The MentDis_ICF65+ study protocol: prevalence, 1-year incidence and symptom severity of mental disorders in the elderly and their relationship to impairment, functioning (ICF) and service utilisation.

BACKGROUND: The EU currently lacks reliable data on the prevalence and incidence of mental disorders in older people. Despite the availability of several national and international epidemiological studies, the size and burden of mental disorders in the elderly remain unclear due to various reasons. Therefore, the aims of the MentDis_ICF65+ study are (1) to adapt existing assessment instruments, and (2) to collect data on the prevalence, the incidence, and the natural course and prognosis of mental disorders in the elderly. METHOD/DESIGN: Using a cross-sectional and prospective longitudinal design, this multi-centre study from six European countries and associated states (Germany, Great Britain, Israel, Italy, Spain, and Switzerland) is based on age-stratified, random samples of elderly people living in the community. The study program consists of three phases: (1) a methodological phase devoted primarily to the adaptation of age- and gender-specific assessment tools for older people (e.g., the Composite International Diagnostic Interview, CIDI) as well as psychometric evaluations including translation, back translation; (2) a baseline community study in all participating countries to assess the lifetime, 12 month and 1 month prevalence and comorbidity of mental disorders, including prior course, quality of life, health care utilization and helpseeking, impairments and participation and, (3) a 12 month follow-up of all baseline participants to monitor course and outcome as well as examine predictors. DISCUSSION: The study is an essential step forward towards the further development and improvement of harmonised instruments for the assessment of mental disorders as well as the evaluation of activity impairment and participation in older adults. This study will also facilitate the comparison of cross-cultural results. These results will have bearing on mental health care in the EU and will offer a starting point for necessary structural changes to be initiated for mental health care policy at the level of mental health care politics.

Communication about adherence to long-term antipsychotic prescribing: an observational study of psychiatric practice.

PURPOSE: Partial or non-adherence is common in people taking antipsychotic medication. A good therapeutic alliance is thought by psychiatrists to encourage engagement with a service and improve adherence. This paper aims to examine how psychiatrists and patients communicate in outpatient consultations about partial or non-adherence to antipsychotic prescribing. METHODS: Ninety-two outpatient consultations involving patients prescribed antipsychotic medication and their psychiatrists were tape recorded. Parts of consultations where partial/non-adherence to antipsychotic medication was discussed were analysed using conversation analysis. RESULTS: In 22 (24 %) consultations, partial/non-adherence was disclosed. Most commonly, it was volunteered without prompting and was more likely to be presented as a deliberate choice than omission by the patient. Psychiatrists responded to all but one disclosure, and patients delivered their reports in ways that minimised the prospect of this response being disciplinary. The most common outcome was a change in prescribing: a medication omission, swap or dosage reduction. CONCLUSIONS: Patients and psychiatrists work together to create a safe conversational environment in which to discuss this potentially difficult issue. Unlike previous studies of patient reports of psychotic symptoms and side effects of drowsiness being ignored, psychiatrists nearly always respond to disclosures of partial/non-adherence. Psychiatrists should apply the same listening skills to patients' disclosures of troubling side effects and psychotic symptoms.

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.

Mental health and employment: much work still to be done.

Mental illness is now the leading cause of both sickness absence and incapacity benefits in most high-income countries. The rising economic and social costs make health and work an increasing priority for policy makers. We discuss the findings from Dame Carol Black's recent review of the health of Britain's working-age population and examine how her recommendations may impact and challenge mental health services.

Informing patients of the teratogenic potential of mood stabilizing drugs: a case note review of the practice of psychiatrists.

Lithium, carbamazepine and valproate are established human teratogens. Women of childbearing potential who are prescribed these drugs should be informed of their teratogenic potential and advised of the need for adequate contraception and the protective role of folate. We reviewed the clinical records of all women of childbearing age in long-term contact with one specialist mental health Trust providing services for a total population of 750,000. One hundred and thirty eight (16%) of 837 women of childbearing age were prescribed one or more of these drugs. There was documented evidence that 29 (21%) of these women had been informed about teratogenicity and that 33 (24%) had been advised about contraception. Fourteen women (10%) had a confirmed pregnancy while taking lithium, carbamazepine or valproate; eight had a complication of pregnancy. If prescribing practice in this large mental health Trust were typical of the UK, between 7000 and 11 000 women of childbearing potential would be prescribed lithium, carbamazepine or valproate by psychiatrists without documented discussion of the risks.

Antipsychotic medication, sedation and mental clouding: an observational study of psychiatric consultations.

Sedation and mental clouding are of concern to people on antipsychotic medication and are implicated in social withdrawal but their severity may be underestimated by psychiatrists. Existing studies of communication about adverse effects of medication are based on reports made by doctors or patients. This study is based on audiotapes of 92 outpatient consultations in two UK mental health trusts involving nine consultant psychiatrists where antipsychotic medication was discussed. When interviewed, these doctors and their colleagues had expressed a commitment to 'patient-centred' practice as well as recording concerns about the difficulties involved in the discussion of medication side effects. The study focuses on the ways in which sedation and mental clouding are presented and engaged with. Analysis of audiotape transcripts showed that patients raise these issues more often than doctors, contrasting with other adverse effects (such as blood changes) where doctors are more frequently the initiators of discussion. Sleepiness is sometimes presented by both patients and doctors as a part of normal experience and therefore to be welcomed. When presented as troublesome, patients' reports were sometimes met by doctors offering no response, changing the subject, or disagreeing with the patient's interpretation of the experience. Equally, there were some attempts by doctors to engage with patients' troubles and seek solutions. These could be unsuccessful where they involved challenges to the patients' medication-taking rationale, or more successful where they involved sympathetic and supportive listening. We speculate that the capacity to avoid addressing these problems is linked to the informal conversational style of these consultations, which means that concerns raised by one party can remain unaddressed without offending conversational norms. Doctors in these consultations are able to exercise considerable discretion over whether to define reports of sedation and mental clouding as medication-related problems.

The permeable institution: an ethnographic study of three acute psychiatric wards in London.

In Asylums, Goffman [1961. Asylums. London: Penguin] identified some permeable features of the old mental hospitals but presented them as exceptions to the rule and focused on their impermeable aspects. We argue that this emphasis is no longer valid and offer an alternative ideal type that better represents the reality of everyday life in contemporary 'bricks and mortar' psychiatric institutions. We call this the "permeable institution". The research involved participant observation of between 3 and 4 months and interviews with patients, patient advocates and staff on 3 psychiatric wards. Evidence for permeability includes that ward membership is temporary and changes rapidly (patients tend to have very short stays and staff turnover is high); patients maintain contact with the outside world during their stay; and institutional identities are blurred to the point where visitors or new patients can easily mistake staff and patients for one another. Permeability has both positive consequences (e.g., reduced risk of institutionalism), and negative consequences (e.g., unwanted people coming into hospital to cause trouble, and illicit drug use among patients). Staff employ various methods to regulate their ward's permeability, within certain parameters. The metaphor of the total/closed institution remains valuable, but it fails to capture the highly permeable nature of the psychiatric institutions we studied. Analysts may therefore find the permeable institution a more helpful reference point or ideal type against which to examine and compare empirical cases. Perhaps most helpful is to conceptualise a continuum of institutional permeability with total and permeable institutions at each extreme.

Sharing decisions in consultations involving anti-psychotic medication: a qualitative study of psychiatrists' experiences.

In psychiatry, and in treating people with a diagnosis of schizophrenia in particular, there are obstacles to achieving concordant, shared decision making and in building a co-operative therapeutic alliance where mutual honesty is the norm. Studies of people with a diagnosis of schizophrenia have revealed critical views of medical authority, particularly over the issue of enforced compliance with antipsychotic medication. Psychiatrists are known to place particular value on such medication. This qualitative study reports the views of 21 general adult psychiatrists working in UK about their experiences of consultations involving discussion of antipsychotic medication. Interviewees reported a general commitment to achieving concordant relationships with patients and described a number of strategies they used to promote this. In this respect, their self-perception differs from the picture of authoritarian practice painted by critics of psychiatry, and by some studies reporting patients' views. Interviewees also described obstacles to achieving concordance, including adverse judgements of patients' competence and honesty about their medication use. Explaining the adverse effects of medication was perceived to discourage some patients from accepting this treatment. Moments of strategic dishonesty were reported. Psychiatrists perceived that trust could be damaged by episodes of coercion, or by patients' perception of coercive powers. We conclude that a self-perception of patient-centredness may not preclude psychiatrists from fulfilling a social control function.

Patterns of antipsychotic and anticholinergic prescribing for hospital inpatients.

The development of atypical antipsychotics has not only given the prescriber more options, but also increased the complexity of decision making. We examined current prescribing practice for antipsychotic and anticholinergic drugs, which involved a 1-day census of all antipsychotic and anticholinergic drugs prescribed for 4191 inpatients in 49 UK mental health services. Eighty-five percent of inpatients were prescribed antipsychotics, 48% of whom were prescribed more than one. Atypical antipsychotics were widely prescribed and combined with typicals in over 60% of cases. Large doses of antipsychotics were frequently prescribed 'as required'. The dose administered was always much less than the dose prescribed and nothing at all was administered against 79% of prescriptions. Antipsychotic prescribing often deviates from recommended practice. Nursing staff have considerable discretion to administer large doses of antipsychotics on an 'as required' basis.

Service users' strategies for managing risk in the volatile environment of an acute psychiatric ward.

Previous research shows that too often acute psychiatric inpatient care is neither safe nor therapeutic for patients. Earlier studies focused on promoting safety through good ward design, staff being able to anticipate and prevent violence, and use of medication. The current evidence base overwhelmingly reflects a staff perspective on risk management, and there is little evidence on how service users cope in this environment or about the strategies they employ to manage the risks they face or pose to others. This paper presents findings on this from two studies: (a) ethnographic research on three UK acute psychiatric wards, undertaken between 2000 and 2002, and (b) a content analysis of qualitative data from a 1999/2000 survey of psychiatric wards in England. Findings show that while some users perceive their ward to be comparatively safe--given the crisis they were in before being admitted--it is nonetheless a volatile environment in which risks are concentrated. Many risks, such as physical assault, are attributable to other patients. However, they are better understood as an outcome of the interplay between a range of interactional and contextual factors: for example, low staffing levels/minimal or poor surveillance may increase the risk of assault. Users were found to employ 10 strategies to manage risk on the ward, including actively avoiding risky situations/individuals, seeking staff protection, and getting discharged. Integral to these strategies are the risk assessments that patients make of one another. These findings shed light on how people cope while living in one of the most anxiety-inducing institutions of a 'risk management society'. Service users routinely take an active role in making a safe environment for themselves, in part because they cannot rely on staff to do this for them. Future clinical practice guidelines should consider how to harness what users are already doing to manage risk.

The Staffing of Inpatient Child and Adolescent Mental Health Services.

BACKGROUND: There is a need for more accurate information regarding the staffing of Child and Adolescent Psychiatric inpatient units. This is both to facilitate clinical governance and to allow planning and focused further development of these services. METHOD: Postal surveys were sent to all units in England and Wales. RESULTS: Seventy-three percent (n = 1060) of the 1460 staff employed by the units were nurses; 43% of nurses were unqualified. On average there was one consultant psychiatrist for every 25 patients. Only 12% of nurses working on a 'census' day held a specialist qualification in nursing children. The use of agency and bank staff was higher in independent sector units than in NHS units (37% vs 10% of all nurses who worked a shift on the census day). CONCLUSIONS: Some child and adolescent inpatient units are not staffed by a multi-disciplinary team. There is evidence of problems of recruitment and retention of nurses.

Characteristics of the Detained and Informal Child and Adolescent Psychiatric In-Patient Populations.

BACKGROUND: This project surveyed the use of the Children Act and the Mental Health Act in in-patient child and adolescent mental health services in England and Wales. METHODS: Data were collected as a day census from child and adolescent psychiatric inpatient units, questionnaire forms completed by consultant psychiatrists or key-workers. Returns were received from 71 of the 80 units. RESULTS: One hundred and twenty-seven of the 663 patients had been admitted formally, the great majority under a section of the Mental Health Act. Compared with those admitted informally, those admitted formally were older, contained a higher proportion of males and had 'adult-type diagnoses', mainly schizophrenia, mood disorders and personality disorder. The clinical and psychosocial characteristics of formal and informal patients were consistent with these differences. CONCLUSIONS: This study provides a timely and useful snapshot of the use of the Acts in this population.

Improving the quality of acute inpatient care.

Over the past ten years, the National Health Service in England has introduced home treatment teams throughout the country. Despite this, and the fact that England now has the fourth lowest number of beds per capita in Europe, no mental health service has been able to dispense with acute admission beds altogether. One unintended consequence of new investment in community alternatives to inpatient care is that the threshold for admission has risen and acute wards now accommodate a patient group that is more severe with regard to levels of disturbance and social disadvantage. This has compounded the challenge of providing high quality inpatient care and repeated national surveys suggest that acute admission wards are the weakest link in the English mental healthcare system. In response to this, the Royal College of Psychiatrists has established an accreditation scheme for acute admission wards. Only 22 of the first 132 wards to have completed the review process so far are considered to be excellent. Although 59 wards (45% of the total) failed to meet one or more essential standard, 43 of these were able to rectify the problem.

High-dose and combination antipsychotic prescribing in acute adult wards in the UK: the challenges posed by p.r.n. prescribing.

BACKGROUND: Clinical guidelines recommend the routine use of a single antipsychotic drug in a standard dose, but prescriptions for high-dose and combined antipsychotics are common in clinical practice. AIMS: To evaluate the effectiveness of a quality improvement programme in reducing the prevalence of high-dose and combined antipsychotic prescribing in acute adult in-patient wards in the UK. METHOD: Baseline audit was followed by feedback of benchmarked data and delivery of a range of bespoke change interventions, and then by a further audit 1 year later. RESULTS: Thirty-two services participated, submitting data for 3,942 patients at baseline and 3,271 patients at the 1-year audit. There was little change in the prevalence of high-dose (baseline 36%; re-audit 34%) or combined antipsychotic prescribing (baseline 43%; re-audit 39%). As required ('p.r.n.') prescriptions were the principal cause of both high-dose and combined antipsychotic prescribing on both occasions. CONCLUSIONS: The quality improvement programme did not have a demonstrable impact on prescribing practice in the majority of services. Future efforts to align practice with clinical guidelines need to specifically target the culture and practice of p.r.n. prescribing.

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 (Cronbach's 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.

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 today's 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.

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.

Trends in the use of Part II of the Mental Health Act 1983 in seven English local authority areas.

BACKGROUND: Data collected by the Department of Health show a continuing increase in the rate of formal detention in hospital under Part II of the Mental Health Act 1983. AIMS: To establish whether the increase in formal detentions is uniform across subgroups of the population. METHOD: Data related to use of Part II of the Act between 1991 and 1997 collected by seven English local authorities were examined. Rates of compulsory admission were standardised to age, gender and ethnicity-specific populations. RESULTS: Over the 8-year period the overall rate of detention under Part II increased by 32%. It increased in all three major ethnic groupings; the rate of increase was greater for men than for women (38%v. 26%) and, in particular, for younger men compared with younger women (43% v. 28%). CONCLUSIONS: A combination of factors probably accounts for these findings, including service factors (particularly reduction in bed numbers), a culture of risk aversion, and changes in the effect of substance misuse on the presentation of mental illness.

Age, gender and ethnicity of those detained under Part II of the Mental Health Act 1983.

BACKGROUND: Aggregate returns give limited information about those detained under the Mental Health Act 1983. AIMS: To use existing data-sets to examine detentions under Part II of the Act. METHOD: Data from 26 areas, with a combined population of 9.2 million, were combined. Population census data were used to standardise rates of detention by age, gender and ethnicity. RESULTS: The 31 702 detentions are distributed bimodally with peaks at age 25-34 years and at over age 80 years. In the younger age group rates of detention are higher for men. The excess of women in the older group is no longer apparent when rates are standardised for age and gender. Detentions are over six times more likely to be of Black people than of White (450 v. 68 per standardised 100 000 population). CONCLUSIONS: The difference in rates of detention between Black and White people is greater than previously thought. The excess of older women detained under Part II of the Act is largely due to the lower life expectancy of men.

Non-clinical and extra-legal influences on decisions about compulsory admission to psychiatric hospital.

BACKGROUND: On the eve of reform of the 1983 Mental Health Act (MHA), little is known about how decisions to admit people under its powers are made. AIMS: To describe non-clinical and extra-legal influences on professionals' decisions about compulsory admission to psychiatric hospital. METHOD: Participant-observation of MHA assessments, including informal and depth interviews with the practitioners involved, and follow-up interviews with the people who had been assessed. RESULTS: A candidate patient's chance of being sectioned is likely to increase when there are no realistic alternatives to in-patient care. This typically occurs when staff have insufficient time to set such alternatives in place and are unsupported by other professionals in doing this. Outcomes may also be affected by local operational norms and the level of professional accountability for specific MHA decisions. CONCLUSION: Non-clinical and extra-legal factors explain some of the geographical variation in MHA admission rates. If compulsion is to be used only in the 'last resort', administrators and policy makers should look beyond legislative change to matters of resource allocation and service organisation.