Elizabeth Kuipers

Disease, deficit or denial? Models of poor insight in psychosis

Objective:  To examine the evidence for the three kinds of aetiological model that dominate the current literature on poor insight in psychosis: clinical models, the neuropsychological model, and the psychological denial model.

Mental health, burnout and job satisfaction in a longitudinal study of mental health staff

Background: This study examines whether the adoption of a more community based model in an inner city psychiatry service is accompanied by increasing “burnout”, deteriorating mental health and decreasing job satisfaction amongst staff. Method: Questionnaires were sent annually for 3 consecutive years to all mental health staff working in three adult mental health sectors in inner London. Main outcome measures were the 12-item General Health Questionnaire, Maslach Burnout Inventory and a general job satisfaction measure. Results: There was no significant change over time in the outcome measures, once confounding by job and demographic variables was examined. Being based in the community was associated with higher GHQ-12 scores (P = 0.02) when compared to in-patient staff over the 3 years. Conclusions: These results suggested that working in the community may be more stressful than working in in-patient services. However, there was no evidence to suggest that levels of stress are increasing over time, either in community-based or hospital-based staff.

Improving support for mental health staff: a qualitative study

Background: High levels of both burnout and job satisfaction have been found in recent studies of mental health professionals. A qualitative methodology was used in a related study to explore reasons for these findings and to investigate staffs accounts of their strategies for coping with their work, and their views of support provided for them and how their jobs might be made less stressful and still more satisfying. Methods: A semi-structured schedule was used to interview a purposive sample of 30 mental health staff drawn from three South London geographical sectors, selected to include junior and senior members of each profession in both hospital and community settings. Interviews were transcribed and analysed using QSR NUD.IST software. Results: Informal contacts with colleagues were the most frequently mentioned way of coping with the difficult and demanding aspects of work in both hospital and community settings, closely followed by time management techniques. The main formal sources of support described by staff were individual supervision and staff support groups. Accounts of the former were generally positive, but there was great variation in opinions about whether support groups are useful. Almost all the interviewees believed that their jobs could be improved by further training. For community mental health staff the main training gaps were the development of skills in various forms of clinical intervention, whilst ward staff identified the need for further skills in diffusing potentially confrontational and aggressive situations.

Service use and costs of people with dual diagnosis in South London.

Objective: To compare the service use and costs of individuals who have a dual diagnosis of psychosis and substance abuse with those who have a diagnosis of psychosis but no substance abuse.

Remission and relapse in psychosis: operational definitions based on case-note data.

BACKGROUND In psychosis, the prime indicator of outcome has been relapse, but hospital readmission can no longer be used for this purpose. Researchers now require methods for assessing relapse that are objective, blind, reliable and valid. We describe the reliability and validity of such a technique using case-notes. METHOD Information from routine clinical notes of participants in the Lambeth Early Onset (LEO) study (less all references that would unblind the assessor) were recorded on a form divided into 1-month sections. Operational definitions of remission and relapse enabled clinicians to identify remissions and relapses blindly from the summary information. We calculated reliability regarding both the fact and the timing of remission and relapse. PANSS ratings at 6 and 18 months provided a measure of validity. RESULTS The kappa value for the identification of remission by individuals ranged from 0.64 to 0.82, while that for consensus between paired raters was 0.56. The corresponding values for relapse were 0.57-0.59 and 0.71. Intra-class correlations for time to remission and to relapse were very high. Raters guessed correctly whether the participants came from the intervention or control group on 60-75% of occasions. Independent PANSS ratings were strongly related to the remission/relapse status of participants. CONCLUSIONS The reliability of the technique described here was moderate to good, its validity was good, and it provides a useful and timely addition to methods of evaluating remission and relapse in psychosis. On the basis of our experience, we recommend consensus rather than individual ratings.

Cognitive-Behavioral Family Interventions in Psychosis

Neurobiological models of psychosis (Garety et al. 2007) alongside cognitive models of caregiving (Kuipers et al. 2010) postulate a key role for families in a patient’s environment. Families can help us to extend our understanding of psychosis and patient outcomes. Given the complexity of psychosis, illness-related difficulties such as disorders of thought and apathy can often interrupt and adversely affect normal patterns of communication between family members. In turn, this may have a negative impact on relationships. Thus, developing optimal communication styles between family members remains an important consideration for service providers.