The treatment gap in mental health care KOHN, Robert; SAXENA, Shekhar; LEVAV, Itzhak ...
Bulletin of the World Health Organization,
11/2004, Letnik:
82, Številka:
11
Journal Article
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Mental disorders are highly prevalent and cause considerable suffering and disease burden. To compound this public health problem, many individuals with psychiatric disorders remain untreated ...although effective treatments exist. We examine the extent of this treatment gap. We reviewed community-based psychiatric epidemiology studies that used standardized diagnostic instruments and included data on the percentage of individuals receiving care for schizophrenia and other non-affective psychotic disorders, major depression, dysthymia, bipolar disorder, generalized anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), and alcohol abuse or dependence. The median rates of untreated cases of these disorders were calculated across the studies. Examples of the estimation of the treatment gap for WHO regions are also presented. Thirty-seven studies had information on service utilization. The median treatment gap for schizophrenia, including other non-affective psychosis, was 32.2%. For other disorders the gap was: depression, 56.3%; dysthymia, 56.0%; bipolar disorder, 50.2%; panic disorder, 55.9%; GAD, 57.5%; and OCD, 57.3%. Alcohol abuse and dependence had the widest treatment gap at 78.1%. The treatment gap for mental disorders is universally large, though it varies across regions. It is likely that the gap reported here is an underestimate due to the unavailability of community-based data from developing countries where services are scarcer. To address this major public health challenge, WHO has adopted in 2002 a global action programme that has been endorsed by the Member States.
To outline mental health service accessibility, estimate the treatment gap and describe service utilization for people with schizophrenic disorders in 50 low- and middle-income countries.
The World ...Health Organization Assessment Instrument for Mental Health Systems was used to assess the accessibility of mental health services for schizophrenic disorders and their utilization. The treatment gap measurement was based on the number of cases treated per 100,000 persons with schizophrenic disorders, and it was compared with subregional estimates based on the Global burden of disease 2004 update report. Multivariate analysis using backward step-wise regression was performed to assess predictors of accessibility, treatment gap and service utilization.
The median annual rate of treatment for schizophrenic disorders in mental health services was 128 cases per 100,000 population. The median treatment gap was 69% and was higher in participating low-income countries (89%) than in lower-middle-income and upper-middle-income countries (69% and 63%, respectively). Of the people with schizophrenic disorders, 80% were treated in outpatient facilities. The availability of psychiatrists and nurses in mental health facilities was found to be a significant predictor of service accessibility and treatment gap.
The treatment gap for schizophrenic disorders in the 50 low- and middle-income countries in this study is disconcertingly large and outpatient facilities bear the major burden of care. The significant predictors found suggest an avenue for improving care in these countries.
Abbreviations: ADHD, attention deficit hyperactivity disorder; CBT, cognitive behavioural therapy; GRADE, Grading of Recommendations Assessment, Development and Evaluation; LAMIC, low- and ...middle-income countries; mhGAP, Mental Health Gap Action Programme; mhGAP-IG, mhGAP Intervention Guide ; MNS, mental, neurological, and substance use; WHO, World Health Organization Provenance: Not commissioned; externally peer reviewed. Summary Points * The treatment gap for mental, neurological, and substance use (MNS) disorders is more than 75% in many low- and middle-income countries. * In order to reduce the gap, the World Health Organization (WHO) has developed a model intervention guide within its Mental Health Gap Action Programme (mhGAP). * The model intervention guide provides evidence-based recommendations developed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. * This article presents the management recommendations for MNS disorders, with a link to the World Health Organization website where all the background material may be accessed. * To our knowledge, this is a first exercise involving such an extensive and systematic evaluation of evidence in this area.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The association between periods of genocide-related exposures and suicide risk remains unknown. Our study tests that association using a national population-based study design. The source population ...comprised of all persons born during1922-1945 in Nazi-occupied or dominated European nations, that immigrated to Israel by 1965, were identified in the Population Register (N = 220,665), and followed up for suicide to 2014, totaling 16,953,602 person-years. The population was disaggregated to compare a trauma gradient among groups that immigrated before (indirect, n = 20,612, 9%); during (partial direct, n = 17,037, 8%); or after (full direct, n = 183,016, 83%) exposure to the Nazi era. Also, the direct exposure groups were examined regarding pre- or post-natal exposure periods. Cox regression models were used to compute Hazard Ratios (HR) of suicide risk to compare the exposure groups, adjusting for confounding by gender, residential SES and history of psychiatric hospitalization. In the total population, only the partial direct exposure subgroup was at greater risk compared to the indirect exposure group (HR = 1.73, 95% CI, 1.10, 2.73; P < .05). That effect replicated in six sensitivity analyses. In addition, sensitivity analyses showed that exposure at ages 13 plus among females, and follow-up by years since immigration were associated with a greater risk; whereas in utero exposure among persons with no psychiatric hospitalization and early postnatal exposure among males were at a reduced risk. Tentative mechanisms impute biopsychosocial vulnerability and natural selection during early critical periods among males, and feelings of guilt and entrapment or defeat among females.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Mental Health of Palestinian Arabs in Israel draws on the first-hand experience of experts working with Palestinians to highlight the mental health issues faced by service users, their families, and ...their communities.
This topic is best explored in the form of an edited collection because it enables a broader approach to both topic and methodology. The editors have taken full advantage of this by inviting contributions from leading social workers, doctors, professors, and mental health workers with first-hand experience in the field.
The collection prioritizes research and first-hand treatment experience, but its clear language and focus also make it accessible to audiences in anthropology, sociology, and gender studies.
Minorities face particular social strains, and these are often manifested in their overall mental health. In Israel, just under a quarter of the citizens are Arab Palestinians, yet very little has been published exploring the spectrum of mental health issues prevalent in this population. The work collected here draws on the first-hand experience of experts working with Israeli Palestinians to highlight the problems faced by service users, their families, and their communities. Palestinians in Israel face unique social, gender, and family-related conditions that also need reliable research and assessment.Mental Health and Palestinian Citizens in Israel offers research and observation on three central topics: socio-cultural determinants of mental health, mental health needs, and mental health service utilization. From suicidal behaviors and addiction to generational trauma and the particular concerns of children and the elderly, this broad and careful collection of research opens new dialogues on treatment, prevention, and methods for providing the best possible care to those in need.
No previous community-based epidemiological study has explored psychiatric disorders among those who survived the Holocaust.
To examine anxiety and depressive disorders, sleep disturbances, other ...health problems and use of services among individuals exposed and unexposed to the Holocaust.
The relevant population samples were part of the Israel World Mental Health Survey. The interview schedule included the Composite International Diagnostic Interview and other health-related items.
The Holocaust survivor group had higher lifetime (16.1%; OR = 6.8, 95% CI 1.9-24.2) and 12-month (6.9%; OR = 22.5, 95% CI 2.5-204.8) prevalence rates of anxiety disorders, and more current sleep disturbances (62.4%; OR = 2.5, 95% CI 1.4-4.4) and emotional distress (P<0.001) than their counterparts, but did not have higher rates of depressive disorders or post-traumatic stress disorder.
Early severe adversity was associated with psychopathological disorder long after the end of the Second World War, but not in all survivors. Age during the Holocaust did not modify the results.
Studies have shown health care disparities among persons of minority status, including in countries with universal health care. Yet, a dearth of studies have addressed disparities resulting from the ...combined effect of two minority status groups: severe mental illness and ethnic-national sector filiation. This study aimed to compare the differential health care of Jewish- and Arab-Israelis with schizophrenia in a country with a universal health insurance.
This study builds on a large case-control epidemiological sample (N = 50,499) of Jewish- (92.9%) and Arab-Israelis (7.1%) service users with (n = 16,833) and without schizophrenia (n = 33,666). Health services records were collected in the years 2000-2009. Diabetes and cardiovascular disease (CVD) served as sentinel diseases. We compared annual number of LDL tests and visits to specialists in the entire sample, Hemoglobin-A1C test among people diagnosed with diabetes, and cardiac surgical interventions for those diagnosed with CVD.
Service users with schizophrenia were less likely to meet identical indexes of care as their study counterparts: 95% of cholesterol tests (p < .001), and 92% visits to specialists (p < .001). These differences were greater among Arab- compared to Jewish-Israelis. Annual frequency of Hemoglobin-A1C test among people diagnosed with diabetes was lower (94%) in people with schizophrenia (p < 0.01), but no ethnic-national differences were identified. Among service users with CVD less surgical interventions were done in people with schizophrenia (70%) compared to their counterparts, with no ethnic-national disparities.
In Israel, service users with schizophrenia fail to receive equitable levels of medical and cardiac surgical care for CVD and regular laboratory tests for diabetes. Although disparities in some health indicators were enhanced among Arab-Israelis, schizophrenia was a greater source of disparities than ethnic-national filiation.
Epidemiological studies show disparities in the provision of physical health-care for people with severe mental illness. This observation includes countries with universal health insurance. However, ...there is limited in-depth data regarding the barriers preventing equality of physical health-care provision for this population. This study applied the capabilities approach to examine the interface between general practitioners and patients with severe mental illness. The capabilities approach provides a framework for health status which conceptualizes the internal and external factors relating to the available options (capabilities) and subsequent health outcomes (functioning).
Semi-structured in-depth interviews were conducted with 10 general practitioners and 15 patients with severe mental illness, and then thematically analyzed.
We identified factors manifesting across three levels: personal, relational-societal, and organizational. At the personal level, the utilization of physical health services was impaired by the exacerbation of psychiatric symptoms. At the relational level, both patients and physicians described the importance of a long-term and trusting relationship, and provided examples demonstrating the implications of relational ruptures. Finally, two structural-level impediments were described by the physicians: the absence of continuous monitoring of patients with severe mental illness, and the shortfall in psychosocial interventions.
The capability approach facilitated the identification of barriers preventing equitable health-care provision for patients with severe mental illness. Based on our findings, we propose a number of practical suggestions to improve physical health-care for this population: 1. A proactive approach in monitoring patients' health status and utilization of services. 2. Acknowledgment of people with severe mental illness as a vulnerable population at risk, that need increased time for physician-patient consultations. 3. Training and support for general practitioners. 4. Increase collaboration between general practitioners and mental-health professionals. 5. Educational programs for health professionals to reduce prejudice against people with severe mental illness.
Objective
Reports show disparities in the health care of people with severe mental illness (SMI). Yet, the moderating effect of mental health reforms on the health care disparities remain unexplored. ...The current study aimed to investigate the outcomes of the mental health reform in Israel on the use of health services among people with SMI.
Method
A case–control epidemiological study comparing the use of health services 3.5 years before and after the mental health reform for service users diagnosed with schizophrenia, schizoaffective disorder, and bipolar disorder. Data on health services included: blood cholesterol test (LDL), hemogalobin-A1C test, and visits to general practitioners (GPs) and specialists. Mortality was recorded.
Results
Following the reform the number of visits to GPs was decreased among service users of the three SMI groups, as well as visits to specialists among service users with a schizoaffective or bipolar disorder. Following the reform service users of the three SMI groups showed no-change in the performance of LDL test. Complex findings were noted with regard to the performance of Hemoglobin-A1C test. Mortality rates were higher among service users with SMI and the relative risk were similar before and after the reform.
Conclusions
Users of the three SMI groups showed no benefits of the mental health reform in terms of use of health services. Improved health care can be attained by a closer collaboration between the primary physicians and community mental health services.
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