Referral to Consumer-run Programs by Mental Health Providers: A National Survey

This study describes mental health providers’ awareness of, attitudes toward, and likelihood to refer to consumer-run programs. A mail survey method was used with a total of 301 questionnaires returned (33.5% response rate) from a national random sample. Findings suggest that providers believe consumers are able to provide effective mental health services, yet have less confidence in consumer-run programs. Slightly over half of the providers were aware of consumer-run programs and fewer had made referrals. Providers in non-public settings, agencies that hire consumers as providers, and agencies that collaborate with consumer-run programs were more likely to have made referrals. To maximize available community supports for service recipients, providers should consider newer, consumer-run service technologies.     

Sectorized psychiatry: Some characteristics of patient population after reorganisation

The University Department of Psychiatry at the Haukeland General Hospital in Bergen, Norway, assumed 1976 the comprehensive responsibility for the mental health service in a geographically defined population in the county of Hordaland, Western Norway. The aims were to guarantee an all-round mental health service, in collaboration with the primary health and social services in geographical proximity to the patients' residence. Changes in demographic and clinical patterns and in the degree of collaboration with the primary health service in the community, were studied by comparing a three year period before, and after the reorganisation.

The number of voluntary as well as compulsory admission increased considerably, while the average stay in hospital progressively decreased. Patients with psychotic states, andor heavy social problems, such as isolation and/or unemployment, increased in number. A decreased number of in- as well as out-patients was referred back to the primary health service.

The necessary conditions for the fullfillment of the aims of comprehensive mental health care seem to lie both in adequate psychiatric resources for treatment and rehabilitation in the catchment area and in an effective collaboration with the primary health service.

Fred Holsten är docent vid Psykiatrisk Institutt, Haukeland sykehus, Universitetet i Bergen och Giacomo d'Elia är professor i psykiatri, Psykiatriska institutionen, Universitetet i Linköping. Under åre, 1978–1981 har han varit professor i psykiatri, Psykiatrisk Institutt, Haukeland sykehus, Bergen.     

State budget cuts, health care reform, and a crisis in rural community mental health agencies

Between 2009 and 2011, states implemented significant budget cuts to community mental health agencies (CMHAs), which are frequently the sole provider of specialized behavioral health services in rural communities. Starting in 2010, federal policy changes created by health care reform and mental health parity are likely to increase the number of individuals who can afford to seek services for a mental illness. CMHAs under financial stress have begun to eliminate services and reduce staff. These trends could result in a growing gap between available behavioral health services and the number of people who can afford to seek treatment for a mental illness.     

Norms for mental health services in South Africa

Background In the aftermath of apartheid, South Africa has inherited a fragmented, under-resourced and inequitable public sector mental health service. Attempts are being made to reform mental health services, in keeping with new health policy, which proposes the downscaling of psychiatric institutions and the development of community-based services. This study set out to develop a set of service norms for the care of people with severe psychiatric conditions (SPC) in South Africa, to assist the implementation of the new policy. Methods A national situation analysis of current public sector mental health services was conducted. A model was developed for estimating the mental health service resource needs of people with SPC. Following consultation with provincial stakeholders, a set of service norms were developed taking into account national indicators from the situation analysis (as a baseline level) and proposals of the model (as a target level). Results The study recommends an increase in the number of acute psychiatric beds in general hospitals; development of community-based residential care; redistribution of staff from hospital to community services, particularly in rural areas; and the development of information systems to monitor the transitions to community-based care. Conclusions The norms proposals presented in this study express mental health service needs in terms of quantifiable service resource and utilisation levels. In doing so, the study attempts to make explicit the assumptions and values on which planning is based.     

Carers and community mental health services

Background There is a growing appreciation of the role and needs of carers for people with mental health problems. Carers are a diverse group, including partners, relatives and friends who are seen as such by service users. Methods Sixty-four carers of people with severe mental health problems served by four different mental health care providers were interviewed using the Experiences of Care-giving Inventory. The districts were selected to differentiate services that are targeted at more severely impaired users from those that include a wider spectrum, and to contrast services that have greater integration between health and social care providers with those whose health and social care agencies operate relatively discretely. Results In the two districts where service users had more severe mental health problems, carers worried more about negative symptoms and thought less about good aspects of the caring relationship. In the two districts where health and social services worked more closely together, carers worried significantly less about the need to back up services. Conclusions These findings suggest that service organisation can affect carers, in particular that integration between health and social care for people with mental health problems may benefit carers in ways that were hitherto unproven. They highlight the needs of carers for younger people. They show that the ECI is a useful instrument in measuring the impact of caring for people with severe mental health problems. Accepted: 19 September 2001     

Creating an innovative youth mental health service in the United Kingdom: The Norfolk Youth Service

Young people attempting to access mental health services in the United Kingdom often find traditional models of care outdated, rigid, inaccessible and unappealing. Policy recommendations, research and service user opinion suggest that reform is needed to reflect the changing needs of young people. There is significant motivation in the United Kingdom to transform mental health services for young people, and this paper aims to describe the rationale, development and implementation of a novel youth mental health service in the United Kingdom, the Norfolk Youth Service. The Norfolk Youth Service model is described as a service model case study. The service rationale, national and local drivers, principles, aims, model, research priorities and future directions are reported. The Norfolk Youth Service is an innovative example of mental health transformation in the United Kingdom, comprising a pragmatic, assertive and “youth‐friendly” service for young people aged 14 to 25 that transcends traditional service boundaries. The service was developed in collaboration with young people and partnership agencies and is based on an engaging and inclusive ethos. The service is a social‐recovery oriented, evidence‐based and aims to satisfy recent policy guidance. The redesign and transformation of youth mental health services in the United Kingdom is long overdue. The Norfolk Youth Service represents an example of reform that aims to meet the developmental and transitional needs of young people at the same time as remaining youth‐oriented.     

Mental health services and research in the Arab world

Although there are 22 Arab countries in the Arab League, the mental health services provided in those countries show several forms of variation. Economic, political, social and cultural factors seem to play a major role in determining the state of the psychiatric profession and the access of the service to citizens. The different needs expressed by Arab colleagues at times seem incompatible with the available allocated resources. Some Arab countries enjoy the highest income per capita, yet this is inconsistent with the quality of mental health services available there. The per capita mental health services, the availability of a Mental Health Act, and the space allocated for mental health in medical curricula are but a few of the concerns that have been expressed by colleagues from the different countries of the Arab region. The following review will attempt to draw up a profile of the situation for mental health services and research in the region, and to suggest some measures for intervention.     

Consumer-run service participation, recovery of social functioning, and the mediating role of psychological factors

OBJECTIVE: This study examined the relationship between participation in consumer-run services and recovery of social functioning among persons diagnosed as having serious mental illness. It also assessed the role of psychological factors in mediating this relationship. METHODS: Research questions investigated were whether involvement in consumer-run services is positively associated with recovery when premorbid and demographic factors are controlled for, whether psychological factors are positively associated with recovery irrespective of involvement in consumer-run services, and whether the relationship between involvement in consumer-run services and recovery is mediated by the psychological factors. The factors examined were self-efficacy, hopefulness, and active coping strategies. Sixty participants with a past or present diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder and at least one past psychiatric hospitalization were recruited from a community mental health center and two consumer-run programs. Data were collected on hopefulness, self-efficacy, coping strategies, social functioning, and premorbid and demographic characteristics. RESULTS: Findings indicated that participants involved in consumer-run services had better social functioning than those involved only in traditional mental health services, that psychological variables were significantly associated with social functioning, and that the relationship between involvement in consumer-run services and social functioning was partly mediated by the use of more problem-centered coping strategies. Premorbid and demographic factors did not account for the relationship between psychosocial variables and social functioning, although education was a significant predictor of social functioning. CONCLUSIONS: The findings support the view that psychosocial factors may play a role in facilitating good community adjustment for individuals diagnosed as having serious mental illness.     

The administration of school-based mental health services.

Challenges and proposed solutions in the administration of school-based mental health services have been addressed. Differences depend on whether the services are provided by the mental health component of an SBHC or by an ISBMHP. Seven common elements relevant in developing and administering school-based mental health services, whether in an SBHC or ISBMHP, have been identified: funding, assessment and resources, program structure, staffing and training, partnership and collaboration, quality assurance, and evaluation. How these elements are addressed varies from school district to indivdual school to individual principal to agencies providing services to specific clinicians. One of the most important lessons learned is that the ecosystem of each school is different; one size does not fit all. When external agencies enter a school, they are in the best case guests, in the worst case foreigners or invaders. Agencies and their clinicians must be respectful, adaptable, flexible, and competent professionals. With such attributes, the chance for an effective collaboration is enhanced. Contributions of school-based mental health services to the child and adolescent mental health delivery system include (1) access to services for disadvantaged and underserved youth, (2) system-wide collaboration, (3) prevention of acute psychiatric intervention, (4) gate-keeper role for more acute or specialized care, (5) systematic program evaluation in a "naturalistic" setting, (6) professional training in working with a range of systems and cultures, and (7) outreach and community-based care. With the emphasis on partnership and collaboration, school-based programs have the potential to benefit the children and families, schools, communities, and managed care organizations. The provision of access and early intervention is cost effective in the long run, and findings indicate that school-based mental health service is as effective as that of a central clinic. With the emphasis on collaboration, partnership, and bridging systems and cultures, the provision of school-based mental health care may be able to offer tools and experience to create integrated systems of care. This is a reciprocal process and an ongoing dialectic, however. Providers and planners of a school-based mental health programs, schools, and managed-care leaders can learn from one another, and all have major contributions to make to the overall delivery system. Schools and mental health service providers contribute knowledge and skills in working with this population; managed care organizations bring administrative and fiscal expertise and a focus on and mandate for quality and cost-effective care. For-profit and not-for-profit agencies must enter into a dialogue to educate and understand each other so that they may become collaborators in the underutilized service for children and youth.     

Planning to meet the needs of offenders with mental disorders in the United Kingdom

During the last decade the planning of services for offenders with mental disorders in the United Kingdom has been geared toward diverting them from the criminal justice system to appropriate levels of psychiatric and social care. Although a seamless service system is yet to be developed, the central government has made a concerted effort to promote a better understanding of the needs of offenders with mental disorders and encourage collaboration between the relevant agencies. A major program of research has been initiated, and local health authorities have been encouraged to use a consortium approach to planning and delivery of specialist services. The authors discuss the activities of the Wessex consortium, composed of five local health authorities and a social services department serving a catchment area with a population of 2.5 million in southern England. The consortium has commissioned needs assessments for all offenders with mental illness from the catchment area and a survey of the resources for secure residential treatment in the region. Based on data from this research, the consortium is planning the development of two long-stay secure units to accommodate offenders with a history of repeated inpatient and prison stays and poor response to previous treatment and rehabilitation efforts.     

The Program for Public Psychiatry: state-university collaboration in Colorado

A major focus of state-university collaboration programs in psychiatry has been providing services and manpower from the university to the public mental health system, which in turns provides valuable educational experiences to the university. The Program for Public Psychiatry, a state-university collaboration program in Colorado, was founded on a 25-year relationship between the department of psychiatry at the University of Colorado Health Sciences Center and the Colorado Division of Mental Health. The program has enabled Colorado's two state hospitals and most of its urban community mental health centers to almost completely fill previously vacant psychiatric positions. The collaboration has expanded to include programs for forensic psychiatry and developmental disabilities, as well as to fund educational and research missions in developing the public psychiatric work force.     

University-state hospital collaboration in an inpatient psychiatric rehabilitation program

From 1981 until present the Department of Psychology of the University of Nebraska-Lincoln has collaborated with the Lincoln Regional Center, a state hospital, on an inpatient psychiatric rehabilitation project. The University provides clinical psychology services under contract, including direct clinical services and consultation on program development. The project includes a 40-bed inpatient treatment unit, which represents a clinical training and research site for University faculty and graduate students. Program evaluation data indicate the collaboration has produced a cost-effective state-of-the-art treatment program, now considered a model for psychiatric rehabilitation services across the state. The collaboration played a key role in securing two major grants, one for specialty training for clinical psychologists in schizophrenia and psychiatric rehabilitation, one for a treatment outcome study. Facilitating factors in the project include convergence of the collaborators' professional and research interests with national and state mental health policy. Obstacles include hospital administrative policies which fail to recognize or appreciate requirements for program management and accountability, and unwillingness to recognize program leadership from nonmedical professionals.     

Barriers to access to mental health services for ethnic seniors: the Toronto study.

OBJECTIVE: To identify and describe barriers to access to mental health services encountered by ethnoracial seniors. METHOD: A multiracial, multicultural, and multidisciplinary team including a community workgroup worked in partnership with seniors, families, and service providers in urban Toronto Chinese and Tamil communities to develop a broad, stratified sample of participants and to guide the study. This participatory, action-research project used qualitative methodology based on grounded theory to generate areas of inquiry. Each of 17 focus groups applied the same semistructured format and sequence of inquiry. RESULTS: Key barriers to adequate care include inadequate numbers of trained and acceptable mental health workers, especially psychiatrists; limited awareness of mental disorders among all participants: limited understanding and capacity to negotiate the current system because of systemic barriers and lack of information; disturbance of family support structures; decline in individual self-worth; reliance on ethnospecific social agencies that are not designed or funded for formal mental health care; lack of services that combine ethnoracial, geriatric, and psychiatric care; inadequacy and unacceptability of interpreter services; reluctance of seniors and families to acknowledge mental health problems for fear of rejection and stigma; lack of appropriate professional responses; and inappropriate referral patterns. CONCLUSIONS: There is a clear need for more mental health workers from ethnic backgrounds, especially appropriately trained psychiatrists, and for upgrading the mental health service capacity of frontline agencies through training and core funding. Active community education programs are necessary to counter stigma and improve knowledge of mental disorders and available services. Mainstream services require acceptable and appropriate entry points. Mental health services need to be flexible enough to serve changing populations and to include services specific to ethnic groups, such as providing comprehensive care for seniors.     

Improving care for families where children and parents have concurrent mental health problems

Background: When mental illness affects children and parents within the same family there is a need for close professional collaboration between the respective psychiatric teams. However, there is no nationally established precedence for this, and the area has not been investigated within the published literature. Method: Retrospective case note study of 322 child psychiatric patients to estimate the prevalence of parental mental illness and analyse the degree of professional liaison taking place. Results: Twenty‐eight children had parents with concurrent mental health problems. Only four of these cases (14.2%) contained evidence of ongoing professional liaison between child and adult mental health teams. Conclusion: Inadequate liaison between child and adult services is a problem within the UK mental health system and detrimental to patient care. Recent national interest in establishing a more integrated family‐focused service is encouraging, but will take time to implement and will not replace the need for separate specialist services. Efficient clinical collaboration must be developed at local levels to create a more comprehensive management strategy for children and parents with concurrent mental health problems.     

Predictors of suicide in a community-based cohort of individuals with severe mental disorder

Background Rate of suicide is probably an indicator of the quality of mental health services within an area. The aim of this study was to identify predictors of suicide in a large community-based cohort of persons with long-term mental disorder.Methods A survey was conducted in Stockholm County, Sweden, in 1997 to identify adults with long-term disabling mental disorder (mental retardation and dementia excluded). The survey included an inventory of unmet needs as perceived by the service providers. The 12,247 cases were linked to the national in-patient register and the cause-of-death register. Predictors of suicide in 1997–2000 were determined by bivariate analysis and multiple logistic regression.Results Predictors of suicide included a history of in-patient psychiatric care, previous suicide attempt, substance abuse and unmet need of a contact person. Personality disorder, especially borderline personality disorder, was the strongest diagnostic predictor of suicide among those with a history of in-patient psychiatric care.Conclusion Unmet needs may signal increased suicide risk in persons with severe mental disorder. Methods to improve suicide prevention in persons with personality disorder should be further developed. Interventions to reduce suicide in persons with a long-term mental disorder will require collaboration between psychiatric and social services.     

Mental health services in the Solomon Islands

The Solomon Islands comprise an archipelago of nearly 1,000 islands and coral atolls and have an estimated population of 549,574 people. Formal mental health services date back to 1950 when an asylum was established. Since then the process of mental health service development has been largely one of incremental change, with a major boost to community services in the last two decades. During the 1990s a mental health outpatient clinic was established in Honiara, together with attempts to recruit nursing staff as psychiatric coordinators in the provinces. In 1996, the Ministry commenced sending registered nurses for psychiatric training in Papua New Guinea. By 2010, there were 13 psychiatric nurses and one psychiatrist, with a second psychiatrist in training. A National Mental Health Policy was drafted in 2009 but is yet to be endorsed by Cabinet. A significant portion of the population still turns to traditional healers or church leaders for purposes of healing, seeking help from Western medicine only after all other alternatives in the community have been exhausted. There is still a long way to go before mental health services are available, affordable and accessible to the whole population, including people living in geographically remote areas. Realization of this vision requires increased resourcing for mental health services; improved communication and collaboration between the centrally‐based, national mental health services and the provincial health services; and closer, ongoing relationships between all stakeholders and partners, both locally and internationally.     

Service costs of caring for adolescents with mental illness in a rural community, 1993-2000

OBJECTIVE: Costs of treating child psychiatric disorders fall on educational, primary care, juvenile justice, and social service agencies as well as on psychiatric services. The authors estimated multiagency mental health costs by integrating service unit costs with utilization rates in an 11-county area. Using psychiatric diagnoses made independently of service use records, the authors calculated costs across agencies as well as the extent of unmet need for psychiatric care. METHOD: Annual parent and child reports were used to measure mental health care needs and units of service across 21 types of settings for the population-based Great Smoky Mountain Study sample of 1,420 adolescents from ages 13 to 16. Unit costs for services were generated from information from service providers and records. The authors calculated costs overall, costs by type of service, and costs by diagnosis. RESULTS: Average annual costs per adolescent treated were $3,146. Juvenile justice and inpatient/residential facilities accounted for well over half of the total costs. Costs for youths with two or more diagnoses were twice as much as costs of those with a single disorder. Among adolescents with service needs, 66.9% received no services. Public health insurance was associated with higher rates of specialty mental health care than either private insurance or no insurance. CONCLUSIONS: Annual costs across all services were three to four times greater than recent health insurance estimates alone. Many costs for adolescents with mental health problems were borne by agencies not designed primarily to provide psychiatric or psychological services. Only one in three adolescents needing psychiatric care received any mental health services.     

Connecting Mentally Ill Detainees in Large Urban Jails with Community Care

Large urban jails have become a collection point for many persons with severe mental illness. Connections between jail and community mental health services are needed to assure in-jail care and to promote successful community living following release. This paper addresses this issue for 2855 individuals with severe mental illness who received community mental health services prior to jail detention in King County (Seattle), Washington over a 5-year time period using a unique linked administrative data source. Logistic regression was used to determine the probability that a detainee with severe mental illness received mental health services while in jail as a function of demographic and clinical characteristics. Overall, 70 % of persons with severe mental illness did receive in-jail mental health treatment. Small, but statistically significant sex and race differences were observed in who received treatment in the jail psychiatric unit or from the jail infirmary. Findings confirm the jail’s central role in mental health treatment and emphasize the need for greater information sharing and collaboration with community mental health agencies to minimize jail use and to facilitate successful community reentry for detainees with severe mental illness.     

Psychiatric Disorder and Unmet Service Needs Among Welfare Clients in a Representative Payee Program

This study assessed psychiatric problems, needs for psychiatric and social services, and service utilization among clients of a public assistance program. Sixty-five clients were assessed using a structured clinical interview to determine the presence of a psychiatric disorder (using the CIDI-A), extent of social service need, and health-related quality of life (RAND SF-36). Seventy-seven percent of the sample met criteria for at least one current or lifetime psychiatric disorder. Health-related quality of life was substantially below published norms. Most clients reported needing financial, housing, and vocational assistance. Many had contact with mental health services, but few were actually receiving psychiatric treatment. Although many clients were assessed as having serious psychiatric, physical, or social needs, very few were receiving appropriate services for these problems. Findings suggest problems or barriers to the provision of services that need to be investigated among this vulnerable community population.