To describe the profile of the intensive use of mental health services over a 4-year period in a population of 1.1 million people.
Data obtained from computerized hospital separation records and physician reimbursement claims were combined to form patient-based histories of mental health care utilization. Users of mental health services in a 24-month period were hierarchically classified as having a psychotic disorder (ICD-9-CM 295-299) or a nonpsychotic disorder (ICD-9-CM 300-301, 306-309, 311). Intensive use was defined as 12 or more contact months or a minimum of 2 episodes of therapy in the 24-month period. The cohort of intensive users were followed over the subsequent 24-month interval to describe the persistence of intensive use.
In the initial observation periods, intensive users constituted 27.4% of individuals in treatment for psychotic disorder and 4.4% of persons in treatment for nonpsychotic disorder. These 2 groups, which represent 7.4% of all users of mental health care, were responsible for 53% of physician services, 72.7% of contacts with psychiatrists, and 64.4% of acute psychiatric bed days in the initial period. In the follow-up period, intensive use status was replicated by 44.6% of the cohort.
The diagnostic and therapeutic characteristics of intensive users of mental health services are heterogeneous. There is substantial persistence of intensive mental health service use over time.
This paper follows from a previous paper which described the basic approaches to economic evaluation of health programs. The discussion in this paper builds and discusses the theoretical and practical concerns felt by practitioners and analysts about economic evaluations in mental health care. Two examples of economic evaluations that compare the costs of hospital care and community-based care are presented to illustrate some of the limitations of economic evaluation. Discussion also focuses on the difficulties involved in developing and conducting economic analyses in the mental health field, as well as problems faced in trying to generalize from one study setting to others.
Comment In: Can J Psychiatry. 1989 Oct;34(7):631-22509060
The study examines the associations of parent, teacher and self-report evaluations of child psychopathology, help-seeking variables and family factors with the use of child mental health services.
The study comprised an 8-year follow-up of the Epidemiological Child Psychiatry Study in Finland. Children were evaluated at age 8 with Rutter parent and teacher scales and with the Child Depression Inventory, and at age 16, with the Child Behavior Checklist and the Youth Self Report. Information was obtained from about 70% of the follow-up sample (n=857).
About 7% of the sample had been in contact with child mental health services during the follow-up. The most potent predictors at age 8 of later referral were total problem behaviours and antisocial problems in parental evaluation, teacher's evaluation of the child's need for referral and living in other than a biological two-parent family. At age 16, externalizing and internalizing problems, total competence and family composition were independently associated with service use.
Both child psychopathology and family disruption were associated with service use. Only a minority of children at risk of psychiatric disorders had used child mental health services.
The present study aimed to identify the needs and describe the use of twenty mental health services in a population of chronic schizophrenic patients living in two regions in Quebec (Estrie and Centre-Sud). An attempt was also made to determine the principal reasons for which some services were not being used when they were identified as clinically required. The population considered was composed of the patients (N = 88) who had been discharged from the psychiatric care units of five general hospitals over a period of five months in 1982, and for whom the attending psychiatrist could confirm with certainty a diagnosis of chronic schizophrenia in accordance with the criteria of DSM-III. Medical files of these patients were reviewed, and the patients and psychiatrists themselves were interviewed separately regarding the patients' needs and use of twenty mental health services over the period from the seventh to the twelfth month after discharge from hospital. Results of the study show that services which were most often identified as clinically required were: 1) taking of neuroleptics, 2) organization of leisure activities, 3) case management, and 4) individual supportive therapy. At the same time, results indicate a poor fit between needs and use for most of rehabilitation and psychosocial services. The main reasons for non-use of services which were identified as clinically required are also presented. The implications of these results for the organization of mental health services for persons suffering from chronic schizophrenia are discussed, especially the importance of case management services.
The aim of this study was to examine long-term changes in symptoms of post-traumatic stress disorder, depression, anxiety, and in health-related quality of life in traumatized refugees 23 months after admission to multidisciplinary treatment. The study group comprised 45 persons admitted to the Rehabilitation and Research Centre for Torture Victims in 2001 to 2002. Data on background, trauma, present social situation, mental symptoms (Hopkins Symptom Checklist-25, Hamilton Depression Scale, Harvard Trauma Questionnaire), and on health-related quality of life (World Health Organization Quality of Life-Bref) were collected before treatment and after 9 and 23 months. No substantial changes in mental health were observed at the 9-month follow-up, and the minor decrease in some symptoms observed between the 9 and 23 months may reflect regression toward the mean or the natural course of symptoms in this cohort. Thus, no clinically significant improvement was observed, but there is a need for further studies, in particular randomized trials evaluating the efficacy of various health-related and social interventions among severely traumatized refugees.
In a longitudinal study, a representative sample of nearly 2000 young people (17-20 years) was followed up in 1985, 1987 and 1989. The Central Bureau of Statistics in Norway was responsible for the collection of data. The results showed that unemployment had a weak but significant impact upon mental health problems. Active job seeking did not seem to moderate the mental health problems experienced by the unemployed. Social support and contact with close friends had a moderating effect upon nervous symptoms in women but not in men. Unemployed men who were especially involved in illegal activity showed increased nervous symptoms during unemployment.
The aim of this study is to examine the possible changes in depressive symptoms related to various adverse experiences, based on a three-year follow-up among adolescents.
All 10(th) graders invited to enter the youth section of the Oslo Health Study 2001 (n = 3,811) constituted a baseline of a longitudinal study. A high level of mental distress (Hscl-10 score = 1.85) according to the different life experiences was compared, at baseline (15 years) and follow-up (18 years).
All adverse experiences were associated with a high Hscl-10 score except parents not living together and death of a close person at 15 and 18 years for boys, and death of a close person at 18 years of age for girls. A development from high Hscl-10 score at baseline to low score at follow up was defined as recovery from mental distress. The proportion of the youth that had a high Hscl-10 score related to reporting adverse life experiences at age 15, followed by a low Hscl-10 score three years later proved to be between 44% and 89% among boys and between 16% and 31% among girls.
From a three year longitudinal perspective the recovery from mental distress is substantial and higher among boys than among girls. However, mental distress seems to persist in a considerable proportion of the adolescents. Consequently, it is insufficient to brush aside traumas and hurt and rely on a time healing process only.
PURPOSE: The purpose of this study was to assess disability and the physical and mental health status 1 year after traumatic brain injury (TBI), using the International Classification of Functioning, Disability and Health (ICF) as a conceptual model for understanding TBI disability. METHODS: A prospective study of 85 patients with moderate-to-severe TBI (aged 16-55 years) due to injury occurring from May 2005 to May 2007 and hospitalised at the Trauma Referral Centre in Eastern Norway were included. The severity of structural brain damage and overall trauma were used as indices of body structure impairments. Activity limitations were measured by the Functional Independence Measure, and participation restrictions were assessed via the Community Integration Questionnaire. Physical and mental health dimensions as reported on the Medical Outcome Survey Short-Form were chosen as outcome measures. RESULTS: Roughly one quarter of the patients reported disability requiring personal assistance. One third [corrected] had major problems with social integration, and 42% were not working. Nearly half of the patients reported poor physical health, and 37% reported poor mental health. Regression models, including demographics, impairments, activity limitations and participation restrictions, accounted for 50% of the variance in physical health and 35% of the variance in mental health. More severe impairments, fewer activity limitations and fewer participation restrictions equated to better overall health. CONCLUSIONS: The results demonstrated that a significant proportion of TBI survivors face substantial disability and impaired overall health 1 year after injury. To optimise health and well-being outcomes, clinicians need to ensure that health needs of patients with less severe TBI are identified and treated during the post-acute period.
Most mental disorders start in childhood and adolescence. Risk factors are prenatal and perinatal, genetic as well as environmental and family related. Research evidence is, however, insufficient to explain the life-course development of mental disorders. This study aims to provide evidence on factors affecting mental health in childhood and adolescence.
The 1987 Finnish Birth Cohort covers all children born in Finland in 1987 (N=59 476) who were followed up until the age of 21 years. The study covers detailed health, social welfare and sociodemographic data of the cohort members and their parents from Finnish registers.
Altogether, 7578 (12.7%) cohort members had had a diagnosed mental disorder. Several prenatal, perinatal and family-related risk factors for mental disorders were found, with sex differences. The main risk factors for mental disorders were having a young mother (OR 1.30 (1.16 to 1.47)), parents' divorce (OR 1.33 (1.26 to 1.41)), death of a parent (OR 1.27 (1.16 to 1.38)), parents' short education (OR 1.23(1.09 to 1.38)), childhood family receiving social assistance (OR 1.61 (1.52 to 1.71)) or having a parent treated at specialised psychiatric care (OR 1.47 (1.39 to 1.55)). Perinatal problem (OR 1.11 (1.01 to 1.22)) and prenatal smoking (OR 1.09 (1.02 to 1.16)) were risk factors for mental disorders, even after controlling for background factors. Elevated risk was seen if the cohort member had only basic education (OR 3.37 (3.14 to 3.62)) or had received social assistance (OR 2.45 (2.30 to 2.60)).
Mental disorders had many social risk factors which are interlinked. Although family difficulties increased the risk for mental disorders, they were clearly determined by the cohort member's low education and financial hardship. This study provides evidence for comprehensive preventative and supporting efforts. Families with social adversities and with parental mental health problems should be supported to secure children's development.
PURPOSE: We aimed to study the occurrence and predictors of medical students' mental health problems that required treatment. SUBJECTS AND METHODS: Medical students from all Norwegian universities (N=421) were surveyed in their first term (T1), and 3 (T2) and 6 (T3) years later. The dependent variable was "Mental health problems in need of treatment". Predictor variables included personality traits, medical school stress and negative life events. RESULTS: The lifetime prevalence of mental health problems was 15% at T1. At T2, of the 31% who reported problems during the first 3years, a majority had not sought help. At T3, 14% reported problems during the preceding year. Adjusted predictors of problems at T2 were previous mental health problems (p
This article deals with certain preliminary findings obtained in a long-term prospective study begun in 1982 using the interview method; the first follow-up was carried out in 1986, the method consisting of a postal inquiry and the collection of recorded data. The sample consists of 200 randomly selected inhabitants of Turku born in 1920 and 189 individuals of the same age living in rural municipalities in the vicinity of Turku. During the 4-year follow-up period the subjects' biopsychosocial situation remained almost unchanged, showing that, for most people, retirement is not a stressor of crucial importance or a life crisis. Of the variables relating to the initial survey, poor subjective physical health, self-assessed work disability, poor financial situation, change into a taciturn and timid individual in adolescence, the spouse's poor mental equilibrium, an excess of leisure time and general dissatisfaction with life were associated with subsequent mental disturbance as measured by use of the General Health Questionnaire.
Major depression makes an important contribution to disease burden in Canada. In principle, the burden of major depression can be reduced by the provision of treatment within the health care system. In a previous data analysis, the National Population Health Survey (NPHS) reported an increase in antidepressant (AD) use between 1994 and 1998. In this paper, the analysis is extended to 2000, and additional aspects of health care utilization are described.
The NPHS provides a unique source of longitudinal data concerning major depression and its treatment in Canada. In this survey, probable cases of major depression were identified using a brief predictive instrument; health care utilization was evaluated using additional survey items; and the latest data release from Statistics Canada (that is, 2000) was used to make weighted estimates of the frequency of health care utilization in relation to major depression status.
The use of ADs has continued to escalate. These increases have been largest in men and in persons aged under 35 years. There has been an increase in polypharmacy: in 2000, almost 9% of persons taking an AD reported taking more than 1 AD medication-a tripling since 1994. The frequency of consultations with alternative practitioners has also grown. Although the overall proportion of persons with major depression who report consulting with health professionals about their mental health has not increased, the number of persons with major depressive disorder reporting 6 or more visits to nurses, social workers, and psychologists may have.
The provision of AD treatment continues to expand in Canada. This probably represents a changing pattern of practice, because the frequency of professional consultation has not increased. More detailed data are required to evaluate the extent to which treatment needs are being met.
Comment In: Evid Based Ment Health. 2005 Feb;8(1):2615671517
The purpose of this study was to investigate the relationship between cognitive disability and performance of daily living skills and stability of cognitive level after discharge in a sample of adult psychiatric inpatients (N = 40).
The Allen Cognitive Level Test-90 (ACL-90) was administered at time of discharge (Time I) and at 21 days to 28 days after discharge (Time II). The self-report version of the revised Routine Task Inventory (RTI-2) was also administered at Time II.
No significant correlation was found between the ACL-90 at Time I and the RTI-2 scores; however, significant correlations were found between the ACL-90 scores at both times and between the ACL-90 score at Time II and the RTI-2 scores.
The findings suggest that cognitive level remains relatively stable over a 1-month period in the postacute stage of a psychiatric illness. Cognitive level and performance of daily living skills are related, but the relationship is sensitive to time. Implications for occupational therapy assessment include recognizing the temporal constraints of functional assessments and refining instruments to be more sensitive to performance of familiar tasks, taking into consideration client adaptation to exigencies.
BACKGROUND: There is no long-term prospective study (>20 years) of the mental health of any refugee group. AIMS: To investigate the long-term course and predictors of psychological distress among Vietnamese refugees in Norway. METHOD: Eighty Vietnamese refugees, 57% of the original cohort previously interviewed in 1982 (T(1)) and 1985 (T(2)), completed a self-report questionnaire prior to a semi-structured interview. Mental health was measured using the Symptom Checklist-90-Revised (SCL-90-R). RESULTS: The SCL-90-R mean Global Severity Index (GSI) decreased significantly from T(1) to T(3) (2005-6), but there was no significant change in the percentage reaching threshold scores (GSI =1.00). Trauma-related mental disorder on arrival and the trajectory of symptoms over the first 3 years of resettlement predicted mental health after 23 years. CONCLUSIONS: Although the self-reported psychological distress decreased significantly over time, a substantial higher proportion of the refugee group still remained reaching threshold scores after 23 years of resettlement compared with the Norwegian population. The data suggest that refugees reaching threshold scores on measures such as the SCL-90-R soon after arrival warrant comprehensive clinical assessment.
The complex nature of recent wars and armed conflicts has forced many war-injured persons into exile. To investigate their long-term mental health, three instruments for assessing mental health (HSCL-25, PTSS-10, and a Well-Being scale) were presented to 44 war-wounded refugees from nine different countries 8 years after arrival in Sweden. The prevalence of psychiatric symptoms was high and corresponds to findings in previous studies of refugee patient populations. A lower level of mental health was associated with higher education, unemployment, and poor physical health. The findings suggest a high psychiatric morbidity and a need for psychiatric interventions in this refugee group. Methodological issues to be considered in research on sequels of war traumas are discussed.
Previous analyses demonstrated an elevated occurrence of perceived unmet need for mental health care among persons with co-occurring mental and substance use disorders in comparison with those with either disorder. This study built on previous work to examine these associations and underlying reasons in more detail.
Secondary data analyses were performed on a subset of respondents to the 2002 Canadian Community Health Survey (unweighted N=4,052). Diagnostic algorithms classified respondents by past-year substance dependence and selected mood and anxiety disorders. Logistic regressions examined the associations between diagnoses and unmet need in the previous year, accounting for recent service use and potential predisposing, enabling, and need factors often associated with help seeking. Self-reported reasons underlying unmet need were also tabulated across diagnostic groups.
Of persons with a disorder, 22% reported a 12-month unmet need for care. With controls for service use and other potential confounders, the odds of unmet need were significantly elevated among persons with co-occurring disorders (adjusted odds ratio=3.25; 95% confidence interval=1.96-5.37). Most commonly, the underlying reason involved a preference to self-manage symptoms or not getting around to seeking care, with some variation by diagnosis.
The findings highlight potential problems for individuals with mental and substance use disorders in accessing services. The elevated occurrence of perceived unmet need appeared to be relatively less affected by contact with the health care system than by generalized distress and problem severity. Issues such as stigma, motivation, and satisfaction with past services may influence help-seeking patterns and perceptions of unmet need and should be examined in future work.
Economic evaluation is becoming an increasingly important part of the evaluation of health and mental health services. Current models for conducting economic evaluation, including cost-effectiveness analysis, cost-benefit analysis, and cost-utility analysis, have great potential for improving the quality of decision-making and for making mental health programs more effective and efficient. This paper presents the basic economic theory underlying the various forms of economic evaluation and provides general guidelines for developing and conducting an economic analysis of a health program.
Comment In: Can J Psychiatry. 1989 Oct;34(7):631-22509060
People who have sustained severe multiple injuries have reduced health and functioning years after the injury. For people who have sustained severe injuries, an optimal degree of predictability in future functioning and health-related quality of life is important. The main aim was to study the impacts of demographic- and injury-related factors as well as functioning at 1 year and 2 years after injury on physical and mental health 10 years after injury.
Fifty-eight participants completed a 10-year follow-up (55.2% of all included patients). Demographic and injury severity characteristics were collected, and assessments at 1, 2, 5, and 10 years after injury were performed. Patient-reported outcome measures were the Short Form 36 (SF-36), the Brief Approach/Avoidance Coping Questionnaire, and the cognitive function scale (COG). The SF-36 Physical and Mental Component Summaries (PCS and MCS, respectively) were the main outcome variables. We performed hierarchical multiple regression analyses to assess functioning on the PCS and MCS.
Mean (SD) age at injury was 37.8 (14.7) years, 74% were male. Mean (SD) New Injury Severity Score (NISS) was 33.7 (13.0). Mean (SD) PCS score was 41.8 (11.7). Mean (SD) MCS was 48.8 (10.7). Predictors of the PCS were change in coping from 2 years to 10 years (p = 0.032), physical functioning (p
This longitudinal study explored associations between psychosomatic symptoms in adolescence and mental health symptoms in early adulthood. The baseline data were collected in 1996 from 14-year-old pupils (n = 235; 116 girls, 119 boys) at schools using a structured questionnaire that included a 14-item scale of psychosomatic symptoms. The follow-up data were collected in 2006 from the same persons at the age of 24 using the Symptom Checklist-90. Follow-up questionnaires were returned by 149 (63.4%) young adults (88 women and 61 men). Young adults who had many psychosomatic symptoms in adolescence suffered more often than the others from somatization and anxiety symptoms in early adulthood. In addition, women had more symptoms of depression and paranoid ideation, and men had more interpersonal sensitivity and psychotic symptoms. Psychosomatic symptoms in adolescence might be important signals of mental health and this should be taken seriously in school health and in general primary care.
The aim of the study was to identify predictors of mental symptoms (posttraumatic stress disorder, depression, and anxiety), and of health-related quality of life in refugees 10 years after referral to the Rehabilitation and Research Centre for Torture Victims, and to study changes in mental health over time. The study sample comprises 139 tortured refugees admitted to a pretreatment assessment in 1991 to 1994. Data on background and trauma, and in a subsample on mental symptoms, were collected at baseline. In 2002 and 2003, data on mental symptoms, health-related quality of life, and the participants' social situation were collected. The level of emotional distress was high at follow-up. Social relations and unemployment at follow-up were important predictors of mental health symptoms and low health-related quality of life. A significant decrease in mental symptoms was observed in the subsample. Social relations and unemployment should be taken into account when developing health-related and social interventions.