Key stakeholder perceptions regarding acute care psychiatry in distressed publicly funded mental health care markets

An Online Peer Educational Campaign to Reduce Stigma and Improve Help Seeking in Veterans with Posttraumatic Stress Disorder

BACKGROUND

Although at least 1 in 10 veterans meet criteria for Posttraumatic Stress Disorder (PTSD) related to their military service, treatment seeking is strikingly low due to perceived stigma and other barriers. The National Center for PTSD produced AboutFace, * a web-based video gallery of veterans with PTSD who share their personal stories about PTSD and how treatment has turned their lives around.

INTRODUCTION

We conducted a two-stage evaluation of AboutFace, which included (1) a usability testing phase and (2) a randomized, controlled trial phase to explore the feasibility of incorporating AboutFace into a specialized outpatient clinic for PTSD.

MATERIALS AND METHODS

Twenty veterans participated in the usability testing phase in which they answered moderator posed questions regarding AboutFace, while actively exploring the website. Sixty veterans participated in the study after completing a PTSD clinic evaluation and were randomized to receive an educational booklet about PTSD treatment or AboutFace before starting treatment. Stigma and attitudes about treatment seeking were assessed at baseline and 2 weeks later.

RESULTS

Veterans had positive attitudes about AboutFace and gave suggestions for improvement. Veterans in both conditions reported improved attitudes toward mental illness and treatment seeking from baseline to the 2-week follow-up.

DISCUSSION

AboutFace is a promising peer-to-peer approach that can be used to challenge stigma and promote help seeking.

CONCLUSIONS

This use of an online peer approach is innovative, relevant to a wide range of healthcare conditions, and has the potential to increase access to care through trusted narratives that promote hope in recovery.

Second Opinions in Psychiatry: A Review

BACKGROUND

Although second opinions are rather restricted to the surgical disciplines, they have become more and more important to the health system in the last 20 years. The demand has been triggered by rising health costs and the economization of the field. The Internet has also made a considerable contribution to the demand for patient-initiated second opinions. Given these developments, it is surprising that second opinions have not become more important in the field of psychiatry. This article highlights the special situation of second opinions in psychiatry, discusses possible barriers to the adoption of second opinions in psychiatry, and the potential for greater use of second opinions in this field.

OBJECTIVE

In psychiatry, second opinions have been neglected by the typical drivers of innovations in health care, including insurers and other commercial drivers as well as psychiatrists and patients themselves. This review identifies current barriers to widespread adoption of second opinions in psychiatric practice, discusses the benefits of second opinions that have been demonstrated in other disciplines, and outlines the potential gains to be realized through use of second opinions in psychiatry.

METHODS

Literature in the area was reviewed through a search of the main medical databases. This literature review was supported by in-depth interviews with health care personnel and insurers.

CONCLUSIONS

Second opinions are rarely obtained in psychiatry and there is little literature on this subject. The stigmatization of psychiatric disorders and patients and the uniqueness of the patient-doctor relationship in psychiatry, especially in psychotherapeutic care, may pose considerable obstacles to the use of second opinions in this field. In addition, more stakeholders, such as social workers, government agencies and regulators, health care and disability insurers, and social security agencies, are involved in the mental health compared with the somatic health sector, which may make it more difficult to achieve a coordinated approach in psychiatric care. However, we have found no convincingly good reason why second opinions have not been at least discussed in psychiatry. Psychiatry could benefit from ongoing discussions concerning the outcomes of second opinions in other medical disciplines.

Feasibility and Efficacy of Prolonged Exposure for PTSD among Individuals with a Psychotic Spectrum Disorder

Objective: Few empirical studies have examined the feasibility of trauma-focused treatment among individuals with schizophrenia. This lack of research is important given the substantial overlap of trauma exposure and subsequent PTSD with psychotic spectrum disorders, and the potential for PTSD to complicate the course and prognosis of schizophrenia and other variants of severe mental illness.

Method: As part of a larger study, 14 veterans with a psychotic spectrum disorder were enrolled to receive prolonged exposure (PE) for PTSD within a single arm open trial study design. Patient reactions and responses to PE were examined using feasibility indices such as attrition, survey reactions, and treatment expectancy; pre and post-changes in PTSD severity and diagnostic status; and thematic interviews conducted post-intervention.

Results: Quantitative and qualitative data indicate that implementation of PE is feasible, subjectively well-tolerated, and may result in clinically significant reductions in PTSD symptoms in patients with psychotic spectrum disorders.

Conclusion: Consistent with treatment outcome data in clinical populations with a broader range of severe mental illnesses, the current results support the use of PTSD exposure-based interventions, such as PE, for individuals with psychotic spectrum disorders.

Protocol for the evaluation of a digital storytelling approach to address stigma and improve readiness to seek services among veterans

BACKGROUND

Research suggests that at least 10% of veterans returning from Iraq and Afghanistan meet criteria for posttraumatic stress disorder (PTSD) related to their military experiences. National dissemination initiatives have increased veterans' access to best-practice interventions. However, treatment-seeking remains low among veterans with PTSD, often due to perceived stigma and other associated barriers. The National Center for PTSD recently developed and launched AboutFace, a digital storytelling (DST) resource designed to help veterans recognize PTSD and motivate them to seek evidence-based treatment. The Ralph H. Johnson Veterans Affairs Medical Center (VAMC) and the National Center for PTSD have partnered to conduct pilot work to evaluate veterans' reactions to AboutFace to set the stage for a large-scale study to examine whether AboutFace effectively reduces stigma and improves attitudes toward treatment-seeking among veterans. If effective, this DST approach may serve as a valuable national model for a variety of treatment-seeking populations.

METHODS

During the first phase of the pilot, in-person usability assessments of AboutFace will be conducted via semi-structured interviews with 20 veterans. Audio recordings of interviews will undergo transcription and coding. A report of the results of qualitative analyses of these interviews will be provided to the National Center for PTSD and will inform revisions to the site. In the second phase of the pilot, 60 veterans referred to a specialized PTSD clinic will be recruited to demonstrate and refine the methodology that we propose to use in a larger randomized controlled trial evaluation of AboutFace. Veterans will be randomly assigned to receive AboutFace plus standard education vs. standard education alone. Baseline and 2-week telephone assessments will be conducted with participating veterans to measure stigma, attitudes toward seeking mental health services, and treatment access/engagement.

DISCUSSION

The feedback we receive in this pilot will be used to strengthen the quality of the DST website in preparation for a large-scale evaluation. Future work will involve evaluation of reach and impact of the site relative to stigma, attitudes toward seeking mental health service, and utilization of care. If AboutFace is found to increase access to care, this finding would have broad and significant implications for overcoming barriers to care for veterans and other populations with stigmatized conditions.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02486692.

Governance and mental health: contributions for public policy approach

OBJECTIVE

To analyze the conceptualization of the term governance on public mental health programs.

METHODS

In this systematic review, we analyzed the scientific literature published in the international scenario during 15 years (from 2000 to 2015). The databases analyzed were: Medline, CINAHL, PsycINFO and PubMed. Governance and mental health were the descriptors. We included relevant articles according to our subject of study and levels of analysis: (i) the concept of governance in mental health; (ii) process and decision spaces; (iii) strategic and pertinent actors who operate in the functioning of the health system, and (iv) social regulations. We excluded letters to the editor, news articles, comments and case reports, incomplete articles and articles whose approach did not include the object of study of this review.

RESULTS

We have found five conceptualizations of the term governance on mental health in the area of provision policies and service organization. The agents were both those who offer and those who receive the services: we identified several social norms.

CONCLUSIONS

The concept of governance in mental health includes standards of quality and attention centered on the patient, and incorporates the consumers of mental healthcare in the decision-making process.

OBJETIVO

Analizar la conceptualización del término gobernanza en las políticas de salud mental.

MÉTODOS

En esta revisión sistemática se analizó literatura científica publicada en el ámbito internacional durante 15 años (de 2000 hasta 2015). Las bases de datos analizadas fueron: Medline, CINAHL, PsycINFO y PubMed. Los descriptores fueron gobernanza y salud mental. Fueron incluidos artículos relevantes de acuerdo a nuestro objeto de estudio y niveles de análisis: (i) concepto de gobernanza en salud mental; (ii) proceso y espacios de decisión; (iii) actores estratégicos y de interés que intervienen en el funcionamiento del sistema de salud, y (iv) normas sociales. Se excluyeron cartas al editor, noticias, comentarios y reporte de caso, artículos incompletos y artículos que no incluyeran en su abordaje el objeto de estudio de esta revisión.

RESULTADOS

Se reportaron cinco conceptualizaciones del término gobernanza en salud mental en el ámbito de políticas de provisión y organización de servicios. Los actores fueron desde proveedores a usuarios de servicios; se identificaron diversas normas sociales.

CONCLUSIONES

El concepto de gobernanza en salud mental incorpora estándares de calidad y atención centrada en el paciente, e incluye a los usuarios en la toma de decisiones.

Community navigation to reduce institutional recidivism and promote recovery: initial evaluation of opening doors to recovery in Southeast Georgia

New approaches for preventing repeated inpatient psychiatric stays, detention in jails and prisons, and homelessness among individuals with serious mental illnesses with established histories of such recidivism, while promoting recovery, are direly needed. We present findings from an initial program evaluation of a new community-based, recovery-oriented "community navigation" program in southeast Georgia, called Opening Doors to Recovery. Twenty-three in-depth interviews were conducted with key stakeholders, program participants, community navigation specialist team members, and referring mental health professionals to identify hopes and strengths, challenges and weaknesses, and recommendations pertaining to the new program. Cited strengths included teamwork and pooling of resources from various partners, as well as the novel recovery-based, community navigation team approach. An initial lack of fidelity processes across teams and an ongoing scarcity of safe and affordable housing were identified as weaknesses, with the latter seen as a liability of the overall mental health and social service systems rather than the program itself. Findings from this evaluation highlight strengths and opportunities of this new community navigation approach, including those related to the involvement of certified peer specialists and multiple community partners.

Trauma exposure and posttraumatic stress disorder in adults with severe mental illness: a critical review

There is a great deal of research on the prevalence, correlates, and treatment of PTSD in the general population. However, we know very little about the manifestation and consequences of PTSD in more complicated patient populations. The purpose of the current paper is to provide a comprehensive review of PTSD within the context of severe mental illness (SMI; i.e., schizophrenia spectrum disorders, mood disorders). Extant data suggest that trauma and PTSD are highly prevalent among individuals with SMI relative to the general population, and both are associated with adverse clinical functioning and increased healthcare burden. However, trauma and PTSD remain overlooked in this population, with low recognition rates in public-sector settings. Additionally, there are few data on the clinical course and treatment of PTSD among individuals with SMI. Particularly lacking are longitudinal studies, randomized controlled treatment trials, and studies using ethno-racially diverse samples. Furthermore, there is a need to better understand the interplay between trauma, PTSD, and severe forms of mental illness and to further develop and disseminate evidence-based PTSD treatments in this population. The current state of the literature and future directions for practice are discussed.