The Impact of Integrating Crisis Teams into Community Mental Health Services on Emergency Department and Inpatient Demand.

This investigation focused on the impact of integrating crisis team members into community mental health services on emergency department and adult mental health inpatient unit demand within an Australian public health service. Mixed methods were used including (a) the comparison of service use data with that of two other comparable services (both of which had community-based crisis teams), (b) surveys of (i) patients and carers and (ii) staff, and (c) focus groups with staff. The numbers of emergency department presentations with mental health conditions and adult mental health inpatient separations increased 13.9 and 5.7 %, respectively, from FY2006/07 to FY2012/13. Between the three services, there were minimal differences in the percentages of presentations with mental health conditions, the distribution of mental health presentations across a 24-h period, and the triage categories assigned to these patients. Survey participants reported that patients used the emergency department due to the urgency of situations, perceptions that gaining access to mental health services would take less time, and the unavailability of mental health services when help is needed. Staff identified several issues (e.g. inappropriate referrals) that may be unnecessary in increasing emergency department demand. The integration of crisis team members into community mental health services does not seem to have produced an increase in emergency department admissions or inpatient separations beyond what might be expected from population growth. The potential may exist, however, to reduce emergency department admissions through addressing the issue of inappropriate referrals.

Reflections on facilitated discharge from a mental health service.

OBJECTIVE: The aim of this paper is to review research evidence and describe our experience of facilitated discharge from mental health services to primary care. METHOD: A literature review of facilitated discharge was conducted. In addition, the clinical characteristics of 21 discharged and 21 non-discharged patients from one shared care service were compared in a retrospective file review. Thirty-one patients in another facilitated discharge program were surveyed. RESULTS: Discharged patients had a higher level of function. There was a trend towards discharged patients being female and employed with less chronic illness, involuntary treatment, behavioural symptoms, depot medication, triage contact, service contact with family, and more mood disorder. Of the 10 survey respondents, 60% reported feeling better compared with their last service contact, 70% felt not having contact was a good thing and most saw their doctors regularly and reported a good relationship. CONCLUSIONS: There was a trend towards more stable patients being discharged and it appeared that they responded positively to this, without a clear indication of which factors best determine suitability for discharge. Consequently, we elected to incorporate discharge planning processes as a core function of case management and increase shared care with the primary care sector.

Outcome of planned discharge from case management: a 3 year retrospective study.

OBJECTIVE: To investigate the rates of relapse of mental illness in adults requiring acute intervention at a mental health service following a planned discharge process from community case management. METHOD: A planned approach to identifying and facilitating patient discharge was identified and incorporated into clinical team reviews. Data regarding service contacts of all discharged patients were collected at 1 year and then 3 years following planned discharge and reviewed in detail. Demographic factors and clinical variables were collected in anticipation that useful predictors for successful discharge might be identified. RESULTS: Using a planned approach, a greater number of patients were discharged from case management to the care of a primary treating practitioner. Discharges increased from 11 in 2000 to 46 in 2001. Of the 46 patients discharged from case management, 22 patients (47.8%) had no contact with the service during the first 12 months. Twenty-four patients accessed the Service requiring no further action, but at some point nine (19.6%) required acute intervention. The remaining 15 patients (32.6%) were managed successfully either by the triage service or non-urgent referral for psychiatric consultation. During the 3 year period 10 patients (21.7%) continued to have no contact with the service. Nineteen patients (41.3%) required acute intervention; the remaining 17 (36.9%) were successfully managed through triage or via non-urgent psychiatric review requiring no further action by the Service. Of the seven patients who had been on a community treatment order during their treatment, only one had further contact with the Service. CONCLUSIONS: A planned approach to the discharge of patients from case management to the community resulted in an increased number of patient discharges. While most patients did not rapidly relapse, a number of patients did have contact with the Service and 19 (41.3%) required at least one acute intervention during the 3 year follow-up period. The findings reflect the importance of relapse prevention and management and service re-entry planning with triage services, patients, carers and other key workers. The frequency of service use and the variation of services required by patients highlight the importance of availability of a variety of adequately resourced levels of service response.

Side-effects and treatment with clozapine: a comparison between the views of consumers and their clinicians.

This study sought to clarify the prevalence of various side-effects experienced by consumers taking clozapine (n = 27) and to elucidate the impact of clozapine on their quality of life. Responses of consumers were contrasted with those of clinicians to highlight any discrepancies between the two groups, thus providing a focus for the improvement of clinical practice. Consumers completed a demographic questionnaire, the Liverpool University Neuroleptic Side-Effect Rating Scale. They next took part in a semistructured interview, which explored their attitudes to clozapine treatment. File searches provided historical data for antipsychotic use before the prescription of clozapine. Clinicians completed the same instruments and submitted them by mail. Most clinicians overestimated the prevalence and severity of clozapine side-effects. Consumers reported drooling mouth as the most prevalent and severe side-effect, whereas clinicians estimated that difficulty staying awake was the most prevalent side-effect, and the most severe side-effect was sleeping too much. Clinicians and consumers agreed that clozapine lifts mood. Only 19% of consumers were unhappy about blood tests, whereas 52% of clinicians estimated that consumers were unhappy about blood tests. This study suggests that despite significant side-effects and regular blood tests, most stable consumers taking clozapine were happier and more satisfied with their treatment than many of their clinicians believed they were. The study also highlights the need for clinicians to ask consumers about the different side-effects they may be experiencing, so they can provide clinical support to improve their quality of life.

Monitoring the safe use of clozapine: a consensus view from Victoria, Australia.

Clozapine is an important antipsychotic agent that has a unique profile of clinical benefits, but that has also been associated with several serious and potentially life-threatening safety concerns. In order to minimise the impact of haematological adverse events, health professionals treating patients with clozapine are currently required to register their patients on a centrally administered data network and to conform to strict protocols. The consensus statement documented in this article extends existing protocols by recommending monitoring of patients treated with clozapine for additional adverse effects during treatment. This consensus statement reflects the current practice at five major public psychiatric hospitals in Victoria, Australia, for the monitoring and management of clozapine-related adverse events, and has been implemented at these sites because of emerging safety concerns associating clozapine with cardiovascular and metabolic adverse effects.

A pilot randomized, double-blind, placebo-controlled study of granisetron in the treatment of sexual dysfunction in women associated with antidepressant use.

A pilot study was conducted to evaluate the usefulness of granisetron for the treatment of antidepressant induced sexual dysfunction in women. Twelve women with antidepressant induced sexual dysfunction (AISD) were assigned granisetron (n=5) or placebo (n=7) in a 14-day randomized, double-blind, placebo-controlled study. One participant in the granisetron group did not complete the study. Participants were assessed at baseline, day 7 and day 14 using the Feiger Sexual Function and Satisfaction Questionnaire and the Arizona Sexual Experience Scale. No statistical differences were measured at baseline or at endpoint between the granisetron or placebo group. This study did not produce evidence supporting the usefulness of granisetron in AISD.

N-acetyl cysteine as a glutathione precursor for schizophrenia--a double-blind, randomized, placebo-controlled trial.

BACKGROUND: Brain glutathione levels are decreased in schizophrenia, a disorder that often is chronic and refractory to treatment. N-acetyl cysteine (NAC) increases brain glutathione in rodents. This study was conducted to evaluate the safety and effectiveness of oral NAC (1 g orally twice daily [b.i.d.]) as an add-on to maintenance medication for the treatment of chronic schizophrenia over a 24-week period. METHODS: A randomized, multicenter, double-blind, placebo-controlled study. The primary readout was change from baseline on the Positive and Negative Symptoms Scale (PANSS) and its components. Secondary readouts included the Clinical Global Impression (CGI) Severity and Improvement scales, as well as general functioning and extrapyramidal rating scales. Changes following a 4-week treatment discontinuation were evaluated. One hundred forty people with chronic schizophrenia on maintenance antipsychotic medication were randomized; 84 completed treatment. RESULTS: Intent-to-treat analysis revealed that subjects treated with NAC improved more than placebo-treated subjects over the study period in PANSS total [-5.97 (-10.44, -1.51), p = .009], PANSS negative [mean difference -1.83 (95% confidence interval: -3.33, -.32), p = .018], and PANSS general [-2.79 (-5.38, -.20), p = .035], CGI-Severity (CGI-S) [-.26 (-.44, -.08), p = .004], and CGI-Improvement (CGI-I) [-.22 (-.41, -.03), p = .025] scores. No significant change on the PANSS positive subscale was seen. N-acetyl cysteine treatment also was associated with an improvement in akathisia (p = .022). Effect sizes at end point were consistent with moderate benefits. CONCLUSIONS: These data suggest that adjunctive NAC has potential as a safe and moderately effective augmentation strategy for chronic schizophrenia.