Addiction Vulnerability: Exploring Relationships Among Cigarette Smoking, Substance Misuse, and Early Psychosis.

OBJECTIVE: Smoking rates in adolescents at risk for psychosis are significantly greater than in those who are not at risk. Recent research suggests that cigarette smoking in adolescence may be a potential marker of transition to psychosis, although the exact relationship between the two remains unclear. Our aim was to examine whether tobacco smoking is a potential marker of transition to psychosis or subsequent episodes of psychosis, independently of other substance use, or alternatively whether smoking is essentially a general marker of later mental illness episodes. METHODS: This substudy was conducted as part of an audit of a specialized early psychosis community mental health service, the Psychological Assistance Service (PAS). A multilayered audit over 10 years (January 1997 to December 2007) of PAS presentations was conducted (N = 1997), which documented baseline sociodemographic and clinical characteristics and subsequent illness episodes and service usage. Among clients with baseline smoking status information (n = 421, mean age = 18.3 years), this study examined predictors of transition to or subsequent episodes of psychosis, substance misuse, and affective disorder. RESULTS: A recent psychosis episode at baseline and receiving ongoing treatment from PAS predicted transition to or subsequent psychosis episodes; however, baseline ultra-high-risk status was not predictive. In addition, baseline smoking/substance misuse status was a significant predictor, with smokers being twice as likely to experience a subsequent episode of psychosis, even after controlling for other baseline comorbidity. Baseline smoking status also independently predicted subsequent substance misuse episodes, but not subsequent affective disorder. Among clients experiencing post-PAS comorbid substance misuse and psychosis, the majority (80.3%) reported smoking at baseline. CONCLUSIONS: Smoking status at service presentation appeared to function as a general proxy for addiction vulnerability among young help seekers and thereby as a potential marker for the development of severe mental illness (including psychosis) and associated health problems. Routine evaluations of presenting problems need to incorporate comprehensive assessments of early substance misuse and tobacco smoking. Adjunctive lifestyle interventions promoting smoking cessation, physical health, and well-being need to be offered in conjunction with conventional mental health interventions tailored to key presenting problems, recovery, and psychological strengthening.

An Integrated Recovery-oriented Model (IRM) for mental health services: evolution and challenges.

BACKGROUND: Over past decades, improvements in longer-term clinical and personal outcomes for individuals experiencing serious mental illness (SMI) have been moderate, although recovery has clearly been shown to be possible. Recovery experiences are inherently personal, and recovery can be complex and non-linear; however, there are a broad range of potential recovery contexts and contributors, both non-professional and professional. Ongoing refinement of recovery-oriented models for mental health (MH) services needs to be fostered. DISCUSSION: This descriptive paper outlines a service-wide Integrated Recovery-oriented Model (IRM) for MH services, designed to enhance personally valued health, wellbeing and social inclusion outcomes by increasing access to evidenced-based psychosocial interventions (EBIs) within a service context that supports recovery as both a process and an outcome. Evolution of the IRM is characterised as a series of five broad challenges, which draw together: relevant recovery perspectives; overall service delivery frameworks; psychiatric and psychosocial rehabilitation approaches and literature; our own clinical and service delivery experience; and implementation, evaluation and review strategies. The model revolves around the person's changing recovery needs, focusing on underlying processes and the service frameworks to support and reinforce hope as a primary catalyst for symptomatic and functional recovery. Within the IRM, clinical rehabilitation (CR) practices, processes and partnerships facilitate access to psychosocial EBIs to promote hope, recovery, self-agency and social inclusion. Core IRM components are detailed (remediation of functioning; collaborative restoration of skills and competencies; and active community reconnection), together with associated phases, processes, evaluation strategies, and an illustrative IRM scenario. The achievement of these goals requires ongoing collaboration with community organisations. CONCLUSIONS: Improved outcomes are achievable for people with a SMI. It is anticipated that the IRM will afford MH services an opportunity to validate hope, as a critical element for people with SMI in assuming responsibility and developing skills in self-agency and advocacy. Strengthening recovery-oriented practices and policies within MH services needs to occur in tandem with wide-ranging service evaluation strategies.

Implementation of a recovery-oriented model in a sub-acute Intermediate Stay Mental Health Unit (ISMHU).

BACKGROUND: An ongoing service evaluation project was initiated following the establishment of a new, purpose-built, 20-bed sub-acute Intermediate Stay Mental Health Unit (ISMHU). This paper: provides an overview of the targeted 6-week program, operating within an Integrated Recovery-oriented Model (IRM); characterises the clients admitted during the first 16 months; and documents their recovery needs and any changes. METHODS: A brief description of the unit's establishment and programs is initially provided. Client needs and priorities were identified collaboratively using the Mental Health Recovery Star (MHRS) and addressed through a range of in-situ, individual and group interventions. Extracted client and service data were analysed using descriptive statistics, paired t-tests examining change from admission to discharge, and selected correlations. RESULTS: The initial 154 clients (165 admissions, average stay = 47.86 days) were predominately male (72.1%), transferred from acute care (75.3%), with schizophrenia or related disorders (74.0%). Readmission rates within 6-months were 16.2% for acute and 3.2% for sub-acute care. Three MHRS subscales were derived, together with stage-of-change categories. Marked improvements in MHRS Symptom management and functioning were identified (z-change = -1.15), followed by Social-connection (z-change = -0.82) and Self-belief (z-change = -0.76). This was accompanied by a mean reduction of 2.59 in the number of pre-action MHRS items from admission to discharge (z-change = 0.98). Clinician-rated Health of the Nation Outcome Scales (HoNOS) improvements were smaller (z-change = 0.41), indicative of illness chronicity. Staff valued the elements of client choice, the holistic and team approach, program quality, review processes and opportunities for client change. Addressing high-levels of need in the 6-week timeframe was raised as a concern. CONCLUSIONS: This paper demonstrates that a recovery-oriented model can be successfully implemented at the intermediate level of care. It is hoped that ongoing evaluations support the enthusiasm, commitment and feedback evident from staff, clients and carers.

Effectiveness of a 10-week group program based on Dialectical Behaviour Therapy skills among patients with personality and mood disorders: findings from a pilot study.

OBJECTIVES: Community mental health services are often required to manage people experiencing repeated crises. Personality disorders are not uncommon, accounting for up to one-third of such presentations. These patients are often difficult to treat, leading to a revolving-door phenomenon. This study evaluated the effectiveness of a pilot intervention in reducing psychological symptoms and distress, and examined the impact of the intervention on mental health service utilization. METHODS: A pre- versus post-treatment evaluation was conducted of the effectiveness of a 10-week group psychological intervention based on Dialectical Behaviour Therapy skills, conducted in a regional Australian community mental health service with patients diagnosed with either Cluster B personality disorder or a mood disorder. RESULTS: Of those who completed the program ( N = 38 patients), 84% were female, with an average age of 35.13 years. Participants were active clients of the service for an average of 58.3 weeks prior to the program. They demonstrated significant improvements in quality of life and self-control, and a reduction in hopelessness, cognitive instability and dependence on mental health services. CONCLUSIONS: Limiting the Dialectical Behaviour Therapy program to a short-term skills-based group component was successful with the targeted patient group; however, more research is required to establish the generalizability of these results.

Ten-year audit of clients presenting to a specialised service for young people experiencing or at increased risk for psychosis.

BACKGROUND: Despite strong research interest in psychosis risk identification and the potential for early intervention, few papers have sought to document the implementation and evaluation of specialised psychosis related services. Assessment of Ultra High Risk (UHR) has been given priority, but it is equally as important to identify appropriate comparison groups and other baseline differences. This largely descriptive service evaluation paper focuses on the 'baseline characteristics' of referred clients (i.e., previously assessed characteristics or those identified within the first two months following service presentation). METHODS: Data are reported from a 10-year layered service audit of all presentations to a 'Psychological Assistance Service' for young people (PAS, Newcastle, Australia). Baseline socio-demographic and clinical characteristics (N =1,997) are described (including clients' psychosis and UHR status, previous service contacts, hospitalisation rates, and diagnostic and comorbidity profiles). Key groups are identified and comparisons made between clients who received ongoing treatment and those who were primarily assessed and referred elsewhere. RESULTS: Clients averaged 19.2 (SD =4.5) years of age and 59% were male. One-tenth of clients (9.6%) were categorised as UHR, among whom there were relatively high rates of attenuated psychotic symptoms (69.1%), comorbid depression (62.3%), anxiety (42.9%), and attentional and related problems (67.5%). Overall, one-fifth (19.8%) experienced a recent psychotic episode, while a further 14.5% were categorised as having an existing psychosis (46.7% with a schizophrenia diagnosis), amongst whom there were relatively high rates of comorbid substance misuse (52.9%), psychosocial (70.2%) and physical health (37.7%) problems. The largest group presenting to PAS were those with non-psychotic disorders (43.7%), who provide a valuable comparison group against which to contrast the health trajectories of those with UHR and recent psychosis. Ongoing treatment by PAS was preferentially given to those experiencing or at risk for psychosis and those reporting greater current distress or dysfunction. CONCLUSIONS: Whether or not UHR clients transition to psychosis, they displayed high rates of comorbid depression and anxiety at service presentation, with half receiving ongoing treatment from PAS. Although international comparisons with similar services are difficult, the socio-demographic and comorbidity patterns observed here were viewed as largely consistent with those reported elsewhere.

Shift climate profiles and correlates in acute psychiatric inpatient units.

PURPOSE: Inpatient psychiatric units are dynamic in nature, potentially creating a different treatment experience for each person, which may be difficult to quantify. Among the goals of this multi-centre service evaluation project was an assessment of shift-to-shift changes in unit-level events and their impact on the social-emotional environment. METHODS: Over 1 year, various nurse-completed logs were used within the 11 participating Australian psychiatric units (n = 5,546 admissions) to record patient- and unit-level events per shift, including ratings of the overall social-emotional climate using a novel shift climate ratings (SCR) scale (n = 8,176 shifts). These were combined with admission-level patient characteristics to investigate shift climate profiles and correlates. RESULTS: Occupancy rates averaged 88% and two-thirds of admissions were involuntary. The psychometric performance of the SCR scale was considered to be satisfactory (e.g., high internal consistency, unidimensional factor structure, and evidence of discriminant and predictive validity). A series of hierarchical regressions revealed considerable variation in SCR total scores, with poorer climates being significantly associated with: day/afternoon shifts; higher occupancy levels; higher proportions of experienced staff, and male, older, or involuntary patients; higher rates of less serious aggressive incidents; reporting of additional staffing demands; and unit location in a stand-alone psychiatric hospital. CONCLUSIONS: The day-to-day social-emotional climate can have important consequences for patient engagement and recovery. Improved understanding of the role played by unit, staff and patient characteristics, together with routine monitoring, should facilitate the development and evaluation of targeted interventions to reduce adverse incidents and improve the overall social-emotional climate.

Hunter DBT project: randomized controlled trial of dialectical behaviour therapy in women with borderline personality disorder.

OBJECTIVE: Deliberate self-harm (DSH), general hospital admission and psychiatric hospital admission are common in women meeting criteria for borderline personality disorder (BPD). Dialectical behaviour therapy (DBT) has been reported to be effective in reducing DSH and hospitalization. METHOD: A randomized controlled trial of 73 female subjects meeting criteria for BPD was carried out with intention-to-treat analyses and per-protocol analyses. The intervention was DBT and the control condition was treatment as usual plus waiting list for DBT (TAU+WL), with outcomes measured after 6 months. Primary outcomes were differences in proportions and event rates of: any DSH; general hospital admission for DSH and any psychiatric admission; and mean difference in length of stay for any hospitalization. Secondary outcomes were disability and quality of life measures. RESULTS: Both groups showed a reduction in DSH and hospitalizations, but there were no significant differences in DSH, hospital admissions or length of stay in hospital between groups. Disability (days spent in bed) and quality of life (Physical, Psychological and Environmental domains) were significantly improved for the DBT group. CONCLUSION: DBT produced non-significant reductions in DSH and hospitalization when compared to the TAU+WL control, due in part to the lower than expected rates of hospitalization in the control condition. Nevertheless, DBT showed significant benefits for the secondary outcomes of improved disability and quality of life scores, a clinically useful result that is also in keeping with the theoretical constructs of the benefits of DBT.

Distinguishing suicidal from non-suicidal deliberate self-harm events in women with Borderline Personality Disorder.

OBJECTIVE: Deliberate self-harm (DSH) is common in Borderline Personality Disorder, may be due to a variety of reasons, and is associated with different degrees of suicidal intent. Understanding the reasons for episodes of DSH in this population may be helpful in developing interventions to reduce the rate of DSH or to assist in the clinical judgement of suicidal intention after DSH has occurred. METHODS: The Parasuicide History Interview, version 2 (PHI-2) was used to determine the reasons for DSH events in 70 Australian women diagnosed with Borderline Personality Disorder. Factor analysis of the responses identified four empirically derived component factors. Multivariate models were developed to identify the independent predictors of suicidal deliberate self-harm (S-DSH) versus non-suicidal deliberate self-harm (NS-DSH) events. RESULTS: Participants and raters showed strong agreement in classifying S-DSH and NS-DSH events. Methods used that involved self-poisoning, jumping or stabbing showed increased risk for S-DSH, adjusted odds ratio 12.07 (95% CI 2.17, 67.29), compared to the referent group, external damage to skin with no rescue contact being sought. Although no grouping of reasons were independently significant, the lower the effectiveness of the DSH event to resolve the reasons for the event, the higher the risk of it having been a S-DSH event. CONCLUSION: In clinical situations, any Borderline Personality Disorder patient seeking help or medical attention, using any method other than superficial external injury to skin, or reporting a failure to effectively resolve the reasons for the DSH event, should be considered as likely to have had a S-DSH event (greater suicidal intention). However, specific reasons for the DSH event, or individual subject characteristics, did not meaningfully distinguish S-DSH from NS-DSH events.

Care pathways, engagement and outcomes associated with a recovery-oriented intermediate stay mental health program.

This study examined care pathways, program engagement, and key outcomes associated with a sub-acute inpatient stay in a 20-bed stand-alone Intermediate Stay Mental Health Unit (ISMHU; NSW, Australia). A 6-week evidenced-based tailored intervention program was offered, utilizing a recovery-oriented model of care. Service data from multiple record systems were combined, including admissions and service contacts 2-years prior to and following the index admission. During the initial 16-months there were 146 index admissions with a length of stay greater than 7 days. The majority (75.3%) were transfers from acute-care, with an average ISMHU stay of 50.3 days. Service and clinical outcomes were examined in relation to care pathways, recovery needs, program engagement and benefits achieved. Substantial engagement was detected (e.g., 74.0% >10 intervention types), together with significant improvements on self-report and clinician rated measures (e.g., social connection, symptoms, and self-belief). Logistic regression analyses revealed that arrival category was the strongest outcome predictor, with community referrals experiencing the largest reduction in subsequent acute mental health admissions (58.3% to 16.7%), followed by involuntary inpatient referrals (80.3% to 60.7%). Potential recovery-focused benefits are not limited to community treatment settings, while pathways to care may help identify clients with differing needs and opportunities for treatment.

Adverse incidents in acute psychiatric inpatient units: rates, correlates and pressures.

OBJECTIVE: This paper reports findings from a multicentre service evaluation project conducted in acute psychiatric inpatient units in NSW, Australia. Overall rates of aggression, absconding and early readmission are reported, as well as length-of-stay profiles and associations between these outcomes and selected sociodemographic and clinical characteristics routinely collected by health services. METHOD: Data from the 11 participating units were collected for a 12month period from multiple sources, including electronic medical records, routine clinical modules, incident forms, and shift based project-specific logs. For the current analyses, two admission-level datasets were used, comprising aggregated patient-level events (n=3242 admissions) and basic sociodemographic, clinical, admission and discharge information (n=5546 admissions by 3877 patients). RESULTS: The participating units were under considerable strain: 23.3% of admissions were high acuity; 60.4% had previous hospital stays; 47.6% were involuntary; 25-30% involved adverse incidents; bed occupancy averaged 88.4%; median length of stay was 8 days (mean=14.59 days); and 17.4% had a subsequent early readmission. Reportable aggressive incidents (11.2% of admissions) were intermittent (averaging 0.55 incidents per month per occupied bed) and associated with younger age, personality disorder, less serious aggression, longer periods of hospitalization, and subsequent early readmission. Less serious aggressive incidents (15.0% of admissions) were maximal in the first 24h (averaging 3.73 incidents per month per occupied bed) and associated with younger age, involuntary status, bipolar and personality disorders, the absence of depression, and longer hospital stays. Absconding (15.7% of admissions) peaked in the second week following admission and was associated with drug and alcohol disorder, younger age, and longer periods of hospitalization. CONCLUSIONS: By examining relationships between a core set of risk factors and multiple short-term outcomes, we were able to identify several important patterns, which were suggestive of the need for a multi-level approach to intervention, shifting from a risk management focus during the early phase of hospitalization to a more targeted, therapeutic approach during the later phase. But the latter approach may not be achievable under current circumstances with existing resources.

Utility of risk-status for predicting psychosis and related outcomes: evaluation of a 10-year cohort of presenters to a specialised early psychosis community mental health service.

Psychosis transition rates by those at clinical high risk have been highly variable and few studies have compared service presenters across the full psychosis risk spectrum with respect to medium-term outcomes. A 10-year service cohort was examined (N=1997), comprising all presentations to an early psychosis service for young people experiencing a recent psychotic episode or at increased risk ('Psychological Assistance Service', Newcastle, Australia). Baseline and longitudinal service data (median follow-up =7.3 years) were used in a series of logistic regressions to examine relationships between psychosis risk-status and subsequent illness episodes, hospital admissions, and community contacts. Six baseline groups were identified: existing (14.5%) and recent psychosis (19.8%); ultra-high risk (UHR, 9.6%); non-psychotic disorders without (35.4%, the reference group) and with psychiatric admissions (8.3%); and incomplete assessments (12.5%). High comorbidity levels were reported by the cohort (psychosocial problems, 61.1%; depression, 54.1%; substance misuse, 40.7%). UHR clients experienced similar psychosis transition rates to the reference group (17.3% vs. 14.6%; 8.9% vs. 9.1% within 2-years) and comparable rates of subsequent non-psychosis outcomes. A 25.9% conversion rate from early psychosis to schizophrenia was detected. However, among transitioning individuals, UHR clients faired relatively better, particularly with respect to changes in comorbidity and mental health contacts. Interventions tailored to current problems, recovery and psychological strengthening may be more appropriate than those based on estimated psychosis risk, which currently lacks clinical utility.

Measuring observed mental state in acute psychiatric inpatients.

BACKGROUND: Relationships within acute psychiatric units between patient-level experiences and events and fluctuations in mental state have rarely been examined. AIM: Data from a multi-centre service evaluation (11 units, 5,546 admissions) were used to examine mental state patterns and associations with clinical characteristics, events and adverse incidents. METHOD: During the 12-month evaluation period, nursing staff completed shift-level ratings using a new rating scale, the observed mental state (OMS) scale, which assessed active psychopathology (emotional distress, disinhibition, psychosis, cognitive impairment) and withdrawal (45,885 sets of day/afternoon shift ratings). RESULTS: The OMS scale performed satisfactorily and is worth considering elsewhere (e.g., active psychopathology: internal consistency, alpha=0.72; short-term stability, r=0.72; sensitivity to change, adjusted standardised difference, ASD=0.71). Levels of active psychopathology were much higher on shifts in which reportable (ASD=1.47) and less serious aggression occurred (ASD=1.44), compared with other shifts in which pro re nata medications were also administered (ASD=0.76), suggesting that medication usage often followed these events, and possibly that agitation and distress levels either rose rapidly or went initially unnoticed on these shifts. Although mental state improved steadily across the admission, one-fifth of the patients with schizophrenia received OMS psychosis ratings in the moderate to severe range during the days prior to discharge. CONCLUSIONS: Observed mental state ratings were strongly linked with diagnosis and reflected key events and incidents. Routine recording using the OMS scale may assist clinical decision-making and evaluation in acute psychiatric units.