Meeting the mental health needs of people with multiple sclerosis: a qualitative study of patients and professionals

Purpose: To explore perspectives and experiences of people with multiple sclerosis (MS) and health care professionals of mental health support for MS in the UK.

Method: 24 people with MS, 13 practice nurses, 12 general practitioners (GPs) and 9?MS specialist nurses were recruited through community groups and primary care practices across North West England. Semi-structured interviews were conducted, and data analyzed thematically using constant comparative analysis within and across the data sets. The theoretical framework of candidacy was used to interrogate data.

Results: Four themes were identified: candidates for care, management choices, defining roles, and permeability and responsiveness.

Discussion: Candidacy for care, and symptom management, depended on the framing of symptoms through a social or medical model of depression. Normalizing symptoms could prevent help-seeking by patients. Reported referral behavior varied by professional group, based on perceived remit, competency and training needs. GPs were perceived by patients and other professionals as central for management of mental health needs in MS, but may not perceive this role themselves, suggesting a need for increased knowledge, training, and improved access to specialist care.

• Implications for Rehabilitation

• Anxiety and depression are common in people with MS.

• Management of mental health needs in people with MS relies on complex decisions made by both people with MS and health care professionals.

• General practitioners may play a key role in the ongoing management of mental health needs of people with MS.

     

Comorbid insomnia in patients with chronic pain: a study based on the Swedish quality registry for pain rehabilitation (SQRP)

Abstract

Purpose: This study investigates the prevalence of insomnia and its relationship to other symptoms and health aspects in patients with chronic pain. Methods: Patients with chronic pain conditions (n?=?845) referred to a multidisciplinary pain centre completed surveys provided by the Swedish quality registry for pain rehabilitation (SQRP). The SQRP collects data on socio-demographics, health status, symptoms of pain, mood and insomnia and life satisfaction. Results: The majority of patients (65.3%) had clinical insomnia according to the insomnia severity index (ISI). Insomnia correlated significantly but weakly with pain, depression, anxiety and coping; the strongest multivariate correlations were found with depression and anxiety followed by pain interference and pain severity. Pain intensity, depression and anxiety correlated stronger than ISI with respect to the two investigated aspects of health. Conclusions: The prevalence of insomnia is high in patients with chronic pain conditions, but the level of importance in relation to other symptoms for health aspects is low, and the associations with other important symptoms are relatively weak. One way to increase the effects of multimodal rehabilitation programs may be to provide interventions directed specifically at insomnia rather than focusing only on interventions that address pain, depression and anxiety.

• Implications for Rehabilitation

• The prevalence of insomnia is high in patients with complex chronic pain conditions.

• Relatively low correlations existed between insomnia and pain intensity, depression, anxiety and other psychological aspects.

• Pain intensity, anxiety and depression were more important for perceived health aspects than insomnia.

• One way to increase the effects of multimodal rehabilitation programs may be to also include interventions directed directly to insomnia.

     

Creating a safety net for patients with depression in primary care; a qualitative study of care managers’ experiences

Abstract

Objective: The aim of this study was to explore nurses’ experiences and perceptions of working as care managers at primary care centers.

Design: Qualitative, focus group study. Systematic text condensation was used to analyze the data.

Setting: Primary health care in the region of Västra Götaland and region of Dalarna in Sweden.

Subjects: Eight nurses were trained during three days including treatment of depression and how to work as care managers. The training was followed by continuous support.

Main outcome measures: The nurses’ experiences and perceptions of working as care managers at primary care centers.

Results: The care managers described their role as providing additional support to the already existing care at the primary care center, working in teams with a person-centered focus, where they were given the opportunity to follow, support, and constitute a safety net for patients with depression. Further, they perceived that the care manager increased continuity and accessibility to primary care for patients with depression.

Conclusion: The nurses perceived that working as care managers enabled them to follow and support patients with depression and to maintain close contact during the illness. The care manager function helped to provide continuity in care which is a main task of primary health care.

• Key Points

• The care managers described their role as an additional support to the already existing care at the primary care center.

• ?? They emphasized that as care managers, they had a person-centered focus and constituted a safety net for patients with depression.

• ?? Their role as care managers enabled them to follow and support patients with depression over time, which made their work more meaningful.

• ?? Care managers helped to achieve continuity and accessibility to primary health care for patients with depression.

     

The relation of social support and depression in patients with chronic low back pain

Purpose: Depression is a common condition in adults with low back pain (LBP), and is associated with poorer patient outcomes. Social support is a modifiable factor that may influence depressive symptoms in people with LBP and, if so, could be a consideration in LBP management when depression is an issue. The aim of this study was to examine social support as a prognostic factor for depressive symptoms and recovery from depression in patients with LBP.

Method: Patients with LBP (n?=?483), recruited from four imaging centers in Canada, completed an initial survey following imaging and a follow-up survey one year later, including the Medical Outcomes Study (MOS) Social Support Survey and the Center for Epidemiologic Studies Depression Scale. Multivariable regression analyses were used to examine the relationship between social support and depression.

Results: More social support (overall functional social support) at baseline was associated with recovery from depression (OR?=?0.24; 95% CI 0.10, 0.55) and less depressive symptoms (β?=?1.68; 95% CI?=?0.36, 3.00) at one-year follow-up. In addition, associations were found between specific aspects (subscales) of social support and the two depression outcomes.

Conclusions: Functional social support as a prognostic factor for depression and possible target of LBP management warrants further investigation.

• Implications for Rehabilitation

• Depression is a common condition in adults with low back pain (LBP), and is associated with poorer patient outcomes.

• This study provides evidence for social support as a prognostic factor for depressive symptoms and recovery from depression in patients with LBP problems.

• Management of pain conditions may be enhanced by a better understanding of modifiable risk factors for depression, such as social support.

     

Awareness of hypertension and depressive symptoms: a cross-sectional study in a primary care population

Objective: To investigate the association of hypertension awareness and depressive symptoms, and to analyse factors predisposing aware hypertensives to depressive symptoms.

Design: Cross-sectional study in a primary care population.

Setting: Cardiovascular risk factor survey in two semi-rural towns in Finland.

Subjects: Two thousand six hundred seventy-six middle-aged risk persons without an established cardiovascular or renal disease or type 2 diabetes.

Main outcome measures: Depressive symptoms, previous and new diagnosis of hypertension.

Results: Hypertension was diagnosed in 47.9% of the subjects, of whom 34.5% (442/1 282) had previously undetected hypertension. Depressive symptoms were reported by 14% of the subjects previously aware of their hypertension, and by 9% of both unaware hypertensives and normotensive subjects. In the logistic regression analysis, both the normotensive (OR 0.62, 95% CI 0.45–0.86) (p?=?0.0038) and the unaware hypertensive subjects (OR 0.54, 95% CI 0.35–0.84) (p?=?0.0067) had lower risk for depressive symptoms than the previously diagnosed hypertensives. Among these aware hypertensives, female gender (OR 3.61, 95% CI 2.06–6.32), harmful alcohol use (OR 2.55, 95% CI 1.40–4.64) and obesity (OR 2.50, 95% CI 1.01–6.21) predicted depressive symptoms. Non-smoking (OR 0.57, 95% Cl 0.33–0.99) and moderate leisure-time physical activity compared to low (OR 0.53, 95% CI 0.33–0.84) seemed to buffer against depressive symptoms.

Conclusion: Depressive symptoms are common in hypertensive persons even without comorbidities, if the person is already aware of his/her hypertension. Many modifiable, lifestyle associated factors may contribute to the association of hypertension and depressive symptoms.

• Key Points

• Hypertension and depressive symptoms are known to form a toxic combination contributing even to all-cause mortality.

• Comorbidities or the labelling effect of the diagnosis of hypertension can confound their association.

• Our study shows that depressive symptoms are common in hypertensive persons even without comorbidities, if the person is already aware of his/her hypertension.

• Many modifiable, lifestyle-associated factors may contribute to the association of hypertension and depressive symptoms.

• When treating hypertensive patients, consideration of depressive symptoms is important in order to promote favorable lifestyle and control of hypertension.

     

A single-group pilot feasibility study of cognitive behavioural therapy in people with multiple sclerosis with depressive symptoms

Purpose: The aims were to evaluate (a) the feasibility of face-to-face cognitive behavioural therapy (CBT) in people with MS (PwMS) with depressive symptoms; (b) the feasibility of methods and measurements used; and (c) the outcome of the intervention before the conducting of an equivalence study of comparative methods of face-to-face CBT.

Design: A single-group pilot feasibility study.

Patients: PwMS (n?=?15) with sub-threshold to moderate depressive symptoms, recruited at the Karolinska University Hospital, Stockholm, Sweden.

Methods: The intervention consisted of 15–20 sessions of face-to-face CBT. Feasibility outcomes included recruitment rate, recruitment procedure and adverse events. Primary clinical outcome was the Beck Depression Inventory-II (BDI-II). Follow-ups were conducted after 3 weeks and 3 months. An estimated sample size calculation was conducted.

Results: The face-to-face CBT intervention, methods and measurements used were feasible. The outcome on BDI-II indicated that face-to-face CBT is an effective method for alleviating sub-threshold to moderate depressive symptoms in PwMS.

Conclusion: Face-to-face CBT is feasible for use in PwMS aiming at decrease depressive symptoms. For an equivalence study, a screening process for depressive symptoms and two comparative intervention arms including traditional face-to-face CBT and low-intensity face-to-face CBT is recommended. Primary outcomes should include the BDI-II and also assessment of anxiety symptoms.

• Implications for Rehabilitation

• Depression is common among people with MS (PwMS), however, depressed PwMS do not always receive adequate treatment for depression which may lead to increased disability and worse health-related quality of life (HRQL).

• Cognitive behavioural therapy (CBT) is a psychological treatment method that might be beneficial for PwMS with depressive symptoms, but the evidence is still weak and further research is needed.

• The results from our pilot feasibility study demonstrate that for an effectiveness study of face-to-face CBT for PwMS with sub-threshold to moderate depressive symptoms the following points should be acknowledged.

• The design of an effectiveness study should be a randomized controlled trial including two treatment arms: traditional face-to-face CBT and a low-intensity face-to-face CBT.

• To increase the inclusion rate a screening process for depressive symptoms is recommended.

• Primary outcomes besides the Beck Depression Inventory-II should include the Hospital Anxiety and Depression Scale in order to capture anxiety symptoms and the Multiple Sclerosis Impact Scale-29 to capture HRQL.

     

Patients’ ideas,concerns, expectations and satisfaction in primary health care – a questionnaire study of patients and health care professionals’ perspectives

Abstract

Objective: Explore the perceptions of patients and health care professionals about patients’ ideas, concerns, expectations (ICE), and satisfaction in consultations with general practitioners (GPs), district nurses (DNs) and physiotherapists (PTs).

Design: Cross-sectional questionnaire study of participants in planned consultations.

Setting: Five primary health care centers and two rehabilitation centers in Stockholm, Sweden.

Subjects: Pairs of patients and GPs (n?=?156), patients and DNs (n?=?73), and patients and PTs (n?=?69).

Main outcome measures: Multiple-choice questions about patients’ ICE and satisfaction.

Results: Approximately 75% of patients and GPs reported that patients’ thoughts and explanations about their symptoms emerged during the consultation. For patient-DN pairs, the figure was 60%, and for patient-PT pairs, 80%. A majority of patients reported not having concerns and anxiety about the investigation/treatment, whereas health care professionals thought patients were more concerned. One-third of patients consulting GPs and PTs expected to receive a reason/explanation for their symptoms. Figures were lower for the DNs. About 70% of patients were satisfied with the consultation.

Conclusions: Most patients expressed their ideas, a minority had concerns, and a minority expected an explanation of their illness. Patients and health care professionals rated patient satisfaction high, but health care professionals tended to believe patients were less satisfied than patients reported they were.

• Key points

• Patient surveys show that important aspects of patient-centeredness remain weak in Swedish primary health care; for example, shared decision-making.

• In this study of planned consultations, few patients expected to receive an explanation of their symptoms, but most were satisfied with the consultation.

• Health care professionals thought patients’ experiences were more negative than they were.

• This discrepancy was observed in responses to questions about patients’ concerns, expectations and satisfaction.

     

Psychoeducation against depression,anxiety, alexithymia and fibromyalgia: a pilot study in primary care for patients on sick leave

Objectives: Feasibility testing of a psychoeducational method -The Affect School and Script Analyses (ASSA) – in a Swedish primary care setting. Exploring associations between psychological, and medically unexplained physical symptoms (MUPS).

Design: Pilot study.

Setting: Three Swedish primary care centers serving 20,000 people.

Intervention: 8 weekly 2-hour sessions with a 5–7 participant group led by two instructors - followed by 10 individual hour-long sessions.

Subjects: Thirty-six patients, 29 women (81%), on sick-leave due to depression, anxiety, or fibromyalgia.

Outcome measures: Feasibility in terms of participation rates and expected improvements of psychological symptoms and MUPS, assessed by self-report instruments pre-, one-week post-, and 18 months post-intervention. Regression coefficients between psychological symptoms and MUPS.

Results: The entire 26-hour psychoeducational intervention was completed by 30 patients (83%), and 33 patients (92%) completed the 16-hour Affect School. One-week post-intervention median test score changes were significantly favorable for 27 respondents, with p?Conclusions: A psychoeducational method previously untested in primary care for mostly women patients on sick-leave due to depression, anxiety, or fibromyalgia had?>80% participation rates, and clear improvements of self-assessed psychological symptoms and MUPS. The ASSA intervention thus showed adequate feasibility in a Swedish primary care setting.

• Key Points

• ?A pilot study of a psychoeducational intervention – The Affect School and Script Analyses (ASSA) – was performed in primary care

• ??The intervention showed feasibility for patients on sick-leave due to depression, anxiety, or fibromyalgia

• ??92% completed the 8 weeks/16?hours Affect School and 83% completed the entire 26-hour ASSA intervention

• ??9 of 11 self-reported measures improved significantly one-week post intervention

• ??7 of 11 self-reported measures improved significantly 18 months post-intervention

     

Melatonin receptor 1B gene rs10830963 polymorphism,depressive symptoms and glycaemic traits

Abstract

Background: The association between depression and type 2 diabetes is bidirectional. Underlying biological determinants remain elusive. We examined whether a common melatonin receptor 1B gene diabetes risk variant rs10830963 influenced the associations between depressive symptoms and glycaemic traits.

Materials: The Prevalence, Prediction and Prevention of Diabetes-Botnia Study participants (n?=?4,455) with no diabetes who underwent an oral glucose tolerance test were genotyped for rs10830963 and completed the Mental Health Inventory on depressive symptoms.

Results: The rs10830963 did not influence significantly the associations between depressive symptoms and glycaemic traits. Yet, the addition of each copy of the minor G allele of the rs1080963 and higher depressive symptoms were both, independent of each other, associated significantly with higher glucose response (glucose area under the curve), higher insulin resistance (Insulin Sensitivity Index) and lower insulin secretion (Disposition Index). Depressive symptoms, but not rs1080963, were also significantly associated with higher fasting insulin, insulin area under the curve and insulin resistance (Homeostasis Model Assessment, Homeostasis Model Assessment-2); rs1080963, but not depressive symptoms, was significantly associated with higher fasting glucose and lower Corrected Insulin Response.

Conclusions: Our study shows that the diabetes risk variant rs10830963 does not contribute to the known comorbidity between depression and type 2 diabetes.

• Key messages

• The association between depression and type 2 diabetes is bidirectional.

• We tested whether a common variant rs10830963 in the gene encoding Melatonin Receptor 1B influences the known association between depressive symptoms and glycaemic traits in a population-based sample from Western Finland.

• The MTNR1B genetic diabetes risk variant rs10830963 does not contribute to the known comorbidity between depression and type 2 diabetes.

• Depressive symptoms and rs10830963 are associated with a worse glycaemic profile independently of each other.

     

Generalised anxiety disorder symptoms and utilisation of health care services. A cross-sectional study from the “Northern Finland 1966 Birth Cohort”

Objective: To analyse the utilization of health care services of people who tested positive for GAD compared to those who tested negative. Setting: A cross-sectional study from the Northern Finland 1966 Birth Cohort. Subjects: A total of 10,282 members followed from birth in a longitudinal study were asked to participate in a follow-up survey at the age of 46. As part of this survey they filled in questionnaries concerning health care utilization and their illness history as well as the GAD-7 screening tool. Althogether 5,480 cohort members responded to the questionnaries. Main outcome measures: Number of visits in different health care services among people who tested positive for GAD with the GAD-7 screening tool compared to those who tested negative. Results: People who tested positive for GAD had 112% more total health care visits, 74% more total physician visits, 115% more visits to health centres, 133% more health centre physician visits, 160% more visits to secondary care, and 775% more mental health care visits than those who tested negative. Conclusion: People with GAD symptoms utilize health care services more than other people.

• Key Points

• Generalised anxiety disorder (GAD) is a common but poorly identified mental health problem in primary care.

• People who tested positive for GAD utilise more health care services than those who tested negative.

• About 58% of people who tested positive for GAD had visited their primary care physician during the past year.

• Only 29% of people who tested positive for GAD had used mental health services during the past year.

     

Contact with primary health care physicians before an acute hospitalisation

Abstract

Objectives: To assess contacts with general practitioners (GPs), both regular GPs and out-of-hours GP services (OOH) during the year before an emergency hospital admission.

Design: Longitudinal design with register-based information on somatic health care contacts and use of municipality health care services.

Setting: Four municipalities in central Norway, 2012–2013.

Subjects: Inhabitants aged 50 and older admitted to hospital for acute myocardial infarction, hip fracture, stroke, heart failure, or pneumonia.

Main outcome measures: GP contact during the year and month before an emergency hospital admission.

Results: Among 66,952 identified participants, 720 were admitted to hospital for acute myocardial infarction, 645 for hip fracture, 740 for stroke, 399 for heart failure, and 853 for pneumonia in the two-year study period. The majority of these acutely admitted patients had contact with general practitioners each month before the emergency hospital admission, especially contacts with a regular GP. A general increase in GP contact was observed towards the time of hospital admission, but development differed between the patient groups. Patients admitted with heart failure had the steepest increase of monthly GP contact. A sizable percentage did not contact the regular GP or OOH services the last month before admission, in particular men aged 50–64 admitted with myocardial infarction or stroke.

Conclusion: The majority of patients acutely admitted to hospital for different common severe emergency diagnoses have been in contact with GPs during the month and year before the admission. This points towards general practitioners having an important role in these patients’ health care.

• KEY MESSAGES

• There is scarce knowledge about primary health care contact before an emergency hospital admission.

• The percentage of patients with contacts differed between patient groups, and increased towards hospital admission for most diagnoses, particularly heart failure.

• More than 50% having monthly general practitioner contact before admission underscores the general practitioners’ role in these patients’ health care.

• Our results underscore the need to consider medical diagnosis when talking about the role of general practitioners in preventing emergency hospital admissions.

     

Struggling at work – a qualitative study of working Danes with depressive symptoms

Abstract

Purpose: Little is known on how employees at work with mental health problems experience their work environment. This study explores how a selected sample of Danish employees with depressive symptoms experience the interaction with their work environment and how they respond to and deal with problems at work. Methods: From a survey study on work and mental health in Denmark, we invited participants for in-depth interviews. Using grounded theory, we conducted 13 semi structured interviews with employees, at work, experiencing depressive symptoms. Findings: Work was pivotal for the informants who were in an on-going process that we conceptualised as struggling at work. Informants struggled with the negative experiences of work that led to emotional, cognitive and somatic symptoms. Relationships with supervisors and colleagues, work load and work pressure and their self-image as a good worker conditioned the struggle. The informants found themselves unable to change their problematic working situation. This gradually led to different strategies to endure work and take care of one-self. These strategies were as follows: tending to symptoms and altering prospects for their future. The consequence of the on-going struggle was that the informants distanced themselves from their work. Conclusions: This study provided insight to the process of struggling at work, which the interviewed employees with depressive symptoms experienced.

• Implications for Rehabilitation

• Behaviour of supervisors is a key element for employees with depressive symptoms struggling at work. Practitioners and other health and rehabilitation practitioners working with people with depressive symptoms and other mental health problems could inquire about supervisor's behaviour and relation between supervisors and employees.

• Interventions that targets both the individual employee as well as work environment focused interventions at the organisational level could be beneficial for employees with mental health problems as well as the workplaces.

     

A systematic review of rehabilitation interventions to prevent and treat depression in post-stroke aphasia

Purpose: Stepped psychological care is the delivery of routine assessment and interventions for psychological problems, including depression. The aim of this systematic review was to analyze and synthesize the evidence of rehabilitation interventions to prevent and treat depression in post-stroke aphasia and adapt the best evidence within a stepped psychological care framework.

Method: Four databases were systematically searched up to March 2017: Medline, CINAHL, PsycINFO and The Cochrane Library.

Results: Forty-five studies met inclusion and exclusion criteria. Level of evidence, methodological quality and results were assessed. People with aphasia with mild depression may benefit from psychosocial-type treatments (based on 3 level ii studies with small to medium effect sizes). For those without depression, mood may be enhanced through participation in a range of interventions (based on 4 level ii studies; 1 level iii-3 study and 6 level iv studies). It is not clear which interventions may prevent depression in post-stroke aphasia. No evidence was found for the treatment of moderate to severe depression in post-stroke aphasia.

Conclusions: This study found some interventions that may improve depression outcomes for those with mild depression or without depression in post-stroke aphasia. Future research is needed to address methodological limitations and evaluate and support the translation of stepped psychological care across the continuum.

• Implications for Rehabilitation

• Stepped psychological care after stroke is a framework with levels 1 to 4 which can be used to prevent and treat depression for people with aphasia.

• A range of rehabilitation interventions may be beneficial to mood at level 1 for people without clinically significant depression (e.g., goal setting and achievement, psychosocial support, communication partner training and narrative therapy).

• People with mild symptoms of depression may benefit from interventions at level 2 (e.g., behavioral therapy, psychosocial support and problem solving).

• People with moderate to severe symptoms of depression require specialist mental health/behavioral services in collaboration with stroke care at levels 3 and 4 of stepped psychological care.

     

Experiences of a student-run clinic in primary care: a mixed-method study with students,patients and supervisors

Objective: To explore how a student-run clinic (SRC) in primary health care (PHC) was perceived by students, patients and supervisors.

Design: A mixed methods study. Clinical learning environment, supervision and nurse teacher evaluation scale (CLES?+?T) assessed student satisfaction. Client satisfaction questionnaire-8 (CSQ-8) assessed patient satisfaction. Semi-structured interviews were conducted with supervisors.

Setting: Gustavsberg PHC Center, Stockholm County, Sweden.

Subjects: Students in medicine, nursing, physiotherapy, occupational therapy and psychology and their patients filled in questionnaires. Supervisors in medicine, nursing and physiotherapy were interviewed.

Main outcome measures: Mean values and medians of CLES?+?T and CSQ-8 were calculated. Interviews were analyzed using content analysis.

Results: A majority of 199 out of 227 student respondents reported satisfaction with the pedagogical atmosphere and the supervisory relationship. Most of the 938 patient respondents reported satisfaction with the care given. Interviews with 35 supervisors showed that the organization of the SRC provided time and support to focus on the tutorial assignment. Also, the pedagogical role became more visible and targeted toward the student’s individual needs. However, balancing the student’s level of autonomy and the own control over care was described as a challenge. Many expressed the need for further pedagogical education.

Conclusions: High student and patient satisfaction reported from five disciplines indicate that a SRC in PHC can be adapted for heterogeneous student groups. Supervisors experienced that the SRC facilitated and clarified their pedagogical role. Simultaneously their need for continuous pedagogical education was highlighted. The SRC model has the potential to enhance student-centered tuition in PHC.

• Key Points

• Knowledge of student-run clinics (SRCs) as learning environments within standard primary health care (PHC) is limited.

• We report experiences from the perspectives of students, their patients and supervisors, representing five healthcare disciplines.

• Students particularly valued the pedagogical atmosphere and the supervisory relationship.

• Patients expressed high satisfaction with the care provided.

• Supervisors expressed that the structure of the SRC supported the pedagogical assignment and facilitated student-centered tuition – simultaneously the altered learning environment highlighted the need for further pedagogical education.

• Student-run clinics in primary health care have great potential for student-regulated learning.

     

Care managers can be useful for patients with depression but their role must be clear: a qualitative study of GPs’ experiences

Abstract

Objective: Explore general practitioners’ (GPs’) views on and experiences of working with care managers for patients treated for depression in primary care settings. Care managers are specially trained health care professionals, often specialist nurses, who coordinate care for patients with chronic diseases.

Design: Qualitative content analysis of five focus-group discussions.

Setting: Primary health care centers in the Region of Västra Götaland and Dalarna County, Sweden.

Subjects: 29 GPs.

Main outcome measures: GPs’ views and experiences of care managers for patients with depression.

Results: GPs expressed a broad variety of views and experiences. Care managers could ensure care quality while freeing GPs from case management by providing support for patients and security and relief for GPs and by coordinating patient care. GPs could also express concern about role overlap; specifically, that GPs are already care managers, that too many caregivers disrupt patient contact, and that the roles of care managers and psychotherapists seem to compete. GPs thought care managers should be assigned to patients who need them the most (e.g. patients with life difficulties or severe mental health problems). They also found that transition to a chronic care model required change, including alterations in the way GPs worked and changes that made depression treatment more like treatment for other chronic diseases.

Conclusion: GPs have varied experiences of care managers. As a complementary part of the primary health care team, care managers can be useful for patients with depression, but team members’ roles must be clear.

• KEY POINTS

• A growing number of primary health care centers are introducing care managers for patients with depression, but knowledge about GPs’ experiences of this kind of collaborative care is limited.

• GPs find that care managers provide support for patients and security and relief for GPs.

• GPs are concerned about potential role overlap and desire greater latitude in deciding which patients can be assigned a care manager.

• GPs think depression can be treated using a chronic care model that includes care managers but that adjusting to the new way of working will take time.

     

Communication and collaboration among return-to-work stakeholders

Abstract

Purpose: Workers who are injured or become ill on the job are best able to return-to-work when stakeholders involved in their case collaborate and communicate. This study examined health care providers’ and case managers’ engagement in rehabilitation and return-to-work following workplace injury or illness.

Method: In-depth interviews were conducted with 97 health care providers and 34 case managers in four Canadian provinces about their experiences facilitating rehabilitation and return-to-work, and interacting with system stakeholders.

Results: A qualitative thematic content analysis demonstrated two key findings. Firstly, stakeholders were challenged to collaborate as a result of: barriers to interdisciplinary and cross-professional communication; philosophical differences about the timing and appropriateness of return-to-work; and confusion among health care providers about the workers' compensation system. Secondly, these challenges adversely affected the co-ordination of patient care, and consequentially, injured workers often became information conduits, and effective and timely treatment and return-to-work was sometimes negatively impacted.

Conclusions: Communication challenges between health care providers and case managers may negatively impact patient care and alienate treating health care providers. Discussion about role clarification, the appropriateness of early return-to-work, how paperwork shapes health care providers’ role expectations, and strengthened inter-professional communication are considered.

• Implications for Rehabilitation

• Administrative and conceptual barriers in workers’ compensation systems challenge collaboration and communication between health care providers and case managers.

• Injured workers may become conduits of incorrect information, resulting in adversarial relationships, overturned health care providers’ recommendations, and their disengagement from rehabilitation and return-to-work.

• Stakeholders should clarify the role of health care providers during rehabilitation and return-to-work and the appropriateness of early return-to-work to mitigate recurring challenges.

• Communication procedures between health care specialists may disrupt these challenges, increasing the likelihood of timely and effective rehabilitation and return-to-work.

     

A qualitative study analyzing access to physical rehabilitation for traffic accident victims with severe disability in Brazil

Purpose To identify access barriers to physical rehabilitation for traffic accident (TA) victims with severe disability and build a theoretical model to provide guidance towards the improvement of these services. Methods Qualitative research carried out in the city of Natal (Northeast Brazil), with semi-structured interviews with 120 subjects (19?key informer health professionals and 101 TA victims) identified in a database made available by the emergency hospital. The interviews were analyzed using Alceste software, version 4.9. Results The main barriers present in the interviews were: (1) related to services: bureaucratic administrative practises, low offer of rehabilitation services, insufficient information on rehabilitation, lack of guidelines that integrate hospital and ambulatory care and (2) related to patients: financial difficulties, functional limitations, geographic distance, little information on health, association with low education levels and disbelief in the system and in rehabilitation. Conclusion The numerous access barriers were presented in a theoretical model with causes related to organizational structure, processes of care, professionals and patients. This model must be tested by health policy-makers and managers to improve the quality of physical rehabilitation and avoid unnecessary prolongation of the suffering and disability experienced by TA survivors.

• Implications for rehabilitation

• Traffic accidents (TAs) are a global health dilemma that demands integrality of preventive actions, pre-hospital and hospital care and physical rehabilitation (PR). This study lays the foundation for improving access to PR for TA survivors, an issue of quality of care that results in preventable disabilities.

• The words of the patients interviewed reveal the suffering of victims, which is often invisible to society and given low priority by health policies that relegate PR to a second plan ahead of prevention and urgent care.

• A theoretical model of the causes of the problem of access to PR was built. The identified barriers are potentially preventable through the intervention of health policy-makers, managers, regulators and rehabilitation professionals, and by encouraging the participation of patients.

• Addressing timely access barriers involves the expansion of the supply of services and rehabilitation professionals, regulation and standardization of referencing practises and encouraging the provision of information to patients about continuity of care and their health needs.

     

The measurement of psychological constructs in people with osteoarthritis of the knee: a psychometric evaluation

Purpose To examine the measurement properties of measures of psychological constructs in people with knee osteoarthritis. Method Participants with osteoarthritis of the knee completed the beck depression inventory (BDI-II), state-trait anxiety inventory (STAI), arthritis helplessness index (AHI), fatigue severity scale (FSS), coping strategies questionnaire (CSQ), beliefs about pain control questionnaire (BPCQ), illness perceptions questionnaire-revised (IPQ-R), pain self-efficacy questionnaire (PSEQ) at home as part of a set of measures covering different aspects of osteoarthritis pain. The questionnaires were returned by pre-paid envelope. Rasch analysis was used to check the psychometric properties of the scales in people with osteoarthritis. Results The STAI-SF was an acceptable measure of anxiety and the revised FSS an acceptable measure of fatigue, with removal of items 1 and 2. The BDI subscales were acceptable for measuring negative thoughts and behaviours related to depressive symptomatology with some modifications to the scale. The helplessness scale of the AHI was acceptable as a measure of helplessness. The PSEQ was an acceptable measure of self-efficacy and the CSQ as a measure of cognitive coping strategies. The BPCQ and IPQ-R did not fit the Rasch model. Conclusions These findings indicate that questionnaires need to be checked for their ability to measure psychological constructs in the clinical groups to which they will be applied.

• Implications for Rehabilitation

• For people with osteoarthritis, the STAI-SF is an acceptable measure of anxiety and the revised FSS an acceptable measure of fatigue with removal of items 1 and 2.

• The BDI subscales, but not the total score, are acceptable for measuring depressive symptomatology with some modifications to the scoring of the scale. And helplessness can be measured using the Helplessness subscale of the AHI.

• The PSEQ was an acceptable measure of self-efficacy and cognitive coping strategies can be measured with the CSQ.

• Rasch analysis highlighted lack of unidimensionality, disordered response thresholds and poor targeting in some measures commonly used for people with osteoarthritis

     

Assessing health and rehabilitation needs of people with disabilities in Cameroon and India

Purpose: To assess the association between disability and serious health problems, and the access and uptake of health and rehabilitation services in Cameroon and India.

Methods: We undertook a population-based case–control study, nested within a survey in Fundong Health District, North West Cameroon (August–October 2013) and in Mahbubnagar District, Telangana State, India (February–April 2014). Disability was defined as the presence of self-reported difficulties in functioning or clinical impairments. One control without disability was selected per case, matched by age, gender and cluster. Information was collected using structured questionnaires on: socioeconomic status, health, access to health services and rehabilitation.

Results: Cases with disability were significantly more likely to report a serious health problem in the last year compared to controls in both India (OR?=?3.2, 95% CI 2.1–4.8) and Cameroon (OR?=?1.9, 1.4–2.7). The vast majority of people sought care when seriously ill, and this did not vary between cases and controls. Awareness and use of rehabilitation services was extremely low in both Cameroon and India.

Conclusions: Further focus is needed to improve awareness of rehabilitation services among people with disabilities in India and Cameroon to ensure that their rights are fulfilled and to achieve the goal of Universal Health Coverage.

• Implications for Rehabilitation

• People with and without disabilities equally seek health care in India and Cameroon.

• However, people with disabilities experience more frequent serious health problems than people without.

• Extremely few people with disabilities were aware of rehabilitation services despite their existence in the study settings.