Antenatal Psychiatric Hospitalization: Factors Associated With Newborns' Custody Under Child Protective Services (CPS)

BACKGROUND

Psychiatric illness during pregnancy is associated with adverse obstetric outcomes, but investigations into its impact on parenting capacity are limited. Child Protective Services (CPS) contact disproportionately impacts families marginalized by poverty, mental health disorders, and substance use disorders. Recently, there have been investigations into the significance of psychiatric illness and nonmental health-related factors that predict CPS custody arrangements.

OBJECTIVE

To identify clinical factors associated with newborns' custody under CPS for mothers with antenatal psychiatric hospitalization.

METHODS

We conducted a retrospective review of electronic medical records over a 10-year period (2012-2021) for patients who were pregnant during their inpatient psychiatric hospitalizations. We followed 81 patients (18 to 43 years old) who delivered within the hospital. The study endpoint was whether the newborn was placed under CPS custody. For the purposes of this study, psychiatric illness was categorized by the presence or absence of psychotic symptoms. We utilized logistic regressions to investigate the associations of these demographic and clinical factors with the study outcome of CPS custody.

RESULTS

For the entire study population, 64.2% of newborns had CPS custody arrangements. In multivariate analysis, after adjusting for potential confounders, patients with psychotic symptoms were at increased odds of having CPS custody arrangements (odds ratio = 8.43; 95% confidence interval 2.16-32.85) compared with patients without psychotic symptoms. Furthermore, multivariate analyses revealed that patients with a history of homelessness also had a higher risk (odds ratio = 6.59; 95% confidence interval: 1.24-35.13) of CPS custody arrangements for their newborns than those without a history of homelessness.

CONCLUSIONS

The results of this study suggest that among pregnant and psychiatrically hospitalized patients, those with psychotic symptoms are significantly more likely to have CPS custody arrangements compared to those without psychotic symptoms. However, it is important to note that psychotic symptoms were not definitive for the inability to parent appropriately. In fact, nearly 25% of the study population who had psychotic symptoms were able to successfully transition home with their newborns as mothers. This emphasizes the importance of optimizing the management of psychotic symptoms, particularly among those who have children or plan to have children. The findings of this study also highlight the chronic impacts that those who have struggled with homelessness may experience, including parenting capacity after homelessness resolves.

Disseminating action-based cognitive remediation to an early psychosis network: Clinician perspectives on feasibility and implementation barriers

AIM

Action-based cognitive remediation (ABCR) is a group cognitive remediation treatment that aims to improve neurocognitive impairments experienced in patients with severe mental illness. Developed in research settings, ABCR is not yet widely available in community settings. As such, this study examines the feasibility of implementing ABCR in community clinics in an early psychosis network.

METHODS

Eighty-five allied health professionals who work within an early psychosis intervention network were trained in the provision of ABCR. They were surveyed 6-months after training to gather information regarding their experience implementing ABCR within their clinical settings (e.g., barriers, perceived helpfulness of the treatment, modifications made to the manualized treatment). Access to ongoing training supports (e.g., treatment manual, asynchronous digital communication, conference calls) was also assessed.

RESULTS

Fifty-one clinicians responded to the survey. Staff time, manager support, and equipment were rated as organizational barriers. Geographic location, other responsibilities, and motivation were rated as patient barriers. Over half of the sample modified the overall dose of ABCR to offer fewer sessions and/or shorter duration of sessions than the manualized approach. Clinicians that reduced the dose of ABCR reported significantly higher barriers with manager support than staff who delivered ABCR as manualized but did not report worse patient outcomes. We found asynchronous learning opportunities (i.e., manual, online discussion forum) were perceived as the most accessible and helpful methods of ongoing training support.

CONCLUSIONS

The results provide preliminary information about barriers to implementing time-intensive cognitive treatments into clinical settings and may inform future training practices to increase successful implementation of cognitive remediation treatments.

Clinical Outcome in Persons with Severe Mental Disorders Attending a Mental Health Day Center during the COVID-19 Pandemic

BACKGROUND

Studies assessing the psychological impact of the COVID-19 pandemic on populations highlight the emergence of mental health difficulties, especially if a mental health disorder is already present. Patients with severe mental illnesses (SMIs) may be even more vulnerable to the psychosocial effects of the pandemic. However, little is known regarding the possible impact of the pandemic on SMI patients supported by community-based mental health day centers.

METHODS

A two-year prospective study comprising 29 individuals with SMI was conducted by the Skitali Mental Health Day Center in Ioannina, Northwest Greece. The described group of examined patients consisted mainly of psychotic patients (65.5%). Patients were assessed using the Health of Nations Outcome Scale and the Global Assessment of Functioning scale, and scores prior to and after the onset of the pandemic were compared.

RESULTS

The results indicated that participants did not present any significant decline in their overall clinical status during the COVID-19 pandemic and the national lockdown measures.

CONCLUSIONS

This finding is relevant because previous research has shown that the pandemic may negatively impact adherence to treatment and service attendance and that the symptomatology of patients with SMIs may further deteriorate. It is suggested that the operation of mental health day centers during collective stressful events should be preserved, but further research is needed to evaluate their role in maintaining continuity of care during such events.

Perceptions of community mental health services among culturally diverse adult Singaporeans with major depressive disorder: A descriptive qualitative study

Persons with major depressive disorder (PMDDs) often experience pernicious ramifications on the biopsychosocial aspects of their health. While community mental health services (CMHSs) in Singapore are increasingly leveraged to meet the escalating demand for mental healthcare, shortcomings such as a substantial treatment gap and the lack of holistic, culturally sensitive care have been highlighted. Of note, the perspectives of the service users, which have hardly been studied in the literature, are crucial to our understanding of their needs to continuously improve CMHSs. Accordingly, this qualitative descriptive study explored the perceptions and experiences of community-dwelling adults with major depressive disorder in their use of CMHSs in Singapore. Seventeen adults with major depressive disorder purposefully sampled from a CMHS provider were interviewed through a semi-structured guide between October and November 2021. Data analysis via Braun and Clarke's six-step thematic framework yielded five themes corresponding to three different phases: pre-CMHS encounter ((i) procrastination to seek help and (ii) factors influencing CMHS utilization); intra-CMHS encounter ((iii) incongruous perceptions of the impacts on biopsychosocial health and (iv) differing perceptions and experiences of culturally sensitive care); and post-CMHS encounter ((v) enhancing CMHSs for PMDDs based on end-users' experiences). Our findings underscore the need to improve the delivery of personalized mental healthcare services, use of settings- and culturally-specific anti-stigma strategies, and nationwide mental health literacy in symptom recognition and awareness of help-seeking resources.

"It's not just the residents who need to be motivated for activity": a qualitative study of the perspectives of staff on providing activity support for people with psychiatric disabilities in supported housing in Sweden

Background

The goals for staff in Supported Housing for people with psychiatric disabilities include helping to develop the residents' independence and self-confidence in activities. However, staff have expressed frustration about providing this type of support when motivating residents to engage in meaningful activities and also about the difficulty in finding suitable levels of independence within a housing setting with limitations.

Objective

The aim is to explore the views and experiences of housing staff in Supported Housing on how they can stimulate and support engagement in activities for people with psychiatric disabilities.

Methods

Twenty-six members of staff from 20 supported housing units in 10 municipalities in Sweden were interviewed in five focus groups. A semi-structured interview guide was used, and the transcribed material was analyzed using qualitative content analysis.

Results

Three main categories emerged from the analysis: Multi-faceted factors influencing the staff's provision of activity support, Staff's approach for supporting activities, and Staff's struggles to develop their work. Obstacles to participating in activities in the community were identified. Many contrasting factors were found, such as spontaneous or structured activities and individual or group activities, which affected the staff's ability to motivate to activity.

Conclusion

A broad approach encompassing in-house training including a focus on values, recruitment policies, staff supervision and interventions focusing on both residents and staff are ways to support staff in motivating residents toward being more active within Supported Housing.

Long-term mental health care in Portugal: A portrait of the first years of activity

INTRODUCTION

In Portugal, a reform to implement Long-term mental health care (LTMHC) started in 2017 allowing patients with severe mental illness receiving psychosocial rehabilitation to regain their autonomy and be reintegrated into their communities.

AIM

To describe the first steps of the Portuguese LTMHC implementation and to assess the relationship between the LTMHC's demand (referrals) and supply (vacancies and occupancy).

METHODS

We conducted a national retrospective observational study to analyse the LTMHC referrals, vacancies and occupancy between mid-2017 (LTMHC establishment) and December 2022. We described and analysed the associated indicators through time and geography, as well as performed a simultaneous regression model to evaluate the relationship between supply and demand.

RESULTS

There were 1,192 referrals to the LTMHC, of which 99 (8.3%) were made for childhood and adolescence structures. The maximum support residence (RAMa, 'Residência de apoio máximo'), designed for patients with higher disabilities, had the highest number of referrals. Additionally, since the opening of vacancies in different institutions, residential structures became quickly saturated. On the other hand, domiciliary services were those with the lowest occupancy. Our estimates support that the vacancies (supply) are induced by the referrals (demand), and referrals are also related to the location of LTMHC facilities.

CONCLUSION

LTMHC is still in the initial stage of development in Portugal, and it is expected to receive financial support through the Recovery and Resilience Programme. According to the occupancy rates and referrals made, residential structures seem to be a priority, being also important to explore the partial use of domiciliary services. The geographical distribution of vacancies can also be a concern, considering the important proximity to the community in LTMHC.

[Can intensive home care solve the problem of overcrowded psychiatric beds?]

The growing demand for psychiatric care raises questions about the place and value of alternatives to hospitalization. Community-based intensive care, such as home-based intensive care teams, are models that have been extensively studied and precisely described in international literature. They make it possible to avoid or shorten hospital stays, and have interesting variations for providing access to care in rural areas.

COVID-19 and Psychiatric Admissions: A Comparative Study of Pre-pandemic and Post-pandemic Psychosis Admissions in a South Florida Emergency Department

We noticed a subjective increase in psychosis admissions within our emergency department (ED) with the onset of the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to identify trends concerning admissions due to psychosis in the ED before and after the beginning of the COVID-19 pandemic. We analyzed 508 psychiatric admissions through the ED from October 2019 to October 2020, of which 367 cases of psychosis were identified. Statistical analysis was performed using T-tests and Pearson's correlation coefficient. T-testing showed mean psychosis admissions during the pandemic (March 2020 to July 2020) to be greater than admissions occurring during the pre-pandemic period (October 2019 to February 2020) (p = 0.04). Pearson's correlation coefficient identified the relationships between COVID-19 admissions and psychosis admissions during this time as positive (r = 0.5) but did not reach statistical significance (p = 0.06). Therefore, within our time frame, we did see a noted increase in psychosis by 22.9% during the pandemic compared to pre-pandemic times. Current research remains conflicted concerning psychiatric ED admissions during COVID-19, with some stating an increase and others finding a decrease. Our data showed a significant statistical increase in the mean number of psychosis cases when comparing pre-pandemic and pandemic admissions. These findings help add pertinent data to understand how psychosis admissions trended before and during the beginning of the COVID-19 pandemic, specifically in South Miami, Florida. It also provides a foundation for future studies by providing data points concerning mental illness within the vulnerable population of patients served in our community.

Translating measurement into practice: Brazilian norms for the Patient Health Questionnaire (PHQ-9) for assessing depressive symptoms

OBJECTIVE

To provide practical norms for measuring depressive symptoms using the Patient Health Questionnaire 9 (PHQ-9) in Brazil using a state-of-art psychometrics analysis.

METHODS

We used a large and representative Brazilian dataset from the 'Pesquisa Nacional de Saúde - 2019'(PNS-2019), which includes 90,846 Brazilian citizens. First, to assess the scale structure, we assessed the unidimensional model using Confirmatory Factor Analysis (CFA). Second, we used Item Response Theory (IRT) to characterize depressive symptoms´ distribution. Then, we linked summed- and meanbased PHQ-9 scores with the IRT-based score by using generalized additive models. Finally, we generated percentiles, T scores, and a newly developed score, called D scores (decimal scores), to describe the PHQ-9 norms for Brazilian population.

RESULTS

CFA revealed a good fit to the unidimensional model, showing to be invariant to age and sex. IRT captured item-level information of the latent trait (reliable from 1 to 3 standard deviations above the mean). Brazilian norms were presented using summed-, T-scores, and D-scores.

CONCLUSIONS

This is the first study to define Brazilian´s norms for the PHQ-9 among a large representative sample, using robust psychometric tools. More precise PHQ-9 scores are now available and may be widely used in primary and specialized clinical care settings.

Evidence of mental health-related morbidities and its association with socio-economic status among previously hospitalized patients with symptoms of COVID-19 in Bangladesh

Introduction

The long-term impact of COVID-19 on mental health, particularly in relation to socio-economic vulnerabilities, has received little attention. This study reports the prevalence of mental health-related symptoms among previously hospitalized patients after recovery from COVID-19, and its association with socio-economic status (SES).

Methods

Data collection of this cross-sectional study was conducted during February-April 2021, among previously hospitalized patients with COVID-19 like symptoms, on average six months after their discharge from the hospital. Using DASS-21, a validated scale to document symptoms of depression, anxiety, and stress, information on mental health-related symptoms were recorded from 481 respondents along with sociodemographic and economic information through telephone interviews. Chi-square tests were performed to identify significant group differences. Multinomial logistic regression analyzed the association between the changes in socioeconomic characteristics and mental health-related symptoms. Relative index of inequality (RII), slope index of inequality (SII), and concentration index (CIX) were applied to capture relevant inequalities in relation to mental health-related symptoms.

Results

Eleven percent of the respondents reported changes in employment status, nearly half changes in income and expenditure. Forty-five percent reported symptoms of depression, anxiety and/or stress, and 12% reported coexistence of all three symptoms. Women [Adjusted Odds Ratio, AOR: 2.95; 95% Confidence Interval, CI: 1.39-5.68], and those who reported changes in occupation [AOR: 3.04; 95% CI: 1.01-9.08] and expenditure [AOR: 2.46; 95% CI: 1.12-5.37] were more likely to report all three mental health-related symptoms compared to men and those without changes in occupation and expenditure. The older age group was less likely [AOR: 0.96; 95%CI: 0.93-0.99] to report coexistence of all three symptoms compared to their younger counterparts. Negative values of concentration index (CIX) indicate that any one mental health-related symptom was significantly concentrated among those with lower expenditure and poor SES.

Conclusion

This study will help in addressing mental health-related challenges after recovery from COVID-19 among the identified vulnerable groups through relevant community-based and clinical response, including counseling services, in Bangladesh and similar LMIC contexts.

Is 'another' psychiatry possible?

In this paper, we examine a number of approaches that propose new models for psychiatric theory and practices: in the way that they incorporate 'social' dimensions, in the way they involve 'communities' in treatment, in the ways that they engage mental health service users, and in the ways that they try to shift the power relations within the psychiatric encounter. We examine the extent to which 'alternatives' - including 'Postpsychiatry', 'Open Dialogue', the 'Power, Threat and Meaning Framework' and Service User Involvement in Research - really do depart from mainstream models in terms of theory, practice and empirical research and identify some shortcomings in each. We propose an approach which seeks more firmly to ground mental distress within the lifeworld of those who experience it, with a particular focus on the biopsychosocial niches within which we make our lives, and the impact of systematic disadvantage, structural violence and other toxic exposures within the spaces and places that constitute and constrain many everyday lives. Further, we argue that a truly alternative psychiatry requires psychiatric professionals to go beyond simply listening to the voices of service users: to overcome epistemic injustice requires professionals to recognise that those who have experience of mental health services have their own expertise in accounting for their distress and in evaluating alternative forms of treatment. Finally we suggest that, if 'another psychiatry' is possible, this requires a radical reimagination of the role and responsibilities of the medically trained psychiatrist within and outside the clinical encounter.

Community mental health interventions for people with major depressive disorder: A scoping review

People with major depressive disorder continue to be marred by chronically pernicious yet preventable outcomes in the biopsychosocial aspects. With the reallocation of healthcare resources towards the fight against the coronavirus 2019 pandemic, much emphasis has been placed on existing community mental health interventions to ameliorate the disruption of mental health services. Moreover, the recent propulsion of community mental health services by the World Health Organization Mental Health Action Plan 2013-2030 ignited the need to bolster existing community interventions by providing comprehensive, responsive and integrated mental healthcare. The enhanced emphasis on mental healthcare in the community and the heightened demands of people with major depressive disorder underscores the need to explore the current state of community mental health interventions. This scoping review examined 51 primary studies published from year 2010 to 2020 using Arskey & O'Malley's five-stage framework and provided an overview of the impact of existing community mental health interventions for people with major depressive disorder. Findings using thematic analysis have recommended the adoption of person-centred community mental healthcare via the biopsychosocial approach for people with major depressive disorder. Enablers of community mental health interventions were driven by culturally appropriate care and augmented by technology-driven modalities. Challenges and gaps of community mental health interventions include the perpetuation of stigma and misconception, complex demands of persons with major depressive disorder and lack of holistic and long-term outcomes. Given the impact of major depressive disorder on the various biopsychosocial aspects, it is envisioned that our insights into the enablers and barriers of community mental health interventions will guide prospective interdisciplinary and nurse-led interventions in holistically improving the care of persons with major depressive disorder in the community settings.

Development of a transdiagnostic, resilience-focused intervention for at-risk adolescents

BACKGROUND

Environmental adversity and subclinical symptoms of psychopathology in adolescents increase their risk for developing a future psychiatric disorder, yet interventions that may prevent poor outcomes in these vulnerable adolescents are not widely available.

AIMS

To develop and test the feasibility and acceptability of a prevention-focused program to enhance resilience in high-risk adolescents.

METHOD

Adolescents with subclinical psychopathology living in a predominantly low-income, Latinx immigrant community were identified during pediatrician visits. A group-based intervention focused on teaching emotion recognition and regulation skills was piloted in three cohorts of adolescents (n = 11, 10, and 7, respectively), using a single arm design. The second and third iterations included sessions with parents.

RESULTS

Eighty-eight percent of participants completed the program, which was rated as beneficial. Also, from baseline to end of treatment, there was a significant decrease in subclinical symptoms and a significant increase in the adolescents' positive social attribution bias (all p < 0.05).

CONCLUSIONS

A resilience-focused intervention administered to high-risk adolescents was found to be feasible and acceptable to participants. Future work is needed to determine whether such a program can reduce the incidence of negative outcomes, such as the development of psychiatric disorders and related disability, in this population.

Investigation of a group of Iranian theater artists' mental health and attitude toward patients with mental disorders

Introduction

Stigmatizing attitude toward patients with severe mental disorders is one of the main obstacles of improving the mental health of societies. Media plays an important role in how the public views mental health issues. Thus, we have performed this study to investigate the Iranian theater artists' mental health status, and their view toward patients with severe mental disorders.

Methods

This cross-sectional study was performed via an online anonymous survey including the Social Distance Scale and the Dangerousness Scale measuring the attitude of participants toward patients with severe mental disorders, and the 28-item General Health Questionnaire (GHQ-28). It was disseminated to artists who had the experience of working in theater in the past year in Iran.

Results

Our survey was responded by 104 artists. Social Distance Scale scores' mean was 10.67 (scores can range from 0 to 21) and the Dangerousness Scale scores' mean was 28.87 (scores can range from 8 to 56); higher scores indicate worse discrimination. Our participants' strongest fears were to let someone with a severe mental disorder to take care of their children, and for these groups of patients to obtain a hunting license. Twenty-six (25%) participants were at risk of moderate to severe anxiety, and 18 (17.3%) participants were at risk of moderate to severe depression.

Conclusion

By and large, our participants did not have a positive attitude toward patients with severe mental disorders. Providing the knowledge of mental health issues can help the general public to be more tolerant of the mentally ill and specifically, theater can be employed to fight stigmatizing mental health issues by educating its audience.

Housing and loneliness among individuals with serious mental illnesses

BACKGROUND

People with serious mental illnesses (SMI) have higher levels of loneliness than the general population. Furthermore, people with SMI tend to be less satisfied with their housing and tend to move more frequently.

AIM

This study aims to examine relationships between housing variables (whom they live with, duration of residence, and satisfaction) and loneliness among individuals with SMI.

METHODS

Data were collected from 188 adults with SMI in greater Philadelphia area. Classification and Regression Trees (CART) were used to examine whether whom they live with, duration of residence, and housing satisfaction were associated with loneliness.

RESULTS

Housing satisfaction was found to be the most prominent predictor of loneliness. Those who were unsatisfied with their overall housing conditions always had the highest level of loneliness, regardless of other factors. Even if they were satisfied with their housing conditions, their loneliness was higher if they had just moved to the new residence. Participants had lower loneliness the longer they lived in a residence and had the lowest loneliness levels after about three years.

CONCLUSION

Housing is associated with loneliness among people with SMI. Psychiatric service providers should increase support to factors contributing to housing satisfaction and duration of residence, including active engagement in the community.

Attitude of Iranian medical specialty trainees toward providing health care services to patients with mental disorders

Introduction

The stigma of mental illness has a negative impact on the diagnosis and treatment of these disorders. Considering the high prevalence of mental illness, the attitude of medical specialists toward mental disorders, who are front liners in diagnosing and treating these patients, is critical. Therefore, we examined the attitude of Iranian medical specialty trainees toward providing health care services for patients with mental illness.

Methods

We included 143 residents in the fields that have the most interactions with patients with mental disorders, including internal medicine, surgery, neurology, cardiovascular diseases, and psychiatry. A demographic checklist, as well as the opening minds scale for health care providers stigma assessment questionnaire, was provided, which measures five dimensions of improvement, social responsibility, social distance, exposure, and other (such as risk) in health care providers toward delivering the healthcare services to patients with mental disorders.

Results

The mean score of stigma for mental illness in medical specialty trainees was 61.36 ± 4.83 out of 100. Psychiatric residents have the least stigmatizing attitude (58.38 ± 3.54), and internal medicine and cardiology residents have the highest score, respectively, (62.96 ± 6.05, 62.45 ± 3.80). As for comparing subscales between specialties, only the social responsibility subscale showed a significant difference, with psychiatry having less stigma toward social responsibility (12.93 ± 2.01) than cardiology (15.09 ± 1.50) trainees.

Conclusion

The attitude of medical specialty trainees toward providing health care services for patients with mental illness is not uniform; internal medicine and cardiology residents have more stigmatizing attitude, while psychiatric residents have less stigmatizing attitude. It seems that not every contact could be useful in making a better attitude toward mental illness, but it needs preconditions, like a structured contact that leads to positive outcomes. Anti-stigma interventions are needed to improve the attitude of medical specialty trainees toward providing health care services to patients with mental illness.

A camp approach of community psychiatry in India: Past, present, and the future

Camps are a popular approach to deliver medical care in India. While it is usually a one-off event for physical ailments, it is a long-term affair in Psychiatry. One of the first camps in psychiatry was rolled out as early as in 1967 at Mandar, Ranchi, followed by Raipur Rani (Haryana) in 1976 and at Gunjur, Karnataka in 1977. This camp approach became extremely popular and got expanded across India as they were thought to be synonymous with community-based outreach for mental illnesses. In the past 5 years, however, newer models of community care have emerged, necessitating a relook at this traditional approach. In this paper, the authors trace the origin, utility and future directions of these camps, taking data from community psychiatry camps conducted by the National Institute of Mental Health and Neurosciences, Bengaluru, a premier neuropsychiatric tertiary care institute in India. Data have been collated from the annual reports of the Institute, database from the District Mental health Program, Government of Karnataka, India, and compared with published literature on the same field. While camps remain as one of the important avenues to reach the unreached, there is a need to change the approach of their functioning by incorporating training (primary care providers) aspects and collaborative care. The latter may make the initiative more meaningful and sustainable.

Developing an Educational Package to Improve Attitude of Medical Students Toward People With Mental Illness: A Delphi Expert Panel, Based on a Scoping Review

INTRODUCTION

The importance of stigma toward patients with mental illness in medical students as future physicians cannot be overemphasized. There is currently no formal training to reduce stigma toward mental illness in medical students in their educational curriculums in Iran like most other low and middle income countries. Therefore, aiming to provide a practical and effective training package focused on reducing stigma toward patients with mental illness in medical students, the current study conducted, as an expert panel with Delphi method, based on a scoping review, to develop an education package to improve attitude of medical students toward patients with mental illness.

MATERIALS AND METHODS

We surveyed the available international databases including PubMed, Google Scholar, Scopus, PsycINFO, Tripdatabase, Web of Science, Cochrane Database of Systematic Reviews as well as Persian databases including Iranmedex, SID, Irandoc and Magiran in February and March 2020. After an extensive review of related resources, 13 articles met our inclusion criteria. Then, we extracted the related data including type and duration of the interventions, sample size, mean and standard deviation of stigma scores before and after interventions. To develop the package among the included interventions, we asked 16 experts in psychology, psychiatry, and social medicine to rate the interventions based on a number of variables such as effectiveness, feasibility and applicability in a Delphi process.

RESULTS

The selected intervention in Delphi method with consensus of experts included a set of four sequential interactive interventions: showing a movie and discussing it, psychiatric training including contact with people who affected psychiatric disorders, social communication with people who affected psychiatric disorders, and group discussion on defining stigma and personal experiences.

CONCLUSION

In the present study, we recommend a set of interventions to reduce stigma toward patients with mental illness among medical students in the form of a package of combined, interactive and sequential interventions that have been previously been shown to be effective in reducing stigma related to mental illness. We expect that implementation of these interventions would reduce mental illness stigma in medical students; which needs further verification.

Longitudinal Single Photon Emission Computed Tomography Neuroimaging as an Indication of Improvement in Psychiatric Disorders in a Community Psychiatric Practice

In the community, there is a need to more objectively evaluate the response of common chronic psychiatric disorders to treatment. Brain single photon emission computed tomography (SPECT) indirectly measures cerebral functional activity by uptake of a radiotracer, which follows regional cerebral blood flow. Brain 3D Thresholded SPECT scans are thresholded three dimensional images derived from brain SPECT data. A retrospective community study of longitudinal (before and after treatment) brain 3D Thresholded SPECT scans of 73 patients with all-cause psychiatric disorders (most frequent diagnostic clusters: attention-deficit hyperactivity disorder, post-mild traumatic brain injury, affective disorders, psychotic disorders, post-viral chronic syndromes), shows these baseline SPECT scans predict improvement (non-worsening to large improvement) in clinical functioning with a sensitivity of 94% (95% confidence interval 86-98%) and a specificity of 67% (95% confidence interval 21-94%). In contrast, contemporaneous analysis by the same radiologist of conventional 2D reading of the same before and after treatment brain SPECT scan data of the same 73 patients, predicted improvement (non-worsening to large improvement) in clinical functioning with a sensitivity of only 26% (95% confidence interval 17-37%) although with a specificity of 100% (95% confidence interval 44-100%). These data suggest 3D Thresholded SPECT scans can provide the clinician with a more objective measure for verifying improvement in psychiatric disorders seen in the community, consistent with prior studies of SPECT as a measure of neurobiological change. Furthermore, these data suggest 3D Thresholded SPECT scans may have clinical application in guiding treatment and potentially improving outcomes.

Primary Care Physician Adherence to Telepsychiatry Recommendations: Intermediate Outcomes from a Randomized Clinical Trial

Objective: To compare clinical recommendations given by psychiatrists and the adherence to these recommendations by primary care physicians (PCP) following consultations conducted by asynchronous telepsychiatry (ATP) and synchronous telepsychiatry (STP). Materials and Methods: ATP and STP consultations were compared using intermediate data from a randomized clinical trial with adult participant enrollment between April 2014 and December 2017. In both study arms, PCPs received written recommendations from the psychiatrist after each encounter. Independent clinicians reviewed PCP documentation to measure adherence to those recommendations in the 6 months following the baseline consultation. Results: Medical records were reviewed for 645 psychiatrists' consult recommendations; 344 from 61 ATP consultations and 301 from 62 STP consultations. Of those recommendations, 191 (56%) and 173 (58%) were rated fully adherent by two independent raters for ATP and STP, respectively. In a multilevel ordinal logistic regression model adjusted for recommendation type and recommended implementation timing, there was no statistically significant difference in adherence to recommendations for ATP compared with STP (adjusted odds ratio = 0.91, 95% confidence interval = 0.51-1.62). The profiles of recommendation type were comparable between ATP and STP. Conclusions: This is the first PCP adherence study comparing two forms of telemedicine. Although we did not find evidence of a difference between ATP and STP; this study supports the feasibility and acceptability of ATP and STP for the provision of collaborative psychiatric care. Clinical Trial Identifier NCT02084979.

Provider perceived barriers and facilitators to integrating routine outcome monitoring into practice in an urban community psychiatry clinic: A mixed-methods quality improvement project

BACKGROUND AND AIMS

Although mental health clinics are under increasing pressure to demonstrate value and routine outcome monitoring (ROM) has become a mandated component of care, providers have been slow to adopt ROM into practice, with some estimating that less than 20% of mental health clinicians use it consistently in the United States. This article explores perceived barriers and facilitators to integrating ROM into practice among clinicians and administrators in a large urban US community psychiatry clinic.

METHOD

One hundred and thirty-eight clinical and administrative staff were administered an anonymous web-based survey to elicit attitudes towards ROM. Responses were summarized descriptively and qualitatively synthesized into a conceptual model using inductive thematic analysis.

RESULTS

Common barriers to integration included insufficient time to collect and/or use measures, not knowing what measures to use, measures being difficult to access, and insufficient training. Facilitators included increased access/ease of use, training and support, measure relevance/validity, and accountability.

CONCLUSIONS

In order for psychiatry clinics to successfully implement ROM into practice, they must diagnose organization-side barriers and translate this knowledge into actionable quality improvement initiatives ranging from the infrastructural to the cultural.

[Crisis intervention for serious mental disorders. The example of the First Department of Psychiatry of Athens University]

We describe the crisis management and resolution service for serious mental disorders established by the First Department of Psychiatry of the National and Kapodistrian University of Athens. The service is intended to meet patients' needs for adequate management of acute mental crisis without hospitalization, while implementing modern standards in mental care and considering existing restrictions in mental health resources and public expenditure. Last decade we witness an increase in demand for psychiatric beds in Psychiatric clinics of General Hospitals resulting in a drastic increase of auxiliary beds that becomes a serious problem in mental health provision. The shutdown of big psychiatric hospitals in the process of psychiatric reform, accompanied by a delay in the establishment of all the anticipated beds in general hospitals together with overloaded and insufficient network of mental health services in the community are the major determinants. Additionally, fiscal economic crisis of the last decade intensified even more the problem by diminishing funding for the recruitment of new personnel and drastically reducing allocated funding for new and old services. In 2016 we set up a crisis intervention service for serious mental disorders within the operational framework of the emergency psychiatric services of the Department of Psychiatry in Eginition Hospital in Athens. The crisis resolution team is composed by two psychiatrists, a psychiatric nurse, social workers, a psychologist, mental health volunteers, and mental health trainees/students. The patient enters the service through the emergency service when an indication for hospitalization is given by the emergency psychiatrist, followed by the clinical estimation of a member of our team. The therapeutic team convenes twice a week for the new entrants and for follow-up sessions with the participation of the patient and the family members whenever feasible. The rest of the therapeutic interventions take place during the week. The work 'with' the person and not 'to' the person encapsulates the philosophy of the service, which is characterized by a holistic treatment approach aiming to empower the individual strengths and sense of control of the patient for crisis resolution on the basis of a safe therapeutic milieu. Therapeutic interventions include family and supportive members, as well as community interventions. In summation, interventions consist of a) comprehensive evaluation (psychiatric/ physical) and therapeutic plan, b) psychopharmacological treatment, c) psychotherapeutic support for the patient and the family for management of the crisis, d) training for the management of future crises and e) referral to appropriate community services for follow up management and treatment. Treatment lasts approximately 6-8 weeks. Initial data of the evaluation study indicate clinical effectiveness and high levels of satisfaction for patients and family. Conclusively, crisis management and resolution services are feasible even in a time of heavy restrictions in recourses, and anticipated benefits are multiple for the economy, mental health provision, the public health system, patients and relatives alike.

Community Psychiatry Care: An Urgent Need in Nigeria

Nigeria's mental health policy was formulated in 1991, but it did not make adequate provision for community-based psychiatric care. Since there are only seven government-owned psychiatry facilities in Nigeria and these are always overwhelmed, there is the need to overhaul the existing policy and emphasise the urgency of a shift from inpatient psychiatric mental healthcare towards a community-based multidisciplinary psychiatric healthcare system.

Organization of Community Psychiatric Services in Finland

Background

The Finnish psychiatric treatment system has undergone a rapid transformation from operating in institutional settings to a adopting a community-based approach, through implementation of national plans; this process was carried out quickly, due to a severe economic recession in the early 1990s.

Methods

This paper is a narrative review, based on relevant documents by national authorities, academic dissertations and published scientific literature, between 1984 and 2018, as well as the interviews of key experts in 2019.

Results

The municipality is currently the primary organization, responsible for all health services. Municipalities may also work together in organizing the services, either through unions of municipalities or hospital districts. Services are to a great extent outpatient-oriented. The number of beds is one fifth of the previous number, around four decades ago, despite the increase in population. In 2017, 191,895 patients in total (4% of Finns) had used outpatient psychiatric services, and the number of visits totalled 2.25 million. Psychotherapy is mainly carried out in the private sector by licensed psychotherapists. Homelessness in relation to discharged psychiatric patients has not been in evidence in Finland and deinstitutionalization has not caused an increase in the mortality rate among individuals with severe mental disorders.

Conclusion

Psychiatric patients have, in general, benefitted greatly from the shift from institutions to the community. This does not preclude the fact that there are also shortcomings. The development of community care has, to date, focused too heavily on resource allocation, at the expense of strategic planning, and too little on methods of treatment.

Community-based Mental Health Services in Norway

Community-based mental healthcare in Norway consists of local community mental health centres (CMHCs) collaborating with general practitioners and primary mental healthcare in the municipalities, and with psychiatrists and psychologists working in private practices. The CMHCs were developed from the 1980s to give a broad range of comprehensive mental health services in local catchment areas. The CMHCs have outpatient clinics, mobile teams, and inpatient wards. They serve the larger group of patients needing specialized mental healthcare, and they also collaborate with the hospital-based mental health services. Both CMHCs and hospitals are operated by 19 health trusts with public funding. Increasing resources in community-based mental healthcare was a major aim in a national plan for mental health between 1999 and 2008. The number of beds has decreased in CMHCs the last decade, while there has been an increase in mobile teams including crisis resolution teams (CRTs), early intervention teams for psychosis and assertive community treatment teams (ACT teams). Team-based care for mental health problems is also part of primary care, including care for patients with severe mental illnesses. Involuntary inpatient admissions mainly take place at hospitals, but CMHCs may continue such admissions and give community treatment orders for involuntary treatment in the community. The increasing specialization of mental health services are considered to have improved services. However, this may also have resulted in more fragmented services and less continuity of care from service providers whom the patients know and trust. This can be a particular problem for patients with severe mental illnesses. As the outcomes of routine mental health services are usually not measured, the effects of community-based mental care for the patients and their families, are mostly unknown.

A missed case of lurasidone induced laryngospasm: A case study and overview of extrapyramidal symptom identification and treatment

OBJECTIVE

Many patients with bipolar disorder are treated exclusively in primary care settings, and the use of atypical antipsychotics as primary treatment for bipolar depression is increasing. Extrapyramidal symptoms (EPS) are common side effects of antipsychotic medications, and clinicians should actively monitor for these symptoms when prescribing antipsychotic medications. Accurate diagnosis of EPS is especially important as the symptoms can be highly distressing, and in some cases, life threatening. Our aim is to familiarize primary care providers and other clinicians prescribing antipsychotic medications with EPS and to aid in its rapid diagnosis and treatment.

METHOD

We describe a case of lurasidone induced dystonia with prominent laryngospasm and oculogyric crisis which was missed for many years in the primary care setting, largely due to misdiagnosis of symptoms as being related to anxiety and panic attacks.

RESULTS

In addition to summarizing this illustrative case, we present the most common forms of EPS and summarize the primary therapies for each type of EPS.

CONCLUSIONS

With increased management of bipolar disorder in the primary care setting and increased use of atypical antipsychotics as the primary therapy for bipolar disorder, it is essential that all practitioners are prepared to actively monitor for EPS, followed by its rapid diagnosis and treatment.

Assessment of the Impact of a Daily Rehabilitation Program on Anxiety and Depression Symptoms and the Quality of Life of People with Mental Disorders during the COVID-19 Pandemic

Community psychiatry is a modern and effective form of care for patients with mental disorders. The aim of the study was to assess the impact of a rehabilitation program at the Mental Health Support Centre in Tarnowskie Góry (Poland) on reducing severity of anxiety and depression symptoms, as well as improving overall quality of life during the COVID-19 pandemic. The study involved 35 patients, examined with an authors’ questionnaire on sociodemographic data, the Hospital Scale of Anxiety and Depression (HADS) and the Short Form Health Survey (SF-36). Data was obtained during the first national lockdown and compared to data gathered before the pandemic on the same study group. Imposed restrictions, negative emotional state during lockdown, subjectively assessed higher health risk and a low level of knowledge about the COVID-19 pandemic did not significantly correlate with a severity of depression and anxiety, as well as general quality of life. However, the comparison of the results obtained in HADS and SF-36 scales show a significant improvement in both categories. Rehabilitation activities, including physical training, cognitive exercise and social therapy, reduce the severity of the symptoms and have a positive effect on the overall quality of life in patients suffering from schizophrenia and affective disorders. Therefore, holistic mental health support services may positively affect building an individual resilience. The severity of anxiety symptoms during the COVID-19 pandemic shows a negative correlation with the patient’s age.

A Community Psychiatry Nurse Practitioner Fellowship: Preparing Nurse Practitioners for Mental Health Workforce Expansion

The increasing need for psychiatry services in medically underserved communities has proven to be challenging for health care systems. Caring for this population is complex and can be overwhelming for the inexperienced provider. Proper utilization of psychiatric and mental health nurse practitioners in this setting can expedite meeting the mental health needs of the community. A postgraduate fellowship program that provides supervision and additional training specific to community psychiatry facilitates the transition from novice provider to experienced clinician while aiming to improve retention rates. In this Open Forum, the authors outline the structure of a federally qualified health center's Community Psychiatry Nurse Practitioner Fellowship.

Trends and issues in community mental health programs in India: The Ranchi Institute of Neuropsychiatry and Allied Sciences experience

Psychiatric disorders are among the leading causes of disability the world over. With the World Health Organization, spearheading the crusade to incorporate the mental health component into primary health care, developing countries also have accepted the need for community care of patients with psychiatric disorders. Since independence various initiatives by the government has led to a significant change in the place of mental health care as part of the general health care. At the time of independence apart from mental hospitals, there was practically no organized mental health care. Since then General Hospital Psychiatry units and also Psychiatric Nursing homes have started. Currently, mental health issues are actively seen as part of the public agenda in the various forms. The overall effect has been the movement to recognize mental health as an important issue in the community and services to move beyond mental hospital care to care to the community. Majority of population in Jharkhand is residing in rural areas. Due to the lack of proper communications and infrastructure, Ranchi Institute of Neuropsychiatry and Allied Sciences (RINPAS) had started community outreach program way back in 1999. At present, these centers are running in four different areas of the state with great success. RINPAS experience shows that how even with resource constraints, quality services can be provided to unreached population.

Impact Evaluation of VKN-NIMHANS-ECHO Model of Capacity Building for Mental Health and Addiction: Methodology of Two Randomized Controlled Trials

BACKGROUND

Bridging the alarming treatment gap for mental disorders in India requires a monumental effort from all stakeholders. Harnessing digital technology is one of the potential ways to leapfrog many known barriers for capacity building.

AIM AND CONTEXT

The ongoing Virtual Knowledge Network (VKN)-National Institute of Mental Health and Neurosciences (NIMHANS)-Extension of Community Health Outcomes (ECHO) (VKN-NIMHANS-ECHO: hub and spokes model) model for skilled capacity building is a collaborative effort between NIMHANS and the University of New Mexico Health Sciences Centre, USA. This article aims to summarize the methodology of two randomized controlled trials funded by the Indian Council of Medical Research (ICMR) designed to evaluate the effectiveness of the VKN-NIMHANS-ECHO model of training as compared to training as usual (TAU).

METHODS

Both RCTs were conducted in Karnataka, a southern Indian state in which the DMHP operates in all districts. We compared the impact of the following two models of capacity building for the DMHP workforce (a) the VKN-NIMHANS-ECHO model and (b) the traditional method. We use the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) statement to describe the methods of these two trials.Trial 1 is to evaluate the "Effectiveness of addition of Virtual-NIMHANS-ECHO tele-mentoring model for skilled capacity building in providing quality care in alcohol use disorders by the existing staff of DMHP districts of Karnataka." Hub for trial 1 was set up at NIMHANS and the spokes were psychiatrists and other mental health professionals headquartered in the district level office. Trial 2 assesses the implementation and evaluation of the NIMHANS-ECHO blended training program for the DMHP workforce in a rural south-Indian district of Karnataka state. The hub for trial 2 was set up in the district headquarter of Ramanagaram. Hub specialists are DMHP psychiatrists, whereas spokes are the non-doctor workforce (including auxiliary nurse midwives [ANMs] and accredited social health activists [ASHA] workers) medical officers of primary health centers. The location of the HubHub differs in these two studies. Both trials are funded by the ICMR, Government of India.

DISCUSSION

Both these trials, though conceptually similar, have some operational differences which have been highlighted. If demonstrated to be effective, this model of telementoring can be generalized and widely merged into the Indian health care system, thus aiding in reducing the treatment gap for patients unable to access care.

Methodology for Development of a Community Level Intervention Module for Physical Illness in Persons with Mental Illness (CLIPMI)

BACKGROUND AND OBJECTIVES

Medical illnesses seen in persons with psychiatric disorders are important but often ignored causes of increased morbidity and mortality. Hence, a community level intervention program addressing the issue is proposed.

MATERIALS AND METHODS

Patients with severe mental illnesses will be identified by a door-to-door survey and assessed for comorbid physical illnesses like anemia, hypertension, diabetes, and so on. They will then be randomized into two groups. The treatment as usual (TAU) group will not receive intervention from the trained community level workers, while the Intervention group will receive it.

RESULTS

The two groups will be compared for the prevalence and severity of comorbid physical illnesses. The expected outcome is compared to the TAU group, the intervention group will have a greater reduction in the morbidity due to physical illnesses and improved mental health.

CONCLUSION

If successful, the module can be incorporated into the community level mental health delivery system of the District Mental Health Program (DMHP).

Clergy as a frontline mental health service: a UK survey of medical practitioners and clergy

Background

Christian clergy have often been identified as ‘frontline mental health workers’ and gatekeepers to mental health services. However, despite this, collaboration between clergy and mental health services remains poor, with some US clergy referring on as little as 10% of cases.

Aims

In this study, we aimed to evaluate the collaborative relationship between UK clergy and medical practitioners, with the purpose of identifying key issues that should be addressed to improve such collaboration between the two services.

Methods

We surveyed 124 clergy, 48 general practitioners and 13 psychiatrists in Wales. Part 1 of the survey covered four main themes: demographics; types of mental health cases seen by clergy and practitioners; referral rates between clergy and mental health services; attitude and relationship between clergy and mental health services. Part 2 was directed at clergy only and assessed how sensitive clergy were in identifying and referring on mental health disorders by using seven virtual case vignettes.

Results

Clergy frequently encountered mental health cases and around 60%–80% regularly referred on to a healthcare professional. Clergy appeared very effective at identifying and referring on high risk scenarios, such as psychosis, suicidal ideation and substance misuse, however were less effective at identifying and referring on clinical depression and anxiety. Clergy rarely received referrals from medical professionals. Both medical professionals and clergy felt they needed to engage in a more collaborative relationship, and around of one-third of practitioners were prepared to offer training to clergy.

Conclusion

Most clergy in Wales regularly encounter mental health cases and appear effective at recognising and referring on mental health disorders; however, a large minority do not (20%–40%). Clergy generally do not receive referrals from mental health professionals, despite the proven benefits. Therefore, improving collaboration, developing spiritual training for mental health professionals, and mental health training for clergy is likely useful, a notion that many clergy and medical professionals deem important and are prepared to support.

Borderline personality disorder in Irish Travellers: a cross-sectional study of an ultra-high-risk group

BACKGROUND

Irish Travellers are a marginalised ethnic minority with poor health outcomes, especially in mental health: the suicide rate in this population is 6-7 times that in the general population. There is a paucity of research into associated clinical risk factors including self-harm and mental illnesses.

AIMS

To examine the prevalence and treatments of mental disorders among Travellers attending a community mental health team (CMHT) in Galway.

METHODS

This is a cross-sectional study of the CMHT database, and included all Travellers who were active cases on the study day were included in this study.

RESULTS

Travellers formed 12.4% (51 out of 410) of the active caseload of the mental health service. The mean age was 35.7 years (SD 13.1). The most common mental disorder was depressive disorder (16/51, 31.4%). Of 51 patients, 25.5% (13/51) were diagnosed with BPD: 7 had other comorbid mental disorders. Patients diagnosed with BPD are significantly more likely to be prescribed psychopharmacotherapy (t = 2.834, p = 0.007). A diagnosis of BPD was significantly associated with history of self-harm after controlling for age and gender (OR 2.3, p = 0.005).

CONCLUSION

This study shows that there is a significant overrepresentation of Travellers in mental health services, suggesting significant need for accessible and acceptable interventions. Those with a BPD diagnosis have a significantly higher risk of self-harm, representing an ultra-high-risk population. These findings can be used to plan future service development projects to better meet the needs of this population: they may require specially adapted version of the mentalisation-based treatment programme.

Reflections on the Life and Career of Émigré German-Canadian Psychiatrist Sebastian Klaus Littmann (1931-1986)

OBJECTIVE

This article explores the life and career of Sebastian K. Littmann. He was a foundational figure of the University of Calgary's Department of Psychiatry in his role as its second chair and, before this, as an influential administrator at Toronto's Queen Street Mental Health Centre and Clarke Institute during a transitional period in the 1970s-1980s. According to McGill University's Heinz Lehmann, this transitional period was when the field of psychiatry underwent an identity crisis that threatened to dissolve the discipline and see its functions increasingly filled by counsellors, neurologists, and primary physicians. Littmann's professional background and training in Edinburgh was followed by periods of community work in New York, which-by the time he immigrated to Canada-predisposed him to favour a humane and community-based approach to psychiatric work; this approach encompassed the cultural variations that were increasingly characterizing North America's urban social landscape. His compassionate and progressive approach to treatment was remarkable in light of his troubled and deprived upbringing in Nazi-era Germany.

CONCLUSIONS

The present sketch of Littmann's personal and professional biography serves to highlight the ways that major historical events and large-scale migration movements, which affected Central Europe, impacted the development of Canadian psychiatry and, by extension, individual Canadians in the twentieth century.

Workloads in Clinical Psychiatry: Another Way

Caseload and daily volume requirements present clinical and administrative challenges in organized settings primarily serving the public sector. These challenges are examined through lenses of systems-level fiscal viability, population health, and patient experience. Framed by previous efforts in caseload methodology, illustrative data collected from members of the American Association of Community Psychiatrists are discussed, with consideration of issues of professional effort and burnout. A systematic effort is needed to develop guidelines for caseload and volume expectations that support recovery outcomes, account for practitioner skills, and promote high-quality clinical encounters.

Closed for Business? Using a Mixture Model to Explore the Supply of Psychiatric Care for New Patients

OBJECTIVE

To investigate the degree to which psychiatrists are accessible to new outpatients and the factors that predict whether psychiatrists will see new outpatients.

METHODS

We used administrative health data on all practicing full-time psychiatrists in Ontario, Canada, over a 5-year period (2009-2010 to 2013-2014). We used a regression model to estimate the number of new outpatients seen, accounting for case mix, outpatient volume, and psychiatrist practice characteristics.

RESULTS

Approximately 10% of full-time psychiatrists are seeing 1 or fewer new outpatients per month, and another 10% are seeing between 1 and 2 new outpatients per month. Our model identified psychiatrists in 3 distinct practice styles. One practice style (representing 29% of psychiatrists), on average, saw fewer than 2 new outpatients per month and 69 unique outpatients annually. Relative to other practice styles, they tended to see fewer patients with a previous psychiatric hospitalization and fewer patients who lived in lower income neighbourhoods.

CONCLUSIONS

Nearly 1 in 3 full-time psychiatrists in Ontario see very few new outpatients. This has implications for access to care, particularly for outpatients with newly diagnosed mental illness. It also highlights the continued need to address access issues by assessing the role of psychiatrists within the Canadian health care system.

Predictors of quality of life among community psychiatric patients in a peri-urban district of Gauteng Province, South Africa

BACKGROUND

Few studies on quality of life (QoL) among people with mental illness have been conducted in South Africa, and none in community dwelling individuals. However, a greater understanding of subjective QoL may inform community-based medical, psychotherapeutic, or social interventions. This study examined the QoL, clinical and sociodemographic characteristics of psychiatric patients attending community mental health clinics in the Gauteng Province of South Africa.

METHODS

A cross sectional interview-based study was conducted with 121 adult patients attending community psychiatric clinics. To reduce the impact of acute psychiatric symptoms on subjective QoL, only clinically stable patients were included. Sociodemographic details and clinical characteristics were recorded. Subjective QoL was assessed using the World Health Organization QOL-Bref scale (WHOQOL-Bref), and severity of psychiatric illness measured with the Brief Psychiatric Rating Scale, expanded version 4.0 (BPRS-E).

RESULTS

Just over half of the sample rated their overall QoL as good or very good. Residual psychiatric symptomatology was the strongest predictor of a poor QoL in all four domains of the WHOQOL-Bref. The most severe BPRS scores were for the symptoms of depression, anxiety and somatic concern. Perceived social support significantly predicted a better QoL in the psychological, social relationships and environmental domains.

CONCLUSION

This study highlights the negative impact of residual psychiatric symptoms on subjective QoL and the importance of social support in enhancing QoL.

Canadian response to need for transformation of youth mental health services: ACCESS Open Minds (Esprits ouverts)

AIM

Youth mental health is of paramount significance to society globally. Given early onset of mental disorders and the inadequate access to appropriate services, a meaningful service transformation, based on globally recognized principles, is necessary. The aim of this paper is to describe a national Canadian project designed to achieve transformation of mental health services and to evaluate the impact of such transformation on individual and system related outcomes.

METHOD

We describe a model for transformation of services for youth with mental health and substance abuse problems across 14 geographically, linguistically and culturally diverse sites, including large and small urban, rural, First Nations and Inuit communities as well as homeless youth and a post-secondary educational setting. The principles guiding service transformation and objectives are identical across all sites but the method to achieve them varies depending on prevailing resources, culture, geography and the population to be served and how each community can best utilize the extra resources for transformation.

RESULTS

Each site is engaged in community mapping of services followed by training, active stakeholder engagement with youth and families, early case identification initiatives, providing rapid access (within 72 hours) to an assessment of the presenting problems, facilitating connection to an appropriate service within 30 days (if required) with no transition based on age within the 11 to 25 age group and a structured evaluation to track outcomes over the period of the study.

CONCLUSIONS

Service transformation that is likely to achieve substantial change involves very detailed and carefully orchestrated processes guided by a set of values, principles, clear objectives, training and evaluation. The evidence gathered from this project can form the basis for scaling up youth mental health services in Canada across a variety of environments.

Primary care consultation liaison and the rate of psychiatric hospitalizations: a countrywide study in Chile

Objectives

To assess the quality of consultation liaison across all primary health care centers in Chile, and its potential relationship with the psychiatric hospitalization rate.

Methods

We carried out a countrywide ecological cross-sectional study on 502 primary health centers in 275 municipalities (87.3% of total primary health centers in Chile) during 2009. We characterized the presence of consultation liaison using four criteria: availability, frequency, continuity of participants, and continuity across care levels. We also created a dichotomous variable called “optimal consultation liaison” for when all four criteria were met. A quasi-Poisson regression model was used to estimate the rate of hospitalization due to different psychiatric disorders, adjusting by population attributes.

Results

Of the primary health centers, 28.3% of them had had optimal consultation liaison during the preceding year, concentrated in the poorest and richest municipalities. Continuity of care was the criterion that was met least often (38.3%). The presence of optimal consultation liaison at the municipal level was associated with fewer psychiatric discharges, with the following incidence rate ratios and 95% confidence intervals (CIs): schizophrenia, 0.65 (95% CI: 0.49–0.85); other psychoses, 0.68 (95% CI: 0.52–0.89); and personality disorders, 0.66 (95% CI: 0. 49–0.89). Municipalities with optimal consultation liaison showed 2.44 fewer total psychiatric discharges per 10 000 inhabitants, although without reaching statistical significance (-0.85 to 5.70).

Conclusions

Using a nationally representative sample, we found that consultation liaison in primary care was associated with having fewer psychiatric hospitalizations. More studies are required to understand the role of each component of consultation liaison.

Community, Public Policy, and Recovery from Mental Illness: Emerging Research and Initiatives

This commentary examines the roles that communities and public policies play in the definition and processes of recovery for adults with mental illness. Policy, clinical, and consumer definitions of recovery are reviewed, which highlight the importance of communities and policies for recovery. This commentary then presents a framework for the relationships between community-level factors, policies, and downstream mental health outcomes, focusing on macroeconomic, housing, and health care policies; adverse exposures such as crime victimization; and neighborhood characteristics such as social capital. Initiatives that address community contexts to improve mental health outcomes are currently under way. Common characteristics of such initiatives and select examples are discussed. This commentary concludes with a discussion of providers', consumers', and other stakeholders' roles in shaping policy reform and community change to facilitate recovery.

Community treatment orders increase community care and delay readmission while in force: Results from a large population-based study

OBJECTIVE

There is debate about the effectiveness of community treatment orders in the management of people with a severe mental illness. While some case-control studies suggest community treatment orders reduce hospital readmissions, three randomised controlled trials find no effects. These randomised controlled trials measure outcomes over a longer period than the community treatment order duration and assess the combined effectiveness of community treatment orders both during and after the intervention. This study examines the effectiveness of community treatment orders in a large population-based sample, restricting observation to the period under a community treatment order.

METHODS

All persons ( n = 5548) receiving a community treatment order in New South Wales, Australia, over the period 2004-2009 were identified. Controls were matched using a propensity score based on demographic, clinical and prior care variables. A baseline period equal to each case's duration of treatment was constructed. Treatment effects were compared using zero-inflated negative binomial regression, adjusting for demographics, clinical characteristics and pre-community treatment order care.

RESULTS

Compared to matched controls, people on community treatment orders were less likely to be readmitted (odds ratio = 0.90, 95% confidence interval = [0.84, 0.97]) and had a significantly longer time to their first readmission (incidence rate ratio = 1.47, 95% confidence interval = [1.36, 1.58]), fewer hospital admissions (incidence rate ratio = 0.90, 95% confidence interval = [0.84, 0.96]) and more days of community care (incidence rate ratio = 1.55, 95% confidence interval = [1.51, 1.59]). Increased community care and delayed first admission were found for all durations of community treatment order care. Reduced odds of readmission were limited to people with 6 months or less of community treatment order care, and reduced number of admissions and days in hospital to people with prolonged (>24 months) community treatment order care.

CONCLUSION

In this large population-based study, community treatment orders increase community care and delay rehospitalisation while they are in operation. Some negative findings in this field may reflect the use of observation periods longer than the period of active intervention.

Beyond Social Media: A Cross-Sectional Survey of Other Internet and Mobile Phone Applications in a Community Psychiatry Population

OBJECTIVE

Popular media applications have been shown to benefit people with severe mental illness by facilitating communication and social support, helping patients cope with or manage symptoms, and providing a way to monitor or predict mental health states. Although many studies of technology use by individuals with severe mental illness have focused primarily on use of social media, this study provides additional information about use of Internet applications such as blogs, wikis (websites that allow collaborative editing of content and structure by users), video games, and Skype by a community psychiatry population.

METHODS

All English-speaking patients attending an outpatient program during a 4-week period in 2011 (N=274) were surveyed about their technology use and demographic information; 189 patients provided demographic data and comprised the sample.

RESULTS

Among Internet users (n=112), rates of use of message boards, wikis, Skype, role-playing games, and blogs ranged from 26.8% to 34.8%. Among mobile phone users (n=162), 41.4% used their phones to access the Internet and 25.3% used Twitter on their phones. In multivariate analysis, patients who had attended or completed college had much greater odds of accessing the Internet on mobile phones. Older patients were much less likely to access the Internet or use Twitter.

CONCLUSIONS

Our findings indicate that use of several popular forms of media is not uncommon in a community psychiatry population, but that rates of use differ on the basis of age and education. As the digital divide between people with severe mental illness and the general population is lessening, further research is needed to determine how to best leverage various types of media to support mental health recovery and complement clinical care.

Functioning of the various forms of mental health care in Poland in the years 2010-2013. Organizational, economic and financial aspects

OBJECTIVES

The main objective of the study was to verify the hypothesis about the high growth rate of expenditure on the provision of mental health in the past few years. High dynamics of the expenditure increase will result in the development of a model of community psychiatry and a gradual move away from the hospital psychiatric treatment towards mental health care in the open system, including the community one.

METHODS

This research is based on data on the implementation of services for mental health care in the framework of agreements with the National Health Fund, which has been collected in the NFZ IT system. Some information is from 2010, which was adopted as the base date for the implementation of the principles of the National Mental Health Program in 2011. The data from the implementation of individual benefits in 2013 were used for the comparison. In addition, other selected organizational, economic and financial elements of the psychiatric care system were analyzed.

RESULTS

In 2013, compared to 2010, increased the number of mental health care organizations: outpatient mental health clinics (an increase of 37 clinics), outpatient mental health day hospital wards (an increase of 25 wards) and community psychiatric treatment teams (an increase of 74 teams). The largest increase in the value of contracts (approx. 150%) was related to community treatment teams.

CONCLUSIONS

Between 2010 and 2013 there was an increase in the value of cleared contracts in psychiatric care, in general and in each of the three forms of psychiatric care (i.e., in day wards, outpatient mental health clinics and in community teams). The highest increase in investments included community treatment teams, to a lesser extent day wards and outpatient clinics. The adopted organizational, economic and financial solutions in the mental health care system are in line with the objectives of the National Mental Health Program, including the assumed structure of Mental Health Centers.

Japanese Outreach Model Project for patients who have difficulty maintaining contact with mental health services: Comparison of care between higher-functioning and lower-functioning groups

AIM

The Japanese Ministry of Health, Labor and Welfare sponsored the current examination of a new community mental health service, the Japan Outreach Model Project (JOMP), for persons with mental illnesses and who find it difficult to continue with ongoing treatment. Shorter readmission rates and hospital stays were found. In this study, the amount and type of care that were delivered by the JOMP were examined in order to inform the process of establishing the public insurance system.

METHODS

The data were collected from 32 JOMP outreach teams from 21 prefectures in Japan that agreed to participate; 415 patients were included in the analysis. The clients' characteristics, social functions, problematic behavior score, and the amount and type of care that were delivered were examined.

RESULTS

Higher amounts of care were delivered in the first month, compared to the remaining months, and the care was relatively stable from months 2-5. This suggests that consistently high care was needed for the JOMP clients who found it difficult to maintain contact with mental health services. Those clients with an increased overall global assessment functioning score at 6 months (n = 151) had received significantly more care than those whose functioning had decreased or remained stable (n = 150). The types of increased care that were provided to the higher functioning group were: "assistance with daily living tasks," "medical support for psychiatric symptoms," "empowering the client," "communication and coordination," "support for physical health," and "vocational and educational support."

CONCLUSION

The type and amount of care can positively influence good functional outcomes for those in the community who find it difficult to maintain contact with mental health services.

Violence exposure and resulting psychological effects suffered by psychiatric visiting nurses in Japan

WHAT IS KNOWN ON THE SUBJECT?: There is a developing body of research on violence in healthcare workplaces. Although psychiatric visiting nurses (PVNs) are an important group of professionals who provide medical services for people with mental disorders live in the community, little is known about the experiences and characteristics of violence exposure among PVNs, or the characteristics and work situations of PVNs related to violence exposure. WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE?: Approximately 40% of participants were exposed to violence during the previous 12 months; approximately 50% had been exposed during their PVN careers in PVN settings. The most frequent violence was verbal abuse. Longer career length as a PVN and greater number of visits per month were both positively associated with verbal abuse during the previous 12 months. Twenty-eight of the 34 participants (83%) who completed the IES-R-J survey had some residual psychological distress, and two (6%) had a potentially high risk of posttraumatic stress disorder. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: In devising policies and strategies against violence, PVN organizations and administrators should consider the characteristics of the violence, especially verbal abuse, as well as the characteristics and work situations of PVNs that are related to verbal abuse. Furthermore, they might provide relevant information on violence in PVN settings within their violence-prevention manuals or education. It would be important to provide support and to construct a safe workplace environment for PVNs who are experiencing residual psychological distress.

ABSTRACT

Introduction Psychiatric visiting nurses (PVNs) play a crucial role by providing medical services for community-living individuals with mental disorders in Japan. However, little is known about violence towards PVNs. Aim This cross-sectional study investigated violence during visits and the resulting psychological effects for PVNs. Methods PVNs were assessed using a violence exposure questionnaire and the Impact of Event Scale-Revised (IES-R-J); a measure of posttraumatic distress. Result Thirty-eight (41%) of 94 participants had experienced violence during the previous 12 months and 49 (53%) over their entire career. The most frequent violence was verbal abuse. Career length as a PVN and number of visits per month were significantly positively associated with verbal abuse during the previous 12 months. The IES-R-J scores indicated 28 of the 34 participants who completed the questionnaire exhibited psychological distress for the most traumatic violence during their career and two had a potentially high risk of posttraumatic stress disorder. Discussion and Implications Policies and strategies aimed at reducing violence in PVN settings should be developed according to characteristics of the violence, as well as the characteristics and work situation of PVNs. Furthermore, the provision of support and a safe workplace environment would be important for PVNs with residual psychological distress.

Family Burden, Emotional Distress and Service Satisfaction in First Episode Psychosis. Data from the GET UP Trial

Background: Literature has documented the role of family in the outcome of chronic schizophrenia. In the light of this, family interventions (FIs) are becoming an integral component of treatment for psychosis. The First Episode of Psychosis (FEP) is the period when most of the changes in family atmosphere are observed; unfortunately, few studies on the relatives are available.

Objective: To explore burden of care and emotional distress at baseline and at 9-month follow-up and the levels of service satisfaction at follow-up in the two groups of relatives (experimental treatment EXP vs. treatment as usual TAU) recruited in the cluster-randomized controlled GET UP PIANO trial.

Methods: The experimental treatment was provided by routine public Community Mental Health Centers (Italian National Health Service) and consisted of Treatment as Usual plus evidence-based additional treatment (Cognitive Behavioral Therapy for psychosis for patients, Family Intervention for psychosis, and Case Management). TAU consisted of personalized outpatient psychopharmacological treatment, combined with non-specific supportive clinical management and informal support/educational sessions for families. The outcomes on relatives were assessed by the Involvement Evaluation Questionnaire (IEQ-EU), the General Health Questionnaire (GHQ-12), and the Verona Service Satisfaction Scale (VSSS-EU). Differences within and between groups were evaluated.

Results: At baseline, 75 TAU and 185 EXP caregivers were assessed. In the experimental group 92% of relatives participated in at least 1 family session. At follow-up both groups experienced improvement in all IEQ and GHQ items, but caregivers belonging to the EXP arm experienced a significantly greater change in 10 IEQ items (mainly pertaining to the “Tension” dimension) and in GHQ items. Due to the low sample size, a significant effectiveness was only observed for 2 IEQ items and 1 GHQ-12 item. With respect to VSSS data at follow-up, caregivers in the EXP arm experienced significantly greater satisfaction in 8 items, almost all pertaining to the dimensions “Relatives' Involvement” and “Professionals' Skills and Behavior.”

Conclusions: The Family intervention for psychosis delivered in the GET UP PIANO trial reduced family burden of illness and improved emotional distress and satisfaction with services. These results should encourage to promote FIs on caregivers of first-episode psychosis patients.