Paul Lelliott

Obsessive-compulsive beliefs and treatment outcome

Of 49 compulsive ritualizers one-third perceived their obsessive thoughts as a rational and felt that their rituals warded off some unwanted or feared event (the content of their obsessions). The more bizarre the obsessive belief the more strongly it was defended and 12% of cases made no attempt to resist the urge to ritualize. Neither fixity of belief nor resistance to compulsive urges were related to duration of illness. Patients with bizarre and fixed obsessive beliefs responded as well to treatment (all but three received exposure), as did patients whose obsessions were less bizarre and recognized as senseless. There was no difference in outcome between patients who initially found it hard to control their obsessions or never resisted the urge to ritualize and those who initially could control obsessions or resist rituals. One year after starting treatment, patients whose obsessions and compulsions had improved with treatment recognized their irrationality more readily and controlled their compulsive urges more easily. Beliefs appeared to normalize as a function of habituation.

The cost consequences of changing the hospital-community balance: the mental health residential care study.

BACKGROUND Altering the balance of provision between hospital and community care is a key and often contentious component of mental health care policy in many countries. Implementation of this policy in the UK has been slowed by the apparent shortage of suitable community accommodation for people with long-term needs for care and support. Among the consequences could be the silting up of hospital beds by people who could be supported more appropriately elsewhere, in turn denying in-patient treatment to people with acute psychiatric problems and unnecessarily pushing up health service expenditure. METHODS Using data collected in a survey of hospital and residential accommodation services and their residents in eight areas of England and Wales, the cost components of todays balance of care were explored. Comprehensive costs were calculated and their associations with resident characteristics examined using multiple regression analyses. RESULTS On a like-with-like basis, the costs of hospital in-patient treatment for inappropriately placed patients greatly exceeded the costs of community-based care. CONCLUSION Further reduction of hospital beds, however, is not the panacea for an appropriate balance of mental health care, given the unknown but potentially considerable extent of unmet demand, as well as the impact of previous in-patient bed reductions apparent in the services surveyed. Rather, service providers and purchasers should focus on developing community-based care (including increased provision of 24-hour nursed beds) by ensuring that resources released through earlier closure programmes have been redeployed for their intended use and by accessing additional pump-priming or bridging resources.

Screening for the metabolic syndrome in community psychiatric patients prescribed antipsychotics: a quality improvement programme

Objective:  The aim was to evaluate a quality improvement programme designed to increase screening for the metabolic syndrome in community psychiatric patients prescribed antipsychotics.

How pressure is applied in shared decisions about antipsychotic medication: a conversation analytic study of psychiatric outpatient consultations.

The professional identity of psychiatry depends on it being regarded as one amongst many medical specialties and sharing ideals of good practice with other specialties, an important marker of which is the achievement of shared decision-making and avoiding a reputation for being purely agents of social control. Yet the interactions involved in trying to achieve shared decision-making are relatively unexplored in psychiatry. This study analyses audiotapes of 92 outpatient consultations involving nine consultant psychiatrists focusing on how pressure is applied in shared decisions about antipsychotic medication. Detailed conversation analysis reveals that some shared decisions are considerably more pressured than others. At one end of a spectrum of pressure are pressured shared decisions, characterised by an escalating cycle of pressure and resistance from which it is difficult to exit without someone losing face. In the middle are directed decisions, where the patient cooperates with being diplomatically steered by the psychiatrist. At the other extreme are open decisions where the patient is allowed to decide, with the psychiatrist exerting little or no pressure. Directed and open decisions occurred most frequently; pressured decisions were rarer. Patient risk did not appear to influence the degree of pressure applied in these outpatient consultations.

What is life like on acute psychiatric wards

Purpose of review No country has created a mental health care system that can function without ‘acute’ psychiatric wards for the admission of people who require short-term hospital care to treat their mental disorder and prevent them causing harm to themselves or others. Previous research indicates that the quality of care on acute wards is under threat, especially in countries that have undergone a process of ‘deinstitutionalization’. This review describes what life is like on such wards by presenting research findings primarily from qualitative studies. Recent findings Despite great diversity in the structure of mental health services internationally, certain themes or problems appear to be common to all acute wards. First, ward staff are preoccupied with the management of dangerous behaviours and patient throughput. Second, a complex set of factors influence how staff respond to dangerous behaviours: these relate to the patient, the nature of the problem behaviour, staff attitudes and organizational context. Third, ward nurses are dissatisfied with the difficulty they have in forming therapeutic relationships in this particular setting and patients dislike the centrality of pharmacological interventions at the expense of psychological approaches. Summary This review suggests a need to rethink the purpose and function of acute psychiatric wards. Research is required to investigate (1) which interventions improve the safety, and the perception of safety, of the wards, and (2) what strategies improve the quality of therapeutic relationships between staff and patients.

Medication errors in mental healthcare: a systematic review

Background: It has been estimated that medication error harms 1–2% of patients admitted to general hospitals. There has been no previous systematic review of the incidence, cause or type of medication error in mental healthcare services. Methods: A systematic literature search for studies that examined the incidence or cause of medication error in one or more stage(s) of the medication-management process in the setting of a community or hospital-based mental healthcare service was undertaken. The results in the context of the design of the study and the denominator used were examined. Results: All studies examined medication management processes, as opposed to outcomes. The reported rate of error was highest in studies that retrospectively examined drug charts, intermediate in those that relied on reporting by pharmacists to identify error and lowest in those that relied on organisational incident reporting systems. Only a few of the errors identified by the studies caused actual harm, mostly because they were detected and remedial action was taken before the patient received the drug. The focus of the research was on inpatients and prescriptions dispensed by mental health pharmacists. Conclusion: Research about medication error in mental healthcare is limited. In particular, very little is known about the incidence of error in non-hospital settings or about the harm caused by it. Evidence is available from other sources that a substantial number of adverse drug events are caused by psychotropic drugs. Some of these are preventable and might probably, therefore, be due to medication error. On the basis of this and features of the organisation of mental healthcare that might predispose to medication error, priorities for future research are suggested.

A conceptual model of the aims and functions of acute inpatient psychiatry

Background: Acute inpatient care has come under sustained criticism. Services suffer from high occupancy, increased acuity, and patient dissatisfaction with care. The number of beds has been reduced in favour of alternative services. Aim: To articulate clearly the role of acute inpatient care. Method: Drawing on research evidence and the experiences of inpatient and community staff, we present a model to describe the function and tasks of inpatient care. Results: An admission is the result of severity of acute mental disorder, coupled with an acute admission problem. The decision to admit is processed through a filter composed of bed availability, social supports and other services available to the prospective patient. That combined reason provides the primary task of the admission. However patients also bring with them other life and health problems. While not a cause of admission, these problems have to be managed by inpatient staff. Where they can be resolved, they represent an “admission bonus”. Finally, acute care functions because of the legitimate authority of staff, their 24-hour availability for support and supervision, and the provision of treatment and containment. Conclusion: This model explicates many aspects of acute inpatient care that otherwise create confusion.

Questionnaires for 360-degree assessment of consultant psychiatrists: development and psychometric properties

BACKGROUND Expert clinical judgement combines technical proficiency with humanistic qualities. AIMS To test the psychometric properties of questionnaires to assess the humanistic qualities of working with colleagues and relating to patients using multisource feedback. METHOD Analysis of self-ratings by 347 consultant psychiatrists and ratings by 4422 colleagues and 6657 patients. RESULTS Mean effectiveness as rated by self, colleagues and patients, was 4.6, 5.0 and 5.2 respectively (where 1=very low and 6=excellent). The instruments are internally consistent (Cronbachs alpha >0.95). Principal components analysis of the colleague questionnaire yielded seven factors that explain 70.2% of the variance and accord with the domain structure. Colleague and patient ratings correlate with one another (r=0.39, P<0.001) but not with the self-rating. Ratings from 13 colleagues and 25 patients are required to achieve a generalisability coefficient (Erho(2)) of 0.75. CONCLUSIONS Reliable 360-degree assessment of humane judgement is feasible for psychiatrists who work in large multiprofessional teams and who have large case-loads.

The use of prescribing indicators to measure the quality of care in psychiatric inpatients

Objective: To explore the potential for using seven prescribing indicators, individually and in combination, to measure prescribing quality for hospitalised psychiatric patients. Design and setting: The dataset included full details of all psychotropic medication prescribed over a 24 hour period to 4192 inpatients in 49 British mental health services in 1998. Results: Despite the large size of the dataset, for three of the indicators 20 services had fewer than 10 eligible patients. There was great variation between services in indicator scores. Correlations between standardised indicator scores and total score (which omitted the indicator concerned) were above 0.3 for all but one of the indicators. Cronbach’s alpha was 0.73 when this outlying indicator was removed. Conclusions: There are no routinely collected prescribing data that allow for the quality of prescribing for psychiatric patients to be monitored. Six of the seven indicators measured during this census survey appear to reflect a common attribute of the services, and the analysis suggests that they might be combined to give an overall measure of service performance. There was, however, no relationship between performance on the seventh indicator and performance on the other six. This raises questions about case mix and service level factors that might influence indicator scores independent of prescriber decision making. The psychometric properties of prescribing indicators (occurrence rates, consistency over time) are unknown.

Acute inpatient psychiatry in England: an old problem and a new priority.

With the development of community care, the number of National Health Service psychiatric beds in England has been reduced to between one-fifth and one-quarter of those provided in the mid-1950s. Psychiatric bed numbers are close to the irreducible minimum if they have not already reached it. The problems facing todays acute psychiatric admission wards include: poor design, maintenance and ambience; a lack of therapeutic and leisure activities for patients leading to inactivity and boredom; frequent incidents of aggression and low-level violence and problems with staffing. It is suggested that there are a number of underlying causes: First, there has been failure to plan inpatient services, or to define their role, as attention has focused on new developments in community care. Second, the reduction in bed numbers has led to a change in the casemix of inpatients with a concentration on admission wards of a more challenging group of patients. Third, admission ward environments are permeable to the adverse effects of local street life, including drug taking. After years of neglect, acute inpatient psychiatric services in England are now high on the UK Government agenda. The paper lists a number of national initiatives designed to improve their quality and safety. A recent review of qualitative research suggests that acute psychiatric wards in other countries face similar problems to those reported in England. It is suggested that there might be a need for joint action which might take the form either of international research about acute inpatient care or the development of international standards and a common quality improvement system.