北京市社区精神障碍患者康复需求调查研究

[目的]了解目前北京市社区精神障碍患者的康复需求,以期为更好的提供精神卫生服务提供依据。[方法]采用自行设计的调查问卷,对北京市朝阳、西城、大兴、房山4个区在社区康复的精神障碍患者进行现场调查,回收的数据用Epidata 3. 1录入,并用SPSS 22. 0软件进行统计分析。[结果]①社区精神障碍患者以城市京籍中老年无业者居多,学历普遍较低,多为持有精神残疾类别的残疾证的严重精神障碍患者;②近一半的患者更愿意接受社区专业化康复医疗服务(344,48. 6%);③患者选择在社区接受精神卫生服务的原因主要是方便及时(570,80. 5%);④大部分患者认为应该通过提高服务的专业性来促进社区精神卫生服务的发展(299,42. 2%)。[结论]北京市社区精神障碍患者的需求集中体在优质专业的社区精神卫生服务、丰富多样的就业岗位、灵活有效的康复项目、美好和谐的家庭环境和社区氛围等方面,而要更好满足患者的需求需要政府完善相关政策、提高基层服务水平、加强宣传、促进多方合作。     

社区严重精神障碍患者动态监护及同伴支持服务模式研究

目的 探究社区严重精神障碍患者动态监护及同伴支持服务模式(新型管护方案)对患者社区康复和生活质量的影响。方法 随机抽取某社区内管理的严重精神障碍患者50例作为研究对象,通过自身对照比较新型管护方案实施前、实施后1年,患者病情控制率和生活质量情况。结果 实施前疾病控制率为62.00%,实施新型管护方案1年后病情控制率为80.00%,差异有统计学意义(χ²=3.934,P＜0.05);实施后患者的生理功能(79.0±22.5)分、社会功能(64.2±11.5)分、生理职能(49.5±10.4)分、情感职能(69.5±19.2)分、生命活力(69.1±9.5)分等5个指标得分均高于实施前,差异均有统计学意义(均P<0.05)。此外,患者对监护及同伴支持服务模式总体满意度显著提高,实施前、后分别为70.00%和96.00%,差异有统计学意义(χ²=11.977,P＜0.05)。结论 社区严重精神障碍患者的动态监护及同伴支持服务模式(新型管护方案)能有效提升社区管护效果,值得推广应用。     

Effects of housing circumstances on health, quality of life and healthcare use for people with severe mental illness: a review

Individuals with severe and persistent mental illness (SPMI) identify housing as an important factor in achieving and maintaining their health. However, many live in substandard accommodations that are physically inadequate, crowded, noisy and located in undesirable neighbourhoods. In much of the research on housing for persons with SPMI, the central outcome of interest is remaining housed; however, it is worth investigating whether housing has other benefits. This paper is a systematic review of studies that investigated the relationship between housing-related independent variables and health-related dependent variables. Ten online databases were searched for studies published since 1980 that had study populations of adults with SPMI, analysed primary or secondary empirical data, and measured housing-related independent variables and health-related dependent variables. Clearly defined epidemiological criteria were used to assess the strength of evidence of the selected studies. Twenty-nine studies met the suitability criteria, of which 14 reported healthcare utilisation outcomes; 12 examined mental status outcomes; and 9 reported quality-of-life outcomes. The findings of the review suggest that there is good evidence that housing interventions benefit the homeless population; however more research is needed about housing solutions for individuals with SPMI who are housed, but in precarious or inappropriate housing situations. Study methodologies could be improved by emphasising longitudinal designs that focus on participant retention and by implementing matched control groups or randomised interventions to strengthen internal validity. Ensuring that a person is adequately housed upon discharge from hospital should be a treatment priority. When housing eligibility is not dependent on psychiatric treatment compliance and sobriety, providing permanent housing minimises harm and may free people to voluntarily seek treatment. Housing that offers an unlimited length of stay is recommended because SPMI is a chronic and fluctuating condition that requires stable surroundings to maintain health.     

Registering concern: the case of primary care registers for people with severe and enduring mental illness

As the focus of mental health care has shifted from the hospital to the community, so the importance of effectively targeting resources on those with the greatest need has become paramount. One approach to identifying and targeting people deemed to have severe and enduring mental health problems is the establishment of mental health case registers at primary care level. This paper raises a number of conceptual issues associated with these registers and, on the basis of the available literature, offers suggestions to guide those who are contemplating their introduction.     

Exploring healthcare professionals' perspectives of barriers and facilitators to supporting people with severe mental illness and Type 2 diabetes mellitus

Individuals with comorbid severe mental illness (SMI) and diabetes experience an average mortality gap of 20 years compared to individuals without these conditions. There has been some recognition by policies that there is a gap between mental healthcare and physical healthcare for SMI patients. Despite this, there are still no defined care pathways for individuals with SMI and diabetes. The aim of this study was to explore healthcare professionals' (HCPs) perspectives of barriers and solutions to supporting people with SMI and diabetes. HCPs in areas of South London were invited to attend a workshop event to discuss their views of SMI and diabetes pathways. Fifty participants were recruited using the Local Care Network. HCPs included GPs, mental health nurses, psychiatrists, diabetologists and care co‐ordinators. The main themes were as follows: (a) poor coordination of care and care planning between services; (b) key techniques to improve integrated care; (c) perceived difficulties achieving better care and (d) supporting patient empowerment. The findings and recommendations from this workshop may provide some insight into key factors in providing and improving integrated SMI and diabetes care for patients in South East London and further afield.     

重性精神疾病患者肇事肇祸情况干预效果评估

目的 了解海宁市社区重性精神疾病患者肇事肇祸的现状及对比。方法 2010年9—11月对海宁市3 370例在册的重性精神疾病患者进行肇事肇祸危险性评估,并对肇事肇祸危险性评估等级≥1级的1 074例患者进行早期多部门联合干预,于2011年10—12月再次对1 074例患者进行肇事肇祸危险性评估并进行对比分析。结果 干预前后危险性评估1、2、3、4级人数差异均有统计学意义（P<0.05）;干预前后危险性评估≥1级的患者住院次数、监护人变化及服药情况差异有统计学意义（P<0.01）;干预前有肇事肇祸者198例（18.44%）,其中精神分裂症患者最多,为164例（82.83%）;干预后有肇事肇祸者76例（7.18%）,其中精神分裂症患者最多,为64例（84.20%）;干预前后肇事肇祸发生的次数及不良后果程度比较差异均有统计学意义（P<0.05）;干预前后有肇事肇祸的患者住院次数、服药情况差异有统计学意义（P<0.05）;干预前后有肇事肇祸者与无肇事肇祸者疾病种类、年龄、文化程度、病程、监护人变化以及服药依从性比较差异均有统计学意义（P<0.05）。结论 社区重性精神疾病患者的肇事肇祸现状通过政府、卫生、财政、民政、残联等多部门共同的监护和管治,肇事肇祸现状得到明显改善。     

社区综合干预对重性精神病患者复发率影响

目的 定量评估社区综合干预对重性精神病患者复发率的影响。方法 以重性精神病、精神分裂症、社区(severe mental disease,severe psychosis,schizophrenia,community,China)为检索关键词,检索中国学术文献总库(CNKI)、数字化期刊全文数据库(万方)、中文科技期刊数据库(VIP)、中国生物医学文献数据库和外文数据库Pubmed、Elsevier Science Direct、web of knowledge,收集2004年以来发表的社区干预对重性精神病患者复发率影响的随机对照试验(RCT)和非随机对照同期试验(NRCCT)研究,以Stata 12软件进行meta分析。结果 最终纳入中文文献9篇、英文文献1篇,累计干预组人数854例,对照组人数832例;meta分析结果显示,采取社区综合干预组的重性精神病患者在随访期间复发的危险度是对照组的0.322倍(OR=0.322,95% CI=0.241~0.430);漏斗图未观察到显著的不对称性,以0.1为检验水准进行Begger检验和Egger检验,P=0.283和0.151,均>0.1,未观察到本次meta分析受发表偏倚的影响,敏感性分析表明结果较为稳健。结论 社区综合干预能有效预防重性精神病的复发,是提高精神卫生服务可及性以及减轻重性精神病患者对家庭和社会负担的有效措施。     

686项目31个示范市(州)重性精神疾病患者经济水平及参保和治疗情况分析

目的 了解“686项目”地区重性精神疾病患者的经济、参保及治疗情况。方法 对“686项目”的31个示范市(州)采用自编调查问卷收集截至2012年末重性精神疾病患者的汇总统计数据, 分析总体情况并比较东部、中部、西部和东北四大地区患者的经济、参保、治疗情况差异。结果 重性精神疾病患者中家庭无收入者占13.02%, 有收入但收入在当地低保线以下者占33.25%, 低保线以上者占53.73%;城镇职工医疗保险占21.24%, 城镇居民医疗保险占21.73%, 新农合占45.40%, 无医保占11.63%;未治疗者占17.66%, 间断治疗者占45.17%, 连续治疗者占37.17%;东部、中部、西部和东北四大地区的患者经济、参保、治疗情况差异均有统计学意义(P<0.01), 东北地区患者经济情况最差, 且未治疗的患者比例最高为27.30%, 中部地区患者无医保比例最高为18.17%。结论 重性精神疾病患者总体经济水平较差, 医保覆盖率较全国人群低, 连续正规治疗患者比例低, 且患者的经济水平、参保及治疗情况在四大地区存在差异。     

Oral health problems and support as experienced by people with severe mental illness living in community‐based subsidised housing – a qualitative study

The purpose of this study was to explore how persons with severe mental illness (SMI) experience oral health problems (especially dry mouth), and weigh the support they received in this regard from professionals and staff at community‐based congregate housing through a controlled intervention programme. Oral health problems and dry mouth are found in association with apathy and indifference, cognitive deficits, and long‐term medication with psycho‐pharmacological drugs. The present study describes the results from one part of a longitudinal intervention programme, which sought effective ways of mitigating dry mouth through increased support with oral health problems. This part consists of 67 informal interviews with ten participants in two community‐based urban housing projects between November 2006 and June 2007, with a follow‐up session in December 2007. Content analysis of the results yielded five categories: The shame of having poor dental health, history of dental care, experiences of self‐care, handling of oral health problems, and experiences of staff support. Poor oral health caused shame and limited participation in social activities. Participants avoided oral health issues by such circumventions as denial of a tooth ache or dental infections, or postponing oral problems with the hope that they would die away. Offers of support were frequently resisted because of unsatisfactory prior encounters with dental professionals and staff. Our findings suggest that self‐care needs to be facilitated in an unobtrusive manner with minimal staff involvement, and clients should be referred to dental care providers experienced in treating people with SMI.     

The outcomes of partnerships with mental health service users in interprofessional education: a case study

This paper reports findings from a 5-year evaluation (1998-2003) of a postqualifying programme in community mental health in England which made a sustained attempt to develop partnerships with service users. Users were involved in the commissioning of the programme and its evaluation, as trainers and as course members. The evaluation employed mixed methods to assess: learners' reactions to user-trainers and users as course members; changes in knowledge, attitudes and skills; and changes in individual and organisational practice. Data were collected from participant observation of training, 23 individual and 18 group interviews with students and their managers (n=13), and student ratings of knowledge and skills at the beginning and end of the programme (n=49). The quality of care provided by students was rated by service users (n=120) with whom they worked, using a user-defined questionnaire. The quality of care, and mental health and quality of life outcomes were compared to those for two comparison groups (n=44) in areas where no training had taken place. In general, the students reported positive learning outcomes associated with the partnership orientation of the programme, and learning directly from and with service users. A higher proportion of programme users reported good user-centred assessment and care planning, and showed greater improvement in life skills compared to the comparators. This case study provides evidence of the value of partnership working with service users in interprofessional postqualifying education in mental health. The success is attributed to the design of the programme and the responsiveness of the programme board, which included service users. It may provide a useful model for programmes elsewhere and for other user groups. The case study itself provides a possible model for the systematic evaluation of partnerships with users in education and training.     

Two-year outcomes of fee-for-service and capitated medicaid programs for people with severe mental illness

OBJECTIVE: To examine the effects of two models of capitation on the clinical outcomes of Medicaid beneficiaries in the state of Colorado. DATA SOURCE: A large sample of adult, Medicaid beneficiaries with severe mental illness drawn from regions where capitation contracts were (1) awarded to local community mental health agencies (direct capitation), (2) awarded to a joint venture between local community mental health agencies and a large, private managed behavioral health organization, and (3) not awarded and care continued to be reimbursed on a fee-for-service basis. STUDY DESIGN: The three samples were compared on treatment outcomes assessed over 2 years (total n = 591). DATA COLLECTION METHODS: Study participants were interviewed by trained, clinical interviewers using a standardized protocol consisting of the GAF, BPRS, QOLI, and CAGE. PRINCIPAL FINDINGS: Outcomes were comparable across most outcome measures. When outcome diffrences were evident, they tended to favor the capitation samples. CONCLUSIONS: Medicaid capitation in Colorado does not appear to have negatively affected the outcomes of people with severe mental illness during the first 2 years of the program. Furthermore, the type of capitation model was unrelated to outcomes in this study.     

A primary mental health-care model for rural Australia: outcomes for doctors and the community

ABSTRACT: To address the high rate of depression and suicide in rural Australia requires a multifaceted approach to educate the community, improve the skills of health workers and provide user-friendly patient counselling. The present paper describes a model that covers each of these aspects and details the outcomes with respect to the doctors and the community. Improved awareness in the community of mental illness and the availability of treatment, decreasing the stigma of such a diagnosis, and increasing the skills and reducing the isolation of doctors in rural areas who treat mental illness were all positive benefits from this cost-effective way of providing mental health care in a primary setting. The adoption of this model in all primary care settings is advocated.