Tratamiento y uso de recursos en salud mental de pacientes sin patología / Treatment and use of resources in mental health of patients without pathology

Objetivo: Determinar si existen diferencias en el uso de recursos y la actividad terapéutica llevada a cabo con las personas con y sin trastorno mental diagnosticable (códigos Z según CIE-10) en los Servicios de Salud Mental. Metodología: Diseño: estudio descriptivo comparativo. Ámbito: área sanitaria urbana. Población: todos los pacientes derivados al Centro de Salud Mental (n=1187) durante un año. Variables: se han analizado la indicación clínica, el número de citas y la intervención terapéutica a lo largo de un año de seguimiento. Asimismo, se recogieron también variables sociodemográficas, clínicas y asistenciales mediante la entrevista clínica, el test GHQ-28 y una escala de expectativas, para poder completar el estudio. Resultados: Los códigos Z son dados de alta en mayor proporción, reciben un tercio de visitas a lo largo de un año, faltan a mayor número de citas y tienen una probabilidad casi 5 veces mayor de abandonar tras la primera consulta que los trastornos mentales. Los pacientes diagnosticados de trastorno mental llegan con más tratamiento pautado desde atención primaria, se les añade más tratamiento, sobre todo si habían llegado sin ello a consulta, si viven solos y en el caso de ser derivados vía normal, que los códigos Z. A los 12 meses también están tomando psicofármacos en mayor proporción. Conclusiones: La indicación de alta o seguimiento en la primera entrevista, el número de citas y los abandonos discriminan las dos poblaciones mejor que en trabajos previos. Nuestros pacientes tienen más medicación pautada en el momento de la consulta, sobre todo en el caso de los códigos Z, que en los estudios internacionales. No obstante, la intervención farmacológica con los códigos Z suele ir encaminada en su mayoría a suspender los psicofármacos (AU)

Aims: to establish the differences in the use of resorurces and treatment with the people with and without diagnosable mental (Z codes according to CIE 10) in a Community Mental Health Center. Method: Design: comparative descriptive study. Scope: urban area. Population: all patientes referred to de mental health service during a year (n=1187). Variables: clinical indication, number of consults and therapeutic intervention throughout a year of pursuit have been analyzed. Also, were also collected sociodemographic, clinical and health services utilization variables by clinical interview, the test GHQ-28 and a scale of expectations, in order to complete the study. Results: Z codes are discharged to a greater extent, receive one-third of visits over a year, missing more citations and have a nearly 5 times more likely to leave after the first consultation that mental disorders. Patients diagnosed as mental disorder come with more prescribed treatment from primary care, further treatment is added, especially if they come without it to see, if they live alone and if they are re - ferred for normal track than Z. codes At 12 months are also taking psychotropic drugs in greater proportion. Conclusions: The indication of discharge or pursuit in the first interview, the number of consults and drop-outs discriminates the two populations better than in previous works. Our patients have more medication at the moment of the consultation, mainly in the case of the Z codes, than other studies. However, the pharmacology intervention with Z codes usually goes directed in its majority to suspend the psychotropic drug (AU)

Effectiveness of a structured training program in psychotherapeutic skills used in clinical interviews for psychiatry and clinical psychology residents.

The authors evaluated a training program based on a structured manual of psychotherapeutic skills, using a randomized controlled design. The experimental group consisted of 135 residents from 12 teaching units in Spain. To control the improvement in therapeutic skills that could be attributed to the training received during the residency, the authors compared the experimental group with a control group of 35 residents from three teaching units. Two types of assessment instruments were used: a paper-and-pencil questionnaire based on clinical cases and a videotape of a role-playing interview. Both were given before and after the experimental group attended the training program. The experimental group shows a statistically significant improvement compared with the control group in both measurements.

Factores asociados con la resolución de las urgencias psiquiátricas / Factors linked with the resolution of psychiatric emergencies

Para la toma de decisiones en la urgencia psiquiátrica influyen múltiples factores, unos clínicos y otros relacionados con el terapeuta o con el entorno en el que se desarrolla la urgencia (AU)

Different factors are involved in the process of decision making at the psychiatric emergency ward. These may be either clinical or related to the therapist and/or the environment (AU)

[Detection of adolescents at risk of suffering eating disorders]. / Detección de adolescentes en riesgo de presentar trastornos de la alimentación.

OBJECTIVES: To analyse which risk factors are related to eating disorders and to identify useful questions for their early detection in primary care. DESIGN: Observational, cross-sectional study. SETTING: Six secondary schools in Leganés, Madrid, Spain. PARTICIPANTS: Adolescents aged between 12 and 18 years old attending secondary school. MAIN MEASUREMENTS: Risk of suffering an eating disorder (Eating Attitudes Test-26) and questions about weight, height, family, attitudes towards body image, use of health services for eating disorders, and mental illness history. RESULTS: An 8.8% of the adolescents were at risk of developing an eating disorder (4.6% male; 11.8% female). Age in males (OR=0.76) and 24-hour fasting to lose weight (OR for males =7.44; OR for females =3.09) were associated with the risk of eating disorders. Early menarche (OR=1.69), having dieted for social or environmental reasons, and self-induced vomiting (OR=5.71) were associated with eating disorders in women. The specificity and negative predictive value of asking about self-induced vomiting and 24-hour fasting in order to detect an eating disorder were around 95%. CONCLUSIONS: Age is a protective factor for eating disorders, especially in males. In women, early menarche is a risk factor. Asking about self-induced vomiting and 24-hour fasting enables eating disorders in women to be ruled out.

Detección de adolescentes en riesgo de presentar trastornos de la alimentación / Detection of adolescents at risk of suffering eating disorders

Objetivo. Analizar qué factores se asocian con el riesgo de presentar un trastorno de la conducta alimentaria (TCA) e identificar preguntas útiles para su detección precoz en atención primaria. Diseño. Observacional, transversal. Emplazamiento. Seis centros de enseñanza de Leganés (Madrid). Participantes. Adolescentes escolarizados de 12 a 18 años. Mediciones principales. Riesgo de presentar TCA (Eating Attitudes Test-26) y cuestionario sobre peso, talla y composición familiar, actitudes hacia la imagen corporal, el uso de servicios de salud relacionados con los TCA y antecedentes de trastorno mental. Resultados. El 8,8% de los adolescentes está en riesgo de presentar un TCA (un 4,6% de varones y un 11,8% de mujeres). Destaca la asociación del riesgo de TCA con la edad de los varones (odds ratio [OR] = 0,76) y haber ayunado 24 h para perder peso (OR en varones = 7,44; OR en mujeres = 3,09). En las mujeres se asocia con la menarquia temprana (OR = 1,69), haber hecho dieta bajo la influencia de factores socioambientales y autoprovocarse el vómito (OR = 5,71). Preguntar respecto a los vómitos autoprovocados y al ayuno de 24 h para detectar TCA posee una especificidad y un valor predictivo negativo en torno al 95%. Conclusiones. La edad protege del riesgo de presentar TCA, más claramente en varones. En mujeres, la menarquia temprana es un factor de riesgo. Interrogar sobre los vómitos autoprovocados y el ayuno de 24 h permite descartar el TCA en mujeres

Objectives. To analyse which risk factors are related to eating disorders and to identify useful questions for their early detection in primary care. Design. Observational, cross-sectional study. Setting. Six secondary schools in Leganés, Madrid, Spain. Participants. Adolescents aged between 12 and 18 years old attending secondary school. Main measurements. Risk of suffering an eating disorder (Eating Attitudes Test-26) and questions about weight, height, family, attitudes towards body image, use of health services for eating disorders, and mental illness history. Results. An 8.8% of the adolescents were at risk of developing an eating disorder (4.6% male; 11.8% female). Age in males (OR=0.76) and 24-hour fasting to lose weight (OR for males =7.44; OR for females =3.09) were associated with the risk of eating disorders. Early menarche (OR=1.69), having dieted for social or environmental reasons, and self-induced vomiting (OR=5.71) were associated with eating disorders in women. The specificity and negative predictive value of asking about self-induced vomiting and 24-hour fasting in order to detect an eating disorder were around 95%. Conclusions. Age is a protective factor for eating disorders, especially in males. In women, early menarche is a risk factor. Asking about self-induced vomiting and 24-hour fasting enables eating disorders in women to be ruled out

Variaciones del consumo de recursos ambulatorios en la atención especializada de salud mental a niños y adolescentes / Variability in outpatient resource use in mental health services for children and adolescents

Objetivos: Conocer la variabilidad en las respuestas asistenciales que se ofrecen en la atención psiquiátrica ambulatoria a los menores de 18 años, medidas por el número de consultas y el tiempo de duración de los tratamientos. Método: Estudio observacional, analítico, prospectivo con datos históricos y longitudinal de seguimiento de 298 sujetos que consultan por primera vez en las unidades de atención ambulatoria de Leganés y Fuenlabrada (Madrid). Resultados: La mediana del número de consultas por paciente en Leganés fue de 6, mientras que en Fuenlabrada fue de 3 (p < 0,001). La mediana de la duración del tratamiento fue más del doble en Leganés (276 días) que Fuenlabrada (119 días) (p < 0,001). El análisis estratificado muestra que los tratamientos del distrito de Fuenlabrada suponen un menor número de consultas, ya sea el profesional responsable psiquiatra o psicólogo, se lleve a cabo psicoterapia individual, de otro tipo, o no se indique tratamiento de modo explícito, se realice alta concertada o ésta se produzca por abandono. Similares resultados se aprecian para la duración del tratamiento. Conclusiones: Las diferencias encontradas de estilos de práctica clínica ilustran las dificultades para desarrollar un sistema de ajustes de riesgos útil en salud mental, puesto que las diferencias en uso de recursos no son fácilmente atribuibles a variables relacionadas con el paciente, sino al tipo de intervención prestada, que depende de la discrecionalidad del facultativo

Objectives: To assess possible variability in the therapeutic approaches provided to patients aged less than 18 years old in community mental health centres (CMHC) in terms of the number of visits and length of treatment. Method: An observational, analytical, prospective, longitudinal study was performed in a clinical cohort of 298 subjects attending the CMHC of Leganés and Fuenlabrada (Madrid) for the first time. Results: The median number of visits per patient was six in Leganés and three in Fuenlabrada (p < 0.001). The mean length of treatment was more than twice as long in Leganés (276 days) than in Fuenlabrada (119 days) (p < 0.001). Stratified analysis showed that the treatments provided in Fuenlabrada involved fewer visits, irrespective of the health professional in charge (psychiatrist or psychologist), the treatment modality prescribed (individual psychotherapy, other psychotherapies or no explicit treatment prescribed), or whether the patient abandoned treatment or the discharge was agreed. Similar results were found for the length of treatment. Conclusions: The different clinical styles illustrate the difficulty of developing useful risk adjustment systems in mental health. The differences in resource consumption and costs cannot easily be attributed to patient-related variables, but are due rather to the intervention provided, which depends on the staff

[Variability in outpatient resource use in mental health services for children and adolescents]. / Variaciones del consumo de recursos ambulatorios en la atención especializada de salud mental a niños y adolescentes.

OBJECTIVES: To assess possible variability in the therapeutic approaches provided to patients aged less than 18 years old in community mental health centres (CMHC) in terms of the number of visits and length of treatment. METHOD: An observational, analytical, prospective, longitudinal study was performed in a clinical cohort of 298 subjects attending the CMHC of Leganés and Fuenlabrada (Madrid) for the first time. RESULTS: The median number of visits per patient was six in Leganés and three in Fuenlabrada (p < 0.001). The mean length of treatment was more than twice as long in Leganés (276 days) than in Fuenlabrada (119 days) (p < 0.001). Stratified analysis showed that the treatments provided in Fuenlabrada involved fewer visits, irrespective of the health professional in charge (psychiatrist or psychologist), the treatment modality prescribed (individual psychotherapy, other psychotherapies or no explicit treatment prescribed), or whether the patient abandoned treatment or the discharge was agreed. Similar results were found for the length of treatment. CONCLUSIONS: The different clinical styles illustrate the difficulty of developing useful risk adjustment systems in mental health. The differences in resource consumption and costs cannot easily be attributed to patient-related variables, but are due rather to the intervention provided, which depends on the staff.

Psychiatric hospitalization and continuity of care in immigrants treated in Madrid (Spain).

BACKGROUND: The ethnic group and also the socioeconomic level of a patient are linked with the quality of the health care received that is associated, among other factors, with the continuity of care between the different services involved in treatment. The main goal of this study is to identify whether foreigners resident in Madrid run a greater risk than Spaniards of interruption in the continuity of their care after discharge from a psychiatric hospitalization. Other characteristics of the patients associated with disruption of care continuity are identified in order to be able to design specific actions with this group of subjects to foster their compliance with treatment. METHODS: An observational, prospective, controlled study is performed to analyse the risk of not attending the first outpatient appointment after discharge from hospital in 60 foreign patients versus 115 Spaniards admitted to four short-stay psychiatric hospitalization units in Madrid. RESULTS: The multivariate analysis indicates that the relevant factors associated with a break in the continuity of care are the fact of being an immigrant having a monthly income of less than 240 [adjusted OR = 8.05 (2.59-25.05)], not having consulted with a mental health problem in the 6 months prior to admission [adjusted OR = 5.32 (1.84-15.34)], the lack of collaboration with treatment by the family [adjusted OR = 3.73 (1.33-10.42)] and suffering a personality disorder as the main diagnosis for admission [adjusted OR = 7.09 (1.26-39.98)], whereas the longer duration of the admission protects against the failure to attend the appointment after discharge [adjusted OR = 0.94 (0.90-0.99)]. CONCLUSIONS: While it is true that the results confirm the suspicion that the fact of being an immigrant hinders continuity of care in patients admitted to psychiatric hospitalization units in our community, this would not be the variable directly influencing the interruption of treatment, but rather a series of factors that are more likely to be associated with this group than with the native population. These variables are the ones that should alert us to the need for closer follow-up in the transfer of these patients from one mental health service to another.