Correspondence:
New procedure for submitting letters
Casey and Pimm (1 December 2008)
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New procedure for submitting letters
Measuring clinical outcomes in an adult eating disorder service |
16 November 2009 |
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MIQDAD H BOHRA,
ST 5 in Liaison Psychiatry
Mersey Deanery,
Jessica Morgan
Send letter to journal:
Re: Measuring clinical outcomes in an adult eating disorder service
miqdad.bohra{at}nhs.net MIQDAD H BOHRA, et al.
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UK government policy statements on mental health practice have
emphasized the importance of measuring patient outcomes [1]. We conducted
an outcome study of the service provided by the South Cheshire Adult
Eating Disorder Service to evaluate clinical outcomes. This is a NHS
service which serves a population of 650,000 in Cheshire.
All patients referred to the service were included in the study.
Treatment was based on NICE guidelines [2]. Data was collected
prospectively at initial assessment and twice during treatment over a
period of 18 months. Scales used were Beck’s Depression Inventory, Eating
Disorder Inventory-2 and Health of the Nation Outcome scales. User
satisfaction data was also collected.
Of a total of 295 referrals received, 176 were diagnosed with an eating
disorder. 24 % were diagnosed as anorexia nervosa, 43% bulimia nervosa,
33% eating disorder not otherwise specified [EDNOS]. Some patients did
not receive treatment for reasons including patient refusal or presence of
another primary mental disorder. A high drop out rate was observed
initially with only 11% completing treatment and 17% in treatment at the
end of the study. Statistical significance of change in scores was
measured using the student’s t-test.
The improvement in HoNOS score for all patients was statistically
significant but not clinically significant. Improvement in the BDI score
for most patients was statistically and clinically significant with an
reduction from severe to mild. This was not in the case of EDNOS patients
who actually showed an insignificant increase in the BDI. Most patients
showed an improvement in their total EDI scores and but this was not
statistically significant for all patients with anorexia. The response
rate for the user satisfaction questionnaire was 40%. 80% patients were
satisfied with the service provision and 8% regarded the treatment package
as poor.
The difficulties identified included monitoring each referral and
maintaining consistency in the use of scales at appropriate time periods
due to the fluctuating motivation levels of staff. The need of choosing
one staff member as an investigator was recognized.
Another study has reported a diagnostic breakdown of referrals as 24%
for AN, 31% for BN and 34% for atypical cases [3]; which is similar to our
observations. There was a high rate of drop-outs which is similar for
this patient group elsewhere [4]. Drop-out is a complex area and these
patients are less likely to improve on their own [5]. This has been
identified as an area which needs further research.
Recommendations for service improvement included improving
communication with patients on the waiting list and improving staff skills
to provide additional psychotherapeutic interventions. One high risk
referral was missed and a critical event analysis has been carried out to
prevent recurrence. Data meant to be collected at specific intervals was
not followed through which affects validity of the results. The changes
in scores can be attributed to the interventions, natural history of the
illness, regression to the mean etc. Treatment for eating disorders is
not time-limited and patients need longer follow up to get more meaningful
data.
References:
[1] Mental health services: Project on implementation of outcomes
measurement. Department of health 2006; UK
[2] Eating disorders: Core interventions in the treatment and
management of anorexia nervosa, bulimia nervosa and related eating
disorders. NICE guidelines 2004
[3] Bray JC, Simon A, Davson S, Palmer RL. Eating disorder referrals
to a district eating disorder service. Psychiatric bulletin 1994; 18: 748
-750
[4] Eivors A, Button E, Warner S, Turner K. Understanding the
experience of Drop-out from treatment for Anorexia nervosa. European
Eating Disorders Review. 2003; 11: 90-107
[5] Fairburn C, Jones R, Peveler R, Hope R, O’Connor M.
Psychotherapy and bulimia nervosa: the longer- term effects of
interpersonal therapy, behavior therapy and cognitive behavioral therapy
1993; Archives of General Psychiatry 50: 419 – 428
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New procedure for submitting letters
The Ethnic Distribution of Personality Disorder in an inpatient Sample. |
3 November 2009 |
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Asad Raffi,
Specialty Registrar Year 6
Mersey Care NHS Trust,
Aisha Malik, General Practice Registrar, North Lancashire PCT
Send letter to journal:
Re: The Ethnic Distribution of Personality Disorder in an inpatient Sample.
asadraffi{at}hotmail.com Asad Raffi, et al.
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The prevalence of personality disorder in the UK is between 4-33% and
ranges from 13% of general practitioner clients to 40-50% of in-patient
psychiatric patients. There are no figures relating to ethnicity. Ethnic
minorities are over-represented in psychiatric services and especially in
compulsory psychiatric care. Black clients are less likely than White to
be diagnosed with personality disorder, and more likely to be diagnosed
with schizophrenia. Ethnic minorities are under-represented in specialist
psychotherapy services and are less likely than White clients to be
offered counselling or psychological therapy [1].
A cross sectional survey of inpatient data collected over 2 years
(2007-2009), examined the prevalence of personality disorder, with regards
to ethnic distribution, among 6531 psychiatric inpatients. The survey was
conducted in Mersey Care NHS Trust, a mental health care provider in the
North West of England. Ethnicity was divided into 2 broad categories,
White British and Black and Minority Ethnic group (BME).
273 (4.2% of sample) patients were diagnosed with personality
disorder. 91 (33.3%) males and 177 (64.8%) females had personality
disorder diagnosis. 23 (8.4%) BME patients compared to 250 (91.6%) White
British patients were diagnosed with personality disorder, with the most
common personality disorder diagnosis being Emotionally Unstable
personality disorder (184 cases). The results of this survey indicate that
personality disorder is under-diagnosed in this inpatient population
compared to the evidence base. However it supports the research evidence
base, that personality disorder in ethnic minorities is under-diagnosed.
The results of the survey have led the authors to further consider
why there is under-diagnosis of personality disorder in BME groups. There
is a dearth of research evidence and literature examining personality
disorder in BME groups and the authors would encourage further research
interest in this area. Existing evidence refers to studies not
representative of the UK population.
NHS evidence for Mental Health in BME Groups states cultural
differences exist in the way in which psychological distress is presented,
perceived and interpreted, and different cultures develop different
responses for coping with psychological stressors. The evidence base on
risk and protective factors for mental illness is largely drawn from
research on White European or North American populations and hence cannot
be generalized to BME populations. [2]
Cultural and racial stereotyping is a common experience in the
context of assessment and decisions concerning treatment and influences
the types of services and diagnoses individuals from BME grousp seek and
receive. A Sainsbury Centre for Mental Health report entitled, “Breaking
the Circles of Fear” found that there is a cycle of fear fuelled by
prejudice, misunderstanding, misconceptions and sometimes racism. [3].
The concept of personality disorder in itself poses problems with
diagnostic uncertainty and is perceived as a stigmatizing label.
Attempting to redress the balance with regards personality disorder within
BME groups is made more difficult due to the pre-existing attitudes
towards mental illness in these communities. Mental illness can be
regarded as a non-entity, a stigma or a taboo. However it is suggested
that it is not only the patient population that needs educating but also
the professionals responsible for detection and management of personality
disorder.
References:
[1] Geraghty R and Warren F. Ethnic diversity and equality of access
to specialist therapeutic community treatment for severe personality
disorder. Psychiatric Bulletin (2003), 27, 453-456.
[2] NHS Evidence Mental Health. Black and Minority Ethnic groups- a
summary of Evidence.
http://www.library.nhs.uk/mentalHealth/ViewResource.aspx?resID=111332
[3]Minority Ethnic Mental Health Care needs. Lanarkshire Mental
Health.
http://www.lanarkshirementalhealth.org.uk/Resources/20%20Ethnicity.pdf.
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New procedure for submitting letters
Re: Greetings Survey |
29 October 2009 |
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James C. Allen,
Specialty registrar in psychiatry
Hartington Unit, Chesterfield Royal Hospital, Calow, Chesterfield, S44 5BL.
Send letter to journal:
Re: Re: Greetings Survey
james.c.allen{at}doctors.org.uk James C. Allen
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Vinjamuri et al (1) state that there has been little research into
patient preferences about how they are greeted by their psychiatrist. I
have discovered that there is virtually nothing published on how we should
greet those with whom we work, and the issues are similar.
It is quite common for paramedical staff to be addressed by their
first names by doctors, especially consultants, who seem to expect to be
called by their title in return. As a trainee I have been struck by how
often, without asking, I am greeted by my first name by seniors in rank,
but often not in age, who expect me to use their title when speaking to
them. It is hardly surprising then that this sort of power imbalance is
perpetuated in our dealings with patients.
It is worth noting that the 1982 edition of the classic book on
polite behaviour Debrett’s Etiquette and Modern Manners (2) is quite clear
on forms of address in business: “The use of Christian names should work
both ways except where there is a substantial age gap. It is arrogant of
a superior to choose to be addressed formally, yet to call subordinates by
their first names (or by last names only).” We would do well to remember
this and extend this to all with whom we come into contact.
1. Vinjamuri IS, Nehal MAM, Latt MM. Greetings survey (letter).
Psychiatr Bull 2009; 33: 313.
2. Burch Donald, E. Debrett’s Etiquette and Modern Manners. Pan
Books, 1982; p254.
Declaration of interest: none.
Contact numbers: tel 01246 512589 ; fax 01246 512612
ends
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New procedure for submitting letters
Mental Health Wiki seeks contributors |
29 October 2009 |
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Nicola J Reavley,
Research Fellow
University of Melbourne,
Anthony Jorm, Amy Morgan, and David Jorm
Send letter to journal:
Re: Mental Health Wiki seeks contributors
nreavley{at}unimelb.edu.au Nicola J Reavley, et al.
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We wish to inform readers of Psychiatric Bulletin of the launch of
Mental Health Wiki (www.mentalhealthwiki.org), a collaborative web guide
to mental health problems.
We invite contributions to Mental Health Wiki from health professionals,
academic researchers, consumer and carer advocates, and health service
administrators.
About Mental Health Wiki
Mental Health Wiki aims to provide high quality and up-to-date information
about mental disorders. It allows contributors to edit and improve each
other’s information and incorporates material from professional journals,
textbooks, or websites run by government organisations.
The potential of collaborative websites
Websites are now a major source of information about mental disorders.
While some are of high quality, many contain information of variable
quality, have trouble providing locally relevant information, and are hard
to keep up-to-date due to the rapid expansion in knowledge [1].
A potential solution to the out-of-datedness and limited coverage of
information websites is the wiki. A wiki is a type of software that allows
the creation of collaborative websites, with the on-line encyclopedia
Wikipedia the best known example. The large number of contributors allows
wikis to be constantly updated and errors rapidly corrected [2]. This
approach has so far not been specifically applied to the collation of
information about mental disorders.
One of the criticisms of Wikipedia and other similar wiki guides is
that they may include inaccurate or biased information. In order to ensure
that Mental Health Wiki provides high quality information, permission to
contribute to Mental Health Wiki is limited to:
- Mental health professionals
- Employees of government health and human services departments
- Major NGOs dealing with mental health
- University academics working in mental health
- Consumer or carer advocates working for health services or major
organizations representing the interests of consumers and carers.
Contributors have to register and state their affiliations.
Evaluation of Mental Health Wiki
A formal evaluation of Mental Health Wiki will be conducted, examining the
level of use and comparing the quality of information with other sources
such as conventional websites and textbooks.
We invite contributions to Mental Health Wiki from health
professionals, academic researchers, consumer and carer advocates, and
health service administrators.
1. Barnes, C., et al., Review of the quality of information on
bipolar disorder on the internet. Australian and New Zealand Journal of
Psychiatry, 2009. 43(10): p. 934-945.
2. Giles, J., Internet encyclopaedias go head to head. Nature, 2005.
438: p. 900-901.
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