Screening for the psychological consequences of a major disaster in a developing country: Armero, Colombia

Seven months following the volcanic eruption that destroyed the small town of Armero, 200 victims were screened for emotional problems with the Self-Reporting Questionnaire, a simple and reliable instrument. Fifty-five percent of the victims were found to be emotionally distressed. Variables associated with the presence of emotional distress included living alone, having lost previous job, feeling not being helped, not knowing date for leaving temporary shelter, being dissatisfied with living arrangements, complaining of non-specific physical symptoms or epigastric pain, and presenting several physical problems. The high prevalence of emotional distress supports the need to deliver mental care to disaster victims in developing countries through the primary level of care. Our findings provide guidelines for early detection of individuals at risk for developing emotional problems.     

Depressive symptoms and plan switching under managed care.

OBJECTIVE: A central assumption underlying managed care is that plan switching is a viable option for enrollees when they are dissatisfied. The authors used a national employee survey to test the hypothesis that this mechanism is less effective for enrollees with high levels of depressive symptoms than for the remainder of the population. METHOD: The study used data from the Employee Health Care Value Survey, a 1993 survey of 20,283 employees of three major corporations. The authors used the Medical Outcomes Study 36-Item Short-Form Health Survey to identify individuals with the highest decile of depressive and physical symptoms. They examined the relationship between symptoms and dissatisfaction and, for dissatisfied individuals, how symptoms predicted plan switching. Multivariate models were used to control for potential demographic, health, and health coverage confounders. RESULTS: Depressive and physical symptoms were both associated with dissatisfaction with care. Unlike physical symptoms, depressive symptoms were associated with a significantly lower likelihood of actually disenrolling among people who were dissatisfied or who intended to disenroll. This effect was most pronounced for satisfaction with administrative aspects of care (e.g., gatekeeping, utilization review). CONCLUSIONS: People with high levels of depressive symptoms appeared to be less willing or able to act on their dissatisfaction by switching plans. In particular, they were willing to tolerate higher rates of dissatisfaction with the administrative aspects of their health coverage without disenrolling. Plan switching is an essential mechanism underpinning a health care system predicated on competition; it may be less effective for people with depressive disorders.     

People Living in Community with a Severe Mental Illness: Utilization and Satisfaction with Care and Support

The object of this paper was to investigate the experiences of patients with severe mental illness (SMI) living in a community, including their utilization of care and treatment services. Psychiatric care and social services staff members were asked to make an inventory of those they served in two districts of Malmö, Sweden. Participants had to be over 18 years of age and unable to manage their daily lives without help from others. Almost all of the 80 participants (95 %) were under psychiatric care. A majority (86 %) was receiving dental treatment, and 61 % were supported by social services. Fifty-four percent of the participants received somatic care on an ongoing basis. Although the majority reported the care given as sufficient, one-third of this SMI population considered the care and support they received to be insufficient. Satisfying those who are dissatisfied with the care they are being given would be a significant challenge for service providers, since the unsatisfied are shown to have more difficult lives.     

Patient and Family Advocacy: Working with Individuals with Comorbid Mental Illness and Developmental Disabilities and their Families

There are many factors to consider when working with individuals with mental illness and developmental disabilities and their families. Working in collaboration with individuals and their families using a patient- and family-centered care approach is vital. This approach informs the professional's values and practice patterns thereby allowing them to help the individual and family deal with common challenges and stresses such as establishing relationships with care providers, ensuring coordination of care, family concerns, knowledge of important systems of care, and the need for advocacy.     

Longitudinal analysis of inpatient care utilization among people with intellectual disabilities: 1999–2002

Background There has been no longitudinal study in Taiwan to identify the nature and the scale of medical care utilization of people with intellectual disabilities (IDs) up to the present. The aim of this study is to describe inpatient utilization among people under ID care in institutions in order to identify the pattern of medical care needs and the factors affecting utilization in Taiwan. Method The subject cohort was 168 individuals with ID who were cared for by a large public disability institution from 1999 to 2002 in Taipei, Taiwan. Results On the examination of the inpatient care that these persons underwent, it was found that these individuals had a heightened need (inpatient rate: 10.1–14.9%) for inpatient care compared with the general population with disabilities (9.37%) in Taiwan. The main reasons for hospitalization were pneumonia, gastrointestinal disorders, cellulites, orthopaedic problems, epilepsy and bronchitis. Using the full model of Generalized Estimating Equations for inpatient care utilization, the factors including low income family, living in an institution, being a subject with cerebral palsy and being a high outpatient user all influenced the use of inpatient care. Conclusions This study highlights that health authorities need to promote health planning more in order to ensure an excellent quality of health monitoring and health promotion among people with ID cared for by institutions.     

Health care triads and dementia care: integrative framework and future directions

Physicians are usually the first contact in the health care system for persons with dementia and their family caregivers. This paper provides a synopsis of research findings and knowledge gaps regarding interactions among these participants in the health care triad--primary care physicians, family caregivers, and persons with dementia. Research traditions that inform knowledge about health care triads and dementia care include: older patient-physician relationships; the stress-coping social-support health model that dominates family caregiver research; the social learning-self-efficacy model; and literature on the quality of medical care. An integrative framework is presented to illustrate how the quality of interaction in dementia care encounters may be influenced by specific characteristics of members of the health care triad. Domains of dementia care interaction include symptom diagnosis, symptom management, medication management, support service linkage, and emotional support. The integrative framework also links the quality of interaction in these domains with health-related outcomes relevant to each of the health care triad members. Most empirical research in this area has found that family caregivers are dissatisfied with many aspects of physicians' dementia care, but measurement techniques vary widely and little is known about how the quality of physician care is associated with health-related outcomes. Physician surveys have shown that they are least certain about the quality of support service linkage advice they provide. Virtually no research has examined how the person with dementia experiences medical care encounters with physicians and their family members. Much remains to be learned about the longitudinal experience of each member of the health care triad, and how the quality of dementia care encounters changes over the course of the disease process. In this era of rapidly expanding educational and support service interventions for persons with dementia and their family caregivers, as well as computer-based information about dementia care, the influence of these external factors on health care triad interactions and outcomes also remains to be studied.     

Family issues in dementia: finding a new normal

Caring for individuals with dementia poses significant hazards and can have lasting effects on the health, well being, and quality of life of family members. Families need guidance from physicians to support and maintain the dignity of the patient with dementia throughout the degenerative disease trajectory. There is a rational basis for family education and counseling strategies aimed at increasing effectiveness and reducing risks to families who provide care. Family care for patients with Alzheimer's should be directed toward defining a "new normal."     

A brief problem-solving intervention for family caregivers to individuals with advanced cancer

OBJECTIVE: To evaluate a brief problem-solving intervention for family caregivers to individuals with advanced cancer. METHOD: Family caregivers were recruited through oncology clinics of a large tertiary care hospital in Canada. Those providing informed consent completed a baseline survey, received a brief problem-solving intervention, received a detailed home care guide, and completed a follow-up survey over the telephone 4 weeks after receiving the intervention. RESULTS: Thirty-four family caregivers completed all aspects of the study. Sixty-eight percent of caregivers were women, 73.5% were married to the care recipient, and their average age was 53.6 years. This brief intervention resulted in improvements in emotional tension (P<.03), caregiving confidence (P<.06), and positive problem-solving orientation (P<.06). CONCLUSION: These findings suggest that even a brief problem-solving intervention may be beneficial for family caregivers to individuals with advanced cancer.     

Satisfaction of caregivers of patients with schizophrenia in Finland

OBJECTIVE: The aims of the study were to determine whether the caregivers of discharged patients with schizophrenia were satisfied with their situation in general and with psychiatric services in particular and to examine the factors associated with caregiver satisfaction. METHODS: The data were drawn from a national project designed to study the treatment and life situation of deinstitutionalized schizophrenia patients in Finland. The patients were discharged from psychiatric hospitals in 1986, and both the patients (N=775) and their caregivers (N=545) were interviewed after a three-year follow-up. RESULTS: One-fifth of the caregivers were dissatisfied with the situation in general, and one-third were dissatisfied with the psychiatric services the patient received. Caregivers were more likely to be dissatisfied with the situation if they lived with the patient and if the patient's functional state was poor or the patient's use of services, particularly medication and rehabilitation, was low. Caregivers were likely to be dissatisfied with the psychiatric services if the patient had severe psychotic symptoms and poor "maintenance of grip on life" or if the patient was given less psychiatric care and rehabilitation or used more social services. CONCLUSIONS: The satisfaction of caregivers of persons with mental illness appears to have two dimensions. First, caregivers need to be accepted and treated as active partners in the patients' care and rehabilitation. Second, the burden on the families of persons with mental illness can be alleviated with long-term rehabilitation and care to help patients gain as high a functional state as possible.     

Integrating behavioral psychology services into adult day programming for individuals with dementia

Many individuals with dementia and problem behavior are served in nursing home settings long before health issues necessitate constant medical care. Alternative community-based adult day health care programs allow individuals with dementia to remain in their home with their families at a substantially reduced cost; however, many adult day programs face the same difficulties in managing problem behavior as family members do, leading to premature termination of services. This article describes a multiyear project that integrated behavior analytic services into an adult day program for individuals with dementia and problematic behavior. A comprehensive practicum system was developed to provide assessment and treatment services that allowed consumers with problem behavior to remain successfully served in adult day programming while postponing out-of-home nursing home care.     

Patient satisfaction with gender identity clinic services in the United Kingdom

Measuring patient satisfaction is important in assessing healthcare outcomes due to the growing emphasis on greater partnership between providers and consumers. National Health Service (NHS) commissioning bodies in the United Kingdom increasingly expect patient satisfaction to be included as a service performance indicator as it is regarded as part of the definition of quality of care. The aim of this survey is to better understand levels of satisfaction with current gender identity clinic services (GICs) provision and to identify areas for improvement. A Patient Satisfaction Questionnaire (PSQ-GD) was developed specifically for use in GICs in the United Kingdom, which was given to all patients during one month. PSQ-GD covers clinical care, administrative and procedural issues as well as patient experience of local service provision from their General Practitioner, local psychiatric services and speech therapy. A total of 330 PSQ-GD were given with a response rate of 85%. Ninety-four percent would recommend the services if a friend or relative had a gender-related problem. Twenty percent were dissatisfied with the level of support for others close to the patient. Thirty-one percent were dissatisfied with local psychiatric services. Twenty-seven percent were dissatisfied with the wait for the first appointment. Administration scored high on satisfaction. A total of 222 positive and 131 negative comments were made. The PSQ-GD offers an opportunity to understand levels of satisfaction with current gender service provision and identifies areas for improvement, most notably the interface between GICs and local psychiatric services. Findings from this study put individual complaints in perspective and show that despite the challenges inherent in providing transgender care good satisfaction can be achieved. We encourage gender care providers to implement quality assurance and improvement procedures to give people with gender dysphoria the opportunity to provide feedback and have a voice in shaping their own health care.     

The Use of Herbal Medications and Dietary Supplements by People with Mental Illness

This study examined the relationship between herbal medication and dietary supplement (HMDS) use and mental health characteristics. Data are drawn from a national household survey of the United States’ civilian, non-institutionalized population (N = 9,585). Psychiatric medication and HMDS use, psychiatric diagnoses and treatment needs, utilization and satisfaction were assessed. Compared to non-users, HMDS users were more likely to perceive themselves as having mental health needs, to have received mental health and primary care treatment, and to be dissatisfied with their overall healthcare. Psychiatric medication use was not related to HMDS use, and in multivariate analyses, HMDS use was associated with perceived mental health needs. Differences in use of specific HMDS between those with and without a psychiatric disorder were also examined. The use of HMDS warrants particular attention in persons with perceived mental health problems as these individuals may be turning to HMDS use for treatment of their symptoms.     

Effects of declared levels of physical activity on quality of life of individuals with intellectual disabilities

Routine physical fitness improves health and psychosocial well-being of individuals with intellectual and developmental disabilities. The current study investigated impact of physical fitness on quality of life by comparing individuals who maintain a physically active lifestyle with those who do not report exercising. We assessed several indicators of quality of life, including inclusion and community participation; satisfaction with professional services, home life, and day activities; dignity, rights, and respect received from others; fear; choice and control; and family satisfaction. Our data suggested that individuals who regularly exercise reported having more frequent outings into the community than did their peers who reported exercising infrequently; regular exercisers were also more likely to live in intermediate care facilities (ICF) as opposed to living independently or with family members. We discuss possible reasons for this as well as ideas for future research needed to expand on this area.     

Appropriateness in acquiring a family caregiver interview from older adults with suspected cognitive impairment

This study attempted to identify the factors associated with the completion of a family caregiver interview among a sample of older adults with suspected cognitive impairment. From a random-digit dial methodology, we identified 3,726 individuals ≥ 70 years of age with a family caregiver living in Arkansas. Of that number, 730 (19.6%) screened positive for suspected cognitive impairment. Of those who screened positive, we collected complete data on 532 (73% completion rate). Of these 532 participants, we gathered complete data on 376 of their family caregivers (71% completion rate).We developed a multivariate logistic regression model that estimated correlates (sociodemographic, accessibility, awareness, and utilization of services, and health status characteristics) of the older adults with suspected cognitive impairment and a family caregiver who completed an interview. Multivariate analysis found that a complete caregiver interview was associated with being male, engaging in more face-to-face contact with family members other than the family caregiver, having more visits to the physician (excluding a psychiatrist) and having more difficulties performing instrumental activities of daily living. This paper discusses the implications of using telephone interviews to collect and evaluate data on the health status and health service needs of older adults with suspected cognitive impairment. Findings suggest the importance of completing a concomitant interview with a family caregiver. Health care policymakers and providers may want to pay particular attention to older adults with fewer family contacts when planning access to care services.     

Predisposing,Enabling, and Need Factors Associated with High Service Use in a Public Mental Health System

The purpose of this study was twofold: (1) To investigate the individual- and system-level characteristics associated with high utilization of acute mental health services according to a widely-used theory of service use—Andersen’s Behavioral Model of Health Service Use —in individuals enrolled in a large, public-funded mental health system; and (2) To document service utilization by high use consumers prior to a transformation of the service delivery system. We analyzed data from 10,128 individuals receiving care in a large public mental health system from fiscal years 2000–2004. Subjects with information in the database for the index year (fiscal year 2000–2001) and all of the following 3 years were included in this study. Using logistic regression, we identified predisposing, enabling, and need characteristics associated with being categorized as a single-year high use consumer (HU: >3 acute care episodes in a single year) or multiple-year HU (>3 acute care episodes in more than 1 year). Thirteen percent of the sample met the criteria for being a single-year HU and an additional 8% met the definition for multiple-year HU. Although some predisposing factors were significantly associated with an increased likelihood of being classified as a HU (younger age and female gender) relative to non-HUs, the characteristics with the strongest associations with the HU definition, when controlling for all other factors, were enabling and need factors. Homelessness was associated with 115% increase in the odds of ever being classified as a HU compared to those living independently or with family and others. Having insurance was associated with increased odds of being classified as a HU by about 19% relative to non-HUs. Attending four or more outpatient visits was an enabling factor that decreased the chances of being defined as a HU. Need factors, such as having a diagnosis of schizophrenia, bipolar disorder or other psychotic disorder or having a substance use disorder increased the likelihood of being categorized as a HU. Characteristics with the strongest association with heavy use of a public mental health system were enabling and need factors. Therefore, optimal use of public mental services may be achieved by developing and implementing interventions that address the issues of homelessness, insurance coverage, and substance use. This may be best achieved by the integration of mental health, intensive case management, and supportive housing, as well as other social services.     

A qualitative study of the experiences of long-term care for residents with dementia, their relatives and staff

Most older people living in 24-hour care settings have dementia. We employed qualitative interviews to explore positive and negative aspects of the experience of family carers, staff and people with dementia living in 10 homes in London and West Essex, selected to cover the full range of 24-hour long-term care settings. The interview used open semi-structured questions. We interviewed 21 residents, 17 relatives and 30 staff and five main themes were identified: Privacy and choice; relationships (abuse and vulnerability); activities; physical environment; and expectations of a care environment by carers, should they one day live in long-term care themselves. Despite being no longer responsible for the day-to-day care of the residents there was a continuing level of psychological distress among some relatives. We found that residents with a range of severity of dementia were able to participate. The most striking theme from their interviews was the need for choice. All groups talked about improving lines of communication amongst residents, relatives and staff and about the importance of activities. We recommend that homes should set up formal structures for engaging with user and carer views at all levels. This would mean relatives on the board, and regular meetings for residents, relatives, advocates and staff. This should lead to cultural changes where residents are perceived as individuals and care is provided in a more flexible way. There should be a programme of activities in each 24-hour care setting, which all care staff are given time to implement. These activities need to be tailored to the individual resident rather than the whole group.     

Tourette Syndrome and medical treatment in Canada

Self-report data were gathered from a national sample of over two hundred Canadian Tourette Syndrome (TS) patients. Included was previous use of stimulant medication and prior extended use of antihistamines for allergies or sinus condition. Patients were also asked information on Tourette Syndrome-precipitated hospitalization or boarding school placement, the type of physician treating them and on a five-point scale their level of satisfaction with their medical care. Results indicate that over 20% of TS patients have used stimulant medications and 30% have used antihistamine for extended periods. Many patients have spent time in psychiatric settings and most are under the care of psychiatrist or neurologist. Approximately 40% of TS patients reported being satisfied to very satisfied with the medical care they were receiving, and 20% having mixed feelings. Few patients receiving medical care were dissatisfied with their treatment.     

Diagnosis and Treatment of Aggression in Individuals with Developmental Disabilities

Aggressive behavior is a common referral problem for individuals with developmental disabilities (DD), placing them at risk for institutionalization, social isolation, physical restraint, over-use of medication to treat behavior problems, exclusion from services, and becoming a victim of abuse. Aggression strains relationships between individuals being supported and their caregivers, whether professionals or family members. The treatment of aggression is persons with DD, with or without comorbid mental illness, remains a controversial area and changes in practice have been slow to come. The evidence related to pharmacotherapy and psychological treatment is, in general, either lacking or poor. This does not suggest that these treatments are necessarily ineffective but that there is not enough good quality evidence to support their usefulness. This review considers the prevalence and correlates of aggression, as well as possible causative factors. The relationship between mental illness, intellectual disability and aggression is explored. The psychopharmacological and psychological treatment literature is reviewed with implications for clinical care and future research.     

Factors associated with receipt of behavioral health services among persons with substance dependence

OBJECTIVE: This study sought to identify demographic and clinical variables that predict use of behavioral health services among persons with substance dependence. METHODS: Interviews were conducted with 1,893 adults who endorsed items on the National Household Survey on Drug Abuse in 1995 and 1996 that were consistent with a DSM-IV-TR diagnosis of dependence on at least one substance, excluding cigarettes. Logistic regression analyses were conducted to identify significant predictor variables. RESULTS: Among persons with substance dependence, only 18.3 percent had sought substance abuse or mental health treatment, or both, in the previous year. Female sex, high family income, a history of being arrested or booked, concurrent psychiatric comorbidity, self-perception of having a drug or alcohol problem, and the number of substances involved all predicted treatment use. One-third of substance-dependent individuals who used services reported receiving mental health care that did not include any substance use component. Persons with higher education levels were more likely to use mental health care only. In contrast, persons who used public insurance or were uninsured, had been booked or arrested, or perceived themselves as having a drug or alcohol problem were less likely to obtain mental health care only. CONCLUSIONS: Several clinical and demographic variables were predictive of some type of treatment use by substance-dependent individuals. Persons who used mental health care only were more likely to be female, to be of higher socioeconomic status, not to have a history of involvement with the legal system, and to have problems with alcohol or marijuana but not to perceive themselves as needing addiction treatment.