Demand for,access to and use of community mental health care: lessons from a demonstration project in India and Pakistan

BACKGROUND: A widely promoted model of mental health care and prevention appropriate to many low-income countries is one that is integrated into the local primary health care system. AIMS: To examine the influence of health-seeking behaviours (demand-side factors) and the access to/availability of services (supply-side factors) on local service utilisation patterns for people with common mental disorders. METHOD: Two rural catchment populations outside Bangalore (India) and Rawalpindi (Pakistan), one with the standard primary health care system, the other with additional mental health care training and support, were screened for common mental disorders. Diagnosed cases were interviewed about their use of and perceptions of local health care services (repeated three months later). RESULTS: Individuals' use of integrated mental health and other care was modest. Principal (self-rated) supply-side factors were the cost of care, distance from treatment centre, a perception that care would not be effective, and concerns regarding stigma. Perceptions improved over three months, accompanied by an increased preference for public over private providers, but this was not restricted to the integrated care localities. CONCLUSION: The use (and therefore effectiveness) of mental health services integrated into primary care is influenced by the health-seeking behaviours and perceptions of the local population. Efforts to integrate mental health into primary care need to be accompanied by educational activities in order to increase awareness, reduce stigma and draw attention to the availability of effective treatment.     

Behavioral Health Integration in Large Multi-group Pediatric Practice

There is increasing interest in methods to improve access to behavioral health services for children and adolescents. Children’s Community Pediatric Behavioral Health Service (CCPBHS) is an integrated behavioral health service whose method of (a) creating a leadership team with empowered administrative and clinical stakeholders who can act on a commitment to change and (b) having a clear mission statement with integrated administrative and clinical care processes can serve as a model for implementing integration efforts within the medical home. Community Pediatrics Behavioral Health Service (CPBHS) is a sustainable initiative that improved the utilization of physical health and behavioral health systems for youth and improved the utilization of evidence-based interventions for youth served in primary care.     

Dementia

Alzheimer's disease is the most common cause of dementia, but often several other conditions causing dementia are present on brain autopsies. Palliative care medical issues are similar in all late stage progressive degenerative dementias and include; cardiopulmonary resuscitation, transfer to acute care setting, antibiotic therapy, and tube feeding. Behavioral symptoms of dementia include agitation and resistiveness to care. Quality of life of individuals suffering from dementia is enhanced by availability of meaningful activities and by avoidance of restraints. Family support and involvement are crucial for optimal care. Formulation of advanced directives or an advance proxy plan is important for assuring the patient's previous wishes or best interests are considered when decisions about treatment strategies are made.     

Racial and ethnic disparities in SSRI availability in substance abuse treatment

OBJECTIVE: The high rate of co-occurrence of psychiatric and substance use disorders suggests that specialty substance abuse treatment facilities may be an important site for the delivery of psychotropic medications. However, the literature suggests there may be associations between the percentage of racial and ethnic minority clients and the availability of selective serotonin reuptake inhibitors (SSRIs) in these facilities. METHODS: Survey data from the National Treatment Center Study, comprising nationally representative samples of 326 publicly funded and 339 privately funded substance abuse treatment centers, were used to measure the availability of SSRI medications from 2002 to 2004. Independent variables included the percentages of African-American and Hispanic clients, center type, organizational affiliation, region, size, accreditation status, presence of an integrated care program, and physician availability. RESULTS: SSRIs were available in 48% of the centers. Logistic regression analysis indicated that greater minority representation in centers' caseloads was negatively associated with the availability of SSRIs. The association between the percentage of African-American clients and SSRI availability was fully mediated by the addition of factors related to treatment inputs, such as the presence of a physician on staff or contract and the presence of an integrated care program. With organizational and treatment characteristics factored out, there was a negative association between the percentage of Hispanic clients and the availability of SSRIs. CONCLUSIONS: Although SSRIs were available in nearly half of these substance abuse treatment settings, racial and ethnic disparities exist in the availability of these medications.     

Integrating behavioral health and primary care: the Harris County Community Behavioral Health Program

This column describes and evaluates the Harris County Community Behavioral Health Program, a new integrated care program operating in community health centers serving low-income uninsured residents in Houston, Texas. Patient service data, provider satisfaction, patient outcome data, and appointment waiting periods were obtained to evaluate the initial operation of the program. The integrated care program has been successfully implemented on a large scale at an annual cost of about dollars 800,000, or dollars 268 per patient served. About 3,000 patients were treated for behavioral problems by behavioral health staff during the first 11 months of the program. In addition, efforts were made to expand the scope of behavioral health interventions provided by primary care physicians. Providers were satisfied with the program, improvement was detected among patients treated, and there was an increase in the average number of community-based behavioral health services received per patient since the program was implemented.     

Depression care for people with cancer: a collaborative care intervention

Depression management for patients with chronic medical illnesses, including cancer, is often inadequate. “Depression Care for People with Cancer” (DCPC) has been designed to be integrated into specialist cancer services and is being evaluated in the Symptom Management Research Trials (SMaRT) Oncology series of randomized controlled trials. The intervention is an extended form of the collaborative care model and is delivered by a care manager, who receives regular supervision from a psychiatrist. The care manager coordinates the patient's depression management, by liaising with both their primary care physician and their cancer team, and provides a brief talking treatment. This article describes the design and delivery of DCPC as given in the SMaRT Oncology trials.     

The availability of psychiatric programs in private substance abuse treatment centers, 1995 to 2001

OBJECTIVE: The high rate of co-occurrence of substance abuse and mental disorders renders the availability of psychiatric programs, or integrated service delivery, a vital quality-of-care issue for substance abuse clients. This article describes the availability of psychiatric programs and integrated care for clients with severe mental illness in the private substance abuse treatment sector and examines these patterns of service delivery by profit status and hospital status. METHOD:S: Survey data from the National Treatment Center Study, which is based on a nationally representative sample of privately funded substance abuse treatment centers, were used to identify the proportion of centers that offered psychiatric programs in 1995-1996, 1997-1998, and 2000-2001. Centers reported whether they treated clients with severe mental illness on-site or referred them to external providers. Repeated-measures general linear models were used to test for significant changes over time and to assess mean differences in service availability by profit status and hospital status. RESULTS: About 59 percent of private centers offered a psychiatric program, and this proportion did not significantly change over time. The proportion of centers that referred clients with severe mental illness to external providers increased significantly from 57 percent to 67 percent. For-profit centers and hospital-based centers were significantly more likely to offer psychiatric programs and were less likely to refer severe cases to other providers. CONCLUSION:S: Although the importance of integrated care for clients with dual diagnoses is widely accepted, data from the private substance abuse treatment sector suggest that this pattern of service delivery is becoming less available.     

Integration of mental health resources in a primary care setting leads to increased provider satisfaction and patient access

Objective

This evaluation assessed the opinions and experiences of primary care providers and their support staff before and after implementation of expanded on-site mental health services and related system changes in a primary care clinic.

Method

Individual semistructured interviews, which contained a combination of open-ended questions and rating scales, were used to elicit opinions about mental health services before on-site system and resource changes occurred and repeated following changes that were intended to improve access to on-site mental health care.

Results

In the first set of interviews, prior to expanding mental health services, primary care providers and support staff were generally dissatisfied with the availability and scheduling of on-site mental health care. Patients were often referred outside the primary care clinic for mental health treatment, to the detriment of communication and coordinated care. Follow-up interviews conducted after expansion of mental health services, scheduling refinements and other system changes revealed improved provider satisfaction in treatment access and coordination of care. Providers appreciated immediate and on-site social worker availability to triage mental health needs and help access care, and on-site treatment was viewed as important for remaining informed about patient care the primary care providers are not delivering directly.

Conclusions

Expanding integrated mental health services resulted in increased staff and provider satisfaction. Our evaluation identified key components of satisfaction, including on-site collaboration and assistance triaging patient needs. The sustainability of integrated models of care requires additional study.     

Mental health services in Cuba

Despite its limited resources, Cuba has developed an integrated mental health system that emphasizes prevention and community care. It consists of three distinct organizations: the Committee for the Defense of the Revolution, one of many mass community organizations that strive to protect the revolution; the policlinics, which provide comprehensive health services to geographic areas containing 25,000 to 40,000 people; and the psychiatric hospitals. All three use treatment approaches that are based on a social systems model and that emphasize solving current problems and disturbances. Behavioral and milder psychiatric problems are treated by policlinic psychologists, in the community whenever feasible, and major psychiatric disorders are treated by psychiatrists at the hospitals. Services for children and adolescents, research, and staff training in Cuba are also discussed.     

Medicaid managed care model of primary care and health care management for individuals with developmental disabilities

Lack of sufficient accessible community-based health care services for individuals with developmental disabilities has led to disparities in health outcomes and an overreliance on expensive models of care delivered in hospitals and other safety net or state-subsidized providers. A functioning community-based primary health care model, with an integrated care management component, functioning in the general health care practice marketplace, is described and shown to address recent Surgeon General recommendations as well as evaluative criteria for availability, affordability, acceptability, and appropriateness of care. The model functions in both fee-for-service and managed care environments, including Medicaid managed care for individuals with developmental disabilities. Experience shows this model to be both scalable and replicable, resulting in positive health outcomes and increased patient satisfaction.     

Integrated substance use and mental health treatment for adolescents: aligning organizational and financial incentives

The high prevalence of the dual diagnosis of mental and substance use disorders (SUD) has been increasingly documented for both adolescents and adults (Crowley and Riggs 1995; Kandel et al. 1999; Whitmore et al. 1997). For more than a decade, the National Institute of Drug Abuse (NIDA) has included integrated treatment of comorbid psychiatric disorders as one of nine core treatment principles (National Institute on Drug Abuse 1999). Despite empirically supported practice guidelines, implementation of integrated treatment has been slow (New Freedom Commission on Mental Health 2003; U.S. Department of Health and Human Services 1999). In response to the growing call for integrated treatments and systems of care, this paper: (1) identifies systemic and economic barriers that have impeded widespread implementation of integrated care for adolescents with co-occurring SUD, specifically the supply of treatment providers, shifting priorities of gatekeepers to specialty care, and financing streams; and (2) describes possibilities for aligning economic incentives in order to facilitate the dissemination and implementation of integrated care for adolescents with co-occurring SUD.     

Substance Abuse Providers' Assessment of the Massachusetts Behavioral Health Program: Year 6

Substance abuse providers surveyed after Year 6 of the Massachusetts Behavioral Health Plan reported better treatment outcomes and access than in previous years. The Massachusetts Behavioral Health Partnership's clinical practices helped to improve quality of care. Its review process was highly rated. Coordination of substance abuse and mental health services was favorable, but was unfavorable with primary care. Staffing and organizational changes are described. Comparisons of outpatient and detoxification providers' responses with previous mental health and substance abuse surveys are made.     

PRISM-E: comparison of integrated care and enhanced specialty referral models in depression outcomes

OBJECTIVE: This study, entitled Primary Care Research in Substance Abuse and Mental Health for the Elderly, examined six-month outcomes for older primary care patients with depression who received different models of treatment. METHODS: Clinical outcomes were compared for patients who were randomly assigned to integrated care or enhanced specialty referral. Integrated care consisted of mental health services co-located in primary care in collaboration with primary care physicians. Enhanced specialty referral consisted of referral to physically separate, clearly identified mental health or substance abuse clinics. RESULTS: A total of 1,531 patients were included; their mean age was 73.9 years. Remission rates and symptom reduction for all depressive disorders were similar for the two models at the three- and six-month follow-ups. For the subgroup with major depression, the enhanced specialty referral model was associated with a greater reduction in depression severity than integrated care, but rates of remission and change in function did not differ across models of care for major depression. CONCLUSIONS: Six-month outcomes were comparable for the two models. For the subgroup with major depression, reduction in symptom severity was superior for those randomly assigned to the enhanced specialty referral group.     

The Treatment of Anxiety Disorders in a Primary Care HMO Setting

Anxiety disorders are common, yet under diagnosed, in primary care settings. Many patients with anxiety and other psychiatric disorders do not seek care in mental health care settings. An integrated primary care/mental health model offers one approach to improving outcomes for patients with anxiety disorders. This model has been researched for the treatment of depression with positive results but has not been well studied for the treatment of anxiety disorders. We describe the results of care for a cohort of adult patients with Generalized Anxiety Disorder (GAD) and clinically significant anxiety secondary to Major Depressive Disorder (MDD) treated in an integrated model. Compared to a matched cohort of adults treated in a primary care setting with usual care, the intervention cohort experienced significantly improved reduction in symptoms of anxiety at 6 months. The intervention cohort also was significantly more satisfied with care.     

Treatment of depression in patients with opiate dependence.

Depression is common among opiate-dependent patients and has been associated with worse prognosis. This article reviews the literature on treatment of depressive disorders and symptoms among patients with opiate dependence. Depression bears a complex relationship to opiate dependence and may represent an independent disorder or may be engendered by psychosocial stress or toxic and withdrawal effects of drugs. Primary treatments for opiate dependence (e.g., methadone or buprenorphine maintenance or residential treatment) are associated with substantial improvements in depression. Studies of antidepressant medications have produced mixed results, some positive but more negative. It is not clear what accounts for these differences, and more research is needed to determine how to select opiate-dependent patients most likely to benefit from antidepressants. Fewer studies have examined psychosocial or behavioral interventions, but some of these also show promise. The data suggest a stepped model of care in which depression is evaluated and observed during the outset of treatment for opiate dependence and if it does not improve, specific psychosocial interventions or antidepressant medications tried. Research is needed on such integrated models of care and treatment algorithms to determine their efficacy and cost effectiveness.     

Role of biogenic amines in the effects of marijuana on EEG patterns in cats.

The results of pretreatment with drug having selective action on brain biogenic amine levels on the subsequent effects of acute marijuana treatment were assessed for behavior and EEG measures. Behavioral changes and alterations in the spontaneous EEG indicated that pretreatment with drugs affecting brain levels of 5-HT was most effective in altering the dual properties of acute marijuana treatment. The present findings support the interpretation that the availability of serotonin interacts with the effects of acute marijuana treatment but do not eliminate the possible involvement of other neurotransmitters in the action of marijuana.     

The behavioral medicine unit: A new facility

A new type of short-term, psychiatric, inpatient facility is described that utilizes predominantly behavioral techniques and is designed to treat patients manifesting symptoms of severe anxiety, phobias, chronic pain syndromes, and psychosomatic disorders. Salient aspects of its organization and conduct are discussed. This Behavioral Medicine Unit offers a unique program of therapy to a patient population that presently has no appropriate health care facility. It is designed, moreover, to be self-evaluative and, within its own treatment schemes, optimizes conditions for long-term effectiveness. Behavioral medicine as here defined is a systematic approach to illness involving a sequence of assessment and treatment directed towards a specific patient population and represents a clinical application of a holistic-systems approach to medicine.     

Co-occurring severe mental illness and substance use disorders: a review of recent research.

OBJECTIVE: Understanding the complex diagnostic and treatment issues posed by the co-occurrence of severe mental illness and substance use disorders has become a necessary exercise in current psychiatric practice. The authors reviewed research studies from the past six years that have contributed to our knowledge about effective assessment, diagnosis, course of illness, and treatment approaches. Research on special populations, including women, persons infected with HIV, and violent patients, is highlighted. METHODS: PsycINFO, Silver Platter, and MEDLINE were used to search for English-language studies published in the United States and other countries. To augment the search, selected bibliographies were reviewed with a focus on clinical standards. Information was sought on epidemiology, screening and assessment strategies, course of illness, models of treatment delivery, and cost of care. RESULTS AND CONCLUSIONS: Although estimates of the prevalence of substance use disorders vary by population, a higher prevalence among persons with severe mental illness has been confirmed. Routine screening for and assessment of substance use disorders among persons with severe mental illness has become the accepted standard of care. The course of severe mental illness is negatively influenced by a substance use disorder, and an integrated approach to the treatment of both disorders is generally accepted to be the most promising treatment strategy. Components of this strategy include harm reduction, treatment in stages, motivational interviewing, cognitive-behavioral interventions, and modified 12-step self-help groups.     

Randomized controlled trial of motivational interviewing, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders

OBJECTIVE: Comorbidity of substance abuse disorders with schizophrenia is associated with a greater risk for serious illness complications and poorer outcome. Methodologically sound studies investigating treatment approaches for patients with these disorders are rare, although recommendations for integrated and comprehensive treatment programs abound. This study investigates the relative benefit of adding an integrated psychological and psychosocial treatment program to routine psychiatric care for patients with schizophrenia and substance use disorders. METHOD: The authors conducted a randomized, single-blind controlled comparison of routine care with a program of routine care integrated with motivational interviewing, cognitive behavior therapy, and family or caregiver intervention. RESULTS: The integrated treatment program resulted in significantly greater improvement in patients' general functioning than routine care alone at the end of treatment and 12 months after the beginning of the study. Other benefits of the program included a reduction in positive symptoms and in symptom exacerbations and an increase in the percent of days of abstinence from drugs or alcohol over the 12-month period from baseline to follow-up. CONCLUSIONS: These findings demonstrate the effectiveness of a program of routine care integrated with motivational interviewing, cognitive behavior therapy, and family intervention over routine psychiatric care alone for patients with comorbid schizophrenia and alcohol or drug abuse or dependence.