Early Recognition Method - Amplifying relapse management in community mental health care; a comprehensive study of the effects on relapse and readmission.

This naturalistic multicenter study explored the relationship between participating in the Early Recognition Method (ERM) intervention and relapse, defined as spending at least one night at a psychiatric ward. The intervention was tailored to adult patients with schizophrenia or bipolar disorder in an outpatient mental health care setting. Before the intervention, the staff received training in application of the strategy. The ERM strategy is protocolized and includes identification and monitoring of individual early warning signs and development of a personal plan of action. The study showed a reduction in mean number and duration of readmissions during the period the patients participated in the intervention, compared to an equal pre-intervention period. For patients with bipolar disorder the reduction was statistical significant. The difference in outcome between the two diagnostic groups suggests that further tailoring of the application of the ERM strategy might improve the relapse prevention outcome.

Relapse prevention in ambulant mental health care tailored to patients with schizophrenia or bipolar disorder.

WHAT IS ALREADY KNOWN ON THE SUBJECT?: Understanding the need for psychoeducation and management strategies in relapse prevention, for individuals with schizophrenia or bipolar disorder. Interventions for individuals with severe mental illness, especially schizophrenia, often requires support from family or social network to successfully improve mental stability in the life of the mentally ill. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: To our knowledge, no previous review has provided an overview of state of the art intervention elements currently used in ambulant mental health care interventions and how these elements are combined in interventions tailored to individuals with schizophrenia or bipolar disorder. Moreover, this systematic review indicates the effect of the different intervention elements. This review reveals an apparent gab in knowledge regarding patient perceptions of and need for individualized relapse prevention interventions. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The review is a relevant tool for stakeholders and practitioners in community mental health service when planning future interventions. Considering the specific needs for intervention complexity of the target group is likely to improve not only treatment outcome, but also patient satisfaction and treatment adherence. ABSTRACT: Introduction In recent years, there has been a development in ambulant mental health care towards a more preventive approach, resulting in relapse prevention interventions. Interventions may be patient tailored, to a greater or lesser extent, in relation to the treatment elements included. Aim To create an overview of non-pharmacological intervention elements described in relapse prevention interventions for patients with schizophrenia or bipolar disorder based on a systematic review. Method Six scientific databases were systematically searched. The search strategy, identification and selection of literature complied with the PRISMA statement. Results Of 7.429 studies screened, 25 were included for analysis. Six treatment elements were identified: Pharmacological treatment, personalized action plan, patient education, patient skills, treatment adherence and family involvement. Discussion The varying degree of complexity of the interventions indicates that patients with bipolar disorder and schizophrenia have, respectively, different treatment needs. Patients with schizophrenia seem to benefit more from interventions that include support from social network or family than patients with bipolar disorder. More qualitative studies clarifying the patient's perspective on tailored relapse prevention are indicated. Implications for practice Optimally tailoring relapse prevention for patients with schizophrenia and bipolar disorder will improve treatment outcome, and probably also treatment satisfaction and adherence.

User involvement in structured violence risk management within forensic mental health facilities -- a systematic literature review.

AIMS AND OBJECTIVES: To examine empirical literature on user involvement in collaboration between patients and nurses. The scope of the review was limited to structured violence risk management interventions in forensic mental health settings. BACKGROUND: Violence in forensic mental health settings represents a significant problem for patients and staff. Structured violence risk management interventions in forensic mental health have been reported to ignore patient participation, despite the growing attention on user involvement in clinical practice. DESIGN: A systematic review. METHOD: Searches were conducted in six databases: the Cochrane Systematic Reviews, MEDLINE, CINAHL, ProQuest, ScienceDirect and PsycINFO. Papers were assessed according to a predetermined set of inclusion and exclusion criteria. RESULTS: After searches of the reference lists of retrieved articles were conducted, only three papers met the inclusion criteria. CONCLUSIONS: This review has shown that empirical research on the topic of risk management interventions in which patients are involved is scarce. RELEVANCE TO CLINICAL PRACTICE: There is barely any research evidence of the clinical effect of user involvement approaches on violence risk management in forensic mental health practice. Therefore, we suggest that clinicians may learn from positive experiences concerning user involvement in general psychiatry and carefully adapt and test them out in the forensic treatment context.

The investigation of early warning signs of aggression in forensic patients by means of the 'Forensic Early Signs of Aggression Inventory'.

AIMS AND OBJECTIVES: The Forensic Early Warning Signs of Aggression Inventory (FESAI) was developed to assist nurses and patients in identifying early warning signs and constructing individual early detection plans (EDP) for the prevention of aggressive incidents. The aims of this research were as follows: First, to study the prevalence of early warning signs of aggression, measured with the FESAI, in a sample of forensic patients, and second, to explore whether there are any types of warning signs typical of diagnostic subgroups or offender subgroups. BACKGROUND: Reconstructing patients' changes in behaviour prior to aggressive incidents may contribute to identify early warning signs specific to the individual patient. The EDP comprises an early intervention strategy suggested by the patient and approved by the nurses. Implementation of EDP may enhance efficient risk assessment and management. DESIGN: An explorative design was used to review existing records and to monitor frequencies of early warning signs. METHODS: Early detection plans of 171 patients from two forensic hospital wards were examined. Frequency distributions were estimated by recording the early warning signs on the FESAI. Rank order correlation analyses were conducted to compare diagnostic subgroups and offender subgroups concerning types and frequencies of warning signs. RESULTS: The FESAI categories with the highest frequency rank were the following: (1) anger, (2) social withdrawal, (3) superficial contact and (4) non-aggressive antisocial behaviour. There were no significant differences between subgroups of patients concerning the ranks of the four categories of early warning signs. CONCLUSION: The results suggest that the FESAI covers very well the wide variety of occurred warning signs reported in the EDPs. No group profiles of warning signs were found to be specific to diagnosis or offence type. RELEVANCE TO CLINICAL PRACTICE: Applying the FESAI to develop individual EDPs appears to be a promising approach to enhance risk assessment and management.

The development of the Forensic Early Warning Signs of Aggression Inventory: preliminary findings toward a better management of inpatient aggression.

OBJECTIVE: "Early warning signs of aggression" refers to recurring changes in behaviors, thoughts, perceptions, and feelings of the patient that are considered to be precursors of aggressive behavior. The early recognition of these signs offers possibilities for early intervention and prevention of aggressive behaviors in forensic patients. The Forensic Early warning Signs of Aggression Inventory (FESAI) was developed to assist nurses and patients in identifying and monitoring these early warning signs of aggression. METHODS: The FESAI was developed by means of qualitative and quantitative strategies. One hundred seventy six early detection plans were studied to construct a list of early warning signs of aggression. Inventory drafting was done by merging and categorizing early warning signs. Forensic nursing professionals assessed face validity, and interrater agreement was tested. RESULTS: The investigation of early detection plans resulted in the FESAI, which contains 44 early warning signs of aggression subdivided into 15 main categories. The face validity of the form was very good, and the interrater agreement was satisfactory. CONCLUSIONS: Preliminary findings indicate that the FESAI provides a useful listing of early warning signs of aggression in forensic patients. It may facilitate the construction of early detection plans for the prevention of aggressive behaviors in forensic psychiatry.

Preventing aggressive incidents and seclusions in forensic care by means of the 'Early Recognition Method'.

OBJECTIVE: The Early Recognition Method aims at improving collaboration between nurses and patients to prevent aggression in forensic psychiatric care. To achieve this goal, Early Recognition Method strongly focuses on early signs of aggression. In the current study, we investigated whether application of Early Recognition Method led to a significant decrease in inpatient incidents. BACKGROUND: Nurses in forensic settings are often confronted with patients' aggression. Better collaboration between nursing staff and patients may improve patients' ability to self manage aggression and contribute to a decrease in inpatient aggression. DESIGN: Naturalistic one-way case-crossover design. METHODS: The Early Recognition Method was introduced on 16 wards of a maximum security forensic hospital. Using a one-way case-crossover design, where cases were their own controls, the effects of Early Recognition Method were assessed by comparing the number of incidents of 189 patients during 'Treatment As Usual' with the period after Early Recognition Method was implemented. The Early Recognition Method intervention involved weekly evaluations of signs of aggression between staff and patients. The outcome measures were the number of seclusions and the severity of inpatient incidents. RESULTS: A significant decline in the number of seclusions was observed after Early Recognition Method was introduced. Apart from this decrease, the mean severity of inpatient incidents was also found to be lower during the post intervention period. The effect size was most pronounced for patients with substance abuse and personality disorders. Patients with schizophrenia, however, showed modest, yet significant, effect sizes. CONCLUSIONS: The results suggest that Early Recognition Method may be an innovative and effective risk management method for forensic psychiatric patients, in particular for patients with personality disorders. RELEVANCE TO CLINICAL PRACTICE: This article aims to contribute to evidence-based risk management for nurses in collaboration with their patients, resulting in a decrease in inpatient aggression.