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What is the current stateof play and what hasbeen done in the past?
The mental health industry has traditionallybeen pre-technological, emphasised by anapprenticeship system (watching and copyingthe craftsman) as a way of learning vocationalskills, individually provided services, lack of standardisation, and a minimal set of tools.Two roles of the clinical psychologist existed.One was of the psychotherapist who learnedthrough interactions with otherpsychotherapists using knowledge as theironly tool. The other was of the psycho-diagnostician who developed complexpersonality formulations based on projectivetechniques. Do psychotherapists see newinnovations and technologies as a threat tothe prestige associated with their role ascraftsmen?Telepsychiatry has, so far, had little impact onclinical practice and health benefits are yet tobe shown. Technologies tend to be mostuseful in environments which have anadvanced communications infrastructure,difficulties with professional recruitment,geographical barriers to transport and lowpopulation density. Videoconferencinginterventions have been implemented in theSouth London and Maudsley NHS Trust butadoption has been low due to the lack of referrals and staff reluctance. Other concernsare the inability to assess patients’ bodylanguage accurately and patients’ anxietyinteracting with a machine rather than face-to-face. Studies across General Practice (GP)surgeries in Australia also indentified barriersto entry such as lack of familiarity withinformation technology, and insufficientknowledge of available resources.
What are the trends inpatient and clinicianrequirements?
Three trends have been identified within themental health field that appear to fit thepresent definition of mental healthtechnology. Each area is illustrated with theaid of a case study from project partners. Thetrends are in no way exhaustive but act asstimulus for further action and thought. Firstly,workflow tools for the classification of diagnoses and treatments. These can be usedto create assessment guidelines and clinicalpathways. Secondly, professional clinicalinformatics tools such as decision-supportwhich facilitates operational research. Lastly,electronic information intervention tools suchas behaviour monitoring technology to aidtherapy, rehabilitation and wellness.Mental health problems are found in people of all ages, countries, regions and societies. It wasreported that in Great Britain 1 in 4 adults will experience at least one diagnosable mentalhealth problem in any one year, and that 1 in 10 children aged between 1 and 15 has a mentalhealth disorder. Worldwide, it is estimated that approximately 450 million people have amental health problem (World Health Organisation, 2001). Mixed anxiety and depression is themost common mental disorder in Britain with between 8-12% of the population experiencing itany one year. People who receive treatment are twice as likely to recover over an 18-monthperiod than those who don’t. But poorer people, the long-term sick or unemployed are likely tostill be affected. In the age of digital communications, can technologies positively contributetowards a solution?
bulletin
TECHNOLOGY
White Rose HIP Health Technology Bulletins
The White Rose HealthInnovation Partnership(WRHIP) aims to acceleratenew health-relatedtechnologies by facilitatinginteractions betweenacademia, industry and theNHS using an
openinnovation
approach.The new projects fundedas part of this initiative arebuilt upon a foundation of excellence in healthinnovation by thePartnership’s members.This series of HealthTechnology Bulletins offeran introduction to thisresearch excellence andcover a broad range of clinical and technologyareas.Each bulletin is written togive a general introductionto the topic area alongwith short case studies of clinical applications of newknowledge. Information isalso presented on whereto learn more about thesenew technologies andhealth challenges, andhow to access the networkof health innovationprofessionals establishedby the Partnership.
E-Mental Health
Author: Mark Hawker, Teaching Development Officer, Yorkshire Centre for Health Informatics. E-MailM.D.Hawker@leeds.ac.uk
 
Case Study:
ElectronicInformation Interventions
The prevalence of alcohol misuse amongst young peoplecontinues to be highlighted within governmental reports,academic writings and the popular press. Of particularconcern are the high levels of heavy episodic or bingedrinking and the negative effect that this has on physical andpsychological health, and anti-social and risky behaviour. Oneapproach attracting increasing interest is that of providingpersonalised feedback interventions. Brief personalisedfeedback intervention programmes focus on an individual’salcohol consumption and provide personalised risk level andalcohol-related information. Advances in technology have thepotential to deliver personalised feedback to a large audiencein a cost-effective manner.
Solutions, progress anddevelopment areas
Unitcheck is developed at the University of Leeds and isfunded by the Alcohol Education and Research Council. Thecurrent phase of the project began in July 2007 and will rununtil the end of 2008. Unitcheck provides students withpersonalised feedback in three parts: their level of alcoholconsumption; social norms information (i.e. how their level of drinking compares to peers); and, generic information (e.g.how to calculate alcohol units for common drinks). Afterregistering participants are matched and then randomlyallocated to either an immediate-intervention, delayedintervention or control group. All groups are asked tocomplete questions in the survey at various points during theproject period. Participants allocated to the interventionCognitive Behaviour Therapy (CBT) is a form of psychotherapy aimed at helping people experiencing a widerange of mental health difficulties. The basis of CBT is thatwhat people think affects how they feel emotionally andtherefore alters how they act. The demand for CBT therapiesfar outweighs the number of professionals available todeliver them. Alternative delivery options need to beexplored including self-help. The self-help approach fits wellwith the move in the general population to learn more aboutmedical conditions. From toddler taming to depression andeating disorders, many patients will follow this advice beforeapproaching a medical professional.
Solutions, progress anddevelopment areas
Calipso is a range of books, computer-based courses, DVDsand online therapy developed by Media Innovations Ltd.that can be used by healthcare professionals, and also bypatients, to help them manage common mental healthconditions more effectively. The range of professionals whofind Calipso training courses and materials valuable includesgeneral practitioners, practice and district nurses, andoccupational therapists as well as students in medicine,nursing, psychiatry, psychology and other healthcare-relatedsubjects. Each course is evidence-based and developed bylead medical experts in mental health training and patientmanagement.Calipso offers clinical and CBT skills packages to helphealthcare professionals become more confident at caringfor patients with mental health disorders. The maindifference between packages is in the assessment andmanagement approach used. The clinical courses offermental state examination training and offer guidance onforms of treatment. They are more appropriate for generalpractitioners, medical students and trainee psychiatrists. TheCBT courses are ideal for busy healthcare professionals whoneed practical ways to assess patients in a 5-10 minutesession. The courses teach valuable CBT skills and offer self-help materials which can also be given to patients.
Research is under way to further evaluate the acceptability andeffectiveness of both the written and computerised materialsin a variety of different settings including primary care. Do careproviders need to have a mental health background, or is itmore important that they are empathic and good atmotivating patients at working through materials? Could theincorporation of self-help into a counsellor’s practice allowthem to see more patients and allow the patients to be betterprepared and more educated about their treatments? Lastly,are the claimed advantages of computerised self-help true orare we better sticking with self-help in book form? It seemslikely that self-help is likely to become more of a feature of primary care services in the future.
There is tremendous potential for computer packages as atraining resource across health care disciplines, in particularin primary and community health services. Benefits of Calipso, amongst many others, include: empoweringpatients as they are able to follow and learn from materialsat their own pace; providing effective, affordable andreusable training material for practitioners; helpinghealthcare professionals to improve their standard of patientcare; and, keeping practitioners up-to-date with the latest ininterventions and treatments. Whilst computer-basedlearning shouldn’t replace practice-based teaching, Calipsois a tool which is accessible, easy to use and can allowprimary carers to offer patients quicker access to CBT. Thismay reduce referrals to specialist services, enablingsecondary care services to focus on treatment of theseverely mentally ill.
Case Study:
Audio/Visual Material for Cognitive Behaviour Therapy
 
In mental health, caring for patients in the community isusually an active and significant component of the total careprovided. In each case there are two common in-patientpsychiatric events: detention of patients under the MentalHealth Act if they are considered at risk to themselves orothers; and, treatment with Electro-Convulsive Therapy (ECT)most commonly in the case of severe depression. Detentionof a patient under the Act involves a series of stepsimplemented under strict conditions and requiring theconsent, with signatures, of a combination of healthcareprofessionals. A detailed paper-trail is mandatory to satisfyaudits of procedures by the Mental Welfare Commission. Theimportance and frequency of ECT mandates that provision ismade for its documentation in an electronic (or otherwise)form. To what extent do psychiatric clinical managementsystems support the recording of these events?
Solutions, progress anddevelopment areas
In Ayrshire and Arran NHS Trust, electronic health and socialcare records are managed using FACE Recording andMeasurement Systems developed by Intermation Ltd which areinstalled in over 250 sites across the UK. They provide acomprehensive set of risk and functional assessment toolsets aswell as outcomes and forms management software catering formost sub-specialties. These include children and adolescents,general adult, psychogeriatrics, learning disabilities andaddiction services. There is currently no assessment toolset foruse in forensic psychiatry under development. FACE systemsalso provide tools for capturing basic details related to the twocommon events described above:
Detention and treatment of patients under the Mental HealthAct (Scotland) includes a series of steps and adherence tocomplex legal procedures. A mental capacity Assessment(MCA) tool developed for use in England and Wales is notusable in Scotland due to subtle differences between legal jurisdictions. A Scottish version of the tool is yet to bedeveloped as investing energy in its development for fourScottish Trusts compared to over 250 across the rest of the UKcould be a costly and time-consuming process.The documentation used in treatments with ECT includesadverse reactions to previous treatments, medical histories,and any medications administered. At Ayrshire and ArranNHS Trust documentation of ECT treatment is paper-basedand included within the narrative of a patient’s notes. Dr JuliusAwakame, a staff grade psychiatrist and prospective HealthInformatics PhD student at the University of Leeds, notes that“FACE appears to focus on assessment and management of functioning rather than medical interventions including ECTand electronic prescribing”. He suggests “a holistic approachto treatment will require the eventual integration of thesefunctionalities in the fully-fledged system”. Currently, no ECTsoftware is recorded in the FACE new developments registry.The acute hospital, electronic laboratory and GP systems atAyrshire and Arran NHS Trust are ‘stove-piped’ with FACE andeach other rather than being fully-integrated. This means thatinformation is not being shared electronically which can leadto data duplication and errors. Intermation Ltd. hasdeveloped an array of advanced modules which have thecapability to achieve full integration with other systems.However, the under-utilization of FACE has meant that someof these new modules have simply not been requested oradopted at the Trust.group will receive instant feedback on their responses to thesurvey during the first phase of the project. They will be askedto complete the survey a number of times during this period.During the second phase of the project those in the delayedintervention group will receive personalised feedback, and inlater phases, follow up for the entire group will occur. Allparticipants in the control group will be given the opportunityto use the feedback intervention site once the controlledproject period is complete.The intervention was first trialled at the University of Leeds(e-UNICAL) and is currently being tested at four otheruniversities across the UK. Preliminary results from theUniversity of Leeds randomised control trial show theintervention to be effective in reducing certain aspects of alcohol consumption. One survey found that about 5% of those questioned were drinking enough during a week topotentially damage their health. The team are currentlyexploring the potential to modify this intervention for non-student populations including Leeds Sixth form students, andare looking at how tools could be modified and promoted toother intervention groups.Initial results show a reduction in drinking per occasion of approximately one unit during the trial and a three-monthfollow-up shows this lowered intake had persisted. Leadresearcher, Bridgette Bewick said: “Our approach indicatesmany of the young people surveyed did not realise how manyunits they were consuming on an average occasion. Theheaviest drinkers surveyed were surprised to find the majorityof their peers stay within sensible weekly limits. High levels of alcohol taken on a single occasion can be particularlydamaging to health, so a small change in this pattern is a stepin the right direction.”
Case Study:
Psychiatry Clinical Management Systems
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