Montreal Cognitive Assessment (MoCA) as a screening tool for cognitive impairment in early stages of psychosis

Background

Cognitive alterations have been reported in early stages of psychosis including people with First Episode Psychosis (FEP), Clinical High-Risk Mental State (CHR), and Psychotic-Like Experience (PLE). This study aimed to compare the cognitive function in early stages of psychosis using the Montreal Cognitive Assessment (MoCA), a low-cost and brief assessment tool of cognitive functions.

Methods

A total of 154 individuals, including 35 with FEP, 38 CHR, 44 PLE, and 37 healthy controls (HC), were evaluated with the MoCA in Santiago, Chile. We calculated the mean total score of the MoCA and the standard deviation of the mean. Groups were assessed for a trend to lower scores in a pre-determined sequence (HC > PLE > CHR > FEP) using the Jonckheere-Terpstra test (TJT).

Results

The mean total MoCA scores were 24.8 ± 3.3 in FEP, 26.4 ± 2.4 in CHR, 26.4 ± 2.3 in PLE, and 27.2 ± 1.8 in HC. The analyses revealed a significant trend (p < 0.05) toward lower MoCA individual domain scores and MoCA total scores in the following order: HC > PLE > CHR > FEP. The mean total scores of all groups were above the cut-off for cognitive impairment (22 points).

Conclusions

The MoCA describes lower scores in cognition across early stages of psychosis and may be a useful low-cost assessment instrument in early intervention centers of poorly resourced settings.

Healthcare utilization and unmet needs of patients with antisynthetase syndrome: An international patient survey

Antisynthease syndrome (ASSD) is a rare, complex and understudied autoimmune disease. Internet-based studies can overcome barriers of traditional on-site research and are therefore very appealing for rare diseases. The aim of this study was to investigate patient-reported symptoms, diagnostic delay, symptoms, medical care, health status, working status, disease knowledge and willingness to participate in research of ASSD patients by conducting an international web-based survey. The multilingual questionnaire was created by an international group of rheumatologists and patients and distributed online. 236 participants from 22 countries completed the survey. 184/236 (78.0%) were female, mean age (SD) was 49.6 years (11.3) and most common antisynthetase antibody was Jo-1 (169/236, 71.6%). 79/236 (33.5%) reported to work full-time. Median diagnostic delay was one year. The most common symptom at disease onset was fatigue 159/236 (67.4%), followed by myalgia 130/236 (55.1%). The complete triad of myositis, arthritis and lung involvement verified by a clinician was present in 42/236 (17.8%) at disease onset and in 88/236 (37.3%) during the disease course. 36/236 (15.3%) reported to have been diagnosed with fibromyalgia and 40/236 (16.3%) with depression. The most reported immunosuppressive treatments were oral corticosteroids 179/236 (75.9%), followed by rituximab 85/236 (36.0%). 73/236 (30.9%) had received physiotherapy treatment. 71/236 (30.1%) reported to know useful online information sources related to ASSD. 223/236 (94.5%) were willing to share health data for research purposes once a year. Our results reiterate that internet-based research is invaluable for cooperating with patients to foster knowledge in rare diseases.

[Transition from Child and Adolescent to Adult Psychiatry in a German Metropolitan Region: An Explorative Cross-Sectional Study]

CONCERN

In psychiatry, the transition phase presents a particular challenge. The study aims to investigate gaps in care during the transition to adult psychiatry.

METHODOLOGY

After a qualitative preliminary study, 100 patients with previous child and adolescent psychiatric treatment were interviewed in a standardised way about the utilisation behaviour, the need for help and the experience during, before and after the transition phase. The data were analysed descriptively and using interval estimation (probability of coverage).

RESULTS

A treatment gap of more than 3 months was documented in 75% of the patients*. The study showed that treatment interruption was experienced as a risk for further crises and that there was often a lack of information on further treatment options.

CONCLUSION

The transition from child and adolescent to adult psychiatric treatment is not seamless and requires professional support.

Diagnostic delay stages and pre-diagnostic treatment in patients with suspected rheumatic diseases before special care consultation: results of a multicenter-based study

Early and effective discrimination (triage) of patients with inflammatory rheumatic diseases (IRD) and other diseases (non-IRD) is essential for successful treatment and preventing damage. The aim of this study was to investigate diagnostic delays and pre-diagnosis treatment in patients newly presenting to rheumatology outpatient clinics. A total of 600 patients newly presenting to one university hospital and two non-academic centers were included. Time from onset of symptoms to rheumatology consultation "total delay" as well as medical treatment before consultation were recorded. Median time from symptom onset to rheumatologist appointment (total delay) was 30 weeks. Median time to online search, first physician appointment request and first physician appointment was 2, 4 and 5 weeks, respectively. Total delay was significantly shorter for IRD patients compared to non-IRD patients, 26 vs 35 weeks (p = 0.007). Only 17.7% of all patients and 22.9% of IRD patients had a delay of less than 12 weeks. Total delay was significantly lower in patients seen in non-academic centers compared to the university center, 20 vs 50 weeks (p < 0.0001). 32.2% of IRD patients received medical treatment that eased their symptoms prior to the rheumatology appointment. These findings highlight the persistent diagnostic delays in rheumatology; however, they also suggest that current triage strategies effectively lead to earlier appointments for IRD patients. Improvement of triage methods and pre-diagnosis treatment could decrease overall burden of disease in IRD patients.

Implementation of open dialogue in Germany: Efforts, challenges, and obstacles

Purpose

The Open Dialogue (OD) approach has been implemented in different countries worldwide. OD not only depends on therapeutic principles but also requires a distinct set of structural changes that may impede its full implementation. In Germany, OD is currently practiced in different mental health care settings across the country. Yet, full implementation of OD principles is limited due to the extreme structural and financial fragmentation of the German mental health care system. With this as a background, the aim of this study was to investigate the efforts, challenges and obstacles of OD implementation in Germany.

Methods

This article presents the German results from the international HOPEnDIALOGUE survey, supplemented with expert interview data. Thirty eight teams currently providing OD took part in the survey. Sixteen expert interviews were carried out with stakeholders from various care settings. Survey data were analyzed descriptively and the qualitative data were evaluated using a thematic analysis approach.

Results

While having to adapt to the fragmented German health care system, OD has been mainly implemented from outpatient service providers and stand-alone services. About half of the teams implemented OD under the conditions of cross-sectoral model contracts and, thus, are considerably limited when it comes to OD implementation. Altogether, OD is not implemented to its full extent in each of the institutions surveyed. Similarly, the expert interviews revealed various challenges that mainly relate to the realization of OD's structural principles, whereas the implementation of its therapeutic benefits remains less affected. However, these challenges have managed to lead to great commitment by single teams and a certain level of implementation of OD-related concepts.

Conclusion

OD in Germany can currently only be fully implemented under the cross-sectoral care model contract system that is often temporary, thus significantly hindering its continuous development. Any evaluation of OD's effectiveness in Germany thus needs to take into account the fragmented nature of the country's health care system and control for the multiple barriers that impede implementation. Reforms of the German health care system are also urgently needed to create more favorable conditions for the implementation of OD.

[Experience-based items of quality in psychiatric treatment: A first multivariate construct]

In the context of psychiatric care, user-generated measurement instruments may contribute to quality development and assurance. An explorative construct of experience-related quality components was developed in participative-collaborative cooperation that grasps the users' experiences of psychiatric care. After developing the components using a grounded theory methodology, they were quantified, and their interrelations were investigated using a multidimensional scaling method to explore their internal cohesion. The construct makes it possible to separate structural from interpersonal requirements of the quality components. It further indicated which components are more feasible for the home treatment setting, and which ones for an institutional setting. The components and the construct may be perceived as first steps towards the development of user-generated quality indicators; however, further validation steps are necessary.

Physicians' Perspectives on the Implementation of the Second Opinion Directive in Germany-An Exploratory Sequential Mixed-Methods Study

A new Second Opinion Directive (SOD) was introduced in Germany in December 2018 for hysterectomy, tonsillotomy, and tonsillectomy to support shared decision making and to avoid unnecessary surgeries. Owing to its recent implementation, evidence and insights regarding outcomes and challenges encountered with the SOD are lacking, notably from the physicians' perspective. To assess this, we undertook an exploratory sequential mixed-methods design with an initial qualitative phase followed by a quantitative evaluation. A qualitative analysis of 22 interviews with specialists in gynecology and otorhinolaryngology was followed by a statistical analysis of a survey of 136 physicians in those disciplines. The specialists expressed a generally positive opinion of the new SOD, emphasizing the aspects of patient orientation, support in decision making, and patient safety. However, they also highlighted the following structural problems regarding the SOD implementation: In addition to an increased organisational effort, the specialists criticised the SOD with regard to its implementation in rural regions with a low availability of specialists for referral. Barriers that impede the implementation of the current directive, such as the adaptation of the qualifying requirements for authorized second opinion physicians, as well as the inclusion of relevant indications, need focused consideration to obtain better alignment with everyday practice.

Mental and Physical Well-Being and Burden in Palliative Care Nursing: A Cross-Setting Mixed-Methods Study

The working routines in palliative care nursing are associated with a variety of causes of stress with regional and setting-specific differences in Germany. This mixed-methods study aimed to investigate the mental and physical well-being among nurses in German palliative and hospice care and to gain a deeper understanding of procedural and structural aspects that may influence the mental and physical burden in palliative nursing care. The mixed-methods approach combined qualitative interviews, (n = 16) an online survey (n = 101), and subsequent data validation in a focus group (n = 6). Interview and focus group data were analysed using structured qualitative content analysis. Survey data were analysed using descriptive statistics and an explorative quantitative analysis. Moderate to very high levels of stress were reported across all settings, but were highest for nurses in specialized outpatient palliative care settings. Underlying causes of stress related to working conditions in the nursing profession across all palliative care settings were poor working hours, perceived inadequate remuneration, and high demands for documentation. To ensure sustainable high-quality palliative care, adaptations to working conditions that target causes of stress and burden in palliative care nurses are required.

[Flexible and integrative treatment in psychiatry: implementation of specific care components at model and standard care clinics in Germany (PsychCare study)]

BACKGROUND

Since 2003 a new remuneration and care model has been implemented in currently 22 psychiatric clinics in Germany, which provides flexible and integrative treatment (FIT) across different settings of treatment, including assertive outreach care. The FIT is based on a global treatment budget covering costs for all psychiatric hospital services and is related to the number of patients treated per year. Previous research identified 11 program components that describe treatment structures and processes of FIT. The present analysis quantitatively compared FIT with standard care, aiming to validate these components.

METHODS

As part of the PsychCare study, grading according to FIT-specific components was carried out and comparatively analyzed in nine hospitals that used FIT and seven hospitals of standard care. The FIT models were examined in depth in subgroups, which were divided according to the share of the FIT model in the total hospital budget.

RESULTS

Of the 11 FIT program components 7 (flexible care management across settings, therapeutic group sessions across all settings, outreach home care, involvement of informal caregivers, accessibility of services, cooperation across sectors and expansion of professional expertise) showed a high statistical differentiation. These differences were even stronger in the subgroup of those hospitals that had a model contract with all health insurers.

CONCLUSION

Specific components of FIT are suitable for evaluating the quality of implementation of intersectoral, flexible and outreach psychiatric care.

[Biometric properties of QUALIFY: a tool for assessing quality indicators]

INTRODUCTION

Accurate health care evaluation using quality indicators (QIs) is of vital clinical importance for a quality-oriented health care system. The QUALIFY tool is the current research standard for assessing QIs of health care; however, its biometric properties in psychiatry have not yet been evaluated empirically. Our aim was to evaluate the internal consistency and structure of QUALIFY.

METHODS

This study applies a literature-based post-hoc analytical design to a sample of 289 QIs of mental health care. First, the indicators were assessed on the basis of nineteen ordinal QUALIFY criteria as a single measuring tool. Second, using Cronbach's alpha the internal consistency of the measuring tool was evaluated and the structure of QUALIFY using an explorative principal component analysis was tested.

RESULTS AND DISCUSSION

The tool showed an acceptable internal consistency (Cronbach's α=0.75), with three criteria (consideration of potential risks/side effects when using the indicator, implementation barriers taken into account, and the ability to influence the indicator) being inconsistent with the full scale. If these three criteria were not taken into account, the tool had a good internal consistency (Cronbach's α=0.81). The QUALIFY structural matrix comprises three components, one of which reflected six from eight original quality criteria of the scientific category. The other two components represent the semiotic structure of the QIs.

CONCLUSION

QUALIFY is an internally inconsistent instrument, which may be useful to assess mental health care QIs. The information about the structure of QUALIFY can be applied for the purposes of research planning as well as the interpretation and development of QIs.

Patient's Perception of Digital Symptom Assessment Technologies in Rheumatology: Results From a Multicentre Study

Introduction

An increasing number of digital tools, including dedicated diagnostic decision support systems (DDSS) exist to better assess new symptoms and understand when and where to seek medical care. The aim of this study was to evaluate patient's previous online assessment experiences and to compare the acceptability, usability, usefulness and potential impact of artificial intelligence (AI)-based symptom checker (Ada) and an online questionnaire-based self-referral tool (Rheport).

Materials and Methods

Patients newly presenting to three German secondary rheumatology outpatient clinics were randomly assigned in a 1:1 ratio to complete consecutively Ada or Rheport in a prospective non-blinded multicentre controlled crossover randomized trial. DDSS completion time was recorded by local study personnel and perceptions on DDSS and previous online assessment were collected through a self-completed study questionnaire, including usability measured with the validated System Usability Scale (SUS).

Results

600 patients (median age 52 years, 418 women) were included. 277/600 (46.2%) of patients used an online search engine prior to the appointment. The median time patients spent assessing symptoms was 180, 7, and 8 min, respectively using online using search engines, Ada and Rheport. 111/275 (40.4%), 266/600 (44.3%) and 395/600 (65.8%) of patients rated the respective symptom assessment as very helpful or helpful, using online search engines, Ada and Rheport, respectively. Usability of both diagnostic decision support systems (DDSS) was “good” with a significantly higher mean SUS score (SD) of Rheport 77.1/100 (16.0) compared to Ada 74.4/100 (16.8), (p < 0.0001). In male patients, usability of Rheport was rated higher than Ada (p = 0.02) and the usability rating of older (52 years ≥) patients of both DDSS was lower than in younger participants (p = 0.005). Both effects were independent of each other. 440/600 (73.3%) and 475/600 (79.2%) of the patients would recommend Ada and Rheport to friends and other patients, respectively.

Conclusion

In summary, patients increasingly assess their symptoms independently online, however only a minority used dedicated symptom assessment websites or DDSS. DDSS, such as Ada an Rheport are easy to use, well accepted among patients with musculoskeletal complaints and could replace online search engines for patient symptom assessment, potentially saving time and increasing helpfulness.

Flexible and Integrative Psychiatric Care Based on a Global Treatment Budget: Comparing the Implementation in Germany and Poland

Background: The past decade has witnessed the establishment of flexible and integrative treatment (FIT) models in 55 German and Polish psychiatric catchment areas. FIT is based on a global treatment budget (GTB), which integrates funding of all acute psychiatric hospital services for a regional population. Prior research has identified 11 specific program components of FIT in Germany. In this paper we aim at assessing the applicability of these components to the Polish context and at comparatively analysing FIT implementation in Poland and Germany. Methods: Qualitative interviews about the applicability of the 11 FIT-specific components were conducted with the program managers of the Polish FIT models (n = 19). Semi-quantitative data on the FIT-specific components were then collected in 19 Polish and 10 German FIT models. We assessed the grading of each component, their overall degree of implementation and compared them between the two countries. In all study hospitals, structural and statistical parameters of service delivery were collected and compared. Results: The qualitative results showed that the German FIT-specific components are in principle applicable to the polish context. This allowed the comparative assessment of components grading and degree of implementation, which showed only subtle discrepancies between German and Polish FIT models. The little discrepancies point to specific aspects of care such as home treatment, peer support, and cooperation with non-clinical and social welfare institutions that should be further integrated in the components' definition. Conclusions: The specific program components of FIT as first defined from the German experience, serves as a powerful tool to measure, and evaluate implementation of integrated psychiatric care both within and between health systems.

Needs and Experiences in Psychiatric Treatment (NEPT)- Piloting a Collaboratively Generated, Initial Research Tool to Evaluate Cross-Sectoral Mental Health Services

BACKGROUND

Research tools to evaluate institutions or interventions in the field of mental health have rarely been constructed by researchers with personal experience of using the mental health system ("experiential expertise"). This paper presents a preliminary tool that has been developed within a participatory-collaborative process evaluation as part of a controlled, multi-center, prospective cohort study (PsychCare) to evaluate psychiatric flexible and integrative treatment, FIT for short, models in Germany.

METHOD

The collaborative research team consisting of researchers with and without experiential expertise developed 12 experiential program components of FIT models by an iterative research process based on the Grounded Theory Methodology. These components were transformed into a preliminary research tool that was evaluated by a participatory expert panel, and during a pilot and validation study, the latter using a random sample of 327 users from 14 mental health departments. Internal consistency of the tool was tested using Cronbach's alpha. Construct validity was evaluated using a Principal Components Analysis (PCA) and a Jonckheere Terpstra test in relation to different implementation levels of the FIT model. Concurrent validity was tested against a German version of the Client Satisfaction Questionnaire (ZUF-8) using correlation analysis and a linear regression model.

RESULTS

The evaluation of the expert panel reduced 29 initial items to 16 that were further reduced to 11 items during the pilot study, resulting into a research tool (Needs and Experiences in Psychiatric Treatment-NEPT) that demonstrated good internal consistency (Cronbach's alpha of 0.89). PCA yielded a 1-component structure, which accounted for 49% of the total variance supporting the unidimensional structure of the tool. The total NEPT score increased alongside the increasing implementation of the FIT model (p < 0.05). There was evidence (p < 0.001) for convergent validity assessed against the ZUF-8 as criterion measure.

CONCLUSIONS

The NEPT tool seems to be promising for further development to assess the experiences with and fulfillment of needs of psychiatric care models from the perspective of users. This paper demonstrates that it is possible to use a participatory-collaborative approach within the methodologically rigorous confines of a prospective, controlled research design.

[Expectations of patients and relatives for modern hospital care in geriatric psychiatry]

OBJECTIVE

In order to improve health care in geriatric psychiatry, users must be granted a larger role in shaping their treatment. To this aim we identify factors that are essential to psychiatric care from users' perspectives.

METHODS

Focus groups and interviews (n = 12) were conducted to identify the health care factors that were most essential to its users. In addition, patients (n = 72) and relatives (n = 62) evaluated the current health care in a questionnaire.

RESULTS

The most essential factors were longer consultations with doctors and treatment providers, comprehensive and comprehensible information, individualized procedures and therapies, having clearly defined scopes for each professional group, environmental factors and the integration of relatives into the therapy process.

CONCLUSION

The reported factors could help improve health services in geriatric psychiatry by pointing towards potential changes and room for optimization in health care on both structural and process levels.

Multiperspective and Multimethod Evaluation of Flexible and Integrative Psychiatric Care Models in Germany: Study Protocol of a Prospective, Controlled Multicenter Observational Study (PsychCare)

Background: New cross-sectoral mental health care models have been initiated in Germany to overcome the fragmentation of the German health care system. Starting in 2013, flexible and integrative psychiatric care model projects according to §64b SGB V German Social Law (FIT64b) have been implemented. The study "PsychCare" combines quantitative and qualitative primary data with routine health insurance data for the evaluation of these models. Effects, costs and cost-effectiveness from the perspectives of patients, relatives and care providers are compared with standard care. Additionally, quality indicators for a modern, flexible and integrated care are developed. This article describes the rationale, design and methods of the project. Methods: "PsychCare" is built on a multiperspective and multimethod design. A controlled prospective multicenter cohort study is conducted with three data collection points (baseline assessment, follow-up after 9 and 15 months). A total of 18 hospitals (10 FIT64b model and 8 matched control hospitals) have consecutively recruited in- and outpatients with pre-specified common and/or severe psychiatric disorders. Primary endpoints are differences in change of health-related quality of life and treatment satisfaction. Sociodemographic and service receipt data of the primary data collection are linked with routine health insurance data. A cost-effectiveness analysis, a mixed method, participatory process evaluation by means of qualitative surveys and the development of quality indicators are further elements of "PsychCare." Discussion and Practical Implications: The results based on data from different methodological approaches will provide essential conclusions for the improvement of hospital based mental health care in Germany. This should result in the identification of key FIT64b elements that can be efficiently implemented into standard care in Germany and re-structure the care strongly aligned to patient needs. Clinical Trial Registration: German Clinical Trial Register, identifier DRKS 00022535.

Hospital length of stay among older people treated with flexible and integrative psychiatric service models in Germany

OBJECTIVE

Since 2012, a new law (§64b, Book V of the Social Security Code [SGB V]) regulates the implementation of flexible and integrative psychiatric treatment projects (FIT64b) in Germany. FIT64b allows rapid discharge of patients from inpatient to outpatient settings and cost reductions of hospital stays. Several psychiatric centres exclusively provide FIT64b; others provide FIT64b alongside with standard health care. The aim of the study was to assess the average hospital length of stay (AHLS) of older patients with mental illness included in FIT64b projects.

METHODS

A secondary data analysis was conducted using administrative data from eight German mental health centres providing FIT64b. The effects of gender, age, type of centre, and main diagnosis on AHLS were calculated for all older patients with age 65 years or older (n = 3495) treated in FIT64b in the year 2016. Data were analysed with descriptive statistics and robust multiway procedures.

RESULTS

The AHLS of older people with mental illness was 4.8 (SD = 11.5) days. The AHLS was shorter in centres exclusively providing FIT64b than in centres providing FIT64b alongside with standard health care: 3.2 (SD = 6.4) vs 8.4 (SD = 17.8) days, P = .001. This difference was particularly marked among patients with schizophrenia spectrum disorders, mood disorders, and neurotic, stress-related, and somatoform disorders.

CONCLUSIONS

FIT64b relates to very short AHLS even among older people. Centres using FIT64b alongside with standard health care usually provide standard care to most patients, which could lead to lower fidelity in the implementation of FIT64b.

[Specific components for integrative and flexible care models according to § 64b SGB V]

BACKGROUND

There is a need for a theoretical model for evaluating integrative and flexible care models according to § 64b of the Social Security Statutes Book V (SGB V).

MATERIAL AND METHODS

An iterative process of data collection and analysis has been executed according to grounded theory methodology.

RESULTS

A total of 11 specific components have been identified and shown to be robust and practicable and compatible with the data from the literature.

CONCLUSION

These components can be used for implementation, quality management and evaluation of projects for treatment models according to § 64b SGB V.

[Implementation and Stakeholders' Experiences with Home Treatment in Germany's Integrative and Flexible Psychiatric Care Models - A Mixed-Methods Study]

OBJECTIVE

This paper seeks to illustrate current implementation of and the stakeholders' experiences with Home Treatment (=HT) according to §64b of the German Social Code Book V (=SGB V).

METHODS

381 Patients from 8 hospitals were questioned about their experiences and evaluation of HT using a standardized questionnaire (SEPICC-Scale). Further interviews and focus groups with 37 participants (including users, carers and employees) were thematically analysed. In addition, structural and performance data were collected from participating hospitals and HT teams.

RESULTS

HT according to §64b SGB V is implemented quite heterogeneously, especially between rural and urban catchment areas. It provides a long-term, cross-sectoral care, which seems to strengthen the integration of patients' everyday life, treatment flexibility and continuity of care. After having experienced HT once, it is generally rated better.

CONCLUSION

An important strength of HT (§64b SGB V) is its adaption to the users' needs and to regional distinctions. Implications for the implementation of outreach services on a larger scale in Germany can be drawn.

[Implementation of New Flexible and Integrative Psychiatric Care Models (According to §64b SGB V) in Rural Northern Germany in Comparison to Federal Territory]

AIM

New treatment models (according to §64b German Social Code) have been introduced in Germany to improve flexible and integrated forms of psychiatric care. The aim of this study was to analyse the specific conditions under which many of these models have been implemented in the federal state of Schleswig-Holstein (SH) in comparison to other federal regions.

METHODS

A standardized survey reached 383 patients in seven psychiatric departments, among them three departments in SH. In addition, routine data and data evaluating the grade of implementation in these departments were analysed.

RESULTS

Departments in SH showed more developed implementation processes, compared with departments in other regions. Implemented changes were perceived and evaluated as being better by patients in SH.

CONCLUSIONS

Implementation processes of flexible and integrated forms of care according to §64b were particularly successful in SH. Extensive political support is discussed as a major reason, among others, for this development.

Associations between childhood abuse, mental health problems, and suicide risk among male prison populations in Spain

BACKGROUND

There are few studies exploring associations between different types of childhood abuse and mental health problems among adult prisoners.

AIMS

To explore associations between history of childhood abuse, depression or anxiety, and near-lethal suicide attempts among adult prisoners, and test the hypothesis that post-traumatic stress disorder (PTSD) may be a mediator between childhood abuse and adult disorder among prisoners.

METHOD

We enrolled 943 men from three prisons in Spain. Childhood abuse was assessed with the Childhood Trauma Questionnaire at interview and current symptoms were assessed using the 21-item Depression Anxiety and Stress Scale (DASS-21). Self-reported histories of near-lethal suicide attempts were recorded.

RESULTS

Overall, 360 (40%) of the men reported at least one type of childhood abuse; 231 (24.5%) described exposure to emotional abuse, 236 (25%) to physical abuse, and 97 (10%) to sexual abuse. Survivors of all types of childhood abuse had over twice the prevalence of severe depression, anxiety, stress disorder, and near-lethal suicide attempts than men who had not been exposed. Survivors of sexual and emotional violence during childhood had more symptoms of PTSD than survivors of physical abuse. Statistically, PTSD had a mediating effect, but it was very small.

CONCLUSIONS

Although other studies have shown high rates of childhood abuse histories among prisoners, this is the first to link such a history to near-lethal suicide attempts in this population.

The Underlying Structure of Comorbid Mental Health and Substance Use Disorders in Prison Populations

BACKGROUND

High rates of mental disorders have been reported for prison populations. Understanding patterns of comorbidity may be essential for the development of adequate treatment interventions. The present study aimed to assess the underlying structure of comorbidity between mental health and substance use disorders in prison populations.

METHODS

Current mental disorders were assessed using the Mini-International Neuropsychiatric Interview in a cross-sectional observational study of 427 individuals consecutively committed to prison facilities in Santiago, Chile. Five alternative structural models were tested using confirmatory factor analysis (CFA). Latent class analysis of comorbid mental health and substance use disorders was carried out.

RESULTS

CFA indicated the best fit for a bifactor model with a general psychopathology P factor and specific internalizing and externalizing factors. Borderline personality disorder loaded highest on the P factor (0.85). The latent comorbidity structure showed a four-class solution representing one class without relevant comorbidities (48% prevalence) and three classes representing the following comorbidities: (1) externalizing disorders including substance use and antisocial personality disorder (31%), (2) internalizing disorders including anxiety disorders (10%), and (3) all types of disorders co-occurring (11%). Major depression and borderline personality disorder were present across all three latent classes of comorbidity.

CONCLUSIONS

Prison mental health services need to serve a highly comorbid population. Specific approaches may be useful for an externalizing and an internalizing spectrum of disorders. An important group of individuals with all types of mental disorders co-occurring may need new approaches in treatment development.

Evaluation of new flexible and integrative psychiatric treatment models in Germany- assessment and preliminary validation of specific program components

BACKGROUND

Flexible and integrative treatment (FIT) models are rather novel in German mental health care. This study aimed at identifying and evaluating empirically based, practicable, and quantifiable program components that describe the specific treatment structures and processes of German FIT models.

METHODS

A multi-step, iterative research process, based on Grounded Theory Methodology (GTM), was used to identify and operationalise components. A complex algorithm and expert-interviews were applied to quantify the relative weight of each component and to develop a sum score. Face and content validity were examined and internal consistency was tested by Cronbach's α coefficient.

RESULTS

Ten of eleven FIT components could be operationalised, quantified and united in the total score. All operationalised components showed sufficient face and content validity and eight components had a good reliability.

CONCLUSIONS

The components are a first step in the process of operationally defining German FIT models. They considerably overlap with various critical ingredients of international FIT models and may serve as a theoretical basis for constructing fidelity tools and research guides to enable process and outcome evaluation of German FIT models.

Evaluation of Flexible and Integrative Psychiatric Treatment Models in Germany-A Mixed-Method Patient and Staff-Oriented Exploratory Study

Contrary to the practice in some countries, access to flexible and integrated forms of psychiatric care (FIT models) is limited in Germany. Several legislations have been introduced to improve this situation, notably the recent §64b (flexible and integrative treatment model; FIT64b) of the German Social Code, which allows for a capitation-based accounting of fees for services. The aim of this study was to explore the effects of FIT64b implementation on various stakeholders (patients, informal caregivers and staff) in 12 psychiatric hospital departments across Germany. Structural as well as quantitative and qualitative data are included, with integration of different methodological approaches. In all departments, the implementation of the new accounting system resulted into a relatively stable set of structural and processual changes where rigid forms of mainly inpatient care shifted to more flexible and integrated types of outpatient and outreach treatments. These changes were more likely to be perceived by patients and staff, and likewise received better evaluations, in those departments showing higher level or longer duration of implementation. Patients' evaluations, furthermore, were largely influenced by the advent of continuous forms of care, better accessibility, and by their degree of autonomy in steering of their services.

Development and Preliminary Validation of the Scale for Evaluation of Psychiatric Integrative and Continuous Care-Patient's Version

This pilot study aimed to evaluate and examine an instrument that integrates relevant aspects of cross-sectoral (in- and outpatients) mental health care, is simply to use and shows satisfactory psychometric properties. The development of the scale comprised literature research, held 14 focus groups and 12 interviews with patients and health care providers, item-pool generation, content validation by a scientific expert panel, and face validation by 90 patients. The preliminary scale was tested on 385 patients across seven German hospitals with cross-sectoral mental health care (CSMHC) as part of their treatment program. Psychometric properties of the scale were evaluated using genuine and transformed data scoring. To check reliability and postdictive validity of the scale, Cronbach's α coefficient and multivariable linear regression were used. This development process led to the development of an 18-item scale called the "Scale for Evaluation of Psychiatric Integrative and Continuous Care (SEPICC)" with a two-point and five-point response options. The scale consists of two sections. The first section assesses the presence or absence of patients' experiences with various CSMHC' relevant components such as home treatment, flexibility of treatments' switching, case management, continuity of care, cross-sectoral therapeutic groups, and multidisciplinary teams. The second section evaluates the patients' opinions about these relevant components. Using raw and transformed scoring resulted into comparable results. However, data distribution using transformed scoring showed a smaller deviation from normality. For the overall scale, the Cronbach's α coefficient was 0.82. Self-reported experiences with relevant components of the CSMHC were positively associated with the patients approval of these components. In conclusion, the new scale provides a good starting point for further validation. It can be used as a tool to evaluate CSMHC. Methodologically, using transformed data scoring appeared to be preferable because of a smaller deviation from normality and a higher reliability measured by Cronbach's α.

Psychometric properties of the symptom check-list-90-R in prison inmates

The aim of this study was to investigate the reliability, construct and criterion validity of the Symptom Check-List-90-R (SCL-90-R) for prison inmates. A sample of 427 adult prisoners was assessed at admission to the penal justice system in the metropolitan region of Santiago de Chile using the SCL-90-R and the mini international neuropsychiatric interview. We tested internal consistency using Cronbach's alpha. We examined construct validity using Principial Components Analysis and Confirmatory Factor Analysis (PCA and CFA) as well as Mokken Scale Analysis. Receiver Operating Characteristic (ROC) analysis was conducted to examine external criterion validity against diagnoses established using structured clinical interviews. The SCL-90-R showed good internal consistency for all subscales (α=0.76-0.89) and excellent consistency for the global scale (α=0.97). PCA yielded a 1-factor structure, which accounted for 70.7% of the total variance. CFA and MSA confirmed the unidimensional structure. ROC analysis indicated useful accuracy of the SCL-90-R to screen for severe mental disorders. Optimal cut-off on the Global Severity Index between severe mental disorders and not having any severe mental disorder was 1.42. In conclusion, the SCL-90-R is a reliable and valid instrument, which may be useful to screen for severe mental disorders at admission to the prison system.

The course of major depression during imprisonment - A one year cohort study

BACKGROUND

First longitudinal studies in prisoners point to improvements of depressive symptoms during imprisonment. The aim of the present study was to assess the course of major depressive disorder during imprisonment and to identify factors influencing remission.

METHODS

Prisoners with major depressive disorder in a sample of consecutive admissions to the penal justice system in Santiago de Chile were reassessed after one year of imprisonment. Psychiatric diagnoses were established using the Mini-International Neuropsychiatric Interview; psychological symptoms were assessed with the Symptom-Check-List 90 Revised (SCL-90-R). Mean symptom scores were compared at baseline and follow-up using Student's t-test. Odds ratios (OR) of comorbid disorders and socio-demographic factors at baseline to predict depression at follow-up were calculated.

RESULTS

N=79 out of 80 inmates (99%) with major depression at baseline were included. Thirty-five prisoners (44%) had major depression at follow-up. The mean global severity score and all mean subscale scores of the SCL-90-R improved. High suicide risk was present in 37 prisoners (47%) at admission and in 11 (14%) at follow-up. The comorbid diagnosis of PTSD (OR 6.3; p<0.001) at admission and having been previously imprisoned (OR 2.5; p=0.05) predicted major depressive disorder at follow-up.

LIMITATIONS

The study could not account for temporary improvements between the assessments.

CONCLUSION

In spite of important symptom improvements, only about half of the prisoners with major depression at admission remit after one year of imprisonment. New interventions should target people with major depression and comorbid PTSD at admission.

Social characteristics of psychological distress in disadvantaged areas of Berlin

PURPOSE

Living in disadvantaged urban areas is associated with poor mental health. The purpose of this study was to assess which social characteristics were associated with psychological distress within a disadvantaged, multi-ethnic neighbourhood of Berlin.

METHODS

The study was conducted in an area of Berlin with the highest rates of unemployment and highest density of migrants. A total of 143 participants aged 18-57 years were included from a random sample. The social characteristics educational level, employment status, marital status, living alone, per-capita income and background of migration were collected. Psychological distress was assessed using the General Health Questionnaire GHQ-28; scores ≥ 5 indicated psychological distress corresponding to psychiatric caseness.

RESULTS

Psychological distress was found in 40.6% (n = 58) of the sample. Psychological distress was associated with younger age (OR = 0.95, 95% CI = 0.92-0.98, p = .004), female gender (OR = 3.51, 95% CI = 1.55-7.92, p = .003) and living alone (OR = 3.88, 95% CI = 1.58-9.52, p = .003), but not with background of migration, low educational level or with unemployment.

CONCLUSIONS

Young age and female gender may predispose for psychological distress in disadvantaged areas. Living alone could be a social indicator of poor mental health within disadvantaged urban areas. The directionality of the association is unclear.

BACKGROUND

of migration, low income and educational level do not seem to be associated with poor mental health within those areas.

Random sampling for a mental health survey in a deprived multi-ethnic area of Berlin

The aim of the study was to assess the response to random sampling for a mental health survey in a deprived multi-ethnic area of Berlin, Germany, with a large Turkish-speaking population. A random list from the registration office with 1,000 persons stratified by age and gender was retrieved from the population registry and these persons were contacted using a three-stage design including written information, telephone calls and personal contact at home. A female bilingual interviewer contacted persons with Turkish names. Of the persons on the list, 202 were not living in the area, one was deceased, 502 did not respond. Of the 295 responders, 152 explicitly refused(51.5%) to participate. We retained a sample of 143 participants(48.5%) representing the rate of multi-ethnicity in the area (52.1% migrants in the sample vs. 53.5% in the population). Turkish migrants were over-represented(28.9% in the sample vs. 18.6% in the population). Polish migrants (2.1 vs. 5.3% in the population) and persons from the former Yugoslavia (1.4 vs. 4.8% in the population)were under-represented. Bilingual contact procedures can improve the response rates of the most common migrant populations to random sampling if migrants of the same origin gate the contact. High non-contact and non-response rates for migrant and non-migrant populations in deprived urban areas remain a challenge for obtaining representative random samples.

Changes in the provision of institutionalized mental health care in post-communist countries

BACKGROUND

General psychiatric and forensic psychiatric beds, supported housing and the prison population have been suggested as indicators of institutionalized mental health care. According to the Penrose hypothesis, decreasing psychiatric bed numbers may lead to increasing prison populations. The study aimed to assess indicators of institutionalized mental health care in post-communist countries during the two decades following the political change, and to explore whether the data are consistent with the Penrose hypothesis in that historical context.

METHODOLOGY/PRINCIPAL FINDINGS

General psychiatric and forensic psychiatric bed numbers, supported housing capacities and the prison population rates were collected in Azerbaijan, Belarus, Croatia, Czech Republic, East Germany, Hungary, Kazakhstan, Latvia, Poland, Romania, Russia and Slovenia. Percentage change of indicators over the decades 1989-1999, 1999-2009 and the whole period of 1989-2009 and correlations between changes of different indicators were calculated. Between 1989 and 2009, the number of general psychiatric beds was reduced in all countries. The decrease ranged from -11% in Croatia to -51% in East Germany. In 2009, the bed numbers per 100,000 population ranged from 44.7 in Azerbaijan to 134.4 in Latvia. Forensic psychiatric bed numbers and supported housing capacities increased in most countries. From 1989-2009, trends in the prison population ranged from a decrease of -58% in East Germany to an increase of 43% in Belarus and Poland. Trends in different indicators of institutionalised care did not show statistically significant associations.

CONCLUSIONS/SIGNIFICANCE

After the political changes in 1989, post-communist countries experienced a substantial reduction in general psychiatric hospital beds, which in some countries may have partly been compensated by an increase in supported housing capacities and more forensic psychiatric beds. Changes in the prison population are inconsistent. The findings do not support the Penrose hypothesis in that historical context as a general rule for most of the countries.

Psychometric properties of a Russian version of the General Health Questionnaire-28

BACKGROUND

The 28-item General Health Questionnaire (GHQ-28) is a scaled version of the General Health Questionnaire that has been used internationally to screen for mental disorders in nonpsychiatric populations. There is great need to validate international screening instruments in the Russian language for their use in post-Soviet countries.

METHODS

200 persons were surveyed in a deprived area of Almaty, Kazakhstan using the Russian version of the GHQ-28 and socioeconomic measures (income level, employment situation and education). We calculated the median and the mean GHQ-28 scores for different socioeconomic subgroups. The internal reliability was tested using Cronbach's α coefficient and intersubscale correlations. We conducted an exploratory factor analysis using varimax rotation.

RESULTS

The median score of the GHQ-28 was 2 (mean = 3.56; SD = 5.09) for the total sample. Higher age, unemployment and female gender were significantly associated with high mean GHQ-28 scores. Cronbach's α coefficient was 0.92 for the total scale. Exploratory factor analysis revealed four factors explaining 50.07% of the variance. The factor Anxiety/Insomnia accounted for 14.87%, Severe Depression for 13.74%, Social Dysfunction for 13.47% and Somatic Symptoms for 8.81% of the variance.

CONCLUSIONS

The test showed good internal consistency. The median GHQ-28 score was relatively low compared to other countries. The subscale Severe Depression including items on suicidal ideation may have a lower acceptance than the other subscales Somatic Symptoms, Anxiety/Insomnia and Social Dysfunction.