Relationships Between Youth and Caregiver Strengths and Mental Health Outcomes in Community Based Public Mental Health Services

To examine relationships between youth and caregiver strengths and behavioral health outcomes for youth in community service settings. Strengths and behavioral health needs of youth (N = 793) receiving Home and Community Based Services Waiver from 2002–2008 were characterized using the child and adolescent needs and strengths mental health assessment. Comparisons of assessment scores at admission and program completion were conducted using Chi-square, repeated measures ANOVA and Cohen’s d effect size. Associations between strengths at admission and having behavioral health needs met were examined using multivariable logistic regression. Youth had high levels of needs on mental health, risk and functioning dimensions at admission. All needs improved significantly over the course of the service episode. Youth and caregiver strengths at admission were associated with significant improvements in youth behavioral needs areas at discharge. The findings support the importance of assessing and incorporating youth and caregiver strengths in planning and delivering public mental health services.     

Annotation: New research into general psychiatric services for adults with intellectual disability and mental illness

Background   There are a variety of models for the mental health care of adults with comorbid intellectual disability (ID) and mental illness. There has been a long-running debate as to whether this should be provided by general psychiatric or specialised ID services. A previous review concluded that there was no clear evidence to support either model with research being often of a poor quality, lacking replication, and outcome measures were often inappropriate or varied between studies. This review aims assess differences in outcome for patients with ID and mental disorders treated in general or specialised ID mental health services.
Method   A literature review was conducted using electronic databases and websites of ID and mental health organisations to locate all references where people with ID receive mental health care in general psychiatric services from 2003. No meta-analysis was attempted because of the divergent nature of the studies.
Results   People with ID (especially severe ID) have reduced access to general psychiatric services. General psychiatric inpatient care is unpopular especially with carers but can be improved by providing specially trained staff and in-reach from community ID teams. Opportunities may exist to enhance the care of people with borderline intellectual functioning within general psychiatric services.
Conclusions   Although no new randomised controlled trials have been published, the weight of research is accumulating to suggest that provision of general psychiatric services without extra help is not sufficient to meet the needs of people with ID.     

Psychiatric inpatient care for adults with intellectual disabilities: generic or specialist units?

BACKGROUND: When adults with intellectual disabilities (ID) require a psychiatric admission, general adult mental health units are often used. Specialist units have emerged recently as a care option but there is only limited evidence of their effectiveness. Thus this study aims to describe and evaluate the effectiveness of a specialist inpatient unit and report on the utilization of generic and specialist inpatient services. METHOD: All patients admitted to a specialist ID psychiatric unit were evaluated on admission and immediately after discharge on a number of outcome measures. In addition, they were compared with those admitted to general adult mental health units covering the same catchment area. RESULTS: Significant improvements were demonstrated within the specialist unit cohort on measures including psychopathology, global level of functioning, behavioural impairment and severity of mental illness. The specialist unit patients had a longer length of inpatient stay but were less likely to be discharged to out-of-area residential placement. CONCLUSIONS: Specialist units are an effective care option for this group of people.     

Standards and quality measures for services for people with intellectual disabilities

PURPOSE OF REVIEW: In our modern, performance managed National Health Service, quality has become a key target. Quality assurance has become a statutory duty and the National Health Service is inundated with policy documents and performance measures in most areas of mainstream healthcare. Performance against such measures will be monitored by powerful independent regulatory bodies. It is therefore timely to look at what specific quality measures there are for services for people with intellectual disability. RECENT FINDINGS: Tension exists as to the need for developing specific targets for the population with intellectual disabilities when the philosophy of care is for real social inclusion where 'all means all'. To what extent will existing quality standards for mental health services suffice when we know that often people with intellectual disabilities have real issues accessing these services? This paper highlights published quality measures and standards from primary care through mainstream secondary care and specialist mental health services. It also discusses the policy context and current development of regulatory standards as these continue to evolve. SUMMARY: Evidence for meeting quality standards will increasingly dominate the delivery and funding of healthcare in the National Health Service.     

Patterns of service use among persons with schizophrenia and other psychotic disorders

OBJECTIVE: This study assessed 12-month service use patterns among people with psychotic disorders and sought to identify determinants of service use. METHODS: As part of a large two-phase Australian study of psychotic disorders, structured interviews were conducted with a stratified random sample of adults who screened positive for psychosis. Demographic characteristics, social functioning, symptoms, mental health diagnoses, and use of psychiatric and nonpsychiatric services were assessed. Data were analyzed for 858 persons who had an ICD-10 diagnosis of a psychotic disorder and who had been hospitalized for less than six months during the previous year. RESULTS: People with psychotic disorders had high levels of use of health services, both in absolute terms and relative to people with nonpsychotic disorders. Those with psychotic disorders were estimated to have an average of one contact with health services per week. Use of psychiatric inpatient services was associated with parenthood, higher symptom levels, recent attempts at suicide or self-harm, personal disability, medication status, and frequency of alcohol consumption. Services provided by general practitioners (family physicians) were more likely to be obtained by older people, women, people with greater availability of friends, those with fewer negative symptoms, and those whose service needs were unmet by other sources. People who were high users of health services also reported having more contact with a range of non-health agencies. CONCLUSIONS: The predictors of service use accounted for small proportions of the variance in overall use of health services. The role of general practitioners in providing and monitoring treatment programs and other psychosocial interventions needs to be acknowledged and enhanced.     

BIOMED‐MEROPE* project: service provision for adults with intellectual disability: a European comparison

The aim of the present paper is to describe and compare services for adults with intellectual disability (ID) and mental health needs in five European countries: Austria, England, Greece, Ireland and Spain. A framework and structure for collecting information about service provision was designed. This information was collected through a mixture of interviews with service providers, questionnaires and a review of the research literature within each country. Information was collected on historical context, policy, legislation, assessment, treatment and the structure of services for people with ID and mental health problems. Overall, the needs of those with additional mental health needs have not been specifically addressed at a national level with perhaps the exception of England and Ireland, although there are still gaps in services in these nations. Normalization has been adopted in each of the five countries, and there are moves toward deinstitutionalization, integration and inclusion. Families and self‐advocacy groups have grown. The pace of this change varies between and even within countries. The main findings of the study include: unclear policy, trends for legislative changes, increased prevalence of mental health problems, inadequate generic service provision, a need for specialist mental health services, a need for improved interconnections of services, and a need for training developments. Policy and legislation in the five European countries under consideration tend to separate the disability aspects of people with ID from their mental health needs. Consequently, the service needs of this group remain largely invisible. This might be a direct reflection of policy clarity and legislation, or could be the result of a failure to implement existing guidelines. This has a detrimental effect on the lives of people with ID, and their families and carers.     

Experiences of mental health services by people with intellectual disabilities from different ethnic groups: a Delphi consultation

Background Patient experience of those accessing mental health services has been found to be different between ethnic groups. Although the needs of people with intellectual disabilities (ID) from different ethnic communities are being increasingly recognised, little has been published about their experiences of mental health services. The aim of this study was to establish whether there are any differences in the experiences of people with ID and mental health problems from two ethnic communities in South London. Method A two‐round Delphi process was utilised. White British and Black or Black British service users from a specialist community‐based mental health service for adults with ID completed a specially compiled questionnaire. Statements on participants' experiences, including satisfaction with care, staff members' attitudes, cultural awareness and level of support, were rated using a Likert scale. Results Twenty‐four out of 32 participants (75%) completed both rounds of the Delphi consultation. Consensus (≥80% agreement with the group median) was reached for 20 items in the White group and five items in the Black group. All responses that reached consensus were positive about the services that were being received. The Black group were less positive about a range of their experiences, including the use of medication. Conclusions People with ID from two ethnic groups were able to successfully complete a Delphi consultation regarding their experiences of mental health services. Broad consensus on positive experiences of services was reached in the White group but not for the Black participants.     

The Process of Transforming Mental Health Services in Australia

Australia commenced a nationally coordinated transformation of its public and private mental health services in 1993. This paper presents an overview of the changes in mental health service delivery using data from the 2004 Australian National Mental Health Report. In the 10 years from 1993 to 2002, government spending on mental health increased 65 percent in real terms, with a 145 percent growth in expenditure for community-based services. Government subsidies to the private psychiatrist sector have declined. Consumer and carer participation in service planning and delivery increased, measures to improve quality introduced and patient level outcome measures are being adopted widely. However, some consumers with specific needs have been neglected and the transformation has not been implemented uniformly across the country.     

Evaluative Survey of Service Users and Professional Experiences of a Vocational Rehabilitation Unit for the Mentally Ill in Cyprus

From a social and financial perspective, individuals who suffer from mental illness are among the most isolated groups in society. In particular, they are not included in the active labor force. Research studies indicate that this situation could be solved by supported employment, the most efficient type of employment for people in this category. This article explores the efficacy and functioning of a supported employment unit in Cyprus for people with mental health problems. Tools used for this evaluation research were the VSSS-54 (Verona Service Satisfaction Scale-54), WHOQUOL-BREF (Quality of Life Scale), and an occupational skills scale. Qualitative (focus group interviews) and quantitative tools measured service users' satisfaction and quality of life, and the views of professionals about the strengths and weaknesses of the program. Results indicated a good level of service user satisfaction (mean = 3.86) and service efficiency (mean = 3.56) despite the fact that 72 percent of the total sample (n = 18) were not satisfied with their overall quality of life. Several proposals arising out of this study focus on involvement of service users, support by caregivers, and needed improvements to achieve stronger collaborative practice across community mental health services in the local context.     

A Population-based Needs Assessment for Mental Health Services

A needs assessment was done to objectively evaluate client need and determine gaps between these needs and the services provided by mental health services. The services included were standard case management, assertive case management and residential care across the Fraser Health Region in British Columbia, Canada. Assessments involved collection of data on current symptoms, functioning, and service use and needs. Results showed many specific areas where client needs were under met. A level-of-care planning model was applied to the data and results suggest that a high percentage of clients may be in fact receiving too high or too low a level of care for their needs. This method of performing a population-based needs assessment provided findings that have proved useful for planning purposes in order to ensure that community mental health services better match client need.     

Characteristics of patients presenting for emergency psychiatric assessment at an English hospital

OBJECTIVE: The needs and characteristics of patients who are referred for psychiatric emergency services vary by the source of referral. Such differences have wider implications for the functioning of the mental health care system as a whole. This study compared three groups of patients in a two-month cohort of 189 patients who were referred for emergency psychiatric assessment at a hospital in England: those who were referred by general practitioners (family physicians), those who were receiving specialist services from community mental health teams, and those who arrived at the hospital from the broader community. METHODS: The three groups were compared on demographic characteristics, clinical and service use variables, risk to self or others, factors that contributed to the emergency presentation, and ratings on standardized scales of functioning. RESULTS: The patients who were receiving specialist services from community mental health teams had high rates of psychosis, often relapsed, and had a history of contact with a psychiatrist. These patients were the most likely to be admitted to the hospital after emergency assessment. The patients who had been referred by general practitioners tended to have fewer indicators of social problems and were more likely to be experiencing a new episode of mental illness. Their referral to the emergency department was most likely to be deemed inappropriate by emergency department clinicians. The patients who came from the broader community were more likely to be male and to exhibit self-harming behavior, substance misuse, and behavioral difficulties. CONCLUSIONS: The rate of emergency referral is one indicator of the functioning of the service system as a whole. Improvements to the system should include better access to community mental health team services and a greater capacity of the primary care system to manage mental health crises. Services need to be developed that are acceptable to male patients who are experiencing social and behavioral problems.     

What Can the Experiences of People With an Intellectual Disability Tell Us About the Desirable Attributes of a Mental Health Professional?

Introduction: Mental health professionals have reported that they have limited knowledge, skills, and confidence in the area of intellectual disability mental health. This article aims to learn from the experiences of people with intellectual disability about the attributes that may assist mainstream mental health professionals to provide them with a quality mental health service. Methods: Six people with intellectual disability participated in an interview or focus group. Thematic analysis was undertaken applying the Intellectual Disability Mental Health Core Competencies Framework. Results: The findings supported previous research for the need for mental health professionals to be adaptable, able to communicate, and work with a person’s support network. The study reinforced the need for professionals to undertake professional development in the area but also suggested that people with intellectual disability be included as educators and as peer workers. New attributes were identified, including the need for mental health professionals to be able to build rapport and trust through demonstrating their experience and respect for working with people with intellectual disability, and their ability to understand trauma and how it may influence mental health needs. Conclusions: The attributes identified in the study could be used to inform an intellectual disability mental health workforce development framework.     

Characteristics of young people accessing recently implemented Community Forensic Child and Adolescent Mental Health Services (F:CAMHS) in England: insights from national service activity data

Children and young people in contact with forensic child and adolescent mental health services present with more complex needs than young people in the general population. Recent policy in child and adolescent mental health has led to the implementation of new workstreams and programmes to improve service provision. This research examines the characteristics of children and young people referred to recently commissioned Community Forensic Child and Adolescent Services (F:CAMHS) and service activity during the first 24 months of service. The study is a national cohort study to describe the population and investigate service provision and access across England. Secondary data on 1311 advice cases and 1406 referrals are included in analysis. Findings show that 71.9% of the sample had accessed mainstream CAMHS before their referral, 50.9% had experienced/witnessed multiple traumatic events and 58.4% of young people presented with multiple difficulties. The results of the study highlight the complexity of the cohort and a need for interagency trauma-informed working. This is the first study to describe the characteristics of children and young people referred to Community F:CAMHS and provides valuable information on pathways and needs to inform service policy and provision.

     

Alternatives to custodial remand for women in the criminal justice system: A multi‐sector approach

Throughout the world, women involved in criminal justice systems often present with substantial needs and vulnerabilities. Diverting vulnerable people away from prison is government policy in England and Wales, but full psychiatric and social assessments are expensive and hard to access. A screening and quick response initiative ‐ alternatives to custodial remand for women (ACRW) ‐ was implemented across three areas of London (West, South and East) to supplement existing court liaison and diversion services, to assess the feasibility of a supplementary custodial remand service as part of a women's specialist service pathway in the criminal justice system in England. Three mental health trusts and two voluntary sector providers offered this service enhancement – a screening and service link provision in three London boroughs between 2012 and 2014. We conducted a service evaluation using routinely collected service use record data. The service made 809 contacts, of whom 104 had contact on multiple occasions. Many were identified as at risk of self‐harm (46%) or had histories of hospital admission for mental disorder (36%), but few were referred either to the liaison and diversion service or specialist mental health services. The largest group of referrals was to women's community services outside the health service (e.g. counselling, domestic violence or sexual abuse services). 180 women had dependent children and 22 were pregnant, increasing the urgency to find non‐custodial alternatives. As well as confirming high levels of need amongst women entering the criminal justice system, this evaluation confirms the feasibility of working across sectors in this field, providing an extra layer of service that can complement existing liaison and diversion service provision. The service was responsive and most women using it were kept out of custody. Research is now required to understand the appropriateness of the referrals, the extent to which women follow them through and the impact on their mental health and desistance from offending.     

Impact of co-occurring substance use on 6 month outcomes for young people seeking mental health treatment

OBJECTIVE: Co-occurring substance use and mental health disorders are highly prevalent among young people attending services, yet few studies have examined the effect of such comorbidity among those referred for treatment. The aim of the current study was to examine the impact of co-occurring substance use disorders (SUDs) on 6 month outcomes for young people seeking mental health treatment. METHOD: One hundred and six young people (aged 15-24 years) with a non-psychotic DSM-IV Axis I disorder were assessed following referral to a specialist youth public mental health service. Participants were given a structured interview, as well as questionnaires assessing drug use, psychopathology, psychosocial functioning and self-esteem at baseline and 6 month follow up. RESULTS: At baseline, 23 participants met criteria for a co-occurring SUD and 83 had a non-psychotic Axis I disorder. Both the non-SUD and the co-occurring SUD groups had high levels of psychopathology, serious impairments in functioning and moderate levels of suicidal ideation, although those with co-occurring SUD had significantly poorer levels of functioning. At 6 month follow up the co-occurring SUD group continued to experience substantial problems with symptoms and functioning whereas the non-SUD group had significant improvement in both of these domains. CONCLUSIONS: The present findings are consistent with studies examining the impact of co-occurring substance use and mental health issues across different treatment settings, and reinforce recommendations that young people with co-occurring disorders require more intensive and integrated interventions. The present findings also highlight the need for routine assessment and management of substance use issues within youth mental health settings.     

Barriers and Enablers to Accessing Mental Health Services for People With Intellectual Disability: A Scoping Review

Background: It is well established that people with an intellectual disability have high rates of mental health problems, yet rates of uptake of services do not match need. Aim: To identify the current literature pertaining to the barriers and facilitators to access to mental health services for people with an intellectual disability. Method: A systematic search identified English-language articles that addressed barriers or enablers to access, mental health services, and intellectual disability from 2005 to 2016. Results were synthesized according to Gulliford et al.’s four dimensions of access: availability, utilization, relevance and effectiveness, and equity. Results: Barriers and enablers were identified across all the dimensions. Organizational barriers, lack of services, and poor-quality services related to deficits in knowledge were among the barriers discussed in the literature. Facilitators included emphasis on interagency collaboration, and training and education. Substantial gaps were also identified, particularly in relation to the lived experience of these barriers. Conclusions: Further research and evaluation across all aspects of access to mental health care for people with an intellectual disability is needed.     

Utilization of Mental Health Services and Mental Health Status Among Children Placed in Out-of-Home Care: A Parallel Process Latent Growth Modeling Approach

This longitudinal study examined the parallel trajectories of mental health service use and mental health status among children placed in Florida out-of-home care. The results of growth curve modeling suggested that children with greater mental health problems initially received more mental health services. Initial child mental health status, however, had no effect on subsequent service provision when all outpatient mental health services were included. When specific types of mental health services, such as basic outpatient, targeted case management, and intensive mental health services were examined, results suggested that children with compromised functioning during the baseline period received more intensive mental health services over time. However, this increased provision of intensive mental health services did not improve mental health status, rather it was significantly associated with progressively worse mental health functioning. These findings underscore the need for regular comprehensive mental health assessments focusing on specific needs of the child.     

Ethnic factors in mental health service utilisation among people with intellectual disability in high-income countries: systematic review

Background An emerging literature suggests that ethnic and cultural factors influence service utilisation among people with intellectual disability (ID), but this has not previously been reviewed. Aims To investigate possible ethnic variation in uptake of mental health services in children, adolescents and adults with ID in high‐income countries. Method A systematic review using main databases of studies that consider ethnic influences on mental health utilisation of people with ID. Methodological quality of studies was assessed. Results Nine studies that reached selection criteria were identified. Six studies that compared two or more ethnic groups found a variation in levels of mental health service utilisation. The most consistent finding was that South Asian children, adolescents and adults with ID in the UK had lower use of mental health services than White British comparison groups. Conclusion Ethnic influences on mental health service utilisation were identified. Understanding their significance and potential negative consequences requires further investigation.     

Disengagement From Mental Health Treatment Among Individuals With Schizophrenia and Strategies for Facilitating Connections to Care: A Review of the Literature

Disengagement from mental health services can lead to devastating consequences for individuals with schizophrenia and other serious mental illnesses who require ongoing treatment. We review the extent and correlates of dropping out of mental health treatment for individuals with schizophrenia and suggest strategies for facilitating treatment engagement. Although rates vary across studies, reviews of the literature suggest that up to one-third of individuals with serious mental illnesses who have had some contact with the mental health service system disengage from care. Younger age, male gender, ethnic minority background, and low social functioning have been consistently associated with disengagement from mental health treatment. Individuals with co-occurring psychiatric and substance use disorders, as well as those with early-onset psychosis, are at particularly high risk of treatment dropout. Engagement strategies should specifically target these high-risk groups, as well as high-risk periods, including following an emergency room or hospital admission and the initial period of treatment. Interventions to enhance engagement in mental health treatment range from low-intensity interventions, such as appointment reminders, to high-intensity interventions, such as assertive community treatment. Disengagement from treatment may reflect the consumer''s perspective that treatment is not necessary, is not meeting their needs, or is not being provided in a collaborative manner. An emerging literature on patient-centered care and shared decision making in psychiatry provides suggestive evidence that efforts to enhance client-centered communication and promote individuals’ active involvement in mental health treatment decisions can also improve engagement in treatment.