a study of outcome in patients treated at a psychiatric emergency unit

© 2010 Informa H

A study of outcome in patients treated at a psychiatric emergency unit MARIT F. SVINDSETH , JIM AAGE N Ø TTESTAD , ALV A. DAHL

Svindseth MF, N ø ttestad JA, Dahl AA. A study of outcome in patients treated at a psychiatric emergency unit. Nord J Psychiatry 2010;64:363–371.

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Background: Although being an important part of the psychiatric treatment chain, there are few outcome studies of treatment at psychiatric emergency units (PEU). Aims: The aim was to measure changes in psychopathology and humiliation during admission at a PEU. Methods: The sample consisted of 147 patients examined at admission and discharge. The instruments used were the Brief Psychiatric Rating Scale (BPRS), the Narcissistic Personality Inventory-29 (NPI-29), the Hospital Anxiety and Depression Scale (HADS), a combination of questions measuring negative experiences and Cantril ’ s ladder measuring experienced humiliation.Outcome measures were clinically signifi cant improvement [ � 10% reduction of the BPRSconverted (0 – 100) score] and changes on the other instruments. Results: Median hospitalization time was 13 days (mean 20.4 days). Fifty-six per cent of the patients showed clinical signifi cant improvement (95% CI 48 – 64%), 42% showed some degree of improvement and 2% were unchanged. The more improved patients had higher scores at admission than those with less improvement on all scales, indicating a fl oor effect. Small changes were observed for narcissism and experienced humiliation and negative admission events. In multivariate analyses highadmission scores on BPRS subscales, thinking disorder and activation and HADS total score were signifi cantly associated with clinically signifi cant improvement. Type and length of admis-sion did not signifi cantly affect the outcome. The BPRS, HADS and NPI-29 scores at discharge were mainly explained by corresponding admission scores. Conclusions: More than half the patients admitted to PEU have clinically signifi cant reduction of psychopathology during their stay. Higher levels of psychopathology at admission were signifi cantly associated withimprovement. Negative admission experiences and involuntary admission did not infl uence outcome.

• BPRS, Emergency psychiatry units, Humiliation, Involuntary admissions, Narcissism, Outcome.

Marit F. Svindseth, M.H.Sci, Department of Psychiatry, Sunnmore Hospital, N-6026 Aalesund, Norway, E-mail: [email protected]/[email protected]; Accepted 8 February 2010.

Emergency psychiatry is concerned with acute care of

patients who show symptoms or behaviours that

represent a severe risk to themselves or to other per-

sons. Such symptoms and behaviours include suicidal

thoughts and suicide attempts, violent behaviour,

impaired reality testing (psychosis), substance depen-

dence, toxic psychoses and psychiatric side-effects of

various drugs. Other symptoms relevant for emergency

psychiatry are delirium and dementia, and other severe

reductions of cognitive functions, severe anxiety reac-

tions eventual triggered by trauma as well as rapidly

changing severe mental symptoms. Such symptoms and

behaviours often lead to admissions to psychiatric emer-

gency units (PEUs), either on a voluntary or involuntary

basis. The prevalence of such admissions has increased

considerably over time in Norway, whereas the length

of admissions has decreased (1).

ealthcare

The primary aim of PEUs is to reduce psychopathol-

ogy as quickly as possible, and to sort out eventual

patients with somatic diseases in need of treatment by

other medical specialities. At PEUs several treatment

methods are applied, and the treatment team is regularly

multi-professional and well staffed providing around-the-

clock attention and care.

In spite of its pivotal role and the considerable

resources allocated to PEUs within the psychiatric treat-

ment system, there are surprisingly few general outcome

studies related to treatment at PEUs during recent years.

Most studies focus on the effects of voluntary versus

involuntary admission, and no signifi cant outcome differ-

ences between these modes of admission are found in

most studies (2, 3). Involuntary admission to PEUs can

be a humiliating experience (4) according to the defi nition

of humiliation by Hartling & Luchetta (5): “ The internal

DOI: 10.3109/08039481003690273

MF SVINDSETH ET AL.

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experience of humiliation is the deep dysphoric feeling

associated with being, or perceiving oneself as being,

unjustly degraded, ridiculed, or put down — in particular,

one ’ s identity has been demeaned or devalued. ” Changes in

the experience of humiliation and the negative attitudes

related to admission process have been less studied as out-

come variables in PEUs treatment studies.

This prospective study of patients admitted to a Nor-

wegian PEU try to answer two research questions:

1) What are the changes in humiliation, negative expe-

riences, and psychopathology during the admission

measured on interview-based and self-reporting rating

scales?

2) What variables measured at admission are predictors

of outcome at discharge?

Methods Setting The Department of Psychiatry at Sunnmore Hospital of

the Mid-Norway Regional Health Trust has a PEU con-

sisting of two closed wards each with eight single-bed

rooms. The hospital serves a geographical sector of about

95,000 people � 18 years of age consisting of both rural

and urban areas. Each unit had as least two psychiatric

nurses present on each shift. A doctor was always on

call, and a psychiatrist was present during the day and

could be summoned to the ward within 30 min at night.

On each ward, a total of fi ve to seven persons were on

duty during the day, fi ve in the evening and three during

the night.

Patient sampling Consecutively admitted patients to the PEU during the

period between 1 March 2005 and 15 October 2006,

were invited to this study if eligible. Exclusion criteria

were obvious cognitive impairment or organically based

confusion, manic or hypomanic states, re-admittance dur-

ing the sampling period or discharge within 72 h. During

the sampling period, 191 patients with involuntary status

were admitted. Among them, 78 did not meet the eligi-

bility criteria, eight declined to take part or withdrew

consent and seven were lost because of administrative

reasons. This left 98 involuntary patients for the study.

Because of a majority of voluntary admissions, we

only invited patients admitted on Mondays, Wednesdays

and Fridays of one week and Tuesdays, Thursdays and

Saturdays/Sundays the next week, using this procedure

throughout the sampling period. Among the 160 volun-

tary patients admitted on these days, 48 did not meet the

eligibility criteria, 13 declined to take part or withdrew

consent and 11 were lost because of administrative rea-

sons. This left 88 voluntary admitted patients for the

study. All patients had the research examination within

364

72 h after admission, and a second one within 24 h prior

to discharge.

Measurements INTERVIEW-BASED

The Brief Psychiatric Rating Scale (BPRS) is a clinician-

rated test designed to assess status and changes in sever-

ity of psychopathology mainly related to psychosis (6, 7).

The instrument includes 24 items of psychopathology,

and the timeframe of evaluation is the day of the inter-

view. Items are rated on a 7-point Likert-like scale

anchored from 1 (not present) to 7 (extremely severe),

and the range of scores are from 24 to 168 with higher

scores representing more psychopathology. The BPRS

has well-documented properties as an outcome measure

in severe mental illness (8 – 10).

We also included fi ve BPRS subscales Thinking distur-bance (sum score of 10: Hallucinatory behaviours, 11:

Unusual thought content and 15: Conceptual disorganiza-

tion); Withdrawal/Retardation (sum score of 17: Emotio-

nal withdrawal, and 18: Motor retardation); Hostility/Suspiciousness (sum score of 6: Hostility, 9: Suspiciousness

and 20: Uncooperativeness); Anxious/Depression (sum score

of 2: Anxiety, 3: Depression and 5: Guilt feelings); and

Activation (sum score of 19: Tension, 21: Excitement and

24: Mannerisms and posturing). The internal consistencies

(Cronbach ’ s coeffi cient a at admission were for BPRS total

score α � 0.73, Thinking disturbance α � 0.61, Withdrawal/

Retardation α � 0.72, Hostility/Suspiciousness α � 0.61,

Anxiety/Depression α � 0.57 and Activation α � 0.61.

Eight experienced registered psychiatric nurses were

trained by the fi rst author to perform the BPRS interviews.

Reliability testing of the interviewers showed correlation

coeffi cients of 0.87 – 0.97 compared with those of the

supervisor and between the interviewers of 0.74 – 0.97.

DEMOGRAPHIC VARIABLES

Level of education was dichotomized ( � 12 and � 12 years)

based on the number of completed school years. Income

status was dichotomized (paid work or self-employed vs.

unemployed or pensioned). Relationship status was

divided into paired (married, cohabiting) and non-paired

relationships.

Patient-rated We used the Narcissistic Personality Inventory-29 (NPI-

29) developed by Kansi (11) and validated by our group

(12). The NPI-29 consists of 29 dual statements among

which one is considered indicative of narcissism. Each

statement is scored “ yes ” or “ no ” , and there is no time-

frame for the evaluation. Based on summation of the

relevant items, the total NPI-29 score was calculated

(Cronbach ’ s α � 0.85), and higher score means higher

level of narcissism.

NORD J PSYCHIATRY·VOL 64·NO 6·2010

TREATMENT OUTCOME AT A PSYCHIATRIC EMERGENCY UNIT

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The Hospital Anxiety and Depression Scale (HADS)

consists of seven items measuring anxiety (HADS-A)

and seven measuring depression (HADS-D) during the

last week (13). Each item has scores from 0 (minimum

presence) to 3 (maximum presence); the subscales scores

are 0 – 21 with higher values implying more symptoms.

Since fi ndings have indicated that the HADS-Total

(HADS-T) has good psychometric properties (14), we

used that scale in the regression analyses. Cronbach ’ s a

was 0.85 for HADS-T.

Experienced humiliation was measured with the

Cantril Measure Ladder, which is a visual, analogue

scale from 1 (minimum humiliation) to 10 (maximum

humiliation). The ladder is considered a general scale

with good psychometric properties, and has mainly been

used in studies of quality of life, but also in studies

measuring coercion (15 – 17). The interviewer read an

instruction to the patient before he/she scored the lad-

der, explaining that they should score the level of emo-

tional degradation or feeling of being less worth. They

were also given an explanation of the two endpoints of

the ladder.

Several instruments have been use for collection of

patients ’ reactions to admissions , such as the Nordic

Admission Interview (NORAI) and the Admission Expe-

rience Survey (AES) (15). The NORAI was inspired by

the AES and the Admission Experience Interview (AEI),

used in several Nordic studies. The Nordic Study of the

Use of Coercion established the NORAI. In this study,

we asked 10 questions concerning reaction to admission.

Three questions were taken from the NORAI covering

the patients ’ ability to leave the hospital, the necessity

of admission and feelings of offence. Four questions

came from the AES covering whether the patients had

been heard, were allowed to express their opinions,

experienced threats or had been exposed to physical

force. An additional question of being verbally forced to

do something was taken from Lidz et al. (18). Two

additional questions were self-made: “ Do you consider

yourself mentally ill? ” and “ Did you have any good

experiences during the admission process? The responses

to these 10 items were “ yes ” and “ no ” , and the negative

responses were summed up as the Negative experiences

score with a range from 0 to 10, with a higher score

meaning more negative experiences. Cronbach ’ s α was

0.79 for negative experiences at admission and 0.76 at

discharge.

Data from the medical records ICD-10 diagnoses (19) were set by the treating psychia-

trist at discharge. Only the main diagnosis was used in

this study. Psychopharmacological treatment was taken

from the medication sheets, whereas information about

other types of treatment had not been notifi ed in a sys-

tematic way.


The Global Assessment of Functioning (GAF) is an

observer-based rating scale for the current overall func-

tioning of a patient on a continuum ranging from 1

(sickest individuals) to 100 (healthiest individuals).

Recently the GAF has been divided into the GAF Func-

tions (GAF-F) and the GAF Symptoms (GAF-S) (20),

which were scored by a psychiatrist at admission only

and not at discharge.

Statistical analyses Clinical signifi cant improvement was determined for the

primary outcome measure of BPRS total score accord-

ing to the Empirical Rule Effect Size method of Sloan

et al. (ERES) (21). This method has three steps: 1) the

BPRS total score range is recoded from 24 to 168 to 0

to 100; 2) the standard deviation of the recoded BPRS

total score is 16.7 points, corresponding to Cohen ’ s d

effect size of 1.0 (22); and 3) a medium effect size of

d � 0.6 was considered clinical signifi cant improvement,

which corresponded to (16.7 � 0.6) 10 points on the

recoded BPRS total scale. When the differences of the

recoded BRPS total scores at admission and discharge

were � 10 points, the patients were classifi ed as “ more

improved ” ( n � 82) and when the differences was � 10

the patients were “ less improved ” ( n � 65). The “ more

improved ” and the “ less improved ” groups were then

compared.

Continuous measures were analysed by t -tests and

paired sample t -tests. Skewed distributions were exam-

ined with non-parametric tests as appropriate. Categorical

variables were examined with the chi-squared test.

Effects sizes (ESs) were calculated for statistically sig-

nifi cant group differences on continuous variables by

Cohen ’ s coeffi cient d and on 2 � 2 contingency tables

with the differences between arcsine transformed propor-

tions (coeffi cient φ). ESs � 0.40 were considered clini-

cally signifi cant, except for the primary outcome measure

(BPRS total) in which we demanded d � 0.60 (22 – 24).

Internal consistencies of scales were examined with

Cronbach ’ s coeffi cient α . The strength of associations

between independent variables and clinically signifi cant

improvement as a dichotomy (more/less) was examined

with univariate and multivariate logistic regression analy-

sis. Only variables signifi cant in the univariate analyses

were entered into the multivariate analysis. The strength

of the associations was expressed as odds ratios (ORs)

with 95% confi dence intervals (95% CI).

Variables at admission considered relevant for inter-

view-based (the BPRS total score) and self-rated (the

HADS-T and the NPI-29 total scores) outcome at dis-charge were examined with stepwise, hierarchical linear

regression analyses. We used four steps of independent

variables: demography, admission characteristics, inpa-

tient characteristics and rating of the dependent variable

at admission. The strength of associations was expressed

365

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as standardized β -values, explained variance ( R 2 ) and

change in explained variance ( R 2 -change).

The data was analysed on SPSS for PC version 15.0.

The signifi cance level was set at P � 0.05, and all tests

were two-tailed.

Ethics The Regional Committee of Ethics in Medical Research of

Mid-Norway, and The Norwegian Data Inspectorate

approved the study. All patients gave written, informed con-

sent after the procedures had been fully explained to them.

Results Attrition analysis Of the 186 patients included, 147 (79%) were interviewed

and delivered self-ratings on both admission and dis-

charge. Comparing these 147 patients with the 39 patients

366

who delivered data on admission, only signifi cantly lower

mean age of the non-respondents (35.6 � 13.5 vs.

37.8 � 13.4 years) was observed (ES � 0.16).

Description of the sample The sample consisted of 43% females and 57% males

( P � 0.15). The mean age was 37.8 � 13.4 years, and 26%

were in a paired relationship and 25% were working. The

majority of the patients had � 12 years of basic educa-

tion. Fifty-four per cent of the patients had involuntary

and 46% voluntary admissions (Table 1).

Changes from admission to discharge Eighty-two patients (56%, 95% CI 48 – 64%) showed clin-

ically signifi cant improvement ( “ more improved ” group),

62 (42%) showed improvement that did not reach a clini-

cal signifi cant level and three (2%) were unchanged. The

two latter groups were pooled as the “ less improved

Table 1. Characteristics at admission of more improved and less improved patients.

Variables

More improved,

n � 82

Less improved,

n � 65 P

Total sample,

n � 147

Age, mean ( s ) 36.9 (13.5) 38.9 (13.3) 0.36 37.8 (13.4)

n (%) n (%)

Sex 0.15

Females 40 (49) 24 (37) 64 (43)

Males 42 (51) 41 (63) 83 (57)

Paired relationship 0.94

Yes 21 (26) 17 (26) 38 (26)

No 61 (74) 48 (74) 109 (74)

Level of education 0.53

� 12 years 58 (71) 49 (75) 107 (73)

� 12 years 24 (29) 16 (25) 40 (27)

Job status 0.53

Working 19 (23) 18 (28) 37 (25)

Unemployed, pensioned 63 (77) 47 (72) 110 (75)

Admission status 0.98

Voluntary 38 (46) 30 (46) 68 (46)

Involuntary 44 (54) 35 (54) 79 (54)

Previous admissions 0.41

0 – 1 admission 46 (56) 32 (49) 78 (53)

� 2 admissions 36 (44) 33 (51) 69 (47)

Diagnostic groups 0.10

Substance abuse 22 (27) 7 (11) 29 (20)

Schizophrenia 14 (17) 19 (29) 33 (22)

Major depressions 26 (32) 19 (29) 45 (31)

Neurotic disorders 12 (15) 13 (20) 25 (17)

Personality disorders 8 (9) 7 (11) 15 (10)

Duration of stay 0.84

� 2 weeks 44 (54) 36 (55) 80 (54)

� 2 weeks 38 (46) 29 (45) 67 (46)

Prescribed medication

Antipsychotics 51 (62) 41 (63) 0.91 92 (63)

Anxiolytics 7 (9) 7 (11) 0.65 14 (10)

Hypnotics 24 (29) 15 (23) 0.40 39 (27)

Antidepressants 27 (33) 24 (37) 0.61 51 (35)

Antiepileptics 17 (21) 16 (25) 0.58 33 (22)

s , standard deviation.



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group ” . The “ more ” and “ less improved ” groups did not

differ signifi cantly on age, sex, paired relationship, levels

of education, job status, diagnosis, type, number and

duration of admission, diagnostic groups, or prescribed

medication during their stay (Table 1).

The level of humiliation was statistically signifi cantly

reduced in the “ more improved ” group (Table 2) from

admission to discharge, but not in the “ less improved ”

group. The mean negative admission experience score

was signifi cantly reduced from admission to discharge

in the “ more improved ” group, but not in the “ less

improved ” one (Table 2). However, neither the changes

in humiliation nor in negative experiences reached clinical

signifi cance.

Eighty-seven (59%) used some kind of psychotropic

drugs at admission and 119 (81%) at discharge ( P � 0.001,

ES � 0.49).

The BPRS total scale and its subscales, the HADS-A

and HADS-D, and the NPI-29 mean scores all showed

signifi cant reduction from admission to discharge in both

the “ more improved ” and the “ less improved ” patients

(Table 2). For the BPRS and the HADS measures, the

ESs of the changes were considerably larger in the “ more

improved ” than in the “ less improved ” group. In contrast,

the ES for the NPI-29 changes were small in both groups.

All mean scores at admission were higher in the “ more

improved ” compared with the “ less improved ” group.

The associations of independent variables measured at

admission with “ more improved ” vs. “ less improved ”

group (reference) at discharge were tested in logistic regres-

sion analyses (Table 3). In univariate analyses, higher

BPRS subscale scores on Thinking disturbance, Hostility/

Suspicion and Activation, as well as higher HADS-T

scores at admission and having negative experiences during

the admission process, were all signifi cantly associated


with clinically signifi cant improvement at discharge.

Negative experiences and humiliation did not show any

signifi cant association with improvement in the univari-

ate analyses. In multivariable analysis, higher BPRS sub-

scale scores of Withdrawal/Retardation and Activation

and higher HADS-T score at admission were signifi -

cantly associated with “ more improvement ” at discharge.

Our four-step model explained 49% of the variance in

the BPRS total score, 67% of the HADS-T and 90% of

the NPI-29 total scores at discharge (Table 4). The scores

at admission on all three measures made the strongest

contribution, but the step of admission variables also

made signifi cant contribution to all three measures. The

demographic step made a signifi cant but weak contribu-

tion to the BPRS and the NPI-29 total scores at dis-

charge, whereas the inpatient step made such contributions

to the HADS-T and the NPI-29 total scores (Table 4).

At admission, the presence of schizophrenia, being

suicidal and higher GAF-S score were predictive of

higher BPRS total at discharge. Higher HADS-T score at

discharge was also predicted by low level of education

and higher GAF-S score at admission, whereas no other

variables than the NPI-29 score at admission were pre-

dictive of the NPI-29 at discharge.

Discussion In relation to our research questions, we found that the

mean levels of experienced humiliation and negative

admission experiences showed a signifi cant reduction from

admission to discharge in the “ more improved ” group

only. Humiliation and negative experiences were not sig-

nifi cantly related to being more improved in the logistic

regression analyses. On both the interview-based BPRS

total and its subscale scores and the self-rated HADS-T,

Table 2. Scores at admission and discharge for the more and less improve groups of patients.

More improved patients ( n � 82) Less improved patients ( n � 65)

Variables

Scores at

admission

Mean ( s )

Scores at

discharge

Mean ( s ) P * ES

Scores at

admission

Mean ( s )

Scores at

discharge

Mean ( s ) P * ES

BPRS

Total Score 61.2 (13.7) 35.9 (8.0) � 0.001 2.26 44.5 (8.8) 35.7 (9.2) � 0.001 0.98

Thinking disturbance

Withdrawal/Retardation

Anxiety/Depression

Hostility/Suspiciousness

Activation

7.7 (4.1) 4.5 (2.1) � 0.001 0.98 4.9 (2.5) 4.4 (2.1) 0.02 0.22

4.2 (2.4) 2.8 (1.1) � 0.001 0.75 3.5 (1.8) 2.8 (1.4) � 0.001 0.43

10.4 (4.0) 7.8 (2.4) � 0.001 0.79 9.3 (4.2) 8.2 (3.3) 0.001 0.29

7.6 (4.1) 4.1 (1.8) � 0.001 1.11 4.8 (2.2) 3.9 (1.6) � 0.001 0.47

8.2 (3.9) 4.4 (1.4) � 0.001 1.30 4.8 (1.6) 4.0 (1.1) � 0.001 0.58

NPI-29 Total score 6.8 (5.7) 5.9 (4.7) � 0.001 0.17 7.4 (4.5) 6.5 (3.9) 0.001 0.21

HADS-Depression 10.2 (4.3) 6.8 (3.2) � 0.001 0.90 8.0 (4.5) 6.0 (3.9) � 0.001 0.47

HADS-Anxiety 13.1 (4.9) 8.8 (3.5) � 0.001 1.01 10.6 (5.1) 7.9 (4.4) � 0.001 0.57

Experienced humiliation 4.0 (3.3) 3.2 (2.7) 0.001 0.27 3.3 (3.0) 3.0 (2.8) 0.24

Negative Experience Scale 2.8 (2.5) 2.4 (2.2) 0.01 0.28 2.3 (2.3) 2.1 (2.1) 0.15

s , standard deviation.

* Paired samples t -test.

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the “ more improved ” patients showed clinically signifi cant

reduction of their psychopathology, except for the NPI-29

score, which showed statistical signifi cance only. The

group of “ less improved ” patients also showed such clini-

cally signifi cant changes except for BPRS Thinking dis-

turbance, BPRS Anxiety/Depression and NPI-29. Clinically

signifi cant improvement was reached in 56% of the sam-

ple, and 98% had some degree of improvement.

Higher levels on the BPRS subscales Thinking dis-

turbance, Withdrawal/Retardation, Activation and the

HADS-T at admission were signifi cantly associated with

“ more improvement ” at discharge in multivariate analy-

ses. The main predictor of the BPRS-total, HADS-T and

NPI-29 scores at discharge were the scores on the same

scales at admission explaining 20%, 41% and 56% of

the variance, respectively.

The “ more improved ” patients had higher mean

admission scores on all scales compared with the “ less

improved ” ones. This fi nding points to a fl oor effect

showing that higher levels of psychopathology are more

modifi ed with treatment at PEU than intermediate ones.

However, the vast majority of the patients had signifi cant

reduction of their psychopathology. This result confi rms

that treatment in PEU fulfi ls one of its primary aims,

which is reduction of psychopathology. This seems to

concern any kind of psychopathology, either interview-

based or self-rated, except for narcissism. We have in a

368

former paper (25) stated that the NPI-29 score has a stable

trait character in our sample.

The proportion of patients on psychotropic medication

increased signifi cantly during the admission from 59% to

81%, and medication was frequently changed during the

admission. We presume that regulation of medication is

an important reason for the observed reduction of psycho-

pathology, but cannot state that for sure. The infl uence

of other intervention such as psychotherapy, family work,

stimulus reduction and seclusion cannot be evaluated

because of lack of data.

Our study has much in common with that of Wallsten

et al. (26) examining the outcome in 233 patients treated

at four Swedish PEUs. Their outcome measure was an

increase in the interview-based GAF-score � 10%. They

found that 58% of the patients showed this degree of

improvement, a proportion strikingly similar to the 56%

we found with the BPRS as outcome measure. Their

study, like ours, did not show any signifi cant association

between involuntary/voluntary admission status and out-

come, and this is in accordance with the majority of

studies in two reviews (2, 3). Varner et al. (9) also doc-

umented signifi cant reductions on the BPRS total and

most of its subscales within 2 weeks stay at a PEU.

The improvement observed by Varner et al. (9),

Wallsten et al. (26) and our group, and confi rmed in

other studies (2,3) could be explained at least in two

Table 3 . Univariate and multivariate logistic regression analyses of selected independent variables and more improved patients [defi ned by � 10% reduction of the BPRS total score (0 – 100) from admission to discharge] with less improved patients as reference.

Univariate Multivariate

Independent variables OR 95% CI P OR 95% CI P

Age 0.99 0.97 – 1.01 0.36

Being male 0.62 0.32 – 1.19 0.15

Level of education

� 12 years ( � reference) 1.00

� 12 years 0.79 0.38 – 1.65 0.53

Not in paired relation 1.03 0.49 – 2.16 0.94

Working 1.27 0.60 – 2.68 0.53

Involuntary admission 0.99 0.52 – 1.91 0.98

Length of admission 0.99 0.98 – 1.01 0.37

BPRS subscales *

Anxiety/Depression 1.07 0.99 – 1.16 0.09

Thinking disturbance 1.29 1.14 – 1.45 � 0.001 1.13 0.96 – 1.32 0.15

Withdrawal/Retardation 1.18 1.00 – 1.39 0.05 1.33 1.08 – 1.64 0.007

Hostility/Suspicion 1.30 1.15 – 1.47 � 0.001 1.09 0.93 – 1.29 0.28

Activation 1.52 1.29 – 1.78 � 0.001 1.47 1.19 – 1.82 � 0.001

HADS-Total * 1.08 1.03 – 1.12 0.001 1.06 1.00 – 1.11 0.04

NPI-29 Total * 0.98 0.92 – 1.04 0.44

GAF-Symptoms * 0.98 0.95 – 1.01 0.15

Non-schizophrenia (ref.) 1.00

Schizophrenia 0.50 0.23 – 1.09 0.08

Negative experiences * 1.09 0.95 – 1.25 0.24

Humiliation score * 1.07 0.96 – 1.18 0.24

* Rated at admission.



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ways. One is simply regression toward mean (27), which

implies that patients when they are admitted have a

higher than usual level of psychopathology, and during

the admission they simply get closer to their ordinary

level. Another explanation is the effect of treatment and

a sheltered milieu at PEU. Our fi nding of higher levels

of psychopathology at admission in the “ more improved ”

group lends support to the regression toward mean expla-

nation, but does not exclude a contribution by active

treatment modalities.

The reduction of negative admission experiences score

during the admission was signifi cant only in the “ more

improved ” group in our study. This is in accordance

both with a review (2) and a recent study from the UK,

in which at a 1 year follow-up, 60% of involuntary

admitted patients still considered their hospitalization

unjustifi ed (28). However, more negative experiences

was signifi cantly associated with “ more improved ” status

at discharge in univariate analyses. Our tentative expla-

nation is negative experiences are modifi ed somewhat

through improvement of psychopathology in general.

Our focus on humiliation associated with the admis-

sion process is a somewhat new perspective, which we

have touched on in an earlier study of PEU patients (4).

As seen from the defi nition of humiliation given in the

introduction (5), it is a painful feeling triggered by the

experience of devaluation. In relation to the admission


process, we consider the experience of coercion more

cognitive and intellectual, whereas the experience of

humiliation is more emotional. The “ more improved ”

group had a somewhat higher mean level of humiliation

at admission than the “ less improved ” ( P � 0.23), but only

the “ more improved ” group had a signifi cant reduction in

their humiliation scores from admission to discharge. The

humiliation scores showed no signifi cant association with

the outcome variables in the regression analyses. We con-

sider the positive changes in humiliation and negative

experiences as an expression of the “ thank you ” effect

(29). They argued that patients who initially resist treat-

ment will later be grateful of the intervention.

Strength and limitations The exclusion of manic and hypomanic states and severe

cognitive impairment could be considered both a strength

and a limitation. It is a strength because the lack of cri-

tique or cognitive abilities of such patients make their

self-rating of symptoms invalid. The exclusion is also a

limitation since comparison of their treatment outcome

compared with other diagnostic groups had been of con-

siderable interest. The same arguments can be used from

the exclusion of patients with confusion and cognitive

impairment.

We consider it a strength that outcome was measured

both by interview-based (BPRS) and self-rated instruments

Table 4. Stepwise hierarchical linear regression analyses with Brief Psychiatric Rating Scale (BPRS), Hospital Anxiety and Depression Scale (HADS) and Narcissistic Personality Inventory (NPI-29) total scores at discharge as dependent variables.

BPRS total HADS-T NPI-29 total

Independent variables Beta P Beta P Beta P

Step 1: Demography variables

Sex 0.09 0.20 0.06 0.27 −0.00 0.91

Age 0.02 0.83 −0.03 0.60 0.00 0.99

Education ( � 12 � reference) 0.10 0.11 −0.11 0.04 −0.04 0.15

Paired relation (paired � ref.) 0.08 0.27 0.10 0.08 0.05 0.11

Work situation (working � ref.) 0.14 0.04 0.09 0.12 0.01 0.84

Explained variance ( R 2 ) 0.11 0.004 0.07 0.07 0.09 0.02

Step 2: Admission variables

Involuntary (voluntary � ref.) 0.00 0.99 0.13 0.06 0.02 0.62

Humiliating experience 0.06 0.43 −0.02 0.84 −0.00 0.99

Suicidal (non-suicidal � ref.) 0.18 0.02 0.17 0.29 −0.03 0.45

Negative experiences 0.18 0.02 0.04 0.55 0.08 0.05

Explained variance ( R 2 ) 0.25 � 0.001 0.20 � 0.001 0.27 � 0.001

Change of variance ( R 2 -change) 0.14 0.13 0.18

Step 3: Inpatient variables

Length of admission 0.08 0.23 0.04 0.46 0.04 0.20

GAF-S score at admission 0.17 0.02 0.12 0.03 0.02 0.54

Schizophrenia present 0.21 0.01 −0.05 0.39 0.03 0.41

Explained variance ( R 2 ) 0.29 0.07 0.26 0.02 0.34 0.01


Step 4: Rating at admission

Admission score 0.53 � 0.001 0.75 � 0.001 0.94 � 0.001

Explained variance ( R 2 ) 0.49 � 0.001 0.67 � 0.001 0.90 � 0.001


369

MF SVINDSETH ET AL.

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(HADS, NPI-29) that are sensitive to change and with

good psychometric properties.

The attrition analysis showed that the non-partici-

pants at discharge hardly differed from the participants

at admission. This is considered a strength and allows

us to generalize our fi ndings to our total sample

( n � 186). Our questions, used to measure negative

experiences, were put together from various scales,

available at the time we planned the study. This could

be considered a weakness; however, the internal con-

sistencies were excellent, which could be considered a

strength.

The defi nition of clinically signifi cant improvement can

be discussed, since several methods have been recom-

mended (22 – 24). We found the arguments for the ERES

method by Sloan et al. (21) as clinically quite meaningful.

We also calculated the Reliable Change Index recom-

mended by Jacobson & Truax (30) and found that 95% of

our sample was improved according to that index.

Our study was done in a PEU, which is quite typical

for Norwegian psychiatry, where treatment is easily

accessible and free of charge because of the National

Health Care Plan. We consider the external validity of

our fi ndings as restricted, since jurisdictions, payment

and organization of PEUs differ between countries.

However, PEUs are an integrated part of the psychiatric

treatment system in most developed countries, and they

seem to treat patients with much the same acute psy-

chiatric problems. In order to minimize this limitation,

we have described the organization of our PEU in con-

siderable detail. This description should make it possi-

ble for the readers to evaluate whether our fi ndings

could be relevant for their organization of PEUs.

Because of the lack of outcome data from PEU treat-

ment, we fi nd our results worth reporting, and hope that

they can inspire other PEUs to publish outcome from

their units.

Conclusions Our fi ndings show that most patients are improved symp-

tomatically during their stay at PEU, and 56% of them

had clinically signifi cant improvement. This improvement

also concerns involuntary admitted patients. Whether this

improvement is related to regression toward mean, active

treatment or both has to be settled in future studies. There

were fewer changes of the feeling of humiliation and of

negative admission experiences during the stay, and estab-

lishing improvement within these areas is a challenge for

PEU treatment programmes. In spite of these remarks, our

conclusion is that the PEU studied have treatment results

according to its political health intention.

Acknowledgement — Marit F. Svindseth holds a Ph.D. grant from Mid-

Norway Regional Health Trust.

370

Declaration of interest: The authors report no confl icts of

interest. The authors alone are responsible for the content

and writing of the paper.

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Marit F. Svindseth, M.H.Sci., Department of Psychiatry, Sunnmore Hospital, N – 6026 Aalesund; National University of Science and Tech-nology, N-7440 Trondheim; and Aalesund University College, N-6025 Aalesund, Norway. Jim Aage N ø ttestad, Ph.D., National University of Science and Tech-nology, N-7440 Trondheim; and Department of Forensic Psychiatry, Broset, St. Olav ’ s Hospital, N-7440 Trondheim, Norway. Alv A. Dahl, M.D., Ph.D., Department of Clinical Cancer Research, The Norwegian Radiumhospital, Oslo University Hospital, N-0310 Oslo, Norway; and Faculty Division The Norwegian Radiumhospital, University of Oslo, N-0316 Oslo, Norway.

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a study of outcome in patients treated at a psychiatric emergency unit

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