To devise a simple technique to reduce stigmatised attitudes of the general public towards those with mental disorder (schizophrenia and substance misuse). Members of the general public (n=400) completed a questionnaire to measure stigmatised attitudes towards people with schizophrenia and substance misuse disorders. Participants were randomised to receive either a short, ‘upbeat’ leaflet with a description of a patient in remission and a photograph of a man in a business suit; or a simple description of a fictional patient. The 5-item Attitudes to Mental Illness Questionnaire (AMIQ) was used to measure the effect of the various procedures on stigmatised attitudes (score range –10 to +10).

RESULTS

Results were received for 310 (77%) participants. The leaflet produced a large, statistically significant reduction in stigmatised attitudes towards people with opiate dependence (effect size 1.53, CI 1.23-1.82, P<0.0001; median change 4 units) and alcohol dependence (effect size 1.41, CI 1.12-1.70, P<0.0001; median change 4 units) but less so towards people with schizophrenia (effect size 0.54, CI 0.27-0.80, P=0.0002; median change 2 units). There was no difference between participants in respect of the control group at 4-week follow-up (233 responses received; 78% response rate).

CLINICAL IMPLICATIONS

A short illustrated leaflet can be used to reduce stigmatised attitudes towards substance misuse disorders if patients are presented in a positive manner. This is less effective for attitudes towards people with schizophrenia, possibly because people have a more generous attitude towards patients who have overcome substance misuse disorders.

National guidelines for the assessment and treatment of obsessive-compulsive disorder (OCD) and body dysmorphic disorder were published in 2005 by the National Institute for Health and Clinical Excellence (NICE). Local services are unable to treat a small but significant number of the most severely ill patients successfully, and the guidelines recommend that such patients should have access to highly specialised care. From 1 April 2007, the Department of Health decided to centrally fund treatment services for severe, chronic, refractory OCD and BDD. We describe a new National Service for Refractory OCD; its rationale, treatments offered, referral criteria and expected clinical outcomes.

RESULTS

Initial results from one centre show an average 42% reduction in OCD symptoms at the end of treatment.

CLINICAL IMPLICATIONS

The operational challenges and potential generalisability of this model of healthcare delivery are discussed. We present a summary of the progress made so far in establishing a new, coherent National Service for Refractory OCD, 18 months after the NICE guideline was published. The aim of the paper is to educate clinicians about the service and describe its rationale, treatments offered, referral criteria and expected clinical outcomes.

In November 2005, the National Institute for Health and Clinical Excellence published guidelines for the treatment of obsessive-compulsive disorder (OCD) and body dysmorphic disorder. These guidelines incorporated a stepped care approach with different interventions advised throughout the patient pathway. South West London and St George’s Mental Health NHS Trust devised a system of expert clinicians with special expertise in OCD/body dysmorphic disorder to help deliver this model of care. To aid the delivery of service it was decided to operationalise the definitions of severity of OCD/body dysmorphic disorder at each of the stepped-care levels. Examples are given as to how this has been applied in practice. Outcome is presented in terms of clinical hours in the first year of operation.

RESULTS

In total, 108 patients were referred to the service in the first year. Many of these patients were treated by offering advice and support and joint working with the community mental health team and psychotherapy in primary care teams who had referred. Sixty-eight patients were treated by a member of the specialist service alone and 57 of these suffered from severe OCD. Outcome data from these 57 patients is presented using an intention-to-treat paradigm. They showed a clinically and statistically significant reduction in OCD symptoms after 24 weeks of cognitive-behavioural therapy comprising graded exposure and self-imposed response prevention. The mean Yale-Brown Obsessive Compulsive Scale score dropped from 28 (severe OCD) to 19 (considerable OCD). Depressive symptoms on the Beck Depression Inventory also decreased by an average 24% over the same period.

CLINICAL IMPLICATIONS

The feasibility of extending this model of service organisation to other areas and other diagnoses is discussed.

To improve the level of insight (measured using standardised instruments) using a video interview and self-observation. Changes in levels of insight were measured using the Schedule for Assessing Insight (SAI) at the time of admission, at the time of discharge (both prior to and following the viewing of the videotape) and at follow-up a few months later.

RESULTS

The comparison of the SAI scores indicated a significant improvement in insight at the time of discharge (P<0.005), with a further significant improvement after watching the video (P<0.006). This appeared to be sustained at 3- to 6-month follow-up.

CLINICAL IMPLICATIONS

Video self-observation is a simple, inexpensive procedure that can be used to improve insight in psychosis. This study provides further support for the clinical utility of video self-observation in improving client’s insight.

To explore the feasibility of a randomised controlled trial of the effects of two anti-stigma films on medical students’ attitudes to serious mental illness and psychiatry. Attitudes to serious mental illness, perceived dangerousness, social distance and psychiatry, were measured before and after watching the films and at 8 weeks.

RESULTS

Intervention films significantly improved general attitudes to serious mental illness and social distance, with a trend towards reducing perceived dangerousness. These effects appeared to attenuate during the students’ clinical placements, suggesting a possible interaction with their clinical experiences.

CLINICAL IMPLICATIONS

Our results suggest both that it may be possible to conduct a substantive trial of the effects of the intervention films on a larger cohort of medical students and that the films may be effective in reducing stigmatising attitudes in medical students.

To establish the proportion of psychiatrists in Northern Ireland who currently work part-time and the proportion of those working full-time who wish to work part-time. A postal questionnaire was forwarded to psychiatrists and repeated 30 months later.

RESULTS

In 2004, only 18.3% of respondents were working part-time, and 26.8% in 2006. A great majority stated their intent was to always work part-time, the most frequent reason being to achieve work-life balance.

CLINICAL IMPLICATIONS

A significant number of staff working part-time will have implications for the staffing of the service. Policy makers must plan for the adequate provision of part-time working arrangements.

We checked whether psychiatric junior doctors could identify common electrocardiogram (ECG) abnormalities. Participants were directly approached at three London sites during induction or teaching programmes.

RESULTS

The survey had a total response rate of 65% (36/55). Psychiatry junior doctors displayed an overall success rate of 97% in detecting whether an ECG is grossly abnormal, but were much less competent in specifying exact ECG diagnoses (success rate of 41%). Accuracy rates for some diagnoses (e.g. paced rhythm) fell to as low as 11%. General practitioners performed no better than psychiatry trainees.

CLINICAL IMPLICATIONS

There is little consensus about minimum acceptable standards in medical skills such as ECG reporting in junior doctors. These competencies are generally ignored in new curriculums. Questions regarding the appropriate remit of psychiatry doctors in this area are raised and the need for more monitoring and education of these skills is queried.

To elucidate and describe current neuropsychiatry service provision in the UK. A questionnaire was developed and posted to members of the Royal College of Psychiatrists who had expressed an interest in neuropsychiatry. The responses were tabulated and analysed using descriptive statistics and SPSS version 11.0 for Windows. The neuropsychiatry services provided, sources of referrals, setting of the services and funding streams are described.

RESULTS

Out of 251 respondents, 70 reported providing a neuropsychiatry service, 21 having been principally appointed as neuropsychiatrists.

CLINICAL IMPLICATIONS

Neuropsychiatry services in the UK are currently based in a few regional centres, representing a patchy and inadequate service provision.

We assessed the abilities of trainee and consultant psychiatrists in reading and interpreting electrocardiograms (ECGs) and QT intervals using a questionnaire and standardised ECG.

RESULTS

Only 5% of our sample of trainee and consultant psychiatrists could correctly indicate a QTc interval. Performances on other measures, such as rate were also poor, with senior house officers performing better than consultants.

CLINICAL IMPLICATIONS

The increased awareness of problems caused by antipsychotics has not been reflected in improved knowledge of ECGs among psychiatrists. Machines do not reliably calculate QT intervals. We therefore urge better training and understanding of ECGs for psychiatrists.

Liaison psychiatry services in Ireland are currently unequally distributed. In the absence of a specialist liaison psychiatry team, general adult psychiatrists may provide a consultation service to their local hospital. Demographic and clinical characteristics pertaining to all psychiatric consultations at the Louth County Hospital were collected over 12 months to examine one such local service and to highlight the challenges of this mode of service delivery.

RESULTS

A total of 232 consults were audited. The most frequent reasons for referral were assessment following deliberate self-harm (38%), affective symptoms (28%) and alcohol or substance misuse (25%). This differs from documented referral patterns to specialist liaison teams. Referring physicians had a low diagnostic ‘hit-rate’ with respect to affective disorders. Difficulties in service provision included poor communication by referring teams and time constraints due to other sectoral commitments.

CLINICAL IMPLICATIONS

Refinements to service delivery may be beneficial in managing the work-load more effectively. Priority should be placed on fostering communication with non-psychiatric colleagues.

To comprehensively describe a nurseled consultation liaison service for older adults by retrospectively reviewing all referrals received in 2006 and comparing them against other services and benchmark reports.

RESULTS

Of the 298 individuals referred to psychiatric services from other hospital wards, 120 were aged 85–94 years old (40%), 193 were male (65%) and 152 were referred from geriatrics (51%). A majority of 204 have not had previous contact with psychiatric services (69%). The most common diagnosis was dementia (33%, n=88), with 27% individuals (n=65) being referred onwards to secondary care.

CLINICAL IMPLICATIONS

This nurse-led service, using a novel approach of a support worker providing further community support, functions well compared with traditional consultation models. It helps identify many individuals with dementia and engages them into community psychiatric services.

We conducted a retrospective survey of all cases referred to the Drug Interventions Programme in Hertfordshire for the first 9 months in order to compare them with those referred to one of the community drug and alcohol teams.

RESULTS

The Drugs Interventions Programme had significantly more White British clients and clients who had dropped out from previous treatment. Compared with community team clients, the Programme had a higher percentage of clients with an opioid problem (92%), of whom a high percentage also misused other substances (78%) and injected drugs (30%, half of whom shared needles).

CLINICAL IMPLICATIONS

More chaotic clients who had failed previous treatment have entered treatment with the Drug Interventions Programme.

Although the Health of the Nation Outcome Scales (HoNOS) were designed for routine clinical use, completion rates in clinical settings rarely exceed 60%. We evaluated two initiatives to increase completion rates: timely feedback to clinicians, useful at individual, team and service levels, and improved supporting materials (tabulated glossaries for all versions covering the lifespan).

RESULTS

Clinicians in South Shore Health district provided ratings on all out-patient referrals over 12 months as part of routine care. Data were captured using the Nova Scotia routine administrative data system. Completion rates rose from 61% to 86% (n=1190). Clinicians’ ratings of the instrument’s ease of use were significantly improved.

CLINICAL IMPLICATIONS

Use of a tabulated glossary and enhanced feedback of clinically useful information improved clinician support for the routine measurement of health outcomes with HoNOS.

We looked retrospectively at referrals over 1 year and determined the length of time from receipt of the referral to the date when authorisation to see the patient was given, and the time from authorisation to first contact. For in-patients we determined the time from the recommendation for admission to the time authorisation was granted, and the time from authorisation to admission.

RESULTS

Of the 108 referrals, 80 (74%) were seen within 13 weeks (mean=53 days); 7 patients (6%) had to wait over 13 weeks, usually because of delays in authorisation; 10 patients were admitted; 14 were never admitted (although we had recommended admission). The time from recommendation to admit to authorisation of admission, 27 days, was the same as the time they waited for a bed once authorisation had been given.

CLINICAL IMPLICATIONS

Waiting for authorisation seemed in some patients to delay their access to tertiary services. Any advantage of using panels to authorise referrals, like ensuring better use of local resources, may be outweighed by patients taking longer to get the care that best meets their needs.

To study the views of staff and patients on the use of sniffer dogs to detect illicit drugs and the prosecution of in-patients suspected of taking illicit drugs. A 15-item self-report questionnaire was given to all in-patients and staff who had any contact with patients in a medium-secure unit. Responses to the individual statements were measured on a five-point Likert scale and staff and patients’ responses were compared.

RESULTS

We achieved a response rate of 63% (patient response rate, 71.6%; staff response rate, 60.7%). Overall there were fewer differences than anticipated, although, as expected, staff viewed the impact of illicit drugs more negatively than patients, and on the other hand, patients viewed the use of sniffer dogs and police involvement more negatively than the staff did.

CLINICAL IMPLICATIONS

Notice ought to be taken of the discordance between staff and patients’ views (particularly in relation to consent and confidentiality) when attempting to detect and manage illicit drug use among psychiatric in-patients.

To investigate the experiences of Irish psychiatric trainees in relation to safety at work and the related training issues. A questionnaire was posted to 243 psychiatric trainees throughout Ireland.

RESULTS

We obtained 113 responses (46.5%). Results indicated that tutors appear to consider safety at work as an important component of training. The availability of breakaway or similar training is much bigger than previously reported in Ireland. The standard of induction courses appears to be high. However, problems in working environments were revealed: 16% of trainees had been physically assaulted and 72% have felt threatened in the workplace.

CLINICAL IMPLICATIONS

Despite improvements in training in Ireland, workplaces remain largely unsafe, putting staff and patients at risk.

To gauge the acceptability of copying a business-like clinic letter for general practitioners, written by a doctor working in the Newbury Community Mental Health Team for Older Adults. Between August 2004 and March 2006 every letter written by each doctor was stored electronically. The letters contained a clear statement of the diagnosis, the active problems and a bullet-point care plan. Any concerns or reactions to the letters were documented as they were received. Between September and October 2006, 50 service user or carer recipients of the letters were sent a questionnaire, checking whether the letter met standards of clarity, helpfulness and content.

RESULTS

Over 20 months 427 service users and carers received a total of 731 letters. One carer asked for the letter not to be sent in future; four carers asked for details of the letter to be modified; in only one was the content of the letter to the general practitioner modified before it was sent to the service user. The questionnaire about the suitability of the clinic letter had a 90% reply rate and all respondents said the letters were clear, understandable and that their content was of no surprise to them.

CLINICAL IMPLICATIONS

This report of a successful use of a frank business-like letter copied to service users or carers should be understood in the context of the following factors: the doctor who wrote them was familiar with and confident about the clinical work and comfortable with the style of the letter; he had a good rapport with a generally well-educated population and positive support from his colleagues. With these factors in place, the direct style of the letter was well received by patients and carers.

To evaluate the prescribing of valproate in clozapine-treated individuals who may be at risk of seizure. We collected point-prevalent clinical characteristics and demographics of all in-patients prescribed clozapine in an acute mental health trust. Data were collected from case notes, electronic records and drug charts, and analysed against a set audit standard.

RESULTS

Data were collected for 81 in-patients. Of all deemed to be at risk of seizure (n=37) only 24% were prescribed valproate at a therapeutic plasma level.

CLINICAL IMPLICATIONS

The majority of patients prescribed clozapine at risk of seizures were not adequately protected from this risk. Clear guidelines are required.

We hypothesised that the proportion of people referred to two outer London mental healthcare services for older people with cognitive impairment increased after the 2001 National Institute for Health and Clinical Excellence (NICE) guidelines for acetylcholinesterase (AChE) inhibitor use in Alzheimer’s disease, but declined after the amended 2006 guidelines. We reviewed case notes for 546 individuals referred between 1999 and 2007.

RESULTS

The proportion of individuals with cognitive impairment referred increased between 1999 (56.1%) and 2005 (70.5%, ²=5.4, P=0.02), as did the proportion prescribed AChE inhibitor (0.8% to 16.1%, ²=27.5, P<0.001). There were no significant changes between 2005 and 2007.

CLINICAL IMPLICATIONS

The 2006 NICE amendment may have curbed the increase in psychiatric referrals and AChE inhibitor prescribing rates for people with cognitive impairment but so far these rates have not decreased.

We examined the impact of a crisis resolution and home treatment teams (CRHTT) on hospital admission rates, bed days and treatment satisfaction among older people with mental illness and their carers. We compared these factors in the 6 months before the service started and 6 months after its introduction.

RESULTS

The CRHTT significantly reduced admissions (P<0.001), but there was no significant difference in the length of hospital stay as compared before and after the introduction of this service. There was a trend towards carers, but not patients, being more satisfied with treatment after the introduction of the CRHTT.

CLINICAL IMPLICATIONS

The CRHTT reduced hospital admissions for older people by 31% and carers preferred the service. Further research on crisis teams in older people with mental illness is needed using randomised controlled methodology.