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CUMULATIVE TRAUMAS AND RISK THRESHOLDS: 12-MONTH PTSD IN THE WORLD MENTAL HEALTH (WMH) SURVEYS
Background
Clinical research suggests that posttraumatic stress disorder (PTSD) patients exposed to multiple traumatic events (TEs) rather than a single TE have increased morbidity and dysfunction. Although epidemiological surveys in the United States and Europe also document high rates of multiple TE exposure, no population‐based cross‐national data have examined this issue.
Methods
Data were analyzed from 20 population surveys in the World Health Organization World Mental Health Survey Initiative (n = 51,295 aged 18+). The Composite International Diagnostic Interview (3.0) assessed 12‐month PTSD and other common DSM‐IV disorders. Respondents with 12‐month PTSD were assessed for single versus multiple TEs implicated in their symptoms. Associations were examined with age of onset (AOO), functional impairment, comorbidity, and PTSD symptom counts.
Results
19.8% of respondents with 12‐month PTSD reported that their symptoms were associated with multiple TEs. Cases who associated their PTSD with four or more TEs had greater functional impairment, an earlier AOO, longer duration, higher comorbidity with mood and anxiety disorders, elevated hyperarousal symptoms, higher proportional exposures to partner physical abuse and other types of physical assault, and lower proportional exposure to unexpected death of a loved one than cases with fewer associated TEs.
Conclusions
A risk threshold was observed in this large‐scale cross‐national database wherein cases who associated their PTSD with four or more TEs presented a more “complex” clinical picture with substantially greater functional impairment and greater morbidity than other cases of PTSD. PTSD cases associated with four or more TEs may merit specific and targeted intervention strategies.
Journal Article
Measuring positive mental health in Canada: construct validation of the Mental Health Continuum—Short Form
Positive mental health is increasingly recognized as an important focus for public health policies and programs. In Canada, the Mental Health Continuum-Short Form (MHC-SF) was identified as a promising measure to include on population surveys to measure positive mental health. It proposes to measure a three-factor model of positive mental health including emotional, social and psychological well-being. The purpose of this study was to examine whether the MHC-SF is an adequate measure of positive mental health for Canadian adults.
We conducted confirmatory factor analysis (CFA) using data from the 2012 Canadian Community Health Survey (CCHS)-Mental Health Component (CCHS-MH), and cross-validated the model using data from the CCHS 2011-2012 annual cycle. We examined criterion-related validity through correlations of MHC-SF subscale scores with positively and negatively associated concepts (e.g. life satisfaction and psychological distress, respectively).
We confirmed the validity of the three-factor model of emotional, social and psychological well-being through CFA on two independent samples, once four correlated errors between items on the social well-being scale were added. We observed significant correlations in the anticipated direction between emotional, psychological and social well-being scores and related concepts. Cronbach's alpha for both emotional and psychological well-being subscales was 0.82; for social well-being it was 0.77.
Our study suggests that the MHC-SF measures a three-factor model of positive mental health in the Canadian population. However, caution is warranted when using the social well-being scale, which did not function as well as the other factors, as evidenced by the need to add several correlated error terms to obtain adequate model fit, a higher level of missing data on these questions and weaker correlations with related constructs. Social well-being is important in a comprehensive measure of positive mental health, and further research is recommended.
Journal Article
Ethical conflict and moral distress in veterinary practice: A survey of North American veterinarians
Background
Concerns about ethical conflicts, moral distress, and burnout in veterinary practice are steadily increasing. Root causes of these problems have not been rigorously identified. Little research has been done to evaluate the existence of moral distress in North American veterinarians or to explore its impact on career sustainability and poor well‐being.
Hypothesis/Objectives
Ethical conflict and resultant moral distress are common occurrences in contemporary veterinary practice and negatively impact daily practice life, but may not be identified or labeled by veterinarians as such.
Animals
No animals were used in this study.
Methods
Mixed methods sequential explanatory design; confidential and anonymous on‐line sampling of 889 veterinarians in North America.
Results
A majority of respondents reported feeling conflict over what care is appropriate to provide. Over 70% of respondents felt that the obstacles they faced that prevented them from providing appropriate care caused them or their staff moderate to severe distress. Seventy‐nine percent of participants report being asked to provide care that they consider futile. More than 70% of participants reported no training in conflict resolution or self‐care.
Conclusions and Clinical Importance
Veterinarians report widespread ethical conflict and moral distress across many practice types and demographics. Most veterinarians have little to no training on how to decrease the impact of these problems. Ethical conflict and resulting moral distress may be an important source of stress and poor well‐being that is not widely recognized or well defined. Well‐researched and effective tools used to decrease moral distress in human healthcare could be adapted to ameliorate this problem.
Journal Article
Barriers to Mental Health Treatment in the Saudi National Mental Health Survey
Objectives: To examine barriers to initiation and continuation of treatment among individuals with common mental disorders in the Saudi National Mental Health Survey (SNMHS). Methods: The SNMHS is a community-based epidemiological survey in a nationally representative household sample of respondents aged 15–65 in the Kingdom of Saudi Arabia. The World Health Organization Composite International Diagnostic Interview (CIDI) 3.0 was used. Predictors of barriers to treatment were analyzed with multivariable logistic regression. Results: Among participants with a 12-month DSM-IV/CIDI disorder (n = 711), 86.1% reported no service use. Of those (n = 597), 50.7% did not think they needed any help (categorized as “low perceived need”) and 49.3% did perceive need. Of those who perceived need (n = 309), the majority (98.9%) reported attitudinal barriers to initiation. In contrast, 10.3% of those with a perceived need reported structural barriers. Respondents who were previously married or indicated below-average income were more likely to believe they needed help. Conclusions: Among people with a diagnosed mental disorder, low perceived need and attitudinal barriers are the primary barriers to mental health treatment in the KSA. The results suggest that addressing poor mental health literacy may be essential factor in reducing the unmet need for mental health treatment in the KSA.
Journal Article
Factors associated with satisfaction and perceived helpfulness of mental healthcare: a World Mental Health Surveys report
Background
Mental health service providers are increasingly interested in patient perspectives. We examined rates and predictors of patient-reported satisfaction and perceived helpfulness in a cross-national general population survey of adults with 12-month DSM-IV disorders who saw a provider for help with their mental health.
Methods
Data were obtained from epidemiological surveys in the World Mental Health Survey Initiative. Respondents were asked about satisfaction with treatments received from up to 11 different types of providers (very satisfied, satisfied, neither satisfied nor dissatisfied, somewhat dissatisfied, very dissatisfied) and helpfulness of the provider (a lot, some, a little, not at all). We modelled predictors of satisfaction and helpfulness using a dataset of patient-provider observations (
n
= 5,248).
Results
Most treatment was provided by general medical providers (37.4%), psychiatrists (18.4%) and psychologists (12.7%). Most patients were satisfied or very satisfied (65.9-87.5%, across provider) and helped a lot or some (64.4-90.3%). Spiritual advisors and healers were most often rated satisfactory and helpful. Social workers in human services settings were rated lowest on both dimensions. Patients also reported comparatively low satisfaction with general medical doctors and psychiatrists/psychologists and found general medical doctors less helpful than other providers. Men and students reported lower levels of satisfaction than women and nonstudents. Respondents with high education reported higher satisfaction and helpfulness than those with lower education. Type of mental disorder was unrelated to satisfaction but in some cases (depression, bipolar spectrum disorder, social phobia) was associated with low perceived helpfulness. Insurance was unrelated to either satisfaction or perceived helpfulness but in some cases was associated with elevated perceived helpfulness for a given level of satisfaction.
Conclusions
Satisfaction with and perceived helpfulness of treatment varied as a function of type of provider, service setting, mental status, and socio-demographic variables. Invariably, caution is needed in combining data from multiple countries where there are cultural and service delivery variations. Even so, our findings underscore the utility of patient perspectives in treatment evaluation and may also be relevant in efforts to match patients to treatments.
Journal Article
Acute mental health responses during the COVID-19 pandemic in Australia
The acute and long-term mental health impacts of the COVID-19 pandemic are unknown. The current study examined the acute mental health responses to the COVID-19 pandemic in 5070 adult participants in Australia, using an online survey administered during the peak of the outbreak in Australia (27th March to 7th April 2020). Self-report questionnaires examined COVID-19 fears and behavioural responses to COVID-19, as well as the severity of psychological distress (depression, anxiety and stress), health anxiety, contamination fears, alcohol use, and physical activity. 78% of respondents reported that their mental health had worsened since the outbreak, one quarter (25.9%) were very or extremely worried about contracting COVID-19, and half (52.7%) were worried about family and friends contracting COVID-19. Uncertainty, loneliness and financial worries (50%) were common. Rates of elevated psychological distress were higher than expected, with 62%, 50%, and 64% of respondents reporting elevated depression, anxiety and stress levels respectively, and one in four reporting elevated health anxiety in the past week. Participants with self-reported history of a mental health diagnosis had significantly higher distress, health anxiety, and COVID-19 fears than those without a prior mental health diagnosis. Demographic (e.g., non-binary or different gender identity; Aboriginal and Torres Strait Islander status), occupational (e.g., being a carer or stay at home parent), and psychological (e.g., perceived risk of contracting COVID-19) factors were associated with distress. Results revealed that precautionary behaviours (e.g., washing hands, using hand sanitiser, avoiding social events) were common, although in contrast to previous research, higher engagement in hygiene behaviours was associated with higher stress and anxiety levels. These results highlight the serious acute impact of COVID-19 on the mental health of respondents, and the need for proactive, accessible digital mental health services to address these mental health needs, particularly for those most vulnerable, including people with prior history of mental health problems. Longitudinal research is needed to explore long-term predictors of poor mental health from the COVID-19 pandemic.
Journal Article
Towards measuring effective coverage: critical bottlenecks in quality- and user-adjusted coverage for major depressive disorder in São Paulo metropolitan area, Brazil
Background
Major depressive disorder (MDD) contributes to a significant proportion of disease burden, disability, economic losses, and impact on need of treatment and health care in Brazil, but systematic information about its treatment coverage is scarce. This paper aims to estimate the gap in treatment coverage for MDD and identify key bottlenecks in obtaining adequate treatment among adult residents in the São Paulo Metropolitan area, Brazil.
Methods
A representative face-to-face household survey was conducted among 2942 respondents aged 18+ years to assess 12-month MDD, characteristics of 12-month treatment received, and bottlenecks to deliver care through the World Mental Health Composite International Diagnostic Interview.
Results
Among those with MDD (n = 491), 164 (33.3% [SE, 1.9]) were seen in health services, with an overall 66.7% treatment gap, and only 25.2% [SE, 4.2] received effective treatment coverage, which represents 8.5% of those in need, with a 91.5% gap in adequate care (66.4% due to lack of utilization and 25.1% due to inadequate quality and adherence). Critical service bottlenecks identified were: use of psychotropic medication (12.2 percentage points drop), use of antidepressants (6.5), adequate medication control (6.8), receiving psychotherapy (19.8).
Conclusions
This is the first study demonstrating the huge treatment gaps for MDD in Brazil, considering not only overall coverage, but also identifying specific quality- and user-adjusted bottlenecks in delivering pharmacological and psychotherapeutic care. These results call for urgent combined actions focused in reducing effective treatment gaps within services utilization, as well as in reducing gaps in availability and accessibility of services, and acceptability of care for those in need.
Journal Article
Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS): performance in a clinical sample in relation to PHQ-9 and GAD-7
Purpose
This study assesses the construct validity and sensitivity to change of the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) as an outcome measure in the treatment of common mental disorders (CMD) in primary care settings.
Methods
127 participants attending up to 5 sessions of therapy for CMD in primary care self-rated the SWEMWBS, the Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder (GAD-7) scales. SWEMWBS’s construct validity and sensitivity to change was evaluated against the PHQ-9 and GAD-7 across multiple time points in two ways: correlation coefficients were calculated between the measures at each time point; and sensitivity to change over time was assessed using repeated measures ANOVA.
Results
Score distributions on SWEMWBS, but not PHQ-9 and GAD-7, met criteria for normality. At baseline, 92.9% (118/127) of participants scored above clinical threshold on either PHQ-9 or GAD-7. Correlations between SWEMWBS and PHQ-9 scores were calculated at each respective time point and ranged from 0.601 to 0.793. Correlations between SWEMWBS and GAD-7 scores were calculated similarly and ranged from 0.630 to 0.743. Significant improvements were seen on all three scales over time. Changes in PHQ-9 and GAD-7 were curvilinear with greatest improvement between sessions 1 and 2. Change in SWEMWBS was linear over the five sessions.
Conclusions
This exploratory study suggests that SWEMWBS is acceptable as a CMD outcome measure in primary care settings, both in terms of construct validity and sensitivity to change. Given patient preference for positively over negatively framed measures and statistical advantages of measures which are normally distributed, SWEMWBS could be used as an alternative to PHQ-9 and GAD-7 in monitoring and evaluating CMD treatment.
Journal Article
Multidimensional assessment of anxiety through the State-Trait Inventory for Cognitive and Somatic Anxiety
The assessment of mal-adaptive anxiety is crucial, considering the associated personal, economic, and societal burden. The State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA) is a self-report instrument developed to provide multidimensional anxiety assessment in four dimensions: trait-cognitive, trait-somatic, state-cognitive and state-somatic. This research aimed to extend STICSA's psychometric studies through the assessment of its dimensionality, reliability, measurement invariance and nomological validity in the Portuguese population. Additionally, the predictive validity of STICSA-Trait was also evaluated, through the analysis of the relationship between self-reported trait anxiety and both the subjective and the psychophysiological response across distinct emotional situations. Similarly to previous studies, results supported both a four-factor and two separated bi-factor structures. Measurement invariance across sex groups was also supported, and good nomological validity was observed. Moreover, STICSA trait-cognitive dimension was associated with differences in self-reported arousal between groups of high/low anxiety, whereas STICSA trait-somatic dimension was related to differences in both the subjective and psychophysiological response. Together, these results support STICSA as a useful instrument for a broader anxiety assessment, crucial for an informed diagnosis and practice.
Journal Article