Lynda Tait

A new scale (SES) to measure engagement with community mental health services

The need for a measure of engagement with Community Mental Health Services has been identified. This article reports on the development and preliminary psychometric evaluation of a scale, Service Engagement Scale (SES), to measure engagement with community mental health services. Five Community Psychiatric Nurses completed the SES for 66 clients receiving Assertive Outreach services with an ICD-10 diagnosis of schizophrenia. Test–retest reliability of the subscale items and scale total is in the good to excellent range. Validity is supported by good internal consistency and by the criterion group method. Although preliminary psychometric results are promising, further psychometric study is necessary to evaluate the scales factor structure. The SES appears to evaluate engagement with services, and may therefore be a useful tool to identify areas of concern with clients experiencing engagement difficulties.

Design of the BiRmingham Early Detection In untREated psyChosis Trial (REDIRECT): cluster randomised controlled trial of general practitioner education in detection of first episode psychosis [ISRCTN87898421]

BackgroundTreatment delay in first episode psychosis is common. As general practitioners are the first point of contact for many individuals with first episode psychosis, they are well placed to detect the early symptoms and make urgent referrals to specialist secondary care services. However, early psychosis is often difficult to detect. The primary objective of the Redirect trial is to estimate whether an educational intervention targeted at general practitioners increases the general practitioner referral rate of young people with first episode psychosis to Early Intervention Services.Methods/designThis paper describes the design of a stratified-cluster randomised controlled trial of an educational intervention on first episode psychosis in primary care. The primary outcome is the number of general practitioner referrals of young people with first episode psychosis to Early Intervention Services. Secondary outcomes are duration of untreated psychosis, time to recovery, use of the Mental Health Act, and general practitioner consultation rate. Young people with first episode psychosis referred to Early Intervention Services will be recruited over a two-year period from 1 March 2004. Seventy-eight out of 89 eligible general practices were recruited. The educational intervention has been implemented and evaluated by general practitioners. The education was well received and considered relevant to clinical practice by the general practitioners.DiscussionThe results suggest that the recruitment strategy and implementation of the educational intervention are feasible and acceptable in a primary care setting. The Redirect trial will provide robust information about the efficacy of an evidence-based complex educational intervention targeted at general practitioners on referral rates of young people with first episode psychosis to Early Intervention Services.

The development and implementation of an educational intervention on first episode psychosis for primary care

Introduction  This paper describes the development and implementation of an educational intervention to help general practitioners (GPs) recognise young people with first episode psychosis.

The International Study on General Practitioners and Early Psychosis (IGPS)

BACKGROUND In much of the world, general practitioners (GPs) are the health professionals most frequently initially contacted when a young person is developing psychosis. However little is known about their expertise in assessing psychosis and its risk. METHODS To assess the diagnostic patterns and treatment practices related to psychosis of GPs working in a range of health care systems, questionnaires were mailed to 12,516 randomly selected GPs in seven countries: Canada, Australia, New Zealand, England, Norway, Austria and the Czech Republic. Sites were defined as gatekeeping or non-gatekeeping, based on the primary care health system in effect at each site. A gatekeeping system (GK) is one which mandates that patients see a GP before in order to be referred to a specialist. By contrast, in a non-gatekeeping (nGK) system, individuals can seek help directly from specialists without authorization by a GP. RESULTS Twenty-two percent (n=2784) GPs responded to the mailed questionnaire. They reported low prevalence of early psychosis seen in general practice. Using awareness of functional decline as a prognostic sign as a proxy, gatekeeping (GK) GPs were found to be superior in their knowledge of the signs and symptoms of early psychosis than were non-gatekeeping GPs. GPs with less knowledge as to early psychosis were more likely to refer individuals with suspected psychosis to specialists. GPs reported a preference for access to specialized outpatient services as compared with obtaining continuous medical education relevant to early psychosis. The duration of maintenance treatment recommended by GPs was less than that recommended in international guidelines. GPs also underestimated the risk for relapse after a first episode of psychosis. CONCLUSIONS As GPs were largely unaware of features of early psychosis, such as functional decline, this should be the target of educational programs for GPs. However, the incidence of psychosis is low and GPs express a preference for access to appropriate referral over continuing medical education. Therefore, the development of specialized services for the assessment and care of patients who are in the early stages of developing schizophrenia may be warranted.

Influenza vaccination of future healthcare workers: a cross-sectional study of uptake, knowledge and attitudes.

Promotional campaigns recommend immunisation against influenza in healthcare workers (HCWs) but the uptake in this group remains low. We conducted a survey study during the 2008-2009 influenza vaccination period amongst future HCWs to quantify uptake and identify barriers to immunisation. Overall uptake was 8.0% (95% CI 5.9-10.8%), which is lower than the uptake amongst current HCWs (13.4%) and short of current government targets (75%). Knowledge about influenza was good but insufficient to encourage HCWs to get vaccinated. Promotional campaigns are needed that emphasise the role of vaccination in personal and patient protection.

The REFER (REFer for EchocaRdiogram) protocol: a prospective validation of a clinical decision rule, NT-proBNP, or their combination, in the diagnosis of heart failure in primary care. Rationale and design

BackgroundHeart failure is a major cause of mortality and morbidity. As mortality rates are high, it is important that patients seen by general practitioners with symptoms suggestive of heart failure are identified quickly and treated appropriately. Identifying patients with heart failure or deciding which patients need further tests is a challenge. All patients with suspected heart failure should be diagnosed using objective tests such as echocardiography, but it is expensive, often delayed, and limited by the significant skill shortage of trained echocardiographers. Alternative approaches for diagnosing heart failure are currently limited. Clinical decision tools that combine clinical signs, symptoms or patient characteristics are designed to be used to support clinical decision-making and validated according to strict methodological procedures. The REFER Study aims to determine the accuracy and cost-effectiveness of our previously derived novel, simple clinical decision rule, a natriuretic peptide assay, or their combination, in the triage for referral for echocardiography of symptomatic adult patients who present in general practice with symptoms suggestive of heart failure.Methods/designThis is a prospective, Phase II observational, diagnostic validation study of a clinical decision rule, natriuretic peptides or their combination, for diagnosing heart failure in primary care. Consecutive adult primary care patients 55 years of age or over presenting to their general practitioner with a chief complaint of recent new onset shortness of breath, lethargy or peripheral ankle oedema of over 48 hours duration, with no obvious recurrent, acute or self-limiting cause will be enrolled. Our reference standard is based upon a three step expert specialist consensus using echocardiography and clinical variables and tests.DiscussionOur clinical decision rule offers a potential solution to the diagnostic challenge of providing a timely and accurate diagnosis of heart failure in primary care. Study results will provide an evidence-base from which to develop heart failure care pathway recommendations and may be useful in standardising care. If demonstrated to be effective, the clinical decision rule will be of interest to researchers, policy makers and general practitioners worldwide.Trial registrationISRCTN17635379

Development of a patient experience questionnaire for primary care mental health

Introduction: There are no validated measures available for use in assessing patients’ views of the quality of primary care mental healthcare at practice level. Methods: The Patient Experience Questionnaire was developed through an initial information-gathering phase with focus groups followed by questionnaire development and validation with patients in nine general practices in the West Midlands. Statistical analyses were performed to test the internal consistency, validity and reliability of the questionnaire. Results: Fifty-six patients participated in focus groups, and 241 patients completed the questionnaire. The 20-item questionnaire had good internal consistency (Cronbach α = 0.94) and test–retest reliability (r = 0.859; p = 0.01). Discussion: The Patient Experience Questionnaire appears to be a valid and reliable instrument, able to assess patients’ views of the quality of primary care mental healthcare at practice level.

Management of postnatal depression in primary care: a window of opportunity

The postnatal period is a particularly distressing time to experience mental health problems. Detection and appropriate treatment of psychiatric symptoms at this critical time in family life is perhaps more important than at any other time. Postnatal depression (PND) affects more than one in 10 women;1,2 it significantly impacts on partners;3 is associated with an impaired mother–infant bond;4 and has been linked to poor cognitive and emotional development in the infant,5 thus contributing to the inter-generational transmission of poor health. Suicide is a leading cause of maternal death in the UK; the largest proportion due to PND and puerperal psychosis,6 and completed suicides are thought to be the tip of the iceberg in terms of ‘near miss’ events. However, many women are reluctant to disclose PND symptoms to healthcare professionals.7 Strategies for identifying PND and supporting women and their families are therefore very important and must be timely, holistic, and appropriate to new mothers. The perinatal period provides many opportunistic occasions within which to identify and manage mild, moderate, and severe mental illness. This is due to the increased level of health professional contact through routine antenatal and postnatal contact, which does not occur in the non-postpartum population. Although GPs are often the first port of call for women8 or their families seeking help during pregnancy and postnatally, all healthcare professionals in contact with pregnant or postpartum women should be alert to possible symptoms, either those of new onset or of a more chronic nature. Given the evidence for the effectiveness of both pharmacological and psychological interventions in improving health outcomes when PND is identified, there is much to be gained from early identification and management in primary care. …

Generalised anxiety disorder: the importance of life context and social factors.

In this issue of the BJGP , Sherina and colleagues provide us with a reminder that generalised anxiety disorder (GAD) is common among primary care patients.1 GAD is one of the most frequent of all psychiatric disorders seen in primary care — second only to depression — but women are twice as likely as men to have this disorder.2 Compared with other patient groups, patients with GAD have higher rates of medical appointments and clinical investigations.3 GAD therefore incurs a substantial burden not only on patients and their families but also on healthcare resources. Primary care is where most patients with GAD present and receive care. Therefore, GPs have a vital role to play in identifying and managing generalised anxiety, together with its primary cause, among their patients. Recognising and treating patients with GAD in primary care is challenging, which is often due to its complex presentation. GAD can easily be missed due to the wide range of clinical presentations and co-occurrence with other psychiatric disorders, somatic complaints, and physical medical conditions. These coexisting associations are important clinically. Patients who have comorbid anxiety and depressive disorders or medical conditions have an extended clinical course and poorer long-term outcomes than patients with ‘pure’ GAD. To complicate matters further, primary care patients report substantial levels of anxiety that do not always automatically meet diagnostic criteria, but the symptoms result in a substantial degree of suffering and disability. However, it is only recently that evidence-based guidelines have been introduced that are helpful in guiding management and treatment decisions in primary care patients with GAD. A partial update of the National Institute for Health and Clinical …

Observational longitudinal cohort study to determine progression to heart failure in a screened community population: the Echocardiographic Heart of England Screening Extension (ECHOES-X) study

Objectives Rescreen a large community cohort to examine the progression to heart failure over time and the role of natriuretic peptide testing in screening. Design Observational longitudinal cohort study. Setting 16 socioeconomically diverse practices in central England. Participants Participants from the original Echocardiographic Heart of England Screening (ECHOES) study were invited to attend for rescreening. Outcome measures Prevalence of heart failure at rescreening overall and for each original ECHOES subgroup. Test performance of N Terminal pro-B-type Natriuretic Peptide (NT-proBNP) levels at different thresholds for screening. Results 1618 of 3408 participants underwent screening which represented 47% of survivors and 26% of the original ECHOES cohort. A total of 176 (11%, 95% CI 9.4% to 12.5%) participants were classified as having heart failure at rescreening; 103 had heart failure with reduced ejection fraction (HFREF) and 73 had heart failure with preserved ejection fraction (HFPEF). Sixty-eight out of 1232 (5.5%, 95% CI 4.3% to 6.9%) participants who were recruited from the general population over the age of 45 and did not have heart failure in the original study, had heart failure on rescreening. An NT-proBNP cut-off of 400 pg/mL had sensitivity for a diagnosis of heart failure of 79.5% (95% CI 72.4% to 85.5%) and specificity of 87% (95% CI 85.1% to 88.8%). Conclusions Rescreening identified new cases of HFREF and HFPEF. Progression to heart failure poses a significant threat over time. The natriuretic peptide cut-off level for ruling out heart failure must be low enough to ensure cases are not missed at screening.