Social services day care and health services day care in mental health: do they differ?

BACKGROUND: The difference between the services provided by day hospitals and day centres is far from clear. The supposition that day hospitals would provide an acute service, while day centres would offer social support for a more chronic population has been contentious and there is little evidence of how they are currently used. AIMS: We aimed to ascertain the differences between day hospitals (partial hospitalisation) and social service day centres in functions and roles, as perceived by staff, service users and referrers. METHODS: The views of service users and staff at two day hospitals and four day centres were ascertained through questionnaires and interviews, along with those of staff of eight Community Mental Health Teams, who constitute the sole pathway to the two services. RESULTS: Day hospitals were perceived by both referrers and clients to offer short-term, more intensive 'treatment' to more acutely ill people in need of mental health monitoring. Day centres were perceived to offer longer-term support, particularly social support, to people more likely to have longer-term and psychotic illnesses. CONCLUSION: There is currently a clear distinction between day centres and day hospitals, in key features of their services and client groups. It would be unwise to treat them as interchangeable.     

Phobic disorders and anxiety states: how do they differ?

A review of the clinical literature to date has shown that the nature of the relationship between phobic disorders and anxiety states is still unclear. As a wide range of symptoms are shared by patients with all DSM-III anxiety disorder diagnoses, at this stage there is still a need to investigate the latent dimensions which distinguish the anxiety disorder subtypes. In the present study 176 patients with the DSM-III diagnoses of agoraphobia with panic attacks, social phobia, panic disorder and generalized anxiety disorder completed the Fear Survey Schedule, Fear Questionnaire, Hostility and Direction of Hostility Questionnaire, Maudsley Personality Inventory, and the Hamilton Anxiety and Depression Scales. Group membership was significantly predicted by a discriminant analysis which yielded a Fear Questionnaire agoraphobia function and a social phobia function. The results from discriminant analysis suggests that agoraphobia and anxiety states may be closely related. Classification errors were also determined, providing further evidence with which to refute the claim that agoraphobia has "all or none" characteristics.     

Are psychiatrists equipped for management roles in mental health services?

OBJECTIVES: To promote the discussion of leadership and management skills development among psychiatrists in Australia and New Zealand. METHOD: A key informant survey of fellows of the Royal Australian and New Zealand College of Psychiatrists was conducted via a semi-structured interview. This canvassed views about leadership and management issues including levels of confidence and needs for additional skills. RESULTS: There was widespread support for psychiatrists to be in management roles in mental health services; however, on entering management positions, psychiatrists often felt inadequately trained and prepared for their new role. Furthermore, many who had made the transition to management perceived a lack of support from their clinical colleagues. Clinicians appeared to believe that management was not difficult to learn and could be done by any experienced clinician. The provision of short courses and mentoring programmes is the preferred option for most psychiatrists seeking to acquire leadership and management skills. CONCLUSIONS: For psychiatrists to maximize their potential as leaders in Australian and New Zealand mental health services, greater attention to promoting the acquisition of relevant skills throughout training and in the post-fellowship years is required. Psychiatrists need to be supported and encouraged to pursue further education, training and research in this area. Failure to address this issue risks psychiatrists continuing to feel disadvantaged in management roles and hence reluctant to undertake the challenge.     

PRN Sedation–patterns of prescribing and administration in a child and adolescent mental health inpatient service

Objective: To identify utilisation rates of prn (pro re nata) sedation in children and adolescents receiving inpatient psychiatric treatment, and to compare correlates of prn prescribing and administration. Method A retrospective chart review examined 122 medical charts from a child and youth mental health inpatient service. Results 71.3% of patients were prescribed prn sedation and 50.8% were administered prn sedation. Patients received an average of 8.0 doses of prn sedation, with 9.8% receiving 10 or more doses. Chlorpromazine and diazepam were the most commonly utilised agents. Prescribing of prn sedation was only related to use of regular medications (p < 0.01), and non-parent carers (p < 0.01). In contrast, administration of prn sedation was associated with multiple diagnoses (p < 0.01), pervasive development disorder (p < 0.01), mental retardation (p < 0.01) ADHD (p < 0.01), longer hospital admission (p < 0.01), use of atypical antipsychotics (p < 0.01) and polypharmacy (p < 0.01). Conclusions Despite lack of data to inform practice, prn sedation is widely utilised, especially in complex patients. Future research in this area needs to incorporate nurses and examine whether patients benefit from prn sedation, which drugs and dosing patterns optimise safety and efficacy, and what is the role of prn sedation in the context of other medication.     

Are alexithymia, depression, and anxiety distinct constructs in affective disorders?

OBJECTIVE: the present study was undertaken to gain a better insight into the relationship between alexithymia, anxiety, and depression. Two hypotheses were tested: (1) whether a depressive or anxiety disorder is associated with an elevation of one or more dimensions of alexithymia; and (2) whether alexithymia is an independent construct from depression and anxiety in patients with depressive or anxiety disorders. METHOD: a total of 113 patients with depressive or anxiety disorders (DSM-IV) and 113 control subjects completed the 20-item version of the Toronto alexithymia scale (TAS-20) and the hospital anxiety and depression scale (HADS). RESULTS: the TAS-20 total score was higher in depressed and anxious patients than in controls. This finding mainly depended on an increased score for "difficulty identifying feelings"(DIF), and (only in depressed patients) on an increased score for "difficulty communicating feelings" (DCF). The factor analysis of the TAS-20 and HADS items showed that depression is a construct different from alexithymia, whereas some overlap exists between anxiety and DIF dimension. CONCLUSION: our results suggest that in depressive and anxiety disorders, alexithymia and depression are separate constructs that may be closely related; in contrast, there are some overlaps between the DIF dimension and anxiety.     

Editorial: Should child and adolescent mental health professionals be diagnosing personality disorder in adolescence?

Diagnosing personality disorders in adolescence remains a contentious issue, particularly in the United Kingdom (UK). In this debate section we hear from clinicians, service users and family members on this topic; strongly held views are expressed and evidenced.     

Debate: Child and adolescent mental health services in Pakistan; Do we need in-patient mental health facilities for children and young people?

Depression and anxiety are leading causes of morbidity in children and adolescents worldwide. In Pakistan, young people are exposed to many chronic adversities including violence, social and economic inequalities, and are at greater risk of developing mental health problems. Yet there is a lack of trained human resources, in-patient child and adolescent mental healthcare facilities, and training opportunities in child and adolescent psychiatry and mental health in Pakistan. Given the poor economic condition of the country, which has been made even worse by the COVID-19 pandemic, it is very unlikely that dedicated resources will be made available in near future to develop specialist child and adolescent mental health services in Pakistan. To bridge this treatment gap, we propose a multitiered, transdiagnostic, task-shifting strategy-based model for child and adolescent mental health services in Pakistan.     

Assessing the feasibility of a web-based outcome measurement system in child and adolescent mental health services – myHealthE a randomised controlled feasibility pilot study

Background

Interest in internet-based patient reported outcome measure (PROM) collection is increasing. The NHS myHealthE (MHE) web-based monitoring system was developed to address the limitations of paper-based PROM completion. MHE provides a simple and secure way for families accessing Child and Adolescent Mental Health Services to report clinical information and track their child's progress. This study aimed to assess whether MHE improves the completion of the Strengths and Difficulties Questionnaire (SDQ) compared with paper collection. Secondary objectives were to explore caregiver satisfaction and application acceptability.

Methods

A 12-week single-blinded randomised controlled feasibility pilot trial of MHE was conducted with 196 families accessing neurodevelopmental services in south London to examine whether electronic questionnaires are completed more readily than paper-based questionnaires over a 3-month period. Follow up process evaluation phone calls with a subset (n = 8) of caregivers explored system satisfaction and usability.

Results

MHE group assignment was significantly associated with an increased probability of completing an SDQ-P in the study period (adjusted hazard ratio (HR) 12.1, 95% CI 4.7–31.0; p = <.001). Of those caregivers' who received the MHE invitation (n = 68) 69.1% completed an SDQ using the platform compared to 8.8% in the control group (n = 68). The system was well received by caregivers, who cited numerous benefits of using MHE, for example, real-time feedback and ease of completion.

Conclusions

MHE holds promise for improving PROM completion rates. Research is needed to refine MHE, evaluate large-scale MHE implementation, cost effectiveness and explore factors associated with differences in electronic questionnaire uptake.     

Changes in referrals to child and adolescent psychiatric services in Norway 1992–2001

Abstract. Background: The study analyzes changes in types of problems referred to child and adolescent psychiatry in Norway from 1992 to 2001, and investigates if referral practices and media attention account for these changes. Method: All referrals to child and adolescent psychiatry in Norway in the period 1992–2001 were analyzed, as well as frequencies of articles in media on psychiatric problems. Results: The shares of referrals for sadness/depression increased from 0.5 % to 15.4%. Referrals for hyperactivity/attention problems increased from 1.2 % to 13.6%. The increases could be statistically attributed to decreased use of other referral categories, and/or alternatively to media attention on these and related topics. Convergence between diagnosis and corresponding referral problem increased in the period. Conclusions: Referrals for sadness/depression and hyperactivity/attention problems increased sharply in Norway during the 1990s. This increase may be attributed to a different understanding of and a sharper look at these problems by referral agencies and by increased media attention.     

Psychotherapy for anxiety disorders in childhood and adolescence--what is evidence-based?

Anxiety disorders are the most frequent mental disorders in children and adolescents. They are also an important risk factor for psychological disturbances in adulthood and require adequate treatment. The effectiveness of psychotherapy in the treatment of anxiety disorders today can no longer be questioned. However, a meta-analysis of treatment studies shows that so far, only cognitive-behavior therapy has proved, on the basis of randomized, controlled trials (RCT), to be successful in the treatment of anxiety disorders in children and adolescents. Regardless of whether the cognitive behavior therapy took place individually or in a group, or whether it was carried out with the child alone or with the inclusion of the family, no differences in the effectiveness were found. The follow-up data show that the therapy success persisted for several years and that it was not limited only to the symptoms of anxiety. Although for many psychotherapeutic interventions there is still no empirical basis, initial RCT prove the short-term effectiveness of psychopharmacological treatment (SSRI). The central, empirically validated psychotherapeutic interventions include psychoeducation, cognitive treatment of dysfunctional thoughts, and systematic exposure to the situation triggering anxiety. These interventions will be presented briefly and open questions in psychotherapy research will be discussed in the conclusion.     

Are mood disorders and obesity related? A review for the mental health professional

OBJECTIVE: We reviewed evidence regarding a possible relationship between mood disorders and obesity to better inform mental health professionals about their overlap. METHOD: We performed a MEDLINE search of the English-language literature for the years 1966-2003 using the following terms: obesity, overweight, abdominal, central, metabolic syndrome, depression, mania, bipolar disorder, binge eating, morbidity, mortality, cardiovascular, diabetes, cortisol, hypertriglyceridemia, sympathetic, family history, stimulant, sibutramine, antiobesity, antidepressant, topiramate, and zonisamide. We evaluated studies of obesity (and related conditions) in persons with mood disorders and of mood disorders in persons with obesity. We also compared studies of obesity and mood disorders regarding phenomenology, comorbidity, family history, biology, and pharmacologic treatment response. RESULTS: The most rigorous clinical studies suggest that (1). children and adolescents with major depressive disorder may be at increased risk for developing overweight; (2). patients with bipolar disorder may have elevated rates of overweight, obesity, and abdominal obesity; and (3). obese persons seeking weight-loss treatment may have elevated rates of depressive and bipolar disorders. The most rigorous community studies suggest that (1). depression with atypical symptoms in females is significantly more likely to be associated with overweight than depression with typical symptoms; (2). obesity is associated with major depressive disorder in females; and (3). abdominal obesity may be associated with depressive symptoms in females and males; but (4). most overweight and obese persons in the community do not have mood disorders. Studies of phenomenology, comorbidity, family history, biology, and pharmacologic treatment response of mood disorders and obesity show that both conditions share many similarities along all of these indices. CONCLUSION: Although the overlap between mood disorders and obesity may be coincidental, it suggests the two conditions may be related. Clinical and theoretical implications of this overlap are discussed, and further research is called for.     

Exploring 'clinical judgement': how do child and adolescent mental health professionals decide whether a young person needs individual psychotherapy?

This article reports on a small-scale, qualitative study based in a single CAMHS team, exploring the decision-making process used by mental health professionals when deciding whether or not to refer a child for one particular modality of treatment--individual psychotherapy. Building on an initial audit of child psychotherapy referrals within the team, this study analyses a small number of in-depth interviews with members of the multidisciplinary CAMHS team. Three themes emerged from the analysis, suggesting that referral-making decisions depend on wider conceptions of the particular modality of therapy, particular features of the child and family referred (but not reducible to diagnostic categories), and the stage at which therapeutic work with the family has reached at the time of referral. The implications of these findings are discussed specifically in relation to child psychotherapy, and more generally in relation to evidence-based practice. The authors conclude by arguing for the use of more clinically relevant research methodologies within evidence-based research.     

Are eating disorders and their symptoms increasing in prevalence among adolescent population?

Background: A debate concerns whether eating disorders are increasing in prevalence. The role of socio-economic status (SES) for adolescent eating disorders (ED) is another matter of debate.

Aims: To ascertain whether self-reported eating disorders or their symptoms have increased in prevalence in adolescent population from the early 2000s to early 2010s.

Methods: A person-identifiable classroom survey, Adolescent Mental Health Cohort study, was carried out among the 9th graders in comprehensive schools in Tampere, Finland, during academic year 2002–2003, and replicated among then 9th graders during academic years 2012–2013. Eating disorders were elicited with questionnaires tailored according to DSM-IV criteria for anorexia nervosa and bulimia nervosa.

Results: No changes were observed between 2002–2003 and 2012–2013 in the prevalence of anorexia and bulimia, most of the symptoms of anorexia and bulimia, or the proportion of adolescents having received treatment due to eating disorders among the girls or the boys. Eating disorders, treatment contacts due to eating disorders, and eating disorder symptoms were not systematically associated with either low or high parental socio-economic status.

Conclusion: Based on this dataset, eating disorders are not increasing in the adolescent population. Adolescent eating disorders are not associated with socio-economic status of their family.     

Evidence-based prevention practice in mental health: what is it and how do we get there?

A substantial number of children in the United States suffer from mental health problems. These children enter into adulthood at a disadvantage and often continue to experience mental health problems as adults. Historically, much less attention has been paid to prevention of mental health problems than to treatment and rehabilitative services. In recent years, however, great strides have been made in developing and evaluating prevention interventions in the area of mental health. Nevertheless, the study of prevention still lags behind clinical treatment research in identifying and disseminating effective programs and interventions. The following article draws on the work of numerous prevention scholars to develop a conceptual framework of evidence-based prevention practice in the area of mental health. Suggestions for how researchers, policy makers, and service providers can contribute to the development of evidence-based prevention practice in mental health are considered.