CHAPTER 10
Prepared by : *Mohamed Tafesh
*Ahmed Elkhaldy
Supervised by: Dr. Abd Elkareem Redwan
Presentation outlines : 
Introduction 
Service demands 
A system approach 
The evidence base for inpatient mental health 
nursing and services
Extrapolating an evidence base from non- 
inpatient studies
Schizophrenia and psychotic disorders 
Depression and mood disorders 
Medication in inpatient settings 
Counseling versus cognitive behavior therapy in
primary care

•cognitive behavior therapy versus medication
,behavior therapy and "other therapy“
•anxiety disorders
•personality disorders
•substance and alcohol misuse
•assessing and managing the environment
•the delivery of training
•conclusion
Introduction
:
inpatient mental health nursing challenges the nurse
not only to care and intervene with the patients
mental health needs but also to do it in an
environment over which the patient has a little
control .
services demands :
U.K Hospital Episodes statistics (HES) collected over 12
million records detailing episodes of admitted patient
treatment delivered by hospital in England for a year 2002 2003.
But in comparative in Gaza strip statistics from June /2007
to may/2008 in psychiatric hospital as following :
•in out clinics ,number of patients 1389 pts monthly .(males
974 ,females 415pts)
•in hospital , 41 pts monthly (males 25 pts, females 16 pts)
A system approach:
The mental health policy implementation guide (department
of health 20002) recommends the importance of policy in
inpatient settings and recommends that operational policies
should be published and made available locally for referrers
and all stakeholders for the following ;
•referral and admission criteria
•community treatment and support options
•continuity of care arrangements
•managing bed and alternative service availability
•inpatient treatment and care options
•links and support to inpatient services. managing risk
•communication standards
The evidence base for inpatient mental health
nursing services :
-reviews and dissemination of the effectiveness of
mental health services ,linked to recommendation
from the health national services framework for
mental health ,found:
"an absence of any evidence for the effectiveness of
delivery of inpatient mental health services (Jepson
et al 2001)
•it is only possible to consider the evidence base for
nursing and potential intervention as extrapolating
from non-inpatient studies.
Extrapolating an evidence base from non-inpatient
studies:
Due to the lack of an evidence base for inpatient
intervention and services ,it is only possible to gauge
the evidence base for intervention using alternatives
means : outpatient and community studies
Schizophrenia and psychotic disorders :
•the main psychological approaches were reviewed
and the guidelines concluded that cognitive behavior
therapy (CBT).
•The guidelines also recommended that counseling
and supportive psychotherapy are not
recommended as discrete interventions in the
routine care at people with schizophrenia .
Depression and mood disorders :
•There is two co-morbid problems associated with depression are
as following :
*an increased risk of suicide (15-20% of depressive patients commit
suicide
* increased economic and social costs .
-statistics showed that depressive disorders place an enormous
burden on society and are ranked as the fourth leading cause of
burden among all diseases .
Medication in inpatient settings:
•The review supported tricyclic antidepressants as amore
effective treatment with inpatients
•However ,patients were less likely to tolerate the side effects
of tricyclic antidepressants .
Counseling versus CBT in primary care :
•The review examined the efficacy for counseling and CBT in
primary care settings, counseling provided only weak
evidence of a specific benefit in depressive disorders .
CBT versus medication ,behavior therapy and
"other therapies):
•Many questions are often being asked and studied :
•What ,if any , are the core components of a successful
treatment intervention ?
• Should cognitive intervention be used
before behavior ones or vice versa?
•Does cognitive intervention alone without behavioral
intervention have as good a chance of success as the
combined approach and vice versa ?
At result ,it would appear that behavioral approaches are as
effective as CBT approaches.
Anxiety disorders :
•It is rare for people with a primary diagnosis of
anxiety disorders to require hospitalization .
•The English national service framework
(department of health 1999)
•Notes that :
"around 90% of mental health care is provided
solely by primary care ….the most common mental
health problems are depression ,eating disorders
and anxiety disorders.
Post-traumatic stress disorders:
The NHS for review and dissemination (2002)
support the use of behavior therapy ,eye
movement desensitization and reprocessing
,and selective serotonin reuptake inhibitors, or
use them in combination.
Obsessive compulsive disorders :
The review found that "exposure with response
prevention was highly effective in reducing OCD
symptoms .
Personality disorders :
The NHS center found the use of MAOIs,
carbamazepine and neuroleptics ,is likely to be
beneficial ,in relation to rehabilitation and long
term support.
Substance and alcohol misuse :
A recent review of the efficacy of treatments for drug
misuse by the European Association for the treatment of
addiction (2003)found to support a rang of treatment .
these include:
-residential treatment is effective
- the longer the duration of the intervention the greater
the chance of a successful outcome
Assessing and managing the environment :
" it is possible and probable that poor environment not only reduce
satisfaction but also at the same time increase anxiety and maintain
depression. "
The Mental Health policy implementation Guide (department of
health 2002)recognized this and noted that :
Poor standards of design ,lack of space and access to basic amenities
and comforts in much of our current inpatient provision have
contributed to and reinforced service users negative experiences of
inpatient care as unsafe, uncomfortable and untherapeutic.
Finally ,the nurse was asked to recommend a contingency plan and
its availability should that environment be later identified to not best
match the patient care and management needs.
Examples of specific clinical interventions:
•Cognitive behavior therapy
•Behavioral activation
Coping strategy enhancement for acute symptoms
The nurse may attempt to assist patient to develop better 
methods of coping with acute symptom (NISE).
Cse concerned with assisting patients to identify simple but 
effective coping strategies that they could use when their
symptoms become distressing.
Cse use 0-8scale 0=no effect
8=complete cessation of 
symptoms
The key to developing successful coping strategies is that 
the patient has many to choose form .
The more options that are available the more in control and 
less distressed the patient may feel .
MEDICATION MANAGMENT
Who in 2003 state that the improve adherence is
an essentional element in reducing the global
burden of disease .
THE AIME of medication management 
interventions is to enhance the effectiveness of
medication .
Enhancing treatment adherence is faciliting of 
prescribing careful evaluation of effectiveness of
treatment and close monitoring and management
of unwanted side effects.


FACTORS AFFECTING ADHERANCE
1- The illness (lack of knowledge about the illness 
and treatment )
2- The treatment (side effect , rout of 
administration )
3- Prescriber (do they work collaboratively with 
patient )
4- T he individual (forgetting to take medication , 
beliefs about treatment
5- The environment 
6- culture (preference ) 
MEDICATION MANAGEMENT KEY SKILLS
*Problem solving 
*Looking back : 
This involve facilitating discussion about past experiences of
medication what has helped and what has not helped .
*Exploring ambivalence(incomplience) 
It is helpful to explore the good aspects of taking or not 
taking medication
*Talking about beliefs and concerns 
Most people have some concerns about medication it 
dangerous to take it long time .
*Looking forward: 
It helpful to re frame medication apositive strategy that 
enable patient to achieve goals and promotes recovery .


MEDICATION MANAGEMENT IN THE
INPATIENT ENVIROMENT
Medication management is central to the
work of mental health nurses especially
those working in an inpatient settings
They must be observed carefully the side
effect of medication.


DUAL DIAGNOSIS
*Is defined as co-existence of tow 
disorders (schizophrenia + diabetes )
*CO-EXISTENCE of mental health and 
substance use problem (pt have
schizophrenia and smoke cannabis )
*Third people with mental health problems
use substance (alcohol ,cigarettes ,
cannabis )

THE SIX FEATURES CHARACTERIS
INTEGRATED SERVICES FOR PATIENT WITH
DUAL DIAGNOSIS
123456-
COMPREHENSIVENES 
ASSERTIVE TRETMENT 
MOTIVATION BASED INTERVENTIONS
HARM REDUCTION 
MULTIPLE MODES OF DELIVERY 
ALONG TERM PERSPECTIVE 

WORKING WITH DUAL DIAGNOSIS IN AN
INPATIENT ENVIROMENT
Good clinical practice for nurses 
working with dual diagnosis patients
in inpatient units should focus on
keeping patients engaged in
treatment, helping them consider for
themselves if they want to reduce or
stop using and promoting harm
reduction strategies