“You don't need a prescription to go gluten-free”: The scientific self-diagnosis of celiac disease

Do Serological Tests Eliminate the Need for Endoscopic Biopsy for the Diagnosis of Symptomatic Patients with Celiac Disease? A Retrospective Study with Review of Literature

Background: Celiac disease is one of the most common genetic allergies worldwide. The prevalence of celiac disease in Iran is similar to or even higher than the global prevalence. Celiac disease is a chronic inflammatory disease that affects the small intestine. Affected patients are allergic to gluten protein that exists in some grains, such as wheat and barley. Methods: Serological endomysial IgA antibody (EMA-AB) and tissue transglutaminase IgA antibody (TTG-IgA) tests were performed on 114 patients aged the ages of 0-18 years with histopathological findings of celiac disease. The results of these tests were compared to the results of the histopathological study of the duodenal biopsy. Results: Based on the receiver operating characteristic (ROC) curve and a calculation of the TTG-IgA test's sensitivity and specificity, the best diagnostic limit for the TTG-IgA test is 144, which has the best sensitivity and specificity. At this value (cut-off), the test's sensitivity was 62%, and the specificity was 93.7%. For the endomysial test, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 80%, 93%, 90%, and 75%, respectively. Conclusion: The diagnostic accuracy of the endomysial test is better than that of the TTG-IgA test in general for diagnosing patients with celiac disease. In the TTG-IgA test, false-positive cases are high due to a cut-off of 20, reducing the test's specificity. In these false-positive cases, the endomysial test helps in better diagnosis.

Optimization of tannin-containing sorghum bran addition to gluten-free bread

Ingredients used to enhance sensory quality of gluten-free (GF) bread often lack in nutrients. This presents nutritional challenges for celiac-positive individuals and fails to meet expectations of healthfulness for non-celiac GF consumers. Sorghum (Sorghum bicolor L. Moench) flour can provide acceptable GF bread properties, and tannin-containing varieties contain antioxidants concentrated in the bran along with dietary fiber. Using a central composite design, tannin-containing sumac sorghum bran, gum (xanthan + guar), and water levels were optimized in a GF sorghum-based bread formulation. Loaf specific volume and gas cells/cm² were maximized while minimizing hardness and cell wall thickness. The optimum formulation containing 14.2% sorghum bran, 1% gum, and 145% water (flour basis) effectively increased dietary fiber in bread to 13.4% (considered "high fiber") and showed oxygen radical absorbance capacity of 61.6 µmol TE/g. This optimum formulation did not differ from a sorghum flour-based control bread in consumers' (N = 100) liking of color, texture, flavor, overall acceptability, nor willingness to buy (WTB). All mean hedonic scores (numbered 9-point scale) were above 5, whereas average WTB was 4.7 for the optimum formulation and 4.6 for the control (9-point Likert scale) among consumers varying in GF bread consumption habits. Perceived bread bitterness was low (averaging 2.85 on 9-point intensity scale), did not vary between samples despite marked differences in antioxidant capacity, and was not correlated with WTB. When utilizing effective optimization models with key functional ingredients, sumac sorghum bran addition can enhance dietary fiber and antioxidant potential in sorghum-based GF breads without compromising quality attributes.

The gluten-free diet challenge in adults with coeliac disease: the Hellenic survey

Objective

The only available treatment for coeliac disease (CD) is a lifelong strict gluten-free diet (GFD), which can be extremely challenging. Τhe aim of the present study was to gain an insight into patients' perceptions regarding the GFD, in relation to difficulties experienced, disease-specific symptoms, adherence level, and information sources used.

Methods

Two hundred ninety CD patients (247 women and 43 men) aged 18-74 years, completed a self-administered questionnaire.

Results

Self-rated dietary adherence was high in 65.5%, moderate in 27.5% and poor in 6.9% of the patients. The main difficulties encountered were the high cost and limited availability of GF foods and meals in markets and restaurants. The main source of information concerning CD and GFD was the internet, and the most useful source was the Coeliac Society. Dietary adherence correlated positively with Coeliac Society membership and awareness of the monthly CD allowance.

Conclusion

Α substantial proportion of patients did not adhere to a strict GFD. Patients were not adequately followed-up.

Innovation

A self-administered questionnaire was used to explore the practical challenges of a GFD in an understudied population, Greek adult coeliac patients. The results highlighted the need for dietitians with expertise on CD.

"I sort of never felt like I should be worried about it or that I could be worried about it'" an interpretative phenomenological analysis of perceived barriers to disclosure by young people with coeliac disease

OBJECTIVES

There has been little research in the United Kingdom regarding young people's experiences of disclosure of psychological difficulties relating to coeliac disease (CD) to others, particularly healthcare professionals. This study sought to address this systematically with a focus on the lived experiences of young people with CD. This study aimed to gain insight into how paediatric gastroenterology services could improve the patient experience for those with CD and support the identification of patients who may benefit from further psychological support.

DESIGN

This study used interpretive phenomenological analysis (IPA) of patient accounts.

METHODS

Seven young people with CD (aged 11-16 years) were recruited from a UK hospital paediatric gastroenterology service. Semi-structured interviews were carried out and verbatim transcripts were analysed using IPA to explore young people's experiences of CD and why they might feel able or unable to disclose psychological difficulties associated with their condition to clinicians.

RESULTS

Three superordinate themes were interpreted from the data. The first encapsulated experiences of adjusting to the diagnosis within a developmental context, including the role of adults in information provision and the importance of peer support. The second outlined experiences of managing perceived or actual stigma regarding others' perceptions of the condition and themselves. The third incorporated perceived barriers to disclosure relating to power, safety, and beliefs about the role of medical professionals.

CONCLUSIONS

Findings highlight the importance of clinicians continually providing developmentally appropriate information to young people and actively breaking down barriers to disclosure through body language and the use of clear questions regarding emotional experiences.

Quality and Content of Online Patient Resources for Celiac Disease

BACKGROUND AND AIMS

Patient-directed information on celiac disease has been reported to be of variable quality. We assessed the quantity and quality of information on blogs and Web sites intended to inform the layperson of celiac disease information.

METHODS

We performed a cross-sectional study analyzing celiac disease blogs and Web sites intended for the layperson. We searched from 20 cities, resulting in 55 Web sites. These sites were analyzed for 38 criteria that considered relevant clinical information for people with celiac disease. Claims were classified as true, false, or not proven. The readability level of each Web site was determined.

RESULTS

The 55 Web sites were categorized as national organizations, personal blogs, recipe-based blogs, or commercial/marketing Web sites. Only 40% of Web sites contained more than 50% of criteria. Of 212 claims assessed, 97% were found to be accurate. National organizations included the most criteria, followed by recipe-based blogs, then personal blogs, and lastly commercial/marketing Web sites. Additionally, national organizations had the highest proportion of accurate claims, followed by personal blogs, then commercial/marketing Web sites, and recipe-based blogs with the most inaccurate information. The average readability level of overall was 9.7, above the recommended readability level for patient education materials.

CONCLUSIONS

A significant number of online claims regarding celiac disease were true, but the majority of patient-facing Web sites are missing large amounts of relevant information. This warrants efforts to improve the quality of medical information published online.

Understanding the Role of the Diagnostic 'Reflex' in the Elimination of Human African Trypanosomiasis

To successfully eliminate human African trypanosomiasis (HAT), healthcare workers (HCWs) must maintain their diagnostic acuity to identify cases as the disease becomes rarer. HAT experts refer to this concept as a ‘reflex’ which incorporates the idea that diagnostic expertise, particularly skills involved in recognising which patients should be tested, comes from embodied knowledge, accrued through practice. We investigated diagnostic pathways in the detection of 32 symptomatic HAT patients in South Sudan and found that this ‘reflex’ was not confined to HCWs. Indeed, lay people suggested patients test for HAT in more than half of cases using similar practices to HCWs, highlighting the importance of the expertise present in disease-affected communities. Three typologies of diagnostic practice characterised patients’ detection: ‘syndromic suspicion’, which closely resembled the idea of an expert diagnostic reflex, as well as ‘pragmatic testing’ and ‘serendipitous detection’, which depended on diagnostic expertise embedded in hospital and lay social structures when HAT-specific suspicion was ambivalent or even absent. As we approach elimination, health systems should embrace both expert and non-expert forms of diagnostic practice that can lead to detection. Supporting multidimensional access to HAT tests will be vital for HCWs and lay people to practice diagnosis and develop their expertise.

Incidence of Celiac Disease Is Increasing Over Time: A Systematic Review and Meta-analysis

OBJECTIVES

To conduct a systematic review and meta-analysis that defines the worldwide incidence of celiac disease (CD) and examines temporal trends.

METHODS

MEDLINE and EMBASE were searched for population-based studies reporting the incidence of CD in the overall population, children, or adults. No limits were placed on year or language of publication. Studies solely examining at-risk populations (e.g., patients with type 1 diabetes) were excluded. Random-effects models were performed to meta-analyze sex- and age-specific incidence in the 21st century. Temporal trend analyses assessed the average annual percent change in CD incidence over time.

RESULTS

Of 11,189 citations, 86 eligible studies were identified for inclusion, of which 50 were deemed suitable for analyses. In the 21st century, the pooled female incidence of CD was 17.4 (95% confidence interval [CI]: 13.7, 21.1) (I = 99.5%) per 100,000 person-years, compared with 7.8 (95% CI: 6.3, 9.2) (I = 98.6%) in males. Child-specific incidence was 21.3 per 100,000 person-years (95% CI: 15.9, 26.7) (I = 99.7%) compared with 12.9 (95% CI: 7.6, 18.2) (I = 99.9%) in adults. Pooling average annual percent changes showed the incidence of CD to be increasing by 7.5% (95% CI: 5.8, 9.3) (I = 79.6%) per year over the past several decades.

DISCUSSION

Incidence of CD is highest in females and children. Overall, the incidence has been significantly rising in the latter half of the 20th century and into the 21st century throughout the Western world. Population-based studies in Africa, Asia, and Latin America are needed to provide a comprehensive picture of the global incidence of CD.

Using autoimmune strategically: Diagnostic lumping, splitting, and the experience of illness

Experience of illness and sociology of diagnosis literatures offer valuable insights into how people live with chronic illness. In this article, we argue that investigating autoimmune illnesses contributes to the sociological understanding of illness experiences and diagnosis practices. Autoimmune is a broad category of illnesses in which a person's immune system identifies healthy cells as pathological. Drawing on 45 in-depth interviews with people who live with autoimmune illnesses, this article shows how both broad diagnostic classifications (lumping) and narrow diagnostic classifications (splitting) are integral to diagnostic work and illness experiences. Combining the illness experience and sociology of diagnosis literatures, we theorize diagnosis as an iterative process in which people strategically use broad illness categories such as autoimmune in combination with specific illness categories such as multiple sclerosis a way to negotiate heterogeneity and uncertainty and to make sense of what is happening in their bodies. In this article, we argue that in an era of specialization, broad diagnostic categories can help both patients and clinicians navigate the experience of illness.

A Review on the Gluten-Free Diet: Technological and Nutritional Challenges

Consumers, food manufacturers and health professionals are uniquely influenced by the growing popularity of the gluten-free diet. Consumer expectations have urged the food industry to continuously adjust and improve the formulations and processing techniques used in gluten-free product manufacturing. Health experts have been interested in the nutritional adequacy of the diet, as well as its effectiveness in managing gluten-related disorders and other conditions. In this review, we aim to provide a clear picture of the current motivations behind the use of gluten-free diets, as well as the technological and nutritional challenges of the diet as a whole. Alternative starches and flours, hydrocolloids, and fiber sources were found to play a complex role in mimicking the functional and sensory effects of gluten in gluten-free products. However, the quality of gluten-free alternatives is often still inferior to the gluten-containing products. Furthermore, the gluten-free diet has demonstrated benefits in managing some gluten-related disorders, though nutritional imbalances have been reported. As there is limited evidence supporting the use of the gluten-free diet beyond its role in managing gluten-related disorders, consumers are urged to be mindful of the sensorial limitations and nutritional inadequacies of the diet despite ongoing strategies to improve them.

How patients navigate the diagnostic ecosystem in a fragmented health system: a qualitative study from India

Background: Depending on a country’s diagnostic infrastructure, patients and providers play different roles in ensuring that correct and timely diagnosis is made. However, little is known about the work done by patients in accessing diagnostic services and completing the ‘test and treat’ loop.

Objective: To address this knowledge gap, we traced the diagnostic journeys of patients with tuberculosis, diabetes, hypertension and typhoid, and examined the work they had to do to arrive at a diagnosis.

Methods: This paper draws on a qualitative study, which included 78 semi-structured interviews and 13 focus group discussions with patients, public and private healthcare providers, community health workers, test manufacturers, laboratory technicians, program managers and policymakers. Data were collected between January and June 2013 in rural and urban Karnataka, South India, as part of a larger project on barriers to point-of-care testing. We reconstructed patient diagnostic processes retrospectively and analyzed emerging themes and patterns.

Results: The journey to access diagnostic services requires a high level of involvement and immense work from patients and/or their caretakers. This process entails overcoming cost and distance, negotiating social relations, continuously making sense of their illness and diagnosis, producing and transporting samples, dealing with the social consequences of diagnosis, and returning results to the treating provider. The quality and content of interactions with providers were crucial for completion of test and treat loops. If the tasks became overwhelming, patients opted out, delayed being tested, switched providers and/or reverted to self-testing or self-treatment practices.

Conclusion: Our study demonstrated how difficult it can be for patients to complete diagnostic journeys and how the health system works as far as diagnostics are concerned. If new point-of-care tests are to be implemented successfully, policymakers, program officers and test developers need to find ways to ease patient navigation through diagnostic services.

Prior Misdiagnosis of Celiac Disease Is Common Among Patients Referred to a Tertiary Care Center: A Prospective Cohort Study

OBJECTIVES

Interest of patients and physicians in celiac disease is growing worldwide, but without a corresponding increase in the awareness of the disease. Many patients are diagnosed as celiacs even without completing the whole diagnostic process, with consequent risk of misdiagnosis and delay in the evaluation of other diseases. The objective of this study was to assess the rates of prior celiac disease misdiagnosis among patients referred to a tertiary care center.

METHODS

From June 2013 to December 2014, we prospectively recruited patients referred for the first time to our Celiac Disease Center. Patients with a previous diagnosis of celiac disease underwent a diagnostic revaluation by second reading of duodenal tissue slides, dosage of specific antibodies, and/or duodenal biopsy sampling; HLA status was investigated in pertinent cases.

RESULTS

A total of 198 subjects were recruited. Of these, 91 "naïve" patients (46%) started the diagnostic screening for celiac disease; 58 of them (64-29% of the whole sample) were diagnosed as celiacs. The remaining 107 patients (54%) came with a previous diagnosis of celiac disease: of these, 52 (49-26% of the whole sample) presented with confirmed diagnosis of celiac disease, whereas 55 (51-28% of the whole sample) underwent diagnostic revaluation. After the reassessment, diagnosis was rejected in 43 cases (78-22% of the whole sample) and confirmed in the remaining 12 (22-6% of the whole sample). Overall, diagnosis was confirmed in only 64 of the 107 subjects with a previous diagnosis (60-32% of the whole sample). Diagnosis of celiac disease was more frequently confirmed in "naïve" patients compared those with a questionable previous diagnosis (64% vs. 22%; P<0.0001).

CONCLUSIONS

A considerable number of patients referred to a tertiary care center are inaccurately diagnosed with celiac disease. Although we cannot exclude that uncertain diagnosis was a reason for the referral, we suggest greater adherence to guidelines to minimize the burden of celiac disease misdiagnosis.

"But we're not hypochondriacs": the changing shape of gluten-free dieting and the contested illness experience

"Gluten free" exploded onto the American foodscape in recent years: as of January 2013, 30 percent of U.S. adults reported reducing or eliminating gluten in their diets. How do individuals participate in the expansion of gluten-free dieting, and what are the implications of that expansion? This article is based on 31 in-depth, semi-structured interviews conducted between May and October 2012 with gluten-free and -restricted persons. I identify three interrelated factors contributing to the expansion of gluten-free dieting among non-celiacs. Participants broaden the lay understanding of gluten-related disorders, undermine biomedical authority, and diagnose others. Such participant-driven change, termed self-ascriptive looping, is one factor in the diet's rapid popularization. I show how participants question the doctor-patient relationship and increase social contestability for other dieters. My findings challenge previous work on contested illness and suggest food intolerances may require a reconceptualization of contested illness experience.

If you can't eat what you like, like what you can: how children with coeliac disease and their families construct dietary restrictions as a matter of choice

Although it is recognised that a gluten-free diet has many social implications for coeliac disease patients, not much is known about how such patients actually manage these implications in their everyday interactions. This article examines how dietary restrictions are treated by patients and their families. Data from recorded mealtime conversations of seven Dutch families with children suffering from coeliac disease were analysed using discursive psychology. We found two main discursive strategies by which patients and their families manage the diet during mealtime interactions. A reference to pleasure is used to manage the tension between the child's agency and parental responsibility in the face of health requirements and, by softening the denial of food, the diet is normalised and treated as a shared family practice. The analysis shows that the gluten-free diet is demedicalised and treated as a matter of choice rather than prescription. We conclude with the practical implications of these findings.

Can consumers trust web-based information about celiac disease? Accuracy, comprehensiveness, transparency, and readability of information on the internet

Background

Celiac disease is an autoimmune disease that affects approximately 1% of the US population. Disease is characterized by damage to the small intestinal lining and malabsorption of nutrients. Celiac disease is activated in genetically susceptible individuals by dietary exposure to gluten in wheat and gluten-like proteins in rye and barley. Symptoms are diverse and include gastrointestinal and extraintestinal manifestations. Treatment requires strict adherence to a gluten-free diet. The Internet is a major source of health information about celiac disease. Nonetheless, information about celiac disease that is available on various websites often is questioned by patients and other health care professionals regarding its reliability and content.

Objectives

To determine the accuracy, comprehensiveness, transparency, and readability of information on 100 of the most widely accessed websites that provide information on celiac disease.

Methods

Using the search term celiac disease, we analyzed 100 of the top English-language websites published by academic, commercial, nonprofit, and other professional (nonacademic) sources for accuracy, comprehensiveness, transparency, and reading grade level. Each site was assessed independently by 3 reviewers. Website accuracy and comprehensiveness were probed independently using a set of objective core information about celiac disease. We used 19 general criteria to assess website transparency. Website readability was determined by the Flesch-Kincaid reading grade level. Results for each parameter were analyzed independently. In addition, we weighted and combined parameters to generate an overall score, termed website quality.

Results

We included 98 websites in the final analysis. Of these, 47 (48%) provided specific information about celiac disease that was less than 95% accurate (ie, the predetermined cut-off considered a minimum acceptable level of accuracy). Independent of whether the information posted was accurate, 51 of 98 (52%) websites contained less than 50% of the core celiac disease information that was considered important for inclusion on websites that provide general information about celiac disease. Academic websites were significantly less transparent (P = .005) than commercial websites in attributing authorship, timeliness of information, sources of information, and other important disclosures. The type of website publisher did not predict website accuracy, comprehensiveness, or overall website quality. Only 4 of 98 (4%) websites achieved an overall quality score of 80 or above, which a priori was set as the minimum score for a website to be judged trustworthy and reliable.

Conclusions

The information on many websites addressing celiac disease was not sufficiently accurate, comprehensive, and transparent, or presented at an appropriate reading grade level, to be considered sufficiently trustworthy and reliable for patients, health care providers, celiac disease support groups, and the general public. This has the potential to adversely affect decision making about important aspects of celiac disease, including its appropriate and proper diagnosis, treatment, and management.

Diagnostic Accuracy of IGA Anti-Tissue Transglutaminase Antibody Testing in Celiac Disease

Contemporary guidelines for the first-line diagnosis of celiac disease recommend determination of IgA anti-tissue transglutaminase antibodies or IgA antiendomysial antibodies, as well as total serum IgA antibodies. The aim of our study was to assess the validity and clinical significance of serological testing for IgA anti-tissue transglutaminase antibodies in the diagnosis of celiac disease, and to investigate the presence of malabsorption symptoms in celiac patients. IgA anti-tissue transglutaminase antibody testing was performed in 50 subjects with clinically suspected celiac disease (21 men and 29 women). All subjects underwent endoscopy with small intestine biopsy. Celiac disease was confirmed by histopathological findings in four subjects, whereas the IgA anti-tissue transglutaminase test was positive in three subjects. The IgA anti-tissue transglutaminase test showed sensitivity of 75% and specificity of 100%. There were significant differences between men with biopsy-confirmed and excluded celiac disease in the erythrocyte parameters MCV (96.5±7.7 vs. 78.6 ±11.3; p<0.05), MCH (36.9±4.6 vs. 25.9±4.9; p<0.01), and MCHC (382.5±16.3 vs. 326.9±19.1; p<0.005), as well as in the levels of total protein (47.5 ±16.3 vs. 68.3 ± 7.6; p<0.01) and albumins (24.6±9.5 vs. 42.1 ± 6.9; p<0.01). In addition, HDL-cholesterol levels were significantly lower in men with biopsy-confirmed celiac disease (0.42.±0.12 vs. 0.90±0.30; p<0.05). Our results show a high correlation between IgA anti-tissue transglutaminase testing and endoscopy with biopsy as the gold diagnostic standard.

'Get with the Program!': pharmaceutical marketing, symptom checklists and self-diagnosis

During more than a decade of direct-to-consumer advertising (DTC) of pharmaceuticals in the United States, several highly controversial and contested disease states have been promoted to affect diagnostic and prescribing outcomes that are favorable to a company's branded drug. Influencing medical diagnosis is essential to the branding of a disease, which helps to protect pharmaceutical intellectual property and assures higher profits for drug companies. Enormous marketing as well as medical resources are deployed to ensure that new diagnoses of disease states are recognized. While much work has been done investigating the marketing processes necessary to shape and define diagnoses for many of these new disease states, such as Premenstrual Dysphoric Disorder (PMDD), the promotion of self-diagnosis within pharmaceutical marketing campaigns garner little sociological attention. This article reviews and analyzes branded disease awareness campaigns sponsored by pharmaceutical companies that employ self-diagnostic "tools". By using the example of one specific disease state, PMDD, I illustrate how the marketing of self-diagnosis transforms the patient into a consumer in order to achieve the aims of a drug company. This example is contextualized within the larger theoretical framework on the sociology of diagnosis. Consideration is given to how the marketing of self-diagnosis goes beyond Jutel's (2009) description of diagnosis as being the "classification tool of medicine" and becomes a marketing tool to construct a well-educated consumer who will demand medical diagnoses inline with a drug company's objectives.

Identifying potential adverse effects using the web: a new approach to medical hypothesis generation

Medical message boards are online resources where users with a particular condition exchange information, some of which they might not otherwise share with medical providers. Many of these boards contain a large number of posts and contain patient opinions and experiences that would be potentially useful to clinicians and researchers. We present an approach that is able to collect a corpus of medical message board posts, de-identify the corpus, and extract information on potential adverse drug effects discussed by users. Using a corpus of posts to breast cancer message boards, we identified drug event pairs using co-occurrence statistics. We then compared the identified drug event pairs with adverse effects listed on the package labels of tamoxifen, anastrozole, exemestane, and letrozole. Of the pairs identified by our system, 75-80% were documented on the drug labels. Some of the undocumented pairs may represent previously unidentified adverse drug effects.

Assessing possible celiac disease by an HLA-DQ2-gliadin Tetramer Test

OBJECTIVES

Investigation of uncertain celiac disease (CD) in patients already on a gluten-free diet (GFD) is difficult. We evaluated HLA-DQ2-gliadin tetramers for detection of gluten-specific T cells in peripheral blood and histological changes in the duodenum after a short gluten challenge as a diagnostic tool.

METHODS

HLA-DQ2+ individuals on a GFD for at least 4 weeks were investigated; 35 with uncertain diagnosis, 13 CD patients, and 2 disease controls. All participants had a challenge with four slices of gluten-containing white bread, daily for 3 days (d1-d3). An esophagogastroduodenoscopy with biopsy sampling was done on d0 and d4. Biopsies were scored according to revised Marsh criteria. Peripheral blood CD4+ T cells were isolated, stained with HLA-DQ2-gliadin peptide tetramers, and analyzed by flow cytometry on d0 and d6.

RESULTS

After challenge, a positive tetramer test was seen in 11/13 CD patients. Four of these subjects also showed typical histological changes on challenge. Of the 35 patients with uncertain diagnosis, 3 were diagnosed with CD. Two of these three patients had both positive tetramer staining and histological changes in biopsies after challenge.

CONCLUSIONS

Tetramer staining for gluten-specific T cells is a sensitive method in detecting an immune response in CD patients after a short gluten challenge. The prevalence of CD in the group with self-prescribed GFD was about 10%.

Achieving continuity of care: facilitators and barriers in community mental health teams

Background

The integration of mental health and social services for people diagnosed with severe mental illness (SMI) has been a key aspect of attempts to reform mental health services in the UK and aims to minimise user and carer distress and confusion arising from service discontinuities. Community mental health teams (CMHTs) are a key component of UK policy for integrated service delivery, but implementing this policy has raised considerable organisational challenges. The aim of this study was to identify and explore facilitators and barriers perceived to influence continuity of care by health and social care professionals working in and closely associated with CMHTs.

Methods

This study employed a survey design utilising in-depth, semi-structured interviews with a proportionate, random sample of 113 health and social care professionals and representatives of voluntary organisations. Participants worked in two NHS Mental Health Trusts in greater London within eight adult CMHTs and their associated acute in-patient wards, six local general practices, and two voluntary organisations.

Results

Team leadership, decision making, and experiences of teamwork support were facilitators for cross boundary and team continuity; face-to-face communication between teams, managers, general practitioners, and the voluntary sector were facilitators for information continuity. Relational, personal, and longitudinal continuity were facilitated in some local areas by workforce stability. Barriers for cross boundary and team continuity were specific leadership styles and models of decision making, blurred professional role boundaries, generic working, and lack of training for role development. Barriers for relational, personal, and longitudinal continuity were created by inadequate staffing levels, high caseloads, and administrative duties that could limit time spent with users. Incompatibility of information technology systems hindered information continuity. Flexible continuity was challenged by the increasingly complex needs of service users.

Conclusions

Substantive challenges exist in harnessing the benefits of integrated CMHT working to deliver continuity of care. Team support should be prioritised in terms of IT provision linked to a review of current models of administrative support. Investment in education and training for role development, leadership, workforce retention, and skills to meet service users' complex needs are recommended.