The triangular treatment paradigm in dual‐diagnosis clients with a mental illness

Research evidence suggests that a large number of individuals with substance misuse problems also have accompanying psychopathology. Some of those individuals diagnosed with schizophrenia may warrant a dual‐diagnosis. The clinical area of psychiatric ‘dual diagnosis' – that is, serious mental illness associated with substance misuse – is often linked to the ‘revolving door’ admissions of individuals with this complex comorbidity picture. Often, there is limited sharing of information and cooperation between statutory agencies with reference to this highly vulnerable client group. The shortfall in appropriate clinical response to this client group has been highlighted by previous researchers. This article looks at the role of the specialist dual‐diagnosis worker in North Wales and how the appointee to this role has been able to facilitate the seamless transition of these individuals through the ‘system’ of mental health care. This process has been facilitated by the development of an Integrated Pathway of Care, which has been devised by the authors and called the Triangular Treatment Paradigm.     

Can mental illness be prevented under managed care?

Ideally, managed care should force a focus on all the issues involved in prevention and treatment. Unfortunately, the decisions in managed care are based on costs, along with the intervention techniques, as the most important criteria in choice of treatment. Medical treatment accounts for only 10 percent of health. To find a solution means working together, making the goal "healthy people in a healthy community." Programs such as the Healthy Cities initiative, not managed care, are more likely to realize this goal.     

How does stigma affect people with mental illness?

People with mental health problems experience many different types of stigma. This article explores the attitudes and beliefs of the general public towards people with mental illness, and the lived experiences and feelings of service users and their relatives.     

Rationalizing risk? The use of non‐prescribed substances in severe and enduring mental illness

Aims: To investigate reasons for the use of non‐prescribed substances by those with severe and enduring mental illness; to explore beliefs regarding the effects of substances; to examine attitudes towards intervention; and to determine the progression of drug careers.

Design: A phenomenological study, exploring service users' perspectives using semi‐structured interviews.

Setting: The study was conducted within community and inpatient mental health services in County Durham, UK.

Participants: Twenty‐four service users were originally nominated to participate; 11 were subsequently interviewed.

Intervention: Findings formed the basis of needs analysis exploring future redesign of services, to meet the needs of service users more effectively.

Measurement: Grounded theory was applied using a nine‐stage process to analyse data by exposing themes and meaning emerging from interviews.

Findings: Participants felt that they made objective, informed choices about the costs and benefits of their use of substances. However, their appraisals of risks, positive effects and harm minimization strategies were often flawed and contradictory.

Conclusions: Users need services responsive to their individual requirements based upon realistic goals; accurate, understandable information and harm minimization strategies. To achieve this, providers must understand the complex interacting nature of service users' needs and negotiate responsive, achievable packages of care.     

What are the experiences of Emergency Department nurses in caring for clients with a mental illness in the Emergency Department?

Background

Australian Emergency Departments are experiencing increased numbers of clients with a mental illness and Emergency Departments are becoming increasingly utilised as the first point of contact and portal into the mental health care system. Therefore nurses working within the Emergency Departments find themselves having to care for clients with a mental illness as part of their daily work. The aim of this study was to gain an understanding of the experiences of Emergency Department nurses caring for clients with a mental illness in the Emergency Department.

Methods

An interpretive phenomenological study was undertaken using semi structured interviews to enable the lived experiences of Emergency Department nurses to be discovered and articulated. Six Registered Nurses working within an Emergency Department were interviewed, and these participants were asked to tell the story of their experiences in their own words.

Results

Results are based on data collected from six participant interviews. Three major themes emerged related to caring for clients with a mental illness in the Emergency Department: (i) Time as a causative factor, (ii) environment and the influence of surroundings and (iii) understanding the client's personal journey.

Conclusions

Data obtained from participants in this study confirm what has been reported in the literature, that is, that there has been an increase in presentations of clients with a mental illness to the Emergency Department, and the results of this study highlight that time constraints specific to the Emergency Department impact both the client with the mental illness and the Emergency Department nurse caring for these clients. In addition, narratives from Emergency Department nurses purport that the environment within the Emergency Department is not conducive to the provision of optimal care to this client group who have unique care needs and require a specialised management focus. Furthermore, the participants expressed that they had difficulty conceptualising the role of the Emergency Department in the client's personal journey. The concept of recovery in mental health comes into conflict with the culture within the Emergency Department that views recovery as a restoration or return to health rather than the unique journey of the client living with a mental illness.     

Nursing students’ attitudes and experiences with mental illness: A cross-sectional study

Almost half (46%) of people will experience a mental health issue in their lifetime and all nurses need mental health knowledge and skills regardless of their area of specialization. Little is known, however, about student attitudes toward people with mental illness on entry to pre-registration nursing programs. The aims were to investigate Australian pre-registration nursing students’ attitudes toward, and prior experience with, people with mental illness on program commencement. This cross-sectional study used the Community Attitudes Toward Mental Illness (CAMI) scale with pre-registration nursing students, and questions on students’ prior experience with mental illness (self, family, friends). There were n = 311 (271 female/40 male) first year, first semester Bachelor of Nursing students at a national Australian university. Students reported prior experience with mental illness with family (49.5%/n = 154) and friends (61.4%/n = 191). Self-reported (36.3% /n = 113) mental illness, particularly anxiety and depression, significantly exceeded national averages. Most students held accepting attitudes toward people with mental illness, except for perceptions of dangerousness. This study provides new findings on nursing student attitudes and experience with people with mental illness on program entry. The high self-reported prevalence of anxiety and depression at program entry indicates a pressing need for early intervention and mental wellbeing strategies for students from commencement of their tertiary education. Fear-reducing education which challenges perceptions of dangerousness in relation to people with mental illness, and supportive mental health clinical placements during their program, may help improve students’ attitudes and reduce fear and mental health stigma.     

Who cares for older people with mental illness? A survey of residential aged care facilities in the Australian Capital Territory: Implications for mental health nursing

Residential aged care facilities are increasingly becoming locations wherein the most frail and older people with mental illness live out the remainder of their lives, yet it has become apparent in recent years that these institutions are fraught with a variety of social and clinical problems. One issue of concern has been the exodus of registered nurses (both general and psychiatric), who have been increasingly replaced by carers with little or no expertise in psychiatric illness or disorders of cognitive decline. This 'de-professionalizing' of aged care has important implications for the well-being of clients, particularity those with complex mental health problems. In this survey we sought to discover demographic information concerning those who provide front-line care to this population of aged Australians, and we sought also to ascertain how much education in caring for residents who suffer specifically from neurodegenerative disorders (the dementias) and mental illness was provided by the facilities to those who care for such older people. The lack of training in the areas of mental health and cognitive impairment raises a variety of issues that mental health nurses need to address. These issues cover clinical, professional, and social justice dimensions. We believe that mental health nurses are strategically and professionally placed to take a leadership role in raising the profile of aged care in this country and they need to act proactively to secure the well-being of this particularly vulnerable client group.     

Mental illness: diagnostic title or derogatory term? (Attitudes towards mental illness) Developing a learning resource for use within a clinical call centre.A systematic literature review on attitudes towards mental illness

With one in three people likely to experience mental health problems during their lifetime, it is paradoxical that stigma and negative attitudes towards mental illness are so prevalent in the UK today. This systematic literature review was completed to investigate what the most common negative attitudes towards mental illness are, and the most common recommendations made to address them. The findings were used to inform teaching resources used in an National Health Service Direct call centre. Guidelines for undertaking a systematic review, produced by the Centre for Reviews and Dissemination, were used. Terms were set and a search of electronic databases and peer-reviewed academic journals was completed, from which 16 primary research papers (from the UK) were obtained and used. These were assessed, using evidence-based critical appraisal tools, to obtain data pertinent to the original question. This paper describes the process, including a detailed account of the methodologies employed to gather and analyse relevant data. Put into context, alongside key drivers (e.g. government papers), the findings are presented and discussed, along with underlying theories, where appropriate. Recommendations for professional practice are then presented.     

Why is recruitment to trials difficult? An investigation into recruitment difficulties in an RCT of supported employment in patients with severe mental illness

BackgroundUnder-recruitment to randomised controlled trials (RCTs) is often problematic and there may be particular difficulties in recruiting patients with severe mental illness.AimTo evaluate reasons for under-recruitment in an RCT of patients with severe mental illnessMethodsQualitative study during the recruitment phase of an RCT of supported employment. Trial staff and recruiting clinicians were interviewed. Data were analyzed thematically using constant comparative techniques.ResultsRecruitment rates were low. Five main reasons for recruitment difficulties were found. These included: (i) misconceptions about trials, (ii) lack of equipoise, (iii) misunderstanding of the trial arms, (iv) variable interpretations of eligibility criteria, (v) paternalism.ConclusionReasons for recruitment difficulties in trials involving patients with severe mental illness include issues that occur in trials in general, but others are more specific to these patients. Clinician and patient involvement in the study design may improve recruitment in future similar trials.     

What does mental health nursing contribute to improving the physical health of service users with severe mental illness? A thematic analysis

Authors have generally reported that mental health nurses (MHNs) have positive attitudes to providing physical health care to service users with severe mental illness. In the present study, we aimed to explore if this positive attitude translates to enhanced clinical practice by interviewing MHNs and the service users they work with. Semistructured interviews were completed with 15 service users and 18 MHNs from acute, rehabilitation, and community services. These were then transcribed and analysed using thematic analysis. Six themes emerged: (i) not the work of MHNs; (ii) the physical effects of psychiatric drugs are ignored; (iii) the need to upskill; (iv) keeping busy; (v) horrible hospital food/living on takeaways; and (vi) motivation to change. Our overarching meta‐theme was of unmet physical health need among service users.     

Hannover study on long-stay hospitalization – part II: Characteristics and care conditions of long-stay hospitalization in cases of chronic mental illness

Background

Long-stay hospitalization is often a consequence of insufficient care structures. This article examines the characteristics and care conditions of long-stay hospitalization (LSH) in an urban area in Germany.

Methods

Extensive data of patients in the urban catchment area of the Medical School of Hannover, capital of Lower Saxony, were evaluated during a 10 years period.

Results and conclusion

Community psychiatric efforts certainly help to reduce long-stay hospitalization, but cannot fully prevent it. Reference figures are given for comparable urbanized areas: consequently 500 chronically mentally ill persons per 100.000 inhabitants must be expected, 20% of which must be considered as long stay hospitalized according to a given definition. We estimate 250 places per 100.000 inhabitants to be required for institutionalised outpatient care, further 30 places for day clinic and full-time in-patient treatment and 40 places for residential home treatment. We suggest these results as a guidance for psychiatric planning in comparable communities.

     

Fever in acute illness: beneficial or harmful?

Fever has had a long phylogenetic history: it occurs not only in infected birds and mammals, but also in infected reptiles, amphibians, fish and even insects. When these "cold-blooded" animals are prevented from adapting their body temperature to the risen thermoregulatory set-point by behavioral means, a more severe state of disease and a higher mortality are the consequences. It seems unlikely that an energy-dependent process, such as fever, would have been retained for hundreds of millions of years, in so many groups of organisms, if it provided no selective advantage. Fever may represent a leukocyte-based amplification mechanism to affect host challenge: enhanced motility of leukocytes, enhanced lymphocyte response to mitogens, increased production of interferon, enhanced immune response to viral antigens. Evidence for a beneficial effect of fever is also supported by the results of our animal experiments. Intraperitoneal injection of a high dose of bacterial lipopolysaccharide (LPS) in rats induces a septic shock like state which is accompanied by hypothermia on the day of LPS-administration and a robust fever on the following days. Co-injection of a neutralizing synthetic form of the soluble tumor necrosis factor (TNF) type 1 receptor completely neutralizes LPS-induced bioactive TNF in the lavage of the abdominal cavity and in blood plasma. Treatment with the TNF-antagonist results in much faster recovery from the hypothermic state. The rats develop pronounced fever already on the day of injection and there is significantly less reduction in body weight and food and water intake. Similar, but less pronounced effects can be induced by treatment with inhibitors of the inducible form of nitric oxide (NO)-synthase indicating that TNF-induced detrimental effects are, in part, mediated by excessive formation of NO. These results confirm that an accelerated onset of fever or a faster recovery from hypothermia in a septic state may have rather beneficial than maladaptive effects.     

Mental Health Nurse Incentive Program: Facilitating physical health care for people with mental illness?

People with serious mental illness have increased rates of physical ill‐health and reduced contact with primary care services. In Australia, the Mental Health Nurse Incentive Program (MHNIP) was developed to facilitate access to mental health services. However, as a primary care service, the contribution to physical health care is worthy of consideration. Thirty‐eight nurses who were part of the MHNIP participated in a national survey of nurses working in mental health about physical health care. The survey invited nurses to report their views on the physical health of consumers and the regularity of physical health care they provide. Physical health‐care provision in collaboration with general practitioners (GPs) and other health‐care professionals was reported as common. The findings suggest that the MHNIP provides integrated care, where nurses and GPs work in collaboration, allowing enough time to discuss physical health or share physical health activities. Consumers of this service appeared to have good access to physical and mental health services, and nurses had access to primary care professionals to discuss consumers’ physical health and develop their clinical skills in the physical domain. The MHNIP has an important role in addressing physical health concerns, in addition to the mental health issues of people accessing this service.     

Rehabilitation of mental disturbance in patients with stroke

It is considered now that early rehabilitation interventional mechanism is related to the plasticity of brain that means after injury of neural function,cental nervous system has the ability of compensation and functional recombination.OBJECTIVE：To explore the effects of early rehabilitation on paralysis after cerebral infarction.     

Can mental health nurses diagnose in Australia?

The naming of health related conditions has been the traditional province of the medical profession. Occasional concessions have been made in specific narrow domains, such as psychology or speech-related pathology, but diagnosis typically has been seen as medical practitioner business. "Ownership" of language is worthy of critical discussion. The answer to why the tradition has persisted, and nurses have invested lots of energy within the established rules of who can say what, may well be found through the lens of psycholinguistics. Nurses can name states of health and ill health using the currently accepted nomenclature. The authors argue that there is an unconditional "yes," to the question of can nurses diagnose, as long as they are not holding themselves out to be a medical practitioner by doing so. Additionally it is argued that advanced practice nurses must diagnose in order to fulfill their role as advanced practice clinicians.