Provision of Mental Health Services in South African Substance Abuse Treatment Facilities

To date, South African research has not examined mental health service provision in substance abuse treatment facilities, even though these services improve client retention and treatment outcomes. To describe the extent to which substance abuse treatment facilities in Gauteng and KwaZulu-Natal provinces provide clients with mental health services during the course of treatment and to compare mental health service provision in these settings by type of facility and staff composition. Cross-sectional audits of substance abuse treatment facilities were conducted in Gauteng and KwaZulu-Natal provinces. Data were collected using the Treatment Services Audit Questionnaire. A response rate of 84% was obtained. Few treatment facilities provide clients with access to mental health services. Inpatient facilities are more likely than outpatient facilities to provide clients with access to mental health services. Facilities with for-profit ownership status are more likely than facilities with non-profit status to provide access to mental health care. Based on the above findings, a number of recommendations are made to increase the provision of mental health services during the course of substance abuse treatment.     

Screening and Treating Mental Disorders in Addiction Treatment Settings: A Stepped Care Model

The comorbidity of mental and addiction disorders is increasingly apparent. Such comorbidity increases overall client morbidity substantially, and reduces the success rate in treating either type of disorder. In addiction treatment settings, the challenge is twofold: first, to develop a method for detecting mental disorders that is valid and practical, and second, to identify treatment approaches that are appropriate to that setting. Simple referral away of the patient with a mental disorder is rarely successful. Difficulties often arise in finding appropriate mental health treatments in a timely fashion; furthermore client resistance to being referred out poses an additional barrier. This article identifies strategies to improve practical detection of mental health disorders through the use of simple but validated patient self-reports. In addition, this commentary proposes a stepped care approach to the provision of mental health treatments that allows for some universally effective ‘wellness treatments’ to be initiated for all individuals in addiction treatment settings; those with persistent high psychiatric symptoms related to the most common disorders such as depression or anxiety would then receive some additional mental health treatment in the addiction setting. Referral out would be reserved for those individuals with more severe psychiatric illnesses or those with comparatively rarer disorders. This pragmatic approach to screening and stepped care increases the likelihood of success in treating the addictive disorder, as well as providing care for the mental disorder.     

Students with Dual Diagnosis: Can School-Based Mental Health Services Play a Role?

ABSTRACT

This article describes and investigates initial findings from the Esperanza Mental Health Services (EMHS) Program, which is an intensive outpatient program that provides individual and group mental health services for students with “dual diagnosis” or developmental disabilities and co-occurring mental health problems. Previous research substantiates that the mental health needs of this population are significant, yet often go unaddressed in school settings. Preliminary outcomes for a sample of 61 children ages 4–22 suggest improvements in important school indicators, such as suspensions and absences during the year of program implementation, as well as positive changes in parent-reported mental health functioning. Lastly, parent satisfaction regarding these services and supports was high. The implications of these results for a proposed school-based mental health service delivery model within a multi-tiered system of prevention and intervention are discussed.     

Using Information Technology to Evaluate the Detection of Co-Occurring Substance Use Disorders Amongst Patients in a State Mental Health System: Implications for Co-Occurring Disorder State Initiatives

The current study describes a system-wide method of evaluating detection strategies for co-occurring disorders within a state mental health system. Information technology was used to merge administrative datasets from the New Jersey mental health and substance abuse systems and identify individuals treated in both systems. We measured a 53% detection rate of substance use disorders amongst adult patients in the mental health system with particularly low detection rates in acute settings (49.0%) and among female (43.7%), older (36.2%), and psychotic patients (43.6%). The methodology described here could help evaluate critical aspects of ongoing state co-occurring disorder quality improvement initiatives. This paper was presented at the 2005 American Psychiatric Association Annual Meeting (May 21–26, 2005) in Atlanta, Georgia.     

Beyond Criminalization: Toward a Criminologically Informed Framework for Mental Health Policy and Services Research

The problems posed by persons with mental illness involved with the criminal justice system are vexing ones that have received attention at the local, state and national levels. The conceptual model currently guiding research and social action around these problems is shaped by the “criminalization” perspective and the associated belief that reconnecting individuals with mental health services will by itself reduce risk for arrest. This paper argues that such efforts are necessary but possibly not sufficient to achieve that reduction. Arguing for the need to develop a services research framework that identifies a broader range of risk factors for arrest, we describe three potentially useful criminological frameworks—the “life course,” “local life circumstances” and “routine activities” perspectives. Their utility as platforms for research in a population of persons with mental illness is discussed and suggestions are provided with regard to how services research guided by these perspectives might inform the development of community-based services aimed at reducing risk of arrest.     

Stigmatizing Attitudes About Mental Illness and Allocation of Resources to Mental Health Services

This study tests a social psychological model (Skitka & Tetlock, 1992). Journal of Experimental Social Psychology, 28, 491-522; [1993]. Journal of Personality & Social Psychology, 65, 1205-1223 stating that policy maker decisions regarding the allocation of resources to mental health services are influenced by their attitudes towards people with mental illness and treatment efficacy. Fifty four individuals participated in a larger study of education about mental health stigma. Participants completed various measures of resource allocation preferences for mandated treatment and rehabilitation services, attributions about people with mental illness, and factors that influence allocation preferences including perceived treatment efficacy. Results showed significant attitudinal correlates with resource allocation preferences for mandated treatment, but no correlates to rehabilitation services. In particular, people who pity people with mental illness as well as those that endorse coercive and segregated treatments, were more likely to rate resource allocation to mandated care as important. Perceived treatment efficacy was also positively associated with resource allocation preferences for mandated treatment. A separate behavioral measure that involved donating money to NAMI was found to be inversely associated with blaming people for their mental illness and not being willing to help them. Implications of these findings on strategies that seek to increase resources for mental health programs are discussed.     

Integrating Screening and Assessment Tools into Clinical Practice: Where the Rubber Hits the Road

This paper explores what occurs when screening and assessment tools are integrated into clinical practice. Although there is an overall need for a standardized process and a shared mental health screening tool, no such system is currently in place. The challenges faced by addiction and mental health centres in under-serviced regions of Ontario are discussed at length, where minimally trained staff struggle with the high-demand of clientele and low resources. The need for better trained staff as well as standardized terminology are also discussed in terms of challenges incorporating systematic screening and assessment processes.     

Mental Health and Substance Abuse Services to Parents of Children Involved with Child Welfare: A Study of Racial and Ethnic Differences for American Indian Parents

American Indian (AI) parents of children involved with child welfare were compared to White, Black and Hispanic parents on mental health and substance abuse problems and access to treatment. Data came from the National Study of Child and Adolescent Well-Being, a longitudinal study of a nationally representative sample of children aged 0–14 years involved with child welfare. Weighted statistics provided population estimates, and multivariate logistic regression was used to predict the likelihood of caregivers receiving mental health or substance abuse services. There were significant disparities in the likelihood of receiving mental health, but not substance abuse, services. Unmet need for mental health and substance abuse treatment characterized all parents in this study. AI parents fared the worst in obtaining mental health treatment. Parents of children at home and of older children were less likely to access mental health or substance abuse treatment.     

Counselor and Client Characteristics in Mental Health versus Substance Abuse Treatment Settings Providing Services for Co-Occurring Disorders

The study compares counselor and client characteristics of state-funded co-occurring disorder (COPSD) programs in mental health (MH) versus substance abuse (SA) settings. SA counselors more often had graduate degrees and MH counselors rated their knowledge and skills lower on two of nine COPSD best practice principles. MH clients were more frequently diagnosed with schizophrenia, depression, and bipolar disorder, whereas SA clients displayed evidence of greater substance use severity and had higher rates of treatment completion and abstinence at discharge. Results reveal significant implications for workforce development and potential system changes to enhance COPSD services that are unique to each setting.     

Mental Health Screening in Addiction,Corrections and Social Service Settings: Validating the MMS

Objective  This paper tests the validity of a simple and easy to use scale, the Modified Mini Screen (MMS) to identify people with mental health problems in the treatment ecology for chemical dependency, including specialty sector substance abuse treatment settings, and shelters, jails and street community outreach programs. Methods  Four hundred and seventy-six individuals in chemical dependency treatment and in jails, shelters and outreach settings completed a set of 22 items to screen for mental disorders—the MMS—and a validation interview—the Structured Clinical Interview for Diagnosis (SCID). ROC curve analysis was used to (1) determine the optimal range of cut points for identifying mental health problems in this culturally heterogeneous sample and wide range of treatment and community settings, and (2) calculate overall accuracy, sensitivity, specificity, and positive and negative predictive values for the MMS. Results  Forty three percent of the sample met criteria for a DSM-IV diagnosis of anxiety, mood or psychotic disorder. At cut points of 6–9, the sensitivity of the MMS ranged from 0.63–0.82, its specificity ranged from 0.61–0.83, and its overall accuracy ranged from 70–75%. At these cut points, the MMS screen performed equally well for men and women, and for African Americans and Caucasians, and is comparable to the performance of other screens validated for less compromised populations. A decision tool has been developed based on these results that is available from the authors. Conclusion  The MMS performs well in naturalistic chemical dependency treatment settings, jails, shelters and street outreach programs across gender and ethnic groups, and can provide a useful tool in service systems developing a “No Wrong Door” policy for persons with co-occurring mental health and substance abuse problems.

Telepsychiatry and e-Mental Health Services: Potential for Improving Access to Mental Health Care

Reforming mental health care is a focus of many ongoing initiatives in the United States, both at the national and state levels. Access to adequate mental health care services is one of the identified problems. Telepsychiatry and e-mental health services could improve access to mental health care in rural, remote and underserved areas. The authors discuss the required technology, common applications and barriers associated with the implementation of telepsychiatry and e-mental health services.     

Unmet Needs for Mental Health Services for Latino Older Adults: Perspectives from Consumers, Family Members, Advocates, and Service Providers

This study qualitatively assessed the need for mental health services among Latino older adults in San Diego, California. The primary mental health issue was depression. Primary organizational barriers to accessing services were language and cultural barriers secondary to a lack of translators, dearth of information on available services, and scarcity of providers representative of the Latino community. Other challenges included a lack of transportation and housing, and the need for socialization and social support. Latino older adults experienced their unmet needs in ways associated with their cultural background and minority status. Age- and culturally-appropriate services are needed to overcome these barriers.     

Child Welfare Recommendations to Improve Mental Health Services for Children who have Experienced Abuse and Neglect: A National Perspective

This study uses a key informant approach to understand the nature, extent, and quality of outpatient mental health services for children in the child welfare system (CWS) in the United States. We interviewed 89 county child welfare administrators to determine the status of outpatient mental health services and provide recommendations for enhancing care and service delivery. Developed for this study (Caring for Children in Child Welfare), the interview was incorporated in the second formal data collection wave (i.e., 18 months after study baseline assessment) of the National Survey of Child and Adolescent Well-Being. The results highlighted general variability in the degree to which these agencies used evidence-based interventions within outpatient services, demonstrated clinical expertise with this population, and met the needs of their families. Community agency use of evidence-based interventions was found to predict their effectiveness in improving clients’ mental health problems. Proposed suggestions for service improvement varied across domains and reflected the need for more communication/coordination, service access, options and resources, and practice refinements to accommodate families’ needs. We discuss the implications of these recommendations from CWS stakeholders for enhancing the service delivery system. We appreciate the assistance and consultation of Jennifer Rolls-Reutz, Barbara J. Burns, Barbara L. Baumann, Michael Hurlburt, and John Landsverk.     

Correlates of Secondhand Tobacco Smoke Exposure Among Persons with Severe and Persistent Mental Illness (SPMI) Accessing Community Mental Health Services

To examine the correlates of secondhand tobacco smoke (SHS) exposure in a sample of individuals with severe and persistent mental illness (SPMI) accessing community mental health services. Cross-sectional data were collected from a voluntary sample of 788 individuals with SPMI. Nonsmokers were more likely to be exposed on the street or at a bus stop, in a park or public place; whereas smokers were more likely to report SHS exposure where they lived and at their friend’s homes. In a multivariate model, only number of acquaintances who smoked and the number of sources of SHS exposure remained significantly associated with perceived frequency of SHS exposure when accounting for other correlates. There is a need for the enactment and enforcement of policies to curtail SHS exposure in outdoor, public, settings. Future research will be necessary to better understand the extent and impact of SHS exposure in this population.     

Implementation Research in Mental Health Services: an Emerging Science with Conceptual,Methodological, and Training challenges

One of the most critical issues in mental health services research is the gap between what is known about effective treatment and what is provided to consumers in routine care. Concerted efforts are required to advance implementation science and produce skilled implementation researchers. This paper seeks to advance implementation science in mental health services by over viewing the emergence of implementation as an issue for research, by addressing key issues of language and conceptualization, by presenting a heuristic skeleton model for the study of implementation processes, and by identifying the implications for research and training in this emerging field. An earlier version of this paper was presented at the NIMH Services Research Conference, July 23, 2007.     

The Development and Introduction of an In-Patient Student Law Services for Persons with Serious Mental Illness: A Case Study

There is a need to provide legal assistance to persons who suffer with serious mental illness for legal problems over and above problems associated with mental illness. This paper describes a single-case study of the development and introduction of a pilot of a hospital-based, legal service, in partnership with The University of Western Ontario Faculty of Law. The data sources included direct observation and documentation. Law students provide legal services reflecting the application of a therapeutic jurisprudence approach. Interprofessional education and training occurs with law, medical, nursing and other students, and professionals on the principles and scholarship of therapeutic jurisprudence, mental illness and legal rights. A programmatic organizational template, the program logic model, was used to conceptualize the activities, and process, short-term, long-term and ultimate objectives, and indicators. The four core activities were: (1) patient access point to law students; (2) supervision of law students at the London Health Sciences Centre; (3) intake and access to other services, and (4) teaching and additional training of law and other students, physicians and other health caregivers. The development, issues and challenges of the introduction of an in-patient student law service is described.     

Process and Outcome Evaluation of an Emergency Department Intervention for Persons with Mental Health Concerns Using a Population Health Approach

Purpose: To evaluate an emergency department’s use of a mental health triage and mental health crisis counsellor for persons presenting with mental health concerns. Method: Mixed method (qualitative and quantitative), multiple measures. Results: Significant pre- and post-intervention reductions for wait time, security incidents and hospital admissions were found. Follow ups with a community agency, medications and a psychiatrist increased post-intervention, while follow ups with detox decreased post-intervention. Conclusions: The qualitative and quantitative findings are congruent with other studies supporting the use of properly implemented mental health triage and crisis counsellors to improve the care of persons with mental health concerns.