某三级甲等综合医院住院患者精神科会诊3年资料分析

目的:了解某三级甲等综合医院精神/心理服务需求的特点。方法:汇总某三甲综合医院2006年7月1日-2009年6月30日期间所有经心理医学科会诊的患者共2082例次,分析会诊率、会诊科室、会诊原因、精神科诊断及随诊情况。结果:3年来会诊率由1.01%升至1.48%,随诊率为15.77%。重症监护病房会诊率最高(4.77%),特需科室随诊比例最高(27.04%)。占1%以上的邀请会诊原因有10类,其中"目前情绪症状"最多,占28.4%。精神科诊断以"神经症性、应激性障碍及焦虑状态"为主,占44.2%,诊断为躯体形式障碍及医学不能解释的症状(Medical Unexplained symptoms,MUS)的患者随诊比例最高,达26.6%。结论:综合医院对精神/心理服务的需求全面,精神专科应提供全面深入、特点突出的会诊联络服务。     

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。     

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。     

北京市某精神病医院541例联络会诊患者的特点分析

目的: 了解综合医院住院患者精神科会诊的临床特点.方法: 选取2006年6月-2007年6月某精神病院联络会诊科的所有综合医院住院患者共541例,对人口学资料、会诊科室、会诊原因、精神科诊断进行分析.结果: 精神科会诊次数最多的综合医院精神科年会诊率为1.0%.有精神障碍病史的患者占会诊总数的22.6%.精神病发作、抑郁和焦虑是请求会诊的主要原因(分别占31.8%、13.1%、10.9%).会诊后精神科的主要诊断为认知障碍(32.2%)、抑郁障碍(17.7%)、焦虑障碍(13.1%)、精神分裂症和其他精神病性障碍(9.8%).精神科医师的主要处理建议为应用抗精神病药物(72.8%),护理和行为建议(39.2%),建议随访(38.1%),预防自杀(10.2%).结论: 有必要加强精神科联络服务,提高非精神科医生对精神障碍的识别和处理能力.     

昆明市普通人群精神卫生知识知晓率调查

目的调查城市人群精神卫生知识知晓情况,为制定精神卫生工作相关策略和措施提供参考依据。方法采用自编成套调查问卷,对514名社区及学校人群进行无记名的调查。结果普通人群精神卫生知识各项知晓率均低于45%,对精神卫生相关的法律法规的知晓率最低(8.4%),不同职业人群、家人中有无精神障碍患者的人群对精神卫生知识的知晓率存在显著差异。对精神障碍患者的理解与认识方面,85%的人群对精神障碍患者表示关心和同情,47.5%的人认为精神障碍患者只有一部分人是危险人物;家人中有精神障碍患者的被调查者持负面看法的比例更高,且两组间存在显著的差异。结论城市人群精神卫生知识匮乏,应加强精神卫生的宣传和教育,建立健全精神卫生法规和相关政策,全面推进新世纪精神卫生工作的发展。     

浏阳市农村社区抑郁症患者就诊率及其影响因素分析

目的:探讨农村抑郁症患者的就医情况及其影响因素。方法:以浏阳市≥15岁农村居民抑郁症抽样调查中发现并确诊的抑郁症患者295例为研究对象,全部符合DSM-IV标准。由调查员对所有调查对象询问并填写"精神障碍患者求医行为调查表"(自编)。结果:有13.5%(45/295)的患者曾到乡(镇)卫生院及以上医疗机构就诊,女性就诊率(18.9%)显著高于男性(9.1%)。多元Logistic回归分析结果,影响抑郁症患者就诊率因素有性别(OR=0.363)、年龄(OR=1.040)、家庭主事人职业(OR=0.352)、家庭类型(OR=2.593)和精神病家族史(OR=3.642)。45例曾经就诊的患者中,有5例(1.7%)重症抑郁发作患者曾就诊于精神专科,仅有3例(1.0%)既往重症抑郁发作患者接受过精神科药物治疗。结论:浏阳市农村抑郁症患者卫生服务利用率很低,影响卫生服务利用的因素主要是性别、年龄、受教育程度、家庭类型、家庭人均收入、家庭主事人职业等。     

湖南省浏阳市农村社区精神分裂症患者治疗现状及相关因素

目的:了解农村社区精神分裂症患者的治疗现状及相关因素。方法:采用分层整群随机抽样方法,从湖南省浏阳市农村社区(37个乡镇)抽取3个乡镇共23个行政村的≥15岁常住人口61165人,进行精神障碍的线索调查。用DSM-Ⅳ-TR轴I障碍定式临床检查病人版(SCID-I/P)对阳性线索者进行诊断,对确诊为精神分裂症的220例患者进行求医行为问卷调查。结果:精神分裂症的治疗率为81.4%,出现精神症状后1月内接受过专科治疗者仅56例(25.5%),3月内接受过治疗者89例(40.5%),1年以上方获得首次专科治疗者46例(20.9%),从未接受专科治疗者41例(18.6%)。慢性起病,无自知力及就诊距离较远的患者接受专科治疗的可能性更低(OR=4.71、9.14、4.32)。结论:农村社区精神分裂症患者缺乏及时的专科治疗,应通过开展精神卫生宣传教育,增强农村社区精神卫生服务水平,提高居民对精神分裂症的知晓水平及获得社区精神卫生服务的能力,以促进农村社区精神分裂症的及早治疗。     

综合医院心理门诊抑郁症识别情况——专科和非专科医师的差别

目的:比较综合医院精神科门诊中专科和非专科医生对抑郁症的不同识别情况,了解综合医院中抑郁症的特点,分析影响抑郁症识别的相关因素.方法:对就诊于上海市9所综合医院精神科门诊的680例初诊患者,使用复合式国际诊断检查(CIDI) 抑郁部分进行筛查,并进行专家复核,与首诊医师诊断进行比较.共连续收集抑郁症患者297例,对这些患者进行汉密顿抑郁量表24项(HAMDZ4)、汉密顿焦虑量表(HAMA)的评估,用上海市综合医院精神科门诊非专科医师基本情况调查表对抑郁症识别情况进行调查.结果:(1)680例初诊患者中,专科医师诊治380例,非专科医师诊治300例;共有297例患者被诊断为抑郁症,其中专科医师组180例,非专科医师组117例;专科医师正确识别出抑郁症170例,误诊为抑郁症33例,识别率为88.7%,非专科医师正确识别出抑郁症91例,误诊为抑郁症者58例,识别率为72%,两者对抑郁症识别率的差异有统计学意义(P<0.001);(2)专科医师对抑郁症的识别能力高于非专科医师(专科医师诊断正确337人,不正确43人;非专科医师诊断正确216人,不正确84人;χ2=30.73,P<0.001);专科医师组和CIDI复核诊断的一致性高,Kappa值为0.774,非专科医师与CIDI复核诊断的一致性偏低,Kappa值为0.439;(3)两组抑郁症患者在HAMD24、HAMA总分及各因子分分布上均无显著差异,均有中等以上的抑郁症状,伴有普遍的睡眠障碍、焦虑、躯体化等临床特点;(4)从事精神科工作的时间和每年接受精神科知识培训的时间越长,抑郁症的识别率就越高(OR值为1.475和1.769).结论:综合医院精神科室中的非专科医师接受精神卫生专科知识培训不足,对抑郁症的识别能力不如专科医生,需加强对综合医院精神卫生科室服务质量的管理.     

衡水市乡镇卫生院医务人员精神卫生知识现状

目的:了解衡水市乡镇卫生院医务人员精神卫生知识知晓现状,为提高基层医务人员精神卫生服务能力和重性精神疾病管理治疗技能提供科学依据。方法:采用《精神卫生与心理保健知识问卷》和《医务人员基本情况调查表》对全市11个县市区118所乡镇卫生院(含社区卫生服务中心、站)的各级医务人员进行分层整体随机调查,共发放问卷1028份。结果:精神卫生知晓率为84.19%,性别之间知晓率差异无统计学意义(χ2=1.653,P0.05),文化程度、职称、职业和工作年限(χ2=3.175,85.071,42.106,75.165;P0.05)之间知晓率差异有统计学意义,医生知晓率高于护士。结论:衡水市乡镇卫生院医务人员精神卫生知识知晓状况比较乐观,已达到全国精神卫生工作体系发展指导纲要(2008-2015年)的要求,但仍有3个条目的回答正确率明显偏低,应进一步加强针对性培训,提高基层医务人员对精神卫生知识在基层服务中重要性的理解和认知程度。     

不同综合性医院请精神科会诊差异分析

目的:对比设有精神科综合性医院与无精神科综合性医院请精神科会诊的差异,为提升综合性医院精神卫生服务能力提供理论依据和数据支撑。方法:回顾性分析对比2018年天津市港口医院(有精神科)与天津市滨海新区某综合三甲医院(无精神科)邀请精神科会诊记录。结果:2018年有精神科综合医院精神科会诊127例,会诊率1.21%,无精神科综合医院精神科会诊共107例,会诊率0.36%;有精神科综合性医院请精神科会诊率远高于无精神科综合性医院(χ~2=94.96,P0.01),有精神科综合性医院请精神科会诊理由以焦虑抑郁状态(28.35%)、睡眠障碍(22.05%)等精神问题为主,无精神科综合性医院请精神科会诊理由以兴奋躁动等精神问题(25.23%)、焦虑抑郁状态(16.82%)为主;非精神科医师识别精神心理问题能力不足。结论:综合性医院对精神卫生服务需求较大,无精神科综合医院开设精神卫生相关科室需加速,非精神科医师识别精神心理问题能力有待加强。     

Models of mental health training for primary care physicians

Of the 15% of the population with DSM III diagnosable disorders, 54% are seen exclusively by their primary care physician or by other health professionals. To understand how primary care physicians are prepared for this task the authors attempted to develop a taxonomy of mental health training programs for primary care physicians by: review of the literature, interviews with program sponsors, review of NIMH training grants, and site visits to teaching programs. From this process six program types were defined: consultation, liaison, bridge, hybrid, autonomous, and postgraduate specialization. The characteristics and emphasis of these model types are described as well as program needs for future training. Competence in psychosomatic medicine, psychophysiologic reactions, and the interactions of biologic, psychologic, and social factors in health and disease can be imparted to primary care physicians by such mental health training program designs.     

Detection of child mental health disorders by general practitioners

BACKGROUND: Few children with mental disorders access specialist services. Although previous studies suggest that general practitioner (GP) recognition is limited, parents may not be presenting these problems. AIM: To compare GP recognition of disorders with child mental health data and to examine factors affecting recognition, in particular whether recognition is enhanced if the parent expresses concern during the consultation. DESIGN OF STUDY: A two-phase design involving an initial community survey of children between the ages of 5 and 11 years. In the second phase, primary care attenders who were regarded by their GP as having a mental health disorder were compared with those who were not. SETTING: Five general practices in Croydon, outer London. METHOD: For 186 children attending primary care, GP recognition of disorders was compared with the results of a child mental health questionnaire completed by parents. Accuracy and predictors of GP recognition were examined. RESULTS: Seventy-four per cent of children meeting criteria for caseness were not recognised by GPs as having a mental health disorder. The expression of parental concern in the consultation about a mental health problem increased the sensitivity of recognition from 26% to 88%. Expression of concern also increased GP recognition of non-cases; this reflected GP identification of other mental health and learning problems. Only a third of parents who had concerns expressed these during the consultation. CONCLUSIONS: GPs are responsive to concern and take parental views into account. As well as detecting disorders, GPs are also sensitive to other psychosocial and educational problems that may present in primary care. There is a need for parental education about child mental health disorders.     

Mental health intervention programs in primary care: their scientific basis.

This study examines the scientific basis for mental health intervention programs in primary care. The validity of five underlying assumptions is evaluated, using the results of a naturalistic study covering a representative sample of 25 Dutch family practices and data from the literature. Our findings corroborate the validity of the assumptions. Firstly, our study indicates that mental disorders are indeed very prevalent in primary care settings. Secondly, we find that a substantial proportion of mental disorders is not recognized by the general practitioner (GP). Thirdly, our data show that mental disorders in primary care are not transient or self-limiting. Fourthly, it is shown that only half of the GP attenders with a mental disorder receive some form of mental health treatment in the 14 months after their index consultation. Finally, our data suggest that mental disorders, when identified, can be treated effectively in primary care. These findings are in general agreement with the literature. In the discussion we underscore the need for public health intervention programs targeted at primary care providers. Training programs for general physicians must be directed at improving recognition and diagnosis and at enhancing the availability and quality of mental health interventions. The effectiveness of these programs has to be tested in randomized trials.     

Posttraumatic stress disorder and the use of health services

OBJECTIVE: Prior research has demonstrated increased use of medical services among persons with anxiety and depression. This investigation examined the possible association of posttraumatic stress disorder (PTSD) with the use of nonmental health services. METHOD: A case-comparison design enrolled 102 high users of health services and 54 low users who were assessed for PTSD diagnosis and severity of PTSD symptoms. Subjects were male veterans receiving services from the primary care clinics of the VA Boston Healthcare System during an 18-month period. Data were collected by interview by use of standardized instruments including the Clinician Administered PTSD Scale for DSM-IV, the Life Events Checklist, and the Beck Depression Inventory. Data analysis employed odds ratios, linear and logistic regression, and path analyses. RESULTS: High users of health care were almost twice as likely as low users (27.5% vs. 14.8%) to meet diagnostic criteria for current PTSD. The two groups differed significantly on both symptom frequency and intensity. Path analyses showed an indirect positive association between PTSD and health services use, with physician-diagnosed health conditions as a mediating variable. Auxiliary analysis demonstrated that the combined mental health burden of PTSD and depression symptoms also is positively associated with number of health conditions. CONCLUSIONS: The findings indicate that PTSD, alone and in combination with depression, has a direct negative relationship with physical health that, in turn, is associated with more frequent use of primary health care services. These results do not suggest that PTSD leads to inappropriate (eg, distress-motivated) use of services.     

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.     

Comparative staff values on the community mental health ideology scale.

The community mental health ideologies of groups composed of profession and nonprofessional mental health service providers were measured by use of the Baker-Schulberg Community Mental Health Ideology (CMHI) Scale. The study was designed to: (1) compare current CMHI scores with the original criterion scores of mental health workers, (2) compare CMHI scores of mental health workers from different disciplines who work in the same community mental health setting, and (3) measure CMHI scores for previously nonreported workers, ministers, and board and care operators. Results of the present study indicate that CMHI scores had not changed from the criterion scores over a series of studies, and that score consistency is such that the scale appears to be a reliable discriminatory tool. Contrary to previously reported findings, psychiatrists scored as high as other mental health professionals in the system, and no significant difference was found between disciplines within the professional group. The paraprofessional group, however, ranked significantly lower than the professional group. Clerical and administrative staff, and board and care operators had CMHI scores that were significantly lower than all other study groups. Interestingly, the minister group had a mean score higher than all other groups studied. Our findings suggest that the CMHI Scale differentiates, not only between disciplines of mental health workers who work in the same setting, but also between groups of human services providers in the community.     

Psychology in primary health care: effects of brief targeted therapy on children's medical care utilization

Evaluated the impact of psychological treatment for 93 children (ages 1-15) with common behavior, toilet, school, and psychosomatic problems. Children and parents, who were members of a health maintenance organization, had 1-6 visits to a primary care-based psychological consultation service. Individualized treatment was guided by problem-specific behavioral protocols. Parent outcome and behavior checklist ratings indicated improvement or resolution for 74% of children and high satisfaction with the psychological service. Children's use of medical services, especially acute primary care visits, was reduced during the year after treatment; a matched comparison group's use was unchanged. Addressing children's unmet mental health needs reduces medical care utilization. A primary health care model of psychological services provides an integrated system for serving the health and mental health needs of children.     

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.     

Early intervention services in youth mental health

Mental and substance use disorders are leading contributors to the burden of disease among young people in Australia, but young people experience a range of barriers to accessing appropriate treatment for their mental health concerns. The development of early intervention services that provide accessible and effective mental health care has the potential to reduce the individual and community burden associated with mental health problems. Collaborative care arrangements between general practitioners, psychologists and other service providers are a key component of comprehensive and integrated early intervention services, with evidence-based psychological treatments an important part of these collaborative mental health care models. Recently, the Australian Government funded headspace (the National Youth Mental Health Foundation) to promote and support early intervention in youth mental health by establishing accessible and collaborative models of enhanced primary mental health care for young people with emergent mental and substance use disorders. Clinical psychologists in the headspace Community of Youth Service and other settings will play a key role in providing early and effective interventions within multidisciplinary collaborative care arrangements.     

Access to primary health care for Australian young people: service provider perspectives.

BACKGROUND: To adequately address the complex health needs of young people, their access to services, and the quality of services received, must be improved. AIMS: To explore the barriers to service provision for young people and to identify the training needs of primary healthcare service providers in New South Wales (NSW), Australia. DESIGN OF STUDY: A cross-sectional, qualitative study of the perspectives of a range of health service providers. SETTING: A range of primary healthcare organisations across NSW. METHODS: Samples of general practitioners (GPs), youth health workers, youth health coordinators, and community health centre staff were drawn from urban and rural clusters across NSW. Focus groups and interviews were used to identify barriers to service provision and the training needs of service providers. Data were tape recorded, transcribed, and analysed. RESULTS: Barriers to service provision among GPs and community health centre staff included inadequate time, flexibility, skills, and confidence in working with young people, and poor linkages with other relevant services. Training needs included better knowledge of and skills in adolescent health requirements, working with adolescents, and working with other services. Barriers to service provision for youth health workers and coordinators included lack of financial resources and infrastructure. There were few linkages between groups of service providers. CONCLUSION: Models of service provision that allow stronger linkages between service providers, sufficient time for consultation with young people, adequate training and support of health professionals, and flexibility of service provision, including outreach, should be explored and evaluated.