Nick O'Connor

Clinical practice recommendations for bipolar disorder

Objective:  To provide clinically relevant evidence‐based recommendations for the management of bipolar disorder in adults that are informative, easy to assimilate and facilitate clinical decision‐making.

The lived experience of involuntary community treatment: a qualitative study of mental health consumers and carers

Objective: To describe the lived experiences of people subject to community treatment orders (CTOs) and their carers. Method: We recruited 11 participants (five mental health consumers and six carers) through consumer and carer networks in NSW, Australia, to take part in interviews about their experiences. We analysed the interview data set using established qualitative methodologies. Results: The lived experiences were characterised by ‘access’ concerns, ‘isolation’, ‘loss and trauma’, ‘resistance and resignation’ and ‘vulnerability and distress’. The extent and impact of these experiences related to the severity of mental illness, the support available for people with mental illnesses and their carers, the social compromises associated with living with mental illness, and the challenges of managing the relationships necessitated by these processes. Conclusions: The lived experience of CTOs is complex: it is one of distress and profound ambivalence. The distress is an intrinsic aspect of the experience of severe mental illness, but it also emerges from communication gaps, difficulty obtaining optimal care and accessing mental health services. The ambivalence arises from an acknowledgement that while CTOs are coercive and constrain autonomy, they may also be beneficial. These findings can inform improvements to the implementation of CTOs and the consequent experiences.

‘Learning Organizations’: a clinician's primer

Objectives: Most clinicians are poorly informed in relation to the key concepts of organizational learning. Yet the paradigm may offer clinicians a powerful method for using their knowledge and skills to respond to the demands of a changing environment through experimentation and learning. The concept is critically examined. Organizational learning principles are presented, including a conceptual framework for assessing health services as Learning Organizations. Barriers to organizational learning and strategies to overcome these are discussed. Methods: The seminal works of Argyris and Senge are reviewed and a framework for assessing organizational learning in health services is proposed. Current area health service actions are evaluated against the ‘diagnostic’ framework for a Learning Organization. Results: Although critical examination reveals a poor empirical basis for the concept, the metaphor of the Learning Organization provides a useful conceptual framework and tools for individuals and organizations to apply in developing knowledge and effecting change. The Clinical Practice Improvement and Root Cause Analysis programs being conducted across NSW area health services meet the criteria for effective organizational learning. Conclusions: Key concepts from organizational learning theory provide a diagnostic framework for evaluating area health services as Learning Organizations and support two current strategies for overcoming barriers to organizational learning.

Blame and Accountability 2: On Being Accountable

Objective: This second paper follows an exploration of the nature of blame and addresses the balance between a ‘blame-free’ health culture and appropriate accountability. This paper aims to define and describe accountability as a key component of clinical governance and a responsive, fair and transparent health culture. Methods: The literature is examined and the concept of a fair and transparent health culture is explored. The case vignette in Part 1 is used to illustrate a particular issue of accountability. Results: The place of accountability in relation to clinicians and health organisations is elucidated. Conclusions: The necessary conditions for an accountable, responsive, fair and transparent health culture are proposed.

Blame and Accountability 1: Understanding Blame and Blame Pathologies:

Objective: In this first paper the role and dynamics of blame in the context of medical critical incidents is examined. Blame pathologies are described and the complex nature of medical adverse events and the environment are explored. Methods: The literature is examined and a case scenario explored. Results: Evidence regarding effects of a ‘blame culture’ on clinicians and organizations is presented. In an accompanying second paper the place of accountability in relation to clinicians and health organizations is elucidated. Conclusions: The necessary conditions for an accountable, responsive, fair and transparent health culture are proposed.

The Concord Centre for Mental Health's new 'phase of illness' model of care: are we on the right track?

Objective: The aim of this study was to provide an overview of a new ‘phase of illness’ model of care after relocation of Rozelle Hospital to the new purpose built Concord Centre for Mental Health and discuss its implementation and progress thus far. Method: One year after relocation, staff were asked to provide feedback of their views of the new model of care in order to identify implementation barriers and ways forward. Results: The new model has clear benefits for the consumer, but there are a number of practical challenges and dilemmas emerging that necessitate some refinement and evaluation. Feedback from staff provided a wide range of opinions indicating that some were quite cynical of the new model while others were very supportive and thought that patient care was enhanced. Conclusions: Further development and consolidation of the model is required, including more education sessions and a clear mission statement at unit, hospital and community levels. Further research is also required to assess the impact and ability of the new model to deliver better patient outcomes, especially in regard to continuity of care.

Why are some patients admitted to psychiatric hospital while others are not? : a study assessing risk during the admission interview and relationship to outcome

The aim of this study was to determine what patient characteristics are used to decide whether a patient is or is not admitted to a psychiatric hospital, and what happens to those not admitted. A further aim was to determine if high levels of risk on admission predict seclusions, length of stay, or readmission within 28 days. Data were collected prospectively on consecutive presentations to an admission office via case notes and electronic databases. Eighty percent (100/127) of the adults presenting to the admission office over a typical month were admitted to hospital. Patients were more likely to be admitted if they were experiencing psychosis or exacerbation of schizophrenia, referred by other doctors or mental health teams, had a legal reason for referral, or if they were homeless. There was no association between risk for violence or suicide and seclusion rates, length of stay, or being readmitted within 28 days. It was reassuring to find that 85% of those not admitted were referred to other mental health providers, and none required admission over the following month. This study found high rates of seclusion and readmissions within 1 year, which requires further study to find strategies to reduce these rates.

The Development of Consensus Guidelines for the Treatment of Young People with First Episode Psychosis

Objective: The aim is to describe the process adopted in Northern Sydney, Sydney, Australia for developing consensus guidelines for the treatment of young people with first episode psychosis. Method: The process included academic detailing with psychiatrists working in Northern Sydney adolescent and adult mental health services, two clinician forums, and a survey. While the guidelines were based on the Australian Clinical Guidelines for Early Psychosis and published studies, the expertise of clinicians in Northern Sydney was also sought. Results: The consensus guidelines have been endorsed for use in Northern Sydney. The guidelines cover the issues of assessment and treatment of psychosis in young people, investigations, use of parenteral medication, diagnosis, and information for clients. Conclusions: The authors make several observations about the process of guideline development. Academic detailing proved to be a more effective way than questionnaires for obtaining information from clinicians. The process of developing the guidelines seemed to be, in some ways, more important than the final product.

The Many Faces of Risk: A Qualitative Study of Risk in Outpatient Involuntary Treatment.

OBJECTIVE This study aimed to derive a conceptualized model of risk in outpatient involuntary psychiatric treatment that has utility and meaning for stakeholders. METHODS Thirty-eight participants-patients, caregivers, clinicians, and legal decision makers-participated in qualitative interviews about their experiences of outpatient involuntary psychiatric treatment. Interview data were analyzed by using a general inductive method. RESULTS Six types of risk were identified: actual harm, social adversity, therapeutic outcome or compromised treatment, the system, interpersonal distress, and epistemic issues. There were overlaps between discourses on risk but variation in how different aspects of risk were emphasized by participant groups. CONCLUSIONS A comprehensive model of risk contextualized to outpatient involuntary treatment is proposed. It incorporates domains of risk of harm to self or others, risk of social adversity, risk of excess distress, and risk of compromised treatment. This model may have instrumental value in the implementation and the scrutiny of risk-based mental health laws.

Quetiapine causing peripheral oedema

A 28-year-old man of Vietnamese background was an inpatient being treated for psychosis. He had been diagnosed with schizophrenia according to DSM-IV-TR which was considered to be treatment resistant. The acute symptoms included blasphemous, religious delusions and mental images, auditory hallucinations of voices of relatives talking to him and about him, and grandiose ideas related to the purpose of his life and a special ‘mission’ from God.