Exploratory examination of the utility of demoralization as a diagnostic specifier for adjustment disorder and major depression

OBJECTIVE

Demoralization, a state of lowered morale and poor coping, has a prevalence of 13-18% among patients with advanced cancer. We surveyed clinicians' perspectives of the utility of "with demoralization" as a diagnostic specifier for adjustment and depressive disorders.

METHOD

Using comparative clinical vignettes in a field survey, clinicians from a range of disciplines were asked their perception of the utility of diagnosis and treatment options. Response frequencies were compared using Cochran's Q and McNemar's tests, with sensitivity and specificity rated against expert rankings of diagnosis. Analysis of variance and paired t-tests examined significant differences in ratings of utility.

RESULTS

Vignettes were assessed by 280 clinicians; 77% supported utility of the category 'adjustment disorder with demoralization' compared to 33% supporting 'adjustment disorder with anxiety' (McNemar test, p<0.001), while 83% supported the utility of 'with demoralization' for major depressive episode, matching 83% perceiving utility for 'with melancholia.' Sensitivity and specificity ratings were 77% and 94% for adjustment disorder with demoralization and 83% and 91% for major depression with demoralization.

CONCLUSION

Clinicians perceived the specifier 'with demoralization' to deepen diagnostic understanding, treatment choice, and ability to communicate with clinicians and patients, particularly for the category of adjustment disorder with demoralization.

Postnatal demoralisation among women admitted to a hospital mother-baby unit: validation of a psychometric measure

Demoralisation is a psychological state characterised by experiences of distress and sadness, helplessness, subjective incompetence and hopelessness, in the context of a stressful situation. Experiences of demoralisation may be particularly relevant to women who have recently given birth, who can feel incompetent, isolated and helpless. The psychometric properties of the Demoralisation Scale among women in the postnatal period participating in a clinical program were examined. Women admitted with their infants to a hospital mother-baby unit in Australia for five nights were recruited consecutively (N = 209) and assessed at admission and discharge. The Demoralisation Scale was perceived as relevant and exhibited high reliability, acceptable construct validity and good sensitivity to change. The mean demoralisation score was high (M = 30.9, SD = 15.5) and associated with negative experiences of motherhood and functional impairment, independent of depression and anxiety symptoms. Mean demoralisation decreased significantly after program completion (M = 18.4, SD = 12.4). More participants showed a significant improvement in demoralisation (57.5 %) than in depression (34.8 %) and anxiety (9.8 %) symptoms. Demoralisation can provide a useful framework for understanding and measuring the experiences of women participating in postnatal clinical programs and in directing treatment towards helping women to acquire the necessary caregiving skills and increasing parental efficacy. The Demoralisation Scale is a useful clinical tool for assessing intervention effects.

How has the prevalence of cigarette smoking changed among Australian adults? Trends in smoking prevalence between 1980 and 2001

OBJECTIVE

To examine trends in the prevalence of cigarette smoking between 1980 and 2001 among several different sociodemographic groups within the Australian population.

METHOD

National cross sectional surveys conducted by face to face interview every 3 years from 1980. Respondents were classified into five age groups and the occupation of respondents in the workforce were classified into one of upper or lower white collar or upper or lower blue collar.

MAIN OUTCOME MEASURE

Prevalence of smoking at least weekly.

RESULTS

The prevalence of smoking in 2001 was lower than that found in 1980 and this was true for all sociodemographic groups. Among adults smoking prevalence decreased from 35% in 1980 to 23% in 2001. The differential in smoking prevalence between men and women decreased between 1980 and 2001. Although smoking was more common among younger Australians (<24 years) than older Australians throughout the study, the differential between age groups reduced. For all years except 1980, the proportion of smokers among upper white collar workers was significantly lower than in all other occupation groups.

CONCLUSION

There had been a continual decline in the prevalence of smoking among the Australian population since 1980. This decline had occurred across both sexes and in all age and occupation groups. Much of the decline in smoking prevalence between 1998 and 2001 was among blue collar worker group.

Perceived need for mental health care: influences of diagnosis, demography and disability

BACKGROUND

Recent major epidemiological studies have adopted increasingly multidimensional approaches to assessment. Several of these have included some assessment of perceived need for mental health care. The Australian National Survey of Mental Health and Wellbeing, conducted in 1997, included a particularly detailed examination of this construct, with an instrument with demonstrated reliability and validity.

METHODS

A clustered probability sample of 10641 Australians responded to the field questionnaire for this survey, including questions on perceived need either where there had been service utilization, or where a disorder was detected by administration of sections of the Composite International Diagnostic Interview. The confidentialized unit record file generated from the survey was analysed for determinants of perceived need.

RESULTS

Perceived need is increased in females, in people in the middle years of adulthood, and in those who have affective disorders or co-morbidity. Effects of diagnosis and disability can account for most of the differences in gender specific rates. With correction for these effects through regression, there is less perceived need for social interventions and possibly more for counselling in females; disability is confirmed as strongly positively associated with perceived need, as are the presence of affective disorders or co-morbidity.

CONCLUSIONS

The findings of this study underscore the imperative for mental health services to be attentive and responsive to consumer perceived need. The substantial majority of people who are significantly disabled by mental health problems are among those who see themselves as having such needs.

Australian general practice and the meeting of needs for mental health care

BACKGROUND

This report, drawing on a national epidemiological survey conducted in 1997, examines the role of Australian medical general practitioners (GPs) in responding to needs for mental health care.

METHODS

We analysed data from the Australian National Survey of Mental Health and Wellbeing (NSMHWB). The NSMHWB employed clustered probability sampling of all Australian adults, and 10,641 participants were interviewed. The field questionnaire included modules of the Composite International Diagnostic Interview, and instruments assessing disability, service utilisation and perceived needs for care.

RESULTS

Eighty-four percent of people with a mental disorder consulted a GP in the year prior to survey, but only 29% consulted in relation to a mental health problem. GP services were seen as more responsive to needs for medication, counselling and information than needs for social interventions and skills training. People with perceived needs for counselling were more likely to consult with other providers, either as alternative or additional consultations to those with a GP. Counselling needs were reported as less well met when people saw a GP alone than when consulting other service providers.

CONCLUSIONS

Many people with mental health problems attend primary medical care practitioners without presenting these problems to their physicians. When they do present, perceived needs for medication are rated as well met, but there is substantial unmet perceived need for interventions in social and occupational domains. Perceived needs for counselling are less well met where the GP is the sole provider. To close these identified gaps calls for improvements in primary care physicians' skills and effective collaborative models with other providers.