Australian general practice and the meeting of needs for mental health care

Background: This report, drawing on a national epidemiological survey conducted in 1997, examines the role of Australian medical general practitioners (GPs) in responding to needs for mental health care. Methods: We analysed data from the Australian National Survey of Mental Health and Wellbeing (NSMHWB). The NSMHWB employed clustered probability sampling of all Australian adults, and 10,641 participants were interviewed. The field questionnaire included modules of the Composite International Diagnostic Interview, and instruments assessing disability, service utilisation and perceived needs for care. Results: Eighty-four percent of people with a mental disorder consulted a GP in the year prior to survey, but only 29 % consulted in relation to a mental health problem. GP services were seen as more responsive to needs for medication, counselling and information than needs for social interventions and skills training. People with perceived needs for counselling were more likely to consult with other providers, either as alternative or additional consultations to those with a GP. Counselling needs were reported as less well met when people saw a GP alone than when consulting other service providers. Conclusions: Many people with mental health problems attend primary medical care practitioners without presenting these problems to their physicians. When they do present, perceived needs for medication are rated as well met, but there is substantial unmet perceived need for interventions in social and occupational domains. Perceived needs for counselling are less well met where the GP is the sole provider. To close these identified gaps calls for improvements in primary care physicians' skills and effective collaborative models with other providers. Accepted: 18 May 2001     

Experiences of pathways to mental health services for young people and their carers: a qualitative meta-synthesis review

Worldwide, growing concern with young people’s mental health is spurring service reform efforts. Such reform requires a full understanding of the experiences of young people and their carers when seeking mental health help. To generate such an understanding, we conducted a meta-synthesis of qualitative literature on the perspectives of youths and their carers on navigating mental health systems. Five electronic databases were searched (Medline, PsycINFO, EMBASE, CINAHL, HealthSTAR). Studies were included if they explored the experiences of pathways to mental health services of persons aged 11–30 years and/or their carers; were published in English or French; and used qualitative methodology. Quality appraisal was conducted using the CASP tool. The synthesis of 31 included studies yielded three themes—initiating contact with mental health services; characteristics of services’ response; and youths’ and carers’ appraisal of services. Themes about initiating contact included mental health literacy, structural barriers, and social support. Service response-related themes included complex pathways, waitlists, eligibility, and fragmented care. In terms of service appraisal, positive encounters featured providers who were accessible and perceived as caring. Negative appraisals resulted from feeling misunderstood and excluded and being ill-informed about treatment. Across diagnoses and settings, youths and carers had difficult experiences accessing mental healthcare. While individual, social, and healthcare factors shaping pathways to care varied, systemic complexities were a common inhibitor. This synthesis informs recommendations for improving mental health services and youths’ pathways to them. It underlines the need for grounding reform in youths’ and carers’ perspectives and needs.

     

Maintaining contact with people with severe mental illness: 5-year follow-up of assertive outreach

Background Assertive outreach is a central strand of Government mental health policy in England. Are different long-term models of mental health care which include assertive outreach associated with different service user outcomes and cost? Method We conducted a multi-site 5-year follow-up study of people with severe mental illness. From 0 to 18 months all three sites had Intensive Case Management (ICM) teams practising assertive outreach. From 18 to 60 months one team sustained ICM, one team merged and another was disbanded. All 131 original ICM team clients were the study participants. Outcome was measured in terms of sustained engagement with statutory mental health services, psychiatric symptoms, social functioning, resource use and cost. Results All 120 live participants were traced. Only four people had no service contact; when contacted by a researcher they appeared to be coping well. No incidents of serious violence were discovered. No differences existed between teams in the mean total symptom or total social functioning change scores at follow-up, after controlling for baseline differences. No differences existed in mean cost between teams during the first 18 months. Mean (standard deviation) annualised costs varied considerably in the 18–60 month period: sustained team ￡13,734 (10,820); integrated team ￡11,037 (13,603); disbanded team ￡5,742 (7,007) (F=4.4, 105df, p=0.015). Conclusion Continued specialist assertive outreach service models have higher costs than non-specialist services for no apparent benefit. In the long term new assertive outreach services should have procedures in place to transfer people to lower intensity and lower cost care. Accepted: 18 July 2001     

Carers' experiences of accessing and navigating mental health care for older people in a rural area in Australia

Objectives: Mental health care for older people is primarily delivered in the community and is largely dependent on informal carers. Mental health policy encourages partnerships between carers and service providers to facilitate service access, coordination and positive experience of care. However, carers often lack information and support from services, with the potential for carer burden, and negative impacts on their own health and capacity to fulfil caring tasks. This paper explores rural carers' experiences of accessing care from a range of services for older people with mental health problems.

Method: The Pathways Interview Schedule was used to facilitate 9 in-depth care journey interviews with 11 carers of older people with a mental health problem. Interviews explored their journeys to and through mental health, aged care, primary care and social care services. Framework analysis was used to explore carers' experiences and perceptions of care with a focus on access enablers and barriers.

Results: Carers had a significant role in navigating services and operationalising care for their relative. Enablers to accessing care included carer knowledge and workers actively involving carers in planning. Barriers included carer mental health literacy, consumer and carer readiness for services, and worker misinterpretation of confidentiality and privacy laws.

Conclusion: Carers should be considered key partners in mental health care planning that crosses service sectors. For this to occur, changes are required at the worker level, including increased communication between mental health workers and carers, and the service level, involving training for staff in interpreting confidentiality and privacy policy.     

Stroke and mental health care: a record linkage study

Background Stroke is associated with psychiatric morbidity but little is known about mental health care use in stroke patients. Method A probability record linkage study was conducted linking stroke cases admitted to a teaching hospital serving a catchment area between 1987 and 1995 with records from a psychiatric case register covering the same area. Results Stroke patients had a more than twofold increased risk of contact with mental health care than individuals in the general population (yearly prevalences of respectively 88 and 39 per 1000; risk ratio 2.24; 95 % CI 2.04–2.45). One-third of all stroke admissions had had mental health care before and more than half had had mental health care after the stroke. In the year of admission for stroke, the probability of receiving mental health care was highest, while in the more remote years the risk was lower. Conclusion Stroke is associated with an increased probability of contact with mental health services. The pattern of mental health care of a stroke patient is different from that of other mental health patients: more episodic and concentrated around the time of admission for stroke. Accepted: 19 September 2001     

Use of the Behavioral Model of Health Care Use to identify correlates of use of treatment for panic attacks in the community

Background The aim of this study was to identify predisposing, enabling, and need factors associated with health service use for panic attacks among adults in the United States using the Behavioral Model of Health Care Use. Method Data were drawn from the National Comorbidity Survey (n = 8098), a community-based household sample representative of the United States adult (age 15–54) population. Stepwise logistic regression models were used to compute odds ratios (with 95 % confidence intervals) measuring the association between predisposing, enabling, and need factors and the self-reported health service use for treatment of panic attacks. Result In addition to perceived (perception of poor mental health) and evaluated need (severity of panic attacks, psychiatric morbidity), predisposing (being older, married, more educated, white) factors were independently associated with use of treatment for panic attacks. Distinct correlates for use of primary care, specialized mental health treatment, and use of psychotropic medication were found. In addition to need factors, predisposing factors are independently associated with the use of services for panic attacks in the community. Conclusions These results suggest that factors other than severity of panic and degree of psychiatric morbidity may influence use of services for panic. Future studies that examine whether these factors reflect barriers to care for those in need of mental health treatment may help to inform programs aimed at targeting those with unmet need in the community. Accepted: 14 December 2001     

Threshold 3: the feasibility of the Threshold Assessment Grid (TAG) for routine assessment of the severity of mental health problems

Background Evidence-based practice requires the development of measures which are suitable for everyday clinical use (‘feasible’). There is no consensus as to how to establish feasibility. Method The feasibility of a new assessment – the Threshold Assessment Grid (TAG) – for use when making referrals to mental health services was tested by training mental health teams in using the TAG and other standardised assessments, asking referrers to ten mental health services in London also to complete a TAG, surveying TAG users, and evaluating a feedback meeting at which TAG data were presented. Results One hundred and one (61 %) mental health staff received training, and 445 (74 %) referrers of 600 patients completed TAGs. Sixty-five (65 %) questionnaires from TAG users were completed, and 24 (80 %) people attending feedback meetings evaluated the TAG. These allowed the extent to which the TAG is brief, simple, relevant, acceptable, available and valuable to be investigated. Conclusion The TAG exhibited good feasibility when used by mental health staff, and moderate feasibility when used by referrers. This approach can be used to investigate the feasibility of other standardised assessments. Accepted: 5 July 2001     

Accessibility and pathways to psychiatric care in a community-based mental health system

Background The careful analysis of pathways to specialist mental health care, within the context of community-based services, is important because it allows a detailed understanding of the inter-relationship between the component parts of the whole system of care. Moreover, it permits a comparison of service functioning to made over time, and is one way to operationalise the measurement of accessibility to services. The aims of this study are to describe: (i) the pathways followed by patients with new episodes of care to community-based mental health services, (ii) the time intervals from onset of the problem to first contact with services, and then to onward referral to specialist care (accessibility), and (iii) to explore the short-term costs associated with different pathways. Methods Using data from the South-Verona Psychiatric Case Register, all new patients referred to any of the facilities which are part of the South-Verona Community Psychiatric Service (CPS) over a 6-month period (November 1999 – May 2000) were eligible to enter the study. Patients were interviewed by telephone using the Italian translation of the WHO Encounter Form. The costs of care provided in the 3 months following the index contact were assessed for all patients. Results The most common route to mental health services is via a GP (40 %), followed by a referral from a hospital doctor (26 %) and self-referral (23 %). The median interval from onset to direct contact with the South-Verona CPS (12 weeks) was shorter than the intervals from onset to direct contact with other service providers (the median interval for contact with GPs and hospital doctors was 24 weeks). The intervals varied considerably from 1 week (for attempted suicide), to 1.5 years (for disturbed behaviour). The results of backward regression modelling revealed a significant relationship between patients' characteristics and community costs or total psychiatric costs (44 % and 53 % of the variance explained respectively). Conclusion When the results are compared with a directly comparable earlier study in South-Verona, it is apparent that between 1991 and 1999 an increasing proportion of patients with insomnia and somatic disorders presented first to GPs, while a decreasing proportion of patients over the years sought care directly from specialist care. An increase in the role of local GPs as gatekeepers has, therefore, emerged. A prompt assessment by the South-Verona CPS of the patients' presenting problems was also confirmed, and this can be explained by the ‘drop-in’ approach at the Mental Health Centre, where patients can seek specialist care directly, without previously attending GPs. This method of measuring time intervals along pathways is proposed as a way to operationalise accessibility to services in future. Accepted: 16 July 2001     

Outcome of case management based on the strengths model compared to standard care. A randomised controlled trial

Background The outcome of less intensive case management services, such as the strengths model, is still inconclusive, which suggests a need for more controlled studies. The aim of the present study was to investigate the outcome of a strengths model of case management service (SCM) compared to standard care. Methods Seventy-seven clients with a mental illness and a serious impairment in functioning in social contacts, housing or work situation were randomly allocated to SCM or standard care. Outcome was assessed with regard to use of psychiatric services, changes in symptomatology, psychosocial functioning, social network, needs for care, quality of life and client satisfaction with care. The follow-up period was 36 months. Results The results showed a greater reduction in needs for care in clients receiving SCM. No differences in clinical or social outcome were shown. Clients receiving SCM also used significantly less days in psychiatric inpatient services and were generally more satisfied with the psychiatric services offered. Conclusions SCM failed to improve clinical and social outcome compared to standard care, but was more successful in reducing days spent in hospital, and the clients were also more satisfied with the service compared to standard care. Accepted: 5 January 2001     

Early psychosis in the inner city: a survey to inform service planning

Background In recent years, there has been a growing impetus to offer services for people with early psychosis. This paper describes a survey undertaken as the basis for the development of an early psychosis service. Rates of psychosis are known to differ between cities and rural areas and between ethnic groups. Identifying service needs is enhanced if the social and demographic characteristics, as well as the incidence, of people with psychosis in a given catchment area are known. Method The present study identified all presentations of people aged 16 or over with first and second episodes of psychosis in a 6-month period within a specified South London catchment area. A follow-up was carried out at 1 year. Results This survey confirmed existing knowledge on the social and service needs of this population, in finding high rates of unemployment and homelessness, poor engagement with services and frequent involuntary pathways to mental healthcare. Sub-groups were also identified with specific needs, which are less often cited in the literature, such as groups of asylum seekers and people with young dependants. Conclusions The results of the survey indicated that existing services were not adequately meeting the needs of people with early psychosis. They have been used to inform the development of an innovative service for people with early psychosis. The plans for this service are described. Accepted: 5 July 2001     

Schizophrenia and substance misuse problems: a comparison between patients with and without significant carer contact

Aim Many researchers and clinicians in the mental health field have given much attention over the last few years to patients with co-morbid problems of schizophrenia and substance use. This population is becoming a focus of attention for all service providers owing to the suggested increase in numbers of patients with these dual diagnoses and the observed negative effects on patients and costs to services. The advantages for providing family interventions in schizophrenia are now well established and increasingly these interventions are being evaluated for families of dual diagnosis patients. Many dually diagnosed patients do not, however, have a great deal of contact with a carer/relative. This paper looks at whether differences exist between patients with a dual diagnosis that have carer contact and those who do not have carer contact in terms of their illness history and type of substance use. For the purpose of this article ‘carer’ refers to an individual who is an informal carer or relative with whom the client has weekly contact of 10h. Many of these carers provide the client with emotional, physical and material support. Method The identification process for both ‘carer contact’ and ‘no carer contact’ patients was conducted through the screening of the hospital's care programme approach (CPA) lists and through contact with care co-ordinators and consultants. Case notes of all patients identified were screened and information on demographic data, duration of illness, admissions and substance use was collected. Results Results indicated that the ‘no carer contact’ group was older and had significantly more days in hospital at last admission. Conclusions It is possible that as patients get older their contact with significant others decreases, i. e. loss of contact with key relatives is due to age rather than severity of substance use. Furthermore, patients' reduced contact results in them having longer stays in hospital possibly because they will not receive additional support when discharged. Accepted: 16 July 2001     

Bed/population ratios in South African public sector mental health services

Background In post-apartheid South Africa, mental health service planners face critical decisions regarding appropriate and affordable inpatient care. Before a fashion of deinstitutionalisation is followed blindly in South Africa, effective community services should be in place and sufficient psychiatric beds should remain in hospitals for those who cannot be catered for in the community. In order to maintain the delicate balance between hospital and community-based services, it is essential that useful indicators of inpatient care are established. This study documents current bed/population ratios per 100 000 population in public sector mental health services in South Africa. Method A questionnaire was distributed to provincial mental health coordinators requesting psychiatric bed numbers in acute and medium-long stay facilities across all service levels. The information was supplemented by consultations with mental health coordinators in each of the nine provinces. Population data were obtained from preliminary findings of the 1996 census. Results For acute facilities, the mean bed/population ratio was 13 (provincial range: 6–18) per 100 000 population. For medium-long stay facilities, it was 16 (provincial range: 0–29) excluding contracted facilities, and 35 (provincial range: 0–83) including contracted facilities per 100 000 population. Conclusions There were low levels of inpatient service provision in South Africa, and there was considerable variability between provinces. This study gives further support to the need to develop acute inpatient psychiatric services, reduce levels of chronic care where appropriate, and redirect resources towards the development of community-level residential and day-care services. It is crucial to develop accurate indicators to monitor this process. Accepted: 1 March 2002     

Correlates of stress in carers

Background: Mental health services are required to take account of the needs of carers, yet little is known about how services affect carers. Aims: This paper explores the relationship between the user's mental health problems, the services received and the impact of caring on carers. Methods: Sixty-four carers were interviewed, measuring their experiences of care-giving, carer stress and the service user's level of impairment. A robust, composite measure of user severity was derived. Results: Carers were sometimes better judges than care co-ordinators of user impairment. Their experience reflected the independently rated severity of service users' problems. When carers were aware of care plans, they felt less negative about caring. Even in above-average mental health services, carers lacked information about: care plans, medication and complaints procedures. Conclusions: This evidence can be used in allocating resources such respite care, family therapy and CBT to carers. These findings have implications for how mental health services might improve their provision for carers, for instance, involvement in care planning may help carers to cope.     

Psychosocial factors and adequacy of services for children in children's homes

Risk and protective factors of psychosocial development in children in different residential care settings need to be further studied internationally, in order to develop working methods for social and health care services. Standardized methods of the CBCL, TRF, and CGAS, were used to evaluate psychosocial functioning of children in children's homes in Finland. Further, data on sociodemographic situations and traumatic events in their lives were assembled. The percentage of behavioural and emotional problems within clinical or borderline range in the different ratings was 55–80%. Combined traumatization, sexual abuse, school difficulties, male sex, older age (>11 years) and older age at first and on-going placement (>7 years), as well as difficulties in relationships with parents are likely to be associated with more severe behaviour problems and lower general functioning. The results of this study show that children and adolescents in social service residential settings are a highly vulnerable group and that these children have extensive mental health needs. Accepted: 11 November 1998     

Life events preceding suicide by young people

Background Life events are often reported to precede suicide. This paper aims to determine the frequency, timing and type of life events preceding suicide by young people and those with and without a mental illness. Method Informants, usually family members, were interviewed for a sample of young (less than 35 years) suicides. Information was recorded on events occurring in the 6 months before death. Equivalent information was obtained for living controls who had been matched for age and gender and obtained through the general practices of the suicides. Results Suicide was associated with life events in the previous 3 months, and particularly in the previous week. Specifically, interpersonal and forensic (being arrested, charged or sentenced) events distinguished suicides and controls. The number of life events in the different time periods under study did not distinguish suicides with and without severe mental illness, although more suicides without a severe mental illness had a reported life event in the week before their death. Conclusions Adverse life events frequently precede suicide in young people with and without severe mental illness. However, recent life events may have a lesser causal role in those with severe mental illness. Clinical and health promotion measures to improve the way that young people cope with interpersonal problems and other crises may be an important part of any suicide prevention strategy. Accepted: 15 November 2001     

Health and well-being among 70-year-old migrants living in Sweden – results from the H 70 gerontological and geriatric population studies in Göteborg

Background Comparative epidemiological studies in migrants in Sweden have shown increased prevalence of psychosocial morbidity in young adults, but there is paucity of information on health in people aged 65 years and over. Aims We aim to compare prevalence of mental, physical and social health problems, rates of hospital admission, and mortality in Swedish and non-Swedish born people aged 70 years living in Göteborg, Sweden, and examine associations between social factors, physical health, mood and life satisfaction in the ethnic groups. In addition, we aim to test for the hypothesis that differences in mental health between migrants and natives are explained by social disadvantages rather than ethnicity. Method Semi-structured interviews were administered to 84 migrants (47 women and 37 men randomly selected) with the help of bilingual interpreters, and 409 Swedes (183 males and 226 females) used as “controls”. Complementary health and social data obtained from official sources on the total sample (N = 764, including non-participants in overall medical interviews) were used in comparative analyses of in-patient care and mortality and to check for the possibility of sampling bias. Results Migrants – originating mainly from Estonia, Poland, Yugoslavia, Germany, Italy and Nordic countries other than Sweden – reported more dizziness, poor vision and urinary problems, and fewer gall bladder problems than indigenous people (p ≤ 0.05). Migrants also had higher levels of anxiety and depression and bodily pain, and lower levels of general health, social and emotional functioning, satisfaction with physical health status, family contacts, housing conditions and economic status than natives (p ≤ 0.05). Satisfaction with physical health seemed to be one of the strongest factors related to a lower prevalence of anxiety and depression together with family support and time spent in leisure pursuits. No significant differences in in-patient care in several ICD categories and all-cause mortality were found between overall migrants and the control group notwithstanding differences in self-reported health. Conclusion The results indicate poorer subjective health in older migrants than natives in Göteborg, and also point to a “healthy migrant” effect on survival.     

Met and unmet needs of severely mentally ill persons

Background: There has been a process of deinstitutionalisation and mental health care reforms in most countries in Europe. The objective of this study was to discuss the effects of the Psychiatric Care Reform in Sweden in 1995 on the development of needs of severely mentally ill persons and to analyse whether the efforts made by social services and psychiatric care have been more adequate since the reform. Method: Two hundred and eighteen persons who were considered to be severely mentally ill both in 1995/96 and 2000/2001, using the same criteria of definition, were interviewed using the same form of interview and their needs were assessed according to Camberwell Assessment of Need on both occasions. Results: The results were in the expected direction. The total sum of unmet needs and unmet needs in important need-domains had decreased on the occasion of the second interview. The degree of effort by psychiatric care and social services had increased. Conclusions: The target group had made some progress. Due to methodological difficulties, it was not possible to ascribe these results to the reform, but the often negative picture of the reform deserves to be more nuanced. Accepted: 10 January 2003 Correspondence to Hans Arvidsson     

Factors influencing stigma

Background: Stigma about mental illness continues to run deeply in most societies, creating considerable difficulties for patients and families. Previous research points to particularly strong stigmatising attitudes in Greek and Greek Cypriots (Triandis 1989). It is unclear whether these attitudes continue to be held by UK-born Greek Cypriots. Method: In an area of north London which contains a large Greek-Cypriot population, we compared the attitudes towards mental illness by first- and second-generation Greek Cypriots and those of white-English ethnicity. Seventy-nine white-English participants and 91 Greek Cypriots were interviewed using a snowballing method. We used the ‘Community Attitudes to Mental Illness scale’ (Taylor and Dear 1981) to measure attitudes to mental illness. In addition we used questions from Wolff et al. (1996c) to measure subjects' knowledge of mental illness and contact with people with mental health problems. Results: We found that Greek Cypriots had less contact with mentally ill people, were less knowledgeable about mental illness and hold more stigmatising views than their English participants. Contrary to our expectations, we found little difference in attitudes about mental illness held by first- and second-generation Greek Cypriots. Knowledge about mental illness was associated with a positive attitude towards people with mental health problems. Conclusions: Aggressive educational campaigns targeted at specific minority communities such as the Greek-Cypriot community are required to challenge the stigma attached to mental illness. Accepted: 9 April 2002     

Mental Health and Community-Based Rehabilitation: A Qualitative Description of the Experiences and Perspectives of Service Users and Carers in Bangladesh

Since 2016, Promotion of Human Rights of Persons with Disabilities in Bangladesh (PHRPB) has been working to include people with psychosocial disabilities in their community-based inclusive development work, and to increase access to formal mental health care. Field visits were carried out to PHRPBD catchment areas in Dhaka and Chittagong for a case study on the integration of mental health into community-based rehabilitation (CBR). This paper synthesizes the results of twenty-five semi-structured interviews carried out as part of the case study. Participants included people with psychosocial disabilities, intellectual disabilities, epilepsy or other cognitive impairments and their carers as needed. Interviews were audio-recorded, transcribed and translated from Bangla to English, then hand-coded for content analysis. Results were organized into five overarching categories: (1) explanatory models, (2) help-seeking behaviors, (3) impact of services, (4) challenges and barriers to improving mental health, (5) recommendations of users and carers. Respondents either had no explanation for why service users had become unwell or attributed it to physically and/or emotionally traumatic events or supernatural causes. Before attending PHRPBD’s mental health services, most had visited formal or informal health care providers, often with disappointing results. Despite positive feedback on PHRPBD’s services, participants identified ongoing challenges. Stigma, discrimination and human rights abuses persist and are compounded by issues of gender inequality. Participants also identified barriers and made recommendations specific to the program itself, mainly regarding accessibility (e.g., cost, distance, frequency). This study adds to the limited body of qualitative research on mental health in Bangladesh, reinforcing previous findings on explanatory models and health-seeking behaviors while providing new insights into the impact of a CBR program in this context. Feedback of service users and carers suggests that CBR may indeed be a useful approach to increase access to services in Bangladesh for people with psychosocial or intellectual disabilities, epilepsy or other cognitive impairments. However, this program is not without its limitations, some of which are the product of broader issues within the mental health system and others of the social and cultural context. More research is needed to formally evaluate this and other CBR programs in the Global South.