Longitudinal trends in using physical interventions to manage aggression and self-harm in mental health services.

OBJECTIVES: Repetitive aggression by a patient receiving mental health inpatient care is likely to elicit various patterns of response from care staff over time. This study sought to examine patterns of coercive physical intervention in relation to repeated episodes of aggression by particular patients. METHODS: A data set of 9,945 aggression and self-harm incidents over a five-year period in one mental health service in England was constructed. Incidents by a specific individual were categorized according to their position in a sequence (first, second, and so on) and by the use of physical intervention by staff to manage the incident. RESULTS: Trends in the use of physical intervention varied across settings. There was a significant tendency in general (nonforensic) services for use of physical intervention to increase in response to physical aggression (physical intervention in first versus subsequent incidents: odds ratio [OR]=.69, 95% confidence interval [CI]=.54-.90) and to decrease in response to threats (physical intervention in first threat versus subsequent threats: OR=1.62, CI=1.09-2.39). CONCLUSION: There were significant trends over time in the use of physical intervention to manage violence and self-harm. However, the dynamics behind this finding will remain unclear without further research.

Quantitative findings from a mixed methods evaluation of once-weekly therapeutic community day services for people with personality disorder.

BACKGROUND: Quantitative findings are presented from a mixed methods study of four one-day-a-week therapeutic communities for people with personality disorder (qualitative findings from the same study are reported in a separate paper). The evaluation assessed both the clinical efficacy of the model and its acceptability to service users, service employees and those who refer clients to the services. AIMS: The study aimed to clarify whether one-day therapeutic communities can be effective for people with personality disorder. METHOD: Changes in the functioning of service users who attended the day services were assessed every 12 weeks for up to 1 year. RESULTS: We found significant improvements in both the mental health and social functioning of service users. Changes in patterns of self-harm and service use were suggestive of possible underlying improvements but failed to reach significance levels. We also found evidence of the possible offset of costs within 16 months of an individual leaving one of the services. CONCLUSIONS: This study suggests one-day therapeutic communities may be both clinically- and cost-effective for people with personality disorder.

Qualitative findings from a mixed methods evaluation of once-weekly therapeutic community day services for people with personality disorder.

BACKGROUND: This paper presents qualitative findings from a mixed methods study of four one-day-a-week therapeutic communities (TCs) in the north of England for people with personality disorder. Quantitative findings from the study are presented separately. AIMS: The study aimed to ascertain whether one-day-a-week TCs can be effective in addressing the problems associated with personality disorder. METHOD: The qualitative component of the study comprised semi-structured interviews with service users, service user consultants, staff and referrers. This paper reports findings from the interviews with service users. FINDINGS: The qualitative findings indicate underlying changes in thinking that may account for some of the measurable changes in members' mental health and functioning reported in the quantitative findings. In particular, the services enable individuals to address two main problem areas: relating to others and self-harm. CONCLUSIONS: The study suggests that once-weekly TCs provide an effective therapeutic approach to the problems associated with personality disorder.

Impact of exudate and odour from chronic venous leg ulceration.

AIMS: To explore depression in people treated for chronic venous leg ulceration, and to assess the impact of excessive exudate, leading to leakage and odour, on their daily lives, overall health and quality of life. METHODS: Completion of a questionnaire and Hospital Anxiety and Depression Scale to determine the prevalence of anxiety and depression in people with chronic leg ulceration (n = 196), and interviews with 20 people living with chronic leg ulceration. FINDINGS: Odour and excessive exudate leading to leakage had an adverse effect on patients' psychological state, leading to feelings of disgust, self-loathing and low self-esteem. CONCLUSION: Chronic leg ulcers disrupt patients' lives and restrict their social lives, leading to social isolation and depression. Healthcare professionals should better understand the impact of symptoms such as odour and exudate leakage on patients' mental health, physical health and healing.

Self-harm or attempted suicide? Do suicide notes help us decide the level of intent in those who survive?

A suicide note can be a very powerful communication to the family and friends of the deceased. However, in a number of cases a note is written by an individual who survives an apparent act of attempted suicide. These cases will frequently present at a hospital accident and emergency department (A&E) and will be classified as incidents of self-harm. Despite the importance of suicide notes in determining the motivation of people who die by their own hand, research findings have been patchy and ambiguous. This is also true when someone writes a suicide note but survives an act of apparent attempted suicide. In such cases the question is raised whether the person truly intended to complete suicide or whether their actions had some other motivation. This paper seeks to throw some light on this matter by examining the meaning that should be attributed to a suicide note when it has been written by someone who presents at a hospital accident and emergency department after intentionally harming or injuring themselves. More specifically, the study addresses the question whether the presence of a suicide note in such cases is more likely to reflect a serious act of attempted suicide than it is to reflect an act of self-harm with low suicidal intent. Using a large dataset collected over a 5-year period the authors compare note-leavers with self-harm patients who have not written a suicide note, focussing on the presence or absence of other known risk indicators for completed suicide in each of the two patient groups. The aim is to test the hypothesis that patients presenting at A&E with self-harm who have left a suicide note, are at higher risk of future completed suicide than are self-harm presenters who have not left a note. The conclusion reached is that clinical staff in the emergency department should err on the side of caution and regard the presence of a suicide note as an indication of a failed but serious attempt at suicide.

Depression in patients with chronic venous ulceration.

As leg ulcer research has generally focused on aspects of treatment, the psychosocial impact of leg ulceration remains understudied. This article reports the findings of a study exploring the prevalence of anxiety and depression in 190 patients with chronic venous ulceration across 9 Trusts in the northwest of England. The hospital anxiety and depression scale (HADS) was used to screen patients for the presence of anxiety and depression using a cut-off point of 9 for level of "caseness". A total of 52 (27%) people scored as depressed while 50 (26%) scored as anxious. The two symptoms which appeared to be associated with anxiety and depression were pain and odour, while there was no association found between living alone, mobility and exudate. These findings suggest that the focus of care needs to be redirected for many patients for whom cure is not an option, but who are left to live with a chronic wound. Furthermore, psychological factors, including depression, should be a focus in assessment and ongoing review of patients with leg ulceration.

A survey of psychological wellbeing in an adult population.

The British government has called on all NHS staff to help promote good psychological wellbeing in the population. This article reports results from a survey conducted in Merseyside, England, into the prevalence of poor psychological wellbeing across a large part of the region. People registered with one of five Merseyside primary care trusts were stratified by age group and deprivation, and a questionnaire was mailed to 28,000 who had been randomly selected from those aged 15 or over. A total of 11,168 (45%) completed questionnaires were returned. Of these, 2,442 (21.9%) respondents rated their psychological wellbeing as fairly poor or very poor. Mean levels of psychological wellbeing were significantly worse in a number of readily identifiable groups within the population, but overall, the lowest wellbeing ratings were concentrated in the most socioeconomically deprived quartile. We make a number of practical suggestions for the role of the community nurse in promoting good psychological wellbeing in patients. We also highlight our finding that socioeconomic deprivation was strongly associated with poor psychological wellbeing, which was in turn associated with a lifestyle high in risk factors for non-communicable diseases.

Self-harm patients who take early discharge from the accident and emergency department: how do they differ from those who stay?

There is evidence that patients presenting at a hospital Accident and Emergency (A&E) department with self-harm are considerably more likely than many others to discharge themselves before their assessment or treatment are complete. This paper reports a study that is part of a broader analysis of all self-harm presentations to a hospital A&E department over a five-year period. Self-harm patients who chose to remain for assessment and treatment were compared with those who chose to discharge themselves prematurely. We found a mean proportion of 18% of self-harm patients per annum took early discharge between 1996 and 2000 and noted that these patients were more likely than other self-harm patients to have consumed alcohol in the hours immediately prior to their self-harm and attendance at the hospital. Self-harm patients who took early discharge were less likely than other self-harm patients to be admitted to an in-patient bed and less likely to receive a psychosocial assessment from a mental health specialist. We also found that aftercare arrangements were significantly less likely to be made for those patients who took early discharge. Some suggestions are made about approaches that clinical staff could adopt in order to reduce early discharge in self-harm patients.

The impact of community mental health reform on service users: a cohort study.

British mental health services have undergone considerable reform in recent years. This paper reports a study designed to assess the impact of these changes on service users. The functioning of 100 randomly selected users of community mental health services in a North Wales town was assessed before the advent of two significant service changes - the establishment of a local Community Mental Health Team (CMHT) and the introduction of the main community care reforms in April 1993. Repeat assessments of sample members were made on three further occasions over the following 27 months, with a 9-month interval between each. Comparison of baseline and follow-up data suggested that services were appropriately targeted on users with a severe and enduring mental illness and that the functioning of this client group was successfully maintained over the study period. However, the establishment of a CMHT was associated with a temporary fall in social functioning, quality of life and satisfaction with services and there was no evidence to conclude that organizational reforms had led to an improvement in user outcomes in the medium term. Future mental health reorganization should be based on the evidence of research which includes an assessment of the impact of reforms on service users.

Registering concern: the case of primary care registers for people with severe and enduring mental illness.

As the focus of mental health care has shifted from the hospital to the community, so the importance of effectively targeting resources on those with the greatest need has become paramount. One approach to identifying and targeting people deemed to have severe and enduring mental health problems is the establishment of mental health case registers at primary care level. This paper raises a number of conceptual issues associated with these registers and, on the basis of the available literature, offers suggestions to guide those who are contemplating their introduction.