The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in obstetrics

OBJECTIVE: This investigation assessed the detection and treatment of psychiatric disorders and at-risk substance use among pregnant women in the obstetric sector. METHOD: The Primary Care Evaluation of Mental Disorders Patient Health Questionnaire and modified CAGE questionnaires were used to assess current psychiatric disorders and at-risk substance use among 186 women receiving prenatal care. Medical records were reviewed for evidence of obstetrical providers' recognition of psychiatric and substance use symptoms and diagnoses and initiation of evaluations and treatments. The associations between patient characteristics and chart-documented evaluations and treatments were ascertained. RESULTS: Seventy (38%) of the women met screening criteria for psychiatric disorders or substance use. Among women who screened positive, symptoms were recorded in 43% of the charts, diagnoses in 18%, evaluations in 35%, and treatments in only 23% Patients who screened positive for psychiatric disorders and/or substance use were significantly more likely to have a documented mental health evaluation if they were less well educated, had inadequate prenatal care, or had longer hospital stays at delivery. CONCLUSIONS: A substantial number of women treated in obstetrics have unrecognized and untreated psychiatric disorders and substance use. Given the potential impact of antenatal mental disturbances on maternal and infant outcomes, further investigations into the psychiatric evaluation and treatment of pregnant women in the obstetrical sector are required.     

The Effectiveness of a Community-Based Intervention Program for Women At-Risk for Giving Birth to a Child with Fetal Alcohol Spectrum Disorder (FASD)

The goal of this study was to determine whether the First Steps program (modeled after the Parent–Child Assistance Program) resulted in improved outcomes among women at-risk for giving birth to a child with FASD. We conducted a retrospective analysis of data on 70 participants in the First Steps program. Clients were high risk and faced many life challenges, including: being on welfare, substance abuse, physical and sexual abuse as children, mental health issues, criminal activity, and unplanned pregnancies. We found a significant increase in birth control use and decrease in welfare rates from pre- to post-program. At program exit, many participants were abstinent from alcohol and/or drugs and the majority did not experience a subsequent pregnancy. Clients also showed significant increases in goals and decreases in needs from pre-to post-program. The First Steps program demonstrated promising outcomes for women at-risk for giving birth to a child with FASD.     

Perinatal depression care pathway for obstetric settings

Abstract

Perinatal depression is common and can have deleterious effects on mothers, infants, children, partners, and families. Despite this, few women who screen positive for depression receive psychiatric treatment. A comprehensive perinatal depression care pathway includes: (1) screening, (2) assessment, (3) triage and referral, (4) treatment access, (5) treatment initiation, (6) symptom monitoring, and (7) adaptation of treatment based on measurement until symptoms remit. This depression care pathway provides a scaffold on which to frame the challenges encountered when, and the opportunities that exist for, addressing depression in obstetric settings. Comprehensive interventions that address each step on the care pathway are needed to support obstetric practices in providing high-quality, evidence-based, effective treatment including pro-active follow-up for depression management. Despite recent attention being brought to, and significant progress in the field of maternal mental health, gaps in care persist. Ultimately, depression care needs to be fully integrated into obstetric care. Additionally, more targeted maternal mental health support and structure are needed for integration to occur and ultimately be optimized. Specific areas requiring more attention include consistency of screening, evaluation of patients with a positive depression screen for bipolar disorder, anxiety or substance use disorders, and monitoring of symptom improvement.     

Lifetime use of mental health and substance abuse treatment services by incarcerated women felons

OBJECTIVE: This study examined the lifetime use of alcohol, drug, and mental health treatment services by recently incarcerated women prison inmates. METHODS: A total of 805 women entering a North Carolina prison for new felony charges in 1991 and 1992 were interviewed in person shortly after incarceration. The women were assessed for psychiatric disorders and lifetime use of substance abuse and mental health treatment services. Rates of service use were analyzed by inmate characteristics and were compared with rates for a sample of women in the community in North Carolina. RESULTS: The majority of women inmates reported a history of using substance abuse services or mental health services or both. Those with psychiatric disorders and prison recidivists were the most likely to have used such services. Rates of service use were substantially higher for the inmates than for the women in the community, even when the effects of having a psychiatric or substance use disorder were controlled for. CONCLUSIONS: Many of the incarcerated women in the study met lifetime criteria for alcohol, drug, and mental health disorders that were significantly related to their use of substance abuse and mental health treatment services. The majority of the inmates met criteria for a current disorder despite past treatment. Further research is needed to help in developing programs to reduce women inmates' alcohol, drug, and mental health problems.     

Clinical characteristics of perinatal psychiatric patients: a chart review study

Although postpartum depression and other perinatal disorders have been the subject of increased research attention, important questions remain regarding women who actively seek psychiatric treatment during pregnancy and the postpartum period. In this study, we examined clinical records of 500 perinatal psychiatric patients who received treatment in a psychiatric day hospital (N = 398) or outpatient behavioral health clinic (N = 102). Patients' presenting diagnoses, psychiatric history, treatment course, and depressive symptoms were recorded. The majority of women had major depression as their primary diagnosis, with an average Edinburgh Postnatal Depression Scale score of over 20. Many depressed patients were diagnosed with comorbid anxiety and substance abuse disorders. Although most women were willing to take psychotropic medications, a sizable minority were not, particularly those who were breast-feeding. For more than a third of the sample, the treatment sought while pregnant or postpartum represented their first contact with the mental health system. Treatment implications are discussed.     

Influence of comorbid alcohol and psychiatric disorders on utilization of mental health services in the National Comorbidity Survey.

OBJECTIVE: This study sought to determine how comorbidity of psychiatric and substance abuse disorders affects the likelihood of using mental health services. METHOD: The analysis was based on data on adults aged 18-54 years in the National Comorbidity Survey (N = 5,393). Users and nonusers of mental health and substance abuse services were compared in terms of their demographic characteristics, recent stressful life events, social support, parental history of psychopathology, self-medication, and symptoms of alcohol abuse/dependence. RESULTS: The prevalence of service utilization varied by diagnostic configurations. Comorbid psychiatric or alcohol disorders were stronger predictors of service utilization than a pure psychiatric or alcohol disorder. Factors predicting utilization of services differed for each disorder. CONCLUSIONS: Since comorbidity increases the use of mental health and substance abuse services, research on the relationship of psychiatric and alcohol-related disorders to service utilization needs to consider the coexistence of mental disorders. Attempts to reduce barriers to help seeking for those in need of treatment should be increased.     

Comorbidity of severe psychiatric disorders and substance use disorders among women in jail

OBJECTIVE: This article presents the prevalence, patterns, and sequences of severe psychiatric disorders and substance use disorders among female jail detainees. METHOD: Subjects were a randomly selected, stratified sample of 1,272 female arrestees awaiting trial at the Cook County Department of Corrections in Chicago. Independent clinical research interviewers administered the National Institute of Mental Health Diagnostic Interview Schedule Version III-R to assess comorbid psychiatric disorders and substance use disorders. RESULTS: Eight percent of the women had both a current severe mental disorder and a current substance use disorder. Nearly three-quarters of those with severe mental disorders also met criteria for one or more substance use disorders. CONCLUSIONS: Because most detainees return to their communities in a few days, these findings have implications for treatment of high-risk women throughout the mental health system.     

Medical clinic characteristics and access to behavioral health services for persons with HIV

OBJECTIVE: Many persons with HIV do not receive needed behavioral health services. This study examined the impact of medical clinic characteristics on access to mental health and substance abuse care for persons with HIV. METHODS: This was a longitudinal survey of patients and clinic directors participating in the HIV Cost and Services Utilization Study, a national probability sample of persons in care for HIV between 1996 and 1998 (N=2,031). Primary outcomes were receipt of outpatient mental health specialist care, outpatient substance abuse care, and abstinence from substance use in the past 30 days. RESULTS: After adjustment for patient characteristics, the likelihood of care by a mental health specialist was higher for patients in HIV specialty clinics (odds ratio [OR]=2.1, 95% confidence interval [CI]=1.2-3.5) and clinics with a combination of on-site case management and affiliated mental health care (OR=2.3, CI 1.3-4.4, for off-site affiliated care; OR=2.1, CI=1.2-3.7, for on-site care). Outpatient substance abuse care also was more likely for patients in clinics with on-site case management and affiliated substance abuse care (OR=4.3, CI=1.5-12.2, for off-site affiliated care; OR=3.2, CI=1.3-8.0, for on-site care). In a subgroup of persons reporting active substance use, care in clinics with on-site case management predicted 30-day abstinence from substances at follow-up (OR=1.7, CI=1.1-2.5). CONCLUSIONS: The organizational structure of medical clinics can have an important effect on use of mental health and substance abuse specialist care.     

A longitudinal investigation of intimate partner violence among mothers with mental illness

OBJECTIVE: Severe mental illness, substance use, and intimate partner violence have emerged as major intersecting public health problems that adversely and disproportionately impact the lives of women in the United States. This longitudinal study investigated the demographic and clinical correlates of intimate partner violence in a sample of 324 mothers with severe mental illness. METHODS: A secondary analysis of longitudinal data was conducted by using multiple logistic regression. Participants were part of a longitudinal, community-based study of mothers with severe mental illness, which was aimed at understanding how these mothers viewed motherhood. The women were interviewed initially at baseline (interviews were conducted between 1995 and 1996) and then about 20 months later at follow-up (interviews were conducted between 1997 and 1998). RESULTS: At follow-up the prevalence rate of intimate partner violence was 19%. Multiple logistic regression analyses showed a significant positive relationship between alcohol and drug misuse at baseline and intimate partner violence at follow-up, indicating that women with a co-occurring diagnosis of a substance use disorder (dual diagnosis) were more likely than women without such a diagnosis to report intimate partner violence. The number of lifetime psychiatric hospitalizations and the number of symptoms related to psychiatric disability exhibited at baseline were positively associated with intimate partner violence at follow-up, and age was inversely associated with intimate partner violence. CONCLUSIONS: Mental health professionals serving mothers with mental health problems need to be aware of and prepared to assess the significant correlation between these intersecting public health problems in order to influence successful interventions. Particular attention must be given to the special treatment needs related to dual diagnosis and victimization and the impact of these factors on this vulnerable population.     

BOOK REVIEW

The aim of this study was to study associations between sense of coherence (based on Antonovsky's theory), and mental health problems, the use of mental health services, substance use, predisposition to suicide and possible psychiatric diagnosis among Finnish young men. The study included 2314 18-year-old young men who attended military call-up in autumn 1999 and completed the 13-item Orientation to Life Questionnaire (SOC-13) questionnaire (89.1% of the study sample attending military call-up). Furthermore, all young men had a medical examination at military call-up, including evaluation of possible psychiatric disorder. Suicidality, perceived mental health problems, psychiatric diagnosis at military call-up medical examination, use of mental health services, excessive alcohol consumption and use of illicit drugs were identified as independent factors associated with sense of coherence. Sense of coherence is a valuable construction in psychiatric evaluation of adolescents. SOC-13 can be used both in clinical practice and in epidemiological research to evaluate the adolescent's health resources. Future research on its applications in clinical practice is warranted.     

Chart-recorded psychiatric diagnoses in women giving birth in California in 1992.

OBJECTIVE: Although major advances have been made in the diagnosis and treatment of mental disorders in primary care, few population-based investigations have focused on the obstetrical sector. This study examines the occurrence of chart-recorded psychiatric discharge diagnoses among all women delivering in California hospitals in 1992. METHOD: The authors undertook an archival analysis of the California Health Information for Policy Project data set, which consists of linked hospital discharge and birth certificate data for 580,282 deliveries. Frequencies of ICD-9 psychiatric diagnoses were ascertained. RESULTS: Among all women delivering, 1.5% received psychiatric or substance use diagnoses. Of diagnoses recorded, 75% were substance use disorders, 21% were classified generically as "mental disorder of pregnancy," and other psychiatric disorders accounted for 4%. CONCLUSIONS: The occurrence of psychiatric diagnoses in these women is markedly lower than expected, suggesting an underreporting of psychiatric disorders at delivery. Further investigations into the detection of mental disorders in the obstetrical sector are needed.     

Integrated medical care for patients with serious psychiatric illness: a randomized trial.

BACKGROUND: This randomized trial evaluated an integrated model of primary medical care for a cohort of patients with serious mental disorders. METHODS: A total of 120 individuals enrolled in a Veterans Affairs (VA) mental health clinic were randomized to receive primary medical care through an integrated care initiative located in the mental health clinic (n = 59) or through the VA general medicine clinic (n = 61). Veterans who obtained care in the integrated care clinic received on-site primary care and case management that emphasized preventive medical care, patient education, and close collaboration with mental health providers to improve access to and continuity of care. Analyses compared health process (use of medical services, quality of care, and satisfaction) and outcomes (health and mental health status and costs) between the groups in the year after randomization. RESULTS: Patients treated in the integrated care clinic were significantly more likely to have made a primary care visit and had a greater mean number of primary care visits than those in the usual care group. They were more likely to have received 15 of the 17 preventive measures outlined in clinical practice guidelines. Patients assigned to the integrated care clinic had a significantly greater improvement in health as measured by the physical component summary score of the 36-Item Short-Form Health Survey than patients assigned to the general medicine clinic (4.7 points vs -0.3 points, P<.001). There were no significant differences between the 2 groups in any of the measures of mental health symptoms or in total health care costs. CONCLUSION: On-site, integrated primary care was associated with improved quality and outcomes of medical care.     

Correlates of adverse childhood events among adults with schizophrenia spectrum disorders

OBJECTIVE: Multiple studies have found that childhood adversity is related to a range of poor mental health, substance abuse, poor physical health, and poor social functioning outcomes in the general population of adults. However, despite the high rates of childhood adversity in schizophrenia, the clinical correlates of these events have not been systematically evaluated. This study evaluated the relationship between adverse experiences in childhood and functional, clinical, and health outcomes among adults with schizophrenia. METHODS: The authors surveyed 569 adults with schizophrenia regarding adverse childhood events (including physical abuse, sexual abuse, parental mental illnesses, loss of a parent, parental separation or divorce, witnessing domestic violence, and foster or kinship care). The relationships between cumulative exposure to these events and psychiatric, physical, and functional outcomes were evaluated. RESULTS: Increased exposure to adverse childhood events was strongly related to psychiatric problems (suicidal thinking, hospitalizations, distress, and posttraumatic stress disorder), substance abuse, physical health problems (HIV infection), medical service utilization (physician visits), and poor social functioning (homelessness or criminal justice involvement). CONCLUSIONS: The findings extend the results of research in the general population by suggesting that childhood adversity contributes to worse mental health, substance abuse, worse physical health, and poor functional outcomes in schizophrenia.     

Characteristics of Homeless Adults with Serious Mental Illness Served by a State Mental Health Transitional Shelter

Specialized transitional shelters are available in various cities to provide assistance to homeless individuals with serious mental illness. Little is known about the population using such shelters. The authors conducted a retrospective chart review to collect demographic, social, and clinical data of residents in a state-operated mental health transitional shelter in Massachusetts. A total of 74 subjects were included. Schizophrenia-spectrum disorders were present in 67.6 % of the sample and mood disorders in 35.1 %. Substance use disorders were documented in 44.6 %. Chronic medical illness (mostly hypertension, dyslipidemia, asthma, and diabetes) was found in 82.4 %. The co-occurrence of a psychiatric and substance use disorder and chronic medical illness was found in 36.5 %. The majority (75.7 %) of patients had a history of legal charges. Homeless individuals with serious mental illness served by specialized transitional shelters represent a population with complex psychiatric, medical and social needs.     

The factor structure of the SF-36 in early pregnancy

OBJECTIVE: The concept of Quality of Life (QoL) has emerged as an important psychological dimension within pregnancy. The current study sought to establish the psychometric properties of the Medical Outcomes Study Short Form 36 (SF-36) Version 2 in early pregnancy to evaluate the clinical appropriateness of using this measure with women in early pregnancy. METHODS: Exploratory and confirmatory factor analyses were conducted on self-report SF-36 data from 129 women during early pregnancy. Measures of anxiety and depression were also administered to determine the impact of psychiatric case classification on SF-36 subscale scores in this clinical group. RESULTS: The underlying factor structure of the SF-36 comprised a general third-order superordinate domain of health and two second-order factors of physical health and mental health. The SF-36 subscales were observed to be sensitive to the affective status of participants. CONCLUSION: The use of the SF-36 in early pregnancy as a clinical research tool comprising eight subscales is recommended. The relative merits of scoring the instrument as a two-subscale measure of physical health and mental health require further evaluation.     

Sense of coherence among Finnish young men--a cross-sectional study at military call-up

The aim of this study was to study associations between sense of coherence (based on Antonovsky's theory), and mental health problems, the use of mental health services, substance use, predisposition to suicide and possible psychiatric diagnosis among Finnish young men. The study included 2314 18-year-old young men who attended military call-up in autumn 1999 and completed the 13-item Orientation to Life Questionnaire (SOC-13) questionnaire (89.1% of the study sample attending military call-up). Furthermore, all young men had a medical examination at military call-up, including evaluation of possible psychiatric disorder. Suicidality, perceived mental health problems, psychiatric diagnosis at military call-up medical examination, use of mental health services, excessive alcohol consumption and use of illicit drugs were identified as independent factors associated with sense of coherence. Sense of coherence is a valuable construction in psychiatric evaluation of adolescents. SOC-13 can be used both in clinical practice and in epidemiological research to evaluate the adolescent's health resources. Future research on its applications in clinical practice is warranted.     

Locus of mental health treatment in an integrated service system

OBJECTIVE: Epidemiological surveys suggest that half of mental disorders in the community are treated in general medical settings. This paper examines delivery of mental health services in psychiatric, primary care, and specialty medical clinics in the Department of Veterans Affairs (VA), the largest integrated public-sector health care system in the United States. METHODS: The study examined all outpatient visits to VA clinics between October 1996 and March 1998, a time during which VA policy promoted a shift to a primary care model. For veterans with a primary diagnosis of a mental or substance use disorder who made any visit to a VA psychiatric, primary care, or specialty medical clinic, we compared the locus of care and case mix as well as changes in treatment patterns during the study period. RESULTS: Of 437,035 veterans treated for a mental disorder during the final six months of the study period, only 7 percent were seen for their mental disorders exclusively in primary care and specialty medical clinics. Compared with veterans with mental disorders treated in specialty mental health clinics, those treated in medical clinics had less serious psychiatric diagnoses and made fewer visits. While there was a substantial shift of care from specialty to primary care during the study period, no comparable change in the distribution of care between medical and mental health settings was found. CONCLUSIONS: Treatment patterns in VA clinics differ markedly from those in the private sector. Research is needed to determine whether and how staffing models developed in HMOs and community samples should be extended to these public-sector settings.     

Service needs of depressed older adults following acute psychiatric care

Older persons with mental disorder need mental health services, but the extent to which they have service needs in other domains (medical, functional and psychosocial) is not established, although these needs may compromise the attainment of psychiatric outcomes. This study focuses on 169 older adults hospitalized for depression and documents their post-acute service needs in four domains: psychiatric, medical, functional and psychosocial. Seventy-five per cent of these psychiatric patients had medical conditions that required treatment. Eighty-four per cent needed assistance with routine activities. Nearly two-thirds (67%) were experiencing one or more psychosocial or environmental problems that warranted intervention. The mean number of service needs was 6.5 (SD=1.5). Fifty-seven per cent had needs in all four domains. Older adults admitted to acute care for depression have high levels of service needs stemming from multiple domains: psychiatric, medical, functional and psychosocial. We extend the biopsychosocial model, largely used to address the origins of psychopathology, to conceptualize the multiple domains of service that older adults with mental disorder need. This biopsychosocial model suggests that needs in each domain should be identified and addressed if desired psychiatric outcomes are to be attained.     

Shared decision-making preferences of people with severe mental illness

OBJECTIVE: Perceived roles and preferences were explored for shared decision making among persons with severe mental illnesses. METHODS: In this pilot study, 30 adult clients with severe mental illness in a community mental health center were surveyed about decision making regarding psychiatric medications, rehabilitation, and general medical care. RESULTS: Clients generally expressed a desire for greater participation in decisions about psychiatric care than they currently experienced. Regarding use of new psychiatric medications, 23 persons (77%) preferred autonomous or shared roles, but only 11 (37%) rated their current roles as more than passive (z=-2.83, p=.005). Clients were less likely to prefer a passive role in medication decisions about psychiatric care than about general medical care (seven persons, or 23%, versus 23 persons, or 77%; z=-3.01, p=.003). CONCLUSIONS: Most clients with severe mental illnesses prefer shared decision making, particularly in relation to their mental health care.     

The Evolution of a Community-Based Telepsychiatry Program in Rural Alabama: Lessons Learned—A Brief Report

The purpose of this paper is to describe the partnership between a community-based rural mental health clinic and an academic health center to provide telepsychiatry services in rural Alabama. The partnership was developed to meet the needs of a clinic that serves an underserved rural population with limited psychiatric services. This paper offers valuable lessons learned for mental health practitioners who may be considering the benefits and challenges of forming community-based partnerships in use of telepsychiatry to build capacity to deliver clinical mental health services to rural mental health shortage areas.