Global Mental Health and Adolescent Anxiety: Kin,Care and Struggle in New Mexico

While recent developments within the field of global mental health have illuminated the reality of serious mental health difficulties worldwide, particularly in low-income settings, research that focuses on children and adolescents remains underdeveloped. This is especially the case with respect to ethnographic studies of lived experience of adolescents diagnosed with serious mental health conditions. Drawing from an interdisciplinary study of adolescents in New Mexico who were afflicted with a broad range of disorders according to contemporary research diagnostic criteria, this article focuses on anxiety-related conditions with respect to subjective experience and social–ecological contexts of living with such conditions. We offer preliminary observations regarding the value of linking ethnographic and research diagnostic data to address questions of resilience, endurance, capacity and struggle. These observations are intended as the basis for the formulation of more precise hypotheses about adolescent anxiety, kin, and care under conditions of structural violence marked by psychological, residential, and intergenerational adversity.     

Everyday Life, Culture, and Recovery: Carer Experiences in Care Homes for Individuals with Severe Mental Illness

Supported homes or Care Homes (CHs) have become in-services that play a fundamental role in social-health systems, particularly in mental health systems in Europe and the United States. They provide settings where residents' day-to-day routines are supervised by in-house non-clinician professional carers. Ten semi-structured in-depth interviews were conducted by expert professional carers of persons with schizophrenia to explore interactions and activities between carers and users living in special "Care Homes". Analysis focused primarily on the functions of everyday life and daily routines in the recovery process. Social positioning analysis was used to investigate meanings and subjective experiences of professionals. The analysis revealed the importance of personal interactions in daily routines for recovery. We identified two main concerns guiding professionals' interactions with users: "Bring [users] to the here and now" and "give them the initiative to start actions". We suggest that CHs promote the construction of privileged identity in western urban societies, forming part of the process towards recovery and better social integration.     

Preliminary Development and Validation of a New End-of-Life Patient-Reported Outcome Measure Assessing the Ability of Patients to Finalise Their Affairs at the End of Life

Introduction

The ability of patients to finalise their affairs at the end of life is an often neglected aspect of quality of life (QOL) measurement in palliative care effectiveness research despite compelling evidence of the high value patients place on this domain.

Objective

This paper describes the preliminary development and evaluation of a new, single-item, end-of-life patient-reported outcome measure (EOLPRO) designed to capture changes in the ability of patients to finalise their affairs at the end of life.

Methods

Cognitive interviews with purposively sampled Australian palliative care patients (N = 9) were analysed thematically to explore content validity. Simultaneously, secondary analysis of data from a randomised controlled trial comparing ketamine and placebo for the management of cancer pain (N = 185) evaluated: construct validity; test-retest reliability; and responsiveness.

Results

Preliminary findings suggest patients interpret the new measure consistently. The EOLPRO captures the ability to complete physical tasks and finalise practical matters although it is unclear whether emotional tasks or resolution of relationship issues are considered. Personal and financial affairs should be separated to allow for differences in ability for these two types of affairs. The significant correlation between performance status and EOLPRO scores (r = 0.41, p<0.01, n = 137) and expected relationships between EOLPRO and proximity to death and constipation demonstrated construct validity. Pre- and post-treatment EOLPRO scores moderately agreed (n = 14, κ = 0.52 [95% CI 0.19, 0.84]) supporting reliability. The measure’s apparent lack of sensitivity to discriminate between treatment responders and non-responders may be confounded.

Conclusion

Based on the preliminary findings, the EOLPRO should be separated into ‘personal’ and ‘financial’ affairs with further testing suggested, particularly to verify coverage and responsiveness. Initial evaluation suggests that the single-item EOLPRO is a useful addition to QOL outcome measurement in palliative care effectiveness research because common palliative care specific QOL questionnaires do not include or explicitly capture this domain.     

Explaining Mental Health Treatment Disparities: Ethnic and Cultural Differences in Family Involvement

In a large, representative sample of persons receiving public mental health treatment, we examined whether ethnic minority consumers were more likely than white consumers to live with their families and to receive family support. We then evaluated whether differences observed in family involvement explained treatment disparities observed in outpatient and inpatient mental health services. Results indicated that Asian American and Latino consumers, especially, were considerably more likely than white consumers to live with family members and to receive family support. Ethnocultural differences in living with family did explain treatment intensity disparities whether or not consumers described themselves as dependent on family support. The results support the hypothesis that cultural differences in family involvement and support play a role in explaining mental health treatment disparities.     

Controlled-release phentermine/topiramate in severely obese adults: a randomized controlled trial (EQUIP)

A 56-week randomized controlled trial was conducted to evaluate safety and efficacy of a controlled-release combination of phentermine and topiramate (PHEN/TPM CR) for weight loss (WL) and metabolic improvements. Men and women with class II and III obesity (BMI ≥ 35 kg/m(2)) were randomized to placebo, PHEN/TPM CR 3.75/23 mg, or PHEN/TPM CR 15/92 mg, added to a reduced-energy diet. Primary end points were percent WL and proportions of patients achieving 5% WL. Secondary end points included waist circumference (WC), systolic and diastolic blood pressure (BP), fasting glucose, and lipid measures. In the primary analysis (randomized patients with at least one postbaseline weight measurement who took at least one dose of assigned drug or placebo), patients in the placebo, 3.75/23, and 15/92 groups lost 1.6%, 5.1%, and 10.9% of baseline body weight (BW), respectively, at 56 weeks (P < 0.0001). In categorical analysis, 17.3% of placebo patients, 44.9% of 3.75/23 patients, and 66.7% of 15/92 patients, lost at least 5% of baseline BW at 56 weeks (P < 0.0001). The 15/92 group had significantly greater changes relative to placebo for WC, systolic and diastolic BP, fasting glucose, triglycerides, total cholesterol, low-density lipoprotein (LDL), and high-density lipoprotein (HDL). The most common adverse events were paresthesia, dry mouth, constipation, dysgeusia, and insomnia. Dropout rate from the study was 47.1% for placebo patients, 39.0% for 3.75/23 patients, and 33.6% of 15/92 patients. PHEN/TPM CR demonstrated dose-dependent effects on weight and metabolic variables in the direction expected to be beneficial with no evidence of serious adverse events induced by treatment.     

The Outcome of Health Anxiety in Primary Care. A Two-Year Follow-up Study on Health Care Costs and Self-Rated Health

Background

Hypochondriasis is prevalent in primary care, but the diagnosis is hampered by its stigmatizing label and lack of valid diagnostic criteria. Recently, new empirically established criteria for Health anxiety were introduced. Little is known about Health anxiety''s impact on longitudinal outcome, and this study aimed to examine impact on self-rated health and health care costs.

Methodology/Principal Findings

1785 consecutive primary care patients aged 18–65 consulting their family physicians (FPs) for a new illness were followed-up for two years. A stratified subsample of 701 patients was assessed by the Schedules for Clinical Assessment in Neuropsychiatry interview. Patients with mild (N = 21) and severe Health anxiety (N = 81) and Hypochondriasis according to the DSM-IV (N = 59) were compared with a comparison group of patients who had a well-defined medical condition according to their FPs and a low score on the screening questionnaire (N = 968). Self-rated health was measured by questionnaire at index and at three, 12, and 24 months, and health care use was extracted from patient registers. Compared with the 968 patients with well-defined medical conditions, the 81 severe Health anxiety patients and the 59 DSM-IV Hypochondriasis patients continued during follow-up to manifest significantly more Health anxiety (Whiteley-7 scale). They also continued to have significantly worse self-rated functioning related to physical and mental health (component scores of the SF-36). The severe Health anxiety patients used about 41–78% more health care per year in total, both during the 3 years preceding inclusion and during follow-up, whereas the DSM-IV Hypochondriasis patients did not have statistically significantly higher total use. A poor outcome of Health anxiety was not explained by comorbid depression, anxiety disorder or well-defined medical condition. Patients with mild Health anxiety did not have a worse outcome on physical health and incurred significantly less health care costs than the group of patients with a well-defined medical condition.

Conclusions/Significance

Severe Health anxiety was found to be a disturbing and persistent condition. It is costly for the health care system and must be taken seriously, i.e. diagnosed and treated. This study supports the validity of recently introduced new criteria for Health anxiety.     

Evaluating the Impact of the Community-Based Health Planning and Services Initiative on Uptake of Skilled Birth Care in Ghana

Background

The Community-based Health Planning and Services (CHPS) initiative is a major government policy to improve maternal and child health and accelerate progress in the reduction of maternal mortality in Ghana. However, strategic intelligence on the impact of the initiative is lacking, given the persistant problems of patchy geographical access to care for rural women. This study investigates the impact of proximity to CHPS on facilitating uptake of skilled birth care in rural areas.

Methods and Findings

Data from the 2003 and 2008 Demographic and Health Survey, on 4,349 births from 463 rural communities were linked to georeferenced data on health facilities, CHPS and topographic data on national road-networks. Distance to nearest health facility and CHPS was computed using the closest facility functionality in ArcGIS 10.1. Multilevel logistic regression was used to examine the effect of proximity to health facilities and CHPS on use of skilled care at birth, adjusting for relevant predictors and clustering within communities. The results show that a substantial proportion of births continue to occur in communities more than 8 km from both health facilities and CHPS. Increases in uptake of skilled birth care are more pronounced where both health facilities and CHPS compounds are within 8 km, but not in communities within 8 km of CHPS but lack access to health facilities. Where both health facilities and CHPS are within 8 km, the odds of skilled birth care is 16% higher than where there is only a health facility within 8km.

Conclusion

Where CHPS compounds are set up near health facilities, there is improved access to care, demonstrating the facilitatory role of CHPS in stimulating access to better care at birth, in areas where health facilities are accessible.     

Patient-Reported Outcome (PRO) Assessment in Clinical Trials: A Systematic Review of Guidance for Trial Protocol Writers

Background

Evidence suggests there are inconsistencies in patient-reported outcome (PRO) assessment and reporting in clinical trials, which may limit the use of these data to inform patient care. For trials with a PRO endpoint, routine inclusion of key PRO information in the protocol may help improve trial conduct and the reporting and appraisal of PRO results; however, it is currently unclear exactly what PRO-specific information should be included. The aim of this review was to summarize the current PRO-specific guidance for clinical trial protocol developers.

Methods and Findings

We searched the MEDLINE, EMBASE, CINHAL and Cochrane Library databases (inception to February 2013) for PRO-specific guidance regarding trial protocol development. Further guidance documents were identified via Google, Google scholar, requests to members of the UK Clinical Research Collaboration registered clinical trials units and international experts. Two independent investigators undertook title/abstract screening, full text review and data extraction, with a third involved in the event of disagreement. 21,175 citations were screened and 54 met the inclusion criteria. Guidance documents were difficult to access: electronic database searches identified just 8 documents, with the remaining 46 sourced elsewhere (5 from citation tracking, 27 from hand searching, 7 from the grey literature review and 7 from experts). 162 unique PRO-specific protocol recommendations were extracted from included documents. A further 10 PRO recommendations were identified relating to supporting trial documentation. Only 5/162 (3%) recommendations appeared in ≥50% of guidance documents reviewed, indicating a lack of consistency.

Conclusions

PRO-specific protocol guidelines were difficult to access, lacked consistency and may be challenging to implement in practice. There is a need to develop easily accessible consensus-driven PRO protocol guidance. Guidance should be aimed at ensuring key PRO information is routinely included in appropriate trial protocols, in order to facilitate rigorous collection/reporting of PRO data, to effectively inform patient care.     

The Stroke and Carer Optimal Health Program (SCOHP) to enhance psychosocial health: study protocol for a randomized controlled trial

BackgroundStroke is a leading cause of disability and distress, and often profoundly affects the quality of life of stroke survivors and their carers. With the support of carers, many stroke survivors are returning to live in the community despite the presence of disability and ongoing challenges. The sudden and catastrophic changes caused by stroke affects the mental, emotional and social health of both stroke survivors and carers. The aim of this study is to evaluate a Stroke and Carer Optimal Health Program (SCOHP) that adopts a person-centred approach and engages collaborative therapy to educate, support and improve the psychosocial health of stroke survivors and their carers.MethodsThis study is a prospective randomised controlled trial. It will include a total of 168 stroke survivors and carers randomly allocated into an intervention group (SCOHP) or a control group (usual care). Participants randomised to the intervention group will receive nine (8 + 1 booster) sessions guided by a structured workbook. The primary outcome measures for stroke survivors and carers will be health-related quality of life (AQoL-6D and EQ-5D) and self-efficacy (GSE). Secondary outcome measures will include: anxiety and depression (HADS); coping (Brief COPE); work and social adjustment (WSAS); carer strain (MCSI); carer satisfaction (CASI); and treatment evaluation (TEI-SF and CEQ). Process evaluation and a health economic cost analysis will also be conducted.DiscussionWe believe that this is an innovative intervention that engages the stroke survivor and carer and will be significant in improving the psychosocial health, increasing independence and reducing treatment-related costs in this vulnerable patient-carer dyad. In addition, we expect that the intervention will assist carers and stroke survivors to negotiate the complexity of health services across the trajectory of care and provide practical skills to improve self-management.

Trial registration

ACTRN12615001046594. Registered on 7 October 2015.     

The Impact of the Carer Support Needs Assessment Tool (CSNAT) in Community Palliative Care Using a Stepped Wedge Cluster Trial

Family caregiving towards the end-of-life entails considerable emotional, social, financial and physical costs for caregivers. Evidence suggests that good support can improve caregiver psychological outcomes. The primary aim of this study was to investigate the impact of using the carer support needs assessment tool (CSNAT), as an intervention to identify and address support needs in end of life home care, on family caregiver outcomes. A stepped wedge design was used to trial the CSNAT intervention in three bases of Silver Chain Hospice Care in Western Australia, 2012-14. The intervention consisted of at least two visits from nurses (2-3 weeks apart) to identify, review and address caregivers’ needs. The outcome measures for the intervention and control groups were caregiver strain and distress as measured by the Family Appraisal of Caregiving Questionnaire (FACQ-PC), caregiver mental and physical health as measured by SF-12v2, and caregiver workload as measured by extent of caregiver assistance with activities of daily living, at baseline and follow up. Total recruitment was 620. There was 45% attrition for each group between baseline and follow-up mainly due to patient deaths resulting in 322 caregivers completing the study (233 in the intervention group and 89 in the control group). At follow-up, the intervention group showed significant reduction in caregiver strain relative to controls, p=0.018, d=0.348 (95% CI 0.25 to 0.41). Priority support needs identified by caregivers included knowing what to expect in the future, having time for yourself in the day and dealing with your feelings and worries. Despite the challenges at the clinician, organisational and trial levels, the CSNAT intervention led to an improvement in caregiver strain. Effective implementation of an evidence-informed and caregiver-led tool represents a necessary step towards helping palliative care providers better assess and address caregiver needs, ensuring adequate family caregiver support and reduction in caregiver strain.     

我国精神卫生专业机构床位配置及其规划研究

目的 提出我国精神卫生专业机构切实可行的床位配置规划。方法 根据精神卫生发展相关文件以及调研访谈资料，应用世界卫生组织推荐的床位测算方法进行床位需求测算，确定精神卫生防治服务体系所应包含的机构及其功能定位，结合重性精神疾病患者的治疗需要，提出了省、市、县不同级别精神卫生专业机构的床位配置规划。结果 最低、中等、较高配置水平下每万人口床位数分别为2.81张、11.77张和20.21张。结论 未来3～5年内，应该以每万人口床位数2.81张作为精神科床位配置目标。     

Health Literacy Measure for Adolescents (HELMA): Development and Psychometric Properties

Background

Health literacy refers to personal competencies for the access to, understanding of, appraisal of and application of health information in order to make sound decisions in everyday life. The aim of this study was to develop and evaluate the psychometric properties of an instrument for the measurement of health literacy among adolescents (the Health Literacy Measure for Adolescents-HELMA).

Methods

This study was made up of two phases, qualitative and quantitative, which were carried out in 2012–2014 in Tehran, Iran. In the qualitative part of the study, in-depth interviews with 67 adolescents aged 15–18 were carried out in 4 high schools to generate the initial item pool for the survey. The content validity of the items was then assessed by an expert panel review (n = 13) and face validity was assessed by interviewing adolescents (n = 16). In the quantitative part of the study, in order to describe the psychometric properties of the scale, validity, reliability (internal consistency and test-retest) and factor analysis were assessed.

Results

An item pool made up of 104 items was generated at the qualitative stage. After content validity was considered, this decreased to 47 items. In the quantitative stage, 582 adolescents aged 15–18 participated in the study with a mean age of 16.2 years. 51.2% of participants were females. In principal component factor analysis, 8 factors were loaded, which accounted for 53.37% of the variance observed. Reliability has been approved by α = 0.93 and the test-retest of the scale at two-week intervals indicated an appropriate stability for the scale (ICC = 0.93). The final questionnaire was approved with 44 items split into eight sections. The sections were titled: gain access to, reading, understanding, appraise, use, communication, self-efficacy and numeracy.

Conclusion

The Health Literacy Measure for Adolescents (HELMA) is a valid and reliable tool for the measurement of the health literacy of adolescents aged 15–18 and can be used to evaluate different levels of functional, interactive, and critical health literacy in adolescents.     

Development and Validation of the Keele Musculoskeletal Patient Reported Outcome Measure (MSK-PROM)

Objective

To develop and validate a patient report outcome measure (PROM) for clinical practice that can monitor health status of patients with a range of musculoskeletal (MSK) disorders.

Methods

Constructs for inclusion in the MSK-PROM were identified from a consensus process involving patients with musculoskeletal conditions, clinicians, purchasers of healthcare services, and primary care researchers. Psychometric properties of the brief tool, including face and construct validity, repeatability and responsiveness were assessed in a sample of patients with musculoskeletal pain consulting physiotherapy services in the United Kingdom (n=425).

Results

The consensus process identified 10 prioritised domains for monitoring musculoskeletal health status: pain intensity, quality of life, physical capacity, interference with social/leisure activities, emotional well-being, severity of most difficult thing, activities and roles, understanding independence, and overall impact. As the EuroQol (EQ-5D-5L) is a widely adopted PROMs tool and covers the first four domains listed, to reduce patient burden to a minimum the MSK-PROM was designed to capture the remaining six prioritised domains which are not measured by the EQ-5D-5L. The tool demonstrated excellent reliability, construct validity, responsiveness and acceptability to patients and clinicians for use in clinical practice.

Conclusion

We have validated a brief patient reported outcome measure (MSK-PROM) for use in clinical practice to measure musculoskeletal health status and monitor outcomes over time using domains that are meaningful to patients and sensitive to change. Further work will establish whether the MSK-PROM is useful in other musculoskeletal healthcare settings.