Psychiatric reform in Russia

OBJECTIVE: To describe the mental health care system in Russia against the background of rapid social, economic and political change since the late 1980s. METHOD: Indicators of social stress and deteriorating population mental health and official data on service provision are presented. RESULTS: In the current system of psychiatric care dispensaries take a central position. Key issues of the discussion on mental health care include ways of coping with social stress disorders, strategies to redefine psychiatric rehabilitation in a changed social-economic context and steps towards strengthening social support networks for people with mental illness. Following political abuse of psychiatry, professionals have had to face justified and unjustified accusations, and been faced with a general challenge to their role. CONCLUSION: Tackling problems of social stress, the integration of mental health care in the general medical care system and the building-up of general hospital in-patient psychiatric units are of strategic importance.     

Chile mental health country profile

This paper describes main facts about Chile starting with key socio-demographic, socio-economic, political, environmental, epidemiological, social support and social pathology aspects that characterize the context in which current mental and neurological policy and programmes have been put in place since 2000, as part of the National Health Plan and Health Sector Strategy Plan. The ‘National Plan for Mental Health and Psychiatry’, using a community psychiatry approach, has been partially implemented for people covered by the Public Health Insurance, which comprises 62% of the Chilean population (people with lower income). This paper also describes: the management, population needs and demands, financial resources, human resources in primary care, mental health specialist care and community-based care, physical capital, social capital, provision and processes, and outcomes of the plan. Strengths are analyzed, like the health reform, including its values and principles, the active participation of consumer and family groups as well as mental health NGOs, access to mental health services through primary care, quality assurance of the mental health services delivered to the population and progressive development of a culture of respect for human rights, including those of people with mental illnesses. Finally, difficulties for the advance of mental health care are also enumerated: the low priority still given to mental health compared with physical health by the country's leaders, the insufficient emphasis on mental health in both undergraduate and postgraduate professional training, the strong stigma and discrimination associated with mental illness in the general population and the advocacy by some mental health professionals of the traditional model of care (role of the psychiatric hospital).     

Attitudes of mental health professionals toward people with schizophrenia and major depression

Several studies reveal poor knowledge about mental illness in the general population and stigmatizing attitudes toward people with mental illness. However, it is unknown whether mental health professionals hold fewer stigmatizing attitudes than the general population. A survey was conducted of the attitudes of mental health professionals (n = 1073) and members of the public (n = 1737) toward mental illness and their specific reaction toward a person with and without psychiatric symptoms ("non-case" as a reference category). Psychiatrists had more negative stereotypes than the general population. Mental health professionals accepted restrictions toward people with mental illness 3 times less often than the public. Most professionals were able to recognize cases of schizophrenia and depression, but 1 in 4 psychiatrists and psychologists also considered the non-case as mentally ill. The social distance toward both major depression and the non-case was lower than toward schizophrenia. However, in this regard, there was no difference between professionals and the public. The study concludes that the better knowledge of mental health professionals and their support of individual rights neither entail fewer stereotypes nor enhance the willingness to closely interact with mentally ill people.     

Chile mental health country profile

This paper describes main facts about Chile starting with key socio-demographic, socio-economic, political, environmental, epidemiological, social support and social pathology aspects that characterize the context in which current mental and neurological policy and programmes have been put in place since 2000, as part of the National Health Plan and Health Sector Strategy Plan. The 'National Plan for Mental Health and Psychiatry', using a community psychiatry approach, has been partially implemented for people covered by the Public Health Insurance, which comprises 62% of the Chilean population (people with lower income). This paper also describes: the management, population needs and demands, financial resources, human resources in primary care, mental health specialist care and community-based care, physical capital, social capital, provision and processes, and outcomes of the plan. Strengths are analyzed, like the health reform, including its values and principles, the active participation of consumer and family groups as well as mental health NGOs, access to mental health services through primary care, quality assurance of the mental health services delivered to the population and progressive development of a culture of respect for human rights, including those of people with mental illnesses. Finally, difficulties for the advance of mental health care are also enumerated: the low priority still given to mental health compared with physical health by the country's leaders, the insufficient emphasis on mental health in both undergraduate and postgraduate professional training, the strong stigma and discrimination associated with mental illness in the general population and the advocacy by some mental health professionals of the traditional model of care (role of the psychiatric hospital).     

Mental health service utilization by Ethiopian immigrants and refugees in Toronto

The purpose of this study was to examine the mental health service utilization patterns of Ethiopians in Toronto. A cross-sectional epidemiological survey of 342 randomly selected adults was conducted, based on a conceptual model of healthcare utilization suggested by Anderson and Newman. The results suggested that 5% of the respondents sought mental health services from healthcare professionals and 8% consulted nonhealthcare professionals. Although Ethiopians' utilization rate of mental health services did not greatly differ from the rates of the general population of Ontario (6%), only a small proportion (12.5%) of Ethiopians with mental disorders used services from healthcare professionals, mostly family physicians. The data also suggested that Ethiopians were more likely to consult traditional healers than healthcare professionals for mental health problems (18.8% vs. 12.5%). In multivariate logistic regression analyses, while the number of somatic symptoms experienced was positively associated with increased mental healthcare utilization (OR = 1.515, p < 0.05), having a mental disorder was associated with decreased mental healthcare utilization (OR = 0.784, p < 0.01). Our findings have important implications for mental health services. On the one hand, the findings suggest that somatic symptoms could lead to increased use of mental health services, particularly family physicians' services. On the other hand, the data suggested that although the mental healthcare needs of Ethiopians are high, they use fewer mental health services from healthcare professionals. It would seem that family physicians could play important role in identifying and treating Ethiopian clients with somatic symptoms, as these symptoms may reflect mental disorder.     

Recent developments in the care, treatment, and rehabilitation of the chronic mentally ill in Italy

Italy's mental health law of 1978 brought dramatic changes in mental health care to Italy by immediately closing large state hospitals to new patients. The law mandated a trend begun 20 years earlier by a group of professionals dedicated to dismantling large psychiatric hospitals. It is based on models developed by these professionals to move hospitalized patients into the community and to care for them through teams of former hospital personnel working with local social agencies. In 1974, the professionals founded Democratic Psychiatry, a society whose aims included continuing to dismantle the hospitals. The work of the society and the provisions, problems, and successes of the mental health law are summarized. The author believes that valuable lessons can be learned from the gradualism inherent in the models used in devising the law and from the national health insurance support that implemented it.     

Collaboration Between Mental Health Professionals and Family Physicians: A Survey of New Jersey Family Physicians

Background: Mental health problems are frequent in primary care, and there are many barriers to their detection and treatment. Clinical research protocols that include close collaboration between mental health professionals and primary care physicians have been found to be beneficial. This study explores the opinions of community family physicians regarding mental health professionals working directly in the primary care office.Method: Members of the New Jersey Academy of Family Physicians (N = 709) were sent a 25-item questionnaire about collaboration with mental health professionals. Three mailings were sent, with a 62% response rate. The surveys were mailed between May and July 1999.Results: Of family physicians included in the analysis, 13.5% reported having an in-office mental health professional. Of those who did not, 60.2% responded that they would consider having one. Compared with physicians who would not consider having an in-office mental health professional, physicians with a mental health professional and those without an in-office mental health professional but who would consider one were statistically more likely (p < .01) to respond that an in-office mental health professional would result in increased use of mental health services, improved acceptance of referrals to mental health professionals, and improved detection and treatment of mental health problems.Conclusion: Although few family physicians have an in-office mental health professional, many more would consider this arrangement and recognize the potential benefits of such collaboration.     

Psychiatric morbidity and posttraumatic symptoms among earthquake victims in primary care clinics

Three months after the devastating Chi-Chi earthquake (magnitude of 7.3 on the Richter scale) struck the central area of Taiwan, 663 victims were screened for psychiatric morbidity at a local general hospital in a community mental health program. The rate of psychiatric morbidity as defined by the 12-item Chinese Health Questionnaire as greater than 4, was 24.5%. Posttraumatic symptoms were still prevalent. The rate of posttraumatic stress disorder was 11.3%, and the rate of partial PTSD was 32.0%. Variables associated with the presence of psychiatric morbidity and posttraumatic symptoms included female gender, old age, financial loss, obsessive trait, and nervous trait. A disproportionate use of mental health services (18%) was found, suggesting an urgent need to deliver mental health care to disaster victims at local medical settings. In addition, health care professionals who work with the earthquake victims need to be promptly and efficiently trained in mental health crisis intervention.     

Diagnosis and treatment of older adults with depression in primary care.

This article provides an overview of current challenges in the diagnosis and treatment of depressed older adults in primary care and considers suggestions for clinicians, researchers, and policy makers to improve care for this population. Despite the enormous toll of depression on individuals and society and the availability of effective treatments, depressed older adults remain largely untreated or undertreated. They rarely see mental health professionals, but have relatively frequent contact with primary care providers. In primary care, the chronic and recurrent nature of depression and a number of patient, provider, and policy-related barriers interfere with effective depression treatment. Recent research suggests that improving care for individuals with late life depression will require education and engagement of older adults and their primary care providers as active partners in caring for depression. It will also require additional human resources and systematic models of care dedicated to proactively managing depression as a chronic illness. Finally, it will require training of mental health professionals to effectively collaborate with their colleagues in primary care in treating depressed older adults. Further improvement in depression care would likely result from the implementation of true parity for mental health treatments for older adults.     

Person-centred mental health care: the challenge of implementation

Within mental health care, 'person-centredness' has been generally interpreted to convey a holistic approach with an attitude of respect for the individual and his/her unique experience and needs. Although it has been possible to demonstrate that professionals can acquire such skills through training, the impact on clinical outcomes has been more difficult to demonstrate in randomized controlled trials. Indeed what is becoming increasingly apparent in the literature is the need to acknowledge and address the degree of complexity that exists within the health care system that militates against achieving satisfactory implementation and outcomes from person-centred mental health care. In addressing this, we must develop and work with more sophisticated and three-dimensional models of 'patient-centredness' that engage with not only what happens in the consulting room (the relationship between individual service users and healthcare professionals), but also addresses the problems involved in achieving person-centredness through modifying the way that services and organizations work, and finally by engaging families and communities in the delivery of health care. A truly meaningful concept of 'people-centredness' encompasses how the views of the population are taken into consideration not only in healthcare but also in health and social care policy, and wider society too.     

Demand for,access to and use of community mental health care: lessons from a demonstration project in India and Pakistan

BACKGROUND: A widely promoted model of mental health care and prevention appropriate to many low-income countries is one that is integrated into the local primary health care system. AIMS: To examine the influence of health-seeking behaviours (demand-side factors) and the access to/availability of services (supply-side factors) on local service utilisation patterns for people with common mental disorders. METHOD: Two rural catchment populations outside Bangalore (India) and Rawalpindi (Pakistan), one with the standard primary health care system, the other with additional mental health care training and support, were screened for common mental disorders. Diagnosed cases were interviewed about their use of and perceptions of local health care services (repeated three months later). RESULTS: Individuals' use of integrated mental health and other care was modest. Principal (self-rated) supply-side factors were the cost of care, distance from treatment centre, a perception that care would not be effective, and concerns regarding stigma. Perceptions improved over three months, accompanied by an increased preference for public over private providers, but this was not restricted to the integrated care localities. CONCLUSION: The use (and therefore effectiveness) of mental health services integrated into primary care is influenced by the health-seeking behaviours and perceptions of the local population. Efforts to integrate mental health into primary care need to be accompanied by educational activities in order to increase awareness, reduce stigma and draw attention to the availability of effective treatment.     

Ausgaben in der psychiatrischen Versorgung

BACKGROUND: There is no doubt that mental health care should be geared toward evidence, cost-effectiveness, and need. Health care data that allow comparisons of demand and real needs are scarce. This is especially true for outpatient care. METHOD: The aim of this study was to assess and analyze data from health insurance plans and social welfare. RESULTS: The costs of mental health care in Germany amount to 13 mio per year and 100,000 population. Health insurance schemes account for two thirds of total costs and social welfare for one third. The distribution of expenses seems not to be based on need analyses. Especially the chronically mentally ill are disadvantaged. CONCLUSIONS: The redistribution of expenses from inpatient to outpatient care including integrated health care approaches would result in more cost-effective mental health care.     

Recommendations of mental health professionals and the general population on how to treat mental disorders

Objective The objectives of the study are (1) to assess the mental health literacy of mental health professionals, (2) to determine whether there is agreement between different professional groups with respect to different psychopathological conditions and (3) to compare the professionals' knowledge with that of the general population. Methods Two representative samples of mental health professionals and laypersons were presented with a vignette depicting either a person with schizophrenia, major depression or without any psychiatric symptoms (‘non-case’). Out of 18 treatment proposals, the respondents were asked to indicate the proposals regarded as helpful and those considered as being harmful, respectively, for the person depicted. Results Mental health professionals view their profession and less often their treatment methods as helpful. Dealing with the situation alone, electroconvulsive therapy, hypnotics and sedatives are consistently regarded as harmful. For the individual with schizophrenia, mental health professionals agree about helpful treatments. Regarding depression, a lack of consensus is found about treatment proposals such as psychiatric hospitalisation, antidepressants and complementary and alternative medicine. An important part of mental health professionals suggests medical help (psychologists and general practitioners) for the non-case vignette. Fewer nurses, social workers, vocational workers and occupational therapists (‘other therapists’) as compared to psychiatrists and psychologists recommend standard treatment methods. Professionals and the general population significantly differ in their attitudes towards the treatment suggestions, especially regarding medication and alternative medicine. Conclusions To improve the treatment of mental disorders, various strategies must be considered. These include permanent education of all mental health professionals, especially nurses and other therapists. A special focus must be given to affective disorders and a potential (over-) treatment of normal behaviour.     

Facing war,terrorism, and disaster: toward a child-oriented comprehensive emergency care system

The combination of the overwhelming nature of disasters and the massive losses they engender gives rise to a complex clinical and social picture with longterm physical, psychological, and social effects on children, families, and communities. The authors suggest that to assess the damage properly, implement interventions on a large scale, keep tabs on rising needs, and restore societal function, mental health professionals must adopt an ecologic systems approach. This approach entails working within and together with related institutions (education, health, local government) and assisting other committed professionals within these institutions to mediate care. This is of utmost importance in the area of children's care because of their particular vulnerability and their special importance for families and society. For this reason, the authors suggest that emergency mental health systems be better designed and implemented while keeping children at the center of their focus. An essential component of the ecologic systems approach is improved education for mental health professionals, providing them the appropriate tools to cope with widespread disaster and the expertise to apply these tools. This approach, however, is not enough. A good outcome cannot be achieved without preparedness on the part of the other relevant institutions and the community as a whole. Greater awareness is needed among local and national authorities of the importance of metaadaptive systems and of local, national, and international networking. In the current global village that is threatened by pervasive terrorism, no community must face it alone. The challenge of a disaster to one community is a challenge to all. By working together we can lessen the devastating impact of these events, save countless lives, prevent untold suffering, and maintain hope for a better world for children.     

The political evolution of mental health parity

This article traces the evolution of the mental health parity debate in American politics, with a focus on how interest groups and politicians have attempted to influence perceptions about treatment effectiveness and the cost of benefit expansion. When parity laws are in place, they require health plans operating in the private health insurance market to provide an equivalent level of coverage for mental health and general medical care. Business and insurance industry groups oppose parity due to cost concerns. The mental health community has framed parity as an antidiscrimination measure that would achieve greater insurance equity across disease groups. The role of personal experience with mental illness among lawmakers and others in framing the parity debate is also considered.     

Transition from child and adolescent mental health care to adult services for young people with Attention-Deficit/Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder (ASD) in Europe: Barriers and recommendations

Transition in mental health care is the process ensuring continuity of care of a young patient arriving at the CAMHS (Child and Adolescent Mental Health Service) age boundary within mental health services. Transition refers to a transfer to an adult mental health service (AMHS), to private care or other mental health community services. A transition plan can also lead to a managed end of specialized care with involvement of a general practitioner or social services. For young people with a diagnosis of ADHD (Attention Deficit Hyperactivity Disorder) or ASD (Autism Spectrum Disorder), two disorders that persist into adulthood, an optimal transition would ensure continuity of care or facilitate access to specialized care in the case of a discharge. Transition typically occurs during adolescence, a known sensitive period when young people may experience major changes at several levels: physiological, psychological and social. Any barrier in the transition process resulting in discontinuity of care may worsen the symptoms of ADHD or ASD and can ultimately adversely affect the global mental health of young people with such neurodevelopmental disorders. The objectives of this narrative review are: 1/to identify the barriers in the transition process in mental health services often faced by young people with these two disorders; 2/to highlight specific recommendations for strengthening the CAMHS-AMHS interface that have been proposed by various countries in Europe.     

Shame and acute psychiatric inpatient care: healthcare professionals

This qualitative research study convened focus groups to learn about situations that might provoke shame in people receiving mental health services and mental health professionals alike. The focus groups convened for mental health professionals were made up of psychiatrists, social workers, occupational therapists and mental health nurses – six men and eight women in total. Age ranges spanned from early 20 to 55; all had different lengths of service and experience. Ten people with experience of using mental health services also volunteered to take part in the focus groups – five men and five women with an age range of 30–63 years. Varied clinical diagnoses included schizophrenia, bipolar affective disorder, depression and personality disorder. Internationally, there are concerns for the quality of treatment and care offered to people with mental health problems and requiring hospital admission. There is also evidence to suggest that healthcare professionals can experience stigma and shame because of the complexities of their work. Information gained from the focus groups suggests that a better understanding of difficulties encountered by people in need of mental health services is possible. The study also permitted glimpses of the problems and distress faced by mental healthcare professionals because of moral dilemmas and challenges concerned with the overall nature of their chosen work. Although moderate in scope, this research study might help inform health and social policy research agendas along with professional education and training programmes. An awareness of the complexities in relation to ways in which shame is aroused in individuals and groups of people could contribute to improving the quality of care provided to communities.     

Perspectives of psychiatric care in Leipzig--deinstitutionalization from the viewpoint of neurologist/psychiatrist in private practice and the work of consortium of community psychiatric services

Two perspectives of mental health care in Leipzig are outlined. Critical aspects of deinstitutionalization are discussed from the point of view of an office-based Nervenarzt (neurologist and psychiatrist). The limitations of office-based practice in providing care for the severely mentally ill (SMI) are described, i.e. lack of a multidisciplinary community mental health team, community psychiatric nursing and social work back-up in particular. Residential service and nursing homes are often under-staffed and ill-prepared for caring for people with SMI. A second view-point describes the Verbund Gemeindenahe Psychiatrie, a community psychiatric service for the just under 500,000 population of Leipzig in seven community mental health centers each combining day hospital, out-patient clinics and multidisciplinary community psychiatric care. This service is unique in Saxony and well accepted by service users and professionals.     

Pathways to the first contact with specialist mental health care

OBJECTIVE: To examine the pathways to mental health care followed by patients presenting for the first time to community- and hospital-based services and the degree to which individual characteristics, cultural background, illness type, severity and service-related variables influence the time and pathways taken to reach care. METHOD: One hundred and forty-six consecutive Australian-born, Asian and Arabic-speaking patients making their first lifetime contact with mental health services in two area health regions were included. Symptom severity was assessed using the Health of the Nations Outcome Scales. Illness explanatory models, social support, English-language proficiency and acculturation were also assessed. RESULTS: An average of three professional consultations were made prior to first contact with public mental health services. Family physicians occupied a pivotal role in the help-seeking pathway with 53% of patients consulting a general practitioner. The median time taken to reach specialist mental health services was 6 months, with significantly shorter time for patients with psychotic disorders. Individual variables such as gender, social support, ethnicity and English fluency were not associated with delays in receiving public mental health care. Ethnicity was associated with lower utilization of allied health professionals. CONCLUSIONS: The data suggest that social and cultural factors influence the range of professionals consulted by those with a mental illness but do not delay their presentation to public mental health services.     

Suffering and mental health during social crises

In this paper the author analyzes the epidemiological data of the effects of the social crisis on the mental health against the background of the political and social events in Argentine in the last years. These effects are found both in the general population and in the health care professionals. The article reviews the clinical and psychopathological approaches to understand the disorders of the patients during a social crisis.