Needs for care of chronic schizophrenic patients in long-term community treatment

Comparing Perceived Adequacy of Help Received Among Different Classes of Individuals with Severe Mental Disorders at Five-Year Follow-Up: A Longitudinal Cluster Analysis

This study developed a typology describing change in the perceived adequacy of help received among 204 individuals with severe mental disorders, 5 years after transfer to the community following a major mental health reform in Quebec (Canada). Participant typologies were constructed using a two-step cluster analysis. There were significant differences between T0 and T2 for perceived adequacy of help received and other independent variables, including seriousness of needs, help from services or relatives, and care continuity. Five classes emerged from the analysis. Perceived adequacy of help received at T2 increased for Class 1, mainly comprised of older women with mood disorders. Overall, greater care continuity and levels of help from services and relatives related to higher perceived AHR. Changes in perceived adequacy of help received resulting from several combinations of associated variables indicate that MH service delivery should respond to specific profiles and determinants.

Assessment of Needs: Differences between male and female patients with schizophrenia needs in psychiatric hospitals in Baghdad city

BACKGROUND

Gender differences are one of the most important and crucial subjects in evaluating the nursing care as well as mental health care system for psychiatric patients especially patients with schizophrenia.

AIMS

We aimed to identify differences in needs of male and female patients with schizophrenia in psychiatric hospitals in Baghdad city and its relationship with some variables.

METHOD

A descriptive, analytical design that was carried out by using Camberwell needs assessment, short appraisal schedule, self-report version (CANSAS-P) after translating to Arabic.

RESULTS

Results indicated that there were a lot of unmet needs of male and female patients with schizophrenia, according to the entire CANSAS-P domains especially psychological symptoms. Differences were found in types of needs as the majority of men have more social needs while females was found to be more occupied with their fears and need safety.

CONCLUSION

there were differences in types of need between male and female patients with schizophrenia; needs were affected by some variables such as educational level, first 10 days of admission and family visiting.

Fewer re-admissions and bed days following an intensive transitional post-discharge aftercare programme for a mixed diagnostic group of patients

BACKGROUND

The organization of aftercare is important for a successful outcome; still the optimal organization has not been fully explored. An intensive transitional post-discharge aftercare (TA) programme, for a mixed group of non-psychotic patients, was recently developed. Patients with non-psychotic diagnoses are often discharged with low well-being while still symptomatic, placing high demands on aftercare.

AIMS

To evaluate retrospectively the short and long-term mental healthcare service use during and after the TA programme compared with the service use of a retrospective comparison group (RC), receiving less intensive outpatient aftercare.

METHODS

Number of re-admissions, bed days and emergency visits after 10 weeks, 6 months and 1 year was retrospectively collected from electronic patient registers. Descriptive statistics, independent samples T-tests and repeated-measures analysis of variance was used to compare the groups.

RESULTS

The majority of patients in both groups suffered from affective disorders, followed by personality disorders and a small number of other psychiatric diagnoses. Service use in the TA group was lower than in the RC group with fewer bed days after 10 weeks (P = 0.01) and after 6 months (P = 0.003), and fewer re-admissions after 6-12 months (P = 0.04). Emergency contacts did not differ significantly between the two groups at any point.

CONCLUSIONS

The present study indicates beneficial effects of intensive TA, for a mixed group of non-psychotic patients. The lower service use in the TA programme group is in line with day treatment programme research for patients with affective disorders.

Unmet needs in the management of schizophrenia

Studies on unmet needs during the last decades have played a significant role in the development and dissemination of evidence-based community practices for persistent schizophrenia and other severe mental disorders. This review has thoroughly considered several blocks of unmet needs, which are frequently related to schizophrenic disorders. Those related to health have been the first block to be considered, in which authors have examined the frequent complications and comorbidities found in schizophrenia, such as substance abuse and dual diagnosis. A second block has been devoted to psychosocial and economic needs, especially within the field of recovery of the persistently mentally ill. Within this block, the effects of the current economic difficulties shown in recent literature have been considered as well. Because no patient is static, a third block has reviewed evolving needs according to the clinical staging model. The fourth block has been dedicated to integrated evidence-based interventions to improve the quality of life of persons with schizophrenia. Consideration of community care for those reluctant to maintain contact with mental health services has constituted the fifth block. Finally, authors have aggregated their own reflections regarding future trends. The number of psychosocial unmet needs is extensive. Vast research efforts will be needed to find appropriate ways to meet them, particularly regarding so-called existential needs, but many needs could be met only by applying existing evidence-based interventions. Reinforcing research on the implementation strategies and capacity building of professionals working in community settings might address this problem. The final aim should be based on the collaborative model of care, which rests on the performance of a case manager responsible for monitoring patient progress, providing assertive follow-up, teaching self-help strategies, and facilitating communication among the patient, family doctor, mental health specialist, and other specialists.

Relapsing versus non relapsing course of schizophrenia: a cohort study in a community based mental health service

Aim - We examined the effect of several clinical variables on the tendency to relapse and to require hospitalization in a cohort of patients, living in the community and followed up naturalistically for seven years. Method - Forty-six patients affected by schizophrenia and schizoaffective disorder, according to both DSM-IV and ICD-10 criteria, were assessed by Positive and Negative Syndrome Scale and Life Skills Profile (LSP). All patients consecutively enrolled, were assessed in a stable clinical phase of illness and treated as usual by their reference psychiatrist. Social and clinical outcome was assessed yearly for seven years after the study entry and analyzed with survival analysis. Results - Patients who did not relapse, were characterized by higher functioning, lower positive symptoms, higher ability in self-care and non-turbulence and higher IQ at their baseline clinical evaluation. These variables were entered in a Cox regression model to corroborate the predictive power on the relapsing course of illness. Only IQ and non-turbulence scores of LSP were entered in the equation (Wald method: p=0.007 and p=0.002 respectively). Conclusions - Several factors interact with the course of illness and influence the tendency to require hospitalization. In the present study we report that non-turbulence is a significant predictor of a non-relapsing course of illness. Further studies are needed to clarify the role of other mediating variables.

Declaration of Interest: none.

Mixed anxiety and depressive disorder before and after psychodynamic group psychotherapy: a 1-year follow-up study

Abstract Objective. The aim of our study was to observe the outcome of MADD in comparison with depressive (DD) and anxiety (AD) disorders. Method. Patients treated with 12 weeks of group psychodynamic psychotherapy in a psychiatric day care ward were examined using SCAN 2.1 at admission and 1 year after admission. Treatment was indicated on the basis of diagnosis of ICD-10 - F4-F6. A total of 139 patients were included, 110 (79.1%) of whom were examined at the follow-up point. Results. The prevalence of MADD increased from 22.7% at the baseline to 33.6% at the end. The outcome of MADD was statistically different from the outcome of DD (χ(2)=18.4, P=0.0025), but not different from the outcome of comorbid DD and AD (χ(2)=1.8, P=0.84), nor generalized anxiety disorder (χ(2)=8.1, P=0.15), nor other AD (χ(2)=5.3, P=0.38). Conclusion. MADD is a useful diagnosis of a transitional or residual form of comorbid DD and AD in some specific population groups. A diagnosis of personality disorder can sustain long-term diagnosis of MADD.

Prevention of rehospitalization in schizophrenia: results of an integrated care project in Germany

The goal of this study was to prevent rehospitalizations and thus to optimize satisfaction with treatment and quality of life in patients suffering by schizophrenia or schizoaffective disorder. A complex intervention with improved cooperation between in- and outpatient services was applied to 46 "high utilizing" patients after discharge from inpatient care during an intervention phase of 6 months. The study was controlled by a matched group of 47 patients receiving treatment as usual. The intervention was based on a computerized decision support module. Eight psychiatrists in private practices were supplied with this software to obtain guideline-based recommendations according to current psychopathology and clinical state. Suggested complex interventions by the software included psychoeducation, social competence group therapy, integrated psychological therapy, computer-based cognitive training, coping skills training, sociotherapy, nursing care, home visits, social-worker care, assistance to family members, and the use of an emergency call-in line. A local hospital project team arranged specifically suggested interventions. We intended to accomplish a reduction of rehospitalization rates by 50% in the intervention group within a 12-month follow-up phase. Satisfaction with treatment, subjective quality of life, and treatment costs in terms of daily inpatient costs were compared between both groups. Moderator variables such as socio-demographical aspects or influences of certain interventions to rehospitalization rate were analyzed. The sample included patients more seriously ill than originally expected. Subjects in the control group (CG) were older (46 years) than those subjects in the intervention group (IG) (40 years). Other sociodemographical aspects (sex, family status, level of education, and number of former hospitalizations) showed no differences between both groups. The rehospitalization rate and the mean length of inpatient treatment were reduced to nearly 50% in the intervention group. The rate of readmissions increased in the control group, leading to a difference of 23% between both groups. The most important factor to favorably influence rehospitalization rates was the participation in coping skills training. There was an increase in patient satisfaction with treatment, while the subjective quality of life remained constant. Since these improvements were accomplished with lower costs (in terms of inpatient care), cost effectiveness was higher in the IG than in the CG. The most important single factor to favorably influence rehospitalization rates was the participation in coping skills training. Only the guideline consistent complex therapies as common intervention caused the significant overall result. Thereby, satisfaction with treatment increased considerably during the 6 months of intervention and remained constant during 12 months of follow up. The model project described is an important step to gain evidence and experience with integrated care for patients with schizophrenia.

Assessing the opinions of relatives on the causes and social consequences of different mental disorders: are instruments cross-culturally valid?

Obtaining valid information about the opinions of relatives on the causes and social consequences of mental disorders should be an important component in specifically tailoring therapeutic interventions for relatives according to their needs. The available range of instruments is small, however, the most prominent being the Italian Questionnaire on the Opinions of the Family (QOF), developed specifically for schizophrenic disorders. The German validation study of this instrument sought to determine whether the subscale structure of the QOF can be replicated in a group of relatives (N=161) of patients with schizophrenic disorders as well as recurrent depressive and bipolar disorders. Results demonstrate that the original QOF subscales cannot be transferred to groups of relatives of patients with affective disorders, nor to a German group of relatives of patients with only schizophrenic disorders. Therefore, a German version of the QOF was created. Using this modified version of the instrument, researchers established a three-factor solution differentiating the opinions of relatives on chronic mental disorders into three components, reflecting orientation towards pathology, towards normality and towards optimising resources for treatment. None of these factors showed significant relationships with the relatives' causal attributions about mental disorders. Further research is needed to establish cross-nationally valid versions of such instruments.

Predictors of changes in needs for care in patients receiving community psychiatric treatment: a 4-year follow-up study

OBJECTIVE

This study aimed to investigate changes and predictors of change in needs for care, as assessed by both patients and mental health professionals, in a sample of subjects receiving community-based psychiatric care.

METHOD

The study was conducted using a 4-year prospective longitudinal design. A cohort of patients from the South-Verona Community Mental Health Service (CMHS) was assessed at baseline and follow-up using the Camberwell Assessment of Need, both staff and patient versions. Predictors of changes in needs were explored using block-stratified multiple regression analyses.

RESULTS

An overall stability for both patient-rated and staff-rated needs was found over time; however, significant changes in some specific need domains were found, such as self-rated health needs (improvement), self-rated social needs (deterioration) and staff-rated health needs (deterioration). Changes over time in self-rated and staff-rated needs are influenced by different and specific set of predictors, thus indicating that the two measures are not overlapping and convey different types of information.

CONCLUSION

Our data support the adoption of a negotiated approach in which both staff and users' views should be given equal weight when planning and providing needs-led mental health care.

Symptom dimensions and needs of care among patients with schizophrenia in hospital and the community

The purpose of the present paper was to examine the psychiatric symptom dimensions related to needs of care among patients with schizophrenia in hospital and in the community. Subjects were 217 patients with F2 ICD-10 diagnoses. Hospital patients included 102 inpatients (47.0%) in psychiatric long-term care units. Community patients included 115 outpatients (53.0%) living in their homes or residential facilities. Psychiatrists used the Brief Psychiatric Rating Scale (BPRS) to assess patients' psychiatric symptoms. Formal care providers assessed needs of care using a scale developed by the Committee on Case Management Guidelines for People with Mental Disabilities in Japan. Instrumental Activities of Daily Living (IADL) self-performance and difficulty were also measured using a scale from the Minimum Data Set-Home Care (MDS-HC). Multiple regression analyses were applied, using the symptom dimensions as dependent variables and needs of care as independent variables. Patient group (hospital or community) was also used as an independent variable. Hospital patients demonstrated more severe psychiatric symptoms and greater needs of care than community patients. Multiple regression analyses showed that the total needs of care were greater among male patients (B = 0.142, P = 0.005), hospital patients (B = 0.310, P < 0.001), patients with poor IADL self-performance (B = 0.217, P = 0.047), and patients with severe negative symptoms (B = 0.240, P = 0.002; R(2) = 0.515). The present results suggested an association between negative symptoms and needs of care in schizophrenia. Hospital patients had greater needs of care, even though their psychiatric symptoms were controlled for. Further research should examine the relationships between psychiatric symptoms and needs of care in a cohort study following patients when hospitalized and when living in the community.

Increasing trends of tobacco use in medical students in Slovakia--a reason for concern?

OBJECTIVE

The article analyses changes in tobacco use in medical students in Slovakia in 1995, 1999 and 2004.

METHODS

Questionnaire survey in 448 students of the Jessenius Faculty of Medicine, Comenius University in Martin, Slovakia, was carried out in October and November 2004. Data were compared with similar surveys carried out in 1995 and 1999.

RESULTS

Prevalence of daily smoking in men increased from 11.1 in 1995 to 21.8% in 2004. In women, within 1995-2004, daily smoking increased from 5.2% to 12.3%, occasional smoking from 11.6% to 19.8%. Also proportion of women initiating smoking during their university study increased. In both genders the proportion of never smokers dramatically dropped between 1995 and 1999 (in men from 43.2% to 23.2%; in women from 61.9 to 18.2).

CONCLUSION

Upward trend in tobacco use, particularly in women, is a reason for concern. In medical faculties, principles of prevention should be more emphasized and the students motivated for healthy life-style and to fulfill their future role in public health. The situation noted among medical students indicates that a community in Slovakia is still not satisfactory inclined towards non-smoking and a dramatic decrease of tobacco use can hardly be expected either in the near future.

Mental health care in Germany: current state and trends

Germany turned towards community-based mental health care in the mid seventies, during a general climate of social and political reform. The continuing deinstitutionalisation process and the implementation of community mental health services was considerably affected by the reunification of East and West Germany in 1990, which required dramatic changes in the structure and quality of the mental health care system of the former German Democratic Republic (GDR). Overall, German mental health care is organised as a subsidiary system, where planning and regulating mental health care is the responsibility of the 16 federal states. So German mental health care provision is spread among many sectors and characterised by considerable regional differences. A key characteristic is the particularly wide gap between inpatient and outpatient services, which are funded separately and staffed by different teams. In 2003 the total number of psychiatric beds was a mere two thirds of the overall bed capacity in 1991, the first year as a re-unified Germany, when psychiatric beds in East and West Germany totalled 80,275. From 1970 onwards the number of psychiatric beds was cut by roughly half. So the momentum of the reform has been strong enough to assimilate the completely different mental health care system of the former German Democratic Republic and, in the course of a decade, to re-structure mental health services for an additional 17-18 million new inhabitants. In an ongoing struggle to adapt to changing administrative set-ups, legal frameworks, and financial constraints, psychiatry in Germany in currently facing specific problems and is seriously challenged to defend to considerable achievements of the past. A major obstacle to achieving this aim lies in the fragmented system of mental health care provision and mental health care funding.

A Population-based Needs Assessment for Mental Health Services

A needs assessment was done to objectively evaluate client need and determine gaps between these needs and the services provided by mental health services. The services included were standard case management, assertive case management and residential care across the Fraser Health Region in British Columbia, Canada. Assessments involved collection of data on current symptoms, functioning, and service use and needs. Results showed many specific areas where client needs were under met. A level-of-care planning model was applied to the data and results suggest that a high percentage of clients may be in fact receiving too high or too low a level of care for their needs. This method of performing a population-based needs assessment provided findings that have proved useful for planning purposes in order to ensure that community mental health services better match client need.

Distress and functioning in mixed anxiety and depressive disorder

The aim of the present study was to evaluate the validity of mixed anxiety and depressive disorder (MADD) with reference to functional characteristics and symptomatic characteristics in comparison with anxiety disorders, depressive disorders, and groups showing subthreshold symptoms (exclusively depressive or anxiety related). The present study was carried out in the following three medical settings: two psychiatric and one primary care. Patients seeking care in psychiatric institutions due to anxiety and depressive symptoms and attending primary medical settings for any reason were taken into account. A total of 104 patients (65 women and 39 men, mean age 41.1 years) were given a General Health Questionnaire (GHQ-30), Global Assessment of Functioning (GAF) and Present State Examination questionnaire, a part of Schedules for Clinical Assessment in Neuropsychiatry, Version 2.0. There were no statistically relevant differences between MADD and anxiety disorders in median GHQ score (19 vs 16) and median GAF score (median 68.5 vs 65). When considering depressive disorders the median GHQ score (28) was higher, and median GAF score (59) was lower than that in MADD. In groups with separated subthreshold anxiety or depressive symptoms, median GHQ scores (12) were lower and median GAF scores (75) were higher than that in MADD. The most frequent symptoms of MADD are symptoms of generalized anxiety disorder (GAD) and depression. Mixed anxiety and depressive disorder differs significantly from GAD only in higher rates of depressed mood and lower rates of somatic anxiety symptoms. Distinction from depression was clearer; six of 10 depressive symptoms are more minor in severity in MADD than in the case of depression. Distress and interference with personal functions in MADD are similar to that of other anxiety disorders. A pattern of MADD symptoms locates this disorder between depression and GAD.

The "carers' needs assessment for Schizophrenia": an instrument to assess the needs of relatives caring for schizophrenia patients

OBJECTIVE

For the purpose of service planning, an instrument was developed for the systematic assessment of interventions needed by the caregivers of schizophrenia patients.

METHOD

The development of this instrument was based on in-depth interviews and focus groups. It consists of 18 areas describing common problems of schizophrenia caregivers. For each of these problem areas several possible interventions are offered. Concurrent validity, inter-rater and retest reliability were tested among 50 caregivers.

RESULTS

The kappa values for the inter-rater reliability are predominantly excellent (kappa > 0.75). The values for the retest reliability show a wide range between excellent (kappa > 0.75) and fair agreement (kappa 0.40-0.60). The significant correlations found between summary scores of this new instrument and several sub-scales of the Family Problem Questionnaire support the assumption that the concurrent validity is satisfactory.

CONCLUSION

These results suggest that this instrument is both valid and reliable.