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Objective: Persons with severe mental illness have high rates of comorbid substance use disorders. These co-occurring disorders present a significant challenge to community mental health services, and few clinical trials are available to guide the development of effective services for this population. The study aimed to evaluate the effectiveness of a program for case managers that trained them to manage substance use disorders among persons with severe mental illness.Methods: A cluster-randomized controlled trial design was used in South London to allocate case managers either to training or to a waiting list control condition. Outcomes and service costs (health care and criminal justice) over 18 months of 127 patients treated by 40 case managers who received training were compared with those of 105 patients treated by 39 case managers in the control condition.Results: Brief Psychiatric Rating Scale scores for the intervention group indicated significant improvements in psychotic and general psychopathology symptoms. Participants in the intervention group also reported fewer needs for care at follow-up. No significant differences were found between the two groups in levels of substance use at 18 months. At follow-up both groups reported increased satisfaction with care. Service costs were also similar for the two groups.Conclusions: Compared with standard care, integrated treatment for co-occurring disorders provided by nonspecialist mental health staff produced significant improvements in symptoms and level of met needs, but not in substance use or quality of life, at no additional cost. [ABSTRACT FROM AUTHOR]

Behavioural activation is a contemporary behavioural treatment for depression that has the potential advantages of being more readily adopted in psychiatric inpatient environments than more complex psychological treatment approaches and requiring less intensive training than these approaches. In this article the theoretical and empirical foundations of behavioural activation are described along with an outline of the therapeutic process and key interventions used. Consideration is then given to factors influencing the implementation of BA in psychiatric inpatient environments. [ABSTRACT FROM AUTHOR]

Background. Satisfaction with antipsychotic medication is an important outcome variable. To date, there is a lack of a well-established measure to quantify patient satisfaction with psychiatric medication. This paper describes the development, dimensionality, reliability and validity of the Satisfaction with Antipsychotic Medication (SWAM) scale.Method. Clinical and academic experts devised a 33-item Likert scale satisfaction questionnaire. Following a pilot study in a sample of 69 people with schizophrenia, 315 people with schizophrenia on the caseload of local mental health services in three London boroughs completed the questionnaire. The dimensionality, internal consistency and validity of the devised instrument were assessed.Results. Reliability of the SWAM scale was good for subscales and total scores. The alpha coefficient for the two subscales: treatment acceptability and medication insight were 0.92 and 0.84 respectively. The alpha coefficient for the SWAM scale total score was 0.91 and ranged from 0.92 to 0.90.Conclusion. Testing of the psychometric properties of the SWAM scale demonstrate that it is a reliable instrument for measuring patient satisfaction with antipsychotic medication. The measure could be used in routine clinical practice in mental health services to assess patient satisfaction with psychiatric medication. [ABSTRACT FROM AUTHOR]

BACKGROUND: NHS Direct, the United Kingdom's 24-hour nurse-led telephone advice service, was announced in December 1997. By November 2000 the service was available throughout England and Wales. Initial research had shown that people with mental health problems used the service and that, prior to its going live, this was one area about which nurses felt least confident. AIMS: The aim of the study was to measure confidence in dealing with mental health calls, knowledge of mental health issues, and attitudes to mental health before and after training. METHODS: A postal questionnaire was sent to all nurse advisers working in 17 NHS Direct sites in England before and after mental health training had been received. The questionnaire was designed to measure confidence, knowledge and attitudes. This was done through scenarios of real calls to NHS Direct, questions from the World Health Organization guide to Mental Health in Primary Care and the Depression Attitude Questionnaire. RESULTS: Confidence increased in nurses who received mental health training. Although there was no statistically significant increase in knowledge scores after training, those who had received training increased by on average one point. After training, attitudes towards depression had shifted in that nurses now felt more positive towards their role in treating depressed patients. CONCLUSIONS: Training in mental health can lead to increases in confidence and a change in attitudes and would be beneficial for all nurses working in NHS Direct and in other primary care fields. It would also be beneficial to repeat the study with a larger number of nurses and after a longer period of time to assess the long-term effects of training. [ABSTRACT FROM AUTHOR]

AIM OF THE STUDY: The aim of the study was to examine the content of Trust policies concerning the prevention and management of violence in acute in-patient settings in order to establish their usefulness as guidance for staff in this difficult, complex, and controversial aspect of inpatient psychiatric care. BACKGROUND: Violence is a commonly encountered problem in inpatient psychiatric settings. There are legal requirements for workplaces in general and mental health care facilities in particular to develop safe systems of work based upon the findings of assessments of this risk. Policies have a key role to play in making explicit the responsibilities of both employer and employees, and specifying standards of acceptable practice. DESIGN: A cross-sectional survey methodology was used, which entailed examination of the content of management of violence policies that had been forwarded to the authors from 40 Trusts providing acute inpatient psychiatric care throughout England, Scotland, Wales, and Northern Ireland. FINDINGS: Policies were found to vary widely in their content, and serious shortcomings were noted in the extent to which policies included information regarding their status and review, advice on the prevention of violence, the management of violent incidents, and postincident action. CONCLUSIONS: Further research is needed to tease out the extent to policies which are lacking in content, reflect shortcomings in the organizational approach to the prevention and management of violence by Trusts, and the extent to which such shortcomings result in harm being suffered by staff and/or patients. An alternative format for the presentation of management of violence policies is discussed, and items that should be included in inpatient units' management of violence policies are suggested. [ABSTRACT FROM AUTHOR]

Background: Depot antipsychotic medication is used widely in the treatment and prophylaxis of severe mental illness.Aims: To review the literature on patient and nurse satisfaction with, and attitudes towards, depots.Method: A systematic search of Medline, Embase, PsycINFO, CINAHL and The Cochrane Library was undertaken, along with citation searches. Studies were selected if satisfaction/attitude data were described in the title or abstract and original data were included. Study quality was rated.Results: The search produced 1374 articles; 22 articles met the inclusion criteria, 18 of which were cross-sectional surveys. Of the 12 studies with relevant data, 10 conveyed a positive opinion of depot medication. Five out of six studies comparing depot with oral medication showed patient preference for depot.Conclusions: High-quality data examining patient and nurse attitudes regarding depot antipsychotics are sparse. What data there are show a positive attitude to depots from patients. Future randomised controlled trials should include satisfaction as an outcome. [ABSTRACT FROM AUTHOR]

There is little empirical literature on observation as a psychiatric nursing procedure to prevent patients from harming themselves or others. National guidelines for this practice do not exist, with a consequence that local policies might be variable in content and quality. This paper reports a national survey of observation policies and usage based upon a stratified random sample of 27 psychiatric inpatient service providers in England and Wales. Extreme variation in terminology and practice was encountered. The terminological confusion is likely to reduce nurses' clarity about their responsibilities and increase risks to patients. Further variation exists from place to place as to whether, and to what extent, student nurses and family members should be entrusted with the responsibility to observe patients. More than one in 10 services of the sample still have no written observation policy, and four in 10 have no clinical recording system of the procedure in place. Nurses commonly amend the procedure and terminology on an ad hoc basis. The results of this survey confirm that the Department of Health should set national standards for the policies and procedures for patient observation and that as an interim step practice guidance should be issued to all nurses (and other mental health workers) involved in this procedure. [ABSTRACT FROM AUTHOR]

BACKGROUND: The National Service Framework for Mental Health has emphasized the need to prioritize the provision of cognitive behaviour therapy as the central evidence-based non-pharmacological intervention for mental health problems. For 25 years one programme (English National Board Course No. 650--Diploma in Behavioural Cognitive Therapy, formerly called Nursing in Behavioural Psychotherapy) has trained nurses in such methods. This is the only programme in nursing which qualifies graduates to be fully certified as a cognitive behaviour therapist by the British Association of Behavioural Psychotherapy and by the United Kingdom Council for Psychotherapy. The practice of these nurse therapists (most commonly known as nurse behaviour therapists, NBTs) is the most rigorously evaluated in mental health nursing, with several randomized controlled trials to testify to clinical and economic efficacy. AIM: The aim of this study is to continue the systematic follow-up of all NBT graduates previously undertaken in two earlier surveys published in 1986 and 1994. These previous surveys examined clinical practice, organizational context and career and professional development issues. This up-to-date picture of NBTs will provide useful baselines for the implementation of the National Service Framework, and may be used by the Department of Health, education providers and services. METHOD: A postal survey (using the same template for categories of information as the two earlier surveys) was used and questionnaires were sent to 237 of the 274 trained NBTs whose name appears on the Central NBT Register, maintained at the Institute of Psychiatry/Maudsley Training Centre. RESULTS: One hundred and five of 230 eligible respondents (45.6%) returned questionnaires and additional data were obtained from 27 NBTs who provided information to the Register in the year before the survey. Thus, some data were available for 57% of the sample. As in earlier surveys, it was found that the majority of therapists remain in clinical practice, undertake substantial further education and training and are involved in research and teaching as part of their overall role. The two central developments are an increasing move towards working in primary care and an increased emphasis on cognitive interventions. NBTs complete a substantial number of treatments per year and increasingly treat clients with difficulties not encountered during their basic training. NBTs now receive much more supervision than in previous surveys and continue to use valid and reliable measures of change in practice. However, the number of NBTs remains small and the impact on potential populations who would benefit from effective psychological interventions is minimal. This paper discusses the implications for service delivery. [ABSTRACT FROM AUTHOR]

A significant number of incidents of suicide and self-harm occur whilst patients are in receipt of care as in-patients. This audit comprises 31 cases which were referred to the first author for expert opinion, each case being the subject of legal action brought by patients and/or their families. The cases were referred from 31 different NHS trusts across England. All concerned suicide/serious self-harm in people in receipt of in-patient care. The aims of this audit were to carry out a detailed assessment of the 31 individual cases, so as to provide a nursing dimension to already established enquiries in this area and also to examine whether specific issues might be the subject of more systematic research. Further, this paper aims to provide some insights in the area of litigation, where nurses are becoming increasingly involved. The same broad approach to information-gathering and analysis was used, comprising a systematic review of case records, trust policies, expert reports and, where appropriate, inquest transcriptions. The sample comprised 12 suicides and 19 cases of serious self-harm. Factors associated with these events include: being male, having a dual diagnosis of mental illness and drug/alcohol abuse, and age between 21 and 30 years. Of the 12 deaths, five occurred in hospital, four by hanging and one by drowning. The audit highlighted environmental factors associated with these events which, arguably, could be simply addressed. There was a considerable variation in the content and quality of observation policy and practice. The results of this audit point to the need for further research but, above all, provide evidence requiring urgent action by the Department of Health regarding the setting of national standards. [ABSTRACT FROM AUTHOR]

Cognitive behavioural techniques are increasingly used as adjuncts to medication in the treatment of auditory hallucinations for people with schizophrenia. There are now literally hundreds of nurses trained in the use of cognitive behavioural interventions for psychosis. However, there is still disagreement about the nature of the cognitive processes that lead to deficits or biases in patients' processing of information about their psychotic experiences. Using Chadwick & Birchwood's Beliefs About Voices Questionnaire (BAVQ), the investigator collected data regarding voices from a sample of men and women being treated for schizophrenia by secondary mental health services. The investigator then carried out a cross-lagged panel analysis of the data. The investigator found, as predicted, positive relationships between a resistive coping style and an attribution of malevolence to voices, and between an engaging coping style and an attribution of benevolence to voices. Coping and attributional styles were not necessarily stable over time. There was a non-significant difference between women's and men's attributions and coping styles. There was less fluctuation over time in the women's scores on the BAVQ. This research shows that one cannot assume that either coping or attributional style becomes more stable over time. However, while there are strong relationships between attributions and coping styles, and particularly between malevolence and resistance and benevolence and engagement, these relationships are not necessarily mutually exclusive and some people in the study believe their voices to be both malevolent and benevolent. These findings suggest that clinicians need to make a very careful assessment of attribution and coping with regard to hallucinations and that systematic reassessment is very important. Further research is necessary in both the phenomenology of attribution and coping, but also to relate these variables to other aspects of schizophrenic illnesses. [ABSTRACT FROM AUTHOR]

Psychiatric nursing in prison: the state of the art? Psychiatric nursing in prisons has received criticism from within and outside the profession in recent years. In England and Wales this amongst other issues has prompted a review of forensic health care by the United Kingdom Central Council for Nursing, Midwifery & Health Visiting (UKCC). The status of forensic psychiatric nursing as a specialty has also been disputed in the literature and the role of nurses working in this field is seen by some to be more about social control than caring. These arguments are set in the present situation of increasing numbers of mentally ill individuals in the prison system and a crisis in the availability of beds in secure units, a situation that is paralleled throughout the western world. The standard expected of health care services in prisons is equivalence with the service the public receives from the National Health Service (NHS). The number of prisoners needing transfer to hospital has increased during the last decade, resulting in competition for a limited number of suitable beds. The effect on health care centres (HCCs) in English prisons is that they now must provide long-term care for seriously mentally ill prisoners. This paper outlines the development of British psychiatric services in prisons. It then describes the HCC in Her Majesty’s prison (HMP) Belmarsh and reports on recent radical changes in the management structure of this service. The aim of these changes is to produce a clinical environment in which psychiatric nurses can deliver high quality care in an area beset with difficulties for clinicians and managers and to further progress towards the goal of equivalence. These advances have been achieved through a shift of emphasis in management structure that increases the number of clinical posts and minimizes administrative and security-based responsibilities held by clinical grades. We conclude that although external contracts are necessary, much can be achieved through internal review and changes in policy. [ABSTRACT FROM AUTHOR]

BACKGROUND: The move in the United Kingdom (UK) from institutional to community care has led to an inevitable increase in the involvement of practice nurses (PNs) in mental health care. Around 20 000 PNs are currently working in the United Kingdom (UK). However, the extent and nature of PN involvement in delivering mental health interventions has not been adequately explored. Aim: This study aimed to quantify practice nurses' involvement in delivering mental health interventions in primary care settings. Method: A questionnaire was sent to a random sample of 1500 practice nurses registered with the Practice Nurse Forum at the Royal College of Nursing. Sixty per cent of questionnaires were returned; however, once non-eligible respondents were removed an adjusted response rate of 54% was achieved. RESULTS: Practice nurses play a significant role in the assessment and treatment of mental health problems, most frequently via the administration of depot antipsychotics and the screening for depression. However, antipsychotic side-effects were infrequently monitored and PNs' understanding of treatment issues in depression is poor. These findings may be associated with the reported lack of mental health training that PNs have received. CONCLUSIONS: The findings of this study have important implications for the training of practice nurses in mental health, specifically in the areas of medication management and the detection of mental disorders. [ABSTRACT FROM AUTHOR]

Community psychiatric nurses (CPNs) in the United Kingdom are increasingly working in primary health care settings with less serious mental health problems. This paper describes an economic evaluation of their work using a randomized controlled trial in which 231 patients were assigned to continuing general practitioner care or one of two conditions of CPN intervention. This is only the third systematic economic analysis of community mental health nursing in the UK and the first carried out by mental health nurses. Various costs to patients, their families and the health care system were determined. Results showed that patients receiving CPN intervention experienced less absence from work and that this resulted in a net benefit. However, the cost per quality adjusted life year for intervening with this group of patients was probably several times more than for intervening with the seriously mentally ill. Therefore, if one considers both the clinical and economic results of the study, taken together with the recent results of the review of mental health nursing, there seems little justification for CPNs continuing to work in this area. [ABSTRACT FROM AUTHOR]

A postal survey was carried out of all nurse behaviour therapists trained on the English National Board for Nursing, Midwifery and Health Visiting course in adult behavioural psychotherapy (ENB 650) since its inception at Maudsley Hospital London, in 1972. All trained therapists currently in practice in the UK were surveyed, and 113 of 142 eligible respondents returned questionnaires. These were examined to elicit the professional profiles and working practices of the therapists, and to identify similarities and differences between therapists trained in the four training centres in the UK. It was found that the majority of nurse therapists remain in clinical practice after training, and continue to further their education and clinical expertise. There has been a general shift towards cognitive and short-term interventions, and towards practice based on primary care, with general practitioners providing most referrals. There were significant differences between the centres in terms of a number of the therapeutic techniques used, diagnostic categories of clients seen, and several elements of working practice, including referral source and numbers of clients seen and treated. The implications of the findings for clinical practice and for nursing in behaviour therapy are discussed. [ABSTRACT FROM AUTHOR]

Background: Body dysmorphic disorder (BDD) consists of a preoccupation with an 'imagined' defect in appearance which causes significant distress or impairment in functioning. There has been little previous research into BDD. This study replicates a survey from the USA in a UK population and evaluates specific measures of BDD.Method: Cross-sectional interview survey of 50 patients who satisfied DSM-IV criteria for BDD as their primary disorder.Results: The average age at onset was late adolescence and a large proportion of patients were either single or divorced. Three-quarters of the sample were female. There was a high degree of comorbidity with the most common additional Axis l diagnosis being either a mood disorder (26%), social phobia (16%) or obsessive-compulsive disorder (6%). Twenty-four per cent had made a suicide attempt in the past. Personality disorders were present in 72% of patients, the most common being paranoid, avoidant and obsessive-compulsive.Conclusions: BDD patients had a high associated comorbidity and previous suicide attempts. BDD is a chronic handicapping disorder and patients are not being adequately identified or treated by health professionals. [ABSTRACT FROM AUTHOR]

Background: Community psychiatric nurses (CPNs) are increasingly working in primary health care with non-psychotic patients. This study was designed to test the efficacy of this work.Method: The study was carried out in six health centres in north London with a total of 36 participating general practitioners (GPs) and 11 CPNs. Using a randomised controlled trial, 177 patients were referred by their GP and randomly allocated to continuing GP care, immediate community psychiatric nursing intervention, or placed on a 12-week waiting-list, after which time the patient was offered CPN intervention. A range of measures of symptoms and social function were used, and ratings were carried out at assessment and at 24 weeks.Results: Patients improved on all measures over time (P < 0.001 for all measures). However, there was no difference between the group of patients receiving GP care and patients seen by the CPN. Improvements seemed to be independent of the amount of contact. Drop-out rates from CPN intervention were high (50%). CPN drop-outs were more disabled to start with, but did as well as CPN treatment completers. Patients were more likely to drop out with trained than untrained CPNs. There was no evidence that referral to a CPN saved GP time.Conclusions: The results add weight to the argument that CPNs should refocus their activity on people with serious mental health problems, and indicate that CPN education should focus on skill acquisition and interventions of proven effectiveness. [ABSTRACT FROM AUTHOR]