Consultations for refractory cases in mental health services: a descriptive study.

BACKGROUND: Yearly, almost six percent, which is more than 1,000.000 people, in the Netherlands receive mental health treatment, which usually improves their quality of life. Concurrently, mental healthcare professionals recognize clinically refractory cases in which improvement fails to occur, with severe ongoing burdens for patients. The Dutch Centre for Consultation and Expertise (CCE) is available to support such refractory cases. The Dutch government's (financial) facilitation of consultation through the CCE is unique in the world. CCE consultations provide therefore unique insight into and an overview of refractory cases in mental health services. The objective of this study was to gain insight into the commonalities underlying the reasons for CCE consultations and the solutions proposed that play roles in (the reduction of) refractory cases for which consultation has been requested. METHODS: This descriptive study was conducted with quantitative and qualitative data from 472 CCE consultations in the Netherlands. Using descriptive statistics and thematic content analysis, four exemplary situations were distilled from the qualitative data. RESULTS: Most (83%) cases in the sample could be explained with four exemplary situations involving self-harm (24.2%), aggression (21.8%), self-neglect (24.4%), and socially unacceptable behavior (12.5%), respectively. Each situation could be characterized by a specific interaction pattern that unintentionally maintained or aggravated the situation. At the time of closure of the consultation applicants' questions had been answered and their situations had improved in 60.4% of cases. CONCLUSIONS: This study offers an overview of approaches that provided new perspectives for patients and professionals in many refractory cases in the Dutch mental health services.

[Consultation in refractory cases in mental health care: a descriptive study]. / Consultaties bij vastgelopen behandel­situaties: een descriptieve studie.

BACKGROUND: Yearly, over 1.000.000 people receive mental health care treatment in the Netherlands. Treatment usually results in improvement in quality of life. Concurrently, each professional recognizes clinically refractory cases in which improvement fails to occur with severe ongoing burden for the client. In the Netherlands, for these clinically refractory cases the Centre of Consultation and Expertise (CCE) is available. The CCE is an independent nation-wide organisation offering free consultations to care providers. Therefore, CCE-consultations provide a unique insight in and overview of refractory cases. AIM: Providing overview of and insight into backgrounds and themes that play a role in (the reduction of) refractory cases. METHOD: Descriptive study of quantitative and qualitative data from 472 consultations in mental health care. RESULTS: 83% of cases could be explained with 4 exemplary vignettes of refractoriness: self-harm, aggression, self-neglect and socially unacceptable behaviour. CONCLUSION: Refractory cases result from an interaction pattern that unintentionally maintains or aggravates the situation. This study offers an overview of approaches that proved to be helpful in providing new perspective for clients and professionals in many therapy refractory cases in Dutch mental health care.

Decision making on (dis)continuation of long-term treatment in mental health services is an interpersonal negotiation rather than an objective process: qualitative study.

BACKGROUND: Research into termination of long-term psychosocial treatment of mental disorders is scarce. Yearly 25% of people in Dutch mental health services receive long-term treatment. They account for many people, contacts, and costs. Although relevant in different health care systems, (dis)continuation is particularly problematic under universal health care coverage when secondary services lack a fixed (financially determined) endpoint. Substantial, unaccounted, differences in treatment duration exist between services. Understanding of underlying decisional processes may result in improved decision making, efficient allocation of scarce resources, and more personalized treatment. METHODS: A qualitative study design, according to Grounded Theory principles, was used to understand the decision making process. In four teams in three large Dutch mental health services, 29 multidisciplinary case conferences were observed, and 12 semi-structured interviews were conducted. RESULTS: We describe two constituent elements of decision making: the process through which decision making is prepared and executed, and the substantial factors guiding its outcomes. The first consists of: (1) steps towards a team discussion on treatment termination, (2) team-related factors that influence decisions, and (3) the actual team decision making process. The second consists of factors related to patients, professionals, organization, and wider environment. Our main finding was that discussions of treatment (dis)continuation are highly unstructured. Professionals find it difficult to discuss with patients and teams, team discussion are ad-hoc, and clear decisions are scarce. We offer four explanations: first, long-term treatment lacks golden rules on outcome and process to base decisions on. Second, in the absence of such rules professionals rely on experience but underappreciate their own biases. Third, consequently, professionals aim for decisional consensus, which however is scarce among professionals. Fourth, treatment environments are hardly in favour of changing default (continuation) settings. CONCLUSION: Clear decision making, and terminating treatment when appropriate, is systematically hampered within secondary mental health services. Since continuation is the 'easy' default option, discontinuation requires skillful and determined navigation of interpersonal negotiations. Given services' scarce means, people's large demands for help, and patients' unused potential autonomy, it is desirable to invest in decision making skills and procedures - both human and economic benefits may be substantial.

[Psychiatric consultations for nursing-home residents: aspects and course of such consultations]. / Psychiatrische consultatie in het verpleeghuis: een beschrijvend onderzoek naar kenmerken en beloop.

BACKGROUND: Psychiatric symptoms occur frequently in nursing-home residents. The psychiatric expertise and support available to residents vary from one nursing home to another. International studies show that psychiatric consultations can be effective, but in the Netherlands very little research has been done on this topic. AIM: To list the types of psychiatric problems and symptoms for which consultations are requested and to determine whether a psychiatric consultation can have positive results for nursing-home residents and staff. METHOD: The psychiatric consultations requested were tabulated and were analysed. RESULTS: Details of 71 psychiatric consultations were recorded. The percentage of women (average age 74 years) was slightly higher than the percentage of men. More than 75% of the patients suffered from agitation/aggression or irritability, 65% suffered from depression, 63% from anxiety and 56% from dysinhibition. A post-intervention assessment was performed in 54 patients (76%). In this group psychiatric symptoms were found to be greatly reduced, with regard to both frequency and severity. In addition, nursing staff seemed to suffer less of the stress and strain in their work. CONCLUSION: The patients for whom a consultation was requested seemed to suffer from serious psychiatric symptoms and were often aggressive. It was possible to achieve substantial progress as a result of a simple intervention. A possible explanation for this effect is probably the nature of the psychiatric consultation used; it was structured, multi-disciplinary and time-consuming. However, since no control group was involved, it is impossible to say with certainty that the reduction in symptoms can be attributed solely to the consultation.

What makes community psychiatric nurses label non-psychotic chronic patients as 'difficult': patient, professional, treatment and social variables.

PURPOSE: To determine which patient, professional, treatment and/or social variables make community psychiatric nurses (CPNs) label non-psychotic chronic patients as 'difficult'. METHODS: A questionnaire was designed and administered to 1,946 CPNs in the Netherlands. Logistic regression was used to design models that most accurately described the variables that contributed to perceived difficulty. RESULTS: Six variables were retained in the final logistic model. Perception-related variables (feeling powerless, feeling that the patient is able but unwilling to change, and pessimism about the patient's change potential) dominated treatment-related variables (number of contacts per week and admission to a locked ward in the last year) and social variables (number of psychosocial problems). CONCLUSION: This research shows that perceived difficulty is related to complex treatment situations, not so much to individual patient characteristics. If the constructed model has good predictive qualities, which remains to be tested in longitudinal research, it may be possible to accurately predict perceived patient difficulty. When used as a screening tool, such a model could improve treatment outcomes.

Clinical problems in community mental health care for patients with severe borderline personality disorder.

The objective of this research was to assess the problems that professionals perceive in the community mental health care for patients with severe borderline personality disorder that do not fit into specialized therapy. A group of national experts (n = 8) participated in a four-phase Delphi-procedure to identify and prioritize the problems. A total of 36 problems reflecting five categories was found: patient-related, professional-related, interaction-related, social system-related, and mental health care-related. Problems with attachment and dependency and social issues were important patient problems while a lack of skills was an important professional problem. Support from the patient's social system and the mental health system were identified as limited, which resulted in both the patient and the professional feeling isolated. Patient, professional, and organisational characteristics of community care differ substantially from those of specialized care. The field is thus in need of a more tailored approach that takes these differences into account.

[Treating chronic suicidality involves taking risks]. / Behandelen van chronische suïcidaliteit vraagt om risico nemen.

BACKGROUND: Chronic suicidality in patients with borderline personality disorder differs substantially from acute suicidality and therefore requires a different approach. On the basis of a case study and a review of the literature, we argue that treatment should definitely involve the taking of short-term risks for the purpose of achieving long-term success. A thorough assessment of the pros and cons is however a prerequisite for this strategy and some precautions need to be taken.

Seclusion as a necessary vs. an appropriate intervention: a vignette study among mental health nurses.

In a vignette study, mental health nurses were asked to score vignettes on necessity and appropriateness using a Likert scale. Sixty-nine clinical nurses from four mental health institutes scored 64 vignettes on necessity (there is no alternative) and appropriateness (seclusion supports patients' treatment) of seclusion simultaneously. Data analysis focused on the differences between both scores, and included general linear model analysis, t-test statistics and Kendall's tau. The t-test resulted in a significantly higher score on necessity than on appropriateness. Differences between both scores could be explained for 32% by a combination of nurse characteristics and vignette variables. Necessity and appropriateness were found to be strongly associated with each other, showing that underpinning patterns were largely the same. This research enhances the understanding of underlying factors that influence the decision of nurses to use seclusion. This is essential for the development of interventions aimed at the reduction of seclusion use in mental health practice.

Interpersonal community psychiatric treatment for non-psychotic chronic patients and nurses in outpatient mental health care: a controlled pilot study on feasibility and effects.

BACKGROUND: In psychiatric care professionals perceive some patients as 'difficult', especially patients with long-term non-psychotic disorders. For these patients few evidence-based treatments exist. An intervention program, Interpersonal Community Psychiatric Treatment (ICPT), was developed by the authors. It was evaluated with the aim to increase effective behaviours by both patients and community psychiatric nurses (CPNs). OBJECTIVE: To assess the feasibility and effectiveness of an intervention program for use by CPNs in the care of 'difficult' patients with non-psychotic chronic disorders, in a controlled pilot study. DESIGN: A mixed-methods quasi-experimental study using process and outcome measures across several dimensions. Measurements took place at 0, 3, and 6 months. SETTINGS: Three community mental health centres in the centre of The Netherlands. PARTICIPANTS: 14 CPNs and 36 long-term non-psychotic patients who were perceived as 'difficult' were selected. Patients were offered either ICPT (20) or care as usual (16). All patients and CPNs could be followed up at all measurements. METHODS: Quantitative data included type and severity of psychiatric disorder, psychosocial functioning, needs for care, quality of life and social participation. Also, service use, satisfaction with care, and quality of the therapeutic alliance were measured. Qualitative interviews were conducted with all CPNs and patients in the experimental group. RESULTS: ICPT was found feasible by both CPNs and patients. Both the experimental and control condition showed improvement on a number of outcomes. ICPT, however, resulted in significantly better results in some areas. Patients' social network size increased and their care utilization decreased. Also, the quality of the working alliance increased and perceived patient difficulty decreased, both as scored by professionals. CONCLUSIONS: ICPT is one of very few intervention programs aimed at 'difficult' non-psychotic chronic patients. In this pilot study was found that it can be successfully carried out by CPNs, is generally experienced as acceptable and useful by patients and CPNs alike, and results in some significantly better effects on both process and outcome measures. In the main study, some alterations will be made to the instruction manual and training program. Also, the diagnostic interview may be briefer, and the characteristics and treatment integrity of CPNs will be included in measurements. Further controlled and randomized research is needed to test the effectiveness of the program in a larger group of patients.

The treatment of 'difficult' patients in a secure unit of a specialized psychiatric hospital: the patient's perspective.

The aim of this study is to obtain insight, from a patient's perspective, into the results and essential components of treatment in specialist settings for so-called 'difficult' patients in mental health care. In cases where usual hospital treatment is not successful, a temporary transfer to another, specialist hospital may provide a solution. We investigated which aspects of specialist treatment available to 'difficult' patients are perceived as essential by the patients and what are the results of this treatment in their perception. A qualitative research design based on the Grounded Theory method was used. To generate data, 14 semi-structured interviews were held with 12 patients who were admitted to a specialist hospital in the Netherlands. Almost all respondents rated the results of the specialist treatment as positive. The therapeutic climate was perceived as extremely strict, with a strong focus on structure, cooperation and safety. This approach had a stabilizing effect on the patients, even at times when they were not motivated. Most patients developed a motivation for change, marked by a growing and more explicit determination of their future goals. We concluded that a highly structured treatment environment aimed at patient stabilization is helpful to most 'difficult' patients.

How do patients come to be seen as 'difficult'?: a mixed-methods study in community mental health care.

Across all health care settings, certain patients are perceived as 'difficult' by clinicians. This paper's aim is to understand how certain patients come to be perceived and labelled as 'difficult' patients in community mental health care, through mixed-methods research in The Netherlands between June 2006 and October 2009. A literature review, a Delphi-study among experts, a survey study among professionals, a Grounded Theory interview study among 'difficult' patients, and three case studies of 'difficult' patients were undertaken. Analysis of the results of these qualitative and quantitative studies took place within the concept of the sick role, and resulted in the construction of a tentative explanatory model. The 'difficult' patient-label is associated with professional pessimism, passive treatment and possible discharge or referral out of care. The label is given by professionals when certain patient characteristics are present and a specific causal attribution (psychological, social or moral versus neurobiological) about the patient's behaviours is made. The status of 'difficult' patient is easily reinforced by subsequent patient and professional behaviour, turning initial unusual help-seeking behaviour into 'difficult' or ineffective chronic illness behaviour, and ineffective professional behaviour. These findings illustrate that the course of mental illness, or at least the course of patients' contact with mental health professionals and services, is determined by patient and professional and reinforced by the social and mental health care system. This model adds to the broader sick role concept a micro-perspective in which attribution and learning principles are incorporated. On a practical level, it implies that professionals need to look into their own role in the perpetuation of difficult behaviours as described here.

Community psychiatric nursing in the Netherlands: a survey of a thriving but threatened profession.

The aim of this paper is to describe and analyse the Dutch community psychiatric nursing profession. In spite of their large numbers, estimated at 2900, Dutch community psychiatric nurses (CPNs) have contributed little to the international literature. The history of the profession reveals a relatively isolated development, resulting in few connections with nursing and mental healthcare research. Because of various developments in these fields, CPNs appear under threat. A survey design was used to administer a 43-item electronic questionnaire, which yielded a response rate of 40%. The Dutch CPN has a mean age of 48 years, works about 32 h per week and has over 20 years of nursing experience. The Dutch CPN has a caseload of 48 patients, often participates in clinical intervision and hardly works according to evidence-based methods. Dutch community psychiatric nursing is, paradoxically, both thriving and threatened. CPNs seek to maintain a model that pays attention to both social needs and explanations, and to psychiatric diagnoses. This broad orientation may be considered essential to nursing. However, it is also a huge drawback as CPNs have not succeeded to clearly articulate what their profession adds to the care and treatment of psychiatric patients.