How to involve carers in the acute care: An online training for clinicians across four sites in England

Introduction

Involving carers in the care of people with severe mental illness is known to bring positive treatment and psychosocial outcomes. However, evidence-based procedures to guide clinicians on how to involve carers in the acute care are lacking.

Objectives

To provide an online training to clinicians working in the acute care regarding the organisation of a standardised meeting with the service user and their carer within the first week of hospitalisation, and explore their views after its implementation.

Methods

We trained six clinicians across four urban and rural sites in England, asked them to incorporate the meeting in their routine care provision and interviewed them to explore their experiences.

Results

Clinicians reported training advantages such as ease of use, comprehensiveness and transferable skills, and meeting advantages such as shared goals development and acknowledgement of carer involvement value. They also mentioned challenges related to organisational/time constraints, expectations management, and distance to the hospital for carers. Clinicians suggested to further focus on carer motivation to engage, to use skills throughout admission rather than in a one-off session, and to provide a structured meeting summary. Those experiences were shared across sites, indicating similar benefits and challenges, not depending on the specific setting characteristics.

Conclusions

Providing structured training to clinicians may increase carer involvement in routine care in acute settings. Given the workload in such settings training endeavours should be brief and include skills that clinicians can apply to facilitate shared goal development and expectations management. The use of online meetings may allow increased carer participation in the acute care.

Disclosure

No significant relationships.

Carer involvement in the transition from inpatient to community mental healthcare: Experiences of stakeholders

Introduction

The involvement of informal carers (family and friends) in the care of people with severe mental illness (SMI) contributes to positive clinical outcomes, such as relapse prevention and symptom reduction. To date, the care pathway between inpatient and community care is not clearly defined impeding the smooth transition for patients, whilst carers are still barely involved in shared decision-making processes.

Objectives

To investigate the views and experiences of patients with SMI, carers and clinicians regarding the transition from inpatient to community mental health services.

Methods

Four mixed focus groups were conducted with individuals with SMI (n=12), carers (n=10) and clinicians (n=9) across four different mental health catchment areas in England. Participants discussed their experiences and provided their views on facilitators, barriers and solutions for carer involvement during the transition between mental health services. Data were analysed using thematic analysis.

Results

All stakeholders highlighted that factors that impede carer involvement are related to: confidentiality issues, unmet (structural and organisational) needs, and carer expectations. Patients with SMI, carers and clinicians agreed that carer involvement can be improved by providing psychoeducation to carers and training to staff, having accessible and transparent clinical procedures, and allocating specialised staff to carers.

Conclusions

The study findings emphasise that carer involvement is still overlooked, particularly when adults with SMI transition between services. The results provide guidance for practice emphasising the need for systematic involvement of carers across inpatient care, and for future research proposing effective ways of maximising carer involvement in mental health care.

Disclosure

No significant relationships.

Coercive measures in italian inpatient units: results from eunomia study

Introduction

The use of coercive measures in clinical practice represents a common, but understudied problem in Europe. In 2002–2005, the European Commission funded the study “European Evaluation of coercion in psychiatry and harmonization of best clinical practice” (EUNOMIA), coordinated by the Department of Psychiatry of the University of Dresden and carried out in 12 European countries.

Objectives

This study, carried out on the Italian EUNOMIA sample, aims to:

1)

Methods

The Italian sample included 294 admitted patients. Data were collected on coercive measures (physical restraint, seclusion and forced medication)

Results

Almost 30% of the patients received coercive measures during their hospitalization; in particular, 22% received forced medication, 9% were restrained or fixed by mechanic devices, 7% were seclused. The most frequent reason for prescribing coercive measures was aggression against others. Patients who received coercive measures were more frequently male, with higher BPRS scores and a worse social functioning. At three months after discharge, they showed higher levels of positive symptoms, and reported more negative opinions on the need of hospital admission and on the appropriateness of psychiatric treatments.

Conclusions

In Italy coercive measures are in most of the cases applied to the patients affected by more severe psychopathology and disability.

Pharmaceutical industry interactions of psychiatric trainees from 20 European countries

Background:

Interactions between the pharmaceutical industry (PI) and psychiatrists have been under scrutiny recently, though there is little empirical evidence on the nature of the relationship and its intensity at psychiatry trainee level. We therefore studied the level of PI interactions and the underlying beliefs and attitudes in a large sample of European psychiatric trainees.

Methods:

One thousand four hundred and forty-four psychiatric trainees in 20 European countries were assessed cross-sectionally, with a 62-item questionnaire.

Results:

The total number of PI interactions in the preceding two months varied between countries, with least interactions in The Netherlands (M (Mean) = 0.92, SD = 1.44, range = 0–12) and most in Portugal (M = 19.06, SD = 17.44, range = 0–100). Trainees were more likely to believe that PI interactions have no impact on their own prescribing behaviour than that of other physicians (M = 3.30, SD = 1.26 vs. M = 2.39, SD = 1.06 on a 5-point Likert scale: 1 “completely disagree” to 5 “completely agree”). Assigning an educational role to the pharmaceutical industry was associated with more interactions and higher gift value (IRR (incidence rate ratio) = 1.21, 95%CI = 1.12–1.30 and OR = 1.18, 95%CI = 1.02–1.37).

Conclusions:

There are frequent interactions between European psychiatric trainees and the PI, with significant variation between countries. We identified several factors affecting this interaction, including attribution of an educational role to the PI. Creating alternative educational opportunities and specific training dedicated to PI interactions may therefore help to reduce the impact of the PI on psychiatric training.

Patient-controlled hospital admission for patients with severe mental disorders: a nationwide prospective multicentre study

OBJECTIVE

To assess whether implementing patient-controlled admission (PCA) can reduce coercion and improve other clinical outcomes for psychiatric in-patients.

METHODS

During 2013-2016, 422 patients in the PCA group were propensity score matched 1:5 with a control group (n = 2110) that received treatment as usual (TAU). Patients were followed up for at least one year using the intention to treat principle utilising nationwide registers. In a paired design, the outcomes of PCA patients during the year after signing a contract were compared with the year before.

RESULTS

No reduction in coercion (risk difference = 0.001; 95% CI: -0.038; 0.040) or self-harming behaviour (risk difference = 0.005; 95% CI: -0.008; 0.018) was observed in the PCA group compared with the TAU group. The PCA group had more in-patient bed days (mean difference = 28.4; 95% CI: 21.3; 35.5) and more medication use (P < 0.0001) than the TAU group. Before and after analyses showed reduction in coercion (P = 0.0001) and in-patient bed days (P = 0.0003).

CONCLUSION

Implementing PCA did not reduce coercion, service use or self-harm behaviour when compared with TAU. Beneficial effects of PCA were observed only in the before and after PCA comparisons. Further research should investigate whether PCA affects other outcomes to better establish its clinical value.

Mental health care for adult refugees in high-income countries

Approximately one-third of people who have obtained refugee status live in high-income countries. Over recent years, the number of refugees has been increasing, and there are questions on how many of them need mental health care and which type of interventions are beneficial. Meta-analyses showed highly variable rates of mental disorders in adult refugees. This variability is likely to reflect both real differences between groups and contexts, and methodological inconsistencies across studies. Overall prevalence rates after resettlement are similar to those in host populations. Only post-traumatic stress disorder (PTSD) is more prevalent in refugees. In long-term resettled refugees, rates of anxiety and depressive disorders are higher and linked to poor social integration. Research on mental health care for refugees in high-income countries has been extensive, but often of limited methodological quality and with very context-specific findings. The existing evidence suggests several general principles of good practice: promoting social integration, overcoming barriers to care, facilitating engagement with treatment and, when required, providing specific psychological treatments to deal with traumatic memories. With respect to the treatment of defined disorders, only for the treatment of PTSD there has been substantial refugee-specific research. For other diagnostic categories, the same treatment guidelines apply as to other groups. More systematic research is required to explore how precisely the general principles can be specified and implemented for different groups of refugees and in different societal contexts in host countries, and which specific interventions are beneficial and cost-effective. Such interventions may utilise new communication technologies. Of particular importance are long-term studies to identify when mental health interventions are appropriate and to assess outcomes over several years. Such research would benefit from sufficient funding, wide international collaboration and continuous learning over time and across different refugee groups.

In-patient treatment in functional and sectorised care: patient satisfaction and length of stay

BACKGROUND

Debate exists as to whether functional care, in which different psychiatrists are responsible for in- and out-patient care, leads to better in-patient treatment as compared with sectorised care, in which the same psychiatrist is responsible for care across settings. Aims To compare patient satisfaction with in-patient treatment and length of stay in functional and sectorised care.

METHOD

Patients with an ICD-10 diagnosis of psychotic, affective or anxiety/somatoform disorders consecutively admitted to an adult acute psychiatric ward in 23 hospitals across 11 National Health Service trusts in England were recruited. Patient satisfaction with in-patient care and length of stay (LoS) were compared (trial registration ISRCTN40256812).

RESULTS

In total, 2709 patients were included, of which 1612 received functional and 1097 sectorised care. Patient satisfaction was significantly higher in sectorised care (β = 0.54, 95% CI 0.35-0.73, P<0.001). This difference remained significant when adjusting for locality and patient characteristics. LoS was 6.9 days shorter for patients in sectorised care (β = -6.89, 95% CI -11.76 to -2.02, P<0.001), but this difference did not remain significant when adjusting for clustering by hospital (β = -4.89, 95% CI -13.34 to 3.56, P = 0.26).

CONCLUSIONS

This is the first robust evidence that patient satisfaction with in-patient treatment is higher in sectorised care, whereas findings for LoS are less conclusive. If patient satisfaction is seen as a key criterion, sectorised care seems preferable. Declarations of interest None.

Noticeable Role of TFSI- Anion in the Carbon Cathode Degradation of Li-O2 Cells

In this work we address the phenomena at the basis of the performance loss in a Li-O₂ cell operating in the presence of a lithium bis(trifluoromethanesulfonyl)imide (LiTFSI)/tetraethylene glycol dimethyl ether (TEGDME) salt/solvent couple and a porous carbonaceous cathode. The cell was discharged/charged applying both voltage and capacity limits, and the effects of repeated galvanostatic cycling were addressed. The ex situ characterization of carbonaceous cathodes corresponding to different cutoff voltages was based on vibrational spectroscopies, transmission electron microscopy, and X-ray photoelectron spectroscopy. The reversible precipitation/decomposition of undesired products deriving from degradation of both carbon cathode and ethereal solvent is pointed out within a single voltage limited (2.0-4.6 V) discharge/charge cycle, whereas their irreversible accumulation on the surface of the electrode results after 100 capacity limited cycles. At the same time, the presence of polar degradation products (carbonates and carboxylates) at the cathode surface is accompanied by the buildup of a surface electric potential gradient, as revealed by differential binding energy shifts resulting from C 1s photoelectron spectra. This effect, seldom reported for Li-ion batteries, is for the first time put in evidence for a Li-O₂ cell. Furthermore, the use of TFSI^- anion is shown to lead to carbonate-based degradation products not involving the formation of Li₂CO₃. The peculiar occurrence of such degradation phenomena are attributed to the intrinsic low-donor number characteristic of the TFSI^- anion.

Admission to In-patient Psychiatric Care in the Veneto Region (Italy), Specialisation vs. Personal Continuity of Care Approach. Preliminary Findings from the COFI Study-Italian Sites

Introduction

In Italy, considerable variations exist in the organisation of out- and in-patient mental health care. One main issue is whether to prioritise specialisation (distinct clinicians for inpatient and outpatient care) or personal continuity of care (same primary clinician for a given patient within the two settings).

Aims

To study the use of psychiatric in-patient units in the Veneto region (Italy) and to evaluate differences between personal continuity of care and specialization systems.

Methods

Study conducted in the context of the COFI, multisite naturalistic EU-funded research aiming to compare the two care approaches in 5 European countries. In Italy, baseline data collection was carried out in 14 in-patient units. Data on hospitalisation, diagnosis, severity of the illness (Clinical Global Impression Scale- CGI) and patients’ appraisal of inpatient care (Client Assessment of Treatment Scale- CAT) were collected.

Results

Overall, 1118 patients were assessed. Most frequent diagnostic categories were mood (41.6%) and psychotic (38.3%) disorders, while anxiety disorders were less represented (11.9%). The majority of patients were at least at their second admission (69.4%) and had been voluntary admitted (91.5%). Length of stay and CGI scores were significantly higher for patients with mood and psychotic disorders. No difference in CGI score between the two systems was found. Patients in the continuity of care systems reported higher level of satisfaction with initial treatment and longer hospital stay (P < .001).

Conclusions

These preliminary findings suggest higher service satisfaction for personal continuity system, possibly reflecting a more individualised and comprehensive focus on the patient's needs, rather than on symptoms reduction only.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Continuity across inpatient and outpatient mental health care or specialisation of teams? A systematic review

BACKGROUND

A central question for the organisation of mental health care is whether the same clinicians should be responsible for a patient's care across inpatient and outpatient settings (continuity of care) or if there should be separate teams (specialisation). Current reforms in Europe are inconsistent on which to favour, and are based on little research evidence. This review is the first systematic appraisal of the existing evidence comparing continuity of care and specialisation across inpatient and outpatient mental health care.

METHOD

A systematic search for studies of any design comparing mental health care systems based on continuity or specialisation of care was performed. Differences in clinical, social and cost-effective outcomes, and the views and experiences of patients and staff were assessed using narrative synthesis.

RESULTS

Seventeen studies met the inclusion criteria. All studies had methodological shortcomings, but findings point towards reduced length and number of hospitalisations, and faster or more flexible transitions between services in continuity systems. Survey and qualitative findings suggest advantages of both systems, whilst patients and staff appear to prefer a continuity system.

CONCLUSION

The evidence base suggests better outcomes and stakeholder preferences for continuity of care systems, but the quality of existing studies is insufficient to draw definitive conclusions. Higher quality comparative studies across various settings and population groups are urgently needed.

Patient characteristics and symptoms associated with perceived coercion during hospital treatment

OBJECTIVE

Large numbers of psychiatric patients either are involuntarily admitted to hospital treatment or feel coerced despite a legally voluntary admission. For ethical and clinical reasons, their perceived coercion should be reduced as far as possible. There is however limited evidence on patient characteristics associated with perceived coercion during hospital treatment. This study aimed to identify i) sociodemographic and clinical characteristics associated with perceived coercion at admission and ii) changes in symptoms and global functioning associated with changes in perceived coercion over time.

METHOD

Three thousand and ninety three in-patients who were involuntarily admitted or felt coerced to hospital treatment despite a legally voluntary admission were recruited in the European evaluation of coercion in psychiatry and harmonization of best clinical practice - EUNOMIA project in 11 European countries. Perceived coercion, global functioning and symptoms were assessed after admission and at a 3-month follow-up.

RESULTS

Involuntary admission, female gender, poorer global functioning and more positive symptoms were associated with higher levels of perceived coercion at admission. Perceived coercion significantly decreased over time, and the improvements in global functioning and positive symptoms were associated with reduction in perceived coercion.

CONCLUSION

Female patients perceive more coercion in psychiatric hospital treatment. Effective treatment for positive symptoms and improving patients' global functioning may lead to a reduction in perceived coercion.

ECP09-03 - Information technologies in psychiatry

Even if technology and information are omnipresent, they rarely meet harmoniously. Either the lack of sufficient means prevents good information to reach its target or the technology is too complex to integrate flawlessly in the daily workflow.

The use and misuse of information technologies (internet, email, e-learning, social networks) has recently significantly increased among psychiatrists and patients and the changes in behavior of communication and seeking informations are real challenges.

Using the European Federation of Psychiatric Trainees network, the self-questionnaires concerning the usage of information technologies and the local patients-therapists communication were distributed among psychiatric trainees of 31 European countries.

A review of the results of this study, as well as recommendations about netiquette and useful websites for psychiatrists and scientists will be presented in detail.

P01-227-Implementing family psychoeducational intervention in bipolar i disorder: a randomized controlled trial

Introduction

Bipolar disorder is associated with high personal and social burden, impaired social functioning and high levels of disability. The psychoeducational family intervention, found to be effective in the treatment of schizophrenia, may be particularly useful for patients with bipolar disorder and their relatives.

Aims & methods

This study, funded by the Italian Ministry of Health, coordinated by the Department of Psychiatry of the University of Naples SUN and carried out in 11 randomly selected mental health centres, included the following phases

1) development of informative materials;

2) training of 2 mental health workers per center;

3) random selection of 16 families of patients with bipolar disorder for each center: 8 being randomly allocated to the experimental group and 8 to the control group.

Results

62 families have been recruited. Mental health workers reported several advantages in conducting the intervention, in particular in the relationship with patients and families. Significant improvements have been reported in professional skills and relationships with colleagues. The advantages tend to increase over time. The main reported difficulties are lack of time to run the intervention, identification of appropriate families, excessive workload and the need to integrate this intervention with other work commitments.

Conclusions

It is possible to provide psychoeducational family intervention for patients with bipolar I disorder and their families, after a relatively short period of training. In order to facilitate the dissemination of this intervention in routine conditions, a better planning of the activities of the mental health centers may be useful.

ECP09-02 - Psychiatry training in europe: Implementation and evaluation of training programs

Training schemes in psychiatry are developed and evaluated by national education policy makers in the majority of European countries. However, the requirements that a training program in psychiatry should meet are also defined on the European level in a form of recommendations by the Board of Psychiatry - European Union of Medical Specialists (UEMS).

Recently, the European Federation of Psychiatric Trainees (EFPT) which represent trainees from more then 30 European countries, reported data pertaining to the structure of training programs and to the evaluation of training programs in 30 European countries. Whereas in the majority of European countries the structure of training programs and methods of assessment of trainees' competencies are partially compatible with one another and with the existing recommendations at the European level, the quality assurance of training programs varies significantly among countries. Regular evaluations of training programs and mentors, however, contribute to the proper implementation of training programs and help that the theoretical training principles are followed through in practice. As quality assurance of training schemes is an important mechanism how to improve the delivery of training programs, it should gain more focus by responsible authorities who structure the psychiatric training on the national and international European level.

Pathways to Care, Duration of Untreated Psychosis and Treatments Received by Patients with First-Episode Psychosis

Introduction

Pathways to care and duration of untreated psychosis (DUP) strongly influence the long-term outcome of schizophrenia.

Aims

To investigate pathways to care, duration of untreated psychosis (DUP) and treatments received by a sample of individuals aged between 18 and 35 years meeting diagnostic criteria for psychosis.

Methods

Pathways to care and DUP were explored by an “ad-hoc” schedule administered to patients and caregivers.

Results

The sample consists of 30 patients. The first episode of psychosis, which occurred at 19.7 (± 4.7) years, was characterized by negative symptoms and disorganized behaviours in more than half of the sample, suicide attempts (28%) and hospital admissions (26%). DUP was 41.6 ± 60.4 weeks, being longer than that reported in international literature. In 76% of cases patients’ relatives asked for a first contact with health professionals, referring the patients to psychiatrists (34% of cases), general practitioners (31%), neurologists (21%) or psychologists (13%). When professionals other than psychiatrists were contacted, the interval between the contact and receipt of appropriate psychiatric treatment (according to the current guidelines) was particularly long (15.2 ± 32.1 weeks). 34% of patients were treated with a monotherapy of psychotropic drugs: 24% with antipsychotics, 7% with anxiolytics and 3% with antidepressants; 48% received a poly-pharmacotherapy. 35% were treated with psychotherapy (in most of the cases cognitive-behavioural therapy), which was the only treatment for 18% of patients.

Conclusions

These results emphasize the need to train health professionals on diagnosis and treatment of first episode psychosis. DUP may be reduced by anti-stigma campaigns among general population.

ECP09-05 - Psychiatric training in europe: the opinions of early career psychiatrists

Introduction

The recent reforms of mental health legislation occurred in most European countries, together with the continuous advances of technologies and the development of research in all the domains of psychiatry have deeply modified the role of mental health professionals with consequent changes in training needs for early career psychiatrists. The competencies required to psychiatrists today include not only the knowledge of the advances in neuroscience, psychopharmacology, psychotherapy and social psychiatry, but also the ability to understand the different clinical and social needs of the patients. Young psychiatrists report a gap between their knowledge and the skills required during the first years of their job.

Aims

The European Psychiatric Association-Early Career Psychiatrists Committee, in cooperation with the European Federation of Psychiatric Trainees, conducted a survey among European young psychiatrists and psychiatric trainees, aimed at evaluating difficulties and perspectives related to psychiatric training residency.

Methods

86 respondents completed the Psychiatric Training Questionnaire, a multiple-choice and self-reported questionnaire, which evaluates: 1) satisfaction with training received; 2) self-confidence in theoretical and practical skills included in psychiatric training curriculum; 3) educational opportunities received during training.

Results

Respondents were almost equally split between trainees (54%) and young psychiatrists (46%). Seventy per cent of them were completely or partially satisfied with training received. Early Career Psychiatrists reported higher levels of self-confidence in clinical psychiatry (98%), psychopharmacology (69%) and emergency psychiatry (61%), whereas the most problematic areas were forensic psychiatry (64%) psychotherapy (61%) and child and adolescent psychiatry (57%). 41% of respondents was not assigned a tutor for clinical activities, 73% of them could not rely on a dedicated supervisor for training in psychotherapy and 58% had not the possibility to use a log-book to record the competencies acquired during training. Only 37% participated in exchange programs; all early career psychiatrists who had this opportunity found this experience very useful for their professional growth.

Conclusions

Standards of training in psychiatry in Europe are generally satisfactory. However, our results highlight the need to:

1)

ECP09-01 - European federation of psychiatric trainees: Visions for the future

There are significant differences in psychiatric training across Europe. In the light of the current direction of Europe (without borders with free movement of workforce) it is inevitable to harmonize at least basic standards of psychiatric education across Europe. Ideally by working in partnership with relevant national and international bodies (European Union of Medical Specialists, Board of Psychiatry - UEMS, European Psychiatric Association - EPA and European Federation of Psychiatric Trainees - EFPT). A qualitative data analysis on the most important challenges of psychiatric trainees across Europe, carried out by the EFPT in 2009, revealed several interesting findings which might be of interest not only for trainees, but for all involved in the process of psychiatric education. As the most important issue trainees reported the imperfect structure of the training programs and problems with implementation of new ones. That is why new training programs based on a competency based framework are being developed lately in number of countries (e.g. United Kingdom, Ireland, Netherlands). However, not only the structure of the training and its implementation remains an issue, trainees are concerned also with topics related to working conditions, insufficient training opportunities, lack of supervision, funding and availability of psychotherapy courses, etc. Based on these findings EFPT will undertake specific actions which in cooperation with other organizations shall lead in the future to better postgraduate training opportunities in Europe.