Alex Cohen

Early Intervention to Reduce the Global Health and Economic Burden of Major Depression in Older Adults

Randomized trials for selective and indicated prevention of depression in both mixed-aged and older adult samples, conducted in high-income countries (HICs), show that rates of incident depression can be reduced by 20-25% over 1-2 years through the use of psychoeducational and psychological interventions designed to increase protective factors. Recurrence of major depression can also be substantially reduced through both psychological and psychopharmacological strategies. Additional research is needed, however, to address the specific issues of depression prevention in older adults in low- and middle-income countries (LMICs). The growing number of older adults globally, as well as workforce issues and the expense of interventions, makes it important to develop rational, targeted, and cost-effective risk-reduction strategies. In our opinion, one strategy to address these issues entails the use of lay health counselors (LHCs), a form of task shifting already shown to be effective in the treatment of common mental disorders in LMICs. We suggest in this review that the time is right for research into the translation of depression-prevention strategies for use in LMICs.

Mental hospital reform in Asia: the case of Yuli Veterans Hospital, Taiwan

BackgroundYuli Veterans Hospital (YVH) has been the largest mental hospital for the patients with chronic and severe mental illness in Taiwan for the past 50 years. While this hospital used to be a symbol of hopelessness among patients and their families and an unspoken shame among Taiwan psychiatry and mental health circles it now represents an example of how an old, custodial hospital can be transformed into a very different institution. In this case study we will describe the features of this transformation, which, over the past 20 years, has aimed to help extended stay inpatients with severe mental illness to integrate into the local community of Yuli even though it is not their original home.MethodsUsing historical documents and oral narratives from Yuli inhabitants, workers and patients of YVH, we will offer a case study of the Yuli model.ResultsThere are four main components of the Yuli model: holistic medical support, vocational rehabilitation, case management, and the residential program. The four components help patients recover two essential features of their lives: vocational life and ordinary daily routines. As the process of recovery evolves, patients gradually regain inner stability, dignity, self-confidence, and a sense of control. The four components are critical to rebuild the structure and order of life of the patients and are indispensable and interdependent parts of one service package. They operate simultaneously to benefit the patients to the greatest degree possible.DiscussionThere are many challenges to the further development and financial viability of the model of services developed at YVH. There are also important questions concerning the replicability of the Yuli model in other sociocultural and service system contexts.ConclusionThis case study reveals the possibility of transforming a custodial mental hospital into a hospital providing high quality care. Hospital and community are not in opposition. They are part of a continuum of care for the patients. We reinterpret and redefine the boundary and function of hospital and community, and thereby create a new service model, the Yuli Model, to help patients to reintegrate into the community. The Yuli model, which particularly focuses on the needs of people with long-standing illness and prolonged hospital stay, illustrates one approach to linking hospital and community in a creative and constructive manner.

Sitting with others: mental health self-help groups in northern Ghana

BackgroundOver the past four decades, there has been increasing interest in Self-Help Groups, by mental health services users and caregivers, alike. Research in high-income countries suggests that participation in SHGs is associated with decreased use of inpatient facilities, improved social functioning among service users, and decreased caregiver burden. The formation of SHGs has become an important component of mental health programmes operated by non-governmental organisations (NGOs) in low-income countries. However, there has been relatively little research examining the benefits of SHGs in this context.MethodsQualitative research with 18 SHGs, five local non-governmental organisations, community mental health nurses, administrators in Ghana Health Services, and discussions with BasicNeeds staff.ResultsSHGs have the potential to serve as key components of community mental health programmes in low-resource settings. The strongest evidence concerns how SHGs provide a range of supports, e.g., social, financial, and practical, to service users and caregivers. The groups also appear to foster greater acceptance of service users by their families and by communities at large. Membership in SHGs appears to be associated with more consistent treatment and better outcomes for those who are ill.DiscussionThis study highlights the need for longitudinal qualitative and quantitative evaluations of the effect of SHGs on clinical, social and economic outcomes of service users and their carers.ConclusionsThe organisation of SHGs appears to be associated with positive outcomes for service users and caregivers. However, there is a need to better understand how SHGs operate and the challenges they face.

Attitudes of Malaysian general hospital staff towards patients with mental illness and diabetes

BackgroundThe context of the study is the increased assessment and treatment of persons with mental illness in general hospital settings by general health staff, as the move away from mental hospitals gathers pace in low and middle income countries. The purpose of the study was to examine whether general attitudes of hospital staff towards persons with mental illness, and extent of mental health training and clinical experience, are associated with different attitudes and behaviours towards a patient with mental illness than towards a patients with a general health problem - diabetes.MethodsGeneral hospital health professionals in Malaysia were randomly allocated one of two vignettes, one describing a patient with mental illness and the other a patient with diabetes, and invited to complete a questionnaire examining attitudes and health care practices in relation to the case. The questionnaires completed by respondents included questions on demographics, training in mental health, exposure in clinical practice to people with mental illness, attitudes and expected health care behaviour towards the patient in the vignette, and a general questionnaire exploring negative attitudes towards people with mental illness. Questionnaires with complete responses were received from 654 study participants.ResultsStigmatising attitudes towards persons with mental illness were common. Those responding to the mental illness vignette (N = 356) gave significantly lower ratings on care and support and higher ratings on avoidance and negative stereotype expectations compared with those responding the diabetes vignette (N = 298).ConclusionsResults support the view that, in the Malaysian setting, patients with mental illness may receive differential care from general hospital staff and that general stigmatising attitudes among professionals may influence their care practices. More direct measurement of clinician behaviours than able to be implemented through survey method is required to support these conclusions.

Socioeconomic status and anxiety as predictors of antidepressant treatment response and suicidal ideation in older adults

BackgroundSeparate reports from the maintenance treatment for late-life depression (MTLD) trials have shown that low socioeconomic status (SES) and anxiety symptoms at the time of treatment initiation predict lower levels of response to antidepressant treatment and higher levels of suicidal ideation in older adults.AimTo determine whether SES and anxiety independently contribute to worse treatment outcomes, as indicated by persistence of depressive symptoms during treatment and the persistence of suicidal ideation. Consistent with prior evidence that sociodemographic factors and clinical history are both prognostic of depression treatment efficacy, we hypothesized that SES and pre-existing anxiety symptoms will both predict lower levels of response to treatment and higher levels of suicidal ideation.MethodSecondary analyses of data from the MTLD trials.ResultsRegression analyses which controlled for comorbid anxiety indicated that residents of middle- and high-income census tracts were more likely to respond to treatment (HR, 1.63; 95%CI, 1.08–2.46) and less likely to report suicidal ideation during treatment (OR, 0.51; 95%CI, 0.28–0.90) than residents of low income census tracts. The same regression models indicated that pre-existing anxiety symptoms were independently related to lower treatment response (HR, 0.73; 95%CI, 0.60–0.89) and higher risk of suicidal ideation (OR, 1.45; 95%CI, 0.98–2.14).ConclusionThese findings demonstrate the importance of treating anxiety symptoms during the course of treatment for late-life depression and, at the same time, addressing barriers to treatment response related to low SES.

Three models of community mental health services In low-income countries

ObjectiveTo compare and contrast three models of community mental health services in low-income settings.Data Sources/Study SettingPrimary and secondary data collected before, during, and after site visits to mental health programs in Nigeria, the Philippines, and India.Study DesignQualitative case study methodology.Data CollectionData were collected through interviews and observations during site visits to the programs, as well as from reviews of documentary evidence.Principal FindingsA set of narrative topics and program indicators were used to compare and contrast three community mental health programs in low-income countries. This allowed us to identify a diversity of service delivery models, common challenges, and the strengths and weaknesses of each program. More definitive evaluations will require the establishment of data collection methods and information systems that provide data about the clinical and social outcomes of clients, as well as their use of services.ConclusionsCommunity mental health programs in low-income countries face a number of challenges. Using a case study methodology developed for this purpose, it is possible to compare programs and begin to assess the effectiveness of diverse service delivery models.

The explanatory models of depression and anxiety in primary care: a qualitative study from India.

BackgroundThe biggest barrier to treatment of common mental disorders in primary care settings is low recognition among health care providers. This study attempts to explore the explanatory models of common mental disorders (CMD) with the goal of identifying how they could help in improving the recognition, leading to effective treatment in primary care.ResultsThe paper describes findings of a cross sectional qualitative study nested within a large randomized controlled trial (the Manas trial). Semi structured interviews were conducted with 117 primary health care attendees (30 males and 87 females) suffering from CMD. Main findings of the study are that somatic phenomena were by far the most frequent presenting problems; however, psychological phenomena were relatively easily elicited on probing. Somatic phenomena were located within a biopsychosocial framework, and a substantial proportion of informants used the psychological construct of ‘tension’ or ‘worry’ to label their illness, but did not consider themselves as suffering from a ‘mental disorder’. Very few gender differences were observed in the descriptions of symptoms but at the same time the pattern of adverse life events and social difficulties varied across gender.ConclusionOur study demonstrates how people present their illness through somatic complaints but clearly link their illness to their psychosocial world. However they do not associate their illness to a ‘mental disorder’ and this is an important phenomenon that needs to be recognized in management of CMD in primary settings. Our study also elicits important gender differences in the experience of CMD.

Social Inequalities in the Occurrence of Suicidal Ideation Among Older Primary Care Patients

OBJECTIVES To examine whether there is an association between area socioeconomic status and the experience of suicidal ideation among older adults. DESIGN Secondary analyses of data from a prospective study of naturalistic outcomes of depressive symptoms. SETTING Monroe County, NY. PARTICIPANTS A cohort of older adults (≥65 years, N = 515) attending primary care settings. MEASUREMENTS Area socioeconomic status was based on the median household incomes of the census tracts (CTs) in which participants lived. At 6- and 12-month follow-up, the longitudinal interval follow-up evaluation was used to assess weekly depressive symptom status over the previous 6 months, which was used to construct a measure of any suicidal ideation during the study. RESULTS Residents of CTs with median household incomes of less than

Searching for psychosis: INTREPID (1): systems for detecting untreated and first-episode cases of psychosis in diverse settings

30,000/yr were more likely to experience suicidal ideation than residents of higher income CTs (unadjusted odds ratio [OR], 4.60; 95% confidence interval [CI], 1.64-12.86). Adjustment for demographic and baseline clinical factors did not eliminate the association (OR, 5.44; 95% CI, 1.71-17.24). Subsequent models that adjusted for medical, functional, and psychosocial variables did not explain this association either. CONCLUSIONS There is a robust association between lower CT income and the occurrence of suicidal ideation in a primary care cohort of older adults over 1 year. These findings indicate the need for more research into how social worlds come to influence the emotional well being of older adults and whether social factors such as CT income can be used to identify individuals at increased risk for suicidal behavior.

Experiences of stigma and discrimination faced by family caregivers of people with schizophrenia in India

PurposeOur understanding of psychotic disorders is largely based on studies conducted in North America, Europe and Australasia. Few methodologically robust and comparable studies have been carried out in other settings. INTREPID is a programme of research on psychoses in India, Nigeria, and Trinidad. As a platform for INTREPID, we sought to establish comprehensive systems for detecting representative samples of cases of psychosis by mapping and seeking to engage all professional and folk (traditional) providers and potential key informants in defined catchment areas.MethodWe used a combination of official sources, local knowledge of principal investigators, and snowballing techniques.ResultsThe structure of the mental health systems in each catchment area was similar, but the content (i.e., type, extent, and nature) differed. Tunapuna–Piarco (Trinidad), for example, has the most comprehensive and accessible professional services. By contrast, Ibadan (Nigeria) has the most extensive folk (traditional) sector. We identified and engaged in our detection system—(a) all professional mental health services in each site (in- and outpatient services—Chengalpet, 6; Ibadan, 3; Trinidad, 5); (b) a wide range of folk providers (Chengalpet, 3 major healing sites; Ibadan, 19 healers; Trinidad: 12 healers); and c) a number of key informants, depending on need (Chengalpet, 361; Ibadan, 54; Trinidad, 1).ConclusionsMarked differences in mental health systems in each catchment area illustrate the necessity of developing tailored systems for the detection of representative samples of cases with untreated and first-episode psychosis as a basis for robust, comparative epidemiological studies.