Organization of services and pattern of psychiatric care in Nicaragua: result of a survey in 1986

Organization of services and patterns of psychiatric care were studied in Nicaragua in 1986, 7 years after the substantial changes in health policy launched after the revolution. The overall re-organization of the system is indicated by the progressive abandoning of the mental hospital as the center of psychiatric care and the creation of 15 community-based mental health centers now functioning throughout the country. Quality of care judged through analysis of a consecutive sample of 342 patients seen by services over a month confirmed the positive orientation of the system which seemed able to deliver good care following the new perspective of "de-institutionalization". Some problems emerged to a large extent common to psychiatric care in industrialized countries looking at psychotropic drug use and at the relationship between primary health care and the psychiatric system especially when care delivered in urban and rural areas was compared.     

Clinic-Level Process of Care for Depression in Primary Care Settings

Multi-component models for improving depression care target primary care (PC) clinics, yet few studies document usual clinic-level care. This case comparison assessed usual processes for depression management at 10 PC clinics. Although general similarities existed across sites, clinics varied on specific processes, barriers, and adherence to practice guidelines. Screening for depression conformed to guidelines. Processes for assessment, diagnosis, treatment, and follow-up varied to different degrees in different clinics. This individuality of usual care should be defined prior to quality improvement interventions, and may provide insights for introducing or tailoring changes, as well as improving interpretation of evaluation results. Presentation  This work has been presented as a poster of the same title at the Annual Meeting of Academy Health in Orlando, FL, June 2007.     

Mental health care in Germany

Germany turned towards community-based mental health care in the mid seventies, during a general climate of social and political reform. The continuing deinstitutionalisation process and the implementation of community mental health services was considerably affected by the reunification of East and West Germany in 1990, which required dramatic changes in the structure and quality of the mental health care system of the former German Democratic Republic (GDR). Overall, German mental health care is organised as a subsidiary system, where planning and regulating mental health care is the responsibility of the 16 federal states. So German mental health care provision is spread among many sectors and characterised by considerable regional differences. A key characteristic is the particularly wide gap between inpatient and outpatient services, which are funded separately and staffed by different teams. In 2003 the total number of psychiatric beds was a mere two thirds of the overall bed capacity in 1991, the first year as a re-unified Germany, when psychiatric beds in East and West Germany totalled 80,275. From 1970 onwards the number of psychiatric beds was cut by roughly half. So the momentum of the reform has been strong enough to assimilate the completely different mental health care system of the former German Democratic Republic and, in the course of a decade, to re-structure mental health services for an additional 17–18 million new inhabitants. In an ongoing struggle to adapt to changing administrative set-ups, legal frameworks, and financial constraints, psychiatry in Germany in currently facing specific problems and is seriously challenged to defend to considerable achievements of the past. A major obstacle to achieving this aim lies in the fragmented system of mental health care provision and mental health care funding.     

Overview Of Publicly Funded Managed Behavioral Health Care

Using MEDLINE and other Internet sources, the authors perform a systematic review of published literature. A total of 109 articles and reports are identified and reviewed that address the development, implementation, outcomes, and trends related to Managed behavioral health care (MBHC). MBHC remains a work in progress. States have implemented their MBHC programs in a number of ways, making interstate comparisons challenging. While managed behavioral health care can lower costs and increase access, ongoing concerns about MBHC include potential incentives to under-treat those with more severe conditions due to the nature of risk-based contracting, the tendency to focus on acute care, difficulties assuring quality and outcomes consistently across regions, and a potential cost-shift to other public agencies or systems. Success factors for MBHC programs appear to include stakeholder involvement in program and policy development, effective contract development and management, and rate adequacy.Mardi Coleman, B.A., is a Research Associate at the UMass Center for Health Policy and Research. William Schnapp, Ph.D., is a Professor at the University of Texas Medical School at Houston. Debra Hurwitz, M.B.A., B.S.N., R.N., is the Director, Sabine Hedberg, M.A., M.P.A., is a Project Director, Linda Cabral, M.M., is a Project Director, and Aniko Laszlo, M.A., M.B.A., is a Research Associate, all at the UMass Center for Health Policy and Research. Jay Himmelstein, M.D., M.P.H., is a Professor of Family Medicine and Community Health.Material for this article was developed in part to support a comprehensive evaluation of the MassHealth Primary Care Clinician Plan behavioral health carve-out, conducted by the University of Massachusetts Center for Health Policy and Research at the request of Phyllis Peters, M.B.A., Deputy Assistant Secretary for the MassHealth Office of Acute and Ambulatory Care.Address for correspondence: Mardi Coleman, B.A., UMass Center for Health Policy and Research, 222 Maple Avenue, Shrewsbury, MA 01545. E-mail: mardia.coleman@umassmed.edu.     

Building mental health promotion capacity in health care: results from Phase I of a workforce development project

The development of mental-health-promoting health care systems is dependent on having a skilled and informed workforce to effectively integrate mental health promotion (MHP) into programme and service delivery. This paper describes Phase I (September 2009-July 2010) of Health Compass, an innovative, multi-phased project that aims to transform health care practice and shift organizational culture by enhancing the capacity of health care providers to further promote patient, client and family mental well-being. Phase I of Health Compass examined the current state of MHP within British Columbia's Provincial Health Service Authority health care services. The findings, based on group discussions and key informant interviews, examined health care providers' current understanding and knowledge of MHP; identified existing strategies, facilitators and barriers that help or hinder the incorporation of MHP into health care practice and services; and identified preferred learning modalities for development and piloting of future MHP resources in Phases II and III.     

Telepsychiatry and e-Mental Health Services: Potential for Improving Access to Mental Health Care

Reforming mental health care is a focus of many ongoing initiatives in the United States, both at the national and state levels. Access to adequate mental health care services is one of the identified problems. Telepsychiatry and e-mental health services could improve access to mental health care in rural, remote and underserved areas. The authors discuss the required technology, common applications and barriers associated with the implementation of telepsychiatry and e-mental health services.     

Does Consideration of Medicare Use Affect VA Evaluations of Treatment for New Episodes of Depression?

This report evaluates whether consideration of out-of-system use affects Veterans Affairs (VA) health system assessments of depression treatment. We measured effective medication management and optimal practitioner contacts among veterans whose VA data indicated a new episode of depression. Among 3,567 VA patients who were Medicare age-eligible, VA data indicated that 69% received recommended antidepressant coverage and 9% received recommended practitioner contacts. After including Medicare data, 295 patients (8%) no longer met inclusion criteria. Among the remainder, 3% received Medicare depression treatment and 0.5% were re-classified as having recommended contacts. Medicare use does not substantially supplement VA depression treatment. Presented at the VA Annual Health Service Research and Development Meeting (February 2007). This study was approved by our Institutional Review Board.     

Innovations in Practice: Child and adolescent psychiatrists and primary care – innovative models of consultation in the United States

Background: There is a severe shortage of child and adolescent psychiatrists (CAPs) in the United States, an increasingly recognized high prevalence of mental disorders in young people, and widely supported goals to provide more mental health services in the primary care setting. Method: A number of innovative, state‐wide or more local, publically funded programs have been developed in the United States over the last several years to respond to these challenges and to provide CAP consultation to primary care physicians (PCPs) who wish to address the mental health disorders of their patients in the primary care setting. Results: A number of these programs and their approaches to consultation are described. An example of a clinical scenario that might be addressed using this model of CAP/PCP collaboration is offered. Conclusions: An innovative model of consultation to PCPs from CAPs appears able to facilitate the treatment of many young people with mental health disorders in the primary care setting.     

Training primary care medical officers in mental health care: an evaluation using a multiple-choice questionnaire

This report aimed to evaluate the mental health knowledge of primary care medical officers following short-term training in mental health care using a multiple-choice questionnaire. Seventy-eight medical officers who underwent 2 weeks’ training in mental health care were assessed using parallel forms of a standardized multiple-choice questionnaire administered before and soon after the training. Young doctors scored significantly higher in the pretraining assessment. The medical officers demonstrated a significant gain in knowledge, although the amount of gain varied. Doctors who had relatively lower pretraining scores showed a higher gain. Six doctors (8%) showed less than acceptable posttraining scores. These doctors were older than the rest of the group. The doctors’ pretraining knowledge was best with respect to epilepsy and poorest with respect to manic-depressive psychosis. Items pertaining to epidemiology and aetiology elicited relatively less gain than other clinical dimensions.     

Cost comparison of psychiatric outpatient clinics based in hospitals and in primary care (general practice health center)

The first study to compare the costs of hospital-based and primary care (general practice health center)-based psychiatric outpatient clinics is reported. The operating costs of both clinic settings were estimated to be similar. There are many advantages of primary care-based clinics compared with hospital-based clinics. However, as there are no evaluative studies of the comparative efficacy of either clinic setting, before policy decisions to encourage primary care clinics are made such evaluative studies should take place.     

Managing late-life depression in primary care practice: a case study of the Health Specialist's role.

Complexities in the diagnosis and treatment of late-life depression have stimulated various strategies for assisting the primary care physician to fulfil these tasks more effectively. The role of Health Specialist was developed for this purpose in a study to reduce suicidality among older depressed patients. This role includes clinical and case management tasks which aim to provide the physician with timely, patient-specific information and recommendations. Evolution of this role and its rewards/stressors during the study's first year are described.     

Utilization of psychiatric inpatient care. A study of changes related to the introduction of a sectorized care organization

Utilization of inpatient care in a catchment area was studied by means of a 4-year comparison before and after a sectorization of the care organization. There was almost no reduction in the number of patients hospitalized, but the number of admissions was reduced by 20% and the total number of days in hospital by 40%. An initial rise in the hospitalization of nonpsychotic patients was found in the new organization, probably because of the increased accessibility and availability of psychiatric care in the catchment area. The rate of hospitalization decreased for schizophrenic patients and remained unchanged for other psychotic patients. There was a significant reduction in rates of readmission, and mean length of stay in hospital was reduced for all groups of patients except patients with a diagnosis of neurosis or personality disorder. A reduction in rates of compulsory care, primarily for patients with alcohol diagnosis, was found. The sectorized care organization has fulfilled the objective of reducing inpatient care. However, great attention must be paid to evaluating new patient categories reached by the development of outpatient facilities, especially in areas where accessibility to and availability of the care organization were formerly low.     

An analysis of the nature of depressive phenomena in primary health care utilising multivariate statistical techniques

The nature of depressive phenomena in primary health care was explored with data obtained from three primary health care clinics situated in the periphery of the city of Calcutta in India. The Self-Reporting Questionnaire (SRQ) and the Screening for Depression Questionnaire (SDQ-9) were used as the first stage and the Clinical Interview Schedule (CIS) and the Hamilton Rating Scale for Depression (Hamilton) as the second stage instruments respectively. Health workers with limited training administered the first stage instruments to consecutive adult clinic attenders. Principal components analysis followed by multiple linear regression analysis and discriminant function analysis were applied to the data. It was concluded that depressive phenomena in primary health care settings were largely undifferentiated in nature.     

Screening for the psychological consequences of a major disaster in a developing country: Armero, Colombia

Seven months following the volcanic eruption that destroyed the small town of Armero, 200 victims were screened for emotional problems with the Self-Reporting Questionnaire, a simple and reliable instrument. Fifty-five percent of the victims were found to be emotionally distressed. Variables associated with the presence of emotional distress included living alone, having lost previous job, feeling not being helped, not knowing date for leaving temporary shelter, being dissatisfied with living arrangements, complaining of non-specific physical symptoms or epigastric pain, and presenting several physical problems. The high prevalence of emotional distress supports the need to deliver mental care to disaster victims in developing countries through the primary level of care. Our findings provide guidelines for early detection of individuals at risk for developing emotional problems.     

Mental health parity: a review of research and a bibliography

This article summarizes the content of a meeting held in July 2001 to (1) review what is known about the effect of parity based on research already done, (2) identify what is likely to be known from research in progress, and (3) identify the knowledge gaps that still exist. An annotated bibliography of studies and reports on parity from 1996 through 2001 is included.     

Transparent criteria for specialist level adolescent psychiatric care

Background Rising health care costs and long waiting lists pose a challenge to public specialist level health services. In Finland, the Ministry of Social Affairs and Health required all medical specialities to create a priority-rating tool for elective patients, preferably giving a numerical rating ranging 0–100, with 50 as an entry threshold. Objective To create and test the psychometric properties of a point-count measure for prioritising entry to public specialist level adolescent psychiatric services. Method Around 710 referred adolescents were given ratings on 17 items focusing on symptom severity, problem behaviours, functioning, progress of adolescent development and prognosis. The structured ratings were compared to an overall assessment of need for treatment on a VAS scale. In order to ensure that the tool was not inappropriately sensitive to confounding by non-disturbance related factors, the associations between the structured priority rating and sex, age, referring agent, study site and diagnosis were analysed. Results Of the 17 items, 15 were included in the final priority-rating tool. The requirement than threshold score for entry to services being set at 50 points necessitated scoring factors rather than individual items. Four blocks of items were formed: symptoms and risks; impaired functioning; other relevant issues, and prognosis without specialist level treatment. Most of the referred adolescents scored over the threshold of 50. When diagnosis was controlled for, scoring over 50 was largely independent of age, sex, referring agent or study site. Conclusion The structured priority ratings corresponded well with clinical global rating of need for care. The tool was not inappropriately sensitive to age, sex, referring agent or study site. In the future, follow-up studies will be needed to evaluate the predictive value of priority ratings.     

Use of brief psychiatric screening measures in a primary care sample

Patients seen in primary medical clinics report higher rates of major depression [Pérez-Stable et al., 1990: Arch Intern Med 15:1083-1088], and panic disorder [Sherbourne et al., 1996b: Von Korff et al., 1987: Arch Gen Psychiatry 44:152-156] than the general population. Primary care staff therefore need efficient methods of identifying patients with psychiatric disorders. The current study evaluates the use of several brief psychiatric screening measures for identifying patients with major depression and/or anxiety disorders. Participants were 213 primary care patients who received the Center for Epidemiological Studies Depression Scale (CES-D), the Beck Anxiety Inventory (BAI), and two new instruments, the Autonomic Nervous System Questionnaire (ANS) for assessing panic disorder and the Social Phobia Questionnaire (SPQ) for assessing social phobia. Participants received both the screening instruments and a structured diagnostic interview. Results suggest that the CES-D is a useful measure for detecting psychopathology, but it is not particularly specific to depression, the ANS was a highly sensitive and reasonably specific measure for panic disorder, and the SPQ was reasonably sensitive and specific for social phobia. The BAI was a relatively poor screening measure that added no significant information beyond the other measures.