Relationship between Initial Quetiapine Dose and Effectiveness as Reflected in Subsequent Mental Health Service Use among Patients with Schizophrenia or Bipolar Disorder

OBJECTIVE: To investigate the association between initial quetiapine dose and effectiveness as gauged by subsequent use of mental health services. METHODS: Using a health plan database, we identified patients with bipolar disorder or schizophrenia treated with quetiapine monotherapy for at least four consecutive months. The stability of each patient before and after quetiapine treatment was measured by use of mental health services other than antipsychotic drug, measured primarily by charges reported on claims. Regression models controlling for patient differences measured associations between initial quetiapine dose and subsequent mental health service use. RESULTS: Commercially insured patients with schizophrenia (n = 581) or bipolar disorder (n = 2421) received quetiapine monotherapy at mean (SD) initial daily doses of 237 (198) mg and 147 (171) mg, respectively. Both groups showed negative associations between initial daily dose and subsequent mental health charges. Among patients with schizophrenia, mental health charges decreased by US 1.28 dollars for each additional milligram of quetiapine (P = 0.1097). Among patients with bipolar disorder, there was a significant decrease of US 1.31 dollars per additional milligram of quetiapine (P = 0.0484). For schizophrenia, hospitalizations were reduced by 0.4% for each additional milligram of quetiapine (P = 0.0189). For bipolar disorder, the association between quetiapine dose and outpatient charges was negative and trended toward significance (P = 0.074), showing a US 0.54 dollars reduction in these charges for each additional milligram of quetiapine; the association with hospitalization was not significant. CONCLUSIONS: In patients with schizophrenia or bipolar disorder, higher initial doses of quetiapine may be more effective in stabilizing patients as reflected in lower subsequent mental health service use.     

精神分裂症患者照护负担现状及其影响因素分析

目的:了解缓解期精神分裂症患者照护负担现状及其影响因素,为针对性采取干预措施提供科学依据。方法:采用Zarit负担量表、家庭关怀度量表、社会功能量表对湖北省201名缓解期精神分裂症患者及其主要照顾者进行一对一访谈调查。结果:照顾者中163例(81.1%)存在负担,其中轻、中、重度负担分别66、72、25例,分别占比32.8%、35.9%、12.4%。照顾者家庭关怀和患者社会功能都普遍较差。多重线性回归分析结果显示照顾者年龄、照顾者文化程度、照顾者所受家庭关怀、患者医疗费用、患者社会功能是缓解期精神分裂症患者照护负担的影响因素(P<0.05)。结论:政府、精神卫生中心和家属应了解缓解期精神分裂症患者的照护负担水平及其影响因素,并提供有针对性的措施以减轻照护负担。     

Diagnosis and Treatment of Bipolar Disorders in Adults: A Review of the Evidence on Pharmacologic Treatments

Background

Patients with bipolar disorder are exceptionally challenging to manage because of the dynamic, chronic, and fluctuating nature of their disease. Typically, the symptoms of bipolar disorder first appear in adolescence or early adulthood, and are repeated over the patient''s lifetime, expressed as unpredictable recurrences of hypomanic/manic or depressive episodes. The lifetime prevalence of bipolar disorder in adults is reported to be approximately 4%, and its management was estimated to cost the US healthcare system in 2009 $150 billion in combined direct and indirect costs.

Objective

To review the published literature and describe the personal and societal burdens associated with bipolar disorder, the impact of delays in accurate diagnosis, and the evidence for the clinical effectiveness of available pharmacologic therapies.

Methods

The studies in this comprehensive review were selected for inclusion based on clinical relevance, importance, and robustness of data related to diagnosis and treatment of bipolar disorder. The search terms that were initially used on MEDLINE/PubMed and Google Scholar were restricted to 1994 through 2014 and included “bipolar disorder,” “mania,” “bipolar depression,” “mood stabilizer,” “atypical antipsychotics,” and “antidepressants.” High-quality, recent reviews of major relevant topics were included to supplement the primary studies.

Discussion

Substantial challenges facing patients with bipolar disorder, in addition to their severe mood symptoms, include frequent incidence of psychiatric (eg, anxiety disorders, alcohol or drug dependence) and general medical comorbidities (eg, diabetes, cardiovascular disease, obesity, migraine, and hepatitis C virus infection). It has been reported that more than 75% of patients take their medication less than 75% of the time, and the rate of suicide (0.4%) among patients with bipolar disorder is more than 20 times greater than in the general US population. Mood stabilizers are the cornerstone of treatment of bipolar disorder, but atypical antipsychotics are broadly as effective; however, differences in efficacy exist between individual agents in the treatment of the various phases of bipolar disorder, including treatment of acute mania or acute depression symptoms, and in the prevention of relapse.

Conclusion

The challenges involved in managing bipolar disorder over a patient''s lifetime are the result of the dynamic, chronic, and fluctuating nature of this disease. Diligent selection of a treatment that takes into account its efficacy in the various phases of the disorder, along with the safety profile identified in clinical trials and in the real world can help ameliorate the impact of this devastating condition.Bipolar disorder is a chronic, relapsing illness characterized by recurrent episodes of manic or depressive symptoms, with intervening periods that are relatively (but not fully) symptom-free. Onset occurs usually in adolescence or in early adulthood, although onset later in life is also possible.1 Bipolar disorder has a lifelong impact on patients’ overall health status, quality of life, and functioning.2This disorder has 2 major types—bipolar disorder I and bipolar disorder II.3 Bipolar disorder I is defined by episodes of depression and the presence of mania, whereas bipolar disorder II is characterized by episodes of depression and hypomania. Therefore, the main distinction between the 2 types is the severity of manic symptoms: full mania causes severe functional impairment, can include symptoms of psychosis, and often requires hospitalization; hypomania, by contrast, is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization.3Longitudinal studies show that patients with bipolar disorder of either type experience symptomatic depression at least 3 times more frequently than symptomatic mania or hypomania (Figure 1).4–9 The lifetime prevalence of bipolar disorder in adults in the United States is reported to be 3.9%.10Open in a separate windowFigure 1Total Time Ill in First 2 Years After the Index EpisodeM-type: mania, hypomania, psychosis; D-type: depression, dysthymia, dysphoric mixed states.Reprinted with permission from Baldessarini RJ, Salvatore P, Khalsa H-M, et al. Morbidity in 303 first-episode bipolar I disorder patients. Bipolar Disord. 2010;12:264–270.

KEY POINTS

• ▸ Bipolar disorder is a dynamic and serious condition that can have a lifelong impact on a patient''s overall health status, quality of life, and functioning.
• ▸ The treatment of bipolar disorder is challenging and costs the US healthcare system an estimated >$30 billion in direct expenditures and >$120 billion in indirect costs annually.
• ▸ Delayed diagnosis can result in worsening clinical outcomes and increased costs; early recognition of this condition can reduce the total per-patient costs by as much as $2316 annually.
• ▸ Considering the possibility of bipolar disorder in patients with depressive disorders is critical to improving outcomes and reducing costs of treatment.
• ▸ Despite the introduction of new therapies for bipolar disorder, treatment outcomes remain less successful than for major depressive disorder; the use of antidepressants for this condition remains controversial.
• ▸ Medication nonadherence is perhaps the most significant contributor to poor outcomes in this patient population; monotherapy may help improve adherence in some patients.
• ▸ The selection of an appropriate treatment that takes into account efficacy as well as safety can help to ameliorate the devastating impact of bipolar disorder.

Bipolar disorder has an enormous economic impact on the US healthcare system.11,12 The estimated total direct cost of bipolar disorder (including inpatient costs, outpatient costs, pharmaceuticals, and community care) in the United States in 2009 was $30.7 billion.11 In addition, the adverse impact of bipolar disorder on functioning and quality of life translates to a substantial total indirect healthcare cost resulting from the loss of employment, loss of productivity, sick leave,13 and uncompensated care that is estimated at more than $120 billion annually.11From a managed care perspective, bipolar disorder is among the most costly of all mental health conditions. In a major study of commercial insurance claims data from 1996 of almost 1.7 million individuals, although only 3% of patients with a mental health claim were identified with bipolar disorder, these patients accounted for 12.4% of the total plan expenditures.14 High cost was driven largely by a disproportionate rate of inpatient admissions for bipolar disorder versus all other behavioral health claimants (39.1% vs 4.5%, respectively), resulting in a cost of $1.80 for inpatient care per every dollar of outpatient treatment cost.14Another large study of healthcare utilization and costs from 2004 to 2007 compared 122 patients with bipolar disorder with patients with other psychiatric conditions, including 1290 patients with depression, 2770 with asthma, 1759 with coronary artery disease, and 1418 with diabetes.12 The patients with bipolar disorder had higher adjusted mean costs per member per month (approximately $1700) than all other groups, including depression (approximately $1300), with the exception of patients who had both diabetes and coronary artery disease (with approximately $2000 per member per month).12Despite the advent of lithium therapy more than 60 years ago,15 the introduction of other pharmacotherapies and the development of disease-specific behavioral approaches,16 and a generally greater awareness of bipolar disorder, treatment outcomes remain less satisfactory than the outcomes for major depressive disorder (MDD) in all sectors of the US healthcare system, including managed care.2 This represents a challenge and an opportunity for managed care to focus on this disorder to improve outcomes and to reduce healthcare costs.This review article presents the clinical evidence supporting best practice for the diagnosis and treatment of bipolar disorder. The review highlights what little is known about the most effective ways to address specific clinical challenges in caring for patients with bipolar disorder and identifies recent research that documents innovative approaches to improving the effectiveness of care in this setting.     

某三级甲等中医院精神病科住院患者疾病构成分析

目的 分析某三级甲等中医院精神病科疾病构成及分布情况,为精神疾病防治和学科建设提供理论依据.方法 回顾性分析某中医院4178份精神病科住院病案首页资料,收集患者的性别、年龄、出院主要诊断、住院天数、住院费用等信息进行统计分析.结果 精神分裂症、抑郁症、焦虑症、急性应激反应和癫痫性精神病是精神病科住院患者前5位疾病,累积...     

Depression, service utilization, and treatment costs among Medicare elderly: gender differences.

OBJECTIVE: To compare gender differences in mood disorders, service utilization, and health care costs among a random sample of Medicare elderly beneficiaries of Tennessee. DATA SOURCES: Medicare expenditure data from a 5% random sample of Tennessee Medicare beneficiaries (n = 35,673) were examined for 1991-1993. The physician reimbursement files provided data relative to ICD-9 diagnostic codes, physician visits, and the cost of physician services provided. Other service utilization and cost data were obtained for the sample from the outpatient, home health, skilled nursing, hospice and inpatient files. STUDY DESIGN: The dependent variables were: (i) patients with ICD-9 diagnosis for a mood disorder (major depression and other depression), (ii) service utilization (number of outpatient visits, skilled nursing visits, home health visits, physician visits, emergency visits, and inpatient days), and (iii) health care costs (dollar amount of physician cost, outpatient cost, inpatient cost, total mental health cost, total health cost, and other cost). The independent variable was gender. PRINCIPLE FINDINGS: Chi-square tests showed that among the patients with a mood disorder, females had a significantly higher incidence than males of major depression (1.3% vs. .4%, respectively, p < .001) and other depression (1.6% vs. .6%, respectively, p < .001). Further, t-test results indicated that females diagnosed with major depression utilized significantly more outpatient services than males (3.2 vs. 2.6, respectively, p < .04). Total health care costs for those with other depression were significantly higher for males than females ($15,060 vs. $10,240, respectively, p < .002). CONCLUSIONS: The results indicate that mood disorders, outpatient services, and total mental health costs are higher for females than males; however, total health care costs are higher for males than females.     

The Association between Patient Activation and Outcomes among Severely Mentally Ill Patients

Little is known about the association between patient activation, health, service utilization, and cost among mental health (MH) patients. Patients aged 18 to 64 with schizophrenia (Sz, n =?43), bipolar disorder (BD, n =?59), or major depressive disorder (MDD, n =?34) completed the Patient Activation Measure for Mental Health (PAM-MH), the Colorado Symptom Index, demographic, socioeconomic, treatment, and social support questionnaire items. Average PAM-MH score indicated BD patients the most activated (66.6?±?17.5), Sz (57.4?±?10.4) less activated, and MDD the least activated (55.4?±?14.6). The MDD cohort had the highest ($27,616?±?26,229) and the BD had the lowest total annual healthcare cost ($18,312?±?25,091). PAM-MH score was inversely correlated with healthcare costs and regression analysis showed a PAM-MH score × gender interaction. The strongest negative relationship between PAM and cost was for males. These analyses support the inverse association between PAM-MH and healthcare service utilization and cost.

     

Clinician Education Improves Lipid Monitoring in Patients Taking Second-Generation Antipsychotic Agents,Nationally and Locally

BackgroundContinuing medical education (CME) seeks to improve patient health by promoting clinician practice change. Many patients with a diagnosis of either bipolar disorder or schizophrenia are predisposed to cardiovascular risk, and the use of second-generation antipsychotic (SGA) medications that can cause significant weight gain and altering of lipid profiles may compound this risk. An educational analysis identified a performance gap related to psychiatrists' gathering of baseline lipid data in their patients.ObjectiveThis study analyzes the degree to which participation in 2 CME activities improves clinicians' rates of lipid monitoring in patients with mental illness who take SGAs.Study DesignAfter participation in 1 or 2 CME activities on improved cardiometabolic monitoring in patients with major mental illness—in which one activity focused on schizophrenia and the other on bipolar disorder—a nationwide group (NG) of clinician learners was surveyed about lipid monitoring practices among patients during these patients' first 16 weeks of SGA therapy over a 12-month period. Responses from the NG were compared with those from 1) a nationwide control group (CG) and 2) a local group of activity participants at the Lindner Center of HOPE—Cincinnati, Ohio (LG), whose measured rates were documented via medical records data extraction; the LG also received institutional encouragement and support for practice change for lipid monitoring in these patients.ResultsPercentages of patients monitored by clinicians in the NG increased by 18.0 percentage points over 1 year from baseline (P = 0.00001) and represented a rate change that was higher than that seen in the CG (P < 0.00001). Gross, median monitoring rates in the NG increased from 27.5% to 80.0%, and all clinicians at or above the 75th percentile of monitoring rates monitored 100% of their patients after participating. Monitoring rate increases for clinicians in the NG were greater among clinicians with higher patient counts. The LG saw a 28 percentage-point increase (from 27.5% to 55.5%), representing a 102% increase over the baseline LG rate and a 56% increase over the rate change seen in the NG.ConclusionsCME interventions can improve lipid-monitoring practices among clinicians who treat patients with major mental illness who take SGAs. Local, institutional support for guideline-recommended monitoring may increase nationwide CME-induced change yet further.     

Health and Diabetes Self-efficacy: A Study of Diabetic and Non-diabetic Free Clinic Patients and Family Members

Free clinics across the country provide free or reduced fee healthcare to individuals who lack access to primary care and are socio-economically disadvantaged. This study examined perceived health status among diabetic and non-diabetic free clinic patients and family members of the patients. Diabetes self-efficacy among diabetic free clinic patients was also investigated with the goal of developing appropriate diabetes health education programs to promote diabetes self-management. English or Spanish speaking patients and family members (N = 365) aged 18 years or older completed a self-administered survey. Physical and mental health and diabetes self-efficacy were measured using standardized instruments. Diabetic free clinic patients reported poorer physical and mental health and higher levels of dysfunction compared to non-diabetic free clinic patients and family members. Having a family history of diabetes and using emergency room or urgent care services were significant factors that affected health and dysfunction among diabetic and non-diabetes free clinic patients and family members. Diabetic free clinic patients need to receive services not only for diabetes, but also for overall health and dysfunction issues. Diabetes educational programs for free clinic patients should include a component to increase diabetes empowerment as well as the knowledge of treatment and management of diabetes. Non-diabetic patients and family members who have a family history of diabetes should also participate in diabetes education. Family members of free clinic patients need help to support a diabetic family member or with diabetes prevention.     

对初发精神分裂症患者亲属的心理卫生状况评定分析

目的：为观察首次发病住院的精神分裂症患者亲属的心理卫生状况。方法：采用症状自评量表（SCL-90）对60例首次发病的精神分裂症患者亲属及60例正常对照组进行问卷调查。结果：精神分裂症患者亲属的总分及10个因子分均高于对照组，而焦虑，抑郁、人际关系敏感明显高于对照组。结论：精神分裂症患者亲属的心理问题明显，应加强预防措施。     

上海市长宁区家属支援服务对严重精神障碍患者家属的干预效果研究

  目的  探讨家属支援服务干预对于提高社区严重精神障碍患者的康复效果和改善家属的心理健康状况及家庭负担的作用。  方法  采取多阶段随机抽样方法，在抽到的2个社区中将符合严重精神障碍诊断标准的患者随机抽取100例患者，随后根据性别、年龄、诊断在其他几个社区中随机匹配100例符合严重精神障碍诊断标准的患者纳入对照组。严格按照患者和家属纳入标准设立对照组和干预组。  结果  200组研究对象患者平均年龄（48.27±12.67）岁，家属平均年龄（63.61±13.19）岁。干预后各时点对照组日常生活能力量表（activity dailyliving scale，ADL）评分均高于干预组（均有P<0.05）。干预后各时点对照组社会功能缺陷表（social disability screening schedule，SDSS）评分均高于干预组（均有P<0.05）。干预后各时点干预组与对照康复状态量表（morningside rehabilitation status scale，MRSS）评分差异均无统计学意义（均有P>0.05）。干预后各时点对照组患者家属心理健康状况症状（精神症状）自评量表（self-reporting inventory，SCL-90）评分均高于干预组（均有P<0.05）。干预后各时点对照组家庭负担量表（family burden scale of diseases，FBS）评分均高于干预组（均有P<0.05）。  结论  本次干预措施确实提高社区严重精神障碍患者康复效果和改善家属心理和家庭负担，应建立一支专业的家属支援服务工作团队。     

The treatment gap in mental health care

Mental disorders are highly prevalent and cause considerable suffering and disease burden. To compound this public health problem, many individuals with psychiatric disorders remain untreated although effective treatments exist. We examine the extent of this treatment gap. We reviewed community-based psychiatric epidemiology studies that used standardized diagnostic instruments and included data on the percentage of individuals receiving care for schizophrenia and other non-affective psychotic disorders, major depression, dysthymia, bipolar disorder, generalized anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), and alcohol abuse or dependence. The median rates of untreated cases of these disorders were calculated across the studies. Examples of the estimation of the treatment gap for WHO regions are also presented. Thirty-seven studies had information on service utilization. The median treatment gap for schizophrenia, including other non-affective psychosis, was 32.2%. For other disorders the gap was: depression, 56.3%; dysthymia, 56.0%; bipolar disorder, 50.2%; panic disorder, 55.9%; GAD, 57.5%; and OCD, 57.3%. Alcohol abuse and dependence had the widest treatment gap at 78.1%. The treatment gap for mental disorders is universally large, though it varies across regions. It is likely that the gap reported here is an underestimate due to the unavailability of community-based data from developing countries where services are scarcer. To address this major public health challenge, WHO has adopted in 2002 a global action programme that has been endorsed by the Member States.     

多学科团队参与家庭会议干预模式对晚期癌症患者家属焦虑抑郁情绪影响效果评价

目的 探讨晚期癌症患者家属焦虑抑郁情绪的影响因素及多学科团队参与家庭会议干预模式的干预效果。方法 通过对上海市浦东新区某社区卫生服务中心辖区内2019年1—3月期间的72名晚期癌症患者家属(主要照顾者)进行问卷调查,了解其焦虑、抑郁情绪状况,分析其影响因素。在基线调查研究的基础上,按数字随机表法将入选患者家属分为干预组和对照组,两组均给予常规综合服务。干预组在此基础上组织召开多学科参与的家庭会议,采用焦虑(SAS)、抑郁(SDS)量表评价干预效果,干预时间为6个月。结果 干预前,患者家属SAS 和SDS评分明显高于国内常模(P<0.001);干预组和对照组的SAS和SDS评分处于基线平衡(均P>0.05)。单因素分析结果显示:不同性别、教育程度及有无固定职业的家属SAS和SDS评分差异有统计学意义(均P<0.05)。干预6个月后,与对照组相比,干预组患者家属的SAS和SDS评分低于对照组(P<0.001)。结论 晚期癌症患者家属有明显的焦虑、抑郁情绪,且与其性别、受教育程度和职业状况有关。多学科团队参与的家庭会议干预能够有效地改善晚期癌症患者家属的焦虑、抑郁情绪。     

Prevalence of anxiety, depression, and substance use disorders in an urban general medicine practice

BACKGROUND: Most research on the prevalence of mental disorders in primary care has been conducted in practices that serve middle- and upper-income patients. OBJECTIVE: To determine the prevalence of major mental disorders in a primary care practice that serves a predominantly low-income immigrant patient population. DESIGN: Cross-sectional survey; criterion standard. SETTING: Urban general medicine practice. PARTICIPANTS: Systematic sample of consecutive adult patients with scheduled appointments. Of 1266 approached eligible patients, 1007 (80%) participated. MAIN OUTCOME MEASURES: PRIME-MD Patient Health Questionnaire major depression, generalized anxiety disorder, panic disorder, alcohol use disorder, and suicidal ideation; drug use disorder; functional status; work loss; family distress; and mental health treatment. RESULTS: Major depression (18. 9%), generalized anxiety (14.8%), panic (8.3%), and substance use (7. 9%) disorders and suicidal ideation (7.1%) were highly prevalent. Many patients had more than 1 disorder (range, 36.3% [substance use disorder] to 76.9% [panic disorder]). In multivariate analyses, each disorder was significantly associated with an increase in impairment after controlling for demographic characteristics, perceived health, and the other disorders. A minority of patients with each disorder (range, 22.5% [substance use disorder] to 46.4% [panic disorder]) reported receiving mental health treatment in the last month. CONCLUSIONS: Clinically significant depression, anxiety, substance use, and suicidal ideation are quite common in this practice and associated with significant functional impairment. Primary care practices that serve poor urban immigrant populations have a critical need to provide access to mental health services. Arch Fam Med. 2000;9:876-883     

Can social firms contribute to alleviating the economic burden of psychiatric disabilities for the public healthcare system?

In a number of countries, unemployment rates for people with psychiatric disabilities are much higher than in the general population. On the one hand, the expenses for mental health reach 3.5% of the total public health and social services budget in Québec. On the other hand, social firms (SFs) receive government subsidies. The objective was to compare public healthcare expenses for people with psychiatric disabilities who work in SFs with those associated with people with a similar condition who are looking for a job in the competitive labour market. This study followed a retrospective comparative design and considered two groups, namely: 122 employees working in SFs and 64 individuals participating in a supported employment program as job‐seekers. Two complementary datasets were used: a self‐report questionnaire and public healthcare databases. The cost analysis was performed from the perspective of the public healthcare system and included outpatient visit fees to physicians, outpatient visits to health professionals other than physicians in public healthcare centres, inpatient expenses due to hospitalisations, emergency room visits and amounts reimbursed to patients for medication. Regression analyses using generalised linear models with a gamma distribution and log link were used. Our results revealed that when controlling for sociodemographic variables (gender, age, marital status, education, physical disability), global health (EuroQol EQ‐5D‐5L), the severity of psychiatric symptoms (18‐item Brief Symptom Inventory) and self‐declared primary mental health diagnosis, annual healthcare costs paid by the public insurance system were between $1,924 and $3,912 lower for people working in SFs than for the comparison group. An explanatory hypothesis is that working in SFs could act as a substitute for medical treatments such as outpatient visits and medication use. There might be a form of compensation between supporting SFs and financing the public healthcare system, which provides valuable insights for public decision‐making.     

肾病综合征患儿家长社会支持、抑郁水平及家庭亲密度适应性的相关研究

目的 通过问卷调查肾病综合征(NS)患儿家长的家庭亲密度及适应性、社会支持和抑郁水平,探索其相关性,并分析NS患儿家长的家庭亲密度与适应性的影响因素,进而探索提高NS患儿家长亲密度及适应性的方法,为提高NS患儿的生活质量,减少因疾病和治疗带来的心理不良影响提供理论依据.方法 采用问卷调查的方法,于2016年8至12月对西安市儿童医院87名NS患儿家长进行调查研究,研究工具包括:一般资料调查表、家庭亲密度与适应性量表、社会支持量表和Beck抑郁量表四部分.结果 家庭月总收入、照顾者文化程度、医疗费主要来源均不同程度影响NS患儿所在家庭的实际亲密度、实际适应性、社会支持及抑郁值,差异均有统计学意义(r=-0.143~0.498,均P<0.05).87名NS患儿家长家庭的实际亲密度、实际适应性得分均低于常模(t值分别为-12.831、-9.365,均P<0.05),家长抑郁发生率为67.8%.NS患儿家长实际亲密度、理想亲密度、实际适应性、理想适应性均与社会支持之间有显著正相关关系(r值分别为0.558、0.391、0.470、0.378,均P<0.05),与抑郁总分呈负相关关系(r值分别为-0.406、-0.270、-0.369、-0.308,均P<0.05),社会支持与抑郁总分呈负相关关系(r=-0.480,P<0.05).结论 NS患儿家长家庭亲密度、适应性和抑郁值与社会支持关系密切,医护人员应当鼓励NS患儿所在家庭寻求良好的社会支持是非常必要的.     

Applied Communication for Health Professionals,by E. Philips Polack,Virginia P. Richmond,and James C. McCroskey

Drawing on Goldsmith’s (2004) normative theory, this article maps dilemmas family members experience when talking with returning service members (SMs) about seeking mental health care. Eighty family members of United States SMs who served in Iraq or Afghanistan read a scenario where their SM was displaying posttraumatic stress disorder (PTSD) or depression symptoms. Participants described goals they would pursue, barriers they might encounter, and advice they would give others in the situation. Four dilemmas of talking about mental health emerged: (a) getting you to recognize the problem without implying you’re not normal, (b) convincing you to seek help without implying you’re weak, (c) being persistent but patient, and (d) wanting you to open up without implying I can understand. Family members reported using four groups of strategies to manage these dilemmas. Directions for expanding the concept of dilemmas as “paradoxes” and for supporting military families as well as rethinking policy assumptions are discussed.     

The Use of Conventional Antipsychotic Medications for Patients with Schizophrenia in a Medicaid Population: Therapeutic and Cost Outcomes over 2 Years

Objective: To evaluate the association between drug therapy patterns achieved with conventional antipsychotics and direct healthcare costs over 2 years.
Methods: Paid claims data from the California Medicaid (Medi-Cal) program were used to identify 2476 patients with schizophrenia for whom 2 years of data were available. Ordinary least squares (OLS) regression models were used to estimate the association between lack of antipsychotic drug therapy, delayed therapy, changes in medications, and continuous therapy on healthcare costs over a 2-year period.
Results: Nearly 99% of Medi-Cal patients with schizophrenia were treated with conventional antipsychotics. Patients with schizophrenia consumed nearly $48,000 in direct costs over 2 years. Over 16% of patients did not use any antipsychotic medication for 2 years. Untreated patients used more healthcare resources than treated patients did ($10,833, P = .0422), especially psychiatric hospital care ($8,027, P = .0004). However, treated patients frequently experienced suboptimal drug use patterns. Nearly 33% of treated patients delayed antipsychotic therapy for up to 2 years. Delayed therapy was associated with increased costs of $12,285 ( P = .070). Over 56% of patients experienced changes in therapy that were associated with higher total direct costs ($17,644, P < .0001). Finally, only 3.2% of treated patients used an antipsychotic medication consistently for 2 years. However, continuous drug therapy was not associated with lower costs.
Conclusion: Suboptimal drug use patterns are common and costly in Medi-Cal patients with schizophrenia who initiated therapy with conventional antipsychotics.