Patterns of mental health service utilisation in Italy and Spain

BACKGROUND: Methods for comparing local mental health service systems are needed to allow identification of different patterns of service provision and of inequities within and between countries. AIM : The aim of this study was to describe and compare mental health service systems in 13 catchment areas in Spain and Italy. Within each country, a range of area characteristics was represented. METHOD: The European Service Mapping Schedule (ESMS) and European Socio-Demographic Schedule (ESDS) were used to describe: (i) socio-demographic and geographical area characteristics; (ii) services provided; and (iii) service utilisation in each area. RESULTS: Great differences emerged in patterns of service provision and use between and within countries. In contrast to Northern Europe, high unemployment rates were not associated with high service utilisation rates, but areas with large numbers of single-person households tended to have high service use. Most service utilisation rates were substantially below those reported from Northern European studies. Spanish centres tended to have low rates of hospital service utilisation despite limited development of community-based services. Trieste, where there has been a strong emphasis on developing innovative community services, showed a distinctive pattern with low hospital bed use and high rates of day service use and of contacts in the community. CONCLUSION: This methodology yielded useful data, which raise significant questions regarding equity and the implementation of mental health policy. The very large variations indicate that underlying local patterns of service provision must be investigated and taken into account in the interpretation of research evaluations of interventions.     

Assessment of mental health services in Slovenia with The European Service Mapping Schedule

The aim of our study was to examine availability and utilization of mental health services in the 12 Slovenian statistical regions by using the The European Service Mapping Schedule (ESMS) methodology. 251 mental health services were mapped according to their type as presented in schema of ESMS service tree. Marked differences between regions were noticed in patterns of service provision and utilization. In contrast with the scarcity of mental health services in the Zasavska and Notranjsko-kraska region, the Central-Slovenian region offered the most diverse and abundant choice of services of all statistical regions. We lack day and structured activity services offering work or work-related activities. Out-patient and community services are mainly medium intensity non-mobile services that offer continuing care.     

The Barents project in psychiatry: a systematic comparative mental health services study between Northern Norway and Archangelsk County

Background There is virtually no readily accessible systematically recorded evidence on how the organization of mental health services in Europe’s largest country, Russia, may differ from other national systems. This study systematically compares the mental health services in Archangelsk County and Northern Norway using instruments developed for trans-cultural use. Methods The European Service Mapping Schedule (ESMS) and The International Classification of Mental Health Care (ICMHC) were used to describe: (i) resources, organisation and utilisation of the services; (ii) their decentralisation and differentiation; (iii) some interventions delivered by the mental health service units (n = 132) in both regions. Results The Norwegian services are more decentralised and differentiated, while the Russian services are largely hospital-based. The GPs are of considerable importance to the Norwegian services, functioning as gatekeepers-both centrally and peripherally. In contrast, the GP model is still poorly established in Archangelsk County. There are more units for long term stay in the Russian services than in Norway. General health care and taking over daily living activities are more organised in Archangelsk County, while psychopharmacological treatment and psychosocial interventions are more developed in Norway. Conclusion The study has revealed several differences in resources, organisation and utilisation of the mental health services between the two compared areas. The very large variations indicate that underlying local patterns of service delivering must be further investigated and taken into account in the planning of the services development.     

Institutions and services of psychiatric care in Saxony-Anhalt: assessment with the European Services Mapping Schedule.

This article describes and analyses the availability of outpatient, inpatient and community-based psychiatric care in Saxony-Anhalt, one of the federal states in the eastern part of Germany. The European Services Mapping Schedule was used to classify 365 institutions. Outpatient care was provided by an average of four private practice psychiatrists per 100,000 inhabitants, which is low when compared to the German average. Ten secure beds (forensic), 48 acute beds, 13 elective beds and 13 day hospital places per 100,000 inhabitants were available for inpatient care. Non-acute non-hospital residential services with indefinite stay and with 24 h support amounted to 240 places per 100,000, with regional differences ranging from less than 100 to more than 1000. Other facilities offering paid work or work-related activities were scarce and some services providing structured activity or social contact were available only in urban agglomerations. Overall, psychiatric care in Saxony-Anhalt is fragmented as regards providers and funding.     

Mental health services for Latino adolescents with psychiatric disorders

OBJECTIVES: The major objectives of this study were to examine the prevalence of mental disorders and the use of mental health services among Latino adolescents who were receiving services in at least one of five public sectors of care in San Diego County. METHODS: Survey data were gathered for a random sample of adolescents aged 12 to 18 years (N=1,164) who were receiving public-sector care. Mental disorders were assessed with the Diagnostic Interview Schedule for Children, and use of mental health services was assessed with the Service Assessment for Children and Adolescents. RESULTS: Rates of disruptive disorders were significantly lower among Latino adolescents than among white adolescents. Although more than half of the Latino sample received specialty mental health services, those with psychiatric disorders were significantly underserved compared with their white counterparts. Latino adolescents with psychiatric disorders entered specialty mental health services at a later age and had made significantly fewer specialty mental health service visits in the previous year. In multivariate analyses, Latino youths were significantly less likely than white youths to use specialty mental health services independent of diagnosis, gender, age, and the service sector from which they were selected. CONCLUSIONS: Public service systems need to ensure that Latino youths are appropriately assessed for disruptive disorders and that they are provided with appropriate specialty mental health care.     

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

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

Mental health care institutions in nine European countries, 2002 to 2006

OBJECTIVE: Although mental health reforms in the 20th century were characterized by deinstitutionalization, previous research suggested a new era of reinstitutionalization in six European countries between 1990 and 2002. This study aimed to establish whether there has been a trend in Europe toward more institutionalized care since 2002. METHODS: Primary data sources were used to collect data on conventional inpatient beds, involuntary hospital admissions, forensic beds, places in residential care and supervised and supported housing, and the prison population in nine countries: Austria, Denmark, England, Germany, Republic of Ireland, Italy, the Netherlands, Spain, and Switzerland. RESULTS: Between 2002 and 2006 the number of conventional psychiatric inpatient beds tended to fall and changes in involuntary admissions were inconsistent. The number of forensic beds, places in supervised and supported housing, and the prison population increased in most, but not all, of the countries studied. CONCLUSIONS: The findings suggest an ongoing although not consistent trend toward increasing provision of institutionalized mental health care across Europe.     

Pathways to psychiatric care and reform of the public health care system in Poland.

OBJECTIVE: - Since 01.01.1999 a reform of the health care system in Poland has been realised based on the general health insurance act. We attempt to use the pathway method, especially measuring of time intervals along pathways, as a way of making accessibility to mental health services operational. METHOD: - In a period of 2 months all patients aged 15 and over who had not sought care from any public or private psychiatric service during the previous 365 days, were interviewed by psychiatrists, using the Polish version of the WHO Encounter Form. RESULTS: - A total of 228 patients were seen. The study reveals that the median interval between first seeing a primary care giver and arrival at a mental health service was 12 weeks, which is much longer than all other European centres in previous studies. CONCLUSION: - Making use of the pathway method and, in particular, median interval analysis between the onset of the mental health problem and seeing mental health professionals (MHPs) has shown practically limited access of patients, with a new episode of care to psychiatric services in both epidemiological catchment areas. This method seems to be a simple and inexpensive way of monitoring the accessibility to MHP in the period of health care reform.     

The Organization of Mental Health Care in the USSR: Past and Present

Since the 1960s, French public mental health services have been organized in sectors, with each sector team providing mental health care for a mean population of 54,000 inhabitants. This organization is aimed at providing continuity of care for patients from an identified area. The reduction in the number of hospital beds has been more progressive in France than in the United States and other European countries. In 2000, there were 9.4 beds for 10,000 inhabitants over 20 years old. The sectorization system has shown its efficacy in terms of access to care and continuity of care for severe mental illness. It is now challenged by a growing demand expressed by society in a context of restricted funding and by the difficulties generated by a programmed decrease in the number of psychiatrists. The last mental health program published by the Ministry of Health in 2005 identified the areas in which improvement must be made and gave precise figures for resources to be provided to achieve those aims.     

Use of mental health services in Chile

OBJECTIVE:S: To address the growing burden of mental illness in Latin America, a better understanding of mental health service use and barriers to care is needed. Although many Latin American countries have nationalized health care systems that could potentially improve access to care, significant barriers to care remain. The authors report the results of a study examining mental health service utilization in the general population of Chile. METHODS: The data were drawn from the Chile Psychiatric Prevalence Study, a national household survey of 2,987 persons aged 15 years and older conducted in 1992-1999. As part of the survey, psychiatric diagnoses were obtained by using the Composite International Diagnostic Interview, and respondents were asked about their use of general and mental health care services in the past six months and about their experience of barriers to treatment. RESULTS: More than 44 percent of respondents reported use of any health care services in the past six months, and 20 percent reported use of mental health services. Of the respondents who met criteria for a psychiatric disorder, a large proportion (62 percent) did not receive mental health care. Increasing severity of the psychiatric disorder correlated with increasing frequency of overall help seeking, but only a small proportion of the respondents with a psychiatric disorder sought specialized mental health services. Regional disparities and inequities in access to care were found. In addition, indirect barriers to mental health care, such as stigma and misconceptions about the course of psychiatric disorders, were important deterrents to service utilization, particularly among persons with lower socioeconomic status. CONCLUSIONS: To reduce the burden of mental illness in Chile, additional efforts are needed to address both the direct and the indirect barriers to mental health care, including regional inequities in access to care.     

Use of mental health services among older youths in foster care

OBJECTIVE: This study examined lifetime, 12-month, and current mental health service use among older youths in the foster care system and examined variations in mental health care by race, gender, maltreatment history, living situation, and geographic region. METHOD: The Service Assessment for Children and Adolescents, the Child Trauma Questionnaire, and the Diagnostic Interview Schedule were used in interviews with 406 youths in Missouri's foster care system who were aged 17 years. RESULTS: Ninety-four percent of the youths had used a mental health service in their lifetime, 83 percent used a mental health service in the past year, and 66 percent were currently receiving a mental health service. Lifetime rates for inpatient psychiatric care (42 percent) and other residential programs (77 percent) were exceptionally high. A quarter of the youths received mental health services before they entered the foster care system. Among youths who received residential services, half did not receive community-based services before receiving residential services. After the analyses controlled for need, predisposing characteristics, and enabling characteristics, youths of color were less likely to receive outpatient therapy, psychotherapeutic medications, and inpatient services, and they were more likely to receive residential services. Youths who had been neglected and youths in kinship care were less likely to receive some types of services. Geographic differences in service use were common and sometimes mediated the effect of race on service use. CONCLUSIONS: The child welfare system was actively engaged in arranging mental health services for youths in the foster care system, but the system was unable to maintain many youths in less restrictive living situations. The variations by race and geography indirectly indicate quality concerns.     

Old age mental health services in England: implementing the National Service Framework for Older People

BACKGROUND: There is much variation in the services provided for older people with mental health problems. In England, the National Service Framework for Older People (NSFOP) sought to address these inconsistencies and improve care. This study describes the situation three years after its publication. METHODS: A postal survey of old age psychiatrists collected data on the NSFOP mental health model: the range of specialist mental health provision, the nature of the specialist:generic service interface and the degree of interdisciplinary/interagency working. RESULTS: Three hundred and eighteen (72%) consultants responded. Considerable differences existed in the deployment of key professionals within community teams, with more than a third lacking ring-fenced social work time. Few services had dedicated rehabilitation beds and nearly a third lacked separate facilities for people with organic and functional illnesses. Increasing numbers of consultants had access to a memory clinic and there was some suggestion that liaison services were developing, but little indication of increased support for care homes. Several services had yet to agree protocols with primary care, or to implement measures promoting effective information-sharing and integrated care, and there was little evidence that the introduction of the Single Assessment Process (SAP) had significantly changed practice. Although just over half of consultants reported that mental health services were improving, less than a quarter considered community provision adequate. CONCLUSIONS: Three years after the publication of the NSFOP there remained significant gaps in services for older people with mental health problems and substantial variation in provision between districts.     

Refining the Costs Analyses of the Fort Bragg Evaluation: The Impact of Cost Offset and Cost Shifting

A key aim of the evaluation of the Fort Bragg Demonstration was to determine whether delivering services through a continuum of care lowered expenditures on mental health services. The evaluation clearly showed that expenditures were actually higher in the Demonstration. Critics of the evaluation claimed that the evaluation's perspective on costs was too narrow—in particular, that the Demonstration produced cost shifting and cost offset that were not captured by the evaluation. New data allow us to include a broader array of costs: mental health services received outside the catchment areas, general medical services for the children themselves, and mental health services used by family members. Results showed that reductions in other costs do partially offset higher expenditures on mental health services for children at the Fort Bragg Demonstration. However, even when broader costs are included, total family expenditures are still substantially higher at the Demonstration.     

Quality assurance and documentation for community mental health services cooperative (GPV). A standardized procedure for regional health care documentation and planning

This paper describes a standardized assessment-procedure for the so-called "Gemeindepsychiatrische Verbünde" in Germany (GPV-Documentation), which are regional combines of community-based mental health care services. It is the first procedure in Germany which puts data on psychiatric care offers, needs for care and service utilization of all sectors and services in community-based mental health care into standardized measures, thus making offers and care of these services comparable. The procedure can be applied to the daily routine of catchment areas. From a methodical point of view the GPV-Documentation keeps a functional approach to community-based mental health care, but additionally it enables services to describe their specific contribution to regional care separately from others. Annual follow-ups make the GPV-Documentation an ideal tool for planning purposes, care management and quality assurance. Cross-regional comparisons of standards of care are possible. The implementation will also enhance the quality of governmental health reports on the care of chronically mentally ill in Germany remarkably.     

Limits of deinstitutionalization: experience in England

Psychiatric reform and the current system of mental health care in England are outlined, the system context of the National Health Service (NHS) is described. Recent institutional change in the NHS has introduced internal market elements. More than 90 mental hospitals have been closed. The TAPS study, a longitudinal study evaluating mental hospital closure is described. Results show a range of advantages of the post-discharge care arrangements. Studies evaluating services with a home treatment and community focus (DLP, PRiSM) suggest that community mental health care is feasible. Shortages and problems of the current system of care (acute beds, intensive residential and rehabilitation services) are outlined.