Chantal Sylvain

Key enhancing factors for integrating services for patients with mental and substance use disorders

Background: Over the past decade, practice standards have recommended that people experiencing both mental and substance use disorders receive integrated treatment. Yet few institutions offer integrated services, and patients are too often turned away from psychiatric and rehabilitation services. Aim: To identify key enhancing elements for integrating services for patients with co-occurring disorders. Methods: A process evaluation was conducted, using case study research methodology, with the aim of identifying factors that enhance or impede service integration. First, we elaborated a sound conceptual framework of service integration. In-depth case studies analysis using socio-anthropological methods (interviews with managers and professionals, focus groups with patients, non-participant observation, document analysis) were then conducted. Two contrasted forms of services integration, a joint venture and a strategic alliance, were analysed separately, and then compared. Results: Although the forms of inte...

How do general practitioners contribute to preventing long-term work disability of their patients suffering from depressive disorders? A qualitative study.

BackgroundDepression is a major cause of work absenteeism that general practitioners (GPs) face directly since they are responsible for sickness certification and for supervising the return to work (RTW). These activities give GPs a key role in preventing long-term work disability, yet their practices in this regard remain poorly documented. The objectives of this study were therefore to describe GPs’ practices with people experiencing work disability due to depressive disorders and explore how GPs’ work context may impact on their practices.MethodsWe conducted semi-structured individual interviews with 13 GPs and six mental healthcare professionals in two sub-regions of Quebec. The sub-regions differed in terms of availability of specialized resources offering public mental health services. Data were anonymized and transcribed verbatim. Thematic analysis was performed to identify patterns in the GPs’ practices and highlight impacting factors in their work context.ResultsOur results identified a set of practices common to all the GPs and other practices that differentiated them. Two profiles were defined on the basis of the various practices documented. The first is characterized by the integration of the RTW goal into the treatment goal right from sickness certification and by interventions that include the workplace, albeit indirectly. The second is characterized by a lack of early RTW-oriented action and by interventions that include little workplace involvement. Regardless of the practice profile, actions intended to improve collaboration with key stakeholders remain the exception. However, two characteristics of the work context appear to have an impact: the availability of a dedicated mental health nurse and the regular provision of clinical information by psychotherapists. These conditions are rarely present but tend to make a significant difference for the GPs.ConclusionsOur results highlight the significant role of GPs in the prevention of long-term work disability and their need for support through the organization of mental health services at the primary care level.

Studying Implementation of Dual Diagnosis Services: A Review

Objective: Over the past 15 years, considerable time and energy has been devoted to implementing integrated services for individuals with dual disorders. While the key factors in the successful implementation of such services have been documented, applying them remains a challenge. What are we missing? In this article we attempt to answer this question by examining how implementation studies of integrated services have been carried out. The aim is to identify possible avenues for future implementation research. Methods: We updated a recent literature review of published studies on service implementation. Articles written in English and addressing organization-level factors were included. The reviewed articles were categorized based on two aspects of their methodology: their approach to the implementation process (content- or process-centered) and their objective (descriptive or explanatory). Results: In the 15 studies reviewed, we observed a tendency toward a content-centered approach (n = 9) with a majority having an explanatory objective. Studies that reflected this trend identified the most common determining factors in order to explain the level of implementation achieved within a given period of time. These studies did not examine the sequencing and transformation of the implementation process over time. Such a process-centered approach was used in only six studies. Conclusions: Research exploring the evolutive dynamics of implementation projects should be prioritized to counter the lack of knowledge on the subject. Such studies have the potential to greatly enhance our understanding as well as our capacity to master the implementation of integrated services.

How patients’ representations of cystic fibrosis-related diabetes inform their health behaviours

Background: Although diabetes is a frequent complication of cystic fibrosis (CF), patients’ behaviours tend not to comply with best practice recommendations. Using Leventhal’s Common-Sense Model, we address this issue by exploring patients’ representations of CF-related diabetes (CFRD) to better understand the discrepancy between patients’ expected and observed health behaviours. Methods: Semi-structured individual interviews were conducted with patients (n = 39) in six CF clinics in Quebec, Canada. These interviews were part of a larger research project on screening and management practices for CFRD. Results: Illness representations differed between two groups of interviewed patients: (1) one group had either CF without dysglycemia or CF with impaired glucose tolerance; and (2) the other group had CFRD. Both representations were internally consistent and encompassed Leventhal’s five dimensions of illness representation: illness identity, cause, timeline, consequences and control. Conclusions: Patients require specific information on CFRD. The screening phase could be a crucial time to help patients adjust their representations to fit the reality of CFRD.

119 Developmental evaluation: a fruitful strategy for implementing and evaluating a work rehabilitation program for workers with common mental disorders

Introduction In Canada, few early work rehabilitation services are offered to prevent long-term work disability due to common mental disorders (CMD), despite population-level needs. Our study aimed to support and evaluate the implementation and effects of an innovative program designed to promote post-CMD return-to-work (RTW) in primary healthcare. Methods A developmental evaluation approach (Patton, 2011) was retained. Main implementation strategies consisted of periodically revising the program’s logic model and discussing its underlying theory of change with clinicians. Data collection tools included: dashboards of activities conducted with participants (n=41); interviews with participants upon discharge (n=26) and 6 months post-discharge (n=24); questionnaires completed by attending physicians (n=18). Quantitative data underwent descriptive statistical analyses, while qualitative data underwent thematic analysis. Results were presented and discussed periodically with clinicians to ensure their credibility. Result The implemented program included group interventions, one-on-one interventions, and concerted actions with partners. Participants began the program after 5 months of sick leave on average, and participated for 10±2 weeks. 80% of cases included concerted actions, usually with insurers and rarely attending physicians. However, virtually all the physicians saw the program as meeting needs and promoting RTW. Active components identified by participants concerned primarily the interventions’ group format, but also activities, and clinicians themselves. In terms of the program’s final expected outcome, 69% of the participants returned to work upon discharge and 79% were at work 6 months post-discharge. Discussion The program studied is based on the best scientific evidence and is feasible in a primary healthcare context. Results suggest that it facilitates a sustainable RTW of workers with a CMD and that it supports physicians in their interventions with this population. While additional work is required to demonstrate its effectiveness, current results suggest that a group format is an important intervention component for this target population.

120 What are the active components of a work rehabilitation program according to workers sick-listed for a common mental disorder?

Introduction Common mental disorders (CMDs) are highly prevalent and a leading cause of work disability. Although specialised programs are now offered to prevent these workers from developing long-term work disability, little is known about their views on helpful aspects of these programs. Our study sought to describe the active components of a work rehabilitation program based on the best scientific evidence, from the participants’ perspective. Methods This study is the qualitative part of a broader research project aimed at the developmental evaluation of the program using a mixed methods approach over two years. We conducted semi-structured interviews of 26 participants after program completion. The questions concerned the program components they considered beneficial and their reasons. The interviews were conducted by telephone, recorded and analysed using thematic analysis principles. Converging themes were identified and classified by component type. Result The active components identified concerned the interventions’ group format, activities, and occupational therapists (OTs). Participants saw three benefits to the group format: it offsets the feelings of isolation and shame associated with mental disorders; allows them to adjust their view of their work disability and means for reducing it; and reactivates their social interaction skills. The activities seen as most beneficial concerned training on techniques to better cope with work and daily life (e.g. mindfulness meditation). OTs were seen as having three main functions: relaying information to physicians and other stakeholders; coaching (supporting integration of the techniques, giving meaning to the experience, pointing to external resources); and ensuring the therapeutic environment of the group interventions. Discussion Our study results provide valuable insights into components that should be priorities if we are to ensure that work rehabilitation programs meet this population’s needs. While additional work is required, current results suggest that a group format is an important intervention component for workers with CMDs.

Development and Implementation of a Mental Health Work Rehabilitation Program: Results of a Developmental Evaluation

Purpose Long-term work disability due to common mental disorders (CMDs) is a growing problem. Yet optimal interventions remain unclear and little is known about implementation challenges in everyday practice. This study aimed to support and evaluate, in real time, the development and implementation of a work rehabilitation program (WRP) designed to promote post-CMD return-to-work (RTW). Methods A 2-year developmental evaluation was performed using a participatory approach. At program outset, the researchers held five work meetings to revise the program’s logic model and discuss its underlying change theory with clinicians. Data collection tools used throughout the study period were structured charts of activities conducted with workers (n = 41); in-depth interviews with program clinicians and managers (n = 9); and participant observation during work meetings. Quantitative data were analyzed using descriptive statistics. Qualitative data underwent thematic analysis using a processual approach. Results Three types of activity were developed and implemented: individual and group interventions targeting workers, and joint activities targeting partners (physicians, employers, others). While worker-targeted activities were generally implemented as planned, joint activities were sporadic. Analysis of the implementation process revealed five challenges faced by clinicians. Determinants included clinicians, host organization, sociopolitical context and resources provided by the evaluation. Conclusion The program studied is original in that it is based on the best available scientific knowledge, yet adapted to contextual particularities. The identified implementation challenges highlight the need for greater importance to be placed on the external, non-program context to ensure sustainable implementation in everyday practice.

Insurers’ Influences on Attending Physicians of Workers Sick-listed for Common Mental Disorders: What Are the Impacts on Physicians’ Practices?

Purpose In many jurisdictions, general practitioners (GPs) play an important role in the sick-leave and return-to-work (RTW) process of individuals with common mental disorders (CMD). Since it is insurers that decide on workers’ eligibility for disability benefits, they can influence physicians’ ability to act. The nature of these influences remains little documented to date. The aim of this study was therefore to describe these influences and their impacts from the GPs’ perspective. Methods Semi-structured interviews were conducted with GPs having a diversified clientele (n = 13). The interviews were audio-recorded, transcribed verbatim and analyzed according to thematic analysis principles. Results The results indicated that the GPs recognized insurers as influencing their practices with patients on sick leave for CMDs. The documented influences were generally seen as constraints, but sometimes as enablers. The impacts of these influences on the GPs’ practices depended on the organizational characteristics of their work context (such as limited consultation time) and other characteristics of their practice setting (such as lack of timely access to consultations with specialists). Conclusion The results brought three major issues to light: the quality of the information sent to insurers by GPs, the respect shown (or not) for workers’ care preferences, and the relevance of the specialized services offered to support workers’ RTW. These issues in turn reveal potential risks for workers, risks that need to be identified and recognized by all parties concerned if we are to come up with possible solutions.