The number of patients in whom mental illness progresses to stages in which acute, and often forced treatment is warranted, is on the increase across Europe. The overall number of involuntary admissions has increased in countries such as Germany, France, England, Austria, Sweden and Finland [1
]. In the Netherlands, the number of compulsory admissions has doubled between 1979 and 2004, rising from 23 to over 53 per 100.000 inhabitants [4
]. This increase includes both compulsory admissions in crisis situations without reference to the courts ("compulsory admissions") and compulsory admissions after recourse to the courts ("court orders") [4
]. In the Amsterdam area, the number of compulsory admissions even rose by 319% to 86 per 100,000 in the period between 1979 and 2004 [5
As a consequence, more patients are involuntarily admitted to Psychiatric Intensive Care Units (PICU). The proportion of coercive admissions to Amsterdam Psychiatric Intensive Care Units is now as high as 80% [6
PICU's, defined as units providing assessment, care and short-term intensive treatment for acutely disturbed psychiatric patients who cannot be dealt with on regular open wards [7
] have been criticized for a poor environment such as deteriorated rooms and furniture and limitations for patient activities, such as fresh air and exercise, due to shortage of staff [9
], high levels of coercion [10
] and a lack of evidence of regular procedures from controlled trials [11
]. As both mental health providers and governmental authorities are increasingly emphasising the client perspective, the interest into admission- and intervention policies of PICU's has increased over the last 15 years [12
]. At the same time, management- and financial entities also stress the importance of cost-effectiveness and uniformity. Major goals are therefore to decrease the level of coercion and increase treatment quality as well as evaluating current policies [15
] In the last decade, national organisations such as the Psychiatric Intensive Care Advisory Service (PICAS) and the National Association of Psychiatric Intensive Care Units (NAPICU) in the United Kingdom, have been developed to improve the standard of care delivered within PICU's. In 2002, Pereira and Clinton published a report on national minimum standards for general adult services in PICU's and low secure environments. This report provides, among others, guidelines regarding criteria for admission, core interventions, physical environment and personnel [16
]. Kallert et al. [17
] recently performed a European multi centre study to evaluate the levels of coercion in participating PICU's.
From several studies and reports it has become evident that important dissimilarities exist between PICU's in different countries in terms of patient selection, type and quality of care and treatment outcome [2
]. Also within countries, PICU's may show significant variation. Often it is unknown whether such differences in structure and functioning of PICU's are based on clinical considerations or a result of historical or financial developments.
PICU's may differ in organizational structure as well as in treatment policies such as medication prescriptions, quantity of face-to-face time per patient, mean length of stay, use and duration of seclusion, implementation of legal measures, staffing, and availability of individualised treatment regimens [11
]. In a similar way, patient groups may also differ between PICU's. In general, metropolitan areas accommodate higher percentages of ethnic minority and migrant populations, who may differ on characteristics such as psychiatric morbidity, socio-demographic variables, the size and structure of the social network and (prior) (co-morbid) substance abuse [22
]. Differences in levels of urbanization may possibly account for differences in patient selection and psychiatric treatment between units. A number of studies have shown an increasing level of urbanization to be associated with higher incidence rates of psychosis [23
] and other mental disorders such as substance abuse.
The above factors may influence the results of PICU admissions in terms of treatment outcome (degree of recovery of the psychiatric disorder). The question is which characteristics of the organizational structure, the treatment delivered, or the patient are stipulating for recovery. In a recent study, Wynaden et al. [26
] stress the importance of ongoing evaluations of PICU patient populations to promote best practice initiatives in psychiatric care. Since the development of the first PICU's in the early 1970's [12
], several studies have explored and compared PICU's on specific subjects such as patient characteristics and treatment outcome. Yet, to our knowledge no studies have investigated the broad range of all these variables and their mutual relationship using a comprehensive integrated model. Several studies investigated specific PICU characteristics such as bed numbers, staffing levels, admission criteria, physical environment, psychosocial methods and pharmacotherapy, but none of these managed to relate such characteristics to treatment outcome [12
The current study seeks to describe organisational as well as clinical and patient related factors across 10 PICU's in and outside the Amsterdam region, providing also differences in the level of urbanization. The study is part of a larger project also involving a city wide study on factors leading to coercive admission (ASAP-I) [27
The main research questions are: 1) Do the participating PICU's differ with respect to the type of patients they admit? 2) Do these PICU's differ in the way treatment and care are implemented? 3) What are the differences with regard to outcome at discharge? 4) Are these characteristics related to level of urbanization?