Promotion, prevention and treatment interventions for mental health in low- and middle-income countries through a task-shifting approach.

Recently, mental health and ill health have been reframed to be seen as a continuum from health to ill health, through the stages of being asymptomatic 'at risk', to experiencing 'mental distress', 'sub-syndromal symptoms' and finally 'mental disorders'. This new conceptualisation emphasised the importance of mental health promotion and prevention interventions, aimed at reducing the likelihood of future disorders with the general population or with people who are identified as being at risk of a disorder. This concept generated discussion on the distinction between prevention and treatment interventions, especially for those mental health conditions which lie between psychological distress and a formal psychiatric diagnosis. The present editorial aims to clarify the definition of promotion, prevention and treatment interventions delivered through a task-shifting approach according to a global mental health perspective.

Sustained Reduction in Health Care Service Usage after Adjunctive Treatment of Intensive Short-Term Dynamic Psychotherapy in Patients with Bipolar Disorder.

The aim of this study was to evaluate changes in long-term health care costs and symptom severity after adjunctive intensive short-term dynamic psychotherapy (ISTDP) individually tailored and administered to patients with bipolar disorder undergoing standard psychiatric care. Eleven therapists with different levels of expertise delivered an average of 4.6 one-hour sessions of ISTDP to 29 patients with bipolar disorders. Health care service costs were compiled for a one-year period prior to the start of ISTDP along with four one-year periods after termination. Two validated self-report scales, the Brief Symptom Inventory and the Inventory of Interpersonal Problems, were administered at intake and termination of ISTDP. Hospital cost reductions were significant for the one-year post-treatment period relative to baseline year, and all cost reductions were sustained for the follow-up period of four post-treatment years. Self-reported psychiatric symptoms and interpersonal problems were significantly reduced. These preliminary findings suggest that this brief adjunctive psychotherapy may be beneficial and cost-effective in select patients with bipolar disorders, and that gains may be sustained in long-term followup. Future research directions are discussed.

[Impacts of a brief contact intervention in suicide prevention on medical care consumptions]. / Impacts d'un système de veille en prévention du suicide sur les consommations de soins.

INTRODUCTION: Suicide prevention is a major objective in public health. The development of alternative approaches to the prevention of suicide, such as monitoring systems, is growing quickly. The results are encouraging, but the analysis of the effectiveness remains complex. The objective of this study is to evaluate the medico-economic impact of the ALGOS brief contact intervention (BCI) on the consumption of medical care. METHOD: ALGOS is a prospective, comparative, multicentre, single-blind, randomized, controlled trial, which compared two groups after a suicide attempt (SA). The ALGOS algorithm assigned each BCI to the subgroup of participants. The medico-economic impact of each intervention was evaluated at 6 and 13 months after inclusion. RESULTS: In all, 987 patients were included. There was no significant difference between the two groups at 6 months and at 13 months after SA in the total number of patients who had been hospitalized in psychiatry or other care services. However, the average number of rheumatology visits was significantly higher in the control group (P=0.01) at 13 months. The total number of rheumatologist and physiotherapist visits was significantly higher in the control group at 6 and 13 months. CONCLUSION: Our results suggest that the use of a BCI after SA does not lead to increased consumption of medical care.

"The Buoy": Utilization of a low-threshold ambulatory setting for traumatized children and adolescents in Austria.

BACKGROUND: This investigation intended to assess the use of an outpatient clinic providing low-threshold, short-term trauma therapy for children and adolescents across the first 6 years of its existence. METHODS: A retrospective analysis of the records of all patients undergoing treatment in this institution between 2001 and 2007 (n = 2510) has been performed. We evaluated demographic data, reason for contacting the unit, the referring person or institution, the person or institution in charge of the care and custody of the child, the number of contacts with the clinic, presence of physical or psychiatric illness of a parent, and medications prescribed. RESULTS: Ages of patients ranged from 1 to 17. Gender distribution was even. Having experienced the death of a relative, experienced violence, or having witnessed traumatic death were the main reasons for presentation. The utilization rates of immigrants rose throughout the observation period. Children from foster care were seen less frequently than expected. Medication was hardly prescribed. CONCLUSIONS: Ample utilization of this institution clearly demonstrates the need for short-term acute outpatient trauma therapy for children and adolescents. Efforts to provide easily accessible institutions for youth who experience traumatic events should be stepped up.

Can Low-Cost Strategies Improve Attendance Rates in Brief Psychological Therapy? Double-Blind Randomized Controlled Trial.

OBJECTIVES: To assess if telephone text message appointment reminders and orientation leaflets can increase the proportion of patients who attend brief interventions after being assessed as suitable for guided self-help following cognitive behavioral therapy principles. METHOD: Attendance was operationally defined as having accessed at least 1 therapy appointment. A secondary outcome was the proportion of attenders who completed or dropped out of therapy. After initial assessment, 254 patients with depression and anxiety disorders were randomly assigned to 1 of 3 groups: (a) usual waitlist control, (b) leaflet, (c) leaflet plus text message. Differences in the proportions of patients who started and completed therapy across groups were assessed using chi-square and logistic regression analyses. RESULTS: Overall, 63% of patients in this sample attended therapy. Between-group differences were not significant for attendance, x(2) (2) = 3.94, p = .14, or completion rates, x(2) (2) = 2.98, p = .23. These results were not confounded by demographic or clinical characteristics. CONCLUSIONS: Low-cost strategies appear to make no significant difference to therapy attendance and completion rates.

Early assessment of implementing evidence-based brief therapy interventions among secondary service psychiatric therapists.

This implementation study was part of the Ostrobothnia Depression Study, in Finland, which covered implementation of motivational interviewing (MI) and behavioral activation (BA) within regional public psychiatric secondary care. It aimed to evaluate the mid-term progress of implementation and related factors. Altogether, 80 therapists had been educated through the implementation program by the point of the mid-term evaluation. Eligible information for evaluation was gathered using two questionnaires (q1, q2) with a one-year interval. A total of 45 of the 80 therapists completed q1, 30 completed q2, and 24 completed both questionnaires. Professional education was the only background factor associated with adopting the interventions (q1: p=0.059, q2: p=0.023), with higher education indicating greater activity. On the basis of trends such as changes in overall usefulness score from q1 to q2, the most involved therapists were slightly more likely to adopt MI/BA. Our experience so far suggests that encouraging staff to begin using new interventions during education is very important. The Consolidated Framework for Implementation Research was found to be a useful tool for constructing the evaluation.

Screening for unhealthy alcohol and other drug use by health educators: do primary care clinicians document screening results?

OBJECTIVES: Health educators are increasingly being used to deliver preventive care including screening and brief intervention (SBI) for unhealthy substance use (SU) (alcohol or drug). There are few data, however, about the "handoff" of information from health educator to primary care clinician (PCC). Among patients identified with unhealthy SU and counseled by health educators, the objective of this study was to examine (1) the proportion of PCC notes with documentation of SBI and (2) the spectrum of SU not documented by PCCs. METHODS: Before the PCC-patient encounter, health educators screened for SU, assessed severity (Alcohol, Smoking, and Substance Involvement Screening Test), and counseled patients. They also conveyed this information to the PCC before the PCC-patient encounter. Researchers reviewed the electronic medical record for PCC documentation of SBI performed by the health educator and/or the PCC. RESULTS: Among patients with the health educator-identified SU, only 69% (342/495) of PCC notes contained documentation of screening by the health educator and/or the PCC. Documentation was found in all encounters with patients with likely dependent SU, but only 62% and 59% of encounters with patients with risky alcohol and drug use, respectively. Documentation of cocaine or heroin use was higher than that of alcohol or marijuana use but still not universal. Although all SU-identified patients had received a brief intervention (from a health educator and possibly a PCC), only 25% of PCC notes contained documentation of a brief intervention. CONCLUSIONS: Among patients screened and counseled by health educators for unhealthy SU, SBI was often not documented by PCCs. These results suggest that strategies are needed to integrate SBI by primary care team members to advance the quality of care for patients with unhealthy SU.

Randomized controlled trial of mailed personalized feedback for problem drinkers in the emergency department: the short-term impact.

BACKGROUND: Evidence exists for the efficacy of emergency department (ED)-based brief alcohol interventions, but attempts to incorporate face-to-face interventions into routine ED practice have been hampered by time, financial, and attitudinal constraints. Mailed personalized feedback, which is likely to be more feasible, has been associated with reduced alcohol consumption in other settings, but its cost-effectiveness in the ED has not been examined. METHODS: The intervention was evaluated with a randomized controlled trial of patients presenting to 5 rural EDs in New South Wales, Australia. Patients aged 14 years and older were screened using the Alcohol Use Disorders Identification Test, and those scoring 8 or more were randomly allocated to the intervention or control group. Participants in the intervention group received mailed personalized feedback regarding their alcohol consumption. The control group received no feedback. RESULTS: Two hundred and forty-four (80%) participants were successfully followed up at 6 weeks. A significant effect of the mailed feedback was observed only in patients with an alcohol-involved ED presentation. Among this subgroup of participants, those in the intervention group consumed 12.2 fewer drinks per week than the control group after controlling for baseline consumption and other covariates (effect size d = 0.59). The intervention was associated with an average cost of Australian $5.83 per patient, and among participants with an alcohol-involved ED presentation, an incremental cost-effectiveness ratio of 0.48. CONCLUSIONS: Mailed personalized feedback is efficacious in reducing quantity/frequency of alcohol consumption among patients with alcohol-involved ED presentations. Mailed feedback has high cost-efficacy and a low absolute cost, making it a promising candidate for integration into ED care.

Neuropsychological support to relatives of patients with severe traumatic brain injury in the sub-acute phase.

Many studies have reported emotional distress in relatives of patients with brain injury, but few studies have investigated neuropsychological interventions for relatives. The present study assessed the amount of neuropsychological support as well as the actual number of sessions with a neuropsychologist during rehabilitation in a sub-acute unit. The study also examined whether the amount of support was related to the condition of the patient or the relative at admission. The sample consisted of 26 patients and their closest relative, and measures included demographic variables as well as characteristics related to the patient: Glasgow Coma Scale, Injury Severity Score, Early Functional Abilities, Functional Independence Measure, Rancho Los Amigos; and to the relative: symptoms of anxiety and depression (SCL-90-R), quality of life (SF-36) and amount and number of sessions of neuropsychological support. On average, the relatives received about 18 units of 15 minutes and had six sessions with a neuropsychologist during hospitalisation. A total of 38% participated in group sessions. Relatives' symptoms of anxiety at admission were associated with the number of sessions as well as the amount of support, indicating that relatives with more symptoms of anxiety received more support during the hospitalisation.

Treatment and prevention of mental disorders in low-income and middle-income countries.

We review the evidence on effectiveness of interventions for the treatment and prevention of selected mental disorders in low-income and middle-income countries. Depression can be treated effectively in such countries with low-cost antidepressants or with psychological interventions (such as cognitive-behaviour therapy and interpersonal therapies). Stepped-care and collaborative models provide a framework for integration of drug and psychological treatments and help to improve rates of adherence to treatment. First-generation antipsychotic drugs are effective and cost effective for the treatment of schizophrenia; their benefits can be enhanced by psychosocial treatments, such as community-based models of care. Brief interventions delivered by primary-care professionals are effective for management of hazardous alcohol use, and pharmacological and psychosocial interventions have some benefits for people with alcohol dependence. Policies designed to reduce consumption, such as increased taxes and other control strategies, can reduce the population burden of alcohol abuse. Evidence about the efficacy of interventions for developmental disabilities is inadequate, but community-based rehabilitation models provide a low-cost, integrative framework for care of children and adults with chronic mental disabilities. Evidence for mental health interventions for people who are exposed to conflict and other disasters is still weak-especially for interventions in the midst of emergencies. Some trials of interventions for prevention of depression and developmental delays in low-income and middle-income countries show beneficial effects. Interventions for depression, delivered in primary care, are as cost effective as antiretroviral drugs for HIV/AIDS. The process and effectiveness of scaling up mental health interventions has not been adequately assessed. Such research is needed to inform the continuing process of service reform and innovation. However, we recommend that policymakers should act on the available evidence to scale up effective and cost-effective treatments and preventive interventions for mental disorders.

Outpatient psychotherapy in the United States, II: Patterns of utilization.

OBJECTIVE: The purpose of this article is to characterize the use of psychotherapy based on episode duration. METHOD: Data were analyzed from the household section of the 1987 National Medical Expenditure Survey. The authors determined the demographic characteristics, provider and reason for visit distribution, mental and physical health status, and expenditures associated with very short-term (one to two sessions), short-term (three to 10 sessions), intermediate-term (11 to 20 sessions), and long-term (> 20 sessions) psychotherapy. RESULTS: Long-term psychotherapy accounted for 15.7% of psychotherapy users and 62.9% of total psychotherapy expenditures. Age above 65 years, black race, and less than 12 years of education decreased the likelihood of receiving long-term psychotherapy. Whereas long-term psychotherapy episodes tended to be provided by the specialty sector (65.7%) for specific mental conditions (53.8%), very short-term episodes were predominantly provided by the general medical sector (72.2%) for general medical or unspecified conditions (68.3%). Psychotropic medication use and, to less extent, psychiatric hospitalization tended to be more common among longer- as opposed to shorter-term users. CONCLUSIONS: Long-term and short-term psychotherapy tend to be provided by different health care professionals for the treatment of different types of health conditions. To help ensure the future of third-party payment for long-term psychotherapy, research is needed to better define the conditions under which long-term psychotherapy achieves benefits that equal or surpass those of other medical services or procedures of similar cost.