Enhancing recovery rates: Lessons from year one of IAPT

BackgroundThe English Improving Access to Psychological Therapies (IAPT) initiative aims to make evidence-based psychological therapies for depression and anxiety disorder more widely available in the National Health Service (NHS). 32 IAPT services based on a stepped care model were established in the first year of the programme. We report on the reliable recovery rates achieved by patients treated in the services and identify predictors of recovery at patient level, service level, and as a function of compliance with National Institute of Health and Care Excellence (NICE) Treatment Guidelines.MethodData from 19,395 patients who were clinical cases at intake, attended at least two sessions, had at least two outcomes scores and had completed their treatment during the period were analysed. Outcome was assessed with the patient health questionnaire depression scale (PHQ-9) and the anxiety scale (GAD-7).ResultsData completeness was high for a routine cohort study. Over 91% of treated patients had paired (pre-post) outcome scores. Overall, 40.3% of patients were reliably recovered at post-treatment, 63.7% showed reliable improvement and 6.6% showed reliable deterioration. Most patients received treatments that were recommended by NICE. When a treatment not recommended by NICE was provided, recovery rates were reduced. Service characteristics that predicted higher reliable recovery rates were: high average number of therapy sessions; higher step-up rates among individuals who started with low intensity treatment; larger services; and a larger proportion of experienced staff.ConclusionsCompliance with the IAPT clinical model is associated with enhanced rates of reliable recovery.     

Mental health measurement among women veterans receiving co-located,collaborative care services

Routine use of measurement to identify patient concerns and track treatment progress is critical to high quality patient care. This is particularly relevant to the Primary Care Behavioral Health model, where rapid symptom assessment and effective referral management are critical to sustaining population-based care. However, research suggests that women who receive treatment in co-located collaborative care settings utilizing the PCBH model are less likely to be assessed with standard measures than men in these settings. The current study utilized regional retrospective data obtained from the Veterans Health Administration’s electronic medical record system to: (1) explore rates of mental health measurement for women receiving co-located collaborative care services (N = 1008); and (2) to identify predictors of mental health measurement in women veterans in these settings. Overall, only 8% of women had documentation of standard mental health measures. Measurement was predicted by diagnosis, facility size, length of care episode and care setting. Specifically, women diagnosed with depression were less likely than those with anxiety disorders to have standard mental health measurement documented. Several suggestions are offered to increase the quality of mental health care for women through regular use of measurement in integrated care settings.     

Anxiety disorders in African-American and white children

There are little available data on African-American children with anxiety disorders. Treatment-seeking African-American (n=30) and white children (n=139), with a current DSM-III-R anxiety disorder, were compared on sociodemographic background variables, clinical characteristics, and lifetime rates of specific DSM-III-R anxiety disorders. Overall, results suggested that the anxiety-disordered African-American and white children who sought treatment from an outpatient mental health facility were more similar than different. The two groups did, however, differ somewhat on several variables (trend only), including rates of school refusal, severity of primary anxiety disorder, lifetime prevalence of posttraumatic stress disorder, and total scores on the Fear Survey Schedule for Children-Revised. More specifically, white children were more likely to present with school refusal and higher severity ratings, while African American children were more likely to have a history of posttraumatic stress disorder and score higher on the FSSC-R. The impact of these findings and the need for additional research are discussed.This study was supported in part by MH grant 40021 from the National Institute of Mental Health.     

An inventory to measure contact with medical health care professionals

The Koman Contact With Medical Health Care Professionals Inventory is described. It was devised to measure total contact including office visits and telephone calls with medical health care professionals as one component of self-report health-related questions. Use of this inventory indicated that women utilize medical health care professionals more than men.     

Outpatient health care utilization of suicide decedents in their last year of life

The characteristics of health care utilization during the last year of life by Taiwanese who died by suicide were analyzed. The degree of health services utilization was evaluated by extracting the data of National Health Insurance (NHI) outpatient cohort records in 2006. A total of 4,406 fatal suicide cases were matched with the 17,587,901 subjects in the NHI beneficiary registry file. Rate of visit of the suicide decedents for all NHI outpatient services during their last year before death was 85%, and that for mental disorders service only was 30.2%. Average number of visits per person-year of the suicide decedents was 24.5 visits per year, two times higher than that of the survivors. The average numbers of visits (ANV) of male suicide decedents who used the mental disorders services was increased 6.8 times compared to that for all survivors. The increase in female decedents, in contrast, was 2.7 times. The increase in ANV for 15-24 age group was 14.6 times, significantly higher than that for the other age groups (<4 times). Effective prediction or prevention of potential suicides through increased awareness and surveillance of medical care resource utilization is possible, especially for male and young adult patients under mental disorder health care.     

The structure of feared social situations among individuals with a lifetime diagnosis of social anxiety disorder in two independent nationally representative mental health surveys

The present study employed both exploratory and confirmatory factor analytic approaches with nationally representative samples of individuals with a lifetime diagnosis of social anxiety disorder (n=1123; n=3091, respectively) using split-halves of the National Comorbidity Replication Survey (n=9282) and cross-validated with the Canadian Community Health Survey on Mental Health and Wellbeing (n=36,984). Strong support was found for a three-factor solution. This model was obtained from exploratory factor analysis and was further evaluated using two confirmatory factor analytic investigations in the two national samples. The three social situational domains reflected (1) Social Interaction Fears, (2) Observation Fears, and (3) Public Speaking Fears. Individuals with generalized social anxiety disorder (i.e., those who endorsed 7 or more of 13 feared social situations assessed in the survey) were significantly more likely to report Social Interaction Fears and Observation Fears compared to individuals with non-generalized social anxiety disorder (i.e., those who endorsed only 6 or fewer of 13 feared social situations). Individuals with generalized social anxiety were particularly characterized by combinations of Public Speaking Fears plus Social Interaction Fears and Observation Fears. The clinical and classification implications of our study for DSM-V are discussed.     

Spezielle Aspekte bei Angststörungen

Anxiety disorders are among the most common mental health conditions worldwide and frequently cause significant functional impairment. Generalized anxiety disorder is the most commonly occurring impairing anxiety disorder in primary care. The degree of disability attributable to generalized anxiety disorder is comparable to that of major depression and is similar to that of chronic physical illnesses, such as peptic ulceration, arthritis, asthma and diabetes mellitus. Comorbid illnesses, such as mood disorders are commonly seen in clinical practice and have a significant impact on the clinical presentation and the treatment approach. Both psychotherapeutic and pharmacological techniques are recognized as being effective management strategies. The present article focuses on two case-reports of patients with anxiety disorders in an inpatient setting. By describing comorbid conditions subsequent difficulties and challenges in treatment are underlined.     

Family characteristics as mediators of the influence of problem drinking and multiple risk status on child mental health

Structural equation modeling was used to test a theoretical model in which family cohesion and family reframing coping were hypothesized as mediators between family drinking problems, multiple risk factors, negative life events, and child mental health (conduct disorder, depression, anxiety) in two-parent families. Family cohesion mediated the relationships of family drinking problems and negative life events to child conduct disorder and depression. Negative life events mediated the relationships of family drinking problems and family multiple risk to child conduct disorder. Family reframing coping did not function as a mediator nor was it related to child mental health when other factors were considered simultaneously. Results indicate that increasing family cohesion and reducing sources of stress within the family (negative life events) represent promising areas for interventions for children with problem-drinking parents. Work on this study was funded in part by the National Institute for Mental Health Grant 2-P50-MH39246-06 to support a Preventive Intervention Research Center. The authors gratefully acknowledge contributions made by Rita Shell, Marcia Michaels, Joanne Gersten, George Knight, and Carolyn Berg.     

Expectations and attributions in social anxiety disorder: diagnostic distinctions and relationship to general anxiety and depression

Contemporary cognitive models suggest that social anxiety disorder arises from a number of cognitive factors, including tendencies to form pessimistic (rather than optimistic) attributions and expectations for socially-related events. These models also assume that the strengths of such attributions and expectations are more closely linked with social anxiety than with general anxiety or depression. To test these assumptions, a battery of self-report measures was completed by participants with a primary diagnosis of generalized social anxiety disorder (n = 75), panic disorder with agoraphobia (n = 44), or post-traumatic stress disorder (n = 59). To examine differences on these cognitive variables, group comparisons were performed controlling for general anxiety, depression and medication status. Social anxiety disorder, compared with panic disorder with agoraphobia and post-traumatic stress disorder, was characterized by lower expectations for positive social events and higher expectations for negative social events. There was no difference among the groups on expectations for non-social positive or negative events. Stable and global attributions for social negative events were more closely associated with social anxiety disorder than with panic disorder with agoraphobia and post-traumatic stress disorder. Correlational analyses also revealed specific relationships among social-cognitive measures and social anxiety, even after controlling for general anxiety and depression. The results are consistent with cognitive models of social anxiety disorder.     

TRANSITION TO PARENTHOOD AND MENTAL HEALTH IN FIRST‐TIME PARENTS

This study aimed to examine the transition to parenthood and mental health in first‐time parents in detail and explore any differences in this transition in the context of parental gender and postpartum mental health. Semistructured clinical interviews (Birmingham Interview for Maternal Mental Health) were carried out with 46 women and 40 men, 5 months after birth. Parents were assessed on pre‐ and postpartum anxiety, depression, and postpartum posttraumatic stress disorder (PTSD), and a range of adjustment and relationship variables. One fourth of the men and women reported anxiety in pregnancy, reducing to 21% of women and 8% of men after birth. Pregnancy and postpartum depression rates were roughly equal, with 11% of women and 8% of men reporting depression. Postpartum PTSD was experienced by 5% of parents. Postpartum mental health problems were significantly associated with postpartum sleep deprivation (odds ratio [OR] = 7.5), complications in labor (OR = 5.1), lack of postpartum partner support (OR = 8.0), feelings of parental unworthiness (OR = 8.3), and anger toward the infant (OR = 4.4). Few gender differences were found for these variables. This study thus highlights the importance of focusing interventions on strengthening the couple's relationship and avoiding postnatal sleep deprivation, and to address parents’ feelings of parental unworthiness and feelings of anger toward their baby.     

The hospice: Humane care for the dying

The hospice movement arose as a reaction to the dehumanizing atmosphere of acute-care hospitals, where excessive utilization of life support equipment deprived dying patients of a meaningful vision of their destiny. Respecting the spiritual quest of the terminally ill for wholeness and dignity, the hospice concept prescribes the rendering of compassionate and pastoral care by a benevolent community of family, health care staff, friends, and clergy. Approximately 800 hospice programs are currently evolving in the United States. St. Mary's (formerly “Hillhaven”) Hospice in Tucson, Arizona, offers the most comprehensive program of services, including home care, inpatient care, and artistic media through which the dying express their creativity. Numerous demonstration projects funded by several government agencies, principally the Health Care Financing Administration (HCFA), are expected to result in the legislative actions eliminating barriers to reimbursement of the cost of hospice services by Medicare, Medicaid, and other third-party payers. Existential analysis reveals the value of religion and spiritual support in enabling the dying to banish anxiety and muster the hope requisite for fully appreciating the authentic meaning of their destiny.     

Negative and positive health effects of caring for a disabled spouse: longitudinal findings from the caregiver health effects study

Data from the first 2 waves of the Caregiver Health Effects Study (n = 680) were analyzed to examine the effects of changes in caregiving involvement on changes in caregiver health-related outcomes in a population-based sample of elders caring for a disabled spouse. Caregiving involvement was indexed by levels of (a) spouse physical impairment, (b) help provided to the spouse, and (c) strain associated with providing help. Health-related outcomes included perceived health, health-risk behaviors, anxiety symptoms, and depression symptoms. Increases in spouse impairment and caregiver strain were generally related to poorer outcomes over time (poorer perceived health, increased health-risk behaviors, and increased anxiety and depression), whereas increased helping was related to better outcomes (decreased anxiety and depression). Results suggest that caring for a disabled spouse is a complex phenomenon that can have both deleterious and beneficial consequences.     

Detrimental Effects of Discrimination on Mental Health in Asian Americans: Counteracting Roles of Religious Involvement

Few studies have examined the role of religious involvement as a potential protective factor in the mental health of Asian Americans. Using the first national sample from the National Latino and Asian American Study (2002–2003), this study explored the direct effect of religious attendance on the diagnosis of generalized anxiety disorder and self-rated mental health in Asian Americans (n = 2,095), above and beyond that of discrimination and acculturation factors. Hierarchical regression models associated (a) gender and discrimination with generalized anxiety disorder, and (b) gender, employment status, English proficiency, and discrimination with self-rated mental health. Including religious attendance added explanatory power to both models, indicating its influence on mental health. There was no interaction between religious attendance and discrimination, suggesting a suppressing rather than stress-buffering effect of religious attendance. These patterns suggest future investigation in the relationship between religious involvement and mental health in relation to subcultural differences among Asian Americans.     

Associations of Stress Exposures and Social Support With Long-Term Mental Health Outcomes Among U.S. Iraq War Veterans

The long-term mental health effects of war-zone deployment in the Iraq and Afghanistan wars on military personnel are a significant public health concern. Using data collected prospectively at three distinct assessments during 2003–2014 as part of the Neurocognition Deployment Health Study and VA Cooperative Studies Program Study #566, we explored how stress exposures prior, during, and after return from deployment influence the long-term mental health outcomes of posttraumatic stress disorder (PTSD), depression, anxiety disorders, and problem drinking. Longer-term mental health outcomes were assessed in 375 service members and military veterans an average of 7.5 years (standard deviation = 1.0 year) after the initial (i.e., “index”) Iraq deployment following their predeployment assessment. Anxiety disorder was the most commonly observed long-term mental health outcome (36.0%), followed by depression (24.5%), PTSD (24.3%), and problem drinking (21.0%). Multivariable regression models showed that greater postdeployment stressors, as measured by the Post-Deployment Life Events scale, were associated with greater risk of depression, anxiety disorders, and problem drinking. Anxiety disorder was the only outcome affected by predeployment stress concerns. In addition, greater postdeployment social support was associated with lower risk of all outcomes except problem drinking. These findings highlight the importance of assessing postdeployment stress exposures, such as stressful or traumatic life events, given the potential impact of these stressors on long-term mental health outcomes. This study also highlights the importance of postdeployment social support as a modifiable protective factor that can be used to help mitigate risk of long-term adverse mental health outcomes following war-zone exposure.     

Effects of lifestyle and stress on the employee and organization: Implications for promoting health at work

Abstract

This research was designed to determine the extent to which employee health and performance are predicted by lifestyle and stress. Data were collected from 345 employees working in a variety of organizations in southern California. Additionally, supervisors evaluated the work performance of the participating employees whom they directly supervised, and company records of employee health care costs were obtained. Hierarchical multiple regression analyses revealed (a) that physical lifestyle (i.e., exercise pattern, eating habits, and general health practices) predicted unique variance in vitality and positive well-being; (b) that psychosocial lifestyle (i.e., social relations, intellectual activity, occupational conditions, and spiritual involvement) predicted unique variance in vitality, positive well-being, anxiety, depression, lack of self-control, and somatic complaints; (c) that employee stress predicted unique variance in vitality, positive well-being, anxiety, depression, physician visits, somatic complaints, illness absences, and supervisory ratings of job performance, absenteeism and tardiness; (d) that physical lifestyle buffered the adverse consequences of stress for anxiety, depression, physician visits, and company health care costs; and (e) that there was a Physical x Psychosocial Lifestyle interaction for anxiety, depression, and lack of self-control. However, the employee lifestyle factors were not related to supervisory ratings of performance at work. The findings have direct implications for organizational health programs and policies.     

Some correlates of health locus of control among multicultural individuals

The relationship of locus of control to depression, anxiety, hostility, and physical health was assessed in a sample of multicultural college students (N = 162). Powerful Others Health Locus of Control was correlated with depression, anxiety, hostility, and recent physical symptoms while Chance Health Locus of Control (CHLC) was correlated with all of the above as well as chronic physical symptoms and major health problems. When controlling for a variety of health risk factors (viz., age, sex, body mass, exercise, smoking, salt, alcohol, and caffeine), only CHLC remained significant in the physical health models. Results support the cognitive model of mental health which emphasize the importance of adaptive beliefs. Specifically, they suggest that issues about control are related to negative affect and indicate that the often-cited relationship of an external locus of control to depression and anxiety also holds for hostility. The findings do not, however, support the view that anxiety and depression are associated with different types of external locus of control but rather suggest a unified set of locus of control beliefs underlying the three types of negative affect. In addition, evidence is provided for the external validity of the Multidimensional Health Locus of Control (MHLC) Scales with respect to mental health. Further, the results indicate that belief about one’s health may play a significant role in one’s physical health and that the health behavior model of the relationship between locus of control and physical health is insufficient to explain the relationship. As the Chance and Powerful Others MHLC scales were not related to health habits in this sample but were related to mental health (viz., depression, anxiety, and hostility), locus of control beliefs may be related to physical health via their relationship with mental health.     

Application of Problem Solving Therapy for Late-Life Anxiety

Cognitive behavioral therapy for anxiety has demonstrated lower efficacy in older compared with younger adults. Yet, few other evidence-based options for late-life anxiety have been examined. This case series aimed to demonstrate the application of Problem Solving Therapy (PST) to older adults with anxiety disorders building on PST’s strong empirical support for treating late-life depression. PST was implemented to treat three older primary-care patients diagnosed with anxiety disorders. We present treatment outcomes and discuss the feasibility and acceptability of using PST to treat these patients. Implications and lessons learned from these patients are discussed to inform further development of PST to better meet the needs of older patients suffering from late-life anxiety.     

Telephone-delivered psychotherapy for late-life anxiety

A randomized controlled trial (RCT) of telephone-delivered cognitive-behavioral therapy (CBT) was compared with usual care for late-life anxiety disorders. Client satisfaction, as assessed by the Client Satisfaction Questionnaire, was high (M = 27.4, range 8-32), and attrition rates were low (8.3%). Preliminary results suggest that participants receiving CBT, compared with usual care, experience declines in general anxiety, worry, anxiety sensitivity, and insomnia.     

Improving Mental Health Treatment Utilization in Military Veterans: Examining the Effects of Perceived Need for Care and Social Support

Many veterans with mental health problems do not adequately utilize needed care. Research has focused on identifying barriers to mental health care in veterans. The current study adds to existing literature by examining whether perceived need for treatment and social support affect treatment utilization in a national longitudinal survey of Iraq and Afghanistan veterans (n = 1,090). The Health Beliefs Model (HBM) postulates that a key reason why patients fail to obtain needed care is their belief “it’s up to me to handle my own problems.” This view was endorsed by 42% in the current national sample of veterans and was found in multivariate analysis to predict less treatment seeking in the next year. Mediation analysis revealed that veterans with higher ratings of social support were less likely to believe they needed to solve mental health problems on their own, indirectly equating to higher odds of treatment use. Simultaneously, findings indicated that posttraumatic stress disorder (PTSD) had a direct effect on more mental health visits but was also associated with higher endorsement that one needed to handle one’s own problems and thus had an indirect effect of reducing mental health visits. Both social support and PTSD affected veterans’ perceptions of needing to solve one’s own problems, significantly predicted follow-up with mental health care. As a result, the findings indicate that clinicians’ should explore veterans’ belief systems about perceived treatment need as well as investigate the role of social support to improve mental health treatment utilization.     

困境儿童孤独与社交焦虑对抑郁的影响——自尊的中介作用

为探讨困境儿童孤独、社交焦虑、抑郁和自尊的现状、特点、关系以及自尊在其中的中介作用,进而为困境儿童心理帮扶及救助提供依据。本研究使用儿童抑郁障碍自评量表、儿童孤独量表、儿童社交焦虑量表和自尊量表对重庆市17个区县1733名困境儿童进行调查。结果发现:(1)抑郁、社交焦虑和自尊存在性别差异,抑郁、孤独、社交焦虑和自尊存在年龄差异;(2)孤独和社交焦虑与抑郁呈显著正相关并显著预测抑郁,自尊与抑郁呈显著负相关并显著预测抑郁。(3)困境儿童的自尊在孤独和抑郁之间,社交焦虑和抑郁之间起中介作用。结果表明:困境儿童的孤独、社交焦虑既可直接影响其抑郁水平,也可通过自尊的中介作用间接影响其抑郁水平。