Complex Psychosocial Problems Research Articles

Differences between patients with chronic musculoskeletal pain treated in an inpatient or an outpatient multidisciplinary rehabilitation program.

Multidisciplinary rehabilitation for patients with chronic musculoskeletal pain can be provided on an inpatient or on an outpatient basis, but the rationale for choosing between the two programs is unknown. The aim of the study was to identify differences between patients provided inpatient or outpatient rehabilitation. It was a cross-sectional study within usual care. The study included 415 adult rehabilitation patients with chronic musculoskeletal pain with complex psychosocial problems. The measurements used were demographics, Short Form 36 Health Survey, Dutch Personality Questionnaire, Coping with Pain Questionnaire, Tampa Scale of Kinesiophobia, Symptom Checklist 90-Revised. In the multiple logistic analysis, five variables remained significantly different between inpatients and outpatients: inpatients were less likely to have a child aged less than 12 years and to have neck pain; their physical and social functioning were poorer; and their current pain period had lasted longer. The total explained variance was 26%. Five variables were identified as influencing the decision on inpatient or outpatient rehabilitation, but the explained variance was low.

Composing a Core Set of Performance Indicators for Public Mental Health Care: A Modified Delphi Procedure

Public mental health care (PMHC) systems are responsible for the wellbeing of vulnerable groups that cope with complex psychosocial problems. This article describes the development of a set of performance indicators that are feasible, meaningful, and useful to assess the quality of the PMHC system in Amsterdam, the Netherlands. Performance indicators were selected from an international inventory and presented to stakeholders of the PMHC system in a modified Delphi procedure. Characteristics of indicators were judged individually, before consensus on a core set was reached during a plenary discussion. Involving stakeholders at early stages of development increases support for quality assessment.

Mental health nurses in primary care: quantitative outcomes of the Mental Health Nurse Incentive Program

The Mental Health Nurse Incentive Program (MHNIP) is a funding scheme in Australia that enables mental health nurses to work in primary care settings with people with complex mental health problems for as long as necessary. This study examined the outcomes of the programme as reported by nurses. Nurses provided profiles of 64 people with whom they worked, including measures of symptoms and problems on admission to the programme and at a second point in time. The findings showed that people had high levels of symptom severity and distress on admission, and they experienced significant improvements in all problem areas except physical health over their time working with the nurse. The MHNIP appears to be addressing the needs of people with highly complex needs, but more sensitive measures of outcome ought to be routinely collected. The Mental Health Nurse Incentive Program (MHNIP) provides a funding mechanism for credentialed mental health nurses to work in primary care settings in Australia with people with complex and serious psychosocial and mental health problems. This project explored the extent to which the programme contributed to positive outcomes. Sixty-four service user profiles were provided by nurses working within the programme, including the Health of the Nation Outcome Scales (HoNOS), on admission and at the last review point. Mean total HoNOS scores on admission were higher than those typically seen on admission to inpatient care in Australia. Significant reductions in all problem areas except physical health problems were found at the last review point for this sample. These findings support the viewpoint that MHNIP is addressing the needs of people with the most complex needs in primary care and is achieving clinically significant outcomes.

Rebuilding community resilience in a post-war context: developing insight and recommendations - a qualitative study in Northern Sri Lanka.

BackgroundIndividuals, families and communities in Northern Sri Lanka have undergone three decades of war trauma, multiple displacements, and loss of family, kin, friends, homes, employment and other valued resources. The objective of the study was understanding common psychosocial problems faced by families and communities, and the associated risk and protective factors, so that practical and effective community based interventions can be recommended to rebuild strengths, adaptation, coping strategies and resilience.MethodsThis qualitative, ecological study is a psychosocial ethnography in post-war Northern Sri Lanka obtained through participant observation; case studies; key- informant interviews; and focus groups discussions with mental health and psychosocial community workers as well as literature survey of media and organizational reports. Qualitative analysis of the data used ethnography, case studies, phenomenology, grounded theory, hermeneutics and symbolic interactionism techniques. Quantitative data on suicide was collected for Jaffna and Killinochchi districts.ResultsComplex mental health and psychosocial problems at the individual, family and community levels in a post-war context were found to impair recovery. These included unresolved grief; individual and collective trauma; insecurity, self-harm and suicides; poverty and unemployment; teenage and unwanted pregnancies; alcoholism; child abuse and neglect; gender based violence and vulnerability including domestic violence, widows and female headed-household, family conflict and separation; physical injuries and handicap; problems specific for children and elderly; abuse and/or neglect of elderly and disabled; anti-social and socially irresponsible behaviour; distrust, hopelessness, and powerlessness. Protective factors included families; female leadership and engagement; cultural and traditional beliefs, practices and rituals; and creative potential in narratives, drama and other arts. Risk factors that were impeding community rehabilitation and recovery included continuing military governance, depletion of social capital particularly lack of trust, hope and socio-economic opportunity structures for development that would engender a sense of collective efficacy.ConclusionsIn view of the widespread trauma at the individual, family and collective levels, community based programmes to increase local awareness, knowledge and skills to deal with common mental health and psychosocial issues; and training of community level workers and others in basic mental health and psychosocial problem solving are recommended to rebuild family and community agency and resilience. The use of cultural practices and school based programmes would rekindle community processes.

Neuropsychiatric and psychosocial issues of patients with hepatitis C infection: a selective literature review.

ContextWe briefly reviewed the evidence on the association of hepatitis C (HCV) infection with several aspects of mental and psychosocial health.Evidence AcquisitionMedline was searched with appropriate keywords. The primary sources were the systematic reviews. If systematic reviews were not available for a subject, then the most relevant and methodologically sound original studies were selected.ResultsHCV infection is associated with poorer health-related quality of life, and physical, mental, and social health. A part of impaired health of these patients is related to cirrhosis, intravenous drug use, co morbid psychiatric disorders, stigmatization, poor social support, alcohol abuse, and interferon treatment. However, HCV itself is also associated with poorer health status particularly in the physical and cognitive domains, which might be related to brain alterations induced by the virus. Interferon treatment is an important cause of depression in HCV patients and sometimes is associated with irritability, manic episode, or acute confusional state. Social health of HCV patients is significantly impaired by stigmatization, poor social support, psychiatric comorbidties, and impaired coping. Psychosocial impairment of HCV patients significantly impairs their treatment adherence. A supportive and nonjudgmental multidisciplinary team is required for optimal management of these patients.ConclusionsPatients with HCV infection had complex neuropsychiatric and psychosocial problems. These problems are challenges for management of HCV infection, affect the patient’s care significantly, and might alter the course of the disease. A multidisciplinary approach, a supportive environment, and a nonjudgmental healthcare team are required for optimal medical and psychosocial management of patients with HCV.

<b>ICF-DH conceptual approach of the complex medical and psycho-social problems encountered at home and in the community; professional reintegration and the QoL of persons with SCI sequels</b>

<b>ICF-DH conceptual approach of the complex medical and psycho-social problems encountered at home and in the community; professional reintegration and the QoL of persons with SCI sequels</b>

"ICF-DH conceptual approach of the complex medical and psycho-social problems encountered at home and in the community; the quality of life in persons with SCI sequels"

Objective: Evaluation (from the ICF-DH conceptual approach) of the complex medico-psycho-social problems encountered at home, by persons with spinal cord injury (SCI) sequels. Material, Methods: 660 patients with chronic SCI were reviewed by the questionnaire technique (focused mainly on basic, instrumental activities of daily living, medical, social problems encountered after discharge from the Teaching Emergency Hospital "Bagdasar-Arseni - TEHBA, Bucharest). The feed-back rate was 64,4% (425 from 660 subjects). There were 205 quadriplegics (48%), 220 paraplegics (52%). The mortality was 9% during the follow-up period, 2001-2010.

Integrating Social Workers into Primary Care: Physician and Nurse Perceptions of Roles, Benefits, and Challenges

The primary aim of this article is to identify, from the perspective of primary care physicians and nurses, the challenges encountered in provision of health care to older adults and to identify potential roles, challenges, and benefits of integrating social workers into primary care teams. As more older adults live longer with multiple chronic conditions, primary care has been confronted with complex psychosocial problems that interact with medical problems pointing to a potential role for a social worker. From a policy perspective, the lack of strong evidence documenting the benefits that will accrue to patients and providers is a key barrier preventing the wider use of social workers in primary care. This article presents findings from three focus groups with primary care physicians and nurses to examine the perspectives of these key providers about the benefits and challenges of integrating social workers into the primary care team.

Delivering Palliative Care in an Acute Hospital Setting: Views of Referrers and Specialist Providers

There has been a steady expansion of hospital-based palliative care in the United Kingdom but limited published research on health professionals' views of hospital multidisciplinary specialist palliative care services (SPCS). The aim of the study was to describe referrer (SPCS user) and provider (SPCS staff) perspectives on delivery of specialist palliative care in hospital. Interviews were conducted with referrers, including five junior doctors, 13 consultants, and six clinical nurse specialists, to investigate the reasons for referral, beneficial aspects, and barriers to use. Focus groups were conducted with providers, six medical and five nursing, to identify their perspective on delivering the specialist service in hospital. Discussions were tape recorded and transcribed verbatim. Data were analyzed thematically using a framework analysis approach. The study found large areas of agreement between referrers and providers on what hospital palliative care teams should be providing for patients, that is, expertise in managing difficult symptoms and complex psychosocial problems, and this was being achieved locally. Access to the specialist team was also important: visibility on the wards, informal routes of access to advice and a timely response by specialists. However, discordance in views of providing palliative care was also identified; in particular, whether specialists should be providing generalist palliative care (such as basic psychological support) neglected by ward teams and implementation of specialist advice by referrers. Such perspectives on the interface of generalist and specialist provision provide insights into improving care for palliative patients in the acute hospital setting.

Psychiatric morbidity among dental patients attending a tertiary hospital in Lagos

Objective: It has been noted that oral health conditions have significant relationships with mental illnesses. In Nigeria, a large number of individuals with psychological morbidity also visit dental health practitioners regularly and few psychopathological studies have been carried out to determine the prevalence of psychopathology in dental patients in Lagos. The aim of this study was to determine the general psychological wellbeing, symptoms of anxiety and depression among patients who were attending the dental clinic for restorative and oral surgery in Lagos. Method: One hundred and three consecutive dental patients who were attending the dental clinic of the Lagos State University Teaching Hospital (LASUTH), Ikeja, Lagos were recruited for this study. Patients were administered with the 12th version of the General Health Questionnaire (GHQ), and Hospital Anxiety and Depression Scale (HADS). Result: One hundred and three patients (50 males and 53 females) aged 20-61 years (mean age 38.3+ 10.7 years) participated in the study. The reasons for attending the dental clinic ranged from unbearable pain 81(78.6%), filling of teeth 9(8.7%), extraction 6(5.8%), check-up 4(3.9%) and fixing of braces 3(3.0%). Subjects who scored more than 3 in the GHQ were 17.5 %. On the HADS scale, 28.2 % had a high score in anxiety while 14.6 % scored high in depression. Conclusion: This study shows that a high percentage of dental patients also suffer from psychopathology especially anxiety and depression. These findings have been observed to constitute complex psycho-social problems with far reaching social and medical consequences among dental patients. The acquisition of psychotherapeutic tools by dental surgeons for assessing and managing dental patients with psychopathology will enhance the quality of practice and service delivery of dental surgeons. Keywords: psychiatry, morbidity, dental patientsNigerian Dental Journal Vol. 16 (1) 2008: pp. 22-25

Refusal, social exclusion and the cycle of rejection: A cynical analysis?

Despite the best, and at times the worst, efforts of systems of care `to include', there remains a group of people whose refusal to be included remains a problem both for themselves and for society as a whole. Our discussion re-locates the problems arising from the anti-social stance at the heart of this refusal from the internal world of the refuser to phenomena associated with what we have called psychosocial dis-memberment and the ` un-housed mind'. We explore the complex reciprocal relationship between the housed and the un-housed, between society's members and those whom society dis-members and we consider some possible implications for individual workers, staff teams and organizations who are tasked with attempting to house, re-member or otherwise to accommodate such people. We conclude with a challenge to practitioners, academics and policy makers to reframe the philosophical basis of their approach towards these complex psychosocial problems.

Preliminary Report of a Palliative Care and Case Management Project in an Emergency Department for Chronically Ill Elderly Patients

The Palliative Care Service at Montefiore Medical Center (MMC) established a pilot project in the emergency department (ED) to identify chronically ill older adults in need of palliative care, homecare, and hospice services and to link such patients with these services. Two advance practice nurses conducted consultations on elderly patients who were found to have one or more "palliative care triggers" on initial screening. A standardized medical record abstraction form was developed. Service utilization and survival were evaluated using the Clinical Information Systems of MMC. Activity of daily living items were developed from the Outcome and Assessment Information Set and the Palliative Care Performance Scale (PPS). Risk factors for hospitalization and use of the ED were taken from the SIGNET model risk screening tool. Physical and emotional symptoms were evaluated using the 28-item Memorial Symptom Assessment Scale short form. Preliminary outcomes and characteristics are presented for 291 patients who completed the intake needs assessment questionnaire. Almost one third (30.9%) of the study cohort died during the project period. Most of the deaths occurred beyond the medical center (7.7% died in the medical center and 23.3% outside the medical center). Thirty percent of patients who died were enrolled on a hospice. Survival time was predicted by the presence of dyspnea, clinician prediction of death on the current hospitalization, psychosocial distress, and PPS scores. Chronically ill patients visiting an urban community ED had complex medical and psychosocial problems with limited support systems and homecare services. Significant proportions of such patients can be expected to have limited likelihood of survival. The presence of palliative homecare and hospice outreach services in the ED in urban community hospitals may provide an effective strategy for linkage of elderly patients at the end of life with otherwise underutilized services.

Systemic Thinking: A Framework for Research into Complex Psychosocial Problems

Systemic thinking has yet to be widely embraced as a framework for research in psychology. The defining question in systemic research is “How and why does this system as a whole function as it does?” A range of qualitative or quantitative methodologies may be used to answer these questions. Systemic thinking provides a framework for research into complex psychosocial problems by supporting the entire research process from design to data collection and analysis. Systemic principles and constructs support the description of relationships within specific systems. Having mapped the connections between behaviors and perspectives, the question of why the system is behaving in a particular way can be answered by drawing from a wide range of theoretical sources. A particular strength of systemic thinking is that is allows the creative exploration of the relationship between the processes identified. Overall, it supports theory building and integrative thinking.

Psychological trauma and post-traumatic stress disorder among women in community mental health aftercare following psychiatric intensive care

Psychological trauma and post-traumatic stress disorder (PTSD) are prevalent among adults with severe mental illness, but their impact on the psychosocial and physical health-related impairment of women with major mental illnesses is not known. A sample of 35 low-income urban women receiving community mental health services for severe and chronic mental illness was assessed with psychometrically validated structured interview instruments for psychiatric diagnosis, lifetime history of exposure to traumatic stressors, PTSD, substance use, health-related impairment, and complex psychosocial problems. Exposure to multiple types of traumatic stressors was reported by 98% of respondents, and more than half met criteria for lifetime PTSD (44% for current PTSD). Current PTSD prevalence was highest (>56%) when traumatic loss, sexual abuse, physical abuse, traumatic assault, or community violence were reported. A history of childhood sexual abuse or PTSD or both were associated with use of multiple substances and complex psychosocial problems. Assessment and treatment of complex PTSD appears warranted in psychiatric intensive care and community aftercare for women with severe mental illness.

Palliative care in patients with severe multiple sclerosis: two case reports and a survey among German MS neurologists

Due to its chronic and fluctuating time course, multiple sclerosis (MS), thus far, has not been regarded as a focus of palliative care. However, sometimes we are confronted with severely affected MS patients, who suffer from complex medical, physical and psychosocial problems, which are not fully covered by the current health care services. We present two cases of severely affected MS patients we saw in our outpatient MS clinic, and who, we believe, are candidates for palliative care. The first patient, with primary chronic progressive (pcP) MS for many years (Expanded Disability Status Scale (EDSS): 8.0) presented with complex painful dysaesthesias and a depressive syndrome. He refused any treatment, and finally committed suicide with the help of a euthanasia group in Switzerland. The second patient was also severely affected by a secondary chronic progressive (scP) MS (EDSS: 9.0) and was finally admitted to our palliative care unit due to a complex pain syndrome associated with panic attacks and anxiety. She spent three weeks on the palliative care unit and her symptoms improved gradually after changing and optimising her pain medication. The patient was discharged with home care and is seen regularly on the palliative care unit. Additionally, as a first step, a questionnaire was sent to 53 German MS specialists regarding their general view on the needs for palliative care in MS. Our two cases and the results of the questionnaire demonstrated that MS patients and their caregivers are confronted with a variety of symptoms which are difficult to treat, and are a cause of great suffering for the patients, including ataxia, depression and fatigue. The data of the questionnaire also showed that neurologists usually do not deal with end-of-life care issues in MS. More research is needed to define the role of palliative care in MS and establish appropriate interventions to improve the quality of life in advanced stage MS patients and their relatives.

Attention‐deficit/hyperactivity disorder: Are we medicating for social disadvantage? (For)

The diagnosis of attention-deficit/hyperactivity disorder (ADHD) is based on well defined criteria, which describe a number of symptoms. It is important to consider the context of the symptoms, in terms of the influence of the child's family and school. Although stimulant medications benefit selected children they may not benefit all children with symptoms of ADHD. The incidence of ADHD increases with social disadvantage. There is a potential danger of using stimulant medication alone to treat children with complex psychosocial problems, associated with social disadvantage, including Aboriginal children. We desperately need better training in the management of ADHD and better access to child psychiatrists.

Toward Understanding the Clinical Aspects of Geriatric Case Management

Despite the prominence of complex psychosocial problems in aging clients, geriatric case management has generally emphasized the provision of concrete resources and services as its primary function. However, some of the literature as well as the findings of this study, point to competent case management as being contingent on interventions that successfully address key psychosocial problems. This paper presents a qualitative study involving experienced geriatric care managers. Psychosocial problem and intervention categories are identified as well as overarching themes with significant implications for practice. The paper argues that a grounded, thorough, well-explicated and generalizable model for clinically-focused geriatric case management practice is necessary; it also suggests additional research towards the development of such a model.

Prevalence and Predictors of Parenting Outcomes in a Cohort of Mothers With Schizophrenia Admitted for Joint Mother and Baby Psychiatric Care in England

Most women with schizophrenia have children. Schizophrenia has been identified as an independent predictor of poor parenting outcome following joint mother and baby psychiatric admission. We aimed to describe the characteristics of these women postnatally and to estimate the prevalence of, and identify independent predictors of, parenting outcomes. Clinical and psychosocial data from consecutive joint psychiatric admissions of mothers and infants between September 1996 and September 2002 were collected. Diagnoses were based on ICD-10 criteria (N = 239 schizophrenia; N = 693 affective disorders). The prevalence of each parenting outcome at discharge, assessed according to social services intervention and staff-rated measures of parenting ability, was estimated. Factors associated with poor parenting outcomes and independent predictors were identified using "modified" Poisson regression, and prevalence of these parenting outcomes was estimated in subgroups of mothers stratified by combinations of protective/risk factors. Mothers with schizophrenia were characterized as having more complex clinical and psychosocial problems and were considerably more likely to experience all types of poor parenting outcomes, compared to mothers with affective disorders. Mothers with schizophrenia reporting supportive marital and other relationships, those whose partners were well, and those of higher social class showed the best parenting outcomes. Mothers with schizophrenia who experience better parenting outcomes may be protected by certain factors. Successful parenting is related, partly, to stability within the family and access to financial and social resources. The nature of the relationship between identified predictors and parenting outcomes in this group is unclear but may suggest that parenting outcome varies with clinical outcome in schizophrenia. Future research and service development should focus on potential protective factors that may encourage successful parenting outcomes in this vulnerable group.

PROTOCOL: Multisystemic Therapy for social, emotional, and behavioral problems in youth aged 10–17

PROTOCOL: Multisystemic Therapy for social, emotional, and behavioral problems in youth aged 10–17

Reflections on psychodynamic psychotherapy supervision for psychiatrists in clinical practice.

Much has been written about psychotherapy supervision for trainees in psychiatry. Psychiatrists are also encouraged to receive supervision when dealing with difficult patients or when involved in personal events that have the potential to have an impact on their psychotherapeutic work. Nevertheless, a literature search, conducted through Medline, revealed few publications dealing with supervision of psychiatrists who conduct psychotherapy in clinical settings after completion of training. This article discusses the issues involved in psychotherapy supervision for the supervisor, supervised psychiatrists, and their practice settings and patients. The author first discusses the benefits of psychotherapy supervision for psychiatrists in clinical practice, including helping psychiatrists maintain and improve psychotherapeutic skills, assistance in dealing with patients who have complex or especially challenging problems (e.g., personality disorders, intractable depression, difficulties with compliance, complex psychosocial problems), addressing ethical concerns, boundary issues, and transference and countertransference, and helping psychiatrists deal with personal issues that may cause difficulties in providing psychotherapy or issues that arise in working with a multidisciplinary team. The author then reviews key issues related to the supervisory process, including group versus individual supervision, the role of the supervisor, different supervisory styles, and factors that can contribute to feelings of shame or vulnerability in the supervisee. The author also discusses different supervisory styles, clarifies the distinction between therapy and supervision, and discusses issues that arise in the supervision of experienced psychodynamic therapists. Barriers that may keep psychiatrists from seeking psychotherapy supervision are reviewed. Finally the author discusses the supervision of those acting as supervisors for other clinicians.