Differences in timely antenatal care between first and second-generation migrants in the Netherlands.

To assess whether there are differences in the timing of first antenatal care visit between 1st and 2nd-generation migrants, and if so, how such differences could be explained. The study has been conducted in the framework of Generation R Study, a multi-ethnic population-based study conducted in Rotterdam, the Netherlands. The study population consists of 845 women of the six largest ethnic groups. Data were derived from the electronic antenatal charts of the participating midwives and from written questionnaires. Logistic regression analyses have been carried out to investigate whether difference could be explained by need, predisposing and enabling factors. More first than second generation women enter antenatal care after 14 weeks of pregnancy (28.1 vs. 18.7 %). Women who were not likely to adopt healthy behaviour regarding pregnancy--such as timely taking folic acid--equally were not inclined to enter antenatal care early in pregnancy. The role of Dutch language mastery was limited. Given our results, first generation women are less likely to receive timely health educational advice or to benefit from screening opportunities than second generation women. Future studies should pay more attention to adequate assessment of proficiency of the host language.

Gender and health care utilization: the role of mental distress and help-seeking propensity.

Many studies report higher levels of health care utilization among women. Understanding how gender influences health care utilization is still unresolved. We developed a model that could explain these gender-related differences. The possible pathways assumed by this model that relate gender to utilization, can be summarized as follows: (1) utilization may be influenced by somatic morbidity, mental distress, perceived symptoms, poor subjective health and propensity to use services; (2) women have higher levels of these variables than men (mediating effect); and (3) the direct effects of some of these variables on utililization are moderated by gender, i.e. they are stronger for women than for men (moderating effect). Data were drawn from a community-based sample of adult enrollees of a sickness fund in the Netherlands, who had responded to a mailed health survey (N = 8698). This survey contained questions on somatic morbidity, mental distress and other mediating variables. Health care utilization was measured prospectively, using data extracted from a claims database held by the sickness fund that covers all types of general health services except general practitioner consultations. The model was tested using structural equation modelling. Women reported more somatic morbidity and mental distress than men did, as well as elevated levels of other mediating variables, which might explain-at least partly-gender related differences in utilization. Differences in propensity to use services were not found. The expected moderating effect of gender could not be demonstrated. That is, we did not find gender related differences in the strength of the relations between mental distress, other mediating variables and utilization. Mental distress is related to utilization in a way that is not gender specific, however, because women report higher levels of mental distress (as well as somatic morbidity), this results in a greater utilization of somatic health care services.

Is the impact of depressive complaints on the use of general health care services dependent on severity of somatic morbidity?

OBJECTIVE: The aim of this study was to examine the effects of depressive complaints and chronic medical illnesses on prospective somatic health care utilization and the possible heterogeneity of the effect of depressive complaints across levels of medical illness severity. METHODS: Data from a community-based sample of adults (n=9428) were used, of whom a health survey and claims data, indicating health care use, were available. Assessments of depressive complaints and somatic illnesses were based on self-report. Binomial regression analyses were used to study the expected relations. RESULTS: Depressive complaints and somatic morbidity were both positively related to general health care utilization. Somatic morbidity has an attenuating effect on the impact of depressive complaints: If it becomes more severe, the impact of depressive complaints on utilization is reduced. Depressive complaints are especially related to the use of paramedic services, use of prescription drugs, and consultations of medical specialists. CONCLUSION: Depressive complaints predict somatic health care utilization, but somatic morbidity attenuates this relation. Future research on this subject should include interaction effects of depressive complaints and somatic morbidity. Interventions aiming to reduce excess use related to mental distress should be primarily targeted on subjects with mental distress who have no comorbid somatic morbidity.

Emergency psychiatry, compulsory admissions and clinical presentation among immigrants to the Netherlands.

BACKGROUND: Black individuals in the UK have higher rates of contact with psychiatric emergency services than their White counterparts. It is unknown whether this is also the case in other European countries. AIMS: To compare the risk of contact with psychiatric emergency services and of compulsory admission between immigrant groups to The Netherlands and Dutch natives, and to determine the unique contribution of ethnicity to compulsory admission. METHOD: Study of 720 people referred to emergency psychiatric services in Greater Rotterdam, The Netherlands. RESULTS: The relative risks (RRs) for contacts with psychiatric emergency services, for having a psychotic disorder and for compulsory admission were significantly higher in most immigrant groups. Moroccans, Surinamese and Dutch Antilleans had the highest risks of compulsory admission. After controlling for symptom severity, danger, motivation for treatment and level of social functioning, non-Western origin was no longer associated with compulsory admission. CONCLUSIONS: Non-Western immigrant groups were overrepresented in psychiatric emergency care and were admitted compulsorily more frequently, possibly owing to a different clinical presentation.

Assessing the construct validity of three indicators of psychological distress in relation to perceived health and physical illness.

OBJECTIVES: The aim of this study is to compare three indicators of psychological distress (PD) on the strength of their association with subjective (or perceived) health and to analyse to what extent these associations will change after adjusting for physical illness measures and other possible confounding variables. METHODS: Data were used from a community-based sample of adults (N=9,428). Psychological distress was measured using three different instruments: the Negative Affect Scale of Bradburn, a nervousness scale, and a self-reported depressive complaints. Physical illness was measured by seven specific chronic conditions, a co-morbidity index of 17 conditions and two disability measures. Subjective health was assessed by a single question. Ordinary least square and logistic regression as well as structural equation modelling were used to analyse the data. RESULTS: The relation between subjective health and PD is strongest in case nervousness and this, or negative affect, are used as indicators of PD. The measure of depressive complaints is less strongly, but still substantially, related to subjective health. After correction for physical illness variables, the change in strength of the association is slightest for depressive complaints and highest for nervousness. Only small differences between negative affect and nervousness were established. These measures, which were more contaminated by physical ill health than depressive complaints, have the strongest association with subjective health both before as well as after correction for physical illness components. CONCLUSION: Negative affect and nervousness are reliable and valid indicators of PD, which can be used to predict subjective health. However, for this purpose, a correction for the confounding effects of physical illness variables will be necessary. The depressive complaints measure is not only less predictive of subjective health but also less contaminated by physical illness variables, making it a better indicator of PD if correction for physical illness variables is not possible.

Lack of motivation for treatment in emergency psychiatry patients.

BACKGROUND: A lack of motivation for treatment on the part of patients is a major problem for emergency psychiatric services. Little is known about its determinants. The aim of this study was to investigate determinants of treatment motivation in emergency psychiatric patients. METHOD: A cross-sectional study of 719 patients was made. Motivation for treatment and other clinical variables were assessed using the Severity of Psychiatric Illness scale and the Brief Psychiatric Rating Scale. RESULTS: In all, 47% of patients were not motivated for treatment and they also had severe clinical problems. Lack of motivation was associated with danger to others [odds ratio (OR) 2.03; confidence interval (CI) 1.21-3.40], substance abuse (OR 1.71; CI 1.09-2.67), suspiciousness (OR 1.4; CI 1.19-1.64), grandiosity (OR 1.19; CI 1.01-1.4), anxiety (OR 0.74; CI 0.64-0.86), and GAF score (OR 0.98; CI 0.96-0.99). CONCLUSIONS: Lack of motivation for treatment is a common phenomenon among severely mentally ill patients seen by emergency psychiatric services. Lack of motivation was associated with danger and paranoid symptoms. Motivational techniques as well as involuntary treatment may help to overcome problems due to lack of motivation in these patients.

Determinants of indicated versus actual level of care in psychiatric emergency services.

OBJECTIVE: This study was undertaken to improve understanding of the admission decision process by distinguishing between the clinically indicated level of care and actual level-of-care decisions in emergency psychiatry. METHODS: Clinicians in emergency psychiatric services in Rotterdam, The Netherlands, prospectively rated 720 patients by using the Severity of Psychiatric Illness Scale and collected information on demographic, clinical, and contextual parameters. The clinically indicated level of care and actual level-of-care decisions were studied independently, by using multivariate logistic regression analyses. The decision-making process was divided into three consecutive steps: evaluation of clinically indicated inpatient or outpatient level of care (step 1), voluntary or involuntary admission (step 2), and actual admission of patients for whom voluntary admission was indicated (step 3). RESULTS: Each step was determined by separate factors. Specifically, clinically indicated admission (step 1) was associated with family or friends' desire for admission (odds ratio [OR]=3.7), previous admissions (OR=2.9), symptom severity (OR=2.7), and personality disorder (OR=.4). Involuntary admission (step 2) was associated with lack of motivation (OR=5.7), symptom severity (OR=3.7), time of referral (OR=3.5) and danger to self or others (OR=2.7). Actual voluntary admission (step 3) was associated mainly with bed availability (OR=8.7). The overall percentage of correctly predicted cases was 82 percent for all steps in the decision process. CONCLUSIONS: This study showed that each step in the admission decision process is determined by a unique set of variables and provided evidence that contextual factors influence decision making. Guidelines for voluntary admission and civil commitment need to be based on the results of studies that distinguish between the clinical needs of patients and contextual factors.

Length of hospital stay and health services use of medical inpatients with comorbid noncognitive mental disorders: a review of the literature.

We reviewed 23 studies on the association between noncognitive mental disorders and the use of general health care services by medical patients admitted to a general hospital. Only studies with a prospective design and with a correction for possible confounding factors were included. In most studies, only service use during index admission was observed, but eight studies included a longer observation period during follow-up after hospital discharge. The 15 studies that were restricted to service use during index admission showed mixed results: length of hospital stay was related to common mental disorders in some studies, but other studies did not find such an association. The eight studies that used a longer observation period showed findings that are more consistent. They demonstrated mainly that symptoms or complaints of depression are related to a higher resource use within general medical services.