Continuity as patterning: A process perspective on continuity

Insofar as depressive illness can be considered a single diagnostic entity, it probably constitutes the commonest one in mental health care. Although the aetiology and treatment of depression receive constant attention from psychiatric research workers, the usual patterns of mental health care delivered to all patients from a geographically circumscribed population have rarely been the subject of study. The psychiatric case register in Groningen, which since the end of 1973 has covered an urban population of approximately 45,000 offers an ideal opportunity to study patterns of care of specific diagnostic categories. The main objective of this study was to examine the relationship between diagnostic changes during the period of follow-up and patterns of mental health care, also monitored by the case register. The findings suggest not only administrative morbidity rates and patterns of care which are fairly stable over time, but also hierarchical ranking of diagnostic classes which can be related to measures expressing the intensity of mental health care.

Use of telemental health has increased among rural Medicare beneficiaries, particularly among individuals with serious mental illness (SMI). Little is known about what leads to the initiation of telemental health. To categorize the different patterns of mental health care use before initiation of telemental health services among individuals with SMI. A cohort of rural beneficiaries with SMI (defined as schizophrenia/related psychotic disorders or bipolar disorder) with an index telemental health visit in 2010-2017 was built using claims for a 20% random sample of fee-for-service Medicare beneficiaries. The authors used latent class analysis to identify classes of mental health care use in the 6 months before the index telemental health visits. Across the classes, the authors also described characteristics of index and subsequent mental health visits. The cohort included 4930 rural Medicare beneficiaries with SMI. Three classes of mental health care use before initiation of telemental health were identified. The largest class (n=3066) had minimal use of primary care provider mental health care and the second largest class (n=1537) had minimal specialty mental health care. The smallest class (n=327) was characterized by recent hospitalization or emergency department care. In the overall cohort, index visits were frequently established visits and were often with specialty prescribers. Our findings highlight 3 distinct patterns of care before telemental health initiation, providing insight into the role that telemedicine may play in mental health care for rural Medicare beneficiaries with SMI. Overall, telemental health was most often used to maintain care with existing providers.

12100 Background: ADT is associated with an increased risk of depression and anxiety, raising the concern that a substantial portion of men with prostate cancer need mental health care. We sought to investigate the development of depression or anxiety and subsequent patterns of mental health care in men with prostate cancer on ADT. Methods: Clinformatics DataMart, a claims database of commercially insured patients, was used to identify men with prostate cancer who received ADT between 2001-2015 and had continuous enrollment for 1 year before and 2 years after starting ADT. We determined the rate of incident diagnoses of depression or anxiety and the incident use of mental health treatments - psychotherapy and psychiatric medications (≥ 5 day supply) - after the start of ADT. Results: Among 37,388 men in the final analytic cohort, 11.3% (n=4239, 95% confidence interval (CI) 11.0-11.6%) received new diagnoses of depression or anxiety: 5.8% depression (95% CI, 5.5-6.0%), 3.7% anxiety (95% CI 3.5-3.9%), and 1.8% both (95% CI, 1.7-1.9%). Those who received a diagnosis of depression or anxiety were more likely to be white (68% v. 64%, p<0.01); no differences were noted in age, education, or household income. Among those with a new diagnosis of depression or anxiety, 0.07% received psychotherapy (95% CI, 0.02-0.23%), 34.9% a selective serotonin reuptake inhibitor (95% CI, 33.5-36.4%), 11.6% a serotonin norepinephrine reuptake inhibitor (95% CI, 10.7-12.6%), and 19.9% a benzodiazepine (95% CI, 18.7-21.1%). Conclusions: Among men with prostate cancer receiving ADT, more than 1 in 10 received a new diagnosis of depression or anxiety. Of those, 1 in 5 were introduced to a benzodiazepine, a drug class with risks of dependence, cognitive impairment, falls, and fractures, whereas receipt of psychotherapy was rare. Further investigation into how to improve the mental health care of men on ADT is needed. [Table: see text]

Part 1 Patterns of mental health care: current and evolving patterns of mental health care community-based treatment settings for mental disorders home care setting - client and family issues impatient hospitalization - the mental health treatment team and the therapeutic milieu legal and ethical issues in mental health nursing. Part 2 Concepts of psychiatric/mental health nursing: establishing the therapeutic nursing environment building a person-centered therapeutic relationship delivering mental health care in a continuum of settings. Part 3 Basic concepts of mental health: human development and needs influence of family and social environment on the individual the structure and development of personality. Part 4 Mental health and mental disorder: human emotions stress - effective coping and adaptation stress - ineffective coping and defence mechanisms mental status exam. Part 5 Nursing the client with a mental disorder: nursing process in the mental health setting nursing diagnosis in the mental health setting nursing care planning with specific types of disordered mental states nursing care of the older adult with a mental disorder. Part 6 Categories of mental disorders: disorders usually first diagnosed during infancy, childhood, or adolescence delirium, dementia, and amnestic and other cognitive disorders substance-related disorders schizophrenia and other psychotic disorders mood disorders anxiety and somatoform disorders personality disorders. Part 7 Intervention and treatment of mental disorders: crisis intervention milieu therapy and behaviour modification group therapy psychopharmacology and electroshock treatment of mental disorders.

Mental health (MH) care in remote areas is frequently scarce and fragmented and difficult to compare objectively with other areas even in the same country. This study aimed to analyze the adult MH service provision in 3 remote areas of Organization for Economic Cooperation and Development countries in the world. We used an internationally agreed set of systems indicators, terminology, and classification of services (Description and Evaluation of Services and DirectoriEs for Long Term Care). This instrument provided a standard description of MH care provision in the Kimberley region (Australia), Nunavik (Canada), and Lapland (Finland), areas characterized by an extremely low population density and high relative rates of Indigenous peoples. All areas showed high rates of deprivation within their national contexts. MH services were mostly provided by the public sector supplemented by nonprofit organizations. This study found a higher provision per inhabitant of community residential care in Nunavik in relation to the other areas; higher provision of community outreach services in the Kimberley; and a lack of day services except in Lapland. Specific cultural-based services for the Indigenous population were identified only in the Kimberley. MH care in Lapland was self-sufficient, and its care pattern was similar to other Finnish areas, while the Kimberley and Nunavik differed from the standard pattern of care in their respective countries and relied partly on services located outside their boundaries for treating severe cases. We found common challenges in these remote areas but a huge diversity in the patterns of MH care. The implementation of care interventions should be locally tailored considering both the environmental characteristics and the existing pattern of service provision.

Four cohorts of patients of 65 years or more who had contact with a mental health service in the first 3 months of 1975, 1977, 1979 and 1981 were followed for 1 year to study their pattern of care. Data were collected in a psychiatric case register covering a town of approximately 45,000 inhabitants in the north of the Netherlands. Patterns of care were analysed for various diagnostic groups. Findings suggest that the socially determined age of retirement of 65 years, makes less sense from a psychiatric point of view. Typical disorders of the aged, such as dementia manifest themselves in significant numbers at a much older age.

Stroke is associated with psychiatric morbidity but little is known about mental health care use in stroke patients. A probability record linkage study was conducted linking stroke cases admitted to a teaching hospital serving a catchment area between 1987 and 1995 with records from a psychiatric case register covering the same area. Stroke patients had a more than twofold increased risk of contact with mental health care than individuals in the general population (yearly prevalences of respectively 88 and 39 per 1000; risk ratio 2.24; 95 % CI 2.04-2.45). One-third of all stroke admissions had had mental health care before and more than half had had mental health care after the stroke. In the year of admission for stroke, the probability of receiving mental health care was highest, while in the more remote years the risk was lower. Stroke is associated with an increased probability of contact with mental health services. The pattern of mental health care of a stroke patient is different from that of other mental health patients: more episodic and concentrated around the time of admission for stroke.

Changing Patterns of Mental Health Care: A Case Study in the Development of Local Services. By Jackie Powell and Robin Lovelock. Aldershot: Ashgate Publishing. 1992. 210 pp. £32.00. - Volume 163 Issue 3

Introduction: The COVID-19 pandemic has been challenging the health care systems and public wellbeing unprecedentedly. The United Kingdom and Turkiye were the countries worst hit by the pandemic in the World Health Organization European region. Purpose: This review investigated the mental health policies in these countries which draw a contrasting pattern of mental health care, sociodemographic background, and income level. Following the investigation, we recommended the possible directions to be pursued by European policymakers Methodology: The documents were picked from the health policy sections from the websites of international organizations (European Parliament, OECD, WHO, UN), online data and policy reports of national ministerial bodies, and general web search. Later, the papers were reviewed and the author identified the main concepts of the responses to discuss after policy review. The study was designed as a review; therefore, no statistical framework was conducted. Results: Identified concepts were as follows: a) continuing service provision for people with mental health conditions, b) digital mental health care interventions, c) building psychological resilience for citizens. Conclusions: A strategy only focusing on treating mental health conditions will not be sustainable during the post-pandemic era. It is essential to address mental health in all policies to foster a strong mental health care system

Four cohorts of patients entered for the first time during 1974 to 1977 on a psychiatric case-register covering a town in the north of the Netherlands were followed for one year to study patterns of care. Rates of patients first registered were much higher than in two British register areas. The study did not indicate marked distinctions between the patterns of care delivered by the various agencies. data from the Groningen Register, which has the Camberwell Register (Wing and Hailey 1972) as its model.

Androgen deprivation therapy (ADT) use is associated with an increased risk of developing depression and anxiety. Little is known about how the mental health of these men is treated. We identified men with prostate cancer who received ADT between 2001 and 2015 using Optum's de-identified Clinformatics Data Mart Database. We determined the incidence of depression or anxiety diagnoses, mental health treatments, and the specialty of providers initiating psychotropic medications, after the start of ADT. Outcomes were compared with those of men with prostate cancer not receiving ADT and men without prostate cancer. Of 37388 men with prostate cancer treated with ADT, 3964 (10.6%) received a new diagnosis of depression or anxiety. Of those 3964 men, 1892 (47.7%) did not receive a documented treatment, 10 (0.3%) received psychotherapy, 1321 (33.3%) a selective serotonin reuptake inhibitor, and 744 (18.8%) a benzodiazepine. The median time from initiation of ADT to a depression or anxiety diagnosis was 9.3 months. Primary care physicians were the most common prescribers of psychotropic medications (72.2%). The proportion of men not receiving mental health treatments of interest (47.7%) was similar compared to men without prostate cancer (49.1%), but statistically significantly lower compared to men with prostate cancer not receiving ADT (52.7%). In men with prostate cancer receiving ADT with a new diagnosis of depression or anxiety, nearly half are not receiving mental health care while one in five is introduced to a benzodiazepine. Further investigation toward improving the mental health care for men on ADT is needed.

This study sought to describe patterns of mental health care for depressed and suicidal geriatric patients by primary care physicians (MDs) and nurse practitioners (NPs). A probability sample of 300 Illinois MDs from the AMA Physician Masterfile and a national sample of 595 NPs from the American Academy of Nurse Practitioners were surveyed. Sixty-three percent of MDs and 61 percent of NPs responded regarding their approaches to assessing, treating, and referring older adult patients who were depressed or suicidal. Respondents rated their confidence in assessing and treating depression and suicidality and identified barriers to mental health treatment in a primary care setting. Both similarities and differences were found among MDs and NPs in their patterns of managing depressed and suicidal older adults. NPs used more varied approaches in assessing, treating, and referring their geriatric patients with mental health problems. MDs relied more heavily on psychotropic medications for the treatment of depression and on psychiatrists when referring suicidal older patients. NPs were more likely than MDs to note lack of training and referral resources as barriers to treating depression of older patients. NPs rated their training in geriatric mental health more favorably than MDs. In terms of assessment of depression, preferred treatment approaches, the use of referral resources, and perceived barriers to mental health care, there appears to be a greater orientation towards a psychosocial approach among NPs. Primary care MDs and NPs often have different perspectives that in combination could enhance the mental health care of geriatric patients.

The treatment of schizophrenia in the United States during the twentieth century has been a national embarrassment. The (approximately) 2 million schizophrenics in the United States have received short shrift from the government, mental health professionals, and the public at large. In contrast to citizens with severe physical illnesses or mental retardation, schizophrenics have generally been segregated and either mistreated or ignored. This situation first attracted significant public and governmental attention in the late 1950s and early 1960s as a function of the community mental health (CMH) movement. Referred to as the “third mental health revolution” (Hobbs, 1964), the CMH movement had as one of its primary goals the development of new and more effective treatment programs and the improvement of the quality of life for schizophrenics and for the chronic mentally ill in general. The culmination of CMH efforts was the 1963 Community Mental Health Centers Act, which funded the development of local facilities to provide a range of needed services in the community. To be sure, the CMH movement has led to dramatic changes in the pattern of mental health care and the structure of the mental health system. But, like most revolutions, it has not worked out precisely as planned. To the contrary, it has been argued that in many respects the chronic mentally ill are as victimized and ignored by society today as they were before the erstwhile revolution (Gralnick, 1985).

Changes in the patterns of mental health care have led to shifts in the treatment roles of types of mental health personnel. The current contributions of mental health personnel in one geographic region were identified. Over 500 psychiatrists, clinical psychologists, psychiatric social workers, psychiatric nurses, and mental health workers responded to questionnaires covering their personal background, training and education, treatment roles, salary, and attitudes. Unexpected findings about these groups included their overall youthfulness, differences in religion, the high proportions of nurses and mental health workers with advanced degrees; and occupational ratings for families of origin. Despite differences in the types of psychotherapy provided, almost half of each group provided some formal psychotherapy. An important factor in the mental health field's "identity crisis" may be that these groups can no longer define themselves in terms of psychotherapy.

Psychiatric nursing as an entity has really only evolved since the Second World War. Psychiatric nurses (now often referred to as mental health nurses in the United Kingdom and Australasia) can now be found in most countries of the developed world, although in the developing world, psychiatric nursing is still not defined as a specific discipline. In many countries, psychiatric hospitals are still staffed by untrained ‘Attendants’ who may have some supervision from general trained nurses. Nevertheless, a number of initiatives, notably those of the Geneva Initiative in Psychiatry in Eastern Europe and the former Soviet Union and the World Health Organization in African countries, have provided specific training in psychiatric nursing techniques. The development of psychiatric nursing across the world needs to be seen in the context of changing and evolving patterns of mental health care. De-institutionalization, with the attendant setting up of community mental health teams, has prompted a range of innovations in psychiatric nursing and the psychiatric nurse of today, who in the United States and Europe is likely to be a university graduate, is a very different person to that of the nurse working in the post-Second World War asylums of 40 years ago. In this chapter, we examine the development of psychiatric nursing in some detail and particularly emphasize the role of psychiatric nurses working in the community. Community psychiatric nursing first developed in the United Kingdom nearly 50 years ago and this model has been followed in countries such as Australia and New Zealand. However, this community role has not developed to any great extent in the United States, where the main presence of psychiatric nursing remains in hospital-based care. Furthermore, in the United Kingdom and Australasia, the development of community initiatives has seen the role of the psychiatric nurse blurring with that of other mental health professionals. Chapters such as this cannot really do justice to the whole range of techniques used by psychiatric nurses; neither can it examine in any detail the differences between psychiatric nursing practices across the world. However, a description of psychiatric nursing in six important areas will provide the reader with an appreciation of the range and diversity of psychiatric nursing skills:♦ Inpatient care ♦ Psychosocial interventions in the community ♦ Prescribing and medication management ♦ Cognitive behaviour therapy ♦ Primary care ♦ Psychiatric nursing in the developing world.