The feasibility and validity of care mapping in the clinical neurosciences

Dementia Care Mapping (DCM) is an observational tool and process that is widely used in dementia care in measuring and improving person-centred care (PCC). DCM was previously piloted on a neurorehabilitation ward, where it was found to be feasible and acceptable in this setting. Following this, a new modified tool and accompanying manual were developed: Care Mapping – Neurorehabilitation (DCM-NR). The current study aimed to assess the feasibility and validity of DCM-NR by piloting its use in a range of clinical neuroscience settings. A mixed-methods design was used employing both quantitative and qualitative techniques. The new DCM-NR was found to be feasible for use both in terms of the suitability of its coding system and the implementation process. DCM-NR was shown to have a moderate level of concurrent validity with participants' self-report of PCC. Participants' subjective reports on their experiences of care provided validation for the areas of psychological need observed in DCM-NR. The results of this study indicate that DCM-NR is feasible and valid for use in a range of clinical neuroscience settings. Further longitudinal research is required to evaluate the impact of DCM-NR on PCC practices over time.     

Promoting value in dementia care: Staff,resident and family experience of the capabilities model of dementia care

Objectives: This Australian study examined individual experiences of the implementation of the Capabilities Model of Dementia Care (CMDC) and subsequent outcomes for the care of residents with dementia living in long-term care. Furthermore, this study aimed to explore those factors that facilitated and inhibited the implementation of the new model of care.

Methods: The CMDC was developed and then tested in a non-randomised clinical trial. Staff, residents and family experiences of their involvement and perceptions of the model were captured at the end of 12 months. Semi-structured interviews and focus groups were conducted with the 25 participants (12 nursing staff, 6 residents with dementia, 7 family members). Questions varied depending on the participant group but were designed to assess experiences of and changes to care during the intervention. Inductive thematic analysis was used to identify the experiences of the implementation of the CMDC.

Results: Five themes included: general reflections on nursing care, implementation of the CMDC intervention, positive outcomes of the CMDC intervention, challenges in the implementation of the CMDC, difficulty sustaining care and tensions between participants’ perspectives of care.

Conclusion: Positive change resulted from implementation of the CMDC, however, staff mentorship was identified as a key to sustaining changes in practice.     

Depression care services and telehealth technology use for homebound elderly in the United States

Objectives: Despite the increasing evidence for the effectiveness of telehealth technology in screening and treating depression in older adults, they have been slowly adopted by Home Health Care (HHC) agencies. Therefore, this study was conducted to determine how HHC agencies perceive and use telehealth technology for depression care among homebound older adult patients.

Methods: Five-hundred-and-sixteen staff from the National Association for Homecare & Hospice (NAHC) member home health care agencies completed the online survey. Questions were asked of HHC staff regarding performance expectancy, effort expectancy, social influences, facilitating conditions, telehealth use and intention to use/continue to use telehealth.

Results: The majority had a neutral or positive perception towards telehealth. However, participants from agencies that have yet to use telehealth (mean: 3.25, SD: 1.56) reported a less intention to use the technology for depression care versus those from agencies that did (mean: 4.64, SD: 1.37). This may be partially explained by the finding that only 32% perceived themselves as having the knowledge and 25% as having resources to use telehealth. Additionally, facilitating conditions and social influences were significant predictors of intention to use/continue to use telehealth for depression care (p-values < .01).

Conclusion: Overall, staff had a neutral or positive perception towards telehealth. Factors such as fewer years of experience in using telehealth and a small annual budget may explain a negative perception towards telehealth. Therefore, further education and resources are needed to support telehealth use. Future studies may consider comparing telehealth programs and identifying supporting policies.     

Predictors of anxiety recurrence in the Coordinated Anxiety Learning and Management (CALM) trial

Few studies have examined anxiety recurrence after symptom remission in the primary care setting. We examined anxiety recurrence in the Coordinated Anxiety Learning and Management (CALM) trial. From 2006 to 2009, CALM randomized adults with anxiety disorders (generalized anxiety disorder, panic disorder, social anxiety disorder, and post-traumatic stress disorder) in primary care clinics to usual care (UC) or a collaborative care (CC) intervention of pharmacotherapy and/or cognitive behavioral therapy. We examined 274 patients who met criteria for anxiety remission (Brief Symptom Inventory for anxiety and somatization (BSI-12) < 6) after 6 months of randomized treatment and completed a follow-up of 18 months. Logistic regression and receiver operating characteristics (ROC) were used to identify predictors of anxiety recurrence (BSI-12 ≥ 6 and 50% increase from 6-month ratings) during the year following remission. Recurrence was lower in CC (29%) compared to UC (41%) (p = 0.04). Patients with comorbid depression or lower self-perceived socioeconomic status particularly benefited (in terms of reduced recurrence) if assigned to CC instead of UC. In the multivariable logistic regression model, smoking, being single, Anxiety Sensitivity Index score, functional impairment at month 6 due to residual anxiety (measured with the Sheehan Disability Scale), and treatment with benzodiazepines were associated with subsequent anxiety recurrence. ROC identified prognostic subgroups based on the risk of recurrence. Our study was exploratory, and our findings require replication. Future studies should also examine the effectiveness of relapse prevention programs in patients at highest risk for recurrence.     

Demand-oriented care: the development and validation of a measuring instrument

Objectives Demand-oriented care has recently become a key topic in the area of care provision, fitting into the modern pursuit for patient autonomy. This paper introduces a measuring instrument to assess demand-orientation in mental health care. Method A concept mapping procedure was used to understand the concept of demand-orientation. The resulting items were introduced to a validating sample of 204 patients of three mental health facilities. After factor analysis, a 19-item General-Demand Orientated Care Questionnaire (DOC-G), and a supplementary questionnaire (DOC-S) containing 6 sections remained. This questionnaire was submitted to confirmatory analysis in a random sample (n = 304) of psychiatric patients. Results Respondents were predominantly female (57.6%), of Dutch ethnic origin (84.1%), and outpatients (71.4%). The analyses confirmed the 4-factor structure of the questionnaire. Both internal and external validity of the instrument proved to be sufficient. The questionnaire discriminated in the experience of demand-orientation of care between patients who did and those who did not have a treatment plan put up; between those who did and those who did not have a crisis plan, and between those who had a lifetime prevalence of undergoing compulsory treatment, and those who had not. Conclusions We conclude that the DOC is a useful instrument to measure demand-orientation in a population of psychiatric patients. It is useful to measure changes in care quality. The supplementary questionnaires make it possible to evaluate chosen projects or subprojects quickly.     

Challenges of Implementing Depression Care Management in the Primary Care Setting

Empirical evidence shows that care management is an effective tool for improving depression treatment in primary care patients. However, several conceptual and practical issues have not been sufficiently addressed. This article explores questions concerning the scope of care management services within the chronic illness care model; optimal ways to identify depressed patients in the primary care setting; responsibilities and desirable qualifications of depression care managers; the location and manner in which care managers interact with patients; costs of services provided by care managers; and the level of supervision by mental health specialists that is necessary to ensure quality care.     

Prevalence and recognition rates of psychiatric disorder in the elderly clients of a community care service

One hundred and sixty-nine people over the age of 65 receiving home care services in Lewisham were interviewed using the Geriatric Mental State (A) (GMS(A)) and diagnostic output was obtained using AGECAT. The prevalence of psychiatric disorder in this group is reported and is compared with that found in community surveys which have used the GMS/AGECAT package. Of note is the 26.0% prevalence rate of cases of depression. The prevalence rate of AGECAT ‘depressive psychosis’ was found to be 13.6%, which was significantly higher than expected. Measures of agreement between AGECAT diagnostic cases and assessments made by home care staff are presented—‘kappa’ values and negative predictive values are higher for organic cases than for cases of depression. These ‘recognition’ rates are compared with reported recognition rates of psychiatric disorder in the elderly by health care professionals. Suggestions for further research are made so that the stated aims of the White Paper Caring for People can be achieved.     

Collaborative care for depression in European countries: A systematic review and meta-analysis

Objectives

This is a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effectiveness of collaborative care compared to Primary Care Physician's (PCP's) usual care in the treatment of depression, focusing on European countries.

Methods

A systematic review of English and non-English articles, from inception to March 2014, was performed using database PubMed, British Nursing Index and Archive, Ovid Medline (R), PsychINFO, Books@Ovid, PsycARTICLES Full Text, EMBASE Classic + Embase, DARE (Database of Abstract of Reviews of Effectiveness) and the Cochrane Library electronic database. Search term included depression, collaborative care, physician family and allied health professional. RCTs comparing collaborative care to usual care for depression in primary care were included. Titles and abstracts were independently examined by two reviewers, who extracted from the included trials information on participants' characteristics, type of intervention, features of collaborative care and type of outcome measure.

Results

The 17 papers included, regarding 15 RCTs, involved 3240 participants. Primary analyses showed that collaborative care models were associated with greater improvement in depression outcomes in the short term, within 3 months (standardized mean difference (SMD) − 0.19, 95% CI = − 0.33; − 0.05; p = 0.006), medium term, between 4 and 11 months (SMD − 0.24, 95% CI = − 0.39; − 0.09; p = 0.001) and medium–long term, from 12 months and over (SMD − 0.21, 95% CI = − 0.37; − 0.04; p = 0.01), compared to usual care.

Conclusions

The present review, specifically focusing on European countries, shows that collaborative care is more effective than treatment as usual in improving depression outcomes.     

Innovations in Practice: Child and adolescent psychiatrists and primary care – innovative models of consultation in the United States

Background: There is a severe shortage of child and adolescent psychiatrists (CAPs) in the United States, an increasingly recognized high prevalence of mental disorders in young people, and widely supported goals to provide more mental health services in the primary care setting. Method: A number of innovative, state‐wide or more local, publically funded programs have been developed in the United States over the last several years to respond to these challenges and to provide CAP consultation to primary care physicians (PCPs) who wish to address the mental health disorders of their patients in the primary care setting. Results: A number of these programs and their approaches to consultation are described. An example of a clinical scenario that might be addressed using this model of CAP/PCP collaboration is offered. Conclusions: An innovative model of consultation to PCPs from CAPs appears able to facilitate the treatment of many young people with mental health disorders in the primary care setting.     

年轻人离开原生家庭后安置不稳定性及可能的心理健康影响

背景:收容机构中的儿童青少年和同龄人相比可能存在较差的心身健康水平.稳定的机构照料环境对改善早期童年经历所致破坏性影响是非常重要的,童年经历包括心理创伤、虐待和忽视.目前,澳大利亚或其他国家很少有关收容机构中儿童青少年的安置稳定性高质量研究的数据.目标:首次针对澳大利亚在收容机构生活中的儿童青少年进行系统的背景、照料类型、和安置稳定性特征的调查.方法:2014年收集了墨尔本市区的四家民间儿童青少年社区服务机构的数据.样本包括322名年轻人(女性占52.8%),年龄在12-17岁之间[平均年龄=14.86,(SD=1.63)年].结果:在收容机构中,相对于社区收容照料类型(35.7%),大多数年轻人(64.3%)是基于家庭养育照料模式(即寄养、治疗型寄养照料、青少年照料模式、亲属照料、以及认领照料).然而,与所有收容照料的孩子相比,这个年龄组被社区收容比例是较高的(5%).第一次被社区收容的平均年龄为9岁(SD=4.54).不同的照料类型均无性别差异.其中有248人(76.9%)曾在收容照料系统中有一个以上的安置场所,有117人(36.5%)经历了超过5个安置场所.相对于家庭养育照料者,社区收容的儿童青少年经历了更显著的安置不稳定性(χ2=63.018,p<0.001).结论:安置不稳定性在收容照料机构是常见的现象.需要一个稳定的照料环境来改善被虐待儿童所导致的心理创伤和健康影响.精心设计并以干预为基础的研究能够增加安置稳定性,包括强化对儿童青少年收容照料者的治疗能力.     

Balancing restriction and freedom in the care of people with intellectual disability

The case of a 50-year-old man with severe intellectual disability is described. After 20 years of institutional care, the subject was moved to a newly opened community group home. His physical and mental health deteriorated at this location after unproven allegations of sexual abuse which had taken place whilst he had been living in the institution. Although the subject's health continued to deteriorate, there was resistance to his re-admission to the same hospital for assessment. He had always needed to be cajoled into eating, but this approach had not been followed by the home which had contributed towards his weight loss. The situation the subject, the carers and the health personnel found themselves in illustrates how problematic it is to find the right balance between restrictive practices and respect for an individual's choice.     

Family caregiver burden and quality of home care in the context of the Long-Term Care insurance scheme: an overview

This review outlines the findings of 22 studies conducted between 1997 and 2005 by Arai and 19 collaborators regarding caregiver burden and assessment of quality of home care for the elderly. The published research covers the following: cross‐sectional studies on caregiver burden; changes in caregiver burden; appropriateness of the Long‐Term Care insurance assessment scheme; attitudes towards caregiving among caregivers; the development of the short Japanese version of the Zarit Caregiver Burden Interview (J‐ZBI_8); and the effectiveness of service use in reducing caregiver burden and development of a Home Care Quality Assessment Index (HCQAI).     

脑电趋势图监护在神经重症监护病房对癫痫及亚临床癫痫的诊断意义

Objective To explore the association between the trend of electroencephalographic (EEG) alterations and seizure (especially subclinical seizure) and assess the value of EEG trend overview obtained by continuous EEG monitoring in the diagnosis of clinical and subclinical seizures in the neurological intensive care unit (N-ICU). Methods Fifteen epileptic patients including 10 with status epileptieus (SE) in the N-ICU were enrolled in this study. The EEG was monitored using the 10-20 electrode system with 8-chaunel referential derivations (Fp1-A1, C3-A1, T3-A1, O1-A1, Fp2-A2, C4-A2, T4-A2, and O2-A2) to record the amplitude integrated EEG (aEEG), Envelope and band power (BP) trends. For each patient, the data collected during the seizure episodes and the seizure-free intervals were separately averaged for a comparative analysis. The diagnostic capabilities of the 3 EEG trends were estimated using the receiver-operating characteristic (ROC) curve. Results The total incidence of seizure in the N-ICU was 12.30% in the 15 patients, including 10 with SE (8.20%) and 7 with nonconvulsive SE (NCSE, 5.65%). In 62.5% of the patients, the SE episode was followed by NCSE. During the seizure episode, the upper and lower bounds of aEEG increased obviously by 27.9% (t=6.019, P<0.05) and 33.53% ( t=5.438, P<0.05), respectively, as compared with those in the seizure-free interval. In the seizure episodes, the wave amplitude of Envelope increased by 124.09% (t=3.229, P<0.05) in the referential derivation, and the absolute band power (ABP) increased at all the bands with significant changes in α and β band powers (t=2.528 and t=2.627, respectively, P<0.05). Conclusions Clinical and subclinical seizures occur in the N-ICU at high incidences, for which all the 3 EEG trends have diagnostic values, aEEG has a better diagnostic capability than Envelope, and the results of BP may offer references for the diagnosis.     

Validity of the Faces Anxiety Scale for the assessment of state anxiety in intensive care patients not receiving mechanical ventilation

Objectives

Anxiety is a commonly reported discomfort in critically ill patients in the intensive care unit (ICU) but is rarely assessed routinely in a systematic manner. The main aim of this study was to assess criterion validity of the Faces Anxiety Scale in relation to the State-Anxiety Inventory (SAI) in intensive care patients able to respond verbally to the items in the SAI of the Spielberger State-Trait Anxiety Inventory. It also reports on the severity of anxiety in intensive care patients not receiving mechanical ventilation.

Methods

Nonventilated intensive care patients (n=100) self-reported anxiety levels on the Faces Anxiety Scale and on the SAI, administered in random order. Validity was examined using Spearman's ρ.

Results

Patients had a mean age of 59.8 years and 65% were male; were in ICU for mainly cardiovascular, respiratory, and neurological diagnoses; and had median length of stay of 2.1 days. The correlation between the two scales was .70 (P<.0005), indicating good criterion validity. Patients reported low to moderate levels of anxiety on both the Faces Anxiety Scale and the Spielberger SAI.

Conclusion

The Faces Anxiety Scale is a valid single-item, self-report measure of state anxiety in intensive care patients that is easy to administer and imposes minimal respondent burden. It has the potential to be a useful instrument for the assessment of state anxiety by clinicians and for research into the reduction of anxiety in this vulnerable population.     

Vulnerability to psychosis in patients attending primary and psychiatric care. Results of the RADEP study

We studied occurrence of psychotic symptoms and their associations with occurrence of depressive and manic symptoms; 563 patients attending primary care (PrC) and 163 patients attending psychiatric outpatient care (PsC) completed a questionnaire including lists of psychotic, manic and depressive symptoms, and patients with depressive symptoms were interviewed using the same questionnaire 6 months after baseline examination. Of PrC patients, 8.5% and of PsC patients, 36.2% reported at least seven lifetime psychotic symptoms. During the 6-month follow-up, the corresponding figures were 0.22% for PrC and 2.84% for PsC patients. Among PrC patients, men, young, never-married, students and unemployed reported more psychotic symptoms than others. In multivariate analyses, occurrence of psychotic symptoms was associated with young age, never being married, poor functioning and former psychiatric treatment, as well as with occurrence of manic and depressive symptoms. Psychotic symptoms are rather prevalent in primary care and very common in psychiatric care. In primary care, vulnerability to psychosis is associated with the patient's background more strongly than in psychiatric care. Concurrent occurrence of psychotic symptoms with manic and depressive symptoms is common.     

Primary health care and people with an intellectual disability: the evidence base

There is growing awareness of the importance of evidence-based medicine in guiding health care delivery. This paper reviews the evidence pertinent to the delivery of primary health care to people with an intellectual disability. Research concerning issues of health status, specialist knowledge of health care, and barriers and solutions to health care delivery for people with an intellectual disability is presented and discussed. Recommendations for future evidence-based research are made, including suggested areas of importance.