汶川地震后医疗机构提供精神卫生和心理社会支持的能力:来自四川部分地区基层医务人员的问卷调查与深入访谈

目的:了解四川地震后部分极重及重灾区的精神病院及乡镇卫生院、村卫生室提供灾后精神卫生和心理社会支持(mental health and psychosocial support,MHPSS)的能力。方法:参照联合国机构间常委会对MHPSS的定义和分级,自编问卷,包括卫生机构基本信息及目前提供服务的情况,近2年接受MHPSS培训及教材和参考书的情况,提供MHPSS的意愿及可行性。调查来自县级精神病院1所、乡镇级精神病院1所、乡镇卫生院5所和村卫生室5所的医生共30名,从业年限1~42年(中位数12年)。并对其中10人进行深入访谈,了解个人从业经历、地震对医疗机构的影响、学习和提供MHPSS的经历和感受等。结果:县级和乡镇级精神科医师在辖区内的人口比例分别为0.68/10万人和0.83/10万人。震前无相关培训;震后11人接受过1~7天(中位数2天)的非分级培训,且教材和参考书严重不足。仅有19人表示有时间提供MHPSS服务,可能的时间为(6.9±2.5)h/周。县级和乡镇级精神病院需管理地震前的已住院患者及震后新发病例。县精神病院开展了某些形式的心理健康宣传教育。只有2所乡镇卫生院提供灾后约20人/月的门诊心理咨询。精神科医师震前没有受过心理危机干预培训,没有治疗诊治创伤后应激障碍的经验。基层非精神科医生觉得自己的能力有限,无法给受灾群众提供到位的服务。乡镇卫生院仅有地西泮这一种基本精神科药品。地震对医疗机构的建筑有不同程度的破坏,乡镇级精神病院病房全部倒塌。结论:四川地震后县级及以下医疗机构提供精神卫生和心理社会支持的能力极为有限。建议今后对相关人员开展实用的、有针对性的分级培训;采取措施改变基层卫生机构缺乏基本精神科药品的现状;在新建或改造精神病院时,加强硬件的抗灾强度。     

社区精神卫生服务研究进展

目的：发现我国社区精神卫生服务存在的问题,探索符合本地实际情况的社区精神卫生服务。方法：通过文献检索法检索了中国知网、万方数据库和维普等数据库。结果：本研究发现,我国社区精神卫生服务体系不完善、精神健康素养不高、社区精神卫生服务管理不善以及我国社区精神卫生服务资源不足与“过剩”并存等问题。结论：社区精神卫生服务是我国公共卫生的重要组成部分,在应对日益严峻的精神卫生问题方面发挥着重要的作用;需借鉴国内外先进经验,探索符合本地实际情况的社区精神卫生服务。     

浏阳社区精神卫生服务的初步发展

近年来全国很多地区都在积极推动社区精神卫生服务实践,但具体工作模式则各有特点。为推动这一领域的学术交流,本文从政策发展、网络建设和工作内容三个方面介绍了湖南浏阳社区精神卫生服务的现状和存在的问题,并提出了近期的发展计划。     

精神卫生服务评估的基本框架

精神卫生服务(mental health service)是"提供有效精神卫生干预的各种措施"[1].随着社会经济的发展和健康状况的转变,精神障碍作为我国重大的公共卫生问题[2-3],引起了社会各界的广泛关注和重视.近年来,我国各级政府已出台一系列精神卫生政策[4],以满足社会对精神卫生服务不断增长的需求.     

四川泸州市精神卫生资源与服务5年发展趋势调查

目的:对四川泸州市精神卫生资源及服务情况进行调查,了解其精神卫生发展现状及存在的问题。方法:采用自编问卷,对泸州市精神医疗机构2014年至2018年间的床位数、医护人数、住院费用、诊疗信息等进行纵向调查。结果:2014-2018年间,该市精神卫生资源持续增加。新增机构3家,医生、护士、编制床位和开放床位增长率分别为77.8%、81.2%、36.9%和83.5%。收治能力逐年提升,住院和门诊患者数分别增长了81.1%和52.6%,治疗手段更加多样化。相对而言,各年度住院次均费用保持基本稳定。该市两县尚未设置精神专科医院。住院患者的诊断类型以精神分裂症谱系障碍为主(46.8%)。尽管有所发展,物理治疗的开展率仍不足60%。结论:泸州市精神卫生资源与服务逐年稳步发展,但医疗资源仍短缺且分布不够合理。     

深圳市精神卫生服务利用现况调查

目的:调查了解深圳市居民精神卫生服务利用率,分析影响精神卫生服务利用的因素。方法:采用分阶段分层随机抽样的方法,对深圳市户籍及常住非户籍居民共计抽取8920人。采用复合性国际诊断访谈表(CIDI)3.1中文版进行入户调查采集信息,实际完成7134人,计算各类人群的终生和1年精神卫生服务利用率,采用Logistic回归分析精神障碍终生罹患人群精神卫生服务1年利用率的相关因素。结果:深圳市全人群精神卫生服务终生总利用率为4.02%,1年总利用率为1.71%,专业服务终生利用率为2.50%,1年专业服务利用率为0.64%;精神障碍罹患人群精神卫生服务终生总利用率为11.32%,1年总利用率为5.63%,专业服务终生利用率为6.69%,1年专业服务利用率为2.25%;Logistic回归分析结果显示性别、宗教信仰、童年期抚养人精神异常史、自杀观念是影响精神障碍终生罹患人群精神卫生服务1年利用率的因素。结论:深圳区域的精神卫生服务利用水平较低,该地区相当一部分有精神卫生服务需求的居民未能享有专业服务;精神障碍终生罹患人群中男性、有宗教信仰者、童年期抚养人有精神异常史者、有自杀观念者更容易接受精神卫生服务。     

昆明市社区居民精神卫生服务需求调查与分析

目的探讨昆明市社区精神卫生服务需求及其影响因素,为社区开展精神卫生服务工作提供参考依据。方法采用WHO推荐的"精神卫生服务需求调查表",对514名社区及学校人群进行问卷调查,调查内容包括精神卫生服务信息的重要性及可及性。结果大多数人认为精神卫生服务信息"非常重要",而获得精神卫生信息较困难,其中6项回答"不能得到"的比例最高,6项回答"部分能够"的比例最高。因素分析表明:对精神卫生服务部分信息的重要性的认识与收入水平、医疗保障途径以及精神卫生知晓情况有关;精神卫生服务信息的可及性则与其他社会学因素无关。结论昆明市社区居民迫切需要了解精神卫生服务的相关信息,但是居民需求并未得到基本的满足。因此,需要加强精神卫生服务的宣传和教育,提高社区精神卫生服务的可及性和方便程度,才能有效地利用社区精神卫生服务。     

汶川地震灾后心理社会响应高层研讨会在北京召开

2008年10月10日～11日,由联合国人口基金会(UNFPA)、世界卫生组织(WHO)、卫生部疾控局主办,北京大学精神卫生研究所承办的地震灾后心理社会响应高层研讨会在北京召开.来自国内外政府层面的灾难管理官员,北京大学、清华大学、香港中文大学、中国人民大学、哈佛大学等著名高校的专家学者、心理卫生/精神卫生界的专家学者以及中央电视台、中央人民广播电台、光明日报、健康报、北京青年报等二十多家主流媒体共90余人参加了研讨会.     

内蒙古自治区社区5类精神障碍患者精神卫生服务利用现状

目的:描述内蒙古自治区社区5类精神障碍终生患者精神卫生服务利用现况,为健康教育和制定相关政策提供参考。方法:采用分层多阶段不等概率抽样方法抽取内蒙古自治区18岁及以上常住居民共12 315名,采用复合性国际诊断交谈表调查心境障碍、焦虑障碍、物质使用障碍、间歇爆发性障碍、进食障碍等5类精神障碍及精神卫生服务利用现况,以单因素分析方法进行描述性统计。结果:5类精神障碍中,任何一种精神障碍终生患者咨询率为18.7%,治疗率为10.2%,患者接受非医务工作者治疗的比例最高(31.4%),其次是接受精神科或心理科医生治疗;患者中有1.1%的患者接受药物治疗,有2.5%的患者接受心理治疗。结论:内蒙古自治区精神障碍患者精神卫生服务利用率较低,要广泛开展正确求医的健康教育。     

社区朝汉族更年期居民焦虑、抑郁状况及影响因素

目的：了解社区朝汉族更年期居民焦虑、抑郁状况及其影响因素。方法：采用自编一般情况调查表、焦虑自评量表、流调中心用抑郁量表按整群抽样法对延吉市北山街道8个居委会更年期居民1262人进行调查。其中，朝鲜族639人，汉族623人。结果：流调中心用抑郁量表评分≥20分有127人（10．12％），其中朝鲜族69人（54．3％）、汉族58人（45．7％）；朝鲜族男性（42人，占12．5％）多于女性（27人，占8．9％）（∥=18．24，P〈0．01）。焦虑自评量表总标准分／〉50分者有391人（32．24％），其中朝鲜族（240人，61．4％）多于汉族（151人，占38．6％）（x^2=14．03，P〈0．001）。结论：抑郁和焦虑症状朝鲜族更年期居民比汉族多，应加强这类人群的社区精神卫生服务。     

Implementing the role of the primary care mental health worker: a qualitative study

BACKGROUND: Primary care mental health workers are a new role recently introduced into primary care in England to help manage patients with common mental health problems. AIM: To explore the views of GPs, primary care teams and patients on the value and development of the new role of primary care mental health workers in practice. DESIGN OF STUDY: Qualitative study. SETTING: The Heart of Birmingham Primary Care Teaching Trust in the West Midlands, UK. METHOD: Thirty-seven semi-structured interviews involving seven primary care mental health workers, 21 patients and 11 focus groups involving 38 members of primary care teams were held with six teams with a worker. Two teams asked for the worker to be removed. Six practice managers also took part in the study. RESULTS: A number of different approaches were used to implement this new role. Strategies that incorporated the views of primary care trust senior management, primary care teams and workers' views appeared most successful. Rapid access to a healthcare professional at times of stress and the befriending role of the worker were also highly valued. Workers felt that their role left them professionally isolated at times. A number of workers described tension around ownership of the role. CONCLUSION: Primary care mental health workers appear to provide a range of skills valued by patients and the primary care teams and can increase patient access and choice in this area of health care. Successful implementation strategies highlighted in this study may be generalisable to other new roles in primary care.     

Cluster randomised controlled trial of the effectiveness of primary care mental health workers

BACKGROUND: Mental health issues are a core part of the work of primary care and are the second most common reason for consultations. There is some evidence that the quality of primary care mental health provision is variable. AIM: To evaluate the effectiveness of primary care mental health workers with regards to satisfaction with care, mental health symptoms, use of the voluntary sector, and cost effectiveness of care. DESIGN OF STUDY: Cluster randomised controlled trial. SETTING: Practices in the Heart of Birmingham Primary Care Trust, Birmingham, England. METHOD: Nineteen practices and 368 patients (18 to 65 years of age) with a diagnosis of a new or ongoing common mental health problem were recruited. Sixteen practices and 284 patients completed the trial. RESULTS: Patients in intervention practices had a higher mean level of general satisfaction than those in control practices (difference between group scores of 8.3, 95% confidence interval = 1.3 to 15.3, P = 0.023). The two groups did not differ in mental health symptom scores or use of the voluntary sector. CONCLUSION: For patients with common mental health problems, primary care mental health workers may be effective at increasing satisfaction with an episode of care.     

Case finding of lifestyle and mental health disorders in primary care: validation of the 'CHAT' tool.

BACKGROUND: Primary care is accessible and ideally placed for case finding of patients with lifestyle and mental health risk factors and subsequent intervention. The short self-administered Case-finding and Help Assessment Tool (CHAT) was developed for lifestyle and mental health assessment of adult patients in primary health care. This tool checks for tobacco use, alcohol and other drug misuse, problem gambling, depression, anxiety and stress, abuse, anger problems, inactivity, and eating disorders. It is well accepted by patients, GPs and nurses. AIM: To assess criterion-based validity of CHAT against a composite gold standard. DESIGN OF STUDY: Conducted according to the Standards for Reporting of Diagnostic Accuracy statement for diagnostic tests. SETTING: Primary care practices in Auckland, New Zealand. METHOD: One thousand consecutive adult patients completed CHAT and a composite gold standard. Sensitivities, specificities, positive and negative predictive values, and likelihood ratios were calculated. RESULTS: Response rates for each item ranged from 79.6 to 99.8%. CHAT was sensitive and specific for almost all issues screened, except exercise and eating disorders. Sensitivity ranged from 96% (95% confidence interval [CI] = 87 to 99%) for major depression to 26% (95% CI = 22 to 30%) for exercise. Specificity ranged from 97% (95% CI = 96 to 98%) for problem gambling and problem drug use to 40% (95% CI = 36 to 45%) for exercise. All had high likelihood ratios (3-30), except exercise and eating disorders. CONCLUSION: CHAT is a valid and acceptable case-finding tool for most common lifestyle and mental health conditions.     

芦山地震后5年雅安市受灾居民心理健康状况及其相关因素

目的:了解芦山地震后五年雅安市受灾居民的心理健康状况及相关因素。方法:采用整群分层随机抽样的方法,选取雅安市年龄≥15岁受灾居民9000例,采取入户调查方式,于2019年1~5月使用自编受灾居民基本信息调查表、12项一般健康问卷(GHQ-12)评估近期心理健康状况(≥3分为心理健康状况不良)。结果:8876例居民中心理健康状况不良者(GHQ≥3分)613例(6.9%)。Logistics回归分析显示,有工作(OR=0.15,P<0.001)、居住在乡村(OR=0.48,P<0.001)、一般灾区(OR=0.62,P<0.001)、无慢性疾病(OR=0.37,P<0.001)者更不易出现心理健康状况不良,而老年(OR=1.60,P<0.001)、小学及以下受教育程度(OR=2.69,P<0.001),收入≤1万元(OR=4.8,P<0.001)及无配偶(OR=2.02,P<0.001)者更易出现心理健康状况不良。结论:有工作、居住地为乡村、受灾程度为一般灾区、无慢性疾病为芦山地震后五年雅安市受灾居民心理健康状况不良的保护因素,而老年、受教育程度低、收入低以及无配偶为危险因素。     

Graduate mental health worker case management of depression in UK primary care: a pilot study.

BACKGROUND: Based on data from large multicentre US trials, the National Institute for Health and Clinical Excellence (NICE) is advocating a stepped-care model for the management of depression, with 'case management' or 'collaborative care' for selected patients in primary care. AIM: To conduct a pilot study examining the use of graduate mental health workers case managing depressed primary care NHS patients. DESIGN OF STUDY: A randomised controlled trial comparing usual GP care with or without case management over 16 weeks of acute antidepressant drug treatment. SETTING: Three primary care practices in the North East of England. METHOD: Patients with depression, aged 18-65 years, who had failed to adequately respond to antidepressant treatment, were randomised to the two treatments. Assessments were made at baseline, 12, and 24 weeks using a combination of observer and self ratings. RESULTS: Randomisation of 62 patients required screening of 1073 potential patients. There was little difference in outcome between the two treatment arms but a gradual improvement in symptoms over time was seen. Client satisfaction was assessed as high across both treatments. CONCLUSION: While this pilot study confirmed the integrity of the study protocol and the suitability of the outcome measures and randomisation procedure, it raises questions regarding the practicality of recruitment and feasibility of the intervention. It would be crucial to address these issues prior to the implementation of a large multi-centre randomised controlled trial.     

Primary care characteristics and population-orientated health care across Europe: an observational study

Background

The number of patients with chronic diseases is increasing which poses a challenge to healthcare organisations. A proactive, structured, and population-orientated approach is needed: the chronic care model (CCM) provides such a framework.

Aim

To assess organisational conditions for providing structured chronic care according to the CCM across different healthcare systems.

Design of study

International observational study.

Setting

A stratified sample of 315 primary care practices in 10 European countries and Israel in 2008 and 2009.

Method

Practice questionnaires and interviews. Outcome measures were mean practice scores on CCM domains per country, as a percentage of the maximum score, and the influence of practice size and urbanisation on these scores.

Results

Practice size showed large differences with the largest practices in Spain, England, Finland, and Israel. These countries, with a strong primary care orientation, had most physicians and staff involved per practice. The CCM domains ‘clinical information systems’ and ‘decision support’ had total practice means of 90%; other domains scored about 50%. Spain and England scored above average on almost all domains. Practice size and urbanisation had little impact.

Conclusion

Characteristics for chronic care delivery differed for most CCM domains. The most common characteristics related to computerisation, providing a good starting point and high potential everywhere. All countries showed room for improvement. Further research should focus on relations between practice characteristics, organisational features, including health system and primary care orientation, and outcomes. Primary care seems suited for chronic care delivery; however, a stronger primary care was associated with better scores.     

Children's primary health care services: social-cognitive factors related to utilization

OBJECTIVE: To test social-cognitive influences on parent decision-making processes related to children's health care use. METHODS: Eighty-seven primary caretakers of children ages 4 to 9 years completed measures of child health and behavior, parent functioning, and social-cognitive factors related to parenting and health care use. Primary care use was obtained from the children's primary care physician(s) for the 2 years prior to recruitment. RESULTS: Social-cognitive variables accounted for 13.2% of the variance in primary health care use, above and beyond the influence of child health status and psychosocial variables. The best predictive model, accounting for 29.8% of the variance in primary care use, included the interaction between parental stress and self-efficacy to cope with parenting demands, child behavior problems, self-efficacy for accessing physician assistance, medication use, and parent health care use. CONCLUSIONS: Results documented the relationship between self-efficacy and parent stress in decision making about pediatric primary care use. Social-cognitive theory provides a new perspective for evaluating factors that influence health care use.     

A scale to measure nurses’ and providers’ patient centered care in primary care settings

Objectives1) Refine pilot scale measuring patients' experiences of outpatient nurses' and providers' care; 2) Determine variance explained by (a) pilot scale items and (b) “Survey of Health Experiences of Patients" (SHEP)/"Consumer Assessment of Health Care Providers and Systems" (CAHPS) scale items.MethodsRandomly selected Veteran patients with recent visits with primary care outpatient nurses and providers (n = 1192) completed scales: pilot "PCC in Primary Care: Nurses and Providers Scale" and SHEP/CAHPS scale items. Factor analyses conducted using structural equation modeling (SEM), variance measurement using regression strategies.ResultsSEM generated scale comprised 17 items in 3 factors; 2 operationalized nurses' care; 1 providers' care. Fit statistics were acceptable. Variance explained for total PCC: nurses = 42%, providers = 56%. Combined pilot and SHEP/CAHPS item analyses yielded similarly structured scale. 70% of provider care variance explained by single item.ConclusionAppraisal of team, value-based care requires accrediting care to the appropriate clinician. The "PCC in Primary Care: Nurses and Providers Scale (PC²:NaPS)" provides a psychometrically sound measure for this purpose.Practice implicationsPC²:NaPS use would improve primary care leaders' and clinicians' analyses of patient centered care and associated outcomes in their settings, and thus enhance success of quality improvement and organizational projects.