General Adult Services Research Articles

The utilisation of services by patients with psychosis who engage in antisocial behaviours

ABSTRACT Three pathways of antisocial behaviour and psychosis have been described. Three subgroups within a typology have been categorised as (i) schizophrenia preceded by conduct disorder (SZ+CD), (ii) offenders with schizophrenia and no childhood history of antisocial behaviour who begin offending at illness onset (SZ+AS), and (iii) offenders with schizophrenia (SZ). There are no studies investigating how the subgroups utilise services. This study aimed to examine the concurrent validity of typology and examine differences in service utilisation. The sample consisted of 77 male patients admitted to low- and medium-secure units in the United Kingdom. The subgroup of patients was determined from data collected from health records. Analysis assessed the difference in aetiological variables amongst the typology and examined the relationship of subgroup service utilisation. This study provided further evidence of distinguishing characteristics emphasising typology heterogeneity and found differences in service utilisation. The SZ+CD subgroup was more likely to have used services preceding a diagnosis of psychosis. Following the onset of psychosis, the SZ+AS and SZ subgroups had a higher proportion that used general adult psychiatry services. Those patients within the SZ+AS and SZ subgroups had a higher use of general adult services after psychosis onset. Understanding about how these subgroups utilise services will enable clinicians to develop effective management plans that address the distinct characteristics of offenders with psychosis.

PREVENT: Assessing and Improving Knowledge of the Sodium Valproate Pregnancy Prevention Programme in Psychiatric Prescribing

AimsThe sodium valproate PREVENT programme was introduced by the Medicines and Healthcare products Regulatory Agency (MHRA) in March 2018, and is now a legal requirement due to valproate's risks in pregnancy. This project had two main aims: 1) To assess clinician knowledge of PREVENT, and identify deficiencies in current education. 2) To assess the barriers psychiatrists face in achieving compliance with PREVENT.MethodsKnowledge and awareness of PREVENT was assessed through an online survey sent to local consultants and specialty doctors in February 2021. The survey included ten questions, four were Likert style to assess attitudes, two assessed local arrangements and four were knowledge based. A free-text section allowed respondents to describe challenges faced implementing PREVENT. Results were analysed, an educational presentation given at local teaching and a poster was created and distributed - both targeting areas of weakest knowledge. A repeat survey was sent out in June 2021, and results collected to reassess.ResultsThe pre-teaching survey received twelve responses, the post teaching survey received eleven. In both, 75% of respondents represented general adult services, and 25% represented intellectual disability services.There was an improvement in confidence of knowledge with all respondents being either “somewhat” (55%) or “very confident” (45%) post-teaching compared to 75% being “somewhat” confident, 10% “unsure” and 17% “very confident” prior to intervention. Pre-teaching, 10% of respondents were unaware that a risk acknowledgement form must be signed annually, while post-teaching 100% correctly identified this should be annual.Respondents correctly identifying “highly effective” forms of contraception rose from 83% to 100% following teaching. Post-teaching there was an increase of 31% in the number of respondents correctly identifying the necessary documentation where a patient declines the PREVENT programme.Pre-teaching, half of respondents were unsure if their team had a reminder system for risk acknowledgement forms, and 42% reported having no system. Post-teaching, 27% of respondents reported now having a reminder system in place, and 27% had plans to implement one.ConclusionInitial results showed variable knowledge of the PREVENT programme, and a lack of awareness of the administrative requirements including risk acknowledgement forms. Results demonstrated an improvement in knowledge and organisation to help support compliance with the PREVENT programme. Respondents highlighted that knowledge of the PREVENT programme quickly deteriorates given how rarely it is used. Further work includes a full audit of compliance with PREVENT across the health board, as well as considering “refresher” sessions to prevent atrophy of knowledge.

The Ligature Assessment Tool: the development of a structured tool to improve quality of reporting of ligature incidents

Of all deaths by suicide on psychiatric wards, 75% are due to hanging or strangulation by ligature. The act of tying a ligature is complex self harm risk behaviour and can be fatal. There is no consistent framework available to ensure that essential risk information is accurately captured following a patient tying a ligature. This leads to a variable quality of incident reports being generated in inpatient psychiatric wards, which can be challenging for the MDT to interpret second hand and understand the ligature risk in that case. Effective psychiatric care is underpinned by accurate and detailed documentation; thus comprehensive recording of ligature incidents is essential for recognising trends and risk factors, and in building a 'ligature tying profile'. A 'Ligature Assessment Tool' was developed to ensure that certain aspects of a ligature risk incident were recorded in a systematic way on the incident reporting system. The tool consists of 15 criteria and is in a semi-structured format. This was rolled out in a regional female medium secure unit. There was clear improvement in the quality of reports, with an increase in the detail included. For two patients, a 'ligature tying profile' was identified. Staff felt that the tool improved their documentation and was highly usable. Further work is ongoing; there is interest in use of the tool in general adult services and also in the national high secure service for women.

Pre-discharge factors associated with early readmission to psychiatric inpatient services within 90 days

AimsThe aim of this study was to identify pre-discharge risk factors associated with early inpatient readmission in general adult service users, with a particular focus on modifiable factors. We hypothesised that stability prior to discharge would reduce readmission to inpatient services within 90 days.BackgroundEarly readmission to inpatient psychiatric services is a poor outcome for service users, staff and the healthcare system. A variety of clinical, demographic and system factors, mostly non-modifiable, have been investigated previously. The identification of pre-discharge and particularly modifiable factors associated with readmission would give an opportunity for intervention and changes in policy.Method272 medical records of all admissions within an 8 month period to a NHS inner city psychiatric inpatient service were reviewed to identify factors associated with readmission within 90 days of discharge. The data were analysed by simple comparison, calculation of odds ratios and logistic regression.Result26% of service users were readmitted to the mental health trust within 90 days of discharge. Incidents (OR = 3.86; 95% CI 1.39–10.75) and psychotropic medication change in the week before discharge (OR = 2.94; 95% CI 1.43–6.03) were significantly associated with readmission, as were the number of previous admissions, and comorbid substance misuse. Successful overnight leave was found to be significantly protective against readmission (OR = 0.29; 95% CI 0.11–0.72).ConclusionThe ability to predict those at high risk for readmission means they can be targeted for interventions and it can also help develop best practice around inpatient care and the discharge process. The novel findings in this study of pre-discharge modifiable risk factors such as stability and successful overnight leave could have significant implications in discharge planning policy.

Suicide: can we identify and manage those at risk more effectively?

AimsThis study aimed to conduct longitudinal analysis of suicide reviews for mental health service users in Ayrshire to improve local practice and outcomes. Traditional risk factors – middle-age, male and alcohol misuse – were hypothesised to convey greater risk of completing suicide.BackgroundSuicide is an important public health issue in Scotland, with potentially devastating impacts. Practice and policy may lag behind emerging evidence. Mental health problems are associated with an increased suicide risk, and care provided to those who take their own lives is reviewed to identify recommendations and learning points to improve practice and outcomes. However, these reviews and their conclusions are often considered individually, when studying them collectively over time it is necessary to characterise common themes and highlight factors that could be addressed to reduce suicide. Moreover, national averages can obscure local patterns.MethodAccess to reviews of suicides for mental health service users in Ayrshire was granted by the Adverse Event Review Group. Relevant data were extracted for the 35 General Adult service users completing suicide between 2013 and 2015, including details of the act, demographics and clinical factors, and analysed for trends. Those with and without emotional instability as a primary diagnosis or significant problem were dichotomised to facilitate identification of statistically significant factors specific to these symptoms.ResultThere were 35 completed suicides including three inpatients. Suicide was most common in the 25-29 and 45-54 age ranges, and over 68.6% were male. Hanging accounted for 60.0% of deaths, and self-poisoning for 8.6%. Up to 62.9% of patients did not appear to have ongoing scheduled appointments on a regular basis. Diagnoses were difficult to identify – 48.6% had no clear primary diagnosis specified in the reviews, and features of depressive, anxiety, psychotic, substance misuse and personality disorders frequently overlapped and co-occurred. 22.9% had problems with emotional instability; their median age was 14 years younger, and 87.5% were female.ConclusionSmall sample size precluded detailed analysis. The traditional risk profile remains relevant. However, almost 25% of those completing suicide were younger females with emotional instability, despite frequent contact with services. Given the challenges in predicting suicide, we should continue to consider how best to prevent this tragic outcome in all service users, especially in younger females with emotional instability; middle-aged males who misuse alcohol, and those with ill-defined diffuse psychological difficulties who do not fit into discrete categories or are reviewed infrequently.

Understanding care when cure is not likely for young adults who face cancer: a realist analysis of data from patients, families and healthcare professionals

ObjectivesTo understand the experiences of young adults with cancer for whom cure is not likely, in particular what may be specific for people aged 16–40 years and how this might...

Civil and forensic patients in secure psychiatric settings: a comparison.

Aims and method To evaluate differences between male patients in secure psychiatric settings in the UK based on whether they are detained under civil or forensic sections of the Mental Health Act 1983. A cohort of patients discharged from a secure psychiatric hospital were evaluated for length of stay and frequency of risk-related incidents.Results Overall, 84 patients were included in the study: 52 in the forensic group and 32 in the civil group. Civil patients had more frequent incidents of aggression, sex offending, fire-setting and vulnerability, whereas forensic patients had more frequent episodes of self-harm.Clinical implications Secure hospitals should ensure treatment programmes are tailored to each patient's needs. Civil patients require greater emphasis on treatment of their mental illness, whereas forensic patients have additional offence-related treatment needs. Regular liaison between forensic and general adult services is essential to help ensure patients can return to appropriate settings at the earliest opportunity in their recovery.

Community psychiatric service in Hong Kong: Moving towards recovery‐oriented personalized care

AbstractMental health service in Hong Kong has traditionally been hospital‐based. Over the past three decades, community psychiatric service in Hong Kong had been developed into a highly efficient system characterized by high service throughput, with a primary focus on reacting to risk. In 2009, the Government committed substantial resources to increase the manpower and developed a recovery‐oriented multidisciplinary case management model with a primary focus on patients with severe mental illness. The implementation of individualized service plans allows the care delivery process to be more focused and person‐centered. Collaboration with community care partners has been enhanced to deliver holistic care and maintain a sustainable serviceFuture developments should address both service structure and service content. In service structure, community psychiatric service should be integrated into general adult service for facilitating continuity of care when patients move between inpatient and community settings. To meet the fluctuating needs of patients with severe mental illnesses that run a chronic and relapsing course, the service should have the flexibility to provide different levels of case management within one team. In service content, precise description of service, accompanied by robust quality‐assurance mechanism, are mandatory. A wider range of evidence‐based therapeutic modalities should be available. Empowerment and self‐determination should be realized as the key elements of recovery. Effort is also needed beyond the team level; combating stigma of mental illness in society is an essential component of community psychiatric service.

Barriers to care in the mental health service: who gets in - who gets out?

"People with mental health problems are particularly vulnerable to social exclusion" - Vision for Change. People with mental health problems are very vulnerable. However those with mental health problems who have additional social problems are even more vulnerable. Currently psychiatric services in Ireland are provided on a 'catchment area' basis, with a consultant psychiatrist leading a multi-disciplinary team providing a service to the population of a defined geographical area. These services comprise both outpatient and inpatient care, and there is significant regional variation in terms of both bed availability and multidisciplinary team staffing. Sub-specialities, with the exception of child psychiatry and psychiatry of old age, are often unavailable, particularly outside Dublin. In such cases, some additional duties (eg. liaison, rehabilitation, perinatal) are assumed by the local general adult services. However, the overall distribution of services is uneven. Instead of services being concentrated upon those areas of greatest need, the opposite is often the case, with the most deprived areas having the least services in terms of acute beds and community mental health teams per thousand people. These areas also have less psychological services and specialist services despite increased levels of mental illness. Within this vulnerable population there are a number of sub-groups who are even further marginalised, and for whom there are significant barriers both at point of contact with services and with accessing appropriate follow up services. These include the homeless, the ever-increasing cohort of migrants to this country, those in prison and children and adolescents. Stigma and discrimination are the greatest barriers to social inclusion, quality of life and recovery for people with mental illness.

Forensic psychiatry and general psychiatry: re-examining the relationship

Something is going wrong with forensic psychiatry, as a concept and as a service. Beds in medium secure units are logjammed, and relations with general adult services increasingly fraught with disputes over resources and responsibilities. Despite a remarkable investment in buildings, and the 300% growth of the forensic specialty (Goldberg, 2006), offending behaviour by individuals with mental illness shows no sign of decline, either in terms of prison numbers (at record high levels in the UK) or the countless demands for risk assessment (Duggan, 1997; Moon, 2000).

Comparison of outcomes following after-care from forensic and general adult psychiatric services

Forensic psychiatry services are expanding in England and Wales but require support from general services for patient after-care. To compare outcomes following community after-care from forensic or general adult psychiatry services. An observational comparison was made of case management following discharge from medium security in seven pre-reorganisation health regions of England and Wales, by forensic services (n=409) and general adult services (n=652). Criminal convictions, hospital readmissions and deaths were compared over a mean follow-up period of 6.2 years, adjusting for difference in case mix. Forensic services did not supervise more high-risk patients in the community. Neither service was superior in outcome. More patients managed by general services died from natural causes. Neither service was superior on measures of subsequent offending or hospitalisation. Specialist forensic after-care conveyed no added benefit. Case management may have been the same in both services.

Design in Psychiatric Intensive Care Units: problems and issues

Background: The physical environment of a Psychiatric Intensive Care Unit (PICU) or Low Secure Unit (LSU) is one of its defining aspects. The National Minimum Standards for General Adult Services in PICUs and Low Secure Environments published by the Department of Health (2002) outlines the standards to be followed regarding design of PICUs and LSUs. Till date, no comprehensive national data exists about the standard of physical environment of these units.Aim: To determine whether current physical environment of PICUs and LSUs are adequate to meet the therapeutic needs of patients in England.Method: An inventory was sent to all NHS PICUs and LSUs (in England).Results: A total of 231 units were identified as either PICUs or LSUs. Out of these, 164 valid returns were received. Sixty PICU units (62.5%) and 43 LSU units (63.5%) were good or acceptable. Thirty six PICU units (37.5%) and 25 LSU units (36.5%) failed on several issues. Analysis of the data showed that to bring the PICU/LSU Estate to a good standard is anticipated to cost approximately £140million.Conclusion: The Department of Health has allocated funding of £30 million to be distributed amongst all the 28 Strategic Health Authorities. A further funding of £130 million has also been released to address places of safety and for upgrading PICUs and LSUs to meet the National Minimum Standards.Declaration of Interest: The project was funded by the Department of Health.

Ward rounds – patients' views

We have similar concerns regarding patients’ views of ward rounds to White & Karim ( Psychiatric Bulletin , June 2005, 29 , 207–209). Our service is a low secure forensic unit, which provides long-term rehabilitation in the West Midlands, and in contrast to general adult services in-patients

Perinatal psychiatric disorders: a leading cause of maternal morbidity and mortality.

The Confidential Enquiry into Maternal Deaths 1997 to 1999 finds that psychiatric disorder, and suicide in particular, is the leading cause of maternal death. Suicide accounted for 28% of maternal deaths. Women also died from other complications of psychiatric disorder and a significant minority from substance misuse. Some of the findings of the Confidential Enquiry confirm long established knowledge about postpartum psychiatric disorder. The findings highlight the severity and early onset of serious postpartum mental illness and of the risk of recurrence following childbirth faced by women with a previous history of serious mental illness either following childbirth or at other times. These findings led to the recommendation that all women should be asked early in their pregnancy about a previous history of serious psychiatric disorder and that management plans should be in place with regard to the high risk of recurrence following delivery. Other findings of the Enquiry were new and challenged some of the accepted wisdoms of obstetrics and psychiatry. It is likely that the suicide rate following delivery is not significantly different to other times in women's lives and for the first 42 days following delivery may be elevated. This calls into question the so-called 'protective effect of maternity'. The overwhelming majority of the suicides died violently, contrasting with the usual finding that women are more likely to die from an overdose of medication. Compared to other causes of maternal death, the suicides were older and socially advantaged. The Enquiry findings suggest that the risk profile for women at risk of suicide following delivery may be different to that in women at other times and in men. None of the women who died had been admitted at any time to a Mother and Baby Unit and their psychiatric care had been undertaken by General Adult Services. None of the women who died had had a previous episode correctly identified and none had had adequate plans for their proactive care. The conclusion is that there is a need for both Psychiatry and Obstetrics to acknowledge the substantial risk that women with a previous psychiatric history of serious mental illness face following delivery.