Kevin Gournay

Dual diagnosis in the suburbs: prevalence, need, and in-patient service use.

Abstract  Background: Previous research has found comorbid severe mental illness and substance misuse (dual diagnosis) to be highly prevalent and to be associated with serious clinical and social problems, and increased service use in inner-city populations. The present study measures the prevalence of dual diagnosis, patterns of substance misuse, and associated in-patient use in a more demographically representative population in a suburban area of South London Method: We identified representative prevalent cases with psychotic illnesses who had been in contact with services in a geographically defined catchment area in Croydon over the previous 6 months. Cases of alcohol or substance misuse and dependence were identified through standardised interviews with patients and keyworkers, and socio- demographic and in-patient psychiatric service use data were also recorded. Results: Sixty-one of the 124 cases identified were randomly selected for interview, of whom 66% responded (N = 40). The prevalence rates of dual diagnosis (DD) observed were 33% (95% CI 18–47%) for any substance misuse, 20% (95% CI 8–32%) for alcohol misuse only, 5% (95% CI −16 to 26%) for drug misuse only, and 8% (95% CI −0.7 to 16%) for both drug and alcohol misuse. A lifetime history of any illicit drug use was observed in 35% of the sample (95% CI 20–50%). Patients who misuse alcohol and drugs were not found to be more likely to have been admitted to hospital in the previous 2 years, with little difference being observed between DD and psychosis-only patients in the mean number of in-patient admissions in this period (mean difference 0.25, 95% CI for difference −1.5 to 2.0). However, the DD patients were found to have spent on average over twice as long in hospital as other psychotic in-patients over the previous 2 years (mean difference 67.3 days, 95% CI for difference −205.9 to 71.2 days). DD patients were also found to have a greater number of unmet areas of need than the psychosis-only patients, which included accommodation, daytime activity, and social life, as well as substance misuse. Conclusions: The prevalence of substance misuse in patients with severe mental disorders in a suburban area is about as high as that for similar patients in inner-city London. While DD patients are not admitted more often than patients with psychosis alone, they have double the length of in-patient stay, which may be attributable to higher levels of unmet need.

Integrated Care for Co-occurring Disorders: Psychiatric Symptoms, Social Functioning, and Service Costs at 18 Months

OBJECTIVE Persons with severe mental illness have high rates of comorbid substance use disorders. These co-occurring disorders present a significant challenge to community mental health services, and few clinical trials are available to guide the development of effective services for this population. The study aimed to evaluate the effectiveness of a program for case managers that trained them to manage substance use disorders among persons with severe mental illness. METHODS A cluster-randomized controlled trial design was used in South London to allocate case managers either to training or to a waiting list control condition. Outcomes and service costs (health care and criminal justice) over 18 months of 127 patients treated by 40 case managers who received training were compared with those of 105 patients treated by 39 case managers in the control condition. RESULTS Brief Psychiatric Rating Scale scores for the intervention group indicated significant improvements in psychotic and general psychopathology symptoms. Participants in the intervention group also reported fewer needs for care at follow-up. No significant differences were found between the two groups in levels of substance use at 18 months. At follow-up both groups reported increased satisfaction with care. Service costs were also similar for the two groups. CONCLUSIONS Compared with standard care, integrated treatment for co-occurring disorders provided by nonspecialist mental health staff produced significant improvements in symptoms and level of met needs, but not in substance use or quality of life, at no additional cost.

Physical restraint training for nurses in English and Welsh psychiatric intensive care and regional secure units

Background: The physical management of violence in psychiatric in-patient settings is of great concern and interest. However, there are no guidelines concerning training providers, course content, or course length, and little is known about injuries to staff during training. Aim: To investigate training in physical restraint in Psychiatric Intensive Care Units (PICUs) and Regional Secure Units (RSUs) in England and Wales, with a view to comparing course content and length, and injuries in training across the training providers cited by respondents. Method: Questionnaires were completed by randomly selected PICU and RSU nursing staff on 63 participating wards (of a total of 112 such wards in England and Wales). Results: 338 nurses (47% response rate) replied. Training in a wide variety of techniques was reported, although in practice a core curriculum can be identified. Few respondents were able to state which provider conducted their initial training. The reported length of initial training courses and re...

The development and internal consistency of the satisfaction with Antipsychotic Medication Scale.

BACKGROUND Satisfaction with antipsychotic medication is an important outcome variable. To date, there is a lack of a well-established measure to quantify patient satisfaction with psychiatric medication. This paper describes the development, dimensionality, reliability and validity of the Satisfaction with Antipsychotic Medication (SWAM) scale. METHOD Clinical and academic experts devised a 33-item Likert scale satisfaction questionnaire. Following a pilot study in a sample of 69 people with schizophrenia, 315 people with schizophrenia on the caseload of local mental health services in three London boroughs completed the questionnaire. The dimensionality, internal consistency and validity of the devised instrument were assessed. RESULTS Reliability of the SWAM scale was good for subscales and total scores. The alpha coefficient for the two subscales: treatment acceptability and medication insight were 0.92 and 0.84 respectively. The a coefficient for the SWAM scale total score was 0.91 and ranged from 0.92 to 0.90. CONCLUSION Testing of the psychometric properties of the SWAM scale demonstrate that it is a reliable instrument for measuring patient satisfaction with antipsychotic medication. The measure could be used in routine clinical practice in mental health services to assess patient satisfaction with psychiatric medication.

Content of command hallucinations predicts self-harm but not violence in a medium secure unit

Evidence to date has supported negative relationships, a null relationship and a positive relationship between command hallucinations and violence or self-harm. This study was designed to determine the relationship between command hallucinations with violent or self-harm content and incidents of violence and self-harm in forensic inpatients. Patients with (n = 56) and without (n = 54) a lifetime history of command hallucinations and resident in a medium-security hospital were identified through clinical and legal records over 51 months. Measures included: staff-observed violence and self-harm; presence and content of command hallucinations; paranoid delusions; previous violent convictions; length of stay; gender; history of alcohol or illicit drug abuse. Statistical analyses used negative binomial regression. Violent command hallucinations and inpatient violence were unrelated. Self-harming command hallucinations and an absence of paranoid delusions were positively associated with self-harm. The processes that determine compliance with command hallucinations remain unclear.

The effect of medication management training on community mental health nurse's clinical skills

Background. There is evidence that compliance therapy improves treatment adherence and clinical outcomes in patients with schizophrenia. Community Mental Health Nurses (CMHNs) are ideally placed to deliver compliance therapy but require training to develop the necessary clinical skills.Aim. To explore whether a brief medication management training package is effective in developing the compliance therapy skills of CMHNs.Method. The study had a within subjects repeated measures design. A representative sample of 52 CMHNs entered the study. They performed a role-play task pre- and post-training that was videotaped and blind rated by an independent rater using the Cognitive Therapy Scale (CTS). Knowledge was assessed pre- and post-training using a knowledge about medication management questionnaire. Trainees also completed a satisfaction with training questionnaire at the end of the course.Results. Following training there was a statistically significant improvement in mean scores on the primary measure of skills, the CTS (mean pre-training CTS-total score 13.88, mean post-training CTS-total score 31.12; p<0.01). There was also a significant categorical improvement in the number of trainees who demonstrated satisfactory skills. Knowledge about medication management was significantly improved and trainees reported that training was acceptable and relevant to their clinical practice.Conclusions. In this uncontrolled study training improved the medication management skills of CMHNs.

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.

Mental illness, substance abuse, demographics and offending: dual diagnosis in the suburbs

High rates of offending and violence have been found in patients with co-morbid severe mental illness and substance misuse (dual diagnosis), although research has focused upon inner-city populations. This study compares offending and violence rates in patients with dual diagnosis (DD) and patients with psychosis only, drawing on a more demographically representative population. Forty patients with severe mental disorders were interviewed in a geographically defined catchment area in Croydon, Surrey. Cases of alcohol or drug misuse were identified, and measures of lifetime history of offending (including violence) and recent violence were obtained. DD patients were more likely to report a lifetime history of both offending and violence than patients with psychosis only (although gender may play a greater role than substance misuse). Few instances of recent violence were found, and no between-group differences were detected. The medical caserecords of DD patients were significantly more likely to contain a lifetime history of non-substance misuse-related offending, but not violence. However, the extent to which substance misuse contributes to violence and offending independently of contextual variables requires further investigation.

Breakaway and physical restraint techniques in acute psychiatric nursing: Results from a national survey of training and practice

The survey examined training and practice in the prevention and management of violence in nurses working in acute in-patient psychiatric services throughout the UK. Out of 2,152 questionnaires sent out, 771 completed responses were returned (36%). While the response rate was low, there were no obvious biases affecting it, and a high level of statistical power was attained. The study is the largest survey of training in the prevention and management of violence in this population conducted so far. Most respondents reported an acceptable ratio of theoretical input to practical skills training, although some important theoretical aspects received insufficient attention. The use of wrist flexion and pain compliance elements in the restraining holds taught were frequently reported. In clinical practice, breakaway techniques were reported as more frequently used than has been suggested in earlier research. Some redundancies in restraint training were also found, with some commonly-taught techniques being seldom or never used. Respondents were not particularly confident in their ability to use their skills safely or effectively. Training sessions were generally considered to have been safely and well run. The need for national standards in training that the findings suggest, and directions for further research are discussed.

Training for the Mental Health Workforce: A Review of Developments in the United Kingdom

Objective: Implementation of the National Mental Health Strategy has important implications for education and training of the Australian mental health workforce. This paper discusses relevant developments in the United Kingdom that may provide some lessons for Australia. Method: A review was undertaken of a number of specific clinical education and training programs for mental health workers in the United Kingdom which have been subjected to published evaluation. Results and conclusions: A finite mental health resource base dictates that education and training activity should: (i) be evaluated; (ii) target those clients most in need; (iii) include evidence-based approaches such as assertive community treatment, medication management, cognitive—behaviour therapy and family interventions; and (iv) prepare mental health workers in the core competencies needed to implement these approaches. Two programs, developed in the United Kingdom, which meet these criteria are presented as examples of best practice: the nurse therapy model established by Isaac Marks; and the Thorn initiative established in association with the Institute of Psychiatry, London and the University of Manchester.