The pathway to meeting need for mental health services in Sweden

OBJECTIVE: Mental health problems are often underrecognized and undertreated. Knowledge of the characteristics associated with the pathway to having a need for mental health care by appropriate treatment (met need) can help to correct this deficit. This study used data from a population-based study to determine the characteristics of persons whose needs were meetable, who were aware of the need for mental health care, who requested care, and whose needs were met. METHODS: A total of 10,443 randomly selected persons in Stockholm, Sweden, aged 20 to 64 years answered a survey that included questions about mental health problems. A subsample of 1,093 persons was then interviewed by psychiatrists, who determined whether the respondents had a psychiatric disorder according to DSM-IV criteria. The interview also assessed need for care, service use, and whether an evidence-based treatment was available for the mental health problem. RESULTS: Among the 1,093 persons interviewed 462 were found to have a mental health problem for which psychiatric treatment was available (meetable need for care). Among the 462 persons with a meetable need for care, 70 percent fulfilled the DSM-IV diagnostic criteria for having a psychiatric disorder; the rest had various symptoms, mostly depressive. Among the persons with a meetable need for care, 84 percent were aware of this need, 37 percent had requested care, and 17 percent had their needs met by evidence-based treatment. Persons whose needs were met tended to be female, have more education, and have good social support. Also, they were less likely to report that feelings of shame would prevent them from requesting psychiatric care. CONCLUSIONS: The characteristics associated with unmet need suggest that strategies that focus on specific groups (for example, males and persons with less education) could increase the percentage of persons whose needs are met.     

Indian mental health: changes in the delivery of care in northwestern Ontario

For ten years University of Toronto psychiatrists have made regular visits to isolated Indian villages in remote Northwestern Ontario, offering a clinical psychiatric program. Initially, two non-Indian social workers provided ongoing service between the psychiatric visits. Recognizing the difficulty in providing psychotherapy cross-culturally, the members of the treatment team developed the skills of local persons who were not formally trained in the treatment of mental health problems. The paper describes a significant shift in the psychiatric program beginning in 1981. At that time in certain communities local people took over the service, resulting in an increased ability to provide a preventative psychiatric program. Community based workers have dealt more with early marital difficulties, grief reactions, transitional depressive states, and less with major mental illnesses. In the areas which have community based treatment teams, the emphasis in psychiatric service is shifting from direct clinical work to formal teaching and case consultations with the indigenous counsellors. The evidence indicates optimism that the service is reaching more persons before the emergency stage than it did in previous years of the program.     

Aging among persons with intellectual disability in Israel in relation to type of residence, age, and etiology

This study was conducted to compare aging phenomena of persons with intellectual and developmental disability (ID) aged 40 years and older living in community residence (N = 65) with those living with their families (N = 43) in Jerusalem, Israel. All 108 persons and care givers were interviewed to ascertain health problems, sensory impairment, activity of daily living (ADL), cognitive skills, and leisure activities. Health problem had already developed by age 40 years. The most frequent were visual (33%), hearing impairments (20%) and dental problems (30%). The community residence group displayed more medical problems, whereas individuals living at home had more dental problems. Health problems in persons with Down syndrome were significantly higher. ADL functioning for all participants was high, but persons with Down syndrome and cerebral palsy had more dependence. A decline in functioning in both residential groups was observed concerning leisure time, but scores for social life leisure activities were better for the community residential group. The data provided in this study can serve as information to develop geriatric services for persons with ID and provide a basis for comparison with peers in the general population in Israel. Dental service to persons with ID living at home should be improved.     

An exploratory study into health care policy for persons with intellectual disabilities in Taiwan

Background Although Taiwan has already had a higher quality of health care compared with other countries, there still is a need to review the quality and effectiveness of services provided. The lack of health care policy for persons with disabilities is a reflection of health care provision in Taiwan. Health care provision problems will limit persons with disabilities in their access to the health care system. The purpose of the present study was to examine the general beliefs about the current health care policies for persons with intellectual disabilities (ID) in Taiwan. Methods Data were obtained from two sources, namely government policies analysis and interviews with representatives for key stakeholders in the field of ID. Results The results illustrate that health care service problems for persons with ID include: how to enforce the discovery system and early intervention service, disability evaluation system, National Health Insurance medical payment and medical care resource development are still confining their quality of care. Furthermore, the links between social welfare, education and health care have been lost because the different roles and perspectives of people in these fields are fundamentally at odds with one another. Health care professionals have become less reform‐minded as a consequence of the conditions of their work. Consequently, a complete and coordinated health care policy for persons with ID has become unattainable in society. The present paper draws on evidence from research and policies to explore the problems and potential of service development for persons with ID, and to identify review and action points for managing its implementation.     

Supported employment in Maryland: successes and issues

Information was gathered via a mailed questionnaire from approximately 85% of Maryland service providers offering vocational services funded by the Maryland Developmental Disabilities Administration. The weekly earnings of persons placed in supported employment were 3.5 times the earnings of persons employed on the premises of the service provider. Nevertheless, there was strong evidence that substantial improvements are needed, and possible, in supported employment. Among urgently needed improvements are (a) the ability to recruit and retain qualified vocational workers, (b) enhanced procedures for locating more and higher quality jobs, (c) expanded transportation arrangements, (d) improved training for vocational workers, and (e) an information system to measure performance and identify problems.     

Prevalence, severity, and co-occurrence of chronic physical health problems of persons with serious mental illness

OBJECTIVES: This study examined Medicaid claims forms to determine the prevalence, severity, and co-occurrence of physical illness within a representative sample of persons with serious mental illness (N=147). METHODS: Representativeness of health problems in the study sample was established through comparison with a larger sample of persons with serious mental illness enrolled in Medicaid within the same state. Standardized annual costs were then assigned to Medicaid claims diagnoses, and individual health problem severity was measured as the sum of estimated treatment costs for diagnosed conditions. RESULTS: Seventy-four percent of the study sample (N=109) had been given a diagnosis of at least one chronic health problem, and 50 percent (N=73) had been given a diagnosis of two or more chronic health problems. Of the 14 chronic health conditions surveyed, chronic pulmonary illness was the most prevalent (31 percent incidence) and the most comorbid. Persons with chronic pulmonary illness were second only to those with infectious diseases in average annual cost of treatment ($8,277). Also, 50 percent or more of participants in eight other diagnostic categories had chronic pulmonary illness. A regression analysis identified age, obesity, and substance use disorders as significant predictors of individual health problem severity. CONCLUSIONS: Risk adjustment for physical health is essential when setting performance standards or cost expectations for mental health treatment. Excluding persons with chronic health problems from mental health service evaluations restricts generalizability of research findings and may promote interventions that are inappropriate for many persons with serious mental illness.     

Accessing Community-Based and Long-Term Care Services: Challenges Facing Persons with Frontotemporal Dementia and Their Families

There are several barriers to accessing services for persons with frontotemporal dementia (FTD), and few studies have examined service needs and satisfaction with services for family caregivers of persons with FTD. Persons with FTD and their families have reported consistent difficulties in their attempts to access care and support. These are: (1) difficulty obtaining a diagnosis; (2) financial concerns due to loss of employment, job-related income; (3) problems accessing social security disability insurance; and (4) lack of adequate community-based and long-term care services and resources. Successful care practices such as use of an interdisciplinary team and helpful care models such as person-centered care and the antecedent–behavior–consequence method are described. Further investigation and research are needed to understand best care strategies for persons with FTD.     

The treatment relationship in peer-based and regular case management for clients with severe mental illness

OBJECTIVE: This study compared the quality of treatment relationships and engagement in peer-based and regular case management. It also assessed the value of positive relationship qualities in predicting motivation for and use of community-based services for persons with severe mental illness. METHODS: One hundred thirty-seven adults with severe mental illness participated in a 2x2 prospective longitudinal randomized clinical trial with two levels of case management intervention (peer and regular) and two interviews (six and 12 months). Self-report questionnaires assessed treatment relationships, motivation, and service use, and providers rated participants' initial engagement and monthly attendance in treatment. RESULTS: Participants perceived higher positive regard, understanding, and acceptance from peer providers rather than from regular providers at six months only, with initially unengaged clients showing more contacts with case managers in the peer condition and decreasing contacts in the regular condition. Six-month positive regard and understanding positively predicted 12-month treatment motivation for psychiatric, alcohol, and drug use problems and attendance at Alcoholics and Narcotics Anonymous meetings. CONCLUSIONS: Early in treatment, peer providers may possess distinctive skills in communicating positive regard, understanding, and acceptance to clients and a facility for increasing treatment participation among the most disengaged, leading to greater motivation for further treatment and use of peer-based community services. Findings strongly suggest that peer providers serve a valued role in quickly forging therapeutic connections with persons typically considered to be among the most alienated from the health care service system.     

Use of general medical services among Medicaid patients with severe and persistent mental illness

OBJECTIVE: The aim of this study was to examine patterns of use of general medical services among persons with a severe and persistent mental illness enrolled in Medicaid from 1996 to 1998. METHODS: A total of 669 persons with a severe and persistent mental illness were identified by using statewide clinical criteria. A three-year database of Medicaid claims was developed to examine service use. The main outcome measures were use of outpatient services for a general medical problem, use of dental and vision services, and use of screening tests for women. Service use was examined by primary psychiatric diagnosis (schizophrenic, affective, paranoid, and anxiety disorders), and analyses controlled for the presence of a chronic medical condition, age, race, and sex. RESULTS: This study found high levels of service use for outpatient services but very low levels for primary and preventive services. Although 78 percent of persons with a schizophrenic disorder had an office-based visit during the three-year period, all persons with an anxiety disorder had such a visit. Sixty-nine percent of persons with a schizophrenic disorder had at least one emergency department visit, whereas 83 percent of those with an anxiety disorder had such a visit. Dental and vision visits and the use of mammograms and pap tests followed the same pattern; persons with a schizophrenic disorder had fewer visits and had less overall use than the other diagnostic groups. The use patterns across the four groups were significantly different in outpatient service use, dental and vision service use, and screening tests for women. Compared with persons with a schizophrenic disorder, those with an anxiety disorder were more likely to have had an office-based visit and to have received vision services, those with a paranoid disorder were more likely to have used dental services or received a mammogram, and those with an affective disorder were more likely to have had a pap test. CONCLUSION: Although this group of Medicaid patients with severe and persistent mental illness had access to providers, they received an unacceptably low level of preventive care. Use of health services for general medical problems differed somewhat by primary psychiatric illness.     

The treatment of persons with dual diagnoses in a rural community

Persons with dual diagnoses of psychiatric illness and substance abuse represent a large subpopulation within the mental health system, but mental health service delivery systems typically do not adequately address their special needs. The literature on dual diagnoses is marked by the paucity of information on such persons in rural settings. This paper describes the characteristics of a rural community mental health system, which illustrate the difficulties in treating persons with dual diagnoses in rural communities. These problems include a fragmented system of services, centralized services in a large geographic area, overly restrictive regulations, conceptual differences in treatment approaches, confidentiality and stigma in a rural culture, and the academic and professional isolation of mental health workers, leading to high turnover and a shortage of staff having sufficient training and experience to work with persons with dual diagnoses. Some recommendations to address these problems and to improve the delivery of services to persons with dual diagnoses are suggested.     

What makes them feel like they do? Investigating the subjective well-being in people with severe and profound disabilities

BackgroundBecause of the problems measuring subjective well-being in people with severe and profound intellectual disabilities, there are no studies to date which explore the factors contributing to the subjective well-being in these groups. We wanted to explore the client and service characteristics contributing to the subjective well-being of persons with severe and profound intellectual disabilities, as measured by the MIPQ (Ross & Oliver, 2003).Materials and methodsThe MIPQ was completed for 360 persons with severe or profound intellectual disabilities by a member of the direct support staff. They also provided us with information on client, service and informant characteristics.ResultsWe found that the subjective well-being of persons with profound intellectual disabilities was lower than the subjective well-being of people with mild, moderate or severe intellectual disabilities or people without disabilities. Client and informant characteristics but no service characteristics were found to have an influence on the subjective well-being of people with severe and profound intellectual disabilities.ConclusionAs it is important for policy making to identify residence service and staff factors related to subjective well-being of persons with severe and profound intellectual disabilities, further research should try to identify these factors, taking in account the client characteristics that are found to be related to subjective well-being in this study.     

A follow-up study of mortality, health conditions and associated disabilities of people with intellectual disabilities in a Swedish county

Background In the planning of services and health care for individuals with intellectual disability (ID), information is needed on the special requirements for habilitation and medical service and associated disabilities. Material and methods An unselected consecutive series of 82 adult persons with ID was studied. The medical examination consisted of the individual's health condition, associated impairments and disabilities. Medical and habilitation services and support were studied. Results The results indicated that 71% of the persons in the series had severe and 29% mild ID. Forty-seven per cent of the persons with severe ID and 35% of those with mild ID had one or more additional central nervous system (CNS) disabilities. Of the persons with ID, 99% had access to a family doctor and 84% attended regular health visits. Notably, half of persons were referred to a specialist examination as a consequence of their present medical examination. Half of the persons with mental health problems were previously undiagnosed and only a few of these had access to a psychiatrist. Conclusion Our study clearly demonstrates the magnitude and importance of neurological and psychiatric impairments in ID. The findings suggest a strong need for multidisciplinary health service.     

The Church and community psychiatric services in a region of northern Norway

Through questionnaires sent to all priests in a county in northern Norway (n=78) we described and analysed the relations between the priests and a community mental health service. Results showed that the priests had contact with many persons with mental problems and also with many psychiatric patients. Priests described their work with psychiatric problems and psychiatric patients as based on a holistic concept of man, which they did not consider was the case in the professional work carried out by the psychiatric services. These ideological differences did not result in the priests being unwilling to motivate persons to contact the mental health organisations, as four out of five priests had referred persons to psychiatric treatment in the 12 months before the study. There was also a strong wish among the priests for more contact with psychiatric professionals.     

Comparison of users and non-users of mental health services among depressed, older, urban African Americans.

OBJECTIVE: The authors sought to determine differences between depressed older black residents in an urban community who do and do not use formal mental health services. METHODS: The Treatment Group (TG) consisted of 106 black patients age >or=55 with a diagnosis of depression who were recruited from outpatient psychiatric programs in Brooklyn, NY. The Untreated Community Group (UCG) consisted of 101 cognitively intact black subjects age >or=55 from randomly selected block groups in Brooklyn who met symptom criteria for major or minor depression and had no previous history of psychiatric treatment. RESULTS: In logistic regression analysis, TG persons were significantly more likely than the UCG persons to be female, younger, born in the United States, to have impaired daily functioning, have a family history of mental illness, and believe that environmental factors and religious activities could influence mental illness. TG persons were significantly less likely to have social network members who provided advice, to use spiritualists or their products, to have vision or hearing impairments, and to have depressive symptoms. Although most UCG persons visited their doctor at least three times annually, only 11% reported using these physicians for help with mental health problems. CONCLUSIONS: A combination of demographic and attitudinal factors, family psychiatric history, social supports, and functional impairments were associated with the use of mental health services. Despite reluctance of persons in the UCG to use primary-care physicians for mental health reasons, the latter remain the most feasible intervention point within the existing service system.     

Service needs of depressed older adults following acute psychiatric care

Older persons with mental disorder need mental health services, but the extent to which they have service needs in other domains (medical, functional and psychosocial) is not established, although these needs may compromise the attainment of psychiatric outcomes. This study focuses on 169 older adults hospitalized for depression and documents their post-acute service needs in four domains: psychiatric, medical, functional and psychosocial. Seventy-five per cent of these psychiatric patients had medical conditions that required treatment. Eighty-four per cent needed assistance with routine activities. Nearly two-thirds (67%) were experiencing one or more psychosocial or environmental problems that warranted intervention. The mean number of service needs was 6.5 (SD=1.5). Fifty-seven per cent had needs in all four domains. Older adults admitted to acute care for depression have high levels of service needs stemming from multiple domains: psychiatric, medical, functional and psychosocial. We extend the biopsychosocial model, largely used to address the origins of psychopathology, to conceptualize the multiple domains of service that older adults with mental disorder need. This biopsychosocial model suggests that needs in each domain should be identified and addressed if desired psychiatric outcomes are to be attained.     

Barriers to the care of persons with dual diagnoses: organizational and financing issues

Among the frustrations of managing the dual disorders of chronic mental illness and alcohol and drug abuse is the fact that knowing what to do (by way of special programming) is insufficient to address the problem. The system problems are at least as intractable as the chronic illnesses themselves. Organizing and financing care of patients with comorbities is complicated. At issue are the ways in which we administer mental health and alcohol and drug treatment as well as finance that care. Separate administrative divisions and funding pools, while appropriate for political expediency, visibility, and administrative efficiency, have compounded the problems inherent in serving persons with multiple disabilities. Arbitrary service divisions and categorical boundaries at the State level prevent local governments and programs from organizing joint projects or creatively managing patients across service boundaries. When patients cannot adapt to the way services are organized, we risk reinforcing their overutilization of inpatient and emergency services, which are ineffective mechanisms for delivering the care these patients need. This article reviews the barriers in organization and financing of care (categoric and third party financing, including the special problem of diagnosis-related groups limitations) and proposes strategies to enhance the delivery of appropriate treatment.     

Factors influencing admission to a community mental health center

The hypothesis that persistent social problems increase chances of subsequent admission for service applicants to a community mental health center was not supported. Reexamination of data suggested that social involvement is a criterion which delineates predictors of admission. Findings indicate that persons more constrained by ongoing social commitments are unlikely to establish or maintain treatment relationships with a psychiatric facility. Conversely, persons without constraining social positions are much more likely to establish a continuing relationship with institutional psychiatry. Marital status, parenthood, and employment are found to be indicative of crucial involvement. Discussion focuses on the implications of findings for operation of a community mental health center.The research reported here was done under a grant (MH-1385) from the National Institute of Mental Health of the Department of Health, Education and Welfare.     

Help-Seeking for Emotional Problems in Major Depression

To study help-seeking among the general population and people with major depression. 12-month help-seeking for emotional problems was assessed in a cross-sectional 2006 Estonian Health Survey. Non-institutionalized individuals aged 18–84 years (n = 6,105) were interviewed. A major depressive episode was assessed using the Mini-International Neuropsychiatric Interview. The factors associated with help-seeking, received help, and health service use were analyzed. The prevalence of 12-month help-seeking for emotional symptoms was 4.8%. The rate of 12-month help-seeking in the depressed sample was 34.1%. Depressed people used non-mental health services 1.5–3 times more than non-depressed persons even when adjusted for the chronic somatic disorder. Only one third of depressed persons sought help, which was most of all associated with severity of depression. Underdiagnosis and undertreatment of depression leads to an increased use of expensive but non-specific health services by depressed persons.     

Program development and integrated treatment across systems for dual diagnosis: mental illness, drug addiction, and alcoholism (MIDAA)

Numerous bureaus of mental health, drug addiction, and alcoholism are designated to provide service to persons who have discrete singular disorders of mental illness, drug addiction, or alcoholism. Mental health and substance abuse programs (nationally and internationally) have evolved with this singular limited-service capacity. Contrasting incompatible philosophies and treatment methods across the systems have resulted in minimal services for persons with dual diagnoses. The project the authors have outlined is an example of the development of a dual/multiple-disorder program that integrates these diverse systems and provides comprehensive services within each of the programs of each delivery system. These programs are cost-effective, use existing facilities, train and cross-train existing staff, correct the issues of incompatible treatment interventions, and end the dilemma of gaps in services systems and limited referral resources. As a result, the availability and quality of care for persons with dual diagnoses is greatly improved.     

Trends in mental health services for people with intellectual disability in residential care in Israel 1998-2004

Persons with intellectual disability (ID) have more mental health problems than the general population and utilize psychiatric service to a greater extent. This study was conducted to look at trends over time in the number of psychiatrists recruited, psychiatric medication and hospitalization for persons with ID in residential care in Israel. Data was extracted for the 1998-2004 period from the annual surveys conducted of medical service in all residential care centers in Israel by the Office of the Medical Director. Results showed an increase in psychiatrists working with this population, from 1.08 psychiatrist per 1,000 study population in 1998 to 2.23 in 2004, psychotropic medication also increased from 45% to 52% over the same period, but psychiatric inpatient hospitalization decreased from 5.48 to 4.99 per 1,000 study population. It is concluded that there has been an improvement in psychiatric service to this residential care population over the study period, but there is a need for a formal subspecialty in psychiatry, training and research.