Specialist Outpatient Services Research Articles

Other causes of dementia

This contribution considers causes of dementia not discussed elsewhere in the chapter. Within this broad grouping are disorders that would be categorized as the potentially ‘treatable’ dementias as well as other neurodegenerative conditions. Meta-analyses of studies describing populations referred to specialist out-patient services give prevalence rates of potentially reversible dementia of 13–15%, though community studies are likely to yield lower rates. Many ‘reversible’ dementias may be better described as sub-acute confusional states (with a shorter and fluctuating history), focal brain syndromes or mild cognitive disturbance; this is particularly the case for drug-induced states as well as space-occupying lesions, metabolic and endocrine disorders, normal-pressure hydrocephalus (NPH) and the cognitive impairment associated with depression. The important treatable dementias, in particular NPH, hypothyroidism, hyperparathyroidism, alcohol dementia, and B12 and folate deficiency are considered in detail. Depression is not discussed as this is essentially a mimic rather than a dementia. Other important causes of dementia are the extrapyramidal diseases that are frequently associated with cognitive disorders, namely Parkinson's disease, multiple system atrophy, progressive supranuclear palsy (PSP), corticobasal degeneration and Huntington's disease. The symptoms of subcortical dementia – with slowing of cognition, forgetfulness (but an ability to respond to cues), executive dysfunction and decreased verbal fluency – are common to a number of these conditions, namely PSP, Huntington's disease, NPH and some cases of Parkinson's.

A multi-perspective evaluation of a specialist outpatient service for people with personality disorders

This paper reports on a study of a new outpatient service for people with personality disorders (Henderson Outreach Service Team: HOST) during its first 2 years of operation. The study is presented as an example of how service-specific evaluation can be organized using a multiple perspective approach. Four simultaneous strands of investigation were conducted: clinical and socio-demographic characteristics of referrals; clinical activities of the service; service users' views of the service; and views of referring professionals. Findings indicate that HOST referrals had high levels of psychosocial disturbance associated with moderate to severe personality disorders. The service provided psychodynamically oriented individual and group treatments that met service users' needs more appropriately than other local mental health services, but was unable to match the demand for treatment. Referring professionals valued the role of HOST in also providing specialist management advice. High levels of unmet need among the personality disordered population living in the community are highlighted. Findings have contributed to the reshaping of the service and its relationship to its parent institution (a residential therapeutic community), and have implications for the future development of therapeutic community treatment for personality disorders. The role of effectiveness studies in contributing to the mental health evidence base is discussed.

A memory clinic in a department of old-age psychiatry: Its role in clinical and academic research

Memory clinics are specialist outpatient services offering assessment and evaluation in clinical practice. Memory clinics have been criticized for being preoccupied with research. We analysed the outcomes of 405 referrals to a memory clinic, providing a framework for discussion of the contributions of research to clinical practice. Of the 80% of referrals receiving a formal diagnosis, one-third were recruited on to treatment studies, contributing to clinical research. The remaining two-thirds of patients referred were followed up by specialized care services, and findings from assessment procedures were used to contribute towards academic research. These findings are discussed with reference to the role of research for a memory clinic in clinical practice. The benefits of clinical research are noted, in relation to the percentage of patients involved. The nature of academic research is clarified; it is a dual process, with findings both aiding clinical research and contributing to the body of knowledge about dementia as a possible disease process. It is concluded that memory clinics, as specialized outpatient services, are concerned with research as well as clinical practice, and it is essentially this research which enables clinical practice to develop.

English language ability and mental health service utilisation: a census.

To explore the relationship between English language proficiency and mental health service utilisation. In September 1993, a sample census was conducted of all mental health services in the State of Victoria, including public and private hospital wards, outpatient consultations provided by psychiatrists and clinical psychologists, and primary mental health care provided by general practitioners. Response rates ranged from 37% for monolingual general practitioners (GPs) to 96% for inpatient units. Particular emphasis was placed on patients' English language proficiency and the role played by bilingual clinicians. Over 80% of inpatients received a diagnosis of either dementia or psychosis. This proportion was even greater in the case of patients with English language difficulties. The latter group of patients underutilised specialist outpatient services, and those using these services were less likely to receive psychotherapy than fluent English speakers. They utilised GPs for mental disorder at at least the same rate as other patients. There was a marked preference for bilingual GPs, with 80% of patients with poor English language skills consulting GPs who spoke their native language. There appears to be considerable underutilisation of specialist mental health services by patients who are not fluent in English. The liaison-consultation model of psychiatric care may be an effective way of addressing this problem, given the important role already played by billingual GPs in the psychiatric care of those whose native language is not English.

The incidence and prevalence of anorexia nervosa in three suburban health districts in South West London, U.K.

To determine incidence and prevalence of anorexia nervosa in a defined geographical area of south west London, UK, total population 519,900. Hospital and community health workers in the defined area were contacted initially by letter asking them to identify all cases (new or existing) of anorexia nervosa known to them in the period July 1991-June 1992, using DSM-III-R criteria. A semistructured interview was conducted with the respondents to confirm the diagnosis. The large database record of the senior authors' specialist anorexia nervosa service, including inpatient and outpatient service records, was concurrently screened for cases living in the defined area. The prevalence of anorexia nervosa was found by this method to be 20.2 cases per 100,000 population (0.02% total population). Prevalence in females aged 15-29 years was 115.4 cases per 100,000 (0.1% of young females). Similarly, the annual incidence of anorexia nervosa was found to be 2.7 cases per 100,000 total population. In females aged 15-29 years the incidence was 19.2 cases per 100,000. Such prevalence and incidence figures are probably significant underestimates since the disorder can often defy detection or correct diagnosis and, with our own methodology, some identified cases may not have been reported to the study. However, these results can be used as a start for resource planning and service development.

Eating disorders and shoplifting--a study in two settings.

Two groups of female shoplifters drawn from a specialist out-patient service (52) and a Magistrates' Court (50) are compared for their level of eating disorder. Only one person knew of a previous diagnosis of eating disorder. Their levels of eating disorder and general psychopathology are high in both settings but particularly those referred for psychiatric assessment. Those with an eating disorder had significantly higher levels of psychiatric disturbance, depressive illness and hoarding behaviour.