Frank Holloway

An RCT of early intervention in psychosis: Croydon Outreach and Assertive Support Team (COAST)

Despite considerable interest in early intervention in psychosis, the evidence base for its effectiveness is sparse.We aimed to evaluate a new service in South London, UK, Croydon Outreach and Assertive Support Team (COAST) using a randomised controlled trial (RCT) during its first year. Referrals were taken from local adult community mental health teams of those with documented first service contact in the last 5 years and a diagnosis of any functional psychosis. Those who consented (N = 59) were randomised to COAST or treatment as usual (TAU). COAST offered a range of interventions, including optimum atypical medication, psychological interventions (individual cognitive behavioural therapy and family intervention if appropriate) and a range of vocational and welfare help according to need. Whole team training was used to be able to offer these kinds of interventions. Outcomes were evaluated at baseline, 6 months and 9 months on a range of standardised clinical and social measures. Overall both COAST and TAU clients improved over time, but there were no significant improvements for COAST clients; a lack of significant results in the time x treatment interaction. There was a trend for COAST carers’ quality of life to increase. Bed days were also less in COAST, but not significantly so. The lack of clearly demonstrated improvements for COAST is consistent with the published literature so far. The fact that both groups improved in symptoms and functioning over the year suggests that while access to early intervention is helpful, community adult mental health teams should aim to offer high quality input at any stage of psychosis in order to meet client and carer needs.

Case Management for the Mentally Ill: Looking at the Evidence:

Case management is now accepted in the United States as a key element in systems designed to support elderly, mentally handicapped and chronically mentally ill people in the community (Intagliata, 1982). The concept of case management (CM) has recently been enshrined in British Government policy for community care (HMSO, 1989a). The term ’case management’ is quite new. Important reviews of the empirical community care literature published in the early 1980s do not include CM as a service modality (Braun et cel. 1981; Kiesler, 1982), although it has emerged as the key coordinating mechanism for the ’community support systems’ sponsored by National Institute of Mental Health (Intagliata, 1982; NIMH, 1987). Useful reviews of CM are available, all written by enthusiasts for the concept (eg. Intagliata, 1982; Renshaw, 1988; Kanter, 1989; Thornicroft, 1990). However there appears to have been a lack of critical analysis, with authors adopting a variety of mutually contradictory perspectives towards CM (Bachrach, 1989). Indeed the term may be used so broadly as to lack any substantive meaning (Bachrach, 1989). Many questions need to be addressed before any system of CM may usefully be adopted within a locality. What model of CM is to be used? Who should receive CM? How will the system be organised? What case-loads will be carried by case managers? How should the CM system relate to the wider service system? Who should be a case manager and what training will they require? Above all it is vital that any CM system is provided with clear goals. This paper draws upon the extensive US literature on CM and the small number of other relevant studies in the English language literature, comparing and contrasting the empirical evidence with the prescriptions of policy.

What do mental health rehabilitation services do and what are they for? A national survey in England

Background: The specialty of rehabilitation is under represented in current national policy, current service provision is unclear and there are no guidelines on what constitutes a standard rehabilitation service. Aim: To carry out a national survey of rehabilitation services in order to describe current service provision and to formulate a consensus definition of the term “rehabilitation”. Method: A structured telephone survey was carried out with consultants in rehabilitation psychiatry or senior service managers in all Trusts in England. As well as information about their services, interviewees were asked to give a definition of the term “rehabilitation”. Results: A response rate of 89% (65/73 Trusts) was achieved constituting interviews with representatives from 93 local authority regions (75% consultants, 25% service managers). The majority (77%) had short term (length of stay up to 12 months) rehabilitation units with a mean 13 beds. There were no differences between urban and rural services in bed numbers. Most services had input from all members of a multidisciplinary team and where services had short and longer term units, staff tended to cover both. The majority (79%) had specific referral criteria, 42% had exclusion criteria and 85% carried out a preadmission assessment. Over half (56%) had a community rehabilitation team and in 29%, assertive outreach teams were considered part of the rehabilitation service. Two models of community rehabilitation service provision emerged and a consensus definition of “rehabilitation” was formulated. Conclusions: This is the first national survey of rehabilitation services which has allowed the description of current service provision in some detail as well as two models of community rehabilitation services. Declaration of Interest: None.

Subjective quality of life, psychopathology, satisfaction with care and insight: An exploratory study

We have investigated the determinants of global subjective quality of life (GSQOL) using data from a controlled trial of intensive case management for the severely mentally ill. In a multiple regression analysis depression, age, objective quality of life and domain-specific quality of life together explained 59% of the variance in GSQOL. GSQOL was not significantly correlated with measures of positive psychotic symptomatology, insight or attitudes to treatment but was correlated with satisfaction with care (r= .21, p = .011 ). Change in GSQOL over 18 months was correlated with change in domain-specific quality of life (r=-.45, p=.002) and depression (r=-.43, p=.01): multiple regression analysis confirmed that both variables had an independent effect on change in GSQOL.

Satisfaction research and the uncrowned king: Challenges and future directions

Background: After decades of paternalistic health service provision, National Health Service users in the United Kingdom are encouraged to express preferences for services; “the patient is king”. Whilst the mental health service user voice is encouraged in multiple forums, it is in satisfaction research (especially using the survey method) as a commentary on services provided that it is primarily heard. However, methodological concerns exist regarding the use of satisfaction surveys as a measure of healthcare quality. Aim: To discuss the arguments against and for using satisfaction surveys in mental health research. Method: A review of the existing literature on satisfaction surveys. Results: There are a number of significant criticisms of satisfaction surveys and their continued use in mental health research. Conclusions: Despite these criticisms, the limitations of satisfaction surveys do not merit their abandonment. The authors indicate possible future directions for the satisfaction research agenda. Declaration of interest: None.

Review Article Case Management: an Update:

Background: Case management in its various forms represents a major innova tion in mental health care. Its efficacy remains controversial. Aims: To update after a decade a previous review article (Holloway, 1991). Methods: Descriptive literature and controlled trials of case management and its derivative Assertive Community Treatment (ACT) was accessed through four comprehensive and systematic reviews of the literature, repeated Medline and Embase searches and personal contacts. Results and Conclusions: The concept of case management has continued to evolve over the past decade. No controlled trial has been published exploring the model of the case manager as a service broker without responsibility for the provision of care. Basic case management principles have frequently been incorporated within routine clinical practice. Published controlled trials of ACT, which were almost exclusively carried out in North America, have shown markedly positive results. However caution is required in extrapolating these findings to routine clinical practice within different systems of health and social care. Case management is not in itself an effective treatment for severe mental illness.

Burnout in mental health nurses: much ado about nothing?

The syndrome of burnout has been the focus of much research in the caring professions. Maslach and Jackson operationally defined the syndrome as comprising high levels of emotional exhaustion, high depersonalization and a reduced sense of personal accomplishment. They argued that the syndrome could be reliably measured using the 22-item Maslach Burnout Inventory. The present authors gave this scale to 648 ward-based mental health nurses along with a range of other standardized scales. The total sample was then divided into a high burnout group (high scores on all three subscales, N=37 or 5.7 percent) and a low burnout group (low scores on all subscales, N=66 or 10.2 percent). The findings show that burnout is a much less significant problem for mental health nurses than other researchers have indicated. There was, however, clear evidence for the construct validity of the burnout concept. Future directions for burnout research with mental health nurses are outlined. Copyright

Assessing coping skills in mental health nurses: is an occupation specific measure better than a generic coping skills scale?

Abstract The aim of the present study was to compare the reliability and validity of two separate measures of coping skills when used with mental health nurses. The study compared the PsychNurse Methods of Coping Scale, a measure developed specifically for this population, and the more generalisable coping skills subscale from Cooper’s Occupational Stress Indicator. Both measures were administered via a postal questionnaire along with the Maslach Burnout Inventory, the General Health Questionnaire (GHQ-12) and a demographic checklist. Questionnaires were returned by 175 nurses, a response rate of 25%. It was hypothesised that the PsychNurse Scale would be a more reliable and valid measure when applied to mental health nurses. This prediction was confirmed. Specifically the PsychNurse Scale had higher item total correlations, better inter factor correlations, higher internal consistency, and better predictive and item discriminative validity. Interestingly, community mental health nurses scored significantly higher on both coping scales than ward based mental health nurses. The PsychNurse Scale is more psychometrically robust than a generic coping skills scale when applied to mental health nurses.

Effective communication in mental health nurses: Did social support save the psychiatric nurse?

A randomised controlled trial was conducted to test the effectiveness of a social support-based intervention against a feedback-only condition. Fifty-three mental health nurses were randomly allocated and assessed on a range of measures of the stress process. Stressors were measured by the DCL Stress scale, mediating variables by the Rosenberg Self-Esteem scale, the Pearlin Mastery scale and the Significant Others scale and stress outcomes by the General Health Questionnaire and the Maslach Burnout Inventory. Following a successful pilot of the social support package, it was hypothesised that the social support intervention would be more effective in reducing stress and burnout in mental health nurses. Participants in both groups were assessed prior to randomisation, post-treatment and at six months follow-up. Attrition rates were similar in both conditions, at around 30%. The social support groups were run for five consecutive weeks for two hours. In all, three separate groups were conducted by two facilitators. The members of the feedback-only group received detailed written feedback on their stress questionnaires, as well as a small stress management booklet developed by two of the authors. Results of the study show no benefits for participants of the social support groups on the studys dependent variables and indeed there was a trend for the feedback-only group to do slightly better on some of the measures. The reasons for this negative outcome are discussed and suggestions are made for future studies. Methodological difficulties are pointed out with studies that attempt to reduce staff stress.

Clinical assessment of risk decision support (CARDS): The development and evaluation of a feasible violence risk assessment for routine psychiatric practice

Background: Adult psychiatric services are increasingly required to assess and manage the risk of violence, but the evidence base to guide clinical practice is limited. Aims: To develop an evidence-based method of assessing risk of violence and to demonstrate its feasibility in routine practice. Methods: Consensus workshops were held to design a form based decision support system, which was refined using a Delphi consultation. The system was introduced into practice in 7 mental health services in England. Its feasibility was measured through assessment of case notes, questionnaires and focus groups of clinical staff. Results: CARDS is a two-stage assessment, with a screen and full assessment stage (at http://www.iop.kcl.ac.uk/iopweb/virtual/?path = /hsr/prism/cards/). A high degree of consensus was achieved for the structure and content. CARDS met each of the six feasibility criteria: brevity, simplicity, relevance, acceptability, availability and value, though acceptability was only achieved when the assessment of violence risk was supplemented with an assessment of suicide risk. Conclusion: CARDS provides a feasible, evidence-based decision support procedure for assessing risk of violence in patients using adult mental health services. It can help clinicians meet policy requirements to assess risk, though its effect on actual violence is unknown.