The development of the Mental Health Advice Centre in Lewisham Health District

The Mental Health Advice Centre in Lewisham, South East London, represents an innovation in psychiatric service aiming to integrate primary health care with mental health professionals and to provide easy access for patients to psychiatric and psychological help. The Centre has been operating for 3 years and is staffed by a multi-professional team comprising psychiatrists, clinical psychologists, psychotherapists, social workers, community psychiatric nurses, occupational therapists, research workers, and volunteers. This report outlines the development of the Centre and presents the results of two years' evaluative work. Social, demographic, and psychiatric characteristics of the clients who attended the Centre during these two years are described.     

Medical problems of elderly patients admitted to a mental illness hospital--incidence, nature and importance for service provision.

The study deals with 147 elderly patients admitted to acute psychiatric beds in a Health District where access to medical rather than to psychiatric beds for elderly people was easier. Fifteen of these patients were transferred from medical wards and 53 had 56 problems which needed treatment from a physician. Collaboration between physicians and psychiatrists in the management of elderly psychiatric patients requires more extensive facilities than those available in joint assessment units.     

Effects of a Tobacco Ban on Long-term Psychiatric Patients

A total ban on all tobacco products was implemented in a diverse psychiatric institution. A post hoc evaluation examined the effect of the ban on long-term patients by comparing their characteristics the year before the ban to the year after. Several variables measuring physical health, psychiatric symptomatology, feelings of well-being, and interpersonal conflict were coded with very high reliability from health records. For the majority of patients who were in the maximum security forensic division, the tobacco ban was associated with almost no detectable ill effects with some clear benefits. Among the remainder of the long-term patients, the ban might have been associated with a temporary increase in physical aggression towards staff members. It was concluded that successful implementation, and the avoidance of ill effects, depended entirely on the success staff members had in actually preventing patient access to tobacco.     

Emergency telepsychiatry

Telepsychiatry can be used in two kinds of psychiatric emergencies: one-time clinical events and public health situations associated with mass disaster. Emergency telepsychiatry delivered by videoconferencing has the potential to improve patient care in many settings. Although experience is limited, it has been found to be safe and effective, as well as satisfactory to both emergency department staff and the psychiatric patients treated. The development of comprehensive and standardized guidelines is necessary. There has been little use of acute telemedicine in disaster situations to date. However, telemedicine is becoming part of routine emergency medical response planning in many jurisdictions. Emergency telepsychiatry has the potential to reduce emergency department overcrowding, provide much needed care in rural areas and improve access to psychiatric care in the event of a natural or man-made disaster.     

Mental health services for deaf people: a need identified

The unique problems of deaf people suffering from mental health conditions have long been recognised but have received inadequate attention in many parts of the country. In the absence of a specialist psychiatric service for deaf people in Wales a prevalence survey was conducted to estimate the numbers of deaf patients occupying long-stay mental health beds and to assess facilities available to them. A high prevalence of prelingual deafness was found in long-stay psychiatric inpatients, approximating to a relative risk ten times that in the general population. Throughout Wales there are approximately 100 patients with either prelingual or profound postlingual deafness resident in long-stay psychiatric and mental handicap beds. An inadequate provision of specialist support and equipment for all categories of deaf in-patients is demonstrated by the results of this study. Purchasers of mental health services must ensure that an acceptable quality of provision, including both access to a specialist psychiatric service and a supportive in-patient environment, is secured from providers.     

Co-occurring hepatitis C, substance use, and psychiatric illness: Treatment issues and developing integrated models of care

Hepatitis C virus (HCV) infection is transmitted by injection drug use and associated with psychiatric conditions. Patients with drug use or significant psychiatric illness have typically been excluded from HCV treatment trials noting the 1997 National Institutes of Health Consensus Statement on HCV that indicated active drug use and major depressive illness were contraindications to treatment of HCV infection. However, the 2002 NIH Consensus Statement recognized that these patients could be effectively treated for HCV infection and recommended that treatment be considered on a case-by-case basis. Treating HCV infection in these patients is challenging, with drug use relapse possibly leading to psychosocial instability, poor adherence, and HCV reinfection. Interferon therapy may exacerbate preexisting psychiatric symptoms. Co-occurring human immunodeficiency virus or hepatitis B virus provide additional challenges, and access to ancillary medical and psychiatric services may be limited. Patients with co-occurring HCV infection, substance use, and psychiatric illness can complete interferon treatment with careful monitoring and aggressive intervention. Clinicians must integrate early interventions for psychiatric conditions and drug use into their treatment algorithm. Few programs or treatment models are designed to manage co-occurring substance use, psychiatric illness, and HCV infection and therapy. The National Institute on Drug Abuse convened a panel of experts to address the current status and the long-range needs through a 2-day workshop, Co-occurring Hepatitis C, Substance Abuse, and Psychiatric Illness: Addressing the Issues and Developing Integrated Models of Care. This conference report summarizes current data, medical management issues, and strategies discussed.     

Collaborative Care: a Pilot Study of a Child Psychiatry Outpatient Consultation Model for Primary Care Providers

A Child Psychiatry Consultation Model (CPCM) offering primary care providers (PCPs) expedited access to outpatient child psychiatric consultation regarding management in primary care would allow more children to access mental health services. Yet, little is known about outpatient CPCMs. This pilot study describes an outpatient CPCM for 22 PCPs in a large Northeast Florida county. PCPs referred 81 patients, of which 60 were appropriate for collaborative management and 49 were subsequently seen for outpatient psychiatric consultation. The most common psychiatric diagnoses following consultation were anxiety (57%), ADHD (53%), and depression (39%). Over half (57%) of the patients seen for consultation were discharged to their PCP with appropriate treatment recommendations, and only a small minority (10%) of patients required long-term care by a psychiatrist. This CPCM helped child psychiatrists collaborate with PCPs to deliver mental health services for youth. The CPCM should be considered for adaptation and dissemination.     

Psychiatric hospital care and changes in insurance coverage strategies: A national study

The 1975, 1980, and 1986 sample surveys from the National Institute of Mental Health were used to predict the type of inpatient psychiatric facility where people were admitted. Predictors used were demographics (age, gender, race, marital status, and education), psychiatric diagnosis, and insurance status (primary payment source). A discriminant analysis revealed that insurance status was the most important discriminator in predicting hospital type. State hospitals were more likely to care for patients with little or no resources, whereas private hospitals cared for patients with some form of insurance. The authors discuss the implications of insurance status and access to psychiatric treatment.     

Homelessness and the use of acute psychiatric beds: findings from a one-day survey of adult acute and low-level secure psychiatric patients in North and South Thames regions

This paper describes the impact of homelessness on the use of adult acute and low-level secure psychiatric beds in North and South Thames regions. We specifically focus on those homeless patients who no longer required the acute psychiatric facilities in order to determine the complement of accommodation and alternative services necessary to enable them to be discharged. A point prevalence survey of all patients occupying adult acute and low-level secure psychiatric beds in North and South Thames regions was carried out on 15 June 1994. All patients occupying adult acute and low-level secure psychiatric beds in 54 mental health providers and seven private psychiatric units in North and South Thames regions were included in the survey. Demographic, admission, and diagnosis data were collected. Homeless patients were identified as those patients not living in permanent accommodation. Ward managers (nurses) were also asked to identify patients who, in their opinion, no longer required acute care and to identify more appropriate provision for these patients. Of the 3978 adult and low-level secure patients enumerated 20.5% (817) were recorded as homeless. A total of 306 homeless patients were identified by ward staff as inappropriately located, of whom 58.2% of were unsuitable to be discharged into the community but still required some form of alternative health provision, for example staffed-housing in the community and in-patient rehabilitation services based in hospitals. However, 51.8% of patients were suitable to be discharged back into the community and the majority required housing as a key component within their 'package of care'. Homeless psychiatric in-patients have contributed to the increasingly precarious state of mental health services provision and represent a failure to provide a sufficient level of community alternatives for those who can no longer access the long-stay hospital services, and for whom the pool of acute psychiatric beds is ever reducing.     

The provision of secure psychiatric services in Leeds; Paper ii. A survey of unmet need

This paper reports the results of a survey of statutory and voluntary staff who are likely to have contact with people requiring treatment in the secure psychiatric facilities provided in Leeds. The survey seeks to assess whether there is under-provision of Secure Unit beds, and if the three-tier local secure service is adequately addressing the needs of patients in the Special hospitals, prisons and the community. Researchers monitored all demands for psychiatric reports to prison over a six-month period, to identify any unmet need for secure psychiatric facilities. The findings show that patients with a learning disability were unable to transfer from a Special Hospital to a lower level of security. There is also a significant unmet need for medium to long-stay Secure Unit beds, and that many patients in the community have significant unmet needs for access to psychiatric services, including structured, intensively staffed community accommodation.     

兰州市重性精神疾病社区管治效果观察

目的了解兰州市七里河区重症精神疾病患者的既往病史、发病和治疗等情况,为建立健全社区精神疾病防治管理系统和提高精神卫生服务水平提供科学依据。方法将七里河区精神疾病管理系统收录的患者资料录入Epi Data 3.0数据库,应用Excel 2003和SPSS 16.0进行统计分析。结果精神疾病患者起病以亚急性为主,有1 223例,占61.52%,连续病程超过1年的有1 416例(71.23%),接受治疗的患者连续服药者有1 457例,占74.57%;经过治疗有737例(37.72%)痊愈,不同病情状态的患者治疗结果差异显著。结论精神疾病患者的防治康复管理已取得一定的效果,应继续加强对精神疾病患者的防治和管理。     

Psychiatric disorders and labor market outcomes: evidence from the National Latino and Asian American Study

This paper investigates to what extent psychiatric disorders and mental distress affect labor market outcomes in two rapidly growing populations that have not been studied to date-ethnic minorities of Latino and Asian descent, most of whom are immigrants. Using data from the National Latino and Asian American Study (NLAAS), we examine the labor market effects of meeting diagnostic criteria for any psychiatric disorder in the past 12 months as well as the effects of psychiatric distress in the past year. The labor market outcomes analyzed are current employment status, the number of weeks worked in the past year among those who are employed, and having at least one work absence in the past month among those who are employed. Among Latinos, psychiatric disorders and mental distress are associated with detrimental effects on employment and absenteeism, similar to effects found in previous analyses of mostly white, American born populations. Among Asians, we find more mixed evidence that psychiatric disorders and mental distress detract from labor market outcomes. Our findings suggest that reducing disparities and expanding access to effective treatment may have significant labor market benefits-not just for majority populations, as has been demonstrated, but also for Asians and Latinos.     

The Mental Health Advice Centre in Lewisham.

This paper describes the use of a psychiatric service within a catchment area and the effects on existing services of establishing a community-based service, the Mental Health Advice Centre (MHAC). Major effects were the expansion of ambulatory services and an increased access to patients from primary care. Some of these findings are discussed. The importance of monitoring and evaluating novel community services is emphasised.     

Primary care after psychiatric crisis: a qualitative analysis

PURPOSE Patients with serious psychiatric problems experience difficulty accessing primary care. The goals of this study were to assess whether care managers improved access and to understand patients’ experiences with health care after a psychiatric crisis.METHODS A total of 175 consecutive patients seeking care in a psychiatric emergency department were randomly assigned to an intervention group with care managers or a control group. Brief, semistructured interviews about health care encounters were conducted at baseline and 1 year later. Five raters, using the content-driven, immersion-crystallization approach, analyzed 112 baseline and year-end interviews from 28 participants in each group. The main outcomes were patients’ responses about their care experiences, connections with primary care, and integration of medical and mental health care. Scores for physical function and mental function were compared by analysis of variance (ANOVA).RESULTS At baseline, most participants described negative experiences in receiving care and emphasized the importance of listening, sensitivity, and respect. Fully 71% of patients in the intervention group said that having a care manager to assist them with primary care connections was beneficial. Patients in the intervention group had significantly better physical and mental function than their counterparts in the control group at 6 months (P = .03 for each) but not at 12 months. There was also a trend toward functional improvement over the course of the study in the intervention group.CONCLUSIONS This analysis suggests that care management is effective in helping patients access primary care after a psychiatric crisis. It provides evidence on and insight into how care may be delivered more effectively for this population. Future work should assess the sustainability of care connections and longer-term patient health outcomes.     

Role of a Psychiatric Pharmacist in a Los Angeles “Skid-Row” safety-net clinic

Limited access to a psychiatrist prompted a collaborative practice agreement between a psychiatric pharmacist, a psychiatric pharmacy resident, and primary care physicians at the Center for Community Health, a safety-net clinic providing comprehensive care to the homeless in Skid Row, Los Angeles, CA, USA. From July 2009 to February 2010, 36 (75%) of the 48 patients referred to the psychiatric pharmacy resident met the criteria for the chart review. Twenty-six (54%) were seen for regular follow-up care over 7 months. Most referrals were for depression, bipolar disorder, and posttraumatic stress disorder. The types of drug therapy problems, pharmacist interventions, and clinical mental health outcomes are discussed.     

Demand for psychiatric emergency services and immigration. Findings in a Spanish hospital during the year 2003

BACKGROUND: The aim of this study is to investigate differences among immigrants and natives regarding access and pathways to psychiatric care, psychiatric admission rates, length of stay, continuity of care, and main diagnoses. METHODS: Psychiatric emergency visits (1511) and hospitalizations (410) were registered in a Spanish Hospital with a catchment area of 280 000 people (19.3% immigrants) during the year 2003. Motives for demanding emergency psychiatric care, pathways to care, admission rates, length of stay, continuity of care, and main diagnoses were compared among natives and immigrants. RESULTS: Immigrants accounted for 13.0% of consultations to the psychiatric emergency room (15.9% of patients) and 11.0% of admissions to the psychiatric hospitalization unit (13.5% of patients). The pathways to care were different for immigrants and natives. Immigrants had a lower rate of readmission to the psychiatric emergency room. Motives for consultation and hospitalization were also different among immigrants and natives. Immigrants showed more self-aggressive behaviours and neuroses, and lower rates of affective disorders and psychoses. CONCLUSIONS: Immigrants under-used psychiatric emergency and hospitalization services in comparison with natives. They did not consult because of psychoses or affective disorders, but mainly because of reactive conditions related to the stress of migration.     

Rural Versus Suburban Primary Care Needs, Utilization, and Satisfaction With Telepsychiatric Consultation

CONTEXT AND PURPOSE: Rural and suburban populations remain underserved in terms of psychiatric services but have not been compared directly in terms of using telepsychiatry. METHODS: Patient demographics, reasons for consultation, diagnosis, and alternatives to telepsychiatric consultation were collected for 200 consecutive, first-time telepsychiatric consultations at rural and suburban clinics. FINDINGS: Rural patients were more likely than suburban patients to be younger than 18 years, using Medicaid, and needing treatment planning (lest they be referred out of the community). Rural patient and primary care physician satisfaction was higher than that of suburban counterparts. CONCLUSION: Telepsychiatry programs may enhance access, satisfaction, and quality of rural care.