Frequent attendance in family practice and common mental disorders in an open access health care system

Frequent attenders in family practice are known to have higher rates of mental disorder. However little is known about specific psychiatric disorders and whether this behavior extends to specialist services, in an open access fee-for-service health care system.Methods1060 patients from 46 family practices completed the Patient Health Questionnaire and the Client Service Receipt Inventory. During the consultation, family practitioners blind to the questionnaire responses rated the severity of mental health and physical disorders. The 10% of patients with the highest number of 6-month consultations in six age and sex stratified groups were defined as frequent attenders.ResultsAfter adjustments for sociodemographic variables, physical health and other psychiatric diagnoses, patients with a somatoform disorder were more likely to be frequent attenders, with an odds ratio of 2.3 (95% CI: 1.3–3.8, p = .002).ConclusionWhen adjusting for confounders, among the four psychiatric diagnoses investigated only somatoform disorders remain significantly associated with frequent attendance. Physical health and chronic disease were no longer associated with frequent attendance which does not support the hypothesis that in an open access fee-for-service system, patients will consult for a wider range of health problems. Greater investigation into unexplained somatic symptoms could help reduce the frequency of attendance in both primary and secondary care, as this behaviour appears to be a general health-seeking drive than extends beyond family practice.     

Children with psychiatric disorders who are frequent attenders to primary care

Child psychiatric disorder has been found to be linked to enhanced primary care attendance. We studied the somatic and psychological associations of psychiatric disorder amongst frequent (four or more consultations a year) primary care attending school children. We compared 32 children aged 7–12 years with a psychiatric disorder with 77 non-disordered (also frequently attending) children. Psychiatric disorder was not associated with type of presenting complaint at the surgery nor with chronic physical illness. However disordered children were more likely to be described by their mothers as handicapped by existing physical problems, in poor health, with low energy levels and likely to experience physical symptoms under stress. Problems in social relationships and educational difficulties were reported in more disordered children; more of them came from broken homes and had mothers who reported other psycho-social and health stresses and showed characteristic health beliefs. The findings indicate that knowledge about the child's general physical well-being and relationships and about maternal mental health may assist in the primary care identification and management of psychiatric disorders of frequently attending school children. Accepted: 17 September 1998     

Emergency presentations to an inner-city adolescent psychiatric service

There is little research into emergency presentations in child and adolescent mental health. The purpose of this study was to obtain an overview of number and types of presentations to a inner London child and adolescent mental health emergency service and to determine immediate and longer-term service demands. All available data on 107 consecutive child and adolescent emergency attenders were gathered using a structured data collection sheet. Half of those who presented following an episode of deliberate self-harm were considered to have no mental health disorder though a significant minority of emergency attenders had serious mental health problems. Most attenders were already known to child psychiatry or social services. Prospective study of young people who are already linked in with child mental health and/or social services but who require emergency assessments and interventions is warranted. An understanding of what breaks down in the routine care of these young people would facilitate earlier identification and more effective prevention or early intervention for these vulnerable children and adolescents.     

Depressive symptoms amongst adolescent primary care attenders

Abstract. Background: Background High rates of depressive disorder have been documented amongst adolescents attending general practitioners (GPs) in urban areas. However, little is known about the associations of adolescent depression in primary care. Method: We completed a cross-sectional questionnaire survey of adolescents, their parents and general practitioners, following adolescent attendance at the surgery. Results: We found high levels of depressive symptoms to be present in adolescent attenders of a broad range of social backgrounds. Depressive symptoms were associated with the following demographic and contextual factors: older age, female gender and parental psychiatric symptoms. They were also associated with the presence of physical symptoms causing psychosocial impairment, with health risks (use of cannabis and exposure to drugs) and with use of services (both primary care and mental health services). Levels of depressive symptoms were similar in urban and suburban groups. However, associations of depressive symptoms with smoking, exposure to drugs, cannabis use and primary care attendance were demonstrated in the suburban group and not the urban group. Conclusion: Adolescent GP attenders have high levels of depressive symptomatology. GP recognition and intervention should have the potential to impact on adolescent depression and on associated risks.     

Religious service attendance typologies and African American substance use: a longitudinal study of the protective effects among young adult men and women

Purpose

This study sought to identify variation by gender in the associations between religious service attendance from adolescence to young adulthood and seven measures of lifetime and short-term substance use.

Methods

To conduct this nationally representative study, data from the Add Health Surveys was abstracted from Waves I and IV (N = 3,223) to construct four types of service attendance (non-attenders, attenders only as adolescents, attenders only in young adulthood, and consistent attenders). A series of logistic regressions were conducted to identify the independent effects of each pattern of service attendance on each substance among all black young adults, as well as male and female sub-samples.

Results

Analysis revealed consistent attenders were generally less likely to use substances, with the effects being strongest among females. Among young adult only attenders, males recorded lower odds across all three short-term measures whereas females reported lower odds only for monthly cigarette use.

Conclusion

The protective effects of religious service attendance are more robust for African Americans who consistently attend in adolescence and young adulthood, especially among females.

     

The Association between Physical Education and Mental Health Indicators in Adolescents: A Cross-Sectional Study

Objective: To explore the associations between physical education attendance and mental health indicators. Methods: Using data from the Global Student Health Survey, the frequency of physical education attendance, suicidality-related indicators, loneliness, bullying, and anxiety were all assessed using a standardized self-reported questionnaire. Multivariable logistic regression was used to estimate the association between physical education attendance and mental health-related indicators. Results: The study included 276,169 participants from 71 countries (47.3% males, aged 11–18 years old). After controlling for sex, age, food insecurity, close friends, physical activity, sedentary time, others’ help, and parents’ understanding, physical education attendance was not signifi- cantly associated with suicidal attempts, suicidal ideation, and anxiety. However, compared with no physical education attendance, individuals attending physical education for 1, 2, as well as 5 or more days had significantly reduced odds/ratios of suicide; only 2 days of physical education attendance was associated with a lower odds ratio for suffering from loneliness. Even 1 day of physical education was associated with not being bullied by others. Conclusion: This study suggests that physical education attendance may not have an effective role in reducing mental health illnesses in children and adolescents. Future studies are encouraged to corroborate or negate our research discoveries by using better and further improved study designs.     

Life situation and health status of children and adolescents

In the last decades an increasing number of characteristics of the child's life circumstances have been identified as risk factors for mental health problems. Up to now, the natural distribution of these factors in the population has not been systematically investigated. In the Hamburg Health Survey N=1950 children and adolescents between 4 and 18 years of age and their families representative for Germany have been examined. The questionnaire used asks for sociodemographic variables, pregnancy and birth, kindergarten and school attendance, psychosocial burden and utilization of health services. Complications in pregnancy, birth or in the first year of life arise in every fifth child. Severe childhood illnesses, serious accidents, hospital stays for longer than 14 days or early changes of caregivers have 14% of those investigated. Every tenth child has problems in the kindergarten (mostly separation anxiety), every fourth child has problems in school (especially problems in concentration or performance) and 8% suffer from stressful life events (mostly changed family relations). Mental or physical illness and disabilities are found in 8.5% of all families. Although the majority of all children and adolescents live in healthy life circumstances, risk factors are not as rare as to be neglected. Especially the frequency of problems in kindergarten and school as well as stressful life events indicate that preventive interventions are necessary.     

Short term effects of inpatient cognitive behavioral treatment of adolescents with anxious-depressed school absenteeism: an observational study

This observational study examined the changes during inpatient cognitive-behavioral treatment (CBT) of adolescents with chronic anxious-depressive school absenteeism with or without comorbid disruptive symptoms. 147 adolescents (aged 12–18 years) with a specific phobia or other anxiety disorder or a depressive episode or a mixed disorder of conduct and emotions and who had completely ceased to attend school or showed irregular school attendance underwent an inpatient cognitive-behavioral treatment. A further 16 patients aborted the treatment during the first day and were not included in the analyses. The treatment was manual guided and also included parents. Assessments were made pre-inpatient treatment, immediately post-inpatient treatment and at 2-month follow-up. School attendance was the primary outcome variable and secondary outcomes were composite scores of a range of adolescent- and parent-rated mental health problems. Overall, results show a considerable decline of school absenteeism and mental health problems during treatment and subsequent follow-up. Continuous school attendance was achieved by 87.1% of the sample at the end of inpatient treatment and by 82.3% at 2-month follow-up. Comorbid symptoms of anxiety, depression, disruptive and insufficient learning behavior were significantly reduced from pre to follow-up, with effect sizes for the composite scores ranging from 0.44 to 1.15 (p < 0.001). This large observational study in adolescents with school absenteeism and a mixture of emotional and disruptive symptoms is the first to show the benefits of inpatient therapy that included cognitive-behavioral therapy and access to a special school with expertise on teaching children and adolescents with psychiatric disorders. The results must be interpreted conservatively because of the lack of a control condition.     

上海市中学生对心理卫生问题的知晓度调查

目的 了解并比较上海初中生与高中生对心理卫生问题的知晓情况。方法 采用儿童心理卫生知晓问卷和长处与困难问卷（SDQ）对737名中学生进行了研究。结果 初中生在同伴交往和社会行为方面问题多于高中生组。高中生在情绪、注意力上问题多于初中生。高中生对严重心理卫生问题的识别力高于初中生。初中生和高中生对服药和与人谈论来解决心理问题的方法都不认可,尤其是高中生。都认为家庭对心理卫生问题的影响很大,初中生更相信他们的父母能发现并帮助他们解决心理问题,而高中组中则相反。结论 上海初中生和高中生对心理卫生问题的知晓情况存在差别。     

The prevalence, classification and treatment of mental disorders among attenders of native faith healers in rural Pakistan

  Background: Although native faith healers are found in all parts of Pakistan, where they practice in harmony with the cultural value system, their practice is poorly understood. This study investigated the prevalence, classification and treatment of mental disorders among attenders at faith healers. Method: The work of faith healers with 139 attenders was observed and recorded. The mental status of attenders was assessed using a two-stage design: screening using the General Health Questionnaire followed by diagnostic interview using the Psychiatric Assessment Schedule. Results: The classification used by faith healers is based on the mystic cause of disorders: saya (27%), jinn possession (16%) or churail (14%). Sixty-one percent of attenders were given a research diagnosis of mental disorder: major depressive episode (24%), generalized anxiety disorder (15%) or epilepsy (9%). There was little agreement between the faith healers' classification and DSM-IIIR diagnosis. Faith healers use powerful techniques of suggestion and cultural psychotherapeutic procedures. Conclusions: Faith healers are a major source of care for people with mental health problems in Pakistan, particularly for women and those with little education. Further research should assess methods of collaboration that will permit people with mental health problems to access effective and culturally appropriate treatment. Accepted: 9 June 2000     

Locus of control in health: the effects of psychological well-being and contact with the doctor

Previous studies have demonstrated an association between a high score on measures of "external" locus of control of health and high levels of psychosocial distress. In the present study, a measure of illness behaviour (visits to the doctor) has been added to elucidate the association between locus of control and self-reported psychological distress. In a sample of female high and low attenders at two general practices, neither physical health nor psycho-social problems were found to be associated with high scores on the measure of external locus of control. However, high attenders were more likely to score high on this measure. When a logistic model was fitted to the data an interactive variable (attendance rate x psychological symptoms) was found to have a significant effect, suggesting that psychological distress has a different effect upon the beliefs expressed by high and low attenders.     

Towards School Mental Health in Nigeria: Baseline Knowledge and Attitudes of Elementary School Teachers

There is a shortage of child and adolescent mental health (CAMH) professionals all over the world, and this shortage is especially critical in most parts of the developing world. Schools have been identified as ideal settings to reach needy children in the community, and training teachers in CAMH issues can help improve early identification and appropriate referrals of children with mental health problems. As part of a needs assessment for developing a training programme, selected Nigerian elementary school teachers were asked to complete confidential questionnaires to determine their perceptions of mental health problems in school children. Teachers indicated that they had no previous CAMH training. Baseline assessments revealed that teachers' knowledge of CAMH was deficient, and attitudes to children with mental health problems revealed intolerance. Incorporation of CAMH care into teacher education curricula is a critical next step towards integrating school teachers as mental health collaborators in school mental health programmes in Nigeria.     

Establishing ongoing, early identification programs for mental health problems in our schools: a feasibility study

OBJECTIVE: To investigate the feasibility of establishing ongoing, early identification services for mental health problems in school settings. METHOD: School counselors and other mental health professionals (N = 41) in middle, junior, and high schools (N= 23) were given training and supervision in the administration of an evidence-based mental health assessment tool, the Voice Diagnostic Interview Schedule for Children IV (DISC-IV), over the course of 1 1/2 school years. RESULTS: During the study, 530 students were selected to be assessed with the DISC, and 72% were confirmed to be at risk for a mental health problem (DISC+). Among DISC+ cases, 71% had never been in treatment before. The most common problems identified by the DISC were symptoms related to suicide (28%), social phobia (20%), attention-deficit/ hyperactivity disorder (19%), and oppositional defiant disorder (19%). Based on schools' recommendations, 82% of parents with DISC+ children agreed to make an appointment for a follow-up evaluation. Of DISC+ children whose parents agreed to seek further evaluation, 65% of them were evaluated by a health or mental health professional within 2 weeks. CONCLUSIONS: Use of a computerized, evidence-based mental health assessment tool is a feasible strategy for providing early mental health identification services in schools and can help to bridge the gap between mental health providers and the unmet needs of children who are at risk for mental health problems within the community.     

Daycare attendance, stress, and mental health.

OBJECTIVE: Daycare stress can be indexed by cortisol, and elevated levels of cortisol have been implicated in the onset and development of mental health disorders. Our objective was to quantify the associations between daycare and cortisol and to identify individual and environmental conditions under which daycare attendance is associated with cortisol concentrations. METHODS: We used Cohen effect size statistics to quantify these associations and to compare them across 11 published studies that were identified with MEDLINE and PsycINFO. RESULTS: Cortisol levels increased during the daycare day, whereas they decreased when children stayed at home. The mean effect size was d = 0.72. The magnitude of the daycare-stress relation seemed to vary under 3 specific conditions. First, the effect size was larger for children in low-quality daycare (d = 1.15), whereas there was essentially little or no effect for children in high-quality daycare (d = 0.10). Second, the effect size was larger for preschoolers (aged 39 to 59 months) (d = 1.17) than for infants (aged 3 to 16 months) (d = 0.11) or school-aged children (aged 84 to 106 months) (d = 0.09). Third, children with difficult temperaments in daycare were more likely to exhibit a rising pattern of cortisol, compared with children who were not difficult. CONCLUSIONS: Our review suggests that daycare attendance in relatively low-quality daycare conditions and for children with difficult temperaments may result in atypical cortisol elevation. Although the link between atypical cortisol elevation and mental health requires further study, programs aimed at improving the quality of daycare services during the preschool years are expected to lead to better physiological adaptation to daycare and to reduce the risks of mental health problems.     

The Mental Health of Children Exposed to Maternal Mental Illness and Homelessness

In recent years a number of reports have documented an increase in the number of homeless families in the US. Using a sample of 195 mothers who were veterans of the US armed forces we assessed the association of maternal homelessness and clinical status, with measures of children’s mental health, school enrolment and attendance. Although maternal homelessness had no significant association with children’s reported emotional problems it had a profound effect on school enrollment and attendance. Mothers’ mental health status, history of incarceration and cumulative history of trauma, as well as children’s exposure to trauma and their self-esteem were the factors most strongly associated with measures of children’s emotional problems. The study suggests that preventive interventions are needed to minimize the effects of exposure to trauma, both in the community and at home, as well as family interventions to address both the mother’s and child’s emotional and physical needs. A longitudinal study is needed to understand better the association between residential instability and children’s mental health.Ilan Harpaz-Rotem, Ph.D., Robert A. Rosenheck, M.D. and Rani Desai, Ph.D, MPH are affiliated with the Department of Psychiatry, Yale University School of Medicine, West Haven, CT.     

Have there been changes in children's psychiatric symptoms and mental health service use? A 10-year comparison from Finland

OBJECTIVE: To study the differences in children's psychiatric symptoms and child mental health service use at two time points: 1989 and 1999. METHOD: Two cross-sectional representative samples of 8- to 9-year-old children from southern Finland were compared. The 1989 sample consisted of 985 children, of whom 95% participated, and the 1999 sample consisted of 962 children, of whom 86% participated. Information was gathered from parents and teachers using Rutter's questionnaires and other related determinants of service use and from children using the Child Depression Inventory. The sampling, procedure, and methods were similar at both time points. RESULTS: The overall rate of children's problems assessed by parents and teachers had not increased during the period 1989 to 1999. Boys had fewer psychiatric symptoms in 1999 than in 1989, whereas no clear change had occurred in girls' symptoms, except that, according to parents, girls in 1999 had more hyperactive symptoms. However, children themselves reported more depressive symptoms in the 1999 than in the 1989 sample. In 1989, 2.3% and in 1999, 5.3% of children had used child mental health services. The increase in service use among girls was fourfold. Parental evaluations of child psychopathology and teacher evaluations whether the child was psychologically healthy were the strongest determinants for referral at both time points. Parents preferred to seek help for their children's problems from teachers, school nurses, and school psychologists rather than from specialized child psychiatric services. CONCLUSIONS: There has been an increase in mental health service use especially among girls as well as a convergence of symptom levels by gender. It is important to develop child psychiatric services that are as close to the child's living environment as possible to further reduce the threshold for seeking help and to promote early detection and intervention.     

Association of mental health problems in childhood with prenatal and postnatal physical growth.

AIMS: The present study was conducted to examine (i) prenatal and postnatal patterns of growth in relation to the risk of later mental health problems in children and (ii) the possible mediating effect of these patterns of growth in the association between parental socioeconomic status (SES) and children's mental health. SUBJECTS AND METHODS: The present study is part of a blinded, matched case control study, involving a retrospective analysis of prospectively collected data from routine examinations at community health services for children and adolescents. The sample comprised 80 patients, referred between the age of 6-13 years to the Community Mental Health Centre in Maastricht, and 320 matched population controls. RESULTS: Children coming from unemployed families weighed less at birth, but postnatal growth was not associated with this or other indicators of SES. Although children using mental health care were somewhat smaller at birth, there was no evidence that leanness during childhood was a risk factor for the development of mental health problems. CONCLUSIONS: The present results showed some evidence for the impact of intrauterine development on children's mental health problems. In addition, neither prenatal nor postnatal physical growth were on the pathway between parental SES and children's mental health problems.