Spinal cord injury rehabilitation and mental health, SCReaM.

AIMS: The aim of the study was to investigate whether people with a pre-existing mental health disorder (MHD) benefit from rehabilitation following a spinal cord injury (SCI) and how their outcomes differ from those without a pre-existing MHD. METHODS: Rehabilitation outcomes of a cohort of patients with pre-existing MHD discharged from the London SCI Centre over a 6-year period were investigated. A retrospective matched case-control study design was used to compare the Spinal Cord Independence Measure III between those with an SCI and pre-existing MHD and those without and both compared with published expected outcomes. RESULTS: The study found that, overall, those with MHD do benefit from SCI rehabilitation and that their outcomes do not significantly differ from those without MHD. Furthermore, the outcomes were favourable when compared with published expected outcomes. CONCLUSION: Having a pre-existing MHD does not preclude patients with an SCI from benefiting from rehabilitation. These findings are an important basis on which to ensure equal access to rehabilitation for patients with a pre-existing MHD.

Mental health services commissioning and provision: Lessons from the UK?

The commissioning and provision of healthcare, including mental health services, must be consistent with ethical principles - which can be summarised as being "fair", irrespective of the method chosen to deliver care. They must also provide value to both patients and society in general. Value may be defined as the ratio of patient health outcomes to the cost of service across the whole care pathway. Particularly in difficult times, it is essential to keep an open mind as to how this might be best achieved. National and regional policies will necessarily vary as they reflect diverse local histories, cultures, needs and preferences. As systems of commissioning and delivering mental health care vary from country to country, there is the opportunity to learn from others. In the future international comparisons may help identify policies and systems that can work across nations and regions. However a persistent problem is the lack of clear evidence over cost and quality delivered by different local or national models. The best informed economists, when asked about the international evidence do not provide clear answers, stating that it depends how you measure cost and quality, the national governance model and the level of resources. The UK has a centrally managed system funded by general taxation, known as the National Health Service (NHS). Since 2010, the UK's new Coalition* government has responded by further reforming the system of purchasing and providing NHS services - aiming to strengthen choice and competition between providers on the basis of quality and outcomes as well as price. Although the present coalition government's intention is to maintain a tax-funded system, free at the point of delivery, introducing market-style purchasing and provider-side reforms to encompass all of these bring new risks, whilst not pursuing reforms of a system in crisis is also seen to carry risks. Competition might bring efficiency, but may weaken cooperation between providers, and transparency too. On the other hand, it is hard to implement necessary governance and control without worsening bureaucracy and inefficiency. The pursuit of market efficiencies has been particularly contentious in mental health care, where many professionals are defensive about the risks to vulnerable patients and to traditional ways of professional working. Developments and debates in the UK may be instructive for others. We conclude this paper with a set of questions that may help inform debate and evaluation of mental health services internationally.

EPA guidance on the role and responsibilities of psychiatrists.

Psychiatry is that branch of the medical profession, which deals with the origin, diagnosis, prevention, and management of mental disorders or mental illness, emotional and behavioural disturbances. Thus, a psychiatrist is a trained doctor who has received further training in the field of diagnosing and managing mental illnesses, mental disorders and emotional and behavioural disturbances. This EPA Guidance document was developed following consultation and literature searches as well as grey literature and was approved by the EPA Guidance Committee. The role and responsibilities of the psychiatrist include planning and delivering high quality services within the resources available and to advocate for the patients and the services. The European Psychiatric Association seeks to rise to the challenge of articulating these roles and responsibilities. This EPA Guidance is directed towards psychiatrists and the medical profession as a whole, towards other members of the multidisciplinary teams as well as to employers and other stakeholders such as policy makers and patients and their families.

Psychosomatic medicine and liaison psychiatry: empowering patients through imparting information.

Τhe empowerment of patients is a key aspect of professionalism in psychiatry. The sensitive, accurate and timely imparting of information is one of the highest expectations that patients and carers have of health-care professionals. In the course of his clinical work in Liaison Psychiatry the author has developed an information leaflet which reflects established practice and emerging evidence in the broad field of psychosomatic medicine and mind body interactions and psychopathology. Informal feedback from patients, carers and fellow clinicians suggests that it has been well received. Good reception has been found in practice among patients often thought as resistant to psychological approaches to psychosomatics. Necessarily, a single patient information leaflet has limitations in its scope. The focus of the leaflet is primarily on setting the context for understanding processes of somatisation. This supports the establishment of a therapeutic alliance between patient and clinician. However, to make further progress in the care and management of patients presenting thus, excellent interview and communication skills on the part of the clinician are required.

Evidence based mental healthcare and service innovation: review of concepts and challenges.

Health provision systems in the developed western nations are currently facing major financial challenges. In order to meet these challenges, a number of new approaches used to assist the provision of health have been introduced, including the practice of health professionals. These approaches utilize specific methods of data capture and summarization such as: evidence based medicine (EBM) and practice guidelines. Evidence is generated from systematic clinical research as well as reported clinical experience and individually case based empirical evidence. All types of research though (quantitative or qualitative) have limitations. Similarly all types of evidence have advantages and disadvantages and can be complimentary to each other. Evidencebased individual decision (EBID) making is the commonest evidence-based medicine as practiced by the individual clinician in making decisions about the care of the individual patient. It involves integrating individual clinical expertise with the best available external clinical evidence from systematic research. However this sort of evidence-based medicine, focuses excessively on the individual (potentially at the expense of others) in a system with limited budgets. Evidence-based guidelines (EBG) also support the practice of evidence-based medicine but at the organizational or institutional level. The main aim is to identify which interventions, over a range of patients, work best and which is cost-effective in order to guide service development and provision at a strategic level. Doing this effectively is a scientific and statistical skill in itself and the quality of guidelines is based primarily on the quality research evidence. It is important to note that lack of systematic evidence to support an intervention does not automatically mean that an intervention must instantly be abandoned. It is also important that guidelines are understood for what they are, i.e. not rules, or complete statements of knowledge. EBM will never have enough suitable evidence for all and every aspects of health provision in every locality. Innovation signifies a substantial positive change compared to gradual or incremental changes. Innovation using inductive reasoning has to play a major role within health care system and it is applicable to all three level of service provision: clinical practice, policy and organisation structure. The aim of this paper is to examine critically the above concepts and their complimentary role in supporting provision of health care systems which are suitable for the requirements of the population, affordable, deliverable, flexible and adaptable to social changes.

Ideology, psychiatric practice and professionalism.

Psychiatry, associated as it is with social and cultural factors, has undergone profound changes over the last 50 years. Values, attitudes, beliefs and ideology all influence psychiatry. Deinstitutionalisation, the normalization principle, advocacy, empowerment and the recovery model are ideologies that have been closely associated with policy, service developments and clinical practice in psychiatry. A "new professionalism" is emerging as a consequence of a number of changes in mental health care that needs to be guided by the highest standards of care which are best epitomized in psychiatry as a social contract with society. Looking to the future it is important that the profession recognises the impact ideology can make, if it is not to remain constantly on the defensive. In order to engage proactively and effectively with ideology as well as clinical science and evidence based service development, psychiatry as a profession will do best to approach significant future policy, practice and service changes by adopting an ethical approach, as a form a social contract. Psychiatrists must pay increasing attention to understanding values as expressed by ideologies, working in a collaborative way with other mental health professionals, involve service users and manage systems as well as be competent in clinical assessment and treatment. Whether in time of plenty or in times of deprivation, ideology produces effects on practice and in the context of constantly changing knowledge and the current financial stress this is likely to be more the case (and not less) in the foreseeable future. Psychiatrists must take into consideration the new social problems seen in some high income countries with the increased availability of highly potent "street drugs", perceived threats from various immigrant and minority communities and breakdown of "social capital" such as the decline of the nuclear family.

Responding to trainee doctors in difficulty.

Appropriate workload, good clinical and educational supervision and rigorous appraisal routines will prevent a number of trainees developing difficulties. When difficulties do occur the presence of such arrangements will facilitate appropriate emotional and practical handling of these problems.

A prospective study of the psychological impact on patients with a first episode of genital herpes.

OBJECTIVES: To assess the psychological impact of first episode of genital herpes, and to determine whether this changes over time. SETTING AND SUBJECTS: The Departments of Genitourinary Medicine (GUM), and Dermatology, Middlesex Hospital London. The study group consisted of patients attending the department of GUM with a clinically proven first episode of genital herpes. Two control groups were recruited; firstly patients without herpes attending the GUM Department and secondly patients attending the Dermatology Department out patients with chronic dermatoses. METHODS: Patients and controls completed an 87 item, self-administered psychological questionnaire at 3 monthly intervals for a year. The questionnaire consisted of the General Health Questionnaire (GHQ); the Hospital Anxiety and Depression Questionnaire (HADQ); Illness Attitude Scales and Illness Concern. Patients were also asked questions about their sexual behaviour. RESULTS: Ninety one patients (68 women, 23 men) with genital herpes, 61 GUM controls (42 women, 19 men) and 56 dermatology controls (36 women, 20 men) participated. There were no statistically significant demographic differences between patients and controls. At first visit the proportion of patients classified as "cases" by the GHQ (GHQ cases) were similar for primary herpes patients 62% (56/91) and Dermatology controls 52% (29/56) while a significantly smaller proportion of GUM controls 34% (21/61) were classified as GHQ cases. The primary herpes group were significantly more concerned about their illness than either the GUM controls or the Dermatology controls (p < 0.002). The proportion of primary herpes patients classified as "cases" by the GHQ reduced significantly over the initial three month period with 67% of patients classified as "cases" at their first visit becoming "noncases" after three months (p < 0.0001). Also 50% of those classified as "cases" at first visit by the HADQ become "noncases" after the initial three months (p = 0.007). The illness concern scores also decreased significantly from visit one to visit two (means 14.7 vs. 12.3; p < 0.0001). CONCLUSION: The diagnosis of a first episode of genital herpes has a profound emotional effect on patients. If they do not have recurrent episodes, their emotional state improves. For those who do have recurrences, the level of anxiety and concern remains as high as at the time of their first diagnosis. Clinicians must be sensitive to the emotional impact such a diagnosis may bring.

The effect of suppressive oral acyclovir on the psychological morbidity associated with recurrent genital herpes.

OBJECTIVES: To assess the psychological impact of recurrent genital herpes and to determine if longterm acyclovir has any impact on this morbidity. SETTING AND SUBJECTS: Patients with frequently recurring genital herpes attending a department of genitourinary medicine who were considered suitable for longterm acyclovir. METHODS: Patients completed an 80 item, self-administered psychological questionnaire before starting acyclovir and every three months for one year. Treatment was then stopped and three months later a further questionnaire was completed. The questionnaire consisted of the General Health Questionnaire (GHQ); the Hospital Anxiety and Depression Questionnaire (HADQ); Illness Attitude Scales and Illness Concern. Data were analysed by McNemar's test for changes in proportions and by Wilcoxon's test for changes in scores. RESULTS: 102 patients were recruited: 55 men, and 47 women. Eighty two (80%) patients completed three months treatment, 75 (74%) six months, 64 (63%) nine months and 61 (60%) a year. Fifty (49%) of the original 102 patients completed the three months post treatment follow up. At first visit 63% (64/102) were designated as GHQ "cases". Within three months this decreased to 26% (21/82). McNemar's test showed that 67% (34/51) of the patients who were initially classified as GHQ "cases" became "noncases" after three months (p < 0.0001). There was a significant decrease in the proportion of HAD anxiety cases from visit one to visit two (p < 0.0001) and a decrease in illness concern scores from visit one to visit two (p < 0.0001). All these decreases were maintained throughout the years treatment with acyclovir. CONCLUSIONS: There is a substantial morbidity associated with frequently recurring genital herpes. However, acyclovir suppression significantly reduces illness concern and anxiety and is a useful addition to the treatment of this infection.

Psychological disturbance and illness behaviour in a clinic for sexually transmitted diseases.

Patients attending a sexually transmitted diseases (STD) clinic were asked to complete the General Health Questionnaire and the Illness Behaviour Questionnaire. Data were collected from 852 patients. One-third of the sample were found to score positively on the GHQ, indicating possible psychological disturbance. Women were more likely than men to score positively on the GHQ. On the General Hypochondriasis scale of the IBQ the sample's scores were higher than any other normative data except those obtained from psychiatric in-patients. On this scale homosexual and bisexual males scored significantly higher than heterosexual males. It is argued that the IBQ draws attention to important dimensions of psychological distress in STD clinics.

The assessment of patients' distress in genito-urinary medicine clinics.

A sample of patients attending the clinic of a Department of Genito-Urinary Medicine in London completed The General Health Questionnaire, The Illness Behaviour Questionnaire and The Illness Concern Questionnaire. The doctor whom they consulted was also asked to complete rating scales regarding each patient's level of psychological disturbance. Thirty-eight percent of patients scored highly on the GHQ, indicating possible psychological disturbance. However, only one in five of such 'cases' were also rated by the doctor as possibly psychologically disturbed. A number of social variables are examined that may facilitate or limit the communication of psychological distress. No evidence of labelling of deviant groups is found. However, both the sample in general and specific sub-groups in particular scored highly on scales of hypochondriasis and distress in relation to health and such characteristics appeared relevant to doctors' judgements of patients' psychological states.

Survey of psychological disturbance in patients attending a sexually transmitted diseases clinic.

A survey of psychological disturbance was conducted in a sexually transmitted disease (STD) clinic, using the general health questionnaire, the Crown-Crisp experiential index, and the illness concern questionnaire. Of 381 patients who completed the questionnaire, 158 (43%) had general health questionnaire scores indicating that they were psychiatric cases. Psychological disturbance was more common in women. The association between general health questionnaire caseness and patients' reports of concerns and worries about illness in relation to their presenting complaint was significant. The Crown-Crisp experiential index scores of cases were lower than those characteristic of patients attending psychiatric clinics, and much of the psychological disturbance found by this and other surveys of STD clinics may therefore represent distress in relation to the presenting problem. Of the 381 patients, 14 (4%) appeared to have an abnormal or unwarranted level of distress in relation to their presenting complaint.

The recognition of psychological disturbance in a sexually transmitted diseases clinic.

This study examined the rate of psychological disturbance in a series of new patients attending a clinic for sexually transmitted diseases. Forty three per cent of patients were identified as probable psychiatric cases by the General Health Questionnaire. Medical staff in the clinic were asked to assess patients' level of psychological disturbance. Disagreement between GHQ and doctors' ratings occurred in 41% of patients. Some patient and doctor characteristics were examined that might be associated with disagreement, and the results are discussed in terms of possible social--psychological influences upon doctors' recognition of psychological disturbance.