When opened as a post-graduate teaching and research hospital in 1923, the Maudsley made virtually no provision for the treatment of children. Yet its children's department saw sustained growth during the interwar period. This expansion is explored in relation to novel behaviourist hypotheses and the forging of formal links with local government and charitable bodies. The recruitment of psychologists, educators and specialist social workers fostered a multidisciplinary approach through case conferences. This development would structure the theoretical origins of child psychiatry, in particular influencing the role and interpretation of psychoanalytic theory within it. The theoretical orientation of child psychiatry and the practical treatment of children represented an area of dynamic change and innovation at a time when adult psychiatry struggled to discover effective treatments or achieve breakthroughs in causal understanding.

No abstract

Opened in February 1923 to raise the status of academic psychiatry in the UK, the Maudsley Hospital struggled to secure grant income. Without a track record of published research and lacking internationally recognized clinicians, it failed to impress the British Medical Research Council. To challenge leading U.S. and German departments of neuropsychiatry, Edward Mapother, the medical superintendent, looked overseas for investment in an "institute of psychiatry." Intense lobbying and a modified strategy for research and training designed to meet the Rockefeller Foundation's prioritization of psychiatry and medical specialization ultimately led to a significant endowment. Alan Gregg and Daniel O'Brien at the Foundation played a pivotal role in re-defining the Maudsley's programs of research and teaching. Pressure on Mapother to attract funding was matched by that on administrators required to show that their philanthropy had yielded tangible gains in public health. While wealthy charities, like the Rockefeller, often had a vision of the direction that they wished to pull medical science, and they provided much needed income, the impact of their policy agenda was not without drawbacks. Institutions unwilling to embrace a charity's philosophy were unlikely to secure grants, while those that did might find themselves drawn into less optimal areas. KeywordsMaudsley Hospital; Rockefeller Foundation; psychiatric research; mental illness; grants; training; medical education; philanthropy Medical charities are commonly characterized as bringing much needed financial support to speculative research.1 Indeed, it is relatively easy to chart their grants and the publications or products that followed.2 However, the impact of major donors, such as the Commonwealth Fund or the Rockefeller Foundation, went beyond the sums that they gave to laboratories and hospitals. With agendas of their own, which sometimes reflected the interests of their founders or a desire for tangible improvement to the health of a nation, philanthropic organizations could exercise a disproportionate influence on the medical community and on scientific programs in particular.3 Small-scale or innovative research departments, desperate to secure funding, may have tailored projects to meet the aims of medical charities. A researcher working within an experimental environment or a clinician responsive to patient needs might have been a better judge of what was effective or achievable than the executive of a medical charity responsible for setting broad research parameters. As a result, changes introduced to a research program to make it more appealing to a philanthropic organization may have produced projects that yielded less in terms of clinical gain or patient benefit. Although a process of consultation or peer-review was

British psychiatric care during the inter-war period has often been characterised in bleak and even punitive terms: an asylum system that required certification for treatment, radical and often risky clinical interventions of no established benefit to patients and a lack of empathy or creativity among doctors. Although the Maudsley Hospital was designed to break the asylum mould, the received view is that a distinctive admissions policy targeted those with a good prognosis, excluding the unruly and chronic.

BackgroundIn many studies the information of patients who are dying in the hospital is censored when examining the change in length of hospital stay (cLOS) due to hospital-acquired infections (HIs). While appropriate estimators of cLOS are available in literature, the existence of the bias due to censoring of deaths was neither mentioned nor discussed by the according authors.MethodsUsing multi-state models, we systematically evaluate the bias when estimating cLOS in such a way. We first evaluate the bias in a mathematically closed form assuming a setting with constant hazards. To estimate the cLOS due to HIs non-parametrically, we relax the assumption of constant hazards and consider a time-inhomogeneous Markov model.ResultsIn our analytical evaluation we are able to discuss challenging effects of the bias on cLOS. These are in regard to direct and indirect differential mortality. Moreover, we can make statements about the magnitude and direction of the bias. For real-world relevance, we illustrate the bias on a publicly available prospective cohort study on hospital-acquired pneumonia in intensive-care.ConclusionBased on our findings, we can conclude that censoring the death cases in the hospital and considering only patients discharged alive should be avoided when estimating cLOS. Moreover, we found that the closed mathematical form can be used to describe the bias for settings with constant hazards.Electronic supplementary materialThe online version of this article (10.1186/s12874-018-0500-3) contains supplementary material, which is available to authorized users.