Tom Meehan

Recovery-based practice: do we know what we mean or mean what we know?

The concept of recovery is now widely promoted as the guiding principle for the provision of mental health services in Australia and overseas. While there is increasing pressure on service providers to ensure that services are recovery oriented, the way in which recovery-based practice is operationalized at the coalface presents a number of challenges. These are discussed in the context of five key questions that address (i) the appropriateness of recovery as a focus for service delivery, (ii) the distinction between recovery as a process and an outcome, (iii) the assessment of recovery initiatives, (iv) the alignment of recovery with current service delivery models, and (v) the risks associated with recovery-based practice. It is argued that these questions provide a framework for a debate that must extend beyond patients and providers of mental health services to the broader public, whose attitudes will ultimately determine the possibilities and limits of recovery-oriented practice.

Monitoring consumer satisfaction with inpatient service delivery: the Inpatient Evaluation of Service Questionnaire.

Objective: To report on the development, testing and psychometric properties of a brief consumer satisfaction measure for use with psychiatric inpatients. Method: Focus group discussions with inpatients were used to develop a pool of items related to satisfaction with hospital stay. A second cohort of 72 inpatients was invited to rate the 51 items that emerged for importance in contributing to satisfaction. Mean importance scores highlighted 20 items that were subsequently framed into neutrally worded statements. A draft questionnaire comprising these statements was introduced, on a trial basis, in a range of inpatient facilities. Results: Factor analysis of 356 completed questionnaires yielded three factors comprising a staff-patient alliance; doctor/treatment issues; and an environmental component. Psychometric properties include good response variability and high internal consistency. Conclusions: The Inpatient Evaluation of Service Questionnaire addresses many of the shortcomings of existing satisfaction measures. It was developed through extensive consumer involvement, it is simply worded, easy to score and appears to perform well with acute and rehabilitation inpatients.

Australian mental health staff response to antipsychotic medication side effects - the perceptions of consumers

Despite the impact of side effects on adherence to medication regimes, few previous studies have examined the personal concerns of those prescribed antipsychotic medications. This study explores consumer perceptions of the support they receive from mental health staff for antipsychotic medication side effects. Semi-structured interviews were used to elicit the perceptions of 10 mental health consumers in a community care setting in Australia. Content analysis was used to examine the transcripts, and the audio-recordings were replayed to identify important contextual cues. The analysis identified several main themes, including: the relationship between participants and clinicians; information about side effects; and the value of the case-management system. Most participants reported that health professionals appeared disinterested in the antipsychotic medication side effects they experienced and did not understand the detrimental impact of side effects on their lives. The participants were also not equipped with sufficient information about the care they received, the prescribed medications, and possible side effects. Most participants felt excluded from decisions about the care they received, which caused significant distress. Structures and strategies therefore should be developed to ensure that the views of mental consumers are taken into consideration in a more fulsome manner in delivering mental health care in the community.

Consumer strategies for coping with antipsychotic medication side effects

Objective: This study was designed to investigate the strategies employed by consumers to manage the common side effects associated with antipsychotic medication use. Method: Focus group discussions and individual interviews involving 238 consumers, 25 carers and 16 mental health staff were employed to identify key side effects and a range of consumer coping strategies for managing these adverse effects. Results: Nine side effects were selected from a total pool of 32 proposed in the group discussions. Strategies that were perceived by the participants to be useful in coping with the selected side effects were then identified. Conclusions: While the strategies proposed for each side effect differed, common themes included the maintenance of a balanced lifestyle, healthy eating and sleeping routines, and fostering a positive outlook on life. Understanding the strategies employed by consumers to deal with the adverse effects of their medications may help clinicians to engage more effectively with consumers in the discussion and management of side effects.

Clinical profile of people referred to mental health nurses under the Mental Health Nurse Incentive Program

The Mental Health Nurse Incentive Program (MHNIP) was established in Australia during 2007. The program enables mental health nurses to work in partnership with general practitioners (GPs) in the assessment and treatment of people with severe mental health problems. This paper provides insights into the demographic and clinical profile of 403 people enrolled in the MHNIP in the Ipswich area of Queensland. The clinical presentation (illness severity and symptoms) of those referred to the MHNIP is compared to that of: (i) people referred to a related program known as Access to Allied Psychological Services (ATAPS); and (ii) to clients admitted to acute inpatient care in Queensland. While people referred to the MHNIP presented with more severe problems than those referred to ATAPS, they had less severe problems than those admitted to acute inpatient care. The findings indicate that the MHNIP is meeting the needs of people with complex mental and physical health problems. Further evaluation work is required to determine if the findings from this study can be generalized more broadly. At the national level, consideration should be given to the routine collection of clinical, cost, and demographic data to enable the ongoing monitoring of the program.

Outcomes for elderly patients with mental illness following relocation from a stand-alone psychiatric hospital to community-based extended care units

Objective: To assess the outcomes for a group of elderly patients with mental illness following their discharge from a stand-alone psychiatric facility to seven extended care units (ECUs). Method: All patients (n = 60) who were relocated to the ECUs were assessed using a number of standardized clinical and general functioning instruments at 6 months and 6 weeks pre-move, and again at 6 weeks, 6 months and 18 months post-move. Results: By 18 months post-discharge, 13 of the 60 patients (21.7%) had died and seven others had been transferred to nursing homes. Those who died were older and had significantly higher levels of physical ill health when compared to those who did not die. Changes on measures of clinical and behavioural functioning in those who remained in the study did not reach statistical significance by 18 months post-move. However, participants did demonstrate improvements in quality of life with significantly higher scores on measures of social contact and community access. Conclusions: The mortality observed in the follow-up period is likely to be related to physical ill health and old age rather than the trauma associated with relocation. While overall functioning did not improve following relocation, patients had more independence and greater access to community-based activities.

The mental health nurse incentive program: Reactions of general practitioners and their patients

OBJECTIVE To evaluate reactions of general practitioners (GPs) and their patients to the Mental Health Nurse Incentive Program (MHNIP). METHOD A descriptive, exploratory approach was employed using discussion groups with 25GPs and individual interviews with 19 patients receiving treatment through the MHNIP. All discussion groups and interviews were audio taped, transcribed and analysed using thematic content analysis. RESULTS There was overwhelming support for the MHNIP across GP and patient groups. Patients noted that the treatment provided through the program was convenient, holistic and non-stigmatising. GPs valued the collaborative working arrangements with mental health nurses (MHNs) and highlighted the ability of these nurses to provide a wide range of interventions for patients with complex mental health problems. CONCLUSIONS The collaborative working arrangement between GPs and MHNs promoted through the MHNIP was perceived to have significantly enhanced primary care services for those with mental health problems. What is known about the topic? The introduction of MHNs into GP practices under the MHNIP, a new primary care initiative, represents a major reform in the provision of primary care services for those with mental health problems. What does this paper add? This paper reports on the reactions of GPs and patients to the introduction of the MHNIP. What are the implications for practitioners? The collaborative model promoted through the program enables family doctors to play a greater role in the management of mental health conditions within the primary care setting. MHNs working with the program need considerable experience and skill in dealing with a broad range of mental health problems. In general, GPs require a better understanding of the overall program.

Development and evaluation of the Clinician Suicide Risk Assessment Checklist

Abstract This paper describes the development and evaluation of a new instrument – the Clinician Suicide Risk Assessment Checklist (CSRAC). The instrument assesses the clinician’s competency in three areas: clinical interviewing, assessment of specific suicide risk factors, and formulating a management plan. A draft checklist was constructed by integrating information from 1) literature review 2) expert clinician focus group and 3) consultation with experts. It was utilised in a simulated clinical scenario with clinician trainees and a trained actor in order to test for inter-rater agreement. Agreement was calculated and the checklist was re-drafted with the aim of maximising agreement. A second phase of simulated clinical scenarios was then conducted and inter-rater agreement was calculated for the revised checklist. In the first phase of the study, 18 of 35 items had inadequate inter-rater agreement (60%>), while in the second phase, using the revised version, only 3 of 39 items failed to achieve adequate inter-rater agreement. Further evidence of reliability and validity are required. Continued development of the CSRAC will be necessary before it can be utilised to assess the effectiveness of risk assessment training programs.

Impact of the Mental Health Nurse Incentive Programme on patient functioning.

The Mental Health Nurse Incentive Programme (MHNIP) was established across Australia during 2007. The programme enables mental health nurses to work alongside general practitioners (GPs) and other health professionals to assist in the assessment and treatment of people with mental illnesses. This paper reports on the outcomes for 309 patients referred by GPs to the programme in one region of Queensland. Standardized measures were completed pre- and post-treatment to evaluate changes in symptoms and general functioning between baseline and follow up. Patient contact with the programme ranged from 3 weeks to 38 weeks, and the study group (n = 84) demonstrated significant improvement on all of the self-report and clinician-rated measures employed. Effect sizes ranged from 0.59 to 0.74. The findings suggest that the MHNIP is making a positive contribution, with a medium-to-large impact on the mental health and general functioning of individuals supported through the programme. Further evaluation work is required to determine if the findings from this study can be generalized more broadly.

Supporting recovery: challenges for in-home psychiatric support workers

Purpose – The concept of recovery is well accepted internationally as a guiding vision for mental health services. The purpose of this paper is to highlight the challenges faced by in-home psychiatric support workers in implementing this vision in their work with clients with severe psychiatric disability. Design/methodology/approach – The findings reported here are based on interviews with 27 support workers and ten managers of organisations providing support services. These were collected as part of evaluations of two supported housing programmes carried out between 2010 and 2011. Findings – Challenges faced by support workers coalesced around two areas: first, balancing the need to provide care with the need to promote autonomy and second, developing an effective working relationship while working mainly within a clients’ home. Practical implications – These challenges for support workers highlight tensions within the recovery vision that are not easily resolved. To ensure high quality, recovery-orient...