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Optimism is generally accepted by psychiatrists, psychologists and other caring professionals as a feature of mental health. Interventions typically rely on cognitive–behavioural tools to encourage individuals to ‘stop negative thought cycles’ and to ‘challenge unhelpful thoughts’. However, evidence suggests that most individuals have persistent biases of optimism and that excessive optimism is not conducive to mental health. How helpful is it to facilitate optimism in individuals who are likely to exhibit biases of optimism already? By locating the cause of distress at the individual level and ‘unhelpful’ cognitions, does this minimise wider systemic social and economic influences on mental health?
This is a brief commentary on the value of optimism in therapy. It draws on the philosophical writings of Schopenhauer and Aristotle. It suggests that the modern preoccupation with optimism may be as extreme as the bleak pessimistic outlook favoured by Schopenhauer.
To investigate whether socioeconomic status influenced rates of depot medication prescribing, polypharmacy (more than two psychotropic medications), newer (second-generation) antipsychotic prescribing and clozapine therapy. Postcodes, Scottish Index of Multiple Deprivation (SIMD) categories and current medication status were ascertained. Patients in the most deprived SIMD groups (8–10 combined) were compared with those in the most affluent SIMD groups (1–3 combined).
Overall, 3200 patients with ICD-10 schizophrenia were identified. No clear relationship between socioeconomic status and any of the four prescribing areas was identified, although rates of depot medication use in deprived areas were slightly higher.
Contrary to our hypothesis, there was no evidence that patients with schizophrenia within NHS Greater Glasgow and Clyde who live in more deprived communities had different prescribing experiences from patients living in more affluent areas.
To evaluate a comprehensive risk management programme. A Risk Assessment and Management Self-Efficacy Scale (RAMSES) was used to evaluate the impact of a clinical guideline and training course. Fifty-three psychological therapists were randomly allocated to training v. waiting list in a controlled, delayed-intervention design. Differences in mean self-efficacy scores between groups were examined using analysis of covariance (ANCOVA).
The RAMSES measure had adequate factor structure, internal consistency and construct validity. When adjusting for baseline scores and cluster design, the group exposed to training had a higher mean self-efficacy score than controls. Mean differences between groups were not significant after the control group received training, nor at 6 months' follow-up.
Exposure to training and clinical guidelines can improve self-efficacy in risk assessment and management. An important advance put forward by this study is the specification of areas of competence in risk assessment and management, which can be measured using a psychometrically sound tool.
To describe the clinical and demographic characteristics of all in-patients experiencing delayed discharge over 3 months in an English urban mental health National Health Service trust. We carried out a cross-sectional case record study with care coordinator questionnaire.
Overall, 67 in-patients with delayed discharge occupied 18.6% of acute beds. Older in-patients were White, diagnosed with dementia and experienced relatively short admissions. Younger in-patients were often of Black and minority ethnic background with a psychotic diagnosis and long service contact, and sometimes experienced very long admissions. They were similar to a long-stay comparison group. The whole cohort was socially isolated and marginalised, and frequently misused alcohol.
People with complex mental health problems can experience long stays in acute care settings. This particularly affects people with psychosis who are isolated in the community. Alcohol misuse is the most common complicating factor. There are insufficient community-oriented rehabilitation services to meet these patients' diverse needs.
In up to a quarter of patients, schizophrenia is resistant to standard treatments. We undertook a naturalistic study of 153 patients treated in the tertiary referral in-patient unit of the National Psychosis Service based at the Maudsley Hospital in London. A retrospective analysis of symptoms on admission and discharge was undertaken using the OPCRIT tool, along with preliminary economic modelling of potential costs related to changes in accommodation.
In-patient treatment demonstrated statistically significant improvements in all symptom categories in patients already identified as having schizophrenia refractory to standard secondary care. The preliminary cost analysis showed net savings to referring authorities due to changes from pre- to post-discharge accommodation.
Despite the enormous clinical, personal and societal burden of refractory psychotic illnesses, there is insufficient information on the outcomes of specialised tertiary-level care. Our pilot data support its utility in all domains measured.
Risk assessment differs from other medical interventions in that the welfare of the patient is not the immediate object of the intervention. However, improving the risk assessment process may reduce the chance of risk assessment itself being unjust. We explore the ethical arguments in relation to risk assessment as a medical intervention, drawing analogies, where applicable, with ethical arguments raised by general medical investigations. The article concludes by supporting the structured professional judgement approach as a method of risk assessment that is most consistent with the respect for principles of medical ethics. Recommendations are made for the future direction of risk assessment indicated by ethical theory.