Adult Community Mental Health Teams Research Articles

Single case experiment evaluating the effectiveness of an adapted cognitive behavioural therapy intervention for an older adult with a fear of falling

Aim:A single case experiment was carried out for a 77-year-old woman who was referred to the older adult community mental health team for support with anxiety related to a fear of falling.Method:An AB design was implemented, using an adapted cognitive behavioural therapy graded exposure intervention to target her anxiety and fear of falling.Results:There was an overall reduction in the client’s anxiety and an increase in her activity levels.Conclusion:The adapted intervention resulted in decreased anxiety, psychological distress, and a fear of falling and an increase in the frequency of her walking.Consent:The client was provided with information about the purpose of the write up for this case study. She kindly provided informed written consent for the case study to be published within an academic journal. Some demographic details have been amended to protect her identity.

Conditionally Discharged Restricted Patients in a General Adult Community Mental Health Setting

AbstractLittle is known about the proportion and patient profile of conditionally discharged patients supervised by general adult community mental health teams (CMHTs). In this study, the authors evaluate the number of patients and their demographic, clinical and risk profile, and current practice in terms of supervision and structures. Supervision in the community is time‐ and resource‐intensive. There is a need for NHS Trusts to ensure adequate support and structures, supervision, training and joint working opportunity with forensic services to ensure safe quality care.

A Quality Improvement Project to Investigate How Addenbrooke's Cognitive Examination-III (ACE-III) Training Improves the Accuracy of ACE-III Scoring in an Older Adult Community Mental Health Team

A Quality Improvement Project to Investigate How Addenbrooke's Cognitive Examination-III (ACE-III) Training Improves the Accuracy of ACE-III Scoring in an Older Adult Community Mental Health Team

Quality Improvement Project: Lithium Monitoring in an Older Adult Community Mental Health Team

Quality Improvement Project: Lithium Monitoring in an Older Adult Community Mental Health Team

Improving the Sexual Wellbeing of Patients with Psychotic Illness

Introduction Sexual dysfunction (SD) is common in psychotic illness including schizophrenia, occurring in 30-82% of patients. It negatively impacts wellbeing and antipsychotic compliance, resulting in higher risk of relapse and hospitalisation. Due to over-reliance on spontaneous reports from patients, SD is typically under-identified which prevents investigation and treatment.ObjectivesTo establish whether SD is under-identified in patients with psychosis in a general adult community mental health team; to elicit whether the Arizona Sexual Experience Scale (ASEX) improves identification; to investigate and manage identified cases of SD; to make recommendations about identification and monitoring of SD in this patient population.MethodsA 12-month retrospective audit of patients with psychosis prescribed a long-acting injectable (LAI) antipsychotic (n=36) to identify sexual symptoms was completed. The ASEX was subsequently issued to screen for SD.ResultsAudit: 3/36 (8%) patients had documented sexual symptoms. Of the 18/36 patients that completed the ASEX: 10 (56%) exhibited SD. 4 consented to further investigation. 5 patients experienced significant difficulties with the language used in the ASEX. At the end of the project we revised the ASEX with simpler, colloquial language.ConclusionsImplementation of the ASEX results in clear improvements in identification and monitoring of SD. Maudsley Practice Guidelines can inform investigation and management of SD. We suggest a review of NICE guidance to incorporate the above into clinical practice. Further work is needed to establish whether the revised ASEX can be developed and validated.Disclosure of InterestNone Declared

The difficulties of Adult ADHD management within a Community Mental Health Team

IntroductionADHD is a neurodevelopmental disorder characterised by: inattention, hyperactivity and impulsivity.Diagnosis of ADHD in adults is complex, owing to the need for retrospective evidence that symptoms began in childhood as well as the high rates of comorbid mental health conditions. There are no public specialized clinics for adults with ADHD in Ireland. In their absence, referrals are sent to general adult psychiatry.ObjectivesAn audit of standards of care received by patients with ADHD against those set by the NICE guidelines.MethodsCare received pre and 8 weeks post MDT (multi-disciplinary team) educational session. Inclusion criteria: existing adult community mental health team (CMHT) patients with a diagnosis of ADHD. Recommendations as per NICE guideline used for assessment: Specialist MDT team input, OT/ Psychology input, MDT review of reports, Specialist consultant with training in diagnosis and treatment, Diagnosis based on structured assessment e.g. DIVA, Detailed psychiatric assessment, Physical health monitoring before commencing treatment (e.g. ECG), Ongoing physical health monitoring (BP, HR, weight), Patient regularly attending follow upResultsThere were 7 patients with diagnosed ADHD attending the CMHT, 4 male, 3 female aged 19-42yo. 4 patients were diagnosed privately (average age at diagnosis 31yrs). 2 were diagnosed by CAMHS. And 1 was diagnosed by primary care psychology (age 27). 8 weeks following MDT meeting; 2 patients had been commenced on ADHD medication. Those on the wait list for OT/psychology remained on the wait list.ConclusionsADHD is a specialised area which requires a specialist MDT led by a consultant with expertise in diagnosis and treatment. As evidenced by this audit, despite the best efforts of adult psychiatric services, teams are not sufficiently resourced to meet the needs of adults with ADHD and fall short of the expected standards of care.Disclosure of InterestNone Declared

Evaluating the effectiveness of trauma-informed care training delivered to staff in community Older Adult Mental Health Services

PurposeBy older adulthood, the majority of individuals will have experienced at least one traumatic event. Trauma-informed care (TIC) is proposed to improve effectivity of health-care provision and to reduce likelihood of services causing retraumatisation. This study aims to assess the effectiveness of staff training in TIC in older adult services.Design/methodology/approachTIC training was delivered across eight Older Adult Community Mental Health Teams in the same UK organisation. Questionnaires were administered before and after training: a psychometrically robust measure, the Attitudes Related to Trauma-Informed Care, was used to assess TIC-related attitudes, and a service-developed scale was used to measure changes in TIC competence. Data was analysed using linear mixed effects modelling (LMM). Qualitative data regarding the impact of training was gathered one month after training through a free-text questionnaire.FindingsThere were 45 participants, all of whom were white British. LMM on pre- and post-data revealed that staff training significantly increased competencies across all measured TIC domains. Overall, staff attitudes were also significantly more trauma-informed after training. Qualitatively, staff identified time as the only additional resource required to deliver the skills and knowledge gained from training.Practical implicationsTraining was found to be effective in increasing TIC-related skills and attitudes. Organisations aiming to become trauma-informed should consider staff training as one aspect of a wider development plan.Originality/valueTo the best of the authors’ knowledge, this paper is the first to examine TIC training for staff working in Older Adults Mental Health Services. Recommendations for services aiming to develop a trauma-informed culture have been provided.

Care Plan Templates in Adult Community Mental Health Teams in England and Wales: An Evaluation.

Adults accessing community mental health services are required to have a care plan, developed in collaboration with the person accessing the service. The variation in care plan templates in use in England and Wales, and their impact on care planning, is unknown. This study evaluates the community mental health care plan templates in use across England and Wales. Data were obtained from a Freedom of Information request to 50 NHS Mental Health Trusts. An evaluation tool was designed and used to extract data. Data were rated red, amber, or green against clinical and design standards. Forty-seven care plan templates were obtained. The clinical aspect of the care plan template had 60% adherence to the national standards, and the design aspects had 87% adherence. A 'high/low' typology is proposed against the design/clinical standards. The study identifies priority areas for improvement in the care plan templates as space to record the actions that service users and carers will take to contribute to their care plan, space to record the name and contact details for their care coordinator or lead professional, plus others involved in the person's care. This study was not registered.

How Young Adults with Serious Mental Health Diagnoses Navigate Poverty Post-emancipation: The Complex Roles of Community Mental Health Services & Informal Social Support.

Serious mental health diagnoses are prevalent among youth who "age out" of foster care by reaching the maximum age for child welfare service eligibility. Post-emancipation, little is known about how youth engage in community mental health services, or leverage informal social networks, to navigate independence. Twenty emancipating youth completed three interviews over 16months. All emancipated into poverty; most lived alone and initially connected to adult community mental health teams. Four service use and informal support profiles emerged from analysis: (1) Navigators (n = 2) actively used mental health services and provided limited informal support; Treaders (n = 9) passively used mental health services and heavily exchanged informal support; Survivors (n = 5) used mental health services when in crisis and heavily provided informal support; and Strugglers (n = 4) avoided mental health services and took resources from informal connections. Findings have implications for both child and adult mental health and social service providers.

Experiential avoidance in anxiety and depression: Insights from working with an older adult client

This article presents the single case of Janet, whose GP referred her to an Older Adult Community Mental Health Team. Janet engaged in cognitive behaviour therapy (CBT) for depression and generalised anxiety, using Laidlaw’s comprehensive case conceptualisation for older people as a guide, and with a key focus on experiential avoidance as a maintaining factor for her distress in the context of grief. Experiential avoidance, is suggested to significantly mediate the relationship between depression and generalised anxiety, which are both common for older adults; however, the evidence base is limited for treatment and guidelines are unclear. Outcome measures demonstrated reductions in self-reported low mood, anxiety and worry. Further research on the role of experiential avoidance in anxiety and depression in older adults is needed to establish a clearer understanding of its role in maintaining emotional distress within this population. Janet provided consent for the case study to be published within an academic journal. Pseudonyms and amended demographic details are used to preserve confidentiality.

Wheel and talk: A Progressive Supranuclear Palsy case summary

BackgroundThe negative psychological effects of neurogenerative disorders (NDDs) are well known. However, there is limited research identifying ways to ameliorate psychological distress in individuals with progressive supranuclear palsy (PSP).CaseAn 84-year-old gentleman was referred to the Older Adult (OA) Community Mental Health Team (CMHT) due to low mood following a PSP diagnosis. After assessment and formulation, elements of a cognitive-behaviour therapy (CBT) framework which adapted ‘Walk and Talk’ therapy to Wheel and Talk, was used to support a move towards a sense of acceptance following the associated losses of a PSP diagnosis.ConsentVerbal consent was sought and gained from the client. Details have been amended to protect their identity. A pseudonym, Robert, was utilised for this client.ResultsThrough ongoing assessment and reformulation, adapting sessions to have an outdoor focus enabled Robert to move towards a sense of connectedness to his values and identity.ConclusionThis case summary reveals the importance of empowering services to adapt to the needs of the client through simple modifications and modelling.

Worry Intervention in an Older Adult With a Persecutory Delusion: A Single Case Experimental Design.

This report presents the single case of Jack, a 67-year-old referred to our Older Adult Community Mental Health Team (OA CMHT) for his distressing persecutory delusion and high levels of worry. Jack also reported learning difficulties and autistic traits, although neither were formally diagnosed. Ten sessions of worry intervention taken from The Feeling Safe Programme worry module were used to reduce Jack's time spent worrying and increase his engagement in meaningful activity. Weekly face-to-face sessions were held, with Jack's brother acting as a co-therapist. Adaptations to the intervention were made based on Jack's learning preferences. An AB single case experimental design was adopted to compare Jack's scores on measures of worry, paranoia and delusional conviction, and wellbeing and daily functioning before and after intervention. Results demonstrate the worry intervention improved Jack's scores on all measures to a clinically significant degree. This is the first known report of applying the worry intervention to an older adult. The results show the intervention can be of considerable benefit in terms of reducing worry and paranoia, in the context of both older age and suspected neurodiversity.

Could a Virtual Clinic Improve the Quality of Physical Health Monitoring for Safe Antipsychotic Prescribing in an Older Adult Community Mental Health Team (CMHT)? Encouraging Preliminary Results From a CMHT in Wales

AimsAntipsychotics are linked to increased cardiometabolic risk. The National Institute for Health and Care Excellence (NICE) and the Royal College of Psychiatrists have developed guidance on PHM to mitigate this risk. Both risks and guidance are age-blind, and very relevant to Older Adults due to age-related increase in cardiovascular risk. The COVID-19 pandemic boosted digital healthcare, which remains relevant due to rocketing demand and stretched services. This is a Quality Improvement Project aiming to improve physical health monitoring (PHM) for safe antipsychotic prescribing in an Older Adult Community Mental Health Team in South Wales. Baseline data, a virtual clinic model and preliminary results of the first Plan-Do-Study-Act cycle are presented.MethodsAn audit was conducted (06/2021–12/2021), with continuous prospective data collection thereafter. A scoping exercise was conducted to establish available resources. A local protocol/operational framework was developed. Education interventions (03/2022-on-going), a junior-doctor-led virtual PHM clinic and a phlebotomy/electrocardiogram (ECG) pathway (10/2022-on-going) were designed and implemented.ResultsBaseline (06/2021-09/2022): completed lifestyle advice=0%, physical observations=3%, blood tests=3%, ECG=3% of eligible patients. No patient (0%) had the full PHM as per guidance. Mean overall compliance with guidance/patient=9%. Pareto chart: no clear pathway and lack of prescriber awareness were the main reasons (>95%) for poor performance.Scoping exercise: No Health-Board/Trust-wide approach for Older Adults and PHM is problematic in all localities. General Practitioners assertive regarding no responsibility/funding to deliver PHM for at least the first 12 months or until antipsychotic dose and mental state are stable. Geriatric teams, district nurses, general adult teams stretched and unable to support. Care home staff lack training and resources. Phlebotomy and ECG departments of local hospitals could support but no pathway.First PDSA cycle (preliminary):Change idea 1: staff education: clear shift (04/2022 onwards). Proportion of trained staff reached 100% in December 2022, and remains 100% in January 2023.Change idea 2: virtual PHM clinic (10/2022 to 01/2023) – mean overall compliance with guidance/patient = 69% (vs. 9% baseline). Proportion of patients with complete PHM as per guidance reached 50% in January 2023. 75% patient response rate.Change idea 3: phlebotomy/ECG pathway (10/2022 to 01/2023) – proportion of patients with bloods and ECG done reached 67% in January 2023.ConclusionPreliminary data suggest an encouraging trend for significant continuous improvement which, from a clinical perspective, is already significant. However, more data are required to draw safe conclusions regarding the clinical and cost effectiveness of this model of a virtual PHM clinic.

How is physical healthcare experienced by staff, service users, and carers in adult community mental health services in a south London mental health trust? A service evaluation.

Adults with a serious mental illness (SMI) are at greater risk of physical health morbidity and premature death than the general population, largely as a result of preventable physical health issues. Staff working in mental health services have a role to play in addressing these inequalities, but little is known about how they perceive their role and how this impacts on their practice. Understanding this better would enable services to improve their approach and support better health outcomes for SMI patients. A service evaluation was undertaken to investigate how physical healthcare is approached within adult community mental health teams (CMHTs) at a South London (UK) Mental Health Trust. This was a prospective, cross-sectional evaluation design. Interviews and focus groups were conducted with clinical staff, service users and carers (non-professional caregivers e.g., family or friends, of adults living with an SMI), to understand their experiences and to identify key barriers and facilitators to supporting physical healthcare support for adults with SMI. Thematic analysis was conducted to identify key themes which were classified into five main categories. 50 participants took part in the study, 38 were clinical staff, eight were service users and four were carers. We found staff widely recognised the importance of supporting physical healthcare. However, there was variability in how staff approached physical healthcare in routine practice, and differences in how physical healthcare is experienced by service users and carers. Staff were keen to engage in changes to the way physical healthcare is delivered in CMHTs. However, they sought clearer guidance on their roles and responsibilities, and wanted to better understand the rationale for changes in community mental health practice, such as increased screening for physical healthcare. Service users and carers felt equally that the role of CMHTs in physical healthcare was unclear, which limited their ability to access it and understand the benefit for their overall care. Staff articulated gaps in leadership and training that impacted on their ability to implement the overall vision for physical healthcare within the Trust. Mental health staff recognise the role they play in supporting the physical health of adults living with SMI. This evaluation provides insight into common barriers and facilitators faced by staff, service users and carers when providing or accessing physical healthcare within adult CMHTs. These findings indicate a more comprehensive and better articulated approach to physical healthcare in mental health Trusts is needed to ensure service users and their carers understand what support is available and how to access it and to equip staff to provide and sustain that care in routine practice.

Evaluation of radically open dialectical behaviour therapy in an adult community mental health team: effectiveness in people with autism spectrum disorders - ERRATUM.

Evaluation of radically open dialectical behaviour therapy in an adult community mental health team: effectiveness in people with autism spectrum disorders - ERRATUM.

Specialist hoarding training: Should we be providing it within our mental health teams? Evaluating the utility and effectiveness of a Hoarding Disorder (HD) training package within older adult community mental health teams

Hoarding disorder (HD) is usually more prevalent within the OA population, however, CBT treatment protocols for OA with HD show relatively weak outcomes which are not sustained at follow up. Recent research revealed that clinicians lacked understanding, skills or knowledge to incorporate evidence-based approaches into their care plan whilst working with OA with HD. As a result, a specialist HD training package was developed and delivered to staff to enhance their understanding of HD. The current evaluation sought to determine the effectiveness of the training package and staff’s experience of the training, to inform and develop the HD training package for future use. Self-report surveys collected both quantitative data and qualitative data, regarding participants’ (N=24) understanding of HD related to the aims of the session and their general training experiences. Participants’ understanding in HD; knowledge of assessment, formulation and treatment for HD; and confidence in working with OA with HD significantly increased after training. Five superordinate themes and 17 subordinate themes were identified within the qualitative feedback; 1) knowledge about HD; 2) emotional understanding of HD; 3) validation; 4) multidisciplinary approach to HD; 5) training adaptations. The data highlights the importance of delivering HD training to all staff members involved in multidisciplinary team care and treatment for OA with HD, moreover, suggesting adaptions which have been implemented to further develop the training package’s suitability and content.

Comparing the effectiveness of an 8-week and 12-week cognitive behavioural therapy group for bipolar affective disorder

• Group CBT for bipolar affective disorder is effective. • No significant difference between an 8 vs 12-week CBT group for bipolar affective disorder. • Reliable and clinically significant improvement for bipolar affective disorder. Previous systematic reviews have demonstrated efficacy of Cognitive Behavioural Therapy Groups (CBT-G) in treating bipolar affective disorder (BAD). However, effectiveness research of BAD CBT-G (groups delivered in clinical practice rather than a research trial) is sparse. Additionally, the efficacy literature shows variation in the number of sessions delivered, and the number needed for clinically significant change is unclear. Therefore, we examine the effectiveness of a 12-week CBT-G compared to an 8-week group. An 8-week vs 12-week CBT-G was delivered in routine practice in an adult community mental health team. We compared pre-post data for N = 88 participants with a diagnosis of BAD who attended either an 8-week CBT-G ( n = 43) or 12-week CBT-G ( n = 45). All routine outcome measure scores which included measures related to depression, generalised anxiety, psychological distress and functioning improved significantly from baseline to treatment endpoint for both the 8-week and 12-week CBT-G interventions, with no significant differences between the groups at post-treatment. No measure for manic symptoms was included. No follow-up data was collected. The study lacks a comparator control group. This research adds to the literature in two ways by: (i) demonstrating the effectiveness of CBT-G for bipolar affective disorder; (ii) being the first to show no significant difference in outcome measures between an 8-week and 12-week group. The findings can be used to inform the provision of both a clinical and cost-effective intervention.

Service user experience of remote consultations during COVID-19 in an older adult community mental health setting

AimsThe COVID-19 pandemic has had a significant effect on our ability to communicate face-to-face with patients freely. Similar to other medical specialities and general practice (1), to continue providing a service for our service users, we employed other means of communication including telephone and video consultations (although face-to-face consultations were available for high clinical concern and/or identified risk). We set out to explore the acceptability of remote consultation for service users of an older adult (>65 years) Community Mental Health Team (CMHT).Reference: BMJ 2020;371:m3945MethodA total of 34 service users were selected randomly from the CMHT caseload (9% of total 372 caseload). 4 clinicians were involved in collecting data between July and October 2020. We used our trust's (East London Foundation Trust) standard questionnaire on patient satisfaction and contacted individuals by telephone to complete the survey.ResultFor both questions of ‘I felt listened to by the team’ and ‘I feel I have been given enough information regarding my care’ 17 (50%) responders ‘agreed’ with this statement and an additional 13 (38%) ‘strongly agreed’ (total of 88%). For the statement ‘I feel involved in decisions about my care’ 16 (47%) responders ‘agreed’ and a further 11 (32%) responders ‘strongly agreed’ with this statement. The statement ‘The professionals involved in my care talk to each other and we all work as a team’ had 15 (44%) responders ‘agree’ and 13 (38%) responders ‘strongly agree’. When asked ‘If you experienced telephone/video sessions, were these helpful?’ 31 responders said ‘yes’.ConclusionOverall most responders agreed or strongly agreed that they felt listened to, were given enough information about their care, felt involved in decisions about their care and that they worked as a team with the professionals involved in their care. 91% of responders felt that the video/telephone sessions had been helpful. These data have provided reassurance that telemedicine methods were a useful substitute for face-to-face consultations during the early stages of the pandemic. However this was a small scale study. This study cannot tell us about the experience after the initial 6 months of the pandemic, how often it would be optimal for people have face to face reviews, or whether satisfaction with telemedicine altered over a longer period. We were also not able to tell whether the experience varied for those who had less robust and longstanding relationships with their clinicians.

Diagnosing autistic spectrum disorder in adult community mental health teams

This paper describes the process of incorporating Autism Spectrum Disorder (ASD) diagnostic assessments within local community mental health teams as a response to the long waiting times for diagnostic assessment from specialist services. It reflects upon the feasibility, acceptability and potential therapeutic value of this initiative.

Evaluation of radically open dialectical behaviour therapy in an adult community mental health team: effectiveness in people with autism spectrum disorders.

Radically open dialectical behaviour therapy (RO DBT) is a transdiagnostic treatment designed to address disorders associated with overcontrol, including autism spectrum disorders (ASD). To date, no studies have reported on the effectiveness of RO DBT for people with ASD. Forty-eight patients were referred to a RO DBT programme, of whom 23 had a diagnosis of ASD. Outcome was measured using the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE) and the Questionnaire about the Process of Recovery. The intervention was effective, with a medium effect size of 0.53 for improvement in CORE global distress. End-point CORE global distress score was predicted from initial severity and a diagnosis of ASD. Participants with a diagnosis of ASD who completed the therapy had significantly better outcomes than completing participants without an ASD diagnosis. These findings provide preliminary support for RO DBT as an effective intervention for ASD in routine settings.