American Association of Community Psychiatrists' principles for managing transitions in behavioral health services

Continuous engagement in treatment and recovery services is one of the most important aspects of addressing acute episodes of severe behavioral health problems and the ongoing disabilities associated with them. Traditionally, fragmentation in systems of care has been common, and the transition from one provider, location, or intensity of service to another has not been prioritized in treatment planning. The authors describe a set of guidelines for maintaining continuity of care that was developed by the American Association of Community Psychiatrists. These guidelines embrace a progressive conceptualization of an integrated service system. For each element of the guidelines, a sample outcome indicator is presented that could be used to measure implementation. These guidelines can be used to help form transition plans, quality improvement initiatives, and program evaluations.     

Use of a consumer-led intervention to improve provider competencies

OBJECTIVE: Client-centered care is a major aim of health care. In mental health, new client-centered treatment approaches that emphasize recovery, rehabilitation, and empowerment can improve outcomes for people with severe and persistent mental illness. However, these approaches are not widely used, in part because many clinicians lack the necessary competencies. The objective of this study was to evaluate the effectiveness of an innovative, consumer-led intervention, Staff Supporting Skills for Self-Help, which was designed to improve provider quality, empower mental health consumers, and promote mutual support. METHODS: The study was conducted at five large community mental health provider organizations in two western states. One organization in each state received the intervention. The intervention included education, clinician-client dialogues, ongoing technical assistance, and support of self-help. It focused on client-centered care, rehabilitation, and recovery. A one-year controlled trial evaluated the effect of the intervention on clinicians' competencies, care processes, and the formation of mutual support groups. Outcomes were assessed by using competency assessment survey instruments and semistructured interviews with clinicians and managers. RESULTS: A total of 269 clinicians participated in the study: 151 in the intervention group and 118 in the control group. Compared with clinicians at the control organizations, clinicians at intervention organizations showed significantly greater improvement in education about care, rehabilitation methods, natural supports, holistic approaches, teamwork, overall competency, and recovery orientation. CONCLUSIONS: A feasible, consumer-led intervention improves provider competencies in domains that are necessary for the provision of high-quality care.     

The long road home: rebuilding public inpatient psychiatric services in post-Katrina New Orleans

In August 2006, a year after Hurricane Katrina, the first acute inpatient public psychiatric unit for adults was opened in New Orleans to serve patients referred from local emergency departments. This article describes the clinical and administrative experiences of providing inpatient care in post-Katrina New Orleans, including the increased demand for programs to treat patients with co-occurring disorders, the expanded scope of practice for psychiatrists to include primary care, and ongoing staff shortages in a traumatized and displaced workforce. Lessons learned in regard to disaster planning and recovery are also discussed.     

The pregnant psychiatric inpatient: A missed opportunity

The authors describe a group of pregnant psychiatric patients admitted to a psychiatric service in an urban hospital. A high rate of involuntary admission (44%), homelessness (36%), and substance abuse (64%) was noted. In this group of high-risk obstetric patients, we identified risk factors associated with noncompliance with ongoing prenatal care. Brief psychiatric hospitalization can be an important aspect in improving obstetric outcome by providing an opportunity to collect obstetric information and promote ongoing prenatal care.     

Relapse of substance use disorder and its prevention among persons with co-occurring disorders

This article summarizes the scientific literature on the relapse process, describes the basic principles of relapse prevention treatment, highlights the major empirical studies, and offers suggestions for future research and application, especially in terms of ongoing care for persons with co-occurring disorders. Relapse prevention treatments have a well-established efficacy and effectiveness for persons with substance use disorders. Key ingredients include reducing exposure to substances, fostering motivation for abstinence, self-monitoring, recognizing and coping with cravings and negative affect, identifying thought processes with relapse potential, and deploying, if necessary, a crisis plan. Relapse prevention approaches may be best suited for persons in the action of maintenance stages of treatment or recovery. Further research is needed to examine relapse prevention therapies as a key component to continuing care for persons with co-occurring substance use and psychiatric disorders.     

Individualized Intervention to Support Mental Health Recovery Through Implementation of Digital Tools into Clinical Care: Feasibility Study

Myriad digital tools exist to support mental health but there are multiple barriers to using these tools in routine care. This study aimed to assess the feasibility of an intervention incorporating a support role to help the clinical team identify and use technology to promote recovery. The technology specialist intervention is 3 months in duration and comprises four stages: goal setting, researching and evaluating tools, demonstrating and selecting tools, and ongoing support. We implemented the intervention in a community mental health center and a dual diagnosis treatment program, working with eight clients and their case managers. Clients and case managers willingly engaged with the technology specialist and found the intervention beneficial. Integration and collaboration with the care team facilitated implementation of the technology specialist in these real-world settings. Clients reported that the intervention made it easy to try a digital tool. Six of the eight participants stated that they made substantial progress toward their goals. The technology specialist is a promising new role for mental health care delivery to augment traditional services and enhance individualized recovery.

     

Regulation of experimental autoimmune encephalomyelitis: Inhibition of adoptive experimental autoimmune encephalomyelitis by ‘recovery-associated suppressor cells’

We have previously shown the presence of suppressor cells in Lewis rats at the time of spontaneous recovery from experimental autoimmune encephalomyelitis (EAE). These cells, called ‘recovery-associated suppressor cells’ (RASC), are capable of preventing active EAE and inhibiting in vitro the specific proliferative response of encephalitogenic anti-MBP T cell line cells. The present investigations were undertaken in order to lend support to the hypothesis that RASC play an active role in the recovery. We found that RASC can prevent adoptive EAE when admixed with already activated, but not resting, anti-MBP T cells or when injected into the recipients separately from the encephalitogenic cells. They can also arrest the course of an ongoing disease when injected after the beginning of the clinical signs. This study provides the first direct demonstration of the downregulation of an ongoing EAE by suppressor cells.     

Telepsychiatry for children with developmental disabilities: applications for patient care and medical education

Telemedicine is able to provide specialized care to rural patients with limited access. The developmentally disabled population is highly suited to this modality and can be seen in general and specialized clinics. The collaborative care model, which is useful for this population, provides ongoing collaboration with both the local primary care provider and the local treatment team. Telepsychiatry can be used for education of trainees working together with an attending physician. These clinics can become exceptional opportunities to provide exposure to the specialty of child psychiatry for young doctors in training. As new programs develop, telepsychiatry for treatment and telepsychiatry for training should go hand in hand.     

Stress as necessary component of realistic recovery in animal models of experimental stroke

Over the last decade there has been a considerable effort directed toward reformulating the standard approach taken to preclinically model stroke and stroke recovery. The principal objective of this undertaking has been to improve the success with which preclinical findings can be translated. Although several advancements have already been introduced, one potentially critical feature that appears to have been overlooked is psychological stress. Stroke is well recognized to produce high levels of stress in patients, and ongoing exposure to stress is recognized to deleteriously interfere with recovery. The presence of high levels of stress (distress) in stroke patients is also relevant because nearly all clinically deployed neurorestorative interventions occur against this background. Somewhat perplexingly, however, we could find no preclinical stroke studies concerned with investigating the efficacy of putative neurorestorative compounds that did so in the presence of stress. The following article will make the case that failure to recognize or compensate for the effects of ongoing stress in standard preclinical experimental models of recovery is likely to result in overestimation of the effectiveness of pharmacological or behavioral neurorestorative interventions.     

Child-in-Family Therapy to Heal a Traumatically Bereaved 10-Year-Old Boy in Grandparental Kinship Care: A Case Study

This study explores the utility of an innovative therapeutic modality for the intra-familial treatment of children who have experienced traumatic loss. A case study is presented of the application of child-in-family therapy (CIFT) with a 10-year-old boy orphaned in political violence and experiencing severe externalizing and acting-out behaviors in grandparental kinship care. CIFT is conceptualized within the context of social and family support for those coping with trauma and loss. The study underscores the phenomenon of family caregiving, and of grandparents raising grandchildren. It highlights the complexities of kinship care when caregivers are experiencing a parallel process of recovery from traumatic loss. The possibility for posttraumatic growth among grandparental caregivers is raised. The limitations and contraindications of CIFT are considered, as well as the implications of study findings for clinical social work practice with children who have undergone traumatic loss, social policy, and ongoing research.     

THE ROLE OF GENERAL PRACTICE AND THE PRIMARY CARE TEAM IN DEMENTIA DIAGNOSIS AND MANAGEMENT

General practitioners (GPs) and the primary care team are uniquely situated to play a central role both in the diagnosis and ongoing care of dementia. Anecdotal reports and empirical work suggest that GPs face several challenges in fulfilling this role. This paper describes the various roles GPs and the primary care team could play in diagnosis and ongoing management. It then discusses the legitimate anxieties and difficulties faced in fulfilling these roles. The paper concludes with suggestions for how GPs and the primary care team might be supported to maximize their role in dementia diagnosis and management.     

Tension pneumocephalus: a case report and literature review

Following a bifrontal craniotomy with frontal sinus involvement, a 64-year-old woman developed cerebrospinal fluid (CSF) rhinorrhoea. At a second operation the skull base dural defect was repaired from within the anterior cranial fossa. Ten days later, the patient developed signs and symptoms of raised intracranial pressure and mass effect. Following radiological investigation, the diagnosis of tension pneumocephalus was made and confirmed at the time of decompression. Within 24 h air had reaccumulated under pressure and concurrently an ongoing CSF leak, which until then had been subclinical, became apparent. Definitive repair of the fistula was performed via a frontal sinus approach and the patient made a total recovery. The relationship between CSF leak and delayed onset tension pneumocephalus is discussed, along with other significant issues regarding the diagnosis and management of this uncommon but dangerous condition.     

Attention Deficit Hyperactivity Disorder: New Ways of Working in Primary Care

Children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and prescribed pharmacotherapy require ongoing regular follow-up for many years. Recent literature outlining the role of primary care in the ongoing medication monitoring of children and young people with ADHD is reviewed. We propose that a General Practitioner with a Specialist Interest (GPwSI) model could be developed in relation to ADHD to ensure that shared care arrangements between CAMHS and primary care for children with ADHD are in place. Clinical materials to support GPs in this new role are described.     

Inpatient group treatment on short-term acute care units

The diverse levels of individual functioning and constantly changing membership in short-term acute care groups challenge the development of true group process. The authors review the recently developing literature on short-term acute care groups, emphasizing the unique characteristics of the groups, their goals, and the therapeutic techniques that can be used to lead them. They then present an approach to short-term acute care therapy that is based on five processes identified in the literature as therapeutic for inpatient ward milieus: containment, support, structure, involvement, and validation. The applicability of the processes to the ward group serves to unify group therapy with other ongoing inpatient treatment.     

Helping clozapine help: a role for support groups

A successful clozapine support group operates from the principle that the drug is most successful when the person takes it as prescribed. The likelihood of initial and ongoing collaboration with treatment is increased when the tangible gains of the treatment can be experienced in the self and demonstrated in others. Clozapine support groups can advance the goals of collaboration and recovery.     

Can targeted early intervention improve functional recovery in psychosis? A historical control evaluation of the effectiveness of different models of early intervention service provision in Norfolk 1998–2007

Aims: This paper assesses the impact of different models of early intervention (EI) service provision on functional recovery and inpatient hospital admission. The study compares the outcome of a comprehensive EI team with a partial model (community mental health team (CMHT) plus specialist support) and traditional care (generic CMHT) over a 10‐year period. Methods: The design is in comparison with historical control. The study compares the functional recovery outcomes of three cohorts from the same geographical area over the period 1998–2007. The primary outcomes were partial and full functional recovery defined with respect to readily identifiable UK benefit system thresholds and psychiatric inpatient admission days at 1 and 2 years post‐referral. Results: Only 15% of individuals made a full or partial functional recovery at 2 years under the care of a traditional generic CMHT in 1998. In 2007, 52% of the cases were making a full or partial functional recovery under the care of the comprehensive EI team. A large reduction in inpatient admissions was associated with the EI strategy. Conclusions: The implementation of comprehensive EI teams can have a major impact in improving functional recovery outcomes in psychosis and reducing inpatient admissions. Partial implementation using limited funding of specialist workers in collaboration with traditional care appeared to have a more limited effect on these recovery dimensions. The implementation of targeted EI in psychosis strategies can result in substantive functional benefits.     

Acute stroke units in Austria are being set up on a national level following evidence-based recommendations and structural quality criteria

A system of acute stroke units is being set up in Austria, which will care for 70% of all acute strokes by 2005. This nationwide project has been planned according to evidence-based principles and contains pre-specified structural components for acute stroke care. With some exceptions in remote mountain regions, all stroke units can be reached within 90 min from any community. All units are within neurological departments. An ongoing documentation of quality performance shows that these units are being well accepted by the general population and the medical community alike.     

Some Recovery Processes in Mutual-Help Groups for Persons with Mental Illness; II: Qualitative Analysis of Participant Interviews

Previous research suggests that consumer operated services facilitate recovery from serious mental illness. In part I of this series, we analyzed the content of the GROW program, one example of a consumer operated service, and identified several processes that Growers believe assists in recovery. In this paper, we review the qualitative interviews of 57 Growers to determine what actual participants in GROW acknowledge are important processes for recovery. We also used the interviews to identify the elements of recovery according to these Growers. Growers identified self-reliance, industriousness, and self-esteem as key ingredients of recovery. Recovery was distinguished into a process—an ongoing life experience—versus an outcome, a feeling of being cured or having overcome the disorder. The most prominent element of GROW that facilitated recovery was the support of peers. Gaining a sense of personal value was also fostered by GROW and believed to be important for recovery. The paper ends with a discussion of the implications of these findings for the ongoing development of consumer operated services and their impact on recovery. This paper was made possible by grant No. SM 52363 from the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.