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DEVELOPMENTS IN EVIDENCE BASED MENTAL HEALTH NURSING

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DEVELOPMENTS IN EVIDENCE BASED MENTAL HEALTH NURSING. PROF KEVIN GOURNAY CBE. FRCPsych (Hon) ... CBT for OCD, Panic, Social Phobia, PTSD, CFS, agoraphobia etc ... – PowerPoint PPT presentation

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Title: DEVELOPMENTS IN EVIDENCE BASED MENTAL HEALTH NURSING


1
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

2
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

3
FUTURE FOCI
  • Community Mental Health Teams Serious Mental
    Illness
  • Primary Care Common Mental Disorders
  • Improved In patient Care

4
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

5
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

6
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

7
OPTIONS FOR CNS TRAINING
  • GENERIC - SKILLS FOR EVERYTHING
  • FOCUS ON SEMI OR CMD

8
ARGUMENTS FOR FOCUSSED TRAINING
  • AVOID SKILLS DILUTION
  • CURRICULUM TIME
  • DIFFICULT TO SWITCH OVERARCHING APPROACH FOR
    PATIENT GROUP

9
POSSIBLE OPTIONS FOR CNS TRAINING
  • GENERIC FOUNDATION MODULE FOLLOWED BY EITHER SEMI
    OR CMD MODULE
  • DIRECTLY INTO SEMI OR CMD TRAINING

10
THORN PROGRAMME FOR SERIOUS AND ENDURING MENTAL
ILLNESS
11
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)

12
Thorn Programme - Core Modules
  • ACT
  • Family interventions
  • Psychological Interventions

13
ADDITIONAL THORN MODULES
  • MEDICATION MANGEMENT
  • DUAL DIAGNOSIS
  • IN PATIENT CARE

14
MEDICATION MANAGEMENT
15
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

16
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

17
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
18
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)

19
H5 Does training improve clinical skills?
20
H1 What is the effect of training on patients
psychopathology?
p.026
21
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

22
DISSEMINATION PROJECT
  • NATIONAL TRAIN THE TRAINERS PROGRAMME
  • CASCADE STARTS IN AUTUMN 2001
  • CURRENT PROGRAMME IN AUSTRALIA

23
DUAL DIAGNOSIS
24
Epidemiology
  • 30 - 50 in USA samples
  • 37 in Camberwell
  • Heterogeneity of substances
  • Heterogeneity of Reasons for Use

25
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

26
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

27
Possible Components of Training II
  • Functional Analysis
  • Motivational Interviewing
  • Assertive Community Treatment skills
  • - Teamwork
  • - Inter agency working
  • - Outreach

28
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

29
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

30
Evidence for effective psychological treatments
  • CBT for OCD, Panic, Social Phobia, PTSD, CFS,
    agoraphobia etc
  • CBT and IPT for some depression, some GAD

31
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

32
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

33
IMPROVED IN PATIENT CARE
  • Beware skill leakage to community
  • Need to use evidence based
  • UK programmes based on Thorn principles, with
    some modification

34
OTHER ISSUES
  • Child and Adolescent Mental Health
  • Older people with mental health problems
  • Mixed Learning disability and Mental Illness
  • Forensic Care

35
Other Issues
  • Preparation of University Departments
  • Multidisciplinarity
  • Clinical Supervision by suitably skilled staff
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