Prevalence of enduring and disabling mental illness in the inner city.

Previous research identifying the long-term mentally ill in primary care has been outside areas of deprivation. We used a case finding approach by a primary care group to identify the prevalence and characteristics of people with enduring and disabling mental ill health in a disadvantaged inner-city community. We found a high point prevalence (12.9 per 1000 patients) of enduring psychotic and non-psychotic illness (36.1% and 63.9% respectively). This contributed to considerable workload and disability, and included a significant proportion of older people (24.6% aged over 65 years). The approach may be useful for local needs assessment. It highlights a need to consider disability as well as diagnosis for service development.     

Does diagnosis determine delivery? The Islington study of older people's needs and health care costs

BACKGROUND: Little is known about the factors associated with the receipt of care by older people. This study investigates the use. costs and factors associated with service usage among people aged 65 or older living in inner London. METHOD: A community-based survey, using questionnaires, examined psychiatric and physical morbidity, formal and informal care. The relationships between demographic, pathological features and the costs of health and social care were explored using multivariate regression. RESULTS: A total of 1085 people were interviewed at home of these 18% did not receive any service at all. The total cost of services per week for people with dementia was pound 109, with activity limitation pound 14 and with depression pound 12. The greatest effect of physical limitation was on the receipt of social care. Dementia had the strongest effect on receipt of social care services. Depression increased health care costs to a much greater degree than social care costs. Despite presenting to services, black elders received significantly less health care than other people with the same needs. Older people living alone were more likely to receive social care support and appeared less likely to use health services. CONCLUSIONS: Physical dependency significantly affects both health and social care costs. Increasing cognitive impairment mainly leads to increasing social care costs. Overall costs are increased by physical dependency, dementia, depression, subjective health problems, living alone and are negatively affected by being black.     

General practice and the provision of information and services for physically disabled people aged 16 to 65 years.

The study reported here was part of a larger survey investigating the nature and extent of disability in the Grampian region. Interviews with 212 people aged between 16 and 65 years who had a wide range of physical disabilities elicited perceptions of current and past service provision. Respondents expressed a strong need for information on disability services and reported difficulty in knowing whom to approach for this. General practitioners were the most commonly reported source of such information and low usage of the Department of Social Security, social work departments and voluntary organizations was identified. No significant relationship was found between degree of disability and frequency of consultation with a general practitioner. However, the more severe the disability the more likely it was that the general practitioner initiated contact rather than the patient. Although in general those interviewed were satisfied with medical information given regarding their diagnosis, they were more critical of information provided in relation to coping with the disorder, including that concerning benefits and services. The study confirmed the pivotal role of the general practitioner in the care of physically disabled people in the community aged between 16 and 65 years. The need to re-evaluate the role of the general practitioner in the provision of information and services is discussed.     

Attitudes of general practitioners to caring for people with learning disability.

BACKGROUND: The views of general practitioners on their increasing role in caring for people with learning disability in the community are not known. AIM: A study was carried out to assess the views of general practitioners with regard to providing routine care, organizing health promotion and specific health checks for people with learning disability and the role of specialists. METHOD: A postal questionnaire was sent to all 242 general practitioners in Gwent, south Wales. Participants had to mark their level of agreement with 20 attitude statements regarding learning disability. RESULTS: A total of 126 general practitioners (52%) responded. Respondents generally agreed that general practitioners were responsible for the medical care of people with learning disability. Respondents tended to be opposed to providing regular structured health promotion for people with learning disability, such as annual health checks and assessing hearing and eyesight. Specialist services were generally valued by respondents. CONCLUSION: General practitioners largely accepted their role as primary health care providers for people with learning disability. In contrast, their role as providers of health promotion for this patient group was not generally accepted. Further research into the appropriateness and opportunity costs of health screening for people with learning disability is needed.     

The health of clients of a social service department

A survey was undertaken of the health problems and current medical care of new clients making contact with the Social Service Department of an outer London borough. The findings indicated that social-service clients represent a high-morbidity group of the population: 47 per cent of the survey sample showed evidence of major physical illness or disability, and 16 per cent of major mental illness. A sub-group was identified, corresponding to about 300 new clients annually, who suffered from serious ill-health or disability, but were at the time not under medical care.

These findings support the argument for closer liaison between medical and social services in the community and, in particular, for more social-worker attachments in general practice.

     

Using evidence-based internet interventions to reduce health disparities worldwide

Health disparities are a persistent problem worldwide. A major obstacle to reducing health disparities is reliance on "consumable interventions," that is, interventions that, once used, cannot be used again. To reduce health disparities, interventions are required that can be used again and again without losing their therapeutic power, that can reach people even if local health care systems do not provide them with needed health care, and that can be shared globally without taking resources away from the populations where the interventions were developed. This paper presents the argument that automated self-help evidence-based Internet interventions meet the above criteria and can contribute to the reduction of health disparities worldwide. Proof-of-concept studies show that evidence-based Internet interventions can reach hundreds of thousands of people worldwide and could be used in public sector settings to augment existing offerings and provide services not currently available (such as prevention interventions). This paper presents a framework for systematically filling in a matrix composed of columns representing common health problems and rows representing languages. To bring the benefits of evidence-based Internet interventions to the underserved, public sector clinics should establish eHealth resource centers, through which patients could be screened online for common disorders and provided with evidence-based Internet intervention services not currently available at the clinics. These resources should be available in the patients' languages, in formats that do not require literacy, and that can be accessed with mobile devices. Such evidence-based Internet interventions should then be shared with public sector clinics as well as individuals anywhere in the world. Finally, this paper addresses sustainability and describes a continuum of evidence-based Internet interventions to share nationally and across the world. This approach to expanding health service delivery will significantly contribute to a reduction of health disparities worldwide, adding to the often-quoted slogan, "Think globally, act locally," a third line: "Share globally."     

The Ecology of Medical Care in Korea

This study aimed to describe the ecology of medical care in Korea. Using the yearly data of 2012 derived from the Korea Health Panel, we estimated the numbers of people per 1,000 residents aged 18 and over who had any health problem and/or any medical care at a variety of care settings, such as clinics, hospitals, and tertiary hospitals, in an average month. There was a total of 11,518 persons in the study population. While the number of those who had any health problem in an average month was estimated to be 939 per 1,000 persons, the estimated numbers of ambulatory care users were 333 at clinics, 101 at hospital outpatient departments, 35 at tertiary hospital outpatient departments, and 38 for Korean Oriental medical providers. The number of people who used emergency care at least once was 7 per 1,000 persons in an average month. The numbers of people hospitalized in clinics and hospitals were 3 and 8, respectively, while 3 persons were admitted to tertiary hospitals. There was a gap between the number of people experiencing any health problem and that of those having any medical care, and primary care comprised a large share of people’s medical care experiences. It was noteworthy that more patients received ambulatory care at tertiary hospitals in Korea than in other countries. We hope that discussion about care delivery system reform and further studies will be encouraged.     

Frailty in people living with HIV

The life expectancy of people living with HIV (PLHIV) has dramatically improved with effective and well-tolerated antiretroviral therapy. This presents a new challenge in caring for this patient population, with up to 28% of older PLHIV being identified as frail. Studies suggest that the prevalence of frailty is higher in PLHIV compared to the general population, and that the onset of frailty occurs at an earlier age. Frail individuals often present with multiple and non-specific health complaints, fluctuating disability, falls and delirium, and are at higher risk for multiple adverse outcomes, post-operative complications, poor responses to vaccination and functional decline. They tend to require longer hospital admissions, are more likely to require nursing home care, and are at greater risk of mortality. The degree of frailty can fluctuate over time. Limited evidence exists to support the reversal of frailty, but epidemiological evidence suggests that interventions to assess and manage co-morbidities, reducing risk factors such as smoking, increasing exercise and optimising BMI, and improving personal and community resources, are all likely to reduce the risk of frailty. Physicians who care for PLHIV need to recognise and manage frailty in this patient population. This includes an understanding of: when to intervene aggressively in the management of an older patient with a new HIV diagnosis to delay or prevent permanent debility and frailty; when to acknowledge that the patient has become frail; and the role of geriatric medicine in addressing the specific issues and needs of this patient, such as maximising functional ability, preventing falls, reducing social isolation and improving quality of life.     

Mental Health Needs of Older Adults and Primary Care: Opportunity for Interdisciplinary Geriatric Team Practice

The convergence of a number of disparate factors has led to opportunities to help address the mental health needs of older adults in primary care (PC) or "integrated care" settings. Older adults are disproportionately high users of health care resources, and cost projections for coming decades have catastrophic implications. Elders shun mental health services, instead turning to their personal physicians when troubled. The PC system is clogged with patients without medical problems or whose medical conditions are exacerbated by psychosocial factors (estimated at 60% to 70%), resulting in overutilization of services and high costs. However, PC physicians detect and adequately treat or refer only 40% to 50% of patients with mental health problems. Early experience with brief and/or structured interventions in PC settings is promising and suggests opportunities for multidisciplinary team geriatric practice.     

Frailty: an emerging concept for general practice

Ageing of the population in western societies and the rising costs of health and social care are refocusing health policy on health promotion and disability prevention among older people. However, efforts to identify at-risk groups of older people and to alter the trajectory of avoidable problems associated with ageing by early intervention or multidisciplinary case management have been largely unsuccessful. This paper argues that this failure arises from the dominance in primary care of a managerial perspective on health care for older people, and proposes instead the adoption of a clinical paradigm based on the concept of frailty. Frailty, in its simplest definition, is vulnerability to adverse outcomes. It is a dynamic concept that is different from disability and easy to overlook, but also easy to identify using heuristics (rules of thumb) and to measure using simple scales. Conceptually, frailty fits well with the biopsychosocial model of general practice, offers practitioners useful tools for patient care, and provides commissioners of health care with a clinical focus for targeting resources at an ageing population.     

Meeting the Mental Health Needs of Older Adults in Primary Care: How Do We Get the Job Done?

Most elderly persons in the United States with mental health problems such as depression receive no attention or care. Those who receive treatment generally do so in primary care settings, where disorders like depression have a hard time competing with other common and chronic medical problems. Typically, mental illnesses are under-recognized and under-treated in elderly persons attending primary care clinics. The experience of the PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) study is briefly described, indicating that depression, for example, can be treated successfully in primary care elderly using the type of multidisciplinary collaborative care model advocated by Speer and Schneider (2003 ; this issue). The challenge now facing all of us is to create a consumer- and family-driven demand for good mental health services in geriatric clinics and a political consensus to reimburse such services fairly. Recent improvement in Medicare reimbursement for mental health services to victims of Alzheimer's dementia provides a basis for hope.     

Health risk appraisal in older people 2: the implications for clinicians and commissioners of social isolation risk in older people

BACKGROUND: Social isolation is associated with poorer health, and is seen by the World Health Organisation (WHO) as one of the major issues facing the industrialised world. AIM: To explore the significance of social isolation in the older population for GPs and for service commissioners. DESIGN OF STUDY: Secondary analysis of baseline data from a randomised controlled trial of health risk appraisal. SETTING: A total of 2641 community-dwelling, non-disabled people aged 65 years and over in suburban London. METHOD: Demographic details, social network and risk for social isolation based on the 6-item Lubben Social Network Scale, measures of depressed mood, memory problems, numbers of chronic conditions, medication use, functional ability, self-reported use of medical services. RESULTS: More than 15% of the older age group were at risk of social isolation, and this risk increased with advancing age. In bivariate analyses risk of social isolation was associated with older age, education up to 16 years only, depressed mood and impaired memory, perceived fair or poor health, perceived difficulty with both basic and instrumental activities of daily living, diminishing functional ability, and fear of falling. Despite poorer health status, those at risk of social isolation did not appear to make greater use of medical services, nor were they at greater risk of hospital admission. Half of those who scored as at risk of social isolation lived with others. Multivariate analysis showed significant independent associations between risk of social isolation and depressed mood and living alone, and weak associations with male sex, impaired memory and perceived poor health. CONCLUSION: The risk of social isolation is elevated in older men, older persons who live alone, persons with mood or cognitive problems, but is not associated with greater use of services. These findings would not support population screening for individuals at risk of social isolation with a view to averting service use by timely intervention. Awareness of social isolation should trigger further assessment, and consideration of interventions to alleviate social isolation, treat depression or ameliorate cognitive impairment.     

Patient satisfaction surveys as a market research tool for general practices.

BACKGROUND. Recent policy developments, embracing the notions of consumer choice, quality of care, and increased general practitioner control over practice budgets have resulted in a new competitive environment in primary care. General practitioners must now be more aware of how their patients feel about the services they receive, and patient satisfaction surveys can be an effective tool for general practices. AIM. A survey was undertaken to investigate the use of a patient satisfaction survey and whether aspects of patient satisfaction varied according to sociodemographic characteristics such as age, sex, social class, housing tenure and length of time in education. METHOD. A sample of 2173 adults living in Medway District Health Authority were surveyed by postal questionnaire in September 1991 in order to elicit their views on general practice services. RESULTS. Levels of satisfaction varied with age, with younger people being consistently less satisfied with general practice services than older people. Women, those in social classes 1-3N, home owners and those who left school aged 17 years or older were more critical of primary care services than men, those in social classes 3M-5, tenants and those who left school before the age of 17 years. CONCLUSION. Surveys and analyses of this kind, if conducted for a single practice, can form the basis of a marketing strategy aimed at optimizing list size, list composition, and service quality. Satisfaction surveys can be readily incorporated into medical audit and financial management.     

The crimson care collaborative: a student-faculty initiative to increase medical students' early exposure to primary care

The current shortage of primary care physicians (PCPs), particularly as more individuals obtain health insurance and seek primary care services, is a growing national concern. The Crimson Care Collaborative (CCC) is a joint student-faculty initiative in post-health-care-reform Massachusetts that was started with the explicit goal of attracting medical students to primary care careers. It fills a niche for student-run clinics, providing evening access to primary care services for patients without a PCP and urgent care services for patients of a Massachusetts General Hospital-affiliated internal medicine clinic, with the aim of decreasing emergency department use in both groups. Unlike other student-run clinics, CCC is integrated into the mainstream health care structure of an existing primary care clinic and, because of universal health insurance coverage in Massachusetts, can bill for its services. In addition to the clinical services offered, the student-run research team evaluates the quality of care and the patients' experiences at the clinic. This article describes the creation and development of CCC, including a brief overview of clinic operations, social services, research, laboratory services, student and patient education programs, and finance. In the wake of the Patient Protection and Affordable Care Act of 2010, CCC is an example of how students can aid the transition to universal health care in the United States and how medical schools can expose students early in their training to primary care and clinic operations.     

Ageing and mental health in a developing country: who cares? Qualitative studies from Goa, India

BACKGROUND: While there is a growing body of epidemiological evidence on the prevalence of mental illnesses in late-life in developing countries, there is limited data on cultural perceptions of mental illnesses and care arrangement for older people. METHOD: This qualitative study used focus group discussions with older people and key informants to investigate the status of older people and concepts of late-life mental health conditions, particularly dementia and depression, in Goa, India. RESULTS: Vignettes of depression and dementia were widely recognized. However, neither condition was thought to constitute a health condition. Dementia was construed as a normal part of ageing and was not perceived as requiring medical care. Thus, primary health physicians rarely saw this condition in their clinical work, but community health workers frequently recognized individuals with dementia. Depression was a common presentation in primary care, but infrequently diagnosed. Both late-life mental disorders were attributed to abuse, neglect, or lack of love on the part of children towards a parent. There was evidence that the system of family care and support for older persons was less reliable than has been claimed. Care was often conditional upon the child's expectation of inheriting the parent's property. Care for those with dependency needs was almost entirely family-based with little or no formal services. Unsurprisingly, fear for the future, and in particular 'dependency anxiety' was commonplace among older Goans. CONCLUSIONS: There is a need to raise awareness about mental disorders in late-life in the community and among health professionals, and to improve access to appropriate health care for the elderly with mental illness. The study suggests directions for the future development of locally appropriate support services, such as involving the comprehensive network of community health workers.     

Rural mental health: implications for telepsychiatry in clinical service, workforce development, and organizational capacity

In Hawai'i, rural residents suffer disproportionately from poor health and mental health outcomes. Hawai'i's island geography makes rural health service disparities especially compelling. Physician workforce shortages are projected to increase, despite 30 years of programs aimed at recruiting physicians to rural areas. Telepsychiatry has been shown to be a feasible way to provide a variety of health services to individuals living in rural areas with limited access to healthcare. The University of Hawai'i Rural Health Collaboration (UHRHC) was established by the Department of Psychiatry to address the need for workforce development and rural access to mental health services across the State of Hawai'i by using telepsychiatry. Partnerships with community health clinics have been formed to provide patient care and consultation-liaison services through telepsychiatry technology. In addition, UHRHC focuses on workforce development in its residency training curriculum by utilizing a service-learning approach to rural mental health. Evaluation of these efforts is currently underway, with preliminary evidence suggesting that UHRHC is a promising strategy to increase access to critical mental health services and reduce health disparities in rural Hawai'i.     

Evolving trends in medical care-coordination for patients with HIV and AIDS

HIV/AIDS is a condition characterized by a variety of medical and social needs that affect individuals over time. System-level problems of access, rising costs of care, and varying quality of HIV/AIDS care in addition to the individual barriers to care such as stigma, perceived discrimination, competing needs, and comorbid conditions have highlighted the importance of using comprehensive approaches to care delivery. Several types of services have been proposed to improve care coordination for various diseases, including case management, community health workers, promotoras, and patient navigators. In this paper, we will review the characteristics of care coordination interventions for persons with HIV and the findings in the literature about their association with HIV health outcomes. We will conclude with a discussion of the implications and important areas for further investigations on this topic.     

Early intervention services in youth mental health

Mental and substance use disorders are leading contributors to the burden of disease among young people in Australia, but young people experience a range of barriers to accessing appropriate treatment for their mental health concerns. The development of early intervention services that provide accessible and effective mental health care has the potential to reduce the individual and community burden associated with mental health problems. Collaborative care arrangements between general practitioners, psychologists and other service providers are a key component of comprehensive and integrated early intervention services, with evidence-based psychological treatments an important part of these collaborative mental health care models. Recently, the Australian Government funded headspace (the National Youth Mental Health Foundation) to promote and support early intervention in youth mental health by establishing accessible and collaborative models of enhanced primary mental health care for young people with emergent mental and substance use disorders. Clinical psychologists in the headspace Community of Youth Service and other settings will play a key role in providing early and effective interventions within multidisciplinary collaborative care arrangements.     

A survey of athletic medicine outreach programs in wisconsin

In 1985, Sherman (21) reported a lack of organized and supervised health care for athletes in southern Wisconsin high schools and proposed that outreach athletic trainer services could help fill this gap. In order to determine the extent to which outreach programs are providing athletic training services, in January 1990, I surveyed 30 athletic medicine outreach services in Wisconsin to observe the frequency and scope of care being provided. Twenty-six surveys were returned. Results indicated that: (1) nearly half the high schools in Wisconsin subscribe to an outreach service; (2) outreach visits vary per individual school/service agreements, but average 2.5 visits per week, 2 hours per visit; (3) generally, outreach services furnish medical coverage to community athletic events as well as provide a source of continuing education programs for local coaches and administrators; (4) fees for services vary per contract, with nearly one-third of the respondents operating on a “no fee” volunteer basis; (5) nearly two-thirds of the outreach services emanate from a physical therapy department; and (6) 88% of services employ certified athletic trainers to provide outreach care. Outreach services appear as the mode of choice for providing athletic medicine in Wisconsin. Although some care is better than none, the quality and comprehensiveness of this care requires further investigation.     

Does staff-patient agreement on needs for care predict a better mental health outcome? A 4-year follow-up in a community service

BACKGROUND: Patients treated in primary care settings report better mental outcomes when they agree with practitioners about the nature of their core presenting problems. However, no study has examined the impact of staff-patient agreement on treatment outcomes in specialist mental health services. We investigated whether a better staff-patient agreement on needs for care predicts more favourable outcome in patients receiving community-based psychiatric care. METHOD: A 3-month prevalence cohort of 188 patients with the full spectrum of psychiatric conditions was assessed at baseline and at 4 years using the Camberwell Assessment of Need (CAN), both staff (CAN-S) and patient versions (CAN-P), and a set of standardized outcome measures. Baseline staff-patient agreement on needs was included among predictors of outcome. Both clinician-rated (psychopathology, social disability, global functioning) and patient-rated (subjective quality of life and satisfaction with services) outcomes were considered. RESULTS: Controlling for the effect of sociodemographics, service utilization and changes in clinical status, better staff-patient agreement makes a significant additional contribution in predicting treatment outcomes not only on patient-rated but also on clinician-rated measures. CONCLUSIONS: Mental health care should be provided on the basis of a negotiation process involving both professionals and service users to ensure effective interventions; every effort should be made by services to implement strategies aiming to increase consensus between staff and patients.