From the biomedical to the biopsychosocial model: the implementation of a stepped and collaborative care model in Swiss general hospitals

Background and objectives International and national initiatives like the Sustainable Development Goals and the National Strategy on the Prevention of non-communicable diseases aim to reduce the burden of mental health. Early detection of mental health conditions is thus, a major priority of public health. Stepped and Collaborative Care Models (SCCMs) offer an opportunity to early detect and appropriately treat mental health conditions in vulnerable populations, fostering integrated care. This thesis focuses on a SCCM that aims to implement a routine psychosocial distress assessment and offers appropriate treatment to distressed hospital patients. However, integration of mental health services into somatic settings was seen to be challenging in other settings, e.g., primary care. Evidence for patients with mental–somatic multimorbidities in hospital settings is scarce. Thus, the main objectives of this thesis were to assess the integration of mental health services and to assess implementation of a SCCM into general hospitals in Basel-Stadt, Switzerland (Objectives 1 and 2). The unforeseen coronavirus disease 2019 (COVID-19) pandemic additionally triggered further research questions. We investigated the association between COVID-19 restrictions and mental health of non-COVID-19 hospital patients (Objective 3). Additionally, we explored an alternative method to monitor mental health consequences of the COVID-19 pandemic, the use of Big Data (Objective 4). Methods This thesis focuses on a SCCM implemented in four hospitals, three of which were included in the studies presented here: the University Hospital Basel, the University Department of Geriatric Medicine FELIX PLATTER, and the Bethesda Hospital. Including three hospitals differing in structure and focus allowed us to get a broader view of possible facilitators and barriers to the integration of mental health and the implementation of the SCCM. We conducted qualitative interviews with physicians and nurses operating the SCCM at the hospital before (N = 18) and after (N = 18) the implementation of the SCCM. Additionally, we used quantitative data of 873 patients on COVID-19 distress, mental health consequences, and social support collected during periods with different COVID-19 restriction levels, using multiple regression models. The last objective was presented as an opinion paper, highlighting advantages and disadvantages of Big Data based on literature. Results Before the SCCM was implemented in hospital settings in Basel, Switzerland, healthcare professionals perceived mental–somatic multimorbidities to be relevant due to their high perceived frequency (Objective 1). Mental health dimensions had, however, a low priority due to suboptimal environments, suboptimal interprofessional collaboration, existing stigma among healthcare professionals and patients, lack of mental health knowledge, and the strong emphasis on somatic diseases. Particularly physicians reported the low priority of mental health, also due to historical views focusing on biomedical aspects and time constraints. Afterwards, we assessed facilitators and barriers of implementing the first step of the SCCM (Objective 2). The first step of the SCCM is a psychosocial distress assessment of patients through healthcare professionals. Healthcare professionals highlighted the importance of integrating the assessment into preexisting hospital workflows and IT systems. Being able to adapt certain workflows to the needs of the different wards and hospitals was key to adherence and thus, to the sustainability of the SCCM. Still, structural and social barriers to the implementation of the psychosocial distress assessment were emphasized. Hospitals are characterized by a strong focus on somatic diseases with tight working routines. Adding additional tasks like the mental health assessment constituted a challenge. Besides the strong emphasis on somatic diseases and the time constraints, lack of knowledge, awareness, and familiarity and subjectivity of the mental health assessment were impeding the efforts towards integrated care. This, partially, is also caused by the high turnover rate of physicians. The implementation of the SCCM described herewas accompanied by the COVID-19 pandemic. The Swiss government set different COVID-19 restrictions depending on COVID-19 case numbers, hospitalizations, and deaths. Thus, we investigated the association between the COVID-19 restrictions and the COVID-19-related distress, mental health consequences, and social support (Objective 3). Multiple regression analyses of non-COVID-19 patients during different levels of COVID-19 restrictions indicated that hospital patients were more distressed related to leisure time and loneliness when stronger COVID-19 restrictions were in place. Surprisingly, this did not result in increased mental health consequences or changes in social support. Another approach to monitor mental health of the general population or subgroups like hospital patients could be Big Data, such as social media or routine hospital data (Objective 4). These may help to tailor appropriate interventions to populations at risk of mental health consequences. Applying Big Data should always consider ethical and legal concerns to protect privacy and data. Particularly, transparency regarding data analysis may prevent these concerns. Conclusion This thesis adds evidence to the integration of mental health and implementation of a SCCM to hospital settings in Switzerland. Structural and social challenges, such as missing knowledge and awareness, strong emphasis on somatic diseases, time constraints, suboptimal environment, suboptimal interprofessional collaboration, and stigma were emphasized by healthcare professionals. To overcome these challenges, hospitals and policy makers need to think about changes in the healthcare system. For instance, task shifts, new roles, and new processes are needed in the hospital setting to better achieve integrated care. Hospitals are built to care for patients in acute medical situations. Patients with mental–somatic multimorbidities, however, need continuous and long-term care. Certain patient groups (e.g., cancer patients, transplantation patients) receive this care within hospitals. Other patient groups rely on treatment outside hospital. Strong networks between services within and outside hospitals are, thus, essential to guarantee continuity of care. Overall, the current healthcare system with its strong biomedical focus needs to adapt to the increasing number of patients with chronic diseases, including mental–somatic multimorbidities. This system change could be achieved through learning health systems, where interprofessional and interdisciplinary work is a high priority. Continuously collected data supports the adaptation of the healthcare system to the current needs and evidence base. Thus, the change from the biomedical to the biopsychosocial model may be strengthened

Public health communication: Attitudes, experiences, and lessons learned from users of a COVID-19 digital triage tool for children

Background: The pandemic has made public health communication even more daunting because acceptance and implementation of official guidelines and recommendations hinge on this. The situation becomes even more precarious when children are involved. Our child-specific COVID-19 online forward triage tool (OFTT) revealed some of the public health communication challenges. We aimed to explore attitudes, experiences, and challenges faced by OFTT users and their families, in regard to public health recommendations. Methods: We selected key informants (n = 20) from a population of parents, teachers, guardians, as well as doctors who had used the child-specific COVID-19 OFTT and had consented to a further study. Videos rather than face-face interviews were held. Convenience and quota sampling were performed to include a variety of key informants. Interviews were recorded, transcribed verbatim, and analyzed for themes. Results: Several themes emerged, namely; (1) definition and expectations of high-risk persons, (2) quarantine instructions and challenges, (3) blurred division of responsibility between authorities and parents, (4) a novel condition and the evolution of knowledge, (5) definition and implications of socioeconomic status, (6) new normal and societal divisions, and (7) the interconnectedness of these factors-systems thinking. Conclusion: As the virus is evolving and circumstances are changing rapidly, the communication of public health to the different interest groups becomes, both an art and science, even more so when using a new technological communication channel: an OFTT. A myriad of interconnected factors seems to influence attitudes toward public health recommendations, which calls for systems thinking in public health communication

Facilitators and barriers of routine psychosocial distress assessment within a stepped and collaborative care model in a Swiss hospital setting

BACKGROUND Stepped and Collaborative Care Models (SCCMs) have shown potential for improving mental health care. Most SCCMs have been used in primary care settings. At the core of such models are initial psychosocial distress assessments commonly in form of patient screening. We aimed to assess the feasibility of such assessments in a general hospital setting in Switzerland. METHODS We conducted and analyzed eighteen semi-structured interviews with nurses and physicians involved in a recent introduction of a SCCM model in a hospital setting, as part of the SomPsyNet project in Basel-Stadt. Following an implementation research approach, we used the Tailored Implementation for Chronic Diseases (TICD) framework for analysis. The TICD distinguishes seven domains: guideline factors, individual healthcare professional factors, patient factors, professional interactions, incentives and resources, capacity for organizational change, and social, political, and legal factors. Domains were split into themes and subthemes, which were used for line-by-line coding. RESULTS Nurses and physicians reported factors belonging to all seven TICD domains. An appropriate integration of the psychosocial distress assessment into preexisting hospital processes and information technology systems was the most important facilitator. Subjectivity of the assessment, lack of awareness about the assessment, and time constraints, particularly among physicians, were factors undermining and limiting the implementation of the psychosocial distress assessment. CONCLUSIONS Awareness raising through regular training of new employees, feedback on performance and patient benefits, and working with champions and opinion leaders can likely support a successful implementation of routine psychosocial distress assessments. Additionally, aligning psychosocial distress assessments with workflows is essential to assure the sustainability of the procedure in a working context with commonly limited time

Association of Different Restriction Levels With COVID-19-Related Distress and Mental Health in Somatic Inpatients: A Secondary Analysis of Swiss General Hospital Data

BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic and related countermeasures hinder health care access and affect mental wellbeing of non-COVID-19 patients. There is lack of evidence on distress and mental health of patients hospitalized due to other reasons than COVID-19-a vulnerable population group in two ways: First, given their risk for physical diseases, they are at increased risk for severe courses and death related to COVID-19. Second, they may struggle particularly with COVID-19 restrictions due to their dependence on social support. Therefore, we investigated the association of intensity of COVID-19 restrictions with levels of COVID-19-related distress, mental health (depression, anxiety, somatic symptom disorder, and mental quality of life), and perceived social support among Swiss general hospital non-COVID-19 inpatients. METHODS We analyzed distress of 873 hospital inpatients not admitted for COVID-19, recruited from internal medicine, gynecology, rheumatology, rehabilitation, acute geriatrics, and geriatric rehabilitation wards of three hospitals. We assessed distress due to the COVID-19 pandemic, and four indicators of mental health: depressive and anxiety symptom severity, psychological distress associated with somatic symptoms, and the mental component of health-related quality of life; additionally, we assessed social support. The data collection period was divided into modest (June 9 to October 18, 2020) and strong (October 19, 2020, to April 17, 2021) COVID-19 restrictions, based on the Oxford Stringency Index for Switzerland. RESULTS An additional 13% (95%-Confidence Interval 4-21%) and 9% (1-16%) of hospital inpatients reported distress related to leisure time and loneliness, respectively, during strong COVID-19 restrictions compared to times of modest restrictions. There was no evidence for changes in mental health or social support. CONCLUSIONS Focusing on the vulnerable population of general hospital inpatients not admitted for COVID-19, our results suggest that tightening of COVID-19 restrictions in October 2020 was associated with increased COVID-19-related distress regarding leisure time and loneliness, with no evidence for a related decrease in mental health. If this association was causal, safe measures to increase social interaction (e.g., virtual encounters and outdoor activities) are highly warranted. TRIAL REGISTRATION www.ClinicalTrials.gov, identifier: NCT04269005

Infections sexuellement transmissibles à Chlamydia trachomatis

Depuis quelques années, le diagnostic d’infection sexuellement transmissible à Chlamydia trachomatis est de plus en plus souvent posé. Les infections à Chlamydia, qui touchent principalement les jeunes femmes, sont redoutées en raison du risque d’infection ascendante (maladie inflammatoire pelvienne) et des complications potentielles sévères, telles que grossesse extra-utérine et stérilité. Même si ces troubles sont beaucoup plus rares que ce que l’on pensait, la prise en charge des personnes atteintes doit être améliorée

Genomic investigations of unexplained acute hepatitis in children

Since its first identification in Scotland, over 1,000 cases of unexplained paediatric hepatitis in children have been reported worldwide, including 278 cases in the UK1. Here we report an investigation of 38 cases, 66 age-matched immunocompetent controls and 21 immunocompromised comparator participants, using a combination of genomic, transcriptomic, proteomic and immunohistochemical methods. We detected high levels of adeno-associated virus 2 (AAV2) DNA in the liver, blood, plasma or stool from 27 of 28 cases. We found low levels of adenovirus (HAdV) and human herpesvirus 6B (HHV-6B) in 23 of 31 and 16 of 23, respectively, of the cases tested. By contrast, AAV2 was infrequently detected and at low titre in the blood or the liver from control children with HAdV, even when profoundly immunosuppressed. AAV2, HAdV and HHV-6 phylogeny excluded the emergence of novel strains in cases. Histological analyses of explanted livers showed enrichment for T cells and B lineage cells. Proteomic comparison of liver tissue from cases and healthy controls identified increased expression of HLA class 2, immunoglobulin variable regions and complement proteins. HAdV and AAV2 proteins were not detected in the livers. Instead, we identified AAV2 DNA complexes reflecting both HAdV-mediated and HHV-6B-mediated replication. We hypothesize that high levels of abnormal AAV2 replication products aided by HAdV and, in severe cases, HHV-6B may have triggered immune-mediated hepatic disease in genetically and immunologically predisposed children

A qualitative study to investigate Swiss hospital personnel's perceived importance of and experiences with patient's mental-somatic multimorbidities

BACKGROUND Mental-somatic multimorbidity in general hospital settings is associated with long hospital stays, frequent rehospitalization, and a deterioration of disease course, thus, highlighting the need for treating hospital patients more holistically. However, there are several challenges to overcome to address mental health conditions in these settings. This study investigated hospital personnel's perceived importance of and experiences with mental-somatic multimorbidities of patients in hospital settings in Basel, Switzerland, with special consideration of the differences between physicians and nurses. METHODS Eighteen semi-structured interviews were conducted with nurses (n = 10) and physicians (n = 8) in different hospitals located in Basel, Switzerland. An inductive approach of the framework analysis was used to develop the themes. RESULTS Four themes emerged from the data analysis: 1) the relevance of mental-somatic multimorbidity within general hospitals, 2) health professionals managing their emotions towards mental health, 3) knowledge and competencies in treating patients with mental-somatic multimorbidity, and 4) interprofessional collaboration for handling mental-somatic multimorbidity in hospital settings.The mental-somatic multimorbidities in general hospital patients was found to be relevant among all hospital professionals, although the priority of mental health was higher for nurses than for physicians. This might have resulted from different working environments or in efficient interprofessional collaboration in general hospitals. Physicians and nurses both highlighted the difficulties of dealing with stigma, a lack of knowledge of mental disorders, the emphasis place on treating somatic disorders, and competing priorities and work availability, which all hindered the adequate handling of mental-somatic multimorbidity in general hospitals. CONCLUSION To support health professionals to integrate mental health into their work, proper environments within general hospitals are needed, such as private rooms in which to communicate with patients. In addition, changes in curriculums and continuing training are needed to improve the understanding of mental-somatic multimorbidities and reduce negative stereotypes. Similarly, interprofessional collaboration between health professionals needs to be strengthened to adequately identify and treat mentally multimorbid patients. A stronger focus should be placed on physicians to improve their competencies in considering patient mental health in their daily somatic treatment care

Facilitators and barriers of routine psychosocial distress assessment within a stepped and collaborative care model in a Swiss hospital setting.

BackgroundStepped and Collaborative Care Models (SCCMs) have shown potential for improving mental health care. Most SCCMs have been used in primary care settings. At the core of such models are initial psychosocial distress assessments commonly in form of patient screening. We aimed to assess the feasibility of such assessments in a general hospital setting in Switzerland.MethodsWe conducted and analyzed eighteen semi-structured interviews with nurses and physicians involved in a recent introduction of a SCCM model in a hospital setting, as part of the SomPsyNet project in Basel-Stadt. Following an implementation research approach, we used the Tailored Implementation for Chronic Diseases (TICD) framework for analysis. The TICD distinguishes seven domains: guideline factors, individual healthcare professional factors, patient factors, professional interactions, incentives and resources, capacity for organizational change, and social, political, and legal factors. Domains were split into themes and subthemes, which were used for line-by-line coding.ResultsNurses and physicians reported factors belonging to all seven TICD domains. An appropriate integration of the psychosocial distress assessment into preexisting hospital processes and information technology systems was the most important facilitator. Subjectivity of the assessment, lack of awareness about the assessment, and time constraints, particularly among physicians, were factors undermining and limiting the implementation of the psychosocial distress assessment.ConclusionsAwareness raising through regular training of new employees, feedback on performance and patient benefits, and working with champions and opinion leaders can likely support a successful implementation of routine psychosocial distress assessments. Additionally, aligning psychosocial distress assessments with workflows is essential to assure the sustainability of the procedure in a working context with commonly limited time

Can Big Data be used to monitor the mental health consequences of COVID-19?

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