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The Effectiveness of Alcohol Screening and Brief Intervention in Emergency Departments: A Multicentre Pragmatic Cluster Randomized Controlled Trial

The Effectiveness of Alcohol Screening and Brief Intervention in Emergency Departments: A Multicentre Pragmatic Cluster Randomized Controlled Trial | Liaison Psychiatry | Scoop.it
Abstract
Background

Alcohol misuse is common in people attending emergency departments (EDs) and there is some evidence of efficacy of alcohol screening and brief interventions (SBI). This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in England: the SIPS ED trial.

Methods and Findings

Pragmatic multicentre cluster randomized controlled trial of SBI for hazardous and harmful drinkers presenting to ED. Nine EDs were randomized to three conditions: a patient information leaflet (PIL), 5 minutes of brief advice (BA), and referral to an alcohol health worker who provided 20 minutes of brief lifestyle counseling (BLC). The primary outcome measure was the Alcohol Use Disorders Identification Test (AUDIT) status at 6 months. Of 5899 patients aged 18 or more presenting to EDs, 3737 (63·3%) were eligible to participate and 1497 (40·1%) screened positive for hazardous or harmful drinking, of whom 1204 (80·4%) gave consent to participate in the trial. Follow up rates were 72% (n = 863) at six, and 67% (n = 810) at 12 months. There was no evidence of any differences between intervention conditions for AUDIT status or any other outcome measures at months 6 or 12 in an intention to treat analysis. At month 6, compared to the PIL group, the odds ratio of being AUDIT negative for brief advice was 1·103 (95% CI 0·328 to 3·715). The odds ratio comparing BLC to PIL was 1·247 (95% CI 0·315 to 4·939). A per protocol analysis confirmed these findings.

Conclusions

SBI is difficult to implement in typical EDs. The results do not support widespread implementation of alcohol SBI in ED beyond screening followed by simple clinical feedback and alcohol information, which is likely to be easier and less expensive to implement than more complex interventions.

Alex Thomson's insight:

What to make of this? A large, pragmatic multicentre RCT which found that not only was there little benefit from brief interventions for harmful alcohol use, but also that it was so difficult to persuade some of the depts to participate that the research team had to parachute in staff to recruit and deliver the intervention!! The previous RCTs demonstrating a positive effect have been based in emergency depts with a clear leader championing the need for effective alcohol care. Perhaps this is the active ingredient and interventions should focus on changing the working culture rather than delivering interventions to patients in the first instance.

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Immunopsychiatry symposium - Monday, 2 November 2015

Immunopsychiatry symposium - Monday, 2 November 2015 | Liaison Psychiatry | Scoop.it
The Fellowship of Postgraduate Medicine is running a one day Immunopsychiatry Symposium at the Medical Society of London. This unique teaching day aims to introduce attendees to some of the most exciting research taking place at the intersection of psychiatry, neurology and immunology as well as covering the clinical implications which are already impacting on general psychiatric practice.
The last few years have seen a rapid increase in the understanding of the role of immune dysfunction in CN
Alex Thomson's insight:

An interesting programme on an increasingly important area of psychiatry with receives little attention in clinical practice. And a bargain price of £43.05. I've booked already.

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Frontiers | Fifty psychological and psychiatric terms to avoid: a list of inaccurate, misleading, misused, ambiguous, and logically confused words and phrases | Educational Psychology

The goal of this article is to promote clear thinking and clear writing among students and teachers of psychological science by curbing terminological misinformation and confusion. To this end, we present a provisional list of 50 commonly used terms in psychology, psychiatry, and allied fields that should be avoided, or at most used sparingly and with explicit caveats. We provide corrective information for students, instructors, and researchers regarding these terms, which we organize for expository purposes into five categories: inaccurate or misleading terms, frequently misused terms, ambiguous terms, oxymorons, and pleonasms. For each term, we (a) explain why it is problematic, (b) delineate one or more examples of its misuse, and (c) when pertinent, offer recommendations for preferable terms. By being more judicious in their use of terminology, psychologists and psychiatrists can foster clearer thinking in their students and the field at large regarding mental phenomena.
Alex Thomson's insight:

Whoever knew there were so many? And surprisingly, although I agree with most, there is little overlap with my personal "banned words" list which includes:

'Inappropriate'

'Poor historian'

'Medically cleared'

'Acopia' / 'Social admission'

'Chaotic' / 'Bizarre behaviour' (without description)

etc. etc.

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Psychological support needed across cancer pathway

Psychological support needed across cancer pathway | Liaison Psychiatry | Scoop.it
This guidance sets out recommendations for commissioners and providers to improve care and outcomes for people with cancer.
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Good executive summary of the recent report on mental health support in cancer services by the London Strategic Clinical Network, by Alison Turner. Link to full pdf at the bottom.

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Detection of delirium in the acute hospital

Detection of delirium in the acute hospital | Liaison Psychiatry | Scoop.it

Delirium remains a common, serious and under-recognised problem affecting older hospitalised patients. Despite being associated with poor longer-term outcomes, including death and institutionalisation, delirium remains disproportionately ignored relative to impact, and poor recognition remains the greatest obstacle to improved care and research. It is ‘missed’ in up to two-thirds of cases

Alex Thomson's insight:

We know delirium is common in hospital inpatients, and we know that it's often missed. This is the latest UK study to try and quantify the issue. 710 patients were examined for delirium, 110 people had a diagnosis of delirium, but only 31 cases were detected by the treating clinical team (28%). That means a whopping 72% of delirium diagnoses were missed!

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Eeny meeny miny mo , where in this postcode lottery shall I go ? Sprig of lavender anyone ?

Eeny meeny miny mo , where in this postcode lottery shall I go ? Sprig of lavender anyone ? | Liaison Psychiatry | Scoop.it
Around one in four people in the uk will experience a mental health illness each year. Whether mild or severe ,short or long term, these can be scary, upsetting and soul destroying . Especially if ...
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Speaks for itself. An account of the shocking underprovision of mental health services in the UK.

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Mental health breakthrough: Round-the-clock care at A&E in five years

Mental health breakthrough: Round-the-clock care at A&E in five years | Liaison Psychiatry | Scoop.it
AROUND-the-clock mental health care will be provided at all accident and emergency departments within the next five years.
Alex Thomson's insight:

Good news - announcing that all EDs will have a proper liaison psychiatry dept by 2020. However, there's a lot of work to do in order to get there. With about 180 hospitals in England, that works out at around 2,000 nurses and 350 consultants needed, plus similar numbers of occupational therapists and psychologists. There is a need to train people in this specialist area in order to ensure effectiveness. Furthermore, simply parachuting mental health staff into a hospital won't in itself improve access to urgent mental health treatments. There is a need for wholesale review of pathways into mental health services and procedures, attitudes and skills of staff in the acute trust. It also remains to be seen whether clinical commissioning groups will be willing or able to fully fund liaison psychiatry services so that they have the resources to provide effective care. In summary, great news with huge challenges ahead.

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Court rules dementia sufferers classed as in 'state detention' must have inquest when they die

Court rules dementia sufferers classed as in 'state detention' must have inquest when they die | Liaison Psychiatry | Scoop.it
The new ruling has been slammed by MP Ann Coffey as an 'expensive, bureaucratic nightmare'
Alex Thomson's insight:

Interesting implications for general hospital inpatients as well - although rates of DOLS authorisations may be low, there are many people who might technically be considered to be deprived of their liberty in as much as they do not have capacity to decide and they are not free to leave. Potentially anybody who dies in hospital while having delirium or dementia might need to have a coroner's inquest.

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Calming Dementia Patients Without Powerful Drugs

Calming Dementia Patients Without Powerful Drugs | Liaison Psychiatry | Scoop.it
Nursing homes are trying non-drug methods to improve patient behavior
Alex Thomson's insight:

A good description of how attentive, flexible approaches to care can reduce the distress experienced by both patients and caregivers! This does illustrate how important it is to question whether institutional practices and routines are helpful or causing problems.

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Delirium in ICU Ups Risk of Dying in Hospital

Delirium in ICU Ups Risk of Dying in Hospital | Liaison Psychiatry | Scoop.it
A new study has found that one-third of patients admitted to an intensive care unit (ICU) will develop delirium, which lengthens hospital stays and substantially increases the risk of dying in the hospital. “Every patient who develops delirium will...
Alex Thomson's insight:

An account of a meta-analysis finding that delirium doubles one's risk of dying in hospital. Yet again I'm left wondering why it is so difficult for nurses and doctors to recognise delirium and take it as seriously as other medical conditions.

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Physicians' Attitudes toward Integrating Consultation-Liasion Psychiatric Services in four major General Hospitals in Tehran - General Hospital Psychiatry

AbstractObjective

Our objective was to validate a scale for the evaluation of attitudes of physicians toward integrating consultation-liaision psychiatric services and then apply it among the non-psychiatrist attending physicians of four major general hospitals in Tehran.

Method

The 8-item Doctors’ Attitudes toward Collaborative Care for Mental Health (DACC-MH) Scale was translated to Persian and back-translated to English, by non-physician translators, and presented for expert opinion to four psychiatrists, for assessment of face validity. The validated questionnaires were presented to non-psychiatrist attending physicians of four major general university-affiliated hospitals with consultant-liaison psychiatric services in Tehran and the returned questionnaires were analyzed using the 21st version of SPSS software. The score for each physician was generated by counting positive responses of the 8 items questioned.

Results

Of the 300 questionnaires presented, 193 (64.3%) were returned. The mean score of the respondents was 6.62 (+/- 1.33) for the Farsi version of the DACC-MH which was significantly higher than the assumed mean score of 4, according to the independent sample T-test (p<0.001). The mean score of the respondents for the first four items of the DACC-MH was 3.49, which was significantly higher than that of the second four items of the scale which was 3.13 (p<0.01) according to the Wilcoxon test.

Conclusion

The respondents have an above-average positive attitude toward integrating consultation-liaision psychiatric services for the management of psychiatric disorders among in-patients. They had a more positive attitude towards requesting psychiatric consultations than managing the patients’ psychiatric disorders themselves.

Alex Thomson's insight:

According to this survey, physicians in Tehran are keen on collaborative working with liaison psychiatry.

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Efficacy of brief interdisciplinary psychotherapeutic intervention for motor conversion disorder and non-epileptic attacks - General Hospital Psychiatry

AbstractObjective

To compare a brief interdisciplinary psychotherapeutic intervention to standard care as treatments for patients recently diagnosed with severe motor conversion disorder or non-epileptic attacks.

Methods

This randomized controlled trial of 23 consecutive patients compared a) an interdisciplinary psychotherapeutic intervention group receiving 4-6 sessions by a consultation liaison psychiatrist, the first and last sessions adding a neurological consultation and a joint psychiatric and neurological consultation ; b) a standard care group. After intervention, patients were assessed at 2, 6 and 12 months with the Somatoform Dissociation Questionnaire SDQ-20, Clinical Global Index, Rankin scale, use of medical care, global mental health (MADRS, Beck Depression Inventory, mental health component of SF-36), and quality of life (SF-36). We calculated linear mixed models.

Results

Our intervention brought a statistically significant improvement of physical symptoms (as measured by the SDQ-20 (p<0.02), and the Clinical Global Impression scale (p=0.02)), of psychological symptoms (better scores on the mental health component of the SF-36 (p<0.05) and on the Beck Depression Inventory (p<0.05)) and a reduction in new hospital stays after intervention (p<0.05).

Conclusion

A brief psychotherapeutic intervention taking advantage of a close collaboration with neurology consultants in the setting of consultation liaison psychiatry appears effective.

Alex Thomson's insight:

An interesting abstract with some suggestion of the value of liaison psychiatry in the outpatient setting to reduce morbidity of people with functional neurological disorders. However it's a small group and the magnitude of improvement is not described in the abstract.

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The Antidote to Fragmented Health Care

The Antidote to Fragmented Health Care | Liaison Psychiatry | Scoop.it
Pioneers have proven that the integrated care model works.
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A good overview of what's needed to actually integrate healthcare effectively. There's a lot written about the theory of this sort of thing. Far less about the actual experience and results of providing truly integrated care.

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A screening tool to medically clear psychiatric patients in the emergency department. - PubMed - NCBI

AbstractBACKGROUND:

Emergency physicians are frequently called on to medically clear patients presenting with a psychiatric complaint. There is limited guidance on how to conduct this clearance.

OBJECTIVE:

This study evaluated the usefulness of a screening tool in ruling out serious organic disease in emergency department (ED) patients with psychiatric complaints.

METHODS:

A retrospective chart review was performed on 500 consecutive adult ED patients with primarily psychiatric complaints who were evaluated using the tool, and then subsequently transferred to a psychiatric crisis center. The screening tool consists of a series of historical and physical examination criteria derived from the literature intended to identify patients who have a psychiatric manifestation of an organic disease. The physician filled out the screening form and if the proper conditions were met, the patient was transferred to Psychiatry without further laboratory or imaging studies. We reviewed the charts of both the ED visit and the psychiatric crisis center visit to determine if any of the patients required further medical treatment or a medical admission rather than a psychiatric admission.

RESULTS:

Five hundred consecutive ED patient charts were reviewed. Fifteen of the corresponding charts from the psychiatric center could not be found. Of the remaining 485 patients, 6 patients were sent back to the ED for further evaluation. After laboratory work and imaging, none of these 6 patients required more than an outpatient prescription.

CONCLUSION:

The screening tool proved useful in determining if a psychiatric patient needed further medical evaluation beyond a history and physical examination before transfer for a psychiatric evaluation.

Alex Thomson's insight:

This is worth reading - and implementing - if you work in emergency medicine or any psychiatric setting which interfaces with emergency / mental health crisis care. There can be a tendency to needlessly request "medical clearance" for all people with mental health complaints. Not only does this cause delays (and associated distress/frustration) when unnecessary, it can introduce a dangerous ambiguity if staff involved make different assumptions about what "medically cleared" actually means. This study developed and evaluated a brief screening checklist to evaluate whether or not blood tests or further investigations were needed for people with primary psychiatric complaints attending an emergency dept. Of the people who screened negative, only a very small amount subsequently needed medical attention, thus demonstrating that the checklist is safe to use.

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I spoke up about facing stigma in treatment and it led to positive change

I spoke up about facing stigma in treatment and it led to positive change | Liaison Psychiatry | Scoop.it
Sitting in a board room full of heads of nursing and other patients and their representatives, I felt scared. In fact, I felt very scared. I don’t know where my courage came from but I felt I had to s
Alex Thomson's insight:

Good blog on how a patient describing her experience led to improvements in mental health care for people in the medical setting.

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Major Depressive Disorder and Bipolar Disorder Predispose Youth to Accelerated Atherosclerosis and Early Cardiovascular Disease

Major Depressive Disorder and Bipolar Disorder Predispose Youth to Accelerated Atherosclerosis and Early Cardiovascular Disease | Liaison Psychiatry | Scoop.it
A Scientific Statement From the American Heart Association
Alex Thomson's insight:

How interesting. The AHA are recommending that screening for depression be included among other risk factors for cardiovascular risk reduction, on the grounds that the associated risk is as great as for other moderate risk conditions.

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Self-care tips for BPD

Self-care tips for BPD | Liaison Psychiatry | Scoop.it
These tips from the charity Mind have been circulating around twitter and I've been quite surprised by the polarised reactions to them. To be honest if somebody had shown this to me 5 years ago I w...
Alex Thomson's insight:

Well worth a read for anyone working in emergency medicine, mental health or out-of-hours/urgent care. A reminder of what it's like to be having a mental health crisis and how we only see a snapshot of what's going on. Very important to step back and consider the bigger picture.

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Hospital checklists are meant to save lives — so why do they often fail?

Hospital checklists are meant to save lives — so why do they often fail? | Liaison Psychiatry | Scoop.it
An easy method that promised to cut complications in surgery may not be so simple after all.
Alex Thomson's insight:

Good discussion of the factors which differentiate a life-saving checklist from one which is merely a hindrance. Worth considering the operational context and ensuring that it is tested in real-life.

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Hospital-wide Program for Delirium, Alcohol Withdrawal and Suicide/Harm Impacts Readmission Rates

Brigham and Women's Hospital finds that developing and implementing an interdisciplinary care improvement initiative improves outcomes.

Alex Thomson's insight:

This is a curious combination of conditions to address simultaneously, but perhaps better to raise the profile of all mental health-related issues in an acute hospital than tackle it one by one. The particularly useful insights here are not necessarily the clinical details, but the operational details of who needed to commit to improving care throughout the organisation in order to make this a success.

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London’s liaison psychiatry services: survey of service provision

London’s liaison psychiatry services: survey of service provision | Liaison Psychiatry | Scoop.it
Abstract

Aims and method: To describe the liaison psychiatry services of all 30 general hospitals in Greater London and to determine whether services met national recommendations. The results were compared with a similar survey conducted 8 years previously to determine whether there had been significant service development.

Results: We identified wide variations in service provision across London. Fifteen hospitals (50%) had 24-hour services and one had no service. There had been a significant increase in services that assessed older adults. Increases in the size of teams and consultant psychiatry staff were not significant.

Clinical implications: Despite an increasing emphasis on the effectiveness of liaison psychiatry services, no London hospital had staffing levels consistent with national recommendations. Recent evidence for the cost-effectiveness of liaison psychiatry and an emphasis on parity between physical and mental health in National Health Service policy may provide further impetus for growth.

Alex Thomson's insight:

A description of current service provision in liaison psychiatry across London. Notably, despite the expansion over recent years, few depts have the recommended staffing specifications.

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Resources | Mental Health Crisis Care Concordat

Resources | Mental Health Crisis Care Concordat | Liaison Psychiatry | Scoop.it
Alex Thomson's insight:

Links to download the Crisis Care Concordat and associated resources. Highly relevant for all who work in acute hospitals. However, ensuring a prompt, useful and flexible response is the business of all mental health services, not just those depts which happen to be at the 'sharp end'.

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Depression and Cancer: A Dangerous Cocktail

Depression and Cancer: A Dangerous Cocktail | Liaison Psychiatry | Scoop.it
My surgery was deemed a success, and I was cancer-free. I should have been elated. Except I wasn't. The end of my surgery marked the beginning of my marriage shattering depression. Instead of focusing on the second chance at life that I was granted, I felt more like a ticking time bomb.
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A personal account of the impact of depression and cancer on life.

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System-leadership-Kings-Fund-May-2015

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Saving for later. Looks very relevant to the sorts of cross-organisational working that is a daily reality in liaison psychiatry!

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CBT for treating and preventing perinatal depression

CBT for treating and preventing perinatal depression | Liaison Psychiatry | Scoop.it
Sarah McDonald appraises a systematic review of CBT for treating and preventing perinatal depression.
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Headlines:

- CBT can help with perinatal depression

- The evidence isn't particularly strong or robust

- Evidence for CBT being effective at preventing perinatal depression is even more tenuous

- As always, "more research is needed".

 

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Essex County Council v RF & Ors (Deprivation of Liberty and damage) [2015] EWCOP 1 (07 January 2015)

Essex County Council v RF & Ors (Deprivation of Liberty and damage) [2015] EWCOP 1 (07 January 2015) | Liaison Psychiatry | Scoop.it
Alex Thomson's insight:

This is the full text of the judgment reported in the news recently - http://www.telegraph.co.uk/news/uknews/law-and-order/11361472/60k-compensation-for-pensioner-91-locked-away-from-his-cat.html. Worth a read to highlight the importance of considering people's autonomy, wellbeing and wishes when considering best interests rather than just assuming it is always safer to remove people from their homes to institutional care. This case illustrates what happens when things go wrong.

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