The ethical imperative to relieve suffering for people with tuberculosis by ensuring access to palliative care.

Patients diagnosed with tuberculosis (TB) continue to experience clinical uncertainty and high mortality and to bear a high burden of symptoms and other concerns. Additional concerns may be family support needs and stigma, particularly the latter, as TB and human immunodeficiency virus (HIV) coinfection are common. Human rights covenants, global health policy and the End TB Strategy all recommend palliative care as an essential component of care services. As established in the resolution adopted by the World Health Assembly (WHA) on "Strengthening of palliative care as a component of comprehensive care throughout the life course", there is a "need for palliative care across disease groups (non-communicable diseases, and infectious diseases, including HIV and multidrug-resistant tuberculosis), and across all age groups". We address the ethical imperative to respect the dignity and fundamental rights of people with TB by providing palliative care. We review the evidence for the need for person-centred palliative care and highlight novel models that utilise the skills and training functions of specialist palliative care to achieve better care. We outline simple recommendations for the delivery of specialist and generalist palliative care, offer suggestions on how to ensure optimal coverage by enabling access to appropriate good-quality palliative care at all points of the health system, including alongside treatment. Finally, we set out the current priorities for research and policy to ensure that quality care is delivered to all who need it irrespective of treatment outcome, to minimise distress and to optimise engagement in treatment and care.

Care pathways for south Asian and white people with depressive and anxiety disorders in the community.

BACKGROUND: South Asian people with common mental disorders are less likely to have their problems recognised by their general practitioner and have lower rates of uptake of psychiatric services compared to native born white people. Less consideration has been given to their understanding of their mental health problems, their use of alternative supports and the treatment they receive in primary care. METHODS: A general population sample identified, using a semi-structured diagnostic interview, as having DSM-IIIR depressive or anxiety disorders was obtained. South Asian and white participants' appraisal of their mental health problems and their use of informal and formal assistance during the period they were unwell in the previous 6 months were compared. RESULTS: There was no difference between south Asian and white people, either in what they understood to be the matter with them or in what they perceived to be the cause of their problems. No south Asian participants reported seeking help from lay or traditional healers, while white people more often discussed their problems with a relative or friend. Most south Asian people consulted their GP and this was significantly higher than for whites. However, only around half the people in both groups reported disclosing their problem to a GP and only one in ten received psychiatric medication or was referred to specialist psychiatric services. CONCLUSIONS: Along with public education and GP training, the availability of appropriate and acceptable interventions for south Asian, and indeed white people, with common mental disorders consulting in primary care is key to ensuring that they gain access to necessary mental health care.

Risks factors for homelessness among people with psychotic disorders.

BACKGROUND: Although it is widely accepted that rates of severe mental illness amongst single homeless people are high, little is known about the reasons these individuals become homeless. This study aimed to identify risk factors for homelessness among people with psychotic disorders. METHODS: A matched case-control study of homeless and never homeless people with psychotic disorders was carried out, with respondents recruited from mental health services (N = 39 pairs). Data were collected by semi-structured interviews and from medical records. RESULTS: A number of social and behavioural risk factors were identified; key factors being loss of contact with childhood carers, and substance use. Clinical and service use factors appeared less important as predictors of homelessness. CONCLUSIONS: Mental health services have a limited role in circumventing homelessness among people with psychotic disorders. An integrated approach involving other key agencies is required.

Pathways to care for alcohol use disorders.

BACKGROUND: The aim of the present study was to examine access to care for people with alcohol use disorders. METHOD: An alcohol screening questionnaire was completed by 444 respondents in a community survey. During a designated week, 1009 patients presenting in primary care were assessed by their doctor and 773 of these completed the same questionnaire. Over a six month period 223 people with alcohol use disorders were identified using specialist addiction and psychiatric services, of whom 58 were admitted to hospital. One month prevalence rates of alcohol morbidity were determined for people aged between 16 and 64 years at all five levels in the pathways to care model. RESULTS: Around half the people with alcohol morbidity in the community never consulted their general practitioner and of those who did only half had their problem identified. Case recognition was particularly poor for women, young people and Asians. The main filter to people accessing specialist services came at the point of referral from primary care. This was especially marked for young people and for ethnic minorities. CONCLUSIONS: Strategies are required to improve the identification and treatment of alcohol morbidity in primary care. Deficits in access to specialist services for women, young people and ethnic minorities need to be addressed.

Psychiatric morbidity in people born in Ireland.

BACKGROUND: Irish immigrants are reported to be over-represented in psychiatric admission statistics for England when compared to native whites. This study examines whether this finding is sustained for users of psychiatric services as a whole and explicates the reasons for any differential uptake of mental health care by comparison with community morbidity rates in the same population. METHODS: Demographic and clinical data were collected from staff concerning all adults living in a multiethnic inner-city health district and using mental health services during a 6-month period. A separate interview-based survey of private household residents in the same area was undertaken to ascertain the prevalence of psychiatric disorder in the community. RESULTS: Psychiatric service use was found to be greater for Irish-born people compared to the remainder of the white population. However, this finding only persisted for alcohol use disorders, the rates for schizophrenic and affective disorders being comparable in the two groups. Access to psychiatric care was also similar both with respect to overall morbidity as well as for affective and alcohol use disorders, levels of service use being attributable to patterns of morbidity in the population rather than nosocomial factors. CONCLUSIONS: The excess morbidity for alcohol use disorders reported in people born in Ireland is affirmed and the need for longitudinal and ethnographic research into this important public health issue emphasised.

Access to mental health care in an inner-city health district. I: Pathways into and within specialist psychiatric services.

BACKGROUND: Needs for mental health care are likely to be high in urban areas. Purchasers must assess the extent to which these are being met. The pathways to care model provides a framework for this purpose. METHOD: Epidemiological surveys of adults living in deprived multi-ethnic inner-city catchment area were undertaken in psychiatric services, primary care and community settings. Estimated prevalence rates were calculated and the association between clinical and demographic factors and the use of psychiatric services examined. RESULTS: Around a third of people with mental health problems did not consult a GP, and half failed to have their problems recognised by their doctor. Access to psychiatric services and especially to inpatient care was highly restricted. Diagnosis and ethnicity had a marked influence on the use of specialist services. CONCLUSIONS: Many people with psychiatric morbidity are not receiving treatment either from primary care or specialist services. High levels of severe morbidity and compulsory admissions highlight the pressures placed on inner-city psychiatric services.

Access to mental health care in an inner-city health district. II: Association with demographic factors.

BACKGROUND: In addition to clinical and service factors, planners need to take account of the influence of demographic variables, especially ethnicity, on access to mental health care. METHOD: Estimated prevalence rates were calculated from epidemiological surveys undertaken in three settings: psychiatric services, primary care and the general population. Associations between demographic factors and service use were examined using the 'pathways to care' model. RESULTS: Considerable differences in access to mental health care were found, particularly according to ethnicity. The major impediment to Asians accessing care occurred at the interface between primary and secondary care, whereas the most striking feature for Blacks was the poor level of case recognition by GPs. CONCLUSIONS: In order to improve the uptake of mental health care, new initiatives should target those who are most likely to be unwell but least likely to access services. Purchasers and providers need to address differential patterns of use when developing and reviewing services.

A comparison of the socio-demographic and clinical characteristics of private household and communal establishment residents in a multi-ethnic inner-city area.

This study compares the socio-demographic, physical and psychiatric profiles of representative samples of adults resident in communal establishments (n = 170) with those living in private households (n = 544) in a deprived multi-ethnic inner-city health district. Respondents were interviewed about their psychiatric and physical health as well as their early life experiences, close personal relationships, experiences of police contact and episodes of deliberate self-harm. Communal establishment residents were more likely to be single, white men and to be out of work than those in the private household sample. They typically left school at an earlier age, had a more disrupted upbringing, were less likely to have close personal relationships and reported more contact with the police. Both physical and psychiatric morbidity were substantially higher in the communal establishment residents than among those living in private households (especially for psychotic disorders). In contrast to these findings, comparisons between communal establishment residents with and without mental health problems revealed few differences. Our data highlight the extensive needs of those living in communal establishments and the need for a wide range of agencies to co-ordinate their efforts effectively if services to this population are to be effective.

Determinants of general practitioner recognition of psychological problems in a multi-ethnic inner-city health district.

BACKGROUND: With few exceptions, evaluation of the capacity of general practitioners (GPs) to recognise psychiatric disorder in their patients has failed to consider the role of ethnic diversity in the consultation process and whether such knowledge can improve understanding of the degree to which psychiatric morbidity is recognised within GP settings. METHODS: This research was completed in five general practices representative of all those within an inner-city health district. Psychiatric morbidity in patients consecutively attending the practices was then assessed using the General Health Questionnaire; in addition, GPs were asked to complete a checklist of current problems identified during each consultation. RESULTS: Analysis suggested that Asian and Black patients were less likely than White patients to have psychological problems identified; that social problems and a psychiatric history facilitated recognition; and that current physical illness hindered recognition. CONCLUSIONS: GP recognition of psychological problems varies according to patient ethnicity but can be substantially masked by both the physical and social circumstances of patients at consultation.