Primary Health Care for People with a Learning Disability

The delivery of health care to people with a learning disability living in the community has come under increasing scrutiny. Concerns have been raised over both the current quality of this care and its future organisation. In this article we review the evidence on current practice focusing on epidemiology, health status and policy directives affecting primary health care. Four specific areas for service developments are identified: an individual focus within an epidemiological framework, the evaluation of the effectiveness of current therapies, practice organisation and the awareness of health within social care. It is proposed that an effective model of primary health care is possible, supported by research, training, inter-service collaboration and purchasing guidelines.     

Implementation of Treatment Guidelines for Specialist Mental Health Care

Although treatment guidelines are commonly employed in healthcare settings, it remains unclear whether their use has any positive impact on the performance of mental health services or whether they improve patient outcomes. This systematic review is based on a search carried out in March 2012 and includes 5 randomized studies that examined the effectiveness of guideline implementation strategies in improving healthcare services and outcomes for people with mental illness. The 5 studies were generally at unclear risk of bias, and all evidence in the “Summary of Findings” table was graded by review authors as of very low quality. Although single studies provided initial evidence that implementation of treatment guidelines may achieve small changes in mental health practice, with only 5 studies meeting inclusion criteria, and with limited usable information, it is not possible to arrive at definitive conclusions. A gap in knowledge still exists about how guideline implementation strategies might improve patient outcomes and health services. This leaves scant information for people with mental health problems, health professionals, and policy makers. More large-scale, well-designed and well-conducted studies are necessary to fill this gap in knowledge.Key words: guidelines/, implementation/, schizophrenia     

Models of User Involvement in the Mental Health Context: Intentions and Implementation Challenges

Patient-centered care, shared decision-making, patient participation and the recovery model are models of care which incorporate user involvement and patients’ perspectives on their treatment and care. The aims of this paper are to examine these different care models and their association with user involvement in the mental health context and discuss some of the challenges associated with their implementation. The sources used are health policy documents and published literature and research on patient-centered care, shared decision-making, patient participation and recovery. The policy documents advocate that mental health services should be oriented towards patients’ or users’ needs, participation and involvement. These policies also emphasize recovery and integration of people with mental disorders in the community. However, these collaborative care models have generally been subject to limited empirical research about effectiveness. There are also challenges to implementation of the models in inpatient care. What evidence there is indicates tensions between patients’ and providers’ perspectives on treatment and care. There are issues related to risk and the person’s capacity for user involvement, and concerns about what role patients themselves wish to play in decision-making. Lack of competence and awareness among providers are further issues. Further work on training, evaluation and implementation is needed to ensure that inpatient mental health services are adapting user oriented care models at all levels of services.     

Myths and facts in contemporary psychopharmacotherapy: evidence-based vs. evidence-biased treatment algorithms practice

Evidence based psychiatry and treatment guidelines have a significant role in raising the quality of mental health care and treatment, as well as in providing order where chaos reigns. The purpose of treatment guidelines and algorithms is to provide psychiatrists, health authorities, patients and their families with best evidence for making treatment decisions. However, adherence to some guidelines may do more harm than good if they are not flexible enough to take into account individual patient preferences and circumstances. The paradox at the heart of algorithms-based practice is that gold standard treatments are predicated on statistical generalizations about patients, mental disorders and treatments. In contrast, the effectiveness of a treatment is based on the art and practice of learning organization, the uniqueness of the patient, the doctor-patient relationship and the willingness of the patient to change her/his mental model, life philosophy and the relationships in his family. Treatment guidelines are the lifelines of medical psychiatry and clinical psychopharmacology, without which psychiatry will never reach professional maturity and become fully accepted in medical circles.     

Behavioural symptoms of dementia in residential settings: a selective review of non-pharmacological interventions

For people with dementia living in residential settings, behaviours such as aggression, screaming, restlessness, agitation and wandering are a frequent reason for referral to specialist mental health services for older people. Psychosocial models of dementia have grown in prominence and non-pharmacological interventions have been recommended in professional and government policy statements, either as a first line of treatment or alongside medication. Studies of their effectiveness have been criticised for being poorly controlled, focusing on milder behaviour problems and for requiring a disproportionate use of resources. The recent ruling that risperidone and olanzepine should not be used to control behavioural symptoms in dementia makes it timely to review the evidence for alternative treatments. The current review is a selective one of different types of studies including studies of staff training and liaison interventions, studies of a range of different therapeutic interventions and individualized interventions within a single-case methodology. It is argued that different types of research methodology are appropriate for different studies and that there is still too little evidence to provide firm guidelines. In conclusion, a structured decision-making process for selection of interventions is proposed, in which the limited available evidence can be drawn together to provide a basis for targeting clinical resources while the research evidence is strengthened.     

Invited Article: Threats to physician autonomy in a performance-based reimbursement system

Physician autonomy is currently threatened by the external application of pay for performance standards and required conformity to practice guidelines. This phenomenon is being driven by concerns over the economic viability of increasing per capita health care expenditures without a concomitant rise in favorable health outcomes and by the unjustified marked variations among physicians' practice patterns. Proponents contend that altering the reimbursement system to encourage physicians to make choices based upon the best available evidence would be one way to ensure better outcomes per health care dollar spent. Although physician autonomy is most easily justified when decisions are made by appealing to the best available evidence, incentivizing decision-making risks sacrificing physician autonomy to political and social forces if the limitations of evidence-based medicine are not respected. Any reimbursement system designed to encourage physicians to utilize the best available evidence by providing financial incentives must recognize physicians who try to play to the numbers as well as physicians who refuse to follow the best available evidence if doing so would conflict with good medicine or patient preferences. By designing, promulgating, and updating evidence-based clinical practice guidelines, medical specialty societies can limit threats to physician autonomy while improving medical practice.     

Mental health services for children in public care and other vulnerable groups: implications for international collaboration

Children in public care and other vulnerable young groups (homeless, adopted, refugees) are increasingly becoming the focus of policy and service planning. There is strong evidence that all these client populations have high rates of mental health problems which are closely associated with other needs. We also have good knowledge on the factors that predispose individuals to and maintain mental health problems, as well as on the reasons for their not easily accessing and engaging with services. There is less evidence on the effectiveness of interventions or service models, although some interesting patterns are beginning to emerge. These include the need for inter-agency commissioning, clear care pathways, designated provision, applied therapeutic interventions, training for carers and frontline practitioners, and multi modal programmes. This paper discusses these issues, as well as ways forward, both for systems with relatively well developed child mental health services and for low-income countries. Service quality can be greatly strengthened by international collaboration on policy, practice and research networks, training and research.     

Improving Community-Based Mental Health Care for Children: A Commentary

In their article, “Improving Community-Based Mental Health Care for Children,” Garland and colleagues explore and confront quality issues that are endemic to outpatient specialty mental health care for children in the United States. Their article presents evidence supporting the lack of effectiveness of usual care and draws on implementation science to explore areas for improving the quality of outpatient mental health care for young people. This commentary accepts these basic arguments and strategies, explores policy options that support the suggested reforms, and examines evidence-based programs in a broader context that draws on the systems of care approach. Specific issues addressed in this commentary include workforce capacity, policy options for improving care quality, provider incentives, systematic implementation supports, strategies to incorporate evidence-based approaches into practice, youth-guided and family-driven care, and the need to expand the definition of evidence-based practice to include the concepts of community-defined evidence and practice-based evidence.     

Practice guidelines in mental health and addiction services: contributions from the American College of Mental Health Administration

Practice guidelines have proliferated in mental health and addiction services; more than 40 organizations have developed guidelines in the field. However, much confusion, controversy, and contextual issues remain, particularly regarding effective dissemination and the clinical, financial, political, and ethical issues that emerge when evidence-based behavioral health practice guidelines are implemented in systems of care. The American College of Mental Health Administration (ACMHA) focused on these problems in their 1999 and 2000 Santa Fe Summits and produced a number of specific outcomes that contribute to thinking in the field. These include the following: (a) a taxonomy of building blocks for informed decision-making in behavioral health assessment and treatment; (b) a paradigm for the development of practice guidelines; (c) characteristics of a good practice guideline; (d) strategies for disseminating and implementing practice guidelines; and (e) areas in need of future research.     

Mental health care user participation in mental health policy development and implementation in South Africa

This paper describes current support for mental health care user participation in policy development and implementation in South Africa and suggests strategies for improving participation. The World Health Organization (WHO) Mental Health Policy Checklist and WHO Mental Health Legislation Checklist were completed. Between August 2006 and August 2009 96 semi-structured interviews with national, regional and district stakeholders were conducted. Most respondents felt that inclusion of user perspectives in policy processes would improve policy development. In practice, mental health care user consultation in policy development and implementation has been limited during the 16 years of democracy in South Africa. Strategies to create a supportive environment for user participation include social action directed at reducing stigma, advocating for acceptance of users' rights to participate in decision making, crafting a supportive regulatory framework to promote participation, and equipping providers and policy makers to support inclusion. User capacity for participation could be strengthened through early and effective access to treatment and support, development of a national user lobby, skills training and practical exposure to the policy and service development environment.     

Timing is everything: Where status epilepticus treatment fails

Status epilepticus is an emergency; however, prompt treatment of patients with status epilepticus is challenging. Clinical trials, such as the ESETT (Established Status Epilepticus Treatment Trial), compare effectiveness of antiepileptic medications, and rigorous examination of effectiveness of care delivery is similarly warranted. We reviewed the medical literature on observed deviations from guidelines, clinical significance, and initiatives to improve timely treatment. We found pervasive, substantial gaps between recommended and “real‐world” practice with regard to timing, dosing, and sequence of antiepileptic therapy. Applying quality improvement methodology at the institutional level can increase adherence to guidelines and may improve patient outcomes. Ann Neurol 2017;82:155–165     

Mental health care user participation in mental health policy development and implementation in South Africa

This paper describes current support for mental health care user participation in policy development and implementation in South Africa and suggests strategies for improving participation. The World Health Organization (WHO) Mental Health Policy Checklist and WHO Mental Health Legislation Checklist were completed. Between August 2006 and August 2009 96 semi-structured interviews with national, regional and district stakeholders were conducted. Most respondents felt that inclusion of user perspectives in policy processes would improve policy development. In practice, mental health care user consultation in policy development and implementation has been limited during the 16 years of democracy in South Africa. Strategies to create a supportive environment for user participation include social action directed at reducing stigma, advocating for acceptance of users’ rights to participate in decision making, crafting a supportive regulatory framework to promote participation, and equipping providers and policy makers to support inclusion. User capacity for participation could be strengthened through early and effective access to treatment and support, development of a national user lobby, skills training and practical exposure to the policy and service development environment.     

Recovery in England: transforming statutory services?

English mental health policy has explicitly supported a focus on recovery since 2001. More recently, this has been elaborated through policy support for social inclusion, employment and well-being. We review several drivers for this political orientation, including a refocusing of the role of health services as a whole from treating illnesses to helping people to make the most of their lives, the shift to greater power for the individual, reflected in personal social care and personal health budgets, and the evidence informing clinical guidelines issued by the National Institute for Health and Clinical Excellence (NICE). A disjunction remains between policy and practice, with organizational policies espousing a recovery orientation and teams re-branding as 'recovery and support' teams, whilst pursuing clinical practices which prioritize symptomatic treatment rather than recovery support. The next phase of development in English statutory mental health services is therefore bridging this gap, through organizational transformation in mental health services towards a focus on recovery. We describe two funded initiatives to support this process of organizational transformation. The first (ImROC) is a national initiative to develop a pro-recovery organizational climate. The second (REFOCUS) is a multi-site cluster randomized controlled trial (ISRCTN02507940) investigating a team-level pro-recovery intervention.     

Implementation of Guideline-Based Care for Depression in Primary Care

Evidence-based clinical practice guidelines for treating depression in primary care settings were developed, in part, to ensure that health services are provided in a consistent, high-quality, and cost-effective manner. Yet for a variety of reasons, guideline-based primary care for depression remains the exception rather than the rule. This work provides a brief review of effective strategies used to customize and then deliver evidence-based treatment for depression in primary care settings; describes two representative case studies that illustrate locally customized collaborative care strategies for treatment delivery; and concludes with principles and implications for policy and practice based on our practical experiences.     

Attitudes towards mental health care in younger and older adults: similarities and differences

It is commonly assumed that older and younger adults have very different attitudes about seeking mental health services and that this is a major factor in reducing the use of mental health services by the elderly. However, little evidence exists to illustrate how elders actually perceive mental health care. Responses from a survey of 474 older adults age 65 and over were compared with data from a national survey of 1001 persons age 21-65. Results indicate similarities in many attitudes including likelihood of seeking treatment for severe mental disorders, importance of mental health care, and concerns about cost and coverage as barriers to care. Differences included use of services, perceptions about less severe disorders, referral sources, and preferred providers. Clinical, policy and public education implications are discussed.     

Developing clinical practice guidelines for epilepsy: A report from the ILAE Epilepsy Guidelines Working Group

Clinical practice guidelines (CPGs) contain evidence‐based recommendations to guide clinical care, policy development, and quality of care improvement. A recent systematic review of epilepsy guidelines identified considerable variability in the quality of available guidelines. Although excellent frameworks for CPG development exist, processes are not followed uniformly internationally, and resources to develop CPGs may be limited in certain settings. An International League Against Epilepsy (ILAE) working group was charged with proposing methodology to guide the development of future epilepsy‐specific CPGs. A comprehensive literature search (1985–2014) identified articles related to CPG development and handbooks. Guideline handbooks were included if they were publicly available, and if their methodology had been used to develop CPGs. The working group's expertise also informed the creation of methodologies and processes to develop future CPGs for the ILAE. Five handbooks from North America (American Academy of Neurology), Europe (Scottish Intercollegiate Guidelines Network & National Institute for Health and Care Excellence), Australia (National Health and Medical Research Council), World Health Organization (WHO), and additional references were identified to produce evidence‐based, consensus‐driven methodology for development of epilepsy‐specific CPGs. Key components of CPG development include the following: identifying the topic and defining the scope; establishing a working group; identifying and evaluating the evidence; formulating recommendations and determining strength of recommendations; obtaining peer reviews; dissemination, implementation, and auditing; and updating and retiring the CPG. A practical handbook and toolkit was developed. The resulting CPG development toolkit should facilitate the development of high‐quality ILAE CPGs to improve the care of persons with epilepsy.     

The role of algorithms in the detection and treatment of depression in primary care

Many depressed patients present to primary care physicians instead of psychiatrists, and several studies have found that primary care physicians underdiagnose and undertreat depression. Primary care physicians may fail to diagnose and treat depression for many reasons: depression as it appears in primary care is in many ways a different disease than that seen in the psychiatric setting, and the process of detecting and treating it is different as well. Primary care clinicians face 2 main tasks when addressing depression in routine practice: to accurately identify those patients who are most likely to benefit from antidepressant treatment and to provide the best treatment options possible in the limited time available per visit. Treatment algorithms can be useful, but they are often difficult to apply in primary care. This article reviews the evidence about the detection and treatment of depression in primary care, examines current research on the differences between the primary and specialty care environments, and discusses aspects of treatment guidelines and algorithms that are important to primary care physicians.     

Family care of the dementing elderly

Abstract

English mental health policy has explicitly supported a focus on recovery since 2001. More recently, this has been elaborated through policy support for social inclusion, employment and well-being. We review several drivers for this political orientation, including a refocusing of the role of health services as a whole from treating illnesses to helping people to make the most of their lives, the shift to greater power for the individual, reflected in personal social care and personal health budgets, and the evidence informing clinical guidelines issued by the National Institute for Health and Clinical Excellence (NICE). A disjunction remains between policy and practice, with organizational policies espousing a recovery orientation and teams re-branding as ‘recovery and support’ teams, whilst pursuing clinical practices which prioritize symptomatic treatment rather than recovery support. The next phase of development in English statutory mental health services is therefore bridging this gap, through organizational transformation in mental health services towards a focus on recovery. We describe two funded initiatives to support this process of organizational transformation. The first (ImROC) is a national initiative to develop a pro-recovery organizational climate. The second (REFOCUS) is a multi-site cluster randomized controlled trial (ISRCTN02507940) investigating a team-level pro-recovery intervention.     

Teambasierte Gemeindepsychiatrie

The German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) guidelines on psychosocial interventions for people with severe mental illness appraise the transferability of results of trials evaluating community-based mental health services to the German situation. This assessment has to draw on research results on factors determining effectiveness. This must be seen against the background of a lack of high-quality trials in Germany. The article discusses system, context and setting factors related to the transfer of evidence on community-based service models from other countries. These issues are discussed on the basis of evidence concerning the models of case management, assertive community treatment and community mental health teams. International differences in study findings are highlighted and the importance of treatment-as-usual in influencing study results is emphasized. The more control services including elements of community-based care there are and the less the pressure to reduce inpatient treatment (threshold to inpatient care admission), the smaller the relative effect sizes of innovative care models will be.In the absence of direct evidence, careful examination of transferability is required before introducing health care models. Research has revealed solid evidence for several factors influencing the effects of innovative community mental health care. Among key factors in the care of people with severe mental illness, home visits and joint team responsibility for both psychiatric and social care were identified. This evidence can facilitate the adaptation of successful mental health care models in Germany.