War stress

Andrés Fontalba
 

By EFE

Stress is an adaptive reaction. When a change occurs, an effort is made to face the new challenge and, thus the organism itself adapts and can experience emotions, even pleasant ones, in the face of this process. In this case, stress is stimulating and motivating. Unfortunately, in situations as distressing as those caused by the current war, stress becomes so intense that it is seriously detrimental to health and one of its most severe consequences is post-traumatic stress disorder, a disease that arises as a delayed reaction to extremely threatening or catastrophic situations. This disorder is characterized by repeated episodes in which the traumatic event is relived in the form of dreams, flashbacks, or intrusive memories, often accompanied by emotional numbing and dissociation. It may involve detachment from others and avoidance of activities that are reminiscent of the event. Anxiety and depression may also be present, and substance abuse and suicidal thoughts are common.

The power of a call

Andrés Fontalba

In recent months, we have changed the way we behave as a society. And although many of the changes continue, some of them have already been consolidated and are here to stay. One of these changes has been the use of telephone calls for remote follow-up of patients who cannot attend the consultation. With a phone call, you can share specific information, such as the result of a diagnostic test, or attend to a specific request from a patient, but one of the most powerful effects that these calls have produced is that, if they are made in an empathetic way, they can relieve loneliness, anxiety, and depression.

The delirium epidemic in frail hospitalized patients

Marco Inzitari
 

 

Cardiff Delirium Study

Delirium, formerly known as acute confusion syndrome, affects around 20% of patients older than 70 years admitted to hospitals, such as reflected a recent study from Australia, a country of 24.6 million inhabitants with a population less aged than ours. This syndrome significantly increases the stays of hospitalized patients, for example, due to femur fracture (7.4 days on average), or aortic valve replacement (4.2 days), with avoidable extra costs.

Social agriculture

Josep Vidal-Alaball

In this section, we talked about the benefits for the community and public health of things as diverse as including health in all government policies, having community health agents, implementing telemedicine services, or using neighbourhood pharmacies or drug stores and public markets to carry out social and community actions. On the same topic, I would like to relate another initiative aimed at enhancing the community’s capacities such as agriculture and social farms. Social farming is the practice of participating in family farms as a form of social support service. In return, farmers have the opportunity to increase their income by developing the provision of social services, thereby further exploiting their agricultural skills. Participants can go to the farm one to five days a week. Each social farm is unique and offers its program of activities and opportunities. Similarly, participants confirm the activities they want to participate in.

Cyberchondria: improper use of the internet increases healthcare waste

Andrés Fontalba

The growth of the internet has made health information more accessible than ever. Increasingly more people are obtaining health information on the internet, which has probably become the most popular method of gaining knowledge in this field. The internet has brought great benefits and opportunities, such as offering instant answers about the nature, cause, prevention and treatment of any disease, as well as recommendations to maintain healthy habits, with more and more applications in the health field. We can connect to the internet with multiple devices (tablets, smartphones), in such a way that in Spain 93% of the population currently has an internet connection. However, people who are distressed or anxious about their health can access the internet for self-diagnosis and thus allegedly to calm down. This search for content on diseases aims to alleviate anxiety, but produces precisely the opposite phenomenon, increasing stress and worry. And this is even worse if the information obtained is inaccurate, incomplete and erroneous, as it often happens.

Emotional support to cancer patients regarding psycho-oncology

Andrés Fontalba
 

In my first post, “When it’s our turn?”, I addressed the need to promote shared clinical decision in mental disorders, from now on I will focus my interest in commenting on having emotional support in the diagnosis and cancer treatment.

The clinical dialogue between the doctor and the patient on the prognosis and care of cancer in advanced stages significantly influences how it tests both the benefits and the side effects of the treatment. It also affects how the time in which his life ends and how family members adapt to the patient's illness and death. It’s very important to detect personal differences regarding the need to receive information. Aside from a small percentage of patients who prefer not to be informed, most consider all the information they receive related to their prognosis and treatment to be precious. The exchange of information occurs in a sensitive relationship between the professional and the patient, in which they have to deal with highly emotionally charged communication and in which we must guarantee the information to be fully understandable. It’s clear that the patient, with great frequency, is anxious, among many other factors, because of the doubts about his prognosis, the family burden caused by the disease or the results of the tests. And these top levels of anxiety affect both the interpersonal relationship and the processing of information and the decisions made. It’s for all these reasons that research in psycho-oncology provides us with different tools to favour both the therapeutic link and the understanding of the patient's disease, as this review collects.

Recommendations of physical exercise and its relation to mental health

Andrés Fontalba

The Lalonde report marked a milestone in the 1970s, highlighting the importance of lifestyles in health, over the characteristics of the health system or the biology of the person and proposing a change of the model based on the “cure” for one that boosted "health promotion". Among the lifestyles, most related to health is physical exercise. Plato already warned us: "The lack of activity destroys the good condition of every human being, while movement and physical exercise preserve it."

Migration and mental health: the risk of exclusion

Andrés Fontalba

The human being has managed to colonize all habitable regions of our planet thanks to migrations. Due to cultural, economic, political or geographic movements, the population has moved en masse from prehistory to the present day, these movements being in some cases spontaneous and others forced. It is, therefore, a process of mobility intimately linked to us as a species.

Mental health: involuntary treatment and its consequences

Andrés Fontalba

"If Mr. McMurphy doesn’t want to take his oral medication [...], I'm sure we can administer it in another way."

The character of nurse Mildred Ratched in One Flew Over the Cuckoo's Nest presents a serious, strict, orderly and authoritative figure, with a lot of self confidence and all her actions are carried out with the firm conviction that they are aimed at the welfare of the patients in her care. If we asked her if she takes into account the patients' point of view she would answer, without a doubt, affirmatively. The clear example appears in a discussion in which she is asked to watch a game of baseball on television where she goes the extra mile in persuading all that everyone's vote is necessary for any change in the usual programming, thus she finally manage to impose her point of view. She would not hesitate at any time to use persuasion, interpersonal influence, or even threat to guarantee the administration of a prescribed treatment.

The potential of shared decisions

The “Essencial” project of the Quality Agency and Health Evaluations of Catalonia (AQuAS) held a day of reflection on the level of implementation of the recommendations to avoid low-value clinical practices hence those responsible for “Essencial” had the good idea to invite Glyn Elwyn, a researcher specialized in shared decisions at the Dartmouth Institute, to give the inaugural lecture in Barcelona.

According to Elwyn, as seen in the slide: "Shared decisions are a way of acting in which doctors and patients make decisions together, making use of the best available evidence on the probabilities of benefits and adverse effects of each option, relying on patients receiving the necessary support to obtain contrasted information about their preferences." Along this line, a systematic review of the Cochrane Collaboration shows that people who have had the opportunity to make clinical decisions with the support of specific materials (decision aids) admit feeling more prepared, more informed and have the clearest ideas about the value of their clinical processes, and they are probably more aware of the risks of each step they take.

10 priorities for integrating physical and mental health, according to The King's Fund

Andrés Fontalba

The current health care model that classifies patients by system or medical specialty categorises care to for any health problem. The causal attribution to diseases according to the psychic vs. organic dichotomy inhibits seeing the process of the pathologies in their totality and contributes to the problem of patients taking their illness from one service to another, with the risk of overacting in some cases or of non-holistic intervention method of integrated solutions in other complex cases.

Overdiagnosis in depression: there are doors better left closed

Andrés Fontalba

A young Cecilia, aged 13, in Sofia Coppola's brilliant film based on the homonymous novel, "The suicide virgins" advised:

-Obviously doctor, you were never a 13-year-old girl.

It’s obvious that depression in children and adolescents is an important cause of disability and generates great suffering for the person and his or her environment, requiring specific management adapted to the needs of that peculiar age. Based on the severity of this pathology, the availability of effective screening tools in the detection of depression, and a treatment that improves prognosis, the United States Preventive Task Force in 2009 recommended the screening for depression in all adolescents in a medical and integrated with mental health services setting, despite not having any previous trials that would justify this intervention.

Are we all mentally ill? On the subject of Allen Frances

Allen Frances, psychiatrist professor emeritus of Duke University (USA) led the working group that developed the DSM-4 (Diagnostic and Statistical Manual of Mental Disorders). I follow the activity of the author, always critical and always documented on Twitter (@AllenFrancesMD) and, unfamiliar with the framework of psychiatry, a question began to run through my mind. How could it be that someone who had led the fourth edition of the DSM, was now the most lucid voice against the excesses of modern psychiatry? If I wanted to know the answer, I had no choice but to read his latest book "Saving Normal. An insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma and the medicalization of ordinary life"

Beyond the reforms (on the subject of Franco Basaglia)

What can we do when reforms are in short supply? This is a question that many of us ask ourselves when rigidities and bureaucracies show us their sordid face. Without going any further, the integration of services and community work is the only way (I think there are no dissenters in this) to adequately care for complex chronic patients, but when it comes to the truth, it turns out that the levels of care, professionals’ abilities and the fragmentation of medical specialties are a drag on the progress of the necessary reforms.

I’ve pondered on this when I read that The Guardian had just published a book by John Foot, "The man who closed the asylum" that tells the life of Franco Basaglia, a psychiatrist with an exceptional entrepreneurial force. During the war, according to the author, Basaglia was imprisoned as an antifascist and this experience was key to the fact that when he was appointed director of an asylum in the early 1960s, he realized that the psychiatry practiced in that establishment was inspired by and took the shape of prisons.

Are we all mentally ill? About Allen Frances

Allen Frances, psychiatrist professor emeritus at Duke University (USA) led the working group that developed the DSM-4 (Diagnostic and Statistical Manual of Mental Disorders). I follow the author’s activity, always critical and always documented, on twitter (@AllenFrancesMD) and, unaware of the framework of psychiatry, a question started spinning in my head. How could it be that someone who had led the fourth edition of the DSM was now the most lucid voice against the excesses of modern psychiatry? If I wanted to know the answer, I had no choice, but to read his latest book: "Saving Normal: An Insider's Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life".

Mental health: services integration is the key

A systematic review accompanied by a meta-analysis shows that the model Collaborative Chronic Care Models (CCMs), designed by Edward Wagner for chronic patients, offers a robust framework for service integration and may improve health outcomes in psychiatric patients, both mentally and physically.

Let's look in the following table at the components that the authors have used to identify projects that were based on CCMs model:

Mental Health, the strongest transformation

The provision of mental health services have taken a dramatic shift in the last 40 years, which is why I think a blog like this, specialized in "Advances in clinical management," is bound to echo.

The mass closure of asylums

The critique of institutionalizing psychiatric patients in mental hospitals began in the late ‘60s, although the closure of beds was observed during the ‘80s, and especially ‘90s, as seen in the following graph:

According to a report by the London School of Economics and Political Science (Medeiros 2008), where the above graph came from, psychiatric deinstitutionalization has three main components:

• The transfer of patients from psychiatric hospitals to the community
• The involvement of general hospitals
• The deployment of alternative community services

The cited document reflects the vicissitudes that European countries came across when trying to address these policies, starting especially with the famous Italian Law 180 of 1978 which ordered the dismantling of psychiatric institutions. The document admits however, that despite the success of this policy, the difficulties in the operation of each of the three components mentioned above have been large.

Can unnecessary hospitalizations be avoided?

It is said that the best savings in health is in avoidable hospitalisation that doesn’t occur, especially since the use of a hospital bed is the most expensive health resource of all the health offers, but also because if one person, let’s imagine an elderly one with several chronic conditions, can avoid being admitted in hospital, his/her health will suffer less compromising situations. For this reason, all health systems are very active in trying to launch all kinds of measures to reduce the admission of chronic and frail patients.

Dr. Sara Purdy, family physician and Senior Consultant at the University of Bristol, published under the auspices of the King’s Fund, in late 2010, an analysis of what actions reduce the unnecessary hospital admissions and which ones do not. The work of Dr. Purdy is focused only on organisational actions such as home hospitalisation or case management, and, in contrast, does not include strictly clinical factors such as the impact of a new drug for asthma conditions.

See below what actions have been proven to reduce unnecessary hospitalisations (for the source of evidence, consult the King’s Fund paper):