Occupational therapy in mental health: challenges and opportunities

The National Mental Health Policy and National Mental Health Plan published in 1992 provided directions for the reform of mental health services in Australia. They stated that mental health services should be part of the mainstream health system and that integrated mental health programmes should be developed to cover the full range of specialist mental health services, focusing on improved quality of service, the consumers, equity of access, continuity of care and redistribution of resources. The Queensland Mental Health Plan published in 1994 set out specific objectives and strategies for implementing mental health service reform in Queensland. In Queensland there has been a concentration on developing core mental health services involving the reorientation of service delivery from institutions to the community, based on the principles of integration, mainstreaming and regional self-sufficiency. Major restructuring of mental health services is taking place, which has meant changes in service development, organizational structures and work practices. There has been a significant impact on the roles and skills required by the mental health workforce in the context of today's mental health services climate. There is a focus on staff providing individualized assessment and continuing treatment using a case management approach, within a continuum of care. Implications for occupational therapists include developing a generic skill base in preparation for broad-spectrum mental health professional roles while maintaining their professional identity. It is recommended that research be conducted to examine the capacity of occupational therapists to adapt to the changing mental health environment. Copyright © 1999 Whurr Publishers Ltd.     

Implementation of diagnosis-related mental health programs: impact on health care providers

Mental health services are in the midst of change in different countries. In Quebec (Canada), the government has adopted a Mental Health Action Plan (2005-2010). In this context, 2 psychiatric institutions have developed and implemented a mental health services organization model based on diagnosis-related mental health programs and support for frontline services. This article presents the impact on health care providers of implementation of diagnosis-related mental health programs in the context of transformation of mental health services.     

Organization and financing of mental health care in Poland

ORGANIZATION OF CARE: Health care is provided to patients with mental disorders by the state health care facilities as well as by social help agencies. Mental health care services are provided mostly by mental health facilities and partly by primary care units. Outpatient clinics, separate for psychiatric patients and substance abusers, are the most numerous mental health care units, amounting to a total of 1120. Intermediate care facilities include 110 day hospitals, 23 community mobile teams and ten hostels. The number of hospital beds amounts to 31913, i.e. 8.3 beds per 10000 population. 80% of beds are located in mental hospitals. TRENDS OF DEVELOPMENT: The trends in mental health care development are outlined in the Mental Health Programme and accompanying documents accepted by the Minister of Health and Social Welfare. The programme defines specific goals to be achieved by the year 2005 in the primary, secondary and tertiary prevention of mental disorders. In the domain of mental health care accessibility the most important goals are the following: a significant reduction in the number of beds in large mental hospitals, a marked (nearly threefold) rise in the number of beds in psychiatric wards at general hospitals and a significant increase in the number of community-based forms of care (e.g. a fourfold rise in the number of day hospitals). FINANCING OF CARE: Before 1999, the health care system was financed from the state budget and the health care spendings were subject to a political auction each year. Allocation of funds among hospitals and health care centres was based on the total previous year budgetary spendings of particular facilities and did not take into account a detailed cost analysis. Such a financing approach, although giving a feeling of a relative financial safety, did not encourage health care facilities to introduce an organizational flexibility and to expand the scope of their services. In psychiatry, it manifested itself in a very slow development of some community psychiatry forms (mostly day hospitals, mobile community teams and hostels). The Health Care Institutions Act has created a legal framework for the financial management of health care units in their new, independent form. Conditions for health care financing through regional sickness funds were thus created. The financing is currently based on contracts made by sickness funds with health care facilities for specific health services. Both the quantity and price of services should be mutually negotiated. Some simplified measures of services offered were used during the first insurance financing year. In mental hospitals and day hospitals it was a person-day; in out-patient care it was a visit. Both cost indicators were aggregated, including all the components present so far in the functioning a given unit.     

How to accomplish practice change in behavioral healthcare in less than one year

This is a challenging time in the field of public mental health. State and federal funding for public behavioral healthcare is declining in a time when the demand for services is increasing. Philosophical changes in mental healthcare service delivery, underscored by the tenets from the President's New Freedom Commission on Mental Health, are creating additional challenges for practitioners. The Adult Network of Pikes Peak Mental Health (PPMH) has developed a model for providing behavioral healthcare that meets these challenges while providing greater access to care, holistic care delivered in natural settings and, at the same time, maintaining the quality clinical outcomes at reduced costs.     

Evaluating the WHO Assessment Instrument for Mental Health Systems by comparing mental health policies in four countries

Mental health is a low priority in most countries around the world. Minimal research and resources have been invested in mental health at the national level. As a result, WHO has developed the Assessment Instrument for Mental Health Systems (WHO-AIMS) to encourage countries to gather data and to re-evaluate their national mental health policy. This paper demonstrates the utility and limitations of WHO-AIMS by applying the model to four countries with different cultures, political histories and public health policies: Iraq, Japan, the Philippines and The former Yugoslav Republic of Macedonia. WHO-AIMS provides a useful model for analysing six domains: policy and legislative framework; mental health services; mental health in primary care; human resources; education of the public at large; and monitoring and research. This is especially important since most countries do not have experts in mental health policy or resources to design their own evaluation tools for mental health systems. Furthermore, WHO-AIMS provides a standardized database for cross-country comparisons. However, limitations of the instrument include the neglect of the politics of mental health policy development, underestimation of the role of culture in mental health care utilization, and questionable measurement validity.     

The Carter Center Mental Health Program: addressing the public health crisis in the field of mental health through policy change and stigma reduction

Some of the most pervasive and debilitating illnesses are mental illnesses, according to World Health Organization's The World Health Report 2001 — Mental Health: New Understanding, New Hope. Neuropsychiatric conditions account for four of the top five leading causes of years of life lived with disability in people aged 15 to 44 in the Western world. Many barriers prevent people with mental illnesses from seeking care, such as prohibitive costs, lack of insurance, and the stigma and discrimination associated with mental illnesses. The Carter Center Mental Health Program, established in 1991, focuses on mental health policy issues within the United States and internationally. This article examines the public health crisis in the field of mental health and focuses on The Carter Center Mental Health Program's initiatives, which work to increase public knowledge of and decrease the stigma associated with mental illnesses through their four strategic goals: reducing stigma and discrimination against people with mental illnesses; achieving equity of mental health care comparable with other health services; advancing early promotion, prevention, and early intervention services for children and their families; and increasing public awareness about mental illnesses and mental health issues.     

Provider arrangements for mental health services in 'The New NHS'

Mental health services in England, in common with many other European countries, have been the subject of sustained government attention during the 1990s. Since the election of the Labour administration in Britain in May 1997, mental health services have been discussed in most Department of Health documents on health and social care policy, and mental health services in England have a new national strategy. At the same time, the local provision of mental health services within NHS Trusts has been undergoing organisational change. This paper sets out the policy context and evidence base for the reorganisation of provider arrangements for mental health services. In addition, the results of a documentary analysis of unpublished reviews of provider arrangements in 10 localities are presented. The review identified three major themes: firstly, the reconfiguration of NHS Trusts is based around Specialist Mental Health Trusts and Community and Mental Health Trusts; secondly, the joint provision of services and/or the integration of services between health and social services is starting to appear and; thirdly, the delegation of responsibility to localities based on Primary Care Group/Social Services boundaries is being discussed. The paper discerns a number of trends and points to the need for further research, in particular into the relationship between organisational arrangements and effective service delivery.     

Urbanization and mental health in developing countries

It is expected that the urban population in developing countries will double in the next 30 years. While urbanization is accompanied by health problems, population density can lower public health costs. Common mental disorders, such as anxiety, depression, insomnia, fatigue, irritability, and poor memory, account for 90% of all mental disorders, cause behavioral problems in offspring, and impede recovery from physical ailments. Those who suffer most from common mental disorders include women, those between 15 and 49 years old, and low-income populations. Strong links have been established between socioenvironmental factors and common mental disorders, and an urban environment has been associated with many possible risk factors for such disorders. Only a small percentage of people with mental disorders seek primary health care and even less receive secondary- or tertiary-level care. Common mental disorders place a large burden on primary health care services, however, but most of the patients suffering from mental disorders seek care for physical disorders that mask proper diagnosis and treatment. Thus, the World Health Organization advocates the introduction of mental health components in primary health care services in developing countries. In order to reach those who remain outside of the health care system, community-based interventions such as self-help groups or efforts to promote wider social changes or address poverty should be undertaken. Mental health in developing countries is gaining attention as the attendant loss in economic productivity of human capital has become apparent.     

The mental health and addictions quality initiative: Collaboration in public reporting and quality improvement

Provincial and national initiatives to measure healthcare performance have primarily focused on general hospital care, with little or no attention paid to developing indicators appropriate for specialized mental health services. Officially launched in 2011, a key objective of the Mental Health and Addictions Quality Initiative is to improve the quality of care through collaboration and transparency. Standardized mental health and addictions indicators reflective of hospital accountability and accessible to the public were developed and are currently compared among 15 hospitals.     

Implementing the Public Health Social Work Forward Plan: a research-based prevention curriculum for schools of social work.

In 1985, the Division of Maternal and Child Health of the U.S. Public Health Service funded a major working conference entitled "Public Health Social Work in Maternal and Child Health: A Forward Plan." Curriculum recommendations for schools of social work were made, including a recommendation for the integration of health and mental health content in the education of social workers within a public health conceptual framework. In 1986, the National Institute of Mental Health funded a three-year program to develop and evaluate a research-based prevention training curriculum for dissemination to schools of social work and other primary care professional schools. This article examines the Michigan Prevention Training and Curriculum Development Project from the perspective of the recommendations of the Public Health Social Work Forward Plan.     

Ethics and value strategies used in prioritizing mental health services in Oregon

The authors describe the ethical considerations underlying the inclusion of mental health services into a prioritizedhealth care system. The Oregon Health Plan is a process for defining and delivering basic health services to an entire state. As the plan was developed, the mental health community needed to decide whether or not to participate in the process and, if so, how. Lengthy discussions among mental health consumers, family members, and providers led to a strategy that emphasized the integration of mental health and chemical dependency services into a comprehensive and universal health care program. This approach appears to have achieved relative parity for mental health.     

Mind and body primary mental healthcare: new model for integrated services

Primary mental healthcare is different from consultation-liaison psychiatry and behavioral medicine yet has elements of both. This approach calls for complete integration of behavioral health services within the primary care and general medical setting. Primary care providers, rather than mental health specialists, retain direction of patient care. In this model, developed at the Group Health Cooperative of Puget Sound, primary behavioral health clinicians are on site, not on call.     

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.     

Mental health services system research: the National Institute of Mental Health program.

There is a critical need for research to examine the changing mental health services system, to evaluate major innovations in the provision of mental health treatment, and to remove existing barriers to comprehensive and cost-effective care. To achieve these aims, collaboration is needed among government agencies, mental health services programs, academic institutions, and the private sector. The National Institute of Mental Health supports research and research training on the mental health services system primarily through the Division of Biometry and Applied Sciences. This article focuses on the division's three priority research areas of the mental health services system: the provision of mental health care in the primary care sector, the organization and delivery of care for the chronically mentally ill, and financing and reimbursement of care. The various mechanisms of research support are also highlighted.     

The Oregon Health Plan and public health

The Oregon Health Plan would provide all Oregonians with health insurance through a combination of Medicaid expansion, employer mandates and high-risk coverage, with services delivered largely through managed care. The role of public health in a managed care environment is an important national issue, and one which has received much attention in Oregon. "Cultural" differences between Medicaid and public health have arisen over issues such as whether eligibility assures access, whether the private medical model will provide integrated care, the potential for exploitation of vulnerable populations in a capitated system, and the loss of cost-based Medicaid reimbursement to public clinics. In 1991, legislation required that Oregon's Medicaid managed care plans enter agreements with local health departments to assure their continued participation in providing certain public health services; these agreements are now being implemented. Oregon's experience suggests that any national health system will require a continuum of community and individual health services, with an important role for public health departments.     

Inequities in mental health care after health care system reform in Chile

OBJECTIVES: We compared differences in mental health needs and provision of mental health services among residents of Santiago, Chile, with private and public health insurance coverage. METHODS: We conducted a cross-sectional survey of a random sample of adults. Presence of mental disorders and use of health care services were assessed via structured interviews. Individuals were classified as having public, private, or no health insurance coverage. RESULTS: Among individuals with mental disorders, only 20% (95% confidence interval [CI]=16%, 24%) had consulted a professional about these problems. A clear mismatch was found between need and provision of services. Participants with public insurance coverage exhibited the highest prevalence of mental disorders but the lowest rates of consultation; participants with private coverage exhibited exactly the opposite pattern. After adjustment for age, income, and severity of symptoms, private insurance coverage (odds ratio [OR]=2.72; 95% CI=1.6, 4.6) and higher disability level (OR=1.27, 95% CI=1.1, 1.5) were the only factors associated with increased frequency of mental health consultation. CONCLUSIONS: The health reforms that have encouraged the growth of the private health sector in Chile also have increased risk segmentation within the health system, accentuating inequalities in health care provision.     

Linking substance abuse and serious mental illness service delivery systems: Initiating a statewide collaborative

In the past, persons with serious mental illness and substance abuse often found themselves in parallel systems of care that inadequately addressed their needs. Recent advances have seen the development of an integrated approach to care for these disorders in both the public and private sectors. While some state departments of mental health have developed integrated systems of care for public sector patients, no department appears to have developed such a system for both public and private clients, and there appears to be no published journal report of a model to induce cooperation by all stakeholders. This article outlines a two-step approach by the Massachusetts Department of Mental Health to foster stakeholder cooperation in designing an integrated system of care for both public and private clients with co-occurring disorders.     

MHSPY: A Children's Health Initiative for Maintaining At-Risk Youth in the Community

The Massachusetts Mental Health Services Program for Youth (MHSPY) is a home-based clinical intervention that seeks to maintain youth with severe functional impairment in the community via delivery of integrated primary care, mental health, substance abuse, and social services. Using blended public agency funding, traditional and nontraditional services are provided within a private, not-for-profit, managed care organization. Individualized, comprehensive care plans are developed by an MHSPY care manager, who works intensively with the family and the Care Planning Team to identify needs and resources. Data on clinical functioning are collected at baseline and every six months during the program. Service utilization and cost are measured on a quarterly basis. Family, youth, and agency satisfaction ratings are collected at disenrollment. Aggregate analyses based on four years of data show that MHSPY participants have improved clinical functioning, including significant reduction in risk to self and others. They also experience reduced service utilization and cost and high rates of family satisfaction.Brian Mullin, BA, is a Senior Data Analyst at Neighborhood Health Plan, 253 Summer St., Boston, MA 02210, USA.     

Moving an evidence-based intervention into routine mental health care: a multifaceted case example

Many evidence-based interventions fail to translate into routine care for individuals experiencing significant mental health disorders. Moving the evidence-based intervention from the controlled research settings to the broader mental health systems is an ongoing challenge for administrators and practitioners in the mental health delivery network. In the United States, the movement to bring evidence-based mental health interventions into the public mental health system to enhance consumer recovery and improve outcomes has been a major thrust of federal and state efforts over the past 10 years (IOM, 2006; New Freedom Commission on Mental Health, 2003; Michigan Mental Health Commission, 2004; U.S. Department of Health and Human Services, 1999). Using a multifaceted case example, this article will address one state's efforts to implement an evidence-based intervention, Family Group Psychoeducation (FPE), into routine care for individuals living with schizophrenia and their families. The Consolidated Framework for Implementation Research (CFIR) (Damshcroder et al., 2009) guides the discussion of the dissemination efforts. This CFIR framework involves examining five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation.