Predictors for clinical deterioration of mental state in patients assessed by telephone-based mental health triage

Optimizing the response to mental health deterioration: Nurses experiences of using a Mental Health Observation Response Chart

Recognizing mental health deterioration remains a challenge for health systems globally, with evidence of suboptimal care for patients with increasing co-morbid psychiatric illness. Mechanisms exist to detect and respond to physical deterioration with the use of Observation Response Charts, monitoring of vital signs and medical emergency teams but registered nurses lack psychiatric nursing skills to care for this patient population. Currently, there are no validated processes in place to recognize and respond to mental health deterioration in general hospital wards. This qualitative descriptive study explores nurses' experiences of using a Mental Health Observation Response Chart that uses signs of distress to track and trigger tiered responses to mental health deterioration on general hospital wards. Thirty-five surgical and rehabilitation nurses participated in focus groups from January to March 2020. All qualitative data were thematically analysed using an inductive approach. Analysis resulted in four themes: clinical relevance, a useful chart, identifying distress, and working with doctors. The clinical relevance of the chart was influenced by the level of nursing experience; patient distress; existing escalation pathways and ward culture. The study findings will inform the establishment of a process for nurses to recognize mental health deterioration that could improve patient outcomes and promote staff safety. Further research is needed to validate specific signs of distress with patients in general hospital wards and to develop findings for the clinical relevance of this approach to detect mental health deterioration and improve patient outcomes.

Detecting signs of deterioration in young patients with serious mental illness: a systematic review

BACKGROUND

Serious mental illnesses (SMI) such as schizophrenia and bipolar disorder first develop between ages 14 and 25. Once diagnosed, young peoples' health can deteriorate, and it is therefore vital to detect this early to prevent severe outcomes including hospitalisations and deaths by suicide. The main study aim is to describe and discuss observational studies that examine signs of deterioration in young patients with SMI.

METHODS

A systematic review guided by the published protocol was conducted. Cumulative Index to Nursing and allied Health Literature (CINAHL), MEDLINE, Embase, PsycINFO, Health Management Information Consortium (HMIC) and Web of Science were searched against pre-defined criteria until 1 March 2021. Observational studies were extracted according to design, country, participant, indicator, outcome and main finding categories. Quality was assessed independently using the Newcastle Ottawa Scale (NOS).

RESULTS

Of the 15,788 publications identified, 5 studies were included and subjected to narrative synthesis. Two indicators of mental health deterioration were identified: cognitive functioning (decline, worsening and poor school/academic performance) and expressed emotion status. Indicators revealed mixed views on predicting deterioration. Worsening cognitive functioning and expressed emotion status significantly predicted medication non-adherence and relapse respectively. However, a decline in cognitive functioning (poor academic performance) was not found to significantly correlate to deaths by suicide. Study quality was mostly poor and associations between indicators and varied outcomes were weak. The heterogeneous nature of the data made comparisons difficult and did not allow for further statistical analysis.

CONCLUSION

To our knowledge, this is the first review of observational studies to identify indicators of deterioration in young patients with SMI. Worsening cognitive functioning and expressed emotion status could indicate non-adherence and relapse in young patients with SMI but larger sample sizes in good quality studies are needed. The dearth of observational studies means further research is required to ascertain other indicators of deterioration before serious outcomes occur.

FUNDING

This work was supported by the National Institute for Health Research (NIHR) Imperial Patient Safety Translational Research Centre via an NIHR programme grant. The authors are also grateful for support from the NIHR under the Applied Health Research programme for North West London and the NIHR Imperial Biomedical Research Centre. The views expressed in this publication are those of the authors and not necessarily those of the National Health Service (NHS), the NIHR or the Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

TRIAL REGISTRATION

This systematic review has been registered on PROSPERO (registration number: CRD42017075755 ).

Worsening of Preexisting Psychiatric Conditions During the COVID-19 Pandemic

Objectives: To ascertain factors associated with worsening of psychiatric conditions during the coronavirus disease 2019 (COVID-19) pandemic. Methods: This study anonymously examined 2,734 psychiatric patients worldwide for worsening of their preexisting psychiatric conditions during the COVID-19 pandemic. An independent clinical investigation of 318 psychiatric patients from United States was used for verification. Results: Valid responses mainly from 12 featured countries indicated self-reported worsening of psychiatric conditions in two-thirds of the patients assessed that was through their significantly higher scores on scales for general psychological disturbance, posttraumatic stress disorder, and depression. Female gender, feeling no control of the situation, reporting dissatisfaction with the response of the state during the COVID-19 pandemic, and reduced interaction with family and friends increased the worsening of preexisting psychiatric conditions, whereas optimism, ability to share concerns with family and friends, and using social media like usual were associated with less worsening. An independent clinical investigation from the United States confirmed worsening of psychiatric conditions during the COVID-19 pandemic based on identification of new symptoms that necessitated clinical interventions such as dose adjustment or starting new medications in more than half of the patients. Conclusions: More than half of the patients are experiencing worsening of their psychiatric conditions during the COVID-19 pandemic.

Longitudinal evaluation of a programme for safety culture change in a mental health service

Aim

To evaluate whether a two‐part culture improvement programme aimed at nurses in clinical and managerial positions in an inpatient mental health service was associated with culture change, and safety‐related behaviour and knowledge improvements.

Background

Due to serious failings in the delivery of physiological care to mentally disordered inpatients, it was deemed important that interventions be applied to improve service culture.

Methods

A pre‐test and post‐test study was conducted to evaluate change associated with a mandated intervention aimed at culture change. Nurses in clinical and managerial positions at all levels attended relevant sessions. All were invited to participate in evaluation measures.

Results

N = 241 nurses participated in the evaluation (n = 137 and n = 104, pre‐test and post‐test, respectively). There was a small but significant change in organisational culture indicating greater adhocracy and less clan culture in the second survey period and a small decline in reported safety behaviour. Measures of safety culture, knowledge and emergency‐related educational satisfaction were unchanged.

Conclusion

Only a small change in measured culture was associated with the programme.

Implications for Nursing Management

Attempts to evaluate culture change need to align anticipated outcomes with appropriate outcome measures. A mandated programme of culture change had little tangible effect on the outcomes measured.

A novel SCL-90-R six-item factor identifies subjects at risk of early adverse outcomes in public mental health settings

To increase access to treatment, Italy made assessment at community mental health centers (CMHCs) independent of medical referral, resulting in increased numbers of patients to be triaged efficiently. To support this process, we evaluated SCL-90-R item-ratings to identify factors that best predicted adverse early outcomes among persons seeking first-time CMHC care in a 24-month period in Rome. A psychiatric nurse screened subjects with a brief interview and self-administered SCL-90-R and psychiatrists provided CGI ratings and ICD-9 diagnosis. Of 832 screened subjects, 32 (3.85%) were hospitalized or attempted suicide within 90 days. Six SCL-90 items (15,41,55,57,78,88) scored much higher with than without such adverse outcomes; their sum is proposed as a predictive measure ("SCL-6″). In binary multivariable logistic modeling, this factor, but not age, sex, diagnosis, or other SCL-90-derived subscales strongly predicted adverse outcomes. A ROC curve for SCL-6 reflected a strong separation between subjects with versus without adverse outcomes (AUC = 0.76). This simple screening tool may support timely identification of patients at risk of early adverse clinical outcome who require especially close follow-up.

Indicators of deterioration in young adults with serious mental illness: a systematic review protocol

BACKGROUND

The first signs of serious mental illnesses (SMIs) including schizophrenia, bipolar disorder and major depression are likely to occur before the age of 25. The combination of high prevalence of severe mental health symptoms, inability to recognise mental health deterioration and increased likelihood of comorbidity in a complex transitional young group makes detecting deterioration paramount. Whilst studies have examined physical and mental health deterioration in adults, no systematic review has examined the indicators of mental and physical deterioration in young adults with SMI. The study aim is to systematically review the existing evidence from observational studies that examine the indicators of mental and physical deterioration in young adults with SMI and highlight gaps in knowledge to inform future research.

METHODS

Seven databases including CINHAL, MEDLINE, Embase, PsycINFO, Health Management Information Consortium, Cochrane databases and Web of Science will be searched against five main facets (age, serious mental illness, sign, deterioration and patient) and a subsequent comprehensive list of search terms. Searches will be run individually in each database to reflect each unique set of relevant subject headings and appropriate MeSH terms. Inclusion and exclusion criteria were developed and refined by the research team. Two reviewers will participate in each search stage including abstract/title and full text screening, data extraction and appraisal, to ensure reliability. A narrative synthesis of the data will also be conducted.

DISCUSSION

This systematic review will likely make a significant contribution to the field of mental health and help inform future research pertaining to interventions that help highlight deteriorating patients. This may vary depending on the patient group, mental illness or deterioration type.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017075755.