What patients think about involuntary treatment

All over the world large numbers of people are admitted to psychiatric hospitals. The laws governing this are controversial and in the U.K. are governed by the 2007 Mental Health Act. Most laws are based on the assumption that people who are compulsorily admitted to hospital do not recognise their need for care at the time so research has tended to concentrate on whether - looking back on things - people think it was a good idea that they received treatment. A team of researchers, led by Stefan Priebe from Newham Centre for Mental Health, London led a study of 1,613 people in 11 different countries. They were interviewed within a week of admission and again after a month and three months. The number of people who were happy with the decision to involuntarily treat them varied a lot between the different countries and ranged from 71% in Italy to 39% in Lithuania after a month and from 46% in Sweden to 86% in Italy after three months. (The figures for England were 47% and 54% respectively.) Women, people living alone and people with schizophrenia were more likely to be unhappy with their admissions.

Priebe, Stefan ... [et al] - Patients' views of involuntary hospital admission after 1 and 3 months: prospective study in 11 European countries British Journal of Psychiatry March 2010, 196(3), 179-185

Reducing violence on the wards

Healthcare professionals often suffer from violence and one study of nurses in Minnesota found that 13.2% had been assaulted over the last 12 months. Psychiatric nurses are even more at risk and one study found that 20% were assaulted over the course of a working week. There are several approaches to reducing violence on inpatient wards: identifying and helping the most violent patients, helping staff to anticipate risks and calm situations down before they get violent, and changing the culture of organizations by adopting zero-tolerance policies for violence. Researchers from Massachusetts looked at an intervention in the third category, the Violence Prevention Community Meeting. The meetings included both staff and patients and aimed to change the culture of expectations and attitudes towards violence in order to reduce patients' aggression. Over the 20-week study the meetings were found to lead to significant decreases in violence which fell by 89% when the meetings were being held and by 57% in the four weeks after they had finished.

Lanza, Marilyn L. ... [et al] - Reducing violence against nurses: the Violence Prevention Community Meeting Issues in Mental Health Nursing December 2009, 30(12), 745-750

Seclusion and restraint in psychiatric intensive care units

Patients in psychiatric intensive care units (PICUs) often have to be placed in seclusion or restraint for their own or others' protection. U.K. researchers from NHS services in Suffolk, Hampshire and Oxford studied the patterns of seclusion and restraint in 332 patients admitted to 7 PICUs in England. They found that four of the units used seclusion on a total of 16% of their patients. All of the units used restraint on 28% of the admitted patients. Using seclusion did not affect the length of time patients were being restrained for or how many patients were restrained. The use of seclusion and restraint was significantly associated with patient violence and property damage. Restraint was also associated with higher levels of psychological disturbance and a younger patient age.

Dye, Stephen, Brown, Steve and Chhina, Navjyoat - Seclusion and restraint usage in seven English psychiatric intensive care units (PICUs) Journal of Psychiatric Intensive Care December 2009, 5(2), 69-79

Physical restraint in psychiatric hospitals

There is a high level of violence on psychiatric-hospital wards. It has been estimated that almost half of nursing staff and one in seven patients are subject to physical assaults per year. Physical restraint is recommended only as a method of last resort for dealing with violence but relatively little is known about how often it is used and the circumstances of its use. Researchers from City University in London reviewed 45 studies into physical restraint. They found that, on average, five episodes of manual restraint a month might be expected on a typical 20-bed ward. Episodes lasted around ten minutes with about half involving the restraint of patients on the floor, usually in the prone position. Manually-restrained patients tended to be younger, male and detained under mental-health legislation.

Stewart, D. ... [et al] - Manual restraint of adult psychiatric inpatients: a literature review Journal of Psychiatric and Mental Health Nursing October 2009, 16(8), 749-757

Wards face uphill struggle to stub out smoking

On the 1st July, 2008 smoking was banned in psychiatric hospitals in the U.K. However, many hospitals have failed to implement the ban fully - if at all - and there has been a rise in 'secret smoking' by service users. A study of services by the Mental Health Foundation found that 85% of units had not implemented the ban fully. Many units lacked a safe outdoor smoking area for service users and the need to escort patients off the ward was seen to be a considerable drain on resources. Staff felt uncomfortable enforcing the ban and often turned a blind eye to smoking. In wards where the ban had been implemented successfully there had been widespread consultation with staff and patients beforehand, there was support for service users to stop smoking and alternative activities were provided for them.

You can find out more about this study at

http://www.communitycare.co.uk/Articles/2009/06/22/111898/psychiatric-units-unable-to-implement-smoking-ban.html

Single sex but not stress-free

Mixed-sex wards have been common in U.K. psychiatric hospitals in an attempt to provide a more 'normal' environment for service users. However, as people with less-severe mental illness are increasingly treated in the community people in psychiatric hospitals tend to be more disturbed and there have been concerns about the vulnerability of women to intimidation, violence and sexual harassment on mixed-sex wards. The U.K. government has been advocating more single-sex wards and many NHS Trusts have gone back to them. Researchers from Australia and the South London and Maudsley NHS FoundationTrust in London surveyed nursing staff on an acute psychiatric ward which was in the process of changing over from being mixed-sex to male only. They found that staff generally saw the change in negative terms and had particular concerns about the ward atmosphere becoming less therapeutic, more aggressive and their jobs becoming more stressful. These concerns did not get less over time. There were also concerns about the administrative problems caused by the changeover.

Thomas, Neil ... [et al] - Changing from mixed-sex to all-male provision in acute psychiatric care: a case study of staff experiences Journal of Mental Health April 2009, 18(2), 129-136

Milieu therapy: 'raising' good citizens

Milieu therapy is a form of psychotherapy that involves the use of therapeutic communities. Clients join a group of 30 or so people for between 9 and 18 months and during their stay they are encouraged to take responsibility for themselves and others within the unit. It is thought to be useful in treating personality and behaviour disorders and is widely used in Scandinavia. A team of Norwegian researchers looked at how milieu therapy worked in one such unit in Norway. They found that in ways the unit was similar to a traditional nuclear family. The clients were often seen as 'harmed children' and were taught self-management skills. The staff aimed to provide a caring atmosphere while the clients sometimes seemed to behave in a child-like manner. In a sense the milieu was 'raising' the clients to transform their 'odd' behaviour and 'nonconforming' lifestyles and produce 'self-governing' individuals.

Oeye, Christine ... [et al] - Raising adults as children? A report on milieu therapy in a psychiatric ward in Norway Issues in Mental Health Nursing 30(3), 151-158

New report on women inpatients - still room for improvement

The Mental Health Act Commission has produced a report into the experiences of women detained under mental-health legislation. The Commission visited more than 2,000 wards and surveyed 6,000 patients in 2007/8. The most significant issue raised by the report was women's feelings of being unsafe, relating to the continued use of mixed-sex accomodation. Some women were fearful of physical and sexual violence and complained of sexual harassment, verbal intimidation and the use of inappropriate language. The chief executive of the Mental Health Act Commission, Gemma Pearce, said "Many services are providing very good care which is sensitive to issues of privacy and dignity, and ensures and promotes the safety of women (and men) at a time of vulnerability. But we also found services which are not meeting the particular needs of women, including basic assurances of their rights to safety, privacy and dignity."

You can download the full Mental Health Act Commission report at

http://www.mhac.org.uk/files/women_in_detention_FINAL.pdf

Locked doors in inpatient units: a review of the evidence

Many acute inpatient psychiatric wards in the U.K. are kept permanently locked, despite the fact that this is contrary to the current Mental Health Act Code of Practice. Researchers from City University, London, reviewed 11 papers on the subject of door locking. They found that both service users and staff reported advantages of the practice including preventing illegal substances from entering and preventing service users from absconding and harming themselves or others. The disadvantages included making service users feel depressed and confined, and creating extra work for staff. Locked wards were associated with increased patient aggression, poorer satisfaction with treatment and more severe symptoms.

Van der Merwe, M. ... [et al] - Locked doors in acute inpatient psychiatry: a literature review Journal of Psychiatric and Mental Health Nursing April 2009, 16(3), 293-299

Reading for teenage inpatients

A social worker has been honoured by the National Year of Reading for her work promoting reading at an adolescent psychiatric unit in Newcastle. Janice Hutton, who works at the Rycroft Clinic in Gosforth was given the status of 'reading hero,' by the National Year of Reading campaign. She improved access to books at the unit, set up reading groups for young people and hosted reading sessions with well-known authors. She also worked with the local library to promote access to reading for young people preparing to leave the unit.

You can find out more about the National Year of Reading campaign at

http://www.communitycare.co.uk/Articles/2009/02/20/110769/social-worker-honoured-for-championing-reading-at-secure-unit.html

Inpatient care - what are service users' concerns?

User-led research into mental-health services is important because it reflects the perspective of the people for whom the services are intended but there has been very little research carried out specifically on psychiatric acute hospital services with inpatients as participants. A study carried out by service users in Northern Ireland looked at 13 psychiatric hospital sites throughout Northern Ireland and set up 10 focus groups to analyse the main areas of concern for service users. These were: information, communication, relationships, activities, self-help, patient involvement in care treatment plans and the physical environment.

Walsh, Jim and Boyle, Joan - Improving acute psychiatric hospital services according to inpatient experiences. A user-led piece of research as a means to empowerment Issues in Mental Health Nursing 2009, 30(1), 31-38

Ward atmosphere and outcome

The ward environment has, for a long time, been recognised as an important element in inpatient care and several studies have shown that it is related to patient satisfaction. Ordered environments with high levels of support seem to be associated with higher levels of patient satisfaction, especially for the most severely-impaired service users. However, little is known about how ward environment affects the outcome of people's treatment. A study of eighty service users at three different wards, carried out by researchers in Norway, found that differences in ward atmosphere were associated with differences in patient satisfaction but that there was only 'mixed' evidence that it was linked to patient outcomes (i.e. whether they got better or not). No links were found between ward atmosphere and self-efficacy (the feeling that one can deal with one's problems oneself) or life satisfaction.

Jorgensen, K. N., Romma, V. and Rundmo, T. - Associations between ward atmosphere, patient satisfaction and outcome Journal of Psychiatric and Mental Health Nursing March 2009, 16(2), 113-120

Severe personality disorder: in, out, what's it all about?

Until relatively recently the treatment of choice for people with severe personality disorders was admission for long-term treatment in psychotherapy hospitals or therapeutic communities. However, most of these institutions have closed down and the gap has been filled by partial hospitalization and outpatient, community-based approaches. It is uncertain how these two models compare though so researchers in London contrasted a community-based programme provided by the Cassel Hospital in London with inpatient treatment at the same facility. Their study found that people in the community-based programme improved to a significantly greater degree and had a lower dropout rate than people being treated on an inpatient basis.

Chiesa, Marco, Fonagy, Peter and Gordon, John - Community-based psychodynamic treatment program for severe personality disorders: clinical description and naturalistic evaluation Journal of Psychiatric Practice January 2009, 15(1), 12-24

New RCP guidelines on children on adults' wards

The Royal College of Psychiatrists has developed safeguarding standards for young people placed on adult psychiatric wards. The standards were commissioned by the National Institute for Mental Health in England and are designed to help managers meet their duty to end the unsuitable accomodation of young people in adults' wards by April 2010. There are 170 criteria, covering staffing, training, assessment, administrative processes and the physical environments of the wards. The Government is spending £31m to meet the target.

You can download a copy of the standards at

http://www.rcpsych.ac.uk/clinicalservicestandards/centreforqualityimprovement/safecareforypaudittool.aspx

Coerced medication

Laws governing involuntary psychiatric treatment exist in all EU member states and in other developed countries. Under these laws an increased risk to oneself and others provides the ethical and legal justification for detaining and treating people with mental-health problems without their consent. In the U.K. this often takes the form of coerced medication (CM) whereas in the rest of Europe seclusion and mechanical restraint are more likely to be used. Researchers from the Institute of Psychiatry and City University (both London) analysed 14 papers about CM from seven different countries, published between 1987 and 2004. They found that patients receiving CM were more likely to be in their thirties with a diagnosis of schizophrenia, bipolar disorder or another psychotic disorder and most of them had been admitted to psychiatric care on an involuntary basis. Service users experienced a range of negative feelings when they received CM including fear, embarrassment, anger and helplessness, although in retrospect many said they agreed with the practice. The studies showed a lack of detailed exploration into the events leading up to CM and a complete absence of investigation into alternatives. The authors concluded that their review highlighted a lack of clinical evidence on which to base CM and point out that the practice may discourage people from seeking help from, or engaging with, mental-health services.

You can find out more about this study by clicking on the link in the title of this post.

Law Lords ruling on duty of care to inpatients

The Law Lords have ruled that people detained under the Mental Health Act have the same 'right to life' as those in prison. Hospitals must now be seen to take responsibility to take reasonable measures to avoid real and immediate harm to patients who have been sectioned. The ruling results from a case brought by Anna Savage against South Essex NHS Trust, concerning her mother Carol, who killed herself in July 2004 after absconding from Runwell Hospital where she was being detained. The ruling holds health authorities responsible for taking measures to properly assess and prevent the risk of suicide. The High Court had previously ruled that unless gross negligence could be established, they could not be held liable for a breach of the right to life.

You can read the MIND press release about this judgement at

http://www.mind.org.uk/News+policy+and+campaigns/Press/2008-12-11-savage.htm

Self-harm after hospital

The risk of suicide in the month after psychiatric inpatient care is about 100 times greater than that of the general population. Although the high risk of suicide shortly after discharge is well documented less is known about the rates of non-fatal self-harm. A study of 75,401 people discharged from psychiatric inpatient care between April 2004 and March 2005 found that 6.5% of them were admitted at least once for self-harm in the following 12 months. The risk of self-harm was greatest in the four weeks after discharge. The strongest risk factor for self-harm after discharge was an admission for self-harm in the previous 12 months. The risk of self-harm was also higher in women, younger people, those with diagnoses of depression, personality disorder and substance abuse and those with short lengths of stay.

Gunnell, David ... [et al] - Hospital admissions for self-harm after discharge from psychiatric inpatient care: cohort study British Medical Journal December 6, 2008, 1331-1334

'Count me in' shows lack of progress

The Healthcare Commission's annual census of mental-health inpatients - 'Count Me In' - has painted a gloomy picture of a lack of progress on mixed-sex wards and racial equality. The census found that 68% of inpatients are still being housed on mixed-sex wards; no improvement on last year. Women (78%) were more likely than men (61%) to be treated in a mixed-sex ward. People from Black and minority-ethnic groups were three times more likely to be detained than average, and up to 65% more likely to be secluded. After three years of censuses there has been no sign of movement towards improving racial inequalities in mental-health care.

You can download the full report at

http://www.healthcarecommission.org.uk/_db/_documents/Count_me_in_census_2008_Results_of_the_national_census_of_inpatients_in_mental_health_and_learning_disability_services.pdf

Vitamin D deficiency in inpatients

Vitamin D deficiency has been linked to a number of different medical conditions and is known to cause bone problems such as rickets. Its main source is sunlight but it can also be found in fish, eggs, dairy products and fortified margarines and cereals. Researchers at St Bernard's Hospital, Middlesex looked at vitamin D levels in 17 male psychiatric inpatients. They found that 15 of them had vitamin D deficiency while the other two had borderline deficiency. The vitamin levels of the inpatients could be restored with the use of calcium and ergocalciferol tablets but the authors of the study recommended that all psychiatric inpatients should have adequate exposure to sunlight and healthy diets to ensure that they receive their recommended daily amounts of vitamins and minerals.

Tiangga, Eleanor, Gowda, Asha and Dent, John A. - Vitamin D deficiency in psychiatric in-patients and treatment with daily supplements of calcium and ergocalciferol Psychiatric Bulletin 2008, 32: 390-393

Low-secure units: outcomes and risk factors

A study of 86 patients admitted to a low-secure unit in S.E. London aimed to measure the effectiveness of treatment and to identify predictors of change. Significant improvements were found on the Health of the Nation Outcome Scales (HoNOS), the Staff Observed Aggression Scale (SOAS) and the Global Assessment Scale (GAS) and improvements on the GAS and HoNOS were associated with moves to a lower level of security. Patients with a history of conviction for property damage, cannabis use and who were admitted on a forensics section or who had a diagnosis of personality disorder were more likely to move to a higher level of security. Increased length of stay was related to the presence of physical assault, physical health problems and anxiety symptoms.

Beer, M. Dominic ... [et al] - Predicting outcome in low secure environments: a case series from one low secure unit Journal of Psychiatric Intensive Care December 2007, 3(2), 85-92