International mental health outcomes and benchmarking using the FACE (functional analysis of care environments) approach.

This article describes and compares the nature and severity of problems encountered by persons receiving mental health services in the United Kingdom and Australia, and the outcome of their treatment. The perspective of service providers and service users in the two countries was strikingly similar. Treatment was effective in alleviating problems with social circumstances, and in increasing adaptive and interpersonal functioning. Treatment was less effective in addressing psychological or physical problems. Service users in the United Kingdom were more involved in developing their treatment care plan than those in Australia. The study demonstrates how data required for benchmarking and outcome evaluation purposes can be generated as part of routine clinical processes.

About FACE: the applications of a structured approach to mental health information.

This article describes the Functional Analysis of Care Environments (FACE), and demonstrates some of its' applications in mental health services. FACE is a recording and measurement technology designed to integrate clinical and management information. Its major features are a multi-axial framework and measurement tools for assessment and outcome recording. Structured information about mental and physical well being, social circumstances and environmental functioning was recorded for 520 clients receiving either 'assertive' or 'community' forms of mental health care. The information generated formed the basis for comparison between clients, identified significant differences between the two client groups, and highlighted treatment effectiveness.

Mental health status of the South Australian population.

OBJECTIVE: To determine, by the use of a telephone survey, the mental health status of SA adults (18+ years) using the GHQ-28, SF-12 and self-report as indicators of mental health, and to examine risk factors for mental health morbidity. SAMPLE: A random representative sample of South Australian adults selected from the Electronic White Pages. Overall, 2,501 interviews were conducted (74.0% response rate). RESULTS: Overall, 19.5% of respondents had a mental health problem as determined by the GHQ-28, 11.8% as determined by the mental health component summary score of the SF-12 and 11.9% self-reported a mental health condition. The percentage of people with a mental health problem who had used a psychologist or a psychiatrist in the previous 12 months was 9.6% for people diagnosed by the GHQ-28, 16.2% by SF-12 and 23.7% for self-report. The logistic regression analyses undertaken to describe people with a mental health problem as determined by the GHQ-28 and to describe people who visited a psychologist or psychiatrist produced different age categories, demographic and co-morbidity indicators. Variables found in both analyses included living in the metropolitan area, being economically inactive and being a high user of health services. CONCLUSIONS: One in five South Australian adults has a mental problem. Although the prevalence is higher for younger age groups, older adults are more likely to visit a psychologist or a psychiatrist. IMPLICATIONS: Telephone interviewing produces robust indicators of the prevalence of mental health problems and is a cost-effective way of identifying prevalence estimates or tracking changes over time.

The development of the Louis MACRO (Mother and Child Risk Observation) forms: assessing parent-infant-child risk in the presence of maternal mental illness.

OBJECTIVE: The theoretical framework and psychometric properties of the MACRO (Mother and Child Risk Observation) 1 and 2 forms (age 0 to 4 year) are presented. The MACRO forms provide ratings on five domains--three related to parenting, two on infant (or child) characteristics and maternal mental state. Case vignettes illustrate their clinical utility. METHOD: Ratings on the MACRO of 110 mother-infant and 85 mother-toddler consecutive admissions to a South Australian psychiatric in-patient mother-infant unit provided data on internal consistency, interrater, and test-retest reliability. RESULTS: Internal consistency was between .79 and .95 for all MACRO domains. Item-total correlations were between .39 and .90 with the exception of one item. Social Support. Distributions of item scores indicated acceptable discrimination. Interrater reliability was .79 or above for all domains. Test-retest reliability after 7 days was .71 or above. CONCLUSIONS: Preliminary psychometric investigations of the MACRO was favorable. Should further validity investigations prove satisfactory, the MACRO will provide a valuable clinical and research tool. The MACRO offers a convenient framework for assessing risk and interpreting the impact of maternal mental illness upon children within a context that permits consideration of factors such as illness severity, parenting practices, and child contribution to outcome.

A casemix for mental health services: the development of the mental health and substance abuse components of the Australian national diagnosis-related groups.

OBJECTIVE: To describe the development of the mental health and substance abuse sections of the version of the Australian casemix system, Australian national diagnosis-related groups 3 (AN-DRG 3), released in July 1995. METHOD: The guiding principles and data sources used to construct the mental health and substance abuse components of AN-DRG 3 are described by the group who undertook that task. The group used data sets of patients separating from hospitals throughout Australia, and from hospitals in South Australia, to examine the capacity of existing and revised diagnosis-related groups (DRGs) to predict patients' lengths of hospital stay. They also reviewed the lists of conditions allowed as complicating and comorbid conditions within the AN-DRG system. RESULTS: A variety of recommendations were made including: moving organic mental disorder DRGs to a neuroscience area of the AN-DRG; completely reorganising the mental health section of the casemix; creating a number of narrowly defined DRGs covering areas such as schizophrenia, major affective disorders, anxiety disorders and eating disorders, while allowing for a limited number of more heterogenous DRGs and simplifying substance abuse DRGs into groups covering alcohol and other substances, and differentiating intoxication and withdrawal from abuse and dependency. CONCLUSIONS: A casemix dialect based on clinical diagnosis, which describes mental health and substance abuse problems in terms which should be familiar to clinicians, has been developed. Its applications and limitations are briefly discussed.

Casemix and affective disorders: a comparison of private and public psychiatric systems.

OBJECTIVE: To determine whether there is a difference in length of stay for patients with affective disorders between private and public psychiatric hospitals. METHOD: The casemix Australian national diagnosis-related group (AN-DRG) diagnoses of all inpatient separations from private and public psychiatric hospitals in South Australia for 1 year were abstracted from records. The average length of stay for patients with affective disorders was calculated. RESULTS: There was no significant difference in the average length of stay for patients with affective disorders treated in private and public psychiatric hospitals. CONCLUSIONS: These results should allay fears that the treatment of patients with affective disorders in any particular treatment setting will be compromised by the introduction of casemix.

Psychiatric and substance abuse disorder diagnoses as predictors of length of hospital stay.

The mental health and substance abuse components of AN-DRG 3 were examined using data from all inpatient separations in two Australian States over a two-year period. Assignment to a mental health or a substance abuse diagnosis related group (DRG) predicted about 20 per cent of the variability in average length of stay of patients treated for such conditions. Assignment to a substance abuse DRG was a much less robust predictor of length of hospital stay than assignment to a mental health DRG. There was little variation between years or States. Day-only intent patients were excluded, as were long-stay outliers identified using an inter-quartile range trimming process. Psychiatric DRGs are similar to a number of other non-surgically focused diagnosis related groups in their capacity to predict length of hospital stay. They are likely to remain an important component of casemix classification systems.

Making casemix work for psychiatry.

Providers of mental health and substance abuse care cannot afford to ignore the existence of casemix descriptions of their services. As casemix comes to be the predominant language used to describe the products of hospital care, its use will inevitably impinge upon psychiatric services. The psychiatric components of the Australian national diagnosis-related groups classification 1 and 2 (AN-DRG 1 and 2) do not describe the relevant products with great accuracy. We review some possible reasons for this and the effects on the homogeneity of resource consumption of technical procedures, such as trimming of data sets, in the context of the current casemix system and that proposed for AN-DRG-3. The evolution of a casemix system which does justice to current and future psychiatric services will be a complex process. Some of the crucial areas are discussed. Clinicians involved in mental health and substance abuse care must continue to advocate for the resources and effort needed to improve casemix information in their area.

Patient satisfaction among the residential population of a psychiatric hospital.

Patient satisfaction with the interpersonal and amenities aspects of care in a psychiatric hospital was investigated in an Australian setting. The study was carried out among the long-term residential population of a psychiatric hospital and involved 112 out of 195, or 57% of all eligible patients. Cluster analysis identified seven major groups of related items concerning the patients' views of hospital life and their perception of problems. The study largely replicated the findings of an English investigation, showing that many of the same underlying clusters of satisfaction-dissatisfaction with life in a psychiatric hospital emerge, across widely geographically separated settings. The results from the present study further indicate that improvements in autonomy for the patients and a greater say in the running of wards are more important factors contributing to satisfaction with life in a hospital than the physical surroundings themselves.

Virtue rewarded: reinforcement and punishment in an acute psychiatric admission ward.

This study evaluated the naturally occurring behaviour of psychiatric patients in an acute psychiatric setting. Direct behavioural observations were carried out to determine the amount of time patients spent in interaction, with whom they interacted, and the nature of the interaction. Also examined were each respondent group's type and rate of interactive behavior. For much of the time no interactive behaviour was observed to occur, but much of the behaviour exhibited by patients was socially appropriate. When social interactions did occur, both fellow patients and staff tended to reinforce appropriate behaviour. However, nurses reinforced inappropriate crazy behaviour much less than did fellow-patients or non-nursing staff. Treatment implications are discussed.

Patient interactions in four psychiatric wards.

This article describes the interactions between patients and between patients and staff in 4 psychiatric wards. Two of the wards are acute admission units and 2 are for long-stay chronic patients. The hospital is diagnostically streamed so that not only does the average length of stay vary between wards but so, for one ward, does the predominant diagnostic group. Patient interactions were analysed in terms of 5 major interactional categories: individual verbal, individual nonverbal, group verbal, group nonverbal and physical. The results show that, although there was little change in the overall level of verbal interaction as a function of chronicity, there were large shifts in patient-patient and staff-patient interaction rates. Variations between the 4 wards on the 4 other interactional categories are explained in terms of the known diagnostic characteristics of the patients.

A quantitative study of nursing staff interactions in psychiatric wards.

Data from 2 studies investigating staff-patient and staff-staff interaction rates are presented. In the first the staff-patient ratio was varied by holding patient numbers constant and systematically varying staffing levels. The results showed that although the percentage of time nurses spent interacting with patients did not change, staff-staff interaction increased as a function of increased staffing levels. In the second study the interaction rates from 4 wards were combined. These data showed that, as in the first study, staff-patient interaction remained constant, as staff numbers increased, whilst staff-staff interaction increased. However, unlike the first study, when analysed in terms of the staff-patient ratio, both categories of interaction increased as the staff-patient ratio increased.

Evaluation of a residential behavioral program for behaviorally disturbed, mentally retarded young adults.

The Adaptive Behavior Scale (ABS) was used to evaluate a three-level token economy designed to modify some aspects of the behavior of behaviorally disturbed young adults of borderline intelligence. The ABS was administered to all those referred to the program. Those admitted were retested upon discharge and 6 months later. Those not admitted, or rejected, were retested 12 months later. Results showed that initially there were few significant differences in scores between the accepted and rejected groups. Following treatment, however, large improvements occurred in those areas that were logically related to target behaviors within the token economy. These gains were maintained on follow-up. The rejected group showed no improvements over the same period.

The role of ward structure on nursing staff behaviours: an observational study of three psychiatric wards.

Variable rates of staff-patient interaction were found between three wards, which differed in the degree of programme structure, staff-patient ratios, and patient chronicity. Highest rates of staff-patient interaction occurred where a highly structured ward programme operated in a closed ward with chronically disturbed patients, and this was more likely to increase as staff-patient ratios decreased. The lowest staff-patient interaction rates occurred in acute, open and closed wards. Further, acute ward patients received negligible attention from nurses in terms of staff-patient interaction after 10 days following admission.