Needs not diagnosis: towards a more rational approach to community mental health resourcing in Britain

Met and Unmet Needs in an Inpatient Psychiatry Setting in Spain

PURPOSE

Patients with severe mental disorder have health and social needs that require care. The aim of the study was to determine the main areas of perceived needs among inpatients with severe mental disorders and to identify risk factors of the group of patients with the greatest unmet needs.

PATIENTS AND METHODS

A total of 150 patients with severe mental illness were assessed during admission prior to discharge from the hospital. Camberwell Assessment of Needs was used as evaluation measure, in addition to clinical status (The Brief Psychiatric Rating Scale), social functioning (Personal and Social Performance) and sociodemographic variables. A descriptive and a multivariate logistic regression analysis were used to analyse variables related to the group of patients with the highest number of unmet needs (≥3).

RESULTS

Mean number of needs was 7.93, being 4.61 the mean number of needs met and 3.32 the needs unmet. The highest proportion of unmet needs were intimate relationships (44.0%), company (40.7%) and daytime activities (38.7%). A relationship was also found between the presence of three or more unmet needs and the following variables: Brief Psychiatric Rating Scale score (p=0.004), Personal and Social Performance score (p = 0.013), marital status (p=0.018), employment status (p=0.009) and voluntary admission (p=0.032). The multivariate model explained 29.5% of the variance (Nagelkerke's R²: 0.295).

CONCLUSION

Treatments aimed at improving social relationships and daytime activities could be a good option for inpatients with many unmet needs.

Identifying profiles of need among psychiatric inpatients approaching discharge in New York City: a latent class analysis

PURPOSE

Understanding the needs of individuals transitioning to the community following a psychiatric hospitalization can inform community service planning. This study is among the first to examine the needs of a sample of psychiatric inpatients approaching discharge in a large urban area in the USA.

METHODS

Representative data were drawn from 1129 acutely hospitalized psychiatric inpatients from eight New York City hospitals. Descriptive statistics were used to estimate patient needs at discharge across nine domains: housing, employment, income, transportation, education, time use, social support, and help accessing medical and mental health care. Latent class analysis (LCA) was applied to identify subgroups of patients based on needs profiles. Multinomial logistic regression was used to investigate socio-demographic associations with class membership.

RESULTS

Respondents were most likely to have needs related to income (50.7%), housing (49.2%), and employment (48.7%). Results from the LCA suggested a five class solution of patient needs: three domain-specific classes whose members endorsed needs for 'housing and employment' (22.5%), 'social support and time use' (15.0%) and 'access to care' (6.4%) and two classes where overall member needs were high ('high needs,'18.4%) or low ('low needs,' 37.7%) across all needs. Compared to the 'low needs' class, members of the 'high needs' class had significantly greater odds of being black or Latino, male, uninsured, and parents of a child under 18 years.

CONCLUSION

Patients have unique profiles of need that are significantly associated with the socio-demographic characteristics. These findings may help practitioners and policymakers improve mental health services.

Does future resource input reflect need in first-episode psychosis: Examining the association between individual characteristics and 5-year costs

AIM

Coupling data on future resource consumption with baseline characteristics can provide vital information of future consumption patterns for newly diagnosed patients. This study tested whether higher need (as measured by severity of illness) and other baseline characteristics of newly diagnosed patients were associated with higher future service costs.

METHOD

Five hundred forty-seven patients between 18 and 45 years randomized to the OPUS trial was analysed in the study. Multiple regression analysis was applied to estimate the impact of the explanatory variables on mean total costs, which consisted of total health care costs and costs of supportive living facilities.

RESULTS

Lower age, higher level of symptoms (global assessment of functioning), alcohol or cannabis misuse, and being homeless were associated with higher total costs over 5 years, whereas sex, duration of untreated psychosis, and educational level did not show any impact on future resource consumption.

CONCLUSION

The association between future costs and severity of illness suggests that higher needs among patients were associated with higher resource input level. Our results also indicate that other factors than need might affect future costs, for example, parents who serve as advocates for young patients had impact on future health costs. We also found indications of potential barriers among patients with other citizenship in access to health-care services. The strength of the study is that resource data were extracted from official Danish registers and interviewers collected information on clinical characteristics. The results are likely to be context-specific but can be generalized to settings with similar treatment practices.

The New York City Mental Health Needs Assessment Study (MHNAS): Objectives, design, and methods

OBJECTIVES

This paper describes the objectives, design, and methods of the Mental Health Needs Assessment Study (MHNAS). The objective of the MHNAS was to assess the needs of individuals transitioning to the community following psychiatric hospitalization and again 3-5 months later to inform community service planning. Needs were defined broadly to include domains like housing, employment, treatment, and social support.

METHODS

The MHNAS used a 2-stage clustered sampling approach where the primary sampling units were hospitals and secondary sampling units were patients. The study included an in-person patient interview, an assessment of need from a key hospital worker, and a follow-up telephone interview 3-5 months after discharge.

RESULTS

One thousand one hundred twenty-nine patients from 8 randomly selected hospitals participated. The overall response rate was 54.3% with a cooperation rate of 71.8%. The sample was similar to the overall population of psychiatric patients with respect to several key demographics.

CONCLUSION

The MHNAS demonstrates the feasibility of conducting a needs assessment with a random sample of psychiatric inpatients in a large urban setting. Results from this study may improve community service planning to better meet individuals' needs, with the ultimate goal of reducing rehospitalization and promoting recovery.

Needs of Adolescents and Young Adults with Neurodevelopmental Disorders: Comparisons of Young People and Parent Perspectives

This study used the Camberwell Assessment of Need for adults with Developmental and Intellectual Disabilities (CANDID) to examine the social, physical health and mental health needs of 168 young people (aged 14-24 years) with neurodevelopmental disorders and compared young person and parent ratings of need. Agreement was poor in 21 out of 25 domains. Parents consistently reported higher levels of need than young people in the majority of domains although young people with ADHD reported significantly more needs in physical health, eyesight/hearing, seizures, other mental health problems and safety of others than their parents. Both parent and young person perspectives of needs are necessary to ensure that needs that are predictive of current or future poor outcomes are not missed.

Mental health care financing in Italy: current situation and perspectives

Through a review of the studies conducted on the analysis of the costs of the Italian mental health provision of care, this study aimed at describing the current financing system for mental health care in Italy. From the deinstitutionalization to the present days, Italian mental health care financing has evolved in line with both national plans and the actual European directives. The description of the current situation of mental health care financing in Italy can be useful to inform service planning and resource allocation, and to offer a wider European perspective.

A person-centred segmentation study in elderly care: towards efficient demand-driven care

Providing patients with more person-centred care without increasing costs is a key challenge in healthcare. A relevant but often ignored hindrance to delivering person-centred care is that the current segmentation of the population and the associated organization of healthcare supply are based on diseases. A person-centred segmentation, i.e., based on persons' own experienced difficulties in fulfilling needs, is an elementary but often overlooked first step in developing efficient demand-driven care. This paper describes a person-centred segmentation study of elderly, a large and increasing target group confronted with heterogeneous and often interrelated difficulties in their functioning. In twenty-five diverse healthcare and welfare organizations as well as elderly associations in the Netherlands, data were collected on the difficulties in biopsychosocial functioning experienced by 2019 older adults. Data were collected between March 2010 and January 2011 and sampling took place based on their (temporarily) living conditions. Factor Mixture Model was conducted to categorize the respondents into segments with relatively similar experienced difficulties concerning their functioning. First, the analyses show that older adults can be empirically categorized into five meaningful segments: feeling vital; difficulties with psychosocial coping; physical and mobility complaints; difficulties experienced in multiple domains; and feeling extremely frail. The categorization seems robust as it was replicated in two population-based samples in the Netherlands. The segmentation's usefulness is discussed and illustrated through an evaluation of the alignment between a segment's unfulfilled biopsychosocial needs and current healthcare utilization. The set of person-centred segmentation variables provides healthcare providers the option to perform a more comprehensive first triage step than only a disease-based one. The outcomes of this first step could guide a focused and, therefore, more efficient second triage step. On a local or regional level, this person-centred segmentation provides input information to policymakers and care providers for the demand-driven allocation of resources.

Multiple perspectives on mental health outcome: needs for care and service satisfaction assessed by staff, patients and family members

PURPOSE

Community-based mental health care requires the involvement of staff, patients, and their family members when both planning intervention programmes and evaluating mental health outcomes. The present study aimed to compare the perceptions of these three groups on two important subjective mental health outcome measures--needs for care and service satisfaction--to identify potential areas of discrepancy.

METHODS

The sample consisted of patients with a DSM diagnosis of psychosis and attending either outpatient or day centres operating in a community-based care system. Staff, patients and family members were assessed by using the CAN and the VSSS to evaluate, respectively, needs for care and service satisfaction. Kappa statistics were computed to assess agreement in the three groups.

RESULTS

Patients identified significantly fewer basic (e.g. daytime activities, food, accommodation) and functioning needs (e.g. self-care, looking after home, etc.) than staff or family members. Only fair levels of agreement were found in the three groups (average kappa was 0.48 for staff and patients, 0.54 for staff and family members, and 0.45 for patients and relatives), with patients and family members showing more areas of discrepancies in both needs and service satisfaction.

CONCLUSIONS

These findings provide further support for the idea that mental health services should routinely involve patients and their relatives when planning and evaluating psychiatric intervention and that this policy is a premise for developing a partnership care model.

Instruments for comprehensive needs assessment in individuals with cognitive complaints, mild cognitive impairment or dementia: a systematic review

OBJECTIVE

In recent years, it has become more common to complement the objective assessment of symptoms with an assessment of individual needs patterns that are created by the individual pattern of symptoms. However, little is known on needs patterns in individuals with subjective cognitive impairment, mild cognitive impairment and dementia. Thus, on the basis of an analysis of the development of needs in the course of cognitive decline, we provide an overview of the existing needs assessment instruments with respect to feasibility, validity and reliability.

METHOD

We conducted a literature search in PsycINFO and PubMed including all publications up to September 2009. We included needs assessment instruments for use in older individuals with mental or cognitive disorders and dementia.

RESULTS

We identified 17 needs assessment instruments for individuals with mental disorders, cognitive impairment or dementia. The analysis of selected articles demonstrated a wide range of needs indicators within different subgroups. Validity and reliability range between moderate and good.

CONCLUSIONS

Even though a wide range of needs assessment instruments is available, most instruments assess the needs of individuals with subjective cognitive impairment, mild cognitive impairment and dementia on a general level rather than on a more concrete level that may serve better to inform interventions for this growing population. In addition, we suggest basing the development of instruments firmly on an adequate theoretical framework and standardised procedural guidelines.

Do therapeutic homework assignments address areas of need for individuals with severe mental illness?

The current study explores the types of homework assignments used in a recovery orientated case management approach. It also examines the relationship between the types of homework used and the clients' area of need as rated on the CANSAS. There were 129 client and mental health case manager dyads that participated in the study. Written copies of all homework assignments administered during the 12-month research period were collected (N = 1,054). The homework assignments were categorised according to the 'type' and the 'need domain addressed by the task'. The majority of these tasks were behavioural in nature. On a group level homework tended to broadly address areas of need for clients in the study. Only 2 of the 1,054 homework assignments administered directly addressed areas of Intimate Relationships or Sexual Expression. The importance of addressing Intimate Relationship and Sexual Expression within mental health case management is discussed.

Predictors of changes in needs for care in patients receiving community psychiatric treatment: a 4-year follow-up study

OBJECTIVE

This study aimed to investigate changes and predictors of change in needs for care, as assessed by both patients and mental health professionals, in a sample of subjects receiving community-based psychiatric care.

METHOD

The study was conducted using a 4-year prospective longitudinal design. A cohort of patients from the South-Verona Community Mental Health Service (CMHS) was assessed at baseline and follow-up using the Camberwell Assessment of Need, both staff and patient versions. Predictors of changes in needs were explored using block-stratified multiple regression analyses.

RESULTS

An overall stability for both patient-rated and staff-rated needs was found over time; however, significant changes in some specific need domains were found, such as self-rated health needs (improvement), self-rated social needs (deterioration) and staff-rated health needs (deterioration). Changes over time in self-rated and staff-rated needs are influenced by different and specific set of predictors, thus indicating that the two measures are not overlapping and convey different types of information.

CONCLUSION

Our data support the adoption of a negotiated approach in which both staff and users' views should be given equal weight when planning and providing needs-led mental health care.

A taxonomy for homework used by mental health case managers when working with individuals diagnosed with severe mental illness

A survey was completed by 122 case managers describing the types of homework assignments commonly used with individuals diagnosed with severe mental illness (SMI). Homework types were categorized using a 12-item homework description taxonomy and in relation to the 22 domains of the Camberwell Assessment of Need (CAN). Case managers predominately reported using behaviourally based homework tasks such as scheduling activities and the development of personal hygiene skills. Homework focused on CAN areas of need in relation to Company, Psychological Distress, Psychotic Symptoms and Daytime Activities. The applications of the taxonomy for both researchers and case managers are discussed.

Supported housing for people with severe mental disorders

BACKGROUND

There has been a significant reduction in the number of people with severe mental illness who spend extended periods in long-stay hospitals. District health authorities, local authorities, housing associations and voluntary organisations are jointly expected to provide support for people with severe mental disorder/s. This 'support' may well involve some kind of special housing.

OBJECTIVES

To determine the effects of supported housing schemes compared with outreach support schemes or 'standard care' for people with severe mental disorder/s living in the community.

SEARCH STRATEGY

For the 2006 update we searched the Cochrane Schizophrenia Group Trials Register (April 2006) and the Cochrane Central Register of Controlled Trials (CENTRAL, 2006 Issue 2).

SELECTION CRITERIA

We included all relevant randomised, or quasi-randomised, trials dealing with people with 'severe mental disorder/s' allocated to supported housing, compared with outreach support schemes or standard care. We focused on outcomes of service utilisation, mental state, satisfaction with care, social functioning, quality of life and economic data.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated them and undertook data extraction. For dichotomous data, we would have estimated relative risks (RR), with the 95% confidence intervals (CI). Where possible, we would have calculated the number needed to treat statistic (NNT). We would have carried out analysis by intention-to-treat and would have summated normal continuous data using the weighted mean difference (WMD). We would have presented scale data for only those tools that had attained pre-specified levels of quality and undertaken tests for heterogeneity and publication bias.

MAIN RESULTS

Although 139 citations were acquired from the searches, no study met the inclusion criteria.

AUTHORS' CONCLUSIONS

Dedicated schemes whereby people with severe mental illness are located within one site or building with assistance from professional workers have potential for great benefit as they provide a 'safe haven' for people in need of stability and support. This, however, may be at the risk of increasing dependence on professionals and prolonging exclusion from the community. Whether or not the benefits outweigh the risks can only be a matter of opinion in the absence of reliable evidence. There is an urgent need to investigate the effects of supported housing on people with severe mental illness within a randomised trial.

A statewide survey of high-support services for people with chronic mental illness: assessment of needs for care, level of functioning and satisfaction

OBJECTIVE

The primary aim of this study was to describe high support accommodation services available for patients with chronic mental illness living in New South Wales (NSW). The second aim was to ask patients in these facilities about their needs and satisfaction with services and to assess their level of functioning.

METHOD

Non-inpatient services matching NSW Health's definition for high support, very high support and residential rehabilitation were sent a survey regarding type of service, criteria for acceptance, choice of housing options, patient demographics, evaluation methods and staff details. The Camberwell Assessment of Need was used to assess needs and the Life Skills Profile-16 was used to assess level of functioning. Comparisons were made between services operated by NSW Health and non-government organizations (NGOs), rural and urban services and services providing 24-hour support and those with less intensive staffing.

RESULTS

Forty of the 42 identified services were included in the survey (95% response rate) of which 25 were operated by NGOs. There were 753 residential beds and 1132 patients lived in these facilities over the financial year 2001/2002. Interviews were completed at 25 locations across the state with 159 patients. Seventy-four percent were male and the mean age was 43 years. Patients had on average 7.6 needs of which 2.2 were unmet and their mean LSP-16 total score was 16.8. Almost half the patients responded that they were homeless at one time because they could not find appropriate housing.

CONCLUSIONS

There were no significant differences in the number of needs expressed by patients residing in government or non-government operated services, those living in rural or urban areas and those in 24-hour services compared to patients in less intensively staffed services. Existing services are doing a good job of meeting patients' needs for practical assistance, but social and psychological needs remain unmet for a significant proportion.

Threshold 2: the reliability, validity and sensitivity to change of the Threshold Assessment Grid (TAG)

OBJECTIVE

This study investigated the psychometric properties of the Threshold Assessment Grid (TAG), a new assessment of the severity of mental health problems.

METHOD

A total of 605 patients were recruited from 10 mental health adult and elderly services in London, UK. TAG ratings and other standardized definitions of severe mental illness were completed by referrers. TAG, Global Assessment of Functioning (GAF), Camberwell Assessment of Need Short Appraisal Schedule (CANSAS) and Health of the Nation Outcome Scale (HoNOS) ratings were completed by mental health service staff. Construct validation on extreme groups was investigated.

RESULTS

Construct and concurrent validity were good. Referrer TAG scores predicted mental health team view of referral suitability, but not whether assessments were offered. Test-retest reliability was good, interrater reliability ranged from good to poor in different domains (but adequate for total TAG score), internal consistency was appropriate. Sensitivity to change requires further investigation.

CONCLUSION

The TAG can be recommended for use by all agencies when making referrals to mental health services.

Supported housing for people with severe mental disorders

BACKGROUND

There has been a significant reduction in the number of people with severe mental illness who spend extended periods in long-stay hospitals. Psychiatric and social services, both statutory and voluntary, aim to assist these people to stay in their local community. District health authorities, local authorities, housing associations and voluntary organisations are jointly expected to provide support for people with severe mental disorder/s. This 'support' may well involve some sort of special housing.

OBJECTIVES

To determine the effects of supported housing schemes compared with outreach support schemes or 'standard care' for people with severe mental disorder/s living in the community.

SEARCH STRATEGY

Cochrane Schizophrenia Group's Register of trials (February 2001) and the Cochrane Library (Issue 1, 2001) were searched using relevant phrases. These databases are compiled by methodical searches of BIOSIS, CINAHL, Dissertation abstracts, EMBASE, LILACS, MEDLINE, PSYNDEX, PsycINFO, RUSSMED, Sociofile, supplemented with hand searching of relevant journals and numerous conference proceedings. Reference list screening of relevant papers was performed.

SELECTION CRITERIA

Relevant randomised, or quasi-randomised, trials dealing with people with 'severe mental disorder/s' allocated to supported housing, outreach support schemes or standard care focusing on outcomes of service utilisation, mental state, satisfaction with care, social functioning, quality of life, and economic data, were sought.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality rated and data extracted. For dichotomous data, relative risks (RR) would have been estimated, with the 95% confidence intervals (CI). Where possible, the number needed to treat statistic (NNT) was to have been calculated. Analysis would have been by intention-to-treat. Normal continuous data were to have been summated using the weighted mean difference (WMD). Scale data were to have been presented for only those tools that had attained pre-specified levels of quality. Tests of heterogeneity and for publication bias were to have been undertaken.

MAIN RESULTS

No studies met the inclusion criteria although 139 citations were acquired from the searches.

REVIEWER'S CONCLUSIONS

Dedicated schemes whereby people with severe mental illness are located within one site or building with assistance from professional workers have potential for great benefit as they provide a 'safe haven' for people in need of stability and support. This, however, may be at the risk of increasing dependence on professionals and prolonging exclusion from the community. Whether or not the benefits outweigh the risks can only be a matter of opinion in the absence of reliable evidence. There is an urgent need to investigate the effects of supported housing on people with severe mental illness within a randomised trial.

[Analysis and comparative evaluations of the costs of supports and treatments of schizophrenia, affective psychosis, paranoia and neurosis]

OBJECTIVE

The aim of the study was to show, trough the calculation of the direct costs of supports and treatments actually provided by a NHS Mental Health Department, the presence of associations between four diagnostic groups (schizophrenia, affective psychosis, paranoia and neurotic disorders) and their overall and items (community care, rehabilitation facilities and in-patients services) costs.

SETTING

Mental Health Department and CSM "Scalo" (NHS Mental Centre), AUSL "Città di Bologna", Emilia-Romagna Region.

DESIGN

Yearly direct costs were calculated for a sample (n = 75) of all patients (N = 745) who during 365 days had more than four contacts with CSM and also for four randomised diagnostic groups (n = 30 per group).

MAIN OUTCOME MEASURES

We calculated unit costs of 15 types of services provided by CSM, selected according to the yearly number of services provided and the time spent by each health professional, and the in patient-cost per all days spent in a public or private sector hospital for psychiatric care.

RESULTS

The statistic analysis, performed with the help of the Kruskal-Wallis test, showed significantly higher overall costs for the schizophrenic patients than the sample-group and the neurotic disorders-group; besides a significant difference in the item costs for rehabilitation facilities was found between the schizophrenic group and the paranoia, neurotic disorders groups and the sample one, whereas no significant differences in costs of inpatients services and drugs administration were tested between the groups.

CONCLUSIONS

The results of our study allow to demonstrate that there are cost differences between the diagnosis (direct costs are highest for schizophrenic patients and lowest for those with neurotic disorders) and that the costs evaluation can be used to ensure appropriate provisions to Mental Health Department for support and treatment of a wide range of psychiatric disorders.

[Therapeutic needs in psychiatric patients: a systematic review of the literature. I. General concepts and assessment measures. Needs for services]

OBJECTIVE

In Italy, mental health care is in phase of reorganisation. In this frame the measurement of users' needs may be a useful tool in planning individualised mental health service interventions and in their evaluation. Aims of the present study are (I) to highlight the basic concepts of 'needs for care' and give a brief description of the main needs assessment tools specifically developed for psychiatric patients; (II) to review studies assessing needs for mental health services in the general population; (III) to discuss the role played by the assessment of needs in planning mental health care.

METHODS

Studies published in the international literature from January 1980 to June 1999 were reviewed. The studies were located through a computerised search of the databases MEDLINE and PsycLit; in addition, the reference lists of the studies located through the computerised search and the content of main international psychiatric journals were manually scanned in order to avoid possible omissions. Studies assessing needs for services and studies assessing needs on individual level were separately reviewed. Both groups of studies, in turn, were divided in studies assessing needs for mental health care in the general population and in psychiatric patients.

RESULTS

Although most studies on needs for services used indirect methodologies and employed quite heterogeneous experimental design, they provide at large overlapping results. In the general population, about 60%-70% of patients with anxiety, depression and other neurotic disorders and 30%-40% of psychotic patients do not receive any specialist mental health care, suggesting that the majority of subjects suffering from a psychiatric disorder do not receive the mental health care they need.

CONCLUSIONS

Unmet needs for services show a higher frequency in patients with neurotic and depressive disorders, indicating a shortage in services delivery that should be taken into account both by psychiatrists and mental health planners. Moreover, the finding that a large number of patients suffering from psychotic disorders do not receive any kind of mental health care is of particular relevance for planning mental health services, since these subjects are usually the most problematic and difficult to treat.

Progress in Australia's mental health reforms

The Second National Mental Health Report was released in June 1995 and documents progress in the 1993-94 financial year in implementing the five-year National Mental Health Plan. Expenditure on mental health rose by 4.1% and on community mental health services by 9.2%. State and Territory funding for non-government mental health services rose by 18% and more resources for those with disability were made available to those with psychiatric disability. The number of occupied-bed-days in standalone psychiatric hospitals fell by 10%. While the report shows that Australia has moved generally in the agreed direction, considerable work remains to be done in this historically neglected area.