Irish Journal of Psychological Medicine Vol. 29, Issue 3, December 2012 ISSN 0790- 9667
Editor–in-Chief: Brendan Kelly, Senior Lecturer in Psychiatry, Department of Adult Psychiatry, UCD Mater Misericordiae University Hospital, Dublin 7 Deputy Editor: Niall Crumlish, Consultant Psychiatrist, St James’s Hospital, Dublin 8
Editorial 145
A Perfect Demonstration of the Absence of Leadership: Alcohol Policy in Ireland Frank Houghton
Original Papers 147
Methadone Treatment in Irish General Practice: Voices of Service Users Linda Latham
157
Consulting Editor: Larkin Feeney, Consultant Psychiatrist, Cluain Mhuire Services, Blackrock, Co. Dublin
Using Quantitative Research to Measure Recovery Outcomes and Correlates Deirbhile Lavin, Patrick Ryan
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A Qualitative Study of Gender-based Pathways to Problem Drinking in Dublin, Ireland Joanne Cunningham
Founding Editor: Mark Hartman
171
The Dark Cartoon: Intrusive Imagery Secondary to Childhood Sexual Abuse Yoshihiro Katsuura, Vincent Russell
Associate Editor: Ted Dinan (Cork)
176
Burnout and its effect on neurocognitive performance Shane Mc Inerney, Michael Rowan, Brian Lawlor
Administrator: Sibéal Farrell Editorial Board: Brian A Lawlor (Dublin), Patricia Casey (Dublin), Stephen Cooper (Belfast), Michael Fitzgerald (Dublin), Brian Leonard (Galway), Roy McClelland (Belfast), Brian O’Shea (Wicklow), Ian Pullen (Edinburgh), John Waddington (Dublin), Richard Williams (Victoria) Submissions and Correspondence to: The Editor College of Psychiatry of Ireland 5 Herbert Street Dublin 2, Ireland Tel: 00 353 1 6618450 Fax: 00 353 1 6629677 Email: sfarrell@irishpsychiatry.ie Website: www.ijpm.ie Publisher: Irish Medical Information Fir Tree Lodge Craddockstown Road Naas Co. Kildare
Brief Reports 180
Analysis of Episodes of Involuntary Readmission in Ireland (2007-2010) Gerry Cunningham
185
The Teamworking Challenges of Care Planning Patrick McHugh, Michael Byrne
190
Developing an Integrated Mental Health Care Service: Description of a Pilot Mental Health Consultation/Liaison Clinic in a Primary Care Centre Nicolas Ramperti, Daniel De La Harpe Golden, Iro Chinedu, Seathrun O’Casaide, Frank Kelly
Case Report 194
Steroid-Induced Mania: A Case Report Carol Cassidy, Shobhna Sahay, Fiona McNicholas
Book Reviews 196
Fiction & Physicians: Stephen McWilliams Reviewed by Larkin Feeney
198
Struck by Living: From Depression to Hope: Julie K Hersh. Reviewed by Erik Kolshus
199
Depression in Neurologic Disorders: Diagnosis and Management. Edited by Andres M. Kanner Reviewed by D. Curtin and K. O’Rourke
200
Schizophrenia (3rd Edition). Edited by Daniel R. Weinberger and Paul Harrison Reviewed by Brian O’Shea
Obituary
This paper meets the requirements of ANSI/NISO Z39.48-1992 (Permanence of Paper)
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Thomas Stephen Szasz (1920-2012) By Brian O’Shea
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Erratum
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Guidelines for Authors
EDITORIAL
A Perfect Demonstration of the Absence of Leadership: Alcohol Policy in Ireland Frank Houghton Ir J Psych Med 2012; 29 (3): 145-146 February 2012 saw the publication of the Steering Group Report on a National Substance Misuse Strategy.1 This report represents the culmination of an earlier decision to finally acknowledge the true nature of alcohol and to include it within the wider context of substance misuse. The report is impressive, wide-reaching and should be welcomed.
Ireland.21 The 2010 Annual Report noted that alcohol was involved in 41percent of all cases of deliberate self-harm, and in even more cases among males (44 percent).21 The association between alcohol and deliberate self-harm appears self-evident given the noted temporal pattern of A&E presentations. Presentations peaked around midnight on Sundays, Mondays and increasingly on or after public holidays.
However, the launch of this important report was notable by the lack of energetic and vocal support that it immediately received from Government. Opposition from the alcohol industry2,3 and their representative organisations4 was inevitable. Of greater concern though was the lack of endorsement of the report, combined with immediate efforts by four Government Ministers to undermine it.5 The Minister for State with responsibility for primary care only appeared briefly at the beginning of the launch before leaving,5 while the Minister for Health did not even attend the launch to offer support.6 The inclusion of numerous Government Departments on the Steering Group 1 makes the distancing of the Government from the report all the more bizarre.
Exploring the balance between the purported economic benefits of the alcohol industry22 and the costs of alcohol use and misuse in Irish society, the Steering Group on a National Substance Misuse Strategy recently concluded that ‘the burden of health harms and the social consequences of harmful use of alcohol demanded the implementation of further measures to protect and preserve public health’.1 Given the multi-faceted nature of the issue, it is not surprising that the Steering Group report is wide-ranging, making numerous recommendations across a host of fields.1 Perhaps the most notable of these are a ban on all alcohol sponsorship of sporting and large outdoor events, as well as a ban on outdoor advertising of alcohol. The introduction of minimum pricing for alcohol is also advocated, as are higher excise duties on some alcohol products. The report also advocates a reduction in the recommended maximum weekly intake among both men and women (to 17 and 11 units respectively), and the introduction of a social responsibility levy.1
An already established mountain of evidence exists clearly outlining the adverse impact of alcohol.7-9 A wealth of up-to-date evidence from Ireland exists which clearly demonstrates the negative impacts of alcohol here.10-14 Within the EU, which is the heaviest drinking region in the world, the Irish spend more of their income on alcohol than any other European country.8,15 In addition they are the most frequent binge drinkers in Europe,15 and have one of the highest rates of alcohol consumption in Europe.8,16,17 Recent evidence suggests that one-quarter of Irish adults reported binge drink weekly,15 while over half of drinkers have been identified as having a harmful drinking pattern.18
Ambivalent Government reaction to the Steering Group Report mirrors earlier indecisive responses to initiatives to reduce drinkdriving in 2008.23 Government statements concerning more effective control of alcohol in Ireland, which are subsequently found to be unmet, are hardly new in Ireland. Statements by Government suggesting initiatives to tackle the availability of alcohol in garages and service stations,24,25 the abolition of ‘early houses’,26 and the separation of off-licence sales in supermarkets have all failed to materialise.26 In 2008 rather than introducing the expected legal framework to govern alcohol advertising, placement and sponsorship,24,25 the Irish Government opted instead to promote self-regulation.27-28 Despite protestations from the alcohol industry28 it was clear that tinkering and the appearance of action was clearly the aim of the exercise.27,28
Alcohol has been identified as killing approximately 88 people per month.11 This equates to almost one in twenty deaths (4.4 percent).11 Recent research also indicates that it results in 2,000 beds being occupied in acute hospitals in Ireland every night.1 This represents an estimated 10.3 percent of bed-days.12 Hope has identified that over a quarter (28 percent) of all injuries presenting to Accident & Emergency Departments in the period 2003-2004 were recorded as being attributable to alcohol.19 Based on a costing for the year 2007 it has been estimated that alcoholrelated illness costs the healthcare system €1.2 billion per year.20 Other alcohol-related costs identified in Ireland include the costs of crime, lost economic output, and road traffic incidents. Based on 2007 figures these have been estimated to cost a total of €1.19 billion, €527 million, and €530 million respectively.20
The Irish Government’s usual laissez-faire approach to the danger presented by alcohol is typified in a statement by the former Minister for Health, Mr Noonan, at the 1996 launch of the National Alcohol Policy29 when he stated that: “It’s very hard to legislate for virtue. It’s even difficult enough to legislate for good behaviour. The kind of island I would like to see is where we would
Recent evidence from the National Registry of Deliberate Self Harm has also identified the significant adverse impact of alcohol in *Frank Houghton Public Health Geographer & Lecturer, Dept. of Humanities, Limerick Institute of Technology, Moylish, Co Limerick E-mail: Frank.Houghton@LIT.ie *correspondence
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have what I would describe as sovereign individuals who are well educated and mature and that when you give them information which is relevant to their own well-being they will make individual sovereign decisions in their own interest. I think that’s the best approach.”30
References: 1. Department of Health. Steering Group Report on a National Substance Misuse Strategy. Dublin: Department of Health, 2012. 2. Alcohol Beverage Federation of Ireland. The National Substance Misuse Strategy Minority report by the Alcohol Beverage Federation of Ireland. Dublin: ABFI, 2012. 3. The Irish Times. Drinks sector, TDs object to report. February 6th 2012. 4. Mature Enjoyment of Alcohol in Society Limited (2012) National Substance Misuse Strategy 2009-2016 Minority Report by Mature Enjoyment of Alcohol in Society Limited. Dublin: MEAS. 5. The Irish Times. Call to limit alcohol sponsorship. February 7th, 2012. 6. The Irish Examiner. Concern over lack of support by Government. February 8th, 2012. 7. Anderson P, Møller L, Galea G. Alcohol in the European Union: Consumption, harm and policy approaches. Copenhagen: WHO Regional Office for Europe 8. Anderson P, Baumberg B. Alcohol in Europe: a public health perspective. London: Institute of Alcohol Studies, 2006. 9. Babor TF, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, Grube JW, Gruenewald PJ, Hill L, Holder HD, Homel R, Österberg E, Rehm J, Room R, Rossow I. Alcohol: No ordinary commodity - research and public policy. New York: Oxford University Press, 2003. 10. Lyons S, Lynn E, Walsh S, Sutton M, Long J. Alcohol-related deaths and deaths among people who were alcohol dependent in Ireland, 2004 to 2008. Dublin: Health Research Board, 2011. 11. Martin J, Barry J, Goggin D, Morgan K, Ward M, O'Suilleabhain T. Alcohol-attributable mortality in Ireland. Alcohol Alcohol 2010; 45: 379-86. 12. Martin J, Barry J, Skally M. Alcohol Attributable Hospitalisations and Costs in Ireland, 2000-2004. Ir Med J 2011; 104: 140-4. 13. Mongan D. The burden of alcohol-related morbidity on hospital services. Drugnet Ireland 2010; 35: 9-12. 14. Mongan D, Hope A, Nelson M. Social consequences of harmful use of alcohol in Ireland. HRB Overview Series 9. Dublin: Health Research Board, 2009. 15. Butler S. Tipping the Balance? An Irish Perspective on Anderson and Baumberg. Drugs: Education, Prevention and Policy 2006; 13: 493-497. 16. TNS Opinion and Social. EU citizens' attitudes towards alcohol. Special Eurobarometer, 331. Brussels: European Commission, 2010. 17. OECD Health Data 2011. http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT Accessed 2 December 2011. 18. Morgan K, McGee H, Dicker P, Brugha R, Ward M, Shelley E, Van Lente E, Harrington J, Barry M, Perry I, Watson D. SLÁN 2007: Survey of Lifestyle, Attitudes and Nutrition in Ireland. Alcohol use in Ireland: A profile of drinking patterns and alcohol-related harm from SLÁN 2007. Dublin: The Stationery Office, 2009. 19. Hope A. Alcohol-related harm in Ireland. Dublin: Health Service Executive – Alcohol Implementation Group. Dublin: Health Services Executive, 2008. 20. Byrne S. Costs to society of problem alcohol use in Ireland. Dublin: Health Service Executive, 2011. 21. National Suicide Research Foundation. National Registry of Deliberate Self Harm Annual Report 2010. Cork: National Suicide Research Foundation, 2011. 22. Foley A. The economic contribution of the drinks industry. Dublin: Drinks Industry Group of Ireland, 2010. 23. The Irish Times. Political pressure hits new drink-drive policy. June 11th, 2008. 24. The Irish Times. Stricter rules on drinks sponsorship Government plan aims to restrict sale of alcohol. April 23rd, 2008. 25. The Irish Times. Government plan aims to restrict sale of alcohol. April 23rd, 2008. 26. The Irish Times. Government scraps plan to abolish 'early house' pubs. June 25th, 2008. 27. The Irish Times. Curbs on alcohol advertising to begin. July 1st, 2008. 28. The Irish Times. Drinks industry find new rules 'challenging'. July 7th, 2008. 29. Department of Health. National Alcohol Policy. Dublin: Stationery Office, 1996. 30. Butler S. (2009). Obstacles to the Implementation of an Integrated National Alcohol Policy in Ireland: Nannies, Neo-Liberals and Joined-Up Government. Journal of Social Policy 2009; 38(2): 343-359. 31. Jochelson K. Nanny or steward? The role of government in public health. Public Health 2006; 120(12): 1149-55.
However, Ireland can no longer afford to minimise the risks and adverse impact of alcohol. The time for posturing and rhetoric is over. It is no longer acceptable for government to simply mimic action. The last thing required now is another consultation exercise or research project. The facts are plain and the message is clear. Significant further controls on alcohol are required urgently. The Government needs to accept its role and duty to act as steward.31 It is imperative that the Government moves beyond the manipulative sectional self-interest of publicans and the alcohol industry and finally accepts its responsibility in the face of the threat of alcohol to safeguard and foster the health of its citizens.
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Methadone Treatment in Irish General Practice: Voices of Service Users Linda Latham Ir J Psych Med 2012; 29 (3): 147-156 Key words: Methadone treatment, general practice, service users.
methadone maintained patients in general practice. Stabilisation usually takes place in a health board treatment centre but may also be offered by a suitably trained GP colleague (Level 2). A Level 2 GP may initiate treatment, stabilise a drug misuser and provide ongoing maintenance treatment in the primary care setting.5
Abstract This study sets out to make a meaningful and useful contribution to the discussion surrounding the treatment of heroin addiction in Ireland. The study took place in nine urban general practices in Dublin city. Twenty five service users were interviewed in-depth. A phenomenological approach drawing on the psychological research methods of Colazzi for data analysis informed this study. Four themes emerged from the data: Service users’ the significance of methadone for the service user; service users’ understanding of the Methadone Treatment Protocol and the experience of addiction and its effect on families.
Historically, there is little evidence that the needs and wishes of Irish service users have been actively sought in this treatment programme, although users’ views and experiences with methadone treatment have been investigated internationally.6,7,8,9,10,11 Studies demonstrate that client perceptions have been assessed across a number of treatment domains, including the clinic environment, service provision, clinical relationships, medication and treatment outcomes. Although a comprehensive approach to user’s individual needs has been advocated internationally there is still little evidence to support the effect of user involvement and decision-making in drug services.12,13 User involvement has been relatively slow to develop and there are differing opinions as to how user involvement impacts upon service delivery.14
This paper reports on the experiences of service users receiving methadone treatment in urban general practice in Dublin and in so doing highlights the influence of the GP in supporting recovery. It explores the theme - Service User’s Experience of attending general practice for methadone treatment. These accounts provide insight into the harm reduction policy of methadone maintenance and highlight how - from the service users’ experience - the implementation is falling short.
Service providers, however, have been investigated and recent studies have focused on the attitudes of GPs. A postal survey of 600 GPs on the ICGP drugs misuse database explored current attitudes to the MTP. Of the 600 questionnaires sent, 207 responses were received (a 34.5% response rate). The majority of respondents (72%) already had patients on the MTP. Attitudes which focused on the benefits of methadone treatment suggested that GPs overwhelmingly believe that it is an essential service to drug users (95%) and the majority (96%) felt the structure of the MTP provided a regular opportunity to review patients’ progress allowing a good relationship to develop. This survey reflected the views of those who are interested in methadone treatment and bias can not be excluded due to the poor response rate (34.5%) and the fact that all those surveyed had participated in ICGP training.4 In the absence of other research, this survey was useful for gaining cautious insight into the recent attitudes of GPs in Ireland.
Introduction Heroin addiction is a chronic relapsing condition and GPs have a pivotal role to play in the care of patients receiving treatment with methadone.1,2 In Ireland, the prescribing and dispensing of methadone for problem opiate use has had a formal legislative basis since 1998. The format for both how methadone is regulated and how opiate dependent patients are managed is commonly known as the Methadone Treatment Protocol (MTP). There are approximately 8,000 to 10,000 clients receiving methadone, although numbers can fluctuate, and of these almost one-third (32%) currently prescribed methadone are cared for in general practice.3,4 Methadone treatment is also provided by the National Drug Treatment Centre (NDTC), Health Services Executive, addiction clinics and satellite community clinics.
There has, in contrast, been limited experience in either encouraging or investigating drug user consensus viewpoints. A culture of user involvement is underdeveloped, although it is recognised that it is essential to service evaluation and development.15 When reviewing the literature for the National Strategy for Service User Involvement in the Irish Health Service, McEvoy suggested that some of the most provocative and intelligent discussions on service user involvement are to be found in literature that is outside the usual parameters of scientific
The GP’s unique knowledge of the patient and their extended family can make a considerable contribution to the long-term management of these drug using patients. To facilitate this the Irish College of General Practitioners (ICGP) provide Level One and Level Two training in methadone treatment for GPs.5 It is recommended that doctors when completing their training in general practice should have received Level 1 training, which provides the foundation for treating stable
Linda Latham Registered Advanced Nurse Practitioner /Registered Nurse Prescriber Thomas Court Primary Care Centre, 1 St Catherine’s Lane West, Dublin 8 Email: drlinda.latham@gmail.com
Submitted: 22nd May 2011 Accepted: 3rd February 2012
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databases.16 Small studies such as these which exist in Ireland portray largely negative reactions of service users to treatment programmes and also negativity in relation to service provision.17,18,19,20,21,22 These studies - although involving service users - were not carried out exclusively in general practice and did not explore the issues in detail. Table 1: Female=14, Male=11
Thus there has been a serious lack of debate in relation to service users’ views and the evaluation of this treatment modality, and to this end the views of those receiving methadone were considered an important investigation. This study was undertaken against a background of little qualitative work on the lived experience of those attending general practice in Ireland and none that explored methadone service users’ perspective of their treatment solely within this environment. Alternative perceptions had not been addressed and the significance of exploring the insight and understanding of service users’ experiences had been markedly absent and indeed overlooked in previous studies. It was uncertain if discrepancies existed between what the MTP advocates in general practice and the reality of the situation for the drug misuser. It was also unknown whether partnership in treatment existed between the treatment provider and service user. Actual care versus ideal practice -one of the recommended avenues for research advocated by the ICGP research strategy (2003 to 2008) needed to be investigated and highlighted.23
Table 2: Age Range=23-43
The aim therefore was to explore how the MTP was being implemented in general practice from the perspective of the service user, including the following objectives: 1. To describe service users’ lived experience of the MTP 2. To discover the shortcomings and benefits of experiencing methadone treatment in General Practice in Dublin 3 To describe service users’ experience of being involved in decision making and management of their treatment, and 4 To identify the steps required to address any limitations or deficiencies in treatment by considering the perspective of the service users in the context of current practice. This paper expands on the first two objectives. Table 3: Current Methadone Dosage Range 20-150 mgs
Methods The goal of qualitative research is that theories or hypotheses are not established ‘a priori’, and imposing hypotheses on the experience of service users would not have been consistent with the research question posed. The design of the study was within a qualitative model which utilised the methodological strategy of phenomenology. Phenomenology has been described as a philosophy, an approach and a method that possesses a reverence for experience that is useful when the focus of inquiry is narrow (experiences of methadone treatment) and the respondents represent a clearly defined and homogenous unit within an already known context (urban general practice within Dublin).24,25 Guided by this research epistemology it was considered possible to emphasise and describe service user’s experience of treatment. The choice to use a Husserlian approach was based on the focus of the study, which was descriptive rather than interpretive. Descriptive studies are sometimes the only practical way of studying some topics in drugs
Table 4: Length of Time in Treatment 148
research and are helpful as they are thought provoking and can suggest further questions that can be investigated using a different approach. The study was divided into Phases 1 and 2. The pilot phase of the study (Phase 1) was conducted from November 2007 to April 2008. During the pilot phase three respondents who were considered to be ‘key informants’ were interviewed. Methodological, conceptual and pragmatic lessons were learned from a preliminary investigation of these service users receiving methadone in two general practice sites. Both the researcher’s practice and another practice were used exclusively for the pilot phase. Two of the informants were actively involved in service users groups and education of drug users in their respective communities. The third had been treated for many years in several different services, including treatment clinics. The method of using two researchers proved to be effective for both comparing and contrasting interview styles, and testing the methodological approach of phenomenological interviewing which proved apposite for the study. Three main outcomes from the process of piloting were: identification of a sampling methodology, preparation of site and the development of a topic guide.
Table 5 Years in treatment and methadone dosage Low Dose Defined as 40mgs or lower High Dose Defined as 45mgs or higher Whereas some participants ran against the trend (low years/ high dose or high years/ low dose) this graph clearly shows a consistent pattern in the data. That is, a clear relationship between the length of time in treatment and the dosage of methadone with patients in treatment longer being prescribed higher doses.
The sampling methodology was purposive within a maximum variation sampling strategy as advocated by Patton’s typology.26 It was considered that identifying service users who were receiving treatment for longer than one year would more adequately reflect continuity of care in general practice. The preparation of site was facilitated by three GPs who gave guidance on the framing of the approach to GPs. A simple letter was sent to all the practices outlining the process, together with a step-by-step guide to enable a streamlined approach to recruiting participants. The topic guide was piloted and then reshaped and refined following each of the pilot interviews until a desirable dialogue was facilitated for Phase 2 of the work. The interviews were characteristic of phenomenological research – they were in-depth, open-ended and facilitated accounts of meaningful culturally salient responses. Topics for discussion were, for example, ascertaining the service users’ answers to the question, ‘What is it like attending a GP for methadone treatment?’ For phase 2 of the study the following criteria for selecting service users was utilised after reflecting on the process of the pilot study.
Inclusion criteria Those willing to participate and provide informed consent, i.e. stating no coercion or incentives were offered. Level 1 and Level 2 participants. Those who attended a doctor qualified to treat at Level I (i.e. stable patients), and those who attend a doctor qualified to treat at Level 2 (i.e. less stable patients).
Figure 1: Theme I Service Users’ Experience of Attending General Practice
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Exclusion criteria
methadone treatment were identified and transformed into the words of the researcher. This was the first step of preliminary coding. This was expressed as individual free nodes. 3) The researcher attempted to spell out the meaning of each significant statement (synthesizing). These statements reflected the essential point of the selected text. 4) Significant statements were collected and organised into further clusters of themes (theorizing). This was the second step of coding expressed as tree nodes in NVivo8. 5) The individual themes were then clustered to produce a further reduction into general themes that were common to all the subjects’ transcripts. These themes were further broken down from tree nodes to what NVivo describes as ‘child nodes’. Tree nodes can have ‘children’ as such and thereby have a hierarchy on these synthesized statements imposed on them. 6) The researcher then returned the transcript to the participants (18 wished to read their interview) in order to confirm that it accurately reflected the essence of their lived experience, therefore enhancing the trustworthiness of data. Two service users expressed literacy difficulties as a reason for not reading the transcripts. Any relevant new data from telephone followup interviews were worked into a revised final description (15 responded to telephone calls). The researcher moved back and forth between the meaning statements and the revised lists until the themes were accurately reflected in the clusters. The final result of the zig-zag process was the finding of the research, i.e. the overall description of the experience which is the essential structural definition.
Those who refused to be involved. Those experiencing severe psychiatric co-morbidity, as assessed by their own GP. Users under 20 years of age as MTP is not encouraged as first-line treatment for adolescents, and they are not generally in treatment in general practice. As the actual sampling and recruitment took place in the field, potential respondents who fulfilled the sample criteria and the overall sampling strategy were dependant on invitations issued by the GP. This meant that recruitment was subject to ‘the gatekeeper syndrome’.27 The insight of the GP was paramount to effective recruitment as they could attest to the suitability of the co– researchers’ abilities to engage with the process. Each GP identified service users whom they considered had sufficient experience of the research topic of methadone treatment. The GPs also required that the service user have the capacity to provide full and sensitive descriptions of the experience under examination.28 This method of respondent recruitment was effective but not without difficulties. In total the sample comprised 25 participants who were registered with their GP for methadone treatment. These were recruited from nine general practice sites in Dublin. Both Level 1 and Level 2 GPs were approached. The same general practice sites where access was previously granted in 2003, in addition to the independent pilot site, were utilised, building on the researcher’s previous study exploring The Perceptions and Experiences of Practice Nurses in Relation to Patients on a Methadone Treatment Protocol.29
One further step, which Colazzi did not carry out, was to calculate the percentages of the occurrence of statements across the transcripts. This further progression in the analysis was aided by NVivo 8, which also provided an auditable account of the research process of both data collection and analysis.
Not everyone approached to take part agreed, particularly as the length of the interview (indicated in the participant information leaflet) proposed an hour. The refusals were possibly not related to the research topic but rather the length of time required for the interview. Some clients agreed to participate on the morning when they were attending the GP but refused when they had collected their prescription as they said they were rushing to the chemist for their methadone. Others promised on many occasions to attend for interview but did not turn up despite reminders. Deficiencies and biases in the sample were avoided however as there was a sufficient pool of respondents in each practice to provide a sufficient sample based on a maximum variation sampling strategy.
Results Four themes were identified: Service User’s Experience of attending general practice for methadone treatment; the significance of methadone for the service user, service users’ understanding of the MTP; the experience of addiction and its effect on families. This paper explores the theme – Service users’ experience of attending general practice for methadone maintenance. There were 106 significant statements from 23 sources which pertained to the service users’ perceptions of the benefits of attending general practice. The transformed meaning was further broken down into distinct meaning units, which were attributed to the lived experience of service users in general practice as opposed to the experience of attending a treatment clinic. There were 84 references from 22 sources relating to clinic services. The overall description of the experience in general practice was described by the majority of service users as a comparator to past experiences within treatment clinics. Although no specific question was asked about the treatment clinics the experience featured highly in the majority of service users’ experience. Key aspects of attending general practice were identified as: a place to be treated as an individual, a place which is confidential, a place to get clean, a place to reduce, a place to develop relationships and a place to sort things out.
Data analysis The psychological research methods of Colazzi informed this study and the data were analysed using the methodology he described.30 Initial reading of all the transcripts to acquire a feeling for them was followed by Colaizzi’s steps to produce a structural definition of the findings. 1) The transcribed interviews were read thoroughly so that the researcher became immersed in the data (comprehending). Each transcript was imported into the software package NVivo8, assigned to its own identifying folder and linked to the participant’s voice which could be accessed and listened to simultaneously throughout the process of analysis. 2) Significant statements and phrases directly related to
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A place which is confidential Descriptive statistics: Age range was from 23-43 with 14 female and 11 male participants. Nineteen of the participants were parents and the majority had two children. Eighteen had achieved either the Irish academic qualifications of Junior or Group Certification and six had completed their junior certification. Five females and five males knew they were HCV (Hepatitis C) positive. Current methadone dose ranged from 20-150mgs/per day. Those patients in treatment longer were receiving higher doses. Years in treatment ranged from one to 12 years with the majority in treatment in general practice for more than five years. The nine practices visited for the purpose of the study were well-equipped surgeries with secretarial support, IT facilities and all had the services of at least one if not two practice nurses. There were 13 practice nurses, 42 GPs and 487 methadone patients registered with these nine practices (by self assessment). The combined practice lists were approximated at 270,000 patients.
Service users spoke of valuing discretion and confidentiality and spoke positively about the assurance general practice afforded them in the patient/GP consultation: Rhiana: “I find that it’s more private, you know, people don’t know your business because you can be here for anything like? the ‘flu, whatever you’re here for, you feel normal.” Padraig: “What happens here stays here you know what I mean? It doesn’t go any further.” Attracta: “It’s not a drug treatment centre, like it’s a doctor’s surgery but like nobody knows what you’re here for. They knew exactly what you were coming and going for [in the treatment clinic]… you’re not picked out …you’re not just fingered cause you’re… it’s your normal GP do you know what I mean?”
Male to female ratio showed a majority of male GPs. There were a sufficient number of female GPs to ensure anonymity in mentioning their gender. The use of pseudonyms provides anonymity in the following extracts from service users self-report.
A place to get clean and a place to reduce There were 36 references from 18 sources describing how the treatment clinic had never been perceived as a place to become drug-free in contrast with general practice. The following descriptions focus on the importance of treatment context, as general practice is viewed by the service user as a place to “get clean”. This place was described as a setting where it is possible to have a plan to separate from the environment of attending a treatment clinic and the peer pressure exerted by other drug misusers, which is inevitably a deterrent to becoming heroin free.
A place to be treated as an individual General practice was consistently described as a “different place”. There were 31 significant references from 15 sources identifying the importance of being treated as an individual in general practice. The word ‘place’ was mentioned 114 times and ‘different’ 195 times. It is important to highlight that frequency of occurrence of references does not equate with social significance of the topic but is useful for the purpose of transparency and reader information. The majority of service users expressed their preference to be treated in general practice. In the following descriptions the service users describe the difference.
Sean: “People nowadays and going back years, they never seen (the clinic) as a place to get clean… People stand around outside offering you drugs, offering this, so you have none of that (in general practice) and that is a good thing.”
Daithi: “…but in a clinic …cause they treat you all the same, you see they see so many drug addicts in there that they paint them all with the same brush you know.”
The importance of the treatment setting is a perspective shared by professionals, as the following extract describes:
The experience in general practice was highlighted as different.
Erica: “I think I was only down about a year and, ehm, the doctor down there (in clinic) he was kinda saying because there was a lot of stuff going on outside after the clinic, you know? Swapping things and selling the stuff …and he said to me, you will start doing stuff if you stay down here and he said he would try Dr. X as he said he would try and get me a GP in the area.”
Craig: “you’re not treated… here [in general practice] you’re not... they don’t treat you like you’re an outcast.” Sean: “eh, the dread of going down there, [Treatment Clinic] the way you were treated, to start first of all by the security guards going in like you would be going in there day after day after day. (General Practice) Much different, much difference, much more friendly eh which makes it much more easier for me to open up and tell you if I’ve had a slip or tell you if something has gone wrong or whatever, you know?”
There was verbal evidence that the aims of the ICGP guidelines in relation to encouraging reduction strategies and supporting maintenance were being implemented by the majority of service providers. General practice was identified as being potentially beneficial in two important aspects of treatment - reduction in dosage of methadone and control over treatment. Meaning units derived from 112 references obtained from 24 sources described the treatment context as a place to reduce.
These accounts emphasise the institutional environment of the clinic, and the highly regimented mechanisms in place for managing security.
The experience of those who were reducing their dosage or had a
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plan to reduce is described in the following extracts:
Daithi: “Oh no, no, I wouldn’t be here otherwise, on me life, I’ve built up the trust now the doctors you know I could come in here and talk to them about basically anything and they’re genuine they listen to me … I come in here and you’d talk and he would listen to you, to me and another time you just want to come in to talk like and you’d be listened to.”
Sibh (dosage:32mls): “I’d never been where I am today only for coming here. I was on 80 mls and they wouldn’t let me come down (in clinic)…and I wanted to come down. And I came here (general practice) and they gradually have done that now in the four years that I have been here.”
There was evidence however that potential existed for two very different types of relationships to develop when the service user attends their GP for treatment. There were three accounts where service users identified negative experiences and a different consulting style. The term ‘phy doctor’ (Physeptone) was used and contrasted markedly with the consulting style of the majority of the other GPs. These service users perceived the GP to have a lack of interest in their emotional well-being.
Sean: “I will work myself right down to the two [mls] and then I will stop.” The ICGP guidelines advocate that once a level of stability has been reached the patient may wish to consider working towards abstinence by slowly reducing their methadone dose over time. The advantages of reductions in methadone when on maintenance can be planned and each successful step helps to reinforce progress and boost self esteem (ICGP2008:21).
Sean: “Some doctors they come in they get the sample they look at it yeah, grand right there’s your script... go! You know what I mean? Out!”
A place to develop relationships
Olwyn: “…things definitely have changed since… I’ve become his methadone patient …I go in the door now and automatically it’s just, check me urine and he’s writing out a prescription and he’s trying to get me out the door as quick as possible … yeah like all he is to me, now phy to me ……write it down …push it across see you next week… yeah he just automatically assumes that once you’re come in you’re coming in for your phy prescription and nothing else…you just get to see a ‘phy’ doctor now.”
All service users described the doctor/patient relationship and 182 references to the concept of relationship were made from the 25 sources in the study. There were voluminous data and these responses were further broken down from tree nodes to child nodes, which identified both positive and negative experiences. Overall, 100 references from the 25 original sources indicated that although there were some negative experiences in relationship building the overwhelming picture was that general practice provided service users with a place to develop relationships and the majority acknowledged a good relationship with their own GPs.
Researcher: “…would you just think that what you say is important to her?” Helen: “No, no because [doctor] is just…. this is what [doctor] does [mimics looking down at prescription pad] oh what are you on again? I say 80 and what day are we? Ok, ok there it is, come back to me, six weeks, now there it is!”
The following descriptions emphasise the importance of the relationship. Seamas: “I’ve known him (GP) that long like we seem to nearly grow old together like… so it seems like … we’ve grown up together in a different way you know… I’ve been here probably 15 years with him,…I wouldn’t see anybody in the week or the only person I’d see would be Dr X I call him [Christian name] and I actually felt a lot better walking away like he does… he’s a caring man.”
A place to sort things out The general practice experience was sought after as a place where the children of service users attended and were able to ‘sort things out’. Services availed of were described as care for minor illness, child health, women’s health (smears and coil insertion) asthma checks, health promotion (including weight reduction, advice on hyperlipidaemia, phlebotomy and viral screening), infertility, antenatal, pregnancy and post-natal care, blood pressure monitoring, flu vaccinations, childhood vaccinations and managing depression and back pain.
Niamh: “…he [GP] knows by looking at me, I have to say I have a great relationship with the doctor.” Researcher: “… tell me what that means like what does a great relationship mean?” Niamh: “like I can come in and say to my doctor look it I’m just f**king pissed off, what the f**k is wrong with me? I’m like a bull all the time you know? and I … But I think he actually appreciates me doing that and being honest with him you know?”
Niamh: “It’s a place where you can bring your kids.” Ken: “Yeah, I have me own time you know what I mean, I have me own time to come in and sort things out.” Not all participants had these experiences of service provision. There were 59 references from 19 sources describing counselling facilities and the perception that there was a general need for this in general practice.
The majority of service users described the personal relationships with their doctors and being listened to as in itself “a cure”. They described a repeated consultation pattern with the GP who knew them. This relationship involved being listened to, being heard and valued, in other words a therapeutic relationship. 152
Discussion
There were idiosyncratic responses as to whether counselling was considered necessary by the service users although there was evidence that the location of the psychological care that was offered did matter as three of the interviewees were able to access on-site services. Accessing on-site addiction counselling at the same time as visiting the GP was described as:
This study provides a novel insight into service users’ views of the way treatment is delivered in general practice. The findings of this study point to service users’ satisfaction that general practice is a different place from a treatment clinic and a location that provides a valuable service for them. The significance and social meaning of place in relation to the setting of general practice for methadone treatment has had little discussion in the literature prior to this work, although there has been emphasis in recent research on the features of micro environments in relation to safer injecting sites.31 There is now, in addition to this work, a growing recognition of the role that place and setting can play in shaping the health of individuals and populations.32
Craig: “I’d rather that time kill two birds with the one stone.” Even though the relationship with GPs was considered to be good it was considered by all who described their experiences that counselling was a service which met a specific need whether the service user wished to attend or not. This need was considered to be outside the remit of the GP.
The value placed on general practice in this regard in the study has resonance with the recent UK Essence study.33 Using commissioned short pieces of 100 words from both GPs and patients, questions such as, ‘What do you value from your GP?’ identified similar concepts to this study, including being ‘treated as an individual’, ‘valuing the GP’s attention and time’ and ‘valuing the ability to consult well’. The reality of attending weekly in a confidential setting, (without drug-dealing taking place in the immediate vicinity), having designated appointment times “just like every other patient”, having problems sorted out at this time and being afforded the opportunity to normalise their lives was described as distinctly related to the setting of general practice. A recent study has identified that service users who attend the National Drug Treatment Centre (NDTC) want dealing in the vicinity of their treatment site curbed.34
Daithi: “Yeah I went to counselling myself separately; I never used my GP for that.” Researcher: “Do you have counselling here?” Niamh: “No, in the community drug team…. yeah I can talk to the doctor but I wouldn’t go in and deep and talk to me doctor but I do find I can talk to me doctor, which is good …but also the doctor doesn’t have the time to sit and talk and listen…” There was a reluctance to access counselling within a treatment clinic as this required re-engaging with other drug misusers in this environment. Tadgh: “No, there’s nothing here like you have to go down to see the… you’d have to go down to [clinic]…but that’s where they go for the phy, all the worst of the worst go there you know that way?”
All of the service users in the study spoke of valuing general practice for a variety of reasons. Many of the service users in this study (70%) were attending their general practice for five years or more. Experiences of these service users attested to a long-term personal doctor–patient relationship which is a feature of general practice, as in many cases “knowing the patient who has the disease has been identified as as important as knowing the disease that patient has.”35,36,37 This ‘knowability’ of the treatment context and also the apparent change in status of the drug treatment client from what has been described as ‘autonomous agent’ to ‘participant in treatment’ is significant. This was not only defined by the unique nature of the doctor-patient relationship but also described by service users as a trust engendered by a familiarity with past care and where their doctor recognised their professional responsibility to their community in prescribing methadone. This highlights the importance of the GP’s ability to consult well. Effective and intuitive consultation is at the heart of good practice and the ability to engage in a facilitative, rather than autocratic, manner has been advocated in many models of consultation.38,39,40
This overall description of “getting sorted” describes the user’s perception of what services are provided for them in general practice from their perspective. “Getting sorted” is often also applied to the process of obtaining heroin.
Limitations of the study Given the aims and objectives of investigating care in general practice the sampling strategy provided confirmation that those interviewed were indeed currently in receipt of methadone treatment from a general practitioner rather than a treatment centre. Bias is possible and could not be fully controlled but it was considered to be a useful pragmatic approach. With the benefit of hindsight, limitations of this study could be that the use of the GP prescriber as gate keeper may have influenced the accounts of service users, however the fact that negative experiences with these GPs were elicited during the in-depth interviews, without probing, suggests that this approach was useful. The use of the GP as gate keeper to target these service users was a deliberate decision to ensure that vulnerable patients were protected and was also a method of ensuring that the participants would be able to provide rich material. Rich responses to the research question were produced and enabled an in-depth descriptive account to be generated.
Treating drug misusers with respect, listening to their concerns and those of their families has been actively desired and highlighted by drug misusers themselves as crucial to their treatment.41 However, three service users described their GP as a “phy doctor” (in terms of prescribing their methadone only) and expressed their disappointment with this type of consultation style. It would seem that the role of the methadone-prescribing doctor needs consideration, as there is potential to avoid full engagement, which could lead to missed opportunities to look after other
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domains of health. The therapeutic commitment to working with patients addicted to drugs can be enhanced by education and support, as can reflective learning, teaching and training to improve the doctor patient relationship.42,43,44 International studies have suggested that a proactive and even interventionist approach to the consultation in relation to methadone dosing has been found to be important to service users. But this is an approach that needs greater resources as it requires that service providers or their support staff spend more time with patients.45 The unique system of training Level 1 GPs historically encouraged a multidisciplinary team approach to care. Professionals such as pharmacists, psychologists, practice nurses and midwives attended the course together, albeit on an ad-hoc basis. However, since 2008 this training has been provided exclusively for GPs through an online learning format by the ICGP. This is in contrast to the UK, where the Royal College of General Practitioners (RCGP) advocates that treatment of drug misusers is multifaceted and normally requires a multidisciplinary response wherever possible. Training there is provided in collaboration with practice nurses, dispensing pharmacists, practitioners with a special interest and addiction specialists.46
Professor W Cullen MD, MICGP, MRCGP, Professor of General Practice, Graduate Entry Medical School, University of Limerick, Limerick, Ireland. Practice Based Supervisor.
Funding body This study was part funded by a grant from the Irish College of General Practitioners Research & Education Foundation. The funder had no input into the design or running of the study, in writing the paper, or in the decision to submit for publication.
Ethical approval Ethical approval was obtained from the ICGP Research Ethics Committee and the School for Health University of Bath, Research Ethics Panel.
Conflict of interest Practising Registered Nurse Practitioner in Primary Care at one of the sites surveyed.
Two types of psychological services are currently provided in primary care, known as co-locational and autonomous models. Anecdotal evidence from GPs suggest that services involving psychological assessment at primary care level is their first choice for patients and for some patients, primary care is the only acceptable route into psychological services.47 In this study the majority of service users reported being mainly satisfied with their treatment however service users have historically few expectations of care and these issues need further exploration.48 Caution has to be expressed therefore as to what service users reasonably expect to receive from general practice in Ireland in the absence of any nationally negotiated service level agreements, drug service users’ charters or national guidelines. To this end one of the recommendations of this study is that the training needs of practice staff be considered within a multidisciplinary focus in order to equip practitioners to provide a comprehensive approach to service users’ needs in treatment. The experiences described in theme one contribute to understanding current practice and identify areas for improvement in the treatment of drug misusers in general practice. The study in its totality suggests strategies which facilitate user involvement are central to the future success of methadone treatment protocols such as those that operate in Ireland. Future research is required to evaluate the importance of changing client needs and their expectations of what a methadone treatment protocol should deliver.
Author’s contributions The study was conducted by Linda Latham as part of a doctoral research programme affiliated to the University of Bath between September 2006 and September 2010. Dr J Scott PhD MRPharmS, Senior Lecturer in Pharmacy Practice & Medicines Use, University of Bath, Claverton Down, Bath. Academic Supervisor
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2005. 28. Polkinghorne DE Phenomenological Research Methods In: Existential– phenomenological perspectives in psychology (Valle, R.S, Halling, S. eds) Plenum Press, New York, 1989;CH3:41-60. 29. Latham L. An explorative study of the perceptions and Experiences of practice nurses in relation to patients on a methadone treatment protocol. Unpublished MSc Thesis, 2003;UCD. 30. Colaizzi PF. Psychological Research as the Phenomenologist Views It: In: Existential– phenomenological alternatives for psychology. (Valle, R. S. King. M.eds) Oxford University Press, 1978; Ch: 3:48-71 31. Rhodes T, Kimber J, Small W, Fitzgerald J, Kerr T, Hickman M, Holloway G. Public injecting and the need for 'safer environment interventions' in the reduction of drugrelated harm.Addiction,2006; 101(10),1384-1393 32. Kerr T, Kimber J, Rhodes T. Drug user settings: An emerging focus for research and intervention. Int J Drug Policy, 2007; 18(1), 1-4 33. Gillies Mercer S, Lyon A, Scott M, Watt, G. (2009) Distilling the essence of general practice: a learning journey in practice. BJGP, 2009; 59 (562)356-363 34. Ambreen A, Keenan E, Casey P. Consumer satisfaction with methadone maintenance programmes survey. Irish Psychiatrist, 2008; 9(2) 91-93 35. Freeman G, Hjortdahl P. What future for continuity of care in general practice? BMJ, 1997; 314:1870 36. Stokes T, Dixon-Woods M, McKinley R. Ending the doctor–patient relationship in general practice: a proposed model. Fam Pract, 2004; 21(5), 507-514; doi:10.1093/fampra/cmh506 37. McCormick J. Death of the personal doctor. Lancet, 1996; 348:667-8 38. Pendleton D. The Consultation: An approach to learning and teaching. 1984.Oxford University Press 39. Neighbour R. The Inner Consultation: How to develop an effective & intuitive consulting style. 1984. 40. Kurtz SM, Silverman JD, Draper J. Teaching & learning communication skills in medicine. R, 1998; Radcliffe Medical Press, Oxford. 41. Fischer J, Jenkins N, Bloor M, Neale J, Berney L. Drug misuser involvement in treatment decisions. 2007; Joseph Rowntree Foundation, The Homestead, 40, Water End, York YO306WP 1-45. 42. Clarke B. Drug using parents - the child care issues. Ir Soc Worker, 1994; 12 (2) 9. 43. Anderson P, Kaner E, Wutze S, Wensing M, Grol R. Heather N. Saunders J. ‘Attitudes and management of alcohol problems in general practice: Descriptive analysis based on findings of a WHO, international collaborative survey’, Alcohol Alcohol, 2003; 38 (6) 597–601. 44. O’Riordan M, Skelton J. laCroix A. Heartlift patients? An interview –based study of GP trainers and the impact of ‘patients they like’. Fam Pract, 2003; 1-6 45. Lintzeris N, Pritchard E, Sciacchitano L. Investigation of methadone dosing in Victoria: Factors influencing dosing levels. Fitzroy, Victoria: 2007; Turning Point Alcohol & Drug Centre. 46. Ford, C., Barnard, J, Bury, J, Carnwath,T, Gerada, C, Joyce, A.et al. Guidance for the use of methadone for the treatment of opioid dependence in primary care. RCGP Substance Misuse Unit RCGP.2005; Sex, Drugs and HIV Task Group SMMGP. The Alliance. Available at www.smmGP.org.uk 47. Martin E, Hawkins S, Hicks T, O’Flynn, M. Psychological services for adults in primary Care Ir Psychol,2009; 35 (10),281-288. 48. Madden A, Lea T, Bath N, Winstock A. Satisfaction guaranteed? What clients on methadone and buprenorphine think about their treatment. Drug Alcoh Rev,2008; 27, 671-678.
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APPENDIX 1 INTERVIEW TOPIC GUIDE Thank you for agreeing to take part in this interview. As you know from the written consent that you signed, this interview is confidential, and your views will be treated anonymously. TOPIC 1 GENERAL PRACTICE • I’m interested in getting your views on what it’s like attending here? (GP practice - for methadone maintenance) • What are your views on general practice? • Have you had a lot of dealings with GPs (before you started on methadone?) • How much have you used GP services for your health care? (e.g. women’s health, pregnancy? Men’s health etc?) TOPIC 2 METHADONE MAINTENANCE-(THE ROLE OF METHADONE AS A TREATMENT FOR DRUG ADDICTION) • Do you think /feel you have a drug problem? • How does it make you feel to be attending a GP for that problem /for methadone? • Do you feel listened to? Are your views important? • Do you feel that methadone has helped you? - What does it help you with? • What more could be done to help? TOPIC 3 PARTNERSHIP /INVOLVEMENT IN CARE • If you are not happy with some aspect of how your treatment is going how able are you to voice your concerns? • Have you ever had an experience that you negotiated a change in treatment? - can you tell me about that? • What are your future plans? TOPIC 4 PROTOCOL /INFLUENCING FACTORS • What do you understand by the term methadone protocol?(Examples Urine testing/ take away doses/attending the GP every week) • From your experience are there any aspects of this protocol that you would change? • What do you feel influences GPs in taking on patients who are on methadone? IS THERE ANYTHING ELSE YOU WOULD LIKE TO ADD? • Thank you for taking part. If you wish I will give you back the transcript of your interview so you can check whether I have accurately reflected your views.
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O R I G I N A L PA P E R
Using Quantitative Research to Measure Recovery Outcomes and Correlates Deirbhile Lavin, Patrick Ryan Ir J Psych Med 2012; 29 (3): 157-162
Abstract
Introduction
Objective: Recovery has become an increasingly significant concept within mental health literature. Despite this, few studies have investigated the measurement of recovery and its correlates using quantitative methods. The aim of the current study was to measure recovery in people with chronic psychiatric disabilities using a quantitative tool and to investigate what factors were correlated to recovery outcomes. It was hypothesised that measures that investigated the individual’s subjective sense of wellbeing would have a stronger correlation to recovery than more traditional clinician-rated scales.
Historically there has been a pessimistic view of the prognosis for people with chronic psychiatric illness. When schizophrenia was first identified by Krapelin as ‘dementia praecox’ in 1913, he conceptualised its course as an ‘inevitable deterioration’ with a progressively downward degenerating path. In the 1950s the process of de-institutionalisation made it possible for individuals to live within the community. However many individuals who were discharged did not fare well leading to poor levels of quality of life.1 Adequate psychosocial supports were not made available and many individuals experienced isolation within their community. The negative view of chronic psychiatric illness as a ‘life sentence’ therefore continued to pervade through the 20th century leading to much shame and stigma surrounding mental health issues.
Method: Participants were 63 people with a chronic psychiatric disability. They were recruited as a convenience sample from community mental health rehabilitation teams in three locations. Using a cross-sectional design, participants completed measures of psychological well-being (Psychological Well-being Scale (PWB); hope (Adult State Hope Scale) and recovery (Recovery Assessment Scale (RAS). Health professionals rated participants’ psychosocial functioning using the Multnomah Community Ability Scale (MCAS-R).
Outcome studies conducted in the 1970s investigating recovery rates in people with chronic psychiatric disabilities began to challenge the negative view of the course of severe mental illness. The most prominent study was the Vermont Longitudinal Study.2 This study followed a group of 269 people with severe mental illness and found that at 20-25 year follow-up 55% of people were judged to be recovered or functioning very well. Several other studies conducted since then3,4,5 have found similar results and suggest that around two-thirds of people with chronic psychiatric disability can recover.
Results: Analyses found that there was no significant correlation between clinician-rated psychosocial functioning scores and participant-rated recovery outcomes. Psychological well-being variables rated by the participants themselves were found to significantly correlate with recovery outcomes. The variables hope, environmental mastery and relationships with others were found to emerge as independent predictors of recovery scores.
A concept of recovery was also put forward by the mental health consumer movement. First-hand narrative accounts from people who had experienced severe mental illness describe a sense of recovery that does not require the remission of symptoms or other deficits, nor does it constitute a return to normal everyday functioning. Recovery was proposed as a ‘way of living a satisfying, hopeful and contributing life even with the limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.’6
Conclusions: Results underscore the premise that recovery is a distinct construct that is unique to the individual and cannot be fully captured by objective measures of functioning. Implications for practice suggest that services for people with chronic psychiatric disability should utilise recovery focused tools in patient assessment and treatment in order for a comprehensive assessment to be achieved. Recovery interventions should also focus on the individual’s hope, mastery and relationships with others in order to promote recovery.
Recovery is a complex and multidimensional construct and is unique to each individual. However a number of broad themes have been identified by qualitative studies and systematic reviews.7,8,9,10,11 These are hope, sense of identity, engaging in meaningful activity, developing positive relationships with others and actively engaging in strategies to stay well.
Key words: Serious mental illness, recovery (disorders), rating scales, psychological well-being.
Having hope that recovery is possible is a central foundation to the recovery process.12 Despite this, contact with the mental health services can engender a profound feeling of hopelessness and people are given the impression that they have a ‘long-standing
*Deirbhile Lavin, Clinical Psychologist HSE Kildare Mid West Adult Mental Health Service, Dublin Road, Kildare Town, Co. Kildare, Email: deirbhile.lavin@hse.ie *Correspondence
Patrick Ryan, Director Doctoral Programme in Clinical Psychology, University of Limerick, Co. Limerick
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Submitted: 3rd June 2011 Accepted: 27th January 2012
chronic disorder’ from which they are unlikely to recovery.13
reduced symptomatology or improved social functioning between those who left hospital and those who did not. However, positive outcomes were identified on subjective constructs in line with the recovery concept such as more autonomy and a marked preference by patients for community rather than hospital residence.
Maintaining a positive self-identity is significant in recovery narratives. Individuals state that being given a label of mental illness creates a loss of self-identity.14 Recovery begins when one engages in a ‘reconstructive process’ whereby the individual rebuilds themselves, drawing on old parts of the former self and discovering new parts to achieve a coherent and stable sense of identity.8
It is the aim of this study to utilise a quantitative recovery measure in a population of participants with chronic psychiatric disabilities. The recovery measure will be correlated with subjective measures of psychological functioning and clinician-rated measures of psychosocial functioning. It is hypothesised that subjective measures of psychological well-being will be shown to have a stronger correlation to recovery outcomes than objective measures of psychosocial functioning rated by clinicians.
Several recovery stories have reflected the value of engaging in activity that is meaningful to them. This may be formal employment,14 voluntary work,15 or creative endeavour. One author states that meaningful activity motivates her, provides positive structure for her life and gives new skills and something to look forward to on a daily basis.16 Other authors point out that it is also important that the individual’s meaningful activities are recognised and valued by society.17
Method Participants Recruitment of participants took place from three community rehabilitation teams in Ireland. The majority of participants were living in medium to high support hostels while a small group were still living in institutional care. All participants had a severe and enduring mental health difficulty. A total of 83 participants were originally approached to participate in this study. Fourteen of these participants declined to participate in any of the questionnaires. Three more individuals started the interview but were excluded as they were not able to engage with the questionnaire method. Three more individuals started the interview but declined to complete all questionnaires. This gave a final sample of 63 participants.
Developing positive relationships with others plays an enormous role in the recovery process. Many narratives speak of the vital support of a family member, friend or care-giver who provides support, hope and love.13 One author outlines that it is difficult for people with severe mental illness to have faith in others as often their advice may be contrary to the individual’s instincts.9 Others point out that support for individuals is most effective when it is offered in a collaborative way within a trusting relationship that maintains the individual’s sense of control and self-determination.17 Peer networks have been central to the recovery movement and many people state that learning from others who are living well despite the illness has given them inspiration.18
Procedure Ethical approval for this study was granted by the Ethics Committee of two regional hospitals where participant recruitment occurred. The researcher was introduced to potential participants by a staff member who explained that the purpose of the study was to, “Find out more about how people with a mental health difficulty think about themselves and their future”. Participants were given an information sheet which explained the purpose of the study and its possible risks and benefits. They were also given information on who to contact if they required further clarification. This included a health professional known to participants on their rehabilitation team (e.g. consultant psychiatrist, senior psychologist). They were then asked if they would be agreeable to participate in the study and invited to sign a consent form.
Many narrators talk of living with their illness rather than being cured of it. Having a personal understanding of their illness and taking note of symptoms and triggers of ill health as well as indicators of what keeps them well can help individuals in their recovery.17 Developing skills to actively engage in strategies to stay well and manage setbacks such as using the Wellness Recovery Action Plan (WRAP)19 can create a sense of mastery in the individual that can help them maintain their well-being. Despite a large body of literature focusing on recovery themes there remains a lack of clarification on the definition and operationalisation of the recovery concept. Several authors have raised the concern that lack of agreement on how to define recovery may lead to its loss of credibility as a meaningful construct.20, 21 Psychometrically adequate measures to assess proposed components of recovery have only recently been developed and are not widely used.27 The re-orientation of services towards a recovery model requires the development and utilisation of instruments that can be used to support and measure the recovery concept routinely in services.
Participants were administered the research questionnaires in an interview format. The interviewer read the questions aloud to the participants who chose their answer from a graphical illustration depicting the appropriate Likert scale. Interviews on average lasted 45 minutes. Depending on concentration levels of participants some interviews were administered over two occasions.
Research investigating outcomes in participants with chronic psychiatric disabilities has tended to focus on measures of psychopathology and psychosocial functioning22 and have not incorporated the measures of the recovery construct. For example the Team for the Assessment of Psychiatric Services (TAPS)23 monitored 670 long stay patients discharged from two London hospitals into the community from 1985 to 1993. This study found few differences in terms of traditional outcome measures such as
Measures Details of age, diagnosis, age when first diagnosed, time since hospitalisation and level of education were recorded. The Psychological Well-Being scale 24 consists of six seven-item subscales: autonomy, environmental mastery, personal growth, positive relations with others, purpose in life and self-acceptance 158
and a total score. Test-retest reliability was reported to range between .81 and .88; validity was reported to range between .50 and .77.
An analysis of MCAS-R scores demonstrated that 53% of the current sample scored above the 90th percentile on the total MCAS-R score. This suggests that many participants’ psychosocial functioning was at a higher level compared with an ‘average’ person in a mental health population.
The Adult State Hope Scale25 was developed as a measure of hope. It consists of two three-item subscales: agency, which refers to the individual’s perceived capacity for initiating and maintaining actions necessary to reach a goal, and pathway, which refers to an individual’s perceived ability to generate routes to one’s own goal. Test-retest reliability was reported to range from .48 to .93. Concurrent validity was reported to range from .50 to .75.
Correlations between demographics and RAS scores Pearson R correlations were conducted to investigate if there was a significant relationship between demographic variables and RAS scores. No significant correlations were found between age, age at onset or length of time since last hospitalisation and recovery scores. There were no significant differences in recovery scores based on diagnosis. There were no significant differences between groups based on level of education.
The Recovery Assessment Scale26 was developed as an outcome measure of recovery-orientated programmes. The scale was initially developed through narrative accounts of the stories of four consumers of mental health services with specific emphasis on hope and self-determination. Reliability and validity of the Recovery Assessment Scale has been tested using a sample size of 1,824 participants as part of the Consumer Operated Services Program (COSP) Multi-site Research Initiative.27 Test-retest reliability was reported to be .88. Concurrent validity ranged from .55 to .71.
Correlations between MCAS-R scores and RAS scores Spearman rank correlations were conducted in order to investigate the relationship between psychosocial functioning measures and recovery measures. Results found that there was no significant relationship between MCAS-R scores and recovery scores. Relationship between PWB scores and RAS scores Pearson correlations were conducted to evaluate the relationship between measures of psychological well-being and recovery. Results are presented in Table 2 (overleaf).
The Multnomah Community Ability Scale –R (MCAS-R)28 was used to measure the psychosocial functioning of participants. It is an informant questionnaire and is commonly completed by mental health clinicians or staff with a broad knowledge of the individual’s functioning gained by regularly working with the individual over a period of time. It has four subscales: interference with functioning; adjustment to living; social competence; behavioural problems; and a total score. Inter-rater reliability was reported to be .85 and test-retest reliability was found to be .82.
Results found that each of the measures of psychological wellbeing was significantly correlated with recovery score. Agency, relationship with others, environmental mastery and pathway had a large size correlation with recovery score. Self-acceptance, purpose in life, personal growth and autonomy had a medium size correlation with recovery score.
Results
A hierarchical multiple regression analysis was conducted to evaluate how well measures of psychological wellbeing predicted recovery and what variables were independent predictors of recovery above and beyond other variables. The predictor variables were the seven measures of psychological well-being (PWB); autonomy, environmental mastery, personal growth, relations with others, purpose in life, self-acceptance and one measure of HOPE (total of agency and pathway subscales). The criterion variable was the total recovery score. As age was found to significantly correlate with psychological wellbeing, age was entered in the first step and all other variables were entered in the second step.
Demographics The participants were 35 men and 28 women. The mean age was 50 years ranging from 27 to 84 years (SD=14.68). Age of onset ranged from 14 years to 64 years (M=27.9; SD=10.9). Time elapsed since last hospitalisation ranged from eight months to 15 years (M=4.6; SD=3.9). Diagnosis included schizophrenia, 42 (67%), bipolar depression, nine (15%), major depression, nine (15%), anxiety, four (6%) and other, four (6%). In terms of educational level, eight (13%) participants had primary level, 42 (66%) had secondary level and 13 (20%) had tertiary level.
Results found that the linear combination of psychological wellbeing measures was significantly related to recovery score F (8,51)=12.99, p<.001 (see Table 3 overleaf). The correlation coefficient was 0.81 indicating that approximately 65.2% of the variance was accounted for by these variables.
Descriptive statistics Descriptive statistics for Psychological Well-being scores (PWB), Adult State Hope scale (HOPE) and Recovery Assessment Scale (RAS) are presented in Table 1.
Table 3 indicates the relative strength of each of the individual predictors. Three variables were statistically significant (p<.05). These were hope, environmental mastery and relations with others. This suggests that these measures are independent predictors of recovery above and beyond other measures of psychological well-being.
Table 1. Descriptive Statistics for Psychological Wellbeing Scale (PWB), Adult State Hope Scale (HOPE) and Recovery Assessment Scale (RAS).
PWB Total score HOPE Total score RAS Total score
Mean
SD
159.95 32.00 158.61
26.69 9.34 21.52
159
Table 2. Intercorrelations between Measures of Psychological Well-being (PWB) and Recovery Assessment Scale (RAS) scores
Autonomy
Environmental Mastery
Personal Growth
Relationship with Others
Purpose in Life
Self Acceptance
Pathway
Agency
Recovery score
.529**
.149
.409**
.433**
.452**
.374**
.344**
.349**
.331**
.543**
.491**
.532**
.602**
.592**
.664**
.383**
.690**
.356**
.269*
.194
.288*
.407*
.577**
.355**
.374**
.600**
.485**
.496**
.331**
.330**
.479**
.315*
.471**
.565**
.572**
Environmental Mastery Personal Growth Relationship with Others Purpose in Life Self Acceptance Pathway Agency
.692**
*p<.05 **p<.001
Discussion
Table 3. Prediction of Recovery Assessment Scale (RAS) scores from Psychological Well-being (PWB) Measures.
The aim of this study was to utilise a quantitative recovery measure in a population of participants with chronic psychiatric disabilities. It was hypothesised that recovery would be more strongly correlated to subjective measures of wellbeing than to objective measures of psychosocial functioning rated by clinicians. Results found that there was no significant correlation between psychosocial functioning scores and recovery scores and this suggests that the concept of recovery is a highly subjective concept and is distinct from objective measures of psychosocial functioning. These results support previous studies which have investigated the relationship between traditional clinical outcome data and recovery outcomes. One study29 used the Recovery Assessment Scale (RAS) to measure recovery and the Health of the Nations Outcome Scale (HoNOS) to measure psychosocial functioning. Participants were a convenience sample of 168 people with severe and enduring psychiatric disability. Using a cross-sectional analysis the authors did not find overall significant correlations between psychosocial functioning and recovery. The authors concluded that the lack of correlation between measures suggests that the RAS is assessing an aspect of recovery that is external from measures of psychosocial functioning and suggests that the recovery variable is something unique and distinct.
R2 Change
b
P
Step 1 Age
-.024
.858
.001
Step 2 Autonomy Environmental Mastery Personal Growth Relations with others Purpose in Life Self-acceptance Hope
-.081 .275 .123 .292 -.173 .012 .488
.480 .047* .340 .012* .223 .919 .000**
.652
*p<.05 **p<.001
experienced in the past four weeks. This scale was found to correlate with recovery scores. The authors therefore concluded that the recovery measure is a unique construct and is not comprehensively assessed by objective clinical measures. The present study found significant correlations between all psychological wellbeing variables measured and recovery scores, with strengths of correlations ranging from medium to strong. Taken together, psychological variables explained 65% of the variance in recovery scores. Environmental mastery, the two variables comprising hope (agency and pathway) and relationship with others had a large size correlation with recovery score. These variables were identified as being significant independent predictors of recovery above and beyond other psychological wellbeing variables.
A further study30 correlated recovery scores using the RAS with four clinical measures. Using a sample of 110 people who had severe and enduring mental health difficulties this study found that recovery scores did not significantly correlate with measures of the Health of the Nation Outcome Scale (HoNOs); the Life Skills Profile16 (LSP-16) or the Global Assessment Functioning (GAF) scales which are clinician-rated scales. The authors also used the Kessler10 (K-10) which is a consumer-rated measure which assesses the level of anxiety and depressive symptoms the person has 160
Conclusions
Hope was reflected in the recovery literature by themes such as knowing and being told that recovery is possible. The strong correlation between recovery and hope scale reflects the importance of this variable in recovery. Narrative discourses point to the importance of other people in the individual’s lives who foster hope.13, 14 They point out that contact with mental health services can engender a profound sense of hopelessness. Interventions with people with chronic disability should be delivered with an attitude of hope and one that recovery is possible.
Overall results found that recovery was not predicted by objective psychosocial functioning variables and was predicted by subjective psychological wellbeing variables. This illustrates that recovery is a distinct construct that is unique to the individual. This suggests that recovery instruments should be used routinely with people with mental health difficulties in order to provide a more comprehensive assessment of the individual. Furthermore interventions should continue to target individuals’ hope, environmental mastery and relationships with others in order to promote recovery. Service delivery for people with chronic disabilities is now becoming more recovery-orientated. Guidelines for practice embracing models of recovery-oriented psychiatric rehabilitation are now central to many government health policies and there are many models that espouse these principles.33 The current research has underscored the importance of addressing these concepts in service delivery.
The concept of environmental mastery is reflected by themes such as understanding one’s illness and general wellbeing and actively engaging in strategies to stay well and manage setbacks. Narrative discourses have identified the importance of experiencing a sense of control and mastery over one’s environment.17,18 By individuals having knowledge of their ill health and taking note of triggers, events and symptoms, they increase their sense of mastery and ability to stay well. Interventions such as the WRAP programme focus on a range of strategies that aim to increase mastery and help establish and maintain wellbeing.
Conflict of Interest None.
Relationships with others was independently correlated with recovery scores. This is reflected in the qualitative literature by themes such as developing positive relationships with others and having family and friends who are supportive. From narrative discourse it appears that there are multiple ways in which positive relations with other people help those with chronic psychiatric disability. Support from others can inspire hope and can help individuals increase their own awareness.31 Support can help the individual overcome a sense of self-stigma.32 Peer support networks can offer information and practical support.17 What seems to be important however is that support from other people must be offered in a collaborative way and one which respects the way in which the individual makes sense of their illness. As one author points out10 those with chronic psychiatric disabilities may have a different explanation for their difficulties than health professionals. What is therefore required is the building of trust where the individual is open to the advice of health professionals but where their expressed needs and treatment choices are also respected. Limitations of this study include that it is cross sectional in design. This means that one cannot establish the direction of causality for correlations between variables. For example, it is not possible to state whether positive relationships with other people cause the strength of recovery or whether the strength of recovery causes positive relationships with other people. One can only simply conclude that a relationship exists. The sample size of this study was limited and this study was powered to detect medium and large effect size correlations between variables. It is therefore possible that significant relationships which were small in effect may have existed but were not identified. The measures used in this study relied on self-reporting by participants which may have been open to social desirability. Furthermore, the sample was a convenience sample. Potential participants who were excluded or dropped out of the study (e.g. those with active psychosis, cognitive difficulties or who could not give informed consent) may have represented a more severe group than those who did participate.
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November 2008; 2005 28. Barker S, Barron N, McFarland BH, Bigelow DA. A community ability scale for chronically mentally ill consumers: II. Applications. Community Mental Health Journal. 1994;30(5):459-72. 29. McNaught M, Caputi P, Oades LG, Deane FP. Testing the validity of the Recovery Assessment Scale using an Australian sample. Australian and New Zealand Journal of Psychiatry. 2007;41(5):450-7. 30. Andresen R, Caputi P, Oades L. Do clinical outcome measures assess consumer-defined recovery? Psychiatry Research. 2010;177:309-17. 31. Lynch K. The long road back. Journal of Clinical Psychology. 2000;56(11):142732. Corrigan PW, O'Shaughnessy JR. Changing mental illness stigma as it exists in the real world. Australian Psychologist. 2007;42(2):90-7. 33. Mental Health Commission. A recovery approach within the Irish mental health services: A framework for development. Dublin: Stationary Office; 2008.
References: 1. Corrigan PW, Mueser KT, Bond GR, Drake RE, Solomon P. Principles and practices of psychiatric rehabilitation: An empirical approach. New York, NY US: Guilford Press; 2008. 2. Harding CM, Brooks GW, Ashikaga T, Strauss JS. The Vermont longitudinal study of persons with severe mental illness: II. Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. American Journal of Psychiatry. 1987;144(6):727-35. 3. DeSisto M, Harding CM, McCormick RV, Ashikaga T, Brooks GW, Cohen P, et al. The Maine and Vermont three-decade studies of serious mental illness: Longitudinal course comparisons. Historical and geographical influences on psychopathology. Mahwah, NJ US: Lawrence Erlbaum Associates Publishers; 1999. p. 331-48. 4. Hopper K, Harrison G, Janca A, Sartorius N. Recovery from schizophrenia: An international perspective: A report from the WHO Collaborative Project, the international study of schizophrenia. New York, NY US: Oxford University Press; 2007. 5. Ogawa K, Miya M, Watarai A, Nakazawa M. A long-term follow-up study of schizophrenia in Japan - with special reference to the course of social adjustment. British Journal of Psychiatry. 1987;151:758-65. 6. Anthony WA. Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal. 1993;16(4):11-23. 7. Jacobson N, Greenley D. What is recovery? A conceptual model and explication. Psychiatric Services. 2001;52(4):482-5. 8. Mancini MA, Hardiman ER, Lawson HA. Making Sense of It All: Consumer Providers' Theories about Factors Facilitating and Impeding Recovery from Psychiatric Disabilities. Psychiatric Rehabilitation Journal. 2005;29(1):48-55. 9. Marsh DT. Personal accounts of consumer/survivors: Insights and implications. Journal of Clinical Psychology. 2000;56(11):1447-57. 10. Onken SJ, Craig CM, Ridgway P, Ralph RO, Cook JA. An analysis of the definitions and elements of recovery: A review of the literature. Psychiatric Rehabilitation Journal. 2007;31(1):9-22. 11. Young SL, Ensing DS. Exploring recovery from the perspective of people with psychiatric disabilities. Psychiatric Rehabilitation Journal. 1999;22(3):219-31. 12. Deegan PE. Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal. 1988;11(4):11-9. 13. Tenney LJ. It has to be about choice. Journal of Clinical Psychology. 2000;56(11):143345. 14. Davidson J. A peer recovery story. Glasgow: Scottish Recovery Network; 2008 [updated 2008; cited on 22nd November 2008 from http//www.socttishnetwork.net] 15. Boustead J. My own recovery story. SRN Narrative Research Project. Glasgow: Scottish Recovery Network; 2008. 16. Leete E. How I perceive and manage my illness. Schizophrenia Bulletin. 1989;15(2):197-200. 17. Brown W, Kandirikirira N. Recovering mental health in Scotland. Report on narrative investigation of mental health recovery. Glasgow: Scottish Recovery Network; 2007. 18. Andresen R, Oades L, Caputi P. The experience of recovery from schizophrenia: towards an empirically validated stage model. Australian and New Zealand Journal of Psychiatry. 2003;37(5):586-94. 19. Copeland ME. In: Spaniol C, Gagne M, Koehler, editors. Psychological and social aspects of psychiatric disability. Boston: Boston University Centre for Psychiatric Disability; 1997. 20. Liberman RP, Kopelowicz A, Ralph RO, Corrigan PW. Recovery From Schizophrenia: A Criterion-Based Definition. Recovery in mental illness: Broadening our understanding of wellness. Washington, DC US: American Psychological Association; 2005. p. 10129. 21. Roe D, Rudnick A, Gill KJ. The Concept of 'Being in Recovery'. Psychiatric Rehabilitation Journal. 2007;30(3):171-3. 22. Liberman RP. Future directions for research studies and clinical work on recovery from schizophrenia: Questions with some answers. International Review of Psychiatry. 2002;14(4):337-42. 23. Anderson J, Dayson D, Wills W, Gooch C. The TAPS project: XIII. Clinical and social outcomes of long-stay psychiatric patients after one year in the community. British Journal of Psychiatry. 1993;162(19):45-56. 24. Ryff CD, Keyes CLM. The structure of psychological well-being revisited. Journal of Personality and Social Psychology. 1995;69(4):719-27. 25. Snyder CR, Sympson SC, Ybasco FC, Borders TF, Babyak MA, Higgins RL. Development and validation of the State Hope Scale. Journal of Personality and Social Psychology. 1996;70(2):321-35. 26. Corrigan PW, Giffort D, Rashid F, Leary M, Okeke I. Recovery as a psychological construct. Community Mental Health Journal. 1999;35(3):231-9. 27. Campbell-Orde T, Chamberlin J, Carpenter J, Leff H. Measuring the promise: a compendium of recovery measures. Volume II. Cambridge MA: Evaluation Center @ Human Services Research Institute. Retrieved from http://www.tecathsri.org/product_descritpion.asp?pid=129,
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O R I G I N A L PA P E R
A Qualitative Study of Gender-Based Pathways to Problem Drinking in Dublin, Ireland Joanne Cunningham Ir J Psych Med 2012; 29 (3): 163-170 Patrick’s story of entry into Alcoholics Anonymous “I thought I was going into a room full of drunks, winos and that sort of stuff... I went along to the meeting and it was then that I got in touch with just how lonely I was. Someone made me a cup of tea, bringing it over to me and putting their arm around me and saying, ‘Welcome.’ People laughing and just making me feel comfortable. And the fellows gave me their phone numbers. And [said] ‘keep coming back.’ A real soft, gentle stuff that at the time I needed.”
Abstract Objective: High rates of alcohol-related harm have been reported in the European Union, including Ireland, for more than 20 years. This article’s goal is to contextualise such rates by examining gender-based pathways to alcohol use disorders from the perspective of those self-identifying as in recovery using data collected midway through this 20-year trend. Methods: Sixteen informants (nine men and seven women) were interviewed between 1998 and 1999 in Dublin, Ireland. Using qualitative methods, informants were asked to reflect upon their experiences of problem drinking and recovery.
Introduction The European Union (EU) reports the heaviest alcohol consumption and highest rates of alcohol-related harm in the world.1 Within the EU, Ireland’s rates of consumption and alcohol-related harm are higher than average, with the latter termed one of the biggest public health issues facing Ireland.2,3,4 A 2009 EU survey found upwards of 90% of Irish respondents implicated alcohol in the occurrence of street violence, marital difficulties, loss of work productivity and underperformance at school.5 In general population surveys between 2002 and 2006, 21% of Irish respondents reported at least one instance of social harm (defined as fights, or harm to friendships, home life or work) due to their drinking, with men more likely to report such harms than women (28% versus 13%, respectively).6 When respondents’ age and drinking patterns were considered, harm to home life was more likely to be reported by those 35 years and older who engaged in risky drinking.6
Results: Drinking expectancies, pub-based socialising, social anxiety and perceived social expectations to drink were cited as common pathways to problem drinking by informants, highlighting contradictions in drinking practices and the symbolic functions of alcohol. Drinking contexts identified by informants were public pub-based drinking for men and home-based drinking for women. Primary barriers to problem acceptance centered on pub-based socialising norms and gender-based shame. Benefits of support group membership included establishing new social networks and learning alternative ways to cope with negative emotions. Conclusion: Consideration of drinking expectancies, the social contexts in which problematic drinking occurs, gender ideologies, the cultural meanings of drinking behaviours, and attention to feelings of isolation or loneliness experienced by those exhibiting problematic consumption behaviours might further understandings of potentially harmful drinking, especially in periods of economic uncertainty.
Compared with other EU states, the prevalence of binge drinking is highest in Ireland.5 While definitions for heavy and binge drinking are contested, heavy drinking herein is defined as consumption of more than 14 units of alcohol per week for women and greater than 21 units for men.7 In a 1998 national survey – over the time period represented by this research consumption above such limits was reported by 21% of women (22% in 2002) and by 27% of men (30% in 2002) who consumed alcohol.8 Heavy episodic drinking, or binge drinking, is defined as consumption of approximately half of the weekly recommended alcohol allowance during one drinking occasion.7,9 In 2007, potentially harmful drinking patterns (defined as warranting attention) were identified in 70% of male and 42% of female respondents reporting alcohol consumption in a survey conducted by the Irish Department of Health and Children.10
Key words: Alcohol, alcoholism, gender, recovery, qualitative.
The Alcohol Use Disorders Test – Consumption (AUDIT-C) was used to determine harmful drinking, identified by a score above a designated cut-off point.10,11 Across Europe, late adolescence,
Joanne Cunningham, Adjunct Assistant Professor Quinnipiac University, Department of Psychology 275 Mount Carmel Avenue, Hamden, CT 06518, Connecticut, USA Email: jocunn@umich.edu
Submitted: 30th October 2011 Accepted: 15th May 2012
163
Participants
young adulthood and male gender are associated with binge drinking, with social camaraderie and tension reduction acting as prime drinking motivations.7 High-risk drinking tends to peak in early adulthood and then decline in subsequent age groups. This pattern was observable in a 1999 survey of Irish drinking practices,12 the time period of the data for this study, and also in the 2007 one. In the later survey - of those reporting drinking alcohol - 74% of respondents aged 18-29, 57% of those aged 30-44, and 48% of those between 45-64 were identified as drinking at high risk using the Audit – C criteria.10
Sixteen members of two groups (13 AA and three WFS members) were interviewed in Dublin, in 1998-1999. Four AA members and all of the WFS members were women. All respondents classified themselves as being in recovery during the interview, either by describing themselves as a “recovering alcoholic” or by relating their experiences of the process of recovery itself. Respondents’ ages ranged from the early 30s to late 50s. Of the male participants, all but two were married and had children. Of the women, three were married, three were separated, and one had never married. All but one had children. Based upon 12 demographic questionnaires received, eight respondents worked full-time, and eight held university qualifications. Most participants reported they could make ends meet financially, but were not well off, two would have been considered upper middle-class, four working-class, and the remainder middle-class. All but one were Irish-born. To contextualise the research, the author conducted background interviews with two treatment counsellors and one alcohol researcher.
Alcohol use disorders, including dependence, abuse and/or harmful use, are multiply- determined by biological, social, psychological and environmental factors.13 Social networks and resources, community norms, and alcohol availability influence drinking behaviour, with the pub tradition and ‘wet’ versus ‘dry’ environments (characterised, respectively, by high and low per capital consumption) linked to harmful levels of alcohol consumption.14 Alcohol expectancies – i.e. beliefs about the outcomes of drinking – implicate the symbolic functions of alcohol, with positive expectancies linked to increased alcohol consumption.7,15 Public drinking behaviour can convey social status, group solidarity, and gender ideology; contest gender hierarchies; and indicate social relations of inequality and the workings of wider politico-economic structures.16
Study sample Sixteen respondents participated in this research. The sample was non-random and purposive, with the goal of inquiring into both men’s and women’s experiences of drinking and recovery.22 Thematic saturation, which is defined as achieved when no new concepts or themes are identified during the ongoing, iterative process of data collection and analysis, determined the final sample size of 16.22-24 Access to AA informants was provided by alcohol treatment clinic contacts. The names of 18 potential participants were provided, of whom 13 agreed to be interviewed (nine men and four women). To achieve greater gender balance, the author contacted WFS, which resulted in three interviews. This culminated in a sample of nine men and seven women. In total 21 individuals were candidates for participation in the research. Of the 18 AA members, 13 (nine men and four women) agreed to participate. Non-participants could not be reached and/or were men. All invited WFS members participated.
Alcoholism treatment involves biological, behavioural, social and personal factors.17-19 Support groups, such as Alcoholics Anonymous (AA), function frequently in treatment aftercare. Anthropological investigations have examined AA as a site of transformation of gender ideology, identity and social relationships and as a cultural model for organising knowledge and guiding inferences.20 Given the current incidence and trend of problematic drinking among sectors of Irish society, the goal of this paper is to contextualise these issues through the examination of interviews conducted with members of AA and Women for Sobriety (WFS) in Dublin in the late 1990s. While drinking patterns change rapidly, this examination points towards issues potentially applicable in the current social context. The questions framing this examination are: 1) What gender-based differences in drinking experiences were reported by participants; and 2) What experiences and benefits were reported for support group membership?
Procedure All participants were given the choice of an interview location (their home, a private room in a building where AA and WFS group meetings were held, or another location of their choosing). Ultimately, nine opted to be interviewed at the group meeting site, five in their homes, one in a private business office, and one in a café. All interviews were private with the exception of the one held in the café. The semi-structured interview concerned experiences of alcoholic drinking and recovery. At the start of the interview, all respondents were informed that they could stop the interview at any time and could decline to answer any questions. Respondents were handed a sheet listing potential topics, which included: “Why do you think you sought help?”; “After you decided you had a drinking problem, were you concerned that people might think differently about you?” and “Thinking back over your experience with problem drinking, have there been any positive aspects to the experience?” The intent of the question sheet was to allay potential anxiety and to insure coverage of all topics. Informants were free to speak at length on subjects, with follow-up questions asked to clarify specific points.
Method The research was part of a larger research project conducted with members of three support groups in Dublin in 1998-1999, which looked at the relationship between support group membership and understandings of illness experience. Data on the third group, for mood disorders, were published separately.21 Research materials were approved by the University of Michigan’s Institutional Review Board for use in the Dublin-based research, and consent forms were signed by all participants. A follow-up questionnaire containing demographic questions was sent to participants.
164
Data collection and analysis
recovery… There is always the same, ‘What do you do at Christmas? What do you do at parties? Can you go to the pub?’” A working class member of WFS described tensions: “I heard in the beginning [of sobriety] that you eliminate your drinking pals. And I said, ‘Friends don’t make you drink.’” Reflecting she says, “But if you are in that atmosphere and it’s all about drink, and going out and this that and the other, of course you are going to say, ‘What the hell,’ and join.” With her decision to abstain, she experienced criticism: “So, just because I don’t go out with them…it’s just that I am stuck up.”
Interviews were audiotaped and transcribed verbatim, except for one instance where the respondent declined to be audiotaped. For that interview, detailed notes were taken. Interviews ranged from approximately 45 minutes to three and a half hours in length. Qualitative data were analysed using the constant comparative method.25,26 Transcripts were read multiple times, coded and recoded. Themes, developed from the coding and recoding process, were combined into overarching categories. Thematic saturation, when no more information was derived from additional informants, determined the final sample size.22,24 Themes were analysed both within and between cases, with attention paid to elucidating gender differences. Coding was performed by the author and by a graduate-level research assistant, with coding disagreements resolved through consensus.
Latent themes: Symbolic functions of alcohol and contradictions in drinking practices The symbolic functions of alcohol were revealed by a 48-year-old man’s reflections on his youthful drinking. For him, “singing and drinking and poetry and culture and all that sort of stuff seemed to go together.” For several respondents, drinking and Irish identity were linked. According to a WFS respondent: “It’s a culture really in Ireland…we’ve got this image of the drunken Irish. An awful lot of people… feel that they’ve got to perpetuate this image that people have. Afraid to be different, [afraid] to say ‘I don’t drink.’ ‘Say, what,you’re Irish and you don’t drink?’”
Results Four manifest and two latent themes were identified. Manifest drinking themes included psychological motivations, perceived social pressures, pub-based socialising and gendered drinking contexts. Latent themes were the symbolic functions of alcohol and contradictions in Irish drinking practices. Recovery themes identified were learning to connect with one’s emotions and recovery as a group place. Themes are detailed below using illustrative quotes.
Another man said: “Irish… Alcoholic. It’s a great life when you work it out.”
Gendered drinking contexts: Pub drinking as performance of masculinity
Manifest themes: Psychological motivations – Drinking to cope
For male respondents, drinking and pub attendance symbolised masculine adult status. A working-class man recalled: “I don’t think I really got a hit off of it initially, but it was the thing to do, the manly thing to do…the more pints you drink, you become a man.” Another recounted: “T’was always somebody in the pub who I knew…fellas who were working all have their drinks on a Friday as well. So when you knocked off work on a Friday, you would go into the pub.”
Most respondents reported drinking to cope with anxiety, shyness or stress. A working class man described his youth: “I never went to dances. I didn’t do the things that a 16 year old should be doing... It felt more comfortable drinking. I was actually afraid social wise… I needed the drink on me, even to talk… If even a girl came into the pub, and I had a few pints on me, I’d have a go chatting her up then okay…I’d go nowhere sober.”
The pub was a ritual: “I’d go into the bar, which is a normal place for men, and everybody else is doing the same as I’m doing. So they’re the normal things… And I was of the old mentality, a man deserves a drink after working.” Another man queried: “How do you live without going into a pub…because everything else was work.”
Drinking was a means of self-transformation to be good craic. According to a WFS respondent: “I was great in the pub…the drink on me gave me great courage. I could go in and talk to anybody and fit in, and mix with anybody…” Another woman noted: “I was so, so shy. I just could not communicate…When I drank …I could make conversation with people. I could laugh. I could make a joke. And feel like I was involved like in company kind of thing... I thought I was gorgeous when I was drinking.”
For working-class men, a fatalistic surrender characterised attendance: “I had no regard for money… It was as if that was the publican’s money… I was resigned to spending my life like that… I was carrying on – I was falling into line with what they [his brothers] were doing…If they were off early from work, and I went to the pub, they would be there.”
Positive expectations and perceived social pressures to drink
For middle-class men also, the pub formed a social and professional nexus. For one, being a student meant drinking “a lot”, with drink served at college dinners “to give a sense of fellowship.” Later, daily pub attendance seemed a necessity: “That’s where everything besides work took place… it was where you could get connections and work, and you thought you might never be employed again if you couldn’t meet people in that sort of setting.”
For most respondents, the pub was associated with expectations of sociability and gaiety. According to a working-class man: “I remember as a kid when the elder brothers would come in from the pub…you go to the pub to have a good time…And the drunker you are, the more you’re laughing.” Social expectations to drink were mentioned by several respondents. A woman stated: “[I] talk to people about questions they might have about
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For some men, the pub was a place to escape: “I remember sitting in pubs fantasising about what I was going to do with my life. And how I was going to sort such a person out...There was a lot of … false camaraderie in the pub as well.” The pub was a retreat from life’s pressures: “And nobody has ever come down and said, ‘But, I’m under pressure from the ESB [electric company] bill.’ They take their IR£20 out of their pocket…and buy everybody a drink.” For middle-class men the pub served a similar purpose: “Emotionally, sexually, work wise, everything was there. And all the important issues of the day were discussed and decided there…I mean you could go into a pub on a Friday night and you’d meet some of our best politicians, our best economists, our best newspaper people, and it could be wild… And also the entire sexual thing was easier…in pub culture… But that was part of drinking, too.”
“Now, women try and stop men [from drinking], they [men] tell’em to ‘f**k off.’ Men, they just don’t let their wives drink if it’s a problem, so then they really have to do it in the secret…It’s lonely enough as an alcoholic. It’s terrible lonely when you have to wait until all your family are gone to sleep so you can go out and sneak the bottle.” Middle-class women also felt pressured to be secretive. A WFS respondent said: “[I] didn’t want to be going out and making a show of myself or getting into danger.” Adding, “I told myself, this is okay, it’s safer, at least I am staying at home and drinking. But it was worse because it was very lonely drinking.” Thus, women’s kitchens become “their pubs.” A WFS respondent recalled: “[I’d] get some drink” and “that would be kind of reward for the week’s work…there was a ritual in there, too. It was weekend kind of a thing…knowing that you could get drunk and not have to get up for work the next morning.”
Two women, but no men, commented on the limited socialising possibilities for men: “It’s really, really, really hard for men who have made pub drinking [their life]… And suddenly they are left with this void.” Another concurred: “When they do give up drinking, they are expected to kind of go to a pub after a football match or go to the pub after golf. Go to the pub for everything…” Continuing she says, “…it’s not as acceptable…for two men to go the cinema as it is for two women…I mean for men to go and sit in a coffee shop is not as normal as for women to sit in a coffee shop.” A counsellor at an alcohol treatment center interviewed during a preliminary research stage summed up a prevailing attitude, perhaps implicitly directed towards adult men: “We love you when you’re drinking, but hate you when you’re drunk.”
Gender-based shame Notions of “sinful choice” and “moral weakness” colour perceptions of alcoholism, and working-class men face potential ridicule for drinking problems. According to a working-class WFS respondent: “I don’t let everybody know that I have a problem… where I live quite a few know I have a problem with drink. And that doesn’t bother me but in work… They laugh at people that’s drunk or a person that might have a problem with drink… Especially men that has it.” The stigma of alcoholism appears gender-based. Men experienced shame about “not being able to hold the pints,” while women “who drink are morally reprehensible.” A female AA respondent mused, “we’re meant to be more pure than men…we are meant to kind of keep our dignity, our sexual dignity in check.” Another believed “women aren’t supposed to lose control.” The response to a woman’s inebriation would be “she’s a mother and how could she do it?” Continuing, she says, “I think people look unfavourably at women alcoholics because… we’re supposed to be the ones who cherish the children, and take care of the home, and even keep the men out of trouble.” According to another: “If a man goes to a football match on Saturday and goes straight to the pub afterwards and stays there all day, that’s fine …But if a woman goes shopping on a Saturday, and is to go to the pub and stay there all day, then she’s neglecting the children.”
For women kitchens are their pubs Most Irish women drink in pubs and their visibility has greatly increased over the last decades. Nonetheless, in keeping with both earlier and more recent accounts, these respondents reported greater stigmatisation of women with drinking problems.27,28 No respondents ever characterised drinking as the womanly thing to do and there is no old Irish saying, as there is about men, that “Drink is a good woman’s failing.” The prevailing attitude, according to one woman, is “you are not a man if you can’t go out and enjoy yourself. But with women it’s not seen as enjoying yourself, as much as, you know, behaving like a tramp.” In contrast to males’ experiences of public, pub-based drinking, women respondents reported secretive, home-based drinking once alcohol consumption rather than socialising became the goal. The vulnerability of women drinking alone in pubs is highlighted by one working-class male respondent: “A woman who goes in [a pub] is a scrubber…a tart…If I go in and I’m in bits and my beard is down, ‘hard worker.’ If a woman went in like that, she wouldn’t be served…No, women can’t, you know.”
Barriers to problem identification Gender roles and socialising norms make problem identification difficult. For men, “all their - what they think are friends - are in the pub.” For women, using their kitchen as their pubs, “[they] can’t get out of it.” Covering up drinking problems was easier for men due to male norms of pub drinking. Women, in contrast, reported spending more energy hiding it: “I used to have this brilliant idea…‘I’ll drink from 10 to 12 in the morning and I’ll sleep for two hours and then I will be sober enough to pick the kids up from school.’” While males sometimes mentioned crossing over from social to problem drinking, it was a focus for women. Solitary, home-based drinking, contrary to male norms, might function as clear danger sign for men, but it was common for women and took place at an earlier problem stage. According to one man: “I can see that’s why so many women have such a huge
The clear message of encroachment is evident: “They [women] can’t go into a bar and pull up a bar stool…they’d be lucky to be able to get out to the car park without six of them chasing after her. And then, if she doesn’t facilitate … she’d end up getting hit. You know, that all sounds pretty horrible, you know, but …that’s life isn’t it? So a woman must be on a man’s arm.” In working-class life, men enforce gendered drinking norms: 166
problem coming into recovery… they only see the visual what is expected of everybody else…And, it’s a huge problem for the women … So that’s why more women end up drinking secretly at home.”
stress. Drinking occurred in a variety of social contexts, with both men and women reporting problematic levels of consumption occurring in pubs. Gender differences emerged, however, as women tended to retreat from the public sphere and report solitary home-based drinking at earlier problem stages. For all respondents, benefits of recovery cited included finding community and learning how to deal with negative emotions.
He believes negative stereotypes form barriers to problem identification for women: “It’s still not acceptable [for women to drink]….And, you would hear other people talking about them…and the names would brought up fairly regularly. But you’d never hear them talking about fellas in there...” Two women in AA countered charges from their husbands, both of whom had alcohol problems, that they were unfit mothers. Another woman recalls: “I was still very much used as his value and made to feel that. And called a slut and a disgrace. Everybody was talking about me, but he [her husband] would never name anybody who was. And it probably was not true, [but] maybe certain people did.”
A 2009 Health Research Board publication characterised Irish culture as ambivalent towards alcohol and drunkenness.6 Pub conviviality conjures up images of Irish sociality,29,30 with the pub functioning as the ‘hub’ of social life.28 In one survey, a reported 40% of respondents listed drink-related issues as elements of their Irishness.29 A social tolerance for excessive consumption may exist, with alcohol used as a coping strategy for psychological and physical pain.31 This ambivalence finds expression in the saying, most likely directed towards middle-aged men, “We love you when you are drinking, but hate you when you are drunk.” Such ambivalence is not unique to Ireland, however. The association of pub culture, heavy drinking and national identity has been described as characteristic of New Zealand and countries in the UK context.32,33 It is possible that the association of pub-based socialising with national identity may prime drinking behaviours through activation of group-level stereotypes.34,35 Cross-culturally, gender and age influence drinking behaviours, while drinking practices make gender role differences more conspicuous.32,33 Greater gender divergence of drinking practices is associated with increased gender stratification.36 Younger individuals tend to drink more than older ones, with the gender-based drinking gap narrowing in younger cohorts.9 Rather than biologically driven, gender is seen as performative, with masculinities and femininities enacted and contested through public drinking behavior.33 High alcohol consumption has been linked to masculine ideologies, with “holding one’s drink” and drinking for pleasure seen as a components of masculinity.31,33,37 Gender-based social roles are reflected in drinking behaviours, with changes in women’s social and economic positions reflected in increases in women’s alcohol consumption.38 Redefinition, contestation, and assertion of gender identities are enacted through drinking behaviours.33,36 In keeping with such trends, a 1980 study characterised 32% of Irish women as moderate-to-heavy drinkers, consuming six or more units of alcohol per week.27,39 By 1998, consumption of more than 14 units of alcohol per week was reported by 21% of female respondents who consumed alcohol; a figure that rose to 22% in 2002.8 And, after decades of social, political and economic change, a 2007 survey defined 42% of Irish women who consumed alcohol as drinking at potentially harmful levels, although overall 23% of Irish women remained abstemious.10 Thus, these present findings are situated within a developed country trend whereby women’s increased economic and social independence and changing gender roles are linked to increased alcohol consumption32,33 especially among younger cohorts.28
Recovery experiences Pathways to problem identification, acceptance, and recovery varied. Several men encountered problems at work and were pressured to enter treatment. Two were threatened with being legally barred from their homes. Most underwent one or more hospital-based treatment programme. In contrast, fewer than half of the women did so. The women’s motivations for treatment varied, for one, the catalyst was her inebriation at a family gathering; for another, it was her child’s reaction to her intoxication. For a third, it was the only option: “There were two choices: Try to go to the off-licence or go to hospital. And I couldn’t go to the off-licence because I just wasn’t physically capable of going. So I went to hospital...There was no consideration of the children. Or the marriage. Or the home. That didn’t come into it at all. The choice was either drink or help.” For respondents, sobriety and support group membership were intertwined. Recovery was both a process and a state: one goes into it, works towards it, and is in it. It structures time and selfconceptions. Recovery involves changing the conditions loneliness, anxiety - that gave rise to drinking. According to one man: “What does recovery mean to me? Some sort of tentative truce with the self, I suppose, isn’t it? Some release from pain…It’s community, too. The recovery seems to be a kind of group place...It’s the company of people that you otherwise wouldn’t choose to be with [Laughs] if you weren’t drunks together.” Recovery means understanding one’s emotional responses. Before “the pain was got out of by just drinking it away” according to one man. In recovery; “Trying to get back into some kind of relation with your feelings” and learning to keep “emotions like anger in balance” are the tasks. One WFS member says: “I don’t have to please anybody today…I don’t have to sit here and be all laughs and jokes, because you’re laughing or joking. Or if you’re moody, I don’t have to be moody… I never thought I was entitled to have my own feelings.”
In this research, an ideology of drinking and masculinity was voiced by working-class men: drinking was a rite of passage into manhood, with social network-based reproduction of alcoholism and sobriety evident in one man’s account of being socialised into heavy pub drinking by his elder brothers and subsequently following them into AA. Professional men also reported lives structured around alcohol, with work-based pub socialising blurring the lines between commercial transaction and
Discussion In this research, respondents’ early alcohol consumption was fuelled by positive social expectancies (sociability, gaiety, and relaxation) and the use of alcohol to combat social anxiety and 167
camaraderie. However, the association of drinking with masculinity seemed less pronounced for middle-class respondents. Class-based or occupational pressures to drink did not emerge in women’s accounts. The sexual vulnerability of women drinking alone at pubs was cited for respondents’ home-based drinking. The perceived violation of gender drinking norms inherent in the public adoption of ‘masculine styles of drinking’ and the implicit challenge to gender statuses may be associated with sexual aggression against women.36 The ages of the respondents (all were of reproductive age but over 30) may point to a life span gradient such that drinking, especially on the part of single women, may be more tolerated. Whereas with the assumption of adult reproductive roles, more restrictive gender stereotypes are enforced, e.g. ‘She’s a mother, how could she do it?’. Greater stigma attends to women’s drinking, especially if a woman has children.28 And, as women continue to be the primary family caretakers, many may resist treatment for substance misuse for fear being labeled as unfit mothers.40 While a feminisation of binge drinking has been reported elsewhere, deviance is still portrayed as drinking by older women, or women appearing ‘masculine’ through heavy drinking.33,36
increased by 48%, with the most rapid increase occurring between the mid-1990s and 2001.43,44 Economic growth, changes in the availability and affordability of alcohol, an increased emphasis on consumerism in Irish culture and social changes have reportedly fuelled consumption increases.6,12,45,46 After peaking in 2001, alcohol consumption declined in 2003, followed thereafter by relative stability until 2008,44 when further declines were reported.45 Along with changes in the quantity of alcohol consumed, beverage preferences have changed as well. While beer is still the dominant choice for consumers, the consumption of wine has soared,43,44 perhaps indicative of women’s preferences.28,47 While price issues, pub smoking bans, and tougher drunk driving laws are credited with shifting alcohol consumption from the public to private arenas, the majority of alcohol purchases are still from pubs, restaurants and clubs.46 Extrapolations from the UK and British Commonwealth countries would indicate that women are still more likely to opt for home-based drinking, especially during heavy drinking days, and more likely to drink wine than beer. Men also report drinking most heavily at home, but are more likely to drink in a pub, with beer as their preferred beverage.48 Such differences may be interpreted as evidence of continued gender role enactment through drinking behaviours.33
In this research, the social pressures to drink were perceived to be stronger for men, while women reported secretive drinking at earlier problem stages. Arguing for continued gender differentiation in drinking patterns is that finding abstinence is still more common among Irish women than men (23% vs. 15%, respectively), although a smaller percentage of Irish women are abstinent than their European counterparts.10 For these respondents, essentialised reproductive identities formed the basis for the gender-based shame of alcoholism: for men it represents a “failure to hold the pints,” for women it violates normative expectations of sexual control and maternal selflessness. Both men and women reported finding community and learning to deal with problematic emotions – seen as fuelling earlier drinking behaviour – through support group membership.
This research identified specific areas for potential intervention: positive expectancies concerning alcohol consumption (sociability, gaiety and relaxation); social anxiety over socialisation with the opposite sex; and alcohol used to cope and relieve tension and stress. Rather than diminishing over time, these factors may become more pronounced as the gender gap in drinking patterns diminishes and young adults of both sexes report using alcohol to cope, enhance positive affect and increase sociability.49,50 As noted, these respondents were primarily in middle age: most were or had been married, all were employed, and most had children. While women were as likely to be separated as married, men tended to be married. This is consistent with the finding that the middle years (30 to 64 years) are prominent for the reported negative consequences on home and family life of heavy drinking.2,51 This research therefore may prove most informative about those in the mid-adult years, when life-span marital, parenting and/or occupational pressures potentially exert the most pressures on individuals to resolve drink-related problems that had been tolerated at earlier life phases. Given the results of this research, it is suggested that attention to the drinking expectancies; feelings of isolation or loneliness experienced by those exhibiting problematic consumption behaviors; consideration of the social contexts in which problematic drinking occurs; gender ideologies and the cultural meanings of drinking behaviours might further understandings of potentially harmful drinking, especially in periods of economic uncertainty.
At the time this research was conducted, Ireland was in an unprecedented era of economic prosperity (The Celtic Tiger), and was characterised as one of the world’s most globalised countries. No respondents remarked upon perceived stressors stemming from globalising forces, but located their personal difficulties in perceptions of social interaction norms and coping with problematic emotions. Since the research was conducted, Ireland, with other countries worldwide, has suffered an economic slowdown. If, and to what degree, such economic forces may be fuelling the current reported rates of problematic drinking cannot be answered by this research. Earlier research conducted with Irish men in London would indicate that increases in alcohol consumption accompany psycho-social stress,31 while evidence from other countries suggests that economic slowdowns are linked to binge drinking41 and increased alcohol consumption, especially among the single and unemployed.42 In Ireland, according to a 2008 National Drug Treatment Reporting Survey, admissions for alcohol-related problems were associated with unemployment in 45% of cases; however the direction of causality could not be determined.6
Limitations of the research This was a small, non-random sample, with data collected in 19981999; therefore, the ability to generalise on current drinking trends in Ireland, all individuals with alcohol use disorders, or all AA or WFS members may be limited. Respondents’ perceptions of drinking norms may reflect misperceptions or effects of self-chosen social networks.52 As a focus was on support group benefits, different responses (e.g. greater variation) may have been elicited
Concomitant with the economic changes occurring in Ireland since this research was conducted, alcohol consumption patterns have evolved as well. From 1987 through 2006, alcohol consumption 168
had support group experiences solely been examined. Recruitment through an alcohol treatment clinic may have biased the findings in terms of selection and self-selection of participants. Lifespan issues, such that all respondents were in early-to-late middle adulthood, may have influenced the findings. Finally, given the gendered meanings of alcohol consumption, respondents’ representations of their experiences may have been influenced by self-presentation concerns and the desire to conform to gender ideologies.
References: 1. Anderson P, Baumberg B. Alcohol in Europe: a public health perspective. Institute of Alcohol Studies, London, 2006. 2. Ramstedt M, Hope A. The Irish drinking habits of 2002: Drinking and drinking-related harm in a European comparative perspective. Journal of Substance Use. 2005; 10(5):273-83. 3. Butler S. Tipping the balance? An Irish perspective on Anderson and Baumberg. Drugs: Education, Prevention and Policy. 2006; 13(6):493-7. 4. Strategic Task Force on Alcohol: Second Report. Dublin: Health Promotion Unit, Dept of Health & Children 2004. 5. TNS Opinion & Social. EU citizens' attitudes towards alcohol. Special Eurobarometer 331, Brussels: European Commission 2010. 6. Mongan D, Hope A, Nelson M. Social consequences of harmful use of alcohol in Ireland. HRB Overview Series 9. Dublin: Health Research Board, 2009. 7. Kuntsche E, Rehm J, Gmel G. Characteristics of binge drinkers in Europe. Soc. Sci. Med. 2004; 59(1):113-27. 8. Kelleher CC, Friel S, Nic Gabhainn S, Tay JB. Socio-demographic predictors of selfrated health in the Republic of Ireland: findings from the National Survey on Lifestyle, Attitudes and Nutrition, SLÁN. 2003; 57(3):477-86. 9. Emslie C, Lewars H, Batty GD, Hunt K. Are there gender differences in levels of heavy, binge and problem drinking? Evidence from three generations in the west of Scotland. Public Health. 2009; 123(1):12-14. 10. Morgan K, McGee H, Dicker P, Brugha R, Ward M, Shelley E, et al. SLÁN 2007: Survey of lifestyle, attitudes, and nutrition in Ireland. Alcohol in Ireland: A profile of drinking patterns and alcohol-related harm from SLÁN 2007. Department of Health and Children. Dublin: The Stationery Office. 2009. 11. Bush K, Kivlahan DR, McDonell M, Fihn S, Bradley K. The AUDIT Alcohol Consumption Questions (AUDIT-C): An Effective Brief Screening Test for Problem Drinking. Arch. Intern. Med. 1998; 158(16):1789-95. 12. Strategic Task Force on Alcohol. Interim Report. Dublin: Department of Health and Children. May, 2002. 13. Schuckit MA. Alcohol-use disorders. Lancet. 2009; 373(9662):492-501. 14. Moos R, Finney J, Cronkite R. Alcoholism Treatment: Context, Process, and Outcome. New York: Oxford University Press. 1990. 15. Leigh B, Stacy A. Alcohol expectancies and drinking in different age groups. Addiction. 2004; 99(2):215-27. 16. Heath DB. Drinking occasions: Comparative perspectives on alcohol and culture. Philadelphia: Psychology Press; 2000. 17. Willenbring M, Massey S, Gardner M. Helping patients who drink too much: an evidence-based guide for primary care physicians. Am Fam Physician. 2009; 80(1):4450. 18. National Institute on Alcohol Abuse and Alcoholism. Systems Biology: The Solution to Understanding Alcohol-Induced Disorders? Bethesda, MD: National Institutes of Health, 2008 April. Report No. 75. 19. National Institute on Alcohol Abuse and Alcoholism. New Advances in the Treatment of Alcoholism. Bethesda, MD: National Insititues of Health, 2000, October. Report No. 49. 20. Cain C. Personal stories: Identity acquisition and self-understanding in Alcoholics Anonymous. Ethos. 1991; 19:210-53. 21. Cunningham J, Sirey J, Bruce M. Matching Services to Patients' Beliefs About Depression in Dublin, Ireland. Psychiatr. Serv. 2007; 58(5):696-99. 22. Patton MQ. Qualitative evaluation and research methods. 2nd ed. Newbury Park, CA: Sage Publications; 1990. 23. Strauss A, Corbin J. Grounded theory in practice. 2nd ed. Thousand Oaks, CA: Sage; 1998. 24. Guest G, Bunce A, Johnson L. How Many Interviews Are Enough? An Experiment with Data Saturation and Variability. Field Methods 2006; 18(1):59-82. 25. Glaser BG. The Constant Comparative Method of Qualitative Analysis. Soc. Probl. 1965; 12(4):436-45. 26. Boeije H. A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Quality & Quantity 2002; 36(4):391-409. 27. Corrigan E, Butler S. Irish alcoholic women in treatment: Early findings. Int. J. Addict. 1991; 26(3):281-92. 28. Women and Substance Misuse: Alcohol and Women's Health in Ireland. Dublin: Women's Health Council 2009. 29. Inglis T. Global Ireland: Same Difference. New York: Routledge; 2008. 30. Tovey H, Share P. A Sociology of Ireland. 2nd ed. Dublin: Gill & Macmillan; 2003. 31. Tilki M. The social contexts of drinking among Irish men in London. Drugs: Education, Prevention & Policy. 2006; 13(3):247-61. 32. Smith L, Foxcroft D. Drinking in the UK. An exploration of trends. York: Joseph Rountree Foundation, 2009 33. Lyons A, Willott S. Alcohol Consumption, Gender Identities and Women’s Changing
Conflict of Interest None.
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Social Positions. Sex Roles. 2008; 59(9):694-712. 34. Bargh JA, Williams EL. The Automaticity of Social Life. Current Directions in Psychological Science. 2006; 15(1):1-4. 35. Niemann Y. Stereotypes about Chicanas and Chicanos. The Counseling Psychologist. 2001; 29(1):55-90. 36. Peralta R. College Alcohol Use and the Embodiment of Hegemonic Masculinity among European American Men. Sex Roles. 2007; 56(11):741-56. 37. De Visser RO, Smith JA. Alcohol consumption and masculine identity among young men. Psychology & Health. 2007; 22(5):595-614. 38. Gmel G, Bloomfield K, Ahlstrรถm S, Choquet M, Lecomte T. Women's Roles and Women's Drinking: A Comparative Study in Four European Countries. Substance Abuse. 2000; 21(4):249-64. 39. O'Connor J, Daly M. The smoking habit. Dublin: Health Education Bureau.1985. 40. Women & substance misuse in Ireland: Overview. Dublin: Women's Health Council 2009. 41. Dee TS. Alcohol abuse and economic conditions: Evidence from repeated crosssections of individual-level data. Health Econ. 2001; 10(3):257-70. 42. Luoto R, Poikolainen K, Uutela A. Unemployment, sociodemographic background and consumption of alcohol before and during the economic recession of the 1990s in Finland. Int. J. Epidemiol. 1998; 27(4):623-9. 43. Hope A. Alcohol Consumption In Ireland 1986-2006: Report for the Health Service Executive Alcohol Implementation Group. Dublin: Health Service Executive 2007. 44. Hope A, Butler S. Changes in consumption and harms, yet little progress. Trends in alcohol consumption, harms and policy: Ireland 1990-2010. Nordic Studies on Alcohol and Drugs. 2010; 27(5):479-95. 45. Hope A, Mongan D. A profile of self-reported alcohol-related violence in Ireland. Contemporary Drug Problems. 2011; 38(2):237-58. 46. Report of the Government Advisory Group. Dublin: Department of Justice, Equality and Law Reform, 2008. 47. Cleary S. The new female wine culture. Irish Independent. 2009 December 20. 48. Lader D, Steel S. Office for National Statistics. Opinions survey report no 42. Drinking: adults' behaviour and knowledge in 2009. London: Stationary Office; 2010. 49. Jarvinen M, Room R. Youth drinking cultures: European experiences. Jarvinen M, Room R, editors. Aldershot: Ashgate; 2007. 50. Lyvers M, Hasking P, Hani R, Rhodes M, Trew E. Drinking motives, drinking restraint and drinking behaviour among young adults. Addict. Behav. 2010; 35(2):116-22. 51. Hope A. Alcohol-related harm in Ireland. Health Service Executive - Alcohol Implementation Group. 2008. 52. McCrady BS. To Have But One True Friend: Implications for Practice of Research on Alcohol Use Disorders and Social Networks. Psychology of Addictive Behaviors 2004; 18(2):113-21.
Acknowledgements The author would like to thank the Editor and the anonymous reviewers whose thoughtful comments substantially improved the manuscript. The author gratefully acknowledges the generosity and contributions of members of the support groups for their participation in this research. This project was supported by a predoctoral training grant T32-DA-07267 from the National Institutes of Health and National Institute on Drug Abuse to the University of Michigan and by the University of Michigan Rackham School of Graduate Studies.
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The Dark Cartoon: Intrusive Imagery Secondary to Childhood Sexual Abuse Yoshihiro Katsuura, Vincent Russell Ir J Psych Med 2012; 29 (3): 171-175
Abstract
Intrusive images are contents of consciousness that possess visual qualities and tend to be recurrent, uncontrollable and distressing5 and are distinct from verbal intrusive cognitions (ruminations).6,5 They are regarded as a hallmark of PTSD and generally consist of reliving experiences from intact memory of trauma.7,4
We report on the case of a middle-aged woman with a complex psychiatric history in whom atypical intrusive imagery identified in the mental status examination appeared to represent an emergence of childhood dissociative phenomena. These new symptoms led to the reappraisal of her clinical presentation and a diagnostic re-evaluation that they represented a re-emergence of childhood post-traumatic stress disorder secondary to sexual abuse. We discuss the phenomenology identified in our patient with the aim of increasing awareness of unusual symptoms in adults with a history of childhood sexual abuse and the importance of the mental state examination in eliciting and classifying such phenomena. Key words: Intrusive imagery, post-traumatic stress disorder (PTSD), childhood PSTD, childhood sexual abuse
Nonetheless, pathology of memory is also commonly associated with PTSD.8 In cases of post-traumatic amnesia, a traumatic event fails to assimilate into memory schemata due to its overwhelming effect on mental processing.8 In such cases, clear intrusive imagery may still manifest in various forms,1,8 but the diagnostic criteria for PTSD are not fully met (because the patient cannot recollect or experience traumatic memories). Thus, intrusive imagery remains difficult to classify within the clinical definition of PTSD in amnestic states. In this report, we explore the aetiology and classification of unique intrusive images as they presented in a patient who had been sexually abused as a child.
Introduction
Case history
Childhood sexual abuse has profound manifestations in adult psychopathology.1 The range of clinical sequelae is diverse including depression, substance abuse, self-abusive behavior, somatization disorder, dissociative disorders, borderline personality disorder, conversion reactions, and PTSD.1,2 These disorders are modulated in severity by variables such as duration, invasiveness and type of sexual abuse, as well as age and sex of victim.1 Three main models exist regarding the psychopathogenesis of symptoms in victims of childhood sexual abuse.1 First is the psychoanalytical model proposed by Freud that symptoms arise from the repression of unacceptable thoughts; the second, regarded collectively as Sexual Abuse Accommodation Syndrome, postulates that symptoms arise from the childâ&#x20AC;&#x2122;s attempt to accommodate to sexual abuse; lastly, neurophysiologic changes secondary to trauma have been associated with the evolution of symptoms.1
XX, a 48-year-old divorced, unemployed woman with three children and a long and complex psychiatric history, presented to the outpatient review clinic with ongoing complaints of constant worry, agitation, frustration and suicidal ideation. Her background included multiple diagnostic co-morbidities including recurrent depressive disorder, generalised anxiety disorder, mixed personality disorder and recovering alcohol and benzodiazepine dependence. She had several acute in-patient admissions resulting from episodes of self-harm as well as periods of home-based treatment, ongoing anti-depressant pharmacotherapy and out-patient attendance with addiction counselling and clinical psychology. There had been little evidence, to date, of significant benefit from any clinical interventions. During a recent outpatient clinic visit, a medical student conducted a detailed history and mental state examination uncovering symptoms, which until that time had not been recorded in the clinical file. This interview differed from that normally conducted in the setting of a review clinic in that it was not time restricted and was performed under the explicit declaration that the interviewer was a medical student and not therefore in a position to provide any actual clinical intervention. Also, the approach to the interview was formulaic and detailed - adopting the standard headings and sub-headings recommended for an initial diagnostic assessment in psychiatry. Consequently, it is likely that specific areas were addressed - particularly regarding thought content and perceptual abnormalities - that may not have been explored in detail since the initial assessment interview years earlier.
The wide array of psychological sequelae of childhood sexual abuse, and the fact that patients may be reluctant or unable to reveal specific details about the trauma itself, necessitates close attention to clinical symptoms. Special care must be given particularly to posttraumatic symptoms, as these are often overlooked by clinicians.3 These symptoms consist of increased arousal, avoidance of stimuli associated with the event, numbing of responsiveness and persistent reliving of experiences either in dreams or intrusive memories.4 One of the challenges may be that of understanding and classifying phenomena that present in the mental status examination, which may not easily fit into traditional categories of adult PTSD. Intrusive images have been a particular focus of study within syndromes of childhood sexual abuse and PTSD.
*Yoshihiro Katsuura Senior medical student, RCSI 123 St Stephenâ&#x20AC;&#x2122;s Green, Dublin 2 Email: yoshihirokatsuura@rcsi.ie *Correspondence
Vincent Russell Professor/Head, Department of Psychiatry, Penang Medical College, 4 Jalan Sepoy Lines, 10450 Penang, Malaysia
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Submitted: 16th January 2012 Accepted: 13th April 2012
marks bilaterally. She was cooperative with reasonable eye contact. Speech was both coherent and relevant with a normal tone and rate. She appeared agitated and distraught, with subjectively low mood. She doubted whether life was worth living, but denied any specific plans of suicide or self-harm. There was no evidence of passivity phenomena or of thought insertion, withdrawal or broadcast. Similarly, XX denied hallucinations in all perceptual modalities. She was well oriented, showed no short or long-term memory deficit, and scored 27/30 on the Mini Mental State Examination.
In the interview, XX described experiencing recurrent intrusive images of “dark scary cartoons”. These images would appear to her in dreams and then recur throughout the day causing her great distress. She described them as “funny but terrible and strange images” reminiscent of “cartoons she has seen, such as Mickey Mouse and Desperate Dan, but appearing twisted and ruined”. These images would force themselves into her mind and torment her throughout the day. Importantly, XX recognised these images as products of her imagination and not emanating from the external space. They had been bothering her constantly for the previous two years.
Discussion In further discussion of the intrusive images XX revealed how learning that her father had sexually abused her son could have precipitated her current mental state. When her son had told her about his own abuse experiences three years previously, she described experiencing déjà vu. She stated that her son had told her how her father had “gotten close to him in a strange way” and that she distinctly remembered experiencing something comparable. Her son’s account to her seemed to unlock a faint memory that her father had also abused her in a similar way. Nonetheless, she was unable to elaborate on any other specific details or memory of the abuse other than that it would have occurred when she was very young. When asked frankly if her father had abused her, XX nodded affirmatively, but seemed unable to make a verbal response. Critical to this discussion is that although sexual abuse had been suspected previously, it had never been so openly discussed in prior visits to the clinic.
The development of PTSD involves exposure to an extreme traumatic stressor followed by the development of characteristic symptoms, namely persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the event, hyperarousal, and numbing of general responsiveness.4 The DSM IV lists “developmentally inappropriate sexual experiences without threatened or actual violence” as a cause of PTSD in children. Nonetheless, the symptomatic features of PTSD in adult and children victims must be differentiated Classification syndromes have been proposed to globally assess the child and adult survivor of sexual abuse. Goodwin et al proposed a syndrome encompassed by the mnemonic FEARS to designate the various categories of post-traumatic symptoms in child incest victims (Table 1).3,1 In this mnemonic, F stands for fears (i.e. phobias associated with the abuse); E represents ego constriction where there is a loss of developmental gains; A stands for anger dyscontrol in which victims repress and have difficulty expressing anger; R stands for repetition of thoughts or images of the trauma and S represents sleep disturbance including nightmares and sadness.
Of note in her past medical history, XX described that she had been prescribed diazepam for insomnia at age ten years and that she had been hospitalised for what she called a “mini-stroke” at the age of 16 when she experienced a complete right-sided hemiparesis, which resolved spontaneously in a matter of days. Apart from the intrusive imagery, detailed above, on mental state examination XX presented as disheveled and poorly groomed with dirt and tar on her hands and under her fingernails. The volar surfaces of her forearms were covered with self-inflicted scratch
This mnemonic was modified to differentiate the moderate syndrome, which is more common in children compared to the severe syndrome present more often in adult victims.1 In this
Table 1. Moderate and severe post-traumatic symptoms in adult incest victims constituting the five cardinal signs of PTSD.1,3 Moderate syndrome Fears • Hyperalert • Nervous Ego constriction • Sexual inhibitions • Social inhibitions Anger Dyscontrol • Continuing anger • Afraid of anger Repetition • Flashbacks • Nightmares Sleep disturbance • Nightmares Sadness • Guilt • Depression
Severe syndrome Fugues • Dissociative symptoms • Multiple Personality Ego fragmentation • Borderline personality • Multiple personality Antisocial acting- out • Alcohol, substance abuse Reenactments • Rape or other victimisation Somatization • Medical problems Suicidality • Suicidal thoughts • Suicidal attempts
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severe syndrome F represents fugues where high intensity fear and anxiety are relieved by retreating into amnesia and derealisation3,1; E is ego fragmentation resulting in multiple personality disorder or borderline personality disorder; A represents antisocial acting out, where victims are unable to repress their anger or impulses; R for reenactments where victims will subconsciously seek out abusive partners or partners who incestuously abuse the victim’s children in addition to repetitions experienced in the moderate syndrome and S is suciadality and somatization.
they may not have specific trauma-related contents in children.11,2,4 Such dreams in children often contain images of monsters, rescuing others, or threats to self.11,4 Therefore, the intrusive images of dark cartoons XX experienced could represent a manifestation of childhood PTSD because they appeared to her as nightmares, even though they lack the concrete nature of memories typically associated with PTSD flashbacks. This presentation raises a further question as to why, despite being an adult, XX presents with diagnostic criteria closer to that of a child. Unable to work through this adversity as a child, the psychopathology of XX’s may have been incubated for an extended period but re-emerged in middle age through a number of possible mental processes including:
Reviewing XX’s case in light of these criteria, many of her symptoms and co-morbidities are congruent with a severe posttraumatic sexual abuse syndrome (i.e. alcohol dependence, self abuse, borderline personality disorder and dissociative amnesia of the trauma itself). Yet, a critical part of the diagnostic criteria of adult PTSD - a specific traumatic memory on which the patient fixates - is lacking. When questioned about the abuse perpetrated by her father XX was unable to comment on any concrete memory, but stated that she experienced déjà vu when she learned of the nature of her son’s abuse. Thus it would seem the knowledge of her son’s abuse caused the resurfacing of a distant memory or sense of the event.
• the resurfacing of the fractured, immature traumatic memory manifests as a residuum of childhood presentation of PTSD, • a regression state where subconsciously XX retreated to an earlier developmental period to better cope with the traumatising memory, and /or • a chronic form of childhood PTSD that occurred before her repression/obliteration of the memory.
Whether repressed memories exist at all or are part a disorder known as false memory syndrome (in which a dependent patient fabricates memories in order to prolong the therapeutic relationship) has been a topic of much debate9 and deserves further consideration in this case. It is possible to argue that XX’s vague sense of déjà vu does not correspond with evidence of sexual abuse at all, and is instead an artifact of the interviewing process. Proponents of false memory syndrome Ofshe and Waters argue that memory recovery therapy is a product of overzealous, feministic therapists who coerce patients to remember their supposed childhood abuse.10 Of critical importance in XX’s history is that the information regarding her childhood sexual abuse was freely given in her first presentation to medical student, with no prior therapeutic relationship - making the possibility of a false memory syndrome less likely.
Green et al report similar instances of PTSD being triggered in adult victims following disclosure of the sexual abuse of their daughters.12 Furthermore, Goodwin et al report that symptoms expressed in therapy often regress to styles of expression appropriate to the age at which the trauma occurred.3 Nonetheless, as the remainder of XX’s symptoms were suggestive of an adult post-traumatic presentation the argument that her presentation represents a regression state appears less cogent. In addition, because XX’s symptoms were triggered in adulthood, a chronic form of childhood PTSD also becomes less likely. We suggest that the isolated memory of abuse, fractured and all but obliterated, triggered a childhood presentation of PTSD, as the specific memory elements were not present to initiate an adult form of the disorder. When further questioned about the nature of the “scary cartoons” that haunted her, XX conjured a vague yet disturbing picture of funny, terrible images reminiscent of the work of artist Todd Schorr, or any other number of macabre cartoonists. For many, cartoons represent a core element of childhood as parents increasingly utilize them as a central form of entertainment and education during the developmental years.13 Nonetheless, early media exposure from infancy to adolescence has been associated with delayed cognitive development and poor behavioral outcomes.14,15 Media exposure has a particularly negative impact on children from poor socioeconomic groups.16 For these reasons, the American Academy of Pediatrics recommends that no child under the age of 2 should have media exposure of any kind.17 Thus, while images and memories from childhood cartoons remain linked with emotional recollections of a time of innocence, they have potential pathological consequences in the developing mind. Although violent cartoons have been linked specifically with increased aggression,18 whether early exposure to cartoons predisposes to the development of intrusive images is unknown. However, because cartoons often represent an exaggeration or distortion of normal physical appearances and emotional expressions, artists can translate them into powerful depictions of the monstrous. The work of Todd Schorr exemplifies this fact as his paintings render
A further hypothesis in relation to the intrusive images our patient experienced is that they represented an unconscious guilt or selfpunishment response to the tragic news of her son’s sexual abuse, rather than a direct manifestation of herself being abused in the past. However, XX’s long psychiatric history, associated with multiple co-morbidities pre-dating the revelation of her son’s abuse as well as the childhood history suggestive of conversion symptoms are compatible with a sexual abuse syndrome. Nonetheless, while the presentation and course of XX’s psychiatric symptoms as well as her own admission of her own abuse in the interview, strongly support the likelihood of a history of childhood sexual abuse, the news of her son’s abuse certainly destabilised her already fragile coping mechanisms, and compounded what was already a complex clinical picture. While a syndrome of sexual abuse seems clear in XX’s case, repression of the memory of the event in a dissociative amnesia precludes a pure adult form of PTSD. Nonetheless, as stated above the psychological manifestations of childhood PTSD differ from that of the adult, namely in experiencing frightening dreams. While posttraumatic nightmares typically are associated with specific elements of the trauma, which includes sexual imagery1, 173
familiar characters as perverted figures personifying loss of innocence. In this sense, the scary cartoon may serve as the vessel of the distorted image of the abuser, who in a real sense has transformed from protector to monster in the mind of the abused.
examination as referred to above, may have acted in combination to facilitate XX in simply discussing openly what was going on in her mind In this regard our case would seem to offer a salutary lesson regarding the risks of stagnation in the diagnostic formulation and of unproductive patterns of communication developing between clinicians and long-term patients attending mental health services. Secondly, it underscores the importance of re-visiting periodically both the history and mental status examination in a detailed, structured and comprehensive manner in patients who present ongoing diagnostic complexity and treatment challenges.
In this sense, the intrusive images of dark cartoons that tormented XX seem an entirely appropriate manifestation of her childhood. Her father, a presumably once-trusted figure in her life, destroyed that confidence through sexual abuse. Arguably, this was such an abhorrent experience that the memory was repressed in her subconscious only to be triggered years later by learning that her son has suffered a similar experience. Even to this day she lacks a full memory of any abuse, but her multiple psychiatric sequelae may represent, in part, a consequence of psychological repression of memories from a turbulent childhood as diagnostic complexity and, atypicality, are more commonly found in victims of childhood sexual abuse.1,2
As a follow-up to our case report the clinical team felt that the immediate challenge was to gently build on the conversation XX had with the medical student, to include the senior clinicians and then to gradually try to establish new avenues of treatment. It remains to be seen to what extent this results in an improved, long-term clinical and functional outcome for the patient.
The intrusive images reported in our case do not fit into any of the traditional major descriptive categories within the standard mental status examination, yet raise the importance of recognising similar phenomena in adult patients, whether or not they report memories of childhood sexual abuse. The psychopathogenesis associated with childhood sexual abuse is complex and this case highlights the importance of thorough and serial mental state examinations even in long-term patients, especially if they have been refractory to treatment. Discovery of these symptoms led to the reappraisal of what was largely considered a refractory case and opened the door to possible new treatment options. Eliciting such phenomena as mental imagery may be particularly productive in patients likely to have experienced childhood trauma. However, in routine clinical encounters the thought content section of the mental state examination may frequently be limited in practice to the exclusion of psychotic symptoms and suicidal ideation. Time constraints in busy clinical settings may justify the priority of eliciting mental phenomena associated with obvious clinical risk. However, there is also a case to be made for more attention to be focused on other phenomena, including mental imagery, in the training of psychiatry trainees and other mental health professionals so that their presence is not overlooked and their potential diagnostic significance is realised.
Conclusion Here we report the case of XX, a 48-year-old woman with a long and complex psychiatric history largely refractory to a range of interventions in whom intrusive visual images appeared to represent the emergence of childhood dissociative phenomenon. The recognition of these symptoms led to the re-evaluation of her clinical presentation and the revelation of a past history of childhood sexual abuse. The memory of the sexual abuse appears to have been almost entirely erased through dissociative phenomena, yet global evaluation of the case is highly suggestive of a severe syndrome of childhood sexual abuse. We discuss the phenomenonology of the intrusive images experienced by the patient in light of previous literature, and argue that there may be a need for greater awareness of the importance of recognising intrusive images whether or not they are associated with a specific traumatic event, or a concrete memory of sexual abuse exists. We also suggest that there may be training implications for developing systematic approaches to the mental state examination in adult patients suspected of childhood sexual abuse.
Conflict of Interest Why it was possible for a junior healthcare team member to elicit new clinical features in this case raises questions about the potential pitfalls in long-term psychiatric management. As noted in the case description, there were several differences in the approach to the interview from those previously used. Of specific importance to this case may have been the fact that the patient was aware that while the interviewer was still part of the health care team, he was unable to dispense psychotropic medication. During previous interviews, XX was felt to have established a good rapport with her treating clinicians and did not tend to fail appointments. However, she had been preoccupied with seeking medication, notably benzodiazepines and while this was firmly resisted when the extent of her propensity for misusing medications was realised, it nonetheless tended to result in somewhat repetitive, stereotypical conversations about the limitations of medication and the need for psychological approaches to her problems. We suggest therefore that the changed dynamic in the interview with the medical student, in combination with the detailed approach to the mental status
None.
Consent Written consent was obtained from patient.
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References: 1. Kluft R (ed) Incest-Related Syndromes of Adult Psychopathology, American Psychiatric Press, 1990. 2. Hornor G. Child Sexual Abuse: Consequences and Implications. Journal of Pediatric Health Care. 2010; 24(6):383-364. 3. Goodwin J. Post Traumatic Stress disorder in Children Eth S PR, editor, American Psychiatric Press, 1985. 4. The American Psychiatric Association. Diagnostic and Statistical Manual (DSM–IV), 1994. 5. Brewin C, Gregory J, Lipton M, Burgess N. Intrusive Images in Psychological Disorders: Characteristics, Neural Mechanisms, and Treatment Implications. Psychological Review, 2010; 117(1) pp210–232, 6. Birrera E, Michael T, Munsch S. Intrusive Images in PTSD and in Traumatised and NonTraumatised Depressed Patients: A Cross-Sectional Clinical Study. Behaviour Research and Therapy, 2007; 45: pp2053–2065. 7. Hackmann A, Ehlers A, Speckens A, Clark D. Characteristics and Content of Intrusive Memories in PTSD and Their Changes With Treatment. Journal of Traumatic Stress. 2004. 17(3): pp 231-240. 8. van der Kolk B. Psychological trauma, American Psychiatric Press, Inc.,1987. 9. Penfold P. The Repressed Memory Controversy: Is There Middle Ground? CMAJ, 1996; 155(6): pp 647-653. 10. Ofshe R, Watters E. Making Monisters: False Memories, Psychotherapy, and Sexual Hysteria New York, Charles Scribner's Sons, 1995. 11. Murali N, Dhabkar N, Jagadisha. Recognition & Clinical Assessment Of Childhood Ptsd. Indian Journal of Psychiatry, 2002; 44(1): p. 82–83. 12. Green A, Coupe P, Fernandez R, B S. Incest Revisited: Delayed Post-Traumatic Stress Disorder In Mothers Following The Sexual Abuse of Their Children. Child Abuse and Neglect, 1995; 19(10): pp 1275-1282. 13. Wartella E, Vandewater E, Rideout V. Introduction: electronic media use in the lives of infants, toddlers, and preschoolers. Am Behav Sc, 2005; 48(5): pp 501-504. 14. Tomopoulos S, Dreyer D, Berkule S, Fierman A, Brockmeyer C, Mendelsohn A. Infant Media Exposure and Toddler Development. Arch Ppediatr Adolesc Med, 2012; 164(5): pp 1105-1111. 15. Zimmerman F, Christakis D. Children’s television viewing and cognitive outcomes: a longitudinal analysis of national data. Arch Pediatr Adolesc Med, 2005; 159(7): pp 619-625. 16. Mendelsohn A, Berkule S, Tomopoulos S, Tamis-LeMonda C, Huberman H, Alvir J, et al. Infant Television and Video Exposure Associated With Limited Parent-Child Verbal Interactions in Low Socioeconomic Status Households. Arch Pediatr Adloesc Med, 2008; 162(5): pp 411-417. 17. American Academy of Pediatrics, Committee on Public Education. AmericanAcademy of Pediatrics: children, adolescents, and television. Pediatrics, 2001; 107(2): pp 423426. 18. Kirsh S, Olczak P. Violent Comic Books and Judgments of Relational Aggression, Violence and Victims. 2002; 17(3): pp 373-380. 19. Lipton M, Brewin C, Linke S, Halperin J. Distinguishing features of intrusive images in obsessive–compulsive disorder. Journal of Anxiety Disorders, 2010, 24: pp 816–822. 20. Morina N, Deeprose C, Pusowski C, Schmid M, Holmes E. Prospective mental imagery in patients with major depressive disorder or anxiety disorders, Journal of Anxiety Disorders, 2011; pp 1032–1037. 21. Speckens A, Hackmann A, Ehlers A, Cuthbert B. Imagery special issue: Intrusive images and memories of earlier adverse events in patients with obsessive compulsive disorder, Journal of Behavior Therapy and Experimental Psychiatry, 2007; 38: pp 402–410.
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O R I G I N A L PA P E R
Burnout and its Effect on Neurocognitive Performance Shane McInerney, Michael Rowan, Brian Lawlor Ir J Psych Med 2012; 29 (3): 176-179
Abstract
Introduction
Objectives: The hypothesis that burnout is predictive of performance deficits on a number of neuropsychological tests was examined among a group of psychiatric nurses. A possible relationship between burnout and state and trait anxiety levels was also investigated.
Burnout is a word originally used by Freudenberger based his research on those working in healthcare who experienced emotional depletion and a loss of motivation.1 Burnout can be conceptualised as an extreme form of stress where the person has appraised a particular situation and they feel that they can no longer cope with the demands that are being made upon them, both physically and physiologically.2 Burnout has been found to be related to low work performance and productivity, job dissatisfaction, lower quality of life, and decreased professional well-being.3
Methods: A sample of psychiatric nurses (n=45) completed the Maslach Burnout Inventory (MBI) and the State-Trait Anxiety Inventory (STAI). Their performance on a number of neurocognitive tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB) was examined. The neurocognitive tests measured visual memory, verbal memory and attention.
Maslach defined burnout as a “syndrome of emotional exhaustion, depersonalisation, and reduced personal accomplishment that can occur among individuals who do people work of some kind”. She distinguished work-related stress from burnout by reasoning that it was those people who entered their careers with high goals, expectations and motivation that experience burnout. According to Maslach, a person who has no such initial motivation can experience job stress but not burnout.4
Results: Multiple regression analyses were conducted between the burnout subscales and the results of the neuropsychological tests, and also between the burnout subscales and both state and trait anxiety levels. No overall significant relationship was found between neurocognitive performance and burnout. However, trait anxiety was significantly predictive of each of the burnout subscales of emotional exhaustion, depersonalisation and also of decreased personal accomplishment.
Her research found that exhaustion was the central quality of burnout and the most obvious manifestation of this complex syndrome, and that it occurs when the emotional demands of the job become so severe that the person feels they can no longer meet the demands placed upon them. Depersonalisation is an attempt by the person to distance themselves emotionally from their work. Reduced personal accomplishment or work inefficacy appears to develop in parallel with the other two burnout aspects - exhaustion and depersonalisation - rather than sequentially and it refers to a feeling of incompetence at work.5,6
Conclusions: The levels of burnout were in the moderate range for all three subscales and so the population was suffering from burnout. The fact that the trait anxiety variable was predictive of all three of the burnout subscales suggests that predisposition towards anxiety may be a vulnerability factor among people who suffer from burnout. Keywords: Burnout, cognition, memory, neuropsychological testing, psychiatric nursing.
Burnout is conceptualised as a continuous variable, ranging from low to moderate to high degrees of experienced feelings. It is not viewed as a dichotomous variable that is either present or absent but rather judged as being on a continuum ranging from ‘less burnt out’ to ‘more burnt out’. A high degree of burnout is reflected in high scores on the emotional exhaustion and depersonalisation subscales and in low scores on the personal accomplishment subscale.4
Burnout and psychiatric nurses Mental health professionals may be more at risk of developing burnout given the severe emotional exhaustion that is often experienced in their interaction with patients.7 A study by Dolan on psychiatric nurses found that an inverse relationship existed between job satisfaction and burnout.8 Psychiatric nurses interact *Shane McInerney Senior Registrar in Psychiatry, University Hospital Galway, Newcastle Road, Galway. Email: shane.mcinerney@nuigalway.ie *Correspondence
Michael Rowan PhD Professor of Neuropharmacology, Department of Pharmacology and Therapeutics, Trinity Centre, St James’s Hospital, Dublin.
Brian Lawlor Connolly Norman Professor of Old Age Psychiatry at Trinity College Dublin; Consultant Psychiatrist for the Elderly at St Patrick's and St James's Hospitals
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Submitted: 27th January 2012 Accepted: 9th February 2012
with the patients on a personal level and they often have to deal with difficult behaviour on a regular basis. This emotional interaction may be a source of stress that can in some circumstances lead to burnout.
(c) To investigate whether a relationship exists between burnout and levels of either state or trait anxiety.
Fagin et al9 found that the main stressors that psychiatric nurses faced were related to staff shortages, health service changes, poor morale and a lack of communication.9 A study by Turnipseed examined levels of both trait and state anxiety to perceived burnout among a group of registered nurses and found that scores on both trait and state anxiety were significantly related to scores on burnout.10 Factors such as peer and supervisory support, age, and prior knowledge of work-day situations moderated anxiety levels.
Participants A group of psychiatric nurses (n=45) working in two Dublin city psychiatric hospitals participated in the study, which took approximately 40 minutes to complete.
Method
Tests used in the study The Maslach Burnout Inventory3 This is designed to assess the three aspects of the burnout syndrome: emotional exhaustion, depersonalisation, and lack of personal accomplishment. A separate subscale measures each aspect. Respondents are asked to indicate how frequently they experience a particular aspect of burnout relating to 22 statements, each on a seven-point scale. The higher the respondent’s score on depersonalisation and emotional exhaustion, the higher their levels of burnout. The lower the score on personal accomplishment, the higher the burnout level.
Burnout and Cognitive Performance Those experiencing burnout often reported subjective difficulties with memory and clinical observation, indicating that burnout is associated with impairment of cognitive functioning. Sansdstrom et al11 found that there were significant decreases in performance on nonverbal memory and attention tasks but not verbal memory tasks relative to controls.11 This suggests that there are specific neurocognitive impairments in these individuals. Osterberg et al12 found that while burnout cases had considerably more subjective cognitive problems, their ratings were unrelated to their performance on cognitive tasks.12
Cambridge Neuropsychological Test Automated Battery The CANTAB tests13 are designed to test different aspects of mental functioning so that a profile of performance can be constructed for a particular patient.13 The CANTAB package consists of three separate batteries, each addressing a specific area of cognition: visual memory, planning and attention. The tests are administered using a computer with a touch-sensitive screen. In this study CANTAB was used to detect subtle deficits relating to an individual’s ability to attend to a stimulus, ability to encode a stimulus and ability to recognise a previously presented stimulus.
In fact, their sample of work-related burnout patients had no significant cognitive impairment relative to controls on short-term verbal and spatial memory, sustained attention or cognitive speed tasks. Such studies have enrolled participants suffering from burnout but not employed in a healthcare role, whereas, this study sought to examine possible effects of burnout on the cognitive performance of psychiatric nurses who would be theoretically prone to burnout given the emotional aspect of their work.
State-Trait Anxiety Inventory The STAI14 has been used extensively in research and clinical practice. It comprises separate self-report scales for measuring state and trait anxiety.14 The State-Anxiety scale consists of 20 statements that evaluate how respondents feel ‘right now, at this moment’. The Trait-Anxiety scale consists of 20 statements that assess how people generally feel. Scores range in each scale from 20 to a maximum of 80 with normative data for working adults giving a mean of 36.14
Aims of study (a) To identify levels of burnout among a sample of psychiatric nurses using The Maslach Burnout Inventory . (b) To examine the relationship between levels of burnout and performance on cognitive tasks to determine whether aspects of cognition are affected by burnout.
The Rey Auditory Verbal Learning Test (RAVLT) A test of verbal memory was also administered, the Rey Auditory
Table 1. Demographic details Category
N=(%)
N=(%)
N=(%)
Age
19-30:23 (51%)
31-42:16 (36%)
43-54:6 (13%)
Sex
Male: 11 (24%)
Female: 34 (76%)
45
Professional status
Student: 8 (18%)
Staff: 37 (82%)
45
Stage in Profession
More than 10 years: 22 (49%)
Less than 10 years: 23 (51%)
45
Marital status
Single: 29 (64%)
Married: 16 (36%)
45
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Verbal Learning Test.15 The RAVLT is a brief, easily administered pencil and paper test that assesses immediate memory span, shortterm memory and recognition memory. The test involves a list of 15 nouns (List A) being read aloud to the participant for five consecutive trials (A1 to A5). The participant is then asked to recall as many words from the first list as possible without further presentation of the first list (A6). After a 20 minute delay, each subject is again asked to recall words from the first list (A7).
The mean state-trait anxiety levels of the sample were comparable to the normative sample but there was a large range of scores as seen in Table 4. Trait anxiety level was found to be predictive of outcome on each of the three burnout subscales; trait anxiety and emotional exhaustion (t=0.65, P=0.01), depersonalisation (t=0.35, P=0.02) and with personal accomplishment (t=-0.44, P=0.02).
Discussion
Results
No overall significant relationship was found between neuropsychological performance and burnout in this sample population of psychiatric nurses. There are a number of possible reasons for this finding. For instance, there were low levels of burnout in this sample and the MBI scores obtained from this study do not vary considerably from those obtained from Maslach’s normative data; the sample size was small and not representative of this population of nursing staff; and the study is likely not powered adequately to explore the research question, particularly given the low levels of burnout found.
Demographic Information Of the 45 participants, almost three-quarters were female and almost half had worked as a psychiatric nurse for ten or more years. Table 2 shows the results of the 45 participants on the burnout subscales. Table 3 shows the cut-off values for low, moderate and high levels of burnout obtained from Maslach’s normative sample of 720 health professionals._ Comparing the results to those of the normative sample, the participants had a moderate score on the emotional exhaustion subscale, a low score on the depersonalisation subscale and a moderate score on the personal accomplishment subscale.
In addition, the sample population was chosen from a population of student and staff grade psychiatric nurses who were actively working on the wards. There may be the possibility of survival bias with those nurses burnt out early in their careers more likely to leave their position, thereby leaving behind colleagues whom exhibit lower levels of burnout.16 Selection bias may be involved given the voluntary nature of recruitment into the study. It may be that the psychiatric nurses experiencing burnout did not wish to participate in the study or were on sick leave because of experiencing burnout. Another possible confounder is that staff may have a reluctance to report symptoms of burnout due to embarrassment about their condition. As such, the current findings might be underestimating the amount of occupational stress and burnout being experienced by this sample of psychiatric nurses. Additionally, self-report measures are inherently limited in that social desirability bias in reporting may lead to minimisation of negative experiences and symptoms related to burnout while inflating positive aspects of the self such as personal accomplishment.16
Table 2. MBI scores for the group of psychiatric nurses (n=45)
Mean SD
EE 18.4 9.1
DP 5.9 5.9
PA 35.3 6.5
Table 3. Categorisation of MBI scores Subscale EE DP PA
Low 0-16 0-6 0-31
Moderate 17-26 7-12 32-38
High 27 or over 13 or over 39 or over
EE – emotional exhaustion, DP – depersonalisation,
A study carried out among psychiatrists found much higher levels of burnout than the present study, with approximately one-third experiencing burnout.17 The difference may be accounted for by the fact that psychiatrists carry the greater burden of responsibility for patient care. On the other hand, it is intuitive that the closeness of the relationship between the psychiatric nursing staff and the patients on the wards would lead to high levels of burnout.
PA – personal accomplishment
Statistical analysis was carried out using the statistical package SPSS. Multiple regression analysis was carried out to examine the possible relationships between a number of key variables and burnout. Cognitive variables from the CANTAB and RAVLT tests were selected as criterion variables and the burnout subscales, the demographic variable and the anxiety measures were selected as predictor variables. None of the cognitive variables were predictive of levels of burnout from the sample.
From the regression analysis it was found that the trait anxiety was significantly predictive of all three subscales of burnout. This finding is consistent with other studies such as the Turnipseed study_° and another carried out among neonatal nurses which found that trait anxiety was a significant predictor for the emotional exhaustion subscale.18 These findings are a concern as it suggests that those with trait anxiety may have difficulty coping with the emotional aspect of their work. No assessment was made of potential psychiatric disorder within the sample population, which is another confounding factor.
Table 4. State-Trait Anxiety Inventory scores
STAI 1 Pre-testing STAI 2 STAI 1 Post-testing
Mean 36.6 36.7 36.9
Range 20-49 21-50 21-51
SD 6.1 6.7 8.0
While the question may be raised as to whether anxiety and burnout are measuring the same entities, there have been studies 178
that have shown distinction between these two concepts suggesting that burnout is a problem specific to the work context and while anxiety may be a vulnerability factor for burnout, they are separate concepts.6,19
References: 1. Freudenberger HJ. The staff burnout syndrome in alternative institutions. Psychother. Theory Res. Pract. 1975; 12:72-83. 2. Cox T. The recognition and measurement of stress (conceptual and methodological issues). In: Wilson JR & Corlett N (eds.) Evaluation of Human Work (pp. 628-647) London: Taylor & Francis, 1990. 3. Maslach C. The burnout syndrome and patient care. In: C. A. Garfield (ed.) Stress and Survival: The Emotional Realities of Life-Threatening Illness (pp.111-120), 1979 4. Maslach C, Jackson SE. Maslach Burnout Inventory Manual. Palo Alto, CA: Consulting Psychologists Press.1982. 5. Leiter MP. Burnout as a developmental process: Consideration of models. In: Schaufeli WB, Maslach C, Marek T. (eds.) Professional Burnout: Recent Developments in Theory and Research (237–50) Taylor & Francis, ,1993. 6. Maslach C, Schaufeli WB, Leiter MP. Job Burnout. Annu. Rev. Psychol. 2001; 52:397422. 7. Moore, KA, Cooper CL. Stress in mental health professionals: A theoretical overview. International Journal of Social Psychiatry. 1996; 42(2), 82-89. 8. Dolan N. The relationship between burnout and job satisfaction in nurses. Journal of Advanced Nursing, 1986: 12, 3-12. 9. Fagin L, Carson J, Leary J, Devilliers N, Bartlett H, O’Malley, P. Stress, coping and burnout in mental health nurses: Finding from three research studies. International Journal of Social Psychiatry. 1996; 42, 102-111. 10. Turnipseed DL. Anxiety and burnout in the health care work environment. Psychological Reports. 1998; 82(2), 627-642. A, Nyström Rhodin I, Lundberg M, Olssona 11. Sandström T, Nyberg L. Impaired cognitive performance in patients with chronic burnout syndrome. Biological Psychology, 2005; 69, 271–279. 12. Osterberg K, Karlson B, Hansen AM. Cognitive performance in patients with burnout, in relation to diurnal salivary cortisol. Stress 2009; 12(1):70–81. 13. University of Cambridge. CANTAB, The Cambridge Neuropsychological Test Automated Battery. 14. Spielberger CD. Manual for the State-Trait Anxiety Inventory. Palo Alto: Consulting Psychologists Press, 1979. 15. Lezak MD, HowiesenDB, Loring DW. Neuropsychological assessment (4th edn). New York: Oxford University Press, 2004. 16. Huey ST. Occupational Stress, Social Problem Solving, and Burnout among Mental Health Professionals in HIV/AIDS Care. A Thesis Submitted to the Faculty of Drexel University, 1997. 17. Guthrie E, Tatton T, Williams E, Black D, Bacliocotti H. Sources of stress, psychological distress and burnout in psychiatrists. Psychiatric Bulletin, 1999; 23,207-212. 18. Oehler JM, Davidson MG,Starr LE,Lee DA. Burnout, job stress, anxiety, and perceived social support in neonatal nurses. Heart and Lung,1991; 20, 5(1), 500-505. 19. Bakker AB, Van Der Zee KI, Lewig KI, Dollard, MF. The Relationship Between the Big Five Personality Factors and Burnout: A Study Among Volunteer Counselors. The Journal of Social Psychology, 2002; 135(5), 1-19.
In conclusion, there was no relationship found between burnout and neurocognitive performance in this study. Further studies could attempt to select a sample of healthcare staff that has been identified as suffering from burnout to assess their degree of cognitive impairment. The fact that trait anxiety has been further identified in this study as being a factor related to burnout raises the issue of the need for greater role of peer support and supervision for psychiatric nurses and other healthcare employees.
Acknowledgements The authors would like to thank the staff of St Patricks’ and St James’s hospitals for their participation in this project. Thanks to the Department of Statistics of Trinity College Dublin for their input.
Declaration of Interest Eli Lily provided a studentship to Dr Shane McInerney as part of an MSc thesis to complete this project.
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BRIEF REPORT
Analysis of Episodes of Involuntary Re-admission in Ireland (2007-2010) Gerry Cunningham Ir J Psych Med 2012; 29 (3): 180-184
Abstract
Introduction
Objectives: Initial examination of data held by the Mental Health Commission indicated a number of patients having repeated involuntary readmissions (defined as patients having three or more involuntary episodes in a calendar year). The Commission sought more empirical analysis of the data relating to these patients, to determine if there were any trends or commonality regarding their demographic characteristics, length of episode, and diagnoses.
Analysis of rates of involuntary admission for patients with a mental disorder across the European Union (EU) show the rates vary remarkably.1 The available year of data collection varied from country to country over a period from 1998 to 2000 and it was acknowledged that data collection procedures varied from country to country. Rates of involuntary admission for mental disorder in EU countries ranged from six per 100,000 of population in Portugal to 218 per 100,000 of population in Finland. The findings suggest that the variations may be due to the influence of different legal frameworks and procedures. Time series analysis suggests an overall tendency towards more or less stable quotas in most EU states. Ireland reported a 1999 rate of 74 involuntary admissions per 100,000 of total population in 1999 in the EU study and in 2010 a rate of 46.04 was reported by the Mental Health Commission.2
Methods: From 1 November 2006 the Mental Health Commission has been notified of all involuntary admissions in Ireland under the Mental Health Act (2001). From this national database information on patients who have had three or more involuntary admissions per year was analysed. Results: In the period studied there has been an overall reduction in the number of voluntary and involuntary admissions to Irish psychiatric hospitals and units. However, the use of involuntary admission remains constant at around 10% of all admissions. Seven percent (n=569) of involuntary admission orders in this four year period relate to two percent (n=121) of all involuntary patients. Patients who have experienced repeated involuntary admissions are predominantly male (59%), often have a diagnosis of schizophrenia, or schizotypal and delusional disorders (57%), or mania (20%), are in the age band 22-64 (80%) and more often live in rural counties.
An American study evaluated adult inpatients with schizophrenia or schizoaffective disorder (n=262) at hospital discharge and three months later to assess hospital readmission.3 Early readmission was associated with four or more previous hospitalisations (85.7% vs. 57.7%, p=0.004), comorbid substance use disorder (60.3% vs. 35.5%, p=0.0006), major depression (40.6% vs. 26.8%, p=0.04), absence of a family meeting with inpatient staff (58.2% vs. 41.8%, p=0.02), and prescription of a conventional rather than an atypical antipsychotic medication (93.7% vs. 83.8%, p=0.045). Staff had correctly predicted that twelve of the 63 readmitted patients would be rehospitalised. Staff tended to overestimate the risk of rehospitalisation in patients with a poor therapeutic alliance, low global function, or initial involuntary admission and to underestimate the risk in patients with alcohol use disorders or four or more previous psychiatric hospitalisations.
Conclusions: Potential appears to exist to significantly reduce the number of involuntary admissions by focusing on the care given to patients who are repeatedly re-admitted. More analysis is needed of voluntary and involuntary re-admissions if inpatient facilities are to be effectively configured. Key words: Involuntary re-admissions; national data; legislation.
A systematic review of the literature on the outcome of acute hospitalisation for adult general psychiatric patients admitted involuntarily as compared to patients admitted voluntarily showed that length of stay, readmission risk and risk of involuntary readmission were at least equal or greater for involuntary patients than for voluntary patients.4 The studies came mostly from North American and European countries. Involuntary patients showed no increased mortality, but did have higher suicide rates than voluntary patients. There have been a number of studies using national registers that investigated factors predicting readmission to psychiatric hospitals and the interval between readmissions. These were in Finland (early 1990s),5 Israel (1978-1992)6 and Ireland (2001-2005).7 In the Finnish study, factors found to predict readmission were
Gerry Cunningham Director, Mental Health Tribunals, Mental Health Commission St Martinâ&#x20AC;&#x2122;s House, Waterloo Road, Dublin 4 Email: cunninghamgerry07@gmail.com
Submitted 17th May 2011 Accepted 22nd May 2012
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length of stay and diagnosis. Patients with a diagnosis of psychosis or personality disorder were readmitted twice as often as patients with an organic disorder, and patients admitted voluntarily had more repeated readmissions than the patients admitted involuntarily. In the Irish study the strongest predictors of readmission were age, primary diagnosis, gender and having a secondary diagnosis. The Israeli study found a strong association of involuntary legal status at first admission with involuntary status at second admission and with the number of involuntary admissions over time.
System for Involuntary Admission and Tribunals (SIAT), to hold and process the data. The Commission uses this information to arrange legal representation and an independent review by a three person mental health tribunal within 21 days of the date of the making of an order. Involuntary admission procedures for children differ from those for adults and are dealt with in other sections of the Act. The 2001 Act has provisions for two methods of initiating an episode of involuntary admission for an adult; an Involuntary Admission Order for up to 21 days, (Form 6) and a Certificate & Admission Order to detain a Voluntary Patient (Adult), (Form 13) which also detains a patient for up to 21 days. In the four year period, 2007-2010 there have been 8,108 episodes of involuntary admission.2 An episode of involuntary admission is defined by the Commission as a patientâ&#x20AC;&#x2122;s unbroken period of involuntary admission. If the period is broken by discharge or regrading to voluntary status then the episode ends, and should another involuntary admission subsequently reoccur that will count as a new episode.
Fifteen per cent of the cohort in a study in New South Wales, Australia8 was in the Mental Health Review Tribunal (MHRT) system for the full period from their initial contact with the MHRT in 2003. These individuals also accounted for one-third of all the MHRT hearings examined. The authors relate this to the severe and intractable nature of the mental conditions of some individuals appearing before the MHRT and highlight the high workload created for the MHRT by such a modest proportion of clients. Further data is available on the wider Australian mental health tribunal systems9 that shows the effect of involuntary readmission on the resources of the tribunal. However care is needed when making cross national comparisons as the legislative basis for review by a mental health tribunal can differ. For example the Irish legislation has no mechanism for ad hoc requests for a review by a patient or by concerned others.
Over the three year period 2007-2010, available from Health Research Board reports, there has been a six percent decrease in all types of admission to psychiatric units and hospitals.10 Their figures show overall a reduction in the use of admission to Irish psychiatric hospitals and units (-six percent), both voluntary and involuntary, with use of involuntary orders accounting for eight percent of all admissions.
Initial examination of data held by Irelandâ&#x20AC;&#x2122;s Mental Health Commission indicated a number of patients having repeated involuntary readmissions (defined as patients having three or more involuntary episodes in a calendar year). The present study examines data relating to these patientsâ&#x20AC;&#x2122; demographic characteristics, length of episode, and diagnoses.
This study used data from the Mental Health Commission System for Involuntary Admission and Tribunals (SIAT), which has a complete listing of all involuntary orders notified to the Commission in Ireland since November 2006. It is a statutory requirement that these orders be notified to the Commission. Cases where three or more episodes of involuntary admission occurred in a calendar year during the four-year period 2007-2010 were chosen for detailed analysis. There were 121 patients (two percent of total patients in the period) in this category and they had 569 episodes (seven percent of total involuntary episodes in the period). The Mental Health Commission does not receive individualised information on the voluntary admission of adults; therefore analysis of voluntary admissions relating to the 121 patients is not included in this paper.
Methods The Mental Health Act 2001 commenced fully in Ireland on 1 November 2006. From this date new legal procedures were introduced in Ireland for involuntary admission. The 2001 Act introduced provisions for a system of free legal representation for adults and independent reviews during an episode of involuntary admission. Reviews are completed by a mental health tribunal at various stages during each episode of detention. Under the 2001 Act the detention periods last up to 21 days, then renewal orders can be made for periods of up to three months, then up to six months and thereafter for periods of up to 12 months. The Mental Health Commission is informed of each involuntary admission and renewal order and has developed an information system, called
Results Table 1 below shows the number of patients who had one or more episodes of involuntary admission in the four year period 20072010. For example in 2007 there were 1,581 patients who had
Table 1. Episodes of Involuntary Admission (Adults)
No. of patients 2007 No. of patients 2008 No. of patients 2009 No. of patients 2010 Total
Column A One Episode 1,581 1,483 1,574 1,553 6,191
Column B Two Episodes 206 201 174 161 742
Column C Three Episodes 34 29 24 16 103
Column D Four or More Episodes 5 7 7 7 26
Figures include all Involuntary Admission Orders for up to 21 days, (Form 6) and all Certificates & Admission Orders to detain Voluntary Patients, (Form 13).
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Table 2. ICD 10 Diagnostic Group (Coded At Close Of Episode) ICD-10 diagnostic groups 1. Organic Disorders 2. Alcoholic Disorders 3. Other Drug Disorders 4. Schizophrenia, Schizotypal and Delusional Disorders 5. Depressive Disorders 6. Mania 7. Neuroses 8. Eating Disorders 9. Personality and Behavioural Disorders 10. Intellectual Disability TOTAL
ICD-10 Code F00-F09 F10 F11-F19, F55
Total Number of Patients 11 3 1
(%) 9% 2% 1%
F20-F29 F31.3, F31.4, F31.5, F32, F33, F34.1, F34.8, F34.9 F30, F31.0, F31.1, F31.2, F31.6, F31.7, F31.8, F31.9, F34.0 F40-F48 F50 F60-F69 F70-F79
69
57%
9
7%
24 1 0 2 1 121
20% 1% 0% 2% 1% 100%
one episode of involuntary admission, 206 patients had two episodes, 34 had three episodes, and five had four or more episodes of involuntary admission.
Table 2 above shows that patients diagnosed with Schizophrenia, Schizotypal and Delusional Disorders (57%) and patients diagnosed with Mania (20%) appear to be at greater risk of experiencing repeated involuntary readmissions. This finding is in keeping with findings in other studies.6
Table 1 above shows that in the four-year period 2007-2010 there were 103 instances of patients having three involuntary episodes and 26 instances of patients having four or more involuntary episodes, i.e. all instances from Columns C and D.. When the episodes in columns C and D were further analysed it emerged that these related to 121 patients. Each of these 121 patients had a minimum of three or more episodes of involuntary admission in any given year in the four-year period. Some had many more, as they had further involuntary admissions in subsequent years. Further analysis shows this group of patients incurred a total of 569 involuntary episodes in the period, i.e. seven percent of total episodes in the period were incurred by two percent of all involuntary patients in the four-year period. There were 40 patients who had three episodes, 32 patients had four and 49 patients had five or more episodes in the four year period 2007-2010.
Analysis of each involuntary episode was undertaken to determine if revocation was by a mental health tribunal or by the responsible consultant psychiatrist. This shows that twenty three episodes where revoked by a mental health tribunal (four percent) and 93% were revoked by the responsible consultant psychiatrist. Twelve (two percent) were still open at time of reporting, one had been revoked as the result of a judgment in the High Court and 13 had not been renewed by the responsible consultant psychiatrist and thus expired. The Mental Health Commissionâ&#x20AC;&#x2122;s Annual Reports show that 10% of orders were revoked by the mental health tribunal in the same period.
Table 3. Length of Involuntary Episodes (n=569) for 121 Patients Studied
Analysis of the method used to initiate each of the 569 involuntary episodes shows that an Involuntary Admission Order for up to 21 days, (Form 6) was used in 383 (67%) episodes, a Certificate & Admission Order to detain a Voluntary Patient (Form 13) was used in 175 (31%) episodes and 11 (two percent) were episodes that were open at date of commencement of the 2001 Act that became the subject of transitional procedures. Further analysis was undertaken of those 121 patients who had three or more episodes of involuntary admission in the four-year period from 2007-2010, and showed that 58.5% were male, 41.5% female. Fifteen per cent were aged 22 to 30 inclusive; 50% were aged 31 to 50 inclusive; 15% aged 61 to 64 inclusive, and 20% were aged over 65.
Length of Involuntary Episodes
% of Repeated Involuntary Episodes
Cumulative %
Ten days or less 11 to 21 days 21 to 30 days 31 to 90 days 91 to 365 days More than 365 days
19% 35% 9% 21% 14% 2%
19% 54% 63% 84% 98% 100%
* For episodes still open, date of report was used to calculate length (28/02/2011).
Analysis was undertaken of rate of three or more episodes of involuntary admission per 100,000 by county of home address for the 121 patients studied. Counties Laois, Kilkenny, Carlow and Cavan had no patients who had three or more involuntary admissions in years 2007-2010. The average ratio was 2.85 and three counties, Donegal, Westmeath and Longford, had more than double that at 5.82 and above.
Table 3 above shows that in the four-year period analysed 54% of involuntary episodes relating to the 121 patients studied lasted 21 days or less; 30% lasted between 21 and 90 days; and 16% last 91 days or more. These episodes accumulated in total 31,676 bed days in the four year period.
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Discussion of findings
the closure of institutions. Should the extent of repeated episodes of involuntary readmission be reduced, resources expended in reviewing these orders at Mental Health Tribunals could be reinvested in preventative and recovery focused services. It is acknowledged that this study has not been able to analyse the extent of repeated episodes of voluntary readmission, which may provide further information on bed usage by these patients. It is recommended that the feasibility of putting in place a national system that monitors the extent of repeated episodes of voluntary readmission be examined. Future studies would then be in a position to correlate information on voluntary readmissions with information from the Mental Health Commission’s system for notification of involuntary orders and provide more details on service utilisation.
There has been an overall reduction in the number of admissions to Irish psychiatric hospitals and units since commencement of the Mental Health Act 2001 in November 2006. However the use of involuntary admission orders has remained at around eight percent of all admissions in each year. Seven percent (n=569) of all involuntary orders over the four year period 2007-2010 relate to two percent (n=121) of patients who have had repeated involuntary admissions, defined in this study as three or more in a calendar year. This study shows that patients who experience repeated involuntary readmission are predominantly male (59%), often have a diagnosis of schizophrenia or schizotypal and delusional disorders (57% ), or mania (20%), are in the age band 22-64 (80%) and often live in rural counties.
Acknowledgments Repeat involuntary admissions of the 121 patients studied accounted for 31,676 bed days in the four year period studied, 2007-2010. This equates to an average of 65 bed days per year for each patient in the study. As in-patient units are acute facilities where demand for beds is always high, these figures deserve further attention. Analysis of the number of voluntary admissions in the period for these patients is also required and would assist further evaluation, as it is clear from this study that many of the patients who have repeated involuntary admission also have a significant number of voluntary admissions -31% (n=175) of the repeat episodes were initiated by an admission order to detain a voluntary patient. Potential appears to exist to further reduce the number of involuntary admissions to acute facilities if the inpatient and community care of patients who are prone to repeated involuntary readmission could be evaluated at a local level, with a view to better maintaining them in the community. The current study shows 54% of involuntary episodes relate to patients who experience repeated involuntary readmission lasting for 21 days or less. Further evaluation could usefully examine the care they received during their admission, planning for discharge and their care following discharge. A recent Irish study found risk of involuntary readmission is highest at one year following discharge and may be associated with recovery style.11 Recovery style was measured using the Recovery Style Questionnaire (RSQ)12 and broadly classified as ‘integrative’ or ‘sealing over’. Integrative recovery style is characterized by acknowledgement of the illness and active attempts to cope, whereas a sealing over style is characterized by cognitive and behavioural avoidance. Persons with a sealing over style may require more support following discharge to promote insight and coping skills. If these individuals are more readily identified, resources can be targeted to provide them with such support with the aim of preventing readmissions.
The Author acknowledges the access afforded to the Mental Health Commission’s information systems.
Conflict of Interest None.
Conclusions The Mental Health Commission has had an information system (SIAT) since November 2006 that monitors the number of involuntary admissions in Ireland. SIAT data is now available as a result of the notification of involuntary admission orders by hospitals and acute units to the Mental Health Commission under the Mental Health Act 2001. SIAT data shows a significant cohort of patients in receipt of forms of inpatient or community mental health services that has resulted in them experiencing repeated episodes of involuntary readmission. These findings will be of interest to those reconfiguring mental health services as a result of 183
References: 1. Salize, H. J, and Dressing, H. Epidemiology of involuntary placement of mentally ill people across the European Union. Br J Psych 2004: 184, 163-186. 2. Mental Health Commission Ireland Annual Report 2010, Mental Health Commission Ireland Dublin 2011. 3. Olfson, M., Mechanic, D., Boyer, C., Hansell, S, Walkup, J, and Weiden P. Assessing Clinical Predictions of Early Rehospitalization in Schizophrenia. J Nerv Ment Dis 1999 Volume 187(12), 721-729 4. Kallert, T. W., Glockner, M, and Schutzwohl. Involuntary vs. voluntary hospital admission. Eur Arch Psychiatry Clin Neurosci 2008 258: pp195-209 5. Korkeila, J, Lehtinen V, Tuori, T, and Helenius, H. Frequently hospitalized psychiatric patients: a study of predictive factors. Soc Psychiatry Psychiatr Epidemiol 1998, 33: 528-534. 6. Fennig, S, Rabinowitz, D.S.W, and Fennig, S. Involuntary First Admission of Patients with Schizophrenia as a Predictor of Future Admissions. Psychiatr Serv 1999, 50: 10491052 . 7. Daly, A., Doherty, D.T., and Walsh D. Re-admission to Irish psychiatric units and hospitals 2001-2005 Health Research Board Dublin 2007. 8. Cain, M, Karras, M, Beed T., Carney, T. The NSW Mental Health Review Tribunal. An Analysis of clients, matters and determinations. Law and Justice Foundation of New South Wales Sydney 2011. 9. Carney, T, Perry, J., Vernon, A., and Beaupert, F. Australian Mental Health Tribunals: Space for fairness, freedom, protection & treatment? Themis Press Sydney 2011. 10. Daly, A, and Walsh, D. Activities of Irish Psychiatric Units and Hospitals 2010 Main Findings. Health Research Board Statistics Series 15 Dublin 2010. 11. O'Donoghue, B., Lyne, J, Hill, M., O'Rourke, L, Daly, S., Larkin, C, Feeney, L., O'Callaghan, E. Perceptions of involuntary admission and risk of subsequent readmission at one-year follow-up: The influence of insight and recovery style. Journal of Mental Health. 2011 June;20(3):249-59. 12. Drayton, M., Birchwood, M, and Trower, P. Interventions to improve antipsychotic medication adherence. Review of recent literature. Journal of Clinical Psychopharmacology, 1998 23, 389-399.
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BRIEF REPORT
The Teamworking Challenges of Care Planning Patrick McHugh; Micheal Byrne (co-author) Ir J Psych Med 2012; 29 (3): 185-189
Abstract
Introduction
Background: Care planning is a multidisciplinary process used to develop an individualised recovery plan for each service user. The success of this process will depend on the extent to which members of mental health teams can work with one another, with service users, and with other service providers in developing a coordinated plan that meets service user needs across multiple domains.
Individualised care planning is fundamental to quality mental health service provision. Within the context of Community Mental Health Teams (CMHTs), professionals from different disciplines are required to work with each other, with service users, and with carers to formulate and continually review a ‘living’ recovery care plan for each service user. This plan includes the ‘time frame, goals and aims’ relevant to multiple life domains of service users, the ‘strategies and resources to achieve these outcomes, and clear criteria for assessing outcome and user satisfaction’.1 (page 81) The care planning process needs to be consistent with the recovery approach to mental health treatment in both empowering service users to actively manage their own recovery, and in directing treatment towards achieving goals that meaningfully influence their functioning in the community.2,3
Aims: This paper examined the teamworking challenges that Community Mental Health Teams (CMHTs) face during the care planning process and how such challenges may be managed. Method: A narrative review of published articles and policy documents relevant to teamworking and recovery-focused care planning within mental health teams.
While the method of the care planning model may be clear, the processes required for its successful implementation are less well understood. The finding that only 42% of service users have an awareness of their care plan4 suggests that CMHTs may struggle to align the care planning process with recovery principles. This paper considers some of the teamworking challenges that CMHTs may face, both in attempting to co-ordinate interdisciplinary care planning as well as actively facilitating service user empowerment. The environmental factors that inhibit effective teamworking are first discussed, followed by a consideration of the associated structural and functional teamworking challenges.
Findings: Teamworking challenges include the provision of integrated rather than fragmented care, the empowerment of the service user, and development of a distributed model of leadership, responsibility and decision making. Conclusions: CMHTs face a range of substantial but manageable challenges in attempting to implement recovery-focused care planning. Recommendations include the need to integrate recovery-orientated skills and values into professional training, the need for greater multidisciplinary training opportunities, and the need to evaluate CMHTs based on recovery-orientated criteria. Key words: collaboration.
Teamwork;
care
planning;
For the search of published papers, three databases were used: PsychINFO, Psych ARTICLES, and ScienceDirect. The electronic search of these databases used the following keywords: mental health; teams; care planning; recovery; and multidisciplinary. Boolean operators (OR, AND) and synonyms were used as needed. Some articles were found using a manual search, while others were identified from reference lists of already acquired articles.
multidisciplinary
Environmental challenges The traditional unidisciplinary nature of professional training may promote competition within CMHTs as different professionals compete to assert the primacy of their theoretical models of mental health.5 Such competition conflicts with the recovery approach to care planning that aims to integrate a variety of theoretical models in order to meet the diverse needs of service users.6 If unified rather than fragmented care is to be provided, team members need to develop a mutual respect and understanding of each others’ assessment and treatment models. While this can be facilitated by ongoing teamwork training, it ultimately needs to be developed early in professional training when professional identities are being forged and are more flexible.7 For example
Patrick McHugh Research Assistant, Roscommon Integrated Service, HSE West, Ireland. *Correspondence
*Michael Byrne Principal Psychology Manager, Roscommon Integrated Services, HSE West, Ireland. E-mail: michaelj.byrne@hse.ie
185
Submitted: 24th August 2011 Accepted: 19th April 2012
for meaningful co-ordination of care.9 The outcome may include agreement that if certain team members are absent (e.g. on leave), other team members will undertake some of the absent members’ work if this work is critical to progressing the care plan of a particular service user.
multidisciplinary training modules and work experience could be included in the accreditation criteria for professional training. When profiling service users, many professions adopt models of mental health that promote deficit-discourse and the assignment of service users into diagnostic categories. Such conceptualisations implicitly place service users in a ‘passive patient’ role and project professionals as experts seeking compliance from service users.8 In order to build a perception of service users that is consistent with the recovery approach, professional trainings needs to integrate a strengths-based conceptualisation of service users that recognises their potential in enhancing their own care.6
Governance structure The governance structure of CMHTs in Ireland consists of a clinical leader, a team co-ordinator and a practice manager.1,10,15 Both the clinical leader and the team co-ordinator will be responsible for leading and co-ordinating team activities at various points throughout the care planning process. It is important that team members have an explicit awareness of the functions of these leadership roles (e.g. as specified in the team’s operational policy document) as confusion may lead to unnecessary power conflicts.16 Furthermore, the post holders themselves need to refrain from exerting excessive levels of influence (e.g. use of an authoritarian leadership style based on compliance) as this will disempower both team members and service users and restrict effective intra-team collaboration.
In a system with ever-increasing bureaucratic pressures, the drive for efficiency and organisation may restrict the flexibility needed to bring about effective care planning.9 As such, there needs to be a tolerance among higher management of the uncertainty and unpredictability that is inevitable when CMHTs customise care programmes for service users. Broad outcomes and goals can be specified, but teams ultimately need to be given the necessary freedom to adaptively and dynamically meet the diverse needs of service users.10
CMHTs also need to discuss what model of clinical responsibility they will operate by. This can vary from a centralised (or ‘star’) model of clinical responsibility to a more distributed model where responsibility is determined by team members’ relative contribution to the care of a particular service user. While the latter model has the advantage of promoting leadership throughout the team,17 it is important that whatever model is chosen is accepted by all team members.
Structural challenges At a structural level, team members need to break away from their narrow professional role definitions in order to bring about a collective and co-ordinated vision to care planning. Furthermore, the traditional hierarchical power structures need to be replaced with a more distributed model of leadership and responsibility that facilitates effective intra-team collaboration and service user empowerment.
Cohesiveness
Integrating the service user
In a context where there are clear team objectives, team cohesiveness will bring a collective vision to care planning.18 The development of such a shared vision is a key factor in motivating team members towards achieving collaborative goals.19 Team cohesiveness can also facilitate high staff morale that in turn can promote service user involvement.20 To build cohesiveness, team members need to transcend their professional boundaries and prioritise team goals over individual or discipline-specific goals. However, teams need to avoid extreme cohesiveness that is characterised by excessive consensus seeking in decision making (i.e. groupthink) and an unhealthy internal focus that may neglect interactions with external stakeholders.7
Active service user involvement promotes individualised care planning, facilitates self-directed recovery and utilises the knowledge of the service user. The CMHT member assigned as a service user’s care coordinator (or keyworker) needs to facilitate his/her active engagement throughout the care planning process. The role of carers in facilitating recovery is increasingly being recognised. They also need to be encouraged to contribute to the care planning process, provided the service user consents to their involvement.6 Sucessful engagement of service users and carers involves more than simply offering choice. It requires staff having and utilising appropriate relationship building skills (e.g. empathetic, active listening) to create an environment of participative saftey for service users and carers. Furthermore, only by intrinsically valuing service user empowerment and recovery principles will staff be motivated to utilise service users’ contributions in a meaningful way.
Functional challenges Team processes ‘reflect the way that teams handle tasks and interpersonal dynamics’.21(p365) Effective care planning necessitates that CMHTs establish clear procedures regarding workload distribution, decision-making and conflict resolution as well as developing a work environment that facilitates open communication and collaboration.
Team roles If team members rigidly adhere to narrow unidisciplinary role boundaries, care will become fragmented.11 Such role inflexibility may be triggered when team members are exposed to unmanageable stressors, or where role overlap threatens members’ professional identities.12,13 Furthermore, some may fear that adopting flexible role boundaries – including undertaking some generic working – will lead to the distinct contribution of their profession being lost.14 To prevent potential role conflict, CMHTs need to openly negotiate roles and regularly review them so that there is a mutual understanding and acceptance of roles. This ongoing whole-team process will reduce interactions based on inaccurate professional stereotypes and increase the potential
Workload distribution When the burden of clinical work falls too heavily on certain team members, it can generate negative group emotions and lead to individual burnout.22 Furthermore, high levels of individual work pressure my lead to CMHTs neglecting service user involvement. To maximise fairness and balance, CMHTs need to openly discuss workload distribution taking into account factors such as each member’s competency set, caseload complexity and travel commitments. In those cases where the overall CMHT capacity cannot manage the needs of the associated service user 186
significantly compromised (e.g. during an episode of psychosis or mania). Furthermore, staff need to be cautious about placing excessive levels of choice and responsibility on service users as this may negatively impact their subjective well-being36 and ultimately their recovery.
population, the Area Mental Health Management Team may need to prioritise securing extra resources (i.e. staff with the appropriate competencies).
Inter-service collaboration
Conflict
Effective care planning requires CMHTs to coordinate with other mental health and non-mental health services. Within each locality, a system of leadership and management is needed to ensure that that the diverse needs of the associated population are met. For example, if a specialised secondary team (e.g. a Rehabilitation Team) is present in a locality, the associated CMHT will have less of a need to focus on severe and enduring mental health presentations. In the absence of more specialised services, the CMHT may be divided up into sub-teams to carry out specialised functions.1 Inadequate co-ordination in a locality may result in some service users getting bounced around between different services while others fall through the cracks of the system.23 The inter-team collaboration that is necessary to avoid such problems may be facilitated by establishing multiple communication pathways (e.g. electronic media, periodic regional meetings).
While a certain degree of intra-team conflict is inevitable, excessive levels will restrict effective intra-team collaboration. Sources of conflict during the care planning process may include interdisciplinary rivalries3 or role conflict between members. A stepwise conflict resolution strategy needs to be in place to ensure that minor ‘task conflicts’ do not spiral out of control or develop into ‘relationship’ conflict.37 Such a strategy may include initially facilitating communication between team members. Continuing non-resolution of an issue may then necessitate input from progressively higher levels of management. However, the mere existence of a conflict resolution strategy itself may inhibit conflict.38
Training Communication Due to inadequacies in traditional professional training programmes, many professionals are lacking in knowledge and skills relating to recovery-focused care planning and teamworking. Hence, these programmes require a variety of additional modules relating to understanding service user needs, with a particular emphasis on conceptualising service users beyond their deficits and recognising their potential for enhancing their own care. Other training modules could focus on developing empathetic and respectful relationships with service users. In promoting service user empowerment at all levels, service user groups need to be involved in the design and evaluation of such modules.39
Difficulties with both formal and informal communication will disrupt effective care planning. CMHT leaders need to promote an atmosphere of psychological safety whereby team members can openly express ideas or dissent without fear of blame or ridicule24 and where mistakes are seen as an opportunity for improvement rather than an opportunity to apportion blame.25 With regard to service users, it is important that they are encouraged to express their beliefs, values and opinions so that they can meaningfully collaborate in the care planning process. The use of professional jargon and complex terminology needs to be minimised as it will result in service users disengaging from the care planning process.26 User-friendly documentation that informs the service user about their presentation and care plan is also needed.20,27
While resources such as the Mental Health Commission’s resource paper on teamworking10 are available, with regard to educating CMHT staff on how to work effectively within teams, CMHTs need to be provided with ongoing multidisciplinary training in topics such as communication, group decision-making and conflict resolution within an interactive learning environment.40,41 One example of such training in Ireland is the ‘Team-based approaches to supporting mental health in primary care settings’ module in Dublin City University.42 Continuous professional development also needs to address issues specific to individual teams such as promoting an awareness among members of each others’ values, skill sets and responsibilities,43 as well as promoting familiarity with a team’s operational policy document.
Decision making Confusion around the decision making procedure may result in a default strategy based on traditional power hierarchies28 or may result in groupthink where the drive for consensus overrides the drive for accuracy.29 Hence, formal decision-making procedures need to be agreed upon by each CMHT. In gaining multiple inputs from team members, these procedures will utilise the range of knowledge and skills within the team. However, teams need to ensure that multidisciplinary input is utilised in a way that retains team decisiveness, rather than the decision-making process becoming protracted around individual minutiae.30 For example, discretion needs to be given for practitioner-only decisions (e.g. adjustment of a profession-specific therapy) to bypass the group decision process.
Recommendations This paper highlights the teamworking challenges faced by CMHTs when implementing recovery-focused care planning. Teams will ultimately need to work beyond the traditional conceptualisations of mental health in order to provide an integrated service that adaptively meets the range of service users’ needs. The extent to which CMHTs can use teamworking challenges as an opportunity for growth and improvement, rather than blame and stagnation, will be a key determinant of the effectiveness of the care planning process.
Service user involvement in the decision making process is a core aspect of the recovery approach.31 Not only is it beneficial in taking advantage of their own experience (i.e. ‘experts by experience’), it also provides service users with the opportunity of self-managing their problems, a prerequisite for long-term recovery.32 CMHT members need to challenge their own biases based on traditional conceptions of service users as not being skilled enough to take independent decisions.33 In particular, they need to recognise the right of service users to take risks and make decisions that they as professionals may not agree with.34,35 However, team members do need to set limits in those instances where a service user’s decision-making capacity may be
Based on the current review, the following recommendations are proposed to improve recovery-orientated care planning within CMHTs in Ireland.
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Training
References: 1. Department of Health and Children. A Vision for Change: Report of the Expert Group on Mental Health Policy. Dublin: Stationery Office; 2006: 81. 2. Anthony WA. A recovery-oriented service system: Setting some system level standards. Psychiatr Rehabil J 2000; 24(2): 159-68. 3. Jacobson N, Curtis L. Recovery as policy in mental health services: Strategies emerging from the states. Psychiatr Rehabil J 2000; 23(4): 333-41. 4. de Burca S, Armstrong C, Bronson P. Community Mental Health Teams: Determinants of Effectiveness in an Irish Context. Limerick: Health Systems Research Centre; 2010. 5. Singh SP. Running an effective mental health team. Adv in Psychiatric Treatment 2000; 6: 414-22. 6. Mental Health Commission. The Recovery Approach within the Irish Mental Health Services: A Framework for Development. Dublin: Mental Health Commission; 2008. 7. Begley CM. Developing inter-professional learning: Tactics, teamwork and talk. Nurse Educ Today 2009; 29(3): 276-83. 8. Warne T, Stark S. Service users, metaphors and teamworking in mental health. J Psychiatr Ment Health Nurs 2004; 11(6): 654-61. 9. Rosen A, Callaly T. Interdisciplinary teamwork and leadership: issues for psychiatrists. Aust Psychiatry 2005; 13(3): 234-40. 10. Byrne M, Onyett S. Teamwork within Mental Health Services in Ireland. Dublin: Mental Health Commission; 2010. 11. Jones A. Multidisciplinary team working: collaboration and conflict. Int J Ment Health Nurs 2006; 15: 19-28. 12. Belling R, Whittock M, McLaren S, Burns T, Catty J, Jones IR, et al. Achieving Continuity of Care: Facilitators and Barriers in Community Mental Health Teams. Implementation Sci 2011; 6. 13. Norman IJ, Peck E. Working together in adult community mental health services: An interprofessional dialogue. J Ment Health 1999; 8(3): 217-30. 14. Rapaport J, Manthorpe J. Family matters: developments concerning the role of the nearest relative and social worker under mental health law in England and Wales. Br J Social Work 2008; 38: 1115-31. 15. Collins P, Byrne M. A call to co-ordinate mental health teams. The Ir Psychol 2011; 37(8): 212-6. 16. Ovretveit J. Planning and managing teams. Health & Social Care in the Community 1997; 5(4): 269-76. 17. Rosen A. New roles for old: the role of the psychiatrist in the interdisciplinary team. Aust Psychiatry 2001; 9(2): 133-7. 18. Mathisen G, Einarsen S, Jørstad K, Brønnick S. Climate for work group creativity and innovation: Norwegian validation of the team climate inventory (TCI). Scand J of Psych 2004; 45: 383-92. 19. Wilson V, Pirrie A. Multidisciplinary Teamwork Indicators of Good Practice. Edinburgh: Scottish Council for Research in Education, 2000. 20. Anthony P, Crawford P. Service user involvement in care planning: the mental health nurse’s perspective. J Psychiatric Ment Health Nurs 2000; 7(5): 425-34. 21. Mickan SM, Rodger S. Effective health care teams: A shared model of six characteristics developed from shared perceptions. J Interprof Care 2005; 19(4): 358-70. 22. Lankshear AJ. Coping with conflict and confusing agendas in multidisciplinary community mental health teams. J Psychiatric Ment Health Nurs 2003; 10: 457-64. 23. Clark J. On the Bounce: Understanding Mental Health Systems in the North West. NHS North West: Commission on Mental Health Services; 2008. 24. Borrill C, West M, Shapiro D, Rees A. Team working and effectiveness in health care. Br J of Health Care Manag 2000; 6(8): 354–371. 25. Department of Health and Children. Building a Culture of Patient Safety: Report on the Commission on Patient Safety and Quality Assurance. Dublin: Stationery Office; 2008. 26. Mental Health Commission. Quality Framework: Mental Health Services in Ireland. Dublin: Mental Health Commission; 2007. 27. Coulter A. The NHS revolution: health care in the market place - What do patients and the public want from primary care? Br Med J 2005; 331(7526): 1199-1201. 28. Simpson A. The impact of team processes on psychiatric case management. J of Adv Nurs 2007; 60(4): 409-18. 29. Janis IL, Victims of Groupthink. Boston: Houghton-Mifflin, 1982. 30. Ovretveit J. Team decision-making. J of Interprof Care 1995; 9: 41-51. 31. Elstad TA, Eide AH. User participation in community mental health services: exploring the experiences of users and professionals. Scand J of Caring Sci 2009; 23(4): 674681. 32. Davidson L, O'Connell M, Tondora J, Styron T, Kangas K. The top ten concerns about recovery encountered in mental health system transformation. Psychiatric Serv 2006; 57(5): 640-5. 33. Hamann J, Leucht S, Kissling W. Shared decision making in psychiatry. Acta Psychiatrica Scand 2003; 107: 403–9. 34. Deegan PE. Recovering our sense of value after being labelled mentally ill. J of Psychosoc Nurs 1993; 31: 7–11.
Provide more opportunities for interdisciplinary teamworking during professional training. Interdisciplinary training modules and work experience could be made an accreditation requirement. Integrate the values of the recovery approach (e.g. service user empowerment) into professional training. Provide more professional development opportunities that require interactive multidisciplinary teamworking. Provide designated training opportunities for CMHTs to develop their operational policy document and allow members to familiarise themselves with each others’ roles, the decision-making procedure and the governance structure. Develop multiple communication links between mental health services to ensure that service users receive unified care both within and between services.
Service Evaluation Assess teamworking processes as part of CMHT service evaluations. This assessment needs to not only examine whether effective teamworking is taking place but also whether it is consistent with the values of the recovery approach. Resources such as the Mental Health Team Development Audit Tool10,44 and the Pillars of Recovery Service Audit Tool6 may be used.
Communication Provide user-friendly documentation to service users that explains the care planning process and the role service users may play in it.
Conclusions Some may argue that the recovery approach is simply a mindset that will grow organically over time. However, existing values, patterns of working and organisational cultures have been established over many years and it may be simplistic to assume that a recovery approach will materialise with a non-directed mindset change. Hence, CMHTs have a responsibility to proactively nurture a recovery-oriented culture.
Declaration of interest None.
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35. Perkins RE, Repper JM. Compliance or informed choice. J of Ment Health 1999; 8(2): 117-29. 36. Schwartz B. The Paradox of Choice. New York: Ecco/Harper Collins; 2004. 37. Pelled LH. Demographic diversity, conflict, and work group outcomes: An intervening process theory. Organ Sci 1996; 7(6): 615-31. 38. Onyett S, Standen R, Peck E. The challenge of managing community mental health teams. Health and Social Care in the Community 1997; 5: 40-7. 39. Higgins A, Maguire G, Watts M, Creaner M, McCann E, Rani S, et al. Service user involvement in mental health practitioner education in Ireland. J Psychiatric Ment Health Nurs 2011; 18(6): 519-25. 40. Herrman H, Trauer T, Warnock J, Professional Liaison Committee. The roles and relationships of psychiatrists and other service providers in mental health. Aust N Z J Psychiatry 2002; 36(1): 75-80. 41. Cooper H, Carlisle C, Gibbs T, Watkins C. Developing an evidence base for interdisciplinary learning: a systematic review. J of Adv Nurs 2001; 35(2): 228-37. 42. Irish College of General Practitioners. Team-based approaches to supporting mental health in primary care settings. [serial online] 2011; Available from http://www.icgp.ie/go/archive/6C6AD260-19B9-E185-8331B9561FD5F4AF.html 43. Reeves S, Freeth D. Re-examining the evaluation of interprofessional education for community mental health teams with a different lens: understanding presage, process and product factors. J of Psychiatric and Ment Health Nurs 2006; 13(6): 765-70. 44. Roncalli S, Byrne M, Onyett S. Psychometric properties of a Mental Health Team Development Audit Tool. J of Ment Health (submitted).
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BRIEF REPORT
Developing an Integrated Mental Health Care Service: Description of a Pilot Mental Health Consultation/Liaison Clinic in a Primary Care Centre Nicolas Ramperti, Daniel De La Harpe Golden, Iro Chinedu, Seathrun O’Casaide, Frank Kelly Ir J Psych Med 2012; 29 (3): 190-193
Abstract
Objective
To determine if a consultation/liaison mental health clinic in primary care as proposed for Vision for Change, The Primary Care Strategy and the Department of Health is an efficient model of delivering mental health care in Ireland.
In Ireland one in seven adults experience mental health or emotional difficulties every year.1 Most of them will benefit from support within their community, such as that given by family and friends, while others will seek help from their GP if their symptoms persist. Most mental health problems are dealt with within primary care, but a small proportion (4.3%) will require referral to secondary care.2
Methods: The pattern of service use and the clinical characteristics of new patients attending a pilot consultation/liaison clinic in a local primary care centre were studied.
This layered framework of mental health provision (community support, primary and secondary care) requires a degree of flexibility that can respond to the needs of the individual.
Results: During the first 16 months of this clinic 1.2% of patients did not attend the initial assessment in the liaison clinic versus 29.75% in the regular Outpatients Department (OPD). Less than one in five (17.1%) required a follow-up review with the clinician in the consultation/liaison clinic compared to almost all patients first seen in OPD secondary care (96.6%). A small minority of patients (6.1%) needed referral to secondary care due to the complexity of their presentation.
Over the past two decades, there has been a growing international interest in assessing the working relationship between primary care and secondary mental health care.3 The integration between these services is a viable way of ensuring that people receive the mental care they need. A number of interesting models have been proposed ranging from a pure referral model to the primary care training model where formal training sessions, seminars and guidelines are provided by secondary care.4,5 A collaborative care approach where patients are jointly managed by primary and secondary care, sometimes with the support of a case manager, is another example currently in use in Ireland.6,7
Conclusions: A consultation/liaison mental health clinic in primary care results in an efficient use of manpower resources due to the low Did Not Attend (DNA) rates and low proportion of formal referrals to secondary care. As patients seem to favour this type of setting, over traditional outpatient departments, a move towards consultation/liaison clinics in the primary care team should be considered.
Despite the variety of models, there continues to be a lack of evidence regarding which type of interaction is the most clinically effective.5 The increasing consensus is that the type of integration between primary and secondary care should respond to local needs.4,8
Key words: Community mental health services, primary health care, ambulatory care, referral and consultation.
In Ireland, both Vision for Change and the Primary Care Strategy promote a consultation/liaison model.9,10 This involves the community mental health team designating a worker who acts in a consultative capacity to GPs and screens cases if necessary. The purpose of this model is to supplement and enhance the GP’s skills in the detection and management of mental illness while enabling the primary care team staff to screen and refer more effectively to secondary care. This type of model has been successfully introduced in other countries.11-14 With these considerations in mind, we developed a pilot consultation/liaison mental health clinic within the local primary care centre.
*Nicolas Ramperti, Consultant Psychiatrist, Ballyfermot Primary Care and Mental Health Centre, Ballyfermot, Dublin 10 Email: nicolas.ramperti@hse.ie *Correspondence
Daniel De La Harpe Golden, Senior Registrar, Dept of Psychiatry, St Luke’s Hospital, Freshford Road, Kilkenny. Iro Chinedu, Consultant Psychiatrist, Cavan-Monaghan Mental Health Services.
Seathrun O’Casaide, General Practitioner, Kilkenny Primary Care Centre, Ayrfield Medical Practice, Granges Road, Kilkenny.
Mental Health Services, St Luke’s Regional Hospital, Freshford Road, Kilkenny.
Frank Kelly, Executive Clinical Director Carlow/Kilkenny & South Tipperary
Submitted: 17th January 2012 Accepted: 24th April 2012
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Method
Table 1. Demographic and clinical profile of patients attending the liaison clinic
The primary care team (PCT) operating in Kilkenny city centre is staffed by seven GPs and two GP trainees with the support of four practice nurses and other allied health staff. Three community mental health teams provide mental services in Co Kilkenny, covering a population of approximately 95,000 distributed mostly in suburban and rural areas. Each team provides an initial assessment clinic on a weekly basis. The consultation/liaison mental health clinic was set up in April 2010. The senior registrar training in the Carlow/Kilkenny Mental Health Services provides a psychiatric liaison clinic one afternoon every two weeks. Referrals are made through the general practice health information system (waiting time is usually no longer than two weeks). Approximately two to four new patients are booked into each clinic. Patients are seen in one of the clinical rooms of the primary care centre, adjacent to the GP rooms.
Demographics Female Average age
N (%) 55 (67.1) 39
Diagnosis Mood Disorder Anxiety Disorder Other No clear axis I or axis II disorder Substance/alcohol misuse Psychotic Illness
N (%) 30 (36.6) 25 (30.5) 15 (14.6) 6 (9.1) 4 (6.1) 2 (3)
Table 2. Care pathways for patients referred to the clinic
The criteria collaboratively developed to refer patients to this clinic include those adult patients who were traditionally referred to secondary mental health services for further assessment and care. This includes people living in Co Kilkenny and experiencing complex or unresolved mental health symptoms that have failed to respond to at least one intervention; or when there is a difficulty establishing a diagnosis. As we were interested in assessing if unnecessary referrals could be avoided to secondary care, patients already attending the community mental health team were not referred to this clinic, nor were cases requiring an urgent assessment.
Total of patients referred to the liaison clinic Not attendance to first assessment (“DNA”) Requiring further follow up by Senior Registrar Referred to secondary care Requiring admission to a psychiatric unit
N (%) 82 (100) 1 (1.2) 14 (17.1) 5 (6.1) 0 (0)
schizophrenia, and one patient with a diagnosis of generalised anxiety disorder). Regarding the number of times these patients attended this clinic, 68 (82.9%) of them were seen on one occasion only, but 14 patients (17.1%) required at least one follow up review by the senior registrar. Only one patient (with a history of post-natal depression) required two further follow up sessions (Table 2).
Each assessment takes approximately 30 minutes. At the end of the assessment an oral formulation is given back to the patient. The senior registrar documents in the PCT’s health information system the results of the assessment and a suggested management plan for the GP to follow. This typically involves a series of steps regarding management of medication, plus suggestions for appropriate referral to local psychological, social services, peer support groups or appropriate voluntary agencies.
Of note, only one patient (1.2%) did not attend the initial assessment in the liaison clinic. None of them required inpatient care (Table 2). In parallel with the development of this liaison clinic, a reduction in the numbers of referrals to the adult mental health teams from this primary care centre was noticed - from 12 patients in the trimester April – June 2010 to two patients in the same period two years later (Fig 1). This is accompanied by a reduction in the DNA rate for first assessment in secondary care to 0% (January to September 2011).
Cases seen in this clinic are discussed with the consultant psychiatrist during the supervision sessions or by phone. The patients remain under the care of the local primary care team.
Results Over a period of 16 months, 82 patients were referred to the liaison clinic. Of those who attended, 55 were female with an average age of 39 years old (Table 1). More than half of the patients seen (67.1%) presented with a mood or an anxiety disorder (Table 1). Of those patients that were assessed in the clinic, five (6.1%) were referred to secondary care due to the complexity of their presentation (one patient with a diagnosis of paranoid schizophrenia, two patients with an eating disorder, one patient with severe social phobia and one patient with a severe major depressive episode) see Table 2. Two patients (three percent) were previously attending the secondary care services and were redirected to these (one patient with a diagnosis of paranoid
Figure 1: Numbers of referrals from Kilkenny Primary Care Centre to the local regular OPD clinic for initial assessment before and after the establishment of the liaison clinic in April 2010.
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Discussion
A number of issues should be considered when analysing the impact of this type of service. To be efficient from a manpower and time management resource point of view, this type of clinic may require a large primary care centre that is a big source of referral to the secondary mental health services. We are aware that this type of centre is not readily available throughout the country. This clinic may need to be adapted to the infrastructure and the needs of the local/virtual primary care team; for example by either running it in a local health centre or in a centrally located GPsâ&#x20AC;&#x2122; clinic.
Our results show that this type of consultation/liaison clinic could contribute to a better planned and more efficient use of the mental health services due to the low DNA rate and a lower proportion of referrals to secondary care. The DNA rate at the consultation/liaison clinic is extremely low (1.2%), particularly when compared to a rate of 29.75% in our local secondary mental health service. This DNA rate in our OPD is in line with other national and international services.15
A possible limitation when interpreting the results of this pilot project, is that patients seen in this liaison clinic may have not needed referral to the secondary mental health services. A qualitative analysis of patients attending both the initial assessment in the OPD (before and after the introduction of the liaison clinic) might have helped to elucidate if this new clinic was responsible for this drop in the referral rate. On the other hand as Fig 1 shows, the number of patients referred to our traditional OPD fell dramatically once the consultation/liaison clinic was set up. Another possible limitation is that no conclusions could be made regarding the effectiveness of clinical interventions in both settings (e.g. magnitude of response, frequency of remission); this was not the scope of our project.
The low DNA rate at the primary care centre suggests that patients attending a psychiatric assessment find it easier to do so in their own primary care setting rather than in secondary care. This is in line with previous surveys.16 A number of reasons may contribute to this. For example, patients invited to attend an appointment in the department of psychiatry could find it stigmatising, therefore may be less likely to attend. Also, patients might find an increased sense of personal care by attending their GP practice and by interacting with familiar staff. Another possible contributor to this rate is that this primary care team centre operates a system of automatic SMS appointment reminders, which has been shown to reduce the rate of missed appointments.17
We are currently developing the second stage of this project that builds on the experience gained so far. This involves shifting the outpatient psychiatric clinic from the local department of psychiatry to the primary care team facility.
We believe that there are two other factors that make this type of clinic manpower efficient. Firstly, the small proportion of formal referrals to secondary care (6.1%) on behalf of the senior registrar. This referral rate is similar to the mean national rate of referral (4.3%) but was only achieved once the consultation/liaison clinic was set up.2 A pre-existing higher rate of referrals (from GPs in the primary care team) could be explained by the different characteristics of the local population and/or general practitioner referring style. Secondly, fewer than one in five patients required more than one session with the assessing psychiatrist, in contrast to 96.6% of patients first seen in the regular OPD in secondary care by the local team. This was likely to be achieved by a combination of a clear documented management plan in the IT system and the mutual clinical support between the senior registrar and the local GPs.
Conclusion Our pilot study suggests that the model of integration proposed by Vision for Change is successful. From a service provision point of view, this service is efficient due to the low DNA rate and the small proportion of people that need referral to secondary care. Clinicians in primary and secondary care found this type of clinic to be a relevant and effective way of communicating and providing mental health care. In addition, it seems that patients find that this type of service meets their needs better than the traditional mental health outpatient clinics. Patients may benefit from a more extensive integration between primary and secondary care.
This type of clinic could eventually reduce the size of outpatient clinics run in the secondary care setting, allowing the community mental health team to deploy its resources on cases with a higher degree of complexity. In the same line, it could encourage patients to seek help earlier and improve the detection of the early stages of mental illness.
Declaration of Interest None.
While not formally assessed, the GPs in the primary care team were unanimously satisfied with this model of consultation/liaison clinic. They found the opportunity to interact closely, on a clinical and educational level, with the attending senior registrar very helpful. From the senior registrarâ&#x20AC;&#x2122;s point of view, it was very helpful to promptly access clinical information in the medical information system as this assisted the assessment of each patient. Additionally, the possibility of documenting a management plan directly in the GP notes aided communication between the specialist and the GP and actually eliminated the administrative effort and associated cost of producing letters.
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References: 1. Tedstone Doherty D, Kartalova-Oâ&#x20AC;&#x2122;Doherty Y, Walsh D. HRB National Psychological Wellbeing and Distress Survey: Baseline Results: Health Research Board; 2007. 2. Copty M, Whitford, L. D. Mental health in general practice : assessment of current state and future needs. Ir J Psych Med 2005; 22(3): 83-86. 3. Craven MA, Bland R. Shared mental health care: a bibliography and overview. Can J Psychiatry 2002;47:iS-viiiS, 1S-103S. 4. Funk Dr Michelle. DGI. Integrating mental health into primary care: a global perspective.: World Health Organization and World Organization of Family Doctors; 2008. 5. Gask L. et al. Evaluating models of working at the interface between mental health services and primary care. British Journal of Psychiatry 1997:6-11. 6. Kierans J, Byrne M. A potential model for primary care mental health services in Ireland. Ir J Psych Med 2010;27:152-6. 7. Wright B. Integrating mental health and primary care services: a challenge for psychiatric training in Ireland. Ir J Psych Med 2007;24:71-4. 8. Bower P, Gilbody S. Managing common mental health disorders in primary care: conceptual models and evidence base. Bmj 2005;330:839-42. 9. Primary Care: A New Direction: Government of Ireland; 2001. 10. A Vision for Change: Report of the Expert Group on Mental Health Policy: Government of Ireland; 2006. 11. Pullen IM, Yellowlees AJ. Scottish psychiatrists in primary health-care settings. A silent majority. Br J Psychiatry 1988;153:663-6. 12. Strathdee G. Psychiatrists in primary care: the general practitioner viewpoint. Fam Pract 1988;5:111-5. 13. Kates N, Craven MA, Crustolo AM, Nikolaou L, Allen C, Farrar S. Sharing care: the psychiatrist in the family physician's office. Can J Psychiatry 1997;42:960-5. 14. Weingarten M, Granek M. Psychiatric liaison with a primary care clinic--14 years' experience. Isr J Psychiatry Relat Sci 1998;35:81-8. 15. J. Kitcheman CEA, A. Pervaiz, I. Kader, D. Mohandas and G. Brookes. Does an encouraging letter encourage attendance at psychiatric out-patient clinics? The Leeds PROMPTS randomized study. Psychological Medicine 2008;38:717-23. 16. Dunne E. The Views of Adult users of the public sector mental health services - Report of a surver for the mental health commission: Mental Health Commission; 2006 2006. 17. Sims H, Sanghara H, Hayes D, et al. Text message reminders of appointments: a pilot intervention at four community mental health clinics in London. Psychiatr Serv 2012;63:161-8.
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CASE REPORT
Steroid-Induced Mania: A Case Report Carol Cassidy, Shobhna Sahay, Fiona McNicholas Ir J Psych Med 2012; 29 (3): 194-195
Abstract
baseline Young Mania Rating Scale (YMRS) score was elevated at 20. Following a rapid and dramatic response, with a reduction in Young Mania Rating Scale to six, four days later his Risperidone was reduced to 0.75mg twice daily and regular dose of Lorazepam discontinued. This led to a return of florid manic symptoms and resulted in his medications progressively being increased to a maximum of 4mg of Risperidone and 4mg total daily dose of Lorazepam. He gradually responded over a period of three weeks and was discharged on Risperidone, 1mg in the morning and 2mg at night, as well as Lorazepam 0.5mg as required. His YMRS at the time of discharge was zero.
Corticosteroids are commonly used in the treatment of a variety of medical conditions in children and adolescents. However, adverse psychiatric side effects can occur which pose challenges in treatment of medical conditions. This case highlights some of these challenges, in particular the treatment of steroid-induced psychiatric complications in Acute Lymphocytic Leukaemia (ALL). It also accentuates the importance of awareness among pediatricians of the potential adverse psychiatric effects when prescribing corticosteroids in this age group. Families need to be advised accordingly to ensure early recognition and treatment.
Following discharge, he received three courses of dexamethasone including one delayed intensification course without any adverse side effects. Doses of Dexamethasone varied, to a maximum of 20mg per day. His psychotropic medications were gradually discontinued commensurate with improving mental state and, despite intermittent exposure to Dexamethasone, he remained well. He continued to attend the Child Psychiatry outpatient department for monitoring of mental state. YMRS score remained at 0 reflecting sustained improvement in psychiatric symptoms. Over his treatment period, his psychotropic medication continued to be gradually reduced commensurate with improving mental state examinations, to 0.25mg Risperidone at night.
Introduction Treatment with corticosteroids has been associated with adverse psychological effects. Whilst most of the reported cases pertain to adults, an increasing literature on child and adolescent onset is emerging. The authors present a case of mania in a 17-year-old Caucasian male and discuss risk factors and treatment.
Case Report Tommy (alias) presented to his GP and subsequently hospital with a six-week history of intermittent fever, motor weakness and fatigue. Following investigations, he was diagnosed with ALL. His chemotherapy treatment regime included oral Dexamethasone, 10mg once daily for 28 days, whereupon his family noticed a gradual change in his behaviour. From a generally quiet and wellmannered young man, Tommy appeared increasingly labile in mood, energetic, over talkative and with reduced need for sleep, ultimately causing his parents to return to hospital.
Discussion Mania is diagnosed following a distinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least one week.1 In addition, three or more of the following symptoms must be present to a significant degree: • inflated self-esteem or grandiosity, • decreased need for sleep, • more talkative than usual or feeling pressure to keep talking, • flight of ideas or subjective experience that thoughts are racing, • distractibility, • increase in goal-directed activity or psychomotor agitation, and/or • excessive involvement in pleasurable activities that have a high potential for painful consequences.
Upon admission, Tommy was pacing the ward and found it very hard to express himself fluently. He believed his mother to be following him around ‘because God was with him’. He believed he had special gifts including extreme intelligence and was destined for a very distinguished future career. He outlined a rigid clinical hierarchy in the hospital whereby only certain doctors could be identified as having clinical expertise to be consulted about his own clinical course. There was no significant personal or family psychiatric history. Complete physical examination, routine blood investigations, ECG and CT scan were unremarkable except Full Blood Count results which were consistent with his diagnosis of ALL.
This case describes the emergence of mania with psychotic symptoms in a 17-year-old with ALL following treatment with Dexamethasone, who was otherwise functioning very well with no known risk factors for mental health illness. Adverse psychiatric effects in adults post steroid treatment range from mild changes in behaviour and mood (28%), to more severe psychotic and manic episodes in five to six percent of cases.2 Less is known about
A diagnosis of steroid-induced mania with psychotic symptoms was made. He was commenced on Risperidone 1mg twice daily and Lorazepam 1mg twice daily and nursed in a quiet room. His
*Carol Cassidy, Consultant Child & Adolescent Psychiatrist, Lucena Clinic, 59 Orwell Rd, Rathgar, Dublin 6. Email: carol.cassidy@sjog.ie *Correspondence
Shobhna Sahay, Psychiatry Registrar, St Ita’s Hospital, Dublin.
Fiona McNicholas, Consultant Child & Adolescent Psychiatrist, Our Lady’s Children’s Hospital, Crumlin & Lucena Clinic, Rathgar, Dublin 6.
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Submitted 25th January 2012 Accepted 30th May 2012
childhood onset, but Stuart and colleagues3 describe a case series of 16 cases with varied psychiatric presentations following inhaled, oral or intravenous steroid preparations. The adverse effects usually occurred within a few days of commencing treatment but less frequently during tapering, or re-exposure.4,5 In Tommyâ&#x20AC;&#x2122;s case, the onset of symptoms occurred within a few weeks of first commencing Dexamethasone.
References: 1. American Psychiatric Association. Diagnostic criteria from DSM-IV-TR. 2000. 2. Lewis DA, Smith RE. Steroid-induced psychiatric syndromes: a report of 14 cases and a review of the literature. J Affect Disord. 1983; 5: 319-332 3. Stuart FA, Segal TY, Keady S. Adverse psychological effects of corticosteroids in children and adolescents. Arch Dis Child. 2005; 90: 500-506 4. Couturier J, Steele M, Hussey L, Pawliuk G. Steroid-induced mania in an adolescent: Risk factors and management. Can J Clin Pharmacol. 2001; 8(2) 109-112 5. Mullen RS, Romans-Clarkson SE. Behavioural sensitisation and steroid-induced psychosis. Br J Psychiatry 1993; 162: 549-51 6. The Boston Collaborative Drug Surveillance Program. Acute adverse reactions to prednisolone in relation to dosage. Clin Pharmacol 1972; 13: 694-8 7. Dawson KL, Carter ER. A steroid-induced acute psychosis in a child with asthma. Pediatric Pulmonology. 1998; 26(5): 362-364 8. French J, Khan A, White H. Steroid induced psychosis in an asthmatic child: Case report & 10 year literature review. Can Child Adolesc Psychiatr Rev. 2003. November 12(4): 117-118 9. Ularntinon S, Tzuang D, Dahl G, Shaw RJ. Concurrent treatment of steroid-related mood and psychotic symptoms with risperidone. Pediatrics. 2010; 125(5): e1241-e1245
Risk factors identified for developing steroid-induced mania include being female, past psychiatric history, family history of bipolar disorder, use of marijuana, the combined use of steroids and clarithromycin, long-term treatment and steroid doses above 40mg/day.6 In this case, no such risk factors were identified. Treatments of psychotic or manic states in children include administering a mood stabiliser (Lithium or Valproate), antipsychotics (Risperidone), and short-term treatment with benzodiazepines for co-occurring agitation and anxiety. Abrupt resolution of psychotic symptoms may follow steroid discontinuation but this may not always be possible.7,8 There is little in the literature to offer guidance regarding the duration of acute treatment or relapses when ongoing steroids are required. Prophylactic use of mood stabilisers in those with multiple risk factors may be warranted. ALL poses a particular risk, given the necessity for continued steroid use, and higher doses. Standard first-line anti-manic medications may be complicated by their own adverse hematological side effects, compromising clinical monitoring of ALL treatment response. Risperidone use in such cases has been supported.9
Conclusion Corticosteroids are frequently used in childhood and paediatricians should be alert to the possibility of steroid-induced behavioural, cognitive and affective changes, even in the absence of known risk factors. The astute observations on the part of Tommyâ&#x20AC;&#x2122;s family led to a speedy presentation and intervention, which may well have limited both the duration and recurrence of manic and psychotic symptoms.
Conflict of interest None.
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Fiction & Physicians Stephen McWilliams The Liffey Press, Dublin, 2012 (233pp). ISBN 978-1-908308-26-9 Ir J Psych Med 2012; 29 (3): 196-197 Stephen McWilliams is a man of many talents: published novelist, essayist and psychiatrist to name but a few. He is the son of the renowned and greatly missed Brendan McWilliams, who for many years contributed the erudite and vastly entertaining Weather Eye articles to the Irish Times. Fiction & Physicians brings together and expands upon occasional and varied pieces that Stephen McWilliams has been contributing for many years to medical and other publications. McWilliams says that one of his aims in writing this book was to give readers the experience of discovering surprising details about authors and their characters' relationship to the medical profession and, in this, he amply succeeds.
Kraeplin was a published poet. W.H. Auden’s poem about Sigmund Freud offers McWilliams an opportunity to write about the father of psychoanalysis whom, McWilliams laments, did not write poetry. Next, the author gives us some interesting details of Oliver St John Gogarty’s life as a doctor rather than dwelling on his better-known life as a socialite and writer. In the poetry of William Carlos Williams, McWilliams sees the “keen eye of the physician”. Penultimately, A.J. Cronin’s novel, The Citadel - in which he excoriates his profession for their “useless guinea-chasing treatments”, causes McWilliams to reflect on medical ethics in the 21st Century. The 20th Century wraps up with a piece on the life and work of doctor and popular novelist, Michael Crichton.
Although the title suggests that the book will deal only with novels and stories, its scope is much greater than this, with poetry, drama, novels, short stories, memoirs and case histories all included. The book is divided into two parts - the first concerns doctors who were also writers, while the second focuses on doctors and medicine in the writings of non-doctors. The first chapter is an overview of the many doctors and students of medicine who were also writers of note. McWilliams asks if there is anything special about the medical profession that sets its writers apart from authors who are soldiers, nurses, social workers or teachers. McWilliams suggests that although doctors may have big egos and crave fame, their predilection for writing - as opposed to making music or appearing on television - belies a tendency towards soul searching and teaching. Doctors tend to have dramatic human experiences and McWilliams suggests that writing may be a means of dealing with suffering. The public is also eager for the gory details of medical experience. McWilliams also suggests that doctors are good at time management, have great stamina, thick skins and tend to be observant, all of which contribute to their success as writers.
Some of the 21st Century writers discussed will not be known to readers and I am certainly looking forward to some new reading. Medical thriller writers including Paul Carson, Tess Gerritsen, Michael Palmer and Robin Cook are given a section. Doctor and author of The Kite Runner, Khaled Hosseini, features and Ethan Canin’s work is discussed at some length. Various other physician writers are mentioned including two young Irish writers, Juliet Bressan and Seamus Sweeney. In the second half of the book, McWilliams concentrates on doctors as characters in fictional writing. He starts with those works in which incompetence or greed of doctors is satirically or comically portrayed. There is a lengthy and interesting piece on Laurence Sterne’s hilarious Tristam Shandy. In Gustave Flaubert’s Madame Bovary, McWilliams chooses to focus on Charles Bovary and his medical exploits. McWilliams reveals that Victor Frankenstein was not a medical doctor as many mistakenly think, in his treatment of Mary Shelly’s enduring classic. Robert Louis Stevenson’s, Dr Jekyll and Mr. Hyde and Bram Stoker's, Dracula, are also insightfully discussed in a section on Gothic literature.
McWilliams divides his chapters into chapters on pre-19th, 19th, 20th and 21st Century doctor/writers. He briefly touches on Rabelais, who was writing in the mid-16th Century, before giving a detailed account of Nostradamus’s infamous and ambiguous divinations. The book then skips ahead to the 18th Century, where we are scolded for forgetting Oliver Goldsmith’s classic work, The Vicar of Wakefield. Tobias Smollett is another, rather overlooked, writer to whose novels McWilliams devotes some time. Also included is an entertaining discussion on Arthur Conan Doyle's life and detective writings, as well as mention of an eclectic gathering of 19th Century doctor/writers. It was news to me that Charles Darwin had flirted briefly with medicine before going on to greater things; his life and writings are discussed at some length. I was similarly ignorant of the fact that John Keats had trained as a surgeon.
The doctor as hero (or anti-hero) is the subject of another chapter. The successful neurosurgeon, Henry Perowne, whose calm is interrupted by a villain with Huntington’s disease in Ian McEwan’s, Saturday, offers McWilliams the opportunity to discuss the condition in some detail. Other subjects include the romantic idealist, Dr Yuri Zhivago in Boris Pasternak’s Dr Zhivago; the heroic narrator, Dr Bernard Rieux in Albert Camus’ existential classic The Plague; and the self-pitying, self-serving but ultimately heroically redeemed Doc Daneeka in Joseph Heller’s, Catch-22. Infectious diseases and their treatment have been central to many literary classics. In a chapter on the subject, McWilliams discusses portrayals of smallpox in literature and other media, together with the life of Edward Jenner who first developed a vaccine to prevent this dreadful, now thankfully eradicated, disease. Syphilis and its many famous literary sufferers is an endlessly fascinating subject. Love in the Time of Cholera by Gabriel Garcia Marquez; Thomas Mann’s, Death in Venice; and William Somerset Maugham’s, The Painted Veil, offer a chance to discuss cholera. Maugham’s The
The chapter on the 20th Century surprisingly starts off with R.D. Laing, whose poetry McWilliams has an unusually high opinion of, praising his “unique skill in describing complex human dynamics using very simple language”. It was also news to me that Emil
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Rebiere and Thomas Midwinter in Sebastian Faulks’ Human Traces and Hannibal Lecter in Thomas Harris' novels. This is a well-produced book that will be greatly enjoyed by anybody with an interest in medicine and literature. Well written, with a light-hearted tone it is replete with interesting observations and insights. It is not overly-scholarly and any technical terms are explained very clearly for the lay reader. There is also a very useful glossary and index. One can always quibble with some of the choices for inclusion or omission but McWilliams wasn’t intending to produce an exhaustive and authoritative work on his subject. This is a book by a doctor about some of the books that have inspired him to write and to keep reading; his enduring enthusiasm is evident throughout. I certainly look forward after reading this book to rereading some old classics and to some of the new titles that McWilliams has introduced me to. Larkin Feeney Consultant in Adult Psychiatry and Senior Lecturer in Psychiatry Cluain Mhuire Community Mental Health Services And Royal College of Surgeons Ireland Newtownpark Avenue, Blackrock, Co. Dublin. E-mail: larkin.feeney@sjog.ie
Moon And Sixpence, leads to an account of leprosy and Louis de Bernieres’ Captain Corelli’s Mandolin, to the discovery of penicillin. It was curious that McWilliams did not include tuberculosis which features so dramatically in many great novels and other literary works such as Thomas Mann’s The Magic Mountain. There is much in this book that will be of particular interest to psychiatrists and other mental health professionals. Few will have been familiar before with the poetry of R.D. Laing and Emil Kraeplin or the children’s books of Silas Weir Mitchell. A piece on Arthur Conan Doyle includes an interesting debate as to whether or not George Edalaji (from Julian Barnes’ novel, Arthur & George) could have been diagnosed with Asperger’s syndrome. A chapter on fiction and paranoia includes a detailed piece on de Clerambault’s Syndrome in Ian McEwan’s novel Enduring Love. George Orwell’s Nineteen Eighty-Four, Aldous Huxley’s Brave New World, Alan Bennett’s play The Madness of George III and Patricia Highsmith’s The Talented Mr Ripley also feature. A chapter on fictive psychiatrists includes Dick Diver in F. Scott Fitzgerald’s Tender is the Night, Dr Grene in Sebastian Barry’s The Secret Scripture, Martin Sturrock in Alastair Campbell’s All In The Mind, Jacques
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Struck by Living: From Depression to Hope Julie K. Hersh Brown Books Publishing Group, 2010. 1934812633, 9781934812631 Ir J Psych Med 2012; 29 (3): 198 Walk into most bookshops these days and the section for health related memoirs is likely to have increased in size since the last time you were there. A highly unsystematic search of one online book retailer in April 2012 returned 803 results for ‘patient memoirs’. In a review article in the New York Times, Dr. Abigail Zuger classified health-related memoirs generally as “compelling stories, if not literature”.1
attempting to recover from depression. This, however, is a minor point. All in all, her account is easy to read and of sufficient detail to give a complete picture without being onerous. The author remains an active mental health advocate and has appeared on various TV shows as well as writing a blog on the Psychology Today website. Topics on her blog include reducing the stigma of mental illness and promoting awareness of depression and suicide. Her willingness to share the experience of her ECT treatment gives her a rare position within the advocacy field.
These books in general are not aiming to be classic literary tomes, but to share a lived experience and perhaps offer a message, be it of hope, caution or outrage. The growth of this area is reflected in the creation of Narrative Medicine graduate study programmes at some universities. Patient memoirs can certainly be a source of information and inspiration for others going through a similar experience, as well their families and friends. For health professionals these books can be a source of insight both into how illness can affect a person but also a reflection on how we are perceived. Conversely, there are many ‘survivor’ stories that paint the profession in a rather grim light, and although they may reflect individual experiences, they do not correspond to most clinicians’ experience.
I would happily recommend this book to those looking for a non-medical account of living with depression. It might be particularly helpful for people considering ECT and their families. For professionals, this book acts as a reminder of what living with depression can be like. It reflects how we as doctors may often play only a small, albeit important, part in the journey to recovery. 1. Zuger, Abigail. Compelling Stories, if Not Literature. The New York Times. 29/06/2010.
Erik Kolshus Research Registrar St. Patrick’s University Hospital / Trinity College Dublin Steeven’s Lane Dublin 8 E-mail: kolshue@tcd.ie
I therefore approached this book with some trepidation, but was pleased to find it balanced, honest and well-written. It is an autobiographical book, chronicling an American woman’s struggle with depression. She eschews a traditional timeline, instead telling her story through a combination of her life history and contemporary setting. The author is refreshingly direct and self-critical throughout, and does not gloss over her experiences, nor does she sugarcoat her description of her recovery, which includes a relapse. It is written for a general audience but psychiatrists or other health professionals may be particularly interested in aspects of diagnosis, treatments and risk factors whilst reading. These are well described, thanks to the author’s maintenance of a journal from early on in life. The book also describes the experience of receiving ECT realistically, including the side-effects on her memory. One jarring note is the author’s description of being strapped down for the ECT “in case the muscle relaxant failed to stop the spasms”. This may be the practice in some centres in the USA, but I am not aware of it being used in Ireland or the UK. Despite her education, affluence and excellent support network, Ms Hersh’s story reinforces the fact that many episodes of depression can come out of the blue, or in her words, “mental illness is an equal opportunity disease”. Some of her coping strategies, such as hiring a personal shopper to help her prepare for charity events, may not be options for the average person
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Depression in Neurologic Disorders: Diagnosis and Management Edited by Andres M. Kanner Wiley-Blackwell 2012. ISBN: 9781444330588 Ir J Psych Med 2012; 29 (3): 199 Psychiatry and neurology have a shared, tumultuous past. After a harmonious marriage of minds until the early part of the twentieth century, irreconcilable differences ultimately resulted in mutually painful divorce. Neurology laid claim to those disorders of the central nervous system with demonstrable anatomical pathology, while psychiatry pursued diseases of the mind with its more abstract psychopathology. The emergence of Freudian analysis and insight-orientated psychotherapy, particularly in the United States, gave rise to the dichotomies of ‘brain versus mind’ and ‘organic versus functional’, serving to further alienate psychiatry from neurology and, indeed, mainstream medicine.
scenario and, where evidence is lacking, recommendations are made based on pharmacodynamic principles. Each chapter ends with a case study illustrating the ambiguity of symptoms at the interface of psychiatry and neurology as well the complexity of management in this setting. The chapters focusing on depressive disorders in epilepsy, movement disorders and traumatic brain injury are particularly compelling. The book is a collaborative work of psychiatrists, neurologists and neuropsychiatrists. Herein lies both a strength and a weakness of the guide. While each of the authors offers fresh insight, the component chapters lack cohesion and the message is often repetitive. The text is dense and a more generous use of illustrations, figures and tables would have been often welcome. Reference is emphasised at the expense of readability.
Thankfully, times have changed and unprecedented developments in the last four decades have redefined many major psychiatric illnesses as biologically based diseases. Novel neuroimaging techniques and insights into neuroplasticity have shed light on intricacies of brain structure and function. However, despite these developments, and despite the expansion of liaison psychiatry and the development of disciplines such as neuropsychiatry, the specialties continue to lead separate lives. This is reflected in the absence of overlap of the disciplines in their respective training programs.
The anxious, depressed, and worried are the stock in trade of neurological practice. The editor, Andres M. Kanner, argues nonetheless that depression remains largely unrecognized and untreated in this setting, with neurologists primarily focusing on objective signs of ‘organic’ disease. The evidence presented here is impossible to dispute and Kanner and his collaborators have provided an eminently practical guide for neurologists.
Depression in Neurologic Disorders: Diagnosis and Management is a comprehensive overview of the biological basis of depression, its complex yet close relationship to neurological disorders, and offers a practical approach to diagnosis and management. The text, intended for neurologists, attempts to highlight a large and striking blindspot for comorbid depression in neurological evaluation. The opening chapter, provocatively entitled ‘Why Should Neurologists Care?’, reviews the impact of depression on the course and prognosis of neurological disorders. The evidence from an exhaustive literature search is presented in a concise, logical manner and is commendably devoid of opinion or conjecture. The remainder of Part One of the book explores the neurobiological and neuropsychological aspects of depression, as well as the general approach to diagnosis and management.
D. Curtin and K. O’Rourke Dublin Neurological Institute at the Mater Misericordiae University Hospital, Eccles Street. Dublin 7 Email: killian.orourke@gmail.com
Part Two focuses on the specific aspects of depression in major neurological disorders, including migraine, stroke, epilepsy, movement disorders and multiple sclerosis. The well-organised text includes sections on epidemiology, pathogenic mechanisms, clinical manifestations and management. The chapters are orientated towards clinical practice and the neurologist is encouraged to use specific, tailored screening instruments which assist in identifying depression associated with particular neurological disorders. Guidance is offered in relation to the relative merits of one antidepressant versus another in a given
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BOOK REVIEW
Schizophrenia (3rd Edition) Daniel R. Weinberger (Editor), Paul Harrison (Editor) Chichester: Wiley-Blackwell, 2011. ISBN: 978-1-4051-7697-2 Ir J Psych Med 2012; 29 (3): 200 around the world to cover the multitudinous facts of this disorder. There are four sections: descriptive aspects, biological aspects, physical treatments and psychological and social aspects. Topics addressed in the 33 chapters include childhood schizophrenia, prodrome, secondary schizophrenia, electrophysiology, animal models, treatment resistance, psychotherapy and economics.
This edition of Schizophrenia is very different to its predecessors. As science invades psychiatry the language seems to change with it, and one cannot but notice a perceptible distancing between academic and clinical coverage. In the period between editions there has been an avalanche of information, with a bewildering flood of reports concerning genes of ‘small effect’ and an ‘epidemic’ of epidemiological ‘risk factors’, not to be confused with causes. Novel pharmaceuticals have arrived in the meantime, together with heated debate about how different they might be from earlier drugs in relation to cost, pharmacodynamics, efficacy, effectiveness and side-effect profile.
Of particular Irish interest is the chapter on pharmacology and neuroscience of antipsychotic drugs by John Waddington, Colm O’Tuathaigh (both from the Royal College of Surgeons in Ireland) and Gary Remington (Toronto). The reader is oriented to change by an excellent historical overview from Nancy Andreasen (Iowa) in Chapter One. Schizophrenia is essential reading for psychiatrists and trainees, as well as for researchers in sciences ‘basic’ to psychiatry.
Schizophrenia is the definitive, modern reference text dealing with what may arguably be the worst affliction of the human mind. I hesitate to say disease since modern spectrum approaches sometimes view schizophrenia as co-extensive with health or as a side-effect of having a mind at all! The book digests and renders comprehensible complex changes in the information available (usually outdated by the time a book reaches the shelves).
Brian O’Shea Editor, Psychiatry Professional Editor, A Textbook of Psychological Medicine, Tribunal Consultant Psychiatrist with the Mental Health Commission. E-mail: drbosheas@eircom.net
Editors Daniel Weinberger from NIH, Bethesda, US and Paul Harrison from Oxford, UK (the original duo were Steven Hirsch and Daniel Weinberger) have gathered expert contributors from
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Thomas Stephen Szasz (1920-2012)
Ir J Psych Med 2012; 29 (3): 201 Did Szasz do any good? There is much historical truth in the perception of American (and other) asylums as being overcrowded, poorly maintained, and open to abuses. If he had a unique role in changing this disgraceful situation he could be proud. He was, however, only one of many voices involved in this campaign.
Thomas Szasz was born in Budapest and immigrated to the USA with his Jewish parents in 1938. After completing a degree in physics and graduating in medicine in Cincinnati, he moved to Chicago in 1944 where he trained in psychiatry and psychoanalysis. Following a period with the US Navy he went to the State University of New York (SUNY), eventually receiving the chair of psychiatry at SUNY Health Science Center, Syracuse.
Did he do harm? It is difficult to single out one person for denunciation, but Szasz was very influential. While he seems to have genuinely believed in the autonomy of patients, the reality is that he offered no viable alternatives to involuntary treatment.
Szasz viewed mental health problems as problems in living rather than disorders since there was no consistent pathology as is found with neurological disease. His books (especially The Myth of Mental Illness, published in 1961) presented the view that psychiatrists pathologise patients so that they can be incarcerated. He argued that their behaviour is thereby ‘managed’ for the sake of social order. Szasz was a hugely influential figure to the liberal wing of the American legal profession. He was quoted widely in the successful campaign to reduce the avenues open to psychiatrists who believe a patient requires involuntary admission to hospital. Szasz did not want to see patients unless they wanted to see him.
The current high levels of untreated mental illness, homelessness, the exploding prison population, and the emphasis on rights rather than treatment needs can be traced in large measure to Szasz and his acolytes. Today, following a US Supreme Court decision (O’Connor v. Donaldson, 1975), one has to be an immediate threat in order to be detained as an involuntary patient. Take a walk down Mission Street in San Francisco for a real life illustration of the abandonment of people with mental illness, what Appelbaum and Gutheil1 referred to as “rotting with their rights on”.
A skilled writer, Szasz would pair an obviously odious historical event with involuntary admission of patients so that the latter became tarnished by association (e.g. The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement, published in 1970). He could also be amusing, as when he accepted a request by the undersigned to write an article on masturbatory insanity for the then Irish Journal of Psychotherapy (now the Irish Journal of Psychological Medicine).
Brian O’Shea FRCPsych Newcastle Hospital, Greystones, Co. Wicklow Email: drbosheas@eircom.net
Erratum: Child and adolescent mental health services in Laois/Offaly: A one year perspective of services (July 1, 2008 to June 30, 2009)
and Adolescent Mental Health Services- corresponding author Email: heatherchurch1@gmail.com
1. Appelbaum PS, Gutheil TG. “Rotting with their rights on”: constitutional theory and clinical reality in drug refusal by psychiatric patients. Bull Am Acad Psychiatry Law 1979; 7: 306-315.
Akinyele A Iyiola, Psychiatry Registrar, The Laois/Offaly Mental Health Services Rotational Scheme, Ireland.
In the September issue of the Journal (Ir J Psych Med 2012; 29 (2): 107-112) the authorship for the paper titled “Child and adolescent mental health services in Laois/Offaly: A one year perspective of services (July 1, 2008 to June 30, 2009)” was incorrect.
Elena Kostromitina, Psychiatry Registrar, The Laois/Offaly Mental Health Services Rotational Scheme, Ireland. Colette Halpin, Consultant Child & Adolescent Psychiatrist, Midland Regional Hospital, Portlaoise, Ireland.
The correct author list is as follows: Heather Church, Senior Registrar in Child and Adolescent Psychiatry, Lucena Clinic Child 201
Irish Journal of Psychological Medicine Guidelines for Authors Aim and Scope of the Journal The aim of the Irish Journal of Psychological Medicine is to publish original scientific contributions in psychiatry, psychological medicine (including surgery and obstetrics), and related basic sciences (neurosciences, biological, psychological, and social sciences). The scope of the Journal includes any subspecialties of the above, including, but not limited to, behavioural pharmacology, biological psychiatry, child and adolescent psychiatry, intellectual disability, forensic psychiatry, psychotherapies, psychiatry of old age, epidemiology, rehabilitation, psychometrics, substance misuse, sexual studies, linguistics, and the history, philosophy and economics of psychiatry. The Journal is dedicated to providing reliable, valid clinical and scientific information to inform mental health care decisions and improve the quality of mental health care.
Editorial Standards The Irish Journal of Psychological Medicine complies with the “Code of Conduct and Best Practice Guidelines for Journal Editors” of the Committee on Publication Ethics (2011) and the “Editorial Policy Statements” of the Council of Science Editors (2009). • http://publicationethics.org/files/Code_of_conduct_for_journal_editors_Mar11.pdf • http://www.councilscienceeditors.org/i4a/pages/index.cfm?pageid=3286
Submission Guidelines
• • • • •
The Journal will accept for consideration original papers, brief research reports, audits, clinical case reports, review articles, historical papers, perspective articles, editorials, letters to the editor and book reviews. Original data papers receive top priority for speedy publication.
Means should be accompanied by standard deviations. Exact p values should be provided, unless p<0.0001. Recommended non-proprietary drug names should be used. Writing should be clear, simple and direct. Short sentences are preferred.
Abstract and Key Words The page following the title page should carry an abstract followed by a list of three to ten key words drawn, if possible, from the medical subject headings (MeSH) list of the United States National Library of Medicine and National Institutes of Health (www.ncbi.nlm.nih.gov/mesh). The title and key-words should be chosen to help future literature searchers.
Manuscripts should be prepared in accordance with the “Uniform Requirements for Manuscripts (URM) Submitted to Biomedical Journals” of the International Committee of Medical Journal Editors (2010). www.icmje.org
Title Page
The abstract, up to 150 words for an unstructured or 250 words for a structured abstract (Haynes et al, 1991), should state specifically the main purposes, procedures, findings and conclusions of the study, emphasising what is new or important. For original papers, brief research reports, audits and review articles, a structured abstract is required, using the headings: Objectives, Methods, Results and Conclusions.
The title page should include the paper title, author name(s), author qualifications, author job title(s), author affiliation(s) and full address (es). The name, address, email address and telephone number of the corresponding author should be clearly and separately indicated.
Text
Under the Abstract heading of Method, include, wherever applicable the study design, setting, patients/participants (selection criteria, description), interventions, observational and analytical methods and main outcome measures. (For review articles specify the methods of literature search and selection). Under the Abstract heading of Results, give the most important specific data together with their statistical significance.
• The manuscript should be typed, double-spaced, in 12-point Times New Roman font. • Pages should be numbered but do not use any other automated features (such as endnotes, headers or footers), any form of automated referencing software, or any mechanism to track changes to various drafts of a manuscript. • Numbers one to ten should be written as words in the text, unless used as a unit of measurement; all numbers should be written in digits in tables and figures. • All numbers which start sentences should be written in words, not digits. • Bold type-face should be used for headings of sections and subsections within the paper. • Do not use tabs or indents within the text of the paper. • SI units are required for all measurements.
Original Papers Original papers should be divided into sections as follows: Introduction, Methods, Results and Discussion. A Conclusions section is not mandatory but may be included in the original submission if the author wishes, or may be requested at a later stage by peer-reviewers or editors. The Results section should
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Conflict of Interest
present a summary of main results and should not simply refer to tables. Reports of randomised trials must conform to CONSORT 2010 guidelines. http://www.consort-statement.org/consort-statement/overview0/
In the interest of accountability all financial and material support for the research and the work should be clearly stated (DeAngelis et al, 2001). Authors of original data must take responsibility for the integrity of the data and accuracy of the data analysis. All authors must have full access to all the data in the study (Davidoff et al, 1986). Authors must declare any conflict of interest clearly, in accordance with the guidance of the International Committee of Medical Journal Editors (2006):
Audit Papers It is preferable that audit papers present the full cycle of clinical audit, including audit, intervention and re-audit. In exceptional circumstances, papers presenting one element of the audit cycle may be published, but priority will be given to papers presenting full audit cycles. The format for audit papers may differ from that outlined for original papers, and may include, for example, Introduction, Audit, Intervention, Re-Audit, Discussion and Conclusions.
“Public trust in the peer review process and the credibility of published articles depend in part on how well conflict of interest is handled during writing, peer review, and editorial decision making. Conflict of interest exists when an author (or the author's institution), reviewer, or editor has financial or personal relationships that inappropriately influence (bias) his or her actions (such relationships are also known as dual commitments, competing interests, or competing loyalties). These relationships vary from those with negligible potential to those with great potential to influence judgment, and not all relationships represent true conflict of interest. The potential for conflict of interest can exist whether or not an individual believes that the relationship affects his or her scientific judgment. Financial relationships (such as employment, consultancies, stock ownership, honoraria, paid expert testimony) are the most easily identifiable conflicts of interest and the most likely to undermine the credibility of the journal, the authors, and of science itself. However, conflicts can occur for other reasons, such as personal relationships, academic competition, and intellectual passion.”
Clinical Case Reports All clinical case reports must have the patient’s written, informed consent before the paper is submitted.
References Timely references should highlight the paper’s relevance to current research or clinical practice. For references to journal articles (International Committee of Medical Journal Editors, 2006; 2010; Haynes et al, 1991; Bailar & Mosteller, 1998) and to books (Daly et al, 1991; Gardner & Altman, 1989; American Psychiatric Association, 1987) use the ‘Vancouver’ style, i.e. number references in the order they appear in the text, do not alphabetise. Journal titles should be abbreviated as outlined on PubMed by the United States National Library of Medicine and National Institutes of Health (www.ncbi.nlm.nih.gov/nlmcatalog/journals). Please see the sample paper on the website of the College of Psychiatry of Ireland for further details : http://www.irishpsychiatry.ie/Members/MembersInformationTools/i rishjournalofpsychologicalmedicine.aspx
Statement of Informed Consent Where relevant, papers must include a statement regarding informed consent, in accordance with the guidance of the International Committee of Medical Journal Editors (2006): “Patients have a right to privacy that should not be infringed without informed consent. Identifying information, including patients' names, initials, or hospital numbers, should not be published in written descriptions, photographs, and pedigrees unless the information is essential for scientific purposes and the patient (or parent or guardian) gives written informed consent for publication. Informed consent for this purpose requires that a patient who is identifiable be shown the manuscript to be published. Authors should identify Individuals who provide writing assistance and disclose the funding source for this assistance. Identifying details should be omitted if they are not essential. Complete anonymity is difficult to achieve, however, and informed consent should be obtained if there is any doubt. For example, masking the eye region in photographs of patients is inadequate protection of anonymity. If identifying characteristics are altered to protect anonymity, such as in genetic pedigrees, authors should provide assurance that alterations do not distort scientific meaning and editors should so note. The requirement for informed consent should be included in the journal's instructions for authors. When informed consent has been obtained it should be indicated in the published article.”
Tables and Figures Figures and graphs should be clear and of good quality, and should be accompanied by relevant data to facilitate redrawing where necessary. Clear and informative headings and captions should be provided.
Submission Process Manuscripts may be submitted electronically via email to journal@irishpsychiatry.ie or sfarrell@irishpsychiatry.ie Full postal address, telephone and fax numbers should be included. Where possible, tables, figures and text should be included in the same document. There is no need to also submit by post or fax. All submitted material will become the property of the Journal until, and if, publication is refused. Material so referred should not be sent elsewhere for publication.
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Statement of Human and Animal Rights
Other Modes of Review
Where relevant, papers must include a statement regarding human and animal rights, in accordance with the guidance of the International Committee of Medical Journal Editors (2006):
Some guidance on statistical matters for authors is provided by International Committee of Medical Journal Editors (2006; 2010) and Bailar & Mosteller (1998). Notwithstanding this guidance, statistical review may be required for certain papers, and this will be arranged by the Journal editors where indicated. Other, more specialist forms of peer-review may also be required on occasion, and these, too, will be arranged by the Journal editors where indicated.
“When reporting experiments on human subjects, authors should indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). If doubt exists whether the research was conducted in accordance with the Helsinki Declaration, the authors must explain the rationale for their approach, and demonstrate that the institutional review body explicitly approved the doubtful aspects of the study. When reporting experiments on animals, authors should be asked to indicate whether the institutional and national guide for the care and use of laboratory animals was followed.”
Fast-Track Publication Papers which the editors feel warrant fast-track publication will be expedited through the publication process. The decision to ‘fasttrack’ papers lies with the editors.
Plagiarism and Duplicate Publication
Acknowledgements Authors should obtain permission to acknowledge individuals named in any Acknowledgments section, since readers may infer endorsement.
Manuscripts are considered with the understanding that they have not been published previously, either in print or electronic format. In the event that plagiarism or duplicate publication is suspected, the author will be invited to comment on the matter and a decision will be taken by the editors.
Suggested Peer-Reviewers
Appeals
Each submission must be accompanied by the names, professional titles, professional addresses and email addresses of three suggested peer-reviewers. Authors should select these suggested peer-reviewers to include individuals, in any part of the world, who are recognised experts in the area to which the submission refers, and whom the authors believe would provide useful, objective peer-reviews of the manuscript. The editors will give consideration to sending the manuscript to some or all of these peer-reviewers, but are not under any obligation to do so.
In the event that an author wishes to appeal an editorial decision, the author can send a letter of appeal to the Editor-In-Chief. The Editor-In-Chief will pass the relevant materials to the Consulting Editor who may seek external opinion. The Consulting Editor will advise the Editor-In-Chief in relation to the appeal but the final decision on the matter rests with the Editor-In-Chief.
References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington DC: American Psychiatric Association, 1987. Bailar JC, Mosteller F. Guidelines for statistical reporting in articles for medical journals. Ann Intern Med 1988; 108: 266-273. Committee on Publication Ethics. Code of Conduct and Best Practice Guidelines for Journal Editors. London: Committee on Publication Ethics, 2011. http://publicationethics.org/files/Code_of_conduct_for_journal_editors_Mar11.pdf Council of Science Editors. Promoting Integrity in Scientific Journal Publications. Wheat Ridge, CO: Council of Science Editors, 2009. http://www.councilscienceeditors.org/i4a/pages/index.cfm?pageid=3286. Daly LE, Bourke GJ, McGilvray J. Interpretation and Uses of Medical Statistics (4th Edition). Oxford: Blackwell Scientific Publications, 1991. DeAngelis CD, Fontanarosa PB, Flanagin A. Reporting financial conflicts of interest and relationships between investigators and research sponsors. JAMA 2001; 286: 89-91. Davidoff F, DeAngelis CD, Drazen JM, Hoey J, Højgaard L, Horton R, Kotzin S, Nicholls MG, Nylenna M, Overbeke AJ, Sox HC, Van Der Weyden MB, Wilkes MS. Sponsorship, authorship, and accountability. JAMA 2001; 286: 1232-1234. Gardner MJ, Altman DG (editors). Statistics with Confidence: Confidence Intervals and Statistical Guidelines. London: British Medical Journal, 1989. Haynes RB, Mulrow CD, Huth EJ, Altman DG, Gardner MJ. More information abstracts revisited. Ann Intern Med 1990; 113: 69-76. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. Vancouver: International Committee of Medical Journal Editors, 2006. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. Vancouver: International Committee of Medical Journal Editors, 2010. www.icmje.org
Description of the Peer-Review Process All submissions are acknowledged by email. Submissions are initially considered by the Editor-In-Chief or Deputy Editor for suitability for peer-review. Submissions selected for peer-review are sent to three anonymous outside peer-reviewers. Where one or more peer-reviewers recommend acceptance or acceptance after revision, all peer-reviews are sent to the corresponding author, with an invitation to revise the paper. If the author chooses to revise the paper, the revised paper should be accompanied by a detailed cover letter responding to each comment made by each peer-reviewer, indicating precisely how the revision deals with each comment, or why the author disagrees with or cannot incorporate specific comments. Each peer-reviewer will then receive the revised paper, cover letter and comments of the other peer-reviewers. After the peerreviewers’ further comments have been received, a final decision about publication will be made. The editorial process may vary from the above under certain circumstances, at the discretion of the Editor-In-Chief or Deputy Editor.
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