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Francis CJ, Johnson A, Wilson RL. Supported decision-making interventions in mental healthcare: A systematic review of current evidence and implementation barriers. Health Expect 2024; 27:e14001. [PMID: 38433012 PMCID: PMC10909645 DOI: 10.1111/hex.14001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 02/15/2024] [Accepted: 02/15/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND There is a growing momentum around the world to foster greater opportunities for the involvement of mental health service users in their care and treatment planning. In-principle support for this aim is widespread across mental healthcare professionals. Yet, progress in mental health services towards this objective has lagged in practice. OBJECTIVES We conducted a systematic review of quantitative, qualitative and mixed-method research on interventions to improve opportunities for the involvement of mental healthcare service users in treatment planning, to understand the current research evidence and the barriers to implementation. METHODS Seven databases were searched and 5137 articles were screened. Articles were included if they reported on an intervention for adult service users, were published between 2008 and October 2023 and were in English. Evidence in the 140 included articles was synthesised according to the JBI guidance on Mixed Methods Systematic Reviews. RESULTS Research in this field remains exploratory in nature, with a wide range of interventions investigated to date but little experimental replication. Overarching barriers to shared and supported decision-making in mental health treatment planning were (1) Organisational (resource limitations, culture barriers, risk management priorities and structure); (2) Process (lack of knowledge, time constraints, health-related concerns, problems completing and using plans); and (3) Relationship barriers (fear and distrust for both service users and clinicians). CONCLUSIONS On the basis of the barriers identified, recommendations are made to enable the implementation of new policies and programs, the designing of new tools and for clinicians seeking to practice shared and supported decision-making in the healthcare they offer. PATIENT OR PUBLIC CONTRIBUTION This systematic review has been guided at all stages by a researcher with experience of mental health service use, who does not wish to be identified at this point in time. The findings may inform organisations, researchers and practitioners on implementing supported decision-making, for the greater involvement of people with mental ill health in their healthcare.
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Affiliation(s)
| | - Amanda Johnson
- Head of School, Dean of Nursing and MidwiferyUniversity of NewcastleNewcastleNew South WalesAustralia
| | - Rhonda L. Wilson
- University of NewcastleNewcastleNew South WalesAustralia
- Massey UniversityPalmerston NorthNew Zealand
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Schneeberger AR, Werthmueller S, Barco S, Heuss SC. Patients' preference regarding inpatient versus outpatient setting - A systematic review. Int J Health Plann Manage 2023; 38:1409-1419. [PMID: 37293696 DOI: 10.1002/hpm.3669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 03/09/2023] [Accepted: 05/26/2023] [Indexed: 06/10/2023] Open
Abstract
OBJECTIVES Continuously rising healthcare costs have led to financial pressure on the healthcare systems. One of the trends for the reduction of costs is the shift towards outpatient treatment. However, research has not focused on the patients' preferences regarding inpatient versus outpatient treatment settings. The purpose of this review is to examine existing studies surveying patients' preferences related to inpatient and outpatient treatment methods. The aim is to find out whether patients' wishes were queried and considered in the decision-making process. DESIGN Therefore, the reviewers performed a systematic approach utilizing the PRISMA standards and screened 1'646 articles out of 5'606 articles from the systematic search. RESULTS AND CONCLUSION The screening resulted in 4 studies that analyzed exclusively the patient's choice of treatment setting. The search showed an apparent paucity of current literature and highlights the need for further research. The authors' recommendation includes a better involvement of patients in the decision-making process as well as adding preferred treatment settings to advanced treatment directives and patient satisfaction questionnaires.
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Affiliation(s)
| | - Sarah Werthmueller
- University of Applied Sciences Northwestern Switzerland FHNW, Olten, Switzerland
| | | | - Sabina C Heuss
- University of Applied Sciences Northwestern Switzerland FHNW, Olten, Switzerland
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[Joint crisis plans in mental health hospitals-Real practice in an association of psychiatric hospitals]. DER NERVENARZT 2023; 94:18-26. [PMID: 36562789 DOI: 10.1007/s00115-022-01419-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Joint crisis plans (JCPs) are offered in many psychiatric hospitals, but patients only rarely make use of them. OBJECTIVE To assess the rates of JCPs among inpatients of mental health hospitals and to analyze the clinical characteristics of patients who make use of a JCP. MATERIAL AND METHODS We carried out a retrospective analysis of routine data from the statistical database/basis documentation of the LVR hospital association, which consists of nine psychiatric hospitals. The basis documentation is consistent in the nine hospitals. All admissions between 2016 and 2020 were considered. We recorded the existence of a JCP, age, gender and main diagnosis at release, as well as previous hospital stays, detention under the Mental Health Act of the Federal State of NRW and experiences with compulsory measures (seclusion/restraint) in the previous 24 months before index admission. RESULTS Out of a total of 117,662 inpatients 467 (0.4%) had completed a JCP. Patients with JCP were more likely to be diagnosed with schizophrenia, bipolar disorder, or emotionally unstable personality disorder. Patients with a JCP had more previous inpatient stays and they had more frequently experienced detentions and compulsory measures. However, 50% of the patients with a JCP had other diagnoses and the vast majority of them had experienced no detention or compulsory measure in the 24 months preceding the first documentation of a JCP. CONCLUSIONS Overall, the use of JCPs is limited. The targeted group of patients with severe mental illness and previous experience with involuntary placements and compulsory measures make use of the offer of a JCP but so do other patients as well. Additional qualitative analyses are required in order to analyze the content and objectives of JCPs in more detail.
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Monk-Cunliffe J, Borschmann R, Monk A, O'Mahoney J, Henderson C, Phillips R, Gibb J, Moran P. Crisis interventions for adults with borderline personality disorder. Cochrane Database Syst Rev 2022; 9:CD009353. [PMID: 36161394 PMCID: PMC9511988 DOI: 10.1002/14651858.cd009353.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND People diagnosed with borderline personality disorder (BPD) frequently present to healthcare services in crisis, often with suicidal thoughts or actions. Despite this, little is known about what constitutes effective management of acute crises in this population and what type of interventions are helpful at times of crisis. In this review, we will examine the efficacy of crisis interventions, defined as an immediate response by one or more individuals to the acute distress experienced by another individual, designed to ensure safety and recovery and lasting no longer than one month. This review is an update of a previous Cochrane Review examining the evidence for the effects of crisis interventions in adults diagnosed with BPD. OBJECTIVES To assess the effects of crisis interventions in adults diagnosed with BPD in any setting. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, nine other databases and three trials registers up to January 2022. We also checked reference lists, handsearched relevant journal archives and contacted experts in the field to identify any unpublished or ongoing studies. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing crisis interventions with usual care, no intervention or waiting list, in adults of any age diagnosed with BPD. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included two studies with 213 participants. One study (88 participants) was a feasibility RCT conducted in the UK that examined the effects of joint crisis plans (JCPs) plus treatment as usual (TAU) compared to TAU alone in people diagnosed with BPD. The primary outcome was self-harm. Participants had an average age of 36 years, and 81% were women. Government research councils funded the study. Risk of bias was unclear for blinding, but low in the other domains assessed. Evidence from this study suggested that there may be no difference between JCPs and TAU on deaths (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.06 to 14.14; 88 participants; low-certainty evidence); mean number of self-harm episodes (mean difference (MD) 0.30, 95% CI -36.27 to 36.87; 72 participants; low-certainty evidence), number of inpatient mental health nights (MD 1.80, 95% CI -5.06 to 8.66; 73 participants; low-certainty evidence), or quality of life measured using the EuroQol five-dimension questionnaire (EQ-5D; MD -6.10, 95% CI -15.52 to 3.32; 72 participants; very low-certainty evidence). The study authors calculated an Incremental Cost Effectiveness Ratio of GBP -32,358 per quality-adjusted life year (QALY), favouring JCPs, but they described this result as "hypothesis-generating only" and we rated this as very low-certainty evidence. The other study (125 participants) was an RCT conducted in Sweden of brief admission to psychiatric hospital by self-referral (BA) compared to TAU, in people with self-harm or suicidal behaviour and three or more diagnostic criteria for BPD. The primary outcome was use of inpatient mental health services. Participants had an average age of 32 years, and 85% were women. Government research councils and non-profit foundations funded the study. Risk of bias was unclear for blinding and baseline imbalances, but low in the other domains assessed. The evidence suggested that there is no clear difference between BA and TAU on deaths (RR 0.49, 95% CI 0.05 to 5.29; 125 participants; low-certainty evidence), mean number of self-harm episodes (MD -0.03, 95% CI -2.26 to 2.20; 125 participants; low-certainty evidence), violence perpetration (RR 2.95, 95% CI 0.12 to 71.13; 125 participants; low-certainty evidence), or days of inpatient mental health care (MD 0.70, 95% CI -14.32 to 15.72; 125 participants; low-certainty evidence). The study suggested that BA may have little or no effect on the mean number of suicide attempts (MD 0.00, 95% CI -0.06 to 0.06; 125 participants; very low-certainty evidence). We also identified three ongoing RCTs that met our inclusion criteria. The results will be incorporated into future updates of this review. AUTHORS' CONCLUSIONS A comprehensive search of the literature revealed very little RCT-based evidence to inform the management of acute crises in people diagnosed with BPD. We included two studies of two very different types of intervention (JCP and BA). We found no clear evidence of a benefit over TAU in any of our main outcomes. We are very uncertain about the true effects of either intervention, as the evidence was judged low- and very low-certainty, and there was only a single study of each intervention. There is an urgent need for high-quality, large-scale, adequately powered RCTs on crisis interventions for people diagnosed with BPD, in addition to development of new crisis interventions.
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Affiliation(s)
- Jonathan Monk-Cunliffe
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rohan Borschmann
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
- Centre for Adolescent Health, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
- Department of Psychiatry, University of Oxford, Oxford, UK
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Australia
| | - Alice Monk
- School of Primary Care, Severn Postgraduate Medical Education, Bristol, UK
| | - Joanna O'Mahoney
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Claire Henderson
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Rachel Phillips
- Imperial Clinical Trials Unit, Imperial College London, London, UK
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Jonathan Gibb
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Moran
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Mouchabac S, Adrien V, Falala-Séchet C, Bonnot O, Maatoug R, Millet B, Peretti CS, Bourla A, Ferreri F. Psychiatric Advance Directives and Artificial Intelligence: A Conceptual Framework for Theoretical and Ethical Principles. Front Psychiatry 2021; 11:622506. [PMID: 33551883 PMCID: PMC7862130 DOI: 10.3389/fpsyt.2020.622506] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/16/2020] [Indexed: 01/19/2023] Open
Abstract
The patient's decision-making abilities are often altered in psychiatric disorders. The legal framework of psychiatric advance directives (PADs) has been made to provide care to patients in these situations while respecting their free and informed consent. The implementation of artificial intelligence (AI) within Clinical Decision Support Systems (CDSS) may result in improvements for complex decisions that are often made in situations covered by PADs. Still, it raises theoretical and ethical issues this paper aims to address. First, it goes through every level of possible intervention of AI in the PAD drafting process, beginning with what data sources it could access and if its data processing competencies should be limited, then treating of the opportune moments it should be used and its place in the contractual relationship between each party (patient, caregivers, and trusted person). Second, it focuses on ethical principles and how these principles, whether they are medical principles (autonomy, beneficence, non-maleficence, justice) applied to AI or AI principles (loyalty and vigilance) applied to medicine, should be taken into account in the future of the PAD drafting process. Some general guidelines are proposed in conclusion: AI must remain a decision support system as a partner of each party of the PAD contract; patients should be able to choose a personalized type of AI intervention or no AI intervention at all; they should stay informed, i.e., understand the functioning and relevance of AI thanks to educational programs; finally, a committee should be created for ensuring the principle of vigilance by auditing these new tools in terms of successes, failures, security, and relevance.
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Affiliation(s)
- Stéphane Mouchabac
- Sorbonne Université, AP-HP Department of Psychiatry, Hôpital Saint-Antoine, Paris, France
- Sorbonne Université, iCRIN Psychiatry (Infrastructure of Clinical Research In Neurosciences - Psychiatry), Brain and Spine Institute (ICM), INSERM, CNRS, Paris, France
| | - Vladimir Adrien
- Sorbonne Université, AP-HP Department of Psychiatry, Hôpital Saint-Antoine, Paris, France
- Sorbonne Université, iCRIN Psychiatry (Infrastructure of Clinical Research In Neurosciences - Psychiatry), Brain and Spine Institute (ICM), INSERM, CNRS, Paris, France
| | - Clara Falala-Séchet
- Laboratory of Psychopathology and Health Processes, EA 4057, Institute of Psychology, University of Paris, Paris, France
| | - Olivier Bonnot
- CHU de Nantes, Department of Child and Adolescent Psychiatry, Nantes, France
- Pays de la Loire Psychology Laboratory, EA 4638, Nantes, France
| | - Redwan Maatoug
- Sorbonne Université, iCRIN Psychiatry (Infrastructure of Clinical Research In Neurosciences - Psychiatry), Brain and Spine Institute (ICM), INSERM, CNRS, Paris, France
- Sorbonne Université, AP-HP Department of Psychiatry, Hôpital Pitié-Salpêtrière, Paris, France
| | - Bruno Millet
- Sorbonne Université, iCRIN Psychiatry (Infrastructure of Clinical Research In Neurosciences - Psychiatry), Brain and Spine Institute (ICM), INSERM, CNRS, Paris, France
- Sorbonne Université, AP-HP Department of Psychiatry, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Alexis Bourla
- Sorbonne Université, AP-HP Department of Psychiatry, Hôpital Saint-Antoine, Paris, France
- Jeanne d'Arc Hospital, INICEA Group, Saint-Mandé, France
| | - Florian Ferreri
- Sorbonne Université, AP-HP Department of Psychiatry, Hôpital Saint-Antoine, Paris, France
- Sorbonne Université, iCRIN Psychiatry (Infrastructure of Clinical Research In Neurosciences - Psychiatry), Brain and Spine Institute (ICM), INSERM, CNRS, Paris, France
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Moreno-Calvete MC, Ballesteros-Rodriguez FJ. Non-pharmacological strategies for self-directed and interpersonal violence in people with severe mental illness: a rapid overview of systematic reviews. BMJ Open 2021; 11:e043576. [PMID: 33431494 PMCID: PMC7802727 DOI: 10.1136/bmjopen-2020-043576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/09/2020] [Accepted: 12/09/2020] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Self-directed and interpersonal violence among people with severe mental illness has become a health priority. Though non-pharmacological interventions have been investigated, to our knowledge, no summary of all systematic reviews on this topic has been reported. We will conduct a rapid overview of reviews to synthesise evidence available by identifying systematic reviews on non-pharmacological interventions for self-directed or interpersonal violence in people with severe mental illness. METHODS AND ANALYSIS This is a protocol for a rapid overview of reviews. The overview will include any systematic reviews (with or without meta-analyses) of randomised controlled trials (RCTs) or cluster RCTs that examine the effect of non-pharmacological interventions on self-directed or interpersonal violence in people with severe mental illness. This protocol applies the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols, the criteria for conducting overviews of reviews in the Cochrane Handbook of Systematic Reviews of Interventions and the criteria for the Cochrane Rapid Reviews. To identify studies, a search will be performed in the following databases: PubMed, EMBASE, PsycINFO, CINAHL, LILACS, SciELO, Web of Science, Scopus, ProQuest, the Cochrane Database of Systematic Reviews through the Cochrane Library and the Epistemonikos database of systematic reviews. The searches date from inception to September 2020. The study selection process will be described using a PRISMA flow diagram, we will assess the quality of evidence in systematic reviews included and the quality of the systematic reviews themselves and the main results will be summarised in categories to provide a map of the evidence available. ETHICS AND DISSEMINATION No patients or other participants will be involved in this study. The results will be presented at mental health conferences and for publication in a peer-reviewed journal. REGISTRATION DETAILS The protocol was registered on the Open Science Framework (https://osf.io/myzd9/).
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Affiliation(s)
| | - Francisco Javier Ballesteros-Rodriguez
- Department of Neuroscience, Biocruces Bizkaia Health Research Institute, CIBER Salud Mental (CIBERSAM), University of the Basque Country UPV/EHU, Leioa, Biscay, Spain
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Hiu S, Su A, Ong S, Poremski D. Stakeholder perspective on barrier to the implementation of Advance Care Planning in a traditionally paternalistic healthcare system. PLoS One 2020; 15:e0242085. [PMID: 33170875 PMCID: PMC7654826 DOI: 10.1371/journal.pone.0242085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 10/25/2020] [Indexed: 12/14/2022] Open
Abstract
Background Advance psychiatric agreements could guide medical teams in providing care consistent with the incapacitated service user’s wishes. However, these types of agreements are rarely completed in Asian settings. What challenges can a traditionally paternalistic healthcare system expect to encounter when attempting to implement psychiatric advance directives? Methods We answered this research question by exploring the cultural, administrative and logistical challenges that might impede the implementation of the system supporting the service. We interviewed key stakeholders, 28 service users and 22 service providers, to seek their views and interests in the implementation of directives. We structured our analyses along a literature-review-based framework designed to guide further implementation studies, proposed by Nicaise and colleagues (2013). Accordingly, we divided our inductively generated themes into four longitudinal categories: pre-development stage, development stage, implementation stage, post-implementation stage. Results Overall, the findings indicated that many service users and service providers are interested in advance care planning. They believed that foreseeable challenges could be overcome with appropriate measures. However, the multiple challenges of implementation led some service providers to be ambivalent about their implementation and led service users to dismiss them. Specifically, factors related to the local culture in Singapore necessitated adjustments to the content and structure of the directives. These include language barriers in a multicultural society, conflicting wishes in a collectivist society, taboos for speaking about undesirable outcomes in a traditionalist society, and time limitations in a fast-paced society. Conclusion While culture-specific changes may be required to enable service users in a small Asian country to employ existing advance psychiatric agreement approaches, service providers and service users see their benefits. However, service providers must be mindful not to assume that service users are willing to defer every decision to their physician.
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Affiliation(s)
- Stellar Hiu
- Health Intelligence Unit, Institute of Mental Health, Singapore, Singapore
| | - Alex Su
- Medical Board, Institute of Mental Health, Singapore, Singapore
| | - Samantha Ong
- Department of Nursing, Institute of Mental Health, Singapore, Singapore
| | - Daniel Poremski
- Health Intelligence Unit, Institute of Mental Health, Singapore, Singapore
- * E-mail:
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Leavey G, Curran E, Fullerton D, Todd S, McIlfatrick S, Coates V, Watson M, Abbott A, Corry D. Patient and service-related barriers and facitators to the acceptance and use of interventions to promote communication in health and social care: a realist review. BMC Health Serv Res 2020; 20:503. [PMID: 32498684 PMCID: PMC7271433 DOI: 10.1186/s12913-020-05366-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 05/26/2020] [Indexed: 11/23/2022] Open
Abstract
Background More people living into old age with dementia. The complexity of treatment and care, particularly those with multiple health problems, can be experienced as disjointed. As part of an evaluation of a ‘healthcare passport’ for people living with dementia we undertook a realist review of communication tools within health and social care for people living with dementia. Aims To explore how a ‘healthcare passport’ might work in the ‘real world’ of people living with dementia through a better understanding of the theoretical issues related to, and the contextual issues that facilitate, successful communication. Methods A realist review was considered the most appropriate methodology to inform the further development and evaluation of the healthcare passport. We undertook a purposive literature search related to communication tools to identify (a) underlying programme theories; (b) published reports and papers on their use in various healthcare settings; (c) evidence on barriers and facliitators of their use. Results Communication tools were noted as a way of improving communication and outcomes through: (1) improvement of service user autonomy; (2) strengthening the therapeutic alliance; and (3) building integrated care. However, while intuitively perceived to of benefit, evidence on their use is limited and key barriers to their acceptance and use include: (1) difficulties in clearly defining purpose, content, ownership and usage; (2) understanding the role of family caregivers; and (3) preparation among healthcare professionsals. Conclusion Patient-held communication tools may be helpful to some people living with dementia but will require considerable preparation and engagement with key stakeholders.
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Affiliation(s)
- Gerard Leavey
- Bamford Centre for Mental Health and Wellbeing, School of Psychology, Ulster University, Coleraine Campus, Cromore Road, BT52 1, Coleraine, SA, Northern Ireland.
| | - Emma Curran
- Bamford Centre for Mental Health and Wellbeing, School of Psychology, Ulster University, Coleraine Campus, Cromore Road, BT52 1, Coleraine, SA, Northern Ireland
| | - Deirdre Fullerton
- Bamford Centre for Mental Health and Wellbeing, School of Psychology, Ulster University, Coleraine Campus, Cromore Road, BT52 1, Coleraine, SA, Northern Ireland
| | - Steven Todd
- Geriatrics, Altnagelvin Area Hospital (WHSCT) Glenshane Road, Londonderry, BT47 6SB, Northern Ireland
| | - Sonja McIlfatrick
- School of Nursing, Ulster University, Jordanstown Campus, Newtownabbey, BT37 0QB, Northern Ireland
| | - Vivien Coates
- School of Nursing, Ulster University, Coleraine Campus, Cromore Road, BT52 1SA, Coleraine, Northern Ireland
| | - Max Watson
- Adult Services, Northern Ireland Hospice, Whiteabbey Hospital, Doagh Road, Newtownabbey, BT37 9RH, Northern Ireland
| | - Aine Abbott
- Geriatrics, Altnagelvin Area Hospital (WHSCT) Glenshane Road, Londonderry, BT47 6SB, Northern Ireland
| | - Dagmar Corry
- Bamford Centre for Mental Health and Wellbeing, School of Psychology, Ulster University, Coleraine Campus, Cromore Road, BT52 1, Coleraine, SA, Northern Ireland
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Zweifel P. Mental health: A Particular Challenge Confronting Policy Makers and Economists. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:147-153. [PMID: 31172460 DOI: 10.1007/s40258-019-00479-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The first objective of this paper is to expound the particular challenge posed by the occurrence of inconsistency in the expression of preferences by mental health patients to both economists and policy makers. Since this difficulty cannot be resolved, the second aim of the paper is to identify agents who may be counted upon to identify the true patient preferences. A decision rule is developed to help identify these agents who may be family members or judges in court, who have the ability and incentive to make these decisions. No single agent is found to dominate with respect to the five dimensions of preference distinguished, constituting a major challenge to policy makers.
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Affiliation(s)
- Peter Zweifel
- Emeritus University of Zurich, Zurich, Switzerland.
- , Wulfensiedlung 24, 9530, Bad Bleiberg, Austria.
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Chadda RK. Influence of the new mental health legislation in India. BJPsych Int 2020; 17:20-22. [PMID: 34287412 PMCID: PMC8277537 DOI: 10.1192/bji.2019.18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/20/2019] [Accepted: 07/11/2019] [Indexed: 11/25/2022] Open
Abstract
This paper discusses the influence of the Mental Healthcare Act 2017 on mental healthcare in India. The new Act was introduced to meet the recommendations of the United Nations Convention on the Rights of Persons with Disabilities. Reforms proposed in the new legislation, challenges in their implementation and their effects on mental healthcare in the country are further discussed.
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Juliá-Sanchis R, Aguilera-Serrano C, Megías-Lizancos F, Martínez-Riera JR. [Evolution and status of the community model of mental health care. SESPAS Report 2020]. GACETA SANITARIA 2020; 34 Suppl 1:81-86. [PMID: 32883518 PMCID: PMC7457906 DOI: 10.1016/j.gaceta.2020.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 06/10/2020] [Accepted: 06/25/2020] [Indexed: 11/07/2022]
Abstract
The legislative and ideological transition produced in recent years in Spain has favoured the implementation of the community model of mental health care. However, there is still strong resistance to the inclusion of community approaches in the care of people with mental health problems and to the implementation of integrated care and attention with a salutogenic approach. The purpose of the following report is to describe the evolution of the community model of mental health care in the Spanish National Health System and to assess its current status. Initially, a review of the published national mental health plans and strategies was carried out. Subsequently, the evaluation was carried out taking as reference the Consensus Document on the Fundamental Principles and Key Elements of Community Mental Health, which establishes the criteria for evaluating the quality of community care. In the absence of updated plans or strategies, international reports and recommendations were included. The results were grouped into: 1) social perspective, where the controversy about the capacity of the users to make decisions despite the recognition of their rights as autonomous moral agents is evident; 2) perspective of the centrality of the users of mental health care services, where the resistance to the implementation of integrated community care and attention is expressed; and 3) professional perspective in relation to the effectiveness of the interventions and the community network of care principles, which highlights the need to transform the institutions to carry out community interventions in mental health based on evidence and in an intersectoral, comprehensive, integrated and integrating manner.
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Affiliation(s)
- Rocío Juliá-Sanchis
- Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Alicante, San Vicente del Raspeig, Alicante, España
| | - Carlos Aguilera-Serrano
- Unidad de Salud Mental Comunitaria de Motril, Área de Gestión Sanitaria Sur de Granada, Consejería de Salud y Familias, Junta de Andalucía, Motril, Granada, España.
| | | | - José Ramón Martínez-Riera
- Departamento de Enfermería Comunitaria, Medicina Preventiva y Salud Pública e Historia de la Ciencia, Universidad de Alicante, San Vicente del Raspeig, Alicante, España
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Molyneaux E, Turner A, Candy B, Landau S, Johnson S, Lloyd-Evans B. Crisis-planning interventions for people with psychotic illness or bipolar disorder: systematic review and meta-analyses. BJPsych Open 2019; 5:e53. [PMID: 31530302 PMCID: PMC6582216 DOI: 10.1192/bjo.2019.28] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Mental health services lack a strong evidence base on the most effective interventions to reduce compulsory admissions. However, some research suggests a positive impact of crisis-planning interventions in which patients are involved in planning for their future care during a mental health crisis. AIMS This review aimed to synthesise randomised controlled trial (RCT) evidence on the effectiveness of crisis-planning interventions (for example advance statements and joint crisis plans) in reducing rates of compulsory hospital admissions for people with psychotic illness or bipolar disorder, compared with usual care (PROSPERO registration number: CRD42018084808). METHOD Six online databases were searched in October 2018. The primary outcome was compulsory psychiatric admissions and secondary outcomes included other psychiatric admissions, therapeutic alliance, perceived coercion and cost-effectiveness. Bias was assessed using the Cochrane collaboration tool. RESULTS The search identified 1428 studies and 5 RCTs were eligible. One study had high risk of bias because of incomplete primary outcome data. Random-effects meta-analysis showed a 25% reduction in compulsory admissions for those receiving crisis-planning interventions compared with usual care (risk ratio 0.75, 95% CI 0.61-0.93, P = 0.008; from five studies). There was no statistical evidence that the intervention reduced the risk of voluntary or combined voluntary and compulsory psychiatric admissions. Few studies assessed other secondary outcomes. CONCLUSIONS Our meta-analysis suggests that crisis-planning interventions substantially reduce the risk of compulsory admissions among individuals with psychotic illness or bipolar disorder. Despite common components, interventions varied in their content and intensity across the trials. The optimal models and implementation of these interventions require further investigation. DECLARATION OF INTEREST E.M., S.L., S.J. and B.L.-E. received funding from the National Institute for Health Research during the conduct of the study.
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Affiliation(s)
- Emma Molyneaux
- Research Associate, NIHR Mental Health Policy Research Unit, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Amelia Turner
- Trainee Clinical Psychologist, Camden and Islington NHS Foundation Trust & Royal Holloway, University of London, UK
| | - Bridget Candy
- Principal Research Associate, Division of Psychiatry, University College London, UK
| | - Sabine Landau
- Professor of Biostatistics, Biostatistics & Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Sonia Johnson
- Professor of Social and Community Psychiatry, NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, UK
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Quinlivan L, Nowland R, Steeg S, Cooper J, Meehan D, Godfrey J, Robertson D, Longson D, Potokar J, Davies R, Allen N, Huxtable R, Mackway-Jones K, Hawton K, Gunnell D, Kapur N. Advance decisions to refuse treatment and suicidal behaviour in emergency care: 'it's very much a step into the unknown'. BJPsych Open 2019; 5:e50. [PMID: 31530303 PMCID: PMC6582215 DOI: 10.1192/bjo.2019.42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Complex challenges may arise when patients present to emergency services with an advance decision to refuse life-saving treatment following suicidal behaviour. AIMS To investigate the use of advance decisions to refuse treatment in the context of suicidal behaviour from the perspective of clinicians and people with lived experience of self-harm and/or psychiatric services. METHOD Forty-one participants aged 18 or over from hospital services (emergency departments, liaison psychiatry and ambulance services) and groups of individuals with experience of psychiatric services and/or self-harm were recruited to six focus groups in a multisite study in England. Data were collected in 2016 using a structured topic guide and included a fictional vignette. They were analysed using thematic framework analysis. RESULTS Advance decisions to refuse treatment for suicidal behaviour were contentious across groups. Three main themes emerged from the data: (a) they may enhance patient autonomy and aid clarity in acute emergencies, but also create legal and ethical uncertainty over treatment following self-harm; (b) they are anxiety provoking for clinicians; and (c) in practice, there are challenges in validation (for example, validating the patient's mental capacity at the time of writing), time constraints and significant legal/ethical complexities. CONCLUSIONS The potential for patients to refuse life-saving treatment following suicidal behaviour in a legal document was challenging and anxiety provoking for participants. Clinicians should act with caution given the potential for recovery and fluctuations in suicidal ideation. Currently, advance decisions to refuse treatment have questionable use in the context of suicidal behaviour given the challenges in validation. Discussion and further patient research are needed in this area. DECLARATION OF INTEREST D.G., K.H. and N.K. are members of the Department of Health's (England) National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group (which developed the quality standards for self-harm services). He is currently chair of the updated NICE guideline for Depression. K.H. and D.G. are NIHR Senior Investigators. K.H. is also supported by the Oxford Health NHS Foundation Trust and N.K. by the Greater Manchester Mental Health NHS Foundation Trust.
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Affiliation(s)
- Leah Quinlivan
- Research Associate, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester; and NIHR Greater Manchester Patient Safety Translational Research Centre, UK
| | - Rebecca Nowland
- Research Associate, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Sarah Steeg
- Research Associate, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Jayne Cooper
- Senior Research Fellow, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Declan Meehan
- Senior Mental Health Practitioner and Operational Manager, Greater Manchester Mental Health NHS Foundation Trust, UK
| | - Joseph Godfrey
- Emergency Medicine Consultant, Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, UK
| | | | - Damien Longson
- Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, UK
| | - John Potokar
- Consultant Psychiatrist, Avon and Wiltshire Mental Health Partnership NHS Trust; University Hospitals Bristol NHS Foundation Trust; and Department of Population Health Sciences, University of Bristol, UK
| | - Rosie Davies
- Research Fellow, The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust; and Faculty of Health and Applied Sciences, University of the West of England, UK
| | - Neil Allen
- Barrister and Senior Lecturer, School of Law, University of Manchester, UK
| | - Richard Huxtable
- Professor of Medical Ethics and Law, Department of Population Health Sciences, University of Bristol, UK
| | - Kevin Mackway-Jones
- Emergency Medicine Consultant, Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, UK
| | - Keith Hawton
- Professor of Psychiatry, Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, UK
| | - David Gunnell
- Professor of Epidemiology, Department of Population Health Sciences, University of Bristol; and National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK
| | - Nav Kapur
- Professor of Psychiatry and Population Health and Honorary Consultant Psychiatrist, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester; NIHR Greater Manchester Patient Safety Translational Research Centre; and Greater Manchester Mental Health NHS Foundation Trust, UK
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Philip S, Chandran D, Stezin A, Viswanathaiah GC, Gowda GS, Moirangthem S, Kumar CN, Math SB. EAT-PAD: Educating about psychiatric advance directives in India. Int J Soc Psychiatry 2019; 65:207-216. [PMID: 30945582 DOI: 10.1177/0020764019834591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND With India enacting the Mental Health Care Act (MHCA; No. 10 of 2017a), Psychiatric Advance Directives (PADs) have been legalised and have become binding orders for psychiatrists treating patients. There is a paucity of research into acceptability of PADs in Indian mental health care, likely due to a lack of awareness. There are no educational measures about PADs provided for in this Act. Facilitators and facilitation methods have not been elaborated upon as well. AIM The aim of this study is (a) to develop/evaluate the effectiveness of a structured Education-cum-Assessment Tool (EAT) in providing information regarding PADs and (b) to evaluate modes of facilitation required by patients to complete PADs. METHODS A tool was developed as per provisions regarding PADs in the Mental Health Care Bill of 2013. This tool was administered to patients ( n = 100), purposively sampled from the adult psychiatry review out-patient department (OPD). Patients were evaluated on retention of information, completion of PADs, modes of facilitation and time taken to write one. RESULTS Mean years of education was 8.28 (±5.74) years and mean duration of illness was 8.30 (±7.04) years. In all, 65% had Below-Poverty Line (BPL) status. All participants completed valid PADs in an average of 15 minutes. About 93% required facilitation via assistance in writing and reminding. The mean EAT scores implied above 70% retention but did not relate to types of facilitation. CONCLUSIONS EAT scores can be used as an approximate measure of the patient's ability to understand and retain information which is a part of decisional capacity. Types of facilitation can help in understanding patient's ability to communicate their choices. Service providers may find EAT a time-effective tool for uniformly educating service users regarding PADs and indirectly assessing competence.
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Affiliation(s)
- Sharad Philip
- 1 Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Dhanya Chandran
- 2 Neuropsychology Unit, Department of Clinical Psychology, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Albert Stezin
- 3 Department of Clinical Neurosciences, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Geetha C Viswanathaiah
- 4 Center for Addiction Medicine, Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Guru S Gowda
- 1 Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Sydney Moirangthem
- 1 Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Channaveerachari Naveen Kumar
- 1 Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Suresh Bada Math
- 1 Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
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Owen GS, Gergel T, Stephenson LA, Hussain O, Rifkin L, Keene AR. Advance decision-making in mental health - Suggestions for legal reform in England and Wales. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 64:162-177. [PMID: 31122626 PMCID: PMC6544565 DOI: 10.1016/j.ijlp.2019.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This paper argues that existing English and Welsh mental health legislation (The Mental Health Act 1983 (MHA)) should be changed to make provision for advance decision-making (ADM) within statute and makes detailed recommendations as to what should constitute this statutory provision. The recommendations seek to enable a culture change in relation to written statements made with capacity such that they are developed within mental health services and involve joint working on mental health requests as well as potential refusals. In formulating our recommendations, we consider the historical background of ADM, similarities and differences between physical and mental health, a taxonomy of ADM, the evidence base for mental health ADM, the ethics of ADM, the necessity for statutory ADM and the possibility of capacity based 'fusion' law on ADM. It is argued that the introduction of mental health ADM into the MHA will provide clarity within what has become a confusing area and will enable and promote the development and realisation of ADM as a form of self-determination. The paper originated as a report commissioned by, and submitted to, the UK Government's 2018 Independent Review of the Mental Health Act 1983.
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Affiliation(s)
- G S Owen
- Reader and lead, Mental Health, Ethics and Law Research Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London SE5 8AF.
| | - T Gergel
- Wellcome Senior Research Fellow, Mental Health, Ethics and Law Research Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London SE5 8AF
| | - L A Stephenson
- Clinical Research Associate, Mental Health, Ethics and Law Research Group, ST6 General Adult Psychiatry and Medical Psychotherapy., Institute of Psychiatry, Psychology and Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London SE5 8AF
| | - O Hussain
- ST4 in Forensic Psychiatry, South London and Maudsley NHS Foundation Trust, Denmark Hill, London SE5 8AZ
| | - L Rifkin
- Consultant Psychiatrist, Lambeth Home Treatment Team, South London and Maudsley NHS Foundation Trust, Denmark Hill, London SE5 8AZ, Visiting senior lecturer, Institute of Psychiatry, Psychology and Neuroscience, King's College London 16 De Crespigny Park, London SE5 8AF
| | - A Ruck Keene
- Barrister, Wellcome Research Fellow, Visiting Lecturer at the Dickson Poon School of Law, Kings College London, Somerset House, East Wing WC2R 2LS, Visiting senior lecturer, Institute of Psychiatry, Psychology and Neuroscience, King's College London 16 De Crespigny Park, London SE5 8AF
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den Boer K, de Veer AJE, Schoonmade LJ, Verhaegh KJ, van Meijel B, Francke AL. A systematic review of palliative care tools and interventions for people with severe mental illness. BMC Psychiatry 2019; 19:106. [PMID: 30943927 PMCID: PMC6446277 DOI: 10.1186/s12888-019-2078-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 03/14/2019] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Increasing attention to palliative care for the general population has led to the development of various evidence-based or consensus-based tools and interventions. However, specific tools and interventions are needed for people with severe mental illness (SMI) who have a life-threatening illness. The aim of this systematic review is to summarize the scientific evidence on tools and interventions in palliative care for this group. METHODS Systematic searches were done in the PubMed, Cochrane Library, CINAHL, PsycINFO and Embase databases, supplemented by reference tracking, searches on the internet with free text terms, and consultations with experts to identify relevant literature. Empirical studies with qualitative, quantitative or mixed-methods designs concerning tools and interventions for use in palliative care for people with SMI were included. Methodological quality was assessed using a critical appraisal instrument for heterogeneous study designs. Stepwise study selection and the assessment of methodological quality were done independently by two review authors. RESULTS Four studies were included, reporting on a total of two tools and one multi-component intervention. One study concerned a tool to identify the palliative phase in patients with SMI. This tool appeared to be usable only in people with SMI with a cancer diagnosis. Furthermore, two related studies focused on a tool to involve people with SMI in discussions about medical decisions at the end of life. This tool was assessed as feasible and usable in the target group. One other study concerned the Dutch national Care Standard for palliative care, including a multi-component intervention. The Palliative Care Standard also appeared to be feasible and usable in a mental healthcare setting, but required further tailoring to suit this specific setting. None of the included studies investigated the effects of the tools and interventions on quality of life or quality of care. CONCLUSIONS Studies of palliative care tools and interventions for people with SMI are scarce. The existent tools and intervention need further development and should be tailored to the care needs and settings of these people. Further research is needed on the feasibility, usability and effects of tools and interventions for palliative care for people with SMI.
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Affiliation(s)
- Karin den Boer
- Nivel. Netherlands Institute for Health Services Research, P.O. Box 1568, Utrecht, 3500 BN, The Netherlands.
| | - Anke J. E. de Veer
- 0000 0001 0681 4687grid.416005.6Nivel. Netherlands Institute for Health Services Research, P.O. Box 1568, Utrecht, 3500 BN The Netherlands
| | - Linda J. Schoonmade
- 0000 0004 1754 9227grid.12380.38Medical Library, VU University Amsterdam, Amsterdam, the Netherlands
| | - Kim J. Verhaegh
- 0000 0001 0681 4687grid.416005.6Nivel. Netherlands Institute for Health Services Research, P.O. Box 1568, Utrecht, 3500 BN The Netherlands
| | - Berno van Meijel
- 0000 0004 0435 165Xgrid.16872.3aAmsterdam UMC, VU University Medical Center, Department of Psychiatry, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands ,grid.448984.dInholland University of Applied Sciences, Amsterdam, the Netherlands ,Parnassia Psychiatric Institute, The Hague, the Netherlands ,GGZ-VS, Academy for Masters in Advanced Nursing Practice, Utrecht, The Netherlands
| | - Anneke L. Francke
- 0000 0001 0681 4687grid.416005.6Nivel. Netherlands Institute for Health Services Research, P.O. Box 1568, Utrecht, 3500 BN The Netherlands ,0000 0004 0435 165Xgrid.16872.3aAmsterdam Public Health Research Institute (APH), VU University Medical Center, Department of Public and Occupational Health, Amsterdam, the Netherlands ,0000 0004 0435 165Xgrid.16872.3aExpertise Center for Palliative Care Amsterdam, VU University Medical Center, Amsterdam, the Netherlands
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Philip S, Rangarajan SK, Moirangthem S, Kumar CN, Gowda MR, Gowda GS, Math SB. Advance directives and nominated representatives: A critique. Indian J Psychiatry 2019; 61:S680-S685. [PMID: 31040457 PMCID: PMC6482704 DOI: 10.4103/psychiatry.indianjpsychiatry_95_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
With the ratification of the landmark United Nations Convention on Rights of Persons with Disabilities by India, it was imperative to revamp the mental health-care legislation, among other changes. Most notably, a presumption of mental capacity has been introduced, which means a paradigm shift in the client and provider relationship. The Mental Healthcare Act, 2017 empowers all persons to make advance directives (AD) and nominate representatives for shared decision-making. Psychiatric ADs (PADs) also seem to improve the information exchange between the care provider and the service user. PADs may also be used as a vehicle of consent to future treatments. While drafting the PAD, the drafter must also plan how such directed care would be financed. Insurance companies have not been mandated to comply with ADs. In the eventuality that the drafter's family refuse support for treatment specified in the PAD, the drafter would be left holding an unimplementable PAD. The AD saw its origins in the care of the terminally ill and decades later came to be utilized in mental health care. After nearly three decades of use in developed countries, evidence at best remains mixed or inconclusive. This review focuses on the AD from the Indian perspective.
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Affiliation(s)
- Sharad Philip
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Subhashini K Rangarajan
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Sydney Moirangthem
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Channaveerachari Naveen Kumar
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Mahesh R Gowda
- Department of Psychiatry, Spandana Health Care, Bengaluru, Karnataka, India
| | - Guru S Gowda
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Suresh Bada Math
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
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Math SB, Basavaraju V, Harihara SN, Gowda GS, Manjunatha N, Kumar CN, Gowda M. Mental Healthcare Act 2017 - Aspiration to action. Indian J Psychiatry 2019; 61:S660-S666. [PMID: 31040454 PMCID: PMC6482691 DOI: 10.4103/psychiatry.indianjpsychiatry_91_19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
There is no health without mental health. Recently conducted National Mental Health Survey quoted a prevalence of 13.7% lifetime and 10.6% current mental morbidity. To address this mammoth problem, an aspirational law was enacted titled "Mental Healthcare Act, 2017" (MHCA 2017). The act is progressive and rights based in nature. The whole dedicated Chapter 5 on "Rights of the person with mental illness" is the heart and soul of this legislation. However, the act mainly focuses on the rights of the persons with mental illness (PMI), only during treatment in hospital but is not equally emphatic about continuity of treatment in the community. The act fails to acknowledge and foster the role and contribution of family members in providing care to PMI. Although there are many positive aspects to the MHCA 2017, it may impact adversely on the mental health care in India. This article focuses on the shortcomings and challenges of the act and also makes attempts to offer alternatives considering the available resources and ground reality. Concepts such as "Advance directives" and "Nominated representatives" appear to be very attractive, idealistic, and aspirational, but not evidenced based in the Indian context considering the resources. The act fails to make an impact even after 22 months to attain the goal, and will require pervasive efforts to fulfil a purpose that directs its development. This law needs to be amended as per the local resources and requirements of the society.
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Affiliation(s)
- Suresh Bada Math
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Vinay Basavaraju
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | | | - Guru S. Gowda
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Narayana Manjunatha
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Channaveerachari Naveen Kumar
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Mahesh Gowda
- Department of Psychiatry, Spandana Health Care, Bengaluru, Karnataka, India
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Nowland R, Steeg S, Quinlivan LM, Cooper J, Huxtable R, Hawton K, Gunnell D, Allen N, Mackway-Jones K, Kapur N. Management of patients with an advance decision and suicidal behaviour: a systematic review. BMJ Open 2019; 9:e023978. [PMID: 30872542 PMCID: PMC6429970 DOI: 10.1136/bmjopen-2018-023978] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The use of advance care planning and advance decisions for psychiatric care is growing. However, there is limited guidance on clinical management when a patient presents with suicidal behaviour and an advance decision and no systematic reviews of the extant literature. OBJECTIVES To synthesise existing literature on the management of advance decisions and suicidal behaviour. DESIGN A systematic search of seven bibliographic databases was conducted to identify studies relating to advance decisions and suicidal behaviour. Studies on terminal illness or end-of-life care were excluded to focus on the use of advance decisions in the context of suicidal behaviour. A textual synthesis of data was conducted, and themes were identified by using an adapted thematic framework analysis approach. RESULTS Overall 634 articles were identified, of which 35 were retained for full text screening. Fifteen relevant articles were identified following screening. Those articles pertained to actual clinical cases or fictional scenarios. Clinical practice and rationale for management decisions varied. Five themes were identified: (1) tension between patient autonomy and protecting a vulnerable person, (2) appropriateness of advance decisions for suicidal behaviour, (3) uncertainty about the application of legislation, (4) the length of time needed to consider all the evidence versus rapid decision-making for treatment and (5) importance of seeking support and sharing decision-making. CONCLUSIONS Advance decisions present particular challenges for clinicians when associated with suicidal behaviour. Recommendations for practice and supervision for clinicians may help to reduce the variation in clinical practice.
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Affiliation(s)
- Rebecca Nowland
- Centre for Mental Health and Safety, University of Manchester, Manchester, UK
| | - Sarah Steeg
- Centre for Mental Health and Safety, University of Manchester, Manchester, UK
| | - Leah M Quinlivan
- Centre for Mental Health and Safety, University of Manchester, Manchester, UK
- NHIR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK
| | - Jayne Cooper
- Centre for Mental Health and Safety, University of Manchester, Manchester, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - Keith Hawton
- Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - David Gunnell
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Neil Allen
- School of Law, University of Manchester, Manchester, UK
| | | | - Navneet Kapur
- Centre for Mental Health and Safety, University of Manchester, Manchester, UK
- NHIR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Chorlton House, Manchester, UK
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Tekkalaki B, Patil VY, Patil S, Chate SS, Dhabale R, Patil NM. How do Our Patients Respond to the Concept of Psychiatric Advance Directives? An Exploratory Study From India. Indian J Psychol Med 2018; 40:305-309. [PMID: 30093739 PMCID: PMC6065124 DOI: 10.4103/ijpsym.ijpsym_10_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Psychiatric advance directives have been incorporated in the Mental Health Care Act 2017 despite strong concerns about their feasibility and utility in the Indian patient population. Data on its utility in India is very scarce. AIMS To determine the possible treatment options our clients make as a part of psychiatric advance directives. MATERIALS AND METHODS Fifty consecutive individuals with severe mental illness were interviewed using a self-designed semi-structured tool to find out the possible choices they make as part of advance directives and the factors affecting their choices. RESULTS About 10% of the participants failed to understand the concept of advance directives. Of those who understood, 89% were willing to make advance directives, 15% refused future hospitalizations, 47% refused future electroconvulsive therapies (ECTs), and 62% refused physical restraints in future. CONCLUSION The majority of the participants agreed to make advance directives. The majority of those who agreed to make advance directives refused to undergo ECTs and physical restraints in future episodes of illness. Approximately 10% of the patients could not understand the concept of advance directives.
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Affiliation(s)
- Bheemsain Tekkalaki
- Department of Psychiatry, K.L.E. Academy of Higher Education, J.N. Medical College, Belagavi, Karnataka, India
| | - Veerappa Y Patil
- Consultant Psychiatrist, District Mental Health Program, Bagalkot, Karnataka, India
| | - Sandeep Patil
- Department of Psychiatry, K.L.E. Academy of Higher Education, J.N. Medical College, Belagavi, Karnataka, India
| | - Sameeran S Chate
- Department of Psychiatry, K.L.E. Academy of Higher Education, J.N. Medical College, Belagavi, Karnataka, India
| | | | - Nanasaheb M Patil
- Department of Psychiatry, K.L.E. Academy of Higher Education, J.N. Medical College, Belagavi, Karnataka, India
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Lay B, Kawohl W, Rössler W. Outcomes of a psycho-education and monitoring programme to prevent compulsory admission to psychiatric inpatient care: a randomised controlled trial. Psychol Med 2018; 48:849-860. [PMID: 28805175 DOI: 10.1017/s0033291717002239] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND There is a need for interventions that effectively reduce compulsory admission to psychiatry. We conducted a randomised controlled trial to investigate whether an innovative intervention programme prevents compulsory re-admission in people with serious mental illness. METHODS The programme addresses primarily patients' self-management skills. It consists of individualised psychoeducation focusing on behaviours prior to and during illness-related crises, crisis cards and, after discharge from the psychiatric hospital, a 24-month preventive monitoring. A total of 238 inpatients with compulsory admission(s) in the past were randomised to the intervention group or to treatment as usual (TAU). RESULTS Fewer participants who completed the 24-month programme were compulsorily readmitted to psychiatry (28%), compared with those receiving TAU (43%). Likewise, the number of compulsory readmissions per patient was significantly lower (0.6 v. 1.0) and involuntary episodes were shorter (15 v. 31 days), compared with TAU. A negative binomial regression model showed a significant intervention effect (RR 0.6; 95% confidence interval 0.3-0.9); further factors linked to the risk of compulsory readmission were the number of compulsory admissions in the patient's history (RR 2.8), the diagnosis of a personality disorder (RR 2.8), or a psychotic disorder (RR 1.9). Dropouts (37% intervention group; 22% TAU) were characterised by a high number of compulsory admissions prior to the trial, younger age and foreign nationality. CONCLUSIONS This study suggests that this intervention is a feasible and valuable option to prevent compulsory re-hospitalisation in a high-risk group of people with severe mental health problems, social disabilities, and a history of hospitalisations.
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Affiliation(s)
- B Lay
- Department of Psychiatry,Psychotherapy and Psychosomatics,University Hospital of Psychiatry Zurich,Switzerland
| | - W Kawohl
- Department of Psychiatry,Psychotherapy and Psychosomatics,University Hospital of Psychiatry Zurich,Switzerland
| | - W Rössler
- Department of Psychiatry,Psychotherapy and Psychosomatics,University Hospital of Psychiatry Zurich,Switzerland
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Ouliaris C, Kealy-Bateman W. Psychiatric advance directives in Australian mental-health legislation. Australas Psychiatry 2017; 25:574-577. [PMID: 28875720 DOI: 10.1177/1039856217726719] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Following the recent widespread reform of mental-health legislation in Australia, psychiatric advance directives (PADs) have now been incorporated in four jurisdictions. We contextualise the potential role for PADs within the Australian legal framework and note their varying introduction across jurisdictions, with a focus on progressive legislation in the Australian Capital Territory (ACT). CONCLUSION The formal recognition of PADs effectively shifts the trajectory of mental-health law towards a stronger recognition of consumer autonomy, albeit to varying degrees across jurisdictions. The most inspiring of these changes may be seen in the ACT Act, where an innovative framing of PAD provisions creates a safe space for clinicians and patients to engage, build therapeutic alliances and develop appropriate frameworks for further change.
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Affiliation(s)
- Calina Ouliaris
- Medical Student, University of Sydney, Sydney, NSW, Australia
| | - Warren Kealy-Bateman
- Clinical Senior Lecturer, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, NSW, and; Senior Staff Specialist Psychiatrist, Department of Psychiatry, Professor Marie Bashir Centre, Royal Prince Alfred Hospital, Camperdown, NSW, and; Graduate Student, College of Global Public Health, New York University, New York, NY, USA
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Abstract
Shared decision making (SDM) in mental health care involves clinicians and patients working together to make decisions. The key elements of SDM have been identified, decision support tools have been developed, and SDM has been recommended in mental health at policy level. Yet implementation remains limited. Two justifications are typically advanced in support of SDM. The clinical justification is that SDM leads to improved outcome, yet the available empirical evidence base is inconclusive. The ethical justification is that SDM is a right, but clinicians need to balance the biomedical ethical principles of autonomy and justice with beneficence and non-maleficence. It is argued that SDM is "polyvalent", a sociological concept which describes an idea commanding superficial but not deep agreement between disparate stakeholders. Implementing SDM in routine mental health services is as much a cultural as a technical problem. Three challenges are identified: creating widespread access to high-quality decision support tools; integrating SDM with other recovery-supporting interventions; and responding to cultural changes as patients develop the normal expectations of citizenship. Two approaches which may inform responses in the mental health system to these cultural changes - social marketing and the hospitality industry - are identified.
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Affiliation(s)
- Mike Slade
- Institute of Mental Health, School of Health Sciences, University of NottinghamNottinghamUK
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24
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Shalev D, Brewster KK, Levenson JA. End-of-Life Care for Patients with Schizophrenia #332. J Palliat Med 2017; 20:787-788. [PMID: 28520502 DOI: 10.1089/jpm.2017.0164] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Kisely S, Wyder M, Dietrich J, Robinson G, Siskind D, Crompton D. Motivational aftercare planning to better care: Applying the principles of advanced directives and motivational interviewing to discharge planning for people with mental illness. Int J Ment Health Nurs 2017; 26:41-48. [PMID: 27681041 DOI: 10.1111/inm.12261] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2016] [Indexed: 11/30/2022]
Abstract
Improving the input of people with mental illness into their recovery plans can potentially lead to better outcomes. In the present study, we evaluated the introduction of motivational aftercare planning (MAP) into the discharge planning of psychiatric inpatients. MAP is a manualized intervention combining motivational interviewing with advance directives. We measured changes in the level of patient input into discharge planning following training staff in the use of MAP. This included the following: (i) documentation of early relapse signs along with successful past responses; (ii) evidence of aftercare planning; and (iii) the use of the patients' own words in the plan. We used a ward-level controlled before-and-after design comparing one intervention ward with two control wards. We used anonymized recovery plans, with a goal of 50 plans per ward before and after the intervention, to look for evidence of patient input into care planning with a standardized checklist. There were also qualitative interviews with individuals discharged from the unit. We reviewed 100 intervention ward plans and 197 control ones (total n = 297). There were no significant differences in recovery plans from intervention and control wards at baseline. Following MAP training, the intervention ward improved significantly (e.g. identification of triggers increased from 52 to 94%, χ2 = 23.3, d.f. =1, P < 0.001). This did not occur in the control wards. The qualitative data (n = 20 interviews) showed improvements in participants' experiences of discharge planning. MAP increased inpatient input into discharge planning and was valued by participants. The effect on subsequent health service use needs evaluation.
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Affiliation(s)
- Steve Kisely
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Metro South Health Service, Woolloongabba, Queensland, Australia.,Griffith Institute of Health, Griffith University, Gold Coast, Queensland, Australia.,Diamantina Health Partners, Wooloongabba, Queensland, Australia
| | - Marianne Wyder
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Metro South Health Service, Woolloongabba, Queensland, Australia
| | - Josie Dietrich
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Gail Robinson
- Metro South Health Service, Woolloongabba, Queensland, Australia.,Griffith Institute of Health, Griffith University, Gold Coast, Queensland, Australia
| | - Dan Siskind
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Metro South Health Service, Woolloongabba, Queensland, Australia.,Diamantina Health Partners, Wooloongabba, Queensland, Australia
| | - David Crompton
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Metro South Health Service, Woolloongabba, Queensland, Australia.,Griffith Institute of Health, Griffith University, Gold Coast, Queensland, Australia.,Diamantina Health Partners, Wooloongabba, Queensland, Australia
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Paton F, Wright K, Ayre N, Dare C, Johnson S, Lloyd-Evans B, Simpson A, Webber M, Meader N. Improving outcomes for people in mental health crisis: a rapid synthesis of the evidence for available models of care. Health Technol Assess 2016; 20:1-162. [PMID: 26771169 DOI: 10.3310/hta20030] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Crisis Concordat was established to improve outcomes for people experiencing a mental health crisis. The Crisis Concordat sets out four stages of the crisis care pathway: (1) access to support before crisis point; (2) urgent and emergency access to crisis care; (3) quality treatment and care in crisis; and (4) promoting recovery. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of the models of care for improving outcomes at each stage of the care pathway. DATA SOURCES Electronic databases were searched for guidelines, reviews and, where necessary, primary studies. The searches were performed on 25 and 26 June 2014 for NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database, and the Health Technology Assessment (HTA) and PROSPERO databases, and on 11 November 2014 for MEDLINE, PsycINFO and the Criminal Justice Abstracts databases. Relevant reports and reference lists of retrieved articles were scanned to identify additional studies. STUDY SELECTION When guidelines covered a topic comprehensively, further literature was not assessed; however, where there were gaps, systematic reviews and then primary studies were assessed in order of priority. STUDY APPRAISAL AND SYNTHESIS METHODS Systematic reviews were critically appraised using the Risk Of Bias In Systematic reviews assessment tool, trials were assessed using the Cochrane risk-of-bias tool, studies without a control group were assessed using the National Institute for Health and Care Excellence (NICE) prognostic studies tool and qualitative studies were assessed using the Critical Appraisal Skills Programme quality assessment tool. A narrative synthesis was conducted for each stage of the care pathway structured according to the type of care model assessed. The type and range of evidence identified precluded the use of meta-analysis. RESULTS AND LIMITATIONS One review of reviews, six systematic reviews, nine guidelines and 15 primary studies were included. There was very limited evidence for access to support before crisis point. There was evidence of benefits for liaison psychiatry teams in improving service-related outcomes in emergency departments, but this was often limited by potential confounding in most studies. There was limited evidence regarding models to improve urgent and emergency access to crisis care to guide police officers in their Mental Health Act responsibilities. There was positive evidence on clinical effectiveness and cost-effectiveness of crisis resolution teams but variability in implementation. Current work from the Crisis resolution team Optimisation and RElapse prevention study aims to improve fidelity in delivering these models. Crisis houses and acute day hospital care are also currently recommended by NICE. There was a large evidence base on promoting recovery with a range of interventions recommended by NICE likely to be important in helping people stay well. CONCLUSIONS AND IMPLICATIONS Most evidence was rated as low or very low quality, but this partly reflects the difficulty of conducting research into complex interventions for people in a mental health crisis and does not imply that all research was poorly conducted. However, there are currently important gaps in research for a number of stages of the crisis care pathway. Particular gaps in research on access to support before crisis point and urgent and emergency access to crisis care were found. In addition, more high-quality research is needed on the clinical effectiveness and cost-effectiveness of mental health crisis care, including effective components of inpatient care, post-discharge transitional care and Community Mental Health Teams/intensive case management teams. STUDY REGISTRATION This study is registered as PROSPERO CRD42014013279. FUNDING The National Institute for Health Research HTA programme.
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Affiliation(s)
- Fiona Paton
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Ceri Dare
- Department of Health Sciences, University of York, York, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, UK
| | | | - Alan Simpson
- School of Health Sciences, City University London, London, UK
| | - Martin Webber
- Department of Social Policy and Social Work, University of York, York, UK
| | - Nick Meader
- Centre for Reviews and Dissemination, University of York, York, UK
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Sellars M, Fullam R, O'Leary C, Mountjoy R, Mawren D, Weller P, Newton R, Brophy L, McEwan T, Silvester W. Australian Psychiatrists' Support for Psychiatric Advance Directives: Responses to a Hypothetical Vignette. PSYCHIATRY, PSYCHOLOGY, AND LAW : AN INTERDISCIPLINARY JOURNAL OF THE AUSTRALIAN AND NEW ZEALAND ASSOCIATION OF PSYCHIATRY, PSYCHOLOGY AND LAW 2016; 24:61-73. [PMID: 31983939 PMCID: PMC6818287 DOI: 10.1080/13218719.2016.1198224] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
This study examines whether Australian psychiatrists would support requests in a psychiatric advance directive (PAD) and the reasons underlying their decisions in response to a hypothetical vignette. An online survey was completed by 143 psychiatrists. Fewer than 3 out of 10 psychiatrists supported the patient to create a PAD which requested cessation of pharmacotherapy (27%) or remaining out of hospital and not being subject to an involuntary treatment order (24%) should their depression condition deteriorate. A thematic analysis showed that patient autonomy was the strongest theme among those who supported the patient to create a PAD, whereas the clinical profile of and risk to the patient and the professional or ethical imperative of the psychiatrist were strongest among those who were unsure about supporting the patient or who did not support the patient. These findings provide a challenge about how to fulfil obligations under the United Nations Convention on the Rights of Persons with Disabilities (2006).
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Affiliation(s)
- Marcus Sellars
- Respecting Patient Choices, Austin Health, Melbourne, Australia
- Sydney Medical School, University of Sydney, Australia
| | - Rachael Fullam
- Centre for Forensic Behavioural Science, Swinburne University of Technology and Forensicare, Melbourne, Australia
| | | | - Rachel Mountjoy
- Respecting Patient Choices, Austin Health, Melbourne, Australia
| | - Daveena Mawren
- Orygen, the National Centre of Excellence in Youth Mental Health, Melbourne, Australia
| | - Penelope Weller
- Graduate School of Business and Law, RMIT University, Melbourne, Australia
| | - Richard Newton
- Mental Health CSU, Austin Health, Melbourne, Australia
- Department of Psychiatry, University of Melbourne, Australia
| | - Lisa Brophy
- Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, Australia
- Mind Australia, Melbourne, Australia
| | - Troy McEwan
- Centre for Forensic Behavioural Science, Swinburne University of Technology and Forensicare, Melbourne, Australia
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Rao GP, Math SB, Raju MSVK, Saha G, Jagiwala M, Sagar R, Sathyanarayana Rao TS. Mental Health Care Bill, 2016: A boon or bane? Indian J Psychiatry 2016; 58:244-249. [PMID: 28065999 PMCID: PMC5100113 DOI: 10.4103/0019-5545.192015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Gundugurti Prasad Rao
- Division of Schizophrenia and Psychopharmacology, Asha Hospital, Hyderabad, Telangana, India
| | - Suresh Bada Math
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, (Institute of National Importance), Bengaluru, India
| | - M S V K Raju
- Hon. Adjunct Professor, IRSHA, Pune - 411043 and Hon. Consultant, Shanti Nursing Home, Aurangabad, Maharashtra, India
| | - Gautam Saha
- Clinic Brain, 19/C, Pioneer Park, P. O. Barasat North 24 Parganas, Kolkata, West Bengal, India
| | - Mukesh Jagiwala
- Brain Psycho Clinic and De-Addiction Centre, Chowk Bazar, Surat, Gujarat, India
| | - Rajesh Sagar
- Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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Abstract
The recovery model has permeated mental health systems by leading to the development of new psychiatric interventions and services and the reconfiguration of traditional ones. There is growing evidence that these interventions and services confer benefits in clinical and recovery-oriented outcomes. Despite the seeming adoption of recovery by policy makers, the transformation of mental health systems into recovery-oriented systems has been fraught with challenges.
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30
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Houttekier D, Cohen J, Cools F, Deliens L. Advance care planning for end-of-life care. Hippokratia 2016. [DOI: 10.1002/14651858.cd009618.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Dirk Houttekier
- Vrije Universiteit Brussel; End-of-Life Care Research Group Ghent University & Vrije Universiteit Brussel; Brussels Belgium
| | - Joachim Cohen
- Vrije Universiteit Brussel; End-of-Life Care Research Group Ghent University & Vrije Universiteit Brussel; Brussels Belgium
| | - Filip Cools
- CEBAM, Belgian Centre for Evidence-Based Medicine; Kapucijnenvoer 33, blok J, bus 7001 Leuven Belgium 3000
- UZ Brussel; Departement Neonatology; Laarbeeklaan Brussels Belgium
| | - Luc Deliens
- Vrije Universiteit Brussel; End-of-Life Care Research Group Ghent University & Vrije Universiteit Brussel; Brussels Belgium
- Vrije Universiteit Brussel; Department of Public and Occupational Health, EMGO Institute for Health and Care Research and Palliative Care Center of Expertise; Brussels Belgium
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One-year incidence and prevalence of seclusion: Dutch findings in an international perspective. Soc Psychiatry Psychiatr Epidemiol 2015; 50:1857-69. [PMID: 26188503 DOI: 10.1007/s00127-015-1094-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 06/28/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The Netherlands started a nationwide coercion reduction program in 2007. In 2011, accurate registration of coercive measures became obligatory by law. OBJECTIVE The aim of this study was to compare number and duration of coercive measures in the Netherlands with international data. METHODS 2011 data on coercive measures were collected, using a system developed in Germany. To understand determinants of coercion, multilevel logistic regression was performed. RESULTS 12.0 % (n = 5169) of patients (n = 42.960) in 2011 experienced at least one coercive measure. Exposure to coercion was comparable to other countries, and duration was higher. Medication use seemed to half average times in seclusion. In the Netherlands, coercion mainly constituted of seclusion and occurred in bipolar and psychotic disorders. In Germany, coercion was mostly mechanical restraint and occurred in organic disorders and schizophrenia. CONCLUSIONS Gathering comprehensive data allows comparisons between countries, increasing our understanding of the impact of different cultures, legislation and health care systems on coercion. In the Netherlands, seclusion is still the main type of coercion, despite significant improvements in the last few years. It is shorter when applied in combination with enforced medication.
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Zelle H, Kemp K, Bonnie RJ. Advance directives in mental health care: evidence, challenges and promise. World Psychiatry 2015; 14:278-80. [PMID: 26407773 PMCID: PMC4592640 DOI: 10.1002/wps.20268] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Heather Zelle
- University of Virginia School of LawCharlottesville, VA, 22903, USA
| | - Kathleen Kemp
- Department of Child and Adolescent Psychiatry, Rhode Island Hospital, and Warren Alpert Medical School, Brown UniversityProvidence, RI, 02903, USA
| | - Richard J Bonnie
- University of Virginia School of LawCharlottesville, VA, 22903, USA
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Gergel T, Owen GS. Fluctuating capacity and advance decision-making in Bipolar Affective Disorder - Self-binding directives and self-determination. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2015; 40:92-101. [PMID: 25939286 PMCID: PMC4503819 DOI: 10.1016/j.ijlp.2015.04.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
For people with Bipolar Affective Disorder, a self-binding (advance) directive (SBD), by which they commit themselves to treatment during future episodes of mania, even if unwilling, can seem the most rational way to deal with an imperfect predicament. Knowing that mania will almost certainly cause enormous damage to themselves, their preferred solution may well be to allow trusted others to enforce treatment and constraint, traumatic though this may be. No adequate provision exists for drafting a truly effective SBD and efforts to establish such provision are hampered by very valid, but also paralysing ethical, clinical and legal concerns. Effectively, the autonomy and rights of people with bipolar are being 'protected' through being denied an opportunity to protect themselves. From a standpoint firmly rooted in the clinical context and experience of mania, this article argues that an SBD, based on a patient-centred evaluation of capacity to make treatment decisions (DMC-T) and grounded within the clinician-patient relationship, could represent a legitimate and ethically coherent form of self-determination. After setting out background information on fluctuating capacity, mania and advance directives, this article proposes a framework for constructing such an SBD, and considers common objections, possible solutions and suggestions for future research.
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Affiliation(s)
- Tania Gergel
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience, C/O Department of Classics, King's College London, Strand, London WC2R 2LS, UK.
| | - Gareth S Owen
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, UK
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What do service users want? A content analysis of what users may write in psychiatric advance directives in India. Asian J Psychiatr 2015; 14:52-6. [PMID: 25486868 DOI: 10.1016/j.ajp.2014.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 10/07/2014] [Accepted: 10/19/2014] [Indexed: 11/23/2022]
Abstract
Although psychiatric advance directives give service users control over their care, very few studies exist on the content of PADs. This paper aims to contribute to this evidence base by presenting the content of psychiatric advance directives in India. Participants were 75 clients seeking outpatient care at a mental health services organisation in Tamil Nadu, India, who agreed to draft a PAD. Most clients were comfortable with appointing a representative (usually a family member) to make decisions on their behalf during a period of decisional incapacity or relapse, were willing to accept admission to the hospital/clinic and take medication if required, wanted to have a trusted person to discuss their mental health problems. No client used the opportunity to outright refuse treatment. This study highlights an important first step in improving the quality of mental health care by documenting user preferences for care in India. More in-depth research is needed to elicit rich descriptions of experiences of care and user-centred understanding of rights.
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Weich S, McBride O, Twigg L, Keown P, Cyhlarova E, Crepaz-Keay D, Parsons H, Scott J, Bhui K. Variation in compulsory psychiatric inpatient admission in England: a cross-sectional, multilevel analysis. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02490] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundRates of compulsory admission have increased in England in recent decades, and this trend is accelerating. Studying variation in rates between people and places can help identify modifiable causes.ObjectivesTo quantify and model variances in the rate of compulsory admission in England at different spatial levels and to assess the extent to which this was explained by characteristics of people and places.DesignCross-sectional analysis using multilevel statistical modelling.SettingEngland, including 98% of Census lower layer super output areas (LSOAs), 95% of primary care trusts (PCTs), 93% of general practices and all 69 NHS providers of specialist mental health services.Participants1,287,730 patients.Main outcome measureThe study outcome was compulsory admission, defined as time spent in an inpatient mental illness bed subject to the Mental Health Act (2007) in 2010/11. We excluded patients detained under sections applying to emergency assessment only (including those in places of safety), guardianship or supervision of community treatment. The control group comprised all other users of specialist mental health services during the same period.Data sourcesThe Mental Health Minimum Data Set (MHMDS). Data on explanatory variables, characterising each of the spatial levels in the data set, were obtained from a wide range of sources, and were linked using MHMDS identifiers.ResultsA total of 3.5% of patients had at least one compulsory admission in 2010/11. Of (unexplained) variance in the null model, 84.5% occurred between individuals. Statistically significant variance occurred between LSOAs [6.7%, 95% confidence interval (CI) 6.2% to 7.2%] and provider trusts (6.9%, 95% CI 4.3% to 9.5%). Variances at these higher levels remained statistically significant even after adjusting for a large number of explanatory variables, which together explained only 10.2% of variance in the study outcome. The number of provider trusts whose observed rate of compulsory admission differed from the model average to a statistically significant extent fell from 45 in the null model to 20 in the fully adjusted model. We found statistically significant associations between compulsory admission and age, gender, ethnicity, local area deprivation and ethnic density. There was a small but statistically significant association between (higher) bed occupancy and compulsory admission, but this was subsequently confounded by other covariates. Adjusting for PCT investment in mental health services did not improve model fit in the fully adjusted models.ConclusionsThis was the largest study of compulsory admissions in England. While 85% of the variance in this outcome occurred between individuals, statistically significant variance (around 7% each) occurred between places (LSOAs) and provider trusts. This higher-level variance in compulsory admission remained largely unchanged even after adjusting for a large number of explanatory variables. We were constrained by data available to us, and therefore our results must be interpreted with caution. We were also unable to consider many hypotheses suggested by the service users, carers and professionals who we consulted. There is an imperative to develop and evaluate interventions to reduce compulsory admission rates. This requires further research to extend our understanding of the reasons why these rates remain so high.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Scott Weich
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Orla McBride
- School of Psychology, University of Ulster, Londonderry, UK
| | - Liz Twigg
- Department of Geography, University of Portsmouth, Portsmouth, UK
| | - Patrick Keown
- Academic Psychiatry, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jan Scott
- Academic Psychiatry, Newcastle University, Newcastle upon Tyne, UK
| | - Kamaldeep Bhui
- Centre for Psychiatry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Khazaal Y, Manghi R, Delahaye M, Machado A, Penzenstadler L, Molodynski A. Psychiatric advance directives, a possible way to overcome coercion and promote empowerment. Front Public Health 2014; 2:37. [PMID: 24809041 PMCID: PMC4010761 DOI: 10.3389/fpubh.2014.00037] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 04/14/2014] [Indexed: 11/13/2022] Open
Abstract
Psychiatric advance directives (ADs) allow an individual to state their preferences for future treatment at times when they may be unable to make considered decisions. There are differences in their form and legal value and the process associated with their use and completion. Several studies have now been completed to assess the impact of ADs on service use and coercion. Their results give a mixed picture but directives nevertheless have the potential to support the empowerment process, minimize experienced coercion, and improve coping strategies. These may in turn reduce the frequency of in-patient service use. Further studies on the different processes of facilitation involved and on different populations are necessary to improve our knowledge and use of these potentially powerful interventions.
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Affiliation(s)
- Yasser Khazaal
- Geneva University Hospitals , Geneva , Switzerland ; Geneva University , Geneva , Switzerland
| | - Rita Manghi
- Geneva University Hospitals , Geneva , Switzerland
| | | | | | | | - Andrew Molodynski
- Oxford Health NHS Foundation Trust , Oxford , UK ; Department of Psychiatry, Oxford University , Oxford , UK
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Ruchlewska A, Wierdsma AI, Kamperman AM, van der Gaag M, Smulders R, Roosenschoon BJ, Mulder CL. Effect of crisis plans on admissions and emergency visits: a randomized controlled trial. PLoS One 2014; 9:e91882. [PMID: 24647274 PMCID: PMC3960137 DOI: 10.1371/journal.pone.0091882] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 02/12/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To establish whether patients with a crisis plan had fewer voluntary or involuntary admissions, or fewer outpatient emergency visits, than patients without such a plan. DESIGN Multicenter randomized controlled trial with two intervention conditions and one control condition. PARTICIPANTS Adult outpatients diagnosed with psychotic or bipolar disorder who had experienced at least one psychiatric crisis in the previous two years. INTERVENTION Two types of advance statement were used: (1) a crisis plan formulated by the patient with the help of a patient advocate (Patient Advocate Crisis Plan: PACP); and (2) a crisis plan developed together with the clinician (Clinician-facilitated Crisis Plan: CCP). OUTCOME The percentages of patients admitted voluntarily or involuntarily (on an emergency basis or by court order), and the percentage who made outpatient emergency visits over an 18-month follow-up period. RESULTS A total of 212 patients were included: 69 in the PACP condition, 70 in the CCP condition, and 73 in the control condition. No effects of the two interventions were found on the numbers of voluntary admissions, involuntary admissions and emergency visits. Regarding involuntary admissions, there was no significant effect on emergency admissions, which were 17% (12/69) in the PACP condition, 10% (7/70) in the CCP condition, and 19% (14/73) in the control condition. There was a significant effect on planned court-ordered admissions, with 16% (11/69) in the PACP condition, 10% (7/70) in the CCP condition, and 26% (19/73) in the control condition. Finally, the interventions had no effect on outpatient emergency visits, with 32% (22/69) in the PACP group, 31% (22/70) in the CCP group, and 34% (25/73) in the control group. CONCLUSIONS Crisis plans may be an effective intervention for reducing court-ordered admissions in patients with psychotic and bipolar disorders. TRIAL REGISTRATION Current Controlled Trails NTR1166.
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Affiliation(s)
- Asia Ruchlewska
- Epidemiological and Social Psychiatric Research institute, Erasmus MC, Rotterdam, The Netherlands
- * E-mail:
| | - Andre I. Wierdsma
- Epidemiological and Social Psychiatric Research institute, Erasmus MC, Rotterdam, The Netherlands
| | - Astrid M. Kamperman
- Epidemiological and Social Psychiatric Research institute, Erasmus MC, Rotterdam, The Netherlands
| | - Mark van der Gaag
- Parnassia Psychiatric Institute, The Hague, The Netherlands
- VU University and EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - Renee Smulders
- Landelijk Crisiskaart (O)GGZ Informatie en ondersteuningspunt, Utrecht, The Netherlands
| | - Bert-Jan Roosenschoon
- Epidemiological and Social Psychiatric Research institute, Erasmus MC, Rotterdam, The Netherlands
- BavoEuropoort, Centre for Mental Health Care, Rotterdam, The Netherlands
| | - Cornelis L. Mulder
- Epidemiological and Social Psychiatric Research institute, Erasmus MC, Rotterdam, The Netherlands
- BavoEuropoort, Centre for Mental Health Care, Rotterdam, The Netherlands
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Slade M, Amering M, Farkas M, Hamilton B, O'Hagan M, Panther G, Perkins R, Shepherd G, Tse S, Whitley R. Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems. World Psychiatry 2014; 13:12-20. [PMID: 24497237 PMCID: PMC3918008 DOI: 10.1002/wps.20084] [Citation(s) in RCA: 436] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
An understanding of recovery as a personal and subjective experience has emerged within mental health systems. This meaning of recovery now underpins mental health policy in many countries. Developing a focus on this type of recovery will involve transformation within mental health systems. Human systems do not easily transform. In this paper, we identify seven mis-uses ("abuses") of the concept of recovery: recovery is the latest model; recovery does not apply to "my" patients; services can make people recover through effective treatment; compulsory detention and treatment aid recovery; a recovery orientation means closing services; recovery is about making people independent and normal; and contributing to society happens only after the person is recovered. We then identify ten empirically-validated interventions which support recovery, by targeting key recovery processes of connectedness, hope, identity, meaning and empowerment (the CHIME framework). The ten interventions are peer support workers, advance directives, wellness recovery action planning, illness management and recovery, REFOCUS, strengths model, recovery colleges or recovery education programs, individual placement and support, supported housing, and mental health trialogues. Finally, three scientific challenges are identified: broadening cultural understandings of recovery, implementing organizational transformation, and promoting citizenship.
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Affiliation(s)
- Mike Slade
- King's College London, Health Service and Population Research Department, Institute of Psychiatry, Denmark Hill, London, SE5 8AF, UK
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Shields LS, Pathare S, van Zelst SDM, Dijkkamp S, Narasimhan L, Bunders JGF. Unpacking the psychiatric advance directive in low-resource settings: an exploratory qualitative study in Tamil Nadu, India. Int J Ment Health Syst 2013; 7:29. [PMID: 24369909 PMCID: PMC3877945 DOI: 10.1186/1752-4458-7-29] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 11/28/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Psychiatric advance directives, a tool to document preferences for care in advance of decisional incapacity, have been shown to benefit persons with mental illness in a number of countries through improving medication adherence, reducing symptoms from escalating in a crisis, accelerating recovery, and enhancing service user autonomy. While concepts such as autonomy are important in a number of high-income country settings, it remains unclear whether tools like psychiatric advance directives are suitable in a different context. The recent introduction of the psychiatric advance directive into draft legislation in India prompts the question as to how feasible psychiatric advance directives are in the Indian context. The aim of this study is to explore the feasibility and utility of PADs in India, with a focus on the need for individual control over decision making and barriers to implementation, by exploring views of its central stakeholders, service users and carers. METHODS Qualitative semi-structured interviews (n = 51) with clients (n = 39) and carers (n = 12) seeking mental health treatment at outpatient clinics in urban and rural settings provided by a non-profit organisation in Tamil Nadu, India. RESULTS Clients engaged in a number of forms of decision-making (passive, active, and collaborative) depending on the situation and decision at hand, and had high levels of self-efficacy. Most clients and carers were unfamiliar with PADs, and while some clients felt it is important to have a say in treatment wishes, carers expressed concerns about service user capacity to make decisions. After completing PADs, clients reported an increase in self-efficacy and an increased desire to make decisions. CONCLUSIONS The introduction of psychiatric advance directives in India appears to be associated with positive outcomes for some service users, however, there is a need to better understand how this tool can be adapted to better suit the care context in India and hold meaning and value for service users to complete.
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Affiliation(s)
- Laura S Shields
- Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
- Law and Policy Action Lab, Centre for Mental Health Law and Policy, Indian Law Society, Pune, India
| | - Soumitra Pathare
- Law and Policy Action Lab, Centre for Mental Health Law and Policy, Indian Law Society, Pune, India
| | | | - Sophie Dijkkamp
- Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
| | | | - Joske GF Bunders
- Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
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Farrelly S, Brown GE, Flach C, Barley E, Laugharne R, Henderson C. User-held personalised information for routine care of people with severe mental illness. Cochrane Database Syst Rev 2013; 2013:CD001711. [PMID: 24096715 PMCID: PMC8078447 DOI: 10.1002/14651858.cd001711.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND It is important to seek cost-effective methods of improving the care and outcome of those with serious mental illnesses. User-held records, where the person with the illness holds all or some personal information relating to the course and care of their illness, are now the norm in some clinical settings. Their value for those with severe mental illnesses is unknown. OBJECTIVES To evaluate the effects of personalised, accessible, user-held clinical information for people with a severe mental illness (defined as psychotic illnesses). SEARCH METHODS We updated previous searches by searching the Cochrane Schizophrenia Group Trials Register in August 2011. This register is compiled by systematic searches of major databases, and handsearches of journals and conference proceedings. SELECTION CRITERIA We included all relevant randomised controlled trials (RCTs) that:i. have recruited adult participants with a diagnosis of a severe mental illness (specifically psychotic illnesses and severe mood disorders such as bipolar and depression with psychotic features); andii. compared any personalised and accessible clinical information held by the user beyond standard care to standard information routinely held such as appointment cards and generic information on diagnosis, treatment or services available. DATA COLLECTION AND ANALYSIS Study selection and data extraction were undertaken independently by two authors and confirmed and checked by a third. We contacted authors of trials for additional and missing data. Where possible, we calculated risk ratios (RR) and 95% confidence intervals (CI). We used a random-effects model. We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE. MAIN RESULTS Four RCTs (n = 607) of user-held records versus treatment as usual met the inclusion criteria. When the effect of user-held records on psychiatric hospital admissions was compared with treatment as usual in four studies, the pooled treatment effect showed no significant impact of the intervention and was of very low magnitude (n = 597, 4 RCTs, RR 0.99 CI 0.71 to 1.38, moderate quality evidence). Similarly, there was no significant effect of the intervention in three studies which investigated compulsory psychiatric hospital admissions (n = 507, 4 RCTs, RR 0.64 CI 0.37 to 1.10, moderate quality evidence). Other outcomes including satisfaction and mental state were investigated but pooled estimates were not obtainable due to skewed or poorly reported data, or only being investigated by one study. Two outcomes (violence and death) were not investigated by the included studies. Two important randomised studies are ongoing. AUTHORS' CONCLUSIONS The evidence gap remains regarding user-held, personalised, accessible clinical information for people with psychotic illnesses for many of the outcomes of interest. However, based on moderate quality evidence, this review suggests that there is no effect of the intervention on hospital or outpatient appointment use for individuals with psychotic disorders. The number of studies is low, however, and further evidence is required to ascertain whether these results are mediated by the type of intervention, such as involvement of a clinical team or the type of information included.
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Affiliation(s)
- Simone Farrelly
- Institute of PsychiatryHealth Service and Population Research DepartmentKing's College LondonDe Crespigney ParkLondonUKSE5 8AF
| | - Gill E Brown
- Edge Hill UniversityFaculty of Health and Social CareSt Helen's RoadOrmskirkLancashireUKL39 4QP
| | - Clare Flach
- University of ManchesterBiostatistics, Health Sciences‐MethodologySchool of Community Based MedicineJean McFarlane Building, Oxford RoadManchesterUKM13 9PL
| | - Elizabeth Barley
- King's College LondonFlorence Nightingale School of Nursing and Midwifery2.25, James Clerk Maxwell Building57 Waterloo RoadLondonUKSE1 8WA
| | - Richard Laugharne
- Cornwall Partnership NHS Foundation Trust and Peninsula College of Medicine and DentistryMental Health Research GroupVeysey BuildingExeterUK
| | - Claire Henderson
- King's College LondonHealth Service and Population Research Department, Institute of PsychiatryDe Crespigny ParkDenmark HillLondonUKSE5 8AF
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Storm M, Edwards A. Models of user involvement in the mental health context: intentions and implementation challenges. Psychiatr Q 2013; 84:313-27. [PMID: 23076765 DOI: 10.1007/s11126-012-9247-x] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Patient-centered care, shared decision-making, patient participation and the recovery model are models of care which incorporate user involvement and patients' perspectives on their treatment and care. The aims of this paper are to examine these different care models and their association with user involvement in the mental health context and discuss some of the challenges associated with their implementation. The sources used are health policy documents and published literature and research on patient-centered care, shared decision-making, patient participation and recovery. The policy documents advocate that mental health services should be oriented towards patients' or users' needs, participation and involvement. These policies also emphasize recovery and integration of people with mental disorders in the community. However, these collaborative care models have generally been subject to limited empirical research about effectiveness. There are also challenges to implementation of the models in inpatient care. What evidence there is indicates tensions between patients' and providers' perspectives on treatment and care. There are issues related to risk and the person's capacity for user involvement, and concerns about what role patients themselves wish to play in decision-making. Lack of competence and awareness among providers are further issues. Further work on training, evaluation and implementation is needed to ensure that inpatient mental health services are adapting user oriented care models at all levels of services.
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Affiliation(s)
- Marianne Storm
- Department of Health Studies, University of Stavanger, 4036 Stavanger, Norway.
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Affiliation(s)
- Anirudh Kala
- Clinical Director, The Mind Plus, Ludhiana, Punjab, India
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Thornicroft G, Farrelly S, Szmukler G, Birchwood M, Waheed W, Flach C, Barrett B, Byford S, Henderson C, Sutherby K, Lester H, Rose D, Dunn G, Leese M, Marshall M. Clinical outcomes of Joint Crisis Plans to reduce compulsory treatment for people with psychosis: a randomised controlled trial. Lancet 2013; 381:1634-41. [PMID: 23537606 DOI: 10.1016/s0140-6736(13)60105-1] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The CRIMSON (CRisis plan IMpact: Subjective and Objective coercion and eNgagement) study is an individual level, randomised controlled trial that compared the effectiveness of Joint Crisis Plans (JCPs) with treatment as usual for people with severe mental illness. The JCP is a negotiated statement by a patient of treatment preferences for any future psychiatric emergency, when he or she might be unable to express clear views. We assessed whether the additional use of JCPs improved patient outcomes compared with treatment as usual. METHODS Patients were eligible if they had at least one psychiatric admission in the previous 2 years and were on the Enhanced Care Programme Approach register. The study was done with 64 generic and specialist community mental health teams in four English mental health care provider organisations (trusts). Hypotheses tested were that, compared with the control group, the intervention group would experience: fewer compulsory admissions (primary outcome); fewer psychiatric admissions; shorter psychiatric stays; lower perceived coercion; improved therapeutic relationships; and improved engagement. We stratified participants by centre. The research team but not participants nor clinical staff were masked to allocation. This study is registered with ClinicalTrials.gov, number ISRCTN11501328. FINDINGS 569 participants were randomly assigned (285 to the intervention group and 284 to the control group). No significant treatment effect was seen for the primary outcome (56 [20%] sectioned in the control group and 49 [18%] in the JCP group; odds ratio 0·90 [95% CI 0·58-1·39, p=0·63]) or any secondary outcomes, with the exception of an improved secondary outcome of therapeutic relationships (17·3 [7·6] vs 16·0 [7·1]; adjusted difference -1·28 [95% CI -2·56 to -0·01, p=0·049]). Qualitative data supported this finding. INTERPRETATION Our findings are inconsistent with two earlier JCP studies, and show that the JCP is not significantly more effective than treatment as usual. There is evidence to suggest the JCPs were not fully implemented in all study sites, and were combined with routine clinical review meetings which did not actively incorporate patients' preferences. The study therefore raises important questions about implementing new interventions in routine clinical practice. FUNDING Medical Research Council UK and the National Institute for Health Research.
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Affiliation(s)
- Graham Thornicroft
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, UK.
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Müller S, Walter H, Kunze H, Konrad N, Heinz A. [Compulsory treatment under legal uncertainty: part 2: consequences of legal uncertainty in clinical practice - suggestions for improvement]. DER NERVENARZT 2013; 83:1150-5. [PMID: 22911323 DOI: 10.1007/s00115-012-3628-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The current legal uncertainty on compulsory treatment of mentally ill patient incapable of giving consent favors the practice of defensive treatment, such as the increased use of isolation and fixation instead of medication. Such a stance runs the risk of acute or chronic health damage for patients. The dissent between legal practitioners and psychiatrists on compulsory treatment is obviously based on a different understanding of autonomy and its prerequisites. We advocate an individual centered, preferably open form of treatment by medicinal and milieu therapeutic approaches in association with intensified relationships with the aim to restore or improve the ability for self-determination. We also call upon the legislative authorities to establish legal certainty. It is decisive that the characteristics of mental diseases and the possibilities of modern treatment are taken into consideration in order to suitably respect patient autonomy without neglecting the necessary help.
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Affiliation(s)
- S Müller
- Klinik für Psychiatrie und Psychotherapie, Forschungsbereich Mind & Brain, Charité - Universitätsmedizin Berlin, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Deutschland.
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Nicaise P, Lorant V, Dubois V. Psychiatric Advance Directives as a complex and multistage intervention: a realist systematic review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2013; 21:1-14. [PMID: 22452515 DOI: 10.1111/j.1365-2524.2012.01062.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Psychiatric Advance Directives (PADs) are documents that allow users with severe and chronic mental illnesses to notify their treatment preferences for future crisis relapses and to appoint a surrogate decision-maker for a period of incompetence. Despite many supposed clinical and organisational benefits, their take-up rate has remained very low and their clinical evaluation has given contradictory results for organisational outcomes. Intermediary results are available, however, which rely on different theoretical views about how PADs are supposed to work. We carried out a realist systematic review that considered the PAD as a multistage intervention including the definition of the document, its completion and its access and honouring. We identified the theoretical frameworks underlying this kind of intervention and examined the available evidence that supported or contradicted the expectations at each stage of the intervention. Forty-seven references were retrieved, ranging from 1996 to 2009. Three frameworks underlie a PAD intervention: enhancement of the autonomy of the user, improvement of the therapeutic alliance and integration of care through partnership working. Although designed in the first place with a view to sustaining the user's autonomy, results indicate that the intervention is more efficient within a therapeutic alliance framework. Moreover, much is known about the completion process and the content of the document, but very little about its access and honouring. The mixture of expectations makes the purpose of PADs unclear, for example, crisis relapse prevention or management, advance planning of long-term or emergency care, or reduction in the resort to coercion. This may explain their low take-up rates. Hence, frameworks and purpose have to be clarified. The shape of the whole intervention at each stage relies on such clarification. More research is needed, particularly on the later stages of the intervention, as the evidence for how PADs should be implemented is still incomplete.
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Affiliation(s)
- Pablo Nicaise
- Institute of Health & Society, Université catholique de Louvain, Brussels, Belgium.
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Crisis Plans Facilitated by Patient Advocates are Better than those Drawn up by Clinicians: Results from an RCT. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2012; 41:220-7. [DOI: 10.1007/s10488-012-0454-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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[Use of joint crisis plans in psychiatric hospitals in Germany: results of a nationwide survey]. DER NERVENARZT 2012; 83:638-43. [PMID: 21633830 DOI: 10.1007/s00115-011-3311-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Joint crisis plans in psychiatry are consensus-oriented instruments for patients to state their will in case of a crisis. The aim of this survey is to determine the prevalence, practice and barriers for implementation of joint crisis plans in Germany. METHODS In spring 2009, 366 psychiatric hospitals in Germany were asked to complete a questionnaire. RESULTS The return rate was 46.4%; 68% of the participating hospitals offered joint crisis plans. The number of completed joint crisis plans was low (median 2.7/year per clinic). The demand did not increase according to a majority of the hospitals. The main reason for hospitals to abstain from joint crisis plans was low demand. Hospitals providing the option of joint crisis plans reported positive experiences. CONCLUSIONS A theoretical offer of joint crisis plans is widespread in German psychiatric hospitals. Despite positive experiences, patients do not ask for them frequently.
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Sarin A. On psychiatric wills and the Ulysses clause: The advance directive in psychiatry. Indian J Psychiatry 2012; 54:206-7. [PMID: 23226841 PMCID: PMC3512354 DOI: 10.4103/0019-5545.102332] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Alok Sarin
- Department of Psychiatry, Sitaram Bhartia Institute, New Delhi, India
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Abstract
This study examined patients' preferences for coercive methods and the extent to which patients' choices were determined by previous experience, demographic, clinical and intervention-setting variables. Before discharge from closed psychiatric units, 161 adult patients completed a questionnaire. The association between patients' preferences and the underlying variables was analyzed using logistic regression. We found that patients' preferences were mainly defined by earlier experiences: patients without coercive experiences or who had had experienced seclusion and forced medication, favoured forced medication. Those who had been secluded preferred seclusion in future emergencies, but only if they approved its duration. This suggests that seclusion, if it does not last too long, does not have to be abandoned from psychiatric practices. In an emergency, however, most patients prefer to be medicated. Our findings show that patients' preferences cannot guide the establishment of international uniform methods for managing violent behaviour. Therefore patients' individual choices should be considered.
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Houttekier D, Cohen J, Cools F, Deliens L. Advance care planning for end-of-life care. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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