Modern Mental Health Services Research Articles

Running an effective community mental health team

Community psychiatric teams are an integral part of modern mental health services. The development of such teams has allowed the care of patients to be transferred from institutions to the community. A Cochrane review of community-based programmes showed that community team-based psychiatric services led to a reduction in suicide rates, improved patient engagement and were more acceptable to patients (Tyreret al, 1999). Community care also reduces the number of days patients stay in hospital, but not the number of admissions (Marshallet al, 1995). However, community mental health teams (CMHTs) have been criticised for their ambiguous and overambitious aims, and their tendency to neglect people with the most challenging health- and social-care needs (Patmore & Weaver, 1991; Sayceet al, 1991). All mental health workers are not necessarily eager, or skilled, to work effectively in teams. Building and maintaining an effective team requires commitment, clarity of purpose, a shared vision and frequent review of team operations. In a previous issue ofAPT, Burns & Guest (1999) described the adaptation and running of an assertive community treatment team in an inner-city area. Here I examine the attributes of effective CMHTs (Box 1), enumerate barriers and challenges to team-working (Box 2) and suggest strategies for improving team effectiveness (Box 3).

What future for research in mental health nursing.

This paper argues that mental health nursing research is in a poor condition. We believe that it has marginalized itself, and has effectively split itself off from developments such as evidence-based practice (Cochrane Collaboration). We will examine some of the reasons behind the current position. We will argue that there is a history of research largely conducted on nurses and the nature of nursing. Much of this work uses methods that are completely unacceptable to any conventional research discipline. Many published ‘research’ studies amount to no more than anecdotal accounts of nurses and patients’ experiences. Modern mental health services have complex problems that demand skilfully designed studies, executed with rigour and utilizing batteries of valid and reliable outcome measures. However, we firmly believe that several remedial actions could transform the current situation. The first problem is that there is little more than a vestige of an infrastructure of mental health nursing researchers with adequate training. There are probably only a few dozen with doctoral qualifications and fewer still have any substantial research training or experience. When one scrutinizes PhD theses written by psychiatric nurses, many are based on qualitative and uncontrolled studies. To compound the problem there appears to be a considerable variation in pass standards for PhDs between universities, and some theses contain fundamental flaws of design, analysis and write up. Other professions consider a well-controlled study for a PhD as a starting point in research training. For example, many psychologists and psychiatrists have received research training at a post-doctoral level and have managed large grant-funded projects before taking senior academic positions. Sadly, there are professors of nursing (including those from a mental health background) who have no substantial portfolio of decent peer-reviewed publications, let alone the experience of managing grants for large experimentally based projects. A priority is to establish an infrastructure of properly trained researchers. On a positive note opportunities for research training do exist. For example, the Medical Research Council and the NHS R and D Directorate have specifically recognized the need to train nurses for research. Other similar funds exist and are available to train for both doctoral and post-doctoral levels. However, the application rates from suitably qualified persons of a nursing background are low. The second problem concerns the way in which (we) mental health nurses organize ourselves as research teams. Many mental health nurses seem to eschew the idea of working with a multidisciplinary team of researchers, although there is a rhetoric of multidisciplinarity and teamwork. Mental health topics demand input from various perspectives. It is essential to group together not only psychiatrists, psychologists and nurses, but also pharmacists, statisticians and health economists. Statisticians are often overlooked when research grant applications are made, and, now that concepts such as statistical power need to be addressed in detail before a grant application is seriously considered, any team that omits the input of expert statistical advice does so at its peril. Health economists are also invaluable members of the research team as most health services research now has an economic dimension. This domain cannot be overlooked and a proposal for an economic analysis is now essential if a large research grant application is to succeed. The Research Assessment Exercise exposed the poor quality of nursing research, while at the same time showing that multidisciplinary teams reap rich rewards. For example, the Institute of Psychiatry gained a five-star (the very highest) rating by grouping all disciplines, including nursing, within nine specific research interest groups. Similarly the last Department of Health Research funding round (the Mental Health Initiative) awarded all of the major

The hall of dragon metamorphoses: A unique, indigenous asylum for chronic mental patients in Taiwan

This paper describes the spontaneous rise of an indigenous asylum for the chronic mentally ill, called Lung Hwa Tang (The Hall of Dragon Metamorphoses), in contemporary Taiwan. Sociocultural factors relevant to the asylum, including the roles played by Chinese families and the current situation of mental health care in Taiwanese communities, are discussed. Despite its detrimental effect on patients, this asylum stands for an alternative mental health care system in the folk sector; it reflects a great demand from the communities for access to modern mental health services, the development of which have been very slow and inadequate in the past four decades in this rapidly developing country.

Automation in Clinical Systems and Quality Assurance

Earlier papers in this journal issue have addressed the uses of automation in mental health from the perspective of administration and specific examples of automation as applied to the psychiatric record. By and large, administrative applications have become increasingly a part of the delivery of modern mental health services. Specific computerized systems for such diverse tasks as patient billing, admission/discharge and census counts, and personnel administration are considered essential for the efficient operation of all but the smallest mental hospital or community mental health center. Thus, the administrative uses of automation have reached a stage which the principal question to be addressed is not whether to automate but how and at what cost. In contrast, experience in the development and utilization of automation for clinical purposes has been much less clearly positive. Although a wide range of clinical applications has been developed, successful implementations of these applications, especially in facilities not directly under the control of the developer, have been relatively rare, which suggests the need for caution in the selection of systems for clinical use. This paper will briefly review some of the major clinical areas in which automated systems have been developed and will suggest strategies for assessing the potential utility and appropriateness of clinical applications in a specific

The Future of the Mental Hospital

The mental hospitals of the past were overcrowded, prison-like buildings, where patients were forcibly detained in an unreal, artificial world with little hope of cure. The emphasis has now shifted to rapid cure and rehabilitation, with the majority of patients being treated outside the hospital. The psychiatric hospital of the future may be pictured as the headquarters and the training and research centre of the local mental health organization, with only a small residential unit for special treatment and investigation. In an article shortly to be published in the WHO Bulletin, Dr. Geoffrey Tooth, Medical Officer of the Ministry of Health (England and Wales) and WHO Consultant, suggests how these concepts might be applied when designing and building up a modern mental health service under various conditions. His principal arguments and conclusions are summarized below.