Nurses helping nurses. Development of internal specialists in long-term care

The prevalence of psychiatric disorders and behavioral disturbances among nursing home residents, combined with observed deficits in geriatric mental health/illness expertise among LTC staff, supports the need for creative approaches to improve the knowledge, understanding, and management of such problems among LTC providers. The train-the-trainer model described in this article proved to be a viable method to providing geriatric mental health consultation and training that targets both improved quality of life for residents and quality of work life for the staff in charge of residents' care. More collaborative efforts among nursing specialists, subspecialists, and generalists are needed to empower those who work in LTC to utilize strengths and abilities inherent to their positions. Nursing homes nurses, who are all too familiar with the problems and challenges of their patient population, may act not only as mental health trainers but also as resource persons, role models, liaisons with geropsychiatric specialists, and leaders in the application of geropsychiatric care principles to residents within their facility, thus promoting improved resident and staff care alike.     

Sexual relations in a cold-weather shelter for homeless people

This study was carried out in a cold-weather shelter targeting young people sleeping rough in London. A homeless community mental health team added screening questions to assess sexual and relationship problems. Semistructured interviews were carried out in the shelter with residents not referred to the homeless mental health team. Shelter staff were consulted about their experience of residents' sexual and relationship problems as well as their relationship to substance use.     

Primary care in psychiatry residency training

The author summarizes patient perspectives and government initiatives that have fostered closer medicine-psychiatry cooperation and more comprehensive treatment of patients. Despite the growing numbers of people requiring more formal mental health care, most patients are being treated by primary health care providers. This trend will continue as long as there is a decline in the number of medical students entering psychiatry. The author summarizes several general principles that psychiatry residency program directors should consider in designing primary care experiences for their residents and for medical students rotating on their services: longitudinal primary care experiences in organized medical care settings, training in basic medical principles and techniques, and instruction in the biopsychosocial model of disease. The author also recommends there specific training experiences for psychiatry residents that would enhance their ability to provide more effective mental health services to primary care physicians and their patients: consultation psychiatry, primary mental health care, and general psychiatry. The author concludes that medical students, through their contact with primary care-oriented psychiatry residency programs, would be more attracted to psychiatry as a specialty choice and that residents, upon completion of training, would be more inclined to practice in primary care settings.     

IS231A transposition: conservative versus replicative pathway

OBJECTIVE:To explore the attitudes and experiences of abused women to identify characteristics that helped or hindered abuse disclosure to clinicians and to determine how women viewed potential interventions to improve detection and treatment in a medical setting. DESIGN: Focus group data conducted and analyzed with qualitative methodology. SETTING: Three community-based mental health centers and one women's shelter. PARTICIPANTS: Twenty-one women in group therapy for domestic violence. MAIN RESULTS: Eighteen (86%) of the 21 women had seen their "regular doctor" in the prior year; only 1 in 3 had discussed the abuse with the clinician. The major discussion themes were medical problems that were exacerbated with abuse, lack of ability to access medical care due to abuser interference, emotional attitudes about abuse that acted as barriers to disclosure, clinician characteristics that helped or hindered disclosure, and treatment experiences and preferences. Women described how their medical problems began or worsened during the abusive period. one in three women described how abusers blocked them from receiving medical care. Women reported intense shame about the abuse and described their self-denial of abuse. Women stated they were inclined to discuss abuse if they felt the clinician was perceived to be caring, was easy to talk to, had a protective manner, or if the clinician offered a follow-up visit. There was no consistent clinician gender preference among the women. One in four women had received psychotropic medication for problems associated with abuse. Many feared addiction, or a loss of alertness, increasing their risk for more abuse. CONCLUSIONS: Many abused women experience worsening health and seek medical care; most do not volunteer a history of violence even to their regular clinicians. Many of the barriers to disclosure of abuse could be overcome by a physician's knowledge of the link between abuse and medical illness, an understanding of the women's emotions about abuse, and her treatment preferences.     

Children's mental health: The gap between what we know and what we do.

There is widespread agreement that over 11% of our nation's children need mental health treatment, but the majority of these children receive inadequate or inappropriate treatment. This gap between what we know should be provided and what is provided is the result of a poorly structured health care financing system and a poorly coordinated treatment system. The treatment system fails to recognize that children's mental health problems are interactions between intraindividual difficulties and environmental conditions. A wealth of models of prevention and treatment have been developed, and a substantial scientific basis for children's mental health interventions now exists, but there is a shortage of community based services and a lack of coordination across services. Public policy toward children with mental health problems must encourage application of knowledge about effective treatment systems and encourage care in the least restrictive and most cost-effective settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychiatrists' and internists' knowledge and attitudes about delivery of clinical preventive medical services

OBJECTIVE: Changes in the health care environment have placed a greater responsibility on psychiatrists to deliver basic primary care services. The study assessed baseline knowledge and attitudes about clinical preventive medical services among psychiatric faculty and psychiatric residents at a tertiary care medical center. METHODS: Residents and faculty in psychiatry and general internal medicine completed a structured questionnaire, including 20 case scenarios, that assessed their baseline knowledge of clinical preventive medical services, their attitudes concerning delivery of those services, and their beliefs about the effectiveness of those services in changing patients' behavior. The case scenarios and knowledge questions were based on the clinical preventive medical services recommendations outlined by the U. S. Preventive Services Task Force. RESULTS: Psychiatrists reported more frequent assessment of and counseling about the use of illicit drugs and weapons, and internists were more likely to query about measures related to physical health such as cancer screening and immunizations. The two groups reported similar attitudes toward the need for and the efficacy of preventive medical services. Commonly cited barriers to the delivery of preventive care included lack of time and education. Psychiatrists scored reasonably well on baseline knowledge about guidelines for preventive medical services, particularly given their recent lack of specific education in these matters. CONCLUSIONS: Psychiatrists believe clinical preventive services are important and express interest in their delivery. Additional educational interventions are needed to train psychiatrists in clinical preventive services to avoid missed clinical opportunities for intervention in psychiatric populations that may have poor access to other medical care.     

Does a hostel's managing agency determine the access to psychiatric services of its residents?

This study examines the effect of managing agency (local authority, private or voluntary) on the use of other health and social care services by residents in mental health hostels and group homes with different levels of staffing in England and Wales. The sample comprised 1323 residents in 275 facilities in eight districts. The measures of service use were number of days in hospital and number of other service contacts. There were highly significant differences between facilities with similar levels of staffing managed by different agencies. Residents in the voluntary sector used fewer community services overall; residents in low-staffed local authority facilities used more services than those in similar facilities managed by other agencies. These differences were not easily explained by differences in the social or clinical characteristics of residents. This suggests that there may be organisational factors, e.g. hostel staff, knowledge of services, which influence access to and use of community services.     

Paediatric communications with the post-partum patient

Discussions with mothers during their puerperium allows the introduction of thoughts on child care and management to a captive audience at a highly receptive stage. Many mothers lack an understanding of the problems they are likely to face in the first months after delivery and are desperately afraid of "spoiling" their child. They are generally quite ignorant of the problems of feeding, "colic" and others. Discussion group counselling of the parents of babies treated in an intensive care nursery is of value for the parents and for the hospital staff. The mothers have problems of guilt and anxiety over their possible aetiological role, doubts about their ability to cope with an "abnormal" baby, and problems due to lack of contact with their baby.     

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.     

Angiocardiographic digital still images compressed via irreversible methods: concepts and experiments

OBJECTIVE: Primary care occupies a strategic positive in the evaluation, treatment, and prevention of the mental disturbances of later life. This article highlights four themes that are crucial to understanding mental disturbances among older adults: 1) subsyndromal depression, 2) coexisting depression and anxiety, 3) comorbidity of depression and chronic medical conditions, and 4) risk factors for cognitive impairment. METHOD: The literature was selectively reviewed for each theme to ask the central question, "What can primary care physicians learn about mental disturbances of their older patients from epidemiologic and community studies?" RESULTS: The primary care setting itself is an important venue for an examination of aging issues and mental health. Workers in the "middle ground of psychiatric epidemiology"--primary health care--have not yet reached a full appreciation for the value of research in the primary care setting for enhancing our understanding of the mental disturbances of late life, and how these intersect with other salient factors. CONCLUSIONS: Primary care physicians and others who work in primary care should advocate for further mental health integration and research in primary care. Research is needed that will lead to new ways of maximizing the health and quality of life of older adults and their families.     

Linking level of care to level of need: Assessing the need for mental health care for nursing home residents.

What are the mental health status and active treatment needs of nursing home residents? A stratified random sample of 828 residents in 25 facilities serving Medicaid recipients was assessed for levels of physical and psychosocial functioning. Although 91.2% had sufficiently high levels of medical and physical care needs to justify nursing home placement, 79.6% also had moderate to intense needs for mental health care. Older residents, relative to their younger counterparts, had more intense medical and mental health care needs. It was also found that psychiatric diagnosis was a poor indicator of mental health service needs, particularly among elderly individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mental illness and mental retardation: Message from the President of the United States relative to mental illness and mental retardation.

2 health problems of critical size and tragic impact are mental illness and mental retardation. "There are now about 800,000 such patients in this Nation's institutions—600,000 for mental illness and over 200,000 for mental retardation." A 3-fold attack is proposed: (a) Ascertain causes and eradicate them. (b) Strengthen underlying resources of knowledge and of skilled manpower. (c) Strengthen and improve facilities serving the mentally ill and mentally retarded. A national program for mental health is proposed which emphasizes comprehensive community mental health centers, improved care in state mental institutions, and expansion of research activities and increase in professional manpower. A national program to combat mental retardation emphasizing prevention, community services, and research is also proposed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Caring for mentally ill people

Despite legislation to harmonise mental health practice throughout Europe and convergence in systems of training there remains an extraordinary diversity in psychiatric practice in Europe. Approaches to tackling substance misuse vary among nations; statistics on psychiatric morbidity are affected by different approaches to diagnosis and treatment of psychiatric disorders; attitudes towards mental illness show definite international differences. Everywhere, though, mental health care for patients with psychotic illnesses is a "cinderella service," and there is a general move towards care falling increasingly on the family and the community.     

Use of advance directives: facilitating health care decisions by adults with mental retardation and their families

As increasing numbers of adults with mental retardation survive into adulthood and old age, they may face decisions about their health care and end-of-life treatment. Advance directives may serve as a tool for communicating one's preferences about future medical treatment. Information about the types, extent of use, and ethical context of advanced directives is provided and four critical issues regarding use of advanced directives by adults with mental retardation and their families are examined: assessment of decision-making capacity, standards for surrogate decision-making, family involvement in advanced directives planning, and constraints on the use of advanced directives. Implications for professionals are discussed, including ways to facilitate advance care planning.     

Ecosystem health as a clinical rotation for senior students in Canadian veterinary schools

A research nurse interviewed 55 practice staff in 11 general practices to ascertain their views about their needs for occupational health care. In a second parallel study, a specialist in occupational medicine undertook an in-depth audit of occupational health provision in five other general practices with respect to the organization, the health and safety process, the services and the working environment. In the first study, the majority of practice staff reported the need for various aspects of occupational health care, particularly stress at work. In the second study, general practitioners and practice managers possessed a basic awareness of occupational health matters such as Health and Safety legislation, but their limited knowledge was not translated into effective management. General practice staff did not know where to obtain occupational health advice; most practices had no policies or procedures in place to manage health and safety. Both studies illustrate the need for expert occupational health advice in primary care.     

Emerging trends in mental health policy and practice

The continuing deinstitutionalization of patients in public mental hospitals and the growth of managed care are fundamentally altering mental health practice. Managed care provides opportunities for achieving parity of insurance coverage between mental and physical illness, but serious problems persist in integrating mental health, substance abuse, and general medical care and assuring an appropriate range of services and programs for persons with serious mental illness residing in community settings. Hospital and community care are poorly coordinated, and hospital care needs to be integrated into a more balanced system of services. Important new roles are emerging for purchasers, patient advocates, and mental health authorities.     

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.     

Predoctoral training in collaborative primary care: An exam room built for two.

Psychologists have discovered new training and practice opportunities by collaborating with family physicians. This article describes a collaborative practicum experience in which predoctoral psychology students teamed with family medicine residents to provide care for family medicine outpatients. Psychology students improved their clinical skills and reported learning valuable collaborative skills. Family medicine residents increased their postpracticum mental health diagnoses and their mental health referrals and changed their attitudes about providing mental health care. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

A model of health care delivery in a child day-care setting

Many children in our country spend all or part of their days in group day care while their parents work or go to school. These children are not only at risk for day-care-related illnesses, but also may lack preventive health care because their parents have time constraints or financial barriers. A group of nursing faculty members found that by collaborating with early childhood educators, accessible and cost-effective health care could be provided to children at a campus day-care site. This collaboration allowed for the early detection of problems, thereby reducing barriers to learning. Furthermore, by entering a day-care system, nurses found opportunities to conduct health education and promotion that had a positive impact on children, parents, and day-care staff. This model, or components of it, could be replicated in similar settings.     

Health status of and access to health services by residents of urban encampments in Los Angeles

This paper reports findings from a survey of 134 homeless people living in 42 urban encampments in central Los Angeles. These data, of concern to public health officials, include the physical conditions in the camps, the health status of residents, their use of drugs and alcohol, and their access to and use of health care services such as substance abuse treatment. Many encampment residents report poor health status; over 30 percent report chronic illnesses, and 40 percent report a substance abuse problem. Although outreach efforts have had success in bringing HIV and tuberculosis screening services to encampments, residents report significant barriers to using primary health care and drug and alcohol treatment services. Public hospitals and clinics remain the major source of primary medical care for homeless people living in encampments. Outreach and case management continue to be critical components of improved access to health care for homeless people.