Local Mental Health Teams Research Articles

Audit on clozapine dose and plasma level correlation for patients with chronic treatment-resistant psychosis

AimsClozapine is associated with a risk of severe adverse events for which there are current monitoring systems are in place; however, there are no established regimens for monitoring of clozapine plasma levels. Recent Medicines and Healthcare products Regulatory Agency (MHRA) guidance advises clozapine levels should be monitored in certain clinical situations where toxicity may be suspected. This audit aimed to evaluate current practice of clozapine level monitoring within one Local Mental Health Team (LMHT).MethodElectronic (RiO) records of 41 patients (33 male, 8 female; aged from 27 to 76 years; mean age 45 years) registered to the ZTAS system within the Nottingham City Central LMHT were reviewed. 46% had been on clozapine for over 16 years. 73.3% of patients were within clusters 12 and 13; 25.4% of patients were in cluster 11, with one patient in cluster 8. Dates of clozapine plasma level tests for each patient between 2006 and 2020 were found on the electronic NoTIS system, along with clozapine, norclozapine and total clozapine levels. Concurrent clozapine dose and regimens were obtained from pharmacy records from 2018 onwards.Result273 clozapine plasma levels were conducted between 2006 and 2020. The average interval between levels taken was 10 months, 2 weeks but had a wide range, the shortest interval being 2 days, the longest being 13 years. 88 levels taken were >600 ug/L, suggesting increased toxicity risk. 108 levels were <350 ug/L, suggesting possible sub-optimal dosing or non-compliance. Statistical tests on correlation coefficient, although statistically non-significant (R = 0.37), showed a positive trend between total clozapine dose and the plasma level between all 3 parameters (i.e. clozapine, norclozapine and total clozapine).ConclusionThere does not appear to be any routine plasma clozapine level monitoring throughout the LMHT with an average interval between tests of 10 months. There was a non-significant but positive trend between total daily dose of clozapine and clozapine level. 32% of clozapine levels returned were higher than the recommended level. We would recommend as suggested in the guidelines from MHRA, clozapine plasma levels should be monitored in certain clinical situations with increased toxicity risk. Trough levels should be taken with records of time of previous dose taken. Limitations of this study included a small sample size (41 patients) with data collection reliant on electronic systems. It was unclear if these results represent trough levels, making values difficult to interpret. Multifactorial impact on clozapine metabolism causes wide patient variability in plasma levels.

Sodium valproate prescribing safety in women of childbearing potential

AimsThe purpose of this audit was to identify all women being prescribed Sodium Valproate under the Bassetlaw Local Mental Health Team (LMHT) caseload to see how well latest prescribing guidelines are being met, and help set up a system allowing efficient monitoring of Sodium Valproate prescribing in the future.BackgroundDespite early concerns regarding potential teratogenicity, Sodium Valproate became a widely used anticonvulsant and mood stabiliser and is licensed for use in Epilepsy, Migraine prophylaxis and Bipolar affective disorder. Research evidence now shows its use in pregnancy increases risk of neurodevelopmental disorders to 40%, and serious birth defects to 10%. Despite research finding these risks prescribing practice did not significantly change. To better reflect these findings in clinical practice in 2018 the Pharmacovigilance Risk Assessment Committee recommended Sodium Valproate should not be used in pregnancy unless they have a form of epilepsy unresponsive to other anti-epileptic drugs, and all with childbearing potential should be enrolled in a pregnancy prevention programme (PPP). This was endorsed by UK Medicines and Healthcare Devices Regulatory Agency in April 2018 with launch of the PPP.Standards:Must be offered counselling about risks of valproate to unborn child and importance of effective contraception.Annual specialist Review by a specialist now mandatoryRisk acknowledgement form must be updated at least annually.MethodThe electronic RiO records for all female patients on the Bassetlaw LMHT caseload in the year 2019 were checked to identify those prescribed Valproate. For those prescribed Valproate, evidence of annual risk acknowledgement form, date of last appointment, underlying diagnosis and contraceptive method was checked. This data was stored together on an excel file and used to create a patient list to help allow future monitoring.ResultFrom 594 female patients identified, 27 (4.5%) were prescribed Sodium Valproate. Of these, 14 (52%) had PPP documentation uploaded, 24 (89%) had been reviewed within the last 12 months, and 13 (48%) had no documentation of contraceptive method.ConclusionThis audit helped highlight there is likely a large population of patients not yet on the Pregnancy Prevention Programme. Creating a monitoring system in excel for female patients being prescribed Valproate can help improve adherence to latest guidelines, with a colour coding system to highlight those needing risk acknowledgement forms/appointments within the next three or six months. Educating patients and other healthcare professionals about risks will also help improve prescribing practice and avoid use in pregnancy.

The 11th Australian Rural and Remote Mental Health Symposium Communiqué.

The 11th Australian Rural and Remote Mental Health Symposium Communiqué.

Perceptions about mental illness among general practitioners

BackgroundGeneral practitioners (GPs) play an important role in the physical care of patients with severe mental illness, so our aim was to analyse the relationships between GPs’ sociodemographic status and worked-related variables and their perceptions about mental illness.MethodsA descriptive, cross-sectional study was conducted in the Clinical Management Unit of Mental Health (CMU-MH) of the Regional Hospital of Malaga (Spain). The eligible population comprised all GPs working in the 13 primary care centres (PCCs) in the hospital’s catchment area during the study period. GPs were interviewed to collect data on their attitudes to and knowledge of mental illness, psychiatry and the local mental health team, as well as their sociodemographic status, professional qualifications and experience. Bivariate analysis was carried out.Results145 GPs answered the questionnaire (77%). ANOVA revealed that most of the PCCs with the best relationship with their mental health team and best attitude to mental illness were in the Central Community Mental Health Unit, which operated a collaborative model of care.ConclusionsThese results indicated that GPs who worked more closely with their specialist mental health team had a better perception of their relationship with the mental health centre and less stigmatisation in regard to mental illness.

'When you're it': a qualitative study exploring the rural nurse experience of managing acute mental health presentations.

A higher proportion of chronic mental illness is reported for populations residing in inner and outer regional (IOR) areas when compared to major cities in Australia. Conversely, fewer mental health professionals work in IOR areas when compared to major cities indicating poorer access to services for rural populations. Rural emergency departments (EDs) and urgent care centres (UCCs) deliver a broad range of services. Often they are the first point of care for consumers experiencing acute mental health issues. Rural nurses working in EDs and UCCs require a diverse clinical skill set to manage complex presentations, often with limited support and resources. Developments in telehealth services have reportedly improved access for rural consumers. It is known that nurses report a lack of skills and confidence when managing mental health presentations. Despite these challenges, there is little documented regarding the experience of generalist nurses managing acute mental health presentations in rural hospitals that have limited support of community mental health teams and no onsite inpatient mental health facilities. A qualitative study was conducted to explore the experience of rural nurses in managing acute mental health presentations within an emergency context. An interview guide developed from the literature was used to explore issues of experience, safety, knowledge and clinical confidence. Thirteen rural generalist nurses from one rural emergency department and two rural UCCs located in south-west Victoria participated in a semi-structured interview. Interviews were audio-recorded and transcribed verbatim. Transcriptions were thematically analysed by applying an inductive descriptive approach. The majority of participants were experienced generalist registered nurses with no formal qualifications in mental health. Two participants had some clinical experience in mental health and drug and alcohol. Themes elicited from data analysis and discussion between the researchers were (1) 'we are the frontline', (2) 'doing our best to provide care', (3) 'complexities of navigating the system', and (4) 'thinking about change'. Findings indicated that rural generalist nurses deliver the majority of care to mental health consumers in EDs and UCCs. Local mental health clinicians and emergency service providers offer limited support, with a reliance on telephone triage for after-hours assessment. Multiple challenges were cited including coordinating the transfer of consumers to inpatient facilities and feeling inadequately supported. Irrespective of these challenges, nurses reported delivering the best possible care to consumers despite reporting a lack of knowledge and skills. Recommendations for improving the delivery of care included increasing access to emergency mental health training and receiving more support from local mental health teams. The need for more rural mental health facilities was also discussed. The findings from this study suggest generalist nurses are the frontline providers of care for mental health consumers in rural EDs and UCCs. Nurses feel ill-equipped for assessing and managing mental health presentations, relying heavily on local mental health teams and telephone triage who provide limited onsite support. The need to support nurses through training and mentoring relationships with community mental health teams is highlighted by this study in conjunction with improving the delivery of mental health services in rural areas.

Culture and PTSD: Trauma in Global and Historical Perspectiveedited by Devon E. Hinton and Byron J. Good. Philadelphia, University of Pennsylvania Press, 2015, 440 pp., $75.00 (hardcover).

Culture and PTSD: Trauma in Global and Historical Perspectiveedited by Devon E. Hinton and Byron J. Good. Philadelphia, University of Pennsylvania Press, 2015, 440 pp., $75.00 (hardcover).

Association between Reactive Attachment Disorder/Disinhibited Social Engagement Disorder and Emerging Personality Disorder: A Feasibility Study.

A systematic review of reactive attachment disorder (RAD)/disinhibited social engagement disorder (DSED) in adolescence highlighted that young people with the disorder had indiscriminate friendliness with difficulties in establishing and maintaining stable relationships. Most reported experiences of rejection. We were struck by similarities between the above and features of emergence of personality disorders (EPD). This feasibility study aimed to determine best ways of recruiting and retaining vulnerable young people and the proportion of participants with RAD/DSED who might have emerging borderline personality disorder (EBPD). Participants were referred to the study by their treating clinicians from local mental health teams. Results showed strong association between RAD/DSED and EBPD. Participant characteristics showed high levels of out of home placements, early termination of school careers, suicide attempts, quasipsychotic symptoms, and multiagency involvements. They experienced the project as an opportunity to talk about relationships and reported that they would like more of this in usual clinical contacts. They all agreed to be contacted for future studies. Previous studies have shown that early detection and treatment of emergent personality traits can alter trajectory. Future research will continue to explore these trajectories, explore detection of vulnerability factors, and evaluate interventions.

Psychiatric assessment and treatment of survivors of torture

SummaryTorture remains an ongoing global problem. Many individuals who have migrated from areas of conflict and political instability have suffered some form of torture. Survivors of torture can present significant challenges to general practitioners, voluntary bodies and mental health services. This article describes the many physical, psychological and social effects of torture. An understanding of these will hopefully aid comprehensive assessment of survivors of torture by local mental health teams. Also described are the current treatment options and their evidence base.

Employment services as an early intervention for young people with mental illness

To examine the service characteristics and effectiveness of a segregated employment service assisting young clients with mental illness in New Zealand. The service assisted both youth and adults with severe mental illness to find and keep competitive employment. A retrospective case study method was used to examine service effectiveness with respect to employment outcomes attained by 49 clients aged 16–25 years over a 2-year period (2005–2007). These results were compared with recent national and international benchmarks. As a service segregated from public mental health services, there were no formal arrangements with local mental health teams, limiting coordination of services and reducing fidelity to evidence-based practices in supported employment. Despite an inability to collaborate closely with local community mental health services and a contract not specifically targeting youth, the service was high performing on a range of employment outcome variables. Subject to some study design and benchmarking limitations, these results support the continuing use of evidence-based practices in supported employment and supported education as important early interventions for young people with mental illnesses.

Implication of rates of referral to a specialised inpatient neuropsychiatry team.

This study examined and compared the number and pattern of referrals from neurosurgery and neurology specialist services to the inpatient liaison neuropsychiatry service in the years 2002 and 2005. We estimated the prevalence of psychiatric illness and evaluated the results of subsequent psychiatric assessment and follow-up of all patients reviewed by the neuropsychiatry service. The medical notes of those patients referred to the neuropsychiatry team were retrospectively examined to obtain appropriate information on assessment and management of these cases. There were 544 referrals over the two years selected for study. Rates of referral to the inpatient neuropsychiatry service increased overall by 35% between 2002 and 2005. Overall, referrals from neurology comprised 85%, neurosurgery 15%. Patients with epilepsy comprised the majority of referrals (36%). A total of 378 (73%) had an acute psychiatric disorder and this group had a significantly higher rate (p = 0.01) of past psychiatric disorder (40%) than that in those with no acute mental illness (33%). Depressive episode was the most frequent acute psychiatric diagnosis (38%), followed by anxiety and organic psychiatric disorder (both 15%). Overall, 21% of patients diagnosed with acute mental illness were referred on discharge to the neuropsychiatry outpatient clinic for specialist follow up and the remainder followed-up by either local mental health teams or their GP. These findings provide clear evidence that further resources should be allocated to expanding neuropsychiatry mental health services to improve detection and management of mental illness in this vulnerable patient group.

The Wokingham & West Berkshire Mind Crisis House

erceived at one level, the Wokingham Mind crisis house is the simplest of projects – both in conception and in reality. Wokingham & West Berkshire Mind was formed in July 1988 by a group of mental health service users and informal carers who were only too well aware of the local paucity of mental health services. The idea was to fill this gap with things that service users and carers actually needed. Identified as priorities were a drop-in centre, a befriending scheme and crisis beds. The service users had been on the receiving end of psychiatric oppression and the informal carers had had their needs ignored by mental health professionals. We therefore decided from the beginning that professionals would be banned. Thus we ensured that we were and always would be a user-run organisation. We sought affiliation to MIND because their stated aims and values were the same as ours and because we valued membership of the national mental health movement. Our first year’s existence was devoted entirely to the political and the philosophical. We worked out what we were and what we were not before we put any services in place and a lot of our subsequent success is due to the clarity of vision established in those early days. A year later in June 1989 we established a weekly drop-in centre in the heart of the Wokingham community. We soon had a regular attendance of 30 mental health service users and carers from whom a successful befriending scheme was derived. The hall cost £5 per morning. We passed the plate round to raise this and also started our own modest fundraising events. We heard through rumours on the grapevine that a house, Station House in Wokingham, was going to be made available to us. This house had been the headquarters of the local mental health team, which was moving to Wokingham Hospital. However, no meeting was arranged with us to discuss on what basis we were to take possession of the house. First, the P proposed date for moving was Christmas 1989. We were, of course, not ready, but we needn’t have worried. The grinding of bureaucracy was predictably slow, and we eventually got the keys to Station House at Easter 1991. I have no doubt that social services had an agenda for our development once we moved into Station House, but it was never discussed with us. At our own monthly committee meetings we had already decided to set up Station House as a crisis house as soon as we moved in. We were ready now, having established a flourishing drop-in and befriending scheme from whom crisis volunteers could be drawn. The only discussion about our occupation of Station House took place with the property department of the now defunct Berkshire County Council. They prepared a rent-free lease on two conditions. First, that we should allow a small group of service users who had attended social services groups to continue coming to our dropin and, second, that we should allow the Wokingham Volunteer Centre to continue using the premises until they found an alternative venue. Moving into Station House on Tuesday 2 April 1991, we cleaned, decorated and furnished it and immediately opened our first, and at that time, only, crisis sanctuary. A further crisis sanctuary was set up when the Volunteer Centre moved out in April 1993, a third in October 2000, and a fourth (short-term crisis bed) in April 2003. It is a service that has evolved gradually with us acquiring crisis skills and gaining confidence as we go along. The concept is simple: ‘home-spun, as mother made it’. You have a little old house in the heart of the community opposite Wokingham railway station. It is within minutes’ walk of all essential services – doctors’ surgeries, hospital, chemists, shops, job centre, housing department, and statutory mental health services. Inside, the furnishings (provided free of charge by the local community) are cosy and homelike. The house consists of four bedrooms with en-suites, two kitchens (one for the drop-in centre and