Management practice and discharge outcome of patients with psychiatric disorder admitted to psychiatry wards of selected specialized settings in Ethiopia

Study setting and periods

The study was conducted from December 1, 2021, to June 30, 2022, at the Psychiatry Ward of Jimma Medical Center (PWJMC) and St. Amanuel Mental Specialized Hospital (SAMSH). SAMSH is the largest mental specialized hospital in Ethiopia, providing mental health services to clients from all over the country. It is located in Addis Ababa, the capital of Ethiopia. At the outpatient level, it serves more than 800 patients daily. It has a capacity of 270 beds for inpatient care. The number of emergency visits per month is close to 2000 [18, 19]. On the other hand, JMC is located in Jimma Town, 352 km southwest of Addis Ababa, Ethiopia. It is the only teaching, referral, and medical center in the south-western part of the country, with a bed capacity of 800. According to JMC statistics, the center currently serves approximately 15,000 inpatients and 160,000 outpatients each year, with a catchment population of approximately 15 million people. One of the units is the psychiatry department, which was established in 1988 and is next to St. Amanuel mental specialized hospital. Currently, there are approximately 5405 patients on follow-up, and the clinic officially has 53 inpatient beds [20].

Study design

A cross-sectional study was conducted involving adult psychiatry patients admitted to PWJMC and SAMSH.

PopulationSource population

All adult psychiatry patients admitted to PWJMC and SAMSH.

Study population

All adult psychiatry patients admitted to PWJMC and SAMSH who fulfilled the inclusion criteria during the study period.

Inclusion and exclusion criteriaInclusion criteria

All psychiatric patients age ≥ 18 years who were admitted to PWJMC and SAMSH during the study period.

Exclusion criteria

Those who were refused to participate.

Patients who stayed in hospital beyond the study period.

Patients who were unable to communicate.

Sample size and sampling technique

The sample size for patients’ discharge outcome was calculated using a single population proportion formula. A 50% proportion (P) was considered for patients’ unimproved discharge outcome. Considering a 0.05 margin of error (d) and 95% confidence interval, n = the required sample size.

$$\mathrm n=\frac/2\right)^2\mathrm p\left(1-\mathrm p\right)}$$

p = Assumed proportion of patients’ unimproved discharge outcome = 0.5

1-p = q = 0.5

d = Expected margin of error = 0.05

Z α/2 = 95%confidence interval (C.I) = 1.96

Thus, n = ((1.96)2 × 0.5x 0.5)/ (0.05)2 = 384

Since the target population was less than 10,000, the sample size should be corrected using the following correction formula.

$$\mathbf\boldsymbol=\mathbf\boldsymbol/\mathbf1\boldsymbol+\mathbf\boldsymbol/\mathbf N$$

Where nf is the corrected sample size and N is the number of patients admitted in the two hospitals in the last years’ seven month period of similar season, which was 833.

Thus, nf = 384/1 + 384/833 = 264.

After accounting for a 5% non-response (14 patients), the final sample size was 278 patients

Based on previous admission data, this number was proportionally divided in the ratio of 1:5 for both hospitals. Accordingly, 47 and 231 patients were allocated for PWJMC and SAMSH, respectively.

A consecutive sampling technique was used to recruit the study participants.

Data collection instrument and processing

Data was collected through patient interviews and a review of medical records using a questionnaire developed after reviewing relevant literature [12, 15,16,17]. For patient interviews, the questionnaire was translated into the most common local languages (Afan Oromo and Amharic). Socio-demographic and behavioral, clinical, drug, substance abuse, and treatment-related information were collected. The diagnosis of psychiatric illnesses and the assessment of outcome at discharge were made using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and the Clinical Global Impression (CGI) scale, respectively, by a psychiatrist or a senior psychiatric nurse who are not the authors of this article.

The Life Events Questionnaire (LEQ) was used to assess recent life events. It is a 12-item self-rating instrument that assesses common life events that are potentially threatening. Respondents were asked to select life events that had occurred within the past 12 months prior to the onset of their psychiatric symptoms. Each life event was answered dichotomously (yes or no) and was scored 1 if it was ‘yes’ and 0 if it was "no." A total score was the sum of all items [21].

The Oslo Social Support Scale (OSSS-3) was used to assess perceived psychosocial support. The OSSS-3 consists of three items that assess the level of social support. The sum score ranges from 3 to 14, with high values representing strong levels of social support and low values representing poor levels of social support, which was interpreted as [3-8] is poor social support, [9-11] is moderate social support, and [12-14] is strong social support [22].

The adherence assessment tool, the Medication Adherence Rating Scale (MARS-5), was used to assess adherence. MARS-5 is a 5-item self-report scale that is used to detect non-adherent behavior by self-report. It is a measure of non-adherence in general, not for mental disorders in particular. The questions are formulated in a non-threatening and non-judgmental way to minimize social desirability bias. The item responses are scored on a 5-point Likert scale, where 1 = always, 2 = often, 3 = sometimes, 4 = rarely, and 5 = never. Scores range from 5 to 25, with higher scores indicating higher adherence. Psychiatric patients who scored 23 or above were classified as adherent to their psychotropic medication, while those who scored less than 23 were classified as non-adherent [23, 24].

The Mental Health Trigger Tool (MHTT) was used for efficient chart review and identification of adverse drug reactions (ADR) in addition to self-reported ADR by patients themselves. The MHTT was developed with the aim of detecting and measuring both traditionally defined ADRs and other patient safety incidents relevant to mental health settings. It is an easy-to-use tool for understanding and measuring a variety of patient safety incidents in mental health settings and it is designed for use in inpatient mental health settings. The tool contains a list of 25-item triggers related to general care, laboratory, medication-related, and behavior-related items [25].

The clinical global impression (CGI) scale was used to assess the outcome at discharge. The CGI is an overall clinician-determined summary measure that considers all available information, including knowledge of the patient’s history, psychosocial circumstances, symptoms, behavior, and the impact of the symptoms on the patient’s ability to function. It has two components: the CGI-Severity (CGI-S), which rates illness severity, and the CGI-Improvement (CGI-I), which rates change from the initiation (baseline) of treatment. The CGI-S asks the clinician one question: "Considering your total clinical experience with this particular population, how mentally ill is the patient at this time?" which is rated on the following seven-point scale: 1 = normal, not at all ill; 2 = borderline mentally ill; 3 = mildly ill; 4 = moderately ill; 5 = markedly ill; 6 = severely ill; 7 = among the most extremely ill patients. The CGI-I is similarly simple in its format. Each time the patient is seen after treatment has been initiated, the clinician compares the patient’s overall clinical condition to the one-week period just prior to the initiation of treatment (during admission). The CGI-S score obtained at the baseline visit serves as the basis for this assessment. Again, only the following query is rated on a seven-point scale: "Compared to the patient’s condition at admission, this patient’s condition is: 1 = very much improved since the initiation of treatment; 2 = much improved; 3 = minimally improved; 4 = no change from baseline; 5 = minimally worse; 6 = much worse; 7 = very much worse since the initiation of treatment." There are no universally accepted scoring guidelines for the seven anchor points; rather, they were designed to be based solely on clinical judgment. The CGI is applicable across all CNS studies, including depression, schizophrenia, bipolar disorder, and anxiety, no matter the population, drug, or other main study measures. It provides a readily recognizable and universally known efficacy measure that distinguishes it from the more complex, lengthier, and sometimes difficult to administer efficacy scales [26].

Three data collectors were trained on the research tool and data collection procedure. All patients included in the study were followed from the first day in the psychiatry ward until the date of discharge using a follow-up chart included in the questionnaire.

Data quality assurance

The questionnaire was carefully tailored to collect all of the necessary information, and it was translated from English to Afan Oromo and Amharic and then back translated into English. A pretest was conducted on 5% of the study participants from JMC. Three trained psychiatry nurses and clinical pharmacists collected the data. After data was collected, before being exported to STATA V.16 for analysis, the data was cleared, categorized, compiled, coded, and also checked for completeness and accuracy.

Data processing and statistical analysis

Epidata V. 4.2.0 was utilized for data entry, and the data was exported to STATA V.16 for analysis. Continuous variables were summarized using the mean ± standard deviation (SD), while categorical data were reported as frequencies and percentages. A chi-square test was performed to check the adequacy of cells before conducting regression. To examine multicollinearity, the variance inflation factor (VIF) was assessed, and independent variables with a VIF < 6 were included in the model. For the discharge outcome, bivariate logistic regression was used to identify candidate variables for multivariate logistic regression. Variables with a p-value < 0.25 in bivariate regression were considered suitable for multivariate logistic regression. Then, multivariate logistic regression was employed to identify independent predictors of an unimproved discharge outcome. The odds ratio was used as a measure of the strength of association and p-value < 0.05 was considered to declare statistical significance. The Hosmer and Lemeshow test (p > 0.05) was performed, indicating good fit.

Operational definition and definition of termsPatients discharge outcome

Condition of the patient at discharge compared to the patient’s condition at admission. Based on the CGI score and for the convenience of this study the patient’s discharge outcome was classified as ‘currently improved’ if the patient’s condition at discharge was very much improved; much improved or minimally improved since admission. Similarly, the patient’s discharge outcome was classified as ‘currently not improved’ if the patient’s condition at discharge was no change from baseline; minimally worse; much worse; very much worse since the admission, left against medical advice, died, referred or absconded [26].

Medical comorbidity

A medical condition in a patient that causes, is caused by, or is otherwise related to another condition in the same patient [27].

Psychiatric polypharmacy

The prescription of two or more psychotropic medications concurrently to a patient [28].

Substance use

Use of substance(s) on a consistent and habitual basis for a period of more than one month [29]. Substances include psychoactive substances such as alcohol, khat (Catha edulis), cigarette, and cannabis.

Substance abuse

A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one (or more) of the following occurring within a 12-month period: recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home, recurrent substance use in situations in which it is physically hazardous, recurrent substance-related legal problems, and continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance [30].

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