Inpatient mother-and-child postpartum psychiatric care: Factors associated with improvement in maternal mental health

Purpose

This study assessed the underexplored factors associated with significant improvement in mothers’ mental health during postpartum inpatient psychiatric care.

Methods

This study analyzed clinical improvement in a prospective cohort of 869 women jointly admitted with their infant to 13 psychiatric Mother-Baby Units (MBUs) in France between 2001 and 2007. Predictive variables tested were: maternal mental illness (ICD-10), sociodemographic characteristics, mental illness and childhood abuse history, acute or chronic disorder, pregnancy and birth data, characteristics and mental health of the mother's partner, and MBU characteristics.

Results

Two thirds of the women improved significantly by discharge. Admission for 25% was for a first acute episode very early after childbirth. Independent factors associated with marked improvement at discharge were bipolar or depressive disorder, a first acute episode or relapse of such an episode. Schizophrenia, a personality disorder, and poor social integration (as measured by occupational status) were all related to poor clinical outcomes.

Discussion

Most women improved significantly while under care in MBUs. Our results emphasize the importance of the type of disease but also its chronicity and the social integration when providing postpartum psychiatric care.     

Patient’s views on depression care in obstetric settings: how do they compare to the views of perinatal health care professionals?

Objectives

The objectives were to examine patients’ perspectives on patient-, provider- and systems-level barriers and facilitators to addressing perinatal depression in outpatient obstetric settings. We also compare the views of patients and perinatal health care professionals.

Method

Four 90-min focus groups were conducted with women 3–36 months after delivery (n=27) who experienced symptoms of perinatal depression, anxiety or emotional distress. Focus groups were transcribed, and resulting data were analyzed using a grounded theory approach.

Results

Barriers to addressing perinatal depression included fear of stigma and loss of parental rights, negative experiences with perinatal health care providers and lack of depression management knowledge/skills among professionals. Facilitators included psychoeducation, peer support and training for professionals.

Conclusions

Patients perceive many multilevel barriers to treatment that are similar to those found in our previous similar study of perinatal health care professionals’ perspectives. However, patients and professionals do differ in their perceptions of one another. Interventions would need to close these gaps and include an empathic screening and referral process that facilitates discussion of mental health concerns. Interventions should leverage strategies identified by both patients and professionals, including empowering both via education, resources and access to varied mental health care options.     

Comorbidity in posttraumatic stress disorder: a structural equation modelling approach

Objective

Posttraumatic stress disorder (PTSD) is associated with high rates of psychiatric comorbidity. Existing theories consider comorbidity as a consequence of PTSD (model 1), PTSD and comorbidity as a consequence of shared factors of vulnerability (model 2), and comorbidity as a consequence of trauma-type specific mechanisms (model 3).

Method

To compare the explanatory value of these models, we assessed PTSD (model 1), sense of coherence (model 2) and satisfaction with health (model 3) and symptoms of anxiety and depression as indicators of comorbidity 5 days (t1) and 6 months (t2) postaccident in 225 injured accident survivors. Structural equation models representing models 1 to 3 were tested separately and combined.

Results

Combined, models 1 and 3 explained 82% of the variance of comorbid symptoms at t2. Posttraumatic stress disorder and satisfaction with health (t2) exerted strong influences on comorbid symptoms.

Conclusion

Comorbidity besides PTSD is best described by an integration of competing explanatory models.     

Prescribing practices in psychiatric hospitals in Eastern Europe

Background

There has been no evidence about the prescribing practices in psychiatric care in Eastern Europe.

Aims

To examine the patterns of psychotropic prescribing in five countries of Eastern Europe.

Method

We conducted a one-day census of psychiatric treatments used in eight psychiatric hospitals in Albania, Croatia, Macedonia, Serbia and Romania. We examined clinical records and medication charts of 1304 patients.

Results

The use of polypharmacy was frequent across all diagnostic groups. Only 6.8% of patients were on monotherapy. The mean number of prescribed drugs was 2.8 (SD 0.97) with 26.5% receiving two drugs, 42.1% receiving three drugs and 22.1% being prescribed four or more psychotropic drugs. Typical antipsychotics were prescribed to 63% and atypical antipsychotics to 40% of patients with psychosis. Older generations of antidepressants were prescribed to 29% of patients with depression. Anxiolitic drugs were prescribed to 20.4% and benzodiazepines to 68.5% of patients. One third of patients received an anticholinergic drug on a regular basis.

Conclusions

Older generation antipsychotics and antidepressants were used more frequently than in the countries of Western Europe. Psychotropic polypharmacy is a common practice. There is a need for adopting more evidence-based practice in psychiatric care in these countries.     

Patients’ subjective initial response and the outcome of inpatient and day hospital treatment

Objective

This study aimed to establish whether psychiatric patients’ subjective initial response (SIR) to hospital and day hospital treatment predicts outcomes over a one-year follow-up period.

Method

We analysed data from 765 patients who were randomised to acute psychiatric treatment in a hospital or day hospital. SIR was assessed on day 3 after admission. Outcomes were psychiatric symptom levels and social disability at discharge, and at 3 and 12 months after discharge.

Results

After controlling for socio-demographic and clinical characteristics, a more positive SIR was significantly associated with lower symptom levels at discharge and 3 months after discharge and lower social disability at 3 months and 12 months after discharge.

Conclusion

SIR can predict outcomes of complex interventions over a one-year period. Patients’ initial views of acute hospital and day treatment should be elicited and considered as important.     

Use of and satisfaction with support received among survivors from three Scandinavian countries after the 2004 Southeast Asian tsunami

Introduction

There is limited guidance regarding effective preventions for post-disaster mental health problems and what kind of support is preferred by disaster survivors.

Aim

To describe the use of and satisfaction with support in three Scandinavian countries after the tsunami and analyzing the association between support and posttraumatic stress reactions.

Method

The sample comprises 6772 responders who returned to Scandinavia from the tsunami-struck countries of Southeast Asia in 2004.

Results

Most were satisfied with informal support on site. Support from embassies/consulates was not received well, leaving about 64% of the Danes/Norwegians and 73% of the Swedes dissatisfied. After returning home, support from close relatives rendered highest degree of satisfaction. Consultation with general practitioner (GP) was reported by 63% of Norwegians, 40% of Danes, and 16% of Swedes. Most responders (60-77%) were satisfied with their GP, although Norwegians were least satisfied. Using support was associated with higher levels of posttraumatic stress symptoms.

Conclusions

Informal support was used to a high degree and rendered considerable satisfaction in all three countries, while the use of and satisfaction with formal support varied more. Lack of satisfaction with embassies and consulates may indicate deficiencies in the authorities’ preparedness in assisting disaster stricken citizens abroad.     

Medication management of depression: the impact of comorbid chronic medical conditions

Objective

This paper addresses the following question: Does quality of care for depression differ between depressed persons with and without chronic medical conditions (CMCs)?

Methods

We used a population-based mental health survey to identify respondents aged 18 to 64 with the diagnosis of major depression in the past year (N=278). In our model, the dependent variable was guideline-level medication management of depression. Determinants for guideline-level care were modeled using multivariate logistic regression.

Results

Depressed persons with CMCs were significantly more likely to receive guideline-level care for depression than were the depressed persons without CMCs (OR=1.46; 95% C.I.=1.12-1.90). This increased likelihood did not persist when the sample excluded persons seeing physicians at more than eight visits per year (OR=0.81; 95% CI=0.35-1.90). Previous psychiatric hospitalization was the only other significant determinant of guideline-level care.

Conclusion

Depressed persons with comorbid CMCs are more likely to receive guideline-level care for depression than are depressed persons without comorbid CMCs. However, the association did not persist once we excluded respondents who were high utilizers. This finding implies that further understanding of the interaction between depression care and comorbid CMCs will require a longitudinal focus on repeated physician-patient interactions.     

Attitudes of Japanese nursing personnel toward patients who have attempted suicide

Objective

The aim of this study was to examine the attitudes among Japanese nurses together with their perceived need for training in relation to understanding the nature of suicidal behavior and preventive strategies.

Methods

The Understanding Suicidal Patients scale together with additional questions reflecting training and the psychiatric treatment of suicide attempters were administered.

Results

A total of 323 nurses attended this study. Overall, the nurses thought patients who attempted suicide were not treated well. The nurses who worked in the psychiatric unit or had the experience in psychiatric nursing had more favorable attitudes toward suicidal patients and viewed themselves as having more relevant skill training in dealing with suicidal patients than those who did not. The nurses who worked at emergency care/intensive care unit were less likely to understand suicidal patients, and were less inclined to be sympathetic and to verbally interact with suicidal patients concerning their problems. The nurses who have confidence in the psychiatric care of suicidal patients, confidence in their own skills, and have a need for more training had the more positive attitudes.

Conclusions

The results suggest that less favorable attitudes may to some extent be the result of lack of knowledge regarding suicidal patients. Future studies should focus on the evaluation of educational experiences on attitudes and skill acquisition of nurses.     

Meaning in life, anxiety, depression, and general health among smoking cessation patients

Objective

Psychosocial factors play a widely recognized role in health and health care utilization. The present study investigated relations among meaning in life, depression, anxiety, and social support with self-reported general health.

Method

Ninety-nine smoking cessation group patients were recruited to complete questionnaires during their third week of treatment.

Results

Depression was the strongest predictor of perceived general health. However, the interaction of people's experience of meaning in life and their propensity to seek deeper meaning in their lives predicted variance in perceived health above and beyond depression. Furthermore, propensity to seek meaning in life was the only psychosocial correlate of people's perceived social benefits of health care utilization.

Conclusion

Psychosocial factors, particularly depression and the two primary dimensions of meaning in life (experiencing and seeking), were related to perceived health. Meaning in life thus emerges as a variable worth further scrutiny in the health of clinical populations.     

Enhancing the population impact of collaborative care interventions: mixed method development and implementation of stepped care targeting posttraumatic stress disorder and related comorbidities after acute trauma

Objective

The objective of the study was to develop and implement a stepped collaborative care intervention targeting posttraumatic stress disorder (PTSD) and related comorbidities to enhance the population impact of early trauma-focused interventions.

Method

We describe the design and implementation of the Trauma Survivors Outcomes and Support study. An interdisciplinary treatment development team was composed of trauma surgical, clinical psychiatric and mental health services “change agents” who spanned the boundaries between frontline trauma center clinical care and acute care policy. Mixed method clinical epidemiologic and clinical ethnographic studies informed the development of PTSD screening and intervention procedures.

Results

Two hundred seven acutely injured trauma survivors with high early PTSD symptom levels were randomized into the study. The stepped collaborative care model integrated care management (i.e., posttraumatic concern elicitation and amelioration, motivational interviewing and behavioral activation) with cognitive behavioral therapy and pharmacotherapy targeting PTSD. The model was feasibly implemented by frontline acute care masters in social work and nurse practioner providers.

Conclusions

Stepped care protocols targeting PTSD may enhance the population impact of early interventions developed for survivors of individual and mass trauma by extending the reach of collaborative care interventions to acute care medical settings and other nonspecialty posttraumatic contexts.