Psychiatric manpower: an overview.

There are approximately 25,000 to 30,000 psychiatrists in the United States, some 17,000 of whom are in actual clinical practice. As part of an overview of psychiatric manpower, the authors show the distribution of psychiatrists by state and present population-per-psychiatrist ratios. In discussing the distribution of psychiatrists in various work settings, they note that the decreasing percentages of psychiatrists in community mental health centers may be related to such factors as the large number of non-hospital-based centers, growing antimedical attitudes in centers, and psychiatrists' inclination to work in a setting similar to their training site. They believe that federal and state support should be increased for university-affiliated psychiatric training programs based in settings where psychiatrists are needed: state hospitals, VA hospitals, community mental health centers, and similar facilities. Such an approach would result in the recruitment and retention of greater numbers of psychiatrists in public service settings.     

Psychiatric reform in Germany

OBJECTIVE: To describe the ongoing process of German psychiatric reform and the structure and functioning of mental health services. METHOD: Information sources used include official reports describing mental health services, relevant publications related to organization and functioning of services. RESULTS: There has been far-reaching change in mental health care since the late 1960s: psychiatric hospitals have lost about 50% of their beds and one psychiatric hospital has been closed. One hundred and sixty-five general hospital psychiatric units have been built up. Out-patient, community and residential services have been developed. There is a lack of diversified residential and rehabilitation services, particularly for the most severely ill. Co-ordination of care is not always ensured, transfer of patients to remote nursing homes has occurred in some places. Carers and service users articulate their views to an increasing degree. CONCLUSION: Political and professional enthusiasm have been important in implementation of the German reform. Evolving it further will require major efforts.     

Mental health services in Cuba

Despite its limited resources, Cuba has developed an integrated mental health system that emphasizes prevention and community care. It consists of three distinct organizations: the Committee for the Defense of the Revolution, one of many mass community organizations that strive to protect the revolution; the policlinics, which provide comprehensive health services to geographic areas containing 25,000 to 40,000 people; and the psychiatric hospitals. All three use treatment approaches that are based on a social systems model and that emphasize solving current problems and disturbances. Behavioral and milder psychiatric problems are treated by policlinic psychologists, in the community whenever feasible, and major psychiatric disorders are treated by psychiatrists at the hospitals. Services for children and adolescents, research, and staff training in Cuba are also discussed.     

Training psychiatrists in the community: a report of the Italian experience

In 1978 a revolutionary mental health act was passed in Italy. By closing large mental hospitals and replacing them with community programs, it required a radical shift in psychiatric practice. The authors discuss the background philosophy, principles, and practical implications of this change. They describe a model program and training design of a 4-year residency in which psychiatrists learn the skills for community work while actually working in the community. The residency differs from most U.S. residencies in having trainees responsible for patients wherever they are being treated (residents are not rotated between services), its strong team orientation, and the value placed on community work.     

Planning mental health services: I. Background and key issues.

Planning mental health services is a complex task requiring an understanding of background developments and key issues related to mental health services. In Canada, the deinstitutionalization of patients attempted to shift the locus of care from provincial psychiatric hospitals to general hospital psychiatric units. This resulted in the isolation of provincial psychiatric hospitals, general hospital psychiatric units and community mental health programs, with little overall accountability for the services provided--three solitudes. To move toward the creation of responsible, integrated systems a number of issues must be addressed: target population(s); the roles of provincial psychiatric and general hospitals; community support services; continuity of care; co-morbidity; consumerism; and methods of integration. In the development of a comprehensive mental health plan, each issue should be recognized and decisions made which are in keeping with current knowledge. A companion report will survey Canadian initiatives in mental health planning and discuss approaches to many of the issues identified.     

Italian psychiatric reform 20 plus years after

OBJECTIVE: To describe the current situation of mental health care in Italy and implementation of mental health reform legislation. METHOD: The current mental health care system and studies of the implementation of psychiatric reform are described. RESULTS: The 1978 reform law inaugurated fundamental changes in the care system (prohibiting admissions to state mental hospitals, stipulating community-based services, allowing hospitalization only in small general-hospital units). Uneven reform implementation was reported initially. However, in 1984 in- and out-patient services in the community were available to >80% of the population. There is a comprehensive network of in- and out-patient, residential and semi-residential facilities. Recently, services have been jeopardized by the managed-care revolution, and non-profit organizations supplement the public system (especially residential care, employment and self/mutual help). CONCLUSION: Implementation of the psychiatric reform law has been accomplished, and the year 1998 marked the very end of the state mental hospital system in Italy.     

State of psychiatry in Serbia - Problems, advances and perspectives

Abstract Serbia has been exposed to many severe stressors during the last 20 years and as a result there is an increase of the incidence of mental health problems in its population, so that mental disorders are the second largest public health problem, after cardiovascular diseases. The National Strategy for Development of Mental Health Care was approved by the government in January 2007 which initiated the reform of psychiatry in the country. The major advantages of the existing organization of mental healthcare are a sufficient number of psychiatric services and the number of well educated professionals, but there are considerable problems in big psychiatric hospitals which are significantly overcrowded with patients, as well as with the lack of a network of community services. In the future, key points of mental health reform aim to focus on improved cooperation and collaboration between primary, secondary and tertiary healthcare levels, definition of catchment areas and responsibilities, continuing education of general practitioners in mental health issues, and better cooperation between psychiatric and social welfare institutions. The profile of the Institute for Mental Health is described as a case of good practice in the field of mental healthcare in Serbia.     

Barriers to access to mental health services for ethnic seniors: the Toronto study.

OBJECTIVE: To identify and describe barriers to access to mental health services encountered by ethnoracial seniors. METHOD: A multiracial, multicultural, and multidisciplinary team including a community workgroup worked in partnership with seniors, families, and service providers in urban Toronto Chinese and Tamil communities to develop a broad, stratified sample of participants and to guide the study. This participatory, action-research project used qualitative methodology based on grounded theory to generate areas of inquiry. Each of 17 focus groups applied the same semistructured format and sequence of inquiry. RESULTS: Key barriers to adequate care include inadequate numbers of trained and acceptable mental health workers, especially psychiatrists; limited awareness of mental disorders among all participants: limited understanding and capacity to negotiate the current system because of systemic barriers and lack of information; disturbance of family support structures; decline in individual self-worth; reliance on ethnospecific social agencies that are not designed or funded for formal mental health care; lack of services that combine ethnoracial, geriatric, and psychiatric care; inadequacy and unacceptability of interpreter services; reluctance of seniors and families to acknowledge mental health problems for fear of rejection and stigma; lack of appropriate professional responses; and inappropriate referral patterns. CONCLUSIONS: There is a clear need for more mental health workers from ethnic backgrounds, especially appropriately trained psychiatrists, and for upgrading the mental health service capacity of frontline agencies through training and core funding. Active community education programs are necessary to counter stigma and improve knowledge of mental disorders and available services. Mainstream services require acceptable and appropriate entry points. Mental health services need to be flexible enough to serve changing populations and to include services specific to ethnic groups, such as providing comprehensive care for seniors.     

The Italian mental health reform nine years on

It is 9 years since the mental health reform was passed by the Italian Parliament. The author presents a data-based evaluation of the effects of the Italian mental health reform. There are still many problems to be resolved: More than 30,000 inpatients are still in psychiatric hospitals and little is known of the fate of those discharged in recent years. District mental health services are still lacking, especially in the south of the country; Psychiatric units in the general hospital function much the same way as the "old" psychiatric hospitals. The pattern of mental health services consumers have changed: They are younger with less severe psychiatric diagnosis and come from a higher social background.     

Child psychiatry practice patterns in Ontario.

OBJECTIVES: To examine the demographics, training, distribution, venues of practice, remuneration patterns, and professional affiliations of child psychiatrists in Ontario. METHOD: In July 1997, questionnaires were sent to 229 Ontario psychiatrists. A second mailing was sent to nonresponders in the fall of 1997. The overall response rate was 66.8%. RESULTS: Compared with other research regarding the ratio of child psychiatrists to children with mental health problems, Ontario fares relatively well (1:6148). Generally, Ontario child psychiatrists report having received formalized training in the speciality. Child psychiatrists are disproportionately concentrated in Toronto and in midsize cities with medical schools compared with rural regions. Out-reach services to smaller communities are provided by 30% of child psychiatrists, but it is not clear whether the services are sufficient and equitably available. Approximately 50% of current psychiatrists will be aged 65 years or older in 15 years, and it is unclear whether sufficient numbers will replace them. The profession appears to be reaching an equitable gender representation. Most child psychiatrists belong to the professional organizations that support the profession; however, they are least likely to belong to the Ontario Psychiatric Association (OPA). CONCLUSIONS: An optimal ratio of child psychiatrists per population served still needs to be determined, with special consideration given to the needs of rural communities. The small ratio of child psychiatrists to the population of children with mental health needs highlights the importance of collaborating with other medical and mental health professionals. Recruiting and retaining child psychiatrists will need to be monitored. Child psychiatrists in Ontario need a unified voice to address these issues.     

Deinstitutionalization and the private general hospital inpatient unit: implications for clinical care

Deinstitutionalization has led to a rapid shift from reliance on state hospitals to use of community-based inpatient psychiatric services. While these inpatient units were initially envisioned as an integral part of the community mental health system, a number of sociopolitical and clinical pressures have caused general hospitals to respond to their new responsibilities in different ways. The authors review trends in deinstitutionalization, the diverging interests of public and private general hospitals, and problems in patient care that result. Based on a discussion of how Beth Israel Hospital, a nonprofit private general hospital in Boston, has dealt with such issues, they describe adaptive responses in four areas: admission criteria, patient management approaches, aftercare planning, and staff training.     

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.     

Development of Community Care for People with Schizophrenia in Chile

Chile has greatly reformed its approach to psychiatric care in the last two decades, having transitioned from a model centered around a psychiatric hospital to one in which mental health care is based in the community. During this period, patients were moved from large psychiatric hospitals into ambulatory clinics, and the number of people who were in hospitals for extended periods decreased. At the same time, mental health service networks—consisting of ambulatory clinics, day hospitals, rehabilitation centers, and community group homes—were created, each responsible for a specific population. The reform process, however, has occurred in different, unequal degrees throughout the country. The purpose of this investigation is to compare the characteristics, resources, and results of the mental health service networks that have successfully transitioned to and developed in the community with respect to those that are still centered in a hospital. The structural aspects were evaluated with the EvaRedCom-TMS (Evaluación de Redes de Servicios Comunitarios para Trastornos Mentales Severos), and the level of functioning was measured with World Health Organization's International Classification of Mental Health Care. Area networks with higher levels of community-based services show better indicators of geographic and financial accessibility, use less human resources (particularly psychiatrists and nursing assistants), have an equal level of specialization, and yet show better treatment adherence among the patients (84.2 percent versus 41.8 percent), despite the fact that the patients have worse socioeconomic and clinical indicators than area networks with lower levels of community-based services. In conclusion, the community-based psychiatric care model is more effective than the hospital-centered model.     

A brief history of psychiatry in Singapore

The development of psychiatric services in Singapore during the last 150 years can be divided into four distinct, albeit overlapping, phases: (1) the origins of the Lunatic Asylum; (2) the interruption caused by the Japanese Occupation, and the post-war years; (3) the training of local psychiatrists and mental health professionals; and (4) the development of general hospital psychiatry and community mental health services. Early psychiatry in Singapore was essentially British psychiatry as an outpost but modified by local conditions. Modern psychiatry in Singapore has its roots in Singapore's colonial past and is strongly influenced by Western psychiatry. It has come a long way since its humble beginnings when the first mental hospital was established in 1841.     

Help seeking behaviour of psychiatric patients before seeking care at a mental hospital.

BACKGROUND: A wide range of professionals including psychiatrists, psychologists, general physicians, faith-healers and religious healers cater to the needs of mentally ill patients. Psychiatric facilities are available at general hospitals, office based practice and mental hospitals. Psychiatrists are preferred the least due to stigma. The present work reports on treatment options used by a group of psychiatric patients before visiting a mental hospital. AIM: To study the help seeking behaviour of patients visiting a mental hospital. METHOD: Patients attending psychiatric outpatient service at a mental hospital were asked specifically about various treatment facilities utilized by them before coming to the hospital and the reasons thereof. RESULTS: A wide range of services was used by the subjects varying from professional care to faith healers. Trust, easy availability and accessibility, recommendations by the significant others and belief in supernatural causation of illness were the important reasons for choosing a particular facility. Thus sociocultural factors appeared to influence the help seeking behaviour. CONCLUSION: A substantial number of patients suffering from severe mental disorders seek non-professional care. There is a need of studies in community to assess the help seeking behaviour of psychiatric patients and factors associated with it.     

Mental health services in Asia: International perspective and challenge for the coming years

In contrast to European countries and the United States of America, there has been a steady increase in the psychiatric inpatient population in Japan between 1960 and 1993. Japan has the biggest number of psychiatric beds in the world, both in absolute and relative numbers per population. However, Japan now focuses on community based services and the human rights of patients. In other Asian countries, the number of psychiatric beds is relatively small; however, the numbers are increasing each year in China, the Republic of Korea, Philippines, Indonesia and in many other countries in Asia. These countries are still facing the challenge of increasing psychiatric services and to improve the quality of care with scarce mental health resources. Should Asian countries take the similar path to European countries and develop mental health services? This review provides an overview of Asian mental health services and discussing the following issues: how many psychiatric beds do we need in Asia?; public vs private psychiatric services?; financing scheme to promote community based care in Asia; mental health services in primary health care; family education and user involvement in Asia; and the challenge for psychiatrists in Asia.     

Queensland psychiatrists' attitudes and perceptions of adults with intellectual disability

Background Quality mental health care for adults with an intellectual disability (ID) depends upon the availability of appropriately trained and experienced psychiatrists. There have been few surveys of psychiatrists working with this population. Method This Australian study obtained psychiatrists’ attitudes to and perceptions of the mental health needs of adults with an ID. Training needs were also sought. The survey instrument used was a purposely designed, 28‐item self‐administered questionnaire featuring multiple‐choice and open‐ended questions. Results The majority of psychiatrists expressed concerns about treatment of this group, describing unmet needs. A total of 75% considered that antipsychotics were overused to control aggression, and 34% of psychiatrists were reluctant to treat adults with an ID. In total, 85% agreed that mental health in ID should be offered as a training option for psychiatric registrars, and that specialized mental health services would provide a high standard of care for this population. Conclusion Broad concerns are raised regarding pathways to mental health care for adults with an ID in Australia. An Australia‐wide training strategy needs to be developed. Partnerships between mental health, disability and community services that serve the mental health needs of this population, should actively seek to engage psychiatrists.     

Spanish psychiatric reform: what can be learned from two decades of experience?

OBJECTIVE: The objective of the paper is to describe the impact of Spanish psychiatric reform on the organization and functioning of mental health services. METHOD: This paper is based on official administrative reports and on relevant related publications. RESULTS: The most significant achievements of Spanish psychiatric reform have been: (i) the development of a new organization of mental health care, decentralized in character and territorially based; (ii) the integration of psychiatric patients in general health care; (iii) the creation of an extensive community network of health centres; and (iv) the development of more positive attitudes towards mental illness. However, our analysis also reveals the existence of significant deficiencies. CONCLUSION: Analysis of the Spanish experience shows that the process of psychiatric reform depends basically on long-term commitments, which in a system such as Spain's must come from central administration and also from the autonomous communities.     

A brief history of psychiatry in Singapore

The development of psychiatric services in Singapore during the last 150 years can be divided into four distinct, albeit overlapping, phases: (1) the origins of the Lunatic Asylum; (2) the interruption caused by the Japanese Occupation, and the post-war years; (3) the training of local psychiatrists and mental health professionals; and (4) the development of general hospital psychiatry and community mental health services. Early psychiatry in Singapore was essentially British psychiatry as an outpost but modified by local conditions. Modern psychiatry in Singapore has its roots in Singapore's colonial past and is strongly influenced by Western psychiatry. It has come a long way since its humble beginnings when the first mental hospital was established in 1841.     

Toward increased psychiatric presence in community mental health centers.

The presence of psychiatrists in community mental health centers has diminished in recent years, especially in centers that are non-hospital-based and that are located in rural or disadvantaged urban settings. The decrease in psychiatric leadership in the centers is particularly notable. Factors contributing to the trend include lower salaries than in the private sector, a decrease in the number of patients with severe mental disorders coming to the centers, and the impact of a decrease in specialized training programs in community psychiatry. The authors suggest several incentives to increase psychiatric presence in the centers, including developing staffing standards as a condition of funding, giving psychiatrists time to do research and evaluation and to teach, and increasing the medical involvement of centers through links with general hospitals, private psychiatric hospitals, and medical schools.