Working around a contested diagnosis : borderline personality disorder in adolescence

This discourse analytic study sits at the intersection of everyday communications with young people in mental health settings and the enduring sociological critique of diagnoses in psychiatry. The diagnosis of borderline personality disorder (BPD) is both contested and stigmatized, in mental health and general health settings. Its legitimacy is further contested within the specialist adolescent mental health setting. In this setting, clinicians face a quandary regarding the application of adult diagnostic criteria to an adolescent population, aged less than 18 years. This article presents an analysis of interviews undertaken with Child and Adolescent Mental Health Services (CAMHS) clinicians in two publicly funded Australian services, about their use of the BPD diagnosis. In contrast with notions of primacy of diagnosis or of transparency in communications, doctors, nurses and allied health clinicians resisted and subverted a diagnosis of BPD in their work with adolescents. We delineate specific social and discursive strategies that clinicians displayed and reflected on, including: team rules which discouraged diagnostic disclosure; the lexical strategy of hedging when using the diagnosis; the prohibition and utility of informal ‘borderline talk’ among clinicians; and reframing the diagnosis with young people. For clinicians, these strategies legitimated their scepticism and enabled them to work with diagnostic uncertainty, in a population identified as vulnerable. For adolescent identities, these strategies served to forestall a BPD trajectory, allowing room for troubled adolescents to move and grow. These findings illuminate how the contest surrounding this diagnosis in principle is expressed in everyday clinical practice.

He did what? Well that wasn't handed over! Communicating risk in mental health

Mental health inpatient units are dynamic, complex environments that provide care for patients with heterogeneous ages, diagnoses and levels of acuity. These environments commonly expose clinicians and patients to many potential risks. Despite extensive research into risk assessment, prediction and management, no study has investigated how risk information is communicated at handover in acute mental health settings. Given the pivotal role handover plays in informing risk management, this evidence gap is significant. This paper reports on a study that investigated the practices of communicating risk at handover in an Australian acute mental health inpatient unit. The aim of this research was to identify the frequency and type of risk information communicated between nursing shifts, and the methods by which this communication was performed. A secondary aim was to identify effective and ineffective risk communication practices. This study involved an observational design method using a 14-item Clinical Audit Tool derived from handover principles outlined by World Health Organization. Five hundred occasions of patient handover were observed. Few risk information items were observed to be communicated in any method. Risk communication practice was inconsistent, and a key recommendation from the study is the use of standardized handover tools that ensures risk information is adequately reported.

Mental health telephone triage : managing psychiatric crisis and emergency

PURPOSE: The study aims to identify and articulate how mental health telephone triage (MHTT) clinicians manage psychiatric crisis and emergency via the telephone.

DESIGN AND METHODS: An observational design was employed in the study. Wireless headsets were used to observe 197 occasions of MHTT.

FINDINGS: Clinicians use a range of practical strategies, therapeutic skills, and psychosocial interventions to manage psychiatric crises and emergencies via the telephone.

PRACTICE IMPLICATIONS: The evidence base for managing psychiatric crisis/ emergency in MHTT is minimal. These findings contribute to the MHTT knowledge base and provide evidence-based strategies for high-quality emergency mental health care.

Identifying the core competencies of mental health telephone triage

Aims and objectives. The primary aim of this study was to identify the core competencies of mental health telephone triage, including key role tasks, skills, knowledge and responsibilities, in which clinicians are required to be competent to perform safe and effective triage.
Background. Recent global trends indicate an increased reliance on telephone-based health services to facilitate access to health care across large populations. The trend towards telephone-based health services has also extended to mental health settings, evidenced by the growing number of mental health telephone triage services providing 24-hour access to specialist mental health assessment and treatment. Mental health telephone triage services are critical to the early identification of mental health problems and the provision of timely, appropriate interventions. In spite of the rapid growth in mental health telephone triage and the important role these services play in the assessment and management of mental illness and related risks, there has been very little research investigating this area of practice.
Design. An observational design was employed to address the research aims.
Methods. Structured observations (using dual wireless headphones) were undertaken on 197 occasions of mental health telephone triage over a three-month period from January to March 2011.
Results. The research identified seven core areas of mental health telephone triage practice in which clinicians are required to be competent in to perform effective mental health telephone triage, including opening the call; performing mental status examination; risk assessment; planning and action; termination of call; referral and reporting; and documentation.
Conclusions. The findings of this research contribute to the evidence base for mental health telephone triage by articulating the core competencies for practice. Relevance to clinical practice. The mental health telephone triage competencies identified in this research may be used to define an evidence-based framework for mental health telephone triage practice that aims to improve the quality, consistency and accuracy of telephone-based mental health triage assessment.

An evaluation of the Shanghai mental health service schizophrenia rehabilitation program

This study aimed to evaluate the effectiveness of a rehabilitation program for people with schizophrenia in Shanghai, China. Thirty-five people with schizophrenia participated in an eight-module program that focused on a range of psychosocial skills, while 38 others received treatment as usual in the community. Participants were assessed at baseline and subsequently at 4-week intervals over 12 weeks using the Positive and Negative Syndrome Scale, Clinical Global Impression Scale, Drug Attitude Inventory, and Personal and Social Performance Scale. The rehabilitation program participants demonstrated significantly better improvement over the course of the program than did the control participants on all measures. The rehabilitation program is effective in addressing psychosocial deficits evident in many people who have schizophrenia, and it should be implemented more widely.

Increasing the sensitivity of the AQoL inventory for the evaluation of interventions affecting mental health

This paper presents the rationale and psychometric analysis for extending the inventory of the Assessment of Quality of Life (AQoL)-6D instrument. The resulting AQoL-8D has an 8 dimensional, 35 item inventory with greater sensitivity in the domain of mental health.The paper briefly reviews the existing QoL instruments used for economic evaluation of health programs. It outlines the steps adopted in developing the AQoL descriptive inventories and, specifically, the methods adopted for data collection and analysis for the AQoL-8D inventory.Three instruments are presented. The first, PsyQoL, is a 22 item instrument which represents the best statistical fit for the measurement of mental health related quality of life. The second, PsyQoL-Brief is a reduced form instrument which is combined with AQoL-6D as the basis for the third instrument, the AQoL-8D. Psychometric properties of the first instrument are excellent and the second are good. The full AQoL-8D has satisfactory properties. Results from a comparison with the original AQoL-6D are reported. The mental health content of AQoL-8D is unique amongst MAU instruments and, along with other AQoL instruments, unique in its derivation from psychometric analysis. Its application to mental health patients and the public demonstrates its ability to discriminate between the groups with greater sensitivity than the previous AQoL-6D instrument.