Jonathan Bindman

Continuity of care for the severely mentally ill : concepts and measures

Very few useful measures of service functioning are as yet available for the evaluation of mental health services. Continuity of care has been identified as “the strategic first choice” for the development of such process measures. The term “continuity” has been used to refer to a variety of important aspects of service functioning, including whether services maintain contact with patients, whether patients consistently see the same staff, success of transfer between services, degree to which plans for services are followed through, integration between service providers, and comprehensiveness in meeting patients individual needs. In this paper, we reviewed the main theoretical definitions of continuity of care for the severely mentally ill, and discussed the work that has attempted to operationalise these definitions and to apply them in the study of mental health services. We concluded that whilst continuity of care has had a central place in theoretical discussions of community service planning, progress in developing and applying practical measures has so far been sporadic and limited. Obstacles to such research have included great diversity in definitions of continuity and the confounding influence of individual patient characteristics on the relationship between service process and outcome. Despite these limitations, research in this field has indicated that developing and applying measures of continuity of care may be feasible and produce useful results, with findings of some of the studies suggesting a relationship between continuity of care and individual outcome.

Perceived coercion at admission to psychiatric hospital and engagement with follow-up: A cohort study

BackgroundMeasures of perceived coercion at psychiatric hospital admission have been developed. We aimed to investigate predictors of perceived coercion in subjects admitted to psychiatric hospital in the UK, and to test the hypothesis that high perceived coercion at admission predicts poor engagement with community follow-up.MethodA cohort of consecutively admitted subjects were interviewed at admission and before discharge, and were followed prospectively for 10 months. Service use and compliance with care were rated from case notes and by clinicians.ResultsOne hundred interviews were obtained from 118 consecutive admissions (85 %). Compulsory admission was strongly associated with perceived coercion, but one-third of voluntary patients felt highly coerced, and two-thirds were not certain they were free to leave hospital. Greater age, less insight, and non-white ethnicity were associated with high perceived coercion. Perceived coercion did not predict engagement with follow-up.ConclusionsServices recognise provision of care in the least restrictive setting as a key objective. Perceived coercion should be regarded as an important outcome measure in service evaluation.

Sex differences in the subjective tolerability of antipsychotic drugs.

Abstract: In recent years, research efforts have been directed to better characterize the subjective experience of taking psychotropic drugs. This study investigated the sex difference in the subjective tolerability of antipsychotic drugs. Participants were recruited from patients under the care of psychiatric services serving geographical catchment areas in Croydon (UK), Verona (Italy), Amsterdam (Netherlands), and Leipzig (Germany). Clinically unstable patients with a clinical diagnosis of schizophrenia and a research diagnosis of schizophrenia, established using the Item Group Checklist of the Schedule for Clinical Assessment in Neuropsychiatry, were enrolled. Antipsychotic subjective tolerability was rated by means of the Liverpool University Neuroleptic Side Effect Rating Scale. During the recruitment period, 245 men and 164 women with schizophrenia were recruited. In both sexes, the most frequently reported side effects were difficulty in concentrating, tiredness, and weight gain; these side effects occurred in approximately 50% of men and in up to 70% of women. Extrapyramidal and anticholinergic reactions were reported more often by women, whereas men reported sexual problems more often. After background group differences were controlled for, sex was the strongest determinant of the subjective tolerability of antipsychotic drugs. We therefore conclude that sex differences in the subjective tolerability of antipsychotic drugs should be taken into account in the pharmacological management of patients with schizophrenia. Studies should no longer consider men and women as a homogeneous group, given that the subjective tolerability of antipsychotic drugs substantially differs between sexes.

Continuity of care and clinical outcome: a prospective cohort study

Abstract  Background: Continuity of care is a central objective of community psychiatric services, but there is no consensus about its measurement. Aims: We developed measures of continuity of care suitable for routine use, and measured continuity and individual patient outcome over a period in which community services were developing. Method: One hundred patients with severe mental illness receiving continuing care from two sectorised services were sampled and interviewed. Data were collected concerning their care over 20 months prior to interview. After 20 months prospective follow-up, they were re-interviewed. Continuity was defined as: perceived accessibility of services and knowledge about them, the number of keyworkers in a defined period of time, and the proportion of time out of contact with services. Results: Continuity of care improved significantly on all measures over the period of the study. Individual patient outcome also improved, but in multiple regression models including clinical and demographic variables, measures of continuity were not significant predictors of outcome. Continuity was similar for white and non-white patients. Conclusion: Simple measures of continuity are useful in evaluating changes in the process of care, but they are not straightforwardly related to individual outcome.

Do community treatment orders for mental illness reduce readmission to hospital? An epidemiological study.

BackgroundIt has been suggested that community treatment orders (CTOs) will prevent readmission to hospital, but controlled studies have been inconclusive. We aimed to test the hypothesis that hospital discharges made subject to CTOs are associated with a reduced risk of readmission. The use of such a measure is likely to change after its introduction as clinicians acquire familiarity with it, and we also tested the hypothesis that the characteristics of patients subject to CTOs changed over time in the first decade of their use in Victoria, Australia.MethodA database from Victoria, Australia (total population 4.8 million) was used. Cox proportional hazard models compared the hazard ratios of readmission to hospital before the end of the study period (1992–2000) for 16,216 discharges subject to a CTO and 112,211 not subject to a CTO.ResultsCommunity treatment orders used on discharge from a first admission to hospital were associated with a higher risk of readmission, but CTOs following subsequent admissions were associated with lower readmission risk. The risk also declined over the study period.ConclusionsThe effect of using a CTO depends on the patient’s history. At a population level their introduction may not reduce readmission to hospital. Their impact may change over time.Declaration of interestNone.

Poverty, poor services, and compulsory psychiatric admission in England

Background Compulsory admission is a central feature of psychiatric systems internationally but the factors determining its use within different legal systems are not understood. Numbers of compulsory psychiatric admissions vary widely between areas in England. We examined the hypothesis that variation in rates of detention is related to social deprivation and also to the functioning of local mental health services. Methods Rates of detention under sections 2 and 3 of the Mental Health Act (1983) in 1998/9 were obtained in 34 mental health sectors in eight Trusts in England. Measures of socio-economic deprivation and measures of service function were used to conduct an ecological analysis. Results Compulsory admission is associated with measures of deprivation but there is unexplained variation. The range in rates is higher than allowed for by the resource allocation formula. Some indicators of service quality are independently associated with rates of detention. Conclusions Variation in detention rates and its relation to service function need further explanation if the use of compulsion is to be reduced.

An investigation of factors associated with psychiatric hospital admission despite the presence of crisis resolution teams

BackgroundCrisis resolution teams (CRTs) provide a community alternative to psychiatric hospital admission for patients presenting in crisis. Little is known about the characteristics of patients admitted despite the availability of such teams.MethodsData were drawn from three investigations of the outcomes of CRTs in inner London. A literature review was used to identify candidate explanatory variables that may be associated with admission despite the availability of intensive home treatment. The main outcome variable was admission to hospital within 8 weeks of the initial crisis. Associations between this outcome and the candidate explanatory variables were tested using first univariate and then multivariate analysis.ResultsPatients who were uncooperative with initial assessment (OR 10.25 95% CI-4.20–24.97), at risk of self-neglect (OR 2.93 1.42–6.05), had a history of compulsory admission (OR 2.64 1.07–6.55), assessed outside usual office hours (OR 2.34 1.11–4.94) and/or were assessed in hospital casualty departments (OR 3.12 1.55–6.26), were more likely to be admitted. Other than age, no socio-demographic features or diagnostic variables were significantly associated with risk of admission.ConclusionWith the introduction of CRTs, inpatient wards face a significant challenge, as patients who cooperate little with treatment, neglect themselves, or have previously been compulsorily detained are especially likely to be admitted. The increased risk of admission associated with casualty department assessment may be remediable.

Are depot antipsychotics more coercive than tablets? The patient’s perspective

Some clinicians consider depot antipsychotics to be stigmatising, coercive and unacceptable to patients. This cross-sectional study investigated patients’ perspectives of coercion for depot and oral antipsychotics. In all, 72 participants with chronic mental illness on voluntary maintenance antipsychotic medication were interviewed for their views on oral and depot medication and experiences of coercion. The MacArthur Admission Experience (short form) was adapted to explore coercion regarding medication. Mean total coercion levels were higher for those on depot (depot: mean 4.39; oral: 2.80, P = 0.027), as were perceived coercion (2.52 vs 1.73, P = 0.041) and negative pressures subscales (1.17 vs 0.33, P = 0.009). No significant differences were found for the ‘voice’ subscale and affective reactions. Specifically, more participants on depot felt that people try to force them to take medication (30% vs 2%, P< 0.001). Depots were perceived as more coercive than oral antipsychotics. Greater perceived coercion may explain why some consider depots to be a more stigmatising form of treatment. Although forced medication is sometimes required, the experience of coercion should be minimised by giving patients a fair say in treatment decisions, regardless of formulation.

Adherence to medication and quality of life in people with schizophrenia: results of a European multicenter study.

Quality of life is often severely impaired in people with schizophrenia, and adherence to antipsychotic medication has been consistently found to be low in this population. Although there is a considerable amount of evidence on these two variables in schizophrenia research, there is only limited knowledge on how they relate to one another. The aim of this study is to develop a meaningful model of the relationship between quality of life and adherence that includes mediating variables. A multicenter randomized controlled trial recruited 409 subjects in London, Verona, Amsterdam, and Leipzig. Baseline interviews obtained data on adherence, quality of life, and other variables. We used graphical modeling to investigate the relationships between the variables. No direct relation could be discerned between subjective quality of life and adherence to medication. Mediating variables, most importantly symptomatic impairment, global functioning, and medication side effects, were identified by the model. It can be concluded that, when aiming at the improvement of quality of life in people with schizophrenia, variables other than adherence, i.e., symptomatic impairment, global functioning, and medication side effects, should be targeted.

Comparison of Patient and Clinician Perspectives in the Assessment of Antipsychotic Medication Adherence

Background: Factors influencing patient and clinician perspectives in the assessment of medication adherence have never been compared. Method: This study used baseline and 12-month follow-up data from the QUATRO study, an international multicentre study. At baseline, information on patient sociodemographic characteristics, treatment factors, psychopathology, functioning and experience of antipsychotic side effects was gathered. After 12 months of follow-up, psychopathology, functioning and patient experience of antipsychotic side effects were measured once more, and a patient and clinician rating of adherence was obtained by means of the Medication Adherence Rating Scale (MARS) and the Compliance Rating Scale (CRS). Results: During the recruitment period, 409 subjects with a diagnosis of schizophrenia were recruited. Patients were more often men and single. Mean age was 41.5 years. At the time of the assessment, more than 40% were unemployed and on average had been on antipsychotic treatment for more than 10 years. Nearly 70% were receiving second-generation antipsychotics, and 50% received adherence therapy during the 12 months after enrolment. The relationship between the MARS and the CRS scores showed only a small overlap (correlation coefficient = 0.26). In the multivariate model, the only factor significantly associated with both patient and clinician ratings of adherence was psychopathology. Unemployment and poor subjective tolerability of antipsychotics were significantly associated with low levels of patient ratings of adherence. Conversely, length of treatments and use of newer antipsychotics were significantly associated with better clinician ratings of adherence. Conclusion: Patient and clinician ratings of adherence do not measure the same dimension. Factors that may positively affect adherence in terms of compliance with prescribed medication regimens may not affect patients’ views on adherence, and this should be taken into consideration when planning and negotiating treatment modalities with each individual patient suffering from schizophrenia.