Comprehensive community-based mental health outreach services for suburban seniors.

An outreach program to deliver mental health services to mentally ill older adults has been developed in Baltimore County, Maryland. Incorporating prevention and early intervention strategies, this program targets persons aged 60 and over with late-onset or previously undiagnosed psychiatric histories. Services are provided through a novel one-third/one-third/one-third delivery schedule in senior centers, in community mental health centers, and in seniors' homes.     

Implications of a mental health intervention for elderly mentally ill residents of residential care facilities

Unresolved issues of responsibility between mental health and aging systems low priority within the mental health system for serving older RCF residents, and little expectation for the facility to be a treatment environment, all contribute to gaps in service delivery to mentally ill boarding home residents. This article reports the results of a two-year mental health intervention in RCFs. Findings show little intervention impact, but revealed that residents treated were generally socially marginal with weak ego skills, rather than significantly mentally ill. A more intensive program that restructures the facility's milieu to offer planned normal life demands and that models structured programs like milieu treatment, in situ treatment for the younger mentally ill, and programs for developmentally disabled persons is suggested.     

Barriers to improvement of mental health services in low-income and middle-income countries

Despite the publication of high-profile reports and promising activities in several countries, progress in mental health service development has been slow in most low-income and middle-income countries. We reviewed barriers to mental health service development through a qualitative survey of international mental health experts and leaders. Barriers include the prevailing public-health priority agenda and its effect on funding; the complexity of and resistance to decentralisation of mental health services; challenges to implementation of mental health care in primary-care settings; the low numbers and few types of workers who are trained and supervised in mental health care; and the frequent scarcity of public-health perspectives in mental health leadership. Many of the barriers to progress in improvement of mental health services can be overcome by generation of political will for the organisation of accessible and humane mental health care. Advocates for people with mental disorders will need to clarify and collaborate on their messages. Resistance to decentralisation of resources must be overcome, especially in many mental health professionals and hospital workers. Mental health investments in primary care are important but are unlikely to be sustained unless they are preceded or accompanied by the development of community mental health services, to allow for training, supervision, and continuous support for primary care workers. Mobilisation and recognition of non-formal resources in the community must be stepped up. Community members without formal professional training and people who have mental disorders and their family members, need to partake in advocacy and service delivery. Population-wide progress in access to humane mental health care will depend on substantially more attention to politics, leadership, planning, advocacy, and participation.     

Public sector antiretroviral treatment programme in South Africa: health care workers' attention to mental health problems

Although there is a high prevalence of anxiety and depression amongst people receiving antiretroviral treatment (ART), many patients are not screened, diagnosed or referred for mental health problems. This study aims to determine whether public sector health care workers in South Africa observe, screen, diagnose and refer ART patients that show symptoms of common mental disorders. It also aims to ascertain the extent of mental health training received by public sector health care workers working in ART. The study was cross-sectional in design. Self-administered questionnaires were completed by 40 nurses and structured interviews were conducted with 23 lay workers across the five districts in the Free State between July 2009 and October 2009. STATA version 12 was used to perform statistical data analysis. The health care workers reported observing a high frequency of symptoms of common mental disorders among public sector ART patients. While 70% of nurses screened and diagnosed, only 40% of lay workers screened and diagnosed patients on ART for a mental disorder. Health care workers who had received training in mental health were more likely to screen or diagnose a mental disorder, but only 14% of the workers had received such training. We recommend that health care workers should receive task-specific training to screen and/or diagnose patients on ART for common mental disorders using the guidelines of the South African HIV Clinicians Society. A positive diagnosis should be referred to a health care practitioner for appropriate evidence-based treatment in the form of medication or psychotherapy.     

Meeting the mental health needs of older adults

Greater attention to the mental health needs of older adults is critical in light of recent research documenting substantial undertreatment of mental health problems in late life. As often the first and only point of professional contact for mentally ill older adults, primary care physicians have an important and unique role in reducing enduring unmet mental health needs in late life. This article reviews the current state of geriatric mental health care delivery and provides valuable information and resources for use in clinical practice to increase and enhance primary care detection, treatment, and referral of psychological problems in older patients.     

Social capital,health, and care home residence among older adults: a secondary analysis of the Health Survey for England 2000

This secondary analysis of the Health Survey for England 2000 aimed to investigate whether individual-level social capital is associated with care home residence and with function, mental health, and self-assessed health in older adults. Older adults in both care home and community residential settings were included. Two indicators of social capital, perceived social support and group participation, were considered for both care home and community-dwelling respondents. Amongst community dwellers, trust in others was considered as a third indicator. Functional impairment, psychiatric morbidity, and self-assessed health were used as indicators of health. Multivariable modelling was undertaken using logistic or ordinal logistic regression. The results show that severe lack of social support was associated with over twice the odds of care home residence, with increased odds of psychiatric morbidity in both care home and community settings, and with more severe functional impairment and worse self-assessed health in the community but not in care homes. Participation in more groups was associated with lower odds of functional impairment in both settings, and with lower odds of psychiatric morbidity and better self-assessed health among community but not among care home respondents. High levels of trust were associated with lower severity of functional impairment, reduced odds of psychiatric morbidity, and better self-assessed health. It is concluded that individual-level social capital was associated with care home residence and with indicators of physical, mental and self-assessed health. These associations differed between community and care home settings, and were generally stronger in the community.     

Death at Home Following a Targeted Advance-Care Planning Process at Home: The Kitchen Table Discussion

OBJECTIVE: To determine whether home health agency patients' preferences to die at home can be honored following a structured, professionally facilitated advance-care planning (ACP) process provided in the home. DESIGN: A case series of patients who were identified by their home health agency nurses as having a life-limiting illness and then referred for social service assessment, followed for at least 6 months, with median follow-up of 191 days. SETTING: A large, urban, home health agency owned by a not-for-profit integrated healthcare system. PARTICIPANTS: Eighty-four adult patients (median age 75, range 37-94) receiving home care services other than hospice. INTERVENTION: Formally structured social work visits at patients' homes to discuss end-of-life issues, with communication of results to home health nurses and attending physicians. Social workers performed standard psychosocial assessments, obtained patient and family preferences regarding end-of-life care, and provided education about hospice services. MEASUREMENTS: Acceptance of the ACP process, preferences for location of end-of-life care, location of care at the end of life, adequacy of timing of intervention as measured by length of life after ACP, and use of hospice services. RESULTS: Eighty-three of 84 participants (99%) were willing to complete an ACP process in the home setting. Of the 54 patients expressing a clear preference for location of end-of-life care, 46 (82%) wanted this care to be at home. Thirty-nine (46%) of the participants died within 90 days of ACP; 58 (69%) died by the end of the study. Forty-three (75%) of these deaths occurred at home or in a hospice residence. Fifty-one (61%) patients used home, residential, or nursing home-based hospice services during the study. CONCLUSION: In this series of seriously ill home health patients, most preferred to die at home and virtually all were willing to participate in a home-based ACP process. Facilitating ACP among such patients and their families was associated with end-of-life care at home. Use of hospice services was common following ACP in this population.     

Mental health services and the mortality of nursing home residents

This article examines the impact of mental health services on the mortality rate for mentally ill nursing home residents. Previous research has documented the unmet need for mental health services among nursing home residents. Some research using small data sets has indicated patient benefits from treatment. This article examines the issue using data from the nationally representative National Nursing Home Survey. In a series of multivariate logistic regressions, treatment for mental illness provided by either general practice physicians or by mental health specialists appears to have few impacts on mortality. A statistically significant treatment effect is found only for residents with schizophrenia, other psychoses, or anxiety disorders when treated by mental health specialists. The results are discussed with reference to ongoing reforms for mental health care in nursing homes.     

Gerontological education in Japan--in training of social welfare personnel and nurses.

Though Japan is noted for the custom of respect for the elderly, gerontological education is not widely practiced. At present it is only done in the training of several professionals and semi-professionals in health and welfare services for the elderly, i.e., medical doctors, nurses, social workers, and care workers for the disabled and older persons. In the training of social workers who are expected to serve as the pivot of a team for psycho-social help and caregiving, gerontological education is given as a part of social work education. In schools for care workers for the disabled and older persons that are two-year vocational schools, practical gerontological knowledge and skills needed in the care of the elderly are taught as an important base for their future work. In schools of nursing, most of which are two-year or three-year vocational schools in Japan, gerontological education is included as an indispensable component of the curriculum and is being given increasing importance these days.     

The North Dakota Mental Health and Aging Education Project: Curriculum Design and Training Outcomes for a Train-the-Trainer Model

A training curriculum on mental health and aging was developed and disseminated to 32 natural caregivers throughout a frontier state using a train-the-trainer model. Those certified as trainers included social workers, religious professionals, volunteers, long-term care employees, nurses, home health workers, and professional and informal caregivers. Trainers then utilized the materials assembled into toolkits to provide 1,813 hours of education in all eight regions of North Dakota. The purpose of this study was to evaluate the impact of the training on the preparation of trainers to provide mental health and aging education. Several points of evaluation, including a pre/posttest to assess the trainers' knowledge, an appraisal of the self-perceived value of the education to the trainers, and an applied case study to ascertain the trainers' ability to apply what they had learned, demonstrated the benefits of this model.     

Clearinghouse: HIV and mental illness

Research involving the dual diagnosis of HIV and mental illness has been documented in a range of journal articles and other publications. The literature in this reference section includes papers on HIV risk factors among mentally ill adults, AIDS counseling and risk reduction for this population, community health planning, personality disorder and HIV, and the prevalence of HIV and AIDS among psychiatric patients and the homeless. Research contacts are provided for Wahoo, NE and San Francisco, CA.     

Human resources for mental health care: current situation and strategies for action

A challenge faced by many countries is to provide adequate human resources for delivery of essential mental health interventions. The overwhelming worldwide shortage of human resources for mental health, particularly in low-income and middle-income countries, is well established. Here, we review the current state of human resources for mental health, needs, and strategies for action. At present, human resources for mental health in countries of low and middle income show a serious shortfall that is likely to grow unless effective steps are taken. Evidence suggests that mental health care can be delivered effectively in primary health-care settings, through community-based programmes and task-shifting approaches. Non-specialist health professionals, lay workers, affected individuals, and caregivers with brief training and appropriate supervision by mental health specialists are able to detect, diagnose, treat, and monitor individuals with mental disorders and reduce caregiver burden. We also discuss scale-up costs, human resources management, and leadership for mental health, particularly within the context of low-income and middle-income countries.     

Responding to Mental Health Needs of the Elderly in Rural Areas:

In Iowa, the percentage of elderly persons in rural areas has increased dramatically in the past decade. Although delivery of mental health services to the rural elderly is a statewide and national priority, at present, too few health professionals are adequately prepared to meet this need. The rural elderly have limited access to psychiatrists and are underserved by Community Mental Health Centers. Therefore, general practitioners, public health nurses, social service workers and other core disciplines who participate in Iowa Geriatric Education Center (IGEC) educational and training programs must be able to understand the mental health needs of this population, provide basic care, and make referrals for needed services. From the inception of the Iowa Geriatric Education Center, an effort was made to incorporate clincial and service delivery into the IGEC curriculum. Through affiliation with the Rural Elderly Outreach Program, participants in IGEC programs have an opportunity to learn more about geriatric mental health and service delvery issues in rural settings.     

Difficulties in the Diagnosis of Mental Illness in Elderly Mentally Handicapped Patients

The increased life expectancy of mentally handicapped individuals, significant psychiatric morbidity in this population and the contemporary policy of community care is likely to result in increased referrals of elderly mentally handicapped patients with mental illness to psychogeriatric services. This will have implications for the organisation of services. Difficulties in the diagnosis of mental illness in a small series of elderly mentally handicapped patients are described. Techniques for improving diagnostic accuracy are discussed.     

A model of integrated primary care for HIV-positive patients with underlying substance use and mental illness

There is a high burden of underlying substance use and mental illness in HIV-infected populations. HIV-care settings provide an important opportunity to assess substance and mental health needs among HIV-positive patients and to provide or make referrals for appropriate treatment services. In 2003, with funding from the Center for Substance Abuse Treatment (CSAT), we developed a model of integrated substance-use counselling and referral for treatment within a primary care HIV-care setting at The Miriam Hospital in Providence, Rhode Island. The project uses a multidisciplinary approach to provide linkage to treatment services for substance use and mental illness as well as to help participants with social service needs, such as housing and medical coverage, to ensure continuity of care and optimal HIV treatment adherence. Twelve percent of the 965 HIV-infected patients in care at our center have been enrolled in the project. Of these, all have a current substance-use disorder and 79.3% have been diagnosed with a mental illness. In addition, most participants are hepatitis C-positive (HCV) (65.5%). The majority of participants are on antiretroviral therapy (76.7%). Participants have been referred for the following treatment modalities: intensive outpatient services, methadone, buprenorphine, outpatient services and residential as well as individual and group counselling. Our model has been successful in assessing the substance-use and mental health needs of HIV-infected individuals with numerous co-morbidities and referring them for ancillary medical and social services.     

The effect of location on the elderly mentally infirm: relationship to mortality and behavioural deterioration.

An investigation was carried out into the effects of location on the elderly mentally infirm. While location had no bearing on subsequent mortality there was some evidence to suggest that some aspects of behavioural deterioration were influenced by the type of location and in those cases residential home placement seemed to produce the least deterioration over and 18-month period when the effects of mental and behavioural competent were taken into account. The implications of these findings for the provision of long-term care for the elderly are discussed.     

Early-onset drunk driving, violent criminality, and mental disorders

We examined an association between the onset age for drunk driving, psychiatric morbidity and/or violent criminality. Almost half of violent offenders with mental disorder committed their first drunk driving before 18 years of age. The younger the drunk driver was, the greater the probability was of being violent and mentally ill.     

The social organization of HIV/AIDS care in treatment programmes for adults with serious mental illness

As the HIV epidemic expands within the mental health system, mental health professionals (MHPs) are under increased pressure to provide more HIV-related care to clients in treatment for serious mental illness. Scientific understanding of MHPs' readiness to provide these services, however, is limited. This paper examines the distribution of HIV care experience, HIV care-related knowledge, and related attitudes among 524 MHPs employed in three CMHCs and two state psychiatric hospitals in central Indiana. The results indicate that both clinical experience and subjective readiness to provide HIV care are concentrated among a few MHPs--primarily gay, lesbian, or bisexual (g/l/b) staff--within each facility. This informal system for organizing HIV care highlights the unique contributions g/l/b staff members make both in providing direct HIV care and in making sure that HIV-related issues are addressed in mental health settings. The implications of g/l/b staff members' "gate making" function for improving the provision of HIV-related mental health services are discussed.     

不同养老方式下老年人心理健康状况的比较研究

目的 比较不同养老方式下老年人的心理健康状况，并分析其相关因素。方法 采用自编老年心理健康问卷，评定对象为441例年龄55～106岁集中养老者和1010倒年龄55～96岁北京城区居家养老者。结果 两类养老方式下老年人的心理健康状况具有类似特点；心理健康水平有随教育程度的提高而改善的趋势；年龄差异不显著，居家养老者心理健康状况明显好于集中养老者。结论 两类养老方式最大区别在于养老机构中亲情纽带作用减弱。老年人缺少天伦之乐，容易产生负性情绪。使心理健康水平下降，这提示当前养老机构应重视对老年人的精神慰藉，物质与精神养老相结合已提到日程     

Geriatric psychiatry home treatment (GHT): a pilot study on outcomes following hospital discharge for depressive and delusional patients

Elderly people with mental health problems receive much worse outpatient care than younger people. Although the health-promoting factors are known, there are hardly any studies on effective biopsychosocial care models. A 1-year longitudinal study examined the effectiveness of the GHT presented below. For this purpose, 12 depressive and delusional patients discharged from inpatient gerontopsychiatric care received mental and social treatment and care at home for 1 year. Functionality was surveyed by means of the Global Assessment of Functioning Scale (GAF) and psychiatric symptoms by means of the Brief Psychiatric Rating Scale (BPRS). Subjective quality of life (QoL) was surveyed by means of the WHOQOL-BREF self-report questionnaire. The main findings were as follows: (1) no patient had to receive inpatient psychiatric care or be admitted to a nursing home during the study period; (2) mental QoL had improved significantly after 1 year; (3) functionality remained stable; (4) the BPRS scores did not deteriorate. We see this as confirmation that GHT is an effective instrument for extramural care of elderly people with psychiatric disorders. The limitations of the pilot study necessitate further studies to back up the findings.