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.     

Adequacy of prenatal care among women with psychiatric diagnoses giving birth in California in 1994 and 1995

OBJECTIVE: Although poor prenatal care is detrimental to maternal and infant health, few studies have assessed the adequacy of prenatal care among women with psychiatric diagnoses. This investigation examined the association between chart-recorded psychiatric and substance use diagnoses at the time of delivery and adequacy of prenatal care among all women delivering babies in California hospitals during 1994 and 1995. METHODS: The authors undertook an archival analysis of data from the California Health Information for Policy Project (CHIPP), which consists of linked hospital discharge and birth certificate data for 1,094,178 deliveries in 1994 and 1995. The associations between International Classification of Diseases, 9th Revision, Clinical Modification psychiatric and substance abuse diagnoses and level of prenatal care were examined. Logistic regression analyses were conducted to assess the association between maternal diagnostic category and inadequate prenatal care while controlling for payment source, age, education, race, marital status, and parity (previous births). RESULTS: Women who received psychiatric and substance use diagnoses demonstrated significantly increased risk of inadequate prenatal care compared with women without those diagnoses. CONCLUSIONS: Psychiatric diagnoses were associated with an increased risk of inadequate prenatal care; the association between psychiatric and substance use diagnoses and poor prenatal care persisted even after the analysis controlled for known risk factors. Future investigations will need to elucidate the processes of prenatal care for women with psychiatric disorders so that preventive interventions can be developed.     

Screening for and detection of depression, panic disorder, and PTSD in public-sector obstetric clinics

OBJECTIVE: This study assessed rates of detection and treatment of minor and major depressive disorder, panic disorder, and posttraumatic stress disorder among pregnant women receiving prenatal care at public-sector obstetric clinics. METHODS: Interviewers systematically screened 387 women attending prenatal visits. The screening process was initiated before each woman's examination. After the visit, patients were asked whether their clinician recognized a mood or anxiety disorder. Medical records were reviewed for documentation of psychiatric illness and treatment. RESULTS: Only 26 percent of patients who screened positive for a psychiatric illness were recognized as having a mood or anxiety disorder by their health care provider. Moreover, clinicians detected disorders among only 12 percent of patients who showed evidence of suicidal ideation. Women with panic disorder or a lifetime history of domestic violence were more likely to be identified as having a psychiatric illness by a health care provider at some point before or during pregnancy. All women who screened positive for panic disorder had received or were currently receiving mental health treatment outside the prenatal visit, whereas 26 percent of women who screened positive for major or minor depression had received or were currently receiving treatment outside the prenatal visit. CONCLUSIONS: Detection rates for depressive disorders in obstetric settings are lower than those for panic disorder and lower than those reported in other primary care settings. Consequently, a large proportion of pregnant women continue to suffer silently with depression throughout their pregnancy. Given that depressive disorders among perinatal women are highly prevalent and may have profound impact on infants and children, more work is needed to enhance detection and referral.     

Mental disorders among elderly people in primary care: the Linköping study

OBJECTIVE: The aims of this study were to describe the prevalence of mental disorders among elderly patients in primary care and to compare diagnoses from psychiatric interview with diagnoses in medical records. METHOD: Patients aged 70 years and above attending a primary care centre (N = 350) were studied using a psychiatric and medical record examination. RESULTS: The prevalence of mental disorder according to the psychiatric interview was 33% (16% dementia, 17% other mental disorders). Only 49% of these had any psychiatric diagnosis in case records and 17-38% received specific treatments. The frequency of psychiatric symptoms among those with no mental disorder was between 1% and 66%. Patients with mental disorders were more often females, had more visits to a doctor, more diagnoses in medical records, and were prescribed more drugs. CONCLUSION: Mental disorders and symptoms are common among the elderly in primary care. More effort should be made to increase the recognition rate.     

Mental illness in new neurological patients

OBJECTIVE: To determine the prevalence of psychiatric disorders in new neurological inpatients and outpatients, and examine whether they are recognised, treated, or referred to psychiatric consultation. METHODS: 198 consecutive patients referred for the first time to a neurologist were studied using a two phase design. ICD-10 psychiatric diagnoses were established by means of the SCAN (Schedules for Clinical Assessment in Neuropsychiatry). RESULTS: The overall prevalence of current mental disorders was 55.1% (95% CI: 46.2 to 63.8), and 65.0% (95% CI: 56.1 to 73.0) had at least once in their life had a psychiatric disorder. The most frequent current diagnoses were somatoform disorders (33.8%, (95% CI: 25.9 to 42.7%)), followed by phobias (21.8%; 95% CI: 15.3 to 30.0), substance use disorders (13.3%; 95% CI: 8.3 to 20.6) and depression/dysthymia (14.4; 95% CI: 9.1 to 21.8). The psychiatric morbidity markedly declined with increasing age. Compared with 63.5% of the women, 46.4% of the men had a psychiatric disorder. Substance use disorders were more frequent in men than women (p=0.002). Patients with a psychiatric disorder were more frequently seen in the outpatients' clinic than those without. The neurologists detected 14%-40% of the cases, 16.9% were in treatment, and only 4.6% were referred to mental health care. CONCLUSION: Psychiatric disorders, in particular somatoform disorders, are extremely common in neurological patients, especially in young and middle aged patients, outpatients, and women. The results call for more research on mental illness' impact on care and outcome in neurological patients.     

Psychoactive substance use diagnoses among psychiatric in-patients

OBJECTIVE: To estimate the prevalence and possible under-diagnosing of substance use disorders and to consider factors that might influence diagnosing of substance use disorders. METHOD: Data collected from case records and PSE interviews of psychiatric in-patients from 12 psychiatric departments in Denmark admitted during October 1996 were compared with data from the Danish Psychiatric Register. RESULTS: A substantially lower prevalence of substance use diagnoses were found in the register (26.1%) than in the research data (50.0%). A high prevalence of co-occurrence between substance use disorders and mental disorders other than substance use disorders was found (37.3%). In the majority of cases knowledge of the substance use disorders was present in the case records, although they had not resulted in a diagnosis. CONCLUSION: The under-diagnosis of substance use disorders is due not only to concealed diagnostic signs and symptoms but also to an under-diagnosis by the psychiatrists, in spite of the fact that information on the substance use was accessible.     

The detection and treatment of posttraumatic distress and substance intoxication in the acute care inpatient setting

Each year, approximately 2.5 million Americans require inpatient admissions after sustaining traumatic physical injuries. Few investigations have assessed the routine detection and treatment of acute care inpatients with high levels of posttraumatic distress. A representative sample of 101 hospitalized patients with acute injuries was screened for posttraumatic stress disorder (PTSD) and depressive symptoms, as well as substance intoxication. Patients' medical records were reviewed for documentation of psychiatric symptoms and diagnoses and the initiation of early evaluation and treatment. High levels of PTSD and/or depressive symptoms were present in over 50% of patients. Although providers frequently noted symptomatic distress, few symptomatic patients received formal diagnoses, evaluations or treatment. Patients who had positive substance toxicology screens on admission infrequently received in-depth evaluation or treatment. A substantial number of injured trauma survivors have high levels of symptomatic distress that are inconsistently evaluated and treated in the acute care medical setting. Mental health interventions appear to be feasibly and effectively delivered from trauma centers. Therefore, ongoing investigation and policy initiatives informing the detection and treatment of patients with psychiatric disturbances in acute care could substantially enhance the quality of mental health care for injured survivors of individual and mass trauma.     

A prospective study of smoking in young women and risk of later psychiatric hospitalization

Background: It is not known whether smoking is a risk factor for mental disorders. Aims: To investigate the prospective associations between cigarette smoking in pregnant women and a range of psychiatric hospital diagnoses. Method: Using data from the Copenhagen Perinatal Cohort, we followed a cohort of 7926 young women from 1959–61 to 2007, linking data on cigarette smoking with psychiatric admission diagnoses obtained from the Danish Psychiatric Central Register. The women were interviewed by a physician in 1959–61 when data was obtained on smoking and other health related variables. With adjustment for age, social class and psychopharmacological treatment at baseline, the effects of smoking on the risk of (hierarchically ordered) major categories of mental disorders were examined. Results: Significant positive associations were observed between number of cigarettes smoked and schizophrenia spectrum disorder, substance use-related disorder, a broad category of other non-psychotic disorders, and any psychiatric registration. For affective spectrum disorders, there was a significant, but non-linear association. Conclusion: Number of cigarettes smoked in young adulthood significantly predicted a range of psychiatric admission diagnoses and, for most diagnostic categories, evidence of a dose–response relationship was observed.     

Mental disorders among internal medical inpatients: prevalence, detection, and treatment status

OBJECTIVE: To determine the prevalence of ICD-10 mental disorders among internal medical inpatients, the relation between mental disorder, age, and gender, and the recognition and referral of the disordered patients. METHOD: 294 consecutive medical inpatients were examined with a two-phase design using the SCAN (Schedules for Clinical Assessment in Neuropsychiatry) for ICD-10 psychiatric diagnoses. Information from questionnaires and interviews with patients, doctors, nurses, and from medical records. RESULTS: The prevalence of current mental disorders was 38.7%, being heavily increased in young patients. Main diagnoses were somatoform disorders (17.6%), phobias (12.9%), substance use disorders (10.9%), and depression (8.3%). Psychiatric consultations were very few. About 38-56% of the cases were recognized by medical doctors and nurses, and only about 20% were in mental health treatment. CONCLUSION: The prevalence of mental disorders among internal medical inpatients is high and increased in young patients and women. Detection and referral are low, and few are treated.     

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.     

Symptoms of posttraumatic stress disorder in a community sample of low-income pregnant women

OBJECTIVE: The purpose of this study was to examine symptoms of posttraumatic stress disorder (PTSD) in a community sample of low-income pregnant women who met the DSM-IV diagnostic criteria for the disorder. METHOD: Pregnant women (N=948) were screened for trauma, PTSD, depression, and co-occurring illicit substance use. PTSD symptoms were compared in traumatized pregnant women and a sample of nonpregnant traumatized women from the National Comorbidity Survey. RESULTS: Suicidal thoughts and a high degree of psychiatric comorbidity were common in pregnant women with PTSD. Pregnant women were selectively and significantly less likely to endorse reexperiencing symptoms of PTSD (29.5%, N=82), compared to nonpregnant women (79.4%, N=464). CONCLUSIONS: PTSD in pregnancy was associated with comorbidity, poor health behaviors, and lower recall of memory-related PTSD symptoms. Further prospective study is needed.     

The availability of psychiatric programs in private substance abuse treatment centers, 1995 to 2001

OBJECTIVE: The high rate of co-occurrence of substance abuse and mental disorders renders the availability of psychiatric programs, or integrated service delivery, a vital quality-of-care issue for substance abuse clients. This article describes the availability of psychiatric programs and integrated care for clients with severe mental illness in the private substance abuse treatment sector and examines these patterns of service delivery by profit status and hospital status. METHOD:S: Survey data from the National Treatment Center Study, which is based on a nationally representative sample of privately funded substance abuse treatment centers, were used to identify the proportion of centers that offered psychiatric programs in 1995-1996, 1997-1998, and 2000-2001. Centers reported whether they treated clients with severe mental illness on-site or referred them to external providers. Repeated-measures general linear models were used to test for significant changes over time and to assess mean differences in service availability by profit status and hospital status. RESULTS: About 59 percent of private centers offered a psychiatric program, and this proportion did not significantly change over time. The proportion of centers that referred clients with severe mental illness to external providers increased significantly from 57 percent to 67 percent. For-profit centers and hospital-based centers were significantly more likely to offer psychiatric programs and were less likely to refer severe cases to other providers. CONCLUSION:S: Although the importance of integrated care for clients with dual diagnoses is widely accepted, data from the private substance abuse treatment sector suggest that this pattern of service delivery is becoming less available.     

Toward cost-effective care for persons with dual diagnoses

Implementing services that control costs and improve client functioning for persons with both severe psychiatric and substance disorders is paramount in a managed care environment. In this clinical trial, standard mental health care augmented by the behavioral skills intervention was more effective than two other approaches (case management and modified 12-step recovery) in interventions with persons with dual diagnoses across indicators of psychosocial adjustment, psychiatric and substance abuse symptoms, and mental health service costs. These findings reinforce the need to address mental health and substance disorders concomitantly; to provide skill-building interventions as the primary ingredient of active treatment to address various instrumental, coping, and social skill deficits that clients with dual diagnoses have; and to monitor the effectiveness of the services and client progress every six months on multiple adjustment and symptomatology dimensions.     

Police-registered offenses and psychiatric disorders among young males

OBJECTIVE: To study associations between crime and psychiatric disorders among adolescent males in a representative population-based cohort study. METHOD: The sample includes 2,712 Finnish boys born in 1981. Information on criminality consists of offenses registered in the Finnish National Police Register 1998-2001. Crime was classified according to frequency and type (drug, violent, property, traffic, and drunk driving offenses). Information on psychiatric diagnoses between 1999 and 2004 was collected from the Finnish National Military Register. RESULTS: Of the 2,712 boys, 22% had a crime registration during the 4-year period, and 10% had at least one psychiatric disorder according to the Military Register. Those with psychiatric disorders accounted for 49% of all crimes. Of those with more than five crimes (n = 98), 59% had psychiatric diagnoses. After adjusting for other crime types and childhood socio-economic status, property crime was independently associated with several diagnoses: antisocial personality (APD), substance use (SUD), psychotic, anxiety, and adjustment disorders. Drug offending was independently associated with APD, SUD, and psychotic disorder, and traffic offenses with APD. CONCLUSIONS: Youth crime is predominantly associated with antisocial personality and substance use disorders. Crime prevention efforts should focus on boys showing a risk for antisocial and substance use problems. In particular, property, drug, and repeat offenders need mental health and substance use assessment. There is a need to develop integrated mental health and substance use treatment services for young offenders within or alongside the criminal justice system.     

Prevalence and risk factors of threshold and sub-threshold psychiatric disorders in primary care

OBJECTIVE: Prevalence rates of mental health problems in primary care vary according to population and the type of measure used. This study examined the prevalence of a full range of mental health problems, including sub-threshold diagnoses, and the socio-demographic risk factors for psychiatric disorders among a population with low out-of-pocket expenditures for medical care. METHOD: Four validated mental health assessment instruments, including the CIDI-SF, were administered to a sample of 976 users of primary care in Israel between the ages of 25-75 in eight clinics throughout the country. Prevalence estimates were obtained for seven psychiatric diagnoses, two "other mental health disorders" (somatization and disordered eating) and five sub-threshold conditions. RESULTS: The most common types of morbidity were depression and disordered eating (20.6% and 15.0%, respectively), followed by somatization (11.8%) and general anxiety (11.2%). Among respondents, 31.1% had at least one psychiatric diagnosis, 24.3% had 'other mental disorders' and 15.5% had sub-threshold conditions. Panic attack, disordered eating and somatization, as well as a global measure of any psychiatric diagnosis were significantly more prevalent among women than men. Psychiatric diagnoses were also more common among those in the age group 45-64, with less education and insufficient income, the never married and separated/divorced and those not working. No significant differences were found between recent immigrants, veteran immigrants and Israeli-born, between Arab and Jewish Israelis or between secular or religious sectors of the population. CONCLUSIONS: This study establishes the prevalence of the most common disorders in primary care including PTSD, somatization and disordered eating behaviors. The additional of other mental disorders suggests that a more accurate picture of mental disorders in primary care requires an expanded assessment procedure.     

Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States

BACKGROUND: There have been no previous nationally representative estimates of the prevalence of mental disorders and drug use among adults receiving care for human immunodeficiency virus (HIV) disease in the United States. It is also not known which clinical and sociodemographic factors are associated with these disorders. SUBJECTS AND METHODS: We enrolled a nationally representative probability sample of 2864 adults receiving care for HIV in the United States in 1996. Participants were administered a brief structured psychiatric instrument that screened for psychiatric disorders (major depression, dysthymia, generalized anxiety disorders, and panic attacks) and drug use during the previous 12 months. Sociodemographic and clinical factors associated with screening positive for any psychiatric disorder and drug dependence were examined in multivariate logistic regression analyses. RESULTS: Nearly half of the sample screened positive for a psychiatric disorder, nearly 40% reported using an illicit drug other than marijuana, and more than 12% screened positive for drug dependence during the previous 12 months. Factors independently associated with screening positive for a psychiatric disorder included number of HIV-related symptoms, illicit drug use, drug dependence, heavy alcohol use, and being unemployed or disabled. Factors independently associated with screening positive for drug dependence included having many HIV-related symptoms, being younger, being heterosexual, having frequent heavy alcohol use, and screening positive for a psychiatric disorder. CONCLUSIONS: Many people infected with HIV may also have psychiatric and/or drug dependence disorders. Clinicians may need to actively identify those at risk and work with policymakers to ensure the availability of appropriate care for these treatable disorders.     

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.     

Prevalence of psychiatric disorders in New Zealand prisons: a national study

OBJECTIVE: The paper describes the methodologies and results obtained on a large cohort of prison inmates in New Zealand who were screened for psychiatric disorder. METHOD: All women and remanded male inmates in New Zealand prisons, and a randomly selected cohort of 18% of sentenced male inmates were interviewed. Interviewers used the Composite International Diagnostic Interview - Automated to establish DSM-IV diagnoses, and the Personality Disorders Questionnaire to identify personality disorder. All prisons in New Zealand were visited. RESULTS: The results indicate markedly elevated prevalence rates for major mental disorder in the prison population when compared with community samples. This is especially the case for substance misuse, psychotic disorders, major depression, bipolar disorder, obsessive- compulsive disorder and posttraumatic stress disorder. Of particular concern is not only the increased prevalence rates for schizophrenia and related disorders but also the high level of comorbidity with substance misuse disorders demonstrated by this group. While 80.8% of inmates diagnosed with bipolar disorder were receiving psychiatric treatment in the prison, only 46.4% of depressed inmates and 37% of those suffering from psychosis were receiving treatment. Maori inmates were grossly overrepresented in the remand, female and male sentenced inmate population compared with the general population. CONCLUSIONS: A significant increase in provision of mental health services is required to cope with the high number of mentally ill inmates. The level of need demonstrated by this study requires a level of service provision that is quite beyond the capacity of current forensic psychiatry services, Department of Corrections Psychological Services or the prison nursing and medical officers. The elevated rates of common mental disorders argues for the use of improved psychiatric screening instruments, improved assessment and treatment capacities in the prison and an increased number of forensic psychiatric inpatient facilities to care for those psychotic inmates who are too unwell to be treated in the prison.     

Psychological distress and psychiatric morbidity in women prisoners.

The population of a women's prison (n = 92) was screened for psychological distress and psychiatric morbidity with the 12-item General Health Questionnaire, the Hamilton Depression Rating Scale, a Recent Stressful Life Events questionnaire and the Structured Clinical Interview for DSM-III-R. High levels of symptoms of psychological distress were recorded. Distress was correlated with recent stressful life events and was more severe in women awaiting trial. Fifty-three per cent of the prisoners were diagnosed as current cases of a psychiatric disorder and the most frequent diagnoses were adjustment disorder with depressed mood and personality disorders. Lifetime prevalence of psychoactive substance use disorders was 54 per cent. Aboriginal women were over-represented in this prison population. A follow-up survey after 4 months showed no fall in the prevalence of psychological distress and psychiatric morbidity.