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Bradford A, Meyer AND, Khan S, Giardina TD, Singh H. Diagnostic error in mental health: a review. BMJ Qual Saf 2024:bmjqs-2023-016996. [PMID: 38575311 DOI: 10.1136/bmjqs-2023-016996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/04/2024] [Indexed: 04/06/2024]
Abstract
Diagnostic errors are associated with patient harm and suboptimal outcomes. Despite national scientific efforts to advance definition, measurement and interventions for diagnostic error, diagnosis in mental health is not well represented in this ongoing work. We aimed to summarise the current state of research on diagnostic errors in mental health and identify opportunities to align future research with the emerging science of diagnostic safety. We review conceptual considerations for defining and measuring diagnostic error, the application of these concepts to mental health settings, and the methods and subject matter focus of recent studies of diagnostic error in mental health. We found that diagnostic error is well understood to be a problem in mental healthcare. Although few studies used clear definitions or frameworks for understanding diagnostic error in mental health, several studies of missed, wrong, delayed and disparate diagnosis of common mental disorders have identified various avenues for future research and development. Nevertheless, a lack of clear consensus on how to conceptualise, define and measure errors in diagnosis will pose a barrier to advancement. Further research should focus on identifying preventable missed opportunities in the diagnosis of mental disorders, which may uncover generalisable opportunities for improvement.
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Affiliation(s)
- Andrea Bradford
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Ashley N D Meyer
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Sundas Khan
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Traber D Giardina
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Hardeep Singh
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
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Rodríguez-Agudelo Y, Nava-Adán J, Paz-Rodríguez F, Abundes-Corona A, Flores-Rivera J, Corona T. Quality of life and mental health in multiple sclerosis patients during the COVID-19 Pandemic. Mult Scler Relat Disord 2023; 70:104487. [PMID: 36640561 PMCID: PMC9789892 DOI: 10.1016/j.msard.2022.104487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 11/16/2022] [Accepted: 12/22/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND The COVID-19 pandemic had a profound impact on mental health symptoms and quality of life (QoL) in the general population due to necessary public health restrictions such as social distancing. The psychosocial effect of the pandemic on vulnerable groups such as people living with Multiple Sclerosis (PwMS) has been scarcely explored in countries with additional socioeconomical burdens such as access to healthcare disparities METHODS: A questionnaire exploring sociodemographic variables, quality of life, mental health determinants and sleep quality was applied to 92 PwMS to explore changes prior and during the pandemic regarding these domains RESULTS: 58.8% of the subjects were female, median age was 37.1 (± 8.5) years and relapsing-remitting MS was the predominant clinical subtype (83.5%). Unemployment rate significantly increased during the pandemic (12.3% vs 27.8%; p= 0.001). Only 46.4% received medical follow-up care during the pandemic. QoL was affected predominantly due to limitations in instrumented activities of daily life (IADL). Neuropsychiatric symptoms, requiring healthcare during the pandemic, anxiety prior to the pandemic and restricted IADL were predictors of MS-related physical impact worsening, while decreased physical/emotional wellbeing selfcare, neuropsychiatric symptoms, bad sleep quality, anxiety prior to the pandemic and restricted non-instrumental ADL predicted aggravation of MS-related psychological impact measured by the MSIS-29. Curiously, specific items regarding anxiety were more prevalent prior to the pandemic (anxious mood; p=0.02, helplessness; p=0.01), sleep problems; p=0.001 and cardiovascular symptoms; p=0.001, nevertheless, stability was observed for most items. Importantly, 77.3% of PwMS reported at least one neuropsychiatric symptom CONCLUSION: The deleterious effects of the COVID-19 pandemic on psychosocial wellbeing in PwMS, QoL and mental health outcomes are frequently overseen in vulnerable populations such as PwMS. Albeit the limitations of this study, our results may help implement policies that prevent negative outcomes on psychosocial wellbeing due to public health measures (e.g., social distancing) in MS and other neurological diseases that inexorably need constant follow-up.
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Affiliation(s)
| | | | - Francisco Paz-Rodríguez
- Clinical Neuropsychology Laboratory, National Institute of Neurology and Neurosurgery, Mexico
| | - Arturo Abundes-Corona
- Clinical Neurodegenerative Diseases Laboratory, National Institute of Neurology and Neurosurgery
| | - José Flores-Rivera
- Clinical Neurodegenerative Diseases Laboratory, National Institute of Neurology and Neurosurgery
| | - Teresa Corona
- Faculty of Medicine, National Autonomous University of Mexico, Mexico; Clinical Neurodegenerative Diseases Laboratory, National Institute of Neurology and Neurosurgery.
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Cassiani-Miranda CA, Scoppetta O, Cabanzo-Arenas DF. Validity of the Hospital Anxiety and Depression Scale (HADS) in primary care patients in Colombia. Gen Hosp Psychiatry 2022; 74:102-109. [PMID: 33750606 DOI: 10.1016/j.genhosppsych.2021.01.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 01/24/2021] [Accepted: 01/30/2021] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To assess the validity of the Hospital Anxiety and Depression Scale (HADS) for depression and anxiety screening in primary care patients in Colombia. METHODS A criterion validity study was conducted with 243 adults that had completed the HADS and were later assessed using the MINI as a gold standard. Cronbach's alpha, McDonald's omega and factor structure were applied through confirmatory factor analysis (CFA). ROC curve analysis and Youden's statistic were used to determine the cut-off point. RESULTS Cronbach's α was reported to be 0.85 and 0.82 for McDonalds' ω. CFA supported a two-factor solution demonstrating satisfactory fit. Root mean square error of approximation = 0.04, Comparative Fix Index (CFI) and Tucker-Lewis Index (TLI) = 0.97. For HADS-A, the cut-off point was determined as 6 associated with a sensitivity of 0.76, a specificity of 0.72 and Youden's index of 0.50. The ABC was 0.81. For HADS-D, the cut-off point was determined as 4 associated with a sensitivity of 0.78, a specificity of 0.74 and Youden's index of 0.53. The ABC was 0.82. CONCLUSION The HADS is a valid and reliable instrument for anxiety and depression screening in adult patients of primary healthcare services in Colombia.
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Affiliation(s)
- Carlos Arturo Cassiani-Miranda
- University of Santander, Faculty of Health Sciences, Medicine Program, UDES Neuroscience Research Group, Bucaramanga, Colombia.
| | - Orlando Scoppetta
- Catholic University of Colombia, Faculty of Psychology, GAEM Research Group (Research methods applied to behavioral science), Bogotá, Colombia.
| | - Diego Fernando Cabanzo-Arenas
- University of Santander, Faculty of Health Sciences, Medicine Program, Positive Psychiatry Research Incubator, UDES Neuroscience Research Group, Bucaramanga, Colombia
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Haavet OR, Šaltytė Benth J, Gjelstad S, Hanssen-Bauer K, Dahli MP, Kates N, Ruud T. Detecting young people with mental disorders: a cluster-randomised trial of multidisciplinary health teams at the GP office. BMJ Open 2021; 11:e050036. [PMID: 34952870 PMCID: PMC8712985 DOI: 10.1136/bmjopen-2021-050036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Young people with mental health challenges present a major global challenge. More than half of adults with mental disorders experience their onset before age 14, but early detection and intervention may change this course. Shared care with mental health professionals in general practitioner (GP) offices has demonstrated its potential for improvement in these conditions. AIM To investigate whether shared care with mental health professionals in GP offices increases the detection of youth's mental health disorders and is associated with a decrease in use of unspecified symptom diagnoses, as a whole and stratified by patient and physician gender and age, and type of consulting physician. DESIGN AND SETTING This was a stratified cluster-randomised controlled trial with data extraction from electronic records. Two GP offices were recruited from each of three boroughs. Each borough had 3-8 GP offices. One GP office was randomised to the intervention group and the other to the control group. METHOD We used generalised linear mixed models to assess whether the intervention helped GPs identify more International Classification of Primary Care 2 diagnoses of depression, anxiety and unspecified symptoms in youth. RESULTS Over a 18-month period between between 2015 and 2017, the intervention helped GPs identify more youth with anxiety (p=0.002 for interaction), but not depression. The increase was most significant among the patients' regular GPs, less when patients met other GPs and least among external substitute physicians. The frequency of diagnoses with unspecified symptoms decreased in the intervention arm. CONCLUSION Shared care with mental health professionals located in GP office contributed to increased detection of youth with anxiety symptoms. The increase was most prominent when the primary care physician was the patient's regular GP. GPs need to pay greater attention to detecting anxiety in youth and embrace shared care models, thereby contributing to reduced mental health disorders in this age group. TRIAL REGISTRATION NUMBER NCT03624829; Results.
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Affiliation(s)
- Ole Rikard Haavet
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Jūratė Šaltytė Benth
- Health Services Research Unit, Akershus University Hospital, Lorenskog, Norway
- Division of Health Services Research and Psychiatry, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Svein Gjelstad
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Ketil Hanssen-Bauer
- Division of Health Services Research and Psychiatry, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Mental Health Services, Akershus University Hospital, Lorenskog, Norway
| | - Mina Piiksi Dahli
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Nick Kates
- Department of Psychiatry & Behavioural Neurosciences, Michael G. DeGroote School of Medicine McMaster University, Hamilton, Ontario, Canada
| | - Torleif Ruud
- Division of Health Services Research and Psychiatry, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Mental Health Services, Akershus University Hospital, Lorenskog, Norway
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Validity of the Patient Health Questionnaire-9 (PHQ-9) for depression screening in adult primary care users in Bucaramanga, Colombia. ACTA ACUST UNITED AC 2020; 50:11-21. [PMID: 33648690 DOI: 10.1016/j.rcp.2019.09.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/01/2019] [Accepted: 09/20/2019] [Indexed: 02/08/2023]
Abstract
The patient health questionnaire-9 (PHQ-9) is one of the most widely used self-report instruments in primary care. There is no criterion validity of the PHQ-9 in Colombia. The objective was to validate the PHQ-9 as a screening tool in primary care. A cross-sectional, scale criterion validity study was performed using as reference criterion the mini neuropsychiatric interview (MINI) in male and female adult users of primary care centres. We calculated the internal consistency and convergent and criterion validity of the PHQ-9 by analysing the receiver operating characteristics (ROC) and the area under the curve (AUC). We analysed 243 participants; 184 (75.7%) were female. The average age was 34.05 (median of 31 and SD = 12.47). Cronbach's α was 0.80 and McDonald's ω was 0.81. Spearman's Rho was 0.64 for HADS-D (P <0.010) and 0.70 for PHQ-2 (P <0.010). The AUC was 0.92 (95% CI 0.880-0.963). The optimal cut-off point of PHQ-9 was ≥7: sensitivity of 90.38 (95% CI: 81.41-99.36); specificity of 81.68 (95% CI: 75.93-87.42); PPV 57.32 (95% CI: 46.00-68.63); NPV 96.89 (95% CI: 93.90-99.88); Youden index 0.72 (95% CI: 0.62-0.82); LR+ 4.93 (95% CI: 3.61-6.74); LR- 0.12 (95% CI: 0.005-0.270). In sum, the Colombian version of PHQ-9 is a valid and reliable instrument for depression screening in primary care in Bucaramanga, with a cut-off point ≥7.
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Norton J, Oude Engberink A, Gandubert C, Macgregor A, David M, Mann A, Ritchie K, Ancelin ML, Capdevielle D. Frequent attendance and the concordance between PHQ screening and GP assessment in the detection of common mental disorders. J Psychosom Res 2018; 110:1-10. [PMID: 29764597 DOI: 10.1016/j.jpsychores.2018.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/03/2018] [Accepted: 04/05/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Frequent Attenders (FAs) have high rates of both common mental disorders (CMD) and physical disorders, partly justifying this service use behaviour. This study examines both case and non-case concordance between CMDs as estimated by a self-report screening questionnaire and as rated by the general practitioner (GP), in FAs compared to Other Attenders (OAs). METHODS 2275 patients of an overlapping sample of 55 GPs from 2 surveys performed 10 years apart, completed in the waiting room the Patient Health Questionnaire (PHQ) and Client Service Receipt Inventory on 6-month service use. For each patient, the GP rated mental health on a 0-4 scale, with a clear indication that scores of 2 and above referred to caseness. PHQ-CMDs included major and other depressive, anxiety, panic, and somatoform disorders, identified using the original PHQ DSM-IV criteria-based algorithms. FA was defined as the top 10% of attenders in age, sex and survey-year stratified subgroups. RESULTS FAs had higher rates of PHQ-CMDs (42% versus 23% for OAs, p < .0001). They reported more personal and social problems, disability and had higher GP-rated physical illness. Survey-day antidepressant/anxiolytic medication prescription was higher for FAs (p < .0001), with (p = .02) but also without a CMD (p < .0001). Both GP/PHQ case and non-case concordance differed between FAs and OAs, with a non-case concordance odds ratio of 0.5 (95% CI: 0.3-0.7, p = .001) for FAs compared to OAs. CONCLUSION Despite a greater likelihood of GPs detecting CMDs in FAs, our findings suggest a potential risk of 'over-detection' of patients not reaching CMD threshold criteria among FAs.
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Affiliation(s)
- J Norton
- Inserm, U1061, Montpellier, France; University of Montpellier, U1061, Montpellier, France.
| | - A Oude Engberink
- Department of General Practice, Faculty of Medicine, University of Montpellier, France
| | - C Gandubert
- Inserm, U1061, Montpellier, France; University of Montpellier, U1061, Montpellier, France
| | - A Macgregor
- University Department of Adult Psychiatry, Montpellier University Hospital, Montpellier, France
| | - M David
- Department of General Practice, Faculty of Medicine, University of Montpellier, France
| | - A Mann
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - K Ritchie
- Inserm, U1061, Montpellier, France; University of Montpellier, U1061, Montpellier, France; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - M L Ancelin
- Inserm, U1061, Montpellier, France; University of Montpellier, U1061, Montpellier, France
| | - D Capdevielle
- Inserm, U1061, Montpellier, France; University of Montpellier, U1061, Montpellier, France; University Department of Adult Psychiatry, Montpellier University Hospital, Montpellier, France
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Clinician identification of elevated symptoms of depression among individuals seeking treatment for substance misuse. Drug Alcohol Depend 2017; 181:71-76. [PMID: 29035707 DOI: 10.1016/j.drugalcdep.2017.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 09/06/2017] [Accepted: 09/08/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Depression is common among those experiencing alcohol and other drug (AOD) disorders. It has been suggested that identifying depressive symptoms among this group is important for case management. Despite this, there is a lack of research examining how well clinicians perform this task within this setting. AIMS To determine the: (i) accuracy of clinician identified elevated symptoms of depression among clients seeking treatment for AOD misuse as compared to a standardized self-report psychiatric screening tool; and (ii) clinician and client characteristics associated with accurate identification of elevated symptoms of depression. METHODS The study used a descriptive cohort design. Participants from two Australian AOD outpatient clinics reported demographic data and completed the Patient Health Questionnaire (PHQ-9) to identify elevated symptoms of depression. Clinicians were asked to indicate the presence or absence of depression for individual clients. Client and clinician data were compared. RESULTS Sensitivity of clinician identified elevated symptoms of depression, compared with the PHQ-9, was moderate at 73.0% (95% CI=63.7, 81.0) and specificity was low with 49.5% (95% CI=39.9, 61.2) accurately identified as not having elevated symptoms of depression. AOD clinicians' years' of experience, clients' main substance and length of treatment were associated with accuracy of identification. CONCLUSION Clinicians identify elevated symptoms of depression with moderate accuracy amongst individuals with AOD disorders. There is a tendency to over-identify which may contribute to inaccuracies. Routine screening may assist in improving identification of depressive symptoms and place greater focus on mental health comorbidities.
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Norton J, Engberink AO, Gandubert C, Ritchie K, Mann A, David M, Capdevielle D. Health Service Utilisation, Detection Rates by Family Practitioners, and Management of Patients with Common Mental Disorders in French Family Practice. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2017; 62:521-530. [PMID: 28107037 PMCID: PMC5546665 DOI: 10.1177/0706743716686918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Provide up-to-date detection rates for common mental disorders (CMD) and examine patient service-use since the Preferred Doctor scheme was introduced to France in 2005, with patients encouraged to register with and consult a family practitioner (FP) of their choice. METHODS Study of 1133 consecutive patients consulting 38 FPs in the Montpellier region, replicating a study performed before the scheme. Patients in the waiting room completed the self-report Patient Health Questionnaire (PHQ) and Client Service-Receipt Inventory with questions on registration with a Preferred Doctor and doctor-shopping. CMD was defined as reaching PHQ criteria for depression, somatoform, panic or anxiety disorder. For each patient, FPs completed a questionnaire capturing psychiatric caseness. RESULTS 81.2% of patients were seeing their Preferred Doctor on the survey-day. Of those with a CMD, 52.6% were detected by the FP. This increased with CMD severity and comorbidity. Detected cases were more likely to be consulting their Preferred Doctor (84.7% versus 79.4% for non-detected cases, p = 0.05) rather than another FP. They declared more visits to psychiatrists (17.2% versus 6.7%, p = 0.002). There was no association with consultation frequency or doctor-shopping, which both declined between the two studies. CONCLUSION The CMD detection rate is relatively high, with no increase compared to our previous study, despite a decline in doctor-shopping. An explanation is the same high proportion of patients visiting their usual FP on the survey-day at both periods, suggesting a limited impact of the scheme on care continuity. FP action taken highlights the importance of improving detection for providing care to patients with CMDs.
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Affiliation(s)
- Joanna Norton
- 1 Inserm, U1061, University of Montpellier, Montpellier, France
| | | | | | - Karen Ritchie
- 1 Inserm, U1061, University of Montpellier, Montpellier, France.,3 Center for Clinical Brain Sciences, University of Edinburgh, UK
| | - Anthony Mann
- 4 Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK
| | - Michel David
- 2 Department of General Practice, University of Montpellier, France
| | - Delphine Capdevielle
- 1 Inserm, U1061, University of Montpellier, Montpellier, France.,5 University Department of Adult Psychiatry, Montpellier University Hospital, Montpellier, France
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