Ger Driessen

Social disadvantage and schizophrenia. A combined neighbourhood and individual-level analysis.

ObjectiveTo study, in a geographically defined area, associations between the neighbourhood social environment and individual socioeconomic status on the one hand, and treated incidence of schizophrenia and level of subsequent service use on the other.MethodA combined data set of (i) patients with a case register diagnosis of schizophrenia and (ii) population controls was subjected to multilevel analyses, including neighbourhood exposures (neighbourhood socioeconomic disadvantage and social capital) and individual level confounders. Separate analyses were conducted for inpatient and outpatient psychiatric service consumption as indexed by the case register.ResultsNeighbourhood socioeconomic disadvantage and neighbourhood social capital did not impact on the treated incidence of schizophrenia, but quantity of inpatient service consumption was higher in neighbourhoods with higher level of social control (i.e. where it is more likely that neighbours intervene in neighbourhood-threatening situations). In addition, most indicators of lower individual socioeconomic status were associated with higher treated incidence, while treated incidence was lower when individual educational status was low.ConclusionResidents of high social control neighbourhoods may seek greater levels of resolution of psychiatric disorder in patient-residents, and by consequence may induce greater levels of inpatient service consumption in patients diagnosed with schizophrenia. Individual-level indicators of social disadvantage are associated with higher risk of treated psychotic disorder, with the exception of lower educational status, which may confer a lower probability of treatment given the presence of psychotic disorder.

The wider social environment and mental health service use

Objective:  Previous studies associating neighbourhood context with mental health service use typically included limited sets of confounders.

The cumulative needs for care monitor: a unique monitoring system in the south of the Netherlands

IntroductionPatients diagnosed with severe mental illness (SMI) have a complex combination of psychiatric, somatic and social needs for care, requiring an integrated, multidisciplinary health care approach. The present paper describes the methods of the cumulative needs for care monitor (CNCM), a monitoring system in operation in a geographically defined area.MethodsThe CNCM provides information on need for care, functioning and other outcomes in SMI patients in the area. This information can be used not only to plan treatment at the individual level, but also to conduct health services research at the group level.

Managing complex patients on a medical psychiatric unit: An observational study of university hospital costs associated with medical service use, length of stay, and psychiatric intervention

OBJECTIVE Although there is a suggestion that the medical psychiatric unit (MPU) may reduce length of hospital stay (LOS), little is known about costs in terms of medical service use and psychiatric interventions in MPU care. METHOD A record linkage study was conducted, linking cost data of hospital medical service use, LOS, and hospital psychiatric interventions to patients admitted to the MPU of the Maastricht University Medical Centre (MUMC) between 1998 and 2004. The data set was analyzed to enable comparison between cost changes of the same complex patient population following either MPU index admission or index admissions to reference MUMC medical wards. RESULTS Comparisons revealed lower costs of medical service use in favor of the MPU (-euro104; 95% CI -euro174 to -euro35; P<.01). However, cost of psychiatric intervention and cost of LOS were higher after MPU admission (respectively, +euro165; 95% CI +euro25 to +euro305; P<.05; and +euro202; 95% CI +euro170 to +euro235; P<.001). Total costs were higher after MPU admission compared to medical ward admission (+euro263; 95% CI +euro68 to +euro458; P<.05). These differences were not moderated by somatic diagnosis or previous pattern of admissions. CONCLUSION The findings suggest that patients at the interface of psychiatric and somatic morbidity are diagnosed and treated adequately at the MPU, leading to a decrease in medical service use and an appropriate increase in exposure to psychiatric interventions. These results are specifically generalizable to MPUs with a focus on psychosomatic conditions, for instance, somatoform disorders or affective disorders with comorbid somatic diseases. However, failure to show cost savings in terms of LOS compared to medical wards outweighs cost-benefit derived from lower medical service use, suggesting that MPU activities may gain in cost-effectiveness if shifted more to outpatient psychosomatic care solutions.

Dose timing and patient compliance with two antibiotic treatment regimens for lower respiratory tract infections in primary care

The objective of this study was to assess compliance with a 10-day treatment of antibiotics or placebo once-daily (OD) and three-times-daily (TD) for lower respiratory tract infections (LRTIs) using electronic monitoring, and to evaluate whether compliance depends on time since the start of treatment and weekday. Taking compliance, timing compliance, correct dosing compliance and mean interdose intervals were assessed using data from 155 LRTI patients who received either a 10-day treatment of amoxicillin TD and placebo OD or roxithromycin OD and placebo TD using a double-dummy technique. Compliance was assessed by electronic monitoring. Taking compliance was 98.0% for the OD regimen and 91.0% for the TD regimen. Correct dosing was 98.1% for the OD regimen and 91.1% for the TD regimen and timing compliance was 48.2% and 10.9%, respectively. The mean interdose interval before the first daily dose for the TD group was particularly prolonged to >13h. Correct dosing over time showed fewer patients with correct dosing compliance, reaching a low of 79% for the TD group towards the end of the 10-day treatment. Compliance was not influenced by weekday. This study adds important information to the limited evidence on compliance with antibiotics for LRTI, one of the most common reasons for consultation in primary care. Taking compliance was high for both regimens, yet timing compliance was poor. The prolonged mean interdose intervals provide striking new insights into understanding non-compliance with more-than-once-daily regimens. These findings require consideration when exploring ways to improve future compliance in short-term antibiotic treatment for respiratory tract infections.

Function assertive community treatment (FACT) and psychiatric service use in patients diagnosed with severe mental illness

AIM Previous work suggests that the Dutch variant of assertive community treatment (ACT), known as Function ACT (FACT), may be effective in increasing symptomatic remission rates when replacing a system of hospital-based care and separate community-based facilities. FACT guidelines propose a different pattern of psychiatric service consumption compared to traditional services, which should result in different costing parameters than care as usual (CAU). METHODS South-Limburg FACT patients, identified through the local psychiatric case register, were matched with patients from a non-FACT control region in the North of the Netherlands (NN). Matching was accomplished using propensity scoring including, among others, total and outpatient care consumption. Assessment, as an important ingredient of FACT, was the point of departure of the present analysis. RESULTS FACT patients, compared to CAU, had five more outpatient contacts after the index date. Cost-effectiveness was difficult to assess. CONCLUSION Implementation of FACT results in measurable changes in mental health care use.

Prevalence of long‐term mental health care utilization in The Netherlands

The objective of this study is to estimate the proportion of the population in The Netherlands who receive long‐term care for chronic psychiatric problems. The care needs of this population are assessed in terms both of diagnosis and of specific impairments and disabilities. Data from three surveys and two psychiatric case registers in five different areas of The Netherlands provide an estimate of about 3.5 long‐term users of psychiatric care per 1000 members of the population aged 20 years or over. One‐third of them receive a diagnosis of schizophrenia and related psychotic disorders. Patients most frequently suffer from impairments of mood and affect, volition and drives. Nearly all patients are disabled in their occupational role (work), and about half of the population have problems with self‐care and household tasks. Long‐term care is to a large extent (40%) provided in hospitals and sheltered accommodation, and the role of day services is relatively insignificant.

Stroke and mental health care: a record linkage study

Background Stroke is associated with psychiatric morbidity but little is known about mental health care use in stroke patients. Method A probability record linkage study was conducted linking stroke cases admitted to a teaching hospital serving a catchment area between 1987 and 1995 with records from a psychiatric case register covering the same area. Results Stroke patients had a more than twofold increased risk of contact with mental health care than individuals in the general population (yearly prevalences of respectively 88 and 39 per 1000; risk ratio 2.24; 95 % CI 2.04–2.45). One-third of all stroke admissions had had mental health care before and more than half had had mental health care after the stroke. In the year of admission for stroke, the probability of receiving mental health care was highest, while in the more remote years the risk was lower. Conclusion Stroke is associated with an increased probability of contact with mental health services. The pattern of mental health care of a stroke patient is different from that of other mental health patients: more episodic and concentrated around the time of admission for stroke.

Can Assertive Community Treatment Remedy Patients Dropping Out of Treatment Due to Fragmented Services

Previously, many patients with severe mental illness had difficulties to engage with fragmented mental health services, thus not receiving care. In a Dutch city, Assertive Community Treatment (ACT) was introduced to cater specifically for this group of patients. In a pre–post comparison, changes in mental health care consumption were examined. All mental health care contacts, ACT and non-ACT, of patients in the newly started ACT-teams were extracted from the regional Psychiatric Case Register. Analyses of mental health care usage were performed comparing the period before ACT introduction with the period thereafter. After the introduction of ACT, mental health care use increased in this group of patients, although not all patients remained under the care of ACT teams. ACT may succeed in delivering more mental health care to patients with severe mental illness and treatment needs who previously had difficulties engaging with fragmented mental health care services.

Mental Health Care Use in Parkinson’s Disease: A Record Linkage Study

Background/Aim: Parkinson’s disease (PD) is often complicated by psychiatric comorbidity, which is likely to lead to a higher use of mental health care facilities. In addition, psychiatric symptomatology and associated mental health care use may be present even before motor symptoms and PD are diagnosed, as the pathophysiology of PD and its psychiatric consequences are likely to overlap to a degree. This will be reflected in an increasing mental health care use prior to the diagnosis of PD. The aim of this study is to compare the level of mental health care use of PD patients with that of a matched control population, and to assess possible fluctuations in mental health care use in the years surrounding the diagnosis of PD. Methods: Record linkage study comparing the number of mental health care contacts by PD patients with that of a matched control population. Results: Mental health care use by PD patients already increased before the time of diagnosis of PD, and decreased again after diagnosis. The relative risk for mental health care use was increased from 3 years prior (RR 1.41; 95% CI 1.27–1.57) to 2 years after (RR 1.83; 95% CI 1.63–2.05) diagnosing PD. This increase was higher for women than for men, and higher for younger than older individuals. Conclusion: The early pathophysiology of PD is expressed in part as mental health problems, suggesting the possibility of early detection in particular demographic groups and a proactive approach to early intervention for comorbid psychopathology.