Provision Of Psychiatric Care Research Articles

Influences of attribution and stigma on working relationships with providers practicing Western psychiatry in the Taiwanese context.

This study examined influences of causal attributions of schizophrenia and perceived and internalized mental illness stigma on perceived working alliance with, and informational support received from doctors practicing Western psychiatry in the Taiwanese social-cultural context. This cross-sectional quantitative study used a non-probability, purposive sampling technique to recruit 212 Taiwanese diagnosed with schizophrenia from Taiwanese Alliance of the Mentally Ill, 4 community mental health rehabilitation centres and 2 psychiatric hospitals between July 2012 and March 2013. Linear regression models were used for analysis. The results showed that environmental attributions were positively associated with both perceived working alliance and perceived informational support, while supernatural attributions were negatively associated with perceived working alliance and perceived informational support. Perceived stigma had a negative association with perceived working alliance. The discrimination domain of internalized stigma specifically had a positive association with perceived working alliance, while the withdraw domain had a negative association with perceived informational support. Findings inform the importance of culturally sensitive practices in developing an effective working relationship. Western psychiatric care providers need to explore consumers' casual attributions of mental illness and understand the impact of stigma so that providers may successfully engage consumers in care and provide tailored illness education and information.

Identifying and managing problematic substance use in outpatient psychiatric care: a national survey in Sweden

About 25% of psychiatric patients are known to have problematic substance use. The National Board of Health and Welfare in Sweden recommends that treatment providers of psychiatric care systematically identify patients with problematic substance use, and provide Brief Intervention (BI) for them. It is not known to what extent these recommendations are followed. Two surveys were designed, one for directors of outpatient psychiatric clinics, the second for clinical staff at these clinics. The survey to clinic directors focused on guidelines at the clinic for identifying substance use during the assessment phase, and for offering BI to patients with problematic substance use. The survey to staff focused on identification of problematic substance use during the assessment phase and personal experiences in identifying such use as well as offering BI. The response rate for clinic directors was 60% (n=137). Most clinics had guidelines for always asking patients about substance use in the assessment phase (92% for alcohol; 80% for drugs). Guidelines existed for offering BI for hazardous alcohol use at 49%; for hazardous drug use at 42%. The response rate for staff in participating clinics was 40% (n=481), 66% stated that they always ask about alcohol use during the assessment phase. Corresponding figure for drug use was 58%. 36% reported using BI for hazardous alcohol and drug use. Guidelines for identifying problematic substance use had been formulated at almost all outpatient psychiatric clinics, but among staff, only two out of three reported applying them. Guidelines for using BI had been formulated at less than half of the clinics. Actual BI provision by staff to patients was even more rare. During 2013-14, directors and staff participating in this survey will be involved in design and implementation of e-interventions (internet self-help sites, IVR, mobile applications) for problematic substance use.

A study on nonpsychiatric management of psychiatric patients in Minia governorate, Egypt

Background The world is suffering from an increasing burden of mental disorders and a widening gap in treatment. About 450 million people suffer from mental or behavioral disorders; yet, only a small minority receives even the most basic treatment. Objectives The objective of the study was to assess nonpsychiatric treatments and traditional and folklore management of psychiatric disorders and examine the nature of communication between psychiatric and nonpsychiatric care providers in Minia Governorate, Egypt. Participants and methods A total of 1134 patients [638 male (56.2%) and 496 female (43.8%)] were recruited from the outpatient psychiatric clinic of Minia University Hospital. They were interviewed using an unstructured open-ended technique to assess the previous methods by which their psychiatric illness was handled. Results The number of patients who reported that they had undergone nonpsychiatric medical and cultural traditional treatment methods was 985 (82% of the sample). Nonpsychiatric medical management techniques used by the patients (530, 53.8%) included medical treatment and investigations advised by general practitioners in primary healthcare units (231 patients, 43.5%), internal medicine (123, 23.2%), pediatric services (101, 19.1%), neurosurgery (25, 4.8%), and others including emergency room services (50, 9.4%). Nonpsychiatric cultural traditional interventions (455 patients, 46.2%) included following the Holy Koran (274 patients, 60.2%), using herbs and plants (91, 20%), Hegab (written words on a piece of paper, 55, 12.1%), Hegama (23, 5.4%), and physical interactions (12, 2.3%). The rate of referral of these patients from nonpsychiatric to psychiatric attention was limited (119 patients, 12%). Conclusion Our results highlighted the need to enhance communication between psychiatrists and providers of nonpsychiatric care to psychiatric patients.

Prison psychiatry

Prison psychiatry is a secluded area of the psychiatric care system, which in fact often provides treatment for those who do not have access to community-based healthcare systems. The aim of this review is to give an impression of the special challenges of psychiatric work behind bars and to emphasize current trends in prison psychiatry. In prisoners, mental disorders are more common than in the general population. There is evidence that prison suicide rates do not reflect general population suicide rates, suggesting that variation in prison suicide rates possibly also reflects differences in the provision of psychiatric care. Good transitional preparation preceding release seems to be necessary to reduce the risk of poor health outcome, but is hard to achieve. Up to now, there is no clear decision on whether it is useful or possible to treat adult prisoners with attention-deficit/hyperactivity disorder with stimulants. Prison psychiatry has to deal with a disproportionate burden of psychiatric disease in prisoners. Adequate psychiatric treatment options may reduce suicide behind bars. Further research should focus on the special needs of individuals who are out of reach of the conventional community-based health system.

The Psychopharmacological Management of RLS in Psychiatric Conditions

Restless legs syndrome (RLS) is a movement disorder treated with dopamine agonists. RLS is often diagnosed as a comorbid condition with psychiatric disorders, which are treated with dopamine antagonists or antidepressants resulting in onset or exacerbation of RLS symptoms. The objectives of this article are to provide a review of the literature to (a) describe the comorbidity of psychiatric disorders associated with RLS, (b) identify the treatment of psychiatric disorders that cause or exacerbate symptoms of RLS, and (c) provide clinical recommendations for psychiatric health care providers. A review of the literature of English articles included the databases of Medline, Pubmed, PsychINFO, and CINAHL for "Restless Legs Syndrome" with major psychiatric disorders including mood disorders (depression and bipolar), schizophrenia, and anxiety disorders (anxiety, panic disorder, obsessive compulsive disorder). The PRISMA guidelines were used to improve the reporting of the review of the literature. There were 61 articles that met the inclusion and exclusion criteria identified for the review of the literature, including RLS with mood disorders (n = 36), schizophrenia (n = 9), and anxiety disorders (n = 16). Clinical trials are lacking on the best treatment for persons with RLS and psychiatric disorders; the most rigorous research found in the literature related to depression and anxiety. Studies lack evidence to document the best practice for persons with RLS and comorbid psychiatric disorders. Psychiatric health care providers should be aware of RLS, which is influenced by psychiatric medications.

Shared care between specialised psychiatric services and primary care: The experiences and expectations of General Practitioners in Ireland

Objective. The study aims to explore the views of General Practitioners in Ireland on shared care between specialised psychiatric services and primary care. Method. A self-administered questionnaire was designed and posted to 400 randomly selected General Practitioners working in Ireland. Results. Of the respondents, 189 (94%) reported that they would support a general policy on shared care between primary care and specialised psychiatric services for patients who are stable on their treatment. However, 124 (61.4%) reported that they foresaw difficulties for patients in implementing such a policy including: a concern that primary care is not adequately resourced with allied health professionals to support provision of psychiatric care (113, 53.2%); a concern this would result in increased financial burden on some patients (89, 48.8%); a lack of adequate cooperation between primary care and specialised mental health services (84, 41.8%); a concern that some patients may lack confidence in GP care (55, 27.4%); and that primary care providers are not adequately trained to provide psychiatric care (29, 14.4% ). Conclusion. The majority of GPs in Ireland would support a policy of shared care of psychiatric patients; however they raise significant concerns regarding practical implications of such a policy in Ireland.

Treatment of bipolarity + medical comorbidity = costability

This issue of the Acta Psychiatrica Scandinavica reports from an open-label follow-up of 3766 research subjects of the STEP-Bipolar project. At least one medical comorbid condition was found in 58.8%. Baseline data from subjects with bipolar-spectrum disorder and schizoaffective disorder, bipolar type, were analyzed retrospectively to determine the association of historical variables with medical comorbidity (1). A strong linear-by-linear association was noted between the following historical variables and prevalence of any medical comorbidity: More than 10 previous mood episodes; Childhood onset; Smoking; Lifetime of anxiety and substance use disorder. In summary, this study (1) adds support to the notion that medical comorbidity may be a central aspect of the pathophysiology of the bipolar affective disorder spectrum, rather than the result of lifestyle and/or psychotropic medication. This is consistent with prior research that suggests a diathesis toward medical comorbidity in bipolar disorder (2). Pirraglia et al. (2) found that the outcome of bipolar affective disorder correlated with stress and the experience of burden of total physical illness over time – rather than with a simple count of current medical diseases. The authors of the current study (1) offer their interpretation that recurrent severe mood episodes may: Promote additive allostatic stress leading to increased prevalence of medical illness and/or; Share an underlying physiological pathway with chronic medical illness, thereby increasing risk of both psychiatric and medical morbidity. This research (1) has clinical implications that extend beyond what its title suggests. Because the diagnosis of schizoaffective disorder, bipolar type, was included in the study population, the findings may apply to other affective psychiatric conditions. Similar results have been found for other affective disorders. One study, for example, reported that endocrine/metabolic illness was associated with greater depressive symptom severity and poorer treatment outcomes. Therefore, the take-home message, especially relevant to psychiatric and primary care providers, is to pay attention to three easily-overlooked areas of practice. These clinical domains have the potential to improve the outcome of, and/or minimize the severity of, medical conditions that may accompany exacerbations of chronic, recurring affective disorders: Compliance: Non-adherence to medications for bipolar affective disorder and related affective conditions has been found to contribute – albeit at a barely significant level – to greater physical comorbidity in bipolar patients, as measured by the PCS (Physical Component Scale) (3). Providers should encourage implementation and maintenance of systems of medication delivery which ensure compliance in patients with bipolar-spectrum affective disorders. Early intervention: Untreated or poorly treated affective disorders may contribute to the recurrence of, and/or chronicity of, medical comorbid conditions and vice versa. For example, medical conditions were more prevalent in a group of primary care patients with a recurrent depressive episode than in a group with a first episode of depressive disorder. Early medical intervention and consultation from specialists may, for affective disorder patients with medical comorbidities, help prevent worsening and recurrence of both conditions. Prescribing practices: The geriatric proportion of the total population is growing, along with a concomitant increased burden of comorbid medical and psychiatric conditions. Risks inherent in prescribing medication combinations to the aged are obvious. As a result, there has been increased attention in the professional literature to pharmacokinetic/pharmacodynamic principles, parsimonious use of medications, and vigilance toward drug–drug interaction for the geriatric patient (4). Related issues have been raised in a recent article advocating more conservative prescribing principles (5). In sum, the paper reviewed here has inherent recommendations that have the potential to improve the treatment of chronic medical conditions in affective disorders beyond the bipolar patient.

Non-fatal suicide attempt by intentional stab wound: Clinical management, psychiatric assessment, and multidisciplinary considerations

Background:Suicide by means of self-inflicted stab wounds is relatively uncommon and little is known about this population and their management.Materials and Methods:Retrospective review of adult trauma patients admitted to our Level-1 trauma center between January 2005 and October 2009 for management of non-fatal, self-inflicted stab wounds.Results:Fifty-eight patients were evaluated with self-inflicted stab wounds. Four patients died due to their injuries (mortality, 7%). Of the non-fatal stab wounds, 78% were male ranging in age from 19-82 (mean: 45 years). The most common injury sites were the abdomen (46%), neck (33%), and chest (20%). In terms of operative interventions, 56% of abdominal operations were therapeutic, whereas 100% of neck and chest operations were therapeutic. When assessing for suicidal ideation, 44 patients (81%) admitted to suicidal intentions whereas 10 patients (19%) described accidental circumstances. Following psychiatric evaluation, 8 of the 10 patients with “accidental injuries” were found to be suicidal. Overall, 54 patients (98%) met criteria for a formal psychiatric diagnosis with 48 patients (89%) necessitating inpatient or outpatient psychiatric assistance at discharge.Conclusions:Compared to previous reports of stab wounds among trauma patients, patients with self- inflicted stab wounds may have a higher incidence of operative interventions and significant injuries depending on the stab location. When circumstances surrounding a self-inflicted stabbing are suspicious, additional interviews by psychiatric care providers may uncover a suicidal basis to the event. Given the increased incidence of psychiatric illness in this population, it is imperative to approach the suicidal patient in a multidisciplinary fashion.

The medical home model

The Patient-Centered Medical Home (PCMH) model is an approach to providing integrated healthcare through one main point of access. As the PCMH model gains increasing adoption in large health systems, its implications for psychiatric services are becoming increasingly important. This review highlights the development of the medical home model and a number of ways in which it has been adopted in psychiatric delivery systems. Numerous pilot initiatives have demonstrated quality improvement through the provision of psychiatric care in medical settings, medical care in psychiatric settings or fully integrated care through broadly trained providers. The PCMH model offers a useful conceptual framework for the management of complex and chronic psychiatric illness. Early pilots of its use in psychiatric settings have demonstrated that people with psychiatric illness who receive their care in a medical home have better access to care, improved response to treatment, and higher cost-efficiency compared with usual care.

Telepsychiatry for Children and Adolescents

The shortage and inadequate distribution of psychiatric care providers decreases access to mental health care for children and adolescents. One solution to the shortage is telepsychiatry. Studies of telepsychiatry show that it is effective and well received by both clinicians and patients. Despite its obvious benefits, challenges to the use of telepsychiatry remain.

Police Departments' Response in Dealing with Persons With Mental Illness

Many individuals with serious mental illnesses have limited resources and supports for living successfully in the community. This places many at risk for contact with law enforcement officers and has forced jails and prisons to become providers of psychiatric care. Police departments across the nation have implemented mental health intervention programs to train officers in handling calls involving individuals who are experiencing mental health crises. Although these programs seem to be a plausible strategy to reverse the flow of persons with mental illness into jails and prisons, they may not be enough. This article will examine both the traditional approach and models of specialized response and discuss whether these approaches are sufficient for providing officers the tools they need to assist individuals with mental illnesses.

Psychiatric health care provider attitudes towards implantable medication

Medication nonadherence is a major problem in psychiatry. Introduction of implantable psychiatric medication could alleviate the need to take daily medication, significantly decreasing the rate of nonadherence. This survey assessed psychiatric health care professionals' opinions regarding implants. An email was sent to potential participants including an explanation of the study and a link to an online survey. Email addresses of faculty in the Department of Psychiatry were obtained from websites of United States medical schools. To assess which provider characteristics were most important in consideration of implants, logistic regression models were employed. For assessing which patient characteristics were associated with providers' opinions, logistic regression models using generalized estimating equations tested associations between patient factors and implant decision. Eighty-six percent of respondents supported implants for a subset of patients. Four provider characteristics influenced support for implants including type of work, caseload, percent of patients with schizophrenia and percent of patients with bipolar disorder. Seven patient characteristics significantly influenced provider opinions including illness severity, length of illness, medication compliance, diagnosis, type of medication, family support, and patient age. Although dozens of factors influence the future of implants, the surveyed population showed moderate to strong support for this novel treatment.

Prison suicide in 12 countries: an ecological study of 861 suicides during 2003–2007

Although suicide rates among prisoners are high and vary between countries, it is uncertain whether this reflects the importation of risk from the general population or is associated with incarceration rates. We collected data on suicides and undetermined deaths in 12 countries (Australia, Belgium, Canada, Denmark, England and Wales, Finland, Ireland, Netherlands, New Zealand, Norway, Scotland, and Sweden) directly from their prison administrations for 2003-2007. These were compared with rates of suicides in the general population separately by gender using Pearson's correlations. In addition, they were compared with rates of incarceration. Linear regression was used to examine any association after adjustment for rates of incarceration. Data were collected on 861 suicides in prison, of which 810 were in men. In the men, crude relative rates of suicide were at least three times higher than the general population. Western European countries had similar rates of prisoner suicide which were mostly higher than those in Australia, Canada, and New Zealand. There was no association between rates of suicide in prisoners and general population rates or rates of incarceration. In the women, inmate suicide rates varied widely and were mostly raised compared with rates in the general population. In addition, these rates did not appear to be associated with general population rates of suicide. Rates of prison suicide do not reflect general population suicide rates, suggesting that variations in prison suicide rates reflect differences in criminal justice systems including, possibly, the provision of psychiatric care in prison.

“Suffering in Thought”: An Analysis of the Mental Health Needs of Female Domestic Workers Living with Violence in Malawi

The impact of violence on the mental health of women has been acknowledged but with limited exploration in resource-poor countries. Using critical ethnography and feminist methods, we analyzed the impact of violence on the mental health of a sample of Malawian women employed in domestic service. The analysis showed mental health as being situated in the context of poverty, inhumane treatment, social isolation, and the erosion of hope. We offer suggestions on how psychiatric nurses and other health care providers can promote the mental health of women employed in domestic service while acknowledging the limited mental health services in Malawi.

Illness perspectives of Thais diagnosed with schizophrenia

This study explored the perceptions of 18 people diagnosed with schizophrenia from 1-10 years to uncover how they perceived themselves and their illness. It also involved 12 family members who added their perceptions. The data were collected using in-depth interviews, reflective journaling, and observations. The data were analyzed through the lens of Heidegger's hermeneutic phenomenology. Four themes emerged: perceptions of mental illness, perceptions of the causes of illness, perceptions of discrimination, and attempting to live with schizophrenia. The findings included strong underlying cultural and spiritual beliefs, and attitudes unique to the Thai participants, including the causation of schizophrenia by supernatural powers, black magic, and bad karma stemming from past deeds. Understanding the perceptions of the participants might help health-care providers to be more sensitive to those living with schizophrenia in Thailand and elsewhere. In particular, the findings could be useful in informing psychiatric careproviders about developing better caring systems for clients diagnosed with schizophrenia. This should help the sufferers of schizophrenia to live their lives to their own satisfaction and as normally as possible.

Treatment of Tobacco Dependence in Mental Health and Addictive Disorders

People with mental health and addictive (MHA) disorders smoke at high rates and require tobacco treatment as a part of their comprehensive psychiatric care. Psychiatric care providers often do not address tobacco use among people with mental illness, possibly owing to the belief that their patients will not be able to quit successfully or that even short-term abstinence will adversely influence psychiatric status. Progress in the development of treatments has been slow in part because smokers with current MHA disorders have been excluded from most smoking cessation trials. There are several smoking cessation treatment options, including psychological and pharmacological interventions, that should be offered to people with an MHA disorder who smoke. Building motivation and readiness to quit smoking is a major challenge, and therefore motivational interventions are essential. We review the treatment options for people with tobacco dependence and MHA disorders, offer recommendations on tobacco assessment and tailored treatment strategies, and provide suggestions for future research. Treatment efficacy could be enhanced through promoting smoking reduction as an initial treatment goal, extending duration of treatment, and delivering it within an integrated care model that also aims to reduce the availability of tobacco in MHA treatment settings and in the community.

Facing inadequacy and being good enough: psychiatric care providers' narratives about experiencing and coping with troubled conscience

The aim of this study is to illuminate the meaning of encounters with a troubled conscience among psychiatric therapists. Psychiatric care involves ethical dilemmas which may affect conscience. Conscience relates to keeping or losing a sense of personal integrity when making judgments about one's actions. Ten psychiatric therapists were interviewed in June 2006. The interviews were tape-recorded, transcribed verbatim and interpreted using a phenomenological-hermeneutic method. Two themes 'Facing inadequacy' and 'Struggling to view oneself as being 'good enough'' are presented. In the therapists interviewed, awareness of their use of power, a sense of powerlessness and a sense of blame gave rise to feelings of betrayals and shameful inadequacy. By sharing their inadequacy with co-workers, they managed to endure the sense of their inadequacy which otherwise would have threatened to paralyse them. Finding consolation in sharing wearing feelings, becoming realistic and attesting their worthiness, they reached reconciliation and found confirmation of being good enough. The findings are interpreted in light of Lögstrup's ethics of trust, according to which conscience alerts us to silent but radical ethical demand and the risk of self-deception.

Workplace Violence Prevention Programs in Psychiatric Units and Facilities

Psychiatric health care providers have high rates of workplace violence victimization, yet little is known about the strategies used by facilities to reduce violence. This study compared workplace violence prevention (WVP) programs in psychiatric units and facilities in California and New Jersey. Information was collected through interviews, a facility walk-through, and a review of written policies and training material. A similar proportion of hospitals in both states had WVP training programs. A higher proportion of hospitals in California had written WVP policies, and a higher proportion of New Jersey hospitals had implemented environmental and security modifications to reduce violence. Legislation is one of many potential approaches to increase workplace violence prevention programs in health care settings.

Neurological Signs and Involuntary Movements in Schizophrenia: Intrinsic To and Informative on Systems Pathobiology

While it has long been considered whether the pathobiology of schizophrenia extends beyond its defining symptoms to involve diverse domains of abnormality, in the manner of a systemic disease, studies of neuromotor dysfunction have been confounded by treatment with antipsychotic drugs. This challenge has been illuminated by a new generation of studies on first-episode schizophrenia before initiation of antipsychotic treatment and by opportunities in developing countries to study chronically ill patients who have remained antipsychotic naive due to limitations in provision of psychiatric care. Building from studies in antipsychotic-naive patients, this article reviews 2 domains of neuromotor dysfunction in schizophrenia: neurological signs and involuntary movements. The presence and characteristics of neurological signs in untreated vis-à-vis treated psychosis indicate a vulnerability marker for schizophrenia and implicate disruption to neuronal circuits linking the basal ganglia, cerebral cortex, and cerebellum. The presence and characteristics of involuntary movements in untreated vis-à-vis treated psychosis indicate an intrinsic feature of the disease process and implicate dysfunction in cortical-basal ganglia-cortical circuitry. These neuromotor disorders of schizophrenia join other markers of subtle but pervasive cerebral and extracerebral, systemic dysfunction, and complement current concepts of schizophrenia as a disorder of developmentally determined cortical-basal ganglia-thalamo-cortical/cerebellar network disconnectivity.

Long term GP opinions and involvement after a consultation-liaison intervention for mental health problems

BackgroundShared Mental Health care between Psychiatry and Primary care has been developed to improve the care of common mental health problems but has not hitherto been adequately evaluated. The present study evaluated a consultation-liaison intervention with two objectives: to explore long-term GP opinions (relating to impact on their management and on patient medical outcome) and to determine the secondary referral rate, after a sufficient time lapse following the intervention to reflect a "real-world" primary care setting.MethodsAll the 139 collaborating GPs (response rate: 84.9%) were invited two years after the intervention to complete a retrospective telephone survey for each patient (181 patients; response rate: 69.6%).Results91.2% of GPs evaluated effects as positive for primary care management (mainly as support) and 58.9% noted positive effects for patient medical outcome. Two years post-intervention, management was shared care for 79.7% of patients (the GP as the psychiatric care provider) and care by a psychiatrist for 20.3% patients. Secondary referral occurred finally in 44.2% of cases.ConclusionThe intervention supported GP partners in their management of patients with common mental health problems. Further studies are required on the appropriateness of the care provider.