Does mental health service integration affect compulsory admissions?

Abstract. BACKGROUND: Over recent years, the number of compulsory admissions in many countries has increased, probably as a result of the shift from inpatient to outpatient mental health care. This might be mitigated by formal or collaborative relationships between services. METHODS: In a retrospective record linkage study, we compared two neighboring districts, varying in level of service integration. Two periods were combined: 1991-1993 and 2001-2003. We included patients aged 18-60, who had a first emergency compulsory admission (n=830). Their psychiatric history was assessed, and service-use after admission was monitored over a 12-month follow-up. RESULTS: Over a 10-year period, compulsory admission rates increased by 47%. Difference in relative increase between the integrated and non-integrated services was 14%. Patient characteristics showed different profiles in the two districts. Length of stay was >10 days shorter in the integrated district, where the proportion of involuntary readmissions decreased more, and where aftercare was swift and provided to about 10% more patients than in the non-integrated district. CONCLUSIONS: Services outcomes showed better results where mental healthcare was more integrated. However, limited effects were found and other factors than integration of services may be more important in preventing compulsory admissions

Psycho-immunology and HIV infection : biopsychosocial determinants of distress, immunological parameters, and disease progression in homosexual men infected with human immunodeficiency virus-1

Subjects who have tested positive for the presence of antibodies against Human Immunodeficiency Virus Type I (further abbreviated as HIV), have to live with a lifethreatening infection. At present, no definite medical cure is available that prevents progression of HIV infection. Therefore, knowledge of being infected with this virus puts a heavy burden on one's coping capabilities. Although some subjects find a way to live with their HIV infection, others have great difficulties in adjusting to it and may suffer from psychological distress. Whether or not HIV-infected subjects develop psychological distress is determined by several factors. These include for instance the experience of other stressful life events, the type of coping style that is used, and the quality of the social network. However, little is known about the relative importance of each of these variables and the way they interact in predicting distress levels. HIV -infected individuals may benefit from psychosocial interventions that aim at increasing social support and improving coping strategies. Although several types of psychosocial intervention may be effective, the relative effectiveness of different psychotherapeutic intervention strategies is unknown. We investigated factors that determine the level of distress and the effectiveness of two different psychosocial interventions in decreasing distress levels in asymptomatic and early symptomatic HIV-infected homosexual men. These studies are described in Part L In Part IT studies pertaining to the associations between psychosocial factors and progression of HIV infection are described. The length of the period until the development of Acquired Immunodeficiency Syndrome (AIDS) varies considerably among individuals and it is hypothesized that some of the variation is due to psychosocial factors. These factors may include stressful life events, psychological distress, coping styles and social support. In the event that psychosocial factors have an influence, psychosocial interventions may slow down the rate of progression, and enhance the effectiveness of medical treatments. Studying the effect of psychosocial factors on disease progression is therefore of clinical relevance. It is of theoretical relevance because insights are gained into psychoneuroimmunological relationships in a virologically and immunologically mediated disease

“Caring for a Crisis”: Care and Control in Community Mental Health

In the debate on coercion in psychiatry, care and control are often juxtaposed. In this article we argue that this dichotomy is not useful to describe the more complex ways service users, care professionals and the specific care setting interrelate in a community mental health team (CMHT). Using the ethnographic approach of empirical ethics, we contrast the ways in which control and care go together in situations of a psychiatric crisis in two CMHT's: one in Trieste (Italy) and one in Utrecht (the Netherlands). The Dutch and Italian CMHT's are interesting to compare, because they differ with regard to the way community care is organized, the amount of coercive measures, the number of psychiatric beds, and the fact that Trieste applies an open door policy in all care settings. Contrasting the two teams can teach us how in situations of psychiatric crisis control and care interrelate in different choreographies. We use the term choreography as a metaphor to encapsulate the idea of a crisis situation as a set of coordinated actions from different actors in time and space. This provides two choreographies of handling a crisis in different ways. We argue that applying a strict boundary between care and control hinders the use of the relationship between caregiver and patient in care

Evaluation of behavioral changes and subjective distress after exposure to coercive inpatient interventions

BACKGROUND: There is a lack of evidence to underpin decisions on what constitutes the most effective and least restrictive form of coercive intervention when responding to violent behavior. Therefore we compared ratings of effectiveness and subjective distress by 125 inpatients across four types of coercive interventions. METHODS: Effectiveness was assessed through ratings of patient behavior immediately after exposure to a coercive measure and 24 h later. Subjective distress was examined using the Coercion Experience Scale at debriefing. Regression analyses were performed to compare these outcome variables across the four types of coercive interventions. RESULTS: Using univariate statistics, no significant differences in effectiveness and subjective distress were found between the groups, except that patients who were involuntarily medicated experienced significant less isolation during the measure than patients who underwent combined measures. However, when controlling for the effect of demographic and clinical characteristics, significant differences on subjective distress between the groups emerged: involuntary medication was experienced as the least distressing overall and least humiliating, caused less physical adverse effects and less sense of isolation. Combined coercive interventions, regardless of the type, caused significantly more physical adverse effects and feelings of isolation than individual interventions. CONCLUSIONS: In the absence of information on individual patient preferences, involuntary medication may be more justified than seclusion and mechanical restraint as a coercive intervention. Use of multiple interventions requires significant justification given their association with significant distress

Symptomatic and functional remission and its associations with quality of life in patients with psychotic disorder in assertive community treatment teams.

Objectives: The aims of the present study were (1) to determine the proportion and characteristics of patients treated in Assertive Community Treatment teams who achieve symptomatic remission (SR) and/or functional remission (FR) and (2) to explore the association between both types of remission and (3) their bearing on quality of life (QoL). Methods: Data comprised assessments from 278 patients who were repeatedly assessed using the Positive and Negative Syndrome Scale to assess SR, the Health of the Nation Outcome Scales to assess FR, and a shortened version of the Manchester Short Assessment to assess QoL.