PubMed · 7708418
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Douglas Cairns. 1994. Twice bitten.. https://doi.org/10.1016/0304-3959(94)90031-0
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BACKGROUND: Lengths for hospital stays for people with serious mental illness have reduced drastically over the last 30 years. Some argue that this reduction has led to revolving door admissions and worsening mental health outcomes despite apparent cost savings, whilst others suggest longer stays may be more harmful in the long term by institutionalising people to hospital care. This review attempts to answer which is the answer: whether short or long stays are effective. OBJECTIVES: To determine the effect of planned short stay admission policies versus a long or standard stay for people with serious mental illnesses. SEARCH STRATEGY: Biological Abstracts (1982-1995), Cochrane Schizophrenia Group's Register (December 1998), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1974-1995) were searched. Further references were sought from published trials and their authors. SELECTION CRITERIA: All randomised trials of planned short versus long hospital stays for people with serious mental illness (however defined). DATA COLLECTION AND ANALYSIS: Trials were reliably identified and data extracted. Analysis was on an intention-to-treat basis. People who dropped out or lost to follow-up were assumed to have no improvement. Peto odds ratios (OR) and 95% confidence intervals were calculated. MAIN RESULTS: Five randomised controlled trials were included. For those receiving planned short stays, data suggested that this group experienced no more re-admissions (OR 1.1, CI 0.7-1.7), no more losses to follow up (OR 1.09, CI 0.6-1.9), and were more successfully discharged on time (OR 0.47, CI 0.3-0.9) compared to long stay or standard care. The data also suggested some evidence that planned short stay patients were no more likely to leave hospital prematurely and had a greater chance of being employed. Data on mental, social and family outcomes could not be summated and there was little or no data on user satisfaction, deaths, violence, criminal behaviour, and costs. REVIEWER'S CONCLUSIONS: The effects of hospital care and the length of stay is important for mental health policy. This review suggests that a planned short stay policy does not encourage a 'revolving door' pattern of admission and disjointed care for people with serious mental illness. More large, well-designed and reported trials are justified. It may be that the 'developing world', where, in some places, the long stay institutions are still functioning, will be able to provide good data that has failed to appear from research in the 'developed world'.
The main purpose of this paper is to show that the civil commitment acts of the Nordic countries are in conflict with the ideal of symmetry, i.e. the idea that if a person has the competence (and therefore the right) to accept hospitalisation he or she should also be considered competent (and therefore have the right) to refuse hospitalisation. First, we distinguish between one narrow and one wide concept of coercion in relation to hospital admission; second, we demonstrate that the narrow concept of coercion is used or presupposed with reference to hospitalisation in the Nordic countries; and third, we discuss, from a normative point of view, the rather disturbing asymmetrical conception of patient's competence and rights implied by this narrow concept of coercion. Though the ideal of symmetry supports the use of the wide concept of coercion in civil commitment acts, it does not decide the issue. To justify a change from a narrow to a wide concept would also require empirical data about the practical implications.