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Edited by
Roland Dix, Gloucestershire Health and Care NHS Foundation Trust, Gloucester,Stephen Dye, Norfolk and Suffolk Foundation Trust, Ipswich,Stephen M. Pereira, Keats House, London
Psychiatric intensive care units (PICUs) are an important provision but are significantly under-provided internationally. Law, funding and stigma all have significant influence on mental health service provision and the consequent lack of access to appropriate treatment. Whilst this varies from country to country, there are themes throughout which can be applied everywhere. Improving legal frameworks, providing more resources, educating the population and working more closely with patients will be key to creating a truly global approach to severe mental illness. PICUs are a key element in providing safe, effective care for the most unwell people. Practices such as shackling need to end and mental health care in all countries around the world must be brought front and centre in the twenty-first century, having spent so long in the shadows.
Dissociation may be important across many mental health disorders, but has been variously conceptualised and measured. We introduced a conceptualisation of a common type of dissociative experience, ‘felt sense of anomaly’ (FSA), and developed a corresponding measure, the Černis Felt Sense of Anomaly (ČEFSA) scale.
Aims:
We aimed to develop a short-form version of the ČEFSA that is valid for adolescent and adult respondents.
Method:
Data were collected from 1031 adult NHS patients with psychosis and 932 adult and 1233 adolescent non-clinical online survey respondents. Local structural equation modelling (LSEM) was used to establish measurement invariance of items across the age range. Ant colony optimisation (ACO) was used to produce a 14-item short-form measure. Finally, the expected test score function derived from item response theory modelling guided the establishment of interpretive scoring ranges.
Results:
LSEM indicated 25 items of the original 35-item ČEFSA were age invariant. They were also invariant across gender and clinical status. ACO of these items produced a 14-item short-form (ČEFSA-14) with excellent psychometric properties (CFI=0.992; TLI=0.987; RMSEA=0.034; SRMR=0.017; Cronbach’s alpha=0.92). Score ranges were established based on the expected test scores at approximately 0.7, 1.25 and 2.0 theta (equivalent to standard deviations above the mean). Scores of 29 and above may indicate elevated levels of FSA-dissociation.
Conclusions:
The ČEFSA-14 is a psychometrically valid measure of FSA-dissociation for adolescents and adults. It can be used with clinical and non-clinical respondents. It could be used by clinicians as an initial tool to explore dissociation with their clients.
Criminal sanctions including court orders, prosecution and imprisonment persist as responses to suicidality in the UK even where there is no public danger. Their prevalence, the level of clinical involvement and outcomes are unclear. There is an urgent need to examine the national picture of harms, benefits and the responsibilities of mental health professionals.
Catastrophic cognitive appraisals, similar to those in anxiety disorders, are implicated in depersonalisation, a form of dissociation. No scales exist to measure appraisals of dissociative experiences. Dissociation is common in psychosis. Misinterpretations of dissociative experiences may maintain psychotic symptoms. Therefore, assessing appraisals in this context may be valuable.
Aims:
The primary aim was to develop a measure of key appraisals of dissociation in psychosis. Secondary aims were to test the relationship between appraisals and psychotic experiences (paranoia and hallucinations), and determine whether appraisals explain additional variance in psychotic symptoms above dissociative symptoms.
Method:
Fifty items were generated from transcripts of interviews with patients. The measure was developed and psychometrically validated via factor analysis of data from 9902 general population participants and 1026 patients with psychosis. Convergent validity, test–re-test reliability, and internal reliability were assessed. Regression analyses tested relationships with psychotic symptoms.
Results:
A 13-item single-factor measure was developed. Factor analysis indicated good model fit [χ2(65) = 247.173, comparative fit index (CFI) = 0.960, root mean square error of approximation (RMSEA) = 0.052]. The scale had good convergent validity with a rumination (non-clinical: r = 0.71; clinical: r = 0.73) and dissociation measure (r = 0.81; r = 0.80), high internal consistency (α = 0.93; α = 0.93), and excellent 1-week test–re-test reliability [intraclass correlation (ICC) = 0.90]. It explained variance in psychotic symptoms (paranoia: 36.4%; hallucinations: 35.0%), including additional variance compared with dissociation alone (paranoia: 5.3%; hallucinations: 2.3%).
Conclusions:
The Cognitive Appraisals of Dissociation in Psychosis (CAD-P) measure is a psychometrically robust scale identifying appraisals of dissociative experiences in psychosis and is associated with the presence of psychotic experiences. It is likely to prove useful for clinical assessment and research.
Recent years have seen a surge in interest in mental healthcare and some reduction in stigma. Partly as a result of this, alongside a growing population and higher levels of societal distress, many more people are presenting with mental health needs, often in crisis. Systems that date back to the beginning of the National Health Service still form the basis for much care, and the current system is complex, hard to navigate and often fails people. Law enforcement services are increasingly being drawn into providing mental healthcare in the community, which most believe is inappropriate. We propose that it is now time for a fundamental root and branch review of mental health emergency care, taking into account the views of patients and the international evidence base, to ‘reset’ the balance and commission services that are humane and responsive – services that are fit for the 21st century.
The Green et al., Paranoid Thoughts Scale (GPTS) – comprising two 16-item scales assessing ideas of reference (Part A) and ideas of persecution (Part B) – was developed over a decade ago. Our aim was to conduct the first large-scale psychometric evaluation.
Methods
In total, 10 551 individuals provided GPTS data. Four hundred and twenty-two patients with psychosis and 805 non-clinical individuals completed GPTS Parts A and B. An additional 1743 patients with psychosis and 7581 non-clinical individuals completed GPTS Part B. Factor analysis, item response theory, and receiver operating characteristic analyses were conducted.
Results
The original two-factor structure of the GPTS had an inadequate model fit: Part A did not form a unidimensional scale and multiple items were locally dependant. A Revised-GPTS (R-GPTS) was formed, comprising eight-item ideas of reference and 10-item ideas of persecution subscales, which had an excellent model fit. All items in the new Reference (a = 2.09–3.67) and Persecution (a = 2.37–4.38) scales were strongly discriminative of shifts in paranoia and had high reliability across the spectrum of severity (a > 0.90). The R-GPTS score ranges are: average (Reference: 0–9; Persecution: 0–4); elevated (Reference: 10–15; Persecution: 5–10); moderately severe (Reference: 16–20; Persecution:11–17); severe (Reference: 21–24; Persecution: 18–27); and very severe (Reference: 25+; Persecution: 28+). Recommended cut-offs on the persecution scale are 11 to discriminate clinical levels of persecutory ideation and 18 for a likely persecutory delusion.
Conclusions
The psychometric evaluation indicated a need to improve the GPTS. The R-GPTS is a more precise measure, has excellent psychometric properties, and is recommended for future studies of paranoia.
Street triage services are now common but the population they serve is poorly understood. We aimed to evaluate a local service to determine the characteristics of those using it and their outcomes in the 90 day period following contact.
Results
We found that there were high levels of service use and that the vast majority of contacts were via telephone rather than in person. Street triage was used by both existing secondary mental health patients and non-patients. Follow-up rates with secondary services were high in the former and low in the latter case.
Implications
Services are very busy where they exist and may be replacing traditional crisis services. It is not apparent that they work to increase follow-up among those using them, unless they are already in contact with services. In this service, although there was a joint response model nearly all responses were provided by telephone.
Street triage services are increasingly common and part of standard responses to mental health crises in the community, but little is understood about them. We conducted a national survey of mental health trusts to gather detailed information regarding street triage services alongside a survey of Thames Valley police officers to ascertain their views and experiences.
Results
Triage services are available in most areas of the country and are growing in scope. There is wide variation in levels of funding and modes of operation, including hours covered. Police officers from our survey overwhelmingly support such services and would like to see them expanded.
Clinical implications
Mental health crises now form a core part of policing and there are compelling reasons for the support of specialist services. Recent changes to the law have heightened this need, with a requirement for specialist input before a Section 136 is enacted. Those who have experienced triage services report it as less stigmatising and traumatic than a traditional approach, but there remains little evidence on which to base decisions.
St Lucia is a small island in the eastern Caribbean with a population of approximately 200 000 people. Although St Lucia is formally ranked as a high middle-income country, there are pockets of deprivation and relatively low living standards. Mental health services in St Lucia have increased considerably and advanced over recent years because of a coalition between the government of the island and South East Asian partners. The National Mental Wellness Centre opened several years ago and has much improved facilities. There remains a significant shortage of community-based services, no mental health law, and a pervasive community stigma and apprehension regarding those with mental health problems.
Recent reports have highlighted human rights concerns in Ugandan mental healthcare. This article describes the current situation in terms of healthcare funding and provision, concerns regarding legislation, and health inequalities. Possible reasons for the difficult situation are briefly discussed, including the economy, pervasive stigma and ongoing unrest in the region. We then describe some encouraging initiatives in Uganda that are empowering those with mental health problems to have a better quality of life and identify opportunities for change.
Coercion remains a dominant theme in mental healthcare and a source of major concern. While the presence of coercion is ubiquitous internationally, it varies significantly in nature and degree in different countries and is influenced by a variety of factors. Recent reports have raised concerns about physical restraint and the increasing use of legislation in high-income countries. At the same time, a recent Human Rights Watch report on pasung (the practice of tying or restricting movement more generally) in Indonesia has served to highlight the plight of many in middle- and lower-income countries who are subject to degrading and dehumanising ‘treatment’.
Community treatment orders (CTOs) are increasingly embedded into UK practice and their use continues to rise. However, they remain highly controversial. We surveyed psychiatrists to establish their experiences and current opinions of using CTOs and to compare findings with our previous survey conducted in 2010.
Results
The opinions of psychiatrists in the UK have not changed since 2010 in spite of recent evidence questioning the effectiveness of CTOs. Clinical factors (the need for engagement and treatment adherence, and the achievement of adherence and improved insight) remain the most important considerations in initiating and discharging a CTO.
Clinical implications
Given the accumulating evidence from research and clinical practice that CTOs do not improve outcomes, it is concerning that psychiatrists' opinions have not altered in response, particularly given the implications for patient care.
There is robust evidence that electroconvulsive therapy is an effective treatment for some mental illnesses. Despite this, its use remains controversial and is declining in some countries, with a consequent loss of skills and knowledge. This, and the view of it as a ‘treatment of last resort’, may undermine its sustainability.
Coercion has always been integral to the care and treatment of people who are mentally ill and there is no ‘perfect’ model in which coercion is absent. A number of interventions have shown promise in reducing the use of coercion, however, and we believe the evidence points to ways forward that may improve both the experience and the outcome of care.
This paper details the grounds for compulsory treatment, compulsory admissions in an emergency department and compulsory out-patient treatment in Portugal. Portuguese mental health legislation has improved significantly over recent years, with enhanced safeguards, rapid and rigorous review and clear criteria for compulsory treatment, although much remains to be done, especially in relation to the ‘move into the community’.
Community treatment orders (CTOs) were introduced into the UK despite unconvincing international evidence for their effectiveness. The Oxford Community Treatment Order Evaluation Trial (OCTET) is a multisite randomised controlled trial of 333 patients with psychosis conducted in the UK. It confirms an absence of any obvious benefit in reducing relapse despite significant curtailment of liberty. Community mental health teams need to seriously consider whether they should continue using CTOs or shift their clinical focus to strengthening the working alliance.
We surveyed the views and experiences of all mental health professionals in adult community mental health teams and approved mental health professionals in 2Gether and Oxford Health NHS Foundation Trusts, regarding the use of community treatment orders (CTOs).
Results
A total of 288 surveys were completed (response rate 48%). Forty-eight (83%) psychiatrists and 142 (67%) non-psychiatrist mental health professionals were in favour of CTOs. The decision-making regarding CTOs was overwhelmingly clinically oriented for all professional groups. However, there were significant differences in views between groups regarding the effects of bureaucracy, the infringement of human rights and coercion.
Clinical implications
Multidisciplinary team involvement is crucial in decisions regarding CTOs and may protect against idiosyncratic or unhelpful practice. Further training for staff is urgently required and there may be a case for creating small local reference groups that can develop expertise and provide advice and support for clinical teams.