Patients In Psychiatric Settings Research Articles

Literature as a Pedagogical Tool in Medical Education: The Silent Patient Case

The arts have seen increasing use in medical education over the last 4 decades. Literature in particular is now frequently used as an educational tool in different medical humanities programmes. This paper analyses Alex Michaelides’ novel The Silent Patient with the goal of examining the professional issues presented in this psychological thriller and how the novel’s themes can be used to prompt discussion among medical students about professionalism and ethics in psychiatric settings. Following Strauss and Corbin’s qualitative procedure for conventional content analysis, this study employs content analysis of the literary text. The process of analysis began with open coding in which codes were assigned to all relevant sentences and paragraphs addressing professionalism in working with silent patients in psychiatry. These codes were then analysed to identify five major themes: multidisciplinary teamwork; therapy for the therapist; patient-centred care for silent patients; communication with silent patients; professional challenges in working with silent patients. The paper concludes that The Silent Patient novel represents important issues related to ethics and professionalism in working with silent patients in psychiatric settings. The novel can be used as a creative tool to guide discussion surrounding these issues. The paper argues that although the impact of its use is short-term, literature can make a significant contribution by provoking thought and discussion about professional and ethical aspects of practising medicine and caring for patients.

Involuntary psychiatric hospitalization of children and adolescents in Northern Greece: Retrospective epidemiological study and related ethical issues.

The aim of the present study was to investigate epidemiological data on involuntary hospitalization of underage patients in psychiatric settings and illustrate the related ethical issues. The medical records of 131 involuntary psychiatric admissions of children and adolescents ordered by public prosecutor between 2005 and 2014 were examined carefully. The examined variables involved the place of origin, the place of residence of minors after discharge, the length of stay in hospitals, the discharge diagnosis, the rate at which the minors were introduced to police and other authorities before their hospitalization, and the results of the neuropsychological assessment (WISC II). Data were analyzed by SPSS (Statistical Package for the Social Sciences). The mean age of the minors was 14.19 years (Male: Female ratio; 1.6:1). First, a high rate of incidences of compulsory admissions was found [5-year period (2005-2009):(2010-2014) ratio; 1:1.85] most likely due to organizational factors, which, however, could have been avoided in a more patient-oriented healthcare system. It is most likely that the criteria used for making decisions in favor of compulsory admissions were disproportionately (unduly) broad. In parallel, it was observed that, during 2010-2014, despite the increase in the rate of the prosecutor's orders, there was a decrease in the duration of coercive hospitalization of minors in psychiatric departments of hospitals in comparison to the period 2005-2009 [5-year period duration of hospitalization (2005-2009):(2010-2014) ratio; 2.33:1]. Furthermore, family was found likely to wield considerable influence on the decision-making for compulsory admissions. In addition, the effectiveness of a compulsory hospitalization of minors in a child and adolescent psychiatry department was found largely dependent on the type of the underlying mental health problem. In that respect, low rates of recidivism (7.6%) indicated that the measure of involuntary hospitalization was necessary and effective. It was also observed that the short-term removal of the minor from the family environment was a potentially relieving strategy for both the child and the family apart from the need for therapeutic intervention. The paper concludes by highlighting the role of a multi-stakeholder decision-making process (which entails shared decision-making as an integral component of providing mental healthcare to minors) in facilitating a decision about involuntary psychiatric hospitalization that is proportional and respectful to patient autonomy.

Patients' Reports of Traumatic Experience and Posttraumatic Stress in Psychiatric Settings.

To determine the prevalence of traumatic experience (TE) among patients in psychiatric settings in Hong Kong and the associations between TE and levels of distress and anxiety and depressive symptoms. 129 patients who have received inpatient psychiatric services were recruited. Their lifetime TE was assessed using the Life Event Checklist (LEC), and TE in psychiatric settings using the Psychiatric Experiences Questionnaire (PEQ). Their level of distress symptoms was assessed using the Impact of Event Scale-Revised (IES-R), and the level of anxiety and depressive symptoms using the Hospital Anxiety and Depression Scale (HADS). The prevalence of direct and indirect TE was 84.5%, as was the prevalence of TE in psychiatric settings. Common TE in psychiatric settings included witnessing another patient being taken down (61.2%), being put in restraints of any kind (41.1%), and witnessing another patient being physically assaulted by another patient (36.4%). TE in psychiatric settings associated with high prevalence of severe or extreme distress 1 week after the event included being forced to take medication against their will (52.2%), being threatened with physical violence (52.2%), and experiencing a physical assault (50.0%). Lifetime TE (the total number of LEC items reported) was associated with severity of distress and anxiety and depressive symptoms, whereas TE in psychiatric settings (the total number of PEQ items reported) was associated with severity of distress only. The total number of LEC items reported is the only predictor of levels of distress and anxiety and depressive symptoms. Lifetime TE and TE in psychiatric settings are common among patients with SMI. Trauma-informed care is suggested for mental health services.

Psychometric Properties of the Revised Clinical Institute Withdrawal Alcohol Assessment and the Brief Alcohol Withdrawal Scale in a Psychiatric Population.

Psychiatric illness complicates the assessment of alcohol and sedative withdrawal (ASW). This study measured the diagnostic characteristics of the Revised Clinical Institute Withdrawal Alcohol Assessment (CIWA-Ar) and the Brief Alcohol Withdrawal Scale (BAWS) compared with a reference standard in patients with psychiatric illness and evaluated their administration time. This prospective quality improvement (QI) project conducted in November, 2016 evaluated 35 consecutive unique patients in psychiatric settings. Each patient was evaluated on 1 occasion, sequentially by 2 independent examiners with the CIWA-Ar and BAWS. A Diagnostic Statistical Manual of Mental Disorders, Fifth Edition diagnosis of ASW derived after medical record review by 2 psychiatrists blind to the screening results served as a reference standard. Psychometric properties of the CIWA-Ar and BAWS were measured against the reference. Nineteen (54%) patients had ASW diagnosis by the reference standard. The sensitivity (95% confidence interval [CI]) of the CIWA-Ar was 47% (25%-71%) at a cut-off score ≥8; sensitivity of the BAWS was 79% (54%-94%) at a cut-off score ≥3. Specificity (95% CI) for CIWA-Ar and BAWS was 88% (62%-98%) and 88% (62%-98%), respectively. Administration times (interquartile range) for the CIWA-Ar and BAWS were 120 (60-180) and 65 (50-75) seconds, respectively. Receiver operator characteristic area under the curve for CIWA-Ar was 0.77 and for BAWS was 0.76 (P = 0.86). Both instruments performed similarly in assessing for mild to moderate ASW in a sample of patients with psychiatric illness. The BAWS took 65 seconds to administer-almost half as much time as the CIWA-Ar.

Low Serum Testosterone in Outpatient Psychiatry Clinics: Addressing Challenges to the Screening and Treatment of Hypogonadism.

The symptoms of low testosterone frequently overlap with psychiatric complaints including depression and fatigue. Testosterone repletion has been shown to improve mood symptoms in men with low testosterone, although this finding has not been consistent across all studies. Despite the potential importance of low testosterone for psychiatry, the prevalence of low testosterone in men who present to psychiatric clinics with mental health complaints is unknown. To provide an overview of the current state of knowledge of the psychiatric complications of male hypogonadism, the challenges of screening for hypogonadism in a psychiatric population, and the potential mental health treatment implications of hypogonadism. A literature review was conducted using PubMed. Publications pertaining to the epidemiology, psychiatric symptomatology, and impact of treatment of male hypogonadism on psychiatric outcomes. A review of the literature suggests a lack of information on the prevalence of low testosterone in patients presenting with psychiatric complaints despite an overlap in clinical symptoms. The identification of low testosterone could have a significant impact on treatment through urologic referral for testosterone repletion or the use of treatments that spare the gonadal axis. We hope our results will help those who care for patients in psychiatric settings to better assess for the presence of hypogonadism and its potential contribution to depressive illness. Smith JB, Rosen J, Colbert A. Low Serum Testosterone in Outpatient Psychiatry Clinics: Addressing Challenges to the Screening and Treatment of Hypogonadism. Sex Med Rev 2018;6:69-76.

Organizational Justice and Collaboration Among Nurses as Correlates of Violent Assaults by Patients in Psychiatric Care.

This study tested the hypothesis that poor organizational justice and collaboration among nurses are associated with increased stress among nurses, which, in turn, increases the likelihood of violent assaults by patients. A cross-sectional survey was conducted of nurses in 90 psychiatric inpatient wards in five hospital districts and one regional hospital in Finland. A total of 758 nurses (registered nurses or enrolled/mental health nurses) responded to the survey. Self-administered postal questionnaires were used to assess organizational justice, collaboration, nurses' stress, and violent assaults by patients. Structural equation modeling (SEM) was used in model testing. SEM did not support a role for stress in mediating between organizational justice, collaboration between nurses, and violent assaults by patients, given that stress levels were not dependent to a significant degree on organizational justice, nor were patients' assaults dependent on stress levels. However, low organizational justice and poor collaboration between nurses were associated with increased reports of violent assaults by patients in psychiatric inpatient settings (p<.05 for both). The model explained 5.7% of violent assaults at nearly significant levels (p=.052). These findings suggest that organizational justice, collaboration between staff members, and violent assaults by patients are linked in psychiatric inpatient settings. Evaluating a variety of factors, including issues related to organizational justice and collaboration among nurses, may be useful to minimize assaults by patients in psychiatric settings.

‘In situ’ team-based simulation training for psychiatry: Innovation in managing the medically deteriorating patient

Introduction The interconnected nature of physical and mental health has been emphasised in recent times, with eye-catching figures such as people with schizophrenia dying up to 18 years earlier than the general population, with 60% excess mortality due to physical health (Chang et al., 2011). This highlights the need to care for patients' physical health on inpatient psychiatric units, with training generally focusing on knowledge and competency. However, serious untoward incidents, including medically deteriorating patients in psychiatric settings, often evidence failings in communication, teamwork, and systems. Simulation training has the potential to develop communication and teamwork skills, as well as technical knowledge and competency. Aims Evaluate ‘in situ' simulation for managing medically deteriorating patients in psychiatric settings, evaluating knowledge, confidence, attitudes, and changes following training. Methods Six simulation sessions were completed on one inpatient psychiatric ward over 2 months. Specifically-designed self-report measures assessed participants' ( n =35) knowledge, confidence, and attitudes towards managing medically deteriorating patients. Open-questions, focus groups, and follow-up surveys were used to collect qualitative data on course's impact. Results Participants' knowledge, confidence, and attitudes showed statistically significant improvements ( P Conclusion ‘In situ' simulation training has significant potential to benefit psychiatry teams in their management of medically deteriorating patients, which is an important step for both quality and safety of care, as well as tackling the interconnected nature of mental and physical health.

How Patients and Nurses Experience an Open Versus an Enclosed Nursing Station on an Inpatient Psychiatric Unit.

The inpatient environment is a critical space for nurses and patients in psychiatric settings. In this article, we describe nurses' and patients' perceptions of the inpatient environment both before the removal of a Plexiglas enclosure around a nurses' station and after its removal. Nurses had mixed feelings about the enclosure, reporting that it provided for confidentiality and a concentrated work space but also acknowledged the challenge of the barrier for communication with their patients. Patients unanimously preferred the nurses' station without the barrier, reporting increased feelings of freedom, safety, and connection with the nurses after its removal. It is important to consider the implications of environmental decisions in inpatient settings in order to promote a healthy workplace and healing environment for all community members.

Protecting the rights of patients in psychiatric settings: A comparison of the work of the Mental Health Act Commission with the CQC

Since April 2009, the Care Quality Commission (CQC) has been responsible for regulating standards of health and adult social care in England, as well as monitoring the operation of the Mental Health Act 1983. The latter function was previously performed by the Mental Health Act Commission (MHAC). This article compares the role and functions of both bodies in terms of their ability to provide a legitimate system of regulation and an effective safeguard for psychiatric patients who are deprived of their liberty. This paper is important, as there is very little published data to date on the work of the CQC and its predecessor, the MHAC. It is also necessary to evaluate changes to the regulatory landscape and compare the different regimes, to find out whether it has improved the protection and quality of care for mental health patients. The article concludes that the CQC does have the capacity to monitor detention, enforce standards and improve the quality of patient care, as long as it continues to endorse a commitment to human rights and service user involvement, to preserve the expertise and knowledge of visiting inspectors and to maintain accountability and independence from the State.

Philosophy on the Ground: An Appreciation of a “Spirit Master”

This essay is an appreciation of Melvin Pollner’s distinctive sociological approach to topics that are usually associated with philosophy. Pollner’s dissertation and early writings took up the theme of “mundane reason,” which he defined as an incorrigible presumption of a real world that is implicit in everyday conduct. Pollner addressed mundane reason, and the reciprocal idea of “reality disjunctures”—momentary divergences between perceptual accounts of the “same” mundane reality—by describing routine exchanges in traffic court and confrontations between doctors and patients in psychiatric settings. Pollner’s work anticipated current enthusiasms for developing novel “ontologies” in social and cultural studies of science, medicine, and other subjects. Although he did attempt to locate metaphysics in the midst of everyday experience, this essay suggests that his “philosophy on the ground” radically transformed philosophical ontology into an original and imaginative way to investigate constitutive activities.

The horse with stripes: a case of anti-NMDA receptor encephalitis.

The horse with stripes: a case of anti-NMDA receptor encephalitis.

The Horse With Stripes

The Horse With Stripes

Prevalence and correlates of seclusion and restraint use in children and adolescents: a systematic review

Seclusion and restraint are frequent procedures to intervene in aggressive and potentially dangerous patientsin psychiatric settings. However, little is known about their utilization and effectiveness in pediatric populations. We aimed to examine the prevalence and determinants of seclusion and restraint utilization in children and adolescents in psychiatric settings. Using PubMed, PsychInfo and Cinahl, we performed a systematic literature review of studies published in the last 10years reporting on the prevalence of seclusion and restraint use in psychiatrically ill youth (<21years old) treated in psychiatric settings. Only seven publications addressed the topic. Primary outcomes were prevalence rates, reported either as the proportion of patients restrained/secluded or as the number of restraints/seclusions per number of patient days. All studies found relatively high baseline rates of seclusion (26% of patients; 67/1,000 patient days), and restraints (29% of patients; 42.7/1,000 patient days). In four studies, an intervention, implemented to reduce seclusion and restraints, resulted in a dramatic weighted mean reduction in the more restrictive use of restraints by 93.2%, with a 54.2% shorter duration. There was a small, weighted mean reduction in the use of less restrictive seclusions (-0.6%), but results were heterogeneous (-97.2 to +71.0%), with the only increase in seclusions being reported in one study in which the intervention-based padded seclusion room was utilized more frequently instead of more restrictive measures. Otherwise, seclusion episodes reduced by 74.7%, including a 32.4% shorter duration. Few studies reported on risk-factors and predictors, consisting of past or current aggression and/or violence, suicidal behavior, more severe psychopathology, non-White ethnicity, emergency admissions, out-of-home placement, and poorer family functioning, while findings regarding age were inconsistent Except for duration, data about the effectiveness of seclusion and restraints were missing, although there is some indication that seclusion and restraints can lead to severe psychological and physical consequences. Future research should focus on indications, predictors, preventive and alternative strategies, as well as on clinical outcomes of seclusion and restraints in psychiatrically ill youth. In addition, there is a clear need for transparent policies and guidelines.

Attitudes towards patient gender among psychiatric hospital staff: Results of a case study with focus groups

There is an increasing awareness of gender-related issues in psychiatry. However, empirical findings on attitudes of psychiatric staff towards patient gender are limited. Gender-related issues are particularly relevant in the debate about mixed versus segregated sex wards, yet while the appropriateness of mixed-sex wards is questioned in Great Britain this is not the case in Germany. To investigate attitudes of psychiatric staff towards both patient gender and mixed versus segregated sex wards, we conducted a case study using focus groups with members of professional teams. We evaluated the transition process from two single-sex wards to two mixed-sex wards in a 330-bed psychiatric hospital in a rural area in south Germany. Staff described female patients as more externally oriented, motivating of others, demanding, and even sexually aggressive. Male patients, on the other hand, were described as more quiet, modest, or lazy. Furthermore, participants described the mixing process as a positive development whereas they did not see a need for gender-separated wards in order to protect vulnerable female patients. Some gender descriptions by professionals are “reversed” in comparison with gender stereotypes supposed to be present in wider society. The perception of crossed gender norms may affect staff attitudes towards the vulnerability of female patients in psychiatric settings and the provision of single-sex wards in in-patient psychiatric care. Practical implications are discussed against the background of a high rate of female patients with sexual abuse histories.

The use of two-dimensional grid patterns to limit hazardous ambulation in elderly patients with Alzheimer's disease

The ambulation of demented patients into potentiafiy dangerous areas or away from areas where they can be monitored is a problem for the care-providers of such patients in psychiatric settings for the elderly. Current methods of controlling patients likely to move into hazardous areas usually involve physical interventions such as restraint, locked ward doors and sometimes medication. Such methods can be costly, counterproductive and take carers away from other tasks. It has been observed that patients with Alzheimer's disease appear to be affected by certain visual stimuli that do not affect the ambulation of non-demented people or staff members. Such visual stimuli can be a simple two-dimensional grid pattern, which patients with Alzheimer's disease tend to perceive as a barrier. This effect is not usually seen in other types of dementia. Capitalising on this observation, black insulation tapes in two different grid configurations were laid out in an attempt to prevent these patients ambulating through exit doors. Ten demented patients with differential diagnoses participated in this study. It was found that the use of a horizontal grid reduced exit door contact up to 97% for four of these patients with a diagnosis of Alzheimer's disease. As had been predicted, the grid was less effective for patients with other types of dementia. Advantages and inherent dangers in this approach to managing hazardous ambulation by Alzheimer's patients are discussed. [ NT Research 1: 2, 217-227]

The relationship between nurses' limit-setting styles and anger in psychiatric inpatients.

Violence by patients in psychiatric settings is frequently associated with the quality of staff-patient interactions. Impulsivity has been identified as a high risk factor for anger and aggression. This study was designed to test the influence of nurses' limit-setting styles on anger among psychiatric inpatients grouped by high or low levels of impulsivity. Ninety-seven patients with various diagnoses and either high or low levels of impulsivity participated in role-play scenarios in which nurse actors played out six limit-setting styles, ranging from belittlement to explanations of rules to empathy linked with a presentation of an alternative course of action. Patients' level of anger in response to the acted scenario was assessed using the Spielberger State-Trait Anger Scale. Patients' level of anger was highest in response to unempathic limit-setting styles, moderate for explanations, and lowest for empathic styles. Impulsive subjects were more likely to respond with anger than nonimpulsive patients, regardless of the limit-setting style. Although many current intervention programs focus on reducing patients' anger after it occurs, the study results suggest that it may be possible to prevent some of patients' anger by improving nurses' limit-setting styles.

Psychopathology in adult mentally handicapped hospital patients.

In a population of 100 adult mentally handicapped patients, 71% had one or more ICD-9 diagnoses. The most common diagnosis was behavioural disorder, followed by affective psychosis and neurosis. Maladaptive behaviour was highest in younger, brighter patients and in patients who were psychiatrically disturbed. These findings have implications for the selection of patients for community living programmes, and for the appropriateness of providing treatment for particular mentally handicapped patients in psychiatric settings.