Mostrando las entradas con la etiqueta Mental Health. Mostrar todas las entradas
Mostrando las entradas con la etiqueta Mental Health. Mostrar todas las entradas

18 junio, 2013

Grand Challenges: Integrating Mental Health Care into the Non-Communicable Disease Agenda

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Citation: Ngo VK, Rubinstein A, Ganju V, Kanellis P, Loza N, et al. (2013) Grand Challenges: Integrating Mental Health Care into the Non-Communicable Disease Agenda. PLoS Med 10(5): e1001443. doi:10.1371/journal.pmed.1001443
Published: May 14, 2013

Summary Points

  • Non-communicable chronic diseases (NCD) and mental disorders each constitute a large portion of the worldwide health care burden, and they often occur together.
  • Collaborative care models, where NCD care and mental health care are integrated and provided in the primary care setting, are effective for patients, strengthen health care service systems, and reduce costs.
  • Using lay health workers to supplement the services provided by mental health specialists, physicians, and nurses can extend services to more patients, but raises challenges related to training and coordination.
  • Implementation of collaborative care models and scale up of successful models will be enhanced by tapping local knowledge of social, political, cultural, and health system nuances.
  • Collaborative care approaches that integrate services for NCD and mental health conditions require investments in human resources, services, and additional research.
  • This is the third in a series of five articles providing a global perspective on integrating mental health.
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17 junio, 2013

Psychological therapy based on cognitive behavioural therapy (CBT) principles is effective in reducing anxiety symptoms for short - term treatment of generalised anxiety disorder (GAD)

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29 mayo, 2013

The Paradox of Mental Health: Over-Treatment and Under-Recognition

 Source: PLOS MEDICINE
Author: The PLOS Medicine Editors 
Citation: The PLOS Medicine Editors (2013) The Paradox of Mental Health: Over-Treatment and Under-Recognition. PLoS Med 10(5): e1001456. doi:10.1371/journal.pmed.1001456
Published: May 28, 2013
Copyright: © 2013 PLoS Medicine Editors. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The authors are each paid a salary by the Public Library of Science, and they wrote this editorial during their salaried time.
Competing interests: The authors' individual competing interests are at http://www.plosmedicine.org/static/edito​rsInterests.action. PLOS is funded partly through manuscript publication charges, but the PLOS Medicine Editors are paid a fixed salary (their salary is not linked to the number of papers published in the journal).
Abbreviations: ADHD, attention deficit hyperactivity disorders; LMIC, low- and middle-income country
Provenance: Written by editorial staff; not externally peer reviewed.
Among all the conditions in the world of health, mental health occupies a unique and paradoxical place.
On the one hand is over-treatment and over-medicalization of mental health issues, often fueled by a pharmaceutical industry interested in the broadening of the boundaries of “illness” and in the creation of more and wider diagnostic categories and thus markets for “selling sickness.” On the other hand exists profound under-recognition of the suffering and breadth of mental health issues affecting millions of people across geographies, which is a global problem.
As a journal, PLOS Medicine has covered both sides of the mental health “coin,” and we continue to make mental health in general a priority area. We recognize that the whole of the field of mental health research is relatively underdeveloped, and that a particular scarcity of clinical trials exists from outside high-income settings and for non-drug interventions. As a result, we also support efforts to improve capacity in mental health research whilst committing to the publication of the state of the art in research and commentary [1],[2].
Over-treatment, especially when it results from “disease mongering,” is a persistent and troubling issue. The harms of over-treatment arise from situations where normal life experiences (such as menopause, shyness, grief, etc.) are deemed illnesses [3] or when diseases are “created” from mild problems and symptoms (such as restless legs syndrome or female sexual dysfunction) [4],[5]. In both situations, people become patients, and their problems are deemed to need medical treatment when they may not need it or could be harmed by it, or when nonmedical options are available. Over-diagnosis and over-treatment have been shown for a range of human conditions [3], but this phenomenon as it relates to mental health is particularly powerful [6]. For example, the widespread over-diagnosis of conditions such as bipolar disorder, autism spectrum disorder, and attention deficit hyperactivity disorders (ADHD), especially among children, is now being documented—the US Centers for Disease Control recently estimated that 6.4 million children aged 4 to 17 had received an ADHD diagnosis at some point in their lives (amounting to 11% of all US children)—a 41% increase in the last decade that has been met with alarm and concern by many doctors and parents [7]. Two thirds of these children are said to be on medication for the condition. Recent Canadian data [8] reaffirm the concerns with excessive labeling of normal child behavior as pathological. Over-diagnosis in mental health risks unnecessary tests and treatment, the stigma associated with being labeled mentally ill, and the considerable costs of testing, treatment, and wasting resources that could be better utilized elsewhere [3],[5].
The recent DSM-5 process is a lightning rod for these concerns: this month's update of the psychiatric diagnostic manual has been widely criticized for continuing the tradition of broadening diagnostic categories and adding new conditions that redefine more people as having mental illness and in need of pharmaceutical treatment [9],[10]. That decisions about DSM-5 categories are made by experts with financial ties to the industry that benefits most from a widened patient population [11],[12], is particularly worrying.
In perhaps the most dedicated venue for discussions of this topic, the Selling Sickness conferences (http://www.sellingsickness.com), which PLOS Medicine has been instrumental in shaping, have brought together academic researchers, medical reformers, consumer advocates, and health journalists with shared interests in examining the problem of disease mongering and developing strategies and coalitions for change. The inaugural conference in 2006 coincided with our launch of the PLOS Medicine Disease Mongering Collection (http://bit.ly/18i6j6h) that to this day remains astonishingly relevant. In February 2013 we participated again, this time in a roundtable on the role of the medical media where we outlined our responsibility as editors to avoid the spin in published articles and the journal's press releases that can fuel hype about new disease categories and treatment [13]; we also highlighted another important role of journals in fighting disease mongering: to require that all clinical trials be registered and data be reported and shared, so that the full picture of the benefits and harms of tested interventions can be seen (see, for example, http://www.alltrials.net). The conference's Call to Action petition (http://sellingsickness.com/final-stateme​nt/) is available for readers to view and sign. Later in 2013, two comrade conferences, PharmedOut (http://www.pharmedout.org/) and Avoiding Overdiagnosis (http://www.preventingoverdiagnosis.net/), will continue the conversation about both the extent and the prevention of over-diagnosis, and will undoubtedly provide new insights into the problems associated with over-treatment of mental health.
Equally important, however, is the vast under-recognition of mental health conditions, especially in the developing world. This neglect has occurred at multiple levels including at the national level, where many countries have failed to establish adequate mental health policy. At the level of global health agendas, mental health was essentially ignored in the Millennium Development Goal program and failed to elevate to prominence at the recent United Nations special assembly on non-communicable disease.
As many others have noted [14]–[16], this neglect makes little sense: more than 13% of the global burden of disease is attributable to neuropsychiatric disorders, and over 70% of this burden lies in low- and middle-income countries (LMICs). Almost a quarter of the world's disability burden is now attributable to mental and behavioral disorders (including depression, anxiety, Alzheimer disease, and schizophrenia) [17]. And yet mental health has failed thus far to receive the political priority and international funding commensurate with its global toll [14]. There are signs this tide is shifting, and several prominent groups and organizations are working to raise the profile of global mental health. PLOS Medicine has provided a forum for that effort over the last few years, publishing packages of care for mental health disorders in LMICs [18] and an ongoing series on mental health interventions in practice [2]. And this week we conclude a five-part series that sets out an agenda for integrating mental health care into primary care, maternal health, non-communicable disease, and HIV interventions in the developing world [19]. All of these analyses were done by researchers free of financial links to manufacturers with a stake in expanded markets, thus providing the necessary independent opinion.
In addition, we've recently published high-quality research on a range of topics within mental health that contributes to improved clinical practice, policy, and action. This includes definitive evidence on the long-term health consequences of sexual abuse [20] and trafficking [21], a genome-wide analysis establishing the limited ability of genetic data to predict antidepressant response [22], and a meta-analysis reporting the relative benefits and harms of adjunctive antipsychotic medications in depression [23]. These studies add to a growing evidence base, and signal a growing recognition of the importance of mental health.
Still, our understanding of all aspects of mental health is relatively underdeveloped. As others have acknowledged [3],[24], the research base for over-diagnosis and harm from over-treatment remains limited, and so the new initiatives and calls for action are welcomed. So too is growing recognition and research on genuine mental health issues and the best ways to address and prevent mental health problems, especially in terms of policy and human rights action and in a global context. To the extent that these two areas (over-treatment on one hand, under-recognition on the other hand) represent the paradox of mental health, where's the balance point? We don't have all the answers, but as a journal we reaffirm our commitment to publishing rigorous, insightful research and commentary on the breadth of issues around global mental health, and we welcome continued debate on the challenges this paradox represents. The largest challenge may be to recognize and prioritize mental health globally—with the requisite political visibility, funding, research, and attention—without reducing it to an object for disease mongering, pathologizing, and harmful over-treatment.

Author Contributions

Wrote the first draft of the manuscript: JC. Contributed to the writing of the manuscript: JC PS MW LC AR. ICMJE criteria for authorship read and met: JC PS MW LC AR. Agree with manuscript results and conclusions: JC PS MW LC AR.

References

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  7. 7. Schwarz A, Cohen S (1 April 2013) A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise. The New York Times. Available: http://www.nytimes.com/2013/04/01/health​/more-diagnoses-of-hyperactivity-causing​-concern.html. Accessed 6 May 2013.
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  9. 9. Rosenberg RS (12 April 2013) Abnormal Is the New Normal: Why will half of the U.S. population have a diagnosable mental disorder? Slate Magazine. Available: http://www.slate.com/articles/health_and ​_science/medical_examiner/2013/04/diagno​ stic_and_statistical_manual_fifth_editio​ n_why_will_half_the_u_s_population.html. Accessed 6 May 2013.
  10. 10. Crocker L (11 April 2013) DSM-V: Hoarding, Binge Eating & More New Mental-Disorder Diagnoses. The Daily Beast. Available: http://www.thedailybeast.com/articles/20​13/04/11/dsm-v-hoarding-binge-eating-mor​e-new-mental-disorder-diagnoses.html. Accessed 6 May 2013.
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  14. 14. Tomlinson M, Lund C (2012) Why Does Mental Health Not Get the Attention It Deserves? An Application of the Shiffman and Smith Framework. PLoS Med 9(2): e1001178 doi:10.1371/journal.pmed.1001178.
  15. 15. Bass JK, Bornemann TH, Burkey M, Chehil S, Chen L, et al. (2012) A United Nations General Assembly Special Session for Mental, Neurological, and Substance Use Disorders: The Time Has Come. PLoS Med 9(1): e1001159 doi:10.1371/journal.pmed.1001159.
  16. 16. Collins PY, Patel V, Joestl SS, March D, Insel TR, et al. (2011) Grand challenges in global mental health. Nature 475: 27–30.
  17. 17. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, et al. (2012) Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 380: 2197–2223.
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  19. 19. Patel V, Belkin GS, Chockalingam A, Cooper J, Saxena S, et al. (2013) Integrating Mental Health Services into Priority Health Care Platforms: Addressing a Grand Challenge in Global Mental Health. PLoS Med 10(5): e1001448 doi:10.1371/journal.pmed.1001448.
  20. 20. Norman RE, Byambaa M, De R, Butchart A, Scott J, et al. (2012) The Long-Term Health Consequences of Child Physical Abuse, Emotional Abuse, and Neglect: A Systematic Review and Meta-Analysis. PLoS Med 9(11): e1001349 doi:10.1371/journal.pmed.1001349.
  21. 21. Oram S, Stöckl H, Busza J, Howard LM, Zimmerman C (2012) Prevalence and Risk of Violence and the Physical, Mental, and Sexual Health Problems Associated with Human Trafficking: Systematic Review. PLoS Med 9(5): e1001224 doi:10.1371/journal.pmed.1001224.
  22. 22. Tansey KE, Guipponi M, Perroud N, Bondolfi G, Domenici E, et al. (2012) Genetic Predictors of Response to Serotonergic and Noradrenergic Antidepressants in Major Depressive Disorder: A Genome-Wide Analysis of Individual-Level Data and a Meta-Analysis. PLoS Med 9(10): e1001326 doi:10.1371/journal.pmed.1001326.
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23 mayo, 2013

Cribado para depresión

Español: Fenomeno de la depresión cortical pra...
Español: Fenomeno de la depresión cortical prapagada que tiene lugar en la migraña (Photo credit: Wikipedia)
   







Fuente Salud Juntos




21-05-2013













Se descarta el cribado de depresión e en la consulta de atención primaria a personas sin síntomas específicos -> De acuerdo a las nuevas recomendaciones del Grupo de Trabajo Canadiense sobre Salud Preventiva, los médicos de atención primaria no deben revisar regularmente a adultos asintomáticos para la depresión. Sin embargo los médicos deben estar alerta sobre la posibilidad de la enfermedad  cuando hay indicios clínicos como el insomnio, estado de ánimo bajo, falta de interés o pensamientos suicidas.
CMAJ, 15/05/2013 "Recommendations on screening for depression in adults".
Conclusiones de la revisión:
  • La revisión sistemática de estas directrices no identificó evidencia de alta calidad de la eficacia del cribado para la depresión.
  • A pesar de que la revisión sistemática no identificó evidencia directa de efectos nocivos del cribado, seguimos preocupados por los falsos positivos diagnósticos con un tratamiento innecesario.
  • No se recomienda cribado de rutina para la depresión en los centros de atención primaria para los adultos que no presentan síntomas evidentes de depresión, que están en riesgo medio de depresión o que pueden tener mayor riesgo de depresión.
  • Los médicos deben estar alerta ante la posibilidad de depresión, especialmente en pacientes con características que pueden aumentar su riesgo de depresión, y debe buscarla cuando existen indicios clínicos, tales como insomnio, estado de ánimo bajo, anhedonia y pensamientos suicidas.
  • Los ensayos controlados aleatorios con grupo de control que evalúan el efecto del cribado de la depresión clínicamente relevante deben ser una prioridad en la investigación, especialmente en las poblaciones con un mayor riesgo de depresión.

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20 mayo, 2013

Depression Overdiagnosed and Overtreated in U.S. Adults


 Source: Practice update

Depression Overdiagnosed and Overtreated in U.S. Adults

IMNG Medical Media, 2013 May 02, M Rajaraman



Commentary by

Tricia C Elliott, MD, FAAFP
Addressing and treating behavioral and mental health concerns in patients are part of the daily clinical practice of the majority of primary care physicians. It is likely accurate that depression is over diagnosed and antidepressants are overused. However, with limited mental health resources, the use of these medications indeed rises as primary care physicians seek to provide some treatment options for their patients. The increased biopsychosocial demands experienced by patients, the increased time constraints on physicians, and the scarcity of community behavioral and mental health resources highlight an urgent need to explore other models of care, such as the medical home, and to invest in the expansion of our behavioral and mental health services and providers. This study also underscores the potential utility of validated depression-screening tools that are quick and easy to use, such as the Patient Health Questionnaire-9 (PHQ-9). Incorporating these tools in the clinical encounter may help primary care physicians diagnose their depressed patients and facilitate a more informed treatment decision and plan.


Depression is frequently overdiagnosed and overtreated in American adults, according to a national survey study.
The study explored whether patients identified as depressed by their clinicians also met the DSM-IV diagnostic criteria for 12-month major depressive episodes (MDE). Results showed that of the 5,639 participants with clinician-identified depression, only 38.4% actually met the MDE criteria. Additionally, a majority of participants reported using prescribed psychiatric medications, regardless of whether they met MDE conditions.
“This finding highlights the growing trends in prescription and use of psychiatric medications, and especially antidepressants, in the USA, even in the absence of a psychiatric diagnosis,” wrote study author Dr. Ramin Mojtabai of the department of mental health at Johns Hopkins Bloomberg School of Public Health, Baltimore.
A sample of adult participants was drawn from the 2009 and 2010 National Survey of Drug Use and Health (NSDUH). Participants completed an assessment in the form of a computer-assisted in-person interview to determine whether they met DSM-IV criteria for major depressive episodes. Using questions derived from the Composite International Diagnostic Interview (CIDI) from the National Comorbidity Survey Replication, participants had to meet 5 of 9 symptom criteria and the DSM-IV clinical significance criteria (distress or impairment in functioning).
In addition to diagnostic criteria for depression, participants also were asked to report any inpatient or outpatient treatment or medications sought and prescribed over the past 12 months. Demographic information, such as education, general health, and employment status, also was collected.
Results showed that adults in the groups aged 35-49 years and 65 years and older were less likely to meet the 12-month MDE criteria than were adults aged 18-25 years.
“In contrast, participants who were out of the workforce, those who were divorced or separated, the more educated and those with poorer self-rated health were more likely to meet the 12-month MDE criteria,” Dr. Mojtabai wrote.
He added that the rate of false-positive diagnosis found in this study echoes that of prior research, and that numerous factors could contribute to this high rate, such as a generally low incidence of depression in community settings, a lack of clinician knowledge about diagnostic criteria, and “ambiguity regarding subthreshold syndromes.”
Dr. Mojtabai noted a few limitations to this study. First, he speculated that the true prevalence of clinician-diagnosed depression is likely much higher than is estimated in this study, as many doctors might not share their diagnostic impressions with patients. Second, he cautioned that structured interviews and clinician diagnoses are measures of “imperfect sensitivity.” Third, the type of doctor was not specified in the NSDUH survey used to recruit participants. Fourth, some patients diagnosed with depression might in fact have another disorder, such as anxiety or adjustment disorder, which might benefit from antidepressant medication. And lastly, some adults with depression might require long-term treatment to prevent recurrence after remission.
He mentioned a more vigilant approach to diagnosing mental health disorders, originally suggested by Laura Batstra, Ph.D., and Dr. Allen Frances, “which allows clinicians to avoid labeling subthreshold symptoms and mild conditions with psychiatric diagnoses” and encourages the use of less intense psychological interventions when appropriate (Psychother. Psychosom. 2012;81:5-10).
Dr. Mojtabai explained that this study underscores the challenge of accurately diagnosing mental disorders, and as primary care starts to play a larger role in mental health care, special priority should be given to improved diagnosis and treatment of psychiatric conditions.
Dr. Mojtabai disclosed receiving consulting fees from Lundbeck Pharmaceuticals.

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