Investigators:
Dr Kym Jenkins
Professor Nick Keks
Professor David Copolov
Vivienne Howe
Kelly Foister
Background
There has been increasing debate over the past decade about the capacity of persons suffering from psychotic illnesses to give informed consent. Informed consent is the corner stone of ethical research. However, there has been a tendency to deem persons incompetent and exclude research participation based on clinical diagnosis or status under the mental health act.
Research into the area of competence has also largely looked at diagnostic categories, with findings such as 52 %of persons with schizophrenia have impaired capacity (Grisso and Appelbaum 1995). The effects of variables such as phase of illness, presence and extent of positive and negative symptoms, and mental state examination on capacity, have so far been poorly examined
Objectives
This study aims to evaluate the capacities of patients with schizophrenia, bipolar disorder and schizoaffective disorder in different phases of illness to give informed consent, in comparison to subjects with physical illness and well controls.
Subjects will be categorised as competent or incompetent according to legal definitions applicable in Australia. This study will establish associations between particular psychotic symptoms and their severity, with competency to consent at different levels of risk.
The study hypotheses:
- that patients with schizophrenia, bipolar disorder and schizoaffective disorder will have higher impairment scores than patients with diabetes and heart disease who will in turn show greater impairment than well controls, matched for age, gender and maximal educational attainment.
- that psychotic patients who manifest the following illness characteristics will show significantly greater frequency in failing to reach competency thresholds than other psychotic patients - severe formal thought disorder, severe manic symptoms, marked cognitive impairment and severe acute phase illness.
- that the degree of a patients cognitive impairment will be a better predictor of capacity for consent than psychotic symptoms.
Inclusion criteria
- Diagnosis of schizophrenia, bipolar or schizoaffective disorder (all phases of illness)
- 16 - 64 years of age
- Good command of English
Project design
50 patients with each of schizophrenia, bipolar disorder and schizoaffective disorder, a control group of 50 patients with diabetes and 50 patients with ischaemic heart disease, and 50 "well" controls will be studied.
Phase 1 - PANSS and MacCAT-CR (not for controls) Phase 2 - PANSS, MTCRI
SERVICE EVALUATION AND OUTCOMES: ISSUES RELATING TO THE INTERFACE BETWEEN CRISIS ASSESSMENT TEAMS AND EMERGENCY SERVICES WHEN DEALING WITH THE MENTALLY ILL
Investigators
Dr Yitz Hollander
Professor Jayashri Kulkarni
Mr Steven Tahtalian
Mr David Young
Background
Collaboration between mental health and crisis services is required to improve the care and management of people with a mental illness, particularly in times of crisis.
Most often than not, the interactions between these services can become problematic as issues regarding intervention, management and law enforcement of mentally ill people often arise. Since the introduction of recommendations by the Commonwealth Government in 1998, that all jurisdictions develop protocols and service level agreements between mental health services, the police and ambulance services for the management of mentally ill people, little research has been conducted in Victoria regarding the interface between these groups. The systematic study of the complexities of service collaboration is required to develop a more effective service system for the management of people with mental illness. The identification and definition of key issues and concerns regarding the interface between mental health services, the police and ambulance services is vital for this to occur.
Aim and Hypotheses
The aim of the proposed project is to identify key issues associated with the interactions between Crisis Assessment & Treatment Teams (CATT), the police and ambulance services of the Alfred Hospital catchment area. The objective is to collect information regarding key issues and concerns of staff from the relevant services.
Method
A literature review was conducted to ascertain other previous research that has been conducted in this area. The key issues identified were included in the development of the questionnaire which were distributed to staff who have had contact with these services whilst dealing with the mentally ill. Data was analysed, broad themes identified, discussed and included in the development of questions to be used for focus group interviews. These interviews will be conducted with key staff from these services to further delineate issues faced.
Once issues are identified, an action research methodology will be adopted whereby possible strategies and solutions to problems faced will be identified and tested. The efficacy of these strategies will then be evaluated. This process will be repeated until an optimal consensus about their effectiveness is achieved between parties. This approach will allow for improved collaboration between these services and better outcomes for people suffering from mental illness.
Progress /Results:
Police reported a lack of information regarding the mentally ill prior to attending the scene, problems with obtaining risk information from treating professionals, and difficulty receiving feedback regarding the outcomes of individuals. Police also indicated some difficulty in accessing and utilizing mental health services. CAT identified concerns about response from emergency services to be the biggest issue, indicating that response times can be lengthy and that the getting a coordinated response is sometimes difficult. Both CATT and Police indicated that roles and responsibilities can be unclear some of the time.
Initial findings have been presented at:
- The Crisis Assessment and Treatment Conference, 2005, Hamilton, New Zealand.
- The American Academy of Psychiatry & the Law Conference, 2005, Montreal Canada
- Canadian Psychiatric Association Conference, 2005, Vancouver, Canada
- Australasian Society of Psychiatric Research Conference, 2005, Brisbane, Australia
THE IDENTIFICATION OF CONTRIBUTING FACTORS TO THE RELAPSE OF CONTINUING CARE TEAM (CCT) CLIENTS
Investigators
Dr Yitz Hollander
Dr Nic Mims
Dr Rob Sheilds
Dr Sally Wilkins
Mr Anthony Kennedy
Mr Rod Mann
Background
The management of people suffering from mental illness in the community is an important component of the provision of mental health treatment in the state of Victoria. Community Care Teams (CCT) provide a range of community based services for assessment, treatment and consultation in addition to continuing care and case management of mentally ill people.
Despite community-based programs such as these, a substantial portion of these patients frequently relapse and are re-hospitalised. The identification of factors that contribute to the relapse of patients thus becomes pertinent to the development of intervention strategies and relapse prevention programs for this group of clients. The current project will aim to identify factors that contribute to the relapse of CCT clients.
Aims and Hypotheses
This project aims to identify factors that contribute to the relapse of clients managed by Waiora and Junction Clinics. A file audit will be performed to identify themes and patterns of precipitating factors contributing to relapse.
Method
The identification of Waiora and Junction clients who have relapsed in the past year will be made by accessing a database called the Redevelopment of Acute and Psychiatric Information Directions (RAPID). This database provides information about public hospital services that are used or have been used by clients. Once clients have been identified using Rapid, 40 will be randomly selected and client files will be requested from the clinics and medical records. Client files will be examined to identify changes in the client situation or treatment in the past 4 months prior to hospital admission. This examination will identify factors that have contributed to the relapse of these clients.
In addition, there is extensive research that has examined risk factors of relapse in mentally ill patients. These findings will also be used, in addition to the initial file audit, to develop a checklist that will be used for the file audit of the remaining client files.
The remainder of the files will then be requested as required. The checklist will be used to obtain the occurrence of the identified factors. Any factors that have not been identified previously will be added to the checklist and frequency recorded.
Current Status
Statistical analyses will be performed to delineate relationships between factors identified. Following the statistical analyses, focus group interviews will be performed with staff involved in the management of this group of clients. This will be done to ascertain qualitative data from people's experiences regarding contributing factors to relapse.
HOMELESSNESS AND THE IMPACT ON LENGTH OF HOSPITAL STAY AND RELAPSE
Investigators
Dr Yitz Hollander
Ms Adiel Bonett
Mr Steven Tahtalian
Mr Brent Hayward
Background
Accommodation is a fundamental need for people with a mental illness as for the rest of the community. The availability of suitable housing for this group of people is vital to providing community mental health support in the least restrictive way (Barling 1997; Newton & Rosen, 1997; Moxham & Pegg 2000). In Australia, institutions have long recognised the importance of suitable housing for people with a mental illness though over the past 10 years there has been a steady decrease in appropriate accommodation options for this group of people (Kliger et al., 2003). Private rooming houses, crisis shelters and supported accommodation is rapidly disappearing in the Inner-South-East area of Melbourne (Jope, 2000; Kliger et al., 2003), which will inevitably place greater strain on mental health services. Anecdotal evidence suggests that patients are now experiencing longer hospital stays as a result of insufficient accommodation options to which patients can be discharged. If this is the case, expensive hospital resources are being unduly utilized and bed availability subsequently reduced. This is further compounded by research which indicates that the appropriateness and quality of accommodation can have a critical effect on relapse (Baker & Douglas, 1990; Bergin et al., 1997).
Aims and Hypotheses
The current study aims to investigate whether patients who are considered to be in unstable accommodation are experiencing longer hospital stays as compared to those in stable housing.
The results will provide insight in to the dynamic nature of accommodation availability in the Alfred Hospital catchment area and the impact on length of hospital stay and relapse.
The first phase of the project will provide details of length of hospital admission and whether patients are experiencing longer admission due to lack of accommodation stock. In addition, the appropriateness and adequacy of accommodation at admission and discharge will be presented.
The second phase of the study will investigate the circumstances of re-admission of patients who participated in the first stage, particularly in relation to the influence of accommodation type.
It is anticipated that this study will indicate whether the difficulty in finding accommodation for people suffering a mental illness impacts on the use of hospital resources and whether this also contributes to the relapse of this group of people.
Method
Inpatient social workers will collect information of patients from consecutive admissions for a 3 month period.
Information to be collected will consist of:
- the patient's accommodation type at time of admission;
- whether accommodation type is adequate and appropriate*
- accommodation options for discharge;
- time taken to secure accommodation by the social worker;
- time spent in hospital following medical clearance for discharge; and
- length of hospitalisation
*Definition adapted from the World Health Organisation definition.
Demographic information will also be collected and analysed with the factors listed. An additional 6 months will be spent obtaining the same information from patients who have relapsed and been readmitted to hospital during this time period.
The results will provide insight into the dynamic nature of accommodation availability and the impact on length of hospital stay and relapse.
THE IMPLEMENTATION AND EVALUATION OF THE USE OF PERSONAL DIGITAL ASSISTANTS IN INPATIENT PSYCHIATRY
Investigators
Dr Yitz Hollander
Mr Steven Tahtalian
Dr Jenny Majoor
Background
Palm pilots represent a compact, portable easy to use information management and data collection tool.
However, their use in clinical medicine has been limited, especially in Australia and in the non-procedural specialties.
It is generally agreed that the quality and safety of patient care is enhanced through timely access to standardised up-to-date information such as treatment protocols and policies and procedures. Furthermore, the monitoring of patients seen and their outcomes is a valuable feedback tool to trainees and services in general. Palm pilots have great potential to function in both these areas.
Rural medicine and anaesthetics have been the major fields to embrace palm pilot technology, possibly because of the isolated nature of rural practice and because of the quantitative nature of anaesthetics work and their outcomes. A brief search of the published literature has not identified the use of palm pilots in psychiatric settings.
At the Alfred Hospital, Department of Psychiatry, a Registrar training CD-ROM and intranet site has been created with the aim of creating an information resource for junior doctors. However, it is not an interactional resource, and would be ideally placed on a palm pilot system together with data collection forms relating to the tracking of patients and outcomes and training experiences.
Aims and Hypotheses
To introduce and evaluate a palm pilot system that functions as an information resource and a data collection tool to assist the management and tracking of acute psychiatric inpatients as well as junior doctor training experiences.
- To create a palm pilot system for use by junior doctors working in the acute inpatient psychiatric setting;
- To identify, introduce and evaluate the customised reference material that a palm pilot system for junior doctors working in the acute psychiatric inpatient setting should include;
- To identify, introduce and evaluate the personal organiser functions of a palm pilot system that assist junior doctors working in the acute psychiatric inpatient setting
- To identify, introduce and evaluate the specialised calculation programs of a palm pilot system that assist junior doctors working in the acute psychiatric inpatient setting.
- To develop and evaluate a palm pilot inpatient tracking and outcome data system for junior doctors working in an acute psychiatric inpatient setting.
- To develop and evaluate a palm pilot data base to monitor the training experiences of junior doctors working in an acute psychiatric inpatient setting.
Method
Literature review
This would cover the use of palm pilots in medicine generally as well as in psychiatry. Major electronic journal searches and internet searches would be performed. In addition, unpublished literature and information would be sought through interviews with chief Investigators of other palm pilot projects in medicine. The literature review would seek to identify programs and resource material that are currently available.
Survey
A survey of Alfred Hospital Department of Psychiatry senior and junior medical staff would be undertaken to canvass views on the various palm pilot functions, resource material and data fields that would be useful on a palm pilot system in the acute inpatient setting.
Development of palm pilot system
A palm pilot system would be developed. The patient tracking and outcome data base and training data base would be developed using access and excel programs as appropriate.
Field testing
The palm pilots would be issued to all junior doctors working in the acute psychiatry setting at the Alfred Hospital and the after hours duty doctor.
Evaluation
Formal and informal evaluations will be conducted
Informal evaluations will involve the general feedback and comments collected during the course of the project.
Formal quantitative evaluation questionnaires involving junior and senior medical staff and nurse managers will be conducted at 2 weeks, 6 weeks and 12 weeks.
In addition focus groups will be held for the collection of quantitative data.
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