Common ground: a framework for selecting core quality measures for mental health and substance abuse care

There is widespread interest throughout the mental health system in routine quality assessment to facilitate quality improvement, oversight, purchasing, and consumer choice. In the absence of agreement on a limited number of meaningful and feasible quality measures, delivery systems, payers, managed care organizations, regulators, and accreditors have each implemented unique measures and specifications. The resulting heterogeneity among measures has increased the burden on providers, limited the comparability of results, and hindered efforts to focus limited resources on further development of the most promising measures. Policy makers have initiated efforts for stakeholders to reach consensus on a core set of measures for common use, but barriers to progress remain, including differences in stakeholder needs and trade-offs between prioritizing desirable attributes of measures and representing the mental health system broadly. The authors present a framework for the selection of a core set of measures, clarify divergent perspectives, and make recommendations for further development of core quality measures for mental health care.     

Research priorities in mental health,Part 2: an evaluationof the current research effort against stakeholders' priorities

OBJECTIVE: To examine the current distribution of mental health research in Australia and compare this with the priorities of various stakeholder groups. METHOD: A content analysis was carried out on a year's worth of published articles and a year's worth of competitive research grants. A questionnaire for stakeholders was developed in which respondents were asked to rate priorities for research using the same categories. Questionnaires were sent to mental health researchers,members of panels that evaluate mental health research grant applications,general practitioners, psychiatrists, clinical psychologists, mental health nurses, mental health consumer and carer advocates, and members of the National Mental Health Working Group. RESULTS: Different groups of stakeholders tended to have differing perspectives on research priorities, with some major differences between committees that evaluate research grants and consumer and carer groups. Different stakeholder groups also tended to obtain their information about research from different sources. However, there were also a number of areas of agreement. When different research topics are considered,the following tended to be under-researched: affective disorders,suicide, primary care and community settings, prevention and promotion,evaluation of services, Aboriginal and Torres Strait Islander peoples,and socially and economically disadvantaged people. CONCLUSIONS: It is of concern that committees that evaluate research are guided by different values from consumers and carers in setting priorities. Nevertheless, there is consensus across stakeholder groups that a number of areas should be a high priority.     

Connecting science and practice in child and adolescent mental health services research

Collaboration between researchers and stakeholder groups is a potentially powerful mechanism for strengthening the quality of mental health research and for amplifying its public health impact. For stakeholders, collaboration offers opportunities to help shape research questions; participate in data collection and interpretation; and improve local capacity to access and use research findings. For researchers, collaboration can build understanding of what stakeholders want and need from research; enhance capacity to frame research questions and findings in language and metrics of value to stakeholders; and provide opportunities to contribute science-backed knowledge to decision-making processes in real world settings. Key stakeholder groups can include the recipients and providers of care, public and private care systems, health plans, schools, family service and faith-based organizations, correctional systems, and employers providing mental health benefits. This commentary reflects on the path that NIMH has taken in fostering researcher-stakeholder collaboration, particularly regarding child and adolescent mental health research. It describes the goals that NIMH set out to achieve, steps taken to realize those goals, lessons learned from those efforts, and possible next steps.     

Stakeholders' perspectives on the recommendations of the President's New Freedom Commission on Mental Health

OBJECTIVE: The purpose of this study was to understand stakeholder perspectives on school mental health and the mental health system as they relate to the goals identified by the President's New Freedom Commission on Mental Health. METHODS: A total of 11 focus groups were held in Maryland, Ohio, and New Mexico with groups of parents, youths, school- and community-based providers and staff, and child and school mental health advocates and leaders. Across the three sites, 105 individuals participated in the focus groups. RESULTS: The stakeholders provided several important recommendations to advance the field of mental health. They included addressing stigma, implementing culturally competent care, providing mental health training to school staff, and increasing collaboration between community providers. CONCLUSIONS: Obtaining the views of key stakeholders is critical to transforming the mental health system and expanding the focus on mental health in schools.     

Collaboration Strategies for Reforming Systems of Care: A Toolkit for Community-Based Action

The mental health delivery system in the United States is fragmented and disorganized resulting in inappropriate and inconstent care. The cost of mental illness has led to devastating effects on personal lives at an enormous financial cost. Successful community collaboration efforts are worth forming to enhance public health systems. Key stages of successful collaboration include identifying stakeholders, defining a shared vision, implementation, and developing momentum. Reforming systems of care begins at the local level as community collaboratives begin to develop their status in the community, become an important stakeholder voice, and promote action.     

Improving public mental health services for trauma victims in South Carolina

Studies have shown that trauma and posttraumatic stress disorder are highly prevalent among persons with serious mental illness who are treated in state-funded mental health systems. Nevertheless, there is strong evidence that many of these persons receive inadequate mental health services. South Carolina recently became one of at least 15 states whose departments of mental health have initiated efforts to better address these needs. The goals of this initiative are to sensitize stakeholders, influence policies, educate and train clinicians, and increase knowledge by supporting a strong empirical research platform. Current progress and future directions are described in this article.     

A comparison of stigmatizing attitudes toward persons with schizophrenia in four stakeholder groups: perceived likelihood of violence and desire for social distance

This study compared four stakeholder groups regarding the presence of stigmatizing attitudes toward a hypothetical person diagnosed with schizophrenia. Participants included consumers with schizophrenia (n = 104), family members of those with schizophrenia or other severe mental illness (n = 83), mental health clinicians (n = 85), and members of the general public (n = 59); all participants resided in North Carolina. The purpose of the analyses was to investigate whether mental health stakeholder groups differed from the general public and from each other in terms of key attitudes associated with stigmatization of persons with schizophrenia, that is, perceived likelihood of violent behavior, the desire for social distance, and the causes of the illness. Analysis of variance results with follow-up Scheffé tests indicated no statistically significant differences between the mental health stakeholder groups and members of the general public in the likelihood of violence or the desire for social distance. However, there was more variation between both the mental health stakeholder groups and the general public and within the mental health stakeholder groups in the perceptions of the causes of the mental illness. Throughout the analyses, the consumers tended to have the most negative views of the illness. Implications for future stigma research and education are discussed.     

Unmet needs for services for older adults with mental illness: comparison of views of different stakeholder groups.

OBJECTIVE: The authors assessed the need for mental health services among older adults in San Diego County, California, by determining what needs were not being addressed by existing services, what services were necessary to address these needs, and how much consensus there was among different stakeholders with respect to the problems and solutions related to service delivery. METHODS: Semistructured interviews were conducted with 23 health care and social service providers and administrators, 16 services consumers and other older adults (55 years of age and older), and 19 caregivers/family members and patient/client advocates. This was followed by four focus groups comprised of 18 providers and administrators, six focus groups comprised of 50 consumers and other older adults, and five focus groups comprised of 39 caregivers (family members and advocates). RESULTS: The unmet needs fell into three categories: mental health services, physical health services, and social services. Two interrelated themes were identified by participants: 1) the need for age-appropriate and culturally appropriate services to overcome barriers to mental health services access, use, and quality; and 2) the interrelations between unmet needs that address prevention as well as treatment of mental illness, including socialization and social support, transportation, housing, and physical health care. Differences in stakeholder assessment of unmet needs were associated with respective roles in delivery and use of mental health services. CONCLUSION: Age-appropriate and culturally appropriate solutions that address both prevention and treatment may represent the best strategies for addressing the challenges of mental illness and are most likely to be endorsed by all three groups of stakeholders.     

Models of advance directives in mental health care:

OBJECTIVE: The aim of this study was to examine perceptions of the place of advance directives in mental health care. METHODS: Postal survey of stakeholders was carried out to assess their views on different models of advance directives in mental health care. A total of 473 responded. RESULTS: In all, 28% of psychiatrists thought advance directives were needed compared to 89% of voluntary organisations and above two-thirds of the other stakeholder groups. There were clear tensions between patient "autonomy" and "right to treatment" which underpin many of the concerns raised. Autonomy provided by advance directive can be contrasted with a co-operative partnership approach to advance planning. The legal status of advance directives is important for some people in relation to treatment refusal. There was general concern about the practical issues surrounding their implementation. CONCLUSION: There is a wide range of views in all stakeholder groups about the possible form advance directives should take. Although there is a widespread desire to increase patient involvement in treatment decisions, which advance directives could possibly help to realise, they may also have unwanted consequences for mental health services and individuals.     

Community mental health agency views of research

We examined community mental health center staff perceptions of ongoing research within their agency. We interviewed upper management and conducted focus groups with medical staff, non-medical clinicians, and administrative staff. Participants were asked about (1) their attitudes towards research in general, agency research and towards the principal academic institution doing research with clients, (2) their perceptions of the value of research and (3) ideas for improving the collaboration. We identified 5 overarching themes: inter-agency communication, shared goals and equality in research, researchers adding knowledge to the agency, improving attitudes toward research, and agency involvement in research. Under these domains, specific suggestions are made for how to improve the collaboration across all stakeholder groups. Lack of shared values and inadequate communication processes can negatively impact community-based research collaborations. However, clear strategies, and adequate resources have great potential to improve community mental health collaborations.     

An Epidemic of Emotional Disturbance among Leprosarium Nurses in a Setting of Low Morale and Social Change†

Abstract

This study compared four stakeholder groups regarding the presence of stigmatizing attitudes toward a hypothetical person diagnosed with schizophrenia. Participants included consumers with schizophrenia (n = 104), family members of those with schizophrenia or other severe mental illness (n = 83), mental health clinicians (n = 85), and members of the general public (n = 59); all participants resided in North Carolina. The purpose of the analyses was to investigate whether mental health stakeholder groups differed from the general public and from each other in terms of key attitudes associated with stigmatization of persons with schizophrenia, that is, perceived likelihood of violent behavior, the desire for social distance, and the causes of the illness. Analysis of variance results with follow-up Scheffé tests indicated no statistically significant differences between the mental health stakeholder groups and members of the general public in the likelihood of violence or the desire for social distance. However, there was more variation between both the mental health stakeholder groups and the general public and within the mental health stakeholder groups in the perceptions of the causes of the mental illness. Throughout the analyses, the consumers tended to have the most negative views of the illness. Implications for future stigma research and education are discussed.     

A Survey of Stakeholder Knowledge, Experience, and Opinions of Advance Directives for Mental Health in Virginia

An innovative Virginia health care law enables competent adults with serious mental illness to plan for treatment during incapacitating crises using an integrated advance directive with no legal distinction between psychiatric or other causes of decisional incapacity. This article reports results of a survey of 460 individuals in five stakeholder groups during the initial period of the law’s implementation. All respondents held favorable views of advance directives for mental health care. Identified barriers to completing and using advance directives varied by group. We conclude that relevant stakeholders support implementation of advance directives for mental health, but level of baseline knowledge and perception of barriers vary. A multi-pronged approach will be needed to achieve successful implementation of advance directives for mental health.     

A Strategic and Shared Agenda to Advance Mental Health in Schools through Family and System Partnerships

The paper reviews data on the gap between young people who need and young people who receive mental health care. The fact that need far outstrips available resources underscores the importance of moving forward a shared agenda that builds a coalition of shared values and goals among families, schools, mental health agencies and other community programs and stakeholders. The importance of a coordinated public health approach, emphasizing broad systems enhancement, early intervention, and more intensive programs and services, is emphasized, and recommendations for strategic action at local, state and national levels are presented.     

Mental health transformation: moving toward a public health, early-intervention approach in Texas

This column describes a mental health system transformation initiative in Texas that aims to fully integrate mental health as a component of public health and early-intervention efforts. The process has included a formal needs assessment initiative and a broad-based interagency Transformation Workgroup made up of executive-level agency staff, consumers and family members, and representatives of the legislature and governor's office. Community collaboratives have been formed to instigate transformation at the local level. Major objectives include development of consumer and family networks, workforce development and training, and an improved data and technology infrastructure.     

Evidence-based practices for services to families of people with psychiatric disabilities.

Family psychoeducation is an evidence-based practice that has been shown to reduce relapse rates and facilitate recovery of persons who have mental illness. A core set of characteristics of effective family psychoeducation programs has been developed, including the provision of emotional support, education, resources during periods of crisis, and problem-solving skills. Unfortunately, the use of family psychoeducation in routine practice has been limited. Barriers at the level of the consumer and his or her family members, the clinician and the administrator, and the mental health authority reflect the existence of attitudinal, knowledge-based, practical, and systemic obstacles to implementation. Family psychoeducation dissemination efforts that have been successful to date have built consensus at all levels, including among consumers and their family members; have provided ample training, technical assistance, and supervision to clinical staff; and have maintained a long-term perspective.     

Consumers' and Case Managers' Perceptions of Mental Health and Community Support Service Needs

Consumers with serious and persistent mental illness (N = 385) and their case managers rated the amount of help needed and the amount of help received with mental health and community support services. Consumers also identified their primary source of help with each type of need. Results highlighted areas of agreement and disagreement between consumers' and case managers' perceptions. Consumers' reports revealed a strong reliance on sources of support outside the mental health system (e.g., family and friends) for many community support service needs, interpersonal needs, and crisis-related needs. In general, correlations between consumers' and case managers' ratings of help needed and help received were low. Consumers perceived the majority of their needs to be unmet; case managers perceived the majority of consumer needs to be overly met. Discussion focuses on the importance of increasing consensus between consumers and case managers regarding needs by including consumers in treatment planning and providing them with more information about available services. It is recommended that researchers and evaluators examine perceptions of help needed, help received, and sources of help when assessing service needs.     

Influence of Provider Gender on Mental Health Stigma

This study examined gender differences in mental health providers’ stigma toward people with mental illness. As part of a larger professional education needs assessment at a VA healthcare system, 77 mental health providers of various disciplines completed a self-report measure of stigma towards people with various mental health diagnoses. Results indicated that male mental health providers hold significantly more stigmatizing views toward people with schizophrenia and posttraumatic stress disorder (PTSD), which is consistent with provider gender differences found in other areas of study and theories of stigma and masculinity. These results can be used to build on stigma reduction interventions. Future research should continue to examine the underlying reasons for gender differences among providers.

     

Governing board and management staff attitudes toward Community Mental Health Center citizen participation

The present study investigated the attitudes and values of community and mental health center board and management staff of four Community Mental Health Centers and one mental health clinic toward the recent federal mandate calling for increased citizen involvement in center evaluation activities. Three related areas were address: (a) general attitudes toward citizen participation, (b) types of program-evaluation activities in which citizen input would be most useful; and (c) types of individuals who would best serve on citizen review groups. The results indicated that although board members are somewhat more optimistic about benefits received from citizen involvement, overall there was close agreement between the board and staff respondents in the three areas studied. These results were interpreted as substantiating the view that community mental health center boards typically reflect a provider orientation in their approach to mental health governance. A missing evaluation component in most centers is citizen participation as it reflects the values of its service consumers. It is advocated that only by developing consumer participation mechanisms will centers more readily achieve the goal of responsiveness to community needs.     

Best Practices in Behavioral Health Workforce Education and Training

Dramatic changes have occurred in the delivery of mental health and substance abuse services over the past decade and a half. There is growing concern that education programs have not kept pace with these changes and that reforms are needed to improve the quality and relevance of training efforts. Drawing on the published works of experts and a national initiative to develop a consensus among stakeholders about the nature of needed reforms, this article outlines 16 recommended "best practices" that should guide efforts to improve workforce education and training in the field of behavioral health.