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DAY HOSPITALS AND NIGHT HOSPITALS IN PSYCHIATRY
729 club and
DAY HOSPITALS AND NIGHT HOSPITALS IN PSYCHIATRY
PHYSICIAN, BETHLBM ROYAL HOSPITAL AND
A
DAY
hospital
is
a
place
THE
MAUDSLEY
patients spend
substantial portion of their waking time under
a
therafrom which and return to their own they regime peutic home or hostel to sleep at night. Soviet Russia has had day centres as departments of its neuropsychiatric dispensaries at least since 1942. In the Russian centres the emphasis is on occupation and rehabilitation for work, although hospital facilities are also provided (Wortis 1950). The first day hospital in the English-speaking world was started in Montreal (Cameron 1947, 1956), as part of a psychiatric teaching hospital, the Allan Memorial Institute. Since then only two have established themselves firmly in North America, one in the Montreal General Hospital, a large general hospital with a psychiatric department (Moll 1953a and b), and one in the Menninger Clinic, Kansas (Law 1947, Barnard et al. 1952). Several attempts in State mental hospitals in the U.S.A. have proved abortive. But the idea is spreading, and a a
day hospital operating successfully among primitive people in tropical Africa has lately been described (Lambo 1956). In England the first day hospital was started in London as an independent institution unconnected with Since then the any existing hospital (Bierer 1951). number has slowly increased. Some follow the original London model (Aron and Smith 1953), some-such as the Bethlem and Maudsley ones-the Montreal pattern. Some cater for specialised groups of patients, such as old people (Cosin 1955) or chronic unemployable neurotics (W. Mayer-Gross, personal communication). They differ in outlook and methods. There is no uniformity, for example, in the amount of time that each patient spends at the day hospital. In some, as at Oxford, one afternoon a week may be thought adequate for some patients (Cosin 1955), in others, as at Bethlem and the Maudsley, five days is the minimum for all patients. Bethlem and
Maudsley Day Hospitals
Royal Hospital and the Maudsley Hospital form a postgraduate teaching hospital which caters for all types of psychiatric illness except uncomplicated mental deficiency. Although administratively one hospital, the buildings are 81/2 miles apart. The two day hospitals, one at Bethlem and one at the Maudsley, function essentially as wards whose special characteristic is that the patients go home each evening. In other words patients can readily pass from the conventional inpatient wards to the day hospital and from the day hospital to the inpatient wards as their condition requires. In practice, however, most of the day-hospital patients spend their illness in the day hospital and are not transferred to or from the ordinary wards. All the diagnostic and therapeutic facilities of the joint hospital are open to them, and the only forms of psychiatric treatment which it has proved impossible to undertake in the day hospital are deep-insulin coma, continuous narcosis, and neurosurgery. Each day hospital takes 30 patients at a time and has some 100 to 150 admissions a year. The Maudsley day hospital was opened in May, 1953, and is within the grounds of the hospital in the groundfloor and basement of a Victorian house which had been used as a nurses’ hostel (Harris 1954a and b). The day hospital at Bethlem was opened in April, 1956, and is Bethlem
together
without too much social pressure. Two rooms doctors, an office for the nurse in charge, and lavatories complete the indoor accommodation. There is also a tennis-court and grounds in which the patients can walk and play. The Bethlem day hospital, which is farther from the main hospital and therefore has to be more self-contained, also has a kitchen, extra interviewingrooms for psychologists and social workers, and a hut for the administration of electroconvulsion therapy, with a waiting-room, treatment-room, and recovery-room. The day hospitals are open from Monday to Friday and closed on Saturday and Sunday. The patients arrive about 8.30 A.M. and leave about 5.30 P.M., or at times that fit their relatives’ hours of work and convenience. They pass their day in much the same way as the patients in the less acute conventional wards, the morning generally being given over to occupational therapy and the afterBut the programme at the day noon to group activities. meet the need of individuals. varied to is hospital readily For example, those unsuited for group activities continue with occupational therapy in the afternoons. Shopping parties, in the company of a nurse, enable patients whose families are all out at work to return home with the household supplies. If a night sedative is needed it is handed to a relative who sees that the patient takes it at home. for
LONDON
in which
There are two smaller rooms, one for men and, one for women, where the more ill patients can spend their time
quietly
ARTHUR HARRIS M.A., M.D. Mane., D.P.M. HOSPITAL,
a pavilion which used to belong to a sports (Harris 1956). Each has a large room where men women patients can mix and undertake group activities, such as discussions, games, and play-readings.
housed in
Special Articles
Staff The medical care for each hospital is provided by a senior psychiatrist (giving one session a week), a fulltime registrar or psychiatrist in training, and one or at times two clinical assistants. The nursing care is provided by a doubly qualified ward sister and two junior nurses, who are staff nurses or student nurses according to the training situation at the hospital at the time. The part-time services of a clinical psychologist, a psychiatric social worker, and an occupational therapist are also available. Nurses find work in the day hospitals congenial, because the simple type of organisation and absence of bed-linen and other stores relieves the ward’ sister of administrative duties and enables her to give ’the greater part of her time to the patients directly. As there is only one shift, the nurse is in close contact with the whole of the patients’ hospital life, and this increases her sense of responsibility and personal influence. The relatives chat and ask advice when they bring and collect the patients, so that the nurses are brought into the family situation as well. -Patients In selecting patients one of our chief criteria has been that the patient must be so ill as to need admission to a hospital bed if the day hospital did not exist. We have closely adhered to this : all our patients are so far incapacitated by their illness as to be unable to work or lead their normal lives and most are unfit to be left alone at home during the daytime. On the other hand the patient must not be so disturbed as to be too difficult for his family to manage at night or for them to bring him and fetch him. He should not live much more than half an hour’s journey away ; for arrangements will break down if too much travelling is involved. Sensible, stable relatives, with affection and concern for the patient, who are willing to play an active, supporting role, are a very great help, and in their absence dayhospital treatment is likely to prove difficult, though success has been achieved in some unfavourable family situations. Harassed, overworked housewives, with no-one to take their burdens, who try to cram their
730 housework in during the evenings, do not do well and usually have to be admitted as inpatients. With experience we have found that a very large proportion of, potential inpatients can be treated on day-hospital lines, and the pressure of recommended admissions is now greater on the Maudsley day hospital than on the wards. .
Advantages
of the
Day Hospital
The advantages of day-hospital treatment are economic and social. It has been found at the Maudsley that the running costs of a 30-place day hospital are roughly one-third of those of a 30-bedded ward, and Montreal experience is similar. There is only one nursing shift instead of three and no bed-linen or dormitory space are needed. Also kitchen and domestic staff are needed for only a short time. The saving in capital costs is even greater, for new building is unnecessary and existing buildings can be adapted. Thus the day hospital at Bethlem was bought, reconditioned, furnished, and equipped for little more than the cost of one bed in a new
hospital. The patient keeps important matter for
his place in the family-a very the middle-aged and elderly who form the bulk of the day-hospital clientèle. Such people’s homes tend to disintegrate if they are brought into hospital as inpatients. Treatment tends to be shortened, for it is no longer necessary to test the patient’s reaction to his normal environment by sending him home for half-days and then weekends. 60% of patients in the Maudsley day hospital suffer from depressive illnesses and two groups of depressed patients, under the same physician and matched for severity and other relevant features were compared. One group was treated for the whole period of the illness in the day hospital and the other in the inpatient wards, and the average stay of the day-hospital group was between two and three weeks less than that of the inpatients (M. J. Craft, personal communication). Some women present an intractable social problem, because owing to phobias or other symptoms they cannot be left alone and there is nowhere for them to go while their husbands or other relatives are at work. In the absence of the day hospital they must be admitted into hospital (with the risk that their homes will break up), or their husbands must give up their jobs, which usually These causes poverty, resentment, and unhappiness. patients are successfully handled in the day hospital, though many require long treatment-up to one or even two years. Other people whose difficulties the day hospital has solved include a woman who might have lost the custody of her child if she had left home altogether, and a hallucinated paranoid patient who refused to stay as an inpatient but attended the day hospital until she recovered, so that certification was avoided.
and the bedrooms upstairs for sleepingeconomical use of this Victorian house. One nurse stays on from the day hospital to receive them on their return from work ; they see their doctor once a week; and they attend the evening amusements and social events arranged for the inpatients if they wish. There are 14 bedrooms-one floor for men and one for women. Patients usually settle in their jobs and leave the night hospital after a few weeks.
sitting-rooms
an
Comment
These developments are in line with the feeling which is growing up, not only in psychiatry but in other branches of medicine also, that patients are sometimes isolated in hospital more often and for longer than is necessary. Social considerations and the possible harmful effects of a stay in hospital are receiving more attention. Varying patterns of day hospital can be designed to suit different types of parent institution. In the new Montreal General Hospital inpatients and day-patients share the same psychiatric ward, and this model might well be copied by psychiatric departments of general hospitals in this country, which are usually situated in large centres of population and are therefore better placed than most mental hospitals to run day hospitals. REFERENCES
Aron, K. W., Smith, S. (1953) J. ment. Sci. 99, 564. Barnard, R. I., Robbins, L. L., Zetzlaff, F. M. (1952) Bull. Menninger Clin. 16, 20. Bierer, J. (1951) The Day Hospital. London. Cameron, D. E. (1947) Mod. Hosp. 69, no. 3, p. 40. (1956) In Bennett, Hargrove, and Engle’s Practice of Psychiatry in General Hospitals. Berkeley, California. Cosin, L. Z. (1955) J. soc. Psychiat. 1, no. 2, p. 33. Harris, A. (1954a) Hospital, 50, 214. (1954b) Nurs. Times, Aug. 14. (1956) J. soc. Therap. 2, 107. Lambo, T. A. (1956) Brit. med. J. ii, 1388. M. Law, (1947) Mental Hosp. 4, no. 2, p. 7. Moll, A. E. (1953a) Amer. J. Psychiat. 109, 774. (1953b) Canad. Hosp. April. (1955) Ibid, October. Wortis, J. (1950) Soviet Psy chiatry. Baltimore. -
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-
-
-
FREEZE-DRIED BONE-GRAFTS C. R. BERKIN M.B. Leeds, F.R.C.S. TUTOR AND
P. M. YEOMAN M.A., M.B. Camb. ORTHOPÆDIC REGISTRAR
LEEDS GENERAL INFIRMARY
G. M. WILLIAMSON M.D. Leeds LECTURER IN BACTERIOLOGY
K. ZINNEMANN
Night Hospitals At the Montreal General Hospital there is a night hospital to which the patients come after their day’s work ; they spend the evening there, have any necessary treatment, and then sleep until it is time for them to go to work the next morning (Moll 1955). The Maudsley night hospital, which opened in August, 1956, is not for patients undergoing active treatment but for those who have partially recovered and are working though not secure enough to live in ordinary lodgings or hostels. For many years it has been the practice in the joint hospital, as in several other psychiatric hospitals, to allow suitable patients to go out to work and return to the hospital in the evenings. Their adjustment to the outside world is easier if they can make it in two instalments, first to the job and then to normal living conditions. These patients are now collected in the night hospital, which uses the day-hospital accommodation as
SENIOR REGISTRAR IN ORTHOPÆDICS
M.D.
Frankfurt, M.Sc. Leeds
SENIOR LECTURER IN BACTERIOLOGY
F. DEXTER A.I.S.T. TECHNICIAN
SCHOOL OF
A
MEDICINE, LEEDS
of freeze-dried bone established in Leeds in to about 80 patients, of whom 46 are reviewed here, the remainder having been operated on too recently for final radiological assessment. BANK
April, 1955, has supplied grafts Collection and
Preparation of Bone
Bone is taken from donors aged up to 30. A considerable amount of cancellous bone is obtained with the minimum of difficulty from the lower end of the femur and the upper end of the tibia. The limb is draped as for
DAY HOSPITALS AND NIGHT HOSPITALS IN PSYCHIATRY
PHYSICIAN, BETHLBM ROYAL HOSPITAL AND
A
DAY
hospital
is
a
place
THE
MAUDSLEY
patients spend
substantial portion of their waking time under
a
therafrom which and return to their own they regime peutic home or hostel to sleep at night. Soviet Russia has had day centres as departments of its neuropsychiatric dispensaries at least since 1942. In the Russian centres the emphasis is on occupation and rehabilitation for work, although hospital facilities are also provided (Wortis 1950). The first day hospital in the English-speaking world was started in Montreal (Cameron 1947, 1956), as part of a psychiatric teaching hospital, the Allan Memorial Institute. Since then only two have established themselves firmly in North America, one in the Montreal General Hospital, a large general hospital with a psychiatric department (Moll 1953a and b), and one in the Menninger Clinic, Kansas (Law 1947, Barnard et al. 1952). Several attempts in State mental hospitals in the U.S.A. have proved abortive. But the idea is spreading, and a a
day hospital operating successfully among primitive people in tropical Africa has lately been described (Lambo 1956). In England the first day hospital was started in London as an independent institution unconnected with Since then the any existing hospital (Bierer 1951). number has slowly increased. Some follow the original London model (Aron and Smith 1953), some-such as the Bethlem and Maudsley ones-the Montreal pattern. Some cater for specialised groups of patients, such as old people (Cosin 1955) or chronic unemployable neurotics (W. Mayer-Gross, personal communication). They differ in outlook and methods. There is no uniformity, for example, in the amount of time that each patient spends at the day hospital. In some, as at Oxford, one afternoon a week may be thought adequate for some patients (Cosin 1955), in others, as at Bethlem and the Maudsley, five days is the minimum for all patients. Bethlem and
Maudsley Day Hospitals
Royal Hospital and the Maudsley Hospital form a postgraduate teaching hospital which caters for all types of psychiatric illness except uncomplicated mental deficiency. Although administratively one hospital, the buildings are 81/2 miles apart. The two day hospitals, one at Bethlem and one at the Maudsley, function essentially as wards whose special characteristic is that the patients go home each evening. In other words patients can readily pass from the conventional inpatient wards to the day hospital and from the day hospital to the inpatient wards as their condition requires. In practice, however, most of the day-hospital patients spend their illness in the day hospital and are not transferred to or from the ordinary wards. All the diagnostic and therapeutic facilities of the joint hospital are open to them, and the only forms of psychiatric treatment which it has proved impossible to undertake in the day hospital are deep-insulin coma, continuous narcosis, and neurosurgery. Each day hospital takes 30 patients at a time and has some 100 to 150 admissions a year. The Maudsley day hospital was opened in May, 1953, and is within the grounds of the hospital in the groundfloor and basement of a Victorian house which had been used as a nurses’ hostel (Harris 1954a and b). The day hospital at Bethlem was opened in April, 1956, and is Bethlem
together
without too much social pressure. Two rooms doctors, an office for the nurse in charge, and lavatories complete the indoor accommodation. There is also a tennis-court and grounds in which the patients can walk and play. The Bethlem day hospital, which is farther from the main hospital and therefore has to be more self-contained, also has a kitchen, extra interviewingrooms for psychologists and social workers, and a hut for the administration of electroconvulsion therapy, with a waiting-room, treatment-room, and recovery-room. The day hospitals are open from Monday to Friday and closed on Saturday and Sunday. The patients arrive about 8.30 A.M. and leave about 5.30 P.M., or at times that fit their relatives’ hours of work and convenience. They pass their day in much the same way as the patients in the less acute conventional wards, the morning generally being given over to occupational therapy and the afterBut the programme at the day noon to group activities. meet the need of individuals. varied to is hospital readily For example, those unsuited for group activities continue with occupational therapy in the afternoons. Shopping parties, in the company of a nurse, enable patients whose families are all out at work to return home with the household supplies. If a night sedative is needed it is handed to a relative who sees that the patient takes it at home. for
LONDON
in which
There are two smaller rooms, one for men and, one for women, where the more ill patients can spend their time
quietly
ARTHUR HARRIS M.A., M.D. Mane., D.P.M. HOSPITAL,
a pavilion which used to belong to a sports (Harris 1956). Each has a large room where men women patients can mix and undertake group activities, such as discussions, games, and play-readings.
housed in
Special Articles
Staff The medical care for each hospital is provided by a senior psychiatrist (giving one session a week), a fulltime registrar or psychiatrist in training, and one or at times two clinical assistants. The nursing care is provided by a doubly qualified ward sister and two junior nurses, who are staff nurses or student nurses according to the training situation at the hospital at the time. The part-time services of a clinical psychologist, a psychiatric social worker, and an occupational therapist are also available. Nurses find work in the day hospitals congenial, because the simple type of organisation and absence of bed-linen and other stores relieves the ward’ sister of administrative duties and enables her to give ’the greater part of her time to the patients directly. As there is only one shift, the nurse is in close contact with the whole of the patients’ hospital life, and this increases her sense of responsibility and personal influence. The relatives chat and ask advice when they bring and collect the patients, so that the nurses are brought into the family situation as well. -Patients In selecting patients one of our chief criteria has been that the patient must be so ill as to need admission to a hospital bed if the day hospital did not exist. We have closely adhered to this : all our patients are so far incapacitated by their illness as to be unable to work or lead their normal lives and most are unfit to be left alone at home during the daytime. On the other hand the patient must not be so disturbed as to be too difficult for his family to manage at night or for them to bring him and fetch him. He should not live much more than half an hour’s journey away ; for arrangements will break down if too much travelling is involved. Sensible, stable relatives, with affection and concern for the patient, who are willing to play an active, supporting role, are a very great help, and in their absence dayhospital treatment is likely to prove difficult, though success has been achieved in some unfavourable family situations. Harassed, overworked housewives, with no-one to take their burdens, who try to cram their
730 housework in during the evenings, do not do well and usually have to be admitted as inpatients. With experience we have found that a very large proportion of, potential inpatients can be treated on day-hospital lines, and the pressure of recommended admissions is now greater on the Maudsley day hospital than on the wards. .
Advantages
of the
Day Hospital
The advantages of day-hospital treatment are economic and social. It has been found at the Maudsley that the running costs of a 30-place day hospital are roughly one-third of those of a 30-bedded ward, and Montreal experience is similar. There is only one nursing shift instead of three and no bed-linen or dormitory space are needed. Also kitchen and domestic staff are needed for only a short time. The saving in capital costs is even greater, for new building is unnecessary and existing buildings can be adapted. Thus the day hospital at Bethlem was bought, reconditioned, furnished, and equipped for little more than the cost of one bed in a new
hospital. The patient keeps important matter for
his place in the family-a very the middle-aged and elderly who form the bulk of the day-hospital clientèle. Such people’s homes tend to disintegrate if they are brought into hospital as inpatients. Treatment tends to be shortened, for it is no longer necessary to test the patient’s reaction to his normal environment by sending him home for half-days and then weekends. 60% of patients in the Maudsley day hospital suffer from depressive illnesses and two groups of depressed patients, under the same physician and matched for severity and other relevant features were compared. One group was treated for the whole period of the illness in the day hospital and the other in the inpatient wards, and the average stay of the day-hospital group was between two and three weeks less than that of the inpatients (M. J. Craft, personal communication). Some women present an intractable social problem, because owing to phobias or other symptoms they cannot be left alone and there is nowhere for them to go while their husbands or other relatives are at work. In the absence of the day hospital they must be admitted into hospital (with the risk that their homes will break up), or their husbands must give up their jobs, which usually These causes poverty, resentment, and unhappiness. patients are successfully handled in the day hospital, though many require long treatment-up to one or even two years. Other people whose difficulties the day hospital has solved include a woman who might have lost the custody of her child if she had left home altogether, and a hallucinated paranoid patient who refused to stay as an inpatient but attended the day hospital until she recovered, so that certification was avoided.
and the bedrooms upstairs for sleepingeconomical use of this Victorian house. One nurse stays on from the day hospital to receive them on their return from work ; they see their doctor once a week; and they attend the evening amusements and social events arranged for the inpatients if they wish. There are 14 bedrooms-one floor for men and one for women. Patients usually settle in their jobs and leave the night hospital after a few weeks.
sitting-rooms
an
Comment
These developments are in line with the feeling which is growing up, not only in psychiatry but in other branches of medicine also, that patients are sometimes isolated in hospital more often and for longer than is necessary. Social considerations and the possible harmful effects of a stay in hospital are receiving more attention. Varying patterns of day hospital can be designed to suit different types of parent institution. In the new Montreal General Hospital inpatients and day-patients share the same psychiatric ward, and this model might well be copied by psychiatric departments of general hospitals in this country, which are usually situated in large centres of population and are therefore better placed than most mental hospitals to run day hospitals. REFERENCES
Aron, K. W., Smith, S. (1953) J. ment. Sci. 99, 564. Barnard, R. I., Robbins, L. L., Zetzlaff, F. M. (1952) Bull. Menninger Clin. 16, 20. Bierer, J. (1951) The Day Hospital. London. Cameron, D. E. (1947) Mod. Hosp. 69, no. 3, p. 40. (1956) In Bennett, Hargrove, and Engle’s Practice of Psychiatry in General Hospitals. Berkeley, California. Cosin, L. Z. (1955) J. soc. Psychiat. 1, no. 2, p. 33. Harris, A. (1954a) Hospital, 50, 214. (1954b) Nurs. Times, Aug. 14. (1956) J. soc. Therap. 2, 107. Lambo, T. A. (1956) Brit. med. J. ii, 1388. M. Law, (1947) Mental Hosp. 4, no. 2, p. 7. Moll, A. E. (1953a) Amer. J. Psychiat. 109, 774. (1953b) Canad. Hosp. April. (1955) Ibid, October. Wortis, J. (1950) Soviet Psy chiatry. Baltimore. -
-
-
-
-
FREEZE-DRIED BONE-GRAFTS C. R. BERKIN M.B. Leeds, F.R.C.S. TUTOR AND
P. M. YEOMAN M.A., M.B. Camb. ORTHOPÆDIC REGISTRAR
LEEDS GENERAL INFIRMARY
G. M. WILLIAMSON M.D. Leeds LECTURER IN BACTERIOLOGY
K. ZINNEMANN
Night Hospitals At the Montreal General Hospital there is a night hospital to which the patients come after their day’s work ; they spend the evening there, have any necessary treatment, and then sleep until it is time for them to go to work the next morning (Moll 1955). The Maudsley night hospital, which opened in August, 1956, is not for patients undergoing active treatment but for those who have partially recovered and are working though not secure enough to live in ordinary lodgings or hostels. For many years it has been the practice in the joint hospital, as in several other psychiatric hospitals, to allow suitable patients to go out to work and return to the hospital in the evenings. Their adjustment to the outside world is easier if they can make it in two instalments, first to the job and then to normal living conditions. These patients are now collected in the night hospital, which uses the day-hospital accommodation as
SENIOR REGISTRAR IN ORTHOPÆDICS
M.D.
Frankfurt, M.Sc. Leeds
SENIOR LECTURER IN BACTERIOLOGY
F. DEXTER A.I.S.T. TECHNICIAN
SCHOOL OF
A
MEDICINE, LEEDS
of freeze-dried bone established in Leeds in to about 80 patients, of whom 46 are reviewed here, the remainder having been operated on too recently for final radiological assessment. BANK
April, 1955, has supplied grafts Collection and
Preparation of Bone
Bone is taken from donors aged up to 30. A considerable amount of cancellous bone is obtained with the minimum of difficulty from the lower end of the femur and the upper end of the tibia. The limb is draped as for