Case-mix tool,costs and effectiveness in improving primary care mental health and substance abuse services

Background: Despite its importance in improving care and developing services, high-quality data evaluating cost-effectiveness and services in different case-mix populations is scarce in primary care.

Aims: The objective was to investigate the service use of those mental health and substance abuse patients, who use lots of services.

Methods: Primary health care diagnosis-related groups (pDRG) is a tool to evaluate service provider system and improve efficiency, productivity and quality. We viewed all pDRG results available from the year 2015 concerning municipal mental health and substance abuse services.

Results: In primary care mental health and substance abuse services, the most common ICD-10-codes were depression and substance abuse. One-fifth of patients produced 57% of costs. Their medium of appointments was 16 per year versus 6 per year of all patients. Only 54% of their diagnoses were recorded in the electronic health records versus 75% of all patients. They made 5.7 different pDRG episodes, including 1.8 episodes of depression, per patient. The average episode cost for this patient group was 301€.

Conclusions: pDRG makes health care production transparent also in mental health and substance abuse services. It is easy to identify patients, who use a lot of services and thus induce the majority of costs, and focus on their needs in managing and developing services.     

What are the factors that facilitate or hinder resilience in older spousal dementia carers? A qualitative study

Objectives: Much is known about the factors making caring for a spouse with dementia burdensome. However, relatively little is known about factors that help some spouses become resilient. We define resilience as ‘the process of negotiating, managing and adapting to significant sources of stress or trauma’. We aimed to assess whether spousal dementia carers can achieve resilience and to highlight which assets and resources they draw on to facilitate or hinder resilience, using an ecological framework .

Method:Twenty in-depth qualitative interviews with spousal carers from two carer support groups and a care home in North West England.

Results: Eight participants were resilient and 12 were not. A resilient carer was characterised as someone who stays positive and actively maintained their relationship and loved one's former self. Resilient carers were knowledgeable and well supported by family but especially friends, with whom they shared this knowledge. They were more actively engaged with services such as respite care.

Conclusion: There is a need to move towards more ecological models of resilience. We propose that access to assets and resources is not always sufficient to facilitate resilience. Implications of these findings are discussed.     

Perceived needs for mental health care and barriers to treatment across age groups

Purpose: This study aimed to assess responses to a structured measure of perceived need for treatment to understand whether differences in treatment uptake across age groups are related to differences in: (1) perceived need for mental health care; (2) perceptions of treatment needs being met; and/or (3) perceived attitudinal and structural treatment barriers.

Methods: Data from a nationally representative sample of the Australian population (2007 National Survey of Mental Health and Wellbeing) were analysed using logistic and multinomial regression. All participants potentially benefiting from mental health services were included in analyses; including those reporting symptoms of mental disorders, using mental health services, or self-reporting significant mental health problems in the past 12 months (n = 5733). All regression analyses were adjusted for gender, the presence of chronic physical health conditions, disorder type, and disorder severity.

Results: Older adults were the least likely to report any perceived need for mental health care, and specifically reported lower needs for psychotherapy, information about available services, and support improving their ability to work. Older adults perceiving a need for mental health care were also the most likely to report having these needs met. There were no differences in attitudinal and structural barriers to treatment across age groups.

Conclusions: These results highlight that age needs to be considered in strategies for improving engagement and efficacy of mental health services, as well as the need for further research to understand what drives age differences in perceived need for mental health care.     

Integrating mental health in primary healthcare in low-income countries: changing the future for people with mental disorders

Background: Untreated mental disorders are a huge challenge for healthcare systems worldwide. Treatment possibilities are particularly scarce in low-income countries (LICs). WHO estimates that up to 85% of all people with a mental disorder in LICs do not have access to evidence-based treatment.

Aims: This paper seeks to explore the rationale behind the WHO recommendations for improving mental health services in LICs. At the core of these recommendations is an integration of mental health services into existing primary healthcare. This article presents available research supporting this approach. Furthermore, it highlights challenges needing special attention and opportunities demanding additional research to guide a comprehensive restructuring of a healthcare system.

Methods: A literature review of WHO documents and searches on PubMed for relevant supporting literature.

Results: Research from LICs that investigate mental health interventions is scarce. The evidence that does exist favours integration into primary healthcare. There is evidence that collaborative- and stepped-care interventions can provide viable treatment options for patients.

Conclusion: Integration of mental health services into primary healthcare seems like a viable solution to ensure that treatment becomes more available, even though the evidence is limited. Locally conducted research is needed to guide the development of sustainable evidence-based mental health treatment, involving relevant healthcare providers, with optimal task-sharing and possibilities for referral of complex cases. Furthermore, to achieve this, comprehensive political will and investments are necessary pre-requisites.     

Factors associated with mental health service use in Latino and Asian immigrant elders

Objectives: The purpose of this study was to examine factors associated with the mental health service use of Latino and Asian immigrant elders. Adapting Andersen's behavioral health model of health service utilization, predisposing, enabling, and mental health need factors were considered as potential predictors for use of mental health services.

Method: Data were drawn from a nationally representative dataset, the National Latino and Asian American Survey (NLAAS). Hierarchical logistic regression analyses of mental health service use were conducted for Latino (N = 290) and Asian (N = 211) immigrant elders.

Results: For both groups of immigrant elders, poor self-rated mental health was associated with significantly greater mental health service use, even after controlling for all other variables. For Latinos, use of mental health services was significantly associated with both predisposing factors (being younger and female) and mental health need factors (having any mood disorders and poor self-rated mental health). Among Asians, only mental health need factors (having any mood disorders and poor self-rated mental health) significantly affected mental health service use. In addition, poor self-rated mental health mediated the association between mood disorders and mental health service use only in Latino immigrant elders.

Conclusion: Results highlight an important role of self-rated mental health as a potential barrier in the use of mental health services, and suggest intervention strategies to enhance service use.     

A randomized controlled trial comparing self-referral to inpatient treatment and treatment as usual in patients with severe mental disorders

Background: There has been a call for increased patient autonomy and participation in psychiatry. Some Community Mental Health Centres (CMHC) have implemented services called ‘self-referral to inpatient treatment’ (SRIT) for patients with severe mental disorders.

Aims: To investigate whether SRIT could yield better outcomes after 12 months in use of mental health services for people with severe mental disorders than Treatment As Usual (TAU).

Methods: This was a randomized controlled trial at a CMHC in Norway comparing SRIT and TAU in 12 months. Fifty-four patients with severe mental disorders were included. The patients in the SRIT group could admit themselves as inpatients for up to 5 days for each admission with at least a 2 weeks pause between the admittances.

Results: Twenty out of 26 participants (77%) in the SRIT group used the SRIT for a median of 1.5 admissions and 5 inpatient days. With the exception of a somewhat larger number of admissions at the CMHC in the SRIT group, no significant differences were found between the two groups in days as inpatients, admissions, outpatient contacts or coercion. Both groups reduced their inpatients days by 40%.

Conclusions: Both the SRIT and the TAU groups reduced their use of services during the 12 months intervention period. Giving patients with severe mental disorders the possibility to self-refer did not change the use of services.

Clinical implications: Self-referral to inpatient treatment for patients with severe mental disorders might increase patient autonomy, but does not seem to save use of inpatient services.     

Family close but friends closer: exploring social support and resilience in older spousal dementia carers

Objectives: Spousal dementia carers have unique support needs; they are likely to disengage from their existing social networks as they need to devote more time to caring as the disease progresses. Previously we showed that support resources can facilitate resilience in carers, but the relationship is complex and varies by relationship type. The current paper aims to explore social support as a key component of resilience to identify the availability, function and perceived functional aspects of support provided to older spousal dementia carers.

Method: We conducted 23 in-depth qualitative interviews with spousal carers from two carer support groups and a care home in North West England.

Results: Family and friends served a wide range of functions but were equally available to resilient and non-resilient participants. Family support was perceived as unhelpful if it created feelings of over-dependence. Participants were less likely to resist involvement of grandchildren due to their relatively narrow and low-level support functions. Friend support was perceived as most helpful when it derived from those in similar circumstances. Neighbours played a functionally unique role of crisis management. These perceptions may moderate the effect of support on resilience.

Conclusion: Family and friend support is not always sufficient to facilitate resilience. Support functions facilitate resilience only if they are perceived to match need. Implications of these findings are discussed.     

Self-efficacy and health-related quality of life in family carers of people with dementia: a systematic review

Objectives: This review aims to explore the role of self-efficacy (SE) in the health-related quality of life (QoL) of family carers of people with dementia.

Methods: A systematic review of literature identified a range of qualitative and quantitative studies. Search terms related to caring, SE, and dementia. Narrative synthesis was adopted to synthesise the findings.

Results: Twenty-two studies met the full inclusion criteria, these included 17 quantitative, four qualitative, and one mixed-method study. A model describing the role of task/domain-specific SE beliefs in family carer health-related QoL was constructed. This model was informed by review findings and discussed in the context of existing conceptual models of carer adaptation and empirical research. Review findings offer support for the application of the SE theory to caring and for the two-factor view of carer appraisals and well-being. Findings do not support the independence of the negative and positive pathways. The review was valuable in highlighting methodological challenges confronting this area of research, particularly the conceptualisation and measurement issues surrounding both SE and health-related QoL.

Conclusions: The model might have theoretical implications in guiding future research and advancing theoretical models of caring. It might also have clinical implications in facilitating the development of carer support services aimed at improving SE. The review highlights the need for future research, particularly longitudinal research, and further exploration of domain/task-specific SE beliefs, the influence of carer characteristics, and other mediating/moderating variables.     

Psychological and emotional needs,assessment, and support post-stroke: a multi-perspective qualitative study

Background: International stroke care guidelines recommend the routine assessment and management of psychological and emotional problems post-stroke. Understanding the experiences of those delivering and receiving these services is vital to improving the provision of psychological support post-stroke.

Objectives: To explore patients’, carers’, and health professionals’ experiences of psychological need, assessment, and support post-stroke while in hospital and immediately post-discharge.

Methods: Participants were recruited from seven specialist stroke services in the north of England. Qualitative semi-structured interviews and focus groups were conducted with 31 stroke patients, 28 carers, and 66 health professionals. The interviews were recorded and transcribed verbatim and analyzed using thematic analysis.

Results: Two central themes emerged minding the gap: psychological expertise, and protective factors perceived to reduce the need for formal psychological support. The lack of psychological expertise among healthcare professionals working on stroke units was a source of frustration and resulted in other disciplines assuming the role of a psychologist without the required skills and training. Multiple stakeholders discussed the importance of protective factors, including downward social comparison, social support, peer support, communication, and information provision, that were perceived to reduce the need for formal psychological support.

Discussion: Stroke patients need better access to psychological support, including information, advice, and peer or social support. More research is required to establish the effectiveness of alternative options to formal psychological support.     

Attitudes towards people with depression and schizophrenia among social service workers in Denmark

Background: Mental health-related stigma is a major public health issue, and is an obstacle to the possibility for successful treatment, recovery, and reintegration.

Aim: To examine attitudes towards mental illness among employees in the social services.

Methods: The study design was part of a large randomized trial, and data presented in this study are baseline data from this trial. Respondents completed a baseline questionnaire to assess the respondents’ attitudes.

Results: A significant difference was found between employees’ personal attitudes towards depression and schizophrenia. The same significant difference was found in the employees’ perceived attitudes. Furthermore, a significant difference was found between the employees’ personal and perceived attitudes. A significant difference was found between the respondents wish for social distance towards depression and schizophrenia in all cases, except regarding the willingness to provide a job at one’s own workplace.

Conclusion: Employees in the social services are comparable to the general public concerning attitudes towards mental illness.

Implications: The results indicate that the employees in social services could have great use of gaining more knowledge about mental illness and ways in which to recognize a mental illness, in order to be able to offer the right kind of help and reduce the treatment gap concerning people suffering from mental illness.     

Viewing and making art together: a multi-session art-gallery-based intervention for people with dementia and their carers

Objectives: This is the first known study that sought to understand the experience of an eight-week art-gallery-based interventionoffered at two distinctly different galleries for people with mild to moderate dementia and their carers. The study examined impact on social inclusion, carer burden, and quality of life and daily living activities for a person with dementia.

Method: A mixed-methods pre-post design using standardised questionnaires and interviews involved 24 participants (12with dementia) and compared similar interventions at a traditional and a contemporary art gallery. Qualitative data was analysed using thematic analysis.

Results: No significant pre-post difference was found between the traditional or contemporary gallery groups on quantitative measures. There was, however, a non-significant trend towards a reduction in carer burden over the course of the interventionfor both gallery groups. Thematic analysis revealed well-being benefits from both traditional and contemporary art gallery sites that included positive social impact resulting from feeling more socially included, self-reports ofenhanced cognitive capacities for people with dementia, and an improved quality of life.

Conclusion: Participants were unanimous in their enjoyment and satisfaction with the programme, despite the lack of significancefrom standardised measures. Further consideration of art galleries and museums, as non-clinical community resources for dementia care, is warranted. The interventions at both galleries helped to foster social inclusion and social engagement, enhance the caring relationship between the carers and PWD, support the personhood of PWD, and stimulate cognitive processes of attention and concentration.     

Parents in adult psychiatric care and their children: a call for more interagency collaboration with social services and child and adolescent psychiatry

Background: A parental mental illness affects all family members and should warrant a need for support.

Aim: To investigate the extent to which psychiatric patients with underage children are the recipients of child-focused interventions and involved in interagency collaboration.

Methods: Data were retrieved from a psychiatric services medical record database consisting of data regarding 29,972 individuals in southern Sweden and indicating the patients’ main diagnoses, comorbidity, children below the age of 18, and child-focused interventions.

Results: Among the patients surveyed, 12.9% had registered underage children. One-fourth of the patients received child-focused interventions from adult psychiatry, and out of these 30.7% were involved in interagency collaboration as compared to 7.7% without child-focused interventions. Overall, collaboration with child and adolescent psychiatric services was low for all main diagnoses. If a patient received child-focused interventions from psychiatric services, the likelihood of being involved in interagency collaboration was five times greater as compared to patients receiving no child-focused intervention when controlled for gender, main diagnosis, and inpatient care.

Conclusions: Psychiatric services play a significant role in identifying the need for and initiating child-focused interventions in families with a parental mental illness, and need to develop and support strategies to enhance interagency collaboration with other welfare services.     

Tailored mental health care after nursing home admission: improving transfers of people with dementia with behavioral problems. An explorative study

Objectives: In the Netherlands, many community-dwelling people with dementia and behavioral disturbances and their family caregivers receive mental health care from a community psychiatric nurse (CPN). To promote continuity of care for these persons after moving to a nursing home, a transfer intervention was developed. The aim of this explorative study was to evaluate this intervention and its implementation.

Method: A qualitative explorative study design was used. CPNs visited professional nursing home carers, people with dementia and family caregivers six weeks after moving, advised on how to manage behavioral problems of their former clients and provided support to family caregivers. Twenty-two interviews were conducted with participants exposed to the intervention (5 CPNs, 5 family and 12 nursing home carers) and with 11 stakeholders (i.e., nursing home and mental health care managers, professional caregivers) to identify facilitators and barriers to the implementation. Data were collected in 2012 and 2013.

Results: The follow-up visit at six weeks met the need for background information of new admitted patients and helped family caregivers close off the period prior to the move. It did not meet the original purpose of providing nursing home staff with advice about problem behaviors on time: six weeks after the move was experienced as too late.

Conclusion: The transfer intervention increased the awareness of nursing home staff about personal and behavioral characteristics of residents with dementia and supported caregivers in coping with the new situation. The timing of the intervention could be improved by scheduling it immediately after the move.     

Self-rated mental health in socio-structural contexts: an examination with Korean American older adults

Objectives: Following the socio-structural framework of health, the study examined the role of social/interpersonal and environmental/neighborhood factors in predicting self-rated mental health (SRMH) in Korean American older adults.

Method: Using the survey data from 420 older Korean Americans (mean age = 71.6, SD = 7.59), multivariate models of SRMH was estimated with sets of predictors: (1) background information (demographic characteristics and chronic conditions), (2) mental health symptom measures (depressive symptoms and anxiety), (3) social/interpersonal factors (social network and filial satisfaction), and (4) environmental/neighborhood factors (neighborhood safety and residential satisfaction).

Results: Social/interpersonal and environmental/neighborhood factors were found to make a significant contribution to the predictive model even after controlling for background information and mental health symptom measures. Those with higher levels of filial satisfaction and more favorable perceptions of neighborhood safety were likely to have positive ratings of SRMH.

Conclusion: Findings supported the importance of considering socio-structural contexts in the assessment of SRMH and provided implications for mental health services for the target population.