Matching resources to care: the acceptability, validity and inter-rater reliability of a new instrument to assess severe mental illness (MARC-1)

BACKGROUND

Most definitions of severe mental illness (SMI) are categorical and assign the patient to either SMI or not-SMI status. While this is useful for some purposes, it is a rather limited approach. The purpose of the present study is to develop a new method of addressing the issue of 'severity', and to develop a dimensional rather than a categorical approach. The paper reports on the acceptability, reliability and validity of a method developed to collect a standard set of data covering the majority of items specified in the academic and policy literature as characterising SMI.

METHOD

A single page form, Matching Resources to Care (MARC-1), containing most of the items used in definitions of SMI was used to collect data from community mental health staff about their current open caseload, in four co-terminous health and social services settings during a census week (n = 2139). In addition to the data from the four pilot sites, we conducted a substudy (n = 91), in which two raters rated the same cases during the same week.

RESULTS

The MARC-1 scores were able to distinguish between patients in receipt, and those not in receipt, of specific types of community care (level of care, eligibility for care and statutory aftercare) (P < 0.001). The MARC-1 score was modestly but significantly correlated (r = 0.28) with the Global Assessment Scale (P < 0.001). The mean percentage inter-rater agreement for the MARC-1 score items was 87%.

CONCLUSION

It is possible to use a simple census form in both health and social services agencies. The completion rates were good in both services. The levels of reliability were good, and concurrent validity was established with specific types of care in the community.

Effects of irradiance and spectral quality on leaf structure and function in seedlings of two Southeast Asian Hopea (Dipterocarpaceae) species

We studied the development of leaf characters in two Southeast Asian dipterocarp forest trees under different photosynthetic photon flux densities (PFD) and spectral qualities (red to far-red, R:FR). The two species, Hopea helferi and H. odorata, are taxonomically closely related but differ in their ecological requirements; H. helferi is more drought tolerant and H. odorata more shade tolerant. Seedlings were grown in replicated shadehouse treatments of differing PFD and R:FR. We measured or calculated (1) leaf and tissue thicknesses; (2) mesophyll parenchyma, air space, and lignified tissue volumes; (3) mesophyll air volumes (V(mes)/A(surf)) and surfaces (A(mes)/A(surf)); (4) palisade cell length and width; (5) chlorophyll/cm and a/b; (6) leaf absorption; and (7) attenuance/absorbance at 652 and 550 nm. These characters varied in response to light conditions in both taxa. Characters were predominantly affected by PFD, and R:FR slightly influenced many characters. Leaf characters of H. odorata were more plastic in response to treatment conditions. Characters were correlated with each other in a complex fashion. Variation in leaf anatomy is most likely a consequence of increasing leaf thickness in both taxa, which may increase mechanical strength and defense against herbivory in more exposed environments. Variation in leaf optical properties was most likely affected by pigment photo-bleaching in treatments of more intense PFD and was not correlated with A(max). The greater plasticity of leaf responses in H. odorata helps explain the acclimation over the range of light conditions encountered by this shade-tolerant taxon. The dense layer of scales on the leaf undersurface and other anatomical characters in H. helferi reduced gas exchange and growth in this drought-tolerant tree.

Staff looking after children in local authority residential units: the interface with child mental health professionals

Seventy-two members of staff working in children's residential units in a Local Authority were surveyed, to elicit their experiences and evaluations of working with child mental health professionals. Whilst the majority of staff held few or no formal educational qualifications, they emerged as an experienced group, with a level of confidence in their knowledge and skill base. Support was identified as coming predominantly from within units themselves; relatively few staff had direct contact with child psychiatrists or psychologists, although many children received a service. Staff in general felt that child mental health services were not helpful to them in terms of their work with young people. However, the majority of staff indicated a need for greater direct involvement across a range of child behavioural and emotional problems. The findings are discussed in terms of the changing population of "looked after" children and the recommendations of the Warner Report.

Acute pancreatitis in north-eastern peninsular Malaysia: an unusual demographic and aetiological pattern

A survey of 142 cases of acute pancreatitis was undertaken in two major hospitals serving the state of Kelantan in Malaysia. Females outnumbered males by a ratio of more than 3:1. The incidence among females peaked in the third decade of life. Twenty-one percent (23/109) of the females were pregnant. Ultrasonography revealed gallstones in only 9.4% (13/138). However, abnormalities of serum transaminases were found in 35% (35/100), suggesting that occult gallstones or microlithiasis may be the cause in a significant proportion of patients. Alcohol was virtually absent as an aetiological factor. There was a higher frequency of Ascaris infection in this group than a control hospital population (11/35 vs 33/242; p < 0.02) suggesting that ascariasis may be an important cause of acute pancreatitis in Kelantan. Only 8.4% fell into the category of severe pancreatitis. The overall mortality rate was 2.1%.

Psychiatric morbidity in social workers' clients. A comparison between an inner-city area and a small town

The rate of psychiatric disorder in a social services sample in a small town was compared to the rate in an inner-city sample. Nearly 40% of respondents in the small town had a positive General Health Questionnaire score and 37% had case status (ID greater than 5) on the Present State Examination. Most of these were cases of neurotic depression and were generally recognised as such by the social workers. The type of intervention undertaken by social workers differed in the two settings. Small-town social workers were more likely to offer advice, guidance, exploration and mobilisation of resources. The small-town social workers were more likely to have success in helping their clients with problems of social isolation and marital disharmony than were their inner-city counterparts. Mental illness problems, however, showed less improvement than in the inner-city sample, with over one-third of the small-town cases remaining unwell throughout the 12-month follow-up. Both previous psychiatric history and current depression were indicators of a poor outcome. The present findings provide further support for the argument that unless there is close collaboration between social workers, the medical profession, and health care teams, people who present their problems to social services are unlikely to have their mental health problems addressed adequately.

The 1983 Mental Health Act in five local authorities: a study of the practice of approved social workers

This paper represents the first report of an ongoing collaborative project and charts the activities of social workers undertaking their duties within the framework of the 1983 Mental Health Act in five English Local Authorities for one year. Social workers are involved in a range of duties under the Act, but most commonly they are involved in assessments with a view to compulsory detention. The characteristics of people assessed are examined, and a profile emerges of vulnerable subgroups, typically younger men, older women, and people living in socially impoverished situations. Considerable variation between Authorities is found in terms of numbers of assessments, and in numbers of detentions. Low levels of 'diversion' into alternative care are identified. Comparisons are made with a major national study which took place four years earlier. Higher rates of detention are found on average, but lower rates of use of emergency provision (Section 4). An examination of the organisational context within which Approved Social Workers (ASWs) practice reveals a great deal of variation between authorities in terms of the ongoing experience of assessments available to ASWs. Social workers based in Emergency Duty Teams and Hospital Teams are compared, and a distinctive profile of their work emerges, the hospital-based ASWs being more likely to be assessing 'known' people, often already in hospital, and referred for assessment by consultants. The implications of these findings for the management and deployment of Approved Social Workers are briefly discussed. The emphasis is upon the role of the ASW in terms of balancing the rights and needs of people assessed under the Act.

Psychiatric morbidity in clients of social workers: social outcome

141 clients referred to social service department local social work teams (area workers) and general practice attachments were interviewed to assess their levels of psychiatric morbidity. 101 cases received clinical and social reassessment at twelve months. A substantial proportion (63%) had a positive social outcome according to the client and social worker, a finding confirmed by an independent social assessment. Family break up, more common in the area setting, was associated with a better clinical outcome. Attachment clients had significantly higher levels of psychiatric morbidity, and in clinical terms improved more frequently than area cases, but not significantly so. Clinically improved cases had a higher number of GP-social worker contacts. Both social and clinical variables contributed to the prediction of clinical outcome. By reducing the availability of attached workers, social services departments are removing a valuable source of help for people with psychiatric disorders.