Rural Assertive Community Treatment and Telepsychiatry

Assertive community treatment (ACT) is an evidence-based treatment for patients with severe and persistent mental illness. ACT has been shown to reduce inpatient hospitalization and is increasingly being used as a mainstay of evidence-based psychiatric practice for these clinical populations. The increasing implementation of evidence-based practices has led to the expansion of ACT in rural areas. Variability in the adaptation of ACT in rural areas has included accommodation by teams to multiple barriers. One way to increase psychiatric professional efficiency in rural areas is with telepsychiatry and possibly with rural ACT, but with unknown effects on fidelity and outcomes. Telepsychiatry has been considered a means of expanding the reach of and access to ACT. Concerns about the use of telepsychiatry by ACT teams include the psychiatrist's ability to develop a relationship with patients and staff and difficulties observing the patient's entire living environment via telemedicine. The Piedmont Community Services Board (CSB) Program for Assertive Community Treatment (PACT) serves patients in southwestern Virginia in collaboration with the Virginia Tech Carilion School of Medicine. The Piedmont CSB PACT uses telemedicine to expand the treating psychiatrist's reach and contact with PACT patients, increasing the efficiency of the psychiatrist's PACT time. Telemedicine is used for crisis intervention and augmentation of regular ongoing visits. The goals of this project were to measure patient, staff, and psychiatrist comfort and satisfaction with the use of telepsychiatry in ACT in addition to monitoring routine outcome measures.

Food for thought: enabling and constraining factors for effective rural eating disorder service delivery

OBJECTIVE

This study examined the effectiveness of an assessment and referral model of eating disorder service delivery in the Northern Rivers of New South Wales and its potential as a model for rural service delivery.

DESIGN

A qualitative evaluative research design used brief and extended semistructured interviews with clients, and surveys and semistructured extended interviews with service providers who either referred clients to the service or to whom clients were referred.

SETTING

A sole practitioner service based in a small non-government women's health service in rural New South Wales.

PARTICIPANTS

Clients of the service, all but one of whom was woman; service providers including general practitioners, private practice psychologists and social workers, dietitians, mental health service workers.

MAJOR OUTCOME MEASURES

Participant identified enabling and constraining factors which contributed to the effectiveness of the service model.

RESULTS

Whilst all service providers and most clients found the assessment process to be beneficial, they identified a number of constraining factors in the referral part of the service which undermined the effectiveness of the model of service delivery, especially for those with more complex or severe presentations.

CONCLUSIONS

For a rural ED service to be effective, a number of enabling factors must be present including the capacity to provide: treatment services as well as assessment; a multidisciplinary team approach to assessment and treatment; and expert consultation and training to generalist practitioners, counsellors, hospital wards and other service providers.

Consumer advocate and clinician perceptions of consumer participation in two rural mental health services

Consumer participation has been heralded as the integration of consumer perspectives into standard mental health care. Using a qualitative descriptive method, this study had two broad aims. First, the study aimed to explore the perceptions of consumer advocates and clinicians regarding consumer participation in two new regional mental health services. Second, the study aimed to explore how broad policy initiatives, related to consumer participation, are enacted at a service delivery level. In-depth interviews were conducted with 10 participants, recruited from the steering committees of both services. Although all participants uniformly commended consumer participation as a reality in mental health services, its breadth and depth of influence was not enacted. A systemic change to the way consumer participation is funded and incorporated into mental health services is required. The incorporation of consumers as stakeholders within mental health services requires commitment to the idea, the establishment of clear purposes and roles, and commensurate funding to enable consumers to be stakeholders with similar resources to other stakeholder groups.

Early intervention in psychosis: a rural perspective

Over the past decade, there has been great interest in both the development and delivery of early intervention in psychosis services in the United Kingdom, supported by national policy and a Policy Implementation Guide (PIG). Despite this, the PIG fails to distinguish the delivery of early intervention services to different population groups. The paper aims to augment available literature with the range of complex issues that practitioners may face when working in rural settings and link this to the development of early intervention services in rural communities. This paper will also outline some of the fundamental factors that challenge delivery of early intervention to individuals with a first episode of psychosis and their families in rural communities. Important key areas for consideration will be highlighted for both the planning and delivery of early intervention to rural communities.

Impact and management of dual relationships in metropolitan, regional and rural mental health practice

OBJECTIVE

To explore the extent and impact of professional boundary crossings in metropolitan, regional and rural mental health practice in Victoria and identify strategies mental health clinicians use to manage dual relationships.

METHOD

Nine geographically located focus groups consisting of mental health clinicians: four focus groups in rural settings; three in a regional city and two in a metropolitan mental health service. A total of 52 participants were interviewed.

RESULTS

Data revealed that professional boundaries were frequently breached in regional and rural settings and on occasions these breaches had a significantly negative impact. Factors influencing the impact were: longevity of the clinician's relationship with the community, expectations of the community, exposure to community 'gossip' and size of the community. Participants reported greater stress when the boundary crossing affected their partner and/or children. Clinicians used a range of proactive and reactive strategies, such as private telephone number, avoidance of social community activities, when faced with a potential boundary crossing. The feasibility of reactive strategies depended on the service configuration: availability of an alternative case manager, requirement for either patient or clinician to travel. The greater challenges faced by rural and regional clinicians were validated by metropolitan participants with rural experience and rural participants with metropolitan experience.

CONCLUSIONS

No single strategy is used or appropriate for managing dual relationships in rural settings. Employers and professional bodies should provide clearer guidance for clinicians both in the management of dual relationships and the distinction between boundary crossings and boundary violation. Clinicians are clearly seeking to represent and protect the patients' interests; consideration should be given by consumer groups to steps that can be taken by patients to reciprocate.

Developing new services for eating disorders: an evaluation study

OBJECTIVE

This paper aims to evaluate the structures and processes of eating disorders services in two regional cities in Australia.

METHOD

Stakeholder evaluation undertaken between 2002 and 2005 uses interviews, questionnaires and service delivery data to examine: structure and patient profile of the two services, barriers and success factors and local factors influencing development of the services.

RESULTS

The Bendigo service provided secondary consultation and specialist management with upskilling of primary care workers as a key goal. Patients were referred to the service via mental health triage. The Geelong service initially offered assessment only, with direct access for the general public. Treatment was offered from early 2004. The Bendigo service assessed 41 patients, 63% were diagnosed with anorexia nervosa or bulimia nervosa. Most patients had a moderate or severe eating disorder. The Geelong service assessed 186 patients, 55% were diagnosed with anorexia nervosa or bulimia nervosa and 80% of this subset had not previously been treated for an eating disorder. General practitioners identified barriers to development of the services as: problems with capacity building and unrealistic expectations. The success factors were providing a locally based service with credible clinicians and effective communication.

CONCLUSIONS

Activity analysis demonstrates that the goals for both services were met. There is a need to measure both short- and long-term patient outcomes in order to fully assess effectiveness and applicability to other settings. Local factors, such as availability of specialist providers, would need to be taken into account.

Dual relationships in mental health practice: issues for clinicians in rural settings

OBJECTIVE

This paper aims to provide an overview of the literature on non-sexual dual relationships, and to discuss these in the context of rural mental health practice in Australia.

METHOD

An internet-driven literature search was undertaken using OVID databases, which include MEDLINE, PsycINFO, CINAHL, and EMBASE: Psychiatry. Ethical codes of practice for the mental health professions of psychiatry, psychology, occupational therapy, social work and nursing were referred to. Searches were not limited by year of publication. Other unpublished material or information was included where relevant.

RESULTS

Dual relationships are common in rural mental health practice. However, research on non-sexual dual relationship boundary issues in rural mental health is limited. Ethical codes of practice of mental health professional bodies provide little guidance regarding non-sexual dual relationships. Decision-making models addressing the ethics of dual relationships are restricted to considerations of whether to enter a dual relationship rather than how to manage such a relationship.

CONCLUSIONS

Everyday' dual relationships are a predictable part of rural mental health practice. Further research is required to identify the benefits and/or problems in clinical practice resulting from non-sexual dual relationships. Responsibility for identifying and implementing ways of appropriately managing such relationships should be shared by the patient, the clinician, mental health services and professional organizations.