Morale in the English mental health workforce: questionnaire survey.

BACKGROUND: High-quality evidence on morale in the mental health workforce is lacking. AIMS: To describe staff well-being and satisfaction in a multicentre UK National Health Service (NHS) sample and explore associated factors. METHOD: A questionnaire-based survey (n = 2258) was conducted in 100 wards and 36 community teams in England. Measures included a set of frequently used indicators of staff morale, and measures of perceived job characteristics based on Karasek's demand-control-support model. RESULTS: Staff well-being and job satisfaction were fairly good on most indicators, but emotional exhaustion was high among acute general ward and community mental health team (CMHT) staff and among social workers. Most morale indicators were moderately but significantly intercorrelated. Principal components analysis yielded two components, one appearing to reflect emotional strain, the other positive engagement with work. In multilevel regression analyses factors associated with greater emotional strain included working in a CMHT or psychiatric intensive care unit (PICU), high job demands, low autonomy, limited support from managers and colleagues, age under 45 years and junior grade. Greater positive engagement was associated with high job demands, autonomy and support from managers and colleagues, Black or Asian ethnic group, being a psychiatrist or service manager and shorter length of service. CONCLUSIONS: Potential foci for interventions to increase morale include CMHTs, PICUs and general acute wards. The explanatory value of the demand-support-control model was confirmed, but job characteristics did not fully explain differences in morale indicators across service types and professions.

Postincident review of aggression and violence in mental health settings.

Management of violence and aggression remains a challenge to mental health care practitioners. It has been acknowledged that for a small number of incidents involving aggression, use of restraint will continue to be a method of containing potentially dangerous situations. The impact of being involved in these procedures remains under researched, but there is growing acknowledgment that some form of post incident review should take place after restraint use. As part of a larger study, a survey design was used to evaluate whether staff (n = 30) and inpatients (n = 30) had found post incident review helpful after incidents involving restraint. Ninety-seven percent of staff, and 94% of patient participants agreed this approach was useful. This article presents the findings of this survey and discusses the complex factors that should be considered when reviewing the aftermath of restraint for staff and inpatients in acute mental health settings.

An open trial in the NHS of Blues Begone: a new home based computerized CBT program.

BACKGROUND: Computer based treatment for depression and anxiety has been available for several years and has demonstrated useful clinical effects. Most existing computerized CBT products in the UK that are designed to treat depression and co-morbid anxiety require patients to visit a clinic and require staff input to manage the process. Such intervention adds to the costs and bottlenecks in delivering a clinically effective treatment with mass availability. Internet treatment options are becoming more readily available, although data to support use are not yet strong, and most still require human assessment and telephone support. Blues Begone is a new computerized CBT program that has been designed to be used at home with minimal human support. METHOD: This pilot project provides data from an open trial of Blues Begone with both primary and secondary care patients. RESULTS: One hundred patients started Blues Begone, 58 completed the program, 72% (n = 42) of completers achieved reliable change and (n = 36) 62% achieved both reliable and clinically significant change, and may be considered to have recovered by the end of the program. CONCLUSION: These data provide the first demonstration of the potential viability of Blues Begone as a home based computerized treatment for depression and anxiety.

A genome-wide scan for linkage to chromosomal regions in 382 sibling pairs with schizophrenia or schizoaffective disorder.

OBJECTIVE: Some genome-wide scans and association studies for schizophrenia susceptibility genes have yielded significant positive findings, but there is disagreement between studies on their locations, and no mutation has yet been found in any gene. Since schizophrenia is a complex disorder, a study with sufficient power to detect a locus with a small or moderate gene effect is necessary. METHOD: In a genome-wide scan of 382 sibling pairs with a diagnosis of schizophrenia or schizoaffective disorder, 396 highly polymorphic markers spaced approximately 10 centimorgans apart throughout the genome were genotyped in all individuals. Multipoint nonparametric linkage analysis was performed to evaluate regions of the genome demonstrating increased allele sharing, as measured by a lod score. RESULTS: Two regions with multipoint maximum lod scores suggesting linkage were found. The highest lod scores occurred on chromosome 10p15-p13 (peak lod score of 3.60 at marker D10S189) and the centromeric region of chromosome 2 (peak lod score of 2.99 at marker D2S139). In addition, a maximum lod score of 2.00 was observed with marker D22S283 on chromosome 22q12, which showed evidence of an imprinting effect, whereby an excess sharing of maternal, but not paternal, alleles was present. No evidence of linkage was obtained at several locations identified in previous studies, including chromosomes 1q, 4p, 5p-q, 6p, 8p, 13q, 15p, and 18p. CONCLUSIONS: The findings of this large genome-wide scan emphasize the weakness and fragility of linkage reports on schizophrenia. No linkage appears to be consistently replicable across large studies. Thus, it has to be questioned whether the genetic contribution to this disorder is detectable by these strategies and the possibility raised that it may be epigenetic, i.e., related to gene expression rather than sequence variation. Nevertheless, the positive findings on chromosome 2, 10, and 22 should be pursued further.

Spirituality or psychosis?--An exploration of the criteria that nurses use to evaluate spiritual-type experiences reported by patients.

Spiritual experiences and psychotic symptoms have many aspects of form and content in common. Despite this, clinicians make judgements about the pathology of these experiences and base care-plans on these judgements. Semi-structured interviews incorporating vignettes of spiritual-type experiences were given to 14 UK mental health nurses. This revealed that the nurses employed a complex and inter-relating set of criteria when evaluating spiritual-type experiences. The nature of the experience was considered, but the outcome of the experience (positive or negative) was an important evaluative factor, together with the personal and cultural context in which the experience occurred. The nurses demonstrated a tolerance of ambiguity and the need for awareness of their own subjectivity. They emphasised the importance of close-engagement with patients to achieve a rounded and holistic view of the patient's experience. They also emphasised the importance of team working in reducing idiosyncratic decision making.

Our experience of psychological difficulties and mental illness.

Steve Flatt seems to take issue with the notion of mental illness (reflections September 12), referring to 'psychological distress' and 'psychological difficulties', but without defining what he means by these terms.

Understanding the experiences and service needs of siblings of individuals with first-episode psychosis: a phenomenological study.

BACKGROUND: Despite recent focus on developing family-inclusive services to meet the needs of young people with first-episode psychosis, the needs of their siblings are often overlooked. AIMS: This study explored the experiences and needs of siblings of young adults with first-episode psychosis receiving support from two Early Intervention in Psychosis Services in South-East England. METHODS: Thirty-one siblings aged 11-35 years, were given a semi-structured interview to gather their perspectives and accounts of their lived experiences. The resultant rich qualitative data was analysed using responsive-reader and framework methods. RESULTS: Six themes were identified: siblings' roles and involvement; emotions; impact on relationships; coping patterns; resilience; and siblings' service needs. CONCLUSION: All participants had been greatly affected by the onset of the psychosis in their brother or sister. Most siblings did not identify themselves as carers, although most played a significant part in their brother's or sister's life. Participants wanted dynamic, robust and accessible services, especially information and peer support to meet their needs.

Taxometric investigation of the latent structure of nicotine dependence: an epidemiological sample.

A considerable number of daily tobacco users do not fulfill the DSM-IV and ICD-10 diagnostic criteria for nicotine dependence (ND). This suggests that such a diagnostic boundary may be arbitrary. This paper addresses this question empirically by comparing the viability of two models, respectively hypothesizing a dimensional and a categorical latent structure of ND. An epidemiological sample of 6,926 individuals was selected from a cross-sectional probabilistic stratified sampling design. All participants having smoked in the past 30 days were included in the study. Half of this sample was used to select appropriate composite indicators of tobacco consumption. A factor analysis with oblique PROMAX rotation was used as well as the MAXCOV (Maximum Covariance) procedure to identify indicators that maximized between-class distance, and minimize within-class variance. The remaining half of the sample was submitted to a set of three mathematically independent taxometric procedures: Mean Above Minus Below A Cut (MAMBAC), MAXCOV and Maximum Eigenvalues (MAXEIG). In line with the original hypothesis, the results supported a dimensional latent structure for ND. These findings are discussed in terms of their clinical implications for the validation of adequate screening procedures and the etiology and maintenance of ND.

Inverse relation between clinical distractibility and Stroop interference in functional psychoses.

INTRODUCTION: Many patients with psychotic disorders appear distractible. Some theories propose that distractibility causes psychotic symptoms, others propose the reverse. We tested these theories by assessing relations between psychotic symptoms, Stroop interference, and clinical distractibility in patients with schizophrenia or affective psychoses. METHODS: We rated clinical distractibility in patients with acute schizophrenia or affective psychoses and measured their Stroop interference in a single trial colour-naming task. RESULTS: Clinical distractibility related inversely to Stroop interference. Stroop interference was small in drug-naive patients with schizophrenia, but normal in those receiving treatment. Patients with affective psychoses showed the opposite pattern. CONCLUSIONS: The abnormality of attention that clinicians rate as "distractibility" is probably the opposite-attentional capture. Abnormal attention neither results from nor causes psychotic symptoms. Rather, it is an independent correlate of pathophysiology in functional psychoses that merits assessment and treatment in its own right.

Limit-setting and decision-making in the management of aggression.

BACKGROUND: Several published research studies have suggested that inpatient aggression against nursing staff may be directly precipitated by common nurse-patient interactions. This study sought to examine the structure of nurses' judgements in situations of conflict. METHOD: Seventy practising United Kingdom psychiatric nurses were presented with a number of conflict scenarios and were asked to rate a range of intervention options for each scenario according to how appropriate they perceived those interventions to be. Their responses were analysed using multidimensional scaling techniques. RESULTS: The results suggest that issues associated with limit setting and autonomy were perceived as most important by the nurses and that these issues are most likely to lead to disagreements in judgement between nurses of different status. Nurses of higher grades (levels) showed a significantly greater preference for respectful and autonomy-confirming interventions than their more junior nurses. These results have training and policy implications and further research should examine the effects of such nursing judgements on patient care.

Hand preference and hand skill in families with schizophrenia.

Direction and degree of handedness in humans are variable between individuals and thought to be in part inherited. Several studies have shown an increase in non-right handedness among patients with schizophrenia, and some have included unaffected relatives. The present study was designed to determine whether reduced right handedness is more frequent among individuals with schizophrenia as compared with their well relatives and whether it clusters within families having multiple ill members. A total of 259 families comprising 418 individuals diagnosed with schizophrenia or schizoaffective disorder, 54 individuals with other psychoses, 145 family members with depression and other minor diagnoses, and 288 unaffected individuals were included. Hand preference was assessed by the Annett Scale and right relative to left hand skill measured using the Tapley-Bryden test. For all assessments of hand preference and hand skill, females were significantly more lateralised towards the right than males. Those individuals with schizophrenia or schizoaffective disorder had significantly less right hand preference than their unaffected relatives when measured as a quantitative index of items from the Annett Scale (p = .019), but not categorically (right, left or mixed). In contrast, there was no difference in hand skill between diagnostic groups. Hand preference was significantly correlated among male-male affected sibling pairs (p = .01) and similar results were found for hand skill among the total group of affected pairs (p = .001). Although these results only partially support a relationship between handedness and schizophrenia, they nevertheless draw attention to sex differences in hand preference and the familial aspects of hand preference in this disorder. More direct approaches to the genetics of cerebral dominance and psychosis are required.