Validity study of the K6 scale as a measure of moderate mental distress based on mental health treatment need and utilization

The widely-used Kessler K6 non-specific distress scale screens for severe mental illness defined as a K6 score ≥ 13, estimated to afflict about 6% of US adults. The K6, as currently used, fails to capture individuals struggling with more moderate mental distress that nonetheless warrants mental health intervention. The current study determined a cutoff criterion on the K6 scale indicative of moderate mental distress based on mental health treatment need and assessed the validity of this criterion by comparing participants with identified moderate and severe mental distress on relevant clinical, impairment, and risk behavior measures. Data were analyzed from 50,880 adult participants in the 2007 California Health Interview Survey. Receiver operating characteristic curve analysis identified K6 ≥ 5 as the optimal lower threshold cut-point indicative of moderate mental distress. Based on the K6, 8.6% of California adults had serious mental distress and another 27.9% had moderate mental distress. Correlates of moderate and serious mental distress were similar. Respondents with moderate mental distress had rates of mental health care utilization, impairment, substance use and other risks lower than respondents with serious mental distress and greater than respondents with none/low mental distress. The findings support expanded use and analysis of the K6 scale in quantifying and examining correlates of mental distress at a moderate, yet still clinically relevant, level.     

Changing patterns of mental health care in Greece (1984–1996)

Greece joined the European Community in 1981 and, three years later, the Commission of the European Communities provided financial and technical assistance under EEC Regulation 815/84 for the modernisation of the traditional psychiatric care system, with the emphasis on decentralisation of mental health services and the development of community-based services, as well as on deinstutionalization of long-stay patients and improvement of conditions in public mental hospitals. Over the last 11 years, the implementation of the EEC Reg. 815/84 programme contributed to a significant shift towards extramural care and rehabilitation. The role of the large mental hospitals has gradually been diminished and a large number of long-stay patients have been deinstitutionalised. It is commonly accepted that the EEC-funded psychiatric reform programme, despite inadequacies and constraints, had an impact on the changing mental health scene in Greece.     

Expanding the geriatric mental health workforce through utilization of non-licensed providers

Objectives: We evaluate policy and practice strategies for bolstering the geriatric mental healthcare workforce and describe costs and considerations of implementing one approach.

Method: Narrative overview of the literature and policy retrieved from searches of databases, hand searches, and authoritative texts. We identified three proposed strategies to increase the geriatric mental healthcare workforce: (1) production of more geriatric mental health providers; (2) team-based care; and (3) non-licensed providers. We evaluate each in terms of challenges and potential and provide estimates of costs, policy, and practice considerations for training, employing, and supervising non-licensed mental health providers.

Results: Use of non-licensed providers is key to reforms needed to allow a more older adults to access necessary mental healthcare. Licensed and non-licensed providers have achieved similar improvements for generalized anxiety disorder among patients, although non-licensed providers did so at a lower cost.

Conclusion: Supervised non-licensed providers can extend the reach of licensed providers for specific mental health conditions, resulting in lower costs and increased number of patients treated. Although several barriers to implementation exist, policy and infrastructure changes that may support this type of care delivery model are emerging from reforms in financing and associated delivery initiatives created by the Affordable Care Act.     

Norms for mental health services in South Africa

Background In the aftermath of apartheid, South Africa has inherited a fragmented, under-resourced and inequitable public sector mental health service. Attempts are being made to reform mental health services, in keeping with new health policy, which proposes the downscaling of psychiatric institutions and the development of community-based services. This study set out to develop a set of service norms for the care of people with severe psychiatric conditions (SPC) in South Africa, to assist the implementation of the new policy. Methods A national situation analysis of current public sector mental health services was conducted. A model was developed for estimating the mental health service resource needs of people with SPC. Following consultation with provincial stakeholders, a set of service norms were developed taking into account national indicators from the situation analysis (as a baseline level) and proposals of the model (as a target level). Results The study recommends an increase in the number of acute psychiatric beds in general hospitals; development of community-based residential care; redistribution of staff from hospital to community services, particularly in rural areas; and the development of information systems to monitor the transitions to community-based care. Conclusions The norms proposals presented in this study express mental health service needs in terms of quantifiable service resource and utilisation levels. In doing so, the study attempts to make explicit the assumptions and values on which planning is based.     

Determinants of self-reported mental health and utilization of mental health services in Canada

Research evidence suggests that the prevalence of mental health conditions in Canada has increased while a considerable percentage of people with a mental health issue do not seek professional mental health services. Weighted logistic regression models were used to determine whether age, sex, income, and education predict the self-reported mental health status of Canadians and their odds of utilizing mental health services. This study found clear disparities in reporting mental health and utilization of mental health services. Young adults (aged 25 to 44) have 1.4 times (95% CI: 1.3 to 1.6 times) higher odds of reporting poorer mental health status than seniors (aged 65 or older). Females are 2.7 times (95% CI: 2.3 to 3.1 times) more likely to utilize mental services than males. The lowest income group (<$15,000) has 2.2 times (95% CI: 1.9 to 2.4 times) higher odds of rating poorer mental health status than the highest income group (>$80,000). The least educated group (<high school education) has 1.5 times (95% CI: 1.3 to 1.6 times) higher odds of reporting poorer mental health status than the highest educated group (post-secondary education). However, the highest educated group is 1.6 times (95% CI: 1.3 to 2.0 times) more likely to utilize mental health services than the least educated group. Even in a country that has a universal health insurance system such as Canada, disparities and inequities associated with mental health burden and health care utilization persist, specifically among groups with lower education, lower income, and males.     

Patterns of mental health service utilization in a general hospital and outpatient mental health facilities

Purpose Mental health is one of the priorities of the European Commission. Studies of the use and cost of mental health facilities are needed in order to improve the planning and efficiey of mental health resources. We analyze the patterns of mental health service use in multiple clinical settings to identify factors associated with high cost. Subjects and methods 22,859 patients received psychiatric care in the catchment area of a Spanish hospital (2000–2004). They had 365,262 psychiatric consultations in multiple settings. Two groups were selected that generated 80% of total costs: the medium cost group (N = 4,212; 50% of costs), and the high cost group (N = 236; 30% of costs). Statistical analyses were performed using univariate and multivariate techniques. Significant variables in univariate analyses were introduced as independent variables in a logistic regression analysis using “high cost” (>7,263$) as dependent variable. Results Costs were not evenly distributed throughout the sample. 19.4% of patients generated 80% of costs. The variables associated with high cost were: age group 1 (0–14 years) at the first evaluation, permanent disability, and ICD-10 diagnoses: Organic, including symptomatic, mental disorders; Mental and behavioural disorders due to psychoactive substance use; Schizophrenia, schizotypal and delusional disorders; Behavioural syndromes associated with physiological disturbances and physical factors; External causes of morbidity and mortality; and Factors influencing health status and contact with health services. Discussion Mental healthcare costs were not evenly distributed throughout the patient population. The highest costs are associated with early onset of the mental disorder, permanent disability, organic mental disorders, substance-related disorders, psychotic disorders, and external factors that influence the health status and contact with health services or cause morbidity and mortality. Conclusion Variables related to psychiatric diagnoses and sociodemographic factors have influence on the cost of mental healthcare.     

Making progress in mental health policy in conservative times: one step at a time

Progress in mental health services has been made incrementally in a sequence of policy steps. In recent years, in spite of political conservatism, progressive changes have advanced new principles of service delivery. Reports from the surgeon general and the President's New Freedom Commission on Mental Health advanced these principles, including recovery and evidence-based practices. Both of these high-level reports were influenced by the findings of the Schizophrenia Patient Outcomes Research Team (PORT). The Schizophrenia PORT established the effectiveness of mental health treatments and supports, which provided a scientific foundation for the optimistic focus on recovery and its expectation of improved outcomes for individuals with severe mental disorders. The PORT study also established the gap between treatment recommendations and actual services. Concern about this gap has motivated efforts to transform services by implementing evidence-based practices. Advances in broad mental health and social policy, coupled with continued advances in science, have the potential to improve the care of individuals who experience severe mental disorders, such as schizophrenia.     

Interdisciplinary research framework for multisectoral mental health policy development

This paper proposes an interdisciplinary research framework for developing mental health policy in countries where a multisectoral approach to population mental health is not yet on the policy agenda. The proposed mental health policy research framework contains two structural elements: research on the policy content and policy process dimensions. The content dimension defines mental health policy as being a multisectoral policy encompassing positive mental health for all, the prevention and treatment of mental disorders, and the social and human rights consequences of poor mental health. The process dimension is based on the cyclical model of policy processes as described by Kingdon’s theory of agenda-setting and Rochefort’s analysis of the factors which affect mental health policy-making. The framework presents an innovative approach to researching mental health policy, bringing a more interdisciplinary focus and an explicit emphasis on policy-making.     

Prevalence of depression among patients seen in community health centres and community mental health centres

Depression is a common disorder in the general population. However, its prevalence among patients attending various health-care facilities is less well known. There have been very few Finnish studies of this topic. The Tampere Depression Project (TADEP) dealt with the prevalence of depression and factors associated with it in individuals seen in community health centres (CHC) and in psychiatric-service (PS) patients. The diagnosis of depression was based on a standardized Present State Examination interview and a DSM-III-R assessment, carried out on 436 CHC patients and 428 PS patients. The severity of depression was assessed using the Hamilton Rating Scale of Depression. About 10% of CHC patients and 50% of PS patients suffered from clinical depression. In addition to these, some depressive symptoms were displayed by just under 10% of subjects. Similar prevalence rates were obtained by the various methods used. The 1–year prevalence rate of clinical depression was 20% for the CHC patients and almost 60% for the PS patients. Mild depression represented the largest group. In the CHC group, depression was found more often in middle-aged and widowed subjects and in patients with a lower educational level and blue-collar workers than in others. In the PS group, depression was found more often in women, the oldest subjects and the widowed than in others.     

Developing mental health services in Nigeria

This grass-roots level mental health awareness programme considerably increased use of community-based mental health services in a part of Nigeria where knowledge about treatability of mental illness was limited. The benefits of the programme were sustained for a significant period after the initial awareness programme. In order for attitude changes to be reinforced, similar awareness programmes must be repeated at regular intervals.     

Use of mental health resources in the treatment of adult out-patients with no diagnosable mental disorders

Comparisons of adult out-patients diagnosed with V-code conditions and those with mental disorders were conducted in a number of areas related to patient and treatment characteristics. Data were collected from three community mental health centres over a 6-year period (n= 7220) in a semirural region of Nova Scotia, Canada. V-code patients represented approximately one-third of the psychiatric out-patient admissions in these centres. Comparisons of the two patient groups indicated that V-code patients were of a higher socio-economic status than patients diagnosed with mental disorders. The difficulties of patients with V-code conditions appeared to be less severe than those of patients with mental disorders. However, patients with V-code conditions consumed comparable treatment resources to patients with mental disorders. Both groups of patients were evaluated by their therapists as experiencing similar levels of improvement during the course of treatment. The implications of these findings for more efficient use of resources in community mental health centres are discussed.     

From community mental health services to specialized psychiatry: the effects of a change in policy on patient accessibility and care utilization

In 1975, a community mental health (CMH) centre with most of its resources channelled to outpatient services was set up in a defined catchment area of 75,000 inhabitants near Stockholm. In 1981, the CMH centre was allocated 3 inpatient wards of its own. An outpatient unit to treat long-term psychotic patients was also built up from existing resources. Emergency cases were directed to the primary health care services or to the emergency department of a hospital. During the same period, the number of doctors in the area's primary health care services increased fourfold. The social, demographic and diagnostic composition of the patient population and its utilization of in- and outpatient care in connection with these organizational changes are described. The population of the cathment area increased by 12.5% and the patient population decreased by 40%. The decrease was particularly great among first-time visitors (-54%), patients from lower social groups (-53%) and those with crisis diagnosis (-71%). The number of patients with psychoses increased (+26%). Outpatient visits and hospital utilization increased by one third. The number of compulsory admissions increased by 20% (still being far below the mean number in Stockholm). The decrease in the patient population is attributed to the reduction in accessibility to the CMH centre at a time when primary care services in the area were undergoing a sizeable expansion. The increased care utilization is the result of an internal redistribution of resources in favour of resource-demanding, long-term psychotic patients.     

上海市社区精神卫生服务投入调查

目的：探讨上海市社区精神卫生服务投入状况.方法：分别从上海市中心城区、准中心城区、周边城区和农村4个部分中各抽取一个区县,采用定性和定量的方法进行实地调研.结果：目前上海市社区精神卫生服务投入存在的问题：投入严重不足;投入结构不合理;投入政策尚未真正落实.结论：对策为：健全和落实精神卫生法律、法规和政策;改革投入体制和机制,可通过增加和调整精神卫生工作投入、变政府财政直接投入为政府购买、建立科学的绩效评估标准等方法来实现;构建重性精神疾病患者免费服药体系.     

Need for mental health services of the adult population in Finland: results from the Mini Finland Health Survey

This article presents results on the self-perceived and clinically assessed met and unmet need for mental health care as indicated by the Mini Finland Health Survey, an extensive epidemiological study of the Finnish population aged 30 years or over. The prevalence of self-perceived definite or probable need for care was 6.4% in the men and 8.2% in the women. The corresponding clinical assessments were 14.5% in the men and 19.6% in the women. The need for specialist care was 7.5% in the men and 9.6% in the women. The need was greatest in the middle-aged groups. About 60% of persons in need of care were not receiving any treatment. Half of the treatment received was assessed as inadequate. The treatment situation was much better for psychoses than for neuroses, but it varied little between the different parts of the country.     

Mental health care in Germany

Germany turned towards community-based mental health care in the mid seventies, during a general climate of social and political reform. The continuing deinstitutionalisation process and the implementation of community mental health services was considerably affected by the reunification of East and West Germany in 1990, which required dramatic changes in the structure and quality of the mental health care system of the former German Democratic Republic (GDR). Overall, German mental health care is organised as a subsidiary system, where planning and regulating mental health care is the responsibility of the 16 federal states. So German mental health care provision is spread among many sectors and characterised by considerable regional differences. A key characteristic is the particularly wide gap between inpatient and outpatient services, which are funded separately and staffed by different teams. In 2003 the total number of psychiatric beds was a mere two thirds of the overall bed capacity in 1991, the first year as a re-unified Germany, when psychiatric beds in East and West Germany totalled 80,275. From 1970 onwards the number of psychiatric beds was cut by roughly half. So the momentum of the reform has been strong enough to assimilate the completely different mental health care system of the former German Democratic Republic and, in the course of a decade, to re-structure mental health services for an additional 17–18 million new inhabitants. In an ongoing struggle to adapt to changing administrative set-ups, legal frameworks, and financial constraints, psychiatry in Germany in currently facing specific problems and is seriously challenged to defend to considerable achievements of the past. A major obstacle to achieving this aim lies in the fragmented system of mental health care provision and mental health care funding.     

Relationship between parental psychopathology,parenting strategies and child mental health

Background Parental and child psychiatric disorders have been found to be associated, and this association can be mediated by other psychosocial variables, including parenting attitudes and strategies. As most previous studies included clinical samples, the purpose of this study was to establish the relationship between parental psychopathology and parenting strategies with child psychiatric disorders in a national survey population. Methods The sample included 10,438 children of 5–15 years and their parents, from representative UK households. Families were assessed on child psychiatric diagnosis, parental psychopathology, family functioning, and socioeconomic status. Parenting strategies included using rewards, physical and non-physical punishments towards their child. Findings Parental psychopathology scores (OR 3.99, 95% CI 3.13–5.09) and non-physical punishment (OR 1.50, 95% CI 1.27–1.76) were associated with child psychiatric disorders. This association was particularly prominent among children with conduct disorders: parental psychopathology scores (OR 3.13, 95% CI 2.28–4.30) and non-physical punishment (OR 3.19, 95% CI 2.55–3.97). Absence of child psychopathology was associated with a combination of rewarding and non-punitive parenting strategies. Conclusions Although parents in the general population may be using less physical strategies than in the past, non-physical punishment is strongly related to mental health problems in children. Enhancement of positive parenting through universal and targeted interventions is an important preventive strategy.     

Personality correlates of outpatient mental health service utilization

OBJECTIVE: The present paper investigated the relationships between several personality constructs and the use of outpatient mental health services. METHODS: Respondents were from the National Comorbidity Survey (NCS) Part II data set and included those with a past-year mood, anxiety, alcohol/substance use disorder (n=1750). Bivariate logistic regressions were used to examine associations between participants' self-reports of personality traits and outpatient mental health service utilization. Similar multivariate analyses were used to investigate these associations after adjusting for sociodemographic variables and the presence of psychiatric disorders and their comorbidity. RESULTS: The bivariate and multivariate analyses revealed significant positive associations between outpatient mental health service utilization and both Powerful Others Locus of Control and Self-criticism. CONCLUSIONS: These findings suggest that personality traits may play a role in treatment seeking behaviors for mental health problems over and above the presence of psychiatric disorders alone. The assessment of relevant personality constructs has the potential to inform and improve treatment outreach efforts.