Abstract
I am not aware of another text which attempts to achieve this text's stated aims in the Australian setting, namely to create a ‘source book’ for a hypothetical acute psychiatric unit in a public general hospital. This book sees itself as a continuation of the Quality Assurance Project commenced in the 1980s in Australia and New Zealand which led to a series of publications in this journal. That series reported expert consensus opinions on the best management in a number of clinical areas just as this book gives clinical practice guidelines, or ‘treatment protocols’, based on the views of an expert committee. At the same time this book purports to use an evidence-based approach to practical clinical and organisational issues in modern acute inpatient psychiatric practice.
We are told that the expert committee convened to guide the development of the text were elected by medical directors and nurse managers of acute psychiatric units around Australia. The composition of the committee is important since this is a consensus opinion document. The many references cited to back up the assertions in the text do not appear to represent a broad and inclusive review of all citations on the topics covered. In this respect, I believe the claims of an evidence-based approach is not fulfilled.
The book may be of interest to a psychiatry trainee preparing for the consultancy viva for browsing through, and would be a useful source of ideas for psychiatric unit staff preparing service protocols. It gives an overview of different aspects of current practice in Australia and overseas, drawn partly from the scientific literature, and partly, one assumes, from the experience of the authors and expert committee members.
Chapter 1 contains a useful discussion on the influence of health policy in Australia on the composition of inpatient psychiatric units, both type of staff and type of patient. The chapter looks at different models for managing the intensive care needs of inpatients and reports on the status of mainstreaming and changes in average duration of psychiatric admission and how this matches with the Australian National Mental Health Strategy objectives.
Chapter 2 looks at alternatives to hospitalisation. The chapter reports on a number of initiatives described in the literature to reduce the need for hospitalisation, including case management programs and day treatment plans, but does not attempt a systematic review of the literature in favour and against; successes and failures. Anecdotal reports of programs in private mental health services are included, but unfortunately with no attempt to establish how universal or successful these are.
Chapter 3 looks at factors at play in the decision of whether or not to admit to a psychiatric inpatient facility. The chapter cites statistics on patient movements. Recommendations are given on protocols for admission decisions. Some attempt is made to examine the important interface between public and private services, which is to be commended.
Chapter 5 looks at policies and procedures surrounding inpatient care. It includes a useful review of different mental health acts around Australia and comments on the need for a unified national law.
Chapter 6 outlines standards for the organisation and physical design of inpatient units. The appendices list educational resources, quality of care protocols, examples of assessment and admission documents and risk assessment and management forms.
Among some of the specific criticisms that could be levelled at this text is the annoying use of jargon, for instance: ‘the source book is outcome focused …’, but many readers will be relieved that the term ‘patient’ is used throughout. There is a tendency toward strings of motherhood statements about psychiatric care and a lack of meaty analysis. Where important and contentious issues are raised, such as criteria for secluding patients or service response to sexual activity between patients, there is a tendency to cite some data and then sit on the fence or to just describe the problem as ‘difficult issues to consider’ (p. 74).
The text tends to stray from being a clinical management protocol for staff in an inpatient unit, to being a scantily cited psychiatric text on recommended therapeutic strategies. The text cites the key issue that ‘the functions of an acute psychiatric unit appear to be changing from that of providing diagnosis and treatment to people with a wide range of mental disorders to one of providing emergency management for persons who, because of their mental disorder, are too distraught or dangerous to be managed in the community’. The text is irritatingly silent on the expert committee's views and ideas regarding this trend. Surely a key aspect of psychiatric admission is that it provides the capacity to observe closely and to enable more accurate diagnosis of complex cases and/or to safely study response to therapy.
Closely after a description of the multidisciplinary team in chapter 4 is a section titled ‘Role of the family during admission’. In this section are statements such as ‘the family is an important team member’. This reader is left a little concerned that in the enthusiasm of promoting the rights of a patient's family to be informed of diagnosis, progress and clinical management decisions, a duty on the part of the family to contribute to psychiatric care is being created regardless of whether they are willing or able.