Improving mental health service responses to domestic violence and abuse

Abstract

Domestic violence and abuse is a considerable international public health problem, which is associated with mental disorders in both women and men. Nevertheless, victimization and perpetration remain undetected by mental health services. This paper reviews the evidence on mental health service responses to domestic violence, including identifying, referring, and providing care for people experiencing or perpetrating violence. The review highlights the need for mental health services to improve rates of identification and responses to domestic violence and abuse, through the provision of specific training on domestic violence and abuse, the implementation of clear information sharing protocols and evidence-based interventions, and the establishment of care referral pathways. This review also highlights the need for further research into mental health service users who perpetrate domestic violence and abuse.     

Medical illness burden is associated with greater PTSD service utilization in a nationally representative survey

ObjectivePosttraumatic stress disorder (PTSD) is associated with higher rates of many medical conditions and higher use of medical health care services. Growing evidence suggests that comorbid medical illness in PTSD may in turn be associated with greater use of mental health treatment. However, no study to date has examined the impact of cumulative medical illness burden on PTSD service utilization.MethodData come from the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions. PTSD was assessed via structured interview, and cumulative medical illness burden was assessed via a survey of medical conditions. Logistic regression modeling examined associations between cumulative medical illness burden and odds of receiving PTSD treatment.ResultsIn the final sample of 1599 individuals with current PTSD, controlling for demographic characteristics, insurance status, psychiatric comorbidity and PTSD symptom count, higher levels of past-year medical illness were associated with increased odds of receiving past-year treatment for PTSD (odds ratio=1.10, 95% confidence interval=1.01–1.20, P= .029).ConclusionsGreater levels of medical illness are associated with increased odds of PTSD service utilization. Greater medical comorbidity may increase the need for PTSD care by exacerbating symptoms or increase contact with medical services promoting PTSD detection and treatment.     

Suicide in the homeless within 12 months of contact with mental health services

Background Suicide prevention is a health service priority. Homeless mental health patients present a challenge to services because of their complex health and social needs. Aims To establish the numbers of homeless patients in contact with services who die by suicide; to describe their suicide methods and their social and clinical characteristics including aspects of clinical care. Method A national clinical survey based on a 4-year (1996–2000) sample of people in England and Wales who died by suicide. Detailed data were collected on those who had been in contact with mental health services in the year before death. Results A total of 131 individuals who died by suicide were reported to have been homeless at the time of death—3% of all suicides by psychiatric patients, over 30 per year. Hanging was the most common cause of death. The most frequent diagnosis was schizophrenia. Around half were in-patients at the time of death. Social and clinical risk factors for suicide were common, including drug and alcohol misuse, and recent suicidal ideas and behaviour. Despite this, their clinical care was characterised by disengagement from services as a result of missed contacts, self-discharge, lack of follow-up and lack of key worker. Conclusions In order to reduce the number of deaths by suicide in those who are homeless and mentally ill, improvements in in-patient safety and engagement in the community are needed. This may be achieved through assertive community treatment, dual diagnosis services, and dedicated community mental health teams.     

The prediction of mental health service use in residential care

The purpose of this study was to characterize the clinical and psychosocial factors of residents living in psychiatric nursing homes, assess residents' levels of mental health service utilization, and examine the factors that predict the utilization of mental health services. Data were collected from 200 randomly selected residents with schizophrenia living in four intermediate care facilities. Fewer than 60% of residents received mental health services beyond medication and nearly one-half of the residents were readmitted to the hospital in the course of a year. Family contact and involvement in activities were associated with mental health service utilization. Hospital readmission was predicted, not by substance use, but rather by not using substances. There is a growing need among service providers to better identify relevant factors that are important in treatment planning and service delivery. Attention to these issues may impact treatment provision and outcomes for persons with schizophrenia and their families.     

A Scoping Study of a Tertiary Intellectual Disability Mental Health Service: A Family Member and Support Person Perspective

ABSTRACT

Introduction: People with intellectual disability (ID) experience barriers in accessing mental health care. Recommendations have been made to implement specialist intellectual disability mental health (IDMH) services in Australia. However, there is limited evidence to inform service development.

Method: Family members and support persons of people with ID (n = 42) completed an on-line survey about support for, and operation of, a tertiary IDMH service in New South Wales, Australia.

Results: Participants agreed that a tertiary IDMH service would assist in meeting the needs of people with ID. Key service features included that it be delivered within the public health system, by psychiatrists and psychologists, provide face-to-face clinical contact and advice. Key service areas included behaviors of concern, self-harm, assessments, and interventions.

Conclusion: These findings suggest support for a tertiary IDMH service and how it could be delivered. Further research is required from the perspective of people with ID, mental health staff, and clinical experts.     

Carers and community mental health services

Background There is a growing appreciation of the role and needs of carers for people with mental health problems. Carers are a diverse group, including partners, relatives and friends who are seen as such by service users. Methods Sixty-four carers of people with severe mental health problems served by four different mental health care providers were interviewed using the Experiences of Care-giving Inventory. The districts were selected to differentiate services that are targeted at more severely impaired users from those that include a wider spectrum, and to contrast services that have greater integration between health and social care providers with those whose health and social care agencies operate relatively discretely. Results In the two districts where service users had more severe mental health problems, carers worried more about negative symptoms and thought less about good aspects of the caring relationship. In the two districts where health and social services worked more closely together, carers worried significantly less about the need to back up services. Conclusions These findings suggest that service organisation can affect carers, in particular that integration between health and social care for people with mental health problems may benefit carers in ways that were hitherto unproven. They highlight the needs of carers for younger people. They show that the ECI is a useful instrument in measuring the impact of caring for people with severe mental health problems. Accepted: 19 September 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.     

Dangerous or merely ‘difficult’? The new population of forensic mental hospitals

BackgroundDuring recent decades, there has been a substantial increase in admissions to forensic mental hospitals in several European countries. It is not known if reforms implemented in mental health policies and practices are responsible for this development.ObjectiveOur study examined the development of mental health care in Austria and the incidence and prevalence of mentally disordered offenders judged not guilty by reason of insanity (NGRI).MethodsWe analysed data on service provision and data from criminal statistics between 1970 and 2008 from several national sources.ResultsDuring the first decade when reforms to mental health practice were implemented, the incidence and prevalence of offenders judged NGRI remained unchanged, despite a reduction of mental hospital beds by nearly 50% and little outpatient care. Surprisingly, the enormous increase in admissions to forensic inpatient treatment began in Austria only after community mental health services were rolled out across the country in the 1990s. This increase was primarily due to admissions of patients who had committed less severe offences, while rates of those who had committed homicide remained unchanged.ConclusionOur results cannot be explained by details of the reforms such as the downsizing of mental hospitals or a lack of outpatient facilities, nor by changes to criminal sentencing. Rather, the results provide evidence of an increasingly inadequate provision of comprehensive care for “difficult” but not extremely dangerous psychotic patients living in the community. This may result from the attitudes of mental health professionals who have become less inclined to integrate aggressive behaviour into their understanding of psychosis. As a consequence, increasing numbers of “difficult” patients end up in forensic psychiatric institutions. This development, which can be observed in nearly all European countries, raises concerns with regard to efforts to destigmatize both patients and psychiatry.     

Does neuroticism explain variations in care service use for mental health problems in the general population?

AbstractBackground Little is known about the role of personality characteristics in service utilisation for mental health problems. We investigate whether neuroticism: 1) predicts the use of primary and specialised care services for mental health problems, independently of whether a person has an emotional disorder; and 2) modifies any association between emotional disorder and service use.Methods Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS) a prospective cohort study in the general population aged 18–64. Neuroticism was recorded at baseline, and emotional disorder and service use at 12-month follow-up, in a representative sample (N=7076), using the Composite International Diagnostic Interview.Results People with high neuroticism were more likely to receive care in the specialised mental health sector, and after entry to care they made more visits to the services, whether or not they had an emotional disorder. If they had an emotional disorder, their likelihood of receiving specialised mental health care showed an additional increase. Neuroticism also predicted the use of primary care for mental health problems, but greater numbers of visits were made only by clients with both high neuroticism and an emotional disorder.Conclusions It would be useful to incorporate personality characteristics into models to understand variations in service utilisation for mental health problems. The findings suggest that professionals would be wise to focus not just on their clients’ emotional problems and disorders, but also on strengthening their problem-solving abilities through approaches like cognitive behavioural therapy.     

Collaboration between general practitioners and mental health care professionals: a qualitative study

Background

Collaboration between general practice and mental health care has been recognised as necessary to provide good quality healthcare services to people with mental health problems. Several studies indicate that collaboration often is poor, with the result that patient' needs for coordinated services are not sufficiently met, and that resources are inefficiently used. An increasing number of mental health care workers should improve mental health services, but may complicate collaboration and coordination between mental health workers and other professionals in the treatment chain. The aim of this qualitative study is to investigate strengths and weaknesses in today's collaboration, and to suggest improvements in the interaction between General Practitioners (GPs) and specialised mental health service.

Methods

This paper presents a qualitative focus group study with data drawn from six groups and eight group sessions with 28 health professionals (10 GPs, 12 nurses, and 6 physicians doing post-doctoral training in psychiatry), all working in the same region and assumed to make professional contact with each other.

Results

GPs and mental health professionals shared each others expressions of strengths, weaknesses and suggestions for improvement in today's collaboration. Strengths in today's collaboration were related to common consultations between GPs and mental health professionals, and when GPs were able to receive advice about diagnostic treatment dilemmas. Weaknesses were related to the GPs' possibility to meet mental health professionals, and lack of mutual knowledge in mental health services. The results describe experiences and importance of interpersonal knowledge, mutual accessibility and familiarity with existing systems and resources. There is an agreement between GPs and mental health professionals that services will improve with shared knowledge about patients through systematic collaborative services, direct cell-phone lines to mental health professionals and allocated times for telephone consultation.

Conclusions

GPs and mental health professionals experience collaboration as important. GPs are the gate-keepers to specialised health care, and lack of collaboration seems to create problems for GPs, mental health professionals, and for the patients. Suggestions for improvement included identification of situations that could increase mutual knowledge, and make it easier for GPs to reach the right mental health care professional when needed.     

Culturally competent health care for sex workers: an examination of myths that stigmatize sex work and hinder access to care

Abstract

Sex workers are individuals who offer sexual services in exchange for compensation (i.e. money, goods, or other services). Within the United States, the full-service sex work (FSSW) industry generates 14 billion dollars annually there are estimated to be 1–2 million FSSWers, though experts believe this number to be an underestimate. Many FSSWers face the possibility of violence, legal involvement, and social stigmatization. As a result, this population experiences increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to benefit from receiving mental health care however a constellation of individual, organizational, and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally competent mental health care can help empower this traditionally marginalized population. The objective of the current review is to (1) educate clinicians on sex work and describe the unique struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address five common myths about FSSW that perpetuate stigma, and (3) advance a research and culturally competent clinical training agenda that can optimize mental health care engagement and utilization within the sex work community.     

Primary Care and Access to Mental Health Consultations among Immigrants and Nonimmigrants with Mood or Anxiety Disorders: Soins de première ligne et accès aux consultations en santé mentale chez les immigrants et les non-immigrants souffrant de troubles de l’humeur ou anxieux

Objective:To examine the association between usual place of primary care and mental health consultation among those with self-reported mood or anxiety disorders. We also describe access to mental health services among people who are recent immigrants, longer-term immigrants, and nonimmigrants and determine whether the association with place of primary care differs by immigration group.Methods:We used data from the Canadian Community Health Survey (2015 to 2016) to identify a representative sample of individuals with self-reported mood or anxiety disorders. We used logistic regression, with models stratified by immigration group (recent, longer-term, nonimmigrant), to examine the association between usual place of primary care and receiving a mental health consultation in the previous 12 months.Results:Higher percentages of recent and longer-term immigrants see a doctor in solo practice, and a higher percentage of recent immigrants use walk-in clinics as a usual place of care. Compared with people whose usual place of care was a community health center or interdisciplinary team, adjusted odds of a mental health consultation were significantly lower for people whose usual place of care was a solo practice doctor’s office (AOR = 0.71; 95% CI, 0.62 to 0.82), a walk-in clinic (AOR = 0.75; 95% CI, 0.66 to 0.85), outpatient clinic/other place (AOR = 0.72 95% CI, 0.59 to 0.88), and lowest among people reporting no usual place other than the emergency room (AOR = 0.59; 95% CI, 0.51 to 0.67). Differences in access to mental health consultations by usual place of primary care were greatest among immigrants, especially recent immigrants.Conclusions:People with mood or anxiety disorders who have access to team-based primary care are more likely to report mental health consultations, and this is especially true for immigrants. Expanded access to team-based primary health care may help reduce barriers to mental health services, especially among immigrants.     

The Psychotherapeutic Service Delivery System

We can understand the relevance of psychotherapy research for clinical practice only by considering the broader context of the psychotherapy service delivery system. Epidemiologic studies of the incidence and prevalence of emotional disturbance provide estimates of the need for services; surveys of providers and their practice patterns yield estimates of available resources to meet those needs; and studies of patient characteristics and patterns of psychotherapy utilization identify the constituencies served by the psychotherapy delivery system. From these data we know that each person in need of mental health services has available no more than an average of three treatment sessions from a mental health professional in any given year. Despite the fact that a small proportion of such individuals actually seek service, each such individual who consults the speciality mental health sector has available no more than an average of 10 treatment sessions. The most needy, particularly those lacking in education, are least likely to receive treatment in the psychotherapeutic service delivery system. Further, we argue for a clearer focus on service episodes and psychotherapy utilization through the tracking of the mental health “careers” of patients.     

Improving mental health pathways and care for adolescents in transition to adult services (IMPACT): a retrospective case note review of social and clinical determinants of transition

Background

Poor transitions to adult care from child and adolescent mental health services may increase the risk of disengagement and long-term negative outcomes. However, studies of transitions in mental health care are commonly difficult to administer and little is known about the determinants of successful transition. The persistence of health inequalities related to access, care, and outcome is now well accepted including the inverse care law which suggests that those most in need of services may be the least likely to obtain them. We sought to examine the pathways and determinants of transition, including the role of social class.

Method

A retrospective systematic examination of electronic records and case notes of young people eligible to transition to adult care over a 4-year period across five Health and Social Care NHS Trusts in Northern Ireland.

Results

We identified 373 service users eligible for transition. While a high proportion of eligible patients made the transition to adult services, very few received an optimal transition process and many dropped out of services or subsequently disengaged. Clinical factors, rather than social class, appear to be more influential in the transition pathway. However, those not in employment, education or training (NEET) were more likely (OR 3.04: 95% CI 1.34, 6.91) to have been referred to Adult Mental Health Services (AMHS), as were those with a risk assessment or diagnosis (OR 4.89: 2.45, 9.80 and OR 3.36: 1.78, 6.34), respectively.

Conclusions

Despite the importance of a smoother transition to adult services, surprisingly, few patients experience this. There is a need for stronger standardised policies and guidelines to ensure optimal transitional care to AMHS. The barriers between different arms of psychiatry appear to persist. Joint working and shared arrangements between child and adolescent and adult mental health services should be fostered.

     

Self-Reliance,Mental Health Need,and the Use of Mental Healthcare Among Island Puerto Ricans

This paper examines the relationship between self-reliance (preference to solve emotional problems on one's own) and 5 mental healthcare utilization outcomes for Puerto Ricans living in low-income areas. A random probability community sample of noninstitutionalized Puerto Ricans, ages 18–69, living in low-income areas of the island were selected and interviewed in 1992–93 and 1993–94. A series of logistic regression models tested the association between self-reliance and 5 mental health utilization measures, after adjusting for covariates measuring predisposing, enabling, need and barrier factors: any use of mental health services, any use of general health services for mental healthcare, any use of specialty care, use of psychotropic medications, and retention in mental healthcare. Self-reliance was found to be negatively associated with all 5 dependent service utilization measures. Those with a positive self-reliant attitude were 40% less likely to use care on any of the 5 outcome measures. An interaction was also observed between definite need for mental healthcare and having a self-reliant attitude when predicting mental health service use. Definite needers with a self-reliant attitude were 54%–58% less likely to use mental health services compared with definite needers who did not have a self-reliant attitude. Further, decreases in self-reliant attitude over the two data collection periods were associated with increases in mental health service use. Our findings suggest that self-reliance is a significant and robust predictor of mental healthcare utilization among Puerto Ricans living in low-income areas of the island.     

Providing continuity of care for people with severe mental illness

Abstract.Background: Service users and providers have stated that delivering continuity of care to people with severe mental illness should be a service priority. We reviewed literature on continuity of care for people with severe mental illness (SMI) in order to identify factors that promote and impede this process.Method: A systematic search of electronic databases, sources of grey literature and contact with experts in the field. Two reviewers independently rated all papers for possible inclusion. Data extracted from papers formed the basis of a narrative review.Results: We identified 435 papers on continuity of care, of which 60 addressed the study aims. Most did not define continuity of care. Available evidence suggests that assertive community treatment, case management, community mental health teams and crisis intervention reduce the likelihood of patients dropping out of contact with services.Conclusions: Evidence on which to base services that enhance continuity of care for people with SMI is limited because previous research has often failed to define continuity of care or consider the patients perspective.     

Service Contacts Among the Children Participating in the British Child and Adolescent Mental Health Surveys

Method:  A third of the children from the 1999 British Child and Adolescent Mental Health Survey were followed up over 3 years. Parents provided summary information on service contacts for emotional, behavioural and concentration difficulties, with more detailed information being obtained by telephone interview for selected subgroups.
Results:  Having a psychiatric disorder predicted substantially increased contact with social services, special educational needs resources, the youth justice system and mental health services (district CAMHS and tier four, but not tier two). Of those children with psychiatric disorders, 58% had been in contact with at least one of these services for help with emotional, behavioural or concentration difficulties, including 23% who had been in contact with mental health services.
Conclusions:  British children attend a wide variety of services for help with emotional, behavioural and concentration difficulties. The proportion seeing specialist mental health services is higher than that generally reported in the research literature.     

Previous help sought by patients presenting to mental health services in Kumasi,Ghana

Abstract.Objective: There are four services providing mental health care to the people of Kumasi, Ghana. This study aimed to identify previous help sought by patients presenting to the services for an initial assessment.Method: New patients presenting to each of the four services were asked about distance travelled, previous help sought and time since symptoms of illness started. Staff also recorded basic demographic details and clinical diagnoses.Results: Of the 322 patients presenting to the four sites,only 6% had seen a traditional healer whereas 14% had seen a pastor before presentation. There was a greater delay in presenting to that service if the patient had seen a traditional healer or pastor. Many patients had previously used one of the other mental health units in Kumasi.Conclusion: It is possible that fewer patients with mental health problems present to traditional healers in modern, urban Africa compared to rural areas. More patients consult with pastors than traditional healers and liaison with these groups may improve mental health care. It is important to maintain liaison between the four services as patients presenting to one clinic may have presented previously to another local clinic.     

The role of local inpatient psychiatric units and general practitioner on continuity of care in Northern Norway: A case‐register study

ObjectivesThe general practitioners'' (GP) role in the care of mental health patients has received increased attention. The literature underlines the need for integration of primary and specialist services, but cross‐boundary continuity for patients with severe conditions may be particularly poor. The aim of this study was to analyze the collaboration between primary care and different models of specialized psychiatric services for patients with severe conditions.MethodsWe compared a local and a centralized model of mental health care. Service utilization over a 5‐year period was studied.ResultsFindings suggest that a local institution‐based model of services positively affects the use of both GP and specialist outpatient care, with most inpatients utilizing both GP and specialist outpatient consultations. In the centralized model, a substantial proportion of inpatients only used GP outpatient care. Furthermore, inpatients that used both GP and specialist outpatient services received more of both services compared to those who did not enter specialist outpatient care at all.ConclusionLocal inpatient units may positively affect continuity of care and collaboration between general practitioners and specialist psychiatric services compared to more traditional hospital units, probably because better functional integration of services, better facilitation of clinical alliances/relationships, or a more network‐oriented treatment philosophy.