Addressing organizational barriers to continuity of care in the Danish mental health system – a comparative analysis of 14 national intervention projects

Background: Continuity of mental health care is central to improve the conditions of people with enduring mental disorders. In Denmark, several government-funded projects on the improvement of continuity of mental health care have been initiated since 2009.

Aim: The aim of this study was to investigate how national intervention projects on continuity of mental health care have addressed major barriers for continuity of care and extract general learning points from the projects on the improvement of continuity of care.

Method: The study was designed as a thematic document analysis of external evaluations of 14 major national projects on the improvement of continuity of routine mental health care from 2009 to 2017. The data material was processed through thematic coding and comparative analysis.

Results: The analysis was organized around four main barriers for continuity: Lack of models for collaboration, different professional cultures and methods, lack of channels of communication, and intersectoral differences in management, economy, and legislation. The first three barriers were addressed in a predominant part of the projects through development of collaborative models, common tools and communication systems. The latter structural barrier was not addressed in any of the projects.

Conclusion: There is an ongoing need to address barriers for continuity of mental health care. So far, there has been a much larger focus on organizational, cultural and communicational aspects of continuity than on structural aspects. The study calls for an increased focus on how changes in existing managerial, economic and legislative structures can improve continuity of care.     

Mental health knowledge and training needs among direct care workers: a mixed methods study

Objectives: Direct care providers (DCWs) spend the most time with clients in the home, and as such, play an integral role in identifying mental health problems. However, DCWs receive little preparation in mental health and there is little research regarding their role in the mental health care of clients. The purpose of this study was to explore DCWs’ knowledge, attitudes, and experiences of caring for clients with mental health problems from the perspectives of DCWs and key administrators (KAs).

Method: Mixed method design. Structured interviews were conducted with DCWs. Focus groups were conducted with KAs.

Results: Twenty-nine DCWs and 12 KAs took part in the study. Loneliness and memory problems in clients were the most prevalent challenges identified by DCWs. DCWs’ self-reported mental health knowledge was mid to high across all domains, although they had many misconceptions about mental health and aging. Helpful strategies in working with clients included communication skills, rapport-building, behavioral, cognitive, emotion-regulation, and making use of external resources. KAs noted individual differences in DCWs’ mental health knowledge and indicated that mental health issues were often viewed by DCWs as dispositional problems or a normal part of aging. KAs viewed DCWs’ greatest challenges as personalizing difficult client behaviors, lack of knowledge about how to manage specific behaviors, and difficulties managing their own emotions towards clients.

Conclusion: Data from this study suggest important areas for DCW development. However, system issues that affect DCWs such as workload, resources, mental health stigma, and diverse client populations should be addressed concurrently.     

Perceptions of patient-provider communication and receipt of mental health treatment among older adults with depressive symptoms

Objectives: This study aimed to: (1) determine if and how perceptions towards healthcare providers differ between older adults with and without clinically signifcant depressive symptoms (CSDS), and (2) assess whether perceptions towards providers are associated with receipt of mental health treatment among older adults with CSDS.

Methods: Data from the 2013 and 2014 Medical Expenditure Panel Survey were used to examine CSDS prevalence, receipt of mental health treatment, and perceptions of provider communication among community-dwelling adults ≥ age 65 (N = 6,936) using four of the ‘How Well Doctors Communicate’ composite items from the Consumer Assessment of Healthcare Providers and Systems(CAHPS). Multivariate logistic regression was used.

Results: CSDS are associated with greater odds of having ‘poor’ perceptions of provider communication on all four CAHPS communication measures. Perceptions of provider communication are similar among older adults with CSDS who received and did not receive mental health treatment, except on an item measuring a provider's ability to explain information in ways patients understand.

Conclusion: Older adults with CSDS have more negative perceptions of the quality of their communication with healthcare providers than their peers. Healthcare systems should consider how to accommodate these patients’ unique needs and communication preferences to ensure receipt of quality care.     

Background,experience of abuse,and mental health among adolescents in out-of-home care: a cross-sectional study of a Swedish high school national sample

Purpose: To compare experiences for adverse events, especially sexual abuse, and mental health in a group of high school students in out-of-home care with a representative sample of peers of the same age and similar educational attainment living with their parents.

Materials and methods: A sample of 5839 students in the third year of Swedish high school, corresponding to a response rate of 59.7%, answered a study specific questionnaire. Data from 41 students living in out-of-home care were compared with data from peers not in out-of-home care in a cross-sectional analyze.

Results: Students in out-of-home care had more often an immigrant background and a non-heterosexual orientation, had more often experienced physical and penetrative sexual abuse, and more often sought healthcare for mental problems. Disclosure of sexual abuse was less common, and acts of persuasion or adults' use of their social position was more common among students in out-of-home care.

Conclusions: Even where the protective factor ‘senior educational attainment’ is present, risks for abuse and poor mental health are evident for adolescents in out-of-home care. Disclosure of adversity, when it has occurred, ought to be higher among these adolescents with regular contact with social services, but our findings indicate tendencies for the opposite. We therefore suggest routines to be established to screen for adverse life events and mental health actively, along with general and systematic assessments of adversity and mental health during care.     

Prenatal famine exposure and mental health in later midlife

Objectives: Maternal malnutrition during pregnancy may have long-lasting effects on offspring's mental health. We investigate the effect of prenatal exposure to the Dutch famine (mid November 1944 to late April 1945) on mental health in later mid-life.

Methods: Data are from the Netherlands Kinship Panel Study (n = 642). We use difference-in-difference analyses to compare mental health in later midlife (measured with the MHI-5 index) across three cohorts (‘pre-famine cohort’, ‘famine cohort’, ‘post-famine cohort’) and across two regions (famine affected cities vs. rest of the country).

Results: In the affected cities, we find poorer mental health for the famine cohort than for the pre-famine and post-famine cohorts. In the non-affected rest of the country, no significant mental health differences between birth cohorts were found. The mental health differences between birth cohorts differ significantly between the affected cities and the rest of the Netherlands.

Conclusion: Our analyses link prenatal famine exposure to poorer mental health in later midlife. This suggests that in utero malnutrition has a long-lasting detrimental effect on mental health.     

A study on the association of psychiatric diagnoses and childhood adversities with suicide risk

Background: In addition to psychiatric disorders, childhood adversities may increase the risk of suicidal behavior. In previous studies, the effects of clinical co-morbidity and overlap of childhood adversities has rarely been taken into account.

Aim: The study aims to search associations of psychiatric diagnoses and childhood adversities and trauma (CAT) with suicide risk.

Methods: Altogether 415 adult patients attending primary and psychiatric outpatient care filled in the Trauma and Distress Scale, including assessment of five core CAT domains (emotional, physical and sexual abuse, and emotional and physical neglect). The study patients’ current psychiatric disorders and suicide risk were assessed by the Mini International Neuropsychiatric Interview.

Results: Age, poor perceived health, poor social support, current psychiatric treatment, all psychiatric disorders, except hypomania, emotional and physical abuse, and emotional neglect did associate significantly with suicide risk. Number of psychiatric disorders and CAT domains had dose-dependent effects on suicide risk. In multivariate analysis, current psychiatric treatment, current and life-time major depression, social phobia, alcohol, and drug dependency, as well as emotional abuse had direct associations with suicide risk. In females, manic disorders and drug dependence, and in males, dysthymia, social phobia, and emotional abuse associated with suicide risk.

Conclusions: Psychiatric disorders and most CAT domains associate with suicide risk. However, when the effect of co-morbidity and overlap of CAT domains is controlled, major depression, social phobia, alcohol, and drug dependency and emotional abuse seem to increase the risk of suicide. The risk profile varies between the genders.     

Exploring dimensions of social support and resilience when providing care at the end of life: a qualitative study

Background: Research shows that formal and informal social support can facilitate resilience in carers. There is a paucity of research exploring social support and resilience amongst recently bereaved informal carers.

Aim: To examine how the presence or absence of distinct dimensions of social support facilitate or hinder resilience in recently bereaved informal carers.

Participants: 44 bereaved carers, who had been identified by GP as ‘main carer’ of someone recently deceased (3–12 months), aged between 38 and 87 years old (mean= 67).

Methods: Thematic analysis then the Ecological Framework of Resilience as an organisational tool to develop overarching themes in the data. We used the Sherbourne and Stewart model to identify social support that was lacking as well as social support that was present.

Results: A range of social support types were identified. There was an emphasis on the importance of relationships with both health professionals and family members, including the care recipient. However, social support was not necessary for resilience if the participant had other resources.

Conclusions: Social support for carers providing end of life care is almost exclusively based around end of life care ‘work’. In comparison to other research our study suggests that relationships with family and health professionals are paramount. Multidimensional support is needed for carers to enhance their resilience.     

Mental health disorder,pain, and pain treatment among long-term care residents: Evidence from the Minimum Data Set 3.0

Objective: This study evaluated: (a) associations between long-term care residents’ mental health disorder diagnoses and their pain self-reports and pain treatments, and (b) the extent to which communication, cognitive, and physical functioning problems help explain disparities in the pain and pain treatments of long-term care residents with and without mental health disorders.

Method: Minimum Data Set 3.0 records of 8,300 residents of Department of Veterans Affairs Community Living Centers were used to determine statistically unadjusted and adjusted cross-sectional associations between residents' mental health diagnoses and their pain and pain treatments.

Results: Residents diagnosed with dementia and serious mental illness (SMI) were less likely, and those diagnosed with depressive disorder, post-traumatic stress disorder (PTSD), and substance use disorder (SUD) were more likely, to report recent, severe, and debilitating pain. Among residents affirming recent pain, those with dementia or SMI diagnoses were twice as likely to obtain no treatment for their pain and significantly less likely to receive as-needed pain medication and non-pharmacological pain treatments than were other residents. Those with either depressive disorder or PTSD were more likely, and those with SUD less likely, to obtain scheduled pain medication. In general, these associations remained even after statistically adjusting for residents' demographic characteristics, other mental health disorder diagnoses, and functioning.

Conclusion: Long-term care residents with mental health disorders experience disparities in pain and pain treatment that are not well-explained by their functioning deficits. They may benefit from more frequent, thorough pain assessments and from more varied and closely tailored pain treatment approaches.     

Perspectives of carers of people with intellectual disability accessing general practice: “I’d travel to the ends of the earth for the right person”⁣

Background: Informal carers often play an integral role in the lives of people with intellectual disability (ID) residing in the community. In this study, we explored the extent to which carers of people with ID believe that the health care needs of the person they care for are being accommodated by general practice.

Method: Semi-structured interviews were conducted with 25 informal carers to people with ID living in Australia.

Results: Carers of people with ID report that they experience considerable barriers to accessing general practice care on behalf of the people they care for.

Conclusions: Given the ever-increasing number of people with ID now living in the community and their vulnerability to health problems, it is imperative that future research focuses on the development of strategies to overcome the barriers identified in this study.     

Associations of health insurance coverage,mental health problems,and drug use with mental health service use in US adults: an analysis of 2013 National Survey on Drug Use and Health

Objective: To estimate the prevalence of mental health service use among US adults, examine the associations of mental health service use with health insurance coverage, mental health problems and drug use, and detect health disparities.

Methods: This was a cross-sectional study with 5,434 adults receiving mental health service out of 37,424 adult respondents from the 2013 National Survey on Drug Use and Health. Weighted univariate and multiple logistic regression analyses were used to estimate the associations of potential factors with mental health service use.

Results: The overall prevalence of mental health services use was 14.7%. Our results showed that being female, aging, having a major depressive episode, serious psychological distress, and illicit drug or alcohol abuse/dependence were positively associated with mental health service use; whereas being African American, Asian or Hispanic ethnicity, married, and having any form of insurance were negatively associated with mental health service use . Stratified analysis by insurance types showed that Medicaid/CHIP, CHAMPUS, and other insurance were positively associated with mental health service use.

Conclusions: Health insurance coverage, mental health problems, and drug abuse or dependence were associated with mental health service use in US adults. Furthermore, adults with different insurances had disparities in access of mental health service.     

Intellectual disability in Australian nursing education: Experiences in NSW and Tasmania*

Background: Persons with intellectual disability (ID) face significant health challenges. Nurses provide health care to this population in many settings, including general practice, community care, acute care, reproductive health, and palliative care. However, since the demise of the specialist training model in the 1990s, the extent to which general nurses in Australia are educated about the health needs of people with ID is unclear.

Methods: A systematic literature mapping and documentary analysis of educational resources available to nurses in Australia was undertaken, with particular reference to New South Wales and Tasmania.

Results: Minimal education content relating to the health needs of people with ID was found in the academic programs included in this study. Where it existed, it was inconsistently applied, being made available as an aspect of professional development rather than a clearly identified educational pathway.

Conclusions: This study adds to previous findings indicating the need for change to nurse education in this area, and for cross-country comparisons with other models of nurse education in the area.     

Perceptions of psychiatry residents and non-residents on training needs and care related to patients with intellectual disability and mental health problems: A study from Singapore

Background: People with intellectual disability (ID) have higher risk of mental morbidity and specialised training may be required in their management. We explored the training needs and knowledge as well as perceptions of care of such patients among residents and non-residents working in psychiatry.

Method: The study was conducted as an anonymous survey. Questionnaires were sent to all residents and non-residents at a large psychiatric hospital in Singapore.

Results: Forty-eight out of the 76 questionnaires sent out were returned. All participants responded that postgraduate training was required in the area of ID and mental health and according to the majority, available training was inadequate. Over 90% believed that people with ID were vulnerable to exploitation and they should be under a specialist team.

Conclusion: Efforts should be made to include specialist training in psychiatry of ID in the Singapore psychiatry curriculum to enhance the knowledge and expertise of psychiatrists in this field.     

Pain intensity,depressive symptoms,and functional limitations among older adults with serious mental illness

Objective: To examine pain-related activity interference as a mediator for the relationship between pain intensity and depressive symptoms among older adults with serious mental illness (SMI).

Method: Ordinary least-squares regressions were used to investigate the mediation analysis among older adults with SMI (n = 183) from community mental health centers. Analyses used secondary data from the HOPES intervention study.

Results: Higher pain intensity was associated with greater pain-related activity interference. Higher pain intensity and pain-related activity interference were also associated with elevated depressive symptoms. Finally, greater pain-related activity interference significantly mediated the association between higher pain intensity and elevated depressive symptoms.

Conclusions: These findings demonstrate that pain and depressive symptoms may be linked to functional limitations. Clinicians and researchers in the mental health field should better address pain-related activity interference among older adults with SMI, especially among those with higher pain intensity and elevated depressive symptoms.     

The prevalence and patterns of substance use by birth cohort among HIV-positive adults in Florida

Objectives: Antiretroviral therapy is affording longer lifespans for people living with HIV (PLWH), yet factors such as substance use play an increasing role in morbidity and mortality in this population. Though previous studies have examined substance use differences between age cohorts of PLWH, no study has examined the influence of birth cohort on current substance use patterns. Thus, this study investigated the prevalence of past 12-month self-reported substance use between four birth cohorts, <1970 (M age = 54.1), 1970s (M age = 41.5), 1980s (M age = 31.3 years old), and 1990s (M age = 23.2 years old) of PLWH in Florida.

Methods: PLWH (N = 934) recruited from community health clinics in Florida completed a questionnaire assessing sociodemographics, health status, and substance use.

Multivariate logistic regressions utilizing the <1970 cohort as the referent group examined the relationship between birth cohort and substance use.

Results: The 1980s cohort had significantly greater odds of marijuana use compared to the oldest cohort (<1970s), while the three younger cohorts (1970s, 1980s, and 1990s) evidenced a significantly greater odds of ecstasy use compared to the oldest group. Contrastingly, the three younger birth cohorts reported significantly less crack use than the oldest cohort, while the youngest group (1990s) also demonstrated an 80% reduction in injection drug use compared to the oldest group.

Conclusion: The older cohort evidenced significantly greater crack and injection drug use, while the younger cohorts evidenced greater marijuana and ecstasy use. Therefore, it is important to develop age-specific substance use interventions among PLWH.     

Health professionals’ perceptions of developing dementia services in primary care settings in China: a qualitative study

Objectives: Primary care plays a crucial role in the timely diagnosis and proper management of dementia. Evidence from low and middle income countries is much needed to inform service development in primary care and to address the dementia burden in these countries. The aim of this study was to explore community health professionals’ perceptions of dementia service development using China as a case.

Method: An interpretive study design was utilized and focus groups were used for data collection guided by a semi-structured interview guide. Each focus group lasted between 90–120 min. Thematic analysis was applied for data analysis.

Results: Twenty-one community health professionals participated in this study and three major themes were identified. These themes are: incorporating dementia components in the government-subsidized primary care services; an under-prepared workforce to meet the demand for dementia care; and an enabling environment to sustain dementia care.

Conclusion: Government policies, regulations, standards and guidelines need to be established for dementia service development in primary care to improve the home care for people with dementia and to create a dementia-friendly society. Regular education and training activities for health professionals are a way to build dementia care service capacity in primary care.     

Views and experiences of care home staff on managing behaviours that challenge in dementia: a national survey in England

Aim: To determine the views of care home (CH) staff in relation to experiencing and managing behaviour that challenges (BtC) in dementia and their experiences of training.

Method: Cross-sectional survey using a self-report questionnaire, distributed to staff employed in a 20% sample of all registered dementia-specialist CHs in England, either by postal or direct distribution.

Results: Questionnaires were returned from 352 care staff (25%), representing 5% of all dementia-specialist CHs, half were CH without nursing. Respondents estimated caring for 14,585 residents, 9,361 with dementia and 5,258 with BtC. 30.2% of residents with dementia were estimated as being prescribed a medicine to control BtC. BtC reported as experienced by most respondents were: shouting (96.6%), verbal aggression (96.3%) and physical aggression (95.7%), with physical aggression viewed as most difficult to manage. Top behaviours experienced every shift were: wandering (77.8%), perseveration (68.2%) and restlessness (68.2%).

Approaches such as assessing residents, knowing them and treating them as individuals, identifying triggers, having time for them and using an appropriate style of communication, were viewed as key to managing BtC, rather than guideline-specific interventions such as massage, aromatherapy and animal-assisted therapy.

Only 38% agreed/strongly agreed medicines were useful to control BtC, which was related to the extent to which they were prescribed. Training was available, but variable in quality with on-line training being least useful and on-the job training most desirable.

Conclusion: BtC are commonly and frequently experienced by care staff, who consider individual approaches, having time and good communication are key to successful management.     

The intersection of intellectual and developmental disabilities and HIV: A scoping review

Background: HIV among individuals with intellectual and developmental disabilities (IDD) is rarely studied. This scoping review examined the HIV prevalence, health service use, prevention and risk behaviours among individuals with IDD.

Method: Journal articles, book chapters and theses written in English and published from 1991 to 2017 in four academic databases (PubMed, PsycINFO, CINAHL and Web of Science) were eligible for inclusion.

Results: From 1636 unique records, 32 documents were included in this review. They contained limited information on HIV prevalence and health service use by individuals with IDD and HIV. Most studies identified a poor understanding of HIV and high-risk behaviours, such as inconsistent condom use, among individuals with IDD. While HIV education programs were effective for this population, no studies identified educational interventions for their service providers.

Conclusion: There is a need for educational programs and policies on HIV for both service providers and individuals with IDD.     

Unmet care needs,care provision and patient satisfaction in patients with a late life depression: a cross-sectional study

Background: Research has shown that some 30% of total care needs in people with late-life depression (LLD) are unmet. It is not known to what extent patients actually don't receive any care for these needs or consider the care to be insufficient and their satisfaction with the provided care.

Aim: The aim of this study is to obtain insight into the care provided in relation to the reported unmet care needs and satisfaction with the total care provided is examined.

Method: A cross-sectional study of 99 people with LLD in an ambulatory setting.

Results: In 67% of patients, at least one unmet need was ascertained. In most cases (80%) care was actually provided for those needs by professionals and/or informal caregivers. Patients were satisfied with the care delivered for 81% of the reported care needs. Satisfaction was lowest for social care needs (67%). For six specific care needs it was demonstrated that dissatisfied patients were significantly more depressed than satisfied patients.

Conclusion: Even though patients might receive care for certain needs, this does not mean that their needs are met. A substantial proportion of patients with LDD feel that they need additional help for unmet needs.