Developing effective treatments for posttraumatic disorders among people with severe mental illness.

OBJECTIVE: The purpose of the study was to examine strategies for developing effective interventions for clients who have both serious mental illness and posttraumatic symptoms. METHODS: The authors conducted searches for articles published between 1970 and 2000, using MEDLINE, PsycLIT, and PILOTS. They assessed current practices, interviewed consumers and providers, and examined published and unpublished documents from consumer groups and state mental health authorities. RESULTS AND CONCLUSIONS: Exposure to trauma, particularly violent victimization, is endemic among clients with severe mental illness. Multiple psychiatric and behavioral problems are associated with trauma, but posttraumatic stress disorder (PTSD) is the most common and best-defined consequence of trauma. Mental health consumers and providers have expressed concerns about several trauma-related issues, including possible underdiagnosis of PTSD, misdiagnosis of other psychiatric disorders among trauma survivors, incidents of retraumatization in the mental health treatment system, and inadequate treatment for trauma-related disorders. Despite consensus that trauma and PTSD symptoms should be routinely evaluated, valid assessment techniques are not generally used by mental health care providers. PTSD is often untreated among clients with serious mental illness, or it is treated with untested interventions. It is important that policy makers, service system administrators, and providers recognize the prevalence and impact of trauma in the lives of people with severe mental illness. The development of effective treatments for this population requires a rational, orderly process, beginning with the testing of theoretically grounded interventions in controlled clinical trials.     

Appraisal of marketing approaches for consultation-liaison psychiatry

The high prevalence of undetected and undertreated mental disorders in the general health care sector suggests that the active "marketing" strategies proposed in these articles are overdue. However, a more extensive data base that documents the need for psychiatric involvement in the medical setting and assesses the capacities of other mental health professionals to substitute for consultation-liaison (C-L) psychiatrists in clinical care, teaching, and research is urgently needed and will prove to be the most potent marketing tool available to the specialty.     

Promoting "successful aging" in community psychiatric care

Recently, patients with schizophrenia have been progressively aging in a way similar to that of the general population. In Japan, community mental health care has become more active in the context of the policy of promoting the discharge of patients from psychiatric hospitals. Patients with chronic schizophrenia who have been discharged are already approaching old age. "Successful aging" may be a key concept in their community-based psychiatric care. Successful aging does not emphasize a loss of youth, but focuses on gains and growth achieved with aging. In the Sasagawa Project, 78 patients with schizophrenia were gradually transferred from a psychiatric hospital to a community dwelling. Eight years have passed since the project began. Elder patients (>60 years old) showed stable psychiatric symptoms and were rarely readmitted to the psychiatric ward. They were, however, more often readmitted to hospital due to physical disease (for example, lifestyle-related disease or fracture) than were middle -aged patients (<60 years old). Elder patients cannot simultaneously receive mental health services under the Services and Support for Persons with Disabilities Act, and long-term care under the Long-Term Care Insurance Act. We hope that the government will establish a new system and institutions that address the needs of elder psychiatric patients. Elder patients with schizophrenia have an optimistic view of their own aging, but they are not sufficiently prepared for old age. In the mental health care of aging psychiatric patients, it is necessary to not only control psychiatric symptoms, but also promote and improve their quality of life by maintaining their ability to continue living in the community (for example, by supporting their preparations for old age).     

Urgent Psychiatric Services: A Scoping Review

Objective:

Urgent psychiatric services can provide timely access to ambulatory psychiatric assessment and short-term treatment for patients experiencing a mental health crisis or risk of rapid deterioration requiring hospitalization, yet little is known about how best to organize mental health service delivery for this population. Our scoping review was conducted to identify knowledge gaps and inform program development and quality improvement.

Method:

We searched MEDLINE, PsycINFO, CINAHL, Embase, and EBM Reviews for English-language articles, published from January 1993 to June 2014, using relevant key words and subject headings. Reverse and forward citations were manually searched using reference lists and Google Scholar. Articles were included if they described programs providing ambulatory psychiatric assessment (with or without treatment) within 2 weeks of referral.

Results:

We identified 10 programs providing urgent psychiatric services. Programs targeted a diagnostically heterogeneous population with acute risks and intensive needs. Most programs included a structured process for triage, strategies to improve accessibility and attendance, interprofessional staffing, short-term treatment, and efforts to improve continuity of care. Despite substantial methodological limitations, studies reported improvements in symptom severity, distress, psychosocial functioning, mental health–related quality of life, subjective well-being, and satisfaction with care, as well as decreased wait times for post-emergency department (ED) ambulatory care, and averted ED visits and admissions.

Conclusions:

Urgent psychiatric services may be an important part of the continuum of mental health services. Further work is needed to clarify the role of urgent psychiatric services, develop standards or best practices, and evaluate outcomes using rigorous methodologies.     

The Mood Disorders Association of British Columbia Psychiatric Urgent Care Program: A Preliminary Evaluation of a Suggested Alternative Model of Outpatient Psychiatric Care

Objective:

To describe an alternative model of psychiatric outpatient care for patients with mood and anxiety disorders (the Mood Disorders Association of British Columbia Psychiatric Urgent Care Program or the MDA Program) using group medical visits (GMV) and (or) email communications in lieu of individual follow-up appointments.

Method:

Annual costs of the MDA Program were compared with average costs of private psychiatrists offering outpatient care and patients being treated in a mental health centre. In addition, questionnaires as to patient satisfaction with the MDA Program intake, GMV experience, and family physician satisfaction with the MDA Program were administered.

Results:

The MDA Program model of care is significantly more cost effective than individual psychiatric outpatient care or health authority mental health centre care for patients with moderate or severe illness. Patients and family physicians were very satisfied with the model of care and GMVs offered.

Conclusions:

The MDA Program model of care appears to be efficient and cost-effective, and patients and referring physicians appear satisfied with the care offered in this program.     

Qualitative study of a social and health network's expectations for community treatment of severe mental health problems

Treatment of severe mental illness in the community is gaining interest under ethical, clinical and economical pressure, which has led to mental health reform and deinstitutionalisation. However, this can lead to conflicts between all the parties involved in the community. Several countries have initiated extensive efforts to coordinate health services to enhance quality of care without increasing costs. According to Gray [Hum Relat 38 (1985) 911-936.], the first conditions facilitating interorganizational collaboration are the identification of common problems, recognition of partners (legitimacy and expertise) and interest in collaborating gains to be made from such collaboration [int J Health Plann Manage 17(4) (2002) 315-32.]. AIMS: The aims of the study were to assess the representation of problems and needs from people dealing with psychiatric patients in the community with a model of action research. The action part of the study meant to influence collaboration and objective setting in the network. The research part intended to identify the main problems experienced while dealing in the community with people suffering from severe mental illness. METHODS: In depth interviews were conducted with 25 persons involved in the community network (GPs, psychiatrists, nurses, social workers, police, judge, relatives, and users). Five open-ended questions on experienced problematic situations, network's collaboration, and expectations were asked. Content analysis of individual interviews was validated through discussion in six focus groups. Qualitative analysis used a 3 x 3 matrix model inspired from Parsons [Social systems and the evolution of action theory. Free Press; 1977, 420 p.; Health Serv Manage Res 11(1) (1998) 24-41 discussion 41-8.], and Tansella and Thornicroft [Psychol Med 28(3) (1998) 503-508.]. RESULTS: One thousand four hundred and seventy-nine propositions were grouped in 52 themes. Seventeen key problems were identified at individual, population, care-process and network levels, and were validated by the focus groups. Main problems were linked to a change in values regarding the role of psychiatric patients-from paternalistic social control to free empowered citizens-without adequate tools to deal with this in the community. Crisis management, intensive home care, and network cooperation were considered as insufficient, particularly for suicidal, dual diagnosis and difficult to engage patients. CONCLUSION: Deinstitutionalisation and more respect of patients' rights were considered as positive changes for most patients, but as a risk for the most vulnerable ones. Clearer mental health policy targets were requested for suicidal, difficult to engage and dual diagnosis patients. Collaborative efforts must focus on teaching primary care professionals for suicide and dual diagnosis patients, on direct help to welfare services for difficult to engage patients and on psychiatric services for high users. Intensive home care and liaison with primary care are viewed as key components. Identifying common targets in the network may enhance collaboration. Pathways to care need to be studied, including people involved outside a "classical" health network, such as police, welfare services and patients or carers associations.     

A Narrative Review of Recent Developments in Knowledge Translation and Implications for Mental Health Care Providers

Objective:

Attention to knowledge translation (KT) has increased in the health care field in an effort to improve uptake and implementation of potentially beneficial knowledge. We provide an overview of the current state of KT literature and discuss the relevance of KT for health care professionals working in mental health.

Method:

A systematic search was conducted using MEDLINE, PsycINFO, and CINAHL databases to identify review articles published in journals from 2007 to 2012. We selected articles on the basis of eligibility criteria and then added further articles deemed pertinent to the focus of our paper.

Results:

After removing duplicates, we scanned 214 review articles for relevance and, subsequently, we added 46 articles identified through hand searches of reference lists or from other sources. A total of 61 papers were retained for full review. Qualitative synthesis identified 5 main themes: defining KT and development of KT science; effective KT strategies; factors influencing the effectiveness of KT; KT frameworks and guides; and relevance of KT to health care providers.

Conclusions:

Despite limitations in existing evidence, the concept and practice of KT holds potential value for mental health care providers. Understanding of, and familiarity with, effective approaches to KT holds the potential to enhance providers’ treatment approaches and to promote the use of new knowledge in practice to enhance outcomes.     

Managing somatization phenomena in primary care

Patients communicating psychological distress in the form of somatic symptoms and seeking medical care for them pose difficult diagnostic and treatment dilemmas for the primary care physician. Somatization may be conceptualized as an illness-focused behavior style, with multiple etiologies, rather than a single psychiatric disorder. Somatizing behavior is associated with emotional distress, cognitive-perceptual abnormalities, and socially learned illness behaviors. Although recognition of the somatizing patient begins with thorough medical evaluation, assessment should also include careful examination of social history and the affective meaning of symptoms. Management strategies will vary according to the etiology of the psychiatric diagnosis associated with physical symptoms; however, the essential element is provision of a long-term supportive relationship with a physician, who provides effective monitoring of physical and mental health status, appropriate emotional support, and reassurance concerning symptoms.     

The future of consultation-liaison psychiatry

OBJECTIVE: To review the status of consultation-liaison psychiatry and the factors shaping it, and suggest strategies for its future development. METHOD: In addition to searches of the main computerized psychiatric databases and review of relevant Commonwealth of Australia publications, the author drew on discussions with national and international colleagues in his role as convenor of the International Organization for Consultation-Liaison Psychiatry. RESULTS: Physical/psychiatric comorbidity and somatization, the conditions in which consultation-liaison psychiatry specializes, are the commonest forms of psychiatric presentation in the community. They are as disabling as psychotic disorders, and comorbid depression in particular is a predictor of increased morbidity and mortality. Acknowledging this, the Second Australian National Mental Health Plan called for consultation-liaison psychiatry to be allowed to participate fully in the mental health care system. It stated that failure to define the term 'severe mental health problems and mental disorders' in the First Plan had led to some public mental health systems erroneously equating severity with diagnosis rather than level of need and disability. The call has been largely unheeded. The implication for patient care is both direct and indirect; the context created for psychiatry training by such a restricted focus is helping to perpetuate the neglect of such patients. This is a worldwide problem. CONCLUSIONS: Proactive involvement with consumers is required if the problem is to be redressed. At a service level, development of a seamless web of pre-admission/admission/post-discharge functions is required if patients with physical/psychiatric comorbidity and somatoform disorders are to receive effective care, and consultation-liaison psychiatry services are to be able to demonstrate efficacy. Focus on comorbidity in the Australian Third National Mental Health Plan may force resolution of the current problems.     

Use of psychiatric and medical health care by veterans with severe mental illness

Risk behaviors and health care use among 396 initially hospitalized veterans with severe mental illnesses were examined. Health care use was abstracted from Veterans Affairs databases (March 1998 to June 2000) for one year after hospital discharge. Lifetime intravenous drug use was related to increased use of outpatient services, and current alcohol use was related to decreased health care use. Patients with posttraumatic stress disorder had greater use of medical outpatient services than patients with schizophrenia-spectrum disorders, although they had longer hospital stays. These results highlight that veterans with severe mental illness receive more treatment in medical than psychiatric health clinics.     

Identifying risk factors and key strategies in linkage to outpatient psychiatric care

OBJECTIVE: The substantial failure of psychiatric patients to engage in outpatient specialty mental health care after an acute hospitalization at a time when managed care companies and others increasingly hold hospitals accountable for outcomes underscores the importance of identifying patients at high risk for not completing referrals. This study explored patient risk factors for not completing referrals and examined the success of several interventions targeted to achieving linkage with outpatient care. METHOD: A clinically detailed, structured form was used in abstracting information from the medical records of 229 inpatients with a primary psychiatric diagnosis. Clinicians and staff at outpatient programs were contacted to determine whether patients completed their referrals. RESULTS: Approximately two-thirds (65%) of the patients failed to attend scheduled or rescheduled initial outpatient mental health appointments after a hospital discharge. At high risk for unsuccessful linkage to outpatient care were patients with a persistent mental illness and those who had no prior public psychiatric hospitalization, were admitted involuntarily, and had longer lengths of stay. Controlling for risk factors, three clinical interventions used during the hospital stay more than tripled the odds of successful linkage to outpatient care: communication about patients' discharge plans between inpatient staff and outpatient clinicians, patients' starting outpatient programs before discharge, and family involvement during the hospital stay. CONCLUSIONS: Effective clinical bridging strategies can be used to avoid unnecessary gaps in the delivery of psychiatric services. Incorporating these strategies into routine care would enhance continuity of care, especially for some high-risk patients.     

Psychiatric consultations for nursing home residents: a perspective from Turkey and the implications for comparable countries

BACKGROUND: No specialized geriatric psychiatry consultation services are available for elderly people in the institutional care system in Turkey. Our aim was to evaluate psychiatric consultations among the residents of three homes for the elderly in a country with a rapidly aging population, and to investigate possible problems regarding psychiatric consultations. METHODS: The residents of three homes for the elderly, which served partially as "care and rehabilitation centers" (equivalent to nursing homes), were chosen for the study. Data on the use of psychiatric services (mainly patient consultations with a visiting psychiatrist) were collected and analyzed. RESULTS: The percentage of patients in the three homes for the elderly who had psychiatric consultations between 2005 and 2007 was 31.8% (172/540). The main reasons for referral were forgetfulness (61%), depressive symptoms (37.7%), agitation and disruptive behavior (29.6%), and psychotic symptoms (27.9%). Of these patients, 46.5% were diagnosed with dementia, 20.9% with depression, 20.5% with behavioral and psychotic symptoms of dementia, and 18.6 % with primary psychotic disorders such as schizophrenia. CONCLUSION: Homes for the elderly in Turkey are not adequate in terms of consultations for psychiatric problems. Integration of these institutions with hospitals and organizing routine consultation visits from the psychiatry units would enhance the mental health of the elderly. Supporting the staff, maintaining good cooperation between them, and organizing educational programs in the field of mental health of the elderly are also required.     

Screening and Treating Mental Disorders in Addiction Treatment Settings: A Stepped Care Model

The comorbidity of mental and addiction disorders is increasingly apparent. Such comorbidity increases overall client morbidity substantially, and reduces the success rate in treating either type of disorder. In addiction treatment settings, the challenge is twofold: first, to develop a method for detecting mental disorders that is valid and practical, and second, to identify treatment approaches that are appropriate to that setting. Simple referral away of the patient with a mental disorder is rarely successful. Difficulties often arise in finding appropriate mental health treatments in a timely fashion; furthermore client resistance to being referred out poses an additional barrier. This article identifies strategies to improve practical detection of mental health disorders through the use of simple but validated patient self-reports. In addition, this commentary proposes a stepped care approach to the provision of mental health treatments that allows for some universally effective ‘wellness treatments’ to be initiated for all individuals in addiction treatment settings; those with persistent high psychiatric symptoms related to the most common disorders such as depression or anxiety would then receive some additional mental health treatment in the addiction setting. Referral out would be reserved for those individuals with more severe psychiatric illnesses or those with comparatively rarer disorders. This pragmatic approach to screening and stepped care increases the likelihood of success in treating the addictive disorder, as well as providing care for the mental disorder.     

Pathway to psychiatric care in Japan: A multicenter observational study

Background

This study examines pathways to psychiatric care in Japan using the same method as the collaborative study carried out in 1991 under the auspices of the World Health Organization.

Methods

Thirteen psychiatric facilities in Japan were involved. Of the 228 patients who contacted psychiatric facilities with any psychiatric illness, eighty four visiting psychiatric facilities for the first time were enrolled. Pathways to psychiatric care, delays from the onset of illness to treatment prior to reaching psychiatrists were surveyed.

Results

Thirty three patients (39.4%) directly accessed mental health professionals, 32 patients (38.1%) reached them via general hospital, and 13 patients (15.5%) via private practitioners. The patients who consulted mental health professionals as their first carers took a longer time before consulting psychiatrists than the patients who consulted non-mental health professionals as their first carers. The patients who presented somatic symptoms as their main problem experienced longer delay from the onset of illness to psychiatric care than the patients who complained about depressive or anxiety symptoms. Prior to the visit to mental health professionals, patients were rarely informed about their diagnosis and did not receive appropriate treatments from their physicians. Private practitioners were more likely to prescribe psychotropics than physicians in general hospitals, but were less likely to inform their patients of their diagnosis.

Conclusion

This first pathway to psychiatric care study in Japan demonstrated that referral pathway in Japan heavily relies on medical resources. The study indicates possible fields and gives indications, underlining the importance of improving skills and knowledge that will facilitate the recognition of psychiatric disorders presenting with somatic and depressive symptoms in the general health care system and by private practitioners.     

Cigarette smoking and overweight/obesity among individuals with serious mental illnesses: a preventive perspective

BACKGROUND: Cigarette smoking and lifestyle factors underlying overweight/obesity (such as unhealthy diet and physical inactivity) appear to play a major role in the excess medical morbidity and mortality among persons with serious mental illnesses. The literature on the prevalence, etiology, prevention, and treatment of these two risk factors, in the context of serious mental illnesses, are reviewed following a preventive approach. METHODS: The review relied upon searches of the MEDLINE database, from 1996 through April 2006, restricted to the English language. Original research, review articles, and clinical guidelines relevant to the topics of cigarette smoking, unhealthy diet, physical inactivity, and overweight/obesity among individuals with serious mental illnesses were identified. RESULTS: Compared to those without a mental illness, individuals with a current mental illness are more than twice as likely to smoke cigarettes and more than 50% more likely to be overweight/obese, presumably the product of unhealthy diet and physical inactivity. Various biological, iatrogenic, and social factors place psychiatric patients at risk for these and other adverse health behaviors. Studies suggest that many of the same preventive approaches developed for general medical populations are likely to be effective in persons with serious mental disorders, though specialized approaches also are needed. Domains of prevention include primary prevention (population-based strategies to reduce the incidence of these adverse health behaviors), secondary prevention (early detection and treatment), and tertiary prevention (pharmacological and psychosocial treatments to reduce the burden of illness among those with the behaviors in question). However, mental health clinicians commonly lack the training or expertise to provide these services. CONCLUSIONS: The high prevalence, adverse effects, and efficaciousness of treatments for smoking and obesity in persons with serious mental illnesses suggest the importance of addressing these problems in this population. Both further research and dissemination efforts are needed to ensure that patients with serious mental illnesses receive the appropriate preventive and clinical services for these two adverse health conditions.     

USE OF NATIONWIDE OUTCOMES MONITORING DATA TO COMPARE CLINICAL OUTCOMES IN SPECIALIZED MENTAL HEALTH PROGRAMS AND GENERAL PSYCHIATRIC CLINICS IN THE VETERANS HEALTH ADMINISTRATION

There has been a growing interest in the implementation of evidence-based specialized mental health programs. However, there has been little study of the effectiveness of these programs in comparison with standard mental health care in real world mental health systems. This study used a national sample of patients from the Veterans Health Administration to compare changes in mental health status in various specialized mental health outpatient programs and in general psychiatric clinics. Hierarchical linear models were used to compare the association of both regularity and intensity of care in six specialized mental health programs with GAF change scores in patients treated in general psychiatric clinics. While improvements were observed in all programs, two specialized programs performed better overall than general psychiatric care, one was not significantly different, and three had poorer outcomes than general psychiatric clinics. Programmatic differences in target populations accompanied by imperfect risk adjustment for population differences most likely explain why these results differ from those observed in clinical trials. While the analytic strategies demonstrated here may have wider applicability to comparative performance assessment, this study provides a cautionary tale concerning the limits of conclusions that can be drawn from large scale outcomes monitoring efforts.     

Sociotherapy in German social law. Indication,contents, and aspects of public health

In German mental health services, the ill-defined term "sociotherapy" has been used to designate nonmedical, social, and work-related components of the care process. Recently, a new component of outpatient/community mental health care called "sociotherapy" (according to Paragraph 37a of the Fifth German Social Code) which is funded by the public health insurance system has been introduced and is now in the process of being implemented. The paper describes (a) patients eligible for the service and (b) the aims and scope of this case management module. The key objectives are to motivate patients with schizophrenia to utilise mental health services and antipsychotic medication and to liaise with psychosocial services. Therefore, sociotherapy is distinct from (a) multidisciplinary inpatient care for people with severe mental illness, (b) assertive community treatment, (c) community care provided by social workers or community psychiatric nurses, and (d) family interventions. So far there has been little evaluation of sociotherapy.     

Mental health services in Slovenia

BACKGROUND: Development of mental health services in Slovenia has some originalities described in the present article. Slovenia is a small Central European country with a population of 2 million. Its mental health system has been influenced by the western de-institutionalization movement and eastern models of care which are predominately institutional. AIMS: Mental health reform in the 1970s was a silent one with displacement of long-term psychiatric patients to old-people's homes, asylums and to their families. During the last decade community mental health services have been established in the non-government sector, primarily as social institutions providing support to patients with severe mental illness. Psychosocial rehabilitation movement changed some therapeutic approaches in hospitals and has been gaining more and more influence in the NGO services. RESULTS: The article describes Slovene psychiatric hospitals and community rehabilitation services. Mental health services in Slovenia are compared to services in Slovakia, the United Kingdom and The Netherlands. CONCLUSIONS: The authors are proposing guidelines for future development of mental health services for the severely mentally ill in our country in order to improve the present deficient state of care.