Elina Stefanovics

The role of psychiatric diagnosis in satisfaction with primary care : Data from the department of veterans affairs

Background:Although patient satisfaction is widely used as a quality indicator, most such measures do not account for patient subgroups such as those with psychiatric illness. There is also very little data on satisfaction of psychiatric patients with their medical care. Objective:The objective of this study was to assess the role of psychiatric illness in satisfaction with outpatient primary care services in the Department of Veterans Affairs (VA). Method:Data from the VA Customer Feedback Survey (n = 50,532) were merged with administrative data to determine diagnoses and other characteristics. Satisfaction ratings were compared across psychiatric diagnoses and across various aspects of satisfaction with care. Results:After controlling for patient characteristics (eg, gender, age, disability, acute vs. routine visit) and subjective health, patients with schizophrenia, posttraumatic stress disorder, drug abuse, depression, and other psychiatric disorders reported significantly lower satisfaction with their outpatient primary care. Dissatisfaction was particularly reported for access to care and overall coordination of care. Conclusions:Despite VA characteristics that might be thought to improve satisfaction (eg, easier access to specialty mental health services as a result of the integrated VA system), patients with psychiatric disorders are significantly less satisfied than patients without such disorders. Possible explanations include both lower technical quality of care and poorer interpersonal communication between providers and patients with mental illness, including the negative effects of stigma. These findings highlight the need for satisfaction ratings to be case-mix-adjusted, including the incorporation of health and mental health diagnoses, and the need for further research that elucidates the reasons behind lower satisfaction ratings.

Gambling problem severity and psychiatric disorders among Hispanic and white adults: findings from a nationally representative sample

OBJECTIVE To examine differences in the associations of gambling problem severity and psychiatric disorders among a nationally representative sample of Hispanic and white adults. METHOD Chi-square tests and multinomial logistic regression analyses were performed on data obtained from the National Epidemiologic Survey on Alcohol and Related Conditions from 31,830 adult respondents (13% Hispanic; 87% white), who were categorized according to three levels of gambling problem severity (i.e., no gambling or low-frequency gambling [NG], low-risk or at-risk gambling [LRG], problem or pathological gambling [PPG]). RESULTS Hispanic respondents in comparison to white respondents were more likely to exhibit PPG. Problem gambling severity was associated with past-year Axis I and lifetime Axis II psychiatric disorders in both Hispanic and white respondents, with the largest odds typically observed in association with the most severe gambling pathology. A stronger relationship between subsyndromal gambling and a broad range of Axis I disorders (mood, anxiety and substance use disorders) and Axis II disorders (particularly cluster B) was observed in Hispanic respondents as compared to white ones. CONCLUSIONS Levels of problem gambling severity are associated with the prevalence of Axis I and Axis II psychiatric disorders in both Hispanics and whites. Differences in the patterns of co-occurring disorders between subsyndromal levels of gambling in Hispanic and white respondents indicate the importance of considering ethnicity/race-related factors related to subthreshold levels of gambling in developing improved mental health prevention and treatment strategies.

A cross-national factor analytic comparison of three models of PANSS symptoms in schizophrenia

The 30-item Positive and Negative Syndrome Scale (PANSS) is used worldwide in the assessment of symptom severity in schizophrenia. The present study uses confirmatory factor analysis (CFA) to compare three different factorial models and to evaluate the best-fitting representation of schizophrenia symptom structure on the PANSS across four samples of patients diagnosed with schizophrenia from the US (the CATIE schizophrenia trial), São Paulo, Brazil, and from Beijing and Changsha, China. We examine the goodness of fit of several previously proposed models. The traditional trifactorial model for the PANSS and two five-factor models were evaluated using absolute and incremental indices. Single group CFA found that the five-factor model proposed by NIMH researchers based on an extensive literature review demonstrates the best fit in each of the four samples. This model used 20 of the 30 PANSS items grouped into five factors: positive, negative, disorganized, excited, and depressed symptoms. Subgroups defined by age, gender, nationality, hospitalization status, and severity of illness also did not differ in overall symptom structure as assessed by several standard indices. Our findings suggest that the five factor NIMH model showed the best representation among all four samples from different countries and potentially contrasting cultures.

Patient Centered Outcomes in Prostate Cancer Treatment: Predictors of Satisfaction Up to 2 Years After Open Radical Retropubic Prostatectomy

PURPOSE Few groups have examined satisfaction after prostate cancer treatment. We determined 1) predictors of satisfaction between 3 months and 2 years after open radical retropubic prostatectomy, and 2) whether these factors are time dependent. MATERIALS AND METHODS This prospective cohort study included 1,542 men who underwent radical retropubic prostatectomy from October 2000 to July 2008. The primary outcome was satisfaction self-assessed at 3, 6, 12 and 24 months. We used multivariate logistic regression and repeated measures analysis to determine predictors of satisfaction, adjusting for demographic and clinical characteristics. RESULTS Median followup was 24 months. About 93% of the men were satisfied. On multivariate analysis men were significantly less satisfied at 3 months when the urinary catheter was indwelling for 3 weeks or greater (OR 0.23, 95% CI 0.10-0.54), or they required intervention for anastomotic stricture (OR 0.23, 95% CI 0.11-0.49) or experienced 4-point or greater worsening in American Urological Association symptom score (OR 0.26, 95% CI 0.13-0.49). At 6 months worsening urinary function (OR 0.34, 95% CI 0.13-0.88) and biochemical failure (OR 0.15, 95% CI 0.05-0.43) were significantly associated with satisfaction. Worsening sexual function became significant at 12 and 24 months. These associations were confirmed on repeated measures analysis. CONCLUSIONS Most men were satisfied after radical retropubic prostatectomy. Satisfaction determinants showed a nonsignificant trend toward time dependence. Postoperative factors, such as the duration of indwelling Foley catheterization, were associated with short-term satisfaction while sexual and urinary function, and biochemical failure were associated with long-term satisfaction. Based on high satisfaction rates open radical retropubic prostatectomy is an excellent treatment for prostate cancer.

Differences in the associations between gambling problem severity and psychiatric disorders among black and white adults: findings from the National Epidemiologic Survey on Alcohol and Related Conditions.

We examined differences in the associations of gambling problem severity and psychiatric disorders among a nationally representative sample of 32,316 black and white adults. Black respondents were more likely than white ones to exhibit problem or pathological gambling (PPG) and a stronger relationship between subsyndromal gambling and any mood disorder, hypomania, and any substance use disorder. Differences in the patterns of co-occurring disorders between syndromal and particularly subsyndromal levels of gambling in black and white respondents indicate the importance of considering race-related factors in mental health prevention and treatment strategies. 

Attitudes Toward Mental Illness and Changes Associated with a Brief Educational Intervention for Medical and Nursing Students in Nigeria

ObjectiveThis study assessed beliefs about mental disorders and changes in those beliefs following an educational intervention for a convenience sample of Nigerian medical and nursing students.MethodsA 43-item questionnaire was used to assess perceptions regarding mental disorders and attitudes toward people with mental illness before and after a 4-day educational intervention.ResultsFactor analysis identified four domains: (1) socializing with people with mental illness, (2) belief in witchcraft or curses as causes of mental illness, (3) favorable attitudes toward normalization of the lives of people with mental illness, and (4) biopsychosocial approaches to mental illness. The greatest changes were in attitudes favoring normalization of the lives of people with mental illness (p = 0.0002), socializing with the mentally ill (p = 0.01), and biopsychosocial perspectives on mental illness (p = 0.01).ConclusionBrief educational interventions may alter some stigmatizing negative attitudes toward mental illness in healthcare trainees in low- and middle-income countries.

Pathological gambling severity and co-occurring psychiatric disorders in individuals with and without anxiety disorders in a nationally representative sample.

While anxiety disorders (ADs) and pathological gambling (PG) frequently co-occur with each other and other Axis I and Axis II disorders, previous studies have not examined the relative influence of ADs on the co-occurrences between PG severity and non-anxiety psychopathologies. The current study used data from the National Epidemiologic Survey on Alcohol and Related Conditions (N=43,093) to examine the influence of past-year ADs on the associations between past-year PG severity measures based on DSM-IV criteria for PG and non-anxiety psychiatric disorders. The findings revealed that increased PG severity was associated with Axes I and II psychopathology in both the groups with and without ADs. Significant anxiety-by-gambling-group interactions were also observed, particularly with respect to mood and personality disorders. The interactions indicate a stronger relationship between PG severity and psychopathology in participants without ADs than in those with ADs. Future research should investigate specific factors contributing to the co-occurrence of anxiety, gambling, and other psychiatric disorders and how the co-occurrences might influence clinically relevant phenomena such as treatment selection or course.

An Assessment of Attitudes Towards People with Mental Illness Among Medical Students and Physicians in Ibadan, Nigeria

ObjectiveThe authors surveyed attitudes towards mental illness among Nigerian medical personnel at three different levels of training and experience: medical students who had not completed their psychiatry rotation, medical students who had competed their psychiatry rotation, and graduate physicians.MethodsSix questions addressed beliefs about the effectiveness of treatments for four specific mental illnesses (schizophrenia, bipolar disorder, depression, and anxiety) and two medical illnesses (diabetes and hypertension) among the three groups. A self-report questionnaire including 56 dichotomous items was used to compare beliefs about and attitudes towards people with mental illness. Factor analysis was used to identify key attitudes and analysis of covariance (ANCOVA) was used to compare the groups adjusting for age and personal experience with people with mental illness.ResultsThere were no significant trends in attitudes towards the effectiveness of medication. Exploratory factor analysis of the beliefs and attitudes items identified four factors: (1) comfort socializing with people with mental, illness; (2) non-superstitious beliefs about the causes of mental illness; (3) neighborly feelings towards people with mental illness; and (4) belief that stress and abuse are part of the etiology of mental illness. ANCOVA comparing attitudes among the three groups showed that on three (1, 2, and 4) of the four factors medical students who had completed a rotation in psychiatry had significantly higher scores than the medical students who had not completed a rotation in psychiatry. Graduate physicians showed a similar pattern scoring higher than the medical students who had not completed a rotation in psychiatry in two factors (1 and 4) but showed no differences from students who had completed their psychiatry rotation.ConclusionWhile beliefs about medication effectiveness do not differ between medical trainees and graduate professionals, stigmatizing attitudes towards people with mental illness seem to be most strongly affected by clinical training. Psychiatric education and especially clinical experience result in more progressive attitudes towards people with mental illness.

Comparing the PANSS in Chinese and American inpatients: cross-cultural psychiatric analyses of instrument translation and implementation.

This article compares data from the Positive and Negative Syndrome Scale (PANSS) collected from Chinese and American inpatients diagnosed with schizophrenia to show how patterned differences in item ratings may reflect cultural attitudes of the raters. The Chinese sample (N=553) was based on consecutive admissions to four academic hospitals in Changsha, China. Only patients ill for 3 or more years were included in the analysis to match the chronically ill sample represented in the US CATIE sample. A total of 261 PANSS assessments were completed during a month when CATIE subjects had been hospitalized for 15 days or more to optimize equivalence of the US and Chinese samples. Controlling for age and gender, the total PANSS and the three sub-scores were all significantly lower in the Chinese than in the US CATIE sample by 5-8% (all p<.05). However, on 9 items, the Chinese sample scored 10-30% higher than the US sample (all p<.05) and on 5 items they scored over 20% higher (all p<.0001). These items rated increased hostility, poorer attention, lack of judgment and insight, disturbance of volition, and poorer impulse control. We ascribe these differences to cultural variations in the ways individuals relate to others in their social environment within Chinese and American societies.

Cross-National Analysis of Beliefs and Attitude Toward Mental Illness Among Medical Professionals From Five Countries

AbstractThis quantitative study sought to compare beliefs about the manifestation, causes and treatment of mental illness and attitudes toward people with mental illness among health professionals from five countries: the United States, Brazil, Ghana, Nigeria, and China. A total of 902 health professionals from the five countries were surveyed using a questionnaire addressing attitudes towards people with mental illness and beliefs about the causes of mental illness. Chi-square and analysis of covariance (ANCOVA) were used to compare age and gender of the samples. Confirmatory factor analysis was employed to confirm the structure and fit of the hypothesized model based on data from a previous study that identified four factors: socializing with people with mental illness (socializing), belief that people with mental illness should have normal roles in society (normalizing), non-belief in supernatural causes (witchcraft or curses), and belief in bio-psycho-social causes of mental illness (bio-psycho-social). Analysis of Covariance was used to compare four factor scores across countries adjusting for differences in age and gender. Scores on all four factors were highest among U.S. professionals. The Chinese sample showed lowest score on socializing and normalizing while the Nigerian and Ghanaian samples were lowest on non-belief in supernatural causes of mental illness. Responses from Brazil fell between those of the U.S. and the other countries. Although based on convenience samples of health professional robust differences in attitudes among health professionals between these five countries appear to reflect underlying socio-cultural differences affecting attitudes of professionals with the greater evidence of stigmatized attitudes in developing countries.