RESUMEN
BACKGROUND: In England, rates of involuntary admissions increased in subgroups of patients. It is unknown whether this is true in other European countries. AIMS: To establish whether the increase in emergency commitments was uniform across subgroups of patients and dangerousness criteria used to justify commitment in The Netherlands. METHOD: National data on all commitments in the period 2000-2004. RESULTS: Commitments increased from 40.2 to 46.5 (16%) per 100,000 inhabitants. Controlling for population changes in age and sex, relatively large increases were found in patients over 50 years (25-40% increase), in patients with dementia (59%), 'other organic mental disorders' (40%) and substance abuse (36%). 'Arousing aggression', increased most strongly as a dangerousness criterion for commitment (30%). CONCLUSION: Changing patterns of commitments in The Netherlands and England might indicate a wider European shift in diagnoses and reasons for admission of committed patients.
Asunto(s)
Internamiento Obligatorio del Enfermo Mental/estadística & datos numéricos , Trastornos Mentales/epidemiología , Factores de Edad , Anciano , Comparación Transcultural , Conducta Peligrosa , Demencia/epidemiología , Demencia/psicología , Servicios de Urgencia Psiquiátrica/métodos , Servicios de Urgencia Psiquiátrica/estadística & datos numéricos , Inglaterra/epidemiología , Femenino , Humanos , Masculino , Trastornos Mentales/psicología , Persona de Mediana Edad , Países Bajos/epidemiología , Trastornos Neurocognitivos/epidemiología , Trastornos Neurocognitivos/psicología , Trastornos Relacionados con Sustancias/epidemiología , Trastornos Relacionados con Sustancias/psicologíaRESUMEN
OBJECTIVE: The aim was to evaluate a quality improvement programme designed to increase screening for the metabolic syndrome in community psychiatric patients prescribed antipsychotics. METHOD: Baseline audit against evidence-based standards, followed by provision of benchmarked data and a range of change interventions, with re-audit 1 year later. RESULTS: At baseline, 48 assertive outreach teams across the UK submitted data on screening over the previous year for 1966 patients. At re-audit, 35 of the teams submitted data for 1516 patients. Screening for all four aspects of the metabolic syndrome (measuring blood pressure, obesity, blood glucose and plasma lipids) had increased significantly by re-audit. Clinical variables increasing the likelihood of full screening were clozapine treatment and a known diagnosis of diabetes or dyslipidaemia. CONCLUSION: The programme's success may be partly attributed to the use of a widely-accepted audit standard, and bespoke change interventions that directly addressed barriers to screening identified by the participating clinical teams.
Asunto(s)
Antipsicóticos/efectos adversos , Tamizaje Masivo/normas , Síndrome Metabólico/inducido químicamente , Trastornos del Humor/tratamiento farmacológico , Trastornos Psicóticos/tratamiento farmacológico , Garantía de la Calidad de Atención de Salud/normas , Adolescente , Adulto , Anciano , Antipsicóticos/uso terapéutico , Benchmarking/normas , Peso Corporal/efectos de los fármacos , Servicios Comunitarios de Salud Mental/normas , Relaciones Comunidad-Institución/normas , Relación Dosis-Respuesta a Droga , Quimioterapia Combinada , Inglaterra , Femenino , Accesibilidad a los Servicios de Salud , Humanos , Estilo de Vida , Masculino , Auditoría Médica/normas , Síndrome Metabólico/diagnóstico , Síndrome Metabólico/epidemiología , Persona de Mediana Edad , Trastornos del Humor/epidemiología , Examen Físico , Trastornos Psicóticos/epidemiología , Indicadores de Calidad de la Atención de Salud/normas , Estándares de Referencia , Sistemas Recordatorios , Estudios Retrospectivos , Encuestas y CuestionariosRESUMEN
OBJECTIVE: To explore the potential for using seven prescribing indicators, individually and in combination, to measure prescribing quality for hospitalised psychiatric patients. DESIGN AND SETTING: The dataset included full details of all psychotropic medication prescribed over a 24 hour period to 4192 inpatients in 49 British mental health services in 1998. RESULTS: Despite the large size of the dataset, for three of the indicators 20 services had fewer than 10 eligible patients. There was great variation between services in indicator scores. Correlations between standardised indicator scores and total score (which omitted the indicator concerned) were above 0.3 for all but one of the indicators. Cronbach's alpha was 0.73 when this outlying indicator was removed. CONCLUSIONS: There are no routinely collected prescribing data that allow for the quality of prescribing for psychiatric patients to be monitored. Six of the seven indicators measured during this census survey appear to reflect a common attribute of the services, and the analysis suggests that they might be combined to give an overall measure of service performance. There was, however, no relationship between performance on the seventh indicator and performance on the other six. This raises questions about case mix and service level factors that might influence indicator scores independent of prescriber decision making. The psychometric properties of prescribing indicators (occurrence rates, consistency over time) are unknown.
Asunto(s)
Prescripciones de Medicamentos/estadística & datos numéricos , Hospitales Psiquiátricos , Pacientes Internos , Indicadores de Calidad de la Atención de Salud , Medicina Basada en la Evidencia , Investigación sobre Servicios de Salud , Humanos , Reino UnidoRESUMEN
BACKGROUND: No existing instrument measures all or even most of the issues considered important by users of mental health services. AIMS: To develop and test a self-assessment instrument to enable users of mental health services to rate their experience across the range of domains that they consider to be important. METHOD: Relevant domains were identified and a new instrument was drafted and field tested to examine its psychometric properties. RESULTS: The 17-item, self-rated Carers' and Users' Expectations of Services--User version (CUES-U) appears acceptable to most service users. Its items have reasonable test-retest reliability and a 'total CUES-U score' correlates significantly with a total score of the Health of the Nations Outcome Scales (Spearman's rho=0.42; P < 0.01). CONCLUSIONS: The development and testing of CUES-U suggest that it might be feasible to apply a self-rated measure of the expectations and experience of users of mental health services.
Asunto(s)
Cuidadores/psicología , Servicios de Salud Mental/normas , Satisfacción del Paciente , Indicadores de Calidad de la Atención de Salud , Encuestas y Cuestionarios , Adolescente , Adulto , Anciano , Actitud Frente a la Salud , Femenino , Humanos , Masculino , Persona de Mediana Edad , Psicometría , Reproducibilidad de los Resultados , Autoevaluación (Psicología)RESUMEN
BACKGROUND: Underprovision by the National Health Service (NHS) has led to an increase in medium secure psychiatric beds managed by the independent sector. Black people are overrepresented in medium secure care. AIMS: To describe those people from an inner-London health authority occupying all forms of medium secure provision. To compare those in NHS provision with those in the independent sector, and Black patients with White patients. METHOD: A census of those in medium secure care in August 1997. RESULTS: The 90 patients in independent-sector units were similar to the 93 patients in NHS units except that they were more likely to have been referred from general psychiatric services (48% v. 19%) and less likely to have been referred from the criminal justice system or a high-security hospital (37% v. 63%). There were few differences between Black and White patients. CONCLUSIONS: The NHS meets only part of the need for medium secure care of the population of this London health authority. This comparison of the characteristics of Black and White patients does not help to explain why Black people are overrepresented in medium secure settings.
Asunto(s)
Hospitales Psiquiátricos/estadística & datos numéricos , Institucionalización/estadística & datos numéricos , Servicios de Salud Mental/estadística & datos numéricos , Medidas de Seguridad , Control Social Formal , Adolescente , Adulto , Negro o Afroamericano/estadística & datos numéricos , Población Negra , Estudios de Cohortes , Crimen/estadística & datos numéricos , Femenino , Humanos , Londres/epidemiología , Masculino , Trastornos Mentales/epidemiología , Trastornos Mentales/terapia , Servicios de Salud Mental/organización & administración , Persona de Mediana Edad , Sector Privado , Medicina Estatal/organización & administración , Salud Urbana , Población Blanca/estadística & datos numéricosRESUMEN
Despite the development of community care and associated processes of de-institutionalisation, the hospital remains the hub of mental health services in the UK. However, previous quantitative and survey research indicates that quality of care in acute psychiatric (admission) wards has been compromised or is under threat, and points to a bleak experience for people who are admitted. Indicators of this include that there have been increases in admission rates, the proportion of compulsory admissions, and bed occupancy rates. There is also evidence of violence, sexual harassment and substance misuse in this setting, accompanied by rapid staff turnover, low staff morale, and an increasing proportion of 'difficult' patients (especially young men with schizophrenia). This paper reviews the evidence about life on psychiatric wards, focusing on how it is experienced by patients in acute settings. Research conducted in the UK in the 1990s, supports the impression that organisational pressures are having a negative impact on the quality of care. It shows that: nurse-patient (N-P) relationships are perceived to be an important aspect of care, but that N-P contact has declined; and patients are critical of conditions on the ward and view life there as both boring and unsafe. However, very little in-depth ethnographic research has been conducted on acute wards in the UK (and none since the 1970s) leaving us with a 'black box' view of in-patient care in this setting. Studies conducted during earlier 'care paradigms', notably those in the USA by Goffman and Strauss et al., provide useful insights into the patient's experience, but the extent to which these can be conceptually generalised to the present situation is unknown. The paper concludes by outlining questions and priorities for future investigation, focusing on the role of qualitative research.
Asunto(s)
Auxiliares de Psiquiatría/organización & administración , Calidad de la Atención de Salud/normas , Calidad de Vida/psicología , Humanos , Servicios de Salud Mental/normas , Relaciones Enfermero-Paciente , Auxiliares de Psiquiatría/psicología , Encuestas y Cuestionarios , Reino UnidoRESUMEN
BACKGROUND: The Defeat Depression Campaign, which was run by the Royal College of Psychiatrists and the Royal College of General Practitioners (RCGP) from 1992 to 1996, aimed to educate general practitioners (GPs) to recognize and manage depression. AIM: To measure the educational impact on GPs of the Defeat Depression Campaign. METHOD: A postal survey using a structured questionnaire was distributed to 2046 GPs obtained by systematically sampling 1 in 14 GPs from alphabetical lists from family health services authorities (FHSAs) in England and Wales. The questionnaire covered awareness of the campaign, awareness and use of campaign materials, and ratings of the usefulness of the campaign in relation to other educational activities. RESULTS: Two-thirds of GPs were aware of the campaign and 40% had definitely or possibly made changes in practice as a result of it. Impact of materials was highest for a consensus statement on the recognition and management of depression in general practice and for guidelines derived from it, each of which had been read in detail by about one quarter of responders and was known of by an additional one third. Impact was low for the other materials. The campaign had the highest impact among younger GPs, members of the RCGP, and (less strongly) among those who had undertaken a six-month post in psychiatry, those who were working in larger practices and fundholding practices, and women; 56% of GPs had attended a teaching session on depression in the past three years. CONCLUSION: A national campaign of this kind can have a useful impact, but it needs to be supplemented by local and practice-based teaching activities.
Asunto(s)
Trastorno Depresivo/prevención & control , Educación Médica Continua/métodos , Medicina Familiar y Comunitaria/educación , Adulto , Competencia Clínica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Encuestas y Cuestionarios , Materiales de Enseñanza , Reino UnidoRESUMEN
BACKGROUND: Following the development of a child and adolescent version of the Health of the Nation Outcome Scales (HoNOSCA), field trials were conducted to assess their feasibility and acceptability in routine outcome measurement. AIMS: To evaluate the reliability, validity and acceptability of HoNOSCA in routine outcome measurement. METHOD: Following training, 36 field sites provided ratings on 1276 cases at one time point and outcome data on 906. Acceptability was assessed by way of written feedback and at a debriefing meeting. RESULTS: HoNOSCA demonstrated satisfactory reliability and validity characteristics. It was sensitive to change and its ability to measure change accorded with the clinicians' independent rating. HoNOSCA was reasonably acceptable to clinicians' from a range of disciplines and services. CONCLUSIONS: Provided that training needs can be met, HoNOSCA represents a satisfactory brief outcome measure which could be used routinely in child and adolescent mental health services.
Asunto(s)
Trastornos de la Conducta Infantil/terapia , Indicadores de Salud , Trastornos del Humor/terapia , Escalas de Valoración Psiquiátrica/normas , Niño , Preescolar , Femenino , Estado de Salud , Humanos , Masculino , Servicios de Salud Mental/normas , Variaciones Dependientes del Observador , Sensibilidad y Especificidad , Reino UnidoRESUMEN
BACKGROUND: Health of the Nation Outcome Scales (HoNOS) have been developed to measure of outcomes in people with mental health problems. AIMS: The particular physical and cognitive problems affecting older people requires a specific scale for their measurement. We describe the development of such a scale, named HoNOS 65+. METHOD: Pilot, validity and reliability studies were carried out on an amended scale. Validity was assessed by comparison with existing scales reflecting depression, cognitive function, psychiatric symptomatology, activities of daily living and functional abilities. Reliability was measured in two centres. RESULTS: HoNOS 65+ was successfully amended to include specific aspects of mental health problems in older people including the phenomenology of depression, delusions occurring in the presence of dementia, incontinence and agitation/restlessness. HoNOS 65+ was able to discriminate between people suffering from organic and functional illnesses. Correlations with other scales indicated reasonable validity. Reliability was satisfactory. CONCLUSIONS: Aversion of HoNOS 65+ is presented (see pp. 435-438, this issue) which is appropriate for use in elderly people with mental health problems.
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Servicios de Salud para Ancianos/normas , Indicadores de Salud , Trastornos Mentales/terapia , Escalas de Valoración Psiquiátrica/normas , Actividades Cotidianas , Anciano , Humanos , Proyectos Piloto , Sensibilidad y Especificidad , Reino UnidoRESUMEN
This paper describes phase one of a three phase, Department of Health funded project, led by the Mental Health Programme of the Royal College of Nursing Institute in collaboration with the Research Unit of the Royal College of Psychiatrists and the School of Social Work at the University of East Anglia. Its project aims were to establish whether the work of demonstration sites in mental health case management had developed beyond their original structure, to compare their current profile with the general literature on case management and assertive outreach and to use this data to reach consensus about issues affecting the work of those healthcare workers who currently see themselves working as case managers. Central to these aims were the experiences and narratives of the demonstration site case managers themselves. In 1995 data were collected from six fieldwork sites in England using semistructured interviews. Similarities and differences between the literature and the fieldwork data were used to inform a consensus conference. The main areas of investigation were organizational considerations, the nature of innovative projects and user involvement. The paper concludes that there are serious problems with the perceived role of case managers, their support and training and further difficulties attributed to interagency working. Finally, it is clear that the exact nature of the client group most suited to UK case management typology has not yet been resolved.
Asunto(s)
Manejo de Caso/organización & administración , Servicios Comunitarios de Salud Mental/organización & administración , Enfermería Psiquiátrica/educación , Enfermería Psiquiátrica/organización & administración , Humanos , Supervisión de Enfermería/organización & administración , Evaluación de Programas y Proyectos de Salud , Reino Unido , Carga de TrabajoRESUMEN
BACKGROUND: Electroconvulsive therapy (ECT) is a controversial treatment for psychiatric disorders, particularly when it is administered to young people. AIMS: To assess how frequently ECT is administered to people under the age of 18 years in the UK, and why it is given. METHOD: Electroconvulsive therapy clinics, private hospitals, adolescent units and UK members of the Royal College of Psychiatrists were surveyed to ask if they were aware of ECT being administered during 1996 to a young person under the age of 18 years. Consultants identified as having prescribed ECT were sent a follow-up questionnaire. RESULTS: Twelve young people were identified as having received ECT; three were aged 15 years or younger and eight were female. Nine patients were rated as improved following ECT. The indications for its use were similar to those for adults. CONCLUSIONS: Electroconvulsive therapy is rarely administered to young people in the UK.
Asunto(s)
Terapia Electroconvulsiva/estadística & datos numéricos , Trastornos Mentales/terapia , Adolescente , Niño , Internamiento Obligatorio del Enfermo Mental , Trastorno Depresivo/terapia , Femenino , Humanos , Masculino , Trastornos Psicóticos/terapia , Esquizofrenia/terapiaRESUMEN
This study examines the effect of managing agency (local authority, private or voluntary) on the use of other health and social care services by residents in mental health hostels and group homes with different levels of staffing in England and Wales. The sample comprised 1323 residents in 275 facilities in eight districts. The measures of service use were number of days in hospital and number of other service contacts. There were highly significant differences between facilities with similar levels of staffing managed by different agencies. Residents in the voluntary sector used fewer community services overall; residents in low-staffed local authority facilities used more services than those in similar facilities managed by other agencies. These differences were not easily explained by differences in the social or clinical characteristics of residents. This suggests that there may be organisational factors, e.g. hostel staff, knowledge of services, which influence access to and use of community services.
Asunto(s)
Hogares para Grupos/organización & administración , Accesibilidad a los Servicios de Salud/organización & administración , Programas Controlados de Atención en Salud/organización & administración , Trastornos Mentales/rehabilitación , Instituciones Residenciales/organización & administración , Adulto , Anciano , Servicios Comunitarios de Salud Mental/organización & administración , Inglaterra , Femenino , Humanos , Masculino , Persona de Mediana Edad , GalesRESUMEN
BACKGROUND: This is the third large-scale audit in the past 20 years and compares the practice of electroconvulsive therapy (ECT) in England and Wales with the standards derived from the Royal College of Psychiatrists' 2nd ECT handbook. METHOD: Facilities, equipment practice, personnel and training were systematically evaluated during visits to all ECT clinics in the former North East Thames and East Anglia regions and Wales. All other English ECT clinics were surveyed with a postal questionnaire. Information was obtained for 184 (84%) of the 220 ECT clinics identified. RESULTS: Although some aspects of ECT administration had improved since the last audit in 1991, overall only one-third of clinics were rated as meeting College standards. Only 16% of responsible consultants attended their ECT clinic weekly and only 6% had sessional time for ECT duties. Fifty-nine per cent of all clinics had machines of the type recommended by the College and 7% were still using machines considered outdated in 1989. Only about one-third of clinics had clear policies to help guide junior doctors to administer ECT effectively. CONCLUSIONS: Twenty years of activity by the Royal College of Psychiatrists and three large-scale audits have been associated with only modest improvement in local practice.
Asunto(s)
Terapia Electroconvulsiva , Terapia Electroconvulsiva/educación , Terapia Electroconvulsiva/instrumentación , Terapia Electroconvulsiva/normas , Unidades Hospitalarias , Humanos , Capacitación en Servicio , Auditoría Médica , Política Organizacional , Atención al Paciente/normas , Administración de Personal , Guías de Práctica Clínica como Asunto , Calidad de la Atención de Salud , Reino UnidoRESUMEN
Recent advances in knowledge about effective administration of electroconvulsive therapy (ECT) has placed great emphasis on the importance of good training and supervision of those administering it. The American Psychiatric Association requires that doctors be specifically accredited before they are allowed to give ECT. In England and Wales training is much more informal and ECT is often given by junior doctors. Doctors rostered to administer ECT in Wales and in two areas of England were surveyed as part of the College's third audit of ECT. About two-thirds of respondents were at senior house officer level. The training in ECT appeared of variable quality and one-half had not been supervised by an experienced psychiatrist on the first occasion they administered ECT. Responses to exam-type questions revealed that 45% lacked knowledge about one or more basic issue related to effective administration of ECT.
Asunto(s)
Educación Médica Continua/normas , Terapia Electroconvulsiva/educación , Inglaterra , Humanos , Encuestas y Cuestionarios , GalesRESUMEN
OBJECTIVES: To determine how public (NHS or local government), private (for-profit) and voluntary (non-profit) providers of residential mental health care compare. Do they support different clienteles? And do their services cost different amounts? METHODS: Based on a cross-sectional survey of residential care facilities and their residents in eight English and Welsh localities, the characteristics and costs of care in the different sectors (NHS, local government, private, voluntary) were compared. Variations in cost were examined in relation to residents' characteristics using multiple regression analyses, which also allowed standardisation of results before making inter-sectoral comparisons. RESULTS: Private and voluntary providers of residential care support different clienteles from the public sector. The patterns of inter-sectoral cost differences vary between London and non-London localities. In London, voluntary sector facilities may be more cost-efficient than the other sectors, but local government/private sector comparisons show no consistent difference. Outside London, the results suggest clear cost advantages for the private and voluntary sectors over the local government sector. CONCLUSIONS: Private and voluntary providers may have some economic advantages over their public counterparts. However, outcomes for residents were not studied, leaving unanswered the question of comparative cost-effectiveness.