Integration of mental health comorbidity in medical specialty programs in 20 countries.

METHODS: A systematic analysis was performed of the medical specialization academic programs of 20 different countries to establish which medical specialties take into account mental health issues in the specialty curricular design and which mental health content these programs address. The criteria that were explored in the educational programs include: 1) name of the medical specialties that take into account mental health content in curriculum design, 2) name of the mental health issues addressed by these programs. After independent review and data extraction, paired investigators compared the findings and reached consensus on all discrepancies before the final presentation of the data. Descriptive statistics evaluated the frequency of the data presented. RESULTS: Internal medicine, family medicine, neurology, pediatrics and geriatrics were the specialties that included mental health topics in their programs. In four countries: Bangladesh, Serbia, the Netherlands and France, 50%of all graduate specialty training programs include mental health content. In ten countries: Germany, Sweden, the United Kingdom, Mexico, Belgium, India, Russia, Canada, Israel and Spain, between 20% and 49% of all graduate specialty training programs include mental health content. In six countries - Brazil, Chile, Colombia, Croatia, Kenya, and the United States-less than 20% of all graduate specialty training programs include mental health content. DISCUSSION: The proposal that we have made in this article should be taken into account by decision-makers, in order to complement the different postgraduate training programs with mental health issues that are frequently present with other physical symptoms. It is not our intention that the different specialists know how to treat psychiatric comorbidities, but rather pay attention to their existence and implications in the diagnosis, evolution and prognosis of many other diseases. The current fragmentation of medicine into ever finer specialties makes the management of comorbidity ever more difficult: a reorientation of post- graduate training might improve the situation.

Mental health literacy in primary care: Canadian Research and Education for the Advancement of Child Health (CanREACH).

The effectiveness of a continuing education programme in paediatric psychopharmacology designed for primary healthcare providers was objectively measured based on the assumption that training would lead to measurable changes in referral patterns and established clinical measures of referred patients. Using established, valid and reliable measures of clinical urgency embedded in to a regional healthcare system since 2002, the referrals to child and adolescent psychiatric services of physicians who participated in the training (n=99) were compared pretraining and post-training, and to non-participating/untrained referring physicians (n=7753) making referrals over the same time period. Referrals were analysed for evidence of change based on frequencies and measures of clinical urgency. Participants of the training programme also completed standardised baseline and outcome self-evaluations. Congruent with participants self-reported evaluative reports of improved knowledge and practice, analysis of referral frequency and the clinical urgency of referrals to paediatric psychiatric services over the study period indicated that trained physicians made more appropriate referrals (clinically more severe) and reduced referrals to emergency services. Quantitative clinical differences as completed by intake clinicians blind to referrals from the study group designations were observed within the trained physician group pretraining and post-training, and between the trained physician group and the unexposed physician group. The results illustrate a novel model for objectively measuring change among physicians based on training in paediatric mental health management.

The use of the Burden Assessment Scale with families of a pediatric population.

The emotional, financial and social impact on caregivers of those with pediatric psychiatric, emotional and behavioral disorders has been poorly documented. This study sought to begin to remedy this by determining the utility of the Burden Assessment Scale (BAS) with this population. 300 parents seeking services within a major Canadian city were interviewed using the BAS and a follow up questionnaire on the clarity, comprehensiveness and acceptability of the BAS. The BAS was clear, acceptable and comprehensive for >80% of participants. Factor analysis revealed four factors compared to the original five factors found with adults. The BAS had a utility with this population and would be a valuable addition to standard information gathered but use of the total score only is recommended.

Population-based affective-disorder-related biomedical/biophysical multi-hyper-morbidity across the lifespan: A 16-year population study.

BACKGROUND: There are few if any life-span population-based studies of psychiatric disorder-associated biomedical and biophysical disorders and diseases (morbidity). AIM: To scope the present state of research regarding the biomedical and biophysical morbidity associated with affective and mental disorder in epidemiological samples, and to examine the life-span relationship between affective disorders and biomedical/biophysical disorders to illustrate a novel approach employing the odds ratio to represent the intensity of biomedical and biophysical morbidity associated in time in a population. METHODS: A repeatable systematic literature search of PubMed was represented in summary. Additionally, a regional population-based dataset was constructed and analyzed to represent the age- and sex-specific diagnoses (International Classification of Diseases Version 9, ICD-9) for those with and without affective disorder. The analysis presents a novel index of the relative age-specific frequency of life-span biomedical and biophysical diagnoses associated with affective disorder. RESULTS: The volume of biomedical and biophysical morbidity associated with mental disorder literature has increased, yet few studies measure comprehensive temporal hyper-morbidity (over-representation of diseases over time, either before or after the index diagnostic event) in populations. Further, there have been only a few population-based studies examining the morbidity associated with affective disorder and only one that examines the full diagnostic range of lifespan morbidity. Substantial differences arose between males and females with more females than males having greater frequencies of diagnoses. The age-specific distributions of the maximum proportional diagnosis frequency ratios for each sex illustrate the greatest diagnosis-specific differences when comparing the biomedical and biophysical diagnoses of those with and without affective disorder when the same diagnosis was represented in each grouping at the same age. CONCLUSION: Clinical research needs to focus on more than one or two comorbid biomedical or biophysical disorders at a time. Comprehensive population-based examination of the lifespan biomedical and biophysical multi-morbidity associated with affective disorder has the potential to directly inform clinical practice. Representing the proportional ratios of age-specific frequency of diagnoses for the full range of ICD-9 diagnoses is a novel analytical model. Diagnostic frequency appears a viable representation of a given disease state, such as affective disorder. Fortunately, the WPA has developed a global education section to better understand the biomedical and biophysical morbidity associated with all psychiatric disorders. This has been identified by the WPA as the psychiatric practice challenge of the 21st century.

A New Acute-At-Home Child and Adolescent Clinical Service: Evaluation of Impact.

OBJECTIVE: An Acute at Home (AAH) clinical service was implemented to reduce emergency and inpatient admissions to the regional tertiary child and adolescent mental health system. This paper examines describes the served the population and impact on emergency and inpatient admissions. METHODS: Analysis of re-admission rates for those enrolled before and after the May 2019 implementation of the AAH service in comparison over the same time period to an unexposed comparison group. In addition the groups were compared on clinical and demographic variables comparing those exposed and those not exposed to the AAH service. RESULTS: The results indicated that the AAH group experienced reduced rates of readmission and lengths of stay post-exposure. Family composition, sex, seven Adverse Childhood Experience survey items, and nine Western Canada Waitlist Child Mental Health Priority Criteria Score items distinguished those exposed to AAH compared to those who were not. Thirteen of 19 independent variables indicated greater pathology in the AAH group with less likelihood of potential of danger to self. CONCLUSION: The present results indicate a substantial benefit of the AAH service via reducing readmissions and lengths of stay. The quantitative measures warrant a careful qualitative examination of the AAH processes along with ongoing monitoring of the program's effect.

School-based mental health literacy training shifts the quantity and quality of referrals to tertiary child and adolescent mental health services: A Western Canada regional study.

BACKGROUND: We aimed to improve mental health referral quality of young people by helping educators build capacity for early identification of youth at risk of mental illness and facilitate referrals between the education and health systems. METHODS: We applied the Go-To Educator mental health literacy training for early identification, triage and support in 208 schools in Calgary, Alberta between 2013 and 2016. Students presenting to mental health services during this time were compared on a number of clinical, system, and demographic variables, based on the training status of the school (untrained schools; before and after training schools), using retrospective cohort design. Based on clinical and system data, bivariate and multivariable logistic regression analysis were employed to compare the three school status domains. RESULTS: After training, referrals differed significantly from control and pre-training schools. Students presenting to services from these schools were younger, from single parent families; were referred more because of adjustment and learning/attention problems; had complex social/family issues; thought disturbances, and harmful behavior/thoughts towards others. While they waited longer to be admitted they stayed longer in services; had more provisional comorbid diagnoses and demonstrated positive treatment outcomes. CONCLUSIONS: The Go-To Educator training may be an effective intervention helping educators identify students at risk of mental disorders and in substantial need of mental health services, demonstrating improved linkages between education and health sectors.

Association of mental health with health care use and cost: a population study.

OBJECTIVE: To compare the health costs of groups with and without psychiatric diagnoses (PDs) using 9 years of physician billing data. METHODS: A dataset containing registration data for all patients receiving public mental health service was constructed and subsequently matched, on age and sex, in a final patient to comparison patient ratio of 1:8, with health care users who did not receive treatment in the mental health system. Three groups emerged: a patient PD group-patients with psychiatric disorders treated in public mental health care (n = 76 677); a comparison patient PD group-comparison patients with PDs treated in physicians only (n = 277 627); and a patient- comparison patient non-PD group-patients (treated in specialized publicly funded care or by their physician) without PDs (n = 329 177). Examining over 42 million billing records for all of these patients, we compared the average number of visits and the average health only (nonpsychiatric) billing cost per each patient during the 9-year study period across the groups. RESULTS: Among all health care users in the data, the health costs (Total Costs - Mental Health Costs) were greater on average for the patients with PD group ($3437) and the comparison patient PD group ($3265), compared with patient-comparison patient non-PD group ($1345). Forty-six percent of the comparison sample had a PD. CONCLUSIONS: Having a mental health problem is related to greater health-related expenditures. This has important policy implications on how mental health resources are constructed and rationed within the health care system.

The Temporal Hyper-Morbidity of Asthma and Attention Deficit Disorder: Implications for Interpretation Based on Comparison of Prospective and Cross-Sectional Population Samples.

OBJECTIVE: The purpose of this study was to test the hypothesis that a significant temporal relationship exists between asthma and attention deficit hyperactivity disorder (ADHD). METHODS: The population dataset consisted of 95,846,511 physician diagnoses for 768,460 (46% male) individuals spanning 1993-2010. Four groups were labeled as having neither Asthma nor ADHD, Asthma only, ADHD only, or both Asthma and ADHD and formed the basis of calculating the odds ratios for each sex describing the association of Asthma and ADHD by age, and, in addition, a prospective sample age (<5 years) between 1993 and 1996 was utilized to evaluate the temporal association between Asthma and ADHD. RESULTS: There was a significant relationship between ADHD and Asthma within the age strata of the sample, one from the cohort and two from the whole sample. When both ADHD and Asthma were diagnosed in the same patients, the age was younger in both cross-sectional and prospective cohort samples. ADHD arose significantly more often after Asthma in the cross-sectional samples stratified on age and in the prospective cohort sample. CONCLUSION: The results are consistent with previous literature where ADHD has been linked to allergic diseases, such as asthma.

The Economic Impact of Providing Evidence-Based Pediatric Mental Health Literacy Training to Primary Care Physicians.

OBJECTIVE: This paper presents a review of the current state of child and adolescent mental health literacy and provides current evidence of the economic impact of a pediatric mental health literacy (MHL) training program. METHODS: Employing a case-series-comparison design, physician referrals to urgent and specialized mental health services were linked with patient-specific information comparing referrals from MHL participants and non-participating physicians. The economic impact analysis was based on changes in the admitted referral frequency and lengths of stay for the MHL group, compared to themselves pretraining, and over the same time period compared to non-participating physicians. RESULTS: Average scheduled ambulatory admission rates per physician remained constant for trained and untrained pre-post groups. Average scheduled ambulatory admission wait time and length of stay reduced significantly post-training for MHL-trained physicians compared to pre-training and untrained physicians. In addition to reductions in length of stay, the total bed costs saving for emergency/inpatients admission deferrals was $2,932,112 or about $20,000 per MHL-trained physician. CONCLUSION: The estimated economic impact of the MHL training shows a substantial return on investment and supports wider implementation. The MHL training program should be a key feature of mental health reform strategies, as well as continuing and undergraduate medical education.

Impact of Central Intake Development and System Change on Per Capita Child and Adolescent Mental Health Discharges from 2002 to 2017: Implications for Optimizing System Design by Shaping Demand.

INTRODUCTION: After several Canadian public hospital systems merged, a centralized intake system and associated regional access and intake system were developed and implemented for child and adolescent mental health services in 2002. OBJECTIVES: To describe the catchment area's per capita service rates (overall and annual discharges) and changes in staff time per unit of intake activity, client wait times, and length of stay. METHODS: Patient data (2002-2017) and census data permitted calculation of annual and overall per capita mental health service episodes of care on the basis of discharge rates. Population-based discharge rates, wait times, length of stay, and staff workload were described, referring service investment and system changes. RESULTS: From 117,500 referrals (64% admitted and discharged; 53% female) to all regional services, 16,750 unique males and 17,140 unique females were admitted and discharged between April 1, 2002, and March 31, 2017. Per capita annual discharge rates increased over baseline 1.8-fold for both sexes, and investments increased 2.8-fold. Wait times and length of stay decreased in the 90th percentile over time for both scheduled (ambulatory) and urgent/emergent service levels. Staff workload increased. CONCLUSION: Per capita system capacity increased but did not change in linear relation to investment, even though wait times and length of stay decreased. Steps focusing on future optimization of system capacity are discussed using a novel concept termed shaping demand, which refers to strategies for orienting/educating families after referral and before admission. Two new education programs focus on community-based primary care physicians and school-based services.

A 16-Year Cohort Analysis of Autism Spectrum Disorder-Associated Morbidity in a Pediatric Population.

Introduction: This chapter presents the analysis of physician-diagnosed International Classification of Diseases (ICD version 9) disorders and diseases associated with autism spectrum disorders (ASD) in a 16-year pediatric cohort. Materials and Methods: The sample (n = 47,180; 62% male) consisted of children in the Alberta Health Services Calgary Health Region catchment under the age of 3 years, who received any physician-assigned ICD 9 diagnosis before the age of three between April 1993 and December 31, 1994. There were 111 females and 609 males with ASD diagnosed at any time between 1993 and 2010. The results detail the 16-year odds ratio (OR) associations of ASD diagnosis within the major classes of international classification of diseases (ICD 9) stratified by age and sex in the cohort. Further, for those suffering from ASD and any other disorder or disease, the analysis presents by sex, age, and duration, the proportions of all index physician-assigned ICD diagnoses, arising significantly before and after the index ASD diagnosis. Results: The rate of treated ASD in the cohort was 1 in 65 and the 16-year population rate of ASD was 62 per 10,000. For males with an ASD over the 16 year period, the ORs were significantly greater than the value one for 15 of the 17 main ICD classes and for 10 of the main ICD classes for females. Different age strata presented a more specific account of the main ICD class OR profiles. More specifically, 28 ICD disorders significantly preceded and 95 ICD disorders significantly followed ASD for females. Thirty-eight ICD disorders significantly preceded and 234 ICD disorders significantly followed ASD for males. Conclusions: The results largely confirm past studies focusing on more constrained sets of ASD morbidity. The age-stratified ORs gauge the order of risk in time for the cohort. The proportions of specific ICD disorders arising before and after ASD may be useful in respect to informing basic ASD research and ASD clinical management. Limitations are discussed.

Relationship Between Adverse Childhood Experience Survey Items and Psychiatric Disorders.

CONTEXT: Developmental psychopathology theory suggests a relationship between early childhood adversity and mental disorder. OBJECTIVE: To examine the relationship between the specific items on the Adverse Childhood Experiences (ACE) survey and the International Classification of Diseases, Tenth Revision (ICD-10) categories of psychiatric diagnoses in a pediatric sample. DESIGN: The sample included patients enrolled in the Child and Adolescent Addiction Mental Health and Psychiatry Program with both a completed ACE survey and at least 1 diagnosis of record (per admission). These criteria yielded 2 samples for each sex (ACE survey item frequencies and values in collapsed and multiple-admission groups). Data were analyzed employing tetrachoric correlation, hierarchical regression, and polychoric factor analysis. RESULTS: Hierarchical regression analysis identified that ICD-10 diagnostic categories, except for substance disorders, were not consistently related to ACE total score and tended to reduce the magnitude of the ACE total score in the multiple-admission group. Tetrachoric correlation revealed very low (< 0.4) positive and negative correlations between ICD-10 categories and ACE items in both multiple-admission and collapsed sample groups. Polychoric factor analysis indicated that the ACE survey items and the ICD-10 categories for both sexes were independent, with only the diagnostic ICD-10 category substance disorders being marginally associated with the ACE items factor for females. CONCLUSION: The nominal relationship between ACE items and ICD-10 diagnostic categories indicates the need to include ACE assessment in advance of differential diagnosis and implementation of conventional mental health interventions for children and adolescents.

ERRATUM TO: On Becoming Trauma-Informed: Role of the Adverse Childhood Experiences Survey in Tertiary Child and Adolescent Mental Health Services and the Association with Standard Measures of Impairment and Severity.

[This corrects the article DOI: 10.7812/TPP/17-054.].

On Becoming Trauma-Informed: Role of the Adverse Childhood Experiences Survey in Tertiary Child and Adolescent Mental Health Services and the Association with Standard Measures of Impairment and Severity.

CONTEXT: There is a movement toward trauma-informed, trauma-focused psychiatric treatment. OBJECTIVE: To examine Adverse Childhood Experiences (ACE) survey items by sex and by total scores by sex vs clinical measures of impairment to examine the clinical utility of the ACE survey as an index of trauma in a child and adolescent mental health care setting. DESIGN: Descriptive, polychoric factor analysis and regression analyses were employed to analyze cross-sectional ACE surveys (N = 2833) and registration-linked data using past admissions (N = 10,400) collected from November 2016 to March 2017 related to clinical data (28 independent variables), taking into account multicollinearity. RESULTS: Distinct ACE items emerged for males, females, and those with self-identified sex and for ACE total scores in regression analysis. In hierarchical regression analysis, the final models consisting of standard clinical measures and demographic and system variables (eg, repeated admissions) were associated with substantial ACE total score variance for females (44%) and males (38%). Inadequate sample size foreclosed on developing a reduced multivariable model for the self-identified sex group. CONCLUSION: The ACE scores relate to independent clinical measures and system and demographic variables. There are implications for clinical practice. For example, a child presenting with anxiety and a high ACE score likely requires treatment that is different from a child presenting with anxiety and an ACE score of zero. The ACE survey score is an important index of presenting clinical status that guides patient care planning and intervention in the progress toward a trauma-focused system of care.

Temporal order of cancers and mental disorders in an adult population.

BACKGROUND: Population-based examination of comorbidity is an emerging field of study. AIMS: The purpose of the present population level study is to expand our understanding of how cancer and mental illness are temporally associated. METHOD: A sample of 83 648 056 physician billing records for 664 838 (56% female) unique individuals over the age of 18 was stratified on ages 19-49 years and 50+ years, with temporal order of mental disorder and cancer forming the basis of comparison. RESULTS: Mental disorders preceded cancers for both genders within each age strata. The full range of cancers and mental disorders preceding or following each pivot ICD class are described in terms of frequency of diagnosis and duration in days, with specific examples illustrated. CONCLUSIONS: The temporal comorbidity between specific cancers and mental disorders may be useful in screening or clinical planning and may represent indicators of disease mechanism that warrant further screening or investigation. DECLARATION OF INTEREST: None.

Comprehensive Description of Comorbidity for Autism Spectrum Disorder in a General Population.

CONTEXT: Few published studies of autism spectrum disorder (ASD) and comorbidity are population based. OBJECTIVE: To describe the comorbidity of ASD and disorders listed in the main classes of the International Classification of Diseases, Ninth Revision (ICD-9) in a general population. DESIGN: Direct physician billing data for the city of Calgary, Alberta, Canada, for the treatment of any presenting concern in the Calgary Health Zone (n = 763,449) from 1994 to 2009 were extracted. Diagnosed ICD-9 disorders (independent variable) were grouped into 17 categories using ICD-9 diagnosis codes. ASD (dependent variable) was classified under ICD-9 Code 299. Individuals with and without independent disorder classes were counted by the presence or absence of any ASD. Odds ratios (ORs) and 95% confidence intervals of the association were calculated. MAIN OUTCOME MEASURES: ORs of ASD comorbidities. RESULTS: Annual rates of ASD increased 3.9-fold for males and 1.4-fold for females. Diagnosed disorders ranked by OR in the independent ICD-9 categories indicated that males with ASD had overall higher ORs (> 1.0) in 11 main ICD-9 classes, and females with ASD had higher ORs (> 1.0) in 12 main ICD-9 classes. Males with ASD had lower ORs in 4 main ICD-9 disease classes; females with ASD had lower ORs related only to the main class "complications of pregnancy and childbirth." Five main ICD-9 classes were not significant for males or females. CONCLUSIONS: Patients with ASD have significant comorbidity of physical disorders. This finding may inform other areas of research and assessment in clinical management.

From 'Big 4' to 'Big 5': a review and epidemiological study on the relationship between psychiatric disorders and World Health Organization preventable diseases.

PURPOSE OF REVIEW: This study outlines the rationale and provides evidence in support of including psychiatric disorders in the World Health Organization's classification of preventable diseases. The methods used represent a novel approach to describe clinical pathways, highlighting the importance of considering the full range of comorbid disorders within an integrated population-based data repository. RECENT FINDINGS: Review of literature focused on comorbidity in relation to the four preventable diseases identified by the World Health Organization. This revealed that only 29 publications over the last 5 years focus on populations and tend only to consider one or two comorbid disorders simultaneously in regard to any main preventable disease class. SUMMARY: This article draws attention to the importance of physical and psychiatric comorbidity and illustrates the complexity related to describing clinical pathways in terms of understanding the etiological and prognostic clinical profile for patients. Developing a consistent and standardized approach to describe these features of disease has the potential to dramatically shift the format of both clinical practice and medical education when taking into account the complex relationships between and among diseases, such as psychiatric and physical disease, that, hitherto, have been largely unrelated in research.

Temporal comorbidity of mental disorder and ulcerative colitis.

OBJECTIVES: Ulcerative colitis is an inflammatory bowel disease that rarely exists in isolation in affected patients. We examined the association of ulcerative colitis and International Classification of Diseases mental disorder, as well as the temporal comorbidity of three broad International Classification of Diseases groupings of mental disorders in patients with ulcerative colitis to determine if mental disorder is more likely to occur before or after ulcerative colitis. METHODS: We used physician diagnoses from the regional health zone of Calgary, Alberta, for patient visits from fiscal years 1994 to 2009 for treatment of any presenting concern in that Calgary health zone (763,449 patients) to identify 5113 patients age younger than 1 year to age 92 years (2120 males, average age = 47 years; 2993 females, average age = 48 years) with a diagnosis of ulcerative colitis. RESULTS: The 16-year cumulative prevalence of ulcerative colitis was 0.0058%, or 58 cases per 10,000 persons (95% confidence interval = 56-60 per 10,000). Although the cumulative prevalence of mental disorder in the overall sample was 5390 per 10,000 (53.9%), we found that 4192 patients with ulcerative colitis (82%) also had a diagnosis of a mental disorder. By annual rate of ulcerative colitis, patients with mental disorder had a significantly higher annual prevalence. The mental disorder grouping neuroses/depressive disorders was most likely to arise before ulcerative colitis (odds ratio = 1.87 for males; 2.24 for females). CONCLUSIONS: A temporal association was observed between specific groups of International Classification of Diseases mental disorder and ulcerative colitis, indicating a possible etiologic relationship between the disorders or their treatments, or both.

A novel population-based health index for mental disorder.

INTRODUCTION: A novel population-based health index was identified, in addition to calculation of the rates of psychiatric disorder in a random sample from a large urban center. METHODS: With use of the regional population as a sampling frame, 685,684 individuals (45.8% male) were selected randomly, with physician billing visit and cost data from 1994 to 2009 grouped on the basis of the presence or absence of a psychiatric disorder. The prevalence of psychiatric disorder was described and the groups were further analyzed in terms of somatic and biomedical disorders with the profile of depression highlighted. RESULTS: In the sample (45.8% male), the annual prevalence of psychiatric disorder from 1994 to 2009 was found to increase in 3 age strata (children, 5.3%; adults, 4.4%; and geriatric subjects, 6.2%). Depressive disorders as a group provided an example of the population profile. The cumulative rate of psychiatric disorder was 53% over 16 fiscal years. In comparison with the group without psychiatric disorder, the median cost of physical (biomedical/somatic) disorders was 2.9 times higher for the group with any International Classification of Diseases psychiatric disorder. DISCUSSION: The arithmetic ratio of median somatic and biomedical health costs, comparing groups with and without psychiatric disorders, was presented as a novel population health index that holds the potential to directly measure the impact of promotion and prevention programs associated with psychiatric disorders.