Jonathan Campion

Factors Associated With Success of Smoke-Free Initiatives in Australian Psychiatric Inpatient Units

OBJECTIVE Smoking is the largest cause of preventable illness in the United States, the United Kingdom, Canada, Australia, and many other countries. Smokers with mental illness smoke significantly more than those without mental illness and therefore experience even greater smoke-related harm. Internationally, there is increasing pressure on psychiatric inpatient settings to adopt smoke-free policies. This study examined smoke-free policies across psychiatric inpatient settings in Australia and thereby identified factors that may contribute to the success or failure of smoke-free initiatives in order to better inform best practice in this important area. METHODS Semistructured in-depth telephone interviews were conducted with 60 senior administrators and clinical staff with direct day-to-day experience with smoking activities in 99 adult psychiatric inpatient settings across Australia. Quantitative data were analyzed using descriptive statistical analysis and Pearsons chi square correlations measure of association. RESULTS Factors associated with greater success of smoke-free initiatives were clear, consistent, and visible leadership; cohesive teamwork; extensive training opportunities for clinical staff; fewer staff smokers; adequate planning time; effective use of nicotine replacement therapies; and consistent enforcement of a smoke-free policy. CONCLUSIONS A smoke-free policy is possible within psychiatric inpatient settings, but a number of core interlinking features are important for success and ongoing sustainability.

Achieving Smoke-Free Mental Health Services: Lessons from the Past Decade of Implementation Research

The culture of smoking by patients and staff within mental health systems of care has a long and entrenched history. Cigarettes have been used as currency between patients and as a patient management tool by staff. These settings have traditionally been exempt from smoke-free policy because of complex held views about the capacity of people with mental disorder to tolerate such policy whilst they are acutely unwell, with stakeholders’ continuing fierce debate about rights, choice and duty of care. This culture has played a significant role in perpetuating physical, social and economic smoking associated impacts experienced by people with mental disorder who receive care within mental health care settings. The past decade has seen a clear policy shift towards smoke-free mental health settings in several countries. While many services have been successful in implementing this change, many issues remain to be resolved for genuine smoke-free policy in mental health settings to be realized. This literature review draws on evidence from the international published research, including national audits of smoke-free policy implementation in mental health units in Australia and England, in order to synthesise what we know works, why it works, and the remaining barriers to smoke-free policy and how appropriate interventions are provided to people with mental disorder.

European Psychiatric Association (EPA) guidance on prevention of mental disorders.

There is considerable evidence that various psychiatric conditions can be prevented through the implementation of effective evidence-based interventions. Since a large proportion of lifetime mental illness starts before adulthood, such interventions are particularly important during childhood and adolescence. Prevention is important for the sustainable reduction of the burden of mental disorder since once it has arisen, treatment can only reduce a relatively small proportion of such burden. The challenge for clinicians is to incorporate such interventions into non-clinical and clinical practice as well as engaging with a range of other service providers including public health. Similar strategies can be employed in both the European and global contexts. Promotion of mental well-being can prevent mental disorder but is also important in the recovery from mental disorder. This guidance should be read in conjunction with the EPA Guidance on Mental Health Promotion. This guidance draws on preparatory work for the development of England policy on prevention of mental disorder which used a wide range of sources.

Implementing smoke-free policies in mental health inpatient units: learning from unsuccessful experience

Objective: The aim of this paper is to describe the introduction, trial and termination of a smoke-free policy in an acute mental health unit of a regional hospital, and to consider factors that may contribute to the success of such policies in other settings. Methods: This analysis is based on key informant interviews and review of correspondence related to the trial, and examination of the relevant incident-reporting database. Results: Planning for implementation is described. The trial itself was terminated after 6 weeks due to perceived increases in aggression by patients towards staff working in the high dependency unit. Staff perceived that these episodes were directly related to these patients not being allowed to smoke. While there was an increase in events during the trial relating to two seriously ill individuals, examination of formal incident reports over a period of 2 years suggests little change in the overall number of incidents. Conclusions: Despite clear public health benefits, implementation of a smoke-free policy may have untoward behavioural effects in institutional mental health settings. In addition, staff expectations and perceptions are critical. Salient factors appear to be preparation of staff and patients, appropriate training, avoidance of exceptions and inconsistency, considering alternatives to smoking to fill the gap created by the policy, and a culture of critical evaluation in practice. Such processes will facilitate understanding and cooperation so that mental health services are able to participate in important policy processes with implications for the health of patients and staff.

Minding the Mind: The Effects and Potential of a School-Based Meditation Programme for Mental Health Promotion

A meditation programme was introduced into 31 Catholic schools in one diocese in Queensland, Australia in 2006 which engaged more than 10,000 students between the ages of 5 and 18 years. The objective of the study was to conduct an initial evaluation of this meditation programme which might serve as preparation for a larger prospective study. Semi-structured individual and group interviews with 54 students, 19 teachers and seven parents were carried out in three of these schools, each at the elementary level. Feedback from students, teachers and parents on the perceived effects of this programme indicated favourable impressions of programme benefits. Effects consistently cited included increased relaxation and feelings of calm, reduced stress, reduced anger and improved concentration. Many participants also reported that the experience of meditation at school had prompted them to meditate outside school, particularly at times of stress. A whole-school approach appeared to facilitate more regular practice. This preliminary evaluation suggests that school-based meditation may represent an effective mental health promotion intervention worthy of further study.

Bridging the triple divide: performance and innovative multimedia in the service of behavioural health change in remote Indigenous settings.

Objectives: The use of innovative information technology is now well established in health. However, while the gap in health status between Indigenous and other Australians is both significant and unchanging, there is limited application of these new approaches to addressing this national health priority. This may in part reflect the ‘digital divide’, which is another facet of Indigenous disadvantage. This paper describes an approach to address both issues in remote Indigenous settings. Results: The Health Interactive Technology Network began as a proof-of-concept study of touchscreen technology in two Indigenous health settings. It has subsequently expanded to a number of remote Indigenous communities and developed new platforms and applications to respond to emerging health issues. In creating narrative, interactive approaches to address choices in relation to health behaviours, the community development and engagement effects of the creative process have been highlighted. These findings suggest that these approaches will be suited to further expansion in the area of mental health.

Mental health professionals’ perspectives on the implementation of smoke-free policies in psychiatric units across England

Background: The original audit on which this 2013 secondary analysis is based, was conducted in 2010. It explored implementation of smoke-free policies from the perspective of unit managers in 147 psychiatric units across England comprising a randomly selected sample of nine different unit types. Material: Two main themes are presented: positive perspectives of smoke-free policy implementation, and barriers and problems with smoke-free policy implementation. Analysis of unit managers’ experiences and perspectives found that 96% of participants thought smoke-free policy had achieved positive outcomes for staff, patients, services and care. Discussion: Consistency of response was the most prominent factor associated with policy success. Quality of the physical environment and care delivery were clear positive outcomes which enabled the environment to be more conducive to supporting staffs’ and patients’ quit attempts. Lack of consistency and a prevailing culture of acceptance of smoking were identified as some of the most reported perceived continuing problems. Solutions included the need to acknowledge that this type of complex systems change takes time and ongoing staff education and training. Conclusion: Our results demonstrate the importance of taking into account the experiences and attitudes of staff responsible for enacting smoke-free policy.

Religious and indigenous treatment of mental illness in South India—A descriptive study

Abstract In a follow-up to an earlier study we decided to interview a number of religious healers and ascertain their views on mental illness. A sample of ten healers—Hindu, Muslim and Christian—were interviewed at length. In addition, five sites of healing were visited and various religious rituals observed. The general emphasis in care is on a pluralistic holistic approach and individual healers have several models of mental illness in their repertoire. The shrines are virtually specific in dealing with specific psychiatric problems. Some healers were able to identify serious mental illness and were able to refer these individuals to psychiatrists, whereas others felt that they were able to deal with these themselves. We present accounts of our interviews and highlight the advantages of the holistic approach and of qualitative methods of research.

Health inequalities and psychosis: time for action.

People with psychosis face a life-restricting and life-shortening epidemic of obesity, diabetes and cardiovascular disease. This can be predicted by the associated antecedent risk factors evident from early in psychosis, yet remain largely ignored. Greater coordination between primary care, secondary care and public health to systematically prevent and intervene earlier for these physical illnesses offers a realistic solution to reduce this health inequality.

Type of unit and population served matters when implementing a smoke-free policy in mental health settings: Perceptions of unit managers across England.

Background: Globally, smoking remains a significant issue for mental health populations. Many mental health trusts in England are facing challenges of implementing the National Institute for Health and Care Excellence guidance according to which all mental health settings, no matter the type, should be entirely smoke-free and provide comprehensive smoking cessation support. Aim: The aim of this paper was to determine if unit type and unit manager smoking status influence mental health smoke-free policy implementation. Method: This paper reports on the secondary analysis of data from a cross-sectional survey of 147 mental health inpatient settings in England, in 2010. The original study’s main aim was to understand unit managers’ perceived reasons for success or failure of smoke-free policy. Results: Unit managers (n = 131) held a positive stance towards supporting smoke-free policy and most perceived that the policy was successful. Non-smoker unit managers were more likely to adopt complete bans than smoker unit managers, whereas smoker unit managers were more likely than non-smoker unit managers to think that stopping smoking aggravated patients’ mental illness. Smoking rates for staff and patients remain high, as perceived by unit managers, regardless of unit type. Proportion of units offering nicotine replacement therapy and peer support to patients was significantly higher in locked units compared to semi-locked or residential rehabilitation. Applied strategies significantly vary by type of unit, whereas unit managers’ knowledge, attitude and practices vary by their smoking status. Discussion: There are nuanced differences in how smoke-free policy is enacted which vary by unit type. These variations recognise the differing contexts of care provision in different types of units serving different patient groups. Addressing staff smoking rates, promoting consistency of staff response to patients’ smoking and providing staff education and support continue to be key strategies to successful smoke-free policy. Conclusions: Our results demonstrate the importance of taking into account the type of unit and acuity of patients when enacting smoke-free policy and addressing staff smoking.