David Gunnell People recently discharged from inpatient psychiatric care are at high risk of suicide and self-harm, with 6% of all suicides in England occurring in the 3 months after discharge. There is some evidence from a randomized trial carried out in the United States in the 1960s–70s that supportive letters sent by psychiatrists to high-risk patients in the period following hospital discharge resulted in a reduction in suicide. The aim of the current pilot study was to assess the feasibility of conducting a similar trial, but in a broader group of psychiatric discharges, in the context of present day UK clinical practice. The intervention was piloted on 3 psychiatric inpatient wards in southwest England. On 2 wards a series of 8 letters were sent to patients over the 12 months after discharge and 6 letters were sent from the third ward over a 6 month period. A total of 102 patients discharged from the wards received at least 1 letter, but only 45 (44.1%) received the full series of letters. The main reasons for drop-out were patient opt-out (n ¼ 24) or readmission (n ¼ 26). In the context of a policy of intensive follow-up post-discharge, qualitative interviews with service users showed that most already felt adequately supported and the intervention added little to this. Those interviewed felt that it was possible that the intervention might benefit people new to or with little follow-up from mental health services but that fewer letters should be mailed. Keywords
inpatient, intervention, psychiatric patients, self-harm, suicide
BACKGROUND
discharged from inpatient psychiatric care are a particularly high-risk group with about 250 deaths by suicide each year in the 3 months after discharge (Appleby, Shaw, Kapur et al., 2006; Meehan, Kapur, Hunt et al., 2006). Similarly there is an increased
Suicide is the most serious consequence of mental illness. Over 4,000 people take their lives every year in England (Office for National Statistics, 2012). People recently
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risk of non-fatal self-harm in the postdischarge period, with 6% of people discharged from psychiatric hospitals being admitted to a general hospital bed following self-harm within 12 months of psychiatric inpatient discharge and one–third of these episodes occurring within 1 month (Gunnell, Hawton, Ho et al., 2008; Gunnell, Metcalfe, While et al., 2012). A number of trials of follow-up contacts, by letter, postcard, or telephone, with people who have self-harmed have shown promising results in the prevention of repeat self-harm (Kapur, Cooper, Bennewith et al., 2010), though in recent studies effectiveness appears to have varied according to history of previous self-harm and the cultural setting (Beautrais, Gibb, Faulkner et al., 2010; Carter, Clover, Whyte et al., 2005; Hassanian-Moghaddam, Sarjami, Kolahi et al., 2011). In some studies, the contacts were made by emergency department staff, in others they were made by members of the mental health team. It is believed that the effectiveness of such interventions is likely to be related to the ‘‘social connectiveness’’ they engender—a sense of being joined to something meaningful outside oneself that acted as a stabilizing emotional influence (Kapur, Cooper, Bennewith et al., 2010). To the best of our knowledge only one such trial (N ¼ 843) has been carried out among people discharged from inpatient psychiatric care (Motto, 1976; Motto & Bostram, 2001). In that study, in the United States in the 1960s and 1970s, a series of letters were mailed over the 5 years following hospital discharge to people who had refused ongoing care and a lowered risk of suicide was observed in the intervention group during the first 2 years of the trial. The aim of the current pilot study was to assess the usefulness and feasibility of a contact-based intervention for people recently discharged from inpatient psychiatric care in the UK. The intervention was based on the earlier study that focused on this patient group (Motto, 1976;
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Motto & Bostram, 2001), and on information from qualitative interviews and a questionnaire survey with current and recent psychiatric inpatients carried out to inform intervention development. METHOD Participating Hospitals
The intervention was piloted on three wards drawn from three different psychiatric inpatient units in the southwest of England serving different catchment populations: ward A (a 23-bed unit) serving an inner city, ward B (a 19-bed unit) serving a suburban area and ward C (a 22-bed unit) serving a mixed urban=rural population. Subjects
Following approval from the Southmead Research Ethics Committee, consecutive patients discharged from two wards (wards A and B) over a 6-month period (ward A November 1, 2009–April 30, 2010; Ward B January 11, 2010–July 26, 2010) and over a 3-month period from ward C (February 24, 2011–May 23, 2011) were included in the intervention. Intervention
The intervention was broadly based on Motto and Bostrum’s study conducted in the USA (Motto, 1976; Motto & Bostram, 2001). During the development phase qualitative interviews were carried out with 10 people recently discharged from inpatient psychiatric units to assess their attitudes towards the intervention. In the 40 years since Motto and Bostrum’s study there have been major changes in communication technology, with increased access to telephones and use of e-mail and mobile phones, so these interviews also explored the best means of communicating with patients
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following discharge. Participants indicated that their preferred modes of contact were by letter or telephone rather than text or e-mail, although some indicated that they would find telephone calls intrusive. Respondents also thought that the letters should come from someone they knew and that they should be an integrated part of a follow-up care plan. A subsequent questionnaire survey of two-thirds (48=71, 67.6%) of inpatients on 4 psychiatric wards showed similar results, with telephone or letter the preferred modes of contact. A steering group comprising psychiatrists, researchers, and service users devised 8 letters to be mailed to people discharged from psychiatric hospital within 1 week of discharge and at 2 weeks, 4 weeks, and 2, 4, 6, 9, and 12 months following discharge. So that the wording of the letters reflected their care arrangements, some of the content of the letters differed for people discharged to different community settings, e.g., to a community psychiatric team, their primary care team (see Box A at end of article). The core wording on the letters was similar to that used in Motto and Bostrum’s study (1976, 2001), but in response to feedback from the qualitative interviews, reminders of follow-up arrangements and service contact details were included in the first three letters. A support and advice leaflet, with contact details for telephone helplines, local support groups, and mental health crisis services (for those still in receipt of mental health services), was included with each mailing. This meant that only those discharged within the catchment for local mental health services (127=162, 78.4%) could be included in the intervention. In contrast to Motto and Bostrum’s study (1976, 2001), recipients were not invited to make contact with the person signing the letters as this was felt to be inappropriate within the context of local mental health service care pathways where community services are responsible for post-discharge care.
The letters were mailed from the ward from which they had been discharged and were signed by the ward manager (or another member of staff known to the patient) on behalf of the ward team. This was administered by a member of ward staff or a Mental Health Research Network clinical studies officer. As the intervention among those discharged from one of the pilot wards (ward C) started over 1 year after the others, letters from that ward were mailed for only the first 6 months post-discharge, so those patients received only 6 letters. A study database was set up so that the person administering the letter had to respond to a series of questions at each time point that prevented the printing of a letter if the participant had moved out of the area, been readmitted, or died. If a participant was admitted then discharged again during the study period the mailings recommenced (with letter 1). A study information sheet was mailed with the first letter. An opt-out slip and a stamped addressed envelope were included in all mailings up to the penultimate mailing. The patient’s care coordinator (key worker) was mailed a copy of all the letters. Outcomes
To assess the feasibility of the intervention, data were recorded on patient inclusion and retention and staff hours worked on the study for all 3 intervention wards. To pilot the processes for obtaining outcome and economic evaluation data for a large-scale trial, for logistical reasons, information was collected only for participants from intervention wards A and B on the number of (1) psychiatric readmissions, and (2) emergency department attendances= general hospital admissions for self-harm, during the 12 months post-discharge. In addition, anonymized data were obtained on all admissions and readmissions to wards A and B and other general adult acute
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inpatient psychiatric wards (wards X, Y, and Z) at the same hospitals for the 12-month period prior to the pilot and for the period of the pilot study. Similar data on the incidence of self-harm in the pre-intervention period were not available. Data on the number of community mental health service contacts in the 12 months after discharge were collected for a subset of participants (six from each of wards A and B), to identify existing levels of community support=frequency of contact with services, to assess the role of the letter-based contacts in the context of the patients’ overall care. To assess participant views on the usefulness of the intervention, study participants were invited to take part in a qualitative interview 2.5–11 months following the index discharge. After obtaining informed consent, in-depth interviews were carried out using a topic guide which was amended in response to the interviews to facilitate the investigation of arising themes. Questions posed included asking respondents about their background and experience of mental illness; previous experiences of mental health care and contact with mental health services since discharge; usefulness of the intervention; and the format, frequency, duration, source and stopping of the letters. Extensive summaries were written for each interview for qualitative analysis. Data Analysis
Statistical analyses were carried out using Stata version 11.2 for Windows (Stata Corporation, 2009). Descriptive data and 95% CIs were used to report patient readmission, self-harm and community contacts during the intervention period. Thematic analysis of the interview transcripts was carried out using the technique of constant comparison, whereby emerging themes and codes were compared within and across transcripts (Donovan & Sanders, 2005, Miles & Huberman, 1994).
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Transcripts were scrutinized for ‘‘negative cases’’ to uncover examples of views and experiences different to the majority, to add further explanatory power to the analysis. Two descriptive accounts were produced at the mid and end points of the series of interviews. RESULTS Intervention
Across all 3 wards a total of 102 patients received the intervention and 577 letters were mailed. Two-thirds (67=102) of the patients were male and the mean age was 38 years (Table 1). The main diagnostic group was schizophrenia=psychosis— comprising 44% of the participants, though nearly two-thirds (27=43, 62.8%) of data on diagnosis were missing from the discharge summaries on one ward (ward B). Nearly two-thirds (102=162, 63.0%) of patients discharged from wards A, B, and C over the intervention period received at least one letter (Figure 1). The main reason for non-inclusion was that patients resided out of area. Of those who received at least one study letter, only 45 (44.1%) received all eight letters (Figure 1) with a mean of six letters. These comprised 27.8% (45= 162) of all discharges over the relevant periods. The main reasons for cessation of mailings were patient opt-out (24=102, 23.5%) or readmission (26=102, 25.5%). Some people who opted out, or were excluded from further mailings for other reasons, were also subsequently readmitted. The maximum time per week taken to administer the mailing of the letters ranged from 4 hours (ward B) to 7 hours (ward A). Self-Harm
For logistical reasons data on the incidence of self-harm were only obtained for participants discharged from wards A and
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TABLE 1. Number and Characteristics of Patients Recruited to the Study
No. patients Age, mean (range) Gender, n (%) Male Female Diagnosis , n(%) Affective disorders Schizophrenia & other psychoses Personality disorders Substance related disorders Other
Ward A
Ward B
Ward C
37 39.2 (18–70)
43 38.2 (20–67)
22 35.4 (18–57)
Total 102 37.8 (18–70)
26 (70.2) 11 (29.7)
23 (53.5) 20 (46.5)
18 (81.8) 4 (18.2)
67 (65.7) 35 (34.3)
15 (45.5) 10 (30.3) 3 (9.1) 3 (9.1) 2 (6.0)
3 (18.8) 12 (75.0) 0 0 1 (6.2)
6 (27.3) 9 (40.9) 5 (22.7) 1 (4.6) 1 (4.6)
24 (33.8) 31 (43.7) 8 (11.3) 4 (5.6) 4 (5.6)
Note. Based on data for 33 (89.2%) cases for ward A, 16 (37.2%) for ward B, 22 (100%) for ward C, data missing for 31 cases.
B. Twelve (15.0% 95% CI: 6% to 21%) of the 80 patients receiving the intervention on those wards attended a local emergency department for treatment following a selfharm episode in the 12 months postdischarge; 8 (10%, 95% CI 3% to 17%) of these were admitted to a general hospital bed. In addition, one person who had not attended the emergency department for self-harm, died by suicide. Two study participants self-harmed within 2 weeks of
discharge (one the same day), a further 8 within the first 6 months of discharge and two during the 6 to 12 months after discharge. Most (72.7%) of these participants were still receiving the letters at the time of self-harm. Readmission
Thirty-three (41.3%) of the 80 intervention patients discharged from wards
FIGURE 1. Participation and dropout in the CONTACT study.
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Community Mental Health Contacts
A and B were readmitted to a psychiatric ward within 12 months of the index discharge. The proportion of patients readmitted to participating (wards A and B) and non-participating (labelled wards X, Y, and Z) wards in the 12 months before the intervention began and for the period of the intervention is shown in Table 2. There was no clear evidence of a reduction in re-admissions to the pilot wards compared with other (non-pilot) wards. For example on the first hospital site (wards A, X, and Y) there was a 0.4% (95% CI 22%–17%) increase in readmissions in the intervention period for participating ward A whereas readmissions declined by 2.6% (95% CI 20%–15%) and 11.4% (95% CI 4%–28%) on the non-participating wards.
Policy changes within the trust providing mental health services to wards A and B meant that local crisis services were required to make face-to-face contact with at least 70% of patients discharged from inpatient psychiatric care within 48 hours of discharge and a total of 6 such contacts within the first 2 weeks post-discharge (personal communication, Avon and Wiltshire Mental Health Partnership NHS Trust). Eleven of the 12 individuals, for whom data on community mental health service contacts was recorded, had at least 2 follow-up contacts in the first week post-discharge. One person who had no contact during the first week after discharge had 3 face-to-face
TABLE 2. Discharges from Intervention Wards A and B a) Before and b) During the Intervention Period Wards Hospital A
X (non-intervention) Y (non-intervention) A (intervention)
Pre-intervention period (November 1, 2007 to April 30, 2008) Total number of discharges 62 Total readmitted within 12 months 21 (33.9) Intervention period November 1, 2009 to April 30, 2010 Total number of discharges 48 Total readmitted within 12 months (%) 15 (31.3) Difference (%) in readmissions across the 2 time points
89 36 (40.4)
51 18 (35.3)
69 20 (29.0)
56 20 (35.7)
11.4
0.4
2.6
Wards Hospital B Pre-intervention period (January 6, 2008 to July 30, 2008) Total number of discharges Total readmitted within 12 months Intervention period (January 6, 2010 to July 30, 2010) Total number of discharges Total readmitted within 12 months
B (intervention)
Z (non-intervention)
68 30 (44.1)
52 24 (46.2)
58 21 (36.2)
102 37 (36.3)
7.9
9.9
Difference (%) in readmissions across the 2 time points
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contacts during the second week. There was a mean number of 12 contacts (either faceto-face or by telephone) during the first month after discharge (Figure 2). This number of contacts fluctuated over the year after discharge and was lowest at about 4 months post-inpatient discharge, though there was still a mean of about one contact per week at this time. When we stratified our sample to take account of the possible effects of readmission, the peaks in the level of community contacts in the first month after discharge and (to a lesser degree) at 6 months post-discharge, remained. Qualitative Interviews
A total of 13 participants (12.7% of those in receipt of the intervention) were interviewed. The interviews took place on average 14 weeks (median 8 weeks, range 2 weeks–11 months) after the last study letter was received. Five respondents had received 4 intervention letters at the time of the interview, 6 had received 5–7 letters and 2 had received all 8 letters. Respondents broadly reflected the socio-demographic
characteristics of those recruited to the study with nearly two-thirds (61.5%) male and a mean age of 40.8 years. In general, participants appeared to be well-supported post discharge and mentioned a range of services and professionals who were helping them, with some recalling instances of the ward telephoning to check on their welfare. There were, however, instances of discontent with the mental health services and post-discharge support. These views and experiences, both positive and negative, tended to influence participants’ views of the intervention. As the sample comprised primarily long-term service users, most were aware of the services and numbers to call in a crisis situation (so use of the numbers=information provided in the letters=leaflets was minimal). Because if you do get into trouble, because you’ve already been in the ward, you know the people to ring up . . . because like once you’re admitted in, you work with the crisis team and also your CPN [Community psychiatric nurse] is, sort of, you know,
FIGURE 2. Mean number of face-to-face and telephone contacts by month over the 12 months post index inpatient discharge (N ¼ 12).
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they give you all the numbers and things anyway (P8; 41 yrs, Female).
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Such participants therefore felt that the intervention did not offer anything new to them, but would be of more use for those new to the system (none of whom consented to an interview) and those who did not have as much support as themselves. I think I’m quite lucky that the support I was getting from (team name) and I am still getting is, pretty much meets all of my needs and so I can imagine for somebody else, if they weren’t happy with what was going on, it might have been more helpful (P12; 31 years, Female). To the first timers, yeah, and, you know, they come out and they’ve got nowhere to turn, and obviously the information could be vital for them. So I’m not denigrating the information, I think the information was great (P13; 38 years, Male). Although some found the initial letters and support and advice leaflets positive and reassuring, a recurring theme was that after a while these felt too frequent, and could serve as a negative reminder of their hospitalization. I thought it was quite reassuring . . . if I needed contact with anybody, then, you know, the services were available. . . . (laughs) And after the first couple, I thought, ‘‘oh! not another one!’’ (P10; 42 years, Female). When I first got the letters, they were kind of a reassurance as such that there was . . . fall-back service after the crisis team, you know. But what I found, it was a repetition, it was the same letter, same numbers. . . . And then I found it was a reminder that I’d been into hospital (P9; 42 years, Male).
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For me, as somebody with a lot of support and a lot of experience of being unwell, it was more the psychological aspect of receiving a letter . . . and feeling that somebody out there actually does care of the fact that you were in hospital and eventually you’re alright now . . . there’s probably no need to send three or four, one is probably not enough because you’ve recently come out of hospital and there’s a chance it could just slip through the net and two to make sure that you definitely got it, and that you, do you know what I mean? Three and four is overkill (P13; 38 years, Male). The letters were also perceived by some to be impersonal. The letters were impersonal, like round robins. To me, they suggested that you’d written a draft, it was printed off on the computer, and sent to everyone. . . . If you’re looking for a way of reducing self-harm or suicide after a hospital admission you need to have a sense of love. Don’t you agree? You need to have this sense of actual human compassion instead of this computerized letter and a round robin of telephone numbers (P5; 36 years, Male). Reactions to the letters being sent from the ward were mixed, being viewed both positively and negatively. There was some confusion and questioning over not being able to contact the ward, despite the letters coming from there. I think the strange thing was though getting a letter from the hospital, kind of telling me about support, but nothing of it was to do with them and that felt a little bit strange . . . it was like reminding me that they were there but they weren’t going to do anything
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and they can’t help, they’re just giving me information (P12; 31 years, Female).
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One person (who had been asked to leave the ward) had found the letters upsetting and another explained that the salutation (use of their forename and surname) on the letters had triggered their psychotic symptoms. The salutation was subsequently personalized on letters by the members of ward staff who signed the letters. DISCUSSION
To the best of our knowledge this is the first evaluation of a UK contact-based intervention for people discharged from inpatient psychiatric care and only the third internationally (Luxton, Kinn, June et al., 2012; Motto, 1976; Motto & Bostrum, 2001). There are considerable differences between current psychiatric inpatient and post-discharge practices in the UK compared with those in the United States in the 1960s and 70s when the intervention was first evaluated (Department of Health, 2002). Furthermore, patients in Motto and Bostrum’s study (1976, 2001) had been hospitalized due to being in a depressed or suicidal state and had refused therapeutic follow-up on discharge from inpatient care. In contrast, we included in our study consecutively discharged patients with a range of diagnoses. The patients in our study were still in contact with mental health services after discharge from the ward and this is likely to have affected the impact of receiving the letters. Also, due to policy changes in the local mental health trust, the number of post-discharge contacts among people discharged from two of the three intervention wards may have been higher than that in other trusts in England. A recent paper has described the piloting of a contact-based intervention for United States military personnel discharged from inpatient psychiatric care. The post-discharge
mental health service context is likely to have been different to that for the general adult psychiatric patients in our study or Motto’s previous evaluation (Motto, 1976; Motto & Bostram, 2001). The use of a study database in our study meant that the intervention was relatively easy to operationalize, using a maximum of 4 to 7 hours per week of administrator or research staff time. However, interviews with service users showed that most already felt adequately supported after inpatient discharge. Though some found the initial letters reassuring, generally the intervention seemed to add little to the perception of post-discharge support. Clearly, the experience of those who did not respond to the invitation to participate in a qualitative interview and those who were new to mental health services may have been different. However, the high 12-month readmission rates and the fact that a quarter of patients who received at least one copy of the letter opted out, indicates that the intervention may be appropriate for less than a half of patients discharged from inpatient care. Though the intervention may have benefitted those who had little contact with services, the qualitative interviews showed that the relatively impersonal format of the letters—a consequence of piloting an intervention with the potential for implementation in mainstream practice—may have offset the benefit for some individuals. Any personalization of the intervention by staff, who may not have had any contact with the service user for nearly a year since discharge, and possibly only minimal contact on the ward, would be likely to be difficult. While in Motto and Bostrum’s study there was evidence of a decrease in suicide in those receiving post-discharge letters (Motto 1976; Motto & Bostrum, 2001), there was no evidence in our study of any impact on hospital admissions for self-harm, though our pilot study was not designed to have the statistical power to detect this. While 10% (95% CI 3% to 17%) of those
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in receipt of the intervention were admitted to a hospital bed following a self-harm episode, national data indicate that between April 1, 2004 and March 31, 2005 the comparable figure was similar (6.5%) (Gunnell, Hawton, Ho et al., 2008). Similarly, there was no apparent reduction in psychiatric readmissions—while 41% of participants discharged from the intervention wards A and B during the period of the intervention were readmitted within 12 months, nationally between 1 April 2004 and 31 March 2005, this figure was 24.7% (Gunnell, Hawton, Ho et al., 2008). Although differences in policies across trusts and over time will have influenced these figures, there was no evidence of lower readmission rates when intervention wards were compared with other wards in the same inpatient psychiatric units during comparable periods. Similarly, there was also no evidence of lower readmission rates among service personnel taking part in the recent contactbased pilot study in the United States (Luxton, Kinn, June et al., 2012). Those in receipt of the letters in the study of those discharged from inpatient care in the United States in the 1960s and 1970s had refused therapeutic follow-up and the mechanism by which that intervention was thought to be effective was through inducing a sense of social connectedness (Motto, 1976; Motto & Bostram, 2001). It is likely, therefore, that the amount and quality of existing mental health service contacts would have an impact on the effectiveness of a contact-based intervention, as suggested by the results of some other studies (Gunnell, Metcalfe, While et al., 2012; HassanianMoghaddam, Sarjami, Kolahi et al., 2011; Kapur, Cooper, Bennewith et al., 2010).
health policy in England. Participant accounts show that the letters add little to the experience of post-discharge support. There are also difficulties of trialing an intervention where such a high proportion (72.2%) of the study group are either ineligible or do not complete the intervention, due to opt-out or readmission. The relatively high proportion of psychiatric readmissions and general hospital admissions following self-harm, also raise doubts about the efficacy of the intervention, though power to detect this was limited. We cannot rule out a potential benefit in areas where postinpatient discharge follow-up by mental health services is less intensive. There is recent evidence of the possible benefit, through reduced self-harm admissions, of the 48 hour post-inpatient discharge telephone contact from wards provided by all mental health trusts in England (Gunnell, Metcalfe, While et al., 2012). It is also possible that the effectiveness of the intervention might be restricted to certain sub-groups, e.g., first time admissions, though targeting specific sub-groups could cause practical problems in running the intervention on a large-scale. Interviews with participants suggest an intervention with fewer mailings may be more acceptable. Though the results of this pilot study do not appear to justify a full RCT of this intervention specifically, while post-discharge selfharm remains high, other interventions need to be developed for this period of increased risk. More qualitative work, particularly to compare the post-discharge experiences of those who have experienced their first psychiatric admission with those who have had several admissions, would assist with an understanding of the post-discharge period and which interventions might be useful.
CONCLUSION AUTHOR NOTE
Based on the data provided by this pilot study, we have doubts about the usefulness of the letter-based intervention in its present format and in the setting of current mental
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Olive Bennewith, Jonathan Evans, Jenny Donovan, Sangeetha Paramasivan, Amanda Owen-Smith, William Hollingworth, and
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David Gunnell, School of Social and Community Medicine, University of Bristol, Bristol, UK. Rosemary Davies, Faculty of Health and Life Sciences, University of the West of England, Bristol, UK. Susan O’Connor, Somerset Partnership NHS Foundation Trust, Yeovil, UK. Keith Hawton, Center for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford, UK. Navneet Kapur, Center for Suicide Prevention, University of Manchester, Manchester, UK. Correspondence concerning this article should be addressed to David Gunnell, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. E-mail: [email protected] DG initiated the study, DG, OB, JE, RD, SO’C, WH, and NK contributed to the design of the study, OB collated and analyzed the quantitative data, DG, OB, and AOS carried out the qualitative interviews, SP and AOS analyzed and reported on the qualitative data, all authors contributed to the paper. ACKNOWLEDGMENTS
We thank Jerome Motto for information on the content of the letters sent to participants in his contact-based study that contributed to the development of our study and staff on the intervention wards and the Mental Health Research Network for their assistance in administering the mailing of the letters—in particular, Davina Chauhan, Nicola Cook, and Genevieve Riley who also collected data on patient participation and retention and outcome data on community contacts. We also thank Sarah Greef who carried out some of the qualitative interviews, Keith Hall and Stephen Hoddell who contributed to study design, and staff in the AWP Information
Department for providing anonymized outcome data on admissions and readmissions. FUNDING
This article presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0606-1247). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) host the research program. KH, DG, and JD are NIHR Senior Investigators. KH is also supported by Oxford Health NHS Foundation Trust and NK by the Manchester Mental Health and Social Care Trust. REFERENCES Appleby, L., Shaw, J., Kapur, N., Windfuhr, K., Ashton, A., Swinson, N., . . . Stones, P. (2006). Avoidable deaths: Five year report of the National Confidential Inquiry into suicide and homicide by people with mental illness. http://www.bbmh.manchester.ac.uk/ cmhr/research/centreforsuicideprevention/nci/ reports/ Beautrais, A. L., Gibb, S. J., Faulkner, A., Fergusson, D. M., & Mulder, R. T. (2010). Postcard intervention for repeat self-harm: Randomized controlled trial. British Journal of Psychiatry, 197, 55–60. Carter, G. L., Clover, K., Whyte, I. M., Dawson, A. H., & D’Este, C. (2005). Postcards from the EDge project: Randomized controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self-poisoning. British Medical Journal, 331, 805–807. Department of Health (2002). National suicide prevention strategy for England. London: Department of Health. Donovan, J., & Sanders, C. (2005). Key issues in the analysis of qualitative data in health services research. In A. Bowling, S. Ebrahim (Eds.), Handbook of health research methods (pp. 515–532). UK: Open University Press. Gunnell, D., Hawton, K., Ho, D., Evans, J., O’Connor, S., Potokar, J., . . . Kapur, N. (2008).
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Hospital admissions for self-harm after discharge from psychiatric inpatient care: Cohort study. British Medical Journal, 337, 2278. Gunnell, D., Metcalfe, C., While, D., Hawton, K., Ho, D., Appleby, L., & Kapur, N. (2012). The impact of national policy initiatives on fatal and non-fatal self-harm after psychiatric hospital discharge: A time series analysis. British Journal of Psychiatry, 201, 233–238. Hassanian-Moghaddam, H., Sarjami, S., Kolahi, A. A., & Carter, G. L. (2011). Postcards in Persia: Randomized controlled trial to reduce suicidal behaviors 12 months after hospital-treated selfpoisoning. The British Journal of Psychiatry, 198, 309–3168. Kapur, N., Cooper, J., Bennewith, O., Gunnell, D., & Hawton, K. (2010). Postcards, green cards, and telephone calls: Therapeutic contact with individuals following self-harm (editorial). British Journal of Psychiatry, 197, 55–60. Luxton, D. D., Kinn, J. T., June, J. D., Pierre, L. W., Reger, M. A., & Gahm, G. A. (2012). Caring
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letters project: A military suicide-prevention pilot program. Crisis, 33, 5–12. Meehan, J., Kapur, N., Hunt, I. M., Turnbull, P., Robinson, J., Bickley, H. . . . Appleby, L. (2006). Suicide in mental health in-patients and within 3 months of discharge. National clinical survey. British Journal of Psychiatry, 188, 129–134. Miles, M., & Huberman, M. (1994). Qualitative data analysis. London, UK: Sage. Motto, J. A. (1976). Suicide prevention for high-risk persons who refuse treatment. Suicide and Life Threatening Behaviour, 6, 223–230. Motto, J. A., & Bostrom, A. G. (2001). A randomized controlled trial of post crisis suicide prevention. Psychiatric Services, 52, 828–33. Office for National Statistics Suicide rates in the United Kingdom and in England and Wales, 1991 to 2010. Retrieved from: http://www.ons.gov.uk/ons/ publications/re-reference-tables.html?edition=tcm %3A77-245453 StataCorp. (2009). Stata statistical software: Release 11. College Station, TX: StataCorp LP.
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BOX A Examples of Intervention Letters
a) Letter mailed to service users one week after discharge from the ward where follow-up had been arranged with a community mental health team Dear
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It has been a short time since you were on [name of ward]. We know that the time after discharge can be difficult for people so wanted to drop you a line. We are writing to you to remind you that a member of your community mental health team [name of team] should be contacting or visiting you within the next 7 days and that if things get difficult you can contact them on [number]. You can talk to a member of the team about any areas of your life that are causing you concern (e.g., money or housing problems), not just mental health issues. If things get difficult outside 9 a.m. to 5 p.m. and at weekends you can contact the [team name] on [number]. Enclosed is a leaflet that we have put together to provide you with some information about other services that might be of interest to you. These include telephone support lines and support groups. With best wishes, [name of ward manager] On behalf of the ward team b) Letter mailed to service users at discharge from mental health services Dear It is now some time since you left the hospital and we hope that things are going well for you. As you have now been discharged from mental health services we thought you might find it useful to have another copy of the leaflet showing some of the services that are available to you. This is enclosed. If things become difficult for you we hope you will feel that you can contact your GP, [GP name] at [name of surgery] tel: [telephone number]. With best wishes, [name of ward manager] On behalf of the ward team
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