RESUMO
AIM: Develop a strengths-based, person-centred, trauma-informed and recovery-oriented framework to mitigate any potential increase in conflict resulting from the implementation of C19 restrictions. BACKGROUND: Guidance addressing the unique challenges posed by Covid-19 within mental health in-patient settings, including how to support those whose distress may present as behaviour that challenges including violence and self-harm, remains urgently needed. METHODOLOGY/APPROACH: A Delphi design involving four iterative stages was adopted. Stage 1 involved a review and synthesis of COVID-19-related public health and ethical guidance and a narrative literature review. A formative operational framework was then developed. Stage 2 sought to establish the face validity of the framework through engagement with frontline and senior staff in mental health services in Ireland, Denmark and Netherlands. Stage 3 investigated the content validity of the final framework through a plenary presentation and discussion of the framework at a scientific symposium of the European Violence in Psychiatric Research Group (EViPRG, 2020). Stage 4 sought expert appraisal of the framework using a structured evaluation completed by a panel of eighteen multidisciplinary experts from nine countries, including four academics, six clinicians and eight holding dual clinical/academic appointments to assess content validity. RESULTS: The guidance adopts the widely advocated approach to support those whose distress may present as behaviour services find challenging in identifying the need for primary, secondary, tertiary and recovery measures. It emphasizes person-centred care while integrating specific Covid-19 public health requirements into service planning. It also aligns with contemporary best practice in in-patient mental health care, incorporating the principles of Safewards, the core values of trauma-informed care, and an explicit on recovery. CONCLUSION: The guidance developed has face and content validity.
Assuntos
COVID-19 , Serviços de Saúde Mental , Humanos , Saúde Mental , Técnica Delphi , IrlandaRESUMO
BACKGROUND: Compulsory admissions have a strong effect on psychiatric patients and represent a deprivation of personal liberty. Although the rate of such admissions is tending to rise in several Western countries, there is little qualitative research on the mental health-care process preceding compulsory admission. The objective of the study was to identify crucial factors in the mental health-care process preceding compulsory admission of adult psychiatric patients. METHODS: This retrospective, qualitative multiple-case study was based on the patient records of patients with severe mental illness, mainly schizophrenia and other psychotic disorders. Twenty two patient records were analyzed. Patients' demographic and clinical characteristics were heterogeneous. All were treated by Flexible Assertive Community Treatment teams (FACT teams) at two mental health institutions in the greater Rotterdam area in the Netherlands and had a compulsory admission in a predefined inclusion period. The data were analyzed according to the Prevention and Recovery System for Monitoring and Analysis (PRISMA) method, assessing acts, events, conditions, and circumstances, failing protective barriers and protective recovery factors. RESULTS: The most important patient factors in the process preceding compulsory admission were psychosis, aggression, lack of insight, care avoidance, and unauthorized reduction or cessation of medication. Neither were health-care professionals as assertive as they could be in managing early signs of relapse and care avoidance of these particular patients. CONCLUSION: The health-care process preceding compulsory admission is complex, being influenced by acts, events, conditions and circumstances, failing barriers, and protective factors. The most crucial factors are patients' lack of insight and cessation of medication, and health-care professionals' lack of assertiveness.
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Internação Compulsória de Doente Mental/estatística & dados numéricos , Serviços Comunitários de Saúde Mental/organização & administração , Hospitais Psiquiátricos/organização & administração , Transtornos Mentais/terapia , Adulto , Feminino , Humanos , Tempo de Internação , Masculino , Transtornos Mentais/psicologia , Pessoa de Meia-Idade , Países Baixos , Pesquisa Qualitativa , Estudos Retrospectivos , Esquizofrenia/terapiaRESUMO
UNLABELLED: For patients with comorbid complex posttraumatic stress disorder (PTSD) and psychotic disorder, trauma-focused therapy may be difficult to endure. Phase-based treatment including (a) stabilization, (b) trauma-focused therapy, and (c) integration of personality with recovery of connection appears to be the treatment of choice. OBJECTIVE: The objective of this article is to describe and evaluate the therapeutic process of a single case from a holistic perspective. METHOD: We present a case report of a 47-year-old woman treated for severe complex PTSD resulting from repeated sexual and physical abuse in early childhood and moderate psychotic symptoms stemming from Dandy Walker Syndrome with hydrocephalus. RESULTS: The patient was treated with quetiapine (600-1,000 mg) and citalopram (40 mg). Stabilization consisted of intensive psychiatric nursing care in the home and stabilizing group treatment for complex PTSD. After stabilization, the following symptom domains showed improvement: self-regulation, self-esteem, assertiveness, avoidance of social activities, and negative cognitions. However, intrusions and arousal persisted and were therefore subsequently treated with prolonged imaginary exposure that also included narrative writing assignments and a final closing ritual. This intensive multidisciplinary, phase-based approach proved effective: All symptoms of complex PTSD were in full remission. Social integration and recovery were promoted with the reduction of polypharmacy and the provision of social skills training and lifestyle training. CONCLUSION: The present case shows a phase-based treatment approach with multidisciplinary collaborative care to be effective for the treatment of a case of complex PTSD with comorbid psychotic disorder stemming from severe neurological impairment. Replication of this promising approach is therefore called for.
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Sobreviventes Adultos de Maus-Tratos Infantis/psicologia , Síndrome de Dandy-Walker/terapia , Transtornos Psicóticos/terapia , Transtornos de Estresse Pós-Traumáticos/terapia , Antipsicóticos/uso terapêutico , Citalopram/uso terapêutico , Comorbidade , Síndrome de Dandy-Walker/psicologia , Dibenzotiazepinas/uso terapêutico , Quimioterapia Combinada , Feminino , Humanos , Pessoa de Meia-Idade , Psicoterapia de Grupo , Transtornos Psicóticos/psicologia , Fumarato de Quetiapina , Inibidores Seletivos de Recaptação de Serotonina/uso terapêutico , Transtornos de Estresse Pós-Traumáticos/psicologiaRESUMO
PURPOSE: The aim of this study was to analyze the views of patients, police-officers and emergency mental health workers on the use of the police cell as intervention in a mental health crisis. DESIGN AND METHODS: We analyzed interviews with individuals involved in police cell interventions, found first labels and categorized them in concordance with the four principles of biomedical ethics and compared them to relevant scientific literature. FINDINGS AND PRACTICAL IMPLICATIONS: Professionals should know that emergency mental healthcare aimed at controlling the situation is not enough to provide good care. It probably generates better outcomes for patients in the short and long term when patient experiences are taken into consideration.
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Serviços de Saúde Mental , Saúde Mental , Intervenção em Crise , Serviço Hospitalar de Emergência , Pessoal de Saúde , Humanos , PolíciaRESUMO
Background: Outreach psychiatric emergency services play an important role in all stages of a suicidal crisis; however, empirical assessment data are scarce. This study describes characteristics of patients assessed by these services and involved in suicidal crises. Method: During a 5-year period, detailed information from psychiatric emergency service assessments was recorded; 14,705 assessments were included. Characteristics of patients with/without suicidal behavior and with/without suicide attempts were compared. Outcomes were adjusted for clustering of features within individual patients. Results: Suicidal behavior was assessed in 32.2% of patients, of whom 9.2% attempted suicide. Suicidal behavior was most commonly associated with depression or adjustment disorder and these patients were referred to the service by a general practitioner or a general hospital, whereas those who attempted suicide were less likely to be referred by a general practitioner. Those who attempted suicide were more likely to be female and have had a referral by a general hospital. Self-poisoning by medication was the most common method of attempting suicide. Limitations: Bias could be due to missed or incomplete assessments. Primary diagnoses were based on clinical observation at the time of the assessment or on the primary diagnosis previously recorded. In addition, suicidal behavior or attempted suicide might have been underestimated. Conclusions: Suicidal behavior is commonplace in assessments by psychiatric emergency services. Suicidal patients with/without a suicide attempt differed with respect to demographic features, primary diagnoses, and referring entities, but not with respect to treatment policy. About 40% of the suicidal patients with/without an attempt were admitted following assessment.
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Serviços de Emergência Psiquiátrica , Transtornos Mentais/epidemiologia , Ideação Suicida , Tentativa de Suicídio/estatística & dados numéricos , Adulto , Alcoolismo/epidemiologia , Estudos de Coortes , Transtorno Depressivo/epidemiologia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Transtornos Psicóticos/epidemiologia , Suicídio , Adulto JovemRESUMO
Currently, support tools are lacking to prioritize steps in the care coordination process to enable safe practice and effective clinical pathways in the first phase of acute psychiatric admissions. This study describes the development, validity, and reliability of an acute care coordination support tool, the Admission Team Score List (ATSL). The ATSL assists in care provider allocation during admissions. Face validity and feasibility of the ATSL were tested in 77 acute admissions. Endscores of filled out ATSL's were translated to recommended team compositions. These ATSL team (ATSL-T) compositions were compared to the actually present team (AP-T) and the most preferred team (MP-T) composition in hindsight. Consistency between the ATSL-T and the MP-T was substantial; Kw = 0.70, P < 0.001, 95% CI [0.55-0.84]. The consistency between the ATSL-T and AP-T was moderate; Kw = 0.43, P < 0.001, 95% CI [0.23-0.62]. The ATSL has an adequate (inter-rater) reliability; ICC = 0.90, P < 0.001, 95% CI [0.65-0.91]. The ATSL study is an important step to promote safety and efficient care based on care provider allocation, for service users experiencing an acute admission. The ATSL may stimulate structured clinical decision-making during the hectic process around acute psychiatric admissions.
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Transtornos Mentais/terapia , Admissão do Paciente , Unidade Hospitalar de Psiquiatria , Doença Aguda , Adolescente , Adulto , Humanos , Transtornos Mentais/diagnóstico , Pessoa de Meia-Idade , Variações Dependentes do Observador , Escalas de Graduação Psiquiátrica , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Adulto JovemRESUMO
Findings from an increasing number of studies suggest that incorporating systematic short-term risk assessments in treatment planning could lead to safer practice on psychiatric admissions wards. The aim of the present study was to investigate the associations between the scores of three structured observation tools - the Kennedy Axis V (K-Axis-V), the Brief Psychiatric Rating Scale (BPRS), and the Social Dysfunction and Aggression Scale (SDAS) - and seclusion. In total, 1840 weekly risk assessments with these observation scales were collected over 2342 admission weeks. These assessment scores related to 370 acutely-admitted psychiatric patients and were subjected to a multilevel analysis. It was found that several dynamic and static factors were related to seclusion. Dynamic factors included violent behaviour, current substance abuse, suspiciousness, and negativism. Static factors included ethnicity and having been diagnosed with a substance abuse disorder. The findings suggest that the incorporation of the Kennedy-Axis V, the BPRS, and the SDAS into standard practice might be helpful in identifying patients at high risk of seclusion, and could be supportive to treatment planning and clinical decision-making in the prevention of seclusion use in acute psychiatric settings.
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Agressão , Transtornos Mentais/terapia , Isolamento de Pacientes/métodos , Adulto , Agressão/psicologia , Escalas de Graduação Psiquiátrica Breve , Feminino , Humanos , Masculino , Transtornos Mentais/psicologia , Pessoa de Meia-Idade , Países Baixos , Isolamento de Pacientes/psicologia , Medição de Risco , Adulto JovemRESUMO
IMPORTANCE: Compulsory admissions, defined as admissions against the will of the patient (according to local judicial procedures), have a strong effect on psychiatric patients. In several Western countries, the rate of such admissions is tending to rise. Its reduction is urgently needed. OBJECTIVE: To establish which interventions effectively reduce compulsory admissions in adult psychiatric patients in outpatient settings. DATA SOURCES: A systematic computerized literature search was performed using EMBASE, MEDLINE, Web of Science, PsycINFO, CINAHL, PubMed (not yet indexed for MEDLINE), Cochrane Central, and Google Scholar. Every database was searched from its inception until April 30, 2015. STUDY SELECTION: Randomized clinical trials (RCTs) that studied any kind of intervention designed to reduce compulsory admission rates in adult psychiatric patients (age range, 18-65 years) in outpatient settings were eligible. Eligibility was independently assessed by 2 of us. DATA EXTRACTION AND SYNTHESIS: Two of us independently extracted relevant data. The Cochrane Collaboration's tool was used for assessing risk of bias. Overall risk reduction (random-effects estimate) was calculated in the following 4 subgroups of interventions: advance statements, community treatment orders, compliance enhancement, and integrated treatment. MAIN OUTCOMES AND MEASURES: Relative risk (RR) was calculated on the basis of the number of patients who had been compulsorily admitted. RESULTS: Our meta-analyses included 13 RCTs comprising 2970 psychiatric patients. The meta-analysis of the RCTs on advance statements showed a significant 23% (RR, 0.77; 95% CI, 0.60-0.98; I2 = 2.2%) (n = 1102) risk reduction in compulsory admissions. In contrast, the RCTs on community treatment orders (RR, 0.95; 95% CI, 0.81-1.10; I2 = 0.0%) (n = 742), compliance enhancement (RR, 0.52; 95% CI, 0.11-2.37; I2 = 55.7%) (n = 250), and integrated treatment (RR, 0.71; 95% CI, 0.49-1.02; I2 = 49.0%) (n = 876) showed no significant risk reduction in compulsory admissions. CONCLUSIONS AND RELEVANCE: The meta-analysis of the RCTs on advance statements showed a statistically significant and clinically relevant 23% reduction in compulsory admissions in adult psychiatric patients, whereas the meta-analyses of the RCTs on community treatment orders, compliance enhancement, and integrated treatment showed no evidence of such a reduction. To date, only 13 RCTs have used compulsory admissions as their primary or secondary outcome measure. This demonstrates the need for more research in this field.
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Internação Compulsória de Doente Mental/legislação & jurisprudência , Internação Compulsória de Doente Mental/tendências , Adolescente , Adulto , Idoso , Centros Comunitários de Saúde Mental , Europa (Continente) , Feminino , Seguimentos , Humanos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Ensaios Clínicos Controlados Aleatórios como Assunto , Risco , Adulto JovemRESUMO
OBJECTIVE: In 2006, a goal of reducing seclusion in Dutch hospitals by at least 10% each year was set. More than 100 reduction projects in 55 hospitals have been conducted, with 35 million in funding. This study evaluated the results. METHODS: Data (2008 to 2013) were from a national register. Multilevel logistic regression examined determinants of seclusion. RESULTS: Hospital participation in the register ranged from eight in 2008 to 66 in 2013, and admissions ranged from 11,300 to 113,290. The average yearly nationwide reduction of secluded patients was about 9%. Reduction was achieved in half of the hospitals. Some hospitals saw increased rates. In some hospitals where seclusion decreased, use of forced medication increased. Higher seclusion rates were associated with psychotic and bipolar disorders, male gender, and several ward types. CONCLUSIONS: Seclusion decreased significantly, and forced medication increased. Rates varied widely between hospitals. For many hospitals, more efforts to reduce seclusion are needed.
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Coerção , Objetivos , Hospitais Psiquiátricos/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Isolamento de Pacientes/estatística & dados numéricos , Adulto , Feminino , Humanos , Modelos Logísticos , Masculino , Transtornos Mentais/psicologia , Transtornos Mentais/terapia , Serviços de Saúde Mental/organização & administração , Países Baixos , Isolamento de Pacientes/tendênciasRESUMO
The Kennedy Axis V is a routine outcome measurement instrument which can assist the assessment of the short-term risk for violence and other adverse patient outcomes. The purpose of this study was to evaluate the interrater reliability and clinical utility of the instrument when used by mental health nurses in daily care of patients with mental illness. This cross-sectional study was conducted in inpatient and outpatient adult psychiatric care units and in one adolescent inpatient unit at a university hospital in the Netherlands. Interrater reliability was measured based on the independent scores of two different nurses for the same patients. The clinical utility of the instrument was evaluated by means of a clinical utility questionnaire. To gain a deeper understanding of rating difficulties at the adolescent unit, additional data were collected in two focus group interviews. The overall results revealed a substantial level of agreement between nurses (intraclass correlation coefficient and Pearson 0.79). Some rating challenges were identified, including difficulties with scoring the instrument and using tailor-made interventions related to the scores. These challenges can be resolved using refined training and implementation strategies. When the Kennedy Axis V is accompanied by a solid implementation strategy in adult mental health care, the instrument can be used for short-term risk assessment and thereby contribute in efforts to reduce violence, suicide, self-harm, severe self-neglect, and enhanced objectivity in clinical decision-making.
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Transtornos Mentais/enfermagem , Transtornos Mentais/psicologia , Avaliação em Enfermagem/estatística & dados numéricos , Determinação da Personalidade/estatística & dados numéricos , Enfermagem Psiquiátrica , Medição de Risco/estatística & dados numéricos , Violência/prevenção & controle , Violência/psicologia , Adolescente , Adulto , Estudos Transversais , Comportamento Perigoso , Manual Diagnóstico e Estatístico de Transtornos Mentais , Feminino , Hospitais Universitários , Humanos , Comportamento Impulsivo/enfermagem , Comportamento Impulsivo/psicologia , Masculino , Pessoa de Meia-Idade , Países Baixos , Psicometria/estatística & dados numéricos , Reprodutibilidade dos Testes , Resultado do Tratamento , Adulto JovemRESUMO
Research findings indicate that the symptoms and behaviour of acute psychiatric patients can fluctuate drastically within hours, and that structured daily risk assessments can reduce the risk of aggressive incidents and the duration of seclusion. The aim of this study was to investigate the validity of two structured observation tools, the Brøset Violence Checklist (BVC) and the Kennedy Axis V), as an aid in seclusion-related clinical decision-making. In this study, 7403 day-to-day risk assessments were collected over 10 725 admission days (72% of the maximum number of structured assessments). A total of 7055 daily assessment scores from 301 acute psychiatric patients were used for the multilevel analysis. The sample demonstrated that dynamic and static factors were related to seclusion. Dynamic factors included dysfunctional scores on the item 'confusion' of the Brøset Violence Checklist, and psychological impairment and impairment of social skills on the Kennedy Axis V. Static factors included non-Western descent, male sex, age less than 35 years, unmarried, and to some extent, a personality disorder. McFadden's pseudo R(2) value showed that most of the final model was related to the dynamic factors. We concluded that the incorporation of the BVC and the Kennedy Axis V into standard practice was helpful in identifying patients at high risk of seclusion.