Case registers in psychiatry: do they still have a role for research and service monitoring?

High-Precise Bipolar Disorder Detection by Using Radial Basis Functions Based Neural Network

Presently, several million people suffer from major depressive and bipolar disorders. Thus, the modelling, characterization, classification, diagnosis, and analysis of such mental disorders bears great significance in medical research. Electroencephalogram records provide important information to improve clinical diagnosis and are very useful in the scientific community. In this work, electroencephalogram records and patient data from the Hospital Virgen de la Luz in Cuenca (Spain) were processed for a correct classification of bipolar disorders. This work implemented an innovative radial basis function-based neural network employing a fuzzy means algorithm. The results show that the proposed method is an effective approach for discrimination of two kinds of classes, i.e., bipolar disorder patients and healthy persons. The proposed algorithm achieved the best performance compared with other machine learning techniques such as Bayesian linear discriminant analysis, Gaussian naive Bayes, decision trees, K-nearest neighbour, or support vector machine, showing a very high accuracy close to 97%. Therefore, the neural network technique presented could be used as a new tool for the diagnosis of bipolar disorder, considering the possibility of integrating this method into medical software.

Impact of the first COVID-19 outbreak on mental health service utilisation at a Dutch mental health centre: retrospective observational study

BACKGROUND

Previous studies into mental health service utilisation during the COVID-19 pandemic are limited to a few countries or specific type of service. In addition, data on changes in telepsychiatry are currently lacking.

AIMS

We aimed to investigate whether the COVID-19 pandemic is associated with changes in mental health service utilisation, including telepsychiatry, and how these changes were distributed among patients with mental illness during the first COVID-19 outbreak.

METHOD

This retrospective study obtained routinely assessed healthcare data from a large Dutch mental healthcare institute. Data from the second quarter of 2020 (the first COVID-19 outbreak period) were compared with the pre-pandemic period between January 2018 and March 2020. Time-series analyses were performed with the quasi-Poisson generalised linear model, to examine the effect of the COVID-19 lockdown and the overall trend of mental health service utilisation per communication modality and diagnostic category.

RESULTS

We analysed 204 808 care contacts of 28 038 patients. The overall number of care contacts in the second quarter of 2020 remained the same as in the previous 2 years, because the number of video consultations significantly increased (B = 2.17, P = 0.488 × 10-3) as the number of face-to-face out-patient contacts significantly decreased (B = -0.98, P = 0.011). This was true for all different diagnostic categories, although this change was less pronounced in patients with psychotic disorders.

CONCLUSIONS

Diminished face-to-face out-patient contacts were well-compensated by the substantial increase of video consultations during the first COVID-19 outbreak in The Netherlands. This increase was less pronounced for psychotic disorders. Further research should elucidate the need for disorder-specific digital mental healthcare delivery.

iPSYcare: the development of a linked electronic medical records database to study and optimize psychiatric care in Antwerp

Objective

The study of care trajectories of psychiatric patients across hospitals was previously not possible in Belgium as each hospital stores its data autonomously, and government-related registrations do not contain a unique identifier or are incomplete. A new longitudinal database called iPSYcare (Improved Psychiatric Care and Research) was therefore constructed in 2021, and links the electronic medical records of patients in psychiatric units of eight hospitals in the Antwerp Province, Belgium. The database provides a wide range of information on patients, care trajectories and delivered care in the region. In a first phase, the database will only contain information about adult patients who were admitted to a hospital or treated by an outreach team and who gave explicit consent. In the future, the database may be expanded to other regions and additional data on outpatient care may be added.

Results

IPSYcare is a close collaboration between the University of Antwerp and hospitals in the province of Antwerp. This paper describes the development of the database, how privacy and ethical issues will be handled, and how the governance of the database will be organized.

Information for mental health systems: an instrument for policy-making and system service quality

AIMS

Information is crucial in mental healthcare, yet it remains undervalued by stakeholders. Its absence undermines rationality in planning, makes it difficult to monitor service quality improvement, impedes accountability and human rights monitoring. For international organizations (e.g., WHO, OECD), information is indispensable for achieving better outcomes in mental health policies, services and programs. This article reviews the importance of developing system level information with reference to inputs, processes and outputs, analyzes available tools for collecting and summarizing information, highlights the various goals of information gathering, discusses implementation issues and charts the way forward.

METHODS

Relevant publications and research were consulted, including WHO studies that purport to promote the use of information systems to upgrade mental health care in high- and low-middle income countries.

RESULTS

Studies have shown that once information has been collected by relevant systems and analyzed through indicator schemes, it can be put to many uses. Monitoring mental health services, represents a first step in using information. In addition, studies have noted that information is a prime resource in many other areas such as evaluation of quality of care against evidence based standards of care. Services data may support health services research where it is possible to link mental health data with other health and non-health databases. Information systems are required to carefully monitor involuntary admissions, restrain and seclusion, to reduce human rights violations in care facilities. Information has been also found useful for policy makers, to monitor the implementation of policies, to evaluate their impact, to rationally allocate funding and to create new financing models.

CONCLUSIONS

Despite its manifold applications, Information systems currently face many problems such as incomplete recording, poor data quality, lack of timely reporting and feedback, and limited application of information. Corrective action is needed to upgrade data collection in outpatient facilities, to improve data quality, to establish clear rules and norms, to access adequate information technology equipment and to train health care personnel in data collection. Moreover, it is necessary to shift from mere administrative data collection to analysis, dissemination and use by relevant stakeholders and to develop a "culture of information" to dismantle the culture of intuition and mere tradition. Clinical directors, mental health managers, patient and family representatives, as well as politicians should be educated to operate with information and not just intuition.

Fifty years' development and future perspectives of psychiatric register research

OBJECTIVE

This article illustrates the development of psychiatric register research and discusses the strengths, limitations, and possible directions for future activities.

METHOD

Examples illustrating the development from the post-World War II introduction of psychiatric register research until today are selected.

RESULTS

The strengths of register research are seen especially within health service. Until recently, when starting linking registers to biobanks, register research had limited value in cause-seeking. Register research benefits from the possibilities for following identifiable persons over long time (lifelong) and the possibilities for linking to other registers and databases. Important limitations of register research are the heterogeneity and questionable validity of the clinical data collected.

CONCLUSION

Future register research can go in the direction of big is beautiful collecting data from all possible sources creating giga-registers. In that case, low data quality will still be an unsolved problem. Or it can take the direction of smaller local clinical databases which has many advantages, for example, integrating clinical knowledge and experience into register research. However, in that case, registers will not be able to deal with rare conditions and diseases.

Ethnicity, socioeconomic position and severity of problems as predictors of mental health care use in 5- to 8-year-old children with problem behaviour

BACKGROUND

Empirical research on mental health care use and its determinants in young school-aged children is still scarce. In this study, we investigated the role of ethnicity, socioeconomic position (SEP) and perceived severity by both parents and teachers on mental health care use in 5- to 8-year old children with emotional and/or behavioural problems.

METHODS

Data from 1,269 children with a high score([P90) on the Strengths and Difficulties Questionnaire (SDQ) in the school year 2008–2009 were linked to psychiatric case register data over the years 2010–2011. Cox proportional hazards models were used to predict mental health care use from ethnicity, SEP and perceived severity of the child's problems.

RESULTS

During the follow-up period, 117 children with high SDQ scores (9.2 %) had used mental health care for the first time. Ethnic minority children were less likely to receive care than Dutch children (HR Moroccan/Turkish:0.26; 95 % CI 0.13-0.54, HR other ethnicity: 0.26; 95 %CI 0.12-0.58). No socioeconomic differences were found.After correction for previous care use, ethnicity and parental perceived severity, impact score as reported by teachers was significantly associated with mental healthcare use (HR 1.58; 95 % CI 1.01–2.46).

CONCLUSIONS

Ethnicity is an important predictor of mental health care use in young children. Already in the youngest school-aged children, ethnic differences in the use of mental health care are present.A distinct predictor of care use in this age group is severity of emotional and behavioural problems as perceived by teachers. Therefore, teachers may be especially helpful in the process of identifying young children who need specialist mental health care.

Effect of crisis plans on admissions and emergency visits: a randomized controlled trial

OBJECTIVE

To establish whether patients with a crisis plan had fewer voluntary or involuntary admissions, or fewer outpatient emergency visits, than patients without such a plan.

DESIGN

Multicenter randomized controlled trial with two intervention conditions and one control condition.

PARTICIPANTS

Adult outpatients diagnosed with psychotic or bipolar disorder who had experienced at least one psychiatric crisis in the previous two years.

INTERVENTION

Two types of advance statement were used: (1) a crisis plan formulated by the patient with the help of a patient advocate (Patient Advocate Crisis Plan: PACP); and (2) a crisis plan developed together with the clinician (Clinician-facilitated Crisis Plan: CCP).

OUTCOME

The percentages of patients admitted voluntarily or involuntarily (on an emergency basis or by court order), and the percentage who made outpatient emergency visits over an 18-month follow-up period.

RESULTS

A total of 212 patients were included: 69 in the PACP condition, 70 in the CCP condition, and 73 in the control condition. No effects of the two interventions were found on the numbers of voluntary admissions, involuntary admissions and emergency visits. Regarding involuntary admissions, there was no significant effect on emergency admissions, which were 17% (12/69) in the PACP condition, 10% (7/70) in the CCP condition, and 19% (14/73) in the control condition. There was a significant effect on planned court-ordered admissions, with 16% (11/69) in the PACP condition, 10% (7/70) in the CCP condition, and 26% (19/73) in the control condition. Finally, the interventions had no effect on outpatient emergency visits, with 32% (22/69) in the PACP group, 31% (22/70) in the CCP group, and 34% (25/73) in the control group.

CONCLUSIONS

Crisis plans may be an effective intervention for reducing court-ordered admissions in patients with psychotic and bipolar disorders.

TRIAL REGISTRATION

Current Controlled Trails NTR1166.

Specialized service use for psychiatric and neurodevelopmental disorders by age 14 in Finland

OBJECTIVE

Most studies on the diagnostic patterns of usage of specialized services for childhood psychiatric and neurodevelopmental disorders have been cross-sectional, and the aim of this study was to provide longitudinal data.

METHODS

The Medical Birth Register and the Finnish Hospital Discharge Register were used to study the use of inpatient or public outpatient specialized services for psychiatric and neurodevelopmental disorders between birth and age 14 in 2010 (cumulative incidence) and in year 2010 at age 14 (one-year prevalence) among Finnish children born in 1996 (N=58,538 singleton live births).

RESULTS

The cumulative incidence of specialized service use for any psychiatric or neurodevelopmental disorders between birth and age 14 was 12.9%, and the one-year prevalence in 2010 at 14 years was 4.2%. The cumulative incidence by age 14 was 5.5% for learning and coordination disorders, 2.2% for anxiety disorders, 2.0% for hyperkinetic disorders, 1.7% for conduct disorders, 1.4% for depression, 1.0% for autism spectrum disorders, and .7% for stress and adjustment disorders. Learning and coordination, hyperkinetic, and autism spectrum disorders were more prevalent among boys, were often diagnosed before school age, and had 9%-51% lifetime comorbidity with each other. Depressive, anxiety, and stress and adjustment disorders had similar distributions between the sexes, were often diagnosed in early adolescence, and showed 8%-31% lifetime comorbidity with each other.

CONCLUSIONS

Every eighth Finnish child had visited specialized services for psychiatric or neurodevelopmental disorders sometime between birth and age 14. Learning and coordination disorders were diagnosed more than twice as often as anxiety, hyperkinetic, and conduct disorders.

Diagnosing comorbidity in psychiatric hospital: challenging the validity of administrative registers

BACKGROUND

This study will explore the validity of psychiatric diagnoses in administrative registers with special emphasis on comorbid anxiety and substance use disorders.

METHODS

All new patients admitted to psychiatric hospital in northern Norway during one year were asked to participate. Of 477 patients found eligible, 272 gave their informed consent. 250 patients (52%) with hospital diagnoses comprised the study sample. Expert diagnoses were given on the basis of a structured diagnostic interview (M.I.N.I.PLUS) together with retrospective checking of the records. The hospital diagnoses were blind to the expert. The agreement between the expert's and the clinicians' diagnoses was estimated using Cohen's kappa statistics.

RESULTS

The expert gave a mean of 3.4 diagnoses per patient, the clinicians gave 1.4. The agreement ranged from poor to good (schizophrenia). For anxiety disorders (F40-41) the agreement is poor (kappa = 0.12). While the expert gave an anxiety disorder diagnosis to 122 patients, the clinicians only gave it to 17. The agreement is fair concerning substance use disorders (F10-19) (kappa = 0.27). Only two out of 76 patients with concurrent anxiety and substance use disorders were identified by the clinicians.

CONCLUSIONS

The validity of administrative registers in psychiatry seems dubious for research purposes and even for administrative and clinical purposes. The diagnostic process in the clinic should be more structured and treatment guidelines should include comorbidity.

Role of the police in linking individuals experiencing mental health crises with mental health services

BACKGROUND

The police are considered frontline professionals in managing individuals experiencing mental health crises. This study examines the extent to which these individuals are disconnected from mental health services, and whether the police response has an influence on re-establishing contact.

METHODS

Police records were searched for calls regarding individuals with acute mental health needs and police handling of these calls. Mental healthcare contact data were retrieved from a Psychiatric Case Register.

RESULTS

The police were called upon for mental health crisis situations 492 times within the study year, involving 336 individuals (i.e. 1.7 per 1000 inhabitants per year). Half of these individuals (N=162) were disengaged from mental health services, lacking regular care contact in the year prior to the crisis (apart from contact for crisis intervention). In the month following the crisis, 21% of those who were previously disengaged from services had regular care contact, and this was more frequent (49%) if the police had contacted the mental health services during the crisis. The influence of police referral to the services was still present the following year. However, for the majority (58%) of disengaged individuals police did not contact the mental health services at the time of crisis.

CONCLUSIONS

The police deal with a substantial number of individuals experiencing a mental health crisis, half of whom are out of contact with mental health services, and police play an important role in linking these individuals to services. Training police officers to recognise and handle mental health crises, and implementing practical models of cooperation between the police and mental health services in dealing with such crises may further improve police referral of individuals disengaged from mental health services.

Classification of bipolar disorder in psychiatric hospital. A prospective cohort study

BACKGROUND

This study has explored the classification of bipolar disorder in psychiatric hospital. A review of the literature reveals that there is a need for studies using stringent methodological approaches.

METHODS

480 first-time admitted patients to psychiatric hospital were found eligible and 271 of these gave written informed consent. The study sample was comprised of 250 patients (52%) with hospital diagnoses. For the study, expert diagnoses were given on the basis of a structured diagnostic interview (M.I.N.I.PLUS) and retrospective review of patient records.

RESULTS

Agreement between the expert's and the clinicians' diagnoses was estimated using Cohen's kappa statistics. 76% of the primary diagnoses given by the expert were in the affective spectrum. Agreement concerning these disorders was moderate (kappa ranging from 0.41 to 0.47). Of 58 patients with bipolar disorder, only 17 received this diagnosis in the clinic. Almost all patients with a current manic episode were classified as currently manic by the clinicians. Forty percent diagnosed as bipolar by the expert, received a diagnosis of unipolar depression by the clinician. Fifteen patients (26%) were not given a diagnosis of affective disorder at all.

CONCLUSIONS

Our results indicate a considerable misclassification of bipolar disorder in psychiatric hospital, mainly in patients currently depressed. The importance of correctly diagnosing bipolar disorder should be emphasized both for clinical, administrative and research purposes. The findings questions the validity of psychiatric case registers. There are potential benefits in structuring the diagnostic process better in the clinic.

Patterns of mental health care utilisation: distribution of services and its predictability from routine data

OBJECTIVES

Explore if a multi-dimensional analytic approach to routinely registered data provides a comprehensive way to characterise utilisation patterns, and to test if the patients' functional status is a predictor for the use of services.

METHOD

We linked register contact data during a two-year period, including all types of specialised mental health services, in the population of a Norwegian county. Cox regression was applied in the models for prediction of admission and readmission.

RESULTS

Great variability and complexity in patterns of utilisation were found, including multiple transitions between in-patient and out-patient statuses. The distribution of services was characterised by a small group of patients receiving a disproportionally large amount of resources. A majority of 77% appeared as out-patients only. Severity of symptoms as well as of dysfunction, as assessed by the split GAF-score, differentiated amongst utilisation groups. Both dimensions were significant predictors for admission. In contrast, only the severity of dysfunction predicted readmission.

CONCLUSION

Multi-dimensional data architecture and analytical perspectives can be applied to routine data, and should be used to analyse the diverse patterns of utilisation. Risk populations could be predicted by routinely registered information on functional status.

The psychiatric case register middle Netherlands

BACKGROUND

The Psychiatric Case Register Middle Netherlands (PCR-MN) registers the mental healthcare consumption of over Dutch 760,000 inhabitants in the centre of the Netherlands. In 2010 the follow-up period was over ten years. In this paper we describe the content, aims and research potential of this case register.

DESCRIPTION

All mental healthcare institutions in the middle-western part of the province of Utrecht participate in the PCR-MN case register. All in- and out-patients treated in these institutions have been included in the database from the period 2000 to 2010. Diagnosis according to DSM-IV on axis I to IV, visits to in- and out-patient clinics and basic demographics are recorded. A major advantage of this register is the possibility to link patients anonymously from the PCR-MN cohort to other databases to analyze relationships with determinants and outcomes, such as somatic healthcare consumption, mortality, and demographics, which further increases the research potential

CONCLUSIONS

The PCR-MN database has a large potential for scientific research because of its size, duration of follow-up and ability to link with additional databases, and is accessible for academic researchers.

The psychiatric case register: noble past, challenging present, but exciting future

Case registers have been fundamental to mental health research from the early asylum studies onwards. Having declined in popularity over the past 20 years, they are likely to see a resurgence of interest with the advent of electronic clinical records and the technological capacity to derive anonymised databases from these.