Two Clinical Trajectories in General Adult Psychiatry: Divergent Service Use and Mortality

TY - JOUR

T1 - Two Clinical Trajectories in General Adult Psychiatry

T2 - Divergent Service Use and Mortality

AU - Hayward, David

AU - Hughes, Joshua

AU - Johnsson, Hanna

AU - MacIntyre, Donald J.

AU - Steele, J. Douglas

PY - 2026/9/21

Y1 - 2026/9/21

N2 - Background Psychiatric inpatient populations are heterogeneous. Severe and Enduring Psychiatric Illness (SEPI) and Trauma, Stressor-Related and Substance Use (TSRS) presentations differ clinically, but their service demands and mortality within one system are poorly characterised. Aims To characterise inpatient service use and mortality across clinical trajectories in one NHS General Adult Psychiatry (GAP) service. Method Longitudinal cohort study of 5,204 inpatient episodes (2016–2024) aggregated to 2,665 patients classified as SEPI (schizophrenia spectrum, bipolar disorder, severe unipolar depression) or TSRS, the latter subdivided into Borderline Personality Disorder (BPD) and non-psychotic mood, stress-related and substance-use presentations. Analyses used person-years, standardised mortality ratios (SMRs), survival analysis and years of life lost. Results SEPI comprised 28.9% of patients but 69.3% of bed utilisation, with longer, recurrent admissions. TSRS presentations were brief and crisis-driven; BPD had the highest admission frequency with short stays. Cumulative mortality was 53% higher in SEPI than TSRS (13.5% vs 8.8%), but after adjustment for age and illness duration mortality was similar across groups (SMR 4.87). TSRS deaths occurred at younger ages, particularly in BPD, whereas SEPI deaths reflected common physical illnesses occurring far earlier than in the general population. Most deaths (98.5%) occurred outside inpatient settings. Conclusions GAP services accommodate two trajectories with contrasting demands but similarly high mortality (SMR 4.87): enduring, medically managed illness with high cumulative resource use, and episodic brief crisis presentations. Recognising this is essential for service design, since current models combine structurally distinct demands within a single system.

AB - Background Psychiatric inpatient populations are heterogeneous. Severe and Enduring Psychiatric Illness (SEPI) and Trauma, Stressor-Related and Substance Use (TSRS) presentations differ clinically, but their service demands and mortality within one system are poorly characterised. Aims To characterise inpatient service use and mortality across clinical trajectories in one NHS General Adult Psychiatry (GAP) service. Method Longitudinal cohort study of 5,204 inpatient episodes (2016–2024) aggregated to 2,665 patients classified as SEPI (schizophrenia spectrum, bipolar disorder, severe unipolar depression) or TSRS, the latter subdivided into Borderline Personality Disorder (BPD) and non-psychotic mood, stress-related and substance-use presentations. Analyses used person-years, standardised mortality ratios (SMRs), survival analysis and years of life lost. Results SEPI comprised 28.9% of patients but 69.3% of bed utilisation, with longer, recurrent admissions. TSRS presentations were brief and crisis-driven; BPD had the highest admission frequency with short stays. Cumulative mortality was 53% higher in SEPI than TSRS (13.5% vs 8.8%), but after adjustment for age and illness duration mortality was similar across groups (SMR 4.87). TSRS deaths occurred at younger ages, particularly in BPD, whereas SEPI deaths reflected common physical illnesses occurring far earlier than in the general population. Most deaths (98.5%) occurred outside inpatient settings. Conclusions GAP services accommodate two trajectories with contrasting demands but similarly high mortality (SMR 4.87): enduring, medically managed illness with high cumulative resource use, and episodic brief crisis presentations. Recognising this is essential for service design, since current models combine structurally distinct demands within a single system.

M3 - Article

SN - 2056-4724

JO - BJPsych Open

JF - BJPsych Open

ER -