Terry Rabinowitz

Outcome quality indicators are rarely used to evaluate mental health services because most jurisdictions lack clinical data systems to construct indicators in a meaningful way across mental health providers. As a result, important information about the effectiveness of health services remains unknown. This study examined the feasibility of developing mental health quality indicators (MHQIs) using the Resident Assessment Instrument - Mental Health (RAI-MH), a clinical assessment system mandated for use in Ontario, Canada as well as many other jurisdictions internationally.

Aims and objectives. To identify the prevalence of urinary incontinence in inpatient psychiatric settings and its relationship to length of stay. Background. Urinary incontinence is a common and disabling condition. Previous work has shown that urinary incontinence is not always considered to be important in inpatient psychiatry. Design. Retrospective analysis of provincial database for inpatient psychiatry. Method. The study included all psychiatric inpatients in Ontario assessed with the Resident Assessment Instrument Mental Health at both admission and discharge since 1 October 2005. We used sex-based analyses to examine the prevalence of urinary incontinence at admission and change over the inpatient stay. Logistic regression was used to determine the relationship between urinary incontinence and experiencing an above average length of stay in hospital. Results. The prevalence of urinary incontinence at admission was 5·6%; rates were higher among women and the profiles of afflicted men and women differed. Approximately 35% of psychiatric patients were no longer incontinent at the time of discharge, and new cases of incontinence were reported for 1·2% of patients. Both the presence of urinary incontinence at admission and development of urinary incontinence over the inpatient stay were related to increased likelihood of having a longer than average length of stay. These odds were significant for both sexes, but higher for women for the role of urinary incontinence at admission and higher for men for the role of developing urinary incontinence. Conclusion. Urinary incontinence was present among a non-trivial proportion of psychiatric inpatients and persisted for most throughout the inpatient stay. Presence of urinary incontinence was related to increased hospital stay. Relevance to clinical practice. Mental health service providers should identify urinary incontinence quickly and pay attention to it; incorporating treatment into the care plan early on in the inpatient stay may help to ensure a more rapid return to the community.

Psychiatric care for nursing home residents is difficult to obtain, especially in rural areas, and this deficiency may lead to significant morbidity or death. Providing this service by videoconference may be a helpful, cost-effective, and acceptable alternative to face-to-face treatment. We analyzed data for 278 telepsychiatry encounters for 106 nursing home residents to estimate potential cost and time savings associated with this modality compared to in-person care. A total of 843.5 hours (105.4 8-hour work days) of travel time was saved compared to in-person consultation for each of the 278 encounters if they had occurred separately. If four resident visits were possible for each trip, the time saved would decrease to 26.4 workdays. Travel distance saved was 43,000 miles; 10,750 miles if four visits per trip occurred. More than $3,700 would be spent on gasoline for 278 separate encounters; decreased to $925 for four visits per roundtrip. Personnel cost savings estimates ranged from $33,739 to $67,477. Physician costs associated with additional travel time ranged from $84,347 to $253,040 for 278 encounters, or from $21,087 to $63,260 for four encounters per visit. The telepsychiatry approach was enthusiastically accepted by virtually all residents, family members, and nursing home personnel, and led to successful patient management. Providing psychiatric care to rural nursing home residents by videoconference is cost effective and appears to be a medically acceptable alternative to face-to-face care. In addition, this approach will allow many nursing homes to provide essential care that would not otherwise be available.

Although telemental healthcare has been available for many years, is generally accepted as effective, and has steadily growing numbers of consumers and providers, more and better research in this area needs to be done in order to convince insurers, policymakers, and funding agencies that mental healthcare delivered from a distance is at least as good as that delivered face-to-face. Because there is a wide spectrum of potential mental health disorders that might be encountered, there are significant gaps in telemental health research that need to be addressed before payment for services or funding for large-scale studies of this application can be expected. This white paper will review the current state of telemental health research and will offer suggestions for future directions necessary for telemental research to take in order to firmly establish its effectiveness.

From a psychological perspective, denial is the process by which the mind defends itself against painful or threatening thoughts, feelings, perceptions, or information and may manifest in healthy or sick persons as well as in patients or those who care for them. For someone with a possible cancer diagnosis, there are several individual steps involved in the denial process, as the threatened meaning of one or more symptoms is sculpted into a more acceptable reality. Although most often felt to be a dysfunctional response, denial of illness is widespread and may serve an important adaptive or coping function, especially in a person facing the challenge of cancer. It may help a person cope with the various stages of their illness and treatment by allowing them time to process distressing information at a manageable rate. However, denial may also be dysfunctional, especially if it causes delay in seeking treatment for symptoms that present in the context of a true malignancy. Many clinicians misdiagnose denial when avoidance, disavowal, or another coping mechanism is invoked or when cognitive impairment or sensory deficits adversely affect perception. This article discusses denial in the context of cancer diagnosis, treatment, and prognosis and strategies for managing this common condition.

Background: The objective of this study was to examine the Minimum Data Set (MDS) and Geriatric Depression Scale (GDS) as measures of depression among nursing home residents. Methods: The data for this study were baseline, pre-intervention assessment data from a research study involving nine nursing homes and 704 residents in Massachusetts. Trained research nurses assessed residents using the MDS and the GDS 15-item version. Demographic, psychiatric, and cognitive data were obtained using the MDS. Level of depression was operationalized as: (1) a sum of the MDS Depression items; (2) the MDS Depression Rating Scale; (3) the 15-item GDS; and (4) the five-item GDS. We compared missing data, floor effects, means, internal consistency reliability, scale score correlation, and ability to identify residents with conspicuous depression (chart diagnosis or use of antidepressant) across cognitive impairment strata. Results: The GDS and MDS Depression scales were uncorrelated. Nevertheless, both MDS and GDS measures demonstrated adequate internal consistency reliability. The MDS suggested greater depression among those with cognitive impairment, whereas the GDS suggested a more severe depression among those with better cognitive functioning. The GDS was limited by missing data; the DRS by a larger floor effect. The DRS was more strongly correlated with conspicuous depression, but only among those with cognitive impairment. Conclusions: The MDS Depression items and GDS identify different elements of depression. This may be due to differences in the manifest symptom content and/or the self-report nature of the GDS versus the observer-rated MDS. Our findings suggest that the GDS and the MDS are not interchangeable measures of depression.

Delirium, a clinical syndrome characterized by the acute onset of confusion, indicates that there is a disruption in physiological equilibrium that may lead to death unless quick and appropriate action is taken. Despite its frequent appearance, delirium often goes unrecognized, undetected and untreated, leading to poorer outcomes including longer lengths of hospitalization, persistent deficits in cognitive function and the need for nursing home placement following acute treatment. Prevention and treatment strategies do not need to be complex or expensive, but require well co-ordinated interventions from multiple disciplines including nursing, psychiatry, neurology and primary care, as well as the co-operation and significant effort of family and friends who know the affected individual well.