The pattern of psychiatric disorders among the aged in a selected community in Nigeria

OBJECTIVE: To describe the common mental disorders in elderly Nigerians living at home. METHOD: A house-to-house survey of a rural community was conducted to identify subjects who were aged 60 years and above. The subjects were interviewed with the Self-Reporting Questionnaire (SRQ-24) and the Geriatric Mental State Schedule (GMS). Psychiatric syndromal diagnoses were made with the Clinical and Research ICD-10 manuals (ICD-10/ICD-10, DCR). RESULTS: The overall rate of major mental disorders was 23.1%, with depression constituting 79% of all the diagnoses. Specific dementia disorders were not found in any of the subjects (N=164), but 20.7% complained of forgetfulness. Use of tobacco (snuff), (local) alcohol, and other substances were common. No subject with any identified disorder was receiving any medical attention. CONCLUSION: The study reveals the same range of mental disorders as in studies carried out elsewhere. This suggests that if similar methodologies are used, the mental morbidity rates among the elderly in different parts of the world may be about the same. There is a need for adequate planning to accommodate the social security and mental health needs of old Nigerians.     

Critical approach to emergency care in consultation psychiatry]

36 patients consecutively admitted in medical and surgical wards of Reims' University Hospital, and referred to the Psychiatric Emergency Unit, were assessed for their psychiatric morbidity (DMS-III-R, axis I) and their psychiatric dangerousness. Approximately one third of the patients didn't suffer from any mental disorder and belonged to the area of psychological medicine. One third showed reactional disorders, were dangerous and were then admitted in a psychiatric department. The risks of the development of liaison psychiatry are discussed by authors--for example, the hardly admitted concept of psychiatric emergency is in danger of losing value.     

Mental disorders among elderly people in primary care: the Linköping study

OBJECTIVE: The aims of this study were to describe the prevalence of mental disorders among elderly patients in primary care and to compare diagnoses from psychiatric interview with diagnoses in medical records. METHOD: Patients aged 70 years and above attending a primary care centre (N = 350) were studied using a psychiatric and medical record examination. RESULTS: The prevalence of mental disorder according to the psychiatric interview was 33% (16% dementia, 17% other mental disorders). Only 49% of these had any psychiatric diagnosis in case records and 17-38% received specific treatments. The frequency of psychiatric symptoms among those with no mental disorder was between 1% and 66%. Patients with mental disorders were more often females, had more visits to a doctor, more diagnoses in medical records, and were prescribed more drugs. CONCLUSION: Mental disorders and symptoms are common among the elderly in primary care. More effort should be made to increase the recognition rate.     

Psychiatric diagnoses,outcomes and lengths of stay of patients admitted to an acute psychogeriatric unit

One hundred and ten consecutive patients admitted to an acute psychogeriatric unit were assessed with the Geriatric Mental State Schedule, Assigned a DSM-III-R diagnosis and their length of stay in hospital and discharge destination noted. Forty-two per cent of patients had organic disorders (mainly dementia), 32% had affective disorders (mainly depression) 23% had schizophrenia or a related disorder. The median length of stay was 29 days and bore little relation to diagnosis, age, sex or cognitive function. Patients with an organic mental disorder were more likely to enter long-term institutional care, but 78% of patients were able to return to the same level of accommodation (own home, hostel or nursing home) that they had occupied prior to admission. On a four-point non-blind outcome scale, 86% of patients were rated as improved at discharge.     

A contemporary protocol to assist primary care physicians in the treatment of panic and generalized anxiety disorders

Anxiety disorders are prevalent in primary care practice and generate a significant excess of morbidity, health services utilization, and health care expenditures. Complexities in delivering effective care for such disorders have led to stepped collaborative care models that involve nonphysician care managers following guideline-based protocols under the direction of patients' primary care physicians and a medical specialist. With the goal of aiding colleagues attempting to improve the primary care for panic and generalized anxiety disorders, we detail the collaborative care strategy for treatment of these conditions used by our National Institute of Mental Health (NIMH)-funded clinical trial in which a telephone-based care manager performs timely, patient-specific clinical and case management tasks. We illustrate the clinical considerations underlying the steps taken to implement and then sustain our care manager intervention at four geographically dispersed primary care practices linked by a common electronic medical record system and the modifications made as we encountered clinical situations common to typical practice settings. This report serves to familiarize physicians contemplating use of a similar strategy for improving the quality of primary care for an anxiety disorder or any other chronic mental health condition.     

Use of mental health services in a developing country

BACKGROUND: Evidence from developed industrialized countries suggests poor uptake of mental health services. No data exist in developing resource-constrained countries about met and unmet need for mental health service in the community. METHOD: A four-stage stratified probability sample of households was studied in the Yoruba-speaking part of Nigeria (population, approximately 25 million people or 22% of the Nigerian national population). Face-to-face interviews were conducted with persons 18 years old and above (n=4,984) using the World Mental Health version of the Composite International Diagnostic Interview. We determined the proportions of respondents with 12-month Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety, mood, or substance use disorder who had received any mental health treatment and the correlates of treatment receipt. RESULTS: Only 9.0% of those with any 12-month DSM-IV disorder had received treatment. While 11% of those with a mood disorder had received some treatment, none of those with substance use disorders had used a mental health service. Most treatments were received from general medical settings, with only about 1% of those with DSM-IV disorders receiving specialist mental health service. Surprisingly, complementary or alternative health providers were also consulted by only about 4% of those with mental disorders, although a much higher proportion of 57% of those with no DSM-IV disorders but who nevertheless received mental health treatment did so from such providers. Irrespective of the disorders or the sector where treatment was received, virtually no treatment was adjudged minimally adequate. CONCLUSION: There is a striking level of unmet need for mental health service in the community in this developing country setting. While inadequacy of the formal public health sector may be partly responsible for this observation, there is the likelihood that receipt of treatment for mental health problems may also be hampered by the public's poor knowledge of the nature of the disorders and by stigma.     

PREVALENCE OF COGNITIVE IMPAIRMENT IN THE HOSPITALIZED ELDERLY

Surveys of older populations reveal rates of senile dementia varying from 5.2% to 25%. The specialist branch of psychiatry dealing with the elderly advocates that services for these patients and their carers should predominantly be based outside hospital. The following study was conducted in Limerick, Ireland before the arrival of a consultant in old age psychiatry and associated services. Its aim was to assess the extent to which the patients with dementing disorders were using hospital facilities other than those in psychiatric wards. The study assessed 371 patients aged 65 years and over in various medical and surgical units. The Mini Mental State Examination was performed on all patients. Patients with scores of 23/31 or less were considered to have significant cognitive impairment and those with 16 or less to have severe impairment. As mental performance can be impaired by acute illness, methods were used to avoid such patients being wrongly labelled as suffering from dementia. In the acute hospital 112 patients with an average age of 74.7 years were examined and 22.3% of these had significant cognitive impairment. These patients were predominantly sited on medical wards. On acute medical wards 31% of older patients had significant impairment compared to only 7.3% on the surgical wards. In the orthopaedic unit 15.8% of the elderly had evidence of cognitive impairment. In hospitals specializing in continuing care of the elderly the proportion was 70.6% and of these 46% were severely impaired. We conclude that in the absence of specialized dementia services for the elderly, medical beds both in the acute and long-stay sector will be used for these patients more than their medical needs might otherwise require. © 1997 by John Wiley & Sons, Ltd.     

Psychiatric morbidity and acute hospitalization in elderly people

BACKGROUND: Few studies have investigated the association of psychiatric morbidity with acute hospitalization risk in elderly people. METHOD: We examined this association using population-based data for 1092 older adults aged > or =60 years in Singapore, including subjects who reported at least one acute hospitalization from any medical condition(s) in the 12 months prior to interview (N = 136). Psychiatric morbid/comorbid disorders were diagnosed using the Geriatric Mental State examination. RESULTS: In a multivariate analysis, comorbid psychiatric disorders were independently associated with hospitalization [adjusted odds ratio 2.76, 95% confidence interval 1.20-6.33], after controlling for age, ethnicity, employment status, number of medical comorbidities, number of activities of daily living limitations, hearing and visual impairment, SF-12 Physical and Mental Component Summary scores, social, productive, fitness and health activities, and regular visits to health-care providers. Neither dementia diagnosis nor cognitive impairment measured by the Mini-mental State Examination was associated with increased hospitalization risk. CONCLUSION: Psychiatric morbidity in old age was significantly associated with increased hospitalization risk. This finding underlines the importance of treating psychiatric illness to reduce the risk of acute hospitalization in elderly patients.     

The Mini Mental State in those with developmental disabilities

The Mini Mental State Examination is a useful screen for the detection of cognitive disorders among psychiatric patients. In the absence of a developmental disability, the inability to perform satisfactorily on the Mini Mental State (MMS) (score less than 24) is likely to be related to delirium, dementia, or affective disorders. The mildly retarded or learning disabled should perform satisfactorily (greater than 24) on the MMS but may show impairment with delirium, dementia, or affective disorders. In the absence of a psychiatric disorder, it takes moderate mental retardation (IQ less than 55) or severe reading disability with IQ less than 70 to produce an MMS score of less than 24. The MMS should not be considered a screen for mental retardation, because retarded individuals can function adequately (greater than 24) on the MMS.     

Elderly patients with major depressive disorder and delusional disorder are at increased risk of subsequent dementia

All the patients (n=150) admitted to psychogeriatric clinic during a 1-year period were followed up until their death or for 10 years. Fifteen of these were lost during the 10-year follow-up. Thus, follow-up data were available for 135 patients. Twenty-four of these fulfilled at baseline the DSM-III-R diagnostic criteria of major depressive disorder and 18 of delusional disorder after careful medical examination and neuropsychological tests to eliminate organic causes. In the follow-up, the diagnoses were gathered from the death certificates of those patients who died during the 10-year period and all of the patients alive at the end of the study were interviewed to assess their mental state. Six out of the 24 (25%) patients with major depressive and five out of 18 (28%) patients with delusional disorder developed clear organic dementia before death or within 10 years (mean follow-up time 6.7 years). This is approximately double the expected incidence in the general population of that age. The gender, age at index admission, the baseline Mini Mental State Examination scores or findings in computer tomography did not contribute to the risk of dementia. Psychogeriatric patients admitted due to major mental disorder may have an increased risk of organic dementia in the near future.     

Delirium and dementia in acute medical admissions of elderly patients in Iceland

A prospective study was carried out in a general hospital in Reykjavik to evaluate the prevalence of delirium and dementia among 331 patients 70 years and older who were admitted as an emergency to the medical department. Cognitive function was screened with Mental Status Questionnaire (MSQ) and Mini-Mental State Examination (MMSE) and diagnosed according to DSM-III-R for delirium and dementia. Other information obtained included social and demographic factors, drug consumption, the main condition underlying the delirium and outcome. Severe cognitive dysfunction was present in 32% of all acutely admitted patients 70 years and older, which were diagnosed further as delirium 14% and dementia 18%. At follow-up, concurrent dementia was found in 70% of the delirium patients. The main causes for delirium were cardiac failure 27%, stroke 22% and sepsis 16% and the mortality rate was 32% compared with 8% in dementia alone. The prognosis of patients with delirium and dementia depends on detecting these disorders, and the clinical skills of physicians working with acutely ill elderly patients can be improved by relatively simple screening questionnaires such as the MSQ and MMSE.     

Psychogeriatric services for outpatients undergoing long-term care at Mental Silver Clinic

Background:  The Wakae Clinic opened its Mental Silver Clinic in May 2002 to provide psychogeriatric services for outpatients with long-term care insurance, and medical services and care for patients with senile mental disorders, mainly dementia.
Methods:  The present report describes a study of 100 patients who received services from the Mental Silver Clinic over 5 years, from January 2003 to December 2007. It compares the age of first diagnosis and age of onset disorder with confirmed diagnosis, results of the initial Mini-Mental State Examination, and Behavioral and Psychological Symptoms of Dementia (BPSD), as well as other parameters.
Results:  Sixty-three of the patients (63%) were diagnosed with dementia. The most problematic behaviors are identified, the most frequent of which was delusion, followed by hallucination, reversed day and night or insomnia, negligence of fire, and delirium.
Conclusions:  The number of VaD patients was smaller than DLB patients at mental clinic.     

Mortality associated with incident mental health disorders after stroke

OBJECTIVE: Sparse information is currently available about the incidence of the major psychiatric syndromes following a stroke and their long-term contribution to morbidity and mortality. This study was designed to determine: (1) the incidence of first ever mental health disorder in amongst stroke patients; (2) the 10-year mortality associated with incident post-stroke mental health disorders. METHODS: Design: Retrospective cohort study. Setting: Entire Western Australian community. Participants: First-ever stroke in 1990. Subjects with a prior recorded history of any mental health disorder were excluded from the study. Main outcomes of interest: Incident mental health diagnoses and 10-year mortality. RESULTS: 1,129 hospital stroke contacts were recorded in 1990, with 21 people dying on the same day of contact. Between 1990-2002 36.6% of the survivors received a mental health diagnosis (6.1 per 1,000 person-years): alcohol-related disorders (16.2%), dementia (12.1%), delirium (7.6%), psychotic disorders (6.7%), and depression (5.5%). Mental health disorder onset was usually within 6 months of the stroke. Patients with an incident psychotic disorder were twice as likely to die during the subsequent 10 years as post-stroke controls with no mental health disorder (risk ratio = 2.03, 95%CI = 1.39-2.95). Being a widow (HR = 1.61, 95%CI = 1.13-2.30) or having been born in 'other countries' as opposed to Australia (HR = 1.56, 95%CI = 1.15-2.11) was also associated with increased death hazard. CONCLUSIONS: Approximately 1 in 3 patients develop a mental health disorder after stroke, although incidence estimates are relatively low. Post-stroke psychosis is associated with greater 10-year mortality, but the mechanisms underlying such an association are yet to be determined.     

Research priorities in mental health,part 1: an evaluation of the current research effort against the criteria of disease burden and health system costs

OBJECTIVE: To examine the amount of research that various mental disorders are currently receiving in Australia and compare this with the disease burden and health system costs attributable to these disorders. METHOD: A content analysis was carried out on a year's worth of published articles and a year's worth of competitive research grants. Abstracts of articles and grants were coded for a number of attributes, including the type of mental disorder covered. The percentage of articles and grant funding for various mental disorders was compared against published data on the disease burden and health system costs attributable to these disorders. RESULTS: Mental disorders contribute 19.1% of disease burden and 9.8% of health system costs, but receive only 8.9% of National Health and Medical Research Council funding. An examination of the distribution of research within the mental health area showed that substance use disorders are by far the most researched in terms of both publications and grant funding, followed by affective disorders. By contrast, affective disorders account for the most burden, followed by dementia, substance use and anxiety disorders. The biggest consumers of health system costs are dementia, affective disorders, and schizophrenia and other psychoses. CONCLUSIONS: While all mental disorders merit more research attention than they are currently receiving, affective disorders and dementia appear to be particularly under-researched given their contribution to disease burden and health system costs.     

Mental disorders and quality of diabetes care in the veterans health administration

OBJECTIVE: The population of persons with mental disorders is potentially vulnerable to poor quality of medical care. This study examined the relationship between mental disorders and quality of diabetes care in a national sample of veterans. METHOD: Chart-abstracted quality data were merged with outpatient and inpatient administrative database records for a sample of veterans with diabetes who had at least three outpatient visits in the previous year (N=38,020). Mental health diagnoses were identified by use of the administrative data. Quality of diabetes care was assessed with five indicators by chart documentation: annual foot inspection, pedal pulses examination, foot sensory examination, retina examination, and glycated hemoglobin determination. RESULTS: Approximately a quarter of the sample had a diagnosed mental disorder (23.7% with psychiatric disorder only, 1.3% with substance use disorder only, and 2.6% with a dual diagnosis). Overall rates of receipt for the indicators were higher than national benchmarks for all patient subgroups, ranging from 70.8% for retina examination to 95.0% for foot inspection. Rates for both retina examination and foot sensory examination differed significantly by mental health status, mainly because of lower rates among those with a substance use disorder. The associations remained significant in multivariate generalized estimating equation analyses that controlled for demographic characteristics, health status, use of medical services, and hospital-level characteristics. CONCLUSIONS: Rates for secondary prevention of diabetes were remarkably high at Department of Veterans Affairs medical centers, although patients with mental disorders (particularly substance use disorders) were somewhat less likely to receive some of the recommended interventions.     

Clinical utility of computed tomography in the assessment of dementia: a memory clinic study

OBJECTIVE: To define the influence of computed tomography (CT) on clinical decision-making in the outpatient evaluation of dementia. DESIGN: A case series in which two physicians reviewed standardised data extracted from clinical records, first blind to CT results, and then with CT results. Clinical decisions made with and without the input of CT were compared. The study was based in an outpatient referral centre for the assessment of memory disorders and dementia. The study involved 146 participants who were diagnosed with dementia after their first clinic visit, had Mini Mental State Examination scores >12, were aged >65 years, and had no history of neurologic disease. RESULTS: CT impacted on diagnosis in an average of 12% (+/-2), and on treatment plan in 11% (+/-2) of cases. Physicians predicted a priori which cases CT may influence with an average sensitivity of 28% (+/-2), and specificity of 78.5% (+/-1.5). There was no statistically significant relationship between diagnostically uncertain cases and helpful CT scans [average chi(2) = 1.121 (+/-1.116), p = ns]. Blind to CT physicians appropriately identified cerebrovascular disease with an average sensitivity of 63% (+/-3), and specificity of 93.5% (+/-3.5). CONCLUSIONS: In the outpatient setting, CT may be expected to impact on diagnosis and treatment of dementia in 10% to 15% of cases. Memory clinic physicians recognise and treat cerebrovascular risk factors with reasonable sensitivity and specificity without the input of CT.     

The relationship between mental disorders and medical service utilization in a representative community sample

BACKGROUND: Frequent use of health services has been associated with mental disorders and psychological distress. The present study aimed to determine how mental disorders affect the likelihood of using health services in a nationally representative sample. METHOD: The analysis was based on data on 3726 respondents aged 18-65 years from the German National Health Interview and Examination Survey, a nationally representative multistage probability survey conducted from 1997 to 1999. Health care utilization in the previous year was measured by a self-report questionnaire. Psychiatric diagnoses were assessed by a modified version of the Composite International Diagnostic Interview. RESULTS: The relationship between mental illness and medical service utilization was substantial and significant. Twelve-month prevalence rates for respondents with normal health service use were 10.2 % (affective disorders), 11.9 % (anxiety disorders), 8.9 % (somatoform disorders), and 15.4 % (substance use disorder). In contrast, 12-month prevalence rates for high utilizers were 25.1 % (affective disorders), 29.3 % (anxiety disorders), 22.2 % (somatoform disorders), and 17.1 % (substance use disorder). CONCLUSIONS: High utilizers of health care service should be assessed for common mental disorders. Efforts should be made to increase awareness, recognition, and appropriate early intervention of mental disorders.     

Mental disorders and asthma in the elderly: a population-based study

BACKGROUND: Clinical studies have mostly linked anxiety disorders with asthma in young patients, but the data are inconsistent for depression. Few population-based studies have investigated the co-morbid diagnoses of mental disorders with asthma in older adults. METHOD: Cross-sectional study of a population sample of older adults aged 60 and above (n = 1092). The diagnoses of recent depression and anxiety were made using the Geriatric Mental State (GMS) Schedule. The presence of asthma was ascertained by self-reports of physician-diagnosed asthma. RESULTS: Asthma was associated with a higher prevalence of depressive disorders, with odds ratio of 2.45 (95% CI, 1.06-5.69) when compared against non-asthmatic controls; and 2.42 (95% CI, 1.04-5.64) when compared against controls with other chronic illnesses, after adjusting for psychosocial factors, physical co-morbidity and use of depression-causing drugs. Odds ratios were elevated but statistically insignificant for anxiety disorders and dementia. CONCLUSION: We observed that asthma in the elderly was more evidently associated co-morbidly with depression, rather than anxiety disorder. However, possible associations with anxiety and dementia are not excluded, and should be further investigated.     

Prevalence and severity of mental health-related disability and relationship to diagnosis.

OBJECTIVE: Psychiatric disability has been defined largely from measures that focus on serious mental illness. This practice may have led to substantial underestimation of the total impact of mental disorders on community health. In this study a generic measure of mental health-related disability was used to examine disabilities attributable to various common mental disorders. METHODS: Data were drawn from the Australian National Survey of Mental Health and Wellbeing, a household survey of 10,641 adults that assessed participants for 14 DSM-IV disorders with use of the Composite International Diagnostic Interview. Screening instruments were used to identify likely cases of ICD-10 personality disorder, neurasthenia (an undifferentiated somatoform disorder), and psychosis. Mental health disability was assessed with the Medical Outcomes Study 12-item Short Form (SF-12) mental health summary scale, which was administered to all participants. RESULTS: Disability was significantly greater among participants with a current psychiatric diagnosis, and disability varied by type of disorder. Diagnosis remained a strong predictor of disability after sociodemographic factors and physical illness were controlled for. Disorders found to be independently associated with disability were depression, panic disorder, agoraphobia, social phobia, generalized anxiety disorder, alcohol dependence, and drug dependence. CONCLUSIONS: Substantial proportions of persons with mental disorders that are not usually classified as major mental disorders reported moderate and severe disability. A generic measure of mental health-related disability was able to detect variations in disability among persons with different diagnoses. Although such a measure is not as sensitive as a disorder-specific measure developed for use in psychiatric populations, it can facilitate comparison of disability across common mental disorders.