Development of enzyme-linked immunosorbent assays using recombinant borrelial antigens for serodiagnosis of Borrelia burgdorferi infection

The basic tenet of continuous quality improvement is that there is always room for additional improvement in the clinical care provided to patients. The opportunities for this improvement come from the analysis of information collected during the ongoing monitoring of important elements of care. The provision of clinical psychiatric care is seen as a complex process that is dependent on the effective functioning of all of the health and mental health care organization. The concept of continuous quality improvement is the most recent stage in a long process of defining and redefining the basic goals and tenants of medical and psychiatric quality assurance. The determination of the actual improvement of psychiatric and mental health care due to quality assurance is a substantial and important technical problem. The determination of the value of this improvement in mental health care is an even greater ethical and social problem.     

Discharge of psychiatric patients into the community: how many more must die?

Since the advent of community care, mental health services are increasingly coming under scrutiny, particularly the management of people with mental health problems in the community. Several murders committed by psychiatric patients in the community have fuelled public debate. This article reports on a study examining the recommendations of the Department of Health regarding the discharge of psychiatric patients from hospital to community care. It describes the background to events such as the Clunis report and guidance from the Department of Health on the management of mental health services. Semi-structured interviews, questionnaires and document analysis were used to ascertain the views of community psychiatric nurses and managers regarding the discharge of patients into the community. The findings identify areas of good practice and the need for nurses to improve their knowledge of the care-programming approach, risk assessment and inter-agency collaboration.     

The costs of schizophrenia

Schizophrenia is regarded as the most expensive mental illness because of its specific symptoms and characteristics (e.g. early onset, often chronic course, high rates of readmission to hospital treatment, high rate of disabilities and extensive rehabilitative interventions), which prove to be extremely costly. Despite this, studies on the financial aspects of schizophrenia or the provision of care for schizophrenic patients has become an issue of psychiatric research only since the beginning of the reform of mental healthcare. Early cost studies had been conducted in the United States (US) during the fifties. Since then, they have grown in number not only in the US and in Great Britain, but also on the Continent of Europe. On an international level, comprehensive literature concerning methodology has attempted to establish cost studies as an integral part of mental health services research. Germany, however, is far behind international developments. Although the fundamental lack of empirical data on costs both in psychiatry as a whole and in schizophrenia had already been ascertained in a large national survey called "Psychiatrie-Enquête" in the mid-seventies, little has changed since then. One reason for these possibly great methodological problems is associated with the assessment of cost data in fragmented community mental health care networks, which in Germany include the additional obstacle--unlike abroad--of non-availability of access to data from case registers. Psychiatric case registers are not permitted in Germany because of very strict data protection laws. Despite the problems in methodology, there is an urgent need in Germany to remedy the lack of cost data for schizophrenic-patient care. The pressure of curbing costs in health care will probably force the German mental health care services to provide detailed cost data with regular reports in the future.     

Long-term patterns of service use and cost among patients with both psychiatric and substance abuse disorders

OBJECTIVES: This is a longitudinal study designed to determine: (1) if patients dually diagnosed with psychiatric and substance abuse disorders incur higher health care costs than other psychiatric patients and (2) if higher costs can be attributed to particular subgroups of the dually diagnosed or types of care. METHODS: Two cohorts of veterans treated in Veterans Affairs mental health programs at the start of fiscal year 1991 were followed for 6 years: one cohort of inpatients (n = 9,813) and the other of outpatients (n = 58,001). Data were analyzed on utilization of all types of Veterans Affairs health care. Repeated measures analysis of variance was used to examine cost differentials between dually diagnosed patients and other patients. RESULTS: Dually diagnosed outpatients incurred consistently higher health care costs than other psychiatric outpatients, attributable to higher rates of inpatient psychiatric and substance abuse care; however, this difference decreased with time. Costs were substantially higher in the inpatient cohort overall, but there were no differences in cost between dually diagnosed and other patients. CONCLUSIONS: In an atmosphere of cost cutting and moves toward outpatient care, the dually diagnosed may lose access to needed mental health services. Possibilities of developing more intensive outpatient services for these patients should be explored.     

Pathways to mental health care among South African adolescents: analysis of referrals to an adolescent psychiatric unit

Assessment forms of 670 adolescents referred over four years to an adolescent psychiatric unit were analyzed to establish how they entered mental health care. The first part of the study examined referral sources; the second established the appropriateness of referral. Adolescents were referred via a number of pathways, of which school sources, psychiatric services, and social agencies were prominent. Interestingly, 60.7% of the referrals were from persons not trained in mental health care. No significant difference in appropriateness of referral was found between trained and nontrained sources. Thus, the unique referral base of adolescents in need of mental health care must be recognized. Although the majority in this study were not mental health care workers, the findings show that their referrals were clinically appropriate. This suggests that by improving the mental health skills of this sector, the provision of psychiatric care to adolescents could be enhanced.     

Consultation-liaison psychiatric nursing in long-term care

1. The psychiatric and mental health APRN is in an excellent position to use his or her training and expertise to integrate various models of care. 2. Clinical functions of the psychiatric and mental health APRN include patient-focused and staff-centered activities, administrative functions include consulting, performance improvement, and research. 3. The psychiatric and mental health APRN is well-equipped to adapt to developing changes and challenges in the future of long-term care.     

What is the psychiatrist's role in drugs and alcohol?

OBJECTIVE: This article describes a consensus view of the role of psychiatrists in respect of alcohol and other drug (AOD) problems, in response to the view expressed by Wodak [1]. METHOD: The data were selected on the basis of the knowledge and experience of the authors. RESULTS: Psychiatrists have made major contributions in the primary, secondary and tertiary prevention of AOD problems over many years in Australia and New Zealand. In recent years there has been an explosion of new knowledge in the AOD area and a shift from mental health to primary and public health care for these patients. Substance use disorders (SUD) are highly prevalent in all areas of psychiatric practice, requiring treatment in their own right as well as complicating the treatment of coexisting psychiatric illness. CONCLUSION: It is argued that psychiatrists have important roles in harm reduction, prevention and policy development; brief and early intervention in SUD in liaison and child psychiatry; and systematic treatment for those with dependence and other psychiatric comorbidity. A research and collaborative approach to AOD services and patients should be encouraged, rather than engaging in divisive debate over "ownership' of this area of clinical practice.     

Italian ideals

Many reports have been published in the UK about the reform movement in the Italian mental health system, but there has been a relative dearth of information on the practice of psychiatric nursing. Here the author reflects on differences and similarities with Italian colleagues and calls for greater dialogue between psychiatric nurses in the two countries.     

The hidden illness of endoscopy patients: mental health disorders, Part I

Because nearly half of all adults experience some mental health disorders in their lifetime, many endoscopy patients must have psychiatric problems along with their gastrointestinal (GI) illnesses. In addition, all patients undergoing an endoscopic procedure experiences some degree of apprehension and worry; anxiety itself is a major factor in most mental illnesses. Endoscopy nurses are very good at establishing rapport quickly with patients and learning about the patient's health history from all the available sources of information. These nurses spend much of their time teaching, listening, reassuring, and caring for people undergoing GI procedure, and these same skills are an important part of the care in mental health disorders. A series of case studies of GI patients in a busy endoscopy department document and summarize the mental health disorder each experienced and the pertinent care given by the GI nurse during an endoscopy or gastric laboratory procedure. Although it is inappropriate for endoscopy nurses to attempt to diagnose major psychiatric disease or provide psychiatric interventions for these patients, their nursing care and reassurance enable the patients to successfully complete their GI procedures.     

Psychiatric assessments of nursing home residents under OBRA-87: should PASARR be reformed? Pre-Admission Screening and Annual Review

OBJECTIVE: As part of nursing home practice reforms, OBRA-87 mandates formal psychiatric assessments (PASARR) of nursing home residents suspected of having mental disorders, a responsibility it delegates individually to states. We describe the initial year of implementation of the PASARR process in King County, Washington, and characterize the mental disorders and mental health services needs of nursing home residents referred for psychiatric screening. DESIGN: Cross-sectional study. SETTING: The 54 Medicare-certified King County nursing homes (total beds = 7013). PARTICIPANTS: All patients referred for psychiatric evaluation under PASARR (n = 510). MEASUREMENTS: A systematic, multidimensional evaluation including a semistructured psychiatric diagnostic examination, validated measures of cognitive dysfunction, depression, and global psychopathology, functional variables relevant to need for nursing home care, and selected mental health services indicators. RESULTS: Fewer than 10% of all nursing home residents were referred for psychiatric evaluation. A primary mental illness, evenly divided between psychoses and mood disorders, was found in 60% of the sample, and a psychiatric disorder associated with dementia or mental retardation was found in 25%. Six percent had complex neuropsychiatric features defying classification, and 4% had no mental disorder. Other disorders, such as substance abuse, were rare. Cognitive impairment and global psychopathology were prevalent in all diagnostic groups, and depressive symptoms were common even in patients without affective diagnoses. Eighty-eight percent of the sample were appropriately placed, based on their needs for daily care. Fifty-five percent had unmet mental health services needs. CONCLUSIONS: The PASARR referral process detected a group of seriously mentally ill, functionally disabled patients, most of whom required the level of care that nursing homes provide. Depressed and psychiatrically impaired dementia patients were underrepresented in the referral pool as measured against widely accepted prevalence figures for mental disorders in nursing home populations. The PASARR process as currently configured appears to be most efficient in identifying schizophrenic patients, who represent a small minority of nursing home residents, and the skewed sample it generates fails to provide an adequate basis for estimating overall mental health services needed in nursing homes. The PASARR process should be altered to improve referral rates for depressed and behaviorally disturbed dementia patients.     

Mental health promotion in high-risk groups

This article summarises a systematic review of the literature on promoting mental health in high-risk groups. The review suggests that there are a variety of effective interventions for preventing mental health problems in high-risk groups. This has implications for the scope of practice of nurses and others working in a range of services, including midwifery, health visiting, school health, mental health, terminal care, district nursing and primary health care.     

Utilization of mental health services by women in a male-dominated environment: the VA experience

OBJECTIVE: The study examined whether women in the Veterans Affairs system use mental health services at a lower rate than men because the system is geared to treat a mostly male population. METHODS: Data were obtained on a national cohort of patients utilizing specialty mental health services in the VA during a two-week period in fiscal year 1991 (N = 70,979). Analyses included comparison of the proportion of women among treated veterans with the age-adjusted proportion of women among all veterans, comparison across gender of the likelihood of use of any general psychiatric services or substance abuse care in 1991, comparison of the intensity of services used (inpatient days and outpatient contacts) by service users in 1991, and comparison of the likelihood of receiving care and the intensity of mental health services received two years later. RESULTS: Overall, 3.95 percent of veterans who used VA mental health specialty services were women; 4.02 percent of all veterans were women. No significant differences between genders were found in use of general psychiatric services, either in the likelihood of any use or the intensity of services used. However, women were significantly less likely to receive substance abuse care (16.3 percent of women versus 71.2 percent of men); once receiving care, they used a similar intensity of substance abuse services. CONCLUSIONS: Being a woman does not appear to have a substantial effect on overall access to VA mental health services or use of general psychiatric services; however, women use VA substance abuse treatment services at a lower rate than men.     

A retrospective evaluation of traumatized permanent teeth

Seclusion is one of several possible interventions with which patients and health care professionals can be confronted on units for admission and crisis intervention in mental health care institutions. The way in which psychiatric nurses shape their practice with regard to seclusion and how they experience this intervention is unclear. The goal of this study is to describe this practice. The results render insight in the motives and reasons of nurses for use of seclusion, the content of the term emergency situation, the way in which decisions to seclude are taken and which interventions can be labelled as preventive. Finally conclusions are given and the questions raised in this study are discussed.     

Issues in casemix funding for acute inpatient psychiatric services and their relevance to mental health nursing

With increased recognition by government, health administrators, and clinicians of the need to simultaneously contain health expenditure, improve the productivity and efficiency of health services and maintain quality of patient care, applications of casemix funding have been advocated as an alternative means of financing acute hospital care. Currently in Australia, the Commonwealth's casemix development program is encouraging the States and Territories to participate in certain casemix initiatives. Acute psychiatric hospital care and treatment have been excluded from the initial stages of the implementation of casemix in recognition of a number of inherent obstacles or challenges affecting the utility and accuracy of casemix in funding the psychiatric sector. Despite anecdotal claims that the reduced length of stay that often occurs under casemix payment systems may negatively impact upon the quality of care and patient outcomes, to date little empirical research has been directed towards measuring the potential impact of psychiatric casemix on the quality of patient care. Psychiatry cannot afford to ignore the casemix debate on account of its current exclusion from the early phases of implementation. To do so is to run the risk of having casemix imposed at some later stage in the absence of consultation. In the meantime it is vital that mental health professionals, including nurses, participate in the development and implementation of casemix, and contribute to research aimed at increasing or maximizing the relevance of casemix to the funding of psychiatric services.     

Renewing Australia's mental health strategy

The Second National Mental Health Plan, endorsed by Commonwealth, State and Territory governments on 30 July 1998, will pursue three key themes: (1) Promoting mental health, plus prevention of and early intervention in mental disorders, with a specific focus on depression; (2) continuing structural reform of mental health services, including better integration with general practice and the private psychiatric sector; and (3) implementing quality and outcome measures in mental health services, including evidence-based practice.     

The role of the psychiatric nurse practitioner

Policy, organizational management, and research roles have received little attention in this article because the focus has been on the practice role. It must be noted, however, that psychiatric nurse practitioners often assume these roles. Many psychiatric nurse practitioners have discovered that their expertise in communication and systems assessment prepares them well for policy and management positions. The influence of public and private policy on practice and the lives of mentally ill persons has led psychiatric nurse practitioners to become active in the public policy arena. Similarly, psychiatric nurse practitioners' grounding in practice and training in research allows for participation in planning and conducting studies that will inform policy makers as the mental health reform process continues. The psychiatric nurse practitioner title and role have evolved in response to regulatory desire for consistent titling of advanced practice nurses and community need for practitioners with the skills in assessment, psychotherapy, psychopharmacology, and care management. Nursing academic institutions are working to develop new programs to prepare the psychiatric nurse practitioners of the future in the wide range of skills needed for this role. Practice subspecialties and settings vary, but in all instances the psychiatric nurse practitioner offers a blend of nursing and psychiatric specialty care that, in many cases, is substitutive for that of a psychiatrist. In the current era of health-care reform, fiscal constraint, and burgeoning health-care technology, the practice, research, and policy roles available to and occupied by psychiatric nurse practitioners are many. The primary threat to full actualization of the psychiatric nurse practitioners' potential is that advanced practice nursing will choose to be wedded to anachronistic ideologies regarding nurse practitioners and clinical specialists.     

The stigma of mental illness in Asian cultures

OBJECTIVE: This article reviews the attitudes towards mental illness and psychiatric stigma in Asian cultures. METHOD: Relevant literature published in English was reviewed. RESULTS: Psychiatric stigmas in Asian cultures share some common features. However, response to mental illness has many variations across cultures. Psychiatric stigma is prevalent and severe in some but not all Asian cultures. CONCLUSIONS: The stigma of mental illness needs to be studied within its sociocultural context in order to understand its origins, meanings and consequences. It may be relevant to examine the indigenous concepts, experience and implications of psychological problems to address problems in mental health care relating to stigma.     

Psychiatry in crisis

Psychiatry today faces sociopolitical, economic, and philosophical pressures that threaten its existence as a valued medical specialty. Recent legislation that decreases the numbers of foreign medical graduates eligible to practice in the United States, increases the numbers of community mental health centers and types of services they offer, and limits federal support of psychiatric education will affect the future of psychiatry as a profession and discipline. Forthcoming legislation and federal health policies will be related to the ability of the profession to demonstrate its unique role in the provision of mental health and health services. The authors offer suggestions for the education of the American public regarding the important role of psychiatry in America's health and mental health care system.     

Paying for mental health and substance abuse care

Fifty-four billion dollars was spent on alcohol/drug abuse and mental health treatment in 1990. These expenditures were concentrated in the area of inpatient psychiatric care and on persons with severe mental health and substance abuse problems. The data on expenditure patterns for mental health and substance abuse care suggest that successful health care reform in this area must implement mechanisms for controlling inpatient utilization and managing the care of persons with the most severe disorders.