Reducing the psychological distress of family caregivers of home based palliative care patients: longer term effects from a randomised controlled trial.

BACKGROUND: Palliative care incorporates comprehensive support of family caregivers because many of them experience burden and distress. However, evidence-based support initiatives are few. PURPOSE: We evaluated a one-to-one psychoeducational intervention aimed at mitigating the distress of caregivers of patients with advanced cancer receiving home-based palliative care. We hypothesised that caregivers would report decreased distress as assessed by the General Health Questionnaire (GHQ). METHOD: A randomised controlled trial comparing two versions of the delivery of the intervention (one face-to-face home visit plus telephone calls versus two visits) plus standard care to a control group (standard care only) across four sites in Australia. RESULTS: Recruitment to the one visit condition was 57, the two visit condition 93, and the control 148. We previously reported non-significant changes in distress between times 1 (baseline) and 2 (1-week post-intervention) but significant gains in competence and preparedness. We report here changes in distress between times 1 and 3 (8-week post-death). There was significantly less worsening in distress between times 1 and 3 in the one visit intervention group than in the control group; however, no significant difference was found between the two visit intervention and the control group. CONCLUSIONS: These results are consistent with the aim of the intervention, and they support existing evidence demonstrating that relatively short psychoeducational interventions can help family caregivers who are supporting a dying relative. The sustained benefit during the bereavement period may also have positive resource implications, which should be the subject of future inquiry.

Patient factors associated with incidents of aggression in a general inpatient setting.

AIMS AND OBJECTIVES: To determine patient factors associated with aggressive (code grey) events in the setting of a metropolitan hospital during a six-month period, to inform screening and prevention practices. BACKGROUND: Patient aggression continues to place nurses and patients at risk. Nurses need to be able to identify situations that are likely to escalate into aggression in order to ensure their own safety and the quality of care they can provide. Research has focussed on emergency departments and psychiatric units. Approaches that are appropriate for these settings may not fit for the general inpatient setting. DESIGN: A structured audit and epidemiological analysis of hospital population, regarding incidence of aggression. METHODS: A retrospective audit of code grey event reports and medical records of patients admitted to 16 general medical-surgical wards, during a six-month period. All available records of 121 code grey events were audited. Demographic factors for patients with code grey events were compared with factors for 6472 patients admitted. Statistical tests included chi-squared, bivariate and logistic regression. RESULTS: Diagnoses associated with increased risk of code grey were the following: delirium (11 times more likely) and dementia (seven times). Patients were more likely to have a code grey event if they were over 65 years of age (more than twice), were male (more than twice), were a recipient of Veterans' Affairs pension (four times), had never been married or had been admitted through the emergency department (almost twice). CONCLUSION: This study adds to the current knowledge of the distinctive profile of patients in medical-surgical settings who are associated with aggressive events. RELEVANCE TO CLINICAL PRACTICE: It is recommended that nurses increase their focus on assessment of identified risk factors and documentation of behaviours, to help predict aggressive events, and that this focus be supported by hospital safety and care policy.

First episode psychosis in an adult area mental health service-a closer look at early and late-onset first episode psychosis.

OBJECTIVES: To review the characteristics of all patients presenting with a first episode of psychosis between the ages of 16 and 65 years to an adult area mental health service. METHODS: The early psychosis programme at St Vincent's Hospital Melbourne treats all patients presenting in the early stages of psychosis between the ages of 16 and 65 years. A database was developed to capture the demographic and diagnostic characteristics of the group. The characteristics of those with an onset under 26 years were compared with those with a later onset. RESULTS: A large proportion (55%) of those presenting with first episode psychosis presented after the age of 25 years. There were a higher number of cases of depression with psychotic features in the older onset patients (notably so for those over 40) and a trend towards greater metabolic morbidity. DISCUSSION: Older patients presenting with a first episode of psychosis are relatively understudied but appear to have certain distinguishing qualities. Understanding the needs of these patients is important in tailoring optimal treatment packages and service responses.

A longitudinal study of distress (depression and anxiety) up to 18 months after radiotherapy for head and neck cancer.

OBJECTIVE: The aim of the study was to assess symptoms of depression and anxiety in patients with head and neck cancer up to 18 months after radiotherapy. METHODS: Prospective observational study of consecutive head and neck outpatients was conducted at a tertiary cancer centre (n = 101). Eligibility included diagnosis of cancer in the head and neck region, where the patient agreed to radiotherapy with curative intent. Data were collected before commencement of radiotherapy and 3 weeks and 18 months after completion. Symptoms of depression and anxiety were assessed by the Hospital Anxiety and Depression Scale. Tumour/treatment-related physical symptoms were assessed using the 'Additional Concerns' subscale of the Functional Assessment of Chronic Illness Therapy for Head and Neck Cancer. RESULTS: The prevalence of identified probable cases of depression was 15% at baseline, increasing to 29% 3 weeks post-treatment, falling to 8% at 18-month follow-up. The number of probable cases of anxiety was 20% at baseline, 17% at 3 weeks post-treatment and 22% at 18-month follow-up. Depression scores significantly increased from baseline to 3 weeks post-treatment and decreased at 18-month follow-up. Variability in depression scores was accounted for by tumour/treatment-related physical symptoms. Anxiety scores significantly decreased between baseline and 3-week post-treatment and increased at 18-month follow-up. Younger age and more tumour/treatment-related physical symptoms predicted anxiety scores. CONCLUSIONS: The rates of depression in head and neck cancer patients increase following cancer treatment and are related to tumour/treatment-related physical symptoms. Anxiety levels are higher pre-treatment, lower immediately following cancer treatment but rise to near pre-treatment levels more than a year after completion of cancer treatment.

Reducing the psychological distress of family caregivers of home-based palliative care patients: short-term effects from a randomised controlled trial.

BACKGROUND: Palliative care is expected to incorporate comprehensive support for family caregivers given that many caregivers suffer psychological morbidity. However, systematically implemented evidence-based psychological support initiatives are lacking. AIM: The objective of this study was to prepare caregivers for the role of supporting a patient with advanced cancer receiving home-based palliative care by offering a one-to-one psycho-educational intervention. We hypothesised that primary family caregivers who participated in the intervention would report decreased psychological distress (primary outcome), fewer unmet needs and increased levels of perceived preparedness, competence and positive emotions. METHODS: A three-arm randomised controlled trial was conducted comparing two versions of the intervention (one face-to-face visit versus two visits) plus standard care to a control group (standard care) across four sites in Australia. RESULTS: A total of 298 participants were recruited; 148 were in the Control condition, 57 in Intervention 1 (one visit) and 93 in Intervention 2 (two visits). Relative to participants in the control group; the psychological well-being of participants in the intervention condition was improved by a small amount but non-significantly. No significant reduction in unmet needs or improvements in positive aspects of caregiving amongst the intervention group were identified. However, the intervention demonstrated significant improvements in participants' levels of preparedness and competence for Intervention 2. CONCLUSION/IMPLICATIONS: This research adds to accumulating body of evidence demonstrating that relatively short psycho-educational interventions can enable family caregivers to feel more prepared and competent in the role of supporting a dying relative. Further investigation is required to determine the longer term outcomes of such interventions.

An examination of risk factors for readmission to acute adult mental health services within 28 days of discharge in the Australian setting.

OBJECTIVE: The aim of this paper was to identify risk factors associated with readmission within 28 days of discharge from eight Australian adult acute mental health inpatient services. METHOD: A detailed file audit was conducted comparing 222 patients readmitted within 28 days of discharge with 253 patients not readmitted during the same period. RESULTS: There was an association between early readmission and having had contact with the service in the previous 12 months (51% vs 21%), having been admitted in the previous 12 months (65% vs 36%), and having been diagnosed with an emotionally unstable personality disorder (14% vs 4%). Those who were not readmitted had a significantly higher score in the Health of the Nation Outcome Scales on index admission than those who were readmitted. Those who had community team contact on the day of discharge and those who received follow up by the mental health team within 7 days of discharge were more likely to be readmitted (55% vs 45% and 29% vs 19% respectively). CONCLUSIONS: Significant determinants of early readmission identified were a history of recent previous admissions and a diagnosis of unstable personality disorder. The usefulness of this performance measure to Area Mental Health Services and clinicians is discussed.

Meeting the needs of family carers: an evaluation of three home-based palliative care services in Australia.

While policy promotes comprehensive assessment of family career needs and a plan to adequately meet family career needs within palliative care, there is a lack of studies in the Australian context which examine the current type of assessment and types of care provided to family carers. The aims of this study were (1) to determine how career needs are currently assessed and what level of support is available to family carers in three home-based palliative care services within Australia, (2) identify areas for improvement of support to carers and, (3) explore the barriers to offering career support. A focus group and file audit were conducted at two metropolitan and one regional home-based palliative care service in Australia. These palliative care sites reported substantially different levels of services provided to family carers and also reported multiple barriers to providing services for family carers. Only one site had a formal structured procedure to assess career needs and none of the sites used a separate career care plan or offered a structured intervention to assist carers with their role. Family meetings were offered infrequently by most sites. A number of barriers to supporting carers were highlighted including lack of resources, and areas for improvement were also suggested by health professionals from the sites.

A systematic review of instruments related to family caregivers of palliative care patients.

Support for family caregivers is a core function of palliative care. However, there is a lack of consistency in the way needs are assessed, few longitudinal studies to examine the impact of caregiving, and a dearth of evidence-based interventions. In order to help redress this situation, identification of suitable instruments to examine the caregiving experience and the effectiveness of interventions is required. A systematic literature review was undertaken incorporating representatives of the European Association for Palliative Care's International Palliative Care Family Caregiver Research Collaboration and Family Carer Taskforce. The aim of the review was to identify articles that described the use of instruments administered to family caregivers of palliative care patients (pre and post-bereavement). Fourteen of the 62 instruments targeted satisfaction with service delivery and less than half were developed specifically for the palliative care context. In approximately 25% of articles psychometric data were not reported. Where psychometric results were reported, validity data were reported in less than half (42%) of these cases. While a considerable variety of instruments have been administered to family caregivers, the validity of some of these requires further consideration. We recommend that others be judicious before developing new instruments for this population.

Outcome measurement in chronic mental illness.

This review begins with an outline of outcome measurement in the country where it has been most thoroughly implemented, namely Australia. There follows a consideration of what constitutes an outcome in mental illness generally, and chronic mental illness in particular. Some instruments, such as the Health of the Nation Outcome Scales (HoNOS), focus primarily on illness severity, and examples of their use in the area of chronic mental illness are presented. Other instruments, such as the Life Skills Profile (LSP), assess personal functioning or disability, and that literature is reviewed. One major area of attention in the chronically mentally ill is quality of life. Another fruitful approach to assessing outcome is to look at needs, especially unmet needs, for which the leading instrument is the Camberwell Assessment of Need; relevant findings are reviewed. The most recent area of interest is recovery. While several scales have been developed, there are as yet relatively few reports of their application with patients with chronic mental illness. The concluding section considers the benefits and weaknesses of using the same standard instruments with all consumers within a service, and shows the utility of outcome results in groups and individuals with generally small overall changes.

Borderline personality disorder and interagency response.

OBJECTIVE: People with borderline personality disorder (BPD) confront multiple agencies with behaviours that are often alarming and bewildering. However, different service providers appear to respond to the same patient population in different ways. We aimed to explore the emotional reactions, concerns and beliefs related to working with the person with BPD by health and non-health related agencies. METHOD: A specifically designed questionnaire was completed by different agencies prior to their receiving educational training on an organizational and community-based model of care for people with BPD. RESULTS: Police believed that people with BPD are best medicated and hospitalized until they are no longer suicidal. A universal human response was noted as was support for interagency collaboration. CONCLUSIONS: Different agencies respond in different ways towards people with BPD. These differences reflect ideological splits between agency groups.

Objections to routine clinical outcomes measurement in mental health services: any evidence so far?

BACKGROUND: Routine clinical outcomes measurement (RCOM) is gaining importance in mental health services. AIMS: To examine whether criticisms published in advance of the development of RCOM have been borne out by data now available from such a programme. METHOD: This was an observational study of routine ratings using HoNOS65+ at inception/admission and again at discharge in an old age psychiatry service from 1997 to 2008. Testable hypotheses were generated from each criticism amenable to empirical examination. Inter-rater reliability estimates were applied to observed differences between scores between community and ward patients using resampling. RESULTS: Five thousand one hundred eighty community inceptions and 862 admissions had HoNOS65+ ratings at referral/admission and discharge. We could find no evidence of gaming (artificially worse scores at inception and better at discharge), selection, attrition or detection bias, and ratings were consistent with diagnosis and level of service. Anticipated low levels of inter-rater reliability did not vitiate differences between levels of service. CONCLUSIONS: Although only hypotheses testable from within RCOM data were examined, and only 46% of eligible episodes had complete outcomes data, no evidence of the alleged biases were found. RCOM seems valid and practical in mental health services.

Readmission to an acute psychiatric unit within 28 days of discharge: identifying those at risk.

OBJECTIVE: To examine factors that could help identify those most at risk of readmission to an acute psychiatric in-patient unit within 28 days of a discharge. METHOD: A detailed file audit was conducted comparing 54 consecutive patients who had been readmitted within 28 days of discharge with 61 patients, chosen at random, who had not been readmitted during the same period. RESULTS: Readmission within 28-days of discharge was associated with having been admitted in the previous year (P = 0.004), receiving the Disability Support Pension (P = 0.015), not having a discharge plan sent to the patient's GP on discharge from the index admission (P = 0.05), receiving follow-up by the mental health team within 7 days of discharge (P = 0.007) and being unemployed (P = 0.015). CONCLUSIONS: Targeting those with previous admissions for focussed discharge planning may help organisations reduce the numbers of unnecessary early readmissions.

Psychiatric comorbidity and impact on health service utilization in a community sample of patients with epilepsy.

We aimed to determine the level of psychological distress in community-treated patients with epilepsy and to determine if this distress is associated with increased health service use. The Australian National prescription database was used to recruit patients with epilepsy onto the Tasmanian Epilepsy Register (TER). Psychological distress was measured using the K10 in the TER patients and compared to the Tasmanian population using the National Health Survey 2004-5. Of the 1,180 on the TER, 43 withdrew, 36 died, and 262 were excluded. Of 839 patients, 652 completed the K10 (78%). High-very high levels of psychological distress were observed in patients with epilepsy compared with the general population [odds ratio (OR) 2.14, 95% confidence interval (CI) 1.79-2.56]. Patients with high-very high psychological distress had increased attendance at general practitioners (p < 0.001), specialists (p = 0.02), and emergency departments (p = 0.004). Psychological distress is increased in community-treated patients with epilepsy compared to the general population, and is associated with increased health service use.

An effectiveness trial of cognitive behaviour therapy in a representative sample of outpatients with psychosis.

OBJECTIVES: The efficacy of cognitive behaviour therapies for psychosis (CBTp) has been sufficiently established for its inclusion in some national treatment guidelines. However, treatment efficacy does not guarantee effectiveness in routine practice, where clinician expertise and patient mix may be different. Thus, we evaluated the applicability, acceptability and effectiveness of CBTp when offered routinely in a public mental health service. DESIGN: A prospectively recruited representative sample (N=94) of patients with psychotic disorders from a geographic catchment area in Melbourne, Australia, was randomized to CBTp or treatment as usual. METHOD: The CBTp intervention included psychoeducation, positive symptom, and co-morbid problem components. Therapists collaboratively negotiated goals with patients and utilized treatment components from a manual. Intention-to-treat analyses used data at baseline, 9 months and 18 months. RESULTS: Working alliance and client satisfaction measures indicated excellent acceptability. Both groups improved to a similar degree on the Positive And Negative Syndrome Scale, with no advantage for the CBTp group. The most frequent CBTp components implemented were co-morbid disorders/personal issues and personalized psychoeducation; working with persisting symptoms was the main focus in relatively few sessions. CONCLUSIONS: The lack of advantage for the CBTp group may be due to: the infrequent focus on positive symptoms (the most replicated outcome domain for CBTp); the unselected nature of the patients (rather than those with distressing symptoms or referred by clinicians); or, to insufficient therapist expertise.

What does 'clinical significance' mean in the context of the Health of the Nation Outcome Scales?

OBJECTIVE: The aim of this paper was to improve understanding of what 'clinical significance' means in relation to the Health of the Nation Outcome Scales (HoNOS) and its older persons and child/adolescent equivalents (the HoNOS65+ and HoNOSCA). METHOD: An anonymous, web-based survey was completed by 94 outcome measurement experts, most of whom had clinical responsibilities. Respondents were asked to indicate for acute inpatient and ambulatory settings: the rating on each item which represented a clinically significant problem; the relative importance of each item in determining overall clinical severity; and the items which would not be expected to improve between admission and review, admission and discharge, review and review, and review and discharge. RESULTS: A score of 2 ('mild problem but definitely present') on each HoNOS/HoNOS65 + /HoNOSCA item resonates with experts as being evidence of a clinically significant problem that requires active monitoring or intervention. In the main, all items on these instruments are viewed as equally important in making an overall judgement of clinical severity. The items making up the impairment and, to a lesser extent, social subscales are least likely to demonstrate change during the course of an episode of care, according to expert opinion. Generally, these findings apply across instruments and service settings. CONCLUSIONS: Overall, the findings provide support for the content validity and clinical utility of the HoNOS/HoNOS65 + /HoNOSCA. Further exploration of the question of clinical significance as reflected in these instruments could take a number of forms.

Approach to treatment of mental illness and substance dependence in remote Indigenous communities: results of a mixed methods study.

OBJECTIVE: To develop and evaluate a culturally adapted brief intervention for Indigenous people with chronic mental illness. DESIGN: A mixed methods design in which an exploratory phase of qualitative research was followed by a nested randomised controlled trial. SETTING: Psycho-education resources and a brief intervention, motivational care planning (MCP), were developed and tested in collaboration with aboriginal mental health workers in three remote communities in northern Australia. PARTICIPANTS: A total of 49 patients with mental illness and 37 carers were recruited to a randomised controlled trial that compared MCP (n = 24) with a clinical control condition (treatment as usual, n = 25). INTERVENTION: The early treatment group received MCP at baseline and the late treatment group received delayed treatment at six months. MAIN OUTCOME MEASURES: The primary outcome was mental health problem severity as measured by the health of the nation outcome scales. Secondary measures of well-being (Kessler 10), life skills, self-management and substance dependence were chosen. Outcome assessments were performed at baseline, six-month, 12-month and 18-month follow up. RESULTS: Random effects regression analyses showed significant advantage for the treatment condition in terms of well-being with changes in health of the nation outcome scales (P < 0.001) and Kessler 10 (P = 0.001), which were sustained over time. There was also significant advantage for treatment for alcohol dependence (P = 0.05), with response also evident in cannabis dependence (P = 0.064) and with changes in substance dependence sustained over time. CONCLUSIONS: These results suggest that MCP is an effective treatment for Indigenous people with mental illness and provide insight into the experience of mental illness in remote communities.

The effect of guidance in the use of routine outcome measures in clinical meetings.

Routine outcome measures (ROM) have now been introduced into all Australian public mental health services, but experience suggests that many clinical staff lack expertise in using them. In 2005 under the Quality Through Outcomes Network (QUATRO), the Victorian Department of Human Services set up three teams aimed at consolidating the use of ROM and furthering sustainability through a variety of peer-support activities. We report on an initiative undertaken by one of these teams. QUATRO team members attended team meetings of four adult community teams (three metropolitan and one rural) fortnightly over about 3 months. QUATRO staff contributed to discussion of outcome measures during routine clinical review, using local and national outcome measurement data and tools, and their own expertise. Attitudes of clinicians toward ROM in general and the specific instruments were assessed at the beginning and end of the period, and again after about 5 months. Qualitative findings consist of observations of factors that assist and hinder use of ROM. The initiative identified steps that staff can take to make ROM more useful in their work.

Consumer attitudes towards the use of routine outcome measures in a public mental health service: a consumer-driven study.

In this study conducted by consumer consultants, 50 consumers who have a Barwon Health case manager (the majority of whom were nurses) were interviewed using a structured questionnaire to ascertain their attitudes towards the routine use of outcome measures. Forty participants (80% of those interviewed) reported they had been offered the Behaviour and Symptom Identification Scale (BASIS-32) to complete in routine care by their case managers and of those, 95% (n = 38) completed it. On those who completed the BASIS-32, 42% said their case manager had explained what the BASIS-32 would be used for, 45% said that the case manager had discussed their responses with them, 76% stated that completing the BASIS-32 had helped the case manager to understand them better and 66% believed that completing the BASIS-32 had led to them receiving better care. Only 30% of the group interviewed were aware that their case manager regularly completed a Health of the Nation Outcome Scales and Life Skills Profile. Feedback about the process of completing the BASIS-32 was obtained as well as suggestions on how the process may be improved. The results indicate that consumers see the benefit of routine outcome measurement and believe it leads to improved care. More information about outcome measures, including the clinician-rated outcome measures, needs to be provided to consumers if they are to be engaged constructively in this exercise.