Evaluation of potential community resources for mental health]

OBJECTIVES: Within the framework of the mental health services regional organization, the objectives are to describe and assess a day-care type alternative, informal mental health care service model. METHOD: One hundred and twenty-nine subjects were studied in a stratified sample from 3 community organizations in a mostly urban subregion in Quebec. The data were collected in several steps with 3 types of respondents: the user, the clinical team, and the community organization. In addition to the GAS and MRSS scales, a questionnaire was used to establish a sociodemographic profile and a health profile (diagnosis, medication, hospitalizations, outpatient follow-up). The EDBES was also used to assess the need (or lack thereof) for 25 mental health care services and their use during the last month. RESULTS: Users are mostly individuals with severe and persistent disorders. Community organizations meet 40% of their needs. CONCLUSION: The 3 organizations play a key role in mental health care services. Their contribution, however, could be enhanced by increasing subsidies; this would allow for permanent staff and longer office hours and would improve coordination and cooperation with clinical treatment teams.     

Perceived barriers to health care access in a treated population

OBJECTIVE: Health care access may be a significant contributor to health outcome. However, few data exist on perception of barriers by patients in treatment, and attending a clinic visit does not mean that no barriers exist. Understanding barriers for treated populations is particularly important in optimizing care for high vulnerability populations, such as those with mental illness and the elderly. METHOD: A structured interview, demographic questionnaire, and SF-12 were administered to 324 veterans presenting for primary care or mental health appointments at a Veterans Affairs medical center. Principle components analysis was performed and relationships to vulnerability characteristics were identified. RESULTS: Most interview items showed modest mean levels but high variance. Responses were stable over three to six weeks. As hypothesized, perceived total barriers were greater in participants from several vulnerable populations: those receiving treatment for mental health problems, those with disabilities, and those with worse physical and mental function. Minority participants did not perceive greater barriers. An "inverted-U" relationship with age was found. Principal components analysis assigned 18 items across six clinically meaningful subscales. Participants with mental health treatment perceived greater barriers in three subscales including provider communication. Curvilinear relationships were again seen between subscales and age. CONCLUSIONS: Even individuals "in care" perceive barriers. Members of vulnerable populations, particularly those receiving mental health treatment, perceive greater barriers. Data support a multi-dimensional conceptualization of perceived barriers, and different subgroups experience different patterns of barriers.     

Primary care patients' opinions regarding the importance of various aspects of care for depression

The objectives of this study were to 1) ascertain the importance of various aspects of depression care from the patient's perspective and 2) select items and scales for inclusion in a new instrument to measure primary care patients' attitudes toward and ratings of depression care. We used a cross-sectional survey at a university-based urban primary care clinic; the subjects were adult patients being recruited for a study of minor depression. To help prioritize attitudinal domains, including 126 items identified previously in focus groups, we asked patients to rate the importance of each aspect of depression care on a five-point scale. Items were ranked according to mean scores and the percentage of patients ranking the items as extremely important. The items were selected for inclusion in an instrument to measure patients' attitudes toward depression care based on their importance ratings. We performed reliability and validity testing of scales comprising the 30 most important items and a shortened version that includes 16 items. The sample included 76 patients (mean age 34.8 years; mean CES-D score, 22.2; 72% women; 36% African-American; 32% college graduates). Forty-six percent had visited a mental health professional in the past. The top 30 items for the overall sample came from the following domains: 1) health care providers' interpersonal skills, 2) primary care provider recognition of depression, 3) treatment effectiveness, 4) treatment problems, 5) patient understanding about treatment, 6) intrinsic spirituality, and 7) financial access to services. Scales comprising items from these domains show adequate internal consistency (Cronbach's alpha >0.70) as well as convergent and discriminant validity. We have designed a brief patient-centered instrument for measuring attitudes toward depression care that has evidence for internal item consistency reliability and discriminant validity.     

Mental health service delivery to older people in New South Wales: perceptions of aged care, adult mental health and mental health services for older people

OBJECTIVE: To compare the perceptions of aged care services, adult mental health services and mental health services for older people regarding aspects of mental health service delivery for older people in New South Wales, Australia. METHOD: The NSW Branch of the Faculty of Psychiatry of Old Age in association with the NSW Centre for Mental Health, sent a postal survey to all aged care services, adult mental health services and mental health services for older people in NSW. The survey canvassed issues ranging across service profiles, regional variations, availability of resources, processes of care, views on working relationships between services, difficulties and gaps experienced, and ways to improve co-ordination and service delivery. Clinical issues such as the management and practice of psychiatric disorders of old age, educational/training requirements and skill and experience in working with older people were explored. RESULTS: An overall response rate of 86% was achieved, including 95% from aged care services (n = 58), 74% from adult mental health services (n = 62) and 90% from mental health services for older people (n = 20). Only 59% of aged care services and adult mental health services considered that their local mental health services for older people provided an adequate service; resource and budget limitations were portrayed as the main constraint. Mental health services for older people varied widely in structure, settings and activities undertaken. Access to mental health beds for older people was also variable, and alongside staffing levels was considered problematic. Lack of staff training and/or inexperience in psychogeriatrics posed a challenge for aged care services and adult mental health services. CONCLUSION: Relationships between aged care services, adult mental health services and mental health services for older people are affected by lack of access to psychogeriatric staff, resource limitations of mental health services for older people, and inadequate liaison and support between the service types. Joint case conferences, education, increased funding of mental health services for older people, and cross referrals were considered ways to address these issues.     

Mental health care reform in The Netherlands

OBJECTIVE: To describe the major changes in mental health care for adults in the Netherlands during the past 25 years. METHOD: Scientific literature and official documents. RESULTS: Phases of the reform process are the integration of ambulatory services in the early 1980s and the following implementation of community mental health centres (RIAGGs); the differentiation and extramuralization of mental hospitals; the differentiation within the field of living accommodations; and the final fusion process between these three into integrated regional mental health care organizations. Current issues in the development of services are, e.g. the ever growing demand for mental health care, special programmes for defined target populations, legislation and patient rights, rehabilitation and empowerment. CONCLUSION: The Dutch mental health care system has a low threshold and a comparatively good quality. There is a long-lasting and strong influence of user and family organizations on the content and quality of services. Recently important organizational changes are taking place.     

Satisfaction in Child and Adolescent Mental Health Services: Translating Users’ Feedback into Measurement

The present research addressed gaps in our current understanding of validity and quality of measurement provided by patient reported experience measures. We established the psychometric properties of a freely available experience of service questionnaire (ESQ), based on responses from 7,067 families of patients across 41 UK providers of child and adolescent mental health services, using the two-level latent trait modeling. Responses to the ESQ were subject to strong ‘halo’ effects, which were thought to represent the overall positive or negative affect towards one’s treatment. Two strongly related constructs measured by the ESQ were interpreted as specific aspects of global satisfaction, namely satisfaction with care, and with environment. The Care construct was sensitive to differences between less satisfied patients, facilitating individual and service-level problem evaluation. The effects of nesting within service providers were strong, with parental reports being the most reliable source of data for the between-provider comparisons. We provide a scoring protocol for converting the hand-scored ESQ to the model-based population-referenced scores with supplied standard errors, which can be used for benchmarking services as well as individual evaluations.     

Experiences of mental health services by people with intellectual disabilities from different ethnic groups: a Delphi consultation

Background Patient experience of those accessing mental health services has been found to be different between ethnic groups. Although the needs of people with intellectual disabilities (ID) from different ethnic communities are being increasingly recognised, little has been published about their experiences of mental health services. The aim of this study was to establish whether there are any differences in the experiences of people with ID and mental health problems from two ethnic communities in South London. Method A two‐round Delphi process was utilised. White British and Black or Black British service users from a specialist community‐based mental health service for adults with ID completed a specially compiled questionnaire. Statements on participants' experiences, including satisfaction with care, staff members' attitudes, cultural awareness and level of support, were rated using a Likert scale. Results Twenty‐four out of 32 participants (75%) completed both rounds of the Delphi consultation. Consensus (≥80% agreement with the group median) was reached for 20 items in the White group and five items in the Black group. All responses that reached consensus were positive about the services that were being received. The Black group were less positive about a range of their experiences, including the use of medication. Conclusions People with ID from two ethnic groups were able to successfully complete a Delphi consultation regarding their experiences of mental health services. Broad consensus on positive experiences of services was reached in the White group but not for the Black participants.     

Recognizing psychologically masked illnesses: the need for collaborative relationships in mental health care

Background: Both research and clinical experience support the view that unrecognized medical illnesses in mental health, as well as in primary care, treatment settings can directly cause or exacerbate a patient's presenting psychological symptoms. No study has compared medical and nonmedical health care professionals on their respective abilities to identify common medical illnesses that frequently masquerade as psychological disorders.Method: In this study, 24 psychiatrists, 20 primary care physicians, 31 psychologists, and 17 social workers, recruited between November 2005 and April 2007, were asked to complete a questionnaire designed to measure the respondents' knowledge of masked medical illness. The questionnaire consisted of 10 different clinical vignettes in which a patient is seeking treatment for psychological problems that are due to a hidden medical illness. Statistical (analysis of covariance) comparisons of questionnaire scores were conducted between the medically trained and nonmedically trained participants.Results: After adjusting for clinical experience, medical mental health care professionals demonstrated significantly greater knowledge of medical illnesses that commonly masquerade as psychological disorders (F = 177.02, df = 1,82, p = .000, partial eta(2) = .68) than did nonmedical providers. In addition, correlational results showed a strong relationship (r = .82, N = 92, p < .001) between the presence of medical training and knowledge of masked medical illness in mental health care.Conclusions: Study findings suggest that non-medical mental health care providers may be at increased risk of not recognizing masked medical illnesses in their patients. On the basis of these findings, proposed collaborative and educational approaches to minimize this risk and improve patient care are described.     

Integration of mental health resources in a primary care setting leads to increased provider satisfaction and patient access

Objective

This evaluation assessed the opinions and experiences of primary care providers and their support staff before and after implementation of expanded on-site mental health services and related system changes in a primary care clinic.

Method

Individual semistructured interviews, which contained a combination of open-ended questions and rating scales, were used to elicit opinions about mental health services before on-site system and resource changes occurred and repeated following changes that were intended to improve access to on-site mental health care.

Results

In the first set of interviews, prior to expanding mental health services, primary care providers and support staff were generally dissatisfied with the availability and scheduling of on-site mental health care. Patients were often referred outside the primary care clinic for mental health treatment, to the detriment of communication and coordinated care. Follow-up interviews conducted after expansion of mental health services, scheduling refinements and other system changes revealed improved provider satisfaction in treatment access and coordination of care. Providers appreciated immediate and on-site social worker availability to triage mental health needs and help access care, and on-site treatment was viewed as important for remaining informed about patient care the primary care providers are not delivering directly.

Conclusions

Expanding integrated mental health services resulted in increased staff and provider satisfaction. Our evaluation identified key components of satisfaction, including on-site collaboration and assistance triaging patient needs. The sustainability of integrated models of care requires additional study.     

The determinants and effect of shared care on patient outcomes and psychiatric admissions

OBJECTIVE: The aim of this study was to determine the factors associated with receipt of different levels of shared care, and the effect of shared care on patient outcomes. METHOD: A total of 349 patients with severe mental illness were selected from general practice lists. Patient functioning was assessed using standardised questionnaires, and GPs completed a questionnaire about patients' shared care arrangements at baseline (response-rate 79%). Patients were followed up at 12 months. RESULTS: Receipt of high shared care was associated with greater patient satisfaction with services and social functioning at baseline (p < 0.005). Patients receiving high shared care showed greater improvements in SF-12 mental health scores at follow-up compared to low shared care groups (p = 0.02). This effect was abolished after adjustment for age, sex and psychiatric diagnosis. CONCLUSION: Receipt of high shared care was not associated with demographic or clinical characteristics. High shared care had limited value for patients in terms of improved clinical, social or general health functioning over one year.     

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.     

Matching resources to care: the acceptability, validity and inter-rater reliability of a new instrument to assess severe mental illness (MARC-1)

Background: Most definitions of severe mental illness (SMI) are categorical and assign the patient to either SMI or not-SMI status. While this is useful for some purposes, it is a rather limited approach. The purpose of the present study is to develop a new method of addressing the issue of ‘severity’, and to develop a dimensional rather than a categorical approach. The paper reports on the acceptability, reliability and validity of a method developed to collect a standard set of data covering the majority of items specified in the academic and policy literature as characterising SMI. Method: A single page form, Matching Resources to Care (MARC-1), containing most of the items used in definitions of SMI was used to collect data from community mental health staff about their current open caseload, in four co-terminous health and social services settings during a census week (n = 2139). In addition to the data from the four pilot sites, we conducted a sub-study (n = 91), in which two raters rated the same cases during the same week. Results: The MARC-1 scores were able to distinguish between patients in receipt, and those not in receipt, of specific types of community care (level of care, eligibility for care and statutory aftercare) (P < 0.001). The MARC-1 score was modestly but significantly correlated (r = 0.28) with the Global Assessment Scale (P < 0.001). The mean percentage inter-rater agreement for the MARC-1 score items was 87%. Conclusion: It is possible to use a simple census form in both health and social services agencies. The completion rates were good in both services. The levels of reliability were good, and concurrent validity was established with specific types of care in the community. Accepted: 7 March 2000     

Cross‐cultural measurement invariance of the General Health Questionnaire‐12 in a German and a Colombian population sample

While the General Health Questionnaire, 12‐item version (GHQ‐12) has been widely used in cross‐cultural comparisons, rigorous tests of the measurement equivalence of different language versions are still lacking. Thus, our study aims at investigating configural, metric and scalar invariance across the German and the Spanish version of the GHQ‐12 in two population samples. The GHQ‐12 was applied in two large‐scale population‐based samples in Germany (N = 1,977) and Colombia (N = 1,500). To investigate measurement equivalence, confirmatory factor analyses were conducted in both samples. In the German sample mean GHQ‐12 total scores were higher than in the Colombian sample. A one‐factor model including response bias on the negatively worded items showed superior fit in the German and the Colombian sample; thus both versions of the GHQ‐12 showed configural invariance. Factor loadings and intercepts were not equal across both samples; thus GHQ‐12 showed no metric and scalar invariance. As both versions of the GHQ‐12 did not show measurement equivalence, it is not recommendable to compare both measures and to conclude that mental distress is higher in the German sample, although we do not know if the differences are attributable to measurement problems or represent a real difference in mental distress. The study underlines the importance of measurement equivalence in cross‐cultural comparisons.     

Challenges and solutions to integrating mental and physical health care

A critical step in addressing excess medical morbidity and mortality in persons with serious mental illness is to better understand, and seek to improve, the medical care that they receive. Medical quality deficits for persons with serious mental illnesses include problems including overuse of certain medical services such as emergency room care; underuse of some evidence-based general medical services; and misuse, or medical error. The origins of poor quality care for persons with mental disorders are rooted in interrelated contributory factors from patients, providers, and the medical and mental health systems. At a system level, at least 4 types of separation between mental and medical health care may exacerbate the problems for persons with serious mental illnesses: 1) geographic (lack of co-located medical and mental health services), 2) financial (separate funding streams for medical and mental health services), 3) organizational (difficulty in sharing information and expertise across these systems), and 4) cultural (providers' focus on particular symptoms or disorders, rather than on the patients with those problems). Research studies and demonstration programs for improving medical care in this population have spanned a continuum of medical provider involvement from psychiatrist and patient training, to on-site consultation by medical staff, multidisciplinary collaborative care approaches, and facilitated linkages between community and mental health and medical providers. Ultimately, it will be important to develop, test, and implement a range of models for improving the medical care of persons with serious mental disorders tailored to patients' needs, mental health system capacities, and local community resources.     

Demand-oriented care: the development and validation of a measuring instrument

Objectives Demand-oriented care has recently become a key topic in the area of care provision, fitting into the modern pursuit for patient autonomy. This paper introduces a measuring instrument to assess demand-orientation in mental health care. Method A concept mapping procedure was used to understand the concept of demand-orientation. The resulting items were introduced to a validating sample of 204 patients of three mental health facilities. After factor analysis, a 19-item General-Demand Orientated Care Questionnaire (DOC-G), and a supplementary questionnaire (DOC-S) containing 6 sections remained. This questionnaire was submitted to confirmatory analysis in a random sample (n = 304) of psychiatric patients. Results Respondents were predominantly female (57.6%), of Dutch ethnic origin (84.1%), and outpatients (71.4%). The analyses confirmed the 4-factor structure of the questionnaire. Both internal and external validity of the instrument proved to be sufficient. The questionnaire discriminated in the experience of demand-orientation of care between patients who did and those who did not have a treatment plan put up; between those who did and those who did not have a crisis plan, and between those who had a lifetime prevalence of undergoing compulsory treatment, and those who had not. Conclusions We conclude that the DOC is a useful instrument to measure demand-orientation in a population of psychiatric patients. It is useful to measure changes in care quality. The supplementary questionnaires make it possible to evaluate chosen projects or subprojects quickly.     

Training primary care health workers in mental health care: evaluation of attitudes towards mental illness before and after training

One hundred and fifty primary care paramedical health workers who underwent a short term training in mental health care were evaluated to understand their attitudes towards mental health before, and immediately after, the training course. The trainees showed a significant change in attitudes in the desirable direction towards different mental health problems. Baseline attitude of health workers was not related to age, sex, level of education or duration of their professional service. However, health workers with low baseline attitude scores registered a significantly higher gain. Item analysis revealed that 10 of the 35 items of the attitude questionnaire failed to reveal significant post training changes.     

Improving medical care for persons with serious mental illness: challenges and solutions

A critical step in addressing excess medical morbidity and mortality in persons with serious mental illness is to better understand and seek to improve the medical care that they receive. Medical quality deficits for persons with serious mental illness include problems related to overuse of certain medical services, such as emergency room care; underuse of some evidence-based general medical services; and misuse, or medical error. The origins of poor quality care for persons with mental disorders are rooted in interrelated contributory factors from patients, providers, and the medical and mental health care systems. At a system level, at least 4 types of separation between mental and medical health care may exacerbate the problems for persons with serious mental illnesses: (1) geographic (lack of co-located medical and mental health services), (2) financial (separate funding streams for medical and mental health services), (3) organizational (difficulty in sharing information and expertise across these systems), and (4) cultural (providers' focus on particular symptoms or disorders, rather than on the patients with those problems). Research studies and demonstration programs for improving medical care in this population have spanned a continuum of medical provider involvement from psychiatrist and patient training to on-site consultation by medical staff, multidisciplinary collaborative care approaches, and facilitated linkages between community and mental health and medical providers. Ultimately, it will be important to develop, test, and implement a range of models for improving the medical care of persons with serious mental disorders that are tailored to patients' needs, mental health system capacities, and local community resources.     

Secluded/restrained patients' perceptions of their treatment: validity and reliability of a new questionnaire

Aim: To develop a standardized self‐reporting questionnaire to evaluate patients' perceptions of their overall treatment in specific relation to the use of seclusion and/or restraint (SR) measures as part of the treatment program. Methods: A 17‐item self‐rating questionnaire was given to 56 patients with experience of SR‐related treatment to develop a new scale, the Secluded/Restrained Patients' Perceptions of their Treatment (SR‐PPT). Concurrent validity was examined against the Client Satisfaction Questionnaire‐8 Japanese Version (CSQ‐8J). In addition, Patient burden induced by answering the SR‐PPT was evaluated. Results: On factor analysis, two factors named as Cooperation with Staff (nine items) and Perceptions of SR (two items) were derived. Cronbach's coefficient alphas were 0.928 and 0.887, and correlation coefficients against the CSQ‐8J were 0.838 and 0.609, respectively. Answering the SR‐PPT was found to induce little burden on the patients. Conclusion: Adequate internal consistency and concurrent validity of the final version of the SR‐PPT, which consists of 11 items, indicate that it is acceptable as a measurement scale. Use of this questionnaire will add the patient's view to the assessment of overall treatment involving SR.     

Health professionals' attitudes and emotions towards working with adults with intellectual disability (ID) and mental ill health

Objectives Mainstream mental health services are providing more care for individuals with an intellectual disability (ID); this has implications for staff and service users. Attitudes of staff towards people with ID in mental health services may be negative and negative staff attitudes may have a detrimental impact on service provision. Design A cross‐sectional design was used. Methods A questionnaire designed to investigate the attitudes and emotions of staff towards delivering mental health care to adults with ID was completed by 84 staff from mainstream and specialist ID services. Results Staff in both services experienced more positive emotions when working with clients whom they are currently employed to work with. When the frequency of contact with adults with ID, the number of individuals worked with and the amount of formal ID training received were considered, there was no significant difference between the attitudes of staff in both services. Positive correlations were found between attitude scores and positive emotional experiences in both services. Conclusions The research suggests that numerous factors, including the role of emotional experience and a number of environmental aspects, need to be considered in the context of providing mental health services to adults with ID to ensure the highest quality. Research limitations and clinical implications of the study are also considered.     

Cost measurement and cost data in mental health settings

Costs play a major role in determining the types of mental health services that are delivered and thus are a key factor in any discussion of the future of mental health services. The author presents some of the available cost data for care provided in three kinds of settings: hospitals; nonhospital settings such as halfway houses, health maintenance organizations, and community mental health centers; and comprehensive community programs. He discussed the methodological and measurement problems in the estimation of costs and the difficulties in comparing costs across settings. He emphasizes the need for cost data that permit accurate an comparable predictions of costs that will assist policymakers in making intelligent choices between types of services.