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ANZJP Correspondence
Complex care patients within acute care beds Titus Mohan, Allan Nelson and Michael Nance Flinders Medical Centre, Australia Corresponding author: Michael Nance, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042, Australia. Email: [email protected] DOI: 10.1177/0004867414559134
To the Editor We follow with interest the articles pertaining to sub-acute care (Allison et al., 2014).We wish to highlight complexities in the general adult inpatient case-mix, which provides additional perspective to this important issue. It has been observed (Thompson et al., 2004) and is our experience that about 10% of patients have a prolonged inpatient length of stay (LOS). These patients have illness courses complicated by multidimensional problems including treatment resistance, challenging behaviours, forensic issues or intellectual disabilities. They are often admitted to acute wards when existing supports fail; not necessarily because these wards can provide appropriate care but because no community service is equipped to manage them.
Suicide attempt and externalizing behaviours in posttraumatic stress disorder (PTSD): Possible role of the activating effect of antidepressants Madhulika A Gupta Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada Corresponding author: MA Gupta, Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, 585 Springbank Drive, Suite 101, London, Ontario, N6J 1H3, Canada. Email: [email protected] DOI: 10.1177/0004867414538676
The complex subgroup of patients mentioned above have severely limited or complex rehabilitation goals and are better cared for under a disability paradigm. Without broader reforms like supported/rehabilitation accommodation a proportion of the acute inpatient unit (by virtue of its non-exclusionary nature) is thus diverted to disability support. In the past such patients may have been referred to long stay rehabilitation wards. As Allison et al. (2014) point out, South Australia now has very low numbers of inpatient rehabilitation beds and supported accommodation, leading patients with exceptional needs to gravitate towards acute inpatient wards (South Australian Office of the Public Advocate, 2013: 26) with a disproportionate LOS. This inevitably impacts on the availability of acute beds. Sub-acute (intermediate care centre) beds in South Australia are above the national average (Allison et al., 2014) and designed for a subgroup of people without major challenging behaviours for a LOS of around two weeks. While we acknowledge the adjunctive role of such beds, we are concerned that they are commissioned at the expense of general acute inpatient units, which are already 18% below the national average (Allison et al., 2014) and further affected by the blocks discussed. This tenuous acute bed base significantly increases
upstream pressures in the emergency department and general hospital. Acute beds provide a safe, evidence based and ethical model of care. We agree with Allison et al. (2014) that resource allocation should first consolidate such a time tested non-exclusionary service. Sub-acute beds could then be a valuable addition to the repertoire of services available. However, based on the evidence presented, and in our experience, they cannot replace the range of functions of an acute inpatient bed.
To the Editor
contribute to increased suicidality and externalizing behaviours in some patients. Consent was obtained from the Office of Research Ethics, University of Western Ontario, Canada. Both patients met the DSMIV-TR criteria for PTSD with delayed onset; other psychiatric comorbidities including bipolar disorder were ruled out. Patient A is a 42-year-old hospital ward clerk who was referred after she impulsively hit and pushed a coworker. This behaviour was totally out of character for her. She had been started on paroxetine 20 mg daily after a 2 month history of insomnia, nightmares, anxiety, and
Suicide risk and externalizing behaviours (Shin et al., 2012) in posttraumatic stress disorder (PTSD) can be difficult to manage. Selective serotonin reuptake inhibitor (SSRI) antidepressants including paroxetine and sertraline (Jeffreys, 2009) are the only US Food and Drug Administrationapproved pharmacotherapies for PTSD. Many antidepressants, including SSRIs, are known to have an activating effect on mood (Tondo et al., 2010). The two case studies below suggest that antidepressants may enhance the emotional regulation difficulties in PTSD, which in turn may
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References Allison S, Bastiampillai T and Goldney R (2014) Acute versus sub-acute care beds: Should Australia invest in community beds at the expense of hospital beds? Australian and New Zealand Journal of Psychiatry 48: 952–954. South Australian Office of the Public Advocate (2013) Annual Report. Available at: http:// www.opa.sa.gov.au/resources/annual_report (accessed 26 August 2014). Thompson A, Shaw M, Harrison G, et al. (2004) Patterns of hospital admission for adult psychiatric illness in England: analysis of Hospital Episode Statistics data. British Journal of Psychiatry 185: 334–341.
Australian & New Zealand Journal of Psychiatry, 49(1)
Downloaded from anp.sagepub.com at NORTHERN ARIZONA UNIVERSITY on June 17, 2015
ANZJP Correspondence
Complex care patients within acute care beds Titus Mohan, Allan Nelson and Michael Nance Flinders Medical Centre, Australia Corresponding author: Michael Nance, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042, Australia. Email: [email protected] DOI: 10.1177/0004867414559134
To the Editor We follow with interest the articles pertaining to sub-acute care (Allison et al., 2014).We wish to highlight complexities in the general adult inpatient case-mix, which provides additional perspective to this important issue. It has been observed (Thompson et al., 2004) and is our experience that about 10% of patients have a prolonged inpatient length of stay (LOS). These patients have illness courses complicated by multidimensional problems including treatment resistance, challenging behaviours, forensic issues or intellectual disabilities. They are often admitted to acute wards when existing supports fail; not necessarily because these wards can provide appropriate care but because no community service is equipped to manage them.
Suicide attempt and externalizing behaviours in posttraumatic stress disorder (PTSD): Possible role of the activating effect of antidepressants Madhulika A Gupta Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada Corresponding author: MA Gupta, Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, 585 Springbank Drive, Suite 101, London, Ontario, N6J 1H3, Canada. Email: [email protected] DOI: 10.1177/0004867414538676
The complex subgroup of patients mentioned above have severely limited or complex rehabilitation goals and are better cared for under a disability paradigm. Without broader reforms like supported/rehabilitation accommodation a proportion of the acute inpatient unit (by virtue of its non-exclusionary nature) is thus diverted to disability support. In the past such patients may have been referred to long stay rehabilitation wards. As Allison et al. (2014) point out, South Australia now has very low numbers of inpatient rehabilitation beds and supported accommodation, leading patients with exceptional needs to gravitate towards acute inpatient wards (South Australian Office of the Public Advocate, 2013: 26) with a disproportionate LOS. This inevitably impacts on the availability of acute beds. Sub-acute (intermediate care centre) beds in South Australia are above the national average (Allison et al., 2014) and designed for a subgroup of people without major challenging behaviours for a LOS of around two weeks. While we acknowledge the adjunctive role of such beds, we are concerned that they are commissioned at the expense of general acute inpatient units, which are already 18% below the national average (Allison et al., 2014) and further affected by the blocks discussed. This tenuous acute bed base significantly increases
upstream pressures in the emergency department and general hospital. Acute beds provide a safe, evidence based and ethical model of care. We agree with Allison et al. (2014) that resource allocation should first consolidate such a time tested non-exclusionary service. Sub-acute beds could then be a valuable addition to the repertoire of services available. However, based on the evidence presented, and in our experience, they cannot replace the range of functions of an acute inpatient bed.
To the Editor
contribute to increased suicidality and externalizing behaviours in some patients. Consent was obtained from the Office of Research Ethics, University of Western Ontario, Canada. Both patients met the DSMIV-TR criteria for PTSD with delayed onset; other psychiatric comorbidities including bipolar disorder were ruled out. Patient A is a 42-year-old hospital ward clerk who was referred after she impulsively hit and pushed a coworker. This behaviour was totally out of character for her. She had been started on paroxetine 20 mg daily after a 2 month history of insomnia, nightmares, anxiety, and
Suicide risk and externalizing behaviours (Shin et al., 2012) in posttraumatic stress disorder (PTSD) can be difficult to manage. Selective serotonin reuptake inhibitor (SSRI) antidepressants including paroxetine and sertraline (Jeffreys, 2009) are the only US Food and Drug Administrationapproved pharmacotherapies for PTSD. Many antidepressants, including SSRIs, are known to have an activating effect on mood (Tondo et al., 2010). The two case studies below suggest that antidepressants may enhance the emotional regulation difficulties in PTSD, which in turn may
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References Allison S, Bastiampillai T and Goldney R (2014) Acute versus sub-acute care beds: Should Australia invest in community beds at the expense of hospital beds? Australian and New Zealand Journal of Psychiatry 48: 952–954. South Australian Office of the Public Advocate (2013) Annual Report. Available at: http:// www.opa.sa.gov.au/resources/annual_report (accessed 26 August 2014). Thompson A, Shaw M, Harrison G, et al. (2004) Patterns of hospital admission for adult psychiatric illness in England: analysis of Hospital Episode Statistics data. British Journal of Psychiatry 185: 334–341.
Australian & New Zealand Journal of Psychiatry, 49(1)
Downloaded from anp.sagepub.com at NORTHERN ARIZONA UNIVERSITY on June 17, 2015
