•The implementation of community mental health care shows a great cross-country variation.•Many states still use mental hospitals, others embraced a balanced care model.•Missing data, low data ...quality, variation in service definitions hinder comprehensive analyses.•Leadership and international consensus are needed to ensure quality monitoring.
The shift of mental health care from mental institutions to community-based services has been implemented differentially throughout the EU. However, because a comprehensive overview of the current mental health provision in member states is lacking, it is challenging to compare services across nations. This study investigates the extent of implementation of community-based mental health services within the EU using data collected from the WHO Mental Health Atlas. Results show that, although great cross-country variation exists in the implementation of community-based services, mental hospitals remain the prominent model of care in most countries. A few countries endorsed a balanced care model, with the co-occurrence of community services and mental hospitals. However, missing data, low quality of data and different service definitions hamper the possibility of a thorough analysis of the status on deinstitutionalization. Although policies on the closing and downsizing of mental institutions have been endorsed by the EU, the strong presence of mental hospitals slows down the shift towards community-based mental health care. This study highlights the need for an international consensus on definitions and a harmonization of indicators on mental health services. Together with the commitment of member states to improve the quality of data reporting, leadership must emerge to ensure quality monitoring of mental health-related data, which will help advance research, policies and practices.
Couple therapy for depression Barbato, Angelo; D'Avanzo, Barbara; Parabiaghi, Alberto ...
Cochrane database of systematic reviews,
06/2018, Letnik:
2018, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Background
Couple therapy for depression has the twofold aim of modifying negative interaction patterns and increasing mutually supportive aspects of intimate relationships, changing the ...interpersonal context of depression. Couple therapy is included in several guidelines among the suggested treatments for depression.
Objectives
1. The main objective was to examine the effects of couple therapy compared to individual psychotherapy for depression.
2. Secondary objectives were to examine the effects of couple therapy compared to drug therapy and no/minimal treatment for depression.
Search methods
The Cochrane Common Mental Disorders Group Controlled Trials Register (CCMDCTR), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid) and PsycINFO (Ovid) were searched to 19 February 2018. Relevant journals and reference lists were checked.
Selection criteria
Randomised and quasi‐randomised controlled trials examining the effects of couple therapy versus individual psychotherapy, drug therapy, or no treatment/minimal treatment for depression were included in the review.
Data collection and analysis
We considered as primary outcomes the depressive symptom level, the depression persistence, and the dropouts; the relationship distress level was a secondary outcome. We extracted data using a standardised spreadsheet. Where data were not included in published papers, we tried to obtain the data from the authors. We synthesised data using Review Manager software version 5.3. We pooled dichotomous data using the relative risk (RR), and continuous data calculating the standardised mean difference (SMD), together with 95% confidence intervals (CIs). We employed the random‐effects model for all comparisons and also calculated a formal test for heterogeneity, the natural approximate Chi2 test.
Main results
We included fourteen studies from Europe, North America, and Israel, with 651 participants. Eighty per cent of participants were Caucasian. Therefore, the findings cannot be considered as applicable to non‐Western countries or to other ethnic groups in Western countries. On average, participants had moderate depression, preventing the extension of results to severely depressed patients. Almost all participants were aged between 36 and 47 years.
There was no evidence of difference in effect at the end of treatment between couple therapy and individual psychotherapy, either for the continuous outcome of depressive symptoms, based on nine studies with 304 participants (SMD −0.17, 95% CI −0.44 to 0.10, low‐quality evidence), or the proportion of participants remaining depressed, based on six studies with 237 participants (RR 0.94, 95% CI 0.72 to 1.22, low‐quality evidence). Findings from studies with 6‐month or longer follow‐up confirmed the lack of difference between the two conditions.
No trial gave information on harmful effects. However, we considered rates of treatment discontinuation for any reason as a proxy indicator of adverse outcomes. There was no evidence of difference for dropout rates between couple therapy and individual psychotherapy, based on eight studies with 316 participants (RR 0.85, 95% CI 0.51 to 1.41, low‐quality evidence).
Few data were available for the comparison with drug therapy. Data from a small study with 12 participants showed no difference for the continuous outcome of depressive symptoms at end of treatment (SMD −0.51, 95% CI −1.69 to 0.66, very low‐quality evidence) and at 6‐month follow‐up (SMD −1.07, 95% CI ‐2.45 to 0.31, very low‐quality evidence). Data on dropouts from two studies with 95 participants showed a clear advantage for couple therapy (RR 0.31, 95% CI 0.15 to 0.61, very low‐quality evidence). However, this finding was heavily influenced by a single study, probably affected by a selection bias favouring couple therapy.
The comparison between couple therapy plus drug therapy and drug therapy alone showed no difference in depressive symptom level, based on two studies with 34 participants (SMD −1.04, 95% CI ‐3.97 to 1.89, very low‐quality evidence) and on dropouts, based on two studies with 45 participants (RR 1.03, 95% CI 0.07 to 15.52, very low‐quality evidence).
The comparison with no/minimal treatment showed a large significant effect favouring couple therapy both for depressive symptom level, based on three studies with 90 participants: (SMD −0.95, 95% CI −1.59 to −0.32, very low‐quality evidence) and persistence of depression, based on two studies with 65 participants (RR 0.48, 95% CI 0.32 to 0.70, very low‐quality evidence). No data were available for dropouts for this comparison.
Concerning relationship distress, the comparison with individual psychotherapy showed that couple therapy appeared more effective in reducing distress level at the end of treatment, based on six studies with 187 participants (SMD −0.50, CI −0.97 to −0.02, very low‐quality evidence) and the persistence of distress, based on two studies with 81 participants (RR 0.71, 95% CI 0.51 to 0.98, very low‐quality evidence). The quality of evidence was heavily affected by substantial heterogeneity (I2 = 59%). In the analysis restricted to studies including only distressed couples, no heterogeneity was found and the effect in distress level at the end of treatment was larger (SMD −1.10, 95% CI −1.59 to −0.61). Very few data on this outcome were available for other comparisons.
We assessed the certainty of the evidence using the GRADE system. The results were weakened by the low quality of evidence related to the effects on depressive symptoms, in comparison with individual psychotherapy, and by very low quality evidence for all other comparisons and for the effects on relationship distress. Most studies were affected by problems such as the small number of cases, performance bias, assessment bias due to the non‐blinding outcome assessment, incomplete outcome reporting and the allegiance bias of investigators. Heterogeneity was, in particular, a problem for data about relationship distress.
Authors' conclusions
Although there is suggestion that couple therapy is as effective as individual psychotherapy in improving depressive symptoms and more effective in improving relations in distressed couples, the low or very low quality of the evidence seriously limits the possibility of drawing firm conclusions. Very few data were available for comparisons with no/minimal treatment and drug therapy. Future trials of high quality should test in large samples with a long follow‐up of the effects of couple therapy in comparison to other interventions in discordant couples with a depressed partner, considering the role of relationship quality as a potential effect mediator in the improvement of depression.
Congenital tracheomalacia is the most common congenital tracheal abnormality and occurs in approximately 1:2,100 children. Tracheomalacia can be isolated or associated with other airway anomalies ...such as laryngomalacia, bronchomalacia, and large laryngeal clefts. Also, an abnormal division of the embryonic foregut is frequently associated with congenital tracheomalacia; mostly in the form of proximal esophageal atresia with distal tracheoesophageal fistula. In such cases, the ratio between the cartilage ring and the posterior membranous wall drops from the normal ratio of 4 to 5:1 to 2 to 3:1. The diagnosis can be made upon clinical history and physical examination as well as by pulmonary function testing, computed tomography, dynamic magnetic resonance imaging, and fiberoptic bronchoscopy. Other approaches such as tracheobronchography have been used, but have not been validated for the diagnosis of tracheomalacia; fluoroscopy can be specific for diagnosing tracheomalacia, but lacks a reasonable sensitivity. Tracheomalacia is often self-limited and will resolve or become asymptomatic by the second year of life without intervention. For patients who remain symptomatic, possible treatments include pharmacotherapy, positive pressure application, and surgery.
Primary ciliary dyskinesia (PCD) is a rare genetic disorder that alters mucociliary clearance, with consequent chronic disease of upper and lower airways. Diagnosis of PCD is challenging, and genetic ...testing is hampered by the high heterogeneity of the disease, because autosomal recessive causative mutations were found in 34 different genes. In this study, we clinically and molecularly characterized a cohort of 51 Italian patients with clinical signs of PCD. A custom next-generation sequencing panel that enables the affordable and simultaneous screening of 24 PCD genes was developed for genetic analysis. After variant filtering and prioritization, the molecular diagnosis of PCD was achieved in 43% of the patients. Overall, 5 homozygous and 27 compound heterozygous mutations, 21 of which were never reported before, were identified in 11 PCD genes. The DNAH5 and DNAH11 genes were the most common cause of PCD in Italy, but some population specificities were identified. In addition, the number of unsolved cases and the identification of only a single mutation in six patients suggest further genetic heterogeneity and invoke the need of novel strategies to detect unconventional pathogenic DNA variants. Finally, despite the availability of mutation databases and in silico prediction tools helping the interpretation of variants in next-generation sequencing screenings, a comprehensive segregation analysis is required to establish the in trans inheritance and support the pathogenic role of mutations.
Lombardy was the epicenter of the Covid-19 outbreak in Italy, and in March 2020 the rapid escalation in cases prompted the Italian Government to decree a mandatory lockdown and to introduce safety ...practices in mental health services. The general objective of the study is to evaluate the early impact of the Covid-19 emergency and quarantine on the well-being and work practices of mental health service personnel and professionals. Data were collected through an online survey of workers and professionals working with people with mental health problems in Lombardy in several outpatient and inpatient services. Their socio-demographic characteristics, professional background, description of working conditions during lockdown and psychological distress levels were collected. All analyses were performed on a sample of 241. Approximately, 31% of the participants obtained a severe score in at least one of the burnout dimensions, 11.6% showed moderate or severe levels of anxiety, and 6.6% had a moderate or severe level of depression. Different work conditions and patterns of distress were found for outpatient service workers and inpatient service workers. The overall impact of the Covid-19 emergency on mental health workers' level of distress was mild, although a significant number of workers experienced severe levels of depersonalization and anxiety. More research is needed to assess specific predictive factors.
The management of a health system is a matter of economics and business administration because of the costs induced by goods and services delivered. Economics teaches us that the positive effects ...induced by competition in free markets cannot be expected in health care, which is a classic example of market failure from both demand and supply sides. The most sensible key concepts to refer for managing a health system are funding and provision. While the logical solution for the first variable is universal coverage through general taxation, the second one requires a deeper understanding. Integrated care is the modern approach that better supports the choice in favour of the public sector also for service provision. A major threat against this approach is dual practice legally allowed for health professionals, which inevitably raises financial conflicts of interest. An exclusive contract of employment for civil servants should be the sine qua non for providing public services effectively and efficiently. Integrated care is particularly important for long-term chronic illnesses associated with high levels of disability, such as neurodegenerative diseases and mental disorders, where the mix of health and social services needed can be very complex. Nowadays the growing number of community-dwelling patients with multiple physical and mental health needs is the major challenge for the European health systems. This happens also in public health systems, which should provide universal health coverage in principle, and the case of mental disorders is striking. In the light of this theoretical exercise, we strongly believe that a public National Health and Social Service should be the most indicated model for both funding and providing health and social care in modern societies. The big challenge of the common model of European health system here envisaged would be to limit the negative influences of politics and bureaucracy.
The tension at the aponeurotic edges of abdominal wall defects is an important factor of dehiscence and incisional hernia formation. The purpose of this study is to map and compare the traction force ...necessary for medial mobilization in various levels of the anterior rectus sheath in cadavers.
Twenty four adult male cadavers, raging from 22 to 59 years old, with the abdominal wall intact and without prior preservation techniques, were dissected. A complete excision of the linea alba was performed. Traction loops of 10 mm in diameter were made in the anterior rectus sheath and were placed: 2, 4, 6 and 8 cm below the lower edge of the umbilicus and 3, 6 and 9 cm above the upper edge of the umbilicus. Each loop was mobilized 10 mm in the medial direction, using an analog dynamometer. The values obtained in each level were compared using Friedman's analysis of Variance for p < 0.05.
The average traction values obtained at the various levels were compared and there was no statistical significant difference.
There is no variation in tension along the whole extension of the anterior rectus sheath.
Objective
To systematically review the evidence from randomized controlled trials comparing the effects of goal‐oriented care against standard care for multimorbid adults.
Data Sources/Study Setting
...The literature presenting the results of randomized trials assessing the outcomes of goal‐oriented care compared with usual care for adults with multimorbidity.
Study Design
Systematic review and meta‐analysis.
Data Collection/Extraction Methods
We searched the Cochrane Database of Systematic Reviews (CENTRAL), EMBASE, MEDLINE, CINHAL, trial registries such as ClinicalTrial.gov and World Health Organization International Clinical Trials Registry Platform (ICTRP), and the references of eligible trials and relevant reviews. Goal‐oriented care was defined as an approach that engages patients, establishes personal goals, and sets targets for patients and clinicians to plan a course of action and measure outcome. We reviewed 228 trials, and 12 were included. We extracted outcome data on quality of life, hospital admission, patients' satisfaction, patient and caregiver burden. Risk of bias was assessed and certainty of evidence was evaluated using GRADE.
Principal Findings
No study was fully free of bias. No effect was found on quality of life (standardized mean difference SMD: 0.05; 95% CI: −0.05 to 0.16) and hospital admission (risk ratio RR: 0.87; 95% CI: 0.65 to 1.17). There was a very small effect for patients' satisfaction (SMD: 0.15; 95% CI: 0.00 to 0.29) and caregiver burden (SMD: −0.13; 95% CI: −0.26 to 0.00). Certainty of evidence was low for all outcomes.
Conclusions
No firm conclusions can be reached about the effects of goal‐oriented care for multimorbid adults. Future research should overcome the shortcomings of trials assessed in this meta‐analysis. Sound application of the indications for research of complex healthcare interventions is warranted.
Outdoor air pollution contributes to asthma development and exacerbations, yet its effects on airway pathology have not been defined in children.
To explore the possible link between air pollution ...and airway pathology, we retrospectively examined the relationship between environmental pollutants and pathological changes in bronchial biopsy specimens from children undergoing a clinically indicated bronchoscopy.
Structural and inflammatory changes (basement membrane BM thickness, epithelial loss, eosinophils, neutrophils, macrophages, mast cells, and lymphocytes) were quantified in biopsy specimens by using immunohistochemistry. The association between exposure to particulate matter less than 10 μm in aerodynamic diameter (PM
), SO
and NO
and biopsy findings was evaluated by using a generalized additive model with Gamma family to allow for overdispersion, adjusted for atmospheric pressure, temperature, humidity, and wheezing.
Overall, 98 children were included (age 5.3 ± 2.9 yr; 53 with wheezing/45 without wheezing). BM thickness increased with prolonged exposure to PM
(rate ratio RR, 1.29; 95% confidence interval CI, 1.09-1.52), particularly in children with wheezing. Prolonged exposure to PM
was also associated with eosinophilic inflammation in children with wheezing (RR, 3.16; 95% CI, 1.35-7.39). Conversely, in children without wheezing, increased PM
exposure was associated with a reduction of eosinophilic inflammation (RR, 0.12; 95% CI, 0.02-0.6) and neutrophilic inflammation (RR, 0.36; 95% CI, 0.14-0.89). Moreover, NO
exposure was also linked to reductions in neutrophil infiltration (RR, 0.57; 95% CI, 0.34-0.93) and eosinophil infiltration (RR, 0.33; 95% CI, 0.14-0.77).
Different patterns of association were observed in children with wheezing and in children without wheezing. In children without wheezing, exposure to PM
and NO
was linked to reduced eosinophilic and neutrophilic inflammation. Conversely, in children with wheezing, prolonged exposure to PM
was associated with increased BM thickness and eosinophilic inflammation, suggesting that it might contribute to asthma development by promoting airway remodeling and inflammation.
Highlights • There was a marked increase in residential beds in Lombardy in 2007–2016. • The residential care provision was highly supervised in both years. • A wider offer introduced by the 2007 ...reorganisation triggered off increased demand. • The imbalance towards highly supervised solutions remained after the 2007 reorganisation.
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