Psychological and social evaluation in cases of deliberate self-poisoning admitted to a general hospital.

In a prospective clinical trial 312 cases of self-poisoning (276 patients) consecutively admitted to hospital were randomly allocated to medical teams or to psychiatrists for an initial psychiatric assessment and a decision as to "disposal." Junior doctors and nurses received some instruction in this work. Both groups of assessors asked for help from social workers when necessary. Once the medical teams had completed their assessments, psychiatrists provided most of the hospital treatment. Follow-up at one year showed no significant difference between the two groups of patients in the numbers who repeated their self-poisoning or self-injury (or both), or committed suicide. Provided junior doctors and nurses are taught to assess self-poisoned patients, we think medical teams can evaluate the suicidal risk and identify patients requiring psychiatric treatment or help from social workers, or both. Contrary to the Department of Health''s recommendation that all cases of deliberate self-poisoning should be seen by psychiatrists, we have reached the conclusion that physicians should decide for each of their patients if specialist psychiatric advice is necessary.     

Working with the Family Doctor: A Programme for Mental Health

A new type of assessment for mental health in four Scottish counties has been based on multidisciplinary teams comprising psychiatrists, psychiatric social worker, nursing administrator, and a secretary. Each team collaborated with 15 to 20 family doctors and they established four main patterns of contact: around an outpatient clinic; by informal availability; by administrative and teaching seminars; or by regular consultation sessions. This improved contact was found to help both the team and the family doctors and reduced the number of patients admitted to hospital and the length of their stay and the number of urgent referrals. It emphasizes the need for team work in mental health care and that the hospital needs to remain in touch with the outside community.     

An evaluation of the multidisciplinary approach to psychiatric diagnosis in elderly people.

OBJECTIVE--To determine the accuracy of psychiatric diagnoses made by two community psychogeriatric teams operating a multidisciplinary assessment procedure. DESIGN--Comparison of team diagnosis with independent formal assessment and consensus diagnosis by research psychiatrists. SETTING--Two community psychogeriatric teams with similar operational policies in an inner London health district. SUBJECTS--100 people aged 65-90 (70 women) newly referred to the teams. MAIN OUTCOME MEASURES--Concordance between team and research diagnoses. RESULTS--Agreement between team and research diagnoses ranged from 90% to 99% for the specific psychiatric disorders studied. There was no significant difference between medical and non-medical team members in their diagnostic performance compared with the research psychiatrists. Increased diagnostic accuracy by team members was associated with longer experience of team working, regardless of the team members'' professional background. CONCLUSIONS--The multidisciplinary approach to the assessment of referrals to these community teams for the elderly is not associated with misdiagnosis of psychiatric disorder.     

Psychiatry in General Practice

Psychiatrists should include the family doctor in their plans for future psychiatric services. The general practitioner now treats most of the patients who seek help for psychiatric disorder and he could not give up his psychiatric practice even if he wanted to. Furthermore, there are not now nor will there ever be enough psychiatrists to take over all patients with mental ills. Most emotionally disturbed patients can be better handled by their family physicians than by a specialist.To provide the best care for emotionally disturbed people the communication between family doctors and psychiatrists must be improved. The specialist must acknowledge the importance of the general practitioner''s role in psychiatric diagnosis and treatment and give him more help. Medical schools must provide better undergraduate and postgraduate psychiatric training for the students who will become family doctors. Health plans and other prepayment agencies should properly compensate the general practitioner for giving psychiatric treatment. The specialist in psychiatry should consult more readily with the general practitioner and help him carry out some of the therapy. General hospitals should permit family doctors to admit mental patients to psychiatric wards in a general hospital and to carry out psychiatric treatment with the help of the specialist in psychiatry.     

Nurse therapists in behavioural psychotherapy.

Five registered mental nurses (R.M.N.s) were trained over two years to become behavioural psychotherapists for adult neurotic disorders. They achieved results comparable to those obtained with similar patients and methods by psychologists and psychiatrists. Similar results were maintained when over a third year the therapists were seconded to work in four hospitals and a general practice. Patients were satisfied at being treated by nurses. After initial teething difficulties nurse therapists became valuable members of treatment teams during both training and secondment, becoming accepted by most nurses, psychologists, and psychiatrists with whom they came into contact. The training of further nurse therapists would facilitate treatment of many disabled neurotics who would otherwise go without effective treatment. Training nurse therapists takes less time and money than training psychologists and psychiatrists because less of their education is redundant to the skills involved. The pool of R.M.N.s suitable for training is much larger than that of psychiatrists and psychologists. The nurse therapists can be integrated relatively easily into treatment teams. The present nursing structure imposes restrictions on the advancement of clinical nurse specialists and a clinical tree is badly needed parallel with present administrative and teaching hierarchies. An 18-month course in adult behavioural psychotherapy has been recognized by the Joint Board of Clinical Nursing Studies for England and Wales so that nurse therapists seem destined to be a lasting feature of future treatment teams.     

Family Life and Social Medicine: Discourses and Discontents Surrounding Puebla’s Psychiatric Care

Drawing on clinical data from 15 months of on-site participant observation in the only public psychiatric hospital in the state of Puebla, Mexico, this article advances our understanding of globalization in relation to psychiatry. I challenge the construction of psychiatry as only treating the individual patient and provide grounded doctor-patient-family member interaction in a Mexican psychiatric clinic in order to review what happens when doctors cannot interact with patients as atomized individuals even though in theory they are trained to think of patients that way. Challenged by severe structural constraints and bolstered by lessons from other nations’ efforts at deinstitutionalization, psychiatrists in Puebla push to keep patients out of the inpatient wards and in their respective communities. To this end, psychiatrists call upon co-present kin who are identified both as the customer and part of the caretaking system outside the clinic. This modification to the visit structure changes the dynamic and content of clinical visits while doctors seamlessly respond to unspoken beliefs and values that are central to local life, ultimately showing that efforts to define a “global psychiatry” informed by global policy will fail because it cannot exist in a uniform way—interpersonal interaction and personal experience matters.     

évaluation des pratiques professionnelles dans le cadre de l’accréditation des établissements psychiatriques

As regards evaluation of professionnal practices (EPP), Formep’s has decided to stay in the limits of psychiatric institutions, for reason of experience. Every medical doctor working in these institutions is concerned by evaluation, but also institutions in the specific framework of V2 44, 45 and 46 references. The EPP is multidisciplinary and involves everybody who takes part of patient caring. Formep’s is adviser, training agent, and partner. Follow-up takes place both on-site and off-site all along the EPP, by a team including psychiatrists, medical practitioners, quality and risk management engineers. They are all experienced to work in psychiatric institutions. Formep’s program includes preliminary and definitive choice of themes, putting methology is place, work of teams, initial analysis of results and deviations, further work of teams, final analysis, which purpose is to improve practices and therefore medical benefit.     

Palliative care: views of patients and their families.

OBJECTIVE--To investigate the current problems and needs of terminally ill cancer patients and their family members, and to discover their views of hospital, community, and support team services. DESIGN--Prospective study of patients and families by questionnaire interviews in the patients'' homes. SETTING--Inner London and north Kent (London suburbs). SUBJECTS--65 Patients, each with a member of their family or a career. MAIN OUTCOME MEASURES--Ratings of eight current problems and ratings and comments on three services-hospital doctors and nurses, general practitioners and district nurses, and the support team staff-obtained after a minimum of two weeks'' care from palliative care support teams. RESULTS--Effect of anxiety on the patient''s nearest career. and symptom control were rated as the most severe current problems by both patients and families; a few patients and families identified other severe problems. Families'' ratings of pain control, symptom control, and effect of anxiety on the patient were significantly worse than the patients'' ratings (p less than 0.05). Support teams received the most praise, being rated by 58 (89%) patients and 59 (91%) of family members as good as excellent. General practitioners and district nurses were rated good or excellent by 46 (71%) patients and 46 (71%) family members, but six (9%) in each group rated the service as poor or very bad, and ratings in the inner London district were significantly worse than those in the outer London district. Hospital doctors and nurses were rated good or excellent by 22 (34%) patients and 35 (54%) of family members, and 14 (22%) patients and 15 (23%) family members rated this service as poor or very bad. Negative comments referred to communication (especially at diagnosis), coordination of services, the attitude of the doctor, delays in diagnosis, and difficulties in getting doctors to visit at home. Family members were more satisfied with the services than were patients. CONCLUSIONS--Palliative care needs to include both the patient and family because the needs of the family may exceed those of the patient. Support teams and some hospital and community doctors and nurses met the perceived needs of dying patients and families, but better education and organisation of services are needed.     

Psychiatric illness in inpatients with neurological disorders: patients' views on discussion of emotional problems with neurologists.

The prevalence of psychiatric morbidity in inpatients with neurological disorders and the extent to which it is detected by neurologists were measured by using a two stage model of psychiatric assessment and from information recorded in the patients'' medical notes. The prevalence of psychiatric morbidity was estimated as 39%, of which 72% was unrecognised by the neurologists. Only a minority of patients with an uncertain physical diagnosis had a psychiatric illness, showing the error in assuming that a patient''s physical symptoms arise from a psychological disturbance if an organic aetiology cannot be determined. When the patients were interviewed on their discharge from hospital they were divided on whether they had wished to discuss their mood with neurologists while they were in hospital. The reasons that they gave suggested that interactions between patients and doctors and the lack of ward facilities for private consultations with doctors are important determinants of hidden psychiatric morbidity in medical inpatients.     

Quality Improvement Report: Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan teaching hospital

Problem In-hospital cardiac arrest often represents failure of optimal clinical care. The use of medical emergency teams to prevent such events is controversial. In-hospital cardiac arrests have been reduced in several single centre historical control studies, but the only randomised prospective study showed no such benefit. In our hospital an important problem was failure to call the medical emergency team or cardiac arrest team when, before in-hospital cardiac arrest, patients had fulfilled the criteria for calling the team.Design Single centre, prospective audit of cardiac arrests and data on use of the medical emergency team during 2000 to 2005.Setting 400 bed general outer suburban metropolitan teaching hospital.Strategies for change Three initiatives in the hospital to improve use of the medical emergency team: orientation programme for first year doctors, professional development course for medical registrars, and the evolving role of liaison intensive care unit nurses.Key measures for improvement Incidence of cardiac arrests.Effects of the change Incidence of cardiac arrests decreased 24% per year, from 2.4/1000 admissions in 2000 to 0.66/1000 admissions in 2005.Lessons learnt Medical emergency teams can be efficacious when supported with a multidisciplinary, multifaceted education system for clinical staff.     

WPA guidance on how to combat stigmatization of psychiatry and psychiatrists

In 2009 the WPA President established a Task Force that was to examine available evidence about the stigmatization of psychiatry and psychiatrists and to make recommendations about action that national psychiatric societies and psychiatrists as professionals could do to reduce or prevent the stigmatization of their discipline as well as to prevent its nefarious consequences. This paper presents a summary of the Task Force’s findings and recommendations. The Task Force reviewed the literature concerning the image of psychiatry and psychiatrists in the media and the opinions about psychiatry and psychiatrists of the general public, of students of medicine, of health professionals other than psychiatrists and of persons with mental illness and their families. It also reviewed the evidence about the interventions that have been undertaken to combat stigma and consequent discrimination and made a series of recommendations to the national psychiatric societies and to individual psychiatrists. The Task Force laid emphasis on the formulation of best practices of psychiatry and their application in health services and on the revision of curricula for the training of health personnel. It also recommended that national psychiatric societies establish links with other professional associations, with organizations of patients and their relatives and with the media in order to approach the problems of stigma on a broad front. The Task Force also underlined the role that psychiatrists can play in the prevention of stigmatization of psychiatry, stressing the need to develop a respectful relationship with patients, to strictly observe ethical rules in the practice of psychiatry and to maintain professional competence.     

Psychiatry in the Soviet Union

The services for chronically handicapped people with psychiatric disorders in the Soviet Union are described. The system is based upon a network of community units, each of which includes a day centre, a follow-up clinic, and a sheltered workshop. British services could profitably learn from the experience of these units. The diagnostic system used by many Soviet psychiatrists is different from that incorporated in the International Classification of Diseases. In particular, the term “schizophrenia” is used to describe conditions which British psychiatrists would label in other ways.This clinical difference partly explains the different concept of “criminal responsibility,” but another large component of the difference is political rather than medical. There are also variations from British practice in certain juridical procedures. These differences together make Soviet psychiatric practice in the case of political dissenters unacceptable to most British psychiatrists. It is too soon to say that frank discussions of these matters could not lead to improvement. British and Soviet psychiatrists still have something to learn from each other.     

Therapeutic Abortion in a Canadian City

In a city of 200,000, 119 therapeutic abortions were performed during the period 1962 to 1968. Multiple grounds were commonly given for abortion; these often included depression. Very frequently the absence of support from other people was a factor in deciding to perform abortion. Only five psychiatrists were involved in 82 cases seen in psychiatric consultation. Abortions carried out for more conventional medical reasons, including rubella, decreased in 1967 and 1968 but there was an overall increase beginning in 1967. In the later years of the study (1967-68) a higher proportion of patients were single, younger, had had no previous pregnancy and were aborted later in pregnancy; more were sterilized.A marked increase in abortion rate related particularly to the activity of one of the psychiatrists.One hundred and sixty-six abortions were performed in 1969; a comparable figure (179) was obtained from one other Canadian centre; another centre had performed more (291); two others, 109 and 63; the combined total for 27 other centres from whom replies were obtained was 186.     

The medical student as behavioural psychotherapist.

A group of medical students were randomly selected from a larger group to carry out behaviour therapy under supervision. Ten patients with phobic disorders and two with obsessive-compulsive neurosis were treated, and the results, assessed by ratings of proved reliability, compared favourably with other studies in which psychiatrists or nurses acted as therapists. A questionnaire survey showed that students involved in therapy had a more favourable opinion about this kind of treatment than those receiving only theoretical instruction. The results suggested not only that medical students make good behavioural psychotherapists but also that the subject is a worthwhile training experience which warrants inclusion in the curriculum.     

医务人员职业暴露危险因素分析及对策

为了探讨医务人员职业暴露危险因素及防护对策,对长江大学附属一医院2008年1月1日—2009年12月31日上报的职业暴露依据科室分布、感染途径及暴露原因进行了分析。结果显示,该医院共发生医务人员职业暴露94例,其中,护士62例,医生25例,其它人员7例,护士高于医生;35岁以下年轻护士及医生占88例,35岁以上者6例;大学本科以下学历60例,中级职称以下人员75例。因此需对医务人员加强培训,提高自我保护意识,规范操作,加强管理,注重预防。     

Do general practitioners miss dementia in elderly patients?

General practitioners and community nurses were asked to rate the likelihood of dementia for each of their elderly patients. Cases of dementia were identified by research psychiatrists using the Cambridge mental disorders of the elderly examination (CAMDEX), a new structured diagnostic interview. General practitioners correctly identified dementia as at least a possibility in 121 of the 208 cases found. Nevertheless, they mistakenly rated as demented several patients suffering from functional psychiatric disorders, in particular depression. Community nurses correctly identified dementia as at least a possibility in 64 of the 74 demented patients known to them, but they incorrectly suspected dementia in a greater proportion of instances. Both general practitioners and families appeared to have low expectations of what general practice has to offer demented elderly people. General practitioners should take the initiative in diagnosing dementia in very elderly patients who show signs of the condition. In some cases it may be secondary to treatable disorders, and in others all that may be required are understanding, support, and advice to families.     

Diagnostic Overshadowing and Other Challenges Involved in the Diagnostic Process of Patients with Mental Illness Who Present in Emergency Departments with Physical Symptoms – A Qualitative Study

We conducted a qualitative study in the Emergency Departments (EDs) of four hospitals in order to investigate the perceived scope and causes of ‘diagnostic overshadowing’ – the misattribution of physical symptoms to mental illness – and other challenges involved in the diagnostic process of people with mental illness who present in EDs with physical symptoms. Eighteen doctors and twenty-one nurses working in EDs and psychiatric liaisons teams in four general hospitals in the UK were interviewed. Interviewees were asked about cases in which mental illness interfered with diagnosis of physical problems and about other aspects of the diagnostic process. Interviews were transcribed and analysed thematically. Interviewees reported various scenarios in which mental illness or factors related to it led to misdiagnosis or delayed treatment with various degrees of seriousness. Direct factors which may lead to misattribution in this regard are complex presentations or aspects related to poor communication or challenging behaviour of the patient. Background factors are the crowded nature of the ED environment, time pressures and targets and stigmatising attitudes held by a minority of staff. The existence of psychiatric liaison team covering the ED twenty-four hours a day, seven days a week, can help reduce the risk of misdiagnosis of people with mental illness who present with physical symptoms. However, procedures used by emergency and psychiatric liaison staff require fuller operationalization to reduce disagreement over where responsibilities lie.     

Ignoring the obvious: doctors' wives as patients.

There is a widely held belief among doctors and nurses that when a colleague is in hospital, if anything can go wrong during the course of his illness it invariably will. To investigate this belief, we studied prospectively a group of pregnant doctors and doctors'' wives, comparing the number of obstetric, paediatric, and psychiatric complications with those in two control groups of similar social class, race, and parity. These were teachers and lecturers and a group of State registered nurses. The occurrence of obstetric and paediatric problems was similar in the three groups. Psychiatric problems, however, were more common among teachers and lecturers (p less than 0.001); this difference was due to the way the nurses on the postnatal wards failed to report mild psychiatric problems among doctors'' wives to their colleagues. This difference was not related to the amount of preferential treatment that doctors and doctors'' wives received while in hospital.     

Feasibility and Impact of Doctor-Nurse Task Delegation in Preventive Child Health Care in the Netherlands,a Controlled Before-After Study

BackgroundIn the Netherlands a need is felt for more flexible Child Health Care services, both efficient and tailored to needs. We set up a study on impact and feasibility of task delegation to child health care nurses performing all regular checkups on children aged 2 months to 4 years. Abnormal findings were discussed with the attending child health care doctor. This article describes impact and feasibility of this task delegation from four viewpoints: competences of nurses; percentage of children assigned to the nurse; change in abnormal findings and referrals; experiences of professionals and parents.MethodsTwo experiment teams and two control teams were compared before and after starting task delegation. Nurses in the experiment teams were trained to carry out regular checkups on healthy children. Assignment to the experiment schedule was a joint decision by doctor and nurse. Nursing competences were measured by means of questionnaires. Percentage of children assigned to the nurse and screening results of eyes, heart, hips, growth and development were extracted from the electronic health record. Difference in change was compared between experiment and control teams. Mann-Whitney tests and logistic generalized estimating equations were used to test for significance. Experiences of professionals and parents were evaluated through focus group interviews, which were subjected to a qualitative analysis.ResultsNurses in the experiment regions showed improvement in medical screening skills. No difference in change was perceived in general nursing competences. In the experiment group, 69% of all children were assigned to the nurse. There were no significant differences in change in the percentages of abnormal findings or referrals in the experiment teams compared to the control teams, except for hips. Interviews showed that both doctors and nurses thought positively of the new working method, yet made some recommendations for improvements. Parents felt well-informed and experienced an equal level of proficiency but less continuity in person.ConclusionThis experiment shows that task delegation from doctor to nurse in preventive child health care is feasible. It is important to pay attention to the acceptation process of professionals during implementation. More investigation is needed in order to assess effectiveness and efficacy of task delegation.