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A well-established literature has identified different selective attentional orienting mechanisms underlying anxiety-related attentional bias, such as engagement and disengagement of attention. These mechanisms are thought to contribute to the onset and maintenance of anxiety disorders. However, conclusions to date have relied heavily on experimental work from subclinical samples. We therefore investigated individuals with diagnosed generalized anxiety disorder (GAD), healthy volunteers, and individuals with high trait anxiety (but not meeting GAD diagnostic criteria). Across two experiments we found faster disengagement from negative (angry and fearful) faces in GAD groups, an effect opposite to that expected on the basis of the subclinical literature. Together these data challenge current assumptions that we can generalize, to those with GAD, the pattern of selective attentional orienting to threat found in subclinical groups. We suggest a decisive two-stage experiment identifying stimuli of primary salience in GAD, then using these to reexamine orienting mechanisms across groups.

Background: Leverage is a particular type of treatment pressure that is used within community mental health services to increase patients' adherence to treatment. Because leverage involves practitioners making proposals that attempt to influence patients' behaviours and choices, the use of leverage raises ethical issues., Aim: To provide guidance that can assist practitioners in making judgements about whether it is ethically acceptable to use leverage in a particular clinical context., Method: Methods of ethical analysis., Results: Four ethical duties relevant to making such judgements are outlined. These four duties are (1) benefitting the individual patient, (2) benefitting other individuals, (3) treating patients fairly and (4) respecting patients' autonomy. The practical requirements that follow from each of these duties are considered in detail. It is argued that practitioners should determine whether the use of leverage will mean that care is provided in ways that are consistent with the requirements of these four duties, regardless of whether the patient accepts or rejects the terms of the proposal made., Conclusion: Particular attention must be paid to determine how the requirements of the four duties should be applied in each specific treatment scenario, and in making careful judgements when these duties pull in opposing directions., (© The Author(s) 2014.)

Background: In 2008, the Swiss Civil Code was amended. From 1 January 2013, each Swiss canton may propose specific provisions for involuntary outpatient treatment (community treatment orders (CTOs)) for individuals with mental disorders., Aim: This review catalogues the legal provisions of the various Swiss cantons for CTOs and outlines the differences between them. It sets this in the context of variations in clinical provisions between the cantons., Methods: Databases were searched to obtain relevant publications about CTOs in Switzerland. The Swiss Medical Association, Swiss Federal Statistical Office, Swiss Health Observatory and all the 26 Cantonal medical officers were contacted to complete the information. Conférence des cantons en matière de protection des mineurs et des adultes (COPMA), the authority which monitors guardianship legislation, and Pro Mente Sana, a patients' right association, were also approached., Results: Three articles about CTOs in Switzerland were identified. Psychiatric provisions vary considerably between cantons and only a few could provide complete or even partial figures for rates of compulsion in previous years. Prior to 2013, only 6 of the 20 cantons, for which information was returned, had any provision for CTOs. Now, every canton has some form of legal basis but the level of detail is often limited. In eight cantons, the powers of the measure are not specified (for example, use of medication). In 12 cantons, the maximum duration of the CTO is not specified. German speaking cantons and rural cantons are more likely to specify the details of CTOs., Conclusion: Highly variable Swiss provision for CTOs is being introduced despite the absence of convincing international evidence for their effectiveness or good quality data on current coercive practice. Careful monitoring and assessment of these new cantonal provisions are essential., (© The Author(s) 2013.)

Introduction: Continuity of care has been demonstrated to be important for service users and carer groups have voiced major concerns over disruptions of care. We aimed to assess the experienced continuity of care in carers of patients with both psychotic and non-psychotic disorders and explore its association with carer characteristics and psychological well-being., Methods: Friends and relatives caring for two groups of service users in the care of community mental health teams (CMHTs), 69 with psychotic and 38 with non-psychotic disorders, were assessed annually at three and two time points, respectively. CONTINUES, a measure specifically designed to assess continuity of care for carers themselves, was utilized along with assessments of psychological well-being and caregiving., Results: One hundred and seven carers participated. They reported moderately low continuity of care. Only 22 had had a carer's assessment and just under a third recorded psychological distress on the GHQ. For those caring for people with psychotic disorders, reported continuity was higher if the carer was male, employed, lived with the user and had had a carer's assessment; for those caring for people with non-psychotic disorders, it was higher if the carer was from the service user's immediate family, lived with them and had had a carer's assessment., Conclusion: The vast majority of the carers had not had a carer's assessment provided by the CMHT despite this being a clear national priority and being an intervention with obvious potential to increase carers' reported low levels of continuity of care. Improving continuity of contact with carers may have an important part to play in the overall improvement of care in this patient group and deserves greater attention.

A challenge in admitting individuals with Alzheimer's disease and related dementias into memory care residential facilities is determining the appropriate level of service based on abilities and care needs. At intake, the incoming tenant's functional performance capacity is obtained through family or proxy report corroborated with screening results of global cognitive function. Based on this information, the agency determines the level of service needs; if misjudged, inadequate placement can be stressful for the individual and family and costly for the facility. This study examined the predictive validity of a clinically administered assessment of cognitive-functional performance, Cognitive Performance Test (CPT), in gauging service needs in 4 activities of daily living (ADL; dressing, eating/feeding, showering, and toothbrushing) with 57 tenants residing in a memory care-assisted living facility. Linear regression results revealed a significant relationship between CPT scores and ADL performance in all areas (P < .001) with CPT scores accounting for 51% to 62% of the variability in performance.

Objective: The correlates of parental burden in schizophrenia may differ between ethnic groups, but few studies have examined this in a UK setting. Our aim was to identify the correlates of burden in a UK sample of first-generation North Indian Punjabi Sikh parents and their white British counterparts., Method: Test the association of burden with a series of clinical, social and service use variables and control for potential confounding factors in a model predicting drivers of burden in a combined sample of the above., Results: The strongest correlates of burden were patient symptoms and parental distress. Differences in correlates of burden between the groups emerged when individual components of service use and parental social network were tested. The group comparisons also revealed differences in expressed emotion (EE) and social networks., Conclusion: The similarities in sources of burden between the groups could be explained by a commonality of sociocultural and economic experience, resulting from the successful acculturation and affluence of this British Sikh group. The differences between the groups may be related to enduring cultural factors such as kin support, since larger family groups were associated with low burden in the British Sikh group. The nature of EE in this British Sikh group may explain why it was not associated with burden in this sample.

Background: The relationship between continuity of care and user characteristics or outcomes has rarely been explored. The ECHO study operationalized and tested a multi-axial definition of continuity of care, producing a seven-factor model used here., Aims: To assess the relationship between user characteristics and established components of continuity of care, and the impact of continuity on clinical and social functioning., Methods: The sample comprised 180 community mental health team users with psychotic disorders who were interviewed at three annual time-points, to assess their experiences of continuity of care and clinical and social functioning. Scores on seven continuity factors were tested for association with user-level variables., Results: Improvement in quality of life was associated with better Experience & Relationship continuity scores (better user-rated continuity and therapeutic relationship) and with lower Meeting Needs continuity factor scores. Higher Meeting Needs scores were associated with a decrease in symptoms., Conclusion: Continuity is a dynamic process, influenced significantly by care structures and organizational change.

Background: Service users with non-psychotic disorders are rarely studied. How continuity of care functions for this group is unknown., Aims: To compare users of community mental health teams with non-psychotic disorders to those with psychotic disorders in terms of demographic and illness characteristics, continuity of care and clinical and social functioning., Methods: Service users with non-psychotic disorders (N = 98) were followed up for one year and compared to 180 service users with psychotic disorders. Continuity of care factors were tested for association with user, illness and service variables., Results: Service users with non-psychotic disorders experienced more care transitions, but there were no differences in team practices in relation to these two different groups., Conclusion: The underlying concepts of continuity of care derived from users with psychotic disorders appear to be meaningful for users with non-psychotic disorders. Their greater likelihood of experiencing disruptive and distressing care transitions needs to be addressed.

Background: Caregiver burden in mental illness is believed to differ between ethnic groups, but few studies have examined this in schizophrenia in the UK., Aim: To measure burden in British North Indian Sikh and white British parents with a son or daughter with established schizophrenia managed in outpatient care., Method: A cross-cultural cohort study measuring family factors, patient psychopathology and levels of burden and distress., Results: Overall levels of burden were low with no significant differences between the groups. Burden subscale scores showed Indian parents were more affected by psychotic behaviours than white parents. The groups also differed on several sociodemographic variables., Conclusion: In stabilized community patients, the overall extent of burden experienced by both Indian and white parents is low and comparable. However, Indian parents were more burdened by psychotic behaviours. This may be a result of co-residence as Indian patients are more likely to live with their families. Social and economic factors in the country of residence and levels of acculturation may also influence levels of burden and the illness behaviours found most bothersome by parents.

Background: A durable therapeutic relationship is central to mental health practice. The Working Alliance Inventory (WAI) and the Helping Alliance Questionnaire (HAQ) are established instruments for measuring such a relationship., Aims: The project aimed to test the correlation between the two scales for patients with severe psychotic illness treated in an Assertive Community Treatment (ACT) team., Methods: Ninety-one patients of an ACT team and their key-workers were recruited to complete the measures., Results: Seventy-one patients (78%) completed the scales, and key-workers completed scales for every eligible patient. Both groups rated the relationship positively. There was a strong and significant correlation between the patient version of the WAI and the HAQ. There were significant but much weaker correlations between the patient-rated WAI and HAQ and the key-worker WAI., Conclusion: The patient version of the WAI and the HAQ seem to measure the patient's view of the relationship equivalently. The HAQ is simpler and easier to administer than the WAI.

Background: The difference between the services provided by day hospitals and day centres is far from clear. The supposition that day hospitals would provide an acute service, while day centres would offer social support for a more chronic population has been contentious and there is little evidence of how they are currently used., Aims: We aimed to ascertain the differences between day hospitals (partial hospitalisation) and social service day centres in functions and roles, as perceived by staff, service users and referrers., Methods: The views of service users and staff at two day hospitals and four day centres were ascertained through questionnaires and interviews, along with those of staff of eight Community Mental Health Teams, who constitute the sole pathway to the two services., Results: Day hospitals were perceived by both referrers and clients to offer short-term, more intensive 'treatment' to more acutely ill people in need of mental health monitoring. Day centres were perceived to offer longer-term support, particularly social support, to people more likely to have longer-term and psychotic illnesses., Conclusion: There is currently a clear distinction between day centres and day hospitals, in key features of their services and client groups. It would be unwise to treat them as interchangeable.

Background: In view of the increasing integration of health and social care, there is an urgent need to know how health service day hospitals and social service day centres are being used, and by whom., Aims: We aimed to compare users of day hospitals and centres in terms of their social networks, needs for care and demographics., Methods: A cross-sectional, comparative study of service users at two day hospitals and four day centres compared their social networks, needs and characteristics., Results: Day centre clients had much larger social networks, including a three-fold difference in total contacts and two-fold difference in confidants, but had more needs for care, particularly relating to psychological distress. They were also older on average than day hospital patients and were a more long-term group., Conclusion: It is vital to understand differences between health service day hospitals and social service day centres given the increasing integration of health and social care. The present study shows that the two user groups are significantly different. It is unlikely that the needs of most day care users could be met by either service interchangeably.

The effects of repetitive work on Alzheimer's disease (AD) patient functioning were examined when nine veterans were moved from a work program to a traditional adult day care program. Subjects were reassessed four months after the move with the Mini-Mental State Examination (MMSE), Cognitive Performance Test (CPT), and Geriatric Depression Scale (GDS). Individual slopes were calculated for seven subjects who had longitudinal scores, and expected scores were predicted based on the rate of decline. Observed scores at reassessment were significantly lower than expected scores. The MMSE was on average 4.9 points lower, and the CPT .64 points lower than expected. The GDS did not change. The spouses of all nine patients reported declines in daily living activities. Compared to traditional day care activities, work activities involve sequencing skills and practice may translate to self-care activities at home.

The aim of this study was to analyse experiences of moral concerns in intensive care nursing. The theoretical perspective of the study is based on relational ethics, also referred to as ethics of care. The participants were 36 intensive care nurses from 10 general, neonatal and thoracic intensive care units. The structural characteristics of the units were similar: a high working pace, advanced technology, budget restrictions, recent reorganization, and shortage of experienced nurses. The data consisted of the participants' examples of ethical situations they had experienced in their intensive care unit. A qualitative content analysis identified five themes: believing in a good death; knowing the course of events; feelings of distress; reasoning about physicians' 'doings' and tensions in expressing moral awareness. A main theme was formulated as caring about--caring for: moral obligations and work responsibilities. Moral obligations and work responsibilities are assumed to be complementary dimensions in nursing, yet they were found not to be in balance for intensive care nurses. In conclusion there is a need to support nurses in difficult intensive care situations, for example, by mentoring, as a step towards developing moral action knowledge in the context of intensive care nursing.

The purpose of this exploratory study was to examine the perceptions of 115 female spouse caregivers of early to moderate stage dementia patients. Based on patients' cognitive status, cross-sectional comparisons of two groups of caregiving wives were conducted. No group differences were found in measures of caregiver burden, depression, or personal gain. However, wives of patients with greater cognitive impairment experienced lower levels of mastery and more relational deprivation when compared to wives of patients with higher mental status. Supportive approaches might be directed toward helping early dementia caregivers restructure their understanding of, and participation in, their marital relationships in anticipation of changes ahead. Interventions aimed at enhancing a caregiver's sense of personal mastery may help reduce the negative effects of dementia on caregivers' well-being.

Background: Deinstitutionalisation has stressed where care is no longer taking place. Home treatment in rehabilitation reflects the steady increase in emphasis on support and treatment for individuals with long-term disorders where it matters for them--in their own homes., Materials and Discussion: Whether dealing with individuals discharged after long periods in hospital or with the increasing number who have experienced repeated short-term admissions, most modern day rehabilitation takes place in the patients' homes and neighbourhoods. We are increasingly convinced that this decentralisation is a positive strength, not a problem. Its advantages include improving social inclusion and the ability to conduct more accurate, personalised assessments of disabilities and strengths. Skills training is more focused and we discuss the components of home treatment and assertive community treatment as they are relevant to rehabilitation. This involves both medication and practical help, brokerage and involvement with the voluntary sector., Conclusions: Rehabilitation remains, at its core, a set of relationships between whole individuals (not just skills and needs). A home-based approach is proposed as the norm, not the exception. It is based on a rounded understanding of the patient as a unique person and emphasises the importance of a strong working alliance.

Background: 'Relapse' is a common outcome indicator in intervention studies in schizophrenia. In community studies it is frequently equated with hospitalisation and in psychopharmacological studies with predetermined symptom scores. Its clinical meaning, however, remains undefined., Method: Consensus on the defining features of 'relapse' in schizophrenia used by academic and clinical schizophrenia experts in the UK, was investigated using a four stage Delphi process. A two panel, four stage, Delphi based methodology was used to investigate the implicit meanings of 'relapse' in clinical practice. A multidisciplinary panel of twelve members each listed anonymously ten indicators of relapse. A second panel, of ten experienced psychiatrists, rated the 188 submitted indicators from essential-unimportant (1-5). This panel completed a one day workshop during the remaining Delphi rounds ending with a structured discussion of the results., Results: Very strong consensus was achieved on the relative importance of potential relapse indicators. There was complete agreement about some aspects of a definition of relapse (such as recurrence of positive symptoms) and a number of the complex issues underlying the concept were clearly articulated., Conclusions: This four stage Delphi process achieved consensus on core features of relapse. The elucidation of the "softer" features at the threshold between normal fluctuations in functioning and the start of relapse require continuing investigations.

A new performance-based assessment instrument for evaluating function in patients with Alzheimer's disease (AD), the Cognitive Performance Test (CPT), is described. This instrument, based on Allen Cognitive Disability Theory, uses six common activities of daily living (ADL) tasks, for which the information-processing requirements can be systematically varied to assess ordinal levels of functional capacity. Seventy-seven patients with mild to moderate Alzheimer's disease (AD) and 15 neurologically normal elderly controls were administered the CPT. Subsets of the AD patients were assessed again at 4 weeks and 1, 2, and 3 years following the initial evaluation. Internal consistency of the CPT estimated by alpha was .84. Intraclass correlation for interrater reliability was .91 and for test-retest reliability at 4 weeks, .89. CPT scores were significantly correlated with Mini-Mental State Examination scores (r = .67) and two measures of caregiver-rated ADL (Instrumental Activities of Daily Living, r = .64; Physical Self-Maintenance Scale, r = .49). Significant declines in CPT scores were seen on 1-, 2-, and 3-year follow-ups. Initial CPT scores predicted risk of institutionalization over a 4-year follow-up period.

Twenty-nine patients (1 high school athlete, 9 college athletes, and 20 recreational or nonathletes) with Neer stage II impingement syndrome were treated by arthroscopic subacromial decompression after their injuries failed to improve with conservative therapy. Followup averaged 32.2 months, and results were rated based on subjective responses and the UCLA Shoulder Rating Scale. Of the results, 82.2% were rated as satisfactory, while 17.2% were unsatisfactory. The greatest margin of improvement was in the pain rating. Postoperatively, 65.5% of the patients returned to their previous level of activity and 56% of the collegiate athletes returned to their previous competitive level. The average time to return to college-level competitive athletics for the recreational or nonathletes was 6.6 months (average 5.4). There were no infections or neurovascular complications in the series.

The transfer to the Indian Health Service (IHS) of 158 alcohol treatment programs that had been administered by the National Institute on Alcohol Abuse and Alcoholism began in 1978. Today, approximately 300 alcohol and substance abuse treatment programs offer services to American Indians, among them primary residential treatment, halfway houses, outreach, and aftercare. This system provides a national network upon which additional activities may be established. Along with increasing its attention to health promotion and disease prevention, the IHS has moved toward the prevention of alcoholism. A variety of preventive programs are in place that emphasize improved self-image, value and attitude clarification, decision-making, and physical and emotional effects of alcohol and substance abuse. Many begin as Head Start programs and continue through adulthood. In 1986, after consulting with both academic and tribal experts, the IHS devised a strategic plan for alcoholism control that stresses comprehensive care and prevention activities; it serves as a guide for further program development. The Secretary of Health and Human Services created a Task Force on Indian Alcoholism in 1986 to serve as a coordinating body for activities carried out by the IHS and other agencies and units of the Department. Passage of the Anti-Drug Abuse Act in 1986 added resources for the development of adolescent treatment centers and, more importantly, for community-based pre- and post-residential care for youths and their families. Concomitant with these initiatives have been several instances of increased attention by various tribes to the problem of alcoholism. The IHS strategic plan, together with the Secretary's initiative, the Anti-Drug Act, and tribal actions, has added substantial momentum to efforts directed at controlling alcoholism among American Indians. Although the mortality rate from alcoholism is about four times greater for the American Indian population than for the entire U.S. population, it decreased from 54.5 per 100,000 population to 26.1 between 1978 and 1985-a reduction of 52 percent.The philosophy of the IHS in emphasizing prevention of disease and promotion of wellness provides an opportunity for continuing the considerable progress already made. The critical and decisive role played by the Indian communities themselves will determine whether ultimate success can be achieved.

Four hundred and sixty seven Swedish psychiatrists (response rate = 52.5%) returned a questionnaire on their understanding of the term "borderline patient". Virtually all had heard of it and 75.2% regularly used it as a diagnosis. Its use was positively associated with female sex, psychotherapy interest and training. 38.8% of the respondents aligned themselves with a predominantly constitutional, and 57.8% with a psychodynamic, understanding of the term. This difference was strongly associated with those diagnoses to which the term was considered equivalent, the symptoms most characteristic of it and with various aspects of the responding psychiatrists' training and work. Swedish psychiatrists emphasized the subjective aspects of the patients' disorder rather than the lability and socially disruptive behaviour which are so prominent in the DSM-III diagnosis. The results of this study underline the urgent need for the establishment of simpler and more practical criteria for the diagnosis.