The mental health expert patient: findings from a pilot study of a generic chronic condition self-management programme for people with mental illness

BACKGROUND: Less than optimal outcomes and escalating costs for chronic conditions including mental illness have prompted calls for innovative approaches to chronic illness management. AIMS: This study aimed to test the feasibility and utility of combining a generic, clinician administered and peer-led self-management group approach for people with serious mental illness. METHOD: General practitioners and mental health case managers used a patient-centred care model (the Flinders model) to assist 38 patients with serious mental illness to identify their self-management needs, and match these with interventions including Stanford peer-led, self-management groups and one-to-one peer support. Self-management and quality of life outcomes were measured and qualitative evaluation elicited feedback from all participants. RESULTS: Collaborative care planning, combined with a problems and goals focused approach, resulted in improved self-management and mental functioning at 3 to 6 months follow-up. The Stanford self-management course was applicable and acceptable to patients with serious mental illnesses. Qualitative feedback was highly supportive of this approach. CONCLUSIONS: Generic, structured assessment and care planning approaches, resulting in self-management education targeted to the individual, improved self-management and quality of life. Patients and service providers reported considerable gains despite the challenges associated with introducing a generic model within the mental health and general practice sector.     

Exploring the relationship between a continuum of care and intrusiveness of children's mental health services.

Intake data for 61 children in three types of mental health programs in Philadelphia--partial hospitalization, home-based services, and outpatient treatment--were compared to examine an assumption of the continuum-of-care concept: the level of a program's intrusiveness is positively related to a child's severity of dysfunction. Results supported the relationship between intrusiveness and dysfunction only when children in outpatient treatment were compared with those in the other two programs. Children treated in the less intrusive home-based program were more dysfunctional than those treated in the more intrusive partial hospitalization program. Factors other than degree of dysfunction, such as a history of outpatient treatment, were more predictive of treatment type. Results suggest that it may be more accurate to speak of an array of services rather than a continuum.     

Mortality in patients with epilepsy: a study of patients in long term residential care.

The causes of death in a group of patients with severe epilepsy in long term residential care over a period of 11 years were assessed and the standardised mortality rate (SMR) determined. A total of 3392 patient-years were surveyed. One hundred and thirteen deaths were recorded in the period and this represents an overall mortality rate which is almost twice the expected rate for this population (SMR = 1.9; 95% CI 1.6-2.3; p < 0.01). Most deaths were due to cancer (26%), bronchopneumonia (25%), circulatory diseases (24%), were seizure-related (12%) or due to sudden unexpected death (6%). The highest SMRs in the neoplasm sub-group were due to cancers of the pancreas (SMR = 6.2) and hepatobiliary tumours (SMR = 17.6). Twenty per cent of patients died of epilepsy or epilepsy related causes (that is accidents, during seizures, status or sudden unexpected death). One in every 480 patients died due to a sudden unexpected death. This study in a highly selected population seems to confirm suggestions that mortality rates are higher in patients with epilepsy than in the general population, but prospective studies are warranted to ascertain underlying mechanisms.     

The relationship between early suicide behaviors and mental health: Results from a nine-year panel study

This paper employs community-level data to examine the relationship between suicide behaviors, measured at age eleven, and two mental health outcomes assessed nine-years later. Specifically, we assess the role and significance of suicide ideation and suicide attempts in substance dependence and depressive symptomatology. We evaluate these linkages in the context of two hypothesized mediators: exposure to social stress and T-1 depressive symptoms. Results indicate suicide ideation and attempts are significant predictors of later mental health problems. However, controlling for T-1 depression and stress exposure explains away the relationship between suicide attempts and later mental health. In contrast, suicide ideation remained a robust predictor of depression and drug dependence. The implications of these findings are discussed.     

Screening for mental health problems among patients with substance use disorders: preliminary findings on the validation of a self-assessment instrument.

OBJECTIVES: We conducted a preliminary study on the validation of the Psychiatric Diagnostic Screening Questionnaire (PDSQ) among patients seeking treatment for substance use disorders (SUDs). METHOD: We assessed 76 patients with SUDs, using the PDSQ, followed by the Structured Clinical Interview for DSM-IV. Sensitivity, specificity, positive and negative predictive values, and receiver operating characteristic (ROC) curves were calculated. RESULTS: Overall, the psychometric properties identified with the PDSQ in patients with SUDs differed from those found in psychiatric outpatient populations. The ROC curves were calculated for major depressive disorder, posttraumatic stress disorder, and panic disorder. The areas under the curves were 0.86 (95% CI, 0.77 to 0.95; P < 0.001), 0.79 (95% CI, 0.68 to 0.90; P < 0.001), and 0.66 (95% CI, 0.51 to 0.82; P = 0.05), respectively. CONCLUSION: The use of the PDSQ to screen for other psychiatric disorders in populations with SUDs is promising but requires larger validation studies to provide data on its psychometric properties and inform the choice of cut-off scores for this population.     

The bidirectional relationship between loneliness and common mental disorders in adults: findings from a longitudinal population-based cohort study

Purpose

Limited longitudinal population-based research exists on the bidirectional association between loneliness and common mental disorders (CMDs). Using 3-year follow-up data, this study examined whether loneliness among adults increases the risk for onset and persistence of mild–moderate or severe CMD; and whether mild–moderate or severe CMD is a risk factor for onset and persistence of loneliness.

Methods

Data were used from the second (‘baseline’) and third (3-year follow-up) waves of the Netherlands Mental Health Survey and Incidence Study-2, a prospective study of a representative cohort of adults aged 18–64 years. Twelve-month CMDs and their severity were assessed with the Composite International Diagnostic Interview 3.0, and current loneliness using the De Jong Gierveld Loneliness Scale. Multivariate analyses were controlled for several potential confounders.

Results

Loneliness predicted onset of severe CMD at follow-up in adults without CMDs at baseline, and increased risk for persistent severe CMD at follow-up in those with CMD at baseline. Conversely, severe CMD predicted onset of loneliness at follow-up in non-lonely adults at baseline, but was not associated with persistent loneliness at follow-up in lonely adults at baseline. Observed associations remained significant after controlling for perceived social support at baseline, except for the relationship between loneliness and persistent severe CMD. No longitudinal relationships were observed between loneliness and mild–moderate CMD.

Conclusions

Attention should be paid to loneliness, both in adults with and without CMD. Further research is needed to better understand the mechanisms underlying the observed associations between loneliness and CMDs to develop successful interventions.

     

Predictors of health care use in patients with Parkinson's disease: a longitudinal study.

PURPOSE: To predict health care use in patients with Parkinson's disease. METHODS: The health care use of 235 patients with Parkinson's disease was studied twice over the course of 1 year. Use consisted of visits to the neurologist and general practitioner (GP) and use of a physiotherapist, a psychotherapist, or home care nurse. The effects of both prior and concurrent sociodemographic, disease-related, and psychosocial characteristics on health care use were examined. RESULTS: Patients who were living with others and patients with private health insurance paid significantly (p <0.01) more visits to their neurologists. For visits to the general practitioner, disease severity and poor quality of life, as measured by the Parkinson's Disease Quality of Life questionnaire (PDQL), were the most important predictors. Other sociodemographic and disease-related characteristics, such as age, gender, and disease duration, were not related to doctor visits. Physiotherapy was associated with disease severity and poor quality of life. Lack of social support, depression, and poor quality of life were correlated with psychotherapy, whereas age, female gender, living alone, disease severity, and disease duration were related to use of a home care nurse. CONCLUSIONS: The number of visits to a neurologist by patients with PD is not associated with disease severity or quality of life impairment, but only with sociodemographic characteristics. Nonmedical care is predicted by disease severity and psychosocial characteristics. The consequences for care and costs are discussed.     

The relationship between parental involvement and adolescent mental health in six sub-Saharan African countries: findings from Global School-based Health Surveys (GSHS)

Sub-Saharan African (SSA) youth have higher rates of poor mental health compared to their counterparts in other low-and-middle-income countries. Empirical studies have found that family support is a crucial deterrent against the development of mental health problems in adolescence. However, little is known about the link between parental involvement and SSA young people mental health. This study examined the correlation between parental involvement and SSA adolescent mental health. About 15,000 adolescents aged 11–17 from six SSA countries participated in the Global School-Based Health Surveys (2003–2007). Based on the findings, low parental involvement was observed. Binomial regression analysis showed that the strength and direction of the relationship between parental involvement and mental health varied across countries. These findings may indicate the need for more intense mental health intervention efforts including the collaboration of professionals, policy-makers, and parents to guide future child and adolescent mental health services.     

Functioning and utility for current health of patients with depression or chronic medical conditions in managed, primary care practices.

BACKGROUND: Health utility is the recommended outcome metric for medical cost-effectiveness studies. We compared health utility and quality of life for primary care patients with depression or chronic medical conditions. METHODS: Respondents were outpatients (N = 17 558) of primary care clinicians (N = 181) in 7 managed care organizations. Utility was assessed by time tradeoff, or the years of life that patients would exchange for perfect health, and standard gamble, or the required chance of success to accept a treatment that can cause immediate death or survival in perfect health. Probable 12-month depressive disorder and affective syndromes were assessed through self-report items from a diagnostic interview. Medical conditions were assessed with self-report. Quality of life was assessed by the 12-Item Short-Form Health Survey. Regression models were used to compare quality of life and utility for patients with depression vs chronic medical conditions. RESULTS: Patients with probable 12-month depressive disorder had worse mental health and role-emotional and social functioning and lower utility for their current health than patients with each chronic medical condition (for most comparisons, P<.001). Depressed patients had worse physical functioning than patients with 4 common chronic conditions but better physical functioning than patients with 4 other conditions (each P<.001). Patients with lifetime bipolar illness and 12-month double depression had the poorest quality of life and lowest utility. CONCLUSIONS: Primary care patients with depressive conditions have poorer mental, role-emotional, and social functioning than patients with common chronic medical conditions, and physical functioning in the midrange. The low utility of depressed patients relative to patients with chronic medical conditions suggests that recovery from depression should be a high practice priority.     

Development of mental disorders one year after exposure to psychosocial stressors; a cohort study in primary care patients with a physical complaint

ABSTRACT: BACKGROUND: Mental disorders, common in primary care, are often associated with physical complaints. While exposure to psychosocial stressors and development or presence of principal mental disorders (i.e. depression, anxiety and somatoform disorders defined as multisomatoforme disorders) is commonly correlated, temporal association remains unproven. The study explores the onset of such disorders after exposure to psychosocial stressors in a cohort of primary care patients with at least one physical symptom. METHOD: The cohort study SODA (SOmatization, Depression and Anxiety) was conducted by 21 private-practice GPs and three fellow physicians in a Swiss academic primary care centre. GPs included patients via randomized daily identifiers. Depression, anxiety or somatoform disorders were identified by the full Patient Health Questionnaire (PHQ), a validated procedure to identify mental disorders based on DSM-IV criteria. The PHQ was also used to investigate exposure to psychosocial stressors (before the index consultation and during follow up) and the onset of principal mental disorders after one year of follow up. RESULTS: From November 2004 to July 2005, 1020 patients were screened for inclusion. 627 were eligible and 482 completed the PHQ one year later and were included in the analysis (77%). At one year, prevalence of principal mental disorders was 30/153 (19.6% CI95% 13.6; 26.8) for those initially exposed to a major psychosocial stressor and 26/329 (7.9% CI95% 5.2; 11.4) for those not. Stronger association exists between psychosocial stressors and depression (RR = 2.4) or anxiety (RR = 3.5) than multisomatoforme disorders (RR = 1.8). Patients who are "bothered a lot" (subjective distress) by a stressor are therefore 2.5 times (CI95% 1.5; 4.0) more likely to experience a mental disorder at one year. A history of psychiatric comorbidities or psychological treatment was not a confounding factor for developing a principal mental disorder after exposure to psychosocial stressors. CONCLUSION: This primary care study shows that patients with physical complaints exposed to psychosocial stressors had a higher risk for developing mental disorders one year later. This temporal association opens the field for further research in preventive care for mental diseases in primary care patients.     

The feasibility of cost-benefit studies of mental health care. An attempt with a Dutch Case Register

ABSTRACT: A cohort of 928 people, aged 20 to 60 years, were entered in a Dutch Case Register for the first time as outpatients during the period from 1974 to 1977. They were each followed up for 1 year in order to identify patterns of care and calculate their cost. The latter was calculated for groups of patients, according to diagnosis and type of service at entry. This approach required registering face-to-face contacts for each patient, and close collaboration with the services involved, to calculate costs.     

Traumatic grief as a disorder distinct from bereavement-related depression and anxiety: a replication study with bereaved mental health care patients

OBJECTIVE: Earlier studies have shown that symptoms of traumatic grief are distinct from those of bereavement-related depression and anxiety. This study was an attempt to replicate that finding. METHOD: Data were derived from 103 patients. Traumatic grief was measured with the Inventory of Traumatic Grief. Depression and anxiety were measured with the Symptom Checklist. The distinctiveness of the three symptom clusters was determined with principal axis factoring. RESULTS: Symptoms of traumatic grief, depression, and anxiety clustered together in three distinct factors. CONCLUSIONS: These results confirm the previous finding of a distinction between symptoms of traumatic grief and symptoms of bereavement-related depression and anxiety.     

Pathways to care,DUP, and types of interventions over 5 years following psychosis onset: findings from a naturalistic study conducted in routine generalist mental health services

Social Psychiatry and Psychiatric Epidemiology - To describe pathways to care, duration of untreated psychosis (DUP), and types of interventions provided to first-episode psychosis (FEP) patients...     

首次住专科医院精神障碍患者家属求医态度、心理状况及家庭关系调查

目的:调查分析首次住专科医院精神障碍患者家属的求医态度、心理状况及家庭关系。方法:对青海地区1 077例首次住专科医院精神障碍患者的家属采用家属就医态度自行编制量表、症状自评量表(SCL-90)、家庭环境量表(FES-CV)中文版进行调查,统计分析。结果:患者家属早期多寻求迷信巫术的帮助,精神卫生知识缺乏;SCL-90评分显著高于常模(P0.01);FES-C评分与常模差异有显著统计学意义(P0.01)。结论:首次住专科医院精神障碍患者家属精神卫生知识缺乏,心理状况不良,家庭关系欠佳。     

Religious beliefs and practices are associated with better mental health in family caregivers of patients with dementia: findings from the REACH study.

OBJECTIVE: Providing care to a loved one with dementia and the death of that loved one are generally considered two of the most stressful human experiences. Each puts family caregivers at risk of psychologic morbidity. Although research has suggested that religious beliefs and practices are associated with better mental health, little is known about whether religion is associated with better mental health in family caregivers. Our objective, then, is to explore the relationship between religion and mental health in active and bereaved dementia caregivers. METHODS: A total of 1,229 caregivers of persons with moderate to severe dementia were recruited from six geographically diverse sites in the United States and followed prospectively for up to 18 months. Three measures of religion: 1) the frequency of attendance at religious services, meetings, and/or activities; 2) the frequency of prayer or meditation; and 3) the importance of religious faith/spirituality were collected. Mental health outcomes were caregiver depression (Center for Epidemiological Studies-Depression [CES-D] scale) and complicated grief (Inventory of Complicated Grief [ICG]). RESULTS: Religious beliefs and practices were important to the majority of caregivers. After controlling for significant covariates, the three measures of religion were associated with less depressive symptoms in current caregivers. Frequent attendance was also associated with less depression and complicated grief in the bereaved. CONCLUSIONS: Religious beliefs and practices, and religious attendance in particular, are associated with better mental health in family caregivers of persons with dementia.     

The 'offset effect' of mental health treatment on ambulatory medical care utilization and charges. Month-by-month and grouped-month analyses of a five-year study

The five-year ambulatory medical care experience of 400 patients with mental disorders was studied to test the "offset" hypothesis that patients receiving timely mental health specialist treatment have lower subsequent utilization of, and charges for, care than patients not receiving such specialist treatment. Specialist treatment was associated with significant offset savings in utilization and charges for the non-psychiatric medical care of treated patients with either severe or less severe mental disorders. However, the visits and charges for such specialist treatment boosted the overall (nonpsychiatric plus mental health specialist) care utilization and charges of the specialist-treated patients above those of patients treated solely by their nonpsychiatric physicians; this overall increase was especially pronounced for patients with severe mental disorders. The findings suggest the need for randomized prospective offset studies comparing utilization, cost, and clinical outcomes.