Addressing needs, finding solutions, implementing policy: contributions to the evidence base for modern mental health services

The National Service Framework for Mental Health (NSF) (1999) and the National Plan (2000) have stimulated a sea change in mental health care. The challenge for services is how to deliver the changes effectively to address local needs, diversity and resources. This project contributes by presenting three linked but discrete papers prepared for publication. They derive from research studies within which the author took a principal role. The first paper analyses the needs, packages of care and clinical outcomes for people in touch with mental health services in three areas of England. It asked, what can we learn about whether, and how effectively, services match need, indifferent service and socio-demographic environments? The second paper describes the implementation of two voluntary sector Assertive Outreach teams, their adherence to the Assertive Community Treatment model and outcomes for their users. It asked, how effective are voluntary sector-based Assertive Outreach teams at engaging appropriate clients and improving their clinical and social outcomes? The third paper examines the experiences and pathways through care for young black men with severe mental illness. It asked what are the key issues affecting their pathways through care and can training GP practices improve the situation? Taken together, three key findings emerged: 1. People with severe mental health problems receive greater than average support from modern mental health systems. However, more care for people with greater need will be more expensive if this consists mainly of inpatient care rather than alternative enhanced community based services. 2. Positive outcomes can be, and are, achieved, even for those with the most severe needs. However, services are not standardised and care pathways to and through them are not always clear, appropriate or smooth. Not adhering to clear, evidence-based models may compromise services' effectiveness. 3. Some vulnerable people still miss out on positive care, especially those who cannot, or will not, willingly engage with services. People with frequent admissions to hospital, homeless people, people with a dual diagnosis and young black men may not have equal access to the services they need, even when services are apparently set up specifically for them. Pawson & Tilley's 'realistic evaluation' model of contexts, mechanisms and outcomes is used as a framework for critical reflection on the project as a whole. The political and professional context for the studies, and their conduct, methodologies, findings and implications for service development are explored extensively

Clinical effects of midazolam or lidocaine co-induction with a propofol target-controlled infusion (TCI) in dogs

Objective: To evaluate the propofol requirement, cardiovascular and respiratory variables using midazolam or lidocaine with a propofol target-controlled infusion (PTCI) for induction of anaesthesia in healthy dogs. Study design: Prospective, randomized, controlled blinded clinical trial. Animals: Sixty client-owned dogs [American Society of Anesthesiologists (ASA) I–II] undergoing surgical procedures. Methods: Thirty minutes after premedication with acepromazine (0.03 mg kg−1) and morphine (0.2 mg kg−1), PTCI was started and maintained at a plasma target concentration of 1 μg mL−1. Three minutes later, dogs (n = 20 per group) received either 5 mL 0.9% sodium chloride (SG), 2 mg kg−1 of lidocaine (LG) or 0.2 mg kg−1 of midazolam (MG) intravenously (IV) as a co-induction agent. Two minutes later, suitability for endotracheal intubation was assessed. If intubation was not possible, the propofol target was increased by 0.5 μg mL−1 every 60 seconds until it was successfully achieved. Heart rate (HR), respiratory rate (fR), and oscillometric systolic arterial pressure (SAP), mean arterial pressure (MAP) and diastolic arterial pressure (DAP) were recorded immediately prior to commencing PTCI (B0), prior to intubation (BI), immediately after (T0), and at 3 (T3) and 5 (T5) minutes post-intubation. End-tidal partial pressures of carbon dioxide (Pe′CO2) were recorded at T0, T3 and T5. The occurrence of excitement at any time point was noted. Results: The median (range) propofol target concentration for endotracheal intubation was significantly lower in MG, 1.5 (1.0–4.0) μg mL−1 compared with LG, 2.5 (1.5–4.5) μg mL−1 or SG, 3.0 (2.0–5.0) μg mL−1. Heart rate, MAP, fR and Pe′CO2 were similar in the three groups at all time points. No excitement was reported in any dog. Conclusions and clinical relevance: Midazolam, but not lidocaine, provided a significant reduction in PTCI requirement for induction of anaesthesia thereby allowing successful intubation. However, cardiovascular and respiratory effects were not different between the groups

Open all hours 24-hour response for people with mental health emergencies

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