Self-care in mental health services: a narrative review

Self-care is an important approach to the management of long-term health conditions and in preventing ill-health by living a healthy lifestyle. The concept has been used to a limited extent in relation to mental health, but it overlaps with the related concepts of recovery, self-management and self-help. These related concepts all entail individuals having more choice and control over treatment and a greater role in recovery and maintaining their health and well-being. This paper reviews qualitative empirical research that provides information on the nature of self-care in mental health from the perspective of people experiencing mental health problems. Twenty qualitative studies were identified from a systematic search of the literature. The methods used in these studies were critically appraised and key themes across studies identified self-care behaviours and processes supporting self-care. The paper also highlights challenges to this approach in mental health and provides a conceptual framework of the relationships between self-care support, self-care behaviours and strategies, and well-being for the individual. It also highlights limitations in the current evidence base and identifies areas for future research.     

A qualitative study of service user experiences of occupation in forensic mental health

Background/aim: This qualitative study explored occupational engagement of those detained in forensic units. Legal and institutional restrictions on occupation have implications for their health and wellbeing. Method: Twenty‐six current forensic mental health service users participated in five focus groups, which were audio‐recorded, transcribed verbatim and subjected to constant comparative analysis. Findings: The participants highlighted previous occupations, current occupations and hopes. Key aspects were control over decision‐making, motivation and support, generating suggestions alongside positive experiences of occupational therapy. Conclusions: Institutional barriers could be overcome with a dynamic balance between risk management and mental health promotion through occupation. This demands a sustained focus on occupation for everyone involved in providing care and treatment in these settings.     

Supporting family engagement with child and adolescent mental health services: A scoping review

A key challenge facing the mental health field is connecting children and families to services when symptoms first appear. Multiple barriers inhibit timely access to treatment, and interventions to resolve barriers to care are not common among health and social care organisations. To address this research‐to‐practice gap this study undertook a scoping review of the empirical literature aimed at identifying key factors in the social ecology of families which influence family engagement with child and adolescent mental health services, then identifying and describing models of intervention designed to help facilitate access to care. Forty studies published between 1 January 2000 and 28 February 2019 were reviewed. Key factors associated with child and adolescent mental health service engagement included family attitudes towards mental illness and help seeking, the flexibility and availability of needed services, community attitudes and stigma surrounding mental illness and mental health treatment, and the degree of coordination and integration across systems of health and social care. Models of intervention to facilitate engagement with mental health services included family outreach, telephone and digital health strategies, and integrated care approaches. Empirical support is strongest for family outreach and integrated care, although telephone and digital health strategies are underexplored with children and families and a potentially promising avenue for future research. To support family engagement with child and adolescent mental health services health and social care organisations should be prepared to identify barriers in their local practice settings and integrate efficacious engagement approaches into their continuum of available services.     

Opportunities for independent living using direct payments in mental health

Mental health service users have yet to reap the benefits of greater choice, control and independent living, which direct payments have facilitated in other groups of community care users, particularly people with physical disabilities. To redress this imbalance a national pilot to promote direct payments to people with mental health needs in five local authority sites across England was set up and evaluated. The evaluation used a multi-method approach incorporating both qualitative and quantitative data, including individual semi-structured interviews and group discussions with key stakeholders across the pilot sites. This article draws on findings from the pilot evaluation to provide a preliminary understanding of how applicable the independent living philosophy is to mental health and what opportunities direct payments offer for service users. When given the opportunity, service users were able to use direct payments creatively to meet a range of needs in ways which increased their choice, control and independence. This suggests that the benefits of greater independent living through direct payments may be realisable in mental health. However, a number of ways in which the principles of direct payments in mental health could be 'downgraded' were identified. The evaluation results indicate that a thorough understanding of the independent living philosophy needs to be developed in the context of mental health.     

What is necessary to transform the quality of mental health care

Improving the quality of care is a national priority in the United States; however, it is not clear how to accelerate progress for mental health care. We recommend advances in three capacities: (1) developing quality improvement resources applicable to a diverse set of mental health disorders, clients, and service settings; (2) improving the infrastructure for providing evidence-based psychotherapy and psychosocial interventions; and (3) promoting innovation in financial incentives for quality improvement in mental health care. We also discuss the need to develop leadership among health care stakeholders and community engagement to promote public commitment to high-quality care in mental health.     

Occupational therapy in mental health: challenges and opportunities

The National Mental Health Policy and National Mental Health Plan published in 1992 provided directions for the reform of mental health services in Australia. They stated that mental health services should be part of the mainstream health system and that integrated mental health programmes should be developed to cover the full range of specialist mental health services, focusing on improved quality of service, the consumers, equity of access, continuity of care and redistribution of resources. The Queensland Mental Health Plan published in 1994 set out specific objectives and strategies for implementing mental health service reform in Queensland. In Queensland there has been a concentration on developing core mental health services involving the reorientation of service delivery from institutions to the community, based on the principles of integration, mainstreaming and regional self-sufficiency. Major restructuring of mental health services is taking place, which has meant changes in service development, organizational structures and work practices. There has been a significant impact on the roles and skills required by the mental health workforce in the context of today's mental health services climate. There is a focus on staff providing individualized assessment and continuing treatment using a case management approach, within a continuum of care. Implications for occupational therapists include developing a generic skill base in preparation for broad-spectrum mental health professional roles while maintaining their professional identity. It is recommended that research be conducted to examine the capacity of occupational therapists to adapt to the changing mental health environment. Copyright © 1999 Whurr Publishers Ltd.     

Measuring and valuing mental health for use in economic evaluation

This article presents research undertaken as part of a wider programme of work concerned with measuring and health and wellbeing for economic evaluation. The focus is on developing quality adjusted life years (QALYs) in mental health, but the issues are common across all areas of health care. The article begins by reviewing the issues of what should be valued (health or broader notions of wellbeing), how mental health and wellbeing should be described, how mental health states should be valued and who should do the valuing. The article presents four pieces of work. The first is a re-analysis of the ONS Psychiatric Morbidity 2000 Survey to provide evidence on the relevance of generic measures across different mental health disorders. It found that common mental health problems, such as anxiety and depression, had a significant impact on the generic preference-based measure of health in the SF-6D, but psychosis and personality disorders did not. The article then presents two studies using the ratings of people experiencing the states of health. Both studies found that people experiencing different health states gave mental health greater weight than physical health compared to members of the general public trying to imagine the health states. Finally, the article presents a study developing a condition-specific preference-based measure for calculating QALYs from an existing measure of mental health, the CORE-OM, using modern psychometric methods to construct health states amenable to valuation. It also considers a proposal to develop an entirely new QALY measure in mental health.     

A discourse analysis on how service providers in non-medical primary health and social care services understand their roles in mental health care

Enhancing collaboration between specialist mental health services, primary health care and social care services has been a key priority in mental health policy reform in many countries for about 20 years and remains so. Yet progress in terms of widespread implementation of demonstrably effective models of collaborative care has been slow. The views that different providers hold regarding the parameters of their roles, and the values that guide their approach to service delivery, are likely to exert profound effects on engagement with collaborative initiatives. Little research has explored these issues.     

Health care professionals’ perspectives on physical activity within the Ugandan mental health care system

BackgroundMental health care systems in Africa are faced with a high burden of mental disorders. There is need to explore evidence-based, scalable interventions to compliment the “traditional” health care system. Physical activity (PA) can augment the effectiveness of existing programs. However, little is known about the perspectives of health care professionals on PA. Understanding this is key to implementation.MethodsThis was a qualitative exploratory study based on 13 key informant interviews among experienced health care professionals working at Butabika National Referral and Teaching Hospital, Uganda. Data was analyzed through content thematic analysis.ResultsParticipants reported PA benefits were: improved individual competences and engagement, social reintegration and reduced family and community burden. Self-stigma, lack of community support, lack of infrastructure and equipment, lack of monitoring capacity, human resource challenges and a focus solely on pharmacotherapy were among the most reported barriers to application of PA in management of mental health problems.ConclusionDespite the high level of understanding of PA among health care professionals, PA promotion largely depends on implementation of strategies to deal with community and health systems barriers. Although patients need to be empowered to deal with their individual barriers, greater support and action is needed by policy makers. Public health programs should support PA through community engagement and social re-integration programs. The government should promote a holistic mental health care perspective and provide adequate infrastructural and human resources to support PA in the existing primary and mental health care systems.     

Improving access to and outcomes from mental health care in rural Australia

OBJECTIVE: Rural Australians face particular difficulties in accessing mental health care. This paper explores whether 51 rural Access to Allied Psychological Services projects, funded under the Better Outcomes in Mental Health Care program, are improving such access, and, if so, whether this is translating to positive consumer outcomes. DESIGN AND METHOD: The paper draws on three data sources (a survey of models of service delivery, a minimum dataset and three case studies) to examine the operation and achievements of these projects, and makes comparisons with their 57 urban equivalents as relevant. RESULTS: Proportionally, uptake of the projects in rural areas has been higher than in urban areas: more GPs and allied health professionals are involved, and more consumers have received care. There is also evidence that the models of service delivery used in these projects have specifically been designed to resolve issues particular to rural areas, such as difficulties recruiting and retaining providers. The projects are being delivered at no or low cost to consumers, and are achieving positive outcomes as assessed by standardised measures. CONCLUSION: The findings suggest that the rural projects have the potential to improve access to mental health care for rural residents with depression and anxiety, by enabling GPs to refer them to allied health professionals. The findings are discussed with reference to recent reforms to mental health care delivery in Australia.     

Our roles are not at ease: The work of engaging a youth advisory council in a mental health services delivery organization

ObjectivesThere is growing policy impetus for including youth voices in health services research and health system reform. This article examines the perspectives of professionals in a mental healthcare organization charged with engaging young people as advisors in service transformation.MethodsAn institutional ethnography of a youth mental health services organization in Ontario, Canada, was conducted. Fieldwork consisted of twelve months of observation of meetings, interviews with youth advisors and adult service providers, with subsequent text analysis of engagement training and policy materials. The present article reports data from six adult professionals and related field observations.ResultsService providers’ efforts to engage youth were observed in three areas: a) supporting youth''s development as advisors, b) retaining and deepening youth participation while waiting for organizational change and c) embedding relationships between youth and adults at various levels within the system of care. This work denotes existing tensions between the values and ideals of youth engagement and the everyday demands of services delivery.ConclusionIn this setting, a fundamental dimension of this work consisted of negotiating tensions between the policy enthusiasm for engagement and its realization in a health services context. In describing these contextual challenges, we outline implications for consideration by other youth mental health services. Engagement efforts that are authentic and sustained require resources and flexibility, and leadership commitment to instil service users’ perspectives throughout multiple levels within the organization.     

Primary care mental health workers: role expectations, conflict and ambiguity

A number of professionals are involved in mental health in primary care. The NHS Plan proposed the introduction of a new professional, the primary care mental health worker (PCMHW), to improve care in this setting. The present study was conducted to examine pilot PCMHW-type roles currently in existence, to explore staff expectations concerning the new PCMHW role and to consider the issues relating to roles in primary care mental health that are raised by this new worker. The study used a case study design, and involved qualitative interviews with 46 managers and clinicians from primary care and specialist mental health services, including pilot PCMHW-type roles. The key findings were as follows: The pilot PCMHW-type roles were almost exclusively related to client work, whereas respondents had far wider role expectations of the new PCMHWs, relating to perceived gaps in current service provision. This highlights the potential for role conflict. Secondly, there was disagreement and ambiguity among some respondents as to the nature of the new PCMHW's role in client work, and its relationship with the work undertaken by other mental health professionals such as counsellors, psychologists and nurses. Given that multiple professionals are involved in mental health care in primary care, issues relating to roles are likely to be crucial in the effective implementation of the new PCMHWs.     

Engaging consumers in the Australian emergency mental health context: a qualitative perspective from clinicians working in the community

Successfully engaging with consumers is seen as an essential component of mental healthcare, yet doing so can be challenging and little is understood about the unique engagement skills and attributes employed by mental health clinicians working in the emergency community context. Consequently, this qualitative study explored the engagement experiences of clinicians to identify the attributes used when engaging with consumers in this unique setting. We conducted two semi‐structured focus groups in July and August 2011 with 16 clinicians employed at one metropolitan mental health organisation in South Australia. Using thematic analysis, we identified two key themes pertaining to the skills and attributes used for successful consumer engagement: (i) building trust, through communication style, an honest approach, facilitating choice and locating trust networks; and (ii) portraying genuine care, through showing respect, offering practical assistance and taking the least restrictive pathway. These findings highlight the unique nature of engagement in the emergency community mental health setting, as well as the flexibility and resourcefulness required to facilitate it.     

Organizing mental health services: an evidence-based approach

BACKGROUND AND AIMS: Health policy makers and program developers seek evidence-based guidance on how to organize and finance mental health services. The Swedish Council on Technology Assessment in Health Care (SBU) commissioned a conceptual framework for thinking about health care services as a medical technology. The following framework was developed, citing empirical research from mental health services research as the case example. FRAMEWORK: Historically, mental health services have focused on the organization and locus of care. Health care settings have been conceptualized as medical technologies, treatments in themselves. For example, the field speaks of an era of "asylum treatment" and "community care". Hospitals and community mental health centers are viewed as treatments with indications and "dosages", such as length of stay criteria. Assessment of mental health services often has focused on organizations and on administrative science. There are two principal perspectives for assessing the contribution of the organization of services on health. One perspective is derived from clinical services research, in which the focus is on the impact of organized treatments (and their most common settings) on health status of individuals. The other perspective is based in service systems research, in which the focus is on the impact of organizational strategies on intermediate service patterns, such as continuity of care or integration, as well as health status. METHODS: Examples of empirical investigations from clinical services research and service systems research are presented to demonstrate potential sources of evidence to support specific decisions for organizing mental health services. RESULTS: Evidence on organizing mental health services may be found in both types of services research. In clinical services research studies, service settings are viewed as treatments (e.g. "partial hospitalization"), some treatments are always embedded in a service matrix (e.g. assertive community treatment), and, where some treatments are organizationally combined (e.g. "integrated treatment" for co-occurring mental disorder and substance abuse), sometimes into a continuum of care. In service system research, integration of services and of the service system are the main focus of investigation. Studies focus on horizontal and vertical integration, primary care or specialty care and local mental health authorities - each of which may be conceptualized as a health care technology with a body of evidence assessing its effectiveness. IMPLICATIONS: A conceptual framework for assessing the organization of services as a health care technology focuses attention on evidence to guide program design and policy development. Mental health services research holds promise for such decision-making guidance.     

The role of family carers in the use of personal budgets by people with mental health problems

Personal budgets aim to increase choice and independence for people with social care needs but they remain underused by people with mental health problems compared to other disability groups. The use of personal budgets may impact on families in a variety of ways, both positive and negative. This paper draws on interviews, undertaken in 2012–2013 with 18 family carers and 12 mental health service users, that explored experiences of family involvement in accessing and managing personal budgets for a person with mental health‐related social care needs. The sample was drawn from three sites across England, with additional carers being recruited via voluntary sector networks. Our findings show that for many people with severe mental health needs who lack motivation and confidence to negotiate access to personal budgets, carers may provide the necessary support to enable them to benefit from this form of social care support. We illustrate the role carers may play in initiating, pursuing and maximising the level of support available through personal budgets. However, some carers interviewed considered that personal budget funding was reduced because of practitioners’ assumptions about carers’ willingness and ability to provide support. We also report perceived tensions between family carers and practitioners around appropriate involvement in decision‐making. The study findings have implications for local authorities, practitioners and family carers in supporting the involvement of family carers in support for people with severe mental health problems.     

Managed care and mental health: personal realities

A review of the literature revealed mixed reviews on the impact of managed care on mental health service delivery. Research supports that managed care contributes to a reduction in inpatient costs and an increase in outpatient service use. Other studies suggest that there are problems with access and quality of care. An additional issue is whether or not, and to what extent, mental health services are "carved out" from physical health for patients. This study discusses the findings of a qualitative analysis of Medicaid managed care recipients on the barriers and enabling factors to obtaining mental health services in a full carve-out managed care model. Results indicate that reduced access, quality of care problems, and a lack of integration of care exist. Additionally, recipients' interactions with managed care, service providers, and caseworkers affect their mental health care. The results also report on the tactics used by recipients to cope with service problems. Implications for social work practice and research are discussed and recommendations for service delivery and evidence-based education are delineated.     

Implementation of diagnosis-related mental health programs: impact on health care providers

Mental health services are in the midst of change in different countries. In Quebec (Canada), the government has adopted a Mental Health Action Plan (2005-2010). In this context, 2 psychiatric institutions have developed and implemented a mental health services organization model based on diagnosis-related mental health programs and support for frontline services. This article presents the impact on health care providers of implementation of diagnosis-related mental health programs in the context of transformation of mental health services.     

Attending to physical health in mental health services in Australia: a qualitative study of service users’ experiences and expectations

Evidence is unequivocal: the premature death of people with severe mental health problems is attributable primarily to cardiovascular disease, and healthcare provided is often suboptimal. With the overarching aim of improving outcomes, policies and guidelines oblige mental health services and psychiatrists to monitor cardio‐metabolic health of patients and intervene as appropriate. Practice is highly variable; however, with ongoing debate about resourcing and responsibilities dominated by clinicians who have identified disinterest among patients as influencing practice. Seeking to balance discussion, we posed the question ‘what do patients experience and expect of mental health services in relation to their physical health?’ To answer it, we interviewed a convenience sample of 40 service users recruited from a mental health service in Australia, early in 2015. Data were analysed using the framework approach. With few regarding themselves as healthy, participants were commonly concerned about side effects of medication, weight and fitness but rarely mentioned tobacco smoking. Participants’ accounts reinforce extensive research demonstrating variability in attention to physical health in mental health services. Reports by some participants of comprehensive care are encouraging, but widespread uncertainty about reasons for various assessments and denial of requests for management of medication side effects, including weight gain, gives cause for concern. Although participants in this study wanted to improve their health and health‐related quality of life, they acknowledged that their motivation and ability to do so fluctuated with mental health. They expected clinicians to work proactively, especially when symptoms compromised capacity for self‐care, and mental health services to provide or enable access to health‐promoting interventions. Attention should be given, as a matter of priority, to creating conditions (culture and infrastructure) needed to support sustained attention to physical health within services and, importantly, to full engagement of service users in management of their physical health.