Adult Community Mental Health Service Research Articles

Team members’ perceptions of clinical psychology in an adult community mental health service

In light of NHS restructuring, community mental health team members were interviewed about the role of clinical psychologists. Recommendations are given for maintaining valued input whilst addressing perceptions of the role of the psychologist as over-subscribed, inflexible and lacking clarity.

Home-based treatment and psychiatric admission rates: Experience of an adult community mental health service in Ireland

Objectives. This study assessed the impact of the introduction of a Home-Based Treatment (HBT) Service on hospital admission rates from two adjacent sectors within a mental health service. Methods. This study used a naturalistic design to compare admissions into the acute inpatient psychiatric unit of Cavan General Hospital from two differently configured sectors - East and West Cavan Psychiatric sectors (East was a community-based and oriented service while the West was a more hospital-based service) prior to and following the introduction of a shared home-based treatment team. Data including demographics, date of admission, diagnosis at admission and sector of admission were retrospectively collected from a mental health register of hospital admissions between 1995 and 2002. Data was analysed using SPSS version 13 for windows. Results. There was a 50% reduction in admission to the inpatient unit in the first two years of the introduction of HBT. This drop was more marked in the West sector compared to the East. Conclusions. The introduction of HBT resulted in a marked reduction in overall hospital admission rates and this reduction was also evident in the sector where other elements of a modern community mental health service already existed.

Supporting the recovery of black individuals who use adult community mental health services

Background/Objectives: Despite an increased emphasis on personal recovery within both mental health services and the literature, there is little empirical research regarding the perspectives on recovery of individuals from black communities. Furthermore, the recovery literature has been described as ‘monocultural', with authors noting a lack of emphasis on race, culture and ethnicity. If services are to be more recovery-orientated, then understanding the perspectives of people from minority ethnic communities will be fundamental in helping them to match the needs of the diverse communities they serve. By developing a framework of recovery for black individuals, this study aims to address this gap within the research.

Failure to improve appropriateness of referrals to adult community mental health services--lessons from a multi-site cluster randomized controlled trial

Non-clinical factors impact on decisions about whether to refer a patient from primary care to specialist mental health services. The aim of this study was to investigate whether introducing a standardized assessment of severity improves agreement on referrals. Multi-site mixed-method cluster randomized controlled trial, investigating GP referrals from 73 practices (408 839 patients) to 11 community mental health teams (CMHTs). Intervention group GPs were asked to complete a Threshold Assessment Grid (TAG) rating of mental health problem severity. CMHTs rated referral appropriateness. Two hundred and eighty-one GPs made 1061 mental health referrals. The intervention was only partly implemented with 25% of intervention group GPs completing TAGs. No difference was found in appropriateness (OR 1.18, 95% CI 0.91-1.53) or secondary outcomes. Post-referral primary care contact rates were higher for the intervention group (IRR 1.36, 95% CI 1.07-1.73). Qualitative data identified professional and organizational barriers to implementation. Asking GPs to complete a TAG when referring to CMHTs did not improve primary-secondary care agreement on referrals. Low implementation means that uncertainty remains about whether introducing a severity-focussed measure into the referral process is beneficial. Introducing local protocols to manage demand at this interface may not be successful and more attention needs to be paid to human and organizational factors in managing interfaces between services.

The Need for the Development and Evaluation of Preventive Psychosocial Forensic Interventions in Mainstream Adult Community Mental Health Services

This paper provides a selective review of forensic research with the aim of making recommendations for the development and evaluation of psychosocial interventions for the mainstream community mental health setting to address the needs of patients with a history of offending. Mainstream community mental health services can be guided by existing findings in the design of psychosocial intervention and prevention programmes. There is growing need to develop and evaluate such interventions.

The need for the development and evaluation of preventive psychosocial forensic interventions in mainstream adult community mental health services

The need for the development and evaluation of preventive psychosocial forensic interventions in mainstream adult community mental health services

Multiple-Family Group Treatment for English- and Vietnamese-Speaking Families Living With Schizophrenia

Multiple-Family Group Treatment for English- and Vietnamese-Speaking Families Living With Schizophrenia

Achieving evidence-based prescribing practice in an adult community mental health service

Aims and MethodPrescribing in everyday practice frequently deviates from evidence-based guidelines. Previous work compared practice in a community mental health service with evidence-based guidelines and identified factors related to suboptimal prescribing. This study reports the impact of a multifaceted intervention on prescribing practice. A Prescribing Practice Quality (PPQ) score was generated from six key aspects of prescribing at initial assessment and again 1 year later after an intervention to reduce suboptimal prescribing practices.ResultsA total of 264 patients were attending the service at both the initial and follow-up phase and were thus exposed to the prescribing intervention. In this population, PPQ scores were significantly lower at follow-up (0.96v.0.67,P<0.001). Improved prescribing practice was predicted by receipt of adjunctive supportive inputs, such as anxiety management (P=0.003).Similarly, mean PPQ scores substantially decreased when the total patient population was considered at each time point (0.75 in 2001 and 0.52 in 2002). These results suggest a reduction in both the initiation and continuation of suboptimal practices.Clinical ImplicationsPrescribing in real-world settings can be improved by interventions that target multiple aspects of service activity. The provision of supportive inputs is a key factor in improving practice.

Sub-optimal prescribing in an adult community mental health service: prevalence and determinants

Aims and Method To compare prescribing practice in a community mental health service with evidence-based guidelines and identify factors related to sub-optimal prescribing. All current patients (n=640) were assessed regarding six key aspects of prescribing (polypharmacy, high-dose treatment, use of thioridazine/maintenance benzodiazepine/maintenance hypnotic or routine anticholinergic treatment). The relationship of quality of prescribing practice to demographic, illness and service variables was examined by regression analysis. Results Five-hundred and five (79%) patients were receiving psychotropic medication. Of these, 232 (46%) had evidence of sub-optimal prescribing practice. Mean prescribing practice quality score was 0.75 ± 0.99. Maintenance benzodiazepine/ hypnotic (31%) and anticholinergic (30%) use were particularly common. Prescribing practice quality score was higher in those receiving depot antipsychotic treatment (P < 0.01) and in older patients (P < 0.01). Scores were significantly lower in patients whose principal medical contacts were with a consultant rather than a junior doctor (P < 0.001). Clinical Implications Prescribing practices in real-world settings frequently deviate from evidence-based guidelines. The quality of prescribing is related to patient, illness and service variables. In particular, greater contact with consultant staff is linked to better practices. Patients receiving depot antipsychotics are especially liable to less judicious prescribing practice.

Sub-optimal prescribing in an adult community mental health service: prevalence and determinants

Aims and MethodTo compare prescribing practice in a community mental health service with evidence-based guidelines and identify factors related to sub-optimal prescribing. All current patients (n=640) were assessed regarding six key aspects of prescribing (polypharmacy, high-dose treatment, use of thioridazine/maintenance benzodiazepine/maintenance hypnotic or routine anticholinergic treatment). The relationship of quality of prescribing practice to demographic, illness and service variables was examined by regression analysis.ResultsFive-hundred and five (79%) patients were receiving psychotropic medication. Of these, 232 (46%) had evidence of sub-optimal prescribing practice. Mean prescribing practice quality score was 0.75 ± 0.99. Maintenance benzodiazepine/ hypnotic (31%) and anticholinergic (30%) use were particularly common. Prescribing practice quality score was higher in those receiving depot antipsychotic treatment (P < 0.01) and in older patients (P < 0.01). Scores were significantly lower in patients whose principal medical contacts were with a consultant rather than a junior doctor (P < 0.001).Clinical ImplicationsPrescribing practices in real-world settings frequently deviate from evidence-based guidelines. The quality of prescribing is related to patient, illness and service variables. In particular, greater contact with consultant staff is linked to better practices. Patients receiving depot antipsychotics are especially liable to less judicious prescribing practice.

Early psychosis identification and intervention.

Early psychosis identification and intervention.

Improving community-based services for older patients with depression: the benefits of an educational and service initiative.

The objective of this study was to report a quality improvement project for older patients with depression. The initiative focused on both clinical practice changes (improvement of medical, neurocognitive and behavioural assessment) and service development (greater continuity of care). After initial identification of key deficits, implementation of a service and educational initiative took place within a district mental health service. The service consisted of an inpatient unit, a specialized psychogeriatric service and two adult community mental health services. Mental health staff received education regarding the specific needs of older patients with depression and were provided with assessment materials, patient education and treatment aids. General practitioners participated in shared long-term management. Following graded implementation, the management of 44 subjects (mean age = 65.4 years, 91% female) recruited over an 8-month period was reviewed. Compared with 99 subjects (mean age = 68.9 years, 69% female) from the earlier 12-month assessment phase, there were significant improvements in medical (43% to 92%), neurocognitive (37% to 84%) and behavioural (e.g. suicidal ideation: 78% to 100%) assessments. Similarly, relevant laboratory investigations (neuroimaging: 21% to 67%) and communication with general practitioners (73% to 97%) improved. The most change occurred in the adult community-based treatment services. A coordinated management and educational initiative resulted in marked improvement in basic medical and psychiatric assessment and more integrated care. These changes did not require expansion of specialist services.

Patterns of use of Antipsychotic Medication in a Regional Community Mental Health Service

Objective: To audit the use of antipsychotic medications in a regional community mental health service. Method: In April 1999 each case manager of the adult and aged care community mental health service documented all medications being prescribed for patients in their care. Results: Out of a total of 792 patients, 572 (72.2%) were prescribed antipsychotic medication. Of those prescribed antipsychotic medication, 67.1% were prescribed atypical or novel antipsychotics, 14.3% were prescribed conventional oral antipsychotics and 23.6% were prescribed a depot antipsychotic preparation. Of the 456 patients prescribed oral antipsychotic medication, 84.2% were prescribed atypical antipsychotics (38.6% were prescribed clozapine, 28.7% olanzapine and 18% risperidone). A total of 100 patients were on a community treatment order (CTO): 40% of patients on a CTO who were prescribed antipsychotics, were prescribed a depot antipsychotic medication compared with 13.7% of patients prescribed antipsychotics who were not on a CTO. Conclusion: The pattern of antipsychotic medication use in this regional community service shows that atypical antipsychotic medication was used more commonly than conventional antipsychotic medication. Over 30% of the use of atypical antipsychotic medication in this service was for conditions other than schizophrenia.

Working together in adult community mental health services: Exploring inter-professional role relations

This is the second of two papers in this issue of JMH that draws upon an initiative by the Centre for Mental Health Services Development (CMHSD) to examine problems of inter-professional working in adult community mental health services. These problems were examined within a series of facilitated group meetings that focused on the community mental health team (CMHT), so establishing an inter-disciplinary dialogue between mental health professionals. This paper reports professionals' perceptions of their own and other mental health disciplines which help to explain why professionals working within multi-professional teams often experience problems in establishing and sustaining inter-professional collaboration. These problems were related mainly to differences in culture between professional groups and to the different values held by group members. These differences originate in professional training and are maintained subsequently by socialisation. The procedure through which inter-professional perceptions were explored emerged as a potentially valuable approach to identifying inter-professional conflict and promoting understanding of professional roles.

Working together in adult community mental health services: An inter-professional dialogue

This paper draws upon an initiative by the Centre for Mental Health Services Development to establish a multi-professional dialogue between senior mental health care professionals in order to explore key problems of inter-professional working in adult community mental health services and to formulate a realistic agenda for addressing them. These aims were pursued through a programme of facilitated discussion and work groups focusing on the community mental health team (CMHT), which is identified in the literature as an arena for inter-professional conflict and frequently characterised by over-ambitious and unfocused aims and confusion about accountability and responsibility of staff. Problems of inter-professional working in health and social care are well known, but within CMHTs these appear to take a particular character. Discussions revealed and explored four key reasons why mental health professionals working within teams are reluctant to comply with operational directives. These are: loss of faith by mental health care professionals in the system within which they work; their strong adherence to uni-professional cultures; absence of a strong and shared philosophy of community mental health services; and a mistrust of managerial solutions to the problems of inter-professional working. The provisional agenda developed by the multi-professional group had four main elements: drawing upon users' aspirations as an explicit philosophy for guiding the development of CMHTs; clarifying accountability and responsibility of CMHT staff; clarifying roles of CMHT staff; developing a framework to explore the relationships between multi-disciplinary groups; and drawing upon theoretical sources for understanding team effectiveness. The first four elements need, the paper suggests, action mainly at the level of national professional organisations, whereas the final element requires action mainly at the level of local mental health services.

Child sexual abuse: Problems for adult survivors

This study surveyed 36 clients of the adult Community Mental Health services in Hull, 18 who were sexually abused as children and 18 who were not. Clinicians were asked to specify the problems which they identified their clients as experiencing. The samples were compared in their response to 38 problems thought to be indicative of a history of childhood sexual abuse. Thirteen problems were found to be more significantly associated with these survivors. The most significant were suicidal thoughts and sexual dissatisfaction. The other 25 problems were found not to be significantly associated with the group of survivors. Although some problems, such as depression and anxiety, were described by the majority of survivors, most members of the control group also experienced them. The pattern of problems is discussed and related to a literature review. Recommendations for clinical practice and future research are made.