Psychiatric Bulletin

Published by Royal College of Psychiatrists
Print ISSN: 0955-6036
Publications
During the last decade there have been a number of legislative changes establishing and extending the rights of patients to have access to their own medical and social service records. The Data Protection Act 1984, as modified by the Subject Access Modification Order 1987, gave patients access to computerised medical records with certain restrictions, in particular for information thought to be harmful to patients. The Access to Personal Files Act of 1987 granted access to Social Services Records. Again there were restrictions, e.g. to protect clients from serious harm or to protect confidential staff judgements. Finally, the Access to Health Records Act of 1990, which took effect on 1 November 1991 gives patients access to their own medical records and enables them to correct inaccuracies which they may find. Information likely to cause serious harm to the physical or mental health of the patient or of any other individual who could be identified can be withheld.
 
Aims and Methods This paper describes the validation of self-report of risk by patients with borderline personality disorder (BPD) as compared with the judgement of experienced psychotherapists in regular contact with them. The aim was to validate the Clinical Outcomes in Routine Evaluation System (CORE) self-report in order to be able to use it to monitor risk change for patients with BPD in psychotherapy and general psychiatric settings. Results There was significant separation correlation between CORE risk sub-scales for self-harm, suicide and risk to others and therapists' estimation of significant risk v . no significant risk. Clinical Implications Using the cut-offs described, we suggest that the CORE questionnaire risk sub-scales can be used to assess significant risk for patients with BPD in psychotherapy, and in psychiatric and community health teams. The sub-scales should also prove valuable in allocating Care Programme Approach status.
 
Aims and Method This study was designed to clarify the nature and extent of psychiatric provision that would be needed if a new health screening protocol were to be introduced into the prison system. The reception screening questionnaires for every inmate coming into the prison over a 15-week period were reviewed using the new protocol. A further mental health assessment was undertaken on those who had screened positive. Results 201 men (32.6%) were found to be positive for serious mental illness Clinical Implications Based on this analysis, large increases in psychiatric resources would not be needed if the proposed new reception health screening processes were in place, although a reorganisation of the way in which services are delivered may be required.
 
Aims and Method Long waiting lists and failure to attend appointments are a common problem in child and adolescent psychiatry. We introduced a novel ‘triage’ stage waiting list initiative to decrease the long waiting time fora first appointment at our child mental health service. Results The waiting time to first appointment was significantly reduced and increased satisfaction with this process was expressed by clinicians, the referred families and referrers. Clinical Implications The reduction in waiting time was sustained over time and the triage process has now been implemented as routine practice. Following this implementation, there is no longer a lengthy waiting list for treatment after initial assessment. We would recommend this initiative, which screened referrals more efficiently and accurately, as a successful model for other child and adolescent services with long waiting lists.
 
Aims and methods: A study was undertaken to investigate the views of professional staff and paid and informal carers’ views of a new integrated mental health service for people with learning disabilities. Results: Twenty semi-structured interviews were conducted and transcribed. Most staff and carers were generally satisfied with the inpatient facility. However, information exchange, ward rounds and the ward environment were identified as areas requiring improvement. Clinical implications: Many of the participants did not have previous experience of supporting a person with learning disabilities and mental health problems in an inpatient setting. However, over time, they became supportive of the mental health service and provided valuable input in improving the service provision for people with learning disabilities. Declaration of interest: This work was supported by a grant from the former Islington Health Authority to Angela Hassiotis
 
Proposals for new mental health legislation make the case for using the ‘least restrictive alternative’ (Scottish Executive, 2001) and the ‘least restrictive environment’ (Department of Health & Home Office, 2000) as guiding principles in deciding the management and treatment of the patient. This appears to be the case made for introducing compulsory treatment in the community. The patient living in the community, while maintained on medication, rather than the hospital would appear to be defined as on the ‘least restrictive alternative’. This, however, takes only a limited approach to what is ‘restrictive’, which should be interpreted more widely, including the patient's view as well as that of clinicians and policy makers. Thus, a patient may see it as less restrictive during an acute phase to be in hospital and not on medication, than in the community but on medication. It is likely, given our knowledge of patients' attitudes to medication (Eastwood & Pugh, 1997), that many patients will prefer to be on oral medication rather than depot, which they see as less restrictive.
 
Advance directives in mental health care are currently attracting interest, although there is some anxiety that they can restrict clinical freedom. The so-called ‘Ulysses contract’ is a form of opt-in to services that has been suggested in the USA. Psychiatrists might thus consider themselves to be the equivalent of Ulysses' crew in being bound by the contract. This paper suggests, in some cases, that they might function more as Circe, who suggested the directions to Ulysses, and considers this in the light of contemporary relationships between psychiatrists and patients.
 
Clinical psychiatrists are today in a position to prescribe an expanded range of antipsychotic drugs for the treatment of schizophrenia and related psychoses. The introduction of chlorpromazine in 1952 was followed by many others. They varied in potency and in side-effect profile, but they shared the capacity to cause extrapyramidal side-effects (EPS). These side-effects were produced by a mechanism intrinsically similar to that responsible for the antipsychotic effectiveness of the drug. They seemed to be the price that had to be paid for the resolution of psychotic symptoms.
 
Self-help resources for depression are widely available in bookshops and via the internet. They are increasingly being recommended for use by healthcare practitioners as part of a stepped care treatment package (Bower & Gilbody, 2005). Such materials provide key information and key skills to help readers tackle mild-to-moderate depression (National Institute for Clinical Excellence, 2004). The recent review of self-help by the National Institute for Mental Health in England confirmed that it is cognitive–behavioural therapy (CBT) self-help that has an evidence base rather than self-help per se (Lewis et al , 2003).
 
There has been little economic evaluation of the costs of closing long-stay institutions. Studies that have been undertaken have rarely had the opportunity to study the before and after effects of complete closure. Most attention has focused on the mentally ill not the mentally handicapped. This study followed a sample of residents leaving Darenth Park Hospital which was closed in 1988.
 
Therapists differ in their effectiveness in the delivery of psychological therapy. Can trainees who are exposed to similar training in psychological therapy achieve the same standard of competence regardless of professional background? This is a timely question given the planned expansion of psychological therapists to treat common mental disorders in England and Wales and the Scottish initiative to increase access to psychological therapies.
 
Illustration of the interconnections between themes.
Aims and method To explore service users’ experiences of receiving a diagnosis of schizophrenia and the stigma associated with the diagnostic label. Seven participants were interviewed about their perceptions of these experiences. Interviews were analysed using interpretative phenomenological analysis. Results Five superordinate themes resulted from the analysis: (1) avoidance of the diagnosis of schizophrenia; (2) stigma and diagnostic labels; (3) lack of understanding of schizophrenia; (4) managing stigma to maintain normality; (5) being ‘schizophrenic’. These, together with their subthemes, highlighted avoidance of the term schizophrenia by participants and use of alternative terms by professionals, which limited opportunities for understanding the label and challenging associated stigma. Participants strived to maintain normality despite potential stigma. Clinical implications There is a need to address the process of giving a diagnosis as a phenomenon of consequence within its own terms. Implications relate to how professionals deliver and discuss the diagnosis of schizophrenia.
 
Aims and Method Although the Health of the Nation Outcome Scales (HoNOS) were designed for routine clinical use, completion rates in clinical settings rarely exceed 60%. We evaluated two initiatives to increase completion rates: timely feedback to clinicians, useful at individual, team and service levels, and improved supporting materials (tabulated glossaries for all versions covering the life-span). Results Clinicians in South Shore Health district provided ratings on all outpatient referrals over 12 months as part of routine care. Data were captured using the Nova Scotia routine administrative data system. Completion rates rose from 61% to 86% ( n =1190). Clinicians' ratings of the instrument's ease of use were significantly improved. Clinical Implications Use of a tabulated glossary and enhanced feedback of clinically useful information improved clinician support for the routine measurement of health outcomes with HoNOS.
 
Experience in group therapy is recommended by The Royal College of Psychiatrists (1986) as an important aspect of training in psychiatry. However direct experience is unusual. It was reported in the Bulletin that a group formed by trainees in psychiatry to study the group process found a demand for personal therapy for its members (Whewell, 1987). In this paper a group is described which attempted to meet both needs.
 
By 1841, advances in communication and education, coupled with an increasing number of medical staff attached to mental asylums, made the idea of a formal grouping of such asylum staff a viable proposition. Although, as the following paragraphs indicate, such a group took many years to become established, the body whose early years are described briefly here, is the direct ancestor of the Royal College of Psychiatrists.
 
A new approach to research and development (R&D) for mental health services is developing in the North-East, Yorkshire and Humber. It derives from experience with service redesign using the ‘collaborative’ approach developed by the US Institute for Health Improvement. Kennedy & Griffiths (2003) described such an approach involving 37 mental health trusts, each with a multidisciplinary team, with the aim of improving acute in-patient wards. After studying the patient's journey through care they agreed a set of improvement targets that all teams would work to achieve. Progress towards targets was measured and reported by all teams, who met periodically to compare performance and learn from each other. Remarkable energy to achieve objectives was released among front-line staff involved. Focus was sustained on what most concerned and benefited patients. Good ideas and results quickly spread to all these services affecting thousands of patients.
 
“Suppose you and I argue. If you win and I lose, are you indeed right and I wrong? And if I win and you lose, am I right and you wrong? Are we both partly right and partly wrong? Are we both all right or both all wrong? If you and I cannot see the truth, other people will find it even harder.”
 
The Experience of Alzheimer's Disease: Life Through a Tangled Veil - Steven R Sabat , Oxford: Blackwell. 2001. 361pp. £50.00 (hb) £16.99 (pb). ISBN: 063126650 (hb); 0631216669 (pb) - Volume 27 Issue 1 - R. Clafferty
 
Inquiries After Homicide Edited by J. Peay . London: Duckworth. 1996. 182 pp. £13.99. - Volume 24 Issue 1 - Antony Maden
 
The Marriage of Heaven and Hell. By Peter Dally . London: Robson. 1999. 225 pp. £ 16.95. ISBN 1-86105-219-7 - Volume 24 Issue 2 - Raj Persaud
 
Child Psychiatry and Child Protection Litigation By Julia Brophy with Louise Brown, Suzanne Cohen and Polly Radcliffe. London: Gaskell. 2001. 160 pp. £20.00 (hb). ISBN: 1-901242-66-8 - Volume 27 Issue 5 - Judith Trowell
 
From 1 April 1996 mental health legislation was expanded to include provision for 'supervised discharge' under the Mental Health (Patients in the Community) Act 1995. However, the use of Section 17 (s17) of the Mental Health Act has always provided an option for an extended leave. This retrospective case note study examines 10 years of practice of s17 use and focuses on characteristics of those patients recalled. Increases in s17 applications represented equivalent increases in admissions and overall sections, although numbers of patients actually recalled had fallen significantly. Patients recalled after discharge were generally middle-aged men with a long history of schizophrenia, on s3, who relapse quickly due to treatment non-compliance.
 
A Beautiful Mind: The Life of John Nash. By Sylvia Nasar . London: Faber & Faber. 1998. 459 pp. £ 17.99 (hb). ISBN 0-571-17794-8 - Volume 24 Issue 2 - Spencer Madden
 
Clinical Research in Psychiatry. A Practical Guide. Edited by Stephan Curran & Christopher Williams . Oxford: Butterworth-Heinemann. 1999.156 pp. £ 17.99 (pb). ISBN 0-7506-4073-1 - Volume 24 Issue 2 - Sarah Marriott
 
Understanding Clinical Papers By David Bowers , Allan House and David Owens . Chichester: Wiley. 2001. 202 pp. £19.95 (pb) ISBN: 0-471-48976-X - Critical Reviews in Psychiatry Edited By Brown Tom and Wilkinson Greg . (2nd edn). London: Gaskell. 2000. 278 pp. £18 ISBN: 1-901242-41-2 - Volume 26 Issue 4 - Jed Boardman
 
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