Faculty of Liaison Psychiatry – Royal College of Psychiatrists
JISC UPDATE January 2013
A busy and thoughtful month – here are some of the issues discussed.
HONOS – is this version useful for liaison? If not, what else?
Two members of the liaison executive at the Royal College have been looking to find
a usable outcome measure for liaison psychiatry and as HoNOS is the standard
measure throughout psychiatry, it was deemed more practical to revise this than to
start from new.
Those involved in this work recognise the competing needs a) not to deviate too much
from the original whilst b) retaining the brevity and therefore usability and c) making
it acceptable to our peer group.
This was their work to date and responses were invited:
HoNOS_PM_revised.
doc
These were some responses
:
1. “My hair turned grey in trying to establish a HoNOS for Eating Disorders. This was
despite holding national conferences of eminent academics and establishing clear
consensus among experts in the field.
After protracted negotiations, we were permitted to create guidance on interpretation
of HoNOS, to be read alongside HoNOS itself, and appearing here:
http://www.rcpsych.ac.uk/pdf/College%20Guidance%20for%20use%20of%20Mental
%20health%20Clustering%20Tool%20for%20ED%20Sept%202011.pdf
However, we were not allowed to create our own modified version of HoNOS, as we
strongly wished.
But few clinicians beyond eating disorder specialism seem to make reference to the
guidance, and the measure continues to under-estimate pathology and disability.”
2.
data collection tool 3
2.doc
Bristol uses this version of the GAF; less onerous to complete than the HoNOS. This
form also captures other relevant data, PBR relevant.
3. From Leeds – this clinician sees an issue with the problem of multi/co-morbidity
which isn't quite the same as physical disorder severity. Multiple disorders in an
individual can bring complexity in healthcare provision even if not all severe. Is an
extra item is called for?
He has concerns that the "adapt HoNOS" approach runs the risk that any measure will
fall between two stools. It's neither [a] a generic measure of HRQL such as EQ5D or
SF12, or of well-being such as GHQ12; nor is it [b] sufficiently domain/disorderspecific that it will prove sensitive to change.
“What about adopting the latter approach - that is, recommending generic measures
and ideally at least one preference-based QL measure, and developing a panel of
simple, brief, disorder or domain-specific measures relevant to liaison? One
advantage of this approach is that it is the one adopted by most researchers and
thereby it becomes easier to assess both the relevance of research studies to one's
clinical practice and also to judge how one is doing in relation to what the research
suggests one should be able to achieve.
HoNOS_PM_AH 27
Dec revised.doc
”
4. This clinician thinks it hard to justify its use as a severity scale measure because of
lack of reliability (both test-retest and inter-rater), validity, sensitivity and
responsiveness.
It does not differentiate frequency vs. impact in the conditions it purports to measure.
This results in some of the questions relating to frequency as one marker of severity
then impact as another; and so, some of the questions (e.g. cognitive problems,
depression and unexplained physical symptoms) appear to poorly differentiate
moderate and severe forms of behaviour, with seeming arbitrary choice of symptoms
at times and this may render it less sensitive to change. We would anticipate change
either as a result of our interventions or simply due to regression to the mean.
Would it not be easier to start with?
Severity:
0 = no problem within the period rated
1 = sub-threshold problem
2 = mild but definitely present
3 = moderate
4 = severe
Then work from there?
“Finally are you planning on sticking to the same timescale? In the original HoNOS I
think this is 2 weeks. This is relevant in relation to test-retest and should be clearly
highlighted at the top of the questionnaire.”
Visual Aids for Capacity
Are there visual aids that can help patients with capacity issues understand the process
etc of intimate examinations, operations etc.?
Recommended was a patient information leaflet on capacity in general on the Royal
College of Psychiatrists'' website:
http://www.rcpsych.ac.uk/expertadvice/problems/mentalcapacityandthelaw.aspx
CBT and visual impairment
“Is anybody aware of any computerised CBT sites that have been suitably modified
for people with significant visual impairment? I can't find anything on RNIB.”
Suggestions:
1. Mental health foundation but it costs £60
2. livinglifetothefull.com with the option of large fonts
Transplant Psychiatry – a complex query internationally answered
‘Are there rating scales for psychiatric morbidity pre, peri and post-transplant? What
about HADS and CES-D as brief and open access, and maybe something like the
Sheehan disability scale to capture the impact of physical illness on functioning – or
are there better options?
The nephrologist at this unit noted that a couple of people who interviewed well preop had problematic post-transplant courses psychiatrically speaking; there were
significant personality vulnerabilities, but is there a scale that would begin to capture
that?
Also is there a useful scale for personality domains in non-directive (i.e. "altruistic")
donors? ‘
An American clinician thought the PACT was useful (it is in public domain) and with
face appeal to non-psychiatric transplant clinicians.
Olbrisch, M.E. et al: The PACT: A rating scale for the study of clinical decision
making in psychosocial screening of organ transplant candidates.
Clinical Transplantation, 3:164-169, 1989.
Leeds also recommends a measure of generic distress as a good indicator. There is
also some ‘old’ evidence that routine tracking of QL can be good and alert clinicians
early to problems.
Velikova G, Booth L, Smith AB, Brown PM, Lynch P, Brown JM, et al. Measuring
quality of life in routine oncology practice improves communication and patient wellbeing: a randomized controlled trial. J Clin Oncol 2004;22:714-24.
He acknowledges that identifying people who are going to do badly was difficult and
recalls years ago that selection for dialysis or transplantation of kidneys was based
upon a notion of “people like us”.
From Canada: “my experience in doing pre screening for various procedures the
standard psychiatric interview to elicit diagnoses doesn't tell you much about what is
going to happen in the future - and as I understand it the literature supports this. I
always though trying to assess narcissism was far more useful and we got so far
as developing a brief narcissism rating scale.”
From Queensland, Australia: “in my work with directed live kidney donors I've
developed a hypothesis about unrealistic fantasised expectations as a major risk factor
in donors. I've included a couple of de-identified case scenarios which outline what I
mean; that sometimes the offer to donate comes within a context of a terribly
complicated relationship, with all its attendant pressures and potential/unrealised payoffs.”
unrealistic fantasised
expectations.ppt
From Leicester: “Please feel free to consider the emotion thermometers a simple selfreport visual analogue scale for emotional complications, to date validated in cancer,
cardiology and neurology. It’s free to use and derived from the US distress
thermometer. http://www.psycho-oncology.info/ET.htm. There is an embedded
implementation version with outcome/clinician responses etc and also a version
incorporating QoL/disease burden both available by request but not on the weblink. A
brief review of diagnostic validity studies of patient reported scales in medical
settings is here http://www.ncbi.nlm.nih.gov/pubmed/22137418 if that helps (but we
didn't find much literature re renal patients).”
And finally an in depth answer from Professor Sensky: “Another option would be to
use our PRISM instrument. We originally developed and validated this as a measure
of suffering, and it is been successfully used as such by colleagues outside our group.
More recent experience indicates that PRISM works as a visual metaphor, assessing
the relationship between a Subject and Object(s) associated with it. In measuring
suffering, the subject is the Self and the object is the person's illness. According to
Cassell's seminal conceptualisation, and other formulations of suffering, this is
defined by the relationship between a person and his/her illness (specifically the threat
of the illness to the individual's Self or Personhood).
PRISM is a very simple instrument, defining subject, object and context, and then
allowing the informants to do the rest. As a measure of suffering, we show the
informant and A4-sized sheet of paper, with a yellow circle in one corner. The
informant is told to imagine that the sheet reflects his/her life at the moment, and that
"the yellow circle reflects your Self". The informant is then handed a red disc and
told "Now imagine that this disc represents your illness. Where would you put the red
disc to reflect the importance of the illness in your life at the moment?” Results from
our group, and others, have consistently demonstrated that the distance between the
self and Illness discs correlates negatively with depression, pain and illness
intrusiveness scores, and positively with SF-36 or SF-12 scores. The quantitative data
(the distance between the self and Illness discs) can easily be complemented by
qualitative data. Informants can be asked why they placed the Illness disc where they
did, and also further supplementary questions such as where they anticipate the Illness
disc might be if they received optimal treatment and what can be done by the
informant and by clinicians to move the Illness disc from its present position to a
more favourable place. In essence, because PRISM is acting as a visual metaphor, it
is possible to elicit very rapidly salient features of the person's illness experience, and
his/her suffering, rather than having to go through a lengthy narrative to put the illness
experience into context.
Given the way PRISM works, I think it very likely that it could be used in assessing
transplant recipients, and also potential donors. For recipients, the fixed yellow disc
on the PRISM board would probably be defined as "your Self", and the informant
might be asked to place on the PRISM board a disc called "my transplanted kidney",
and possibly a further disc called "the donor of my kidney". I suspect that it would be
hard to interpret quantitatively the distance between these two objects and the Self, as
is possible with suffering, patient's comments on why they placed the discs were they
did, and where they envisage the discs being in, say, three and six months' time, or
optimally, would yield rich data. Further object discs can be incorporated into the
task, such as "my spouse" and/or "my work". It should be possible to identify people
who have unrealistic expectations. However, from past experience, I think it would
be important initially to pilot different labels for the Object discs in order to elicit
good quality relevant information.
PRISM is available as an iPad App; just search in the App store for "iPRISM" (it is
available free of charge).
Full references are available on the JISC archive.
How to get an appropriate interview room in A&E – PLAN advise:
Many PLAN members do not initially meet the standard for having a safe space for
high risk assessments. Generally a letter to trust managers/CEOs (with full agreement
from the liaison team) saying 'X is a high performing liaison team meeting the
majority of standards but requires better assessment facilities in order to be accredited'
and a copy of the relevant standards does the trick.
Assessment rooms remain an issue of real concern for many liaison teams and the
PLAN accreditation committee and advisory group (chaired by Jim Bolton) has
recently been discussing ways in which we can convince trusts to provide better
facilities e.g. an inter-collegiate position paper; and there is agreement from the
College of Emergency Medicine to emphasise the importance of this. Colleagues from
the Royal College of Physicians are also keen to help.
ED tool for assessments:
This is a topic we see on JISC from time to time and is always useful to rethink. I am
not sure there has ever been a definitive answer but discussions are always sensible –
as was this one!
“Our ED has requested a review of the tool they use for mental health presentations –
I think they want a “holy grail” tick box which thankfully doesn’t exist. They
currently use a locally adapted version of Anthony Harrison/Chris Harts 2004 tool
(with permission) which I think is as good as anything.”
A responder: “What do they want to do with their tool?
e.g. a tool to remember the various headings in a psychiatric history and mental state?
Or a tool that will usefully divide patients presenting in psychiatric crisis into those at
high risk of future harm to self or others and those at low risk – which does not exist.
Our duty then is to educate EDs.
Leicester uses SH-10 form for referrals from the ED.
http://www.slideshare.net/ajmitchell/leicestershire-sh10-selfharm-assessment-form
Though any referral system needs to be backed up by ongoing teaching programme
and building relationships with ED staff.
Jackie Gordon, Worthing