DEVELOPMENTS IN EVIDENCE BASED MENTAL HEALTH NURSING

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DEVELOPMENTS IN EVIDENCE BASED MENTAL HEALTH
NURSING

• PROF KEVIN GOURNAY CBE
• FRCPsych (Hon) FMedSci FRCN PhD CPsychol RN
• HEALTH SERVICES RESEARCH DEPARTMENT INSTITUTE OF
  PSYCHIATRY, LONDON

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CHANGES IN MENTAL HEALTH SERVICES IN EIRE

• MENTAL HEALTH LEGISLATION
• DEINSTITUTIONALISATION
• COMMUNITY APPROACHES
• PRIMARY CARE
• DRUGS AND MENTAL ILLNESS
• CHANGING PROFESSIONAL ROLES - BLURRING OF
  BOUNDARIES
• CNS and ANP roles

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FUTURE FOCI

• Community Mental Health Teams Serious Mental
  Illness
• Primary Care Common Mental Disorders
• Improved In patient Care

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Nursing workforce issues

• Need to consider numbers of CNSs and ANP for
  CMHTs and Primary Care respectively ( eg case
  loads in assertive Community Treatment ie for
  most acutely ill set at 12-15 in UK)
• Need to deal strategically

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EVIDENCE Serious and Enduring Illnesses ( eg
Scizophrenia, Manic Depression)

• Medication ( nb medication management)
• Assertive Community Treatment (including home
  treatment, crisis resolution)
• Family Interventions
• CBT
• Early Intervention
• ?Dual Diagnosis

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Evidence Common Mental Disorders

• Medication ( range of conditions with or
  without CBT)
• CBT Panic, Phobias, OCD, PTSD
• CBT/IPT Some depression
• NB No evidence to support dynamic psychotherapy,
  counselling

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OPTIONS FOR CNS TRAINING

• GENERIC - SKILLS FOR EVERYTHING
• FOCUS ON SEMI OR CMD

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ARGUMENTS FOR FOCUSSED TRAINING

• AVOID SKILLS DILUTION
• CURRICULUM TIME
• DIFFICULT TO SWITCH OVERARCHING APPROACH FOR
  PATIENT GROUP

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POSSIBLE OPTIONS FOR CNS TRAINING

• GENERIC FOUNDATION MODULE FOLLOWED BY EITHER SEMI
  OR CMD MODULE
• DIRECTLY INTO SEMI OR CMD TRAINING

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THORN PROGRAMME FOR SERIOUS AND ENDURING MENTAL
ILLNESS
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Key characteristics of training for CPNsThe
Thorn Programme

• Commenced in 1992
• Specifically designed for schizophrenia
• Now the National UK Training model
• Evidence based Community approach
• Skills orientated
• Multidisciplinarity (of students and teachers)
• Now at 12 English Universities plus 2 in Ulster
• Other similar courses ( MScSainsbury CMH)

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Thorn Programme - Core Modules

• ACT
• Family interventions
• Psychological Interventions

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ADDITIONAL THORN MODULES

• MEDICATION MANGEMENT
• DUAL DIAGNOSIS
• IN PATIENT CARE

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MEDICATION MANAGEMENT
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MEDICATION MANAGEMENT

• 50-80 of patients non compliant
• Important role in out , day and in patient care
• Nurse skills poor
• Doctor skills sometimes not much better

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Medication management training programme

• Manualised 80 hour training programme
• Key components
• Assessment
• Psychopathology, side effects, attitudes towards
  treatment, insight
• Cognitive and compliance therapy skills
• Treatment rationale, video role-play, supervision
  
• Psychopharmacology
• Maudsley prescribing guidelines
• Clinical supervision

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Methodology

• Recruitment of CPNs
• Geographical clusters
• Randomised
• Experimental
• Control
• Patients recruited (2 Per CPN)
• Baseline assessments
• Research worker
• Trained
• Blind to training
• Experimental group receive training
• Control group continue with standard care
• Week 26 assessments
• Enhanced care in experimental group
• Control group receive training
• Week 52 assessments

Experimental group
Enhanced care
Training
Wk. 0
Wk. 26
Wk. 52
CPNs n60
Control group
Routine care
Training
Wk. 0
Wk. 26
Wk. 52
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Main outcome measures

• Clinician
• Knowledge MCQ
• Cognitive therapy scale (CTS Young and Beck,
  1983)
• Reliability in assessing mental state

• Primary patient
• Positive and Negative Syndrome Scale (PANSS Kay
  et al., 1989)
• Secondary patient
• Drug attitude inventory (DAI-30 Hogan et al.,
  1993)
• Insight Scale for Psychosis (Birchwood et al.,
  1994)
• LUNSERS (Day et al., 1995)

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H5 Does training improve clinical skills?
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H1 What is the effect of training on patients
psychopathology?
p.026
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MEDICATION MANAGEMENT - NEXT STEPS

• DEFINITIVE TRIAL ( ongoing - funded by MRC)
• QUATRO (5 European counties - 1.2 million
  euros)
• CHANGE TO PREREGISTRATION EDUCATION
• PRESCRIPTIVE AUTHORITY FOR NURSES ( Maudsley
  discussion paper No 11)
• DISSEMINATION

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DISSEMINATION PROJECT

• NATIONAL TRAIN THE TRAINERS PROGRAMME
• CASCADE STARTS IN AUTUMN 2001
• CURRENT PROGRAMME IN AUSTRALIA

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DUAL DIAGNOSIS
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Epidemiology

• 30 - 50 in USA samples
• 37 in Camberwell
• Heterogeneity of substances
• Heterogeneity of Reasons for Use

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Interventions - Research Evidence

• Cochrane Review
• Treatment programmes for people with both severe
  mental illness and substance misuse
• Ley A Jeffrey D McClarenS Seigfried N (1999)
  Cochrane Library

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Possible Components of Training I

• Engagement Skills
• Drug and alcohol Assessments
• Assessment of Mental State, Need, Social Function
• Assessment of Medication Side Effects
• Physical Health Assessments

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Possible Components of Training II

• Functional Analysis
• Motivational Interviewing
• Assertive Community Treatment skills
• - Teamwork
• - Inter agency working
• - Outreach

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COMO STUDY - THORNICROFT, GOURNAY, JOHNSON,
CRAIG, BOARDMAN, MARSHALL, WANIGARATNE, BALASZ,
FINCH and CHISOLM

• 1999-2002
• South East London
• RCT
• Training in Dual Interventions
• ( Integrated substance misuse intervention skills
  with ACT Methods)
• 74 Case Managers and 200 patients

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Primary Care Problems

• Infinite Demand
• Finite Resources
• Demand led versus Needs Led
• Perpetuation of various myths (e.g. effectiveness
  of counselling, primary prevention)
• Historical Idiosyncratic Development of services
  in area of least need

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Evidence for effective psychological treatments

• CBT for OCD, Panic, Social Phobia, PTSD, CFS,
  agoraphobia etc
• CBT and IPT for some depression, some GAD

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Training strategy for nurses in primary care

• More nurse therapists
• Specific CBT training for CPNs
• Brief focused training for Practice Nurses
• Training Health Visitors in CBT and Medication
  Management for Depression
• Train all in computer assisted methods
• Train Nurses with GPs

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NURSE THERAPISTS IN PHC

• Started by Isaac Marks in London - 1972
• 18 Month FT training
• Skills based training in BT and CBT
• Core Conditions (Ag, OCD, Sp Phobias)
• Good RCT evidence
• 24 CNSs in CBT in Republic of Ireland

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IMPROVED IN PATIENT CARE

• Beware skill leakage to community
• Need to use evidence based
• UK programmes based on Thorn principles, with
  some modification

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OTHER ISSUES

• Child and Adolescent Mental Health
• Older people with mental health problems
• Mixed Learning disability and Mental Illness
• Forensic Care

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Other Issues

• Preparation of University Departments
• Multidisciplinarity
• Clinical Supervision by suitably skilled staff