Antipsychotic effect of milieu in the acute treatment of schizophrenia

An Integrative Review on Psychiatric Intensive Care

Psychiatric intensive care units (PICUs) provide care and treatment when psychiatric symptoms and behaviors exceed general inpatient resources. This integrative review aimed to synthesize PICU research published over the past 5 years. A comprehensive search in MEDLINE, PsycINFO, PubMed and Scopus identified 47 recent articles on PICU care delivery, populations, environments, and models. Research continues describing patient demographics, and high rates of challenging behaviors, self-harm, and aggression continue being reported. Research on relatives was minimal. Patients describe restrictive practices incongruent with recovery philosophies, including controlling approaches and sensory deprivation. Some initiatives promote greater patient autonomy and responsibility in shaping recovery, yet full emancipatory integration remains limited within PICU environments. Multidisciplinary collaboration is needed to holistically advance patient-centered, equitable, and integrative PICU care. This review reveals the complex tensions between clinical risk management and emancipatory values in contemporary PICU settings. Ongoing reporting of controlling practices counters the recovery movement progressing in wider mental healthcare contexts. However, care innovations centered on patient empowerment and humane environments provide hope for continued evolution toward more liberation-focused PICU approaches that uphold both patient and provider perspectives.

Changes over time of the diagnostic and therapeutic characteristics of patients of a psychiatric intensive care unit in Austria

OBJECTIVE

The aim of this repeated cross-sectional study was to compare patients from a psychiatric intensive care unit (PICU) over ≫30 years regarding their diagnostic and therapeutic characteristics.

METHOD

Three samples including 100 consecutive inpatients each from the Viennese PICU were submitted to a chart review: sample no. 1 from the years 1985/86, no. 2 from 1995/96 and no. 3 from 2007/08.

RESULTS

Changes in referral modes were associated with a decrease of patients with substance induced disorders and an increase of patients with affective disorders over time. The rate of admissions after accidents and suicides was stable. The use of cranial MRI increased, while intravenous psychopharmacotherapy and parenteral nutrition decreased. Involuntary admission occurred in 43% and in 37% of patients physical restraints were necessary. We saw a shift from tricyclic antidepressants to SSRIs and SNRIs from sample 1 to 3. Likewise, we observed the emergence of atypical antipsychotics and a reduction of use of typical neuroleptics mainly from sample 2 to 3. The percentage of patients receiving benzodiazepines increased over time, while the mean dosage of benzodiazepines decreased. 7% of patients received electroconvulsive therapy.

CONCLUSIONS

The changes over time in our samples reflect the medical progress made during the last decades. Future studies should focus on evaluation of efficacy of psychiatric intensive care using standardized measurements.

Factors associated with use of psychiatric intensive care and seclusion in adult inpatient mental health services

AIMS

Within acute psychiatric inpatient services, patients exhibiting severely disturbed behaviour can be transferred to a psychiatric intensive care unit (PICU) and/or secluded in order to manage the risks posed to the patient and others. However, whether specific patient groups are more likely to be subjected to these coercive measures is unclear. Using robust methodological and statistical techniques, we aimed to determine the demographic, clinical and behavioural predictors of both PICU and seclusion.

METHODS

Data were extracted from an anonymised database comprising the electronic medical records of patients within a large South London mental health trust. Two cohorts were derived, (1) a PICU cohort comprising all patients transferred from general adult acute wards to a non-forensic PICU ward between April 2008 and April 2013 (N = 986) and a randomly selected group of patients admitted to general adult wards within this period who were not transferred to PICU (N = 994), and (2) a seclusion cohort comprising all seclusion episodes occurring in non-forensic PICU wards within the study period (N = 990) and a randomly selected group of patients treated in these wards who were not secluded (N = 1032). Demographic and clinical factors (age, sex, ethnicity, diagnosis, admission status and time since admission) and behavioural precursors (potentially relevant behaviours occurring in the 3 days preceding PICU transfer/seclusion or random sample date) were extracted from electronic medical records. Mixed effects, multivariable logistic regression analyses were performed with all variables included as predictors.

RESULTS

PICU cases were significantly more likely to be younger in age, have a diagnosis of bipolar disorder and to be held on a formal section compared with patients who were not transferred to PICU; female sex and longer time since admission were associated with lower odds of transfer. With regard to behavioural precursors, the strongest predictors of PICU transfer were incidents of physical aggression towards others or objects and absconding or attempts to abscond. Secluded patients were also more likely to be younger and legally detained relative to non-secluded patients; however, female sex increased the odds of seclusion. Likelihood of seclusion also decreased with time since admission. Seclusion was significantly associated with a range of behavioural precursors with the strongest associations observed for incidents involving restraint or shouting.

CONCLUSIONS

Whilst recent behaviour is an important determinant, patient age, sex, admission status and time since admission also contribute to risk of PICU transfer and seclusion. Alternative, less coercive strategies must meet the needs of patients with these characteristics.

Limiting Patients as a Nursing Practice in Psychiatric Intensive Care Units to Ensure Safety and Gain Control

PURPOSE

The aim of this study was to describe how the limitation of patients is being practiced in psychiatric intensive care units.

DESIGN AND METHODS

A focused ethnographic methodology was applied. To gather data, the author conducted fieldwork involving participant observation.

FINDINGS

The results of the study are presented in two categories, which describe the limited access patients had to items and in the ward environments.

PRACTICE IMPLICATIONS

It is advisable for practitioners to critically reflect upon local regulations and policies related to the practice of limiting patients during the worst phase of their mental illness.

Stability in intensive psychiatry: a concept analysis

PURPOSE

The aim of this concept analysis is to describe, explore, and explain stability in the context of mental health nursing in intensive psychiatry.

DESIGN AND METHODS

A modified version of Wilson's method of concept analysis was used.

FINDINGS

Stability is the ability to be resistant to changes. Stability can take different directions after a distortion: re-gaining, neo-gaining, and apo-gaining. Stability may also be achieved through active (adding or using power, making adjustments, parrying, and idling) and passive systems (environmental conditions and constituent materials).

PRACTICE IMPLICATIONS

This article contributes by providing knowledge and insight for nurses on the roles they play in intensive psychiatry as stabilizers.

Achieving equilibrium within a culture of stability? Cultural knowing in nursing care on psychiatric intensive care units

This article presents intensive psychiatric nurses' work and nursing care. The aim of the study was to describe expressions of cultural knowing in nursing care in psychiatric intensive care units (PICU). Spradley's ethnographic methodology was applied. Six themes emerged as frames for nursing care in psychiatric intensive care: providing surveillance, soothing, being present, trading information, maintaining security and reducing. These themes are used to strike a balance between turbulence and stability and to achieve equilibrium. As the nursing care intervenes when turbulence emerges, the PICU becomes a sanctuary that offers tranquility, peace and rest.

Psychometric evaluation of the Ward Atmosphere Scale in a Russian psychiatric hospital

AIM

The aim of the study was to evaluate the psychometric properties of the 10 subscales of the Ward Atmosphere Scale (WAS) in a Russian psychiatric hospital.

METHODS

A total of 212 patients and 96 staff members at five wards for acute psychiatric patients completed the WAS. We calculated Cronbach's alpha, the Corrected Item Total Subscale Correlation (CITC), and item-revised subscale intercorrelations.

RESULTS

By removing a total of 32 items, the psychometric properties for all subscales except "Autonomy", reached an acceptable level for the patient scores. Although several of the revised subscales were highly intercorrelated, the specificity of the items of the revised scales appeared acceptable.

CONCLUSIONS

The revised WAS version appeared applicable within this Russian psychiatric hospital context. Several of the items that were dropped appeared inapplicable because of differences between Russian and Western culture and psychiatry.

The core characteristics and nursing care activities in psychiatric intensive care units in Sweden

Internationally, research on psychiatric intensive care units (PICUs) commonly reports results from demographic studies such as criteria for admission, need for involuntary treatment, and the occurrence of violent behaviour. A few international studies describe the caring aspect of the PICUs based specifically on caregivers' experiences. The concept of PICU in Sweden is not clearly defined. The aim of this study is to describe the core characteristics of a PICU in Sweden and to describe the care activities provided for patients admitted to the PICUs. Critical incident technique was used as the research method. Eighteen caregivers at a PICU participated in the study by completing a semistructured questionnaire. In-depth interviews with three nurses and two assistant nurses also constitute the data. An analysis of the content identified four categories that characterize the core of PICU: the dramatic admission, protests and refusal of treatment, escalating behaviours, and temporarily coercive measure. Care activities for PICUs were also analysed and identified as controlling - establishing boundaries, protecting - warding off, supporting - giving intensive assistance, and structuring the environment. Finally, the discussion put focus on determining the intensive aspect of psychiatric care which has not been done in a Swedish perspective before. PICUs were interpreted as a level of care as it is composed by limited structures and closeness in care.

A suggested revision of the Ward Atmosphere Scale

OBJECTIVE

In a previous study, we have suggested a revision of the Anger/Aggression and the Spontaneity subscales. The main aim of this study was to re-evaluate the psychometric properties of the other eight subscales of the Ward Atmosphere Scale.

METHOD

A total of 550 patients and 822 staff members on 54 psychiatric wards for psychotic patients completed the WAS and the Good Milieu Index (GMI). We calculated Cronbach's alpha, the Corrected Item Total subscale Correlation, subscale intercorrelations and the correlation between subscales and GMI.

RESULTS

By removing a total of 16 items, the psychometric properties improved. The revised subscales had acceptable psychometrics and gave a clearer picture of the relationship between the perceived level of patient satisfaction and the WAS subscale scores.

CONCLUSION

The revision suggested in this study 'modernized' several of the subscales. We suggest that this revision is implemented in the future use of the WAS.

Community residential program policies, services, and treatment orientations influence patients' participation in treatment

The study sought to identify community residential program characteristics that predict patients' participation in treatment and to examine the association between these characteristics, participation, and outcomes at discharge from treatment. A sample of 2,790 patients with substance abuse disorders was assessed at entry into and discharge from 87 community residential facilities (CRFs). The CRFs were assessed using a survey that obtained information about program size and staffing, policies and services, and treatment orientation. High expectations for patients' functioning, clear policies, structured programming, a high proportion of staff in recovery from substance abuse problems, and more emphasis on psychosocial treatment were associated with patients' participation in program services and activities. Higher expectations for functioning and a strong treatment orientation enhanced participation more among better functioning patients; program support and structure enhanced participation more among impaired patients. Participation in treatment independently predicted outcomes at discharge even after both patient and program characteristics were controlled. These findings show that community residential program policies, services, and treatment orientations play a key role in influencing patients' engagement in treatment, which, in turn, improves patients' outcomes at discharge.

The Patient-Staff Community Meeting: Old Tools, New Rules

1. Psychiatric inpatient units with rapid turnover and acutely ill clients are vulnerable to the development of antitherapeutic trends, including destructiveness, disorganization, dysphoria, deviance, and dependency. 2. Inpatient therapists can apply the principles and techniques of milieu therapy, with certain modifications, to establish a therapeutic environment. 3. The patient-staff community plays a central role in this transformation, if it is structured to promote experiences of safety, order, support, involvement, and validation. 4. To accomplish these goals, the leaders of the meeting should establish clear rules and healthy norms, energize and guide participation, and focus discussion on topics relevant to unit events and to the processes of treatment and recovery.

Early response to haloperidol treatment in chronic schizophrenia

This study examined the time-course of treatment response to haloperidol in chronic schizophrenia. Furthermore the predictive value of baseline psychopathology and early therapeutic changes for the identification of the eventual treatment outcome was examined. After a two-week drug-free period forty-three chronic schizophrenic patients were treated with haloperidol for five weeks. Psychopathology was assessed on the last drug-free day and on the third and eighth day from the initiation of treatment, and then at weekly intervals. At the end of the study based on a priori criteria patients were classified as responders or non-responders to haloperidol. Seventeen patients met criteria for treatment response at the end of five weeks of treatment, while 26 did not. Already by the third day of treatment, in the responders there was a significant decrease in total BPRS and in the subscales scores for psychosis, tension and anergia, but not for hostility-suspiciousness and depression. These decreases represented approximately half of the eventual improvement obtained by the end of the study. Discriminant function analysis showed that severity of symptoms at baseline and improvement by day 3 correctly classified overall outcome in 72% of the cases.