Alan Quirk

Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial

Background Acute psychiatric wards manage patients whose actions may threaten safety (conflict). Staff act to avert or minimise harm (containment). The Safewards model enabled the identification of ten interventions to reduce the frequency of both. Objective To test the efficacy of these interventions. Design A pragmatic cluster randomised controlled trial with psychiatric hospitals and wards as the units of randomisation. The main outcomes were rates of conflict and containment. Participants Staff and patients in 31 randomly chosen wards at 15 randomly chosen hospitals. Results For shifts with conflict or containment incidents, the experimental condition reduced the rate of conflict events by 15% (95% CI 5.6–23.7%) relative to the control intervention. The rate of containment events for the experimental intervention was reduced by 26.4% (95% CI 9.9–34.3%). Conclusions Simple interventions aiming to improve staff relationships with patients can reduce the frequency of conflict and containment. Trial registration IRSCTN38001825.

How pressure is applied in shared decisions about antipsychotic medication: a conversation analytic study of psychiatric outpatient consultations.

The professional identity of psychiatry depends on it being regarded as one amongst many medical specialties and sharing ideals of good practice with other specialties, an important marker of which is the achievement of shared decision-making and avoiding a reputation for being purely agents of social control. Yet the interactions involved in trying to achieve shared decision-making are relatively unexplored in psychiatry. This study analyses audiotapes of 92 outpatient consultations involving nine consultant psychiatrists focusing on how pressure is applied in shared decisions about antipsychotic medication. Detailed conversation analysis reveals that some shared decisions are considerably more pressured than others. At one end of a spectrum of pressure are pressured shared decisions, characterised by an escalating cycle of pressure and resistance from which it is difficult to exit without someone losing face. In the middle are directed decisions, where the patient cooperates with being diplomatically steered by the psychiatrist. At the other extreme are open decisions where the patient is allowed to decide, with the psychiatrist exerting little or no pressure. Directed and open decisions occurred most frequently; pressured decisions were rarer. Patient risk did not appear to influence the degree of pressure applied in these outpatient consultations.

What is life like on acute psychiatric wards

Purpose of review No country has created a mental health care system that can function without ‘acute’ psychiatric wards for the admission of people who require short-term hospital care to treat their mental disorder and prevent them causing harm to themselves or others. Previous research indicates that the quality of care on acute wards is under threat, especially in countries that have undergone a process of ‘deinstitutionalization’. This review describes what life is like on such wards by presenting research findings primarily from qualitative studies. Recent findings Despite great diversity in the structure of mental health services internationally, certain themes or problems appear to be common to all acute wards. First, ward staff are preoccupied with the management of dangerous behaviours and patient throughput. Second, a complex set of factors influence how staff respond to dangerous behaviours: these relate to the patient, the nature of the problem behaviour, staff attitudes and organizational context. Third, ward nurses are dissatisfied with the difficulty they have in forming therapeutic relationships in this particular setting and patients dislike the centrality of pharmacological interventions at the expense of psychological approaches. Summary This review suggests a need to rethink the purpose and function of acute psychiatric wards. Research is required to investigate (1) which interventions improve the safety, and the perception of safety, of the wards, and (2) what strategies improve the quality of therapeutic relationships between staff and patients.

A conceptual model of the aims and functions of acute inpatient psychiatry

Background: Acute inpatient care has come under sustained criticism. Services suffer from high occupancy, increased acuity, and patient dissatisfaction with care. The number of beds has been reduced in favour of alternative services. Aim: To articulate clearly the role of acute inpatient care. Method: Drawing on research evidence and the experiences of inpatient and community staff, we present a model to describe the function and tasks of inpatient care. Results: An admission is the result of severity of acute mental disorder, coupled with an acute admission problem. The decision to admit is processed through a filter composed of bed availability, social supports and other services available to the prospective patient. That combined reason provides the primary task of the admission. However patients also bring with them other life and health problems. While not a cause of admission, these problems have to be managed by inpatient staff. Where they can be resolved, they represent an “admission bonus”. Finally, acute care functions because of the legitimate authority of staff, their 24-hour availability for support and supervision, and the provision of treatment and containment. Conclusion: This model explicates many aspects of acute inpatient care that otherwise create confusion.

Prevalence of mental disorders in elderly people: the European MentDis_ICF65+ study.

BACKGROUND Except for dementia and depression, little is known about common mental disorders in elderly people. AIMS To estimate current, 12-month and lifetime prevalence rates of mental disorders in different European and associated countries using a standardised diagnostic interview adapted to measure the cognitive needs of elderly people. METHOD The MentDis_ICF65+ study is based on an age-stratified, random sample of 3142 older men and women (65-84 years) living in selected catchment community areas of participating countries. RESULTS One in two individuals had experienced a mental disorder in their lifetime, one in three within the past year and nearly one in four currently had a mental disorder. The most prevalent disorders were anxiety disorders, followed by affective and substance-related disorders. CONCLUSIONS Compared with previous studies we found substantially higher prevalence rates for most mental disorders. These findings underscore the need for improving diagnostic assessments adapted to the cognitive capacity of elderly people. There is a need to raise awareness of psychosocial problems in elderly people and to deliver high-quality mental health services to these individuals.

Behavioural antecedents to pro re nata psychotropic medication administration on acute psychiatric wards

This study examined the antecedents to administration of pro re nata (PRN) psychotropic medication on acute psychiatric wards, with a particular focus on its use in response to patient aggression and other conflict behaviours. A sample of 522 adult in-patients was recruited from 84 acute psychiatric wards in England. Data were collected from nursing and medical records for the first 2  weeks of admission. Two-thirds of patients received PRN medication during this period, but only 30% of administrations were preceded by patient conflict (usually aggression). Instead, it was typically administered to prevent escalation of patient behaviour and to help patients sleep. Overall, no conflict behaviours or further staff intervention occurred after 61% of PRN administrations. However, a successful outcome was less likely when medication was administered in response to patient aggression. The study concludes that improved monitoring, review procedures, training for nursing staff, and guidelines for the administration of PRN medications are needed.

Non-clinical and extra-legal influences on decisions about compulsory admission to psychiatric hospital

Background: On the eve of reform of the 1983 Mental Health Act (MHA), little is known about how decisions to admit people under its powers are made. Aims: To describe non-clinical and extra-legal influences on professionals’ decisions about compulsory admission to psychiatric hospital. Method: Participant-observation of MHA assessments, including informal and depth interviews with the practitioners involved, and follow-up interviews with the people who had been assessed. Results: A candidate patient’s chance of being sectioned is likely to increase when there are no realistic alternatives to in-patient care. This typically occurs when staff have insufficient time to set such alternatives in place and are unsupported by other professionals in doing this. Outcomes may also be affected by local operational norms and the level of professional accountability for specific MHA decisions. Conclusion: Non-clinical and extra-legal factors explain some of the geographical variation in MHA admission rates. If compulsion is to be used only in the ‘last resort’, administrators and policy makers should look beyond legislative change to matters of resource allocation and service organisation.

Risk management by patients on psychiatric wards in London: An ethnographic study

The purpose of this study was to explore everyday life on acute psychiatric admission wards, focusing on the experience of patients. Using a grounded theory approach, data were collected by ethnographic methods on three wards in London, UK. This paper is concerned with the issue of how patients manage risks arising from their interaction with other patients on the ward, such as assault and sexual harassment. Patients were observed doing this in various ways including: (a) avoiding risky situations or individuals; (b) de-escalating potentially risky situations; (c) seeking safety interventions by staff or increased surveillance; and (d) protective involvement with other patients. These findings show that patients routinely take an active role in making a safe environment for themselves, partly because they cannot rely on staff to do this for them. Mental health professionals should consider how to build upon what patients are already doing to maximise ward safety.

Measuring symptoms and diagnosing mental disorders in the elderly community: the test–retest reliability of the CIDI65+

Prevalence findings for the elderly are artificially low, most likely due to insufficient consideration of age‐related cognitive abilities in diagnostic interviews.

Patient preferences and performance bias in a weight loss trial with a usual care arm.

Objectives This qualitative study examines performance bias, i.e. unintended differences between groups, in the context of a weight loss trial in which a novel patient counseling program was compared to usual care in general practice. Methods 14/381 consecutive interviewees (6 intervention group, 8 control group) within the CAMWEL (Camden Weight Loss) effectiveness trial process study were asked about their engagement with various features of the research study and a thematic content analysis undertaken. Results Decisions to participate were interwoven with decisions to change behavior, to the extent that for many participants the two were synonymous. The intervention group were satisfied with their allocation. The control group spoke of their disappointment at having been offered usual care when they had taken part in the trial to access new forms of help. Reactions to disappointment involved both movements toward and away from behavior change. Conclusion There is a prima facie case that reactions to disappointment may introduce bias, as they lead the randomized groups to differ in ways other than the intended experimental contrast. Practice implications In-depth qualitative studies nested within trials are needed to understand better the processes through which bias may be introduced.