Support in the community for people with dementia and their carers: a comparative outcome study of specialist mental health service interventions

BACKGROUND: This study aimed to evaluate outcomes for carers receiving the Admiral Nurse Service, a specialist mental health nursing service for carers of people with dementia. In contrast to many community mental health teams, it works primarily with the caregiver, focuses exclusively on dementia and offers continuing involvement, throughout the caregiving career, including emotional support, provision of information and coordination of practical support. METHOD: 104 carers of people with dementia who were interviewed as soon as possible after being referred to a number of Admiral Nurse (AN) services or conventional services in neighbouring areas, and who were re-interviewed eight months later, form the sample (43 AN; 61 comparison). RESULTS: There were no significant differences between groups, controlling for initial score, on the primary outcome measure at follow-up, the 28-item General Health Questionnaire (GHQ) or its sub-scales, apart from anxiety and insomnia, where outcome was better for the AN group (p = 0.038). Follow-up GHQ scores were associated with ratings of past and current relationship quality. There were no differences in survival in the community between the groups. CONCLUSION: Both conventional and AN services are associated with lower distress scores over an eight-month period. Outcome for people with dementia (in terms of institutional placement) is no worse in the AN group, despite the carer focus. Some support is provided for a model of dementia-specialist service which engages with the caregiver and continues involvement for as long as is required, rather than simply carrying out an assessment and referring the person back to social services or primary care.     

Clinical predictors of severe behavioural problems in people with intellectual disabilities referred to a specialist mental health service

Associations between demographic and clinical variables and severe behavioural problems in people with intellectual disabilities were examined in a cross-sectional survey of 408 adults consecutively referred to a specialist mental health service. Severe behavioural problems were present in 136 (33.3%) of the sample. The demographic and clinical predictors of severe behavioural problems in this sample were identified by logistic regression. Age and gender were not associated with severe behavioural problems. The presence of severe ID independently predicted the presence of severe behavioural problems. Schizophrenia spectrum disorders and personality disorders independently predicted the presence of severe behavioural problems, whereas the presence of an anxiety disorder independently predicted their absence. There is an increasing evidence base of relationships between mental disorders and behavioural problems in people with ID although the pattern of these relationships remains unclear.     

Outreach and support in south London (OASIS): implementation of a clinical service for prodromal psychosis and the at risk mental state.

BACKGROUND: While recent research points to the potential benefits of clinical intervention before the first episode of psychosis, the logistical feasibility of this is unclear. AIMS: To assess the feasibility of providing a clinical service for people with prodromal symptoms in an inner city area where engagement with mental health services is generally poor. METHOD: Following a period of liaison with local agencies to promote the service, referrals were assessed and managed in a primary care setting. Activity of the service was audited over 30 months. RESULTS: People with prodromal symptoms were referred by a range of community agencies and seen at their local primary care physician practice. Over 30 months, 180 clients were referred; 58 (32.2%) met criteria for an at risk mental state, most of whom (67.2%) had attenuated psychotic symptoms. Almost 30% were excluded due to current or previous psychotic illness, of which two-thirds were in the first episode of psychosis. The socio-demographic composition of the 'at risk' group reflected that of the local population, with an over-representation of clients from an ethnic minority. Over 90% of suitable clients remained engaged with the service after 1 year. CONCLUSION: It is feasible to provide a clinical service for people with prodromal symptoms in a deprived inner city area with a large ethnic minority population.     

Young rural people at risk for schizophrenia: time for mental health services to translate research evidence into best practice of care

Early intervention into prodromal schizophrenia has shown promise, but controversy continues regarding the ethical acceptability of identifying a group of 'ultra high risk' individuals of whom only 30 to 50% will develop a psychotic disorder. With well developed early intervention services this group faces the possibility of being labelled as 'pre-psychotic', a condition for which the well known stigma associated with the diagnosis of schizophrenia or bipolar disorder is likely to be associated. In addition, the use of potent antipsychotic and other medications (albeit usually at lower doses than those used for those with manifest psychosis) mandates consideration of the risks associated with their use and neurological and metabolic side effects. The potential for iatrogenic morbidity in the 'false positive' group must be weighed against the need of the 'true positives' identified through screening and assessment. Current evidence for the concept of 'at-risk mental state' was reviewed within a neurodevelopmental framework, including emerging data on the effectiveness of early intervention for the purpose of providing recommendations for community mental health services. The review suggests that different treatment strategies may be appropriate depending on the clinical stage of the condition as long as the benefits of intervention outweigh its risk burden. It further suggests that the severity of psychoses and the evidence of its early onset in utero and its acceleration in adolescence positions 'ultra high risk' intervention as a core model for early intervention for young people by teasing apart the symptomatic components of the 'prepsychotic state' and ensuring the population is reaching targeted mental health services for screening. The model is not restricted to the delivery of intervention for 'pre-psychotic' young people but is applicable for targeted programmes for a number of clinical groups considered at 'ultra high risk'. However, only further research in naturalistic populations embedded in clinical practice and ideally conducted in partnership of mental health services with academic research institutions will help clarify potential risks of early identification and intervention and assist in updating and making more explicit the clinical guidelines services will use in approaching those in the 'ultra high risk' group.     

Obtaining views on health care from people with learning disabilities and severe mental health problems

Despite the rhetoric of involvement of people with learning disabilities in health care there is a dearth of research which examines the extent to which service users are included in evaluating their own care. This paper describes a study of methods for enabling people with learning disabilities and complex health needs to comment on the specialist inpatient care they received. Six service users consented to take part in interviews using analogue scales and photographs. The participants were able to engage in all elements of the interviews even though inclusion was more challenging because of additional health problems such as manic depression and paranoid psychosis. The suitability of research tools and approaches are discussed and barriers to inclusion identified. In this investigation a gap emerged between government policy of inclusion for everyone, and the realities of frontline practice where involvement was not achieved for some users with severe/profound disabilities. The study points to implications for increased resources, education and training if meaningful user involvement is to become established for individuals within routine practice.     

Khat use among Somali mental health service users in South London

Purpose

Khat use has been suggested to be associated with psychosis, but its prevalence and associations among mental health service users have not been described in either traditional use countries or countries with immigrant populations from traditional use countries. We aimed to investigate the clinical and demographic associations of khat use in a sample of Somali users of mental health service users in South London.

Methods

We used an electronic case register of 150,000 mental health patients to investigate the associations of khat use among all 240 Somali patients in the database. We used logistic regression to generate adjusted estimates for a range of exposure variables and used multiple imputation as a principled approach to missing data.

Results

Khat use or non-use was recorded for 172 patients (72% of the total), of whom 80 (47%) were current users. Khat use was very strongly associated with ICD-10 primary diagnosis of schizophrenia, psychosis or drug and alcohol disorder (compared to ICD-10 F43 stress-related disorders and other non-psychotic disorders), male gender, harmful or dependent use of alcohol, and detention under the Mental Health Act.

Conclusions

Recording and monitoring of khat use need to be more consistent in clinical settings, and further studies are required to investigate the much higher rates of use among those with psychotic disorders compared to non-psychotic disorders.     

Homeless people at disadvantage in mental health services

OBJECTIVE: The aims of this study are threefold: to depict characteristics of homeless at discharge from a psychiatric hospital; to describe the utilisation of inpatient care and treatment measures during hospitalisation; and to analyse to what extent psychiatric disorders and clinical variables contribute to the risk for homelessness at discharge. METHODS: Based on case register data we analysed all 28,204 people consecutively referred in 1996-2001 to psychiatric hospitals of a well-defined catchment area in Switzerland. RESULTS: 1% (N=269) of all admissions were homeless at discharge (mean age: 32.0 years; women: 27.9 %). Compared to other psychiatric inpatients, we found among the homeless more males, more people with younger age and lower education. Regarding treatment measures during the inpatient stay, homeless received less often psychopharmacotherapy, ergotherapy and physiotherapy, but more vocational training, occupational therapy and support by social workers. There was no difference between homeless and others regarding compulsory medication or seclusion. Homeless had a shorter length of inpatient stay. Risk factors for being homeless at discharge were: being homeless at admission, not living in a relationship, having a multiple substance abuse or a dual diagnosis, low clinical improvement during inpatient treatment and discharge against medical advice. DISCUSSION: To prevent homelessness at discharge, it is important to consider all independent contributors, i. e. the living situation before admission, health care inequalities during inpatient treatment (care received, low clinical improvement, discharge planning) and psychopathology.     

Outcome of patients attending a specialist educational and mental health service for social anxiety disorders

The purpose of this study was to evaluate the outcome of adolescents with anxiety-based school attendance problems enrolled in a specialist adolescent educational and mental health program that provides educational assistance and social skills development, and to suggest key elements that may account for its apparent effectiveness. Young people attending the Sulman Program in Sydney, Australia, between March 2003 and December 2004 were identified. Baseline information was gathered from the medical records, pre and postintervention personal development questionnaires were given to students, and pre and postratings of function were made. Those attending the program showed improvement in their general level of functioning indicated by completion of a year-long course of study (17 of 24), preparation for employment (17), increased independent travel (5), and self-rated improvement in social skills, stress tolerance and emotional literacy. Pre and poststaff ratings on the Health of the Nation Outcomes Scales Child and Adolescent (HoNOSCA), Children's Global Assessment Scale (CGAS) and Global Assessment of Functioning (GAF) indicated improvement in personal and social functioning. Parental satisfaction was rated as high. The findings confirm the effectiveness of, and need for, flexible programs to support adolescents with social anxiety disorder and other longer-term mental health problems to offset the adverse consequences of early withdrawal from educational and social environments. Several elements may help to explain the program's effectiveness and provide guidance for similar programs elsewhere.     

Mental health service delivery to older people in New South Wales: perceptions of aged care, adult mental health and mental health services for older people

OBJECTIVE: To compare the perceptions of aged care services, adult mental health services and mental health services for older people regarding aspects of mental health service delivery for older people in New South Wales, Australia. METHOD: The NSW Branch of the Faculty of Psychiatry of Old Age in association with the NSW Centre for Mental Health, sent a postal survey to all aged care services, adult mental health services and mental health services for older people in NSW. The survey canvassed issues ranging across service profiles, regional variations, availability of resources, processes of care, views on working relationships between services, difficulties and gaps experienced, and ways to improve co-ordination and service delivery. Clinical issues such as the management and practice of psychiatric disorders of old age, educational/training requirements and skill and experience in working with older people were explored. RESULTS: An overall response rate of 86% was achieved, including 95% from aged care services (n = 58), 74% from adult mental health services (n = 62) and 90% from mental health services for older people (n = 20). Only 59% of aged care services and adult mental health services considered that their local mental health services for older people provided an adequate service; resource and budget limitations were portrayed as the main constraint. Mental health services for older people varied widely in structure, settings and activities undertaken. Access to mental health beds for older people was also variable, and alongside staffing levels was considered problematic. Lack of staff training and/or inexperience in psychogeriatrics posed a challenge for aged care services and adult mental health services. CONCLUSION: Relationships between aged care services, adult mental health services and mental health services for older people are affected by lack of access to psychogeriatric staff, resource limitations of mental health services for older people, and inadequate liaison and support between the service types. Joint case conferences, education, increased funding of mental health services for older people, and cross referrals were considered ways to address these issues.     

Prevalence of suicide risk factors in people at ultra-high risk of developing psychosis: a service audit

Background: Little data is available on the prevalence of suicide risk factors in people at ultra‐high risk (UHR) of developing psychosis. Aim: The aim of this study was to provide an estimate of the cross‐sectional prevalence of possible suicide risk factors in those attending a routine clinical service for people at UHR of developing psychosis. Methods: For all patients in treatment (n = 34) over a 4‐week period, levels of suicidal ideation and depression upon entry to the service were assessed by auditing intake scores on the Beck Depression Inventory, second edition. Level of engagement with services, social isolation, substance and alcohol misuse, ready access to means, current suicidal ideation, previous suicide attempts, current or previous self‐harm, expressions of concern from others, depression, agitation, hopelessness, worthlessness, suspiciousness and fears of mental disintegration were all assessed by case note review and interview with the treating clinician. Results: There was a high prevalence of at least mild suicidal ideation (58.8%, n = 20) and severe depressed mood (47%, n = 16) in this client group at point of entry to the service. Seven people (20.6%) had engaged in serious self‐harm (including attempted suicide) during the time they were in contact with the service. Forty‐seven per cent (n = 16) reported at least 27 suicide attempts between them; the mean number of attempts being 1.69 (standard deviation = 1.08). Conclusion: Suicide risk was high in this small sample of people at UHR of developing psychosis. Controlled research with larger samples and better methodology is urgently required to inform legal, ethical and scientific debates surrounding this group.     

Prevalence of violence risk factors in people at ultra-high risk of developing psychosis: a service audit

Background: There is little data available on the prevalence of violence risk factors in people at ultra‐high risk of developing psychosis. Aim: The aim of this study was to provide an estimate of the cross‐sectional prevalence of violence risk factors in those attending a routine clinical service for people at ultra‐high risk of developing psychosis. Methods: The case notes of all 34 clients receiving treatment over a 4‐week period were reviewed and all clinicians were interviewed. Information was gathered regarding gender, current violent ideation, history of violence (including convictions), expressions of concern from others, problems with alcohol or substance misuse, jealousy, suspiciousness, irritability, anger and relevant subthreshold psychotic symptoms. Information on protective factors, including treatment engagement, was also gathered. Results: Thirty‐eight per cent (n = 13) had a history of violent behaviour, 79.4% (n = 27) were thought to be currently experiencing significant levels of suspiciousness and 47.1% (n = 16) were thought to have problems with anger. Twenty‐nine per cent (n = 10) had previous known convictions for violence. Two‐thirds (n = 8) of those where risk of violence was identified were described as being engaged with treatment. Conclusion: There was a high prevalence of violence risk factors in this small sample. Further research with larger samples and better methodology is urgently required to investigate risk of violence in this group and determine the contribution, if any, of subclinical psychotic symptoms.     

Predictors of mental health service utilization by people using resources for homeless people in Canada

OBJECTIVE: This study used Pescosolido's network episode model to examine mental health service utilization among impoverished people accessing resources for the homeless in Canada's universal health care setting. METHODS: The sample consisted of 439 people who met DSM-IV criteria for affective or psychotic disorders who were assessed as part of a larger study of resources for homeless or impoverished people in Montreal and Quebec City. Interviews were organized into the framework of four network episode model concepts: sociodemographic characteristics, illness characteristics, illness history, and social network. These blocks of variables were then analyzed in terms of their accuracy in predicting mental health service utilization. RESULTS: Eighty-four percent of the sample were male, the mean+/-SD age was 41+/-12 years, and 36% were homeless at the time of the interview, but nearly half (48%) of the population had been homeless previously. The research shows that each network episode model concept except illness history significantly predicted utilization of mental health services. Female gender, youth, never being homeless (sociodemographic characteristics), presence of antisocial personality disorders within the preceding year, past or current alcohol-related disorders (illness characteristics), hospitalization before the preceding year (illness history), and a larger social support network were related to utilization of mental health services. CONCLUSIONS: In the absence of economic barriers to health care, there are other significant barriers to the use of mental health services for people who live in poverty. A better understanding of these factors will help in meeting the service needs of impoverished mentally ill people.