浅议精神卫生法规定的非自愿诊治原则

《精神卫生法》对精神障碍的诊断、住院治疗实行自愿原则为主,非自愿原则为辅。医疗机构准确把握非自愿原则的适用范围,对于更好地落实自愿原则、保障精神障碍患者的合法权益尤其重要,也是防范侵权风险的重要内涵。     

Public policy and mental illnesses: Jimmy Carter's Presidential Commission on Mental Health

President Jimmy Carter's Presidential Commission on Mental Health was intended to recommend policies to overcome obvious deficiencies in the mental health system. Bureaucratic rivalries within and between governments; tensions and rivalries within the mental health professions; identity and interest group politics; the difficulties of distinguishing the respective etiological roles of such elements as poverty, racism, stigmatization, and unemployment; and an illusory faith in prevention all influenced the commission's deliberations and subsequent enactment of the short-lived Mental Health Systems Act. The commission's work led to the formulation of the influential National Plan for the Chronically Mentally Ill, but a system of care and treatment for persons with serious mental illnesses was never created.     

精神卫生法实施后知情不同意问题的再思考

《中华人民共和国精神卫生法》中关于"强行收治""非自愿入院"等争议多年的焦点议题引发了公众极大的关注。对于有精神障碍的患者,医院精神科执业医师依条件和程序作出"需要住院治疗"判定结论,患方对此知情后作出不同意住院治疗的决定,这一决定可能危及患者的生命健康,可能侵犯他人或自己的权利。病情发作时的不同意决定让医方面临艰难选择。针对医疗机构对于知情不同意所引发的一系列问题该如何处置作出思考和研究。     

“Reader, I Detained Him Under the Mental Health Act”: A Literary Response to Professor Fennell’s Best Interests and Treatment for Mental Disorder

This is a response to Professor Fennell's paper on the recent influence and impact of the best interests test on the treatment of patients detained under the Mental Health Act 1983 (MHA) for mental disorder. I discuss two points of general ethical significance raised by Professor Fennell. Firstly, I consider his argument on the breadth of the best interests test, incorporating as it does factors considerably wider than those of medical justifications and the risk of harm. Secondly, I discuss his contention that the apparent permeability of the line between the interests of the patient and the interests of society is something to be concerned about in itself. Since the overarching theme of the paper is the proper place of social and cultural values, my reponse considers the implications of Fennell's arguments in the light of Charlotte Brontë's novel ‘Jane Eyre’, which, through the character of Bertha Mason (the infamous ‘mad woman in the attic’) provides a provocative study of the relationship between mental disorder and society.     

Transforming the Mental Health Field: The Early History of the National Association for Mental Health

The paper begins by noting the absence of any sustained analysis of post-war mental health pressure groups and movements. This is deemed problematic because such movements and groups have had a strong presence during this period and because movements, as such, are afforded a central role in much contemporary sociology on account of their role in the process of social change. Next the paper considers how such analysis should be conducted, and suggests a three-phase model for periodising the activity of the groups and movements of the post-war era. The largest part of the paper is then devoted to an examination of one particular aspect of the first phase: the birth of the National Association For Mental Health and their activities in their first ten years of life. Much can be learned from the study of this group.     

Subjective experiences of compulsory treatment from a qualitative study of early implementation of the Mental Health (Care & Treatment) (Scotland) Act 2003

Compulsory psychiatric treatment is highly contested, and little research has focused specifically on direct experiences. The Mental Health (Care & Treatment) (Scotland) Act, 2003 introduced new roles and provisions including community treatment orders, and was designed to increase participation, ensure treatment was beneficial and was the ‘least restrictive’ alternative. This article draws on findings from semi‐structured interviews with 49 individuals, who had experienced compulsion under this new legislation during 2007–2008, that were part of a broader cohort study. Interviews with service users were conducted at two stages with 80% agreeing to be interviewed twice. The sample included people on a variety of compulsory orders from four Health Board areas, some of whom had been detained for the first time, while others reported ‘revolving door’ experiences. Peer researchers who were mental health service users carried out the interviews in partnership with professional researchers. The findings suggest that legislation had a limited impact on participation in the process of compulsion. Consensus was that although service users felt there was increased opportunity for their voices to be heard, this was not matched by having increased influence over professional decision‐making, especially in relation to drug treatments. According to people's direct experiences, the passing of the legislation in itself had done little to change the dominant psychiatric paradigm. While providing a foundation for improving the process of compulsion, the findings suggest that as well as legislative reform, fundamental shifts in practice are needed both in terms of the nature of therapeutic relationships, and in embracing more holistic and recovery perspectives.     

‘When you haven't got much of a voice’: an evaluation of the quality of Independent Mental Health Advocate (IMHA) services in England

Advocacy serves to promote the voice of service users, represent their interests and enable participation in decision‐making. Given the context of increasing numbers of people detained under the Mental Health Act and heightened awareness of the potential for neglect and abuse in human services, statutory advocacy is an important safeguard supporting human rights and democratising the social relationships of care. This article reports findings from a national review of Independent Mental Health Advocate (IMHA) provision in England. A qualitative study used a two‐stage design to define quality and assess the experience and impact of IMHA provision in eight study sites. A sample of 289 participants – 75 focus group participants and 214 individuals interviewed – including 90 people eligible for IMHA services, as well as advocates, a range of hospital and community‐based mental health professionals, and commissioners. The research team included people with experience of compulsion. Findings indicate that the experience of compulsion can be profoundly disempowering, confirming the need for IMHA. However, access was highly variable and more problematic for people with specific needs relating to ethnicity, age and disability. Uptake of IMHA services was influenced by available resources, attitude and understanding of mental health professionals, as well as the organisation of IMHA provision. Access could be improved through a system of opt‐out as opposed to opt‐in. Service user satisfaction was most frequently reported in terms of positive experiences of the process of advocacy rather than tangible impacts on care and treatment under the Mental Health Act. IMHA services have the potential to significantly shift the dynamic so that service users have more of a voice in their care and treatment. However, a shift is needed from a narrow conception of statutory advocacy as safeguarding rights to one emphasising self‐determination and participation in decisions about care and treatment.     

“Keeping Control”: A user‐led exploratory study of mental health service user experiences of targeted violence and abuse in the context of adult safeguarding in England

The situation for people with mental health problems as a group of disabled people who experience targeted violence and abuse is a complex one. Disabled people, particularly those with mental health problems, are at higher risk of targeted violence and hostility with few effective evidence‐based prevention and protection strategies. Achieving effective safeguarding for adults with mental health problems is characterised by differential attitudes to and understandings of abuse by safeguarding practitioners, as well as systemic issues arising from multi‐agency working. “Keeping Control” was a 16‐month user‐led, co‐produced exploratory qualitative study into service user experiences of targeted violence and abuse that was examined in the context of Care Act 2014 adult safeguarding reforms in England. User‐controlled interviews of mental health service users (N = 23) explored their experiences and concepts of targeted violence and abuse, prevention and protection. Preliminary findings from these interviews were discussed in adult safeguarding and mental health stakeholder and practitioner focus groups (N = 46). The data were also discussed via two facilitated Twitter chats (responses N = 585 and N = 139). Mental health service users’ experiences and concepts of risk from others, vulnerability and neglect can be different to those of practitioners but should be central to adult safeguarding. Histories of trauma, multi‐factorial abuse; living with fear and stigma as well as mental distress; the effects of “psychiatric disqualification” and individual blaming should be addressed in adult safeguarding in mental health. Fragmented responses from services can mean a person becomes “lost in the process”. Staff can feel disempowered, afraid or lacking in confidence to “speak up” for individuals in complex service systems with poor communication and lines of accountability. Adult safeguarding practitioners and stakeholders need to be confident, accessible and respond quickly to service users reporting incidents of targeted violence and abuse particularly in closed environments such as wards or supported housing.     

Best interests decisions: professional practices in health and social care

This paper reports on data collected in 2011 from a national study about the operation of the best interests principle, a key feature of the Mental Capacity Act (MCA) 2005 for England and Wales. The objective was to provide a picture of current professional practices in best interests decision‐making. Four contrasting sample sites were selected, in which National Health Service trusts, social care and other organisations were recruited to participate. A multimethod design was followed, including an online survey with 385 participants, followed by qualitative research through a telephone survey of 68 participants, and face‐to‐face semi‐structured interviews following up 25 best interests cases, with different perspectives on the process in 12 of those cases. The current paper reports only on the qualitative findings. The findings indicate that the MCA was successful in providing a structure for these practitioners, and that the five principles of the MCA were in general adhered to. A variety of perceived risks led to best interests processes being undertaken, and a typical scenario was for a period of hospitalisation or ill health to trigger a best interests decision process about a social care and or a life decision. The study supported previous research in finding the notion of capacity the most difficult aspect of the MCA, and it provides evidence of some specific capacity assessment practices, including problematic ones relating to ‘insight’. Best interests decisions were often made by consensus, with practitioners taking on different roles within the process. Meetings played a key part, but other ways of involving people lacking capacity and significant others were also important. It was recommended that the issues highlighted in this research could be clarified further in the Code of Practice, or within risk guidance.     

Evaluation of a Social Media Strategy to Promote Mental Health Literacy and Help-Seeking in Youth

In Canada, it is estimated that 15-21% of youth have at least one diagnosable mental illness and less than one third access the mental health services they need. Social media (SM) may present a unique opportunity to promote mental health for young people. mindyourmind, a web-facilitated program with a comprehensive SM presence, was designed to raise awareness of mental health issues and improve access to services for youth dealing with mental health concerns. This article presents an evaluation of their SM strategies with the intent to better understand their influence on youth mental health literacy (MHL) and help-seeking behavior.     

云南民族地区初中生心理健康状况

目的了解云南民族地区初中生的心理健康状况,为少数民族地区中学生心理健康教育提供依据.方法采用症状自评量表(SCL-90)调查云南省几个主要民族地区初中生心理健康状况,并与中心城市昆明市初中生进行比较.结果迪庆和澜沧地区初中生SCL-90各因子分明显高于昆明、大理初中生,除个别因子外,昆明与大理初中生之间差异无显著性;云南民族地区初中生SCL-90各因子得分均高于云南其他地区初中生.结论云南省民族地区也多为贫困地区,其初中生的心理健康状况较为严峻.     

Health reform under the patient protection and Affordable Care Act: characteristics of exchange-based health insurance enrollees

The Affordable Care Act (ACA) reformed and expanded healthcare coverage with an exchange-based health insurance program. While millions of Americans have benefited from enrollment in ACA marketplace insurance plans, many individuals are likely to be affected by potential future policy changes. Since few studies on the features of marketplace enrollees exist, we adopted a retrospective, cross-sectional study design using 2016 National Health Interview data to identify sociodemographic and health characteristics of enrollees, comparing them to those without insurance. Chi-square tests and logistic regression examined factors associated with enrollees. Adults with multiple chronic diseases (AOR = 1.90, 95% CI = 1.44, 2.50), a history of smoking (AOR = 2.44, 95% CI = 1.82, 3.26), females, married, age 50–64 years, higher educational attainment, and retirees (AOR = 1.86, 95% CI = 1.06, 3.27) were more likely to be enrollees. Since enrollees are largely higher risk individuals with greater healthcare needs, policies that modify the ACA should take these factors into account to reduce potential adverse impacts on enrollees.     

The Mental Health Status and Long Term Care Needs of the Chinese Elderly in Hong Kong

ABSTRACT

This paper examines the mental health status of 945 Chinese older people who are in need of long term care services in Hong Kong. It was found that for those aged respondents who are already waiting for admission to infirmary, over 59.3% were already living in private aged homes, and only as few as 17.8% of these applicants were still living in their own homes. Besides, it was found that the mean SPMSQ score was lowest amongst those living in medical infirmary (1.52) and highest for those living in their own residences (5.99). Analysis of the relationship between GDS scores and residential types reveals that there were higher proportion of respondents residing in their own residences that fell into the highly depressed category. There is a need for the overall revamp of the planning, provision and financing for long term care and psychogeriatric services for Chinese older people in Hong Kong.     

Mental health system reform in Moldova: Description of the program and reflections on its implementation between 2014 and 2019

In 2014, the Republic of Moldova started a systematic process of reforming its mental health system, implementing priority actions set out in the National Mental Health Programme. The reform entailed a service delivery re-design, instituting mechanisms for collaboration across health and social sectors, and revision of the policy framework. Outcomes of the first 4 years of the reform included: 1) the establishment of a network of mental health services in 4 pilot districts embedding mental health diagnosis, treatment and referral in primary and specialized mental healthcare; 2) creation of an enabling policy environment at the national and district level; and 3) strengthened community support and acceptance of mental health issues. Objectives of the first Phase were achieved and the reform is now in its second Phase (2018–2022). The implementation strategy in Phase 1 focused efforts on 4 pilot districts, whereas Phase 2 harnesses lessons learned from Phase 1 and facilitates local leaders and actors to scale-up the model to all 32 districts and municipalities in Moldova. Ownership over the reform process shifted from project-led in Phase 1 to national and local government-led in Phase 2. We reflect on the process and contents of the mental health reform, discuss lessons learned and implementation challenges encountered. We conclude with learning points for policymakers and researchers considering mental health reform in other countries.     

Health challenges of mothers with special needs children in Pakistan and the importance of integrating health social workers

ABSTRACT

There is concern that mothers of special needs children in developing countries like Pakistan are neglected populations facing hidden health challenges. The aim of this study was to investigate the kinds of health challenges mothers experience and to highlight the role of health social workers in supporting the needs of mothers. Twenty-one mothers were sampled across three cities and findings were analyzed through a thematic content analysis approach. Findings revealed that mothers faced significant and salient challenges under eight sub-categories of mental health and six sub-categories of physical health. We recommend that health social workers collaborate with healthcare practitioners to improve health services for mothers and also coordinate with other social workers, community members, and policymakers for improving both social and structural support for special needs families.     

Health benefits of primary care social work for adults with complex health and social needs: a systematic review

The prevalence of complex health and social needs in primary care patients is growing. Furthermore, recent research suggests that the impact of psychosocial distress on the significantly poorer health outcomes in this population may have been underestimated. The potential of social work in primary care settings has been extensively discussed in both health and social work literature and there is evidence that social work interventions in other settings are particularly effective in addressing psychosocial needs. However, the evidence base for specific improved health outcomes related to primary care social work is minimal. This review aimed to identify and synthesise the available evidence on the health benefits of social work interventions in primary care settings. Nine electronic databases were searched from 1990 to 2015 and seven primary research studies were retrieved. Due to the heterogeneity of studies, a narrative synthesis was conducted. Although there is no definitive evidence for effectiveness, results suggest a promising role for primary care social work interventions in improving health outcomes. These include subjective health measures and self‐management of long‐term conditions, reducing psychosocial morbidity and barriers to treatment and health maintenance. Although few rigorous study designs were found, the contextual detail and clinical settings of studies provide evidence of the practice applicability of social work intervention. Emerging policy on the integration of health and social care may provide an opportunity to develop this model of care.