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"Revolving Door" In Psychiatric Units Seems To Remain a Common Phenomenon in the 21st Century
Eduardo Calmon de Moura1,2, Fernando Venturini1,2, Paula Andrea S Bastos3, Lourdes Conceição Martins3 and Yara Dadalti Fragoso3,4*
1Department of Psychiatry, Universidade Metropolitana de Santos, São Paulo, Brazil2Postgraduate Program in Health Sciences, Universidade Metropolitana de Santos, São Paulo, Brazil3Postgraduate Program in Health Sciences, Universidade Metropolitana de Santos, São Paulo, Brazil4Department of Neurology, Universidade Metropolitana de Santos, São Paulo, Brazil

ABSTRACT
Objective
To assess the frequency of readmissions and the characteristics of patients undergoing two or more hospitalizations for the same psychiatric condition.

Method
Analyses of retrospective data from medical records of patients admitted to the Intensive Mental Healthcare Unit of Santos, Brazil between January 2010 and August 2016. Psychiatric patients admitted to the unit at least three times were considered to fulfill the “revolving door” criteria.

Results
From a total of 2579 admissions in the period of the study, 636 (24.6%) were considered to be “revolving door” cases. Patients fulfilling this “revolving door” criteria were younger (p=0.001), predominantly male (59.1%), and remained hospitalized for 4.8 days longer than other patients (p=0.01). The most frequent diagnoses for patients fulfilling the “revolving door” criteria were non-affective psychotic disorders (39.6%) and cases of use of psychoactive substances (30.3%). It was common for patients to present a combination of two or more diagnoses.

Conclusion
Nearly one quarter of patients admitted to a specialized healthcare unit in Santos, Brazil was cases of “revolving door”.
KEYWORDS
Hospitalization; Illicit drugs; Psychiatry; Psychosis; Schizophrenia

Introduction
Hospitalization for chronic psychiatric conditions constitutes an exceptional type of treatment in modern times. Many authors consider it to be a reflection of difficulties faced by the extra-hospital and/or community care systems in managing patients with mental illness. In Brazil, despite the progress in the psychiatric reforms that began in the 1970s, a long list of improvements needed remains. It is necessary to increase coverage by psychosocial care centers; to increase the integration of mental health with primary healthcare; to expand the number of residential facilities; and to increase provision of specific services for people using alcohol and other drugs [1].

In the coastal region of the state of Sao Paulo, a psychosocial care center was created in the late 1980s with the aim of providing 24-hour extra-hospital care for psychiatric patients. This unit attends patients from an extensive region of the state of São Paulo, Brazil, with around two million inhabitants. Despite the noticeable improvement in psychiatric care in this region since then, many patients seem to be systematically readmitted to Hospital, in a so-called “revolving door” phenomenon [2]. The objective of this study was to assess the frequency of readmissions and the characteristics of patients undergoing two or more hospitalizations for the same psychiatric condition.
Method
This study was approved by the Ethics Committee at Universidade Metropolitana de Santos, SP, Brazil, under the number CAAE 59877516.4.0000.5509. Data were collected between January 2010 and August 2016 from the Intensive Mental Healthcare Unit of Santos, Brazil, from a total of 2579 admissions. Inclusion criteria: patients admitted to the unit at least three times in this period of six and a half years were considered to fulfill the “revolving door” criteria. Patients were included whether they had only one psychiatric diagnosis or an association of diagnoses. Exclusion criteria: incomplete records and patients still hospitalized.
Results
Among the total number of admissions, 636 patients (24.6%) were considered to be “revolving door” cases. Their average age was 36.4±13.3 years. Table 1 summarizes data on the psychiatric patients hospitalized at the Intensive Mental Healthcare Unit in Santos, Brazil. These patients were younger (p=0.001), predominantly male (59.1%), and remained hospitalized for longer periods (on average, 4.8 days longer, p=0.01) than those who were not chronically readmitted. The most frequent diagnoses [3]. For patients fulfilling the “revolving door” criteria were non-affective psychotic disorders (39.6%) and cases of use of psychoactive substances (30.3%). It was common for patients to present a combination of two or more diagnoses. The most common association of diagnosis was non-organic psychoses and psychoactive substance use (n=103) followed by mood disorders and psychoactive substance use (n=33).

Diagnoses of 636 patients admitted to the Intensive Mental Healthcare Unit in Santos, Brazil between January 2010 and August 2016. The main diagnoses for admission were schizophrenia and related disorders, followed by psychoactive substance use. These were also the main reasons leading to repetitive admissions, characterizing the “Revolving Door” patient. Note that patients may present more than one diagnosis.
Discussion
Despite the progress in community care, chronic mental illnesses were found to lead to frequent readmissions among around 25% of the hospitalized patients in the region studied. This rate is higher than what was observed in studies in the USA (repeated admission rate of 14%) [4] and Germany (12%) [5], but lower than what was found in South Africa (65%) [6], in Israel (37.8) [7] and in a previous Brazilian study (50%) [8]. In all reports, schizophrenia seems to be an important risk factor for readmissions, particularly among young men, as also observed in the present study. This finding has not changed since studies carried out in the 1980s [9]. In Singapore, on a specific study on schizophrenia, hospital readmission was observed in 23.9% of patients, with a predominance of males, with recently diagnosed disease and a history of self-harm [10]. In Japan, smoking was a significant factor for schizophrenic patients to be readmitted in hospitals [11], but this information has not been investigated in other centers.

In China, the significant factors associated to re-hospitalization of psychiatric patients was the previous number of hospitalizations [12] and previous length of stay in hospital [13]. The population of recidivist patients in the present study showed high rates of psychoactive drug usage. At least in Brazil, this seems to be a major reason for re-hospitalization [14].

There are few studies on the subject of personality disorders and readmissions. A recent study in the USA showed that the readmission rate was 30% when patients presented personality disorders together with substance abuse [15]. A previous Brazilian study reported this rate to be 19% [8], and the present study found that 4.6% of the sample had personality disorders alone or in combination with other diagnoses.

Danish researchers consider the “revolving door” phenomenon to be a reflection of the present policy of premature discharge of patients with schizophrenia [16]. The same authors consider that community psychiatry may not be providing adequate relapse prevention, thus leading to readmissions. Newer drugs may help to change this scenario [17], but it is important to remember that medication noncompliance is the most common cause of relapse among “revolving door” schizophrenia inpatients [18]. In addition, readmission rates are not a suitable indicator of quality of care in psychiatry but may be an important aspect of planning of mental health services [19].
Conclusion
The readmission rate at a public psychiatric hospital in the coastal region of the state of São Paulo is relatively high, such that around one quarter of the inpatients are classified as “revolving door” cases. The case profile of young males with non-affective psychotic disorders as the main recidivists is concordant with the literature.

References
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Tables
Mental and Behavioral DisordersGroups
Total Number of Patients“Revolving Door”
Number%Number%
Organic (including symptomatic) mental disorders472.9121.4
Mental and behavioral disorders due to psychoactive substance use43226.425830.3
Schizophrenia, schizotypal and delusional disorders6704133839.6
Mood (affective) disorders30718.811313.3
Neurotic, stress-related and somatoform disorders271.760.7
Adult personality and behavior disorders754.6394.6
Mental retardation593.6799.3
Other diagnoses181.180.9
Total1635100853100
Table 1: Diagnoses of patients and percentage of readmissions.

Citation: de Moura EC, Venturini F, Bastos PAS, Martins LC, Fragoso YD (2017) “Revolving Door” In Psychiatric Units Seems To Remain a Common Phenomenon in the 21st Century. J Psychiatry Depress Anxiety 3: 008.