Does psychiatric care by family practitioners reduce the cost of general medical care?

This is the first "impact" type of economic study of psychiatric/counseling services from general practitioners. The paper analyzes a province-wide database that collates statistical data from all inpatient and outpatient psychiatric services as well as from private physicians. This paper asks whether psychiatric services from family physicians also reduce the overall costs of medical care. This research supports the general research findings that medical costs are lower after psychiatrists' care. ECT patients show a marked reduction in their medical costs. Patients with psychotherapy/counseling from family physicians did not show statistically significant reductions in overall medical costs. We need new classifications for the kinds of mental disorders seen in primary care settings.     

On the history of one form of social psychiatric care: family care exemplified on the Leipzig-Dösen asylum

On the basis of archival sources and primary literature the study exemplifies the history of one form of extramural social psychiatric care on the example of one particular institution, the town asylum of Leipzig-D?sen. Family care was introduced in Leipzig in 1904 by Georg Lehmann, primarily as an alternative treatment option. After initial opposition among the local population had been defeated, this form of treatment was soon quite accepted. Due to the socioeconomic changes as a result of World War I, the extent of family care was downsized. From 1940 family care in D?sen was abolished, due to a change in ideology. Part of the patients previously in family care fell victim to the National socialist T-4 programme to murder chronically mental ill. However, this study could also prove that at least one third of these patients survived. It can only be presumed to which extent this was due to their physical work being needed as a result of war shortages.     

Are needs and satisfaction of care associated with quality of life?

Is the quality of life of severe mentally ill patients influenced by the intensity of the care provided, their satisfaction with services and/or the amount of unmet needs? The interrelatedness of these three outcome measures was investigated in a sample of 101 patients dependent on long-term psychiatric care in the Northeast of the Netherlands. Instruments used were the Camberwell Assessment of Needs, the Verona Service Satisfaction Schedule and a health related quality of life instrument, the EuroQoL. Quality of life was unrelated to satisfaction with services but was strongly associated with unmet needs in the area of mental and physical health, and of rehabilitation. Quality of life decreased as needs increased. Needs were also strongly related to diagnosis and cognitive functioning. Furthermore, more intensive care settings were provided as needs increased. Demographic, diagnostic and treatment variables did not explain much extra variance in quality of life. Despite the availability of various services in the region there was a lack of tailor made care which took into account specific unmet needs with regard to information, social contacts, and daily activities.     

Are the care levels of people with dementia correctly assessed for eligibility of the Japanese long‐term care insurance?

BACKGROUND: A new long-term care insurance system was launched in Japan in April 2000. OBJECTIVES: We performed the first national survey on special units of psychiatric hospitals for dementia patients to examine whether their disabilities were well reflected in the eligibility assessment. METHODS: Of all 248 dementia special units of psychiatric hospitals in Japan, 180 units (72.6%) participated in the survey. Five patients were randomly selected in each unit, and we used data of 802 (89.1%) of 900 patients whose care levels were obtained by the primary computer assessment. These patients were assessed using the Mini-Mental State Examination (MMSE), dementia rating scale by Gottfries et al. (1982) (GBS), and Activities of Daily Living (ADL). The mean score (SD) of the MMSE was 9.3 (6.9). RESULTS: Multiple regression analysis revealed that the scores of motor function in GBS, ADL, MMSE, and the degree of bedridden explained 73% of the variation of care level. The higher care levels were inversely related to lower MMSE scores. In the group of people who were not bedridden, the MMSE score sharply decreased even though their physical functions were maintained. There were no significant differences in the MMSE scores among the care level 1 and 5 groups except between care level 1 and 3 after controlling for the motor function scores in GBS. CONCLUSIONS: Our results suggest that care level and cognitive impairment are generally correlated in the primary assessment, but some adjustment measure for cognitive impairment is needed in mildly or moderately physically disabled patients.     

Short-term outcome of inpatient psychiatric care—impact of coercion and treatment characteristics

Aims Little is known about the outcome of brief inpatient treatment interventions in routine psychiatric practice. The aim of this article was to study if subjective and assessed outcome of brief psychiatric inpatient care are related to patient characteristics, coercion at admission and during care, and other treatment characteristics. Method A total of 233 involuntarily and voluntarily admitted patients were interviewed within 5 days from admission and at discharge or after 3 weeks of care. Outcome was measured as reported by patients and by change in GAF (Global Assessment Scale) scores. Results Predictors for a positive subjective outcome were if the patients reported that they had been well treated by the staff and had contact persons at the ward. Predictors for a GAF improvement were a low GAF score at admission and a mood disorder diagnosis. Conclusions Subjectively reported outcome and outcome measured by assessing change in level of functioning differed. Coercion was not related to outcome. The way the patient perceived they had been treated by the staff was strongly related to subjective outcome.     

Impact of shared mental health care in the general population on subjects’ perceptions of mental health care and on mental health status

Objective A community survey evaluated whether the development of a shared mental health care intervention had an impact on health care perceptions and mental health status of subjects with common mental health problems (MHP). Methods Adults <70 years old with common MHP (DSM-IV/CIDI-SF major depressive disorder, generalized anxiety or MHI-SF 36 psychic distress diagnoses), were randomly drawn from the general population in the intervention area (IA, n = 349) and in a control area (CA, n = 360), and evaluated twice at an interval of 18 months (percentage of follow-up: IA = 69.3%, CA = 71.9%, P = .44). CA and IA groups did not differ for the criteria of interest at baseline. Results At 18 months, compared to CA, IA reported significantly different help-seeking attitudes or behaviours (P = .02 for all subjects and .006 for subjects with current MHP) and greater general satisfaction with care (P = .03 for both). Remission rates and daily life functioning did not differ. Conclusions After 4 years of development of a mental health network based on a consultation-liaison model, Shared Mental Health Care was associated with greater satisfaction and access with care among subjects with common MHP. The association was not found with mental health status, but the study lacked power to adequately address the issues.     

Pharmacogenomics--can genetics help in the care of psychiatric patients?

Psychiatric patients demonstrate varied responses to treatment. Consequently, treatment strategies are trial-and-error, which has a negative effect on prognosis and compliance. The aim of pharmacogenomic research is to enable customised drug treatment by identifying variations within multiple candidate genes (those encoding drug-targeted neurotransmitter receptors, transporters and metabolic enzymes) that are likely to confer the inter-individual differences in drug response and development of drug-induced side effects. Pharmacogenetic and pharmacogenomic research to date has identified genetic polymorphisms of dopamine (DA) and serotonin (5-HT) receptor subtypes, the serotonin transporter (5-HTT) and metabolic enzymes (cytochrome P450 [CYP] family) as important contributors to the variability in response to psychiatric drugs and the development of drug-induced side effects such as tardive dyskinesia and weight gain. It is anticipated that technological and methodological advances will provide further candidate genes and refine association analyses of existing candidates, enabling pharmacogenomic research to move towards future treatment regimes that are catered to the individual.     

Educating staff working in long-term care about delirium: the Trojan horse for improving quality of care?

OBJECTIVE: This study aimed to design a multicomponent intervention to improve delirium care in long-term care facilities for older people in the UK and to identify the levers and barriers to its implementation in practice. METHODS: The research incorporated the theoretical phase and Phase 1 of the Medical Research Council's framework. We designed a multicomponent intervention based on the evidence for effective interventions for delirium and for changing practice. We refined the intervention with input from care home staff and field visits to homes. Our intervention incorporated the following features: targeting risk factors for delirium, a 'delirium practitioner' functioning as a facilitator, an education package for care home staff, staff working groups at each home to identify barriers to improving delirium care and to produce tailored solutions, a local champion identified from the working groups, consultation, liaison with other professionals, and audit or feedback. The delirium practitioner recorded her experiences of delivering the intervention in a contemporaneous log. This was analysed using framework analysis to determine the levers and barriers to implementation. RESULTS: We introduced a multicomponent intervention for delirium in six care homes in Leeds. Levers to implementation included flexibility, tailoring training to staff needs, engendering pride and ownership amongst staff, and minimising extra work. Barriers included time constraints, poor organization, and communication problems. CONCLUSION: We were able to design and deliver an evidence-based multicomponent intervention for delirium that was acceptable to staff. The next steps are to establish its feasibility and effectiveness in modifying outcomes for residents of care homes.     

Inpatient care 50 years after the process of deinstitutionalisation

Purpose

Throughout the past 50 years mental health services have aimed to provide and improve high quality inpatient care. It is not clear whether there has been improvement as service users and nursing staff have both expressed frustration at the lack of therapeutic activities. In particular, it may be that the changing levels of symptoms over the past 50 years may affect engagement with ward activities.

Methods

Eight wards in a health care trust in London serving an inner city and urban populations participated. Data were collected on participation in activities and 116 service users’ perceptions of acute care as well as clinical factors.

Results

Less time was spent participating in activities today than 50 years ago, while one quarter of service users reported taking part in no activities at all. Uptake of activities was related to more positive service user perceptions of the wards. Symptom severity did not impact the frequency of participation in activities, although those who took part in no activities at all had higher negative symptoms scores.

Conclusions

Service users’ uptake of activities was not related to the severity of their illness. This belies the belief that the acutely ill cannot take part in meaningful activities. This study supports the view that more therapeutic activities could be taken up by the acutely ill and are in fact appreciated.     

Which level of care is preferred for end-stage dementia? Survey of Taiwanese caregivers

In Western countries, most family caregivers view some degree of palliative care as appropriate for severely demented care recipients. In Asian countries, caregivers' attitudes toward such an important issue have not been sufficiently investigated. Therefore, we surveyed Taiwanese caregivers' attitudes toward the terminal care of demented care recipients by questionnaire. In 115 (48 men, 67 women; mean age 73.7+/-9.5 years) caregivers who completed the questionnaire, most caregivers (61%) preferred highly aggressive care, whereas only 3% preferred solely palliative care at the end of the demented care recipients' life. Caregivers having a lower education level (< or = 12 vs > 12 years) or having care recipients of a younger age (< or =75 vs >75 years) exhibited a higher preference for cardiopulmonary resuscitation (CPR) (P = .020 and P = .010, respectively). Sixteen percent of caregivers accepted postmortem autopsy for their care recipients. Twenty-eight percent of caregivers of home-resident recipients anticipated institutionalization, especially those with care recipients having moderate to severe stages of dementia. Co-surrogate caregivers, including the spouse and the offspring, were the most common proxies (39%) for care recipients with end-stage dementia. By comparison with Western countries, the low acceptance rate of CPR refusal and nursing home placement by our caregivers might result from cultural differences.     

Cost-effectiveness of a collaborative dementia care management—Results of a cluster-randomized controlled trial

IntroductionThe purpose of this study was to determine the cost-effectiveness of collaborative dementia care management (DCM).MethodsThe cost-effectiveness analysis was based on the data of 444 patients of a cluster-randomized, controlled trial, conceptualized to evaluate a collaborative DCM that aimed to optimize treatment and care in dementia. Health-care resource use, costs, quality-adjusted life years (QALYs), and incremental cost per QALY gained were measured over a 24-month time horizon.ResultsDCM increased QALYs (+0.05) and decreased costs (?569€) due to a lower hospitalization and a delayed institutionalization (7 months) compared with usual care. The probability of DCM being cost-effective was 88% at willingness-to-pay thresholds of 40,000€ per QALY gained and higher in patients living alone compared to those not living alone (96% vs. 26%).DiscussionDCM is likely to be a cost-effective strategy in treating dementia and thus beneficial for public health-care payers and patients, especially for those living alone.     

What are the ethics of care in mental health disorders?

Psychiatry is undergoing a major crisis, on both an institutional as well as a clinical level. Numerous players involved in psychiatry feel in difficulty and are increasingly raising questions as to what direction and meaning to give to their practice. It is in such a context that ethics can help us to progress, reflect and build the future together. It is high time to create the specific basis of ethics in psychiatry.