Interactions between use of and insurance for specialty ambulatory mental health services

BACKGROUND: There is continuing interest in the effects of coinsurance rates on the use of ambulatory mental health services. Persons who expect to use mental health services may choose coverage with more generous mental health benefits, as such treatment may be expected to be a recurring activity. However, it may also be the case that if the expected need for such services is somehow reflected in lower perceived human capital in the labor market, then persons who have a higher probability of use may face a less generous set of health insurance options. These behaviors imply some simultaneity in the determinants of the coinsurance rate facing an individual and their mental health use. AIM OF THE STUDY: To explore the joint determination of the use of and coinsurance for ambulatory mental health services, using non-experimental data for a nationally representative sample of the non-institutionalized who had employer-based health insurance in the United States. METHODS: I estimate an instrument for the ambulatory mental health coinsurance rate. I then estimate two models of the demand for ambulatory mental health care as a function of the coinsurance rate for this type of care and other factors, one using the actual coinsurance rate and the other using the estimated instrument for the coinsurance rate. RESULTS: In the instrumental equation, an index of the mental distress of the key worker most likely to be the policy-holder has no statistically significant effect on the worker's coinsurance rate. However, a similar measure for other members of the worker's family has a positive and statistically significant effect on the worker's coinsurance rate. In the demand equations, neither the actual coinsurance rate nor its instrument has a statistically significant coefficient. DISCUSSION: Having another family member who may need mental health care results in some effort to seek a health plan with a higher coinsurance rate for such services. While the mental health index for the key worker would motivate the same type of seeking behavior, a higher level for this index for the key worker might also be correlated with a lower level of perceived human capital in a prospective employer's eyes, and this might result in a more restricted set of plan options for mental health care in the labor market. The absence of statistical significant for the coefficients of the actual coinsurance rate and its instrument also provides some limited but suggestive evidence of employer-side selection effects. LIMITATIONS: It was not possible to model the full complexity of health plans. CONCLUSIONS: The discussions of selection bias with regard to mental health insurance and service use should be expanded to include demand-side effects in the labor market, in addition to the supply-side effects on the part of workers that are often considered. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: It may be difficult to determine the effects on ambulatory mental health care of changes in health insurance provisions. IMPLICATIONS FOR HEALTH POLICY FORMULATION: Caution needs to be used in making estimates of the effects of changes in insurance coverage for ambulatory mental health care. Persons who find their benefits improved may not respond at the rate expected, because initial coinsurance rates are already in part intertwined with expected use. IMPLICATIONS FOR FURTHER RESEARCH: More analyses of the range of selection effects in labor markets and their impacts on health insurance are warranted.     

Substitution between Formal and Informal Care for Persons with Severe Mental Illness and Substance Use Disorders

BACKGROUND: Persons with severe mental illness (SMI) often get extensive informal care from family members and friends as well as substantial amounts of formal treatment from paid professionals. Both sources of care are well documented, but very little is known about how one affects the other. AIMS OF THE STUDY: This analysis estimates the extent of substitution between direct care provided by family and friends and formal treatment for people with severe mental illness and substance use disorders. Separate estimates are generated for short-term and long-term effects. METHODS: Data are from a randomized clinical trial conducted at seven mental health centers in New Hampshire between 1989 and 1995. The study includes detailed data for 193 persons with dual disorders measured at study entry and every six months for three years. Hours of informal care were compared with total treatment costs within each six-month period to measure short-term effects. Average amount of informal care over three years represented long-term caregiving practices. Measures of informal care are from interviews with informal caregivers. Treatment costs are based on combined data from management information systems, Medicaid claims, hospital records, and self reports. We used mixed effects repeated measures regression to estimate longitudinal effects and a multiple imputation technique to test the sensitivity of results to missing data. RESULTS: In the short-term, persons with bipolar disorder used significantly more formal care as informal care increased (complementarity). The relationship between short-term informal and formal care was significantly weaker for persons with schizophrenia. For both diagnostic groups there was a long-term substitution effect; a 4-6% increase in informal care hours was associated with an approximate 1% decrease in formal care costs. DISCUSSION: Although they must be confirmed by further research, these findings suggest that there is a significant and strong relationship between care given by family and friends and that supplied by formal treatment providers. The analysis indicates that the short-term relationship between informal care and formal treatment tends to be complementary, but differs according to diagnosis. Long-term effects, which are possibly related to changing role perceptions, show substitution between the two forms of care. Missing data for family care hours in some time periods was a concern in this study. However, the consistency in results between the analyses that used imputed data and the model using only original data increase our confidence in the findings. Although there may be some endogeneity between formal and informal care in other treatment settings we believe the unique characteristics of the service-rich environment in which this study was conducted limit that concern here. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The amount of care provided by informal caregivers has a significant impact on formal treatment costs. Models of care that explicitly acknowledge the interplay between the two types of care are needed to ensure efficient combinations of formal and informal care. IMPLICATIONS FOR HEALTH POLICY FORMULATION: How to best to encourage informal support, without overburdening caregivers, is a key challenge facing policy makers and providers of mental health services. The merits of various approaches to reducing caregiver burden is a subject that needs more attention from researchers. In the interim, the demands on informal caregivers may mount as efforts to reduce health care spending continue. IMPLICATIONS FOR FURTHER RESEARCH: Informal care is not often included in economic evaluations of mental health treatment. Although additional research is needed to understand better the mechanisms by which informal care and formal treatment are related, we believe our results offer a strong argument for including measures of informal care in future economic evaluations.     

Minority Response to Health Insurance Coverage for Mental Health Services

BACKGROUND: To promote access to mental health services, policy makers have focused on expanding the availability of insurance and the generosity of mental health benefits. Ethnic minority populations are high priority targets for outreach. However, among persons with private insurance, minorities are less likely than whites to seek outpatient mental health treatment. Among those with Medicaid coverage, minorities continue to be less likely than whites to use services. AIMS OF THE STUDY: The present study sought to determine if public insurance is as effective in promoting outpatient mental healthtreatment as private coverage for ethnic minority groups. METHODS: The analysis uses data from the 1987 National Medical Expenditure Survey to model mental health expenditures as a function of minority status and private insurance coverage. An interaction term between the two highlights any differences in response to private and public insurance coverage. The analysis uses a two stage least squares method to account for endogeneity of insurance coverage in the model. RESULTS: Minorities are less responsive to private insurance than whites in two ways. First, minorities are less responsive to private insurance than to public insurance whereas whites do not show this difference. Second, minorities are less responsive to private insurance than whites are to private insurance. DISCUSSION: Results suggest that there is a difference in the effectiveness of public and private health insurance to encourage use of mental health services. Among minorities but not among whites, those with private coverage used fewer mental health services than those with public coverage. Minorities were not only less responsive to private insurance than public insurance, but among those who were privately insured, minorities used fewer mental health services than whites. These results imply that insurance may not be as effective a mechanism as hoped to encourage self-initiated treatment seeking particularly among minority and other low income populations. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These results suggest that increasing private insurance coverage to minority populations will not eliminate racial and ethnic gaps in professional help-seeking for outpatient mental health care. Although the total number of people receiving treatment might increase, these results suggest that whites would seek care in greater numbers than minorities and the size of the minority-white differential might grow. IMPLICATIONS FOR FURTHER RESEARCH: Areas for further research include the impacts of alternative definitions of mental health services, the dynamics of the substitution of inpatient for outpatient mental health care, elucidation of nonfinancial barriers to care for minorities, and determinants of timely help-seeking among minorities.     

An Economic Analysis of Psychotherapy for Borderline Personality Disorder Patients

BACKGROUND: BPD is a serious mental illness in which psychotherapy has been shown to improve patient outcomes and reduce the use of health services. In most studies of psychotherapy, lower use of health services has been taken to imply lower health service costs. However, the costs of psychotherapy can offset any cost savings due to reduced use of other health services. AIMS OF THE STUDY: To estimate the net costs of health service use in a group of BPD patients receiving intensive psychotherapy. METHODS: Data on use of inpatient hospital, emergency hospital, ambulatory care, diagnostic tests and medications were collected for the twelve months before psychotherapy and the twelve months after the completion of treatment. Cost estimates were developed using standardised unit costs. RESULTS: There was a saving of approximately $670,000 in health service use over the thirty patients compared to a cost of $130,000 for psychotherapy, giving a net cost saving of $18,000 per patient. Most of this was due to reduced hospital admissions. Cost saving was higher in those patients who were high users of hospital services. Sensitivity analyses were performed; overall, the findings consistently show a reduction in the cost of health services used. DISCUSSION: The group studied consisted of 30 patients and comprised a before/after design. Therefore it does not overcome criticisms of other work in this area, that is of observational studies and small sample sizes. Nonetheless, the results were based on detailed costing of service use, using conservative assumptions and subject to sensitivity analysis. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The use of intensive psychotherapy in BPD patients who are high users of health services, particularly those who have had multiple hospital admissions, is probably warranted until more evidence is available. IMPLICATIONS FOR HEALTH POLICIES: There is little rigorous evidence on the effectiveness and cost-effectiveness of psychotherapy. BPD patients appear to generate high service costs so it is important to establish effective and cost-effective modes of treatment. IMPLICATIONS FOR FURTHER RESEARCH: Further research is warranted to establish accurate patterns of service use in BPD patients, and to identify those groups who will most benefit from intensive psychotherapy. erans.     

Mental health costs and outcomes under alternative capitation systems in Colorado: early results

BACKGROUND: This study presents preliminary findings for the first nine months of the State of Colorado USA Medicaid capitation Pilot Project. Two different models of capitation (model I and model II) are compared with fee for service (FFS) in providing services to severely and persistently mentally ill adults. In model I the state's mental health authority contracts with community mental health centers (CMHCs) who both manage the care and deliver mental health services, while in model II the state contracted with a joint venture between a for-profit managed care firm who manage the care with either a single CMHC or an alliance of CMHCs who deliver the mental health services. AIMS: Our objective is to examine utilization, cost and outcomes of inpatient and outpatient (including community based) services before and after the implementation of a capitated payment system for Colorado's Medicaid mental health services compared to services that remained under FFS reimbursement. METHODS: The stratified, random sample includes 513 consumers (188 for model I, 179 for model II, and 146 for FFS). Consumer outcomes were collected by trained interviewers and include 17 measures of symptoms, health status, functioning, quality of life and consumer satisfaction. Utilization and cost of services are from the Medicaid claims data and a shadow billing data system (post-capitation) designed by Colorado. The first step of the two-step regression procedure adjusts for the presence of individuals with use or no service use during the specified time while the second step, ordinary least-squares regression, is applied to the sample who utilized services. RESULTS: These preliminary findings indicate consistent reductions in inpatient user costs and probability of outpatient use under capitation. Combining all services, there are consistent reductions in the probability of use in both models: model I had significantly higher initial probability of use for any service. Only model II showed a statistically significant decrease in post-capitation overall user costs, but they were initially higher than model I or FFS. Estimated total cost per person for model I suggests virtually no change from the pre- to post-capitation period. Model II had the highest pre-capitation and the lowest post-capitation estimated cost per person. Examination of pre measures of outcomes across capitated areas suggest that samples drawn from the FFS, model I and model II areas were comparable in severity of psychiatric symptoms, functioning, health status and quality of life. No changes were found in outcomes. DISCUSSION: These early findings are consistent with the limited literature on capitation. Both studies of capitation integrated with medical care and those specific to mental health settings did not find adverse changes in outcomes compared to FFS. Limitations include the short follow-up period, lack of detail and possible under-reporting of outpatient services provided by the shadow billing data system. CONCLUSIONS: For the short term, it is concluded that capitation can reduce service cost per person without significant change in clinical status. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Implications are unclear until we can determine whether (i) reductions in the numbers receiving service indicates favorable consumer outcomes or reductions in access and (ii) lack of change in consumer outcomes is due to the benefits of capitation or the lack of sensitivity of the outcome measures. IMPLICATIONS FOR HEALTH CARE POLICY FORMULATION: Implications are premature for these early findings. IMPLICATIONS FOR FUTURE RESEARCH: Future research should include longer follow-up as well as analysis of long-term consequences for both cost savings and clinical outcomes.     

Rational decision-making in mental health: the role of systematic reviews

BACKGROUND: "Systematic reviews" have come to be recognized as the most rigorous method of summarizing confusing and often contradictory primary research in a transparent and reproducible manner. Their greatest impact has been in the summarization of epidemiological literature - particularly that relating to clinical effectiveness. Systematic reviews also have a potential to inform rational decision-making in healthcare policy and to form a component of economic evaluation. AIMS OF THE STUDY: This article aims to introduce the rationale behind systematic reviews and, using examples from mental health, to introduce the strengths and limitations of systematic reviews, particularly in informing mental health policy and economic evaluation. METHODS: Examples are selected from recent controversies surrounding the introduction of new psychiatric drugs (anti-depressants and anti-schizophrenia drugs) and methods of delivering psychiatric care in the community (case management and assertive community treatment). The potential for systematic reviews to (i) produce best estimates of clinical efficacy and effectiveness, (ii) aid economic evaluation and policy decision-making and (iii) highlight gaps in the primary research knowledge base are discussed. Lastly examples are selected from outside mental health to show how systematic reviews have a potential to be explicitly used in economic and health policy evaluation. RESULTS: Systematic reviews produce the best estimates of clinical efficacy, which can form an important component of economic evaluation. Importantly, serious methodological flaws and areas of uncertainty in the primary research literature are identified within an explicit framework. Summary indices of clinical effectiveness can be produced, but it is difficult to produce such summary indices of cost effectiveness by pooling economic data from primary studies. Modelling is commonly used in economic and policy evaluation. Here, systematic reviews can provide the best estimates of effectiveness and, importantly, highlight areas of uncertainty that can be used in "sensitivity analysis". DISCUSSION: Systematic reviews are an important recent methodological advance, the potential for which has only begun to be realized in mental health. This use of systematic reviews is probably most advanced in producing critical summaries of clinical effectiveness data. Systematic reviews cannot produce valid and believable conclusions when the primary research literature is of poor quality. An important function of systematic reviews will be in highlighting this poor quality research which is of little use in mental health decision making. IMPLICATIONS FOR HEALTH PROVISION: Health care provision should be both clinically and cost effective. Systematic reviews are a key component in ensuring that this goal is achieved. IMPLICATIONS FOR HEALTH POLICIES: Systematic reviews have potential to inform health policy. Examples presented show that health policy is often made without due consideration of the research evidence. Systematic reviews can provide robust and believable answers, which can help inform rational decision-making. Importantly, systematic reviews can highlight the need for important primary research and can inform the design of this research such that it provides answers that will help in forming healthcare policy. IMPLICATIONS FOR FURTHER RESEARCH: Systematic reviews should precede costly (and often unnecessary) primary research. Many areas of health policy and practice have yet to be evaluated using systematic review methodology. Methods for the summarization of economic data are methodologically complex and deserve further research     

Factors that influence the Cost of Deliberate Self-poisoning in Children and Adolescents

BACKGROUND: Ideally, the type and quantity of services received by young people with mental health problems would be determined by need alone. In reality, however, a number of factors will influence resource-use, and thus the total cost of care. AIMS OF THE STUDY: The aim of this study was to evaluate the impact of baseline patient and family characteristics on the total cost of caring for children and adolescents who have deliberately poisoned themselves. It was hypothesised that the cost of this patient group would be associated with severity of suicidality and other psychiatric characteristics, the existence of current problems and demographic and socio-economic characteristics. METHODS: Univariate and multivariate regression analyses were used to examine the associations between baseline characteristics and both total statutory service costs and total NHS costs in 149 young people aged 16 years and under, referred to child mental health teams with a diagnosis of deliberate self-poisoning. RESULTS: Baseline variables found to be significantly associated with relatively more expensive care packages included a definite intention to die, the existence of current problems, being in foster care, poorer parental well being and not having a diagnosis of conduct disorder. No significant relationships were found between cost and measures of illness severity, including suicidal ideation, hopelessness and severity of depression. DISCUSSION: Although costs are not influenced by clinical measures of severity, service provision does appear to respond to more 'practical' notions of severity, such as intent to die and the existence of current problems. Some high-risk sub-groups, such as those with a conduct disorder and those who have experienced episodes of local authority care or accommodation, appear to be slipping through the health services net, although this may be due more to the demand-side problem of non-compliance than to issues of supply. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The evidence presented suggests that health care providers are directing more services towards those who are more in need, where need is defined in a practical rather than a clinical sense. More targeting of certain high-risk sub-groups may be needed, however, particularly those who are traditionally poor attenders and prone to drop-out. IMPLICATIONS FOR HEALTH POLICY FORMULATION: Interventions for young people who have attempted suicide should be better targeted towards high-risk groups, such as those with a diagnosis of conduct disorder. In addition, prevention schemes that target high-risk groups before a suicide attempt is made should be encouraged. IMPLICATIONS FOR FURTHER RESEARCH: This study is limited by small sample sizes. Research that focuses directly on the care of young people at high-risk for repeat suicide attempts is needed, since the results presented here can be viewed only as exploratory and not explanatory.     

South African Mental Health Process Indicators

BACKGROUND: In post-apartheid South Africa the organisation and delivery of mental health care is undergoing significant change. With the heritage of an under-resourced, fragmented, racially inequitable service, heavily reliant on chronic custodial treatment in large centralised institutions, this change is long overdue. New policy has set out a vision for a community-based, comprehensive, integrated mental health service. In order to realise this vision a review is required of the way in which care is currently delivered, or the 'process' of mental health care. To date, no national research has been conducted regarding process of care indicators in South African mental health services. AIMS OF THE STUDY: This study documents four public sector mental health service process indicators in South Africa: bed occupancy rates, admission rates, average length of stay and default rates. METHODS: A questionnaire was distributed to provincial mental health co-ordinators, requesting numbers of occupied and available beds in psychiatric inpatient facilities, annual mental health admissions, average length of stay (ALOS), and default rate in ambulatory care settings. The information was supplemented by consultations with mental health co-ordinators in each of the 9 provinces. RESULTS: The national bed occupancy rate is 83% (range: 63-109%). The national annual rate of admission to psychiatric inpatient facilities is 150 per 100 000 population (range: 33-300). The national average length of admission is 219 days in psychiatric hospitals, 11 days in general regional hospitals and 7 days in general district hospitals. On average 11% of psychiatric patients who attend ambulatory care services on a monthly basis fail to keep their appointments. DISCUSSION: Although the national mean bed occupancy is compatible with international figures, there is considerable discrepancy between provinces, indicating both over- and under- utilisation of inpatient resources. Admission rates are low, relative to developed countries, though comparable to developing countries. Low admission rates are associated with a range of factors including inadequate service provision, unmet need, inaccessible services, cross-border flow between provinces and custodial patterns of care. There is evidence of long periods of admission relative to international settings. There is also considerable diversity between provinces, with certain institutions continuing to provide long term custodial patterns of care. Default rates are low relative to international settings and past reports default in South Africa. IMPLICATIONS FOR HEALTH POLICIES: In keeping with current policies there is an urgent need for local level evaluation and reform of chronic custodial care. The ongoing monitoring of process indicators is important in the transition to community-based mental health care. IMPLICATIONS FOR FURTHER RESEARCH: Limitations of the data, and problems of collecting information on mental health care within an integrated health system indicate the need for further research in this area. There is also a need for further research into unmet need for mental health care in South Africa.     

Where there is no policy: governing the posting and transfer of primary health care workers in Nigeria

The posting and transfer of health workers and managers receives little policy and research attention in global health. In Nigeria, there is no national policy on posting and transfer in the health sector. We sought to examine how the posting and transfer of frontline primary health care (PHC) workers is conducted in four states (Lagos, Benue, Nasarawa and Kaduna) across Nigeria, where public sector PHC facilities are usually the only form of formal health care service providers available in many communities. We conducted in‐depth interviews with PHC workers and managers, and group discussions with community health committee members. The results revealed three mechanisms by which PHC managers conduct posting and transfer: (1) periodically moving PHC workers around as a routine exercise aimed at enhancing their professional experience and preventing them from being corrupted; (2) as a tool for improving health service delivery by assigning high‐performing PHC workers to PHC facilities perceived to be in need, or posting PHC workers nearer their place of residence; and (3) as a response to requests for punishment or favour from PHC workers, political office holders, global health agencies and community health committees. Given that posting and transfer is conducted by discretion, with multiple influences and sometimes competing interests, we identified practices that may lead to unfair treatment and inequities in the distribution of PHC workers. The posting and transfer of PHC workers therefore requires policy measures to codify what is right about existing informal practices and to avert their negative potential. © 2016 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd     

The interdependence of mental health service systems: the effects of VA mental health funding on veterans' use of state mental health inpatient facilities

BACKGROUND: There are relatively few published data on how the financial structures of different health systems affect each other. With increasing financial restrictions in both public and private healthcare systems, it is important to understand how changes in one system (e.g. VA mental healthcare) affect utilization of other systems (e.g. state hospitals). AIMS OF THE STUDY: This study utilizes data from state hospitals in eight states to examine the relationship of VA per capita mental health funding and state per capita mental health expenditures to veterans' use of state hospitals, adjusting for other determinants of utilization. METHODS: This study utilized a large database that included records from all male inpatient admissions to state hospitals between 1984 and 1989 in eight states (n = 152541). Funding levels for state hospitals and VA mental health systems were examined as alternative enabling factors for veterans' use of state hospital care. Logistic regression models were adjusted for other determinants of utilization such as socio-economic status, diagnosis, travel distances to VA and non-VA facilities and the proportion of veterans in the population. RESULTS: The single strongest predictor of whether a state hospital patient would be a veteran was the level of VA mental healthcare funding (OR = 0.81 per $10 of funding per veteran in the population, p = 0.0001), with higher VA funding associated with less use of state hospitals by veterans. Higher per capita state funding, reciprocally, increased veterans' use of state hospitals. We also calculated elasticities for state hospital use with respect to VA mental healthcare funding and with respect to state hospital per capita funding. A 50% increase in VA per capita mental health spending was associated with a 30% decrease in veterans' use of state hospitals (elasticity of -0.6). Conversely, a 50% increase in state hospital per capita funding was associated with only an 11% increase in veterans' use of state hospitals (elasticity of 0.06). IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These data indicate that per capita funding for state hospitals and VA mental health systems exerts a significant influence on service use, apparently mediated by the effect on supply of mental health services. Veterans are likely to substitute state hospital care for VA care when funding restrictions limit the availability of VA mental health services. However, due to the relative sizes of the two systems, VA funding has a larger effect than state hospital funding upon state hospital use by veterans. IMPLICATIONS FOR HEALTH POLICIES: These data indicate that changes in the organizational and/or financial structure of any given healthcare system have the potential to affect surrounding systems, possibly quite substantially. Policy makers should take this into account when making decisions, instead of approaching systems as independent, as has been traditional. IMPLICATIONS FOR FURTHER RESEARCH: Further research is needed in two areas. First, these results should be replicated in other systems of care using more recent data. Second, these results are difficult to generalize to individual behavior. Future research should examine the extent and individual determinants of cross-system use.     

Integrating mental health into primary care in Nigeria: report of a demonstration project using the mental health gap action programme intervention guide

Background

The World Mental Health Surveys conducted by the World Health Organization (WHO) have shown that huge treatment gaps for severe mental disorders exist in both developed and developing countries. This gap is greatest in low and middle income countries (LMICs).Efforts to scale up mental health services in LMICs have to contend with the paucity of mental health professionals and health facilities providing specialist services for mental, neurological and substance use (MNS) disorders. A pragmatic solution is to improve access to care through the facilities that exist closest to the community, via a task-shifting strategy. This study describes a pilot implementation program to integrate mental health services into primary health care in Nigeria.

Methods

The program was implemented over 18 months in 8 selected local government areas (LGAs) in Osun state of Nigeria, using the WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG), which had been contextualized for the local setting.A well supervised cascade training model was utilized, with Master Trainers providing training for the Facilitators, who in turn conducted several rounds of training for front-line primary health care workers. The first set of trainings by the Facilitators was supervised and mentored by the Master Trainers and refresher trainings were provided after 9 months.

Results

A total of 198 primary care workers, from 68 primary care clinics, drawn from 8 LGAs with a combined population of 966,714 were trained in the detection and management of four MNS conditions: moderate to severe major depression, psychosis, epilepsy, and alcohol use disorders, using the mhGAP-IG. Following training, there was a marked improvement in the knowledge and skills of the health workers and there was also a significant increase in the numbers of persons identified and treated for MNS disorders, and in the number of referrals. Even though substantial retention of gained knowledge was observed nine months after the initial training, some level of decay had occurred supporting the need for a refresher training.

Conclusion

It is feasible to scale up mental health services in primary care settings in Nigeria, using the mhGAP-IG and a well-supervised cascade-training model. This format of training is pragmatic, cost-effective and holds promise, especially in settings where there are few specialists.

     

Using epidemiological data to model efficiency in reducing the burden of depression*

BACKGROUND: The Global Burden of Disease study has suggested that mental disorders are the leading cause of disability burden in the world. This study takes the leading cause of mental disorder burden, depression, and trials an approach for defining the present and optimal efficiency of treatment in an Australian setting. AIMS OF THE STUDY: To examine epidemiological and service use data for depression to trial an approach for modelling (i) the burden that is currently averted from current care, (ii) the burden that is potentially avertable from a hypothetical regime of optimal care, (iii) the efficiency or cost-effectiveness of both current and optimal services for depression and (iv) the potential of current knowledge for reducing burden due to depression, by applying the WHO five-step method for priorities for investment in health research and development. METHODS: Effectiveness and efficiency were calculated in disability adjusted life years (DALYs) averted by adjusting the disability weight for people who received efficacious treatment. Data on service use and treatment outcome were obtained from a variety of secondary sources, including the Australian National Survey of Mental Health and Wellbeing, and efficacy of individual treatments from published meta-analyses expressed in effect sizes. Direct costs were estimated from published sources. RESULTS: Fifty-five percent of people with depression had had some contact with either primary care or specialist services. Effective coverage of depression was low, with only 32% of cases receiving efficacious treatment that could have lessened their severity (averted disability). In contrast, a proposed model of optimal care for the population management of depression provided increased treatment contacts and a better outcome. In terms of efficiency, optimal care dominated current care, with more health gain for less expenditure (28 632 DALYs were averted at a cost of AUD295 million with optimal care, versus 19 297 DALYs averted at a cost of AUD720 million with current care). However, despite the existence of efficacious technologies for treating depression, only 13% of the burden was averted from present active treatment, primarily because of the low effective coverage. Potentially avertable burden is nearly three times this, if effective treatments can be delivered in appropriate amounts to all those who need it. DISCUSSION: This paper reports a method to calculate the burden currently averted from cross-sectional survey data, and to calculate the burden likely to be averted from an optimal programme estimated from randomized controlled trial data. The approach taken here makes a number of assumptions: that people are accurate in reporting their service use, that effect sizes are a suitable basis for modelling improvements in disability and that the method used to translate effect sizes to disability weight change is valid. The robustness of these assumptions is discussed. Nonetheless it would appear that while optimal care could do more than present services to reduce the burden of depression, current technologies for treating depression are insufficient. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: There is an urgent need to educate both clinicians (primary and specialist) and the general public in the effective treatments that are available for depression. IMPLICATIONS FOR HEALTH POLICIES: Over and above implementing treatments of known efficacy, more powerful technologies are needed for the prevention and treatment of depression. IMPLICATIONS FOR FURTHER RESEARCH: Modelling burden averted from a variety of secondary sources can introduce bias at many levels. Future research should examine the validity of approaches that model reductions in disability burden. A powerful treatment to relieve depression and prevent relapse is needed.     

The impact of a community-oriented medical school on mental health services

This paper discusses the impact of the community-based medical school on mental health services. The Gezira mental health programme represents a collaborative work involving the university, the community and the government. It aims at achieving specified objectives: (1) to modify community concepts, attitudes and practices concerning mental health, (2) to ensure community involvement and participation, (3) to extend mental health services, (4) to train PHC staff, and (5) to encourage research. The programme was implemented in three phases: preparatory, implementation, and evaluation. In the evaluation of the impact of the programme on changing community attitudes, the training of staff, the extension of mental health services, and on research, qualitative assessment, through interviews, focus group discussion, supervision visits, and review of reports are used. There is an overall agreement that the programme helped in raising public awareness regarding the concept of mental health, the care of the mentally ill and community participation. Members of the health team who received training as part of the programme reported a better understanding of mental health problems and an improvement in their handling of the mentally disturbed patients. Teachers reported an increased awareness of mental health problems in school children and a better collaboration with those involved in the handling of such problems. Social workers and psychologists updated their knowledge and skills and were well prepared to participate in the programme. Members of the different sectors involved reported a better standard of collaboration regarding mental health activities. These findings indicate that this programme, by providing a new model for health services in this field, has induced a large policy change within the Sudan. The community-based activities at the FMUG have resulted in a major change in the delivery of mental health services in Gezira State. The programme has resulted in a major shift in mental health services being provided by central hospitals to PHC settings. In addition it has stimulated research, thereby providing much original information that will help in preparing for future plans.     

Incorporating economic analysis in evidence-based guidelines for mental health: the profile approach

BACKGROUND: Many western health systems are currently developing the role of clinical guidelines to promote effective and efficient health care. However, introducing economic data into guideline methodology designed to assess the effectiveness of interventions raises some methodological issues. These include providing valid and generalizable cost estimates, the weight placed upon cost "evidence" and presenting cost-effectiveness information in a way that is helpful to clinicians. AIM OF THE STUDY: To explore a framework for including economic concepts in the development of a series of primary care guidelines, two of which address mental health conditions. METHODS: A profile approach, setting out best available evidence about the attributes of treatment choices (effectiveness, tolerability, safety, health service delivery, quality of life, resource use and cost), was used to help clinicians to derive treatment recommendations in a manner consistent with both the clinical decision-making process and social objectives. RESULTS: Clinicians involved in guideline development responded well to the process. Although there was often considerable debate about the meaning and importance of different aspects of evidence about treatment, in none of the guideline groups was there failure to agree treatment recommendations. DISCUSSION: The profile approach may be particularly useful in the field of mental health where disease processes may often feature very disparate effects, over long periods of time and impacting upon a broad circle of relatives, carers and agencies in addition to the patients themselves. CONCLUSION: A method has been applied in a series of primary care guidelines, which appears to enable clinicians to consider the issue of resource use alongside the various clinical attributes associated with treatment decisions. The basis of this work is the belief that guidance presenting physical measures describing effectiveness, adverse events, safety, compliance and quality of life, alongside resource consequences, is most likely to appropriately inform doctor-patient interactions. IMPLICATIONS FOR HEALTH CARE PROVISON AND USE: This research may provide a useful platform for other groups considering how to introduce cost-effectiveness concepts into guideline development groups. Whether guidelines change clinical behaviour remains a research question, and the subject of forthcoming trials. IMPLICATIONS FOR HEALTH POLICY FORMULATION: It is important that government agencies realize that guideline development is a health policy tool with prescribed methods to produce valid guidelines. Attempts to tamper with the methodology for cost-containment purposes or other political reasons are likely to discredit a useful mechanism for improving the scientific basis of health care provision. IMPLICATIONS FOR FURTHER RESEARCH: There are a number of limitations to completed work: for example it has a primary care focus and addresses fairly narrowly defined conditions. Work is ongoing to extend the scope to broader disease areas and to secondary care.     

The mental health care delivery system in greece: regional variation and socioeconomic correlates

BACKGROUND: In Greece, the functional capacity of the mental health care system until 1980, was totally inadequate to meet the increasing mental health needs of the population and to provide efficient and community-based services. This situation was brought to the attention of the Commission of European Communities and a special EEC Regulation No 815/84 provided the financial technical support for an extended psychiatric reform programme. The psychiatric reform programme initiated in 1984 and ended in 1995. AIMS OF THE STUDY: This study compared the geographical distribution of neuropsychiatrists and the mental health care delivery system structural components (psychiatric beds, extramural mental health units and places in rehabilitation services), according to the regional socioeconomic development for the years 1984, 1990 and 1996. Additionally the possible effects of the operation of community-based mental health services on the psychiatric hospitalizations were examined. METHODS: Data on the geographical distribution of neuropsychiatrists in the previously mentioned years were drawn from local Medical Association from each of 54 prefectures of the country. The corresponding distribution of the mental health care delivery system components was made available from the database of the Monitoring and Evaluation of Mental Health Services Unit. Pearson product moment correlations of the regional distribution of neuropsychiatrists and the various components of the mental health care system, as population-based ratios, with the corresponding socioeconomic development in the form of the general index of development were performed. Mental hospital age standardized rates were collected from the Hospital Central Register for the periods 1984-1987 and 1990-1993. Discharge rates were elaborated according to the existence of mental health services in specific regions. RESULTS: A wide regional variation in neuropsychiatrists per 100000 population was found in all three years, with the majority of them working in the greater Athens and Thessaloniki areas. In the geographical distribution of health regions, there is an uneven significant decrease in psychiatric beds between 1984 and 1996. However in almost all regions an increase in extramural services between the two critical periods was noticed, as part of the implementation of the psychiatric reform programme. A parallel and more dramatic increase in the places of rehabilitation in 12 out of 13 regions has been observed during the implementation of the reform programme. At the level of prefectures, the changes across time, in the mean ratios of beds, extramural services and rehabilitation places were not found to be significant. A significant decrease of discharges in prefectures covered by newly established extramural services for the period 1990-1993, compared to discharge rates during the period 1984-1987, when none of these services were in operation in these prefectures, was noticed. The intercorrelation matrix between the various mean values (1990-1996) of the mental health care system components in the 54 prefectures and the local general index of development scores produced statistically significant correlation coefficients. It seems that the greater the level of local socioeconomic development the higher the degree of mental health care delivery system growth. DISCUSSION: Our results have shown uneven regional distribution of neuropsychiatrists, as well as extramural mental health units and rehabilitation places, despite the current reorganization of the whole mental health care delivery system. The positive correlation between the various structural components of the system in the 54 prefectures and the local socioeconomic conditions could be interpreted as follows. Urban areas of higher socioeconomic growth had a long history of development of inpatient services in mental hospitals. In these several community-based alternatives have been established for their transformation into modern ones. Urban areas exhibit also higher psychiatric morbidity and therefore increasing mental health needs. Additionally in several cities local University Psychiatric Departments have developed a variety of mental health and rehabilitation services. Many new services highly specialized and complementary to existing mental hospitals were established in urban areas. Rural areas are mostly uncovered by mental health care facilities. However it seems that the establishment of community-based services could have an effect on mental hospital utilization. CONCLUSION: It becomes evident that after the implementation of the psychiatric reform programme in Greece significant progress in the areas of decentralization of mental health and rehabilitation services has been observed. However there are still areas in many prefectures, mainly rural or semirural, lacking the appropriate delivery of mental health care. IMPLICATIONS FOR HEALTH CARE AND POLICY FORMULATION: Our results suggest that flexible models of services should be introduced for the benefit of population living in areas lacking the necessary socioeconomic resourses. IMPLICATIONS FOR FUTURE RESEARCH: Mental health services research in Greece should focus on quasi-experimental studies on the effectiveness of various models of mental health care in areas of different socioeconomic growth.     

调整思路 拓展出路

乡镇卫生院农村卫生服务的主体,如何使乡镇卫生院充满足活力,有效地发挥其社会功能已成为农村卫生工作的重点,农村新形势下办好乡镇卫生院必须认清乡镇卫生院外部环境所发生的变化,高速和确立乡镇卫生院的发展思路,坚持以需求为导向,以市场为依托,以服务为基础,以调控为保障的发展策略。     

Training doctors for family practice in primary health care work in Sri Lanka

Over one-third of the doctors in Sri Lanka are involved in the delivery of PHC. They form one of seven categories of PHC workers—others being the ayurveda physician, the assistant medical practitioner, nurse, midwife, traditional healer and unqualified practitioner. PHC workers function either in the government or private sector. Their functions in the PHC system are not defined and are dependent on state health policies and people's expectations of health care.The secondary and tertiary levels of the health system are managed by the government through a network of hospitals. These hospitals provide Western type health care facilities free to the people. Government PHC workers have access to referral facilities and back up services provided through this hospital system.Doctors functioning within the PHC system had neither undergraduate nor postgraduate training in PHC. Private general practitioners were the first to realise the need for training doctors in PHC. They sought and got government and university approval for postgraduate training in family practice.The family practice training programme is conducted by the Postgraduate Institute of Medicine of the University of Colombo. The course consists of educational and clinical components which could be completed in a minimum of 1 year or maximum of 4 years.Nine private general practitioners and 19 government medical officers registered for the course. Fifteen completed the course in 1 year.Family practice trained doctors will function in a PHC system in which the services provided are not coordinated. Changes in the PHC system are being considered. Government is proposing to establish health centres manned by doctors with sub-centres manned by lesser trained health workers.The medical profession has suggested a unified PHC system and a national health insurance scheme.The exact role of the family practice trained doctor in the country's PHC system cannot be defined. Family practice training should influence and be influenced by changes in the PHC system in Sri Lanka.     

A partial solution: a local mental health authority for the UK

BACKGROUND: the structural problems of the mental health system in the UK have been analyzed by a number of authors over the past several years as the "reforms" of the health and social service systems have continued (Kavanagh and Knapp, 1995; Mechanic, 1995). In a recent article, Hadley and Goldman (1995) suggest that one possible solution to some of these issues may be the creation of a local mental health authority. Such an authority would consolidate the funding, authority and responsibility in a single entity. We believe this model, which is typical of many local public mental health systems in the US, is at least part of the solution to the current problem of financial and service fragmentation of the current system in the UK. The numerous "reforms" of the health and social service systems (which include the Community Care Act, the development of the Internal Market, GP fundholding and the purchaser-provider split) were not designed for the care of the mentally ill (Han, 1996). These policy changes in the design of health and social services have created a complicated and difficult context in which services must be delivered. Too many agencies play a significant role in the delivery and management of mental health services. Health authorities, social service agencies and GP fundholders are direct and indirect funders of the system while community care trusts, social service agencies and GPs are service providers (Hadley, 1996a). RESULTS AND A PROPOSAL: We believe that the development of local mental health authorities may be part of the solution to the structural and economic problems of the current system in the UK. It is not the answer to limited resources or limited skills, but can create a new structure, which will permit and encourage the cooperation and innovation that is now possible only with unusual effort. Local mental health authorities have a number of crucial characteristics, but, most importantly, they refocus the system on the provision of care to the seriously mentally ill. This is the expressed priority of government, advocates and providers, alike.These new entities could be created at either the purchaser or provider level or, as exists in a number of jurisdictions in the US, at both levels, where a single purchaser may be responsible for multiple consolidated providers. This combination is now the emerging model for innovative services in the US. In the UK, the development of a local mental health authority at the purchaser and/or provider level might be relatively simple. Although the creation of a statutory authority would require primary legislation and is therefore probably not a short-term solution, there appears to be a variety of administrative options that would have the same effect. IMPLICATIONS FOR HEALTH POLICY FORMULATION: The creation of a local mental health authority may be a necessary first step towards the development of a coordinated and comprehensive system of care. It seems likely that there is currently more "political" support for the development of a purchaser model but the development of a sophisticated purchsaer is also likely to take considerable time and effort. Although all the structural and policy problems of the mental health system in the UK will not all be solved by local mental health authorities, they may be beneficial if responsibility for mental illness care is to be centralized and fragmentation is to be reduced. Without making structural changes, the best efforts by clinicians, policymakers and managers are most likely to be in vain. Without a clear point of ultimate purchasing and service responsibility, the fragmentation and inefficiency of the current system will remain (Hadley et al., 1996).