The impact of reduced routine community mental healthcare on people from minority ethnic groups during the COVID-19 pandemic: qualitative study of stakeholder perspectives

BACKGROUND

Enduring ethnic inequalities exist in mental healthcare. The COVID-19 pandemic has widened these.

AIMS

To explore stakeholder perspectives on how the COVID-19 pandemic has increased ethnic inequalities in mental healthcare.

METHOD

A qualitative interview study of four areas in England with 34 patients, 15 carers and 39 mental health professionals from National Health Service (NHS) and community organisations (July 2021 to July 2022). Framework analysis was used to develop a logic model of inter-relationships between pre-pandemic barriers and COVID-19 impacts.

RESULTS

Impacts were largely similar across sites, with some small variations (e.g. positive service impacts of higher ethnic diversity in area 2). Pre-pandemic barriers at individual level included mistrust and thus avoidance of services and at a service level included the dominance of a monocultural model, leading to poor communication, disengagement and alienation. During the pandemic remote service delivery, closure of community organisations and media scapegoating exacerbated existing barriers by worsening alienation and communication barriers, fuelling prejudice and division, and increasing mistrust in services. Some minority ethnic patients reported positive developments, experiencing empowerment through self-determination and creative activities.

CONCLUSIONS

During the COVID-19 pandemic some patients showed resilience and developed adaptations that could be nurtured by services. However, there has been a reduction in the availability of group-specific NHS and third-sector services in the community, exacerbating pre-existing barriers. As these developments are likely to have long-term consequences for minority ethnic groups' engagement with mental healthcare, they need to be addressed as a priority by the NHS and its partners.

'Chugging along, plugging in and out of it': Understanding a place-based approach for community-based support of mental health recovery

Community-based Mental Health (MH) organisations in the United Kingdom (UK) are facing challenges for sustaining in-person service delivery. Without empirical evidence that demonstrates the value of a place-based approach for MH recovery, and the types of resources needed to build nurturing spaces for peer support, community-based MH organisations will struggle to maintain their physical spaces. We present empirical insights from a case study involving interviews with 20 students accessing peer support services at the Recovery College Collective, a community-based MH organisation located in the North East of England. The interview study aims to evidence how a place-based approach can afford MH recovery. We draw from discourses on place-making and interpret our interview findings through an established framework that highlights four mechanisms through which place impacts recovery: place for doing, being, becoming and belonging. We use this framework to structure our findings and highlight key qualities of place for establishing and maintaining MH recovery. Our contribution is two-fold: we address a gap in the literature by providing empirical understandings of how place influences MH recovery, whilst extending previous research by considering the role that place plays in community-based organisations. This is timely because of the challenges faced in securing in-person service delivery post-pandemic, and a shift towards remote service provision models. We highlight key implications: (i) Accessing a physical place dedicated to MH support is vital for people who do not have anywhere else to go and are socially isolated due to their health conditions; (ii) Connecting through peer-to-peer interaction is an integral part of the recovery process, and learning from people with lived experience can inform a place-based approach that best suit their needs; and (iii) Recognising the value of place for MH support, and the resources needed for peer support delivery in the community, will help secure places that our research participants described as lifesaving.

Transcending technology boundaries and maintaining sense of community in virtual mental health peer support: a qualitative study with service providers and users

BACKGROUND

This qualitative study explores the experiences of peer support workers (PSWs) and service users (or peers) during transition from in-person to virtual mental health services. During and following the COVID-19 pandemic, the need for accessible and community-based mental health support has become increasingly important. This research aims to understand how technological factors act as bridges and boundaries to mental health peer support services. In addition, the study explores whether and how a sense of community can be built or maintained among PSWs and peers in a virtual space when connections are mediated by technology. This research fills a gap in the literature by incorporating the perspectives of service users and underscores the potential of virtual peer support beyond pandemic conditions.

METHODS

Data collection was conducted from a community organization that offers mental health peer support services. Semi-structured interviews were conducted with 13 employees and 27 service users. Thematic analysis was employed to identify key themes and synthesize a comprehensive understanding.

RESULTS

The findings highlight the mental health peer support needs that were met through virtual services, the manifestation of technology-based boundaries and the steps taken to remove some of these boundaries, and the strategies employed by the organization and its members to establish and maintain a sense of community in a virtual environment marked by physical distancing and technology-mediated interrelations. The findings also reveal the importance of providing hybrid services consisting of a mixture of in person and virtual mental health support to reach a broad spectrum of service users.

CONCLUSIONS

The study contributes to the ongoing efforts to enhance community mental health services and support in the virtual realm. It shows the importance of virtual peer support in situations where in-person support is not accessible. A hybrid model combining virtual and in-person mental health support services is recommended for better accessibility to mental health support services. Moreover, the importance of organizational support and of equitable resource allocation to overcome service boundaries are discussed.

[Assertive Treatment as a regular function within mental health]

BACKGROUND

The setting for providing assertive treatment (AT) has changed during the last 30 years in The Netherlands from assertive community treatment (ACT) and flexible assertive community treatment (FACT) to municipalities. The provision of AT varies between municipalities.

AIM

Describing the concept of AT, the nature and size of the target group, and the reasons why people with severe mental illness (SMI) do not seek treatment and the place of AT in mental health care.

METHOD

We used literature en available quantitative data.

RESULTS

AT regularly provided by mental health care is required in patients with SMI and social problems who do not seek treatment. When mental health care and social care collaborate on the level of the patient, treatment and handling of social problems can strengthen each other. This collaboration prevents discontinuity of care and breaking a trusting relationship because patients do not need to be transferred from social service to mental health care or vice versa. AT is on the continuum of voluntarily to compulsory care.AT provided by mental health care (usually provided by FACT-teams) is indicated for SMI patients with social problems and who do not seek treatment. The size of the target group is around 5000 - 20.000 patients in The Netherlands. Reasons not to seek help for people with SMI include within person factor, mental health related factors, or factors related to the interaction of SMI patients and mental health. We advocate for AT to become a regular part of mental health care, and for mental health care and social domain professionals to collaborate on case level. Acting this way, mental health treatment and addressing social problems can reinforce each other and discontinuity of care and breaking a trusting relationship can be prevented. AT is on the continuum of voluntary to involuntary treatment. That is why we suggest AT to be a better term than assertive outreach.

CONCLUSION

It is a given fact that not all patients with SMI and social problems seek treatment. By making AT a regular part of mental health services, we prevent discontinuity of care and we fill the gap between voluntarily and compulsory care.

Adaptations and Innovations to Minimize Service Disruption for Patients with Severe Mental Illness during COVID-19: Perspectives and Reflections from an Assertive Community Psychiatry Program

Changes to community psychiatry during COVID-19 are unprecedented and without clear guidelines. Minimizing disruption, ensuring quality care to the already vulnerable people with serious mental illness is crucial. We describe and reflect our adaptations and innovations at one community psychiatry program, based on three key principles. In (i) Defining and maintaining essential services while limiting risk of contagion, we discuss such strategies and ways to assess risks, implement infection control, and other creative solutions. In (ii) Promoting health and mitigating physical and mental health impacts, we reflect on prioritizing vulnerable patients, dealing with loss of community resources, adapting group programs, and providing psychoeducation, among others. In (iii) Promoting staff resilience and wellness, we describe building on strength of the staff early, addressing staff morale and avoiding moral injury, and valuing responsive leadership. We also identify limitations and potential further improvements, mindful that COVID-19 and similar crises are likely recurring realities.

Young Adults and Their Families Living With Mental Illness: Evaluation of the Usefulness of Family-Centered Support Conversations in Community Mental Health care Settings

The aim of this study was to evaluate the usefulness of Family-Centered Support Conversations (FCSC) offered in community mental health care in Norway to young adults and their families experiencing mental illness. The FCSC is a family nursing intervention based on the Calgary Family Assessment and Intervention Models and the Illness Beliefs Model and is focused on how family members can be supportive to each other, how to identify strengths and resources of the family, and how to share and reflect on the experiences of everyday life together while living with mental illness. Interviews were conducted with young adults and their family members in Norway who had received the FCSC intervention and were analyzed using phenomenography. Two descriptive categories were identified: "Facilitating the sharing of reflections about everyday life" and "Possibility of change in everyday life." The family nursing conversations about family structure and function in the context of mental illness allowed families to find new meanings and possibilities in everyday life. Health care professionals can play an important role in facilitating a safe environment for young adults and their families to talk openly about the experience of living with and managing mental illness.

Arrest and emergency medical services events among participants from one of the first mental health courts

OBJECTIVE

This study looked at, in addition to subsequent arrest, emergency medical services (EMS) events as an outcome of participation in mental health court (MHC).

METHODS

We linked information from participants of a MHC in Marion County, Indiana with jail booking and EMS services data. To understand programmatic impact, we looked at differences in jail bookings and EMS events within one year prior to and one year after MHC participation. We ran paired t-tests to understand whether correlations were significant. We also considered differences in outcomes between those who successfully completed MHC versus those who did not.

RESULTS

MHC participation was significantly associated with a reduction in jail bookings and EMS events in the 12 months after program participation compared to the 12 months before. When comparing MHC participant groups, a significant reduction in jail bookings is found consistently whereas a significant reduction in EMS events was found in only some participant groups: the entire MHC group and the misdemeanor-level court (PAIR) participants when they successfully completed the program.

CONCLUSIONS

EMS utilization should be an outcome of consideration in evaluating the success and cost savings of MHCs. Where MHCs do not result in significantly reduced EMS events, communities should consider what individual-level and community-level factors contribute to this and adjust accordingly.

Computer-based cognitive rehabilitation program GRADIOR for mild dementia and mild cognitive impairment: new features

BACKGROUND

The growing number of older people and, with it, the increase of neurological impairments such as dementia has led to the implementation of the use of computer programs for cognitive rehabilitation in people with dementia. For 20 years, we have been developing the GRADIOR cognitive rehabilitation program and conducted several studies associated with its usability and effectiveness. This paper describes the development of the latest version of the GRADIOR computer-based cognitive rehabilitation program for people with different neurological etiologies, especially mild cognitive impairment and mild dementia.

RESULTS

GRADIOR is a program that allows cognitive evaluation and rehabilitation of people affected by cognitive impairment. The new version of GRADIOR is characterized by a structure that is dynamic and flexible for both user and therapist, consisting of: Clinical Manager, Clinical History Manager, Treatment Manager and Report Manager. As a structure based on specific requirements, GRADIOR includes a series of modalities and sub-modalities, each modality comprising a series of exercises with different difficulty levels.

DISCUSSION

Previous studies associated with earlier versions of GRADIOR have allowed the development of a new version of GRADIOR. Taking into account aspects associated with user experience, usability and effectiveness. Aspects that have made it possible to achieve a program that can meet the needs of older people with dementia.

The Early Burden of Disability in Individuals With Mood and Other Common Mental Disorders in Ontario, Canada

IMPORTANCE

Large population-based data on the trajectory to disability after the first diagnosis of a mood disorder are lacking.

OBJECTIVE

To assess the time between an incident mood disorder diagnosis and the receipt of disability services during a follow-up period of as long as 20 years.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used health administrative and social service data from ICES for 1 902 792 adults aged 18 to 59 years living in Ontario, Canada. A narrow cohort of individuals who had a new diagnosis of a mood disorder between October 1, 1997, and March 31, 2007, matched by sex and age to individuals with no history of mood disorder, included 278 296 participants. A broader cohort of individuals who had a new diagnosis of other common mental disorders during the same period, matched by sex and age to individuals with no history of mental disorder diagnosis, included 1 624 496 individuals. All individuals were followed up to a maximum end date of March 31, 2017. Data analysis was conducted from November 2017 to June 2018.

EXPOSURE

Incident diagnosis of mood or common mental disorder.

MAIN OUTCOMES AND MEASURES

Disability outcomes were as follows: (1) entry into the Ontario Disability Support Program (ODSP), signifying long-term inability to work because of a disability, and (2) admission into a long-term care (LTC) residence, signifying the inability to live in independent housing. Cox proportional hazards models were used.

RESULTS

In the full cohort of 1 902 792 individuals, 278 296 participants (14.6%) were included in the mood disorder cohort (mean [SD] age, 37.5 [11.9] years; 157 386 [56.6%] women), and 1 624 496 participants (85.4%) were included in the common mental disorder cohort (mean [SD], 36.5 [11.8] years; 932 545 [57.4%] women). The incidence of ODSP initiation was greater among individuals with mood disorders than those without (51.5 per 10 000 person-years vs 25.5 per 10 000 person-years; adjusted hazard ratio [aHR], 2.03; 95% CI, 1.95-2.11) and for those with common mental disorders (45.0 per 10 000 person-years vs 27.6 per 10 000 person-years; aHR, 1.57; 95% CI, 1.55-1.60). The aHR for admission to LTC was also higher among individuals with mood disorders compared with those without (aHR, 2.20; 95% CI, 1.80-2.69) and those with common mental disorders compared with those without (aHR, 1.21; 95% CI, 1.14-1.29). Individuals with bipolar disorders had greater ODSP rates than individuals with major depressive disorders (crude rate ratio: 4.31 [95% CI, 3.56-5.17] vs 1.82 [95% CI, 1.36-2.43]).

CONCLUSIONS AND RELEVANCE

This cohort study found that mood disorders were associated with elevated and early rates of disability services. Effective early intervention strategies targeting functional impairment in this population are encouraged.

Effect of Scheduling a Post-Discharge Outpatient Mental Health Appointment on the Likelihood of Successful Transition From Hospital to Community-Based Care

OBJECTIVE

This study examined a cohort of 15,520 inpatient psychiatric discharges to determine associations between scheduling an outpatient mental health appointment as part of discharge planning and attending outpatient care following discharge after control for patient, hospital, and system characteristics.

METHODS

2012-2013 New York State Medicaid and other administrative databases were used to examine patients who were aged under 65 years, admitted to an inpatient psychiatric unit, and discharged to the community. Outcomes included attending an outpatient mental health service within 7 and 30 days following inpatient discharge. Scheduling a mental health outpatient appointment as part of the discharge plan was the primary predictor variable, and potentially confounding covariates were addressed by adjusting for propensity scores estimating the likelihood of having an outpatient appointment scheduled.

RESULTS

Among 15,520 discharged patients, 11,945 (77%) had an outpatient appointment scheduled with a mental health provider as part of their discharge planning. After adjustment for propensity scores, patients who had an outpatient appointment scheduled were significantly more likely to attend an outpatient mental health service within 7 (OR = 1.69; 95% CI, 1.48-1.94) and 30 days (OR = 1.65; 95% CI, 1.42-1.93) compared to patients who did not have an appointment scheduled. Even among those with a low propensity to have an appointment scheduled, scheduling an outpatient appointment was associated with attending outpatient services.

CONCLUSIONS

Scheduling an outpatient mental health appointment is an effective and low-resource discharge planning practice that should be an important target for inpatient psychiatric clinical quality measurement and improvement.

Consumer expectations and experiences of quality in Australian home-based community services

Australians want to live at home as they age and seek support from health and social care services to achieve this. The consumer driven market-based approach to community services in Australia has resulted in an increases in user's expectations of quality. What constitutes a quality service from the consumer's perspective is an important agenda to understand as the focus of care delivery moves to the domiciliary setting. This paper presents one aspect from a grounded theory PhD study, the aim of which was to understand the lived experience of receiving services in the home and its impact on the meaning of home. Participants were 11 people with dementia and 18 family supporters living in the state of Victoria, Australia. Data were collected between 2015 and 2017 through multiple interviews, photographic images, field notes and memos. NVIVO 10 qualitative analysis software program was used to support constant comparative analysis. Using a grounded theory approach, this study found that the decision to engage with community services was driven by the need to maintain autonomy, self-identity and home life. Participants sought quality services but discovered a dichotomy of positive and negative aspects in the way services were delivered. The most common reaction to the experience of poor-quality care was to reflect on their expectations for care quality; and manage the reality of what was delivered. Team work and service responsiveness were positive characteristics but were offset by service limitations and inefficiencies caused by poor communication and poor staff retention. The interpersonal relationships that participants developed with staff was highlighted; trust was an important factor whereas unreliable, task orientated and poorly trained staff would be rejected. The implications for policy and practice are described.

Initiation of a multidisciplinary telemental health clinic for rural justice-involved populations: Rationale, recommendations, and lessons learned

Videoconferencing technology (VCT) is rapidly increasing in the mental healthcare industry and is becoming an attractive option to reach justice-involved populations. This paper first highlights the need for alternative service delivery solutions and reviews current literature on the use of VCT for correctional clients. We then outline the specific timeline, procedures, and barriers associated with the initiation of a virtual, multidisciplinary telemental health clinic for jailed and community-released offenders in a rural Mississippi county aimed at reducing criminogenic and psychiatric risks. Finally, we summarize generalizable recommendations for establishing community partnerships, developing structural and logistical processes, and delivering VCT while accounting for unique client factors and integrating evidence-based intervention strategies. We hope other community leaders will feel empowered to initiate similar programs that address needs within in their own jurisdictions.

Acquisition of Information About Innovative Practices in Outpatient Mental Health Clinics

This study uses qualitative interviews with leaders of 34 mental health clinics in the context of a statewide rollout of clinical and business innovations to explore how clinics first learn about innovations and which external sources of information they access. Clinic leaders reported accessing information about innovations mainly from government agencies, professional associations, peer organizations, and research literature. Leaders mentioned an average of two external sources of information. There was evidence of variation in how leaders accessed information and how information about innovations was communicated within clinics. Findings have implications for improving dissemination of information about innovations in mental health systems.

Social determinants of mental health care systems: intensive community based Care in the Veterans Health Administration

BACKGROUND

Since deinstitutionalization in the 1950s-1970s, public mental health care has changed its focus from asylums to general hospitals, outpatient clinics and specialized community-based programs addressing both clinical and social determinants of mental health. Analysis of the place of community-based programs within a comprehensive health system such as the Veterans Health Administration (VHA) may illuminate the role of social forces in shaping contemporary public mental health systems.

METHODS

National VHA administrative data were used to compare veterans who exclusively received outpatient clinic care to those receiving four types of specialized community-based services, addressing: 1) functional disabilities from severe mental illness (SMI), 2) justice system involvement, 3) homelessness, and 4) vocational rehabilitation. Bivariate comparisons and multinomial logistic regression analyses compared groups on demographics, diagnoses, service use, and psychiatric prescription fills.

RESULTS

An hierarchical classification of 1,386,487 Veterans who received specialty mental health services from VHA in Fiscal Year 2012, showed 1,134,977 (81.8%) were seen exclusively in outpatient clinics; 27,931 (2.0%) received intensive SMI-related services; 42,985 (3.1%) criminal justice services; 160,273 (11.6%) specialized homelessness services; and 20,921 (1.5%) vocational services. Compared to those seen only in clinics, veterans in the four community treatment groups were more likely to be black, diagnosed with HIV and hepatitis, had more numerous substance use diagnoses and made far more extensive use of mental health outpatient and inpatient care.

CONCLUSIONS

Almost one-fifth of VHA mental health patients receive community-based services prominently addressing major social determinants of health and multimorbid substance use disorders.

Factors to consider during the implementation of nutrition and physical activity trials for people with psychotic illness into an Australian community setting

BACKGROUND

Research in lifestyle interventions focusing on nutrition and physical activity in people living with psychotic illness, highlights anthropometric and metabolic benefits of these interventions. However, little is known about potential factors to consider during implementation into real-world contexts. Community-managed organisations (CMOs) that provide services for people with mental illness, offer an ideal implementation context for lifestyle interventions. Successful translation of lifestyle interventions into CMOs may be achieved though considering the factors associated with program access and delivery in these settings. This study primarily aimed to identify the factors that affect program access in a local CMO from the perspective of consumers and staff. The secondary aim was to describe the elements that impact on program delivery from the perspective of staff.

METHODS

Thirteen semi-structured interviews were conducted with 6 consumers and 7 staff in a CMO in regional Australia. Topics explored in interviews were based on implementation concepts identified in the "Integrated Promoting Action on Research Implementation in Health Systems" (i-PARIHS) knowledge translation framework. Thematic data analysis was conducted using Nvivo software.

RESULTS

Emergent themes on issues that influenced program access were (1) consumer financial status, domestic responsibilities, and health; (2) the design and delivery of programs; (3) structure and practices of the organisation; (4) attitude, skills and effort of staff involved in program delivery; and (5) social connections and stigma experienced by consumers during program access. Moreover, staff perceptions on elements that impacted program delivery highlighted themes on consumer attendance and interest in prospective programs, availability and restrictions to the use of funding, as well as the organisational structure and practices.

CONCLUSIONS

The factors affecting program access and delivery can generally be managed or planned for during the design of lifestyle interventions and subsequent translation into the CMO context. However, resolution of issues related to consumer financial status and health requires the collaboration of various government sectors for system-wide solutions.

Sense of community, pathway to, or bridge from alienation?

Psychological Sense of Community (PSOC) represents a formative conceptual offering of Community Psychology to the social sciences. Nearly five decades ago, PSOC offered a window into the influence of ecological factors to understanding the emotional and behavioral well-being of members of disenfranchised and underserved segments of the population, especially members of minority and low-income subgroups. Our discipline's founders viewed PSOC as one promising vehicle for pursuing the desired paradigmatic shift from individual to systemically focused interventions to achieve intended outcomes of the emerging community mental health movement. This Commentary reflects the authors' shared thoughts to the adoption of PSOC by conservative spokespersons to explain the resistance of some to the diversification of the population and growing voice of progressive advocates.

Barriers in seeking support: Perspectives of service providers who are survivors of sexual violence

Research with survivors of sexual violence suggests that most do not seek supportive services from community organizations. The purpose of this study is to understand the unique barriers that service providers, who are also survivors of sexual violence, may experience and how it informs their work with survivors. We conducted semi-structured interviews with 19 female, trans, and nonbinary survivors of sexual violence who are also employed as domestic violence or sexual assault advocates, community organizers, therapists, health care providers, educators, or substance abuse counselors, and had worked with survivors of sexual violence in their current positions. We coded the data using a multistep strategy derived from grounded theory. Participants indicated sensitivity to community-level barriers including where services are offered, perceived cost of services, and taking time off of work. Internalized blame, shame, minimization of their experiences, and trauma were also mentioned as significant barriers for themselves and impacted their work with survivors. Our findings suggest a need for trauma-informed intervention in community practice and policy.

Leadership that promotes successful implementation of community-based mental health interventions

Community-based interventions (CBIs) have become an effective approach to promote mental well-being. To increase organizational capacity and effectively deliver CBIs, leadership is crucial. The current study aims to identify leadership qualities that are facilitators of CBI implementation. This paper presents evaluation findings from a national effort emphasizing CBIs for improving the mental well-being of men and boys in 16 local communities. The study utilized a mixed-method design, including both examining each grantee as a case study and conducting a cross-site evaluation. Findings revealed five leadership qualities that contributed to CBIs' success: personal vision, value-based leadership, relationship-oriented leadership, task-oriented leadership, and leadership development. The results outline strategies for strengthening organizational capacity through these leadership qualities. This study adds to the limited literature on leadership qualities that strengthen organizational capacity to successfully implement CBIs and can serve as a guide for funders, program planners, and evaluators.

Effectiveness of embedding a specialist preventive care clinician in a community mental health service in increasing preventive care provision: A randomised controlled trial

OBJECTIVE

Clinical practice guidelines recommend that community mental health services provide preventive care for clients' chronic disease risk behaviours; however, such care is often not routinely provided. This study aimed to assess the effectiveness of offering clients an additional consultation with a specialist clinician embedded within a community mental health service, in increasing client-reported receipt of, and satisfaction with, preventive care.

METHOD

A randomised controlled trial was undertaken in one Australian community mental health service. Participants (N = 811) were randomised to receive usual care (preventive care in routine consultations; n = 405) or usual care plus the offer of an additional consultation with a specialist preventive care clinician (n = 406). Blinded interviewers assessed at baseline and 1-month follow-up the client-reported receipt of preventive care (assessment, advice and referral) for four key risk behaviours individually (smoking, poor nutrition, alcohol overconsumption and physical inactivity) and all applicable risks combined, acceptance of referrals and satisfaction with preventive care received.

RESULTS

Analyses indicated significantly greater increases in 12 of the 18 preventive care delivery outcomes in the intervention compared to the usual care condition from baseline to follow-up, including assessment for all risks combined (risk ratio = 4.00; 95% confidence interval = [1.57, 10.22]), advice for all applicable risks combined (risk ratio = 2.40; 95% confidence interval = [1.89, 6.47]) and offer of referral to applicable telephone services combined (risk ratio = 20.13; 95% confidence interval = [2.56, 158.04]). For each component of care, there was a significant intervention effect for at least one of the individual risk behaviours. Participants reported high levels of satisfaction with preventive care received, ranging from 77% (assessment) to 87% (referral), with no significant differences between conditions.

CONCLUSION

The intervention had a significant effect on the provision of the majority of recommended elements of preventive care. Further research is needed to maximise its impact, including identifying strategies to increase client uptake.

Meeting the Developmental Needs of Young Adults Diagnosed with Serious Mental Health Challenges: the Emerge Model

Adult providers struggle to engage 18-25-year olds despite high rates of serious mental health challenges observed among this age group. A new model, called "Emerge," combines the intensive outreach and multidisciplinary team-based approach used in Assertive Community Treatment with Positive Youth Development principles and practices used in the Transition to Independence Process Model. Emerge bridges youth and adult services, focuses on supporting transition-to-adulthood milestone achievement, and is a sister team to Coordinated Specialty Care for recent psychosis onset. This paper describes Emerge components, practices, and findings from a feasibility pilot study using agency administrative data. Most prevalent goals were employment and social support/relationship related. The majority made progress on individual goals, engaged in employment and education, and experienced decreased psychiatric hospitalizations. Community mental health policy and practice implications are discussed, including funding blending of evidence-based practices for those transitioning to adulthood with youth-onset serious mental health conditions.

Sociodemographic characteristics of youth in a trauma focused-cognitive behavioral therapy effectiveness trial in the city of Philadelphia

While randomized controlled trials of trauma-focused cognitive behavioral therapy (TF-CBT) have demonstrated efficacy for youth with posttraumatic stress disorder, TF-CBT effectiveness trials typically show attenuated outcomes. This decrease in effectiveness may be due to the differences in sociodemographic characteristics of youth in these trials; youth in efficacy trials are more often white and middle-income, whereas youth in effectiveness trials are more often racial/ethnic minorities, of low socioeconomic status (SES) and live in high crime neighborhoods. In this study-drawn from an effectiveness trial of TF-CBT in community mental health clinics across Philadelphia-we describe the sociodemographic characteristics of enrolled youth. We measured neighborhood SES by matching participants' addresses to American Community Survey data from their Census tracts, housing stability using the National Outcomes Measurement System, and neighborhood violence using police department crime statistics. Our results suggest that the majority of youth presenting for TF-CBT in mental health clinics in the City of Philadelphia live in poor and high-crime neighborhoods, experience substantial housing instability, and are predominantly ethnic and racial minorities. Thus, youth presenting for treatment experience significant racial and socioeconomic adversity. We also explored the association between these characteristics and youth symptom severity upon presenting for treatment. These factors were not associated with youth symptom severity or overall mental health functioning in our sample (with small effect sizes and p > .05 for all). Implications for future research, such as the need for efficacy and effectiveness trials to more fully characterize their samples and the need for pragmatic trials are discussed.

Montreal Cross-Training Program: The contribution of positional clarification activities to help bridge fragmented prevention and treatment services for co-occurring disorders

Co-occurring disorders in mental health and addiction present a high prevalence, but services available to prevent and treat them are often fragmented. Cross-training activities have been used to help minimise breaks in service continuity. This study assesses to what extent positional clarification (a specific type of cross-training activity) can help bridge fragmented services for co-occurring disorders by providing information and promoting interactions to help professionals better orient and treat their clientele. A total of 2,107 participations were recorded for 11 positional clarification events taking place within the Montreal Cross-Training Program for mental health and substance use disorders between 2010 and 2016. The Kirkpatrick four-level training evaluation model was used to evaluate these activities. Evaluation questionnaires (n = 1,650) and interviews with a convenience sample of 32 participants were analysed using descriptive statistics and thematic analysis. More than three-quarters of participants reported that the activity met their expectations and was relevant to their practice. Respondents also reported receiving useful information to better orient their clientele, discovering new resources, learning about the functioning of other resources, identifying members of other networks who could orient them when needed, and learning more about the theme of the activity and the different mechanisms for collaboration among the related services. Among those who participated in more than one positional clarification event, roughly three-quarters reported that they were able to call upon new resources at least once as a result of their participation, and were able to establish referrals towards resources that were unknown or less familiar to them prior to their participation. Results suggest that the programme meets its service integration objectives and that positional clarification events can lead to changes that can help facilitate the integration of fragmented services by improving participants' knowledge of specific themes and available resources to better orient and treat their clientele.

Coordinating Mental Health Services for People with Serious Mental Illness: A Scoping Review of Transitions from Psychiatric Hospital to Community

Effective coordination as people with serious mental illness (SMI) move between care settings is essential. We aimed to review challenges to care coordination for people with SMI and identify approaches for improving it. Sixteen articles were identified. Two main challenges emerged: people with SMI facing adjustment challenges during transitions and services struggling to provide continuity of care. Effective approaches addressed coordination challenges and resulted in better improvements in service utilization, social functioning and quality of life. Future interventions may benefit from shared decision-making, support for caregivers, and addressing the challenges associated with complicated medication regimes and accessing medications.

Mental health care in Rome

Aim

To describe principles and characteristics of mental health care in Rome.

Method

Based on existing data, service provision, number of professionals working in services, funding arrangements, pathways tocare, user/carer involvement and specific issues are reported.

Results

After the Italian psychiatric reform of 1978, an extensive network of community-based services has been set up in Romeproviding prevention, care and rehabilitation in mental health. A number of small public acute/emergency inpatient units inside general hospitals was created (median length of stay in 2002 = 8 days) to accomplish the shift from a hospital-based to a community-based psychiatric system of care. Some private structures provide inpatient assistance for less acute conditions (median length of stay in 2002 = 28 days), whilst the large Roman psychiatric hospital was closed in 1999.

Discussion

Whilst various issues of mental health care in Rome overlap with those in other European capitals, there also are some specific problems and features. During the last two decades, the mental health system in Rome has been successfully converted to a community-based one. Present issues concern a qualitative approach, with an increasing need to foresee adequate evaluation, especially considering mental health patients' satisfaction with services and economic outcomes.

Mental health care in London

Aim

To describe principles and characteristics of mental health care in London.

Method

Based on existing data, service provision, number of professionals working in services, funding arrangements, pathways intocare, user/carer involvement and specific issues are reported.

Results

London experiences high levels of need and use of mental health services compared to England as a whole. Inpatient andcompulsory admissions are considerably higher than the national average. Despite having more psychiatric beds and mental health staff, London has higher bed occupancy rates and staffing shortages. At the same time there is a trend away from institutionalised care to care in the community.

Conclusion

Mental health services in the UK are undergoing considerable reform. These changes will not remove the greater need formental health services in the capital, but national policy and funding lends support to cross-agency and pan-London work to tackle some of the problems characteristic of mental health in London. Whilst various issues of mental health care in London overlap with those in other European capitals, there also are some specific problems and features.

Mental health care in Belgrade — Challenges and solutions

Aim

To describe principles and characteristics of mental health care in Belgrade.

Methods

Based on existing data, service provision, number of professionals working in services, funding arrangements, pathways intocare, user/carer involvement and specific issues are reported.

Results

Disastrous events in the country and the region caused an increase of mental and behavioral disorders for 13.5% in the last few years, thus making them the second largest public health problem (after cerebro-vascular diseases). The overall morbidity and mortality are on the rise. Intense acute and chronic stress, as well as the accumulated traumas caused significant psychological sequelae, especially to vulnerable people.

Discussion

Whilst various issues of mental health care in Belgrade overlap with those in other European capitals, there are also some specific problems and features. Due to prolonged adversities, the health system has deteriorated and is facing specific challenges. However, the transformation of mental health services has been initiated, with a lot of positive movements, such as preparation of the National policy for mental health care as well as the Law for protection of mentally ill individuals.

Mental health care in Paris

Aim

Characterised by its population density, cultural and ethnic diversity, familial fragmentation and high levels of HIV/AIDS, crime and homelessness, Paris poses specific problems with regard to mental healthcare.

Methods

Epidemiological studies show high rates of generalised anxiety and drug and alcohol abuse and dependence, greater use ofpsychoactive medication and, at the same time, apprehension about looking after mentally ill family members at home.

Results

Although the Greater Paris area has a much higher density of GPs and specialists than the national mean, there are considerable variations within the region itself, with the central area having up to four times as many GPs or psychiatrists as the outer suburbs. On the other hand, although the number of mental health medical acts and the number of people receiving mental health care have been rising dramatically over the last 15 years, Paris has considerably less adult psychiatry beds and day care places per head of population than the rest of France.

Discussion

Current planning targets include a more equitable distribution of mental health care service provision for the rapidly evolving urban population, early prevention of psycho-affective disorders, suicide and drug and alcohol misuse and the creation of low threshold services for adolescents in difficulty.

Mental health care in Berlin

Aim

To provide information on the mental health care system in Berlin, Germany.

Method

Using available data we report on the spectrum of mental health care services provided in Berlin, the number of professionalsworking in these sectors, funding arrangements, pathways into care, and user/carer involvement.

Results

The health care system in Berlin consists of a network of inpatient, outpatient, ancillary, and rehabilitative facilities, all of which are meant to work in a synergistic fashion. However, although the individual treatment options are generally well-planned, there is still a lack of co-ordination between them. Currently, the entire network is threatened by cuts in state funding for ancillary and rehabilitative services, by further reductions in the number of hospital beds, and by insurance company cuts in prescription drug budgets, such as those used for atypical antipsychotics in outpatient care.

Discussion

Despite many similarities with the situation in other European capitals, the system of mental health care in Berlin suffersfrom a variety of problems related to co-ordination and costs that are unique to the German capital.

Impact of a district mental health care plan on suicidality among patients with depression and alcohol use disorder in Nepal

BACKGROUND

Large scale efforts to expand access to mental healthcare in low- and middle-income countries have focused on integrating mental health services into primary care settings using a task sharing approach delivered by non-specialist health workers. Given the link between mental disorders and risk of suicide mortality, treating common mental disorders using this approach may be a key strategy to reducing suicidality.

METHODS AND FINDINGS

The Programme for Improving Mental Health Care (PRIME) evaluated mental health services for common mental disorders delivered by non-specialist health workers at ten primary care facilities in Chitwan, Nepal from 2014 to 2016. In this paper, we present the indirect impact of treatment on suicidality, as measured by suicidal ideation, among treatment and comparison cohorts for depression and AUD using multilevel logistic regression. Patients in the treatment cohort for depression had a greater reduction in ideation relative to those in the comparison cohort from baseline to three months (OR = 0.16, 95% CI: 0.05-0.59; p = 0.01) and twelve months (OR = 0.31, 95% CI: 0.08-1.12; p = 0.07), with a significant effect of treatment over time (p = 0.02). Among the AUD cohorts, there were no significant differences between treatment and comparison cohorts in the change in ideation from baseline to three months (OR = 0.64, 95% CI: 0.07-6.26; p = 0.70) or twelve months (OR = 0.46, 95% CI: 0.06-3.27; p = 0.44), and there was no effect of treatment over time (p = 0.72).

CONCLUSION

The results provide evidence integrated mental health services for depression benefit patients by accelerating the rate at which suicidal ideation naturally abates over time. Integrated services do not appear to impact ideation among people with AUD, though baseline levels of ideation were much lower than for those with depression and may have led to floor effects. The findings highlight the importance of addressing suicidality as a specific target-rather than an indirect effect-of treatment in community-based mental healthcare programs.

A Case Study of Implementing Grant-Funded Integrated Care in a Community Mental Health Center

The US government funds integrated care demonstration projects to decrease health disparities for individuals with serious mental illness. Drawing on the Exploration Preparation Implementation Sustainability (EPIS) implementation framework, this case study of a community mental health clinic describes implementation barriers and sustainability challenges with grant-funded integrated care. Findings demonstrate that integrated care practices evolve during implementation and the following factors influenced sustainability: workforce rigidity, intervention clarity, policy and funding congruence between the agency and state/federal regulations, on-going support and training in practice application, and professional institutions. Implementation strategies for primary care integration within CMHCs include creating a flexible workforce, shared definition of integrated care, policy and funding congruence, and on-going support and training.

Identifying Essential Components of School-Linked Mental Health Services for Refugee and Immigrant Children: A Comparative Case Study

BACKGROUND

Foreign-born children rarely use traditional school mental health services. Comprehensive programs that combine mental health services with academic, economic, and socioemotional supports reach more foreign-born children and improve wellbeing. However, little practical guidance exists regarding how to best combine these diverse services.

METHODS

To identify essential service components and their organization, we interviewed 92 parents, school staff, mental health providers, and community agency staff from 5 school-linked mental health programs designed specifically to serve immigrant and refugee youth.

RESULTS

Foreign-born parents did not distinguish between academic, behavioral, and emotional help for their children; these western categorizations of functioning were not meaningful to them. Consequently, programs needed to combine 4 components, organized in a pyramid: family engagement, assistance with basic needs, assistance with adaptation to a new culture, and emotional and behavioral supports. Family engagement was the foundation upon which all other services depended. Assistance with economic and cultural stressors directly promoted emotional wellbeing and helped parents trust clinical mental health interventions.

CONCLUSIONS

Specific strategies to implement the 4 essential components include home visits by program staff, a one-stop parent center located in the school to help with basic needs, working with cultural brokers, and informed consent procedures that clearly explain recommended care without requiring immigrant and refugee parents to internalize western conceptualizations of psychopathology. Future evaluations should assess the cost and effectiveness of these strategies. These data are essential to advocate payment for these nonclinical services by traditional funding mechanisms.

Mental Health System Reform in Contexts of Humanitarian Emergencies: Toward a Theory of "Practice-Based Evidence"

Humanitarian emergencies such as armed conflicts are increasingly perceived as opportunities to improve mental health systems in fragile states. Research has been conducted into what building blocks are required to reform mental health systems in states emerging from wars and into the barriers to reform. What is less well known is what work and activities are actually performed when mental health systems in war-affected resource-poor countries are reformed. Questions that remain unanswered are: What is it that international humanitarian aid workers and local experts do on the ground? What are the actual activities they perform in order to enable and sustain system reform? This article begins to answer these questions through ethnographic case studies of mental health system reform in Kosovo and Palestine. Based on the findings, a theory of "practice-based evidence" is developed. Practice-based evidence assumes that knowledge is derived from practice, rather than the other way around where practice is believed to be informed by systematic evidence. It is argued that a focus on practice rather than evidence can improving system reform processes as well as the provision of mental health care in a way that is sensitive to local contexts, structural realities, culture, and history.

Perceived inability to help is associated with client-related burnout and negative work outcomes among community mental health workers

Community mental health is a vital service, but it faces ongoing challenges from its high staff-turnover rates. The current study provides a preliminary test of a novel explanation for employee disengagement in community mental health. It is proposed that providing assistance to clients, while simultaneously feeling that only limited progress is being made, is associated with client-related burnout among community mental health providers, leading to negative work outcomes. Employees (N = 349) from three non-governmental community mental health organisations in Australia completed a survey assessing their perceptions of client improvement from treatment, client-related burnout and a range of organisational outcomes. Analyses revealed that perceptions that clients are not improving was associated with burnout, which in turn is related to lower job satisfaction, decreased job engagement, poorer workplace well-being, and increased turnover intentions. These findings suggest that interventions that highlight positive changes among clients could reinforce the important service provided by community mental health employees and may minimise burnout and negative work outcomes.

The Role of Care Coordinators Versus Doctors in the Management of Chronic Mental Illness in the Community

Doctors play an important role in a multidisciplinary team, however therapeutic relationships are not limited to between a doctor and a patient. In Community Mental Health Teams, patients are allocated a care coordinator - usually a community psychiatric nurse or a social worker - and they usually become the healthcare provider the patient is most regularly in contact with. Similarly, a practice nurse in General Practice may be the healthcare professional a patient is most familiar with. In these instances, the patient-provider relationship may be stronger than the doctor-patient relationship. Non-doctor and patient relationships play an increasingly important role in improving the patient experience and contributing to information gathering, shared-decision making, and establishment and adherence to treatment plans. Care coordinators may be in a more superior position than doctors to accurately recognise the ongoing and changing needs of a person with mental illness. Patients value continuity of care, compassion, and mutual trust and respect: these qualities can potentially all be provided by any trained healthcare professional. In this paper, we will review the literature on the emerging role of the care coordinator and other healthcare professionals in the management of chronic mental illness in the community.

Impact of integrated district level mental health care on clinical and social outcomes of people with severe mental illness in rural Ethiopia: an intervention cohort study

AIM

There is limited evidence of the safety and impact of task-shared care for people with severe mental illnesses (SMI; psychotic disorders and bipolar disorder) in low-income countries. The aim of this study was to evaluate the safety and impact of a district-level plan for task-shared mental health care on 6 and 12-month clinical and social outcomes of people with SMI in rural southern Ethiopia.

METHODS

In the Programme for Improving Mental health carE, we conducted an intervention cohort study. Trained primary healthcare (PHC) workers assessed community referrals, diagnosed SMI and initiated treatment, with independent research diagnostic assessments by psychiatric nurses. Primary outcomes were symptom severity and disability. Secondary outcomes included discrimination and restraint.

RESULTS

Almost all (94.5%) PHC worker diagnoses of SMI were verified by psychiatric nurses. All prescribing was within recommended dose limits. A total of 245 (81.7%) people with SMI were re-assessed at 12 months. Minimally adequate treatment was received by 29.8%. All clinical and social outcomes improved significantly. The impact on disability (standardised mean difference 0.50; 95% confidence interval (CI) 0.35-0.65) was greater than impact on symptom severity (standardised mean difference 0.28; 95% CI 0.13-0.44). Being restrained in the previous 12 months reduced from 25.3 to 10.6%, and discrimination scores reduced significantly.

CONCLUSIONS

An integrated district level mental health care plan employing task-sharing safely addressed the large treatment gap for people with SMI in a rural, low-income country setting. Randomised controlled trials of differing models of task-shared care for people with SMI are warranted.

Collaborative care for child and youth mental health problems in a middle-income country: study protocol for a randomized controlled trial training general practitioners

BACKGROUND

Child and youth mental health problems are leading causes of disability and particular problems in low- and middle-income countries where populations are young and child mental health services are in short supply. Collaborative care models that support primary care providers' efforts to detect and treat child mental health problems offer one way to address this need. However, collaborative care for child mental health can be more complex than collaboration for adults for a number of reasons, including two-generational aspects of care, high degrees of co-morbidity, and variations in presentation across developmental stages.

METHODS

The study takes advantage of an existing collaborative care network in Tehran, Iran, in which general practitioners are supported by community mental health centers to care for adult mental health problems. At present, those practitioners are asked to refer children with mental health problems to the collaborating centers rather than treating them themselves. We are conducting a cluster randomized trial in which practitioners in the network will be randomized to receive training in child/youth mental health treatment or a booster training on recognition and referral. Children/youth aged 5-15 years making visits to the practitioners will be screened using the Strengths and Difficulties Questionnaire; those found positive will be followed for six months to compare outcomes between those treated by trained or control practitioners.

DISCUSSION

If the trial demonstrates superior outcomes among children treated by trained practitioners, it will support the feasibility of expanding collaborative care networks to include children.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03144739 . Registered on 8 May 2017.

Strengthening the Voice of Those with Mental Health Issues: A Community Approach to Developing a Mental Health Identification System

This article describes how an action research approach was used to involve a community of individuals with mental health issues and their support systems in the development and adoption of a mental health identification (ID) card. The intent of the card was to provide individuals with mental health issues a way to communicate and manage the idiosyncratic nature of their behaviors. A credit card-size ID card was developed that has the individual's picture, address, diagnosis, idiosyncratic behaviors, best approach with the individual when those behaviors are present, medications, allergies, and emergency contact information. Benefits and concerns about the ID system in regard to the cardholder, card recipients, the provision of consent, Health Insurance Portability and Accountability Act compliance, and the balancing of reducing and increasing stigmas and stereotypes emerged throughout the process. In the end, the ID card has come to be seen as a social justice mechanism that allows for communication and awareness for those with mental health issues.

Profile of home nursing clients with mental health diagnoses: Epidemiological analysis of Australian community home nursing data

Mental health is an important part of overall health status and mental ill health is common within the community. There is, however, little information relating to the mental health status of those in the community accessing services such as home nursing. The aim of this study is to profile mental health diagnoses and service use of persons accessing a community home nursing service. Retrospective data analysis was conducted of routinely collected administrative data from a service providing community home nursing in metropolitan Melbourne, Australia in 2014. Mental health diagnoses extracted from care records were International Classification of Disease code of 291-299 (Version-9) or F10-F99 (Version-10). Past-year prevalence for mental health diagnoses was 17%; lower than overall Australian prevalence (20%) and prevalence displayed in healthcare settings (25%-36%). The most prevalent class were mood [affective] disorders (7.8%), followed by neurotic, stress-related and somatoform disorders (4.8%). Schizophrenia, schizotypal and delusional disorders prevalence (2.5%) were more than twice that in the population (0.3%-1.0%). Those with a mental health diagnosis received between 40%-80% more visits than those without. These data demonstrate that the profile of mental health disorders in this population is complex, and that those with a mental health diagnosis experience higher care burden than those without. These findings will inform service planning and provision into the future.

Mental health in South Sudan: a case for community-based support

This paper² provides a snapshot of the mental health situation in South Sudan between 2013 and 2016, taking account of the personal reflections of both authors who were engaged in mental health and psychosocial support (MHPSS)³ programming in the country at this time.⁴ It begins by presenting an overview of MHPSS activities from this period, including governmental and non-governmental organisation (NGO) services, and relevant research and coordination mechanisms. It goes on to illustrate the challenges to the provision of support, as well as the overarching structural, governance, and human resource constraints faced by the sector. Finally, recommendations are put forward for improving services and care for people suffering from psychosocial and mental health issues, as well as suggestions for areas of focus in the future. The importance of an integrated, community-based model is emphasised, and opportunities for organisations engaged in reconciliation efforts and mental health service provision to collaborate are proposed.

Change in Patient Outcomes After Augmenting a Low-level Implementation Strategy in Community Practices That Are Slow to Adopt a Collaborative Chronic Care Model: A Cluster Randomized Implementation Trial

BACKGROUND

Implementation strategies are essential for promoting the uptake of evidence-based practices and for patients to receive optimal care. Yet strategies differ substantially in their intensity and feasibility. Lower-intensity strategies (eg, training and technical support) are commonly used but may be insufficient for all clinics. Limited research has examined the comparative effectiveness of augmentations to low-level implementation strategies for nonresponding clinics.

OBJECTIVES

To compare 2 augmentation strategies for improving uptake of an evidence-based collaborative chronic care model (CCM) on 18-month outcomes for patients with depression at community-based clinics nonresponsive to lower-level implementation support.

RESEARCH DESIGN

Providers initially received support using a low-level implementation strategy, Replicating Effective Programs (REP). After 6 months, nonresponsive clinics were randomized to add either external facilitation (REP+EF) or external and internal facilitation (REP+EF/IF).

MEASURES

The primary outcome was patient 12-item short form survey (SF-12) mental health score at month 18. Secondary outcomes were patient health questionnaire (PHQ-9) depression score at month 18 and receipt of the CCM during months 6 through 18.

RESULTS

Twenty-seven clinics were nonresponsive after 6 months of REP. Thirteen clinics (N=77 patients) were randomized to REP+EF and 14 (N=92) to REP+EF/IF. At 18 months, patients in the REP+EF/IF arm had worse SF-12 [diff, 8.38; 95% confidence interval (CI), 3.59-13.18] and PHQ-9 scores (diff, 1.82; 95% CI, -0.14 to 3.79), and lower odds of CCM receipt (odds ratio, 0.67; 95% CI, 0.30-1.49) than REP+EF patients.

CONCLUSIONS

Patients at sites receiving the more intensive REP+EF/IF saw less improvement in mood symptoms at 18 months than those receiving REP+EF and were no more likely to receive the CCM. For community-based clinics, EF augmentation may be more feasible than EF/IF for implementing CCMs.

Are resilience and perceived stress related to social support and housing stability among homeless adults with mental illness?

Perceived stress has been associated with adverse health outcomes. Although people experiencing homelessness often report multiple acute and chronic stressors, research on resilience and perceived stress on the general homeless population is limited. This longitudinal study examined homeless adults with mental illness who were part of a 24-month trial of Housing First to explore: (a) changes in levels of resilience and perceived stress during the trial, and (b) the association between levels of resilience and perceived stress with measures of social support, social functioning and percentage of days stably housed over the study period. This longitudinal study (2009-2013) that used trial data included 575 participants in Toronto, Ontario. Of these individuals, 507 were included in this study. Connor-Davidson Resilience Scale and Perceived Stress Scales (PSS) measured the two outcomes, resilience and perceived stress. Time (baseline, 12 and 24 months), housing stability and three measures of social support and social functioning were the main predictors. A longitudinal analysis was done with repeated measures analysis of resilience and perceived stress using linear mixed models with random intercepts. Mean resilience scores increased (baseline: 5.1 [95% CI: 4.9, 5.2], 12 months: 5.5 [95% CI: 5.3, 5.7], 24 months: 5.6 [95% CI: 5.4, 5.8]), and PSS scores decreased (baseline: 22.3 [95% CI: 21.5, 23.0], 24 months: 18.6 [95% CI: 17.9, 19.4]). In the multivariable analyses, increased resilience was associated with higher scores on the three social support and social functioning measures, (estimates = 0.12, 0.04, 0.02) but not percentage days stably housed. Lower PSS scores were associated with higher scores on all three social support and social functioning measures (-0.20, -0.33, -0.21) and higher percentages of days stably housed (-0.015). Strong social support and social functioning may minimise the harmful effects of stressful life events on homeless individuals by increasing resilience and reducing stress. Interventions to help homeless people build appropriate support networks should be delivered in parallel to efforts that increase housing stability.

[A French recovery-oriented mental health service based on housing.]

INTRODUCTION

The article aims at examining the various forms of mental healthcare services’ organization based on housing, in a context influenced by the innovative experiments of the deinstitutionalization struggles of the 1970’s. A Housing Service, having operated for decades to facilitate social integration, is currently focusing on promoting patients’ autonomy in their own apartment. An orientation to recovery has been adopted in the assistance of more autonomous patients who have not suffered any long-term hospitalization: they are considered as contractual users of the service.

METHOD

An ethnographic approach applied to a case study, combined with the tools of the sociology of engagement regimes, aims at analyzing how an instance of non-compliance affects the capacity-oriented organization of the service, through the apartment.

RESULTS

In the case that we have observed, the user’s refusal triggers an assessment procedure and a series of tests implied by the capacity-support approach of the service which eventually leads to the re-orientation of the assistance from the apartment to a medical facility.

CONCLUSION

The medical objective has been prioritized over social integration. We explore alternative ways to maintain the apartment as a therapeutic and social integration tool.

Delphi study to identify key features of community-based child and adolescent mental health services in the East of England

OBJECTIVE

To identify priorities for the delivery of community-based Child and Adolescent Mental health Services (CAMHS).

DESIGN

(1) Qualitative methods to gather public and professional opinions regarding the key principles and components of effective service delivery. (2) Two-round, two-panel adapted Delphi study. The Delphi method was adapted so professionals received additional feedback about the public panel scores. Descriptive statistics were computed. Items rated 8-10 on a scale of importance by ≥80% of both panels were identified as shared priorities.

SETTING

Eastern region of England.

PARTICIPANTS

(1) 53 members of the public; 95 professionals from the children's workforce. (2) Two panels. Public panel: round 1,n=23; round 2,n=16. Professional panel: round 1,n=44; round 2,n=33.

RESULTS

51 items met the criterion for between group consensus. Thematic grouping of these items revealed three key findings: the perceived importance of schools in mental health promotion and prevention of mental illness; an emphasis on how specialist mental health services are delivered rather than what is delivered (ie, specific treatments/programmes), and the need to monitor and evaluate service impact against shared outcomes that reflect well-being and function, in addition to the mere absence of mental health symptoms or disorders.

CONCLUSIONS

Areas of consensus represent shared priorities for service provision in the East of England. These findings help to operationalise high level plans for service transformation in line with the goals and needs of those using and working in the local system and may be particularly useful for identifying gaps in ongoing transformation efforts. More broadly, the method used here offers a blueprint that could be replicated by other areas to support the ongoing transformation of CAMHS.

The crime, mental health, and economic impacts of prearrest diversion of people with mental health problems: A systematic review

BACKGROUND

Prearrest diversion strategies are being adopted across the Western world, enabling the police to identify and divert people suspected of having mental disorder towards health and community services rather than the criminal justice system.

AIMS

To quantify longer-term criminal justice and mental health outcomes after prearrest diversion of people with suspected mental disorder and consider economic correlates.

METHODS

A systematic review of published literature on longer term outcomes after prearrest diversion.

RESULTS

Only two quasi-experimental studies, with four independent samples, could be included. Findings for criminal and mental health outcomes were inconclusive, but potential for adverse outcomes was identified. Ten studies with cost data suggested that prearrest diversion can lead to overall cost savings.

CONCLUSIONS

There is still inadequate evidence on which to base prearrest diversion programmes. Although some benefits have been identified by the review, so have possible harms. Future research and funding strategies must build in high-quality, systematic evaluation of outcomes before implementing a theoretically attractive strategy more widely.

Collaboration with Urban Community Stakeholders: Refining Paraprofessional-led Services to Promote Positive Parenting

This paper describes the process of a community-academic partnership to navigate implementation challenges for a school-based service model led by paraprofessionals to promote positive parenting in high poverty urban communities. We describe the process by which we (a) identified implementation challenges, (b) sustained a university-community collaboration to redesign the paraprofessional service model, and (c) assessed the feasibility of the new model involving four social service agencies in 16 schools with over 600 families. The structure and process of the collaboration and refinement are described with attention to who was best positioned to engage in the collaboration and how the partnership worked to balance scientific rigor with responsiveness to paraprofessional workforce strengths. Feasibility data indicated that the revised model was successfully implemented by paraprofessional staff; 92.2% of possible staff monthly reports were completed and discussion of key goals was incorporated into 94.2% of interactions. Continual monitoring provided critical feedback from stakeholders as we drew on and interpreted these various sources of information to build and refine the service model. We suggest that these processes are critical steps to bridge the research-to-practice gap, by promoting practices that are aligned with the needs of children and families, and the staff who serve them.

Child and Family Team Meeting Characteristics and Outcomes in a Statewide System of Care

Systems of care (SOC) have relied on the wraparound care process to individualize community-based services for children and youth with serious emotional and behavioral difficulties. A core element of wraparound care is Child and Family Team meetings (CFTs), which are designed to give youth and families a leadership role in developing and guiding their plan of care. The National Wraparound Initiative (NWI) has identified Practice Standards regarding CFT implementation. This study examined CFT characteristics and the association between those characteristics and youth and family outcomes in a statewide SOC. Participants were 363 youth (M_age  = 10.89, SD = 3.72) and their caregivers. Families completed measures of youth and caregiver functioning and symptoms at enrollment and 6-month follow-up. Care coordinators completed a survey assessing CFT implementation and characteristics following each meeting. Multiple regression analyses were used to examine the relationship between CFT characteristics and youth and caregiver outcomes. Results indicated that a higher number of CFTs was associated with poorer outcomes, while a higher percentage of natural supports at meetings was associated with better youth outcomes. Number of days to the first CFT was associated with greater caregiver strain. Implications for CFT implementation within wraparound are discussed.

Agreement and Discrepancy Between Supervisor and Clinician Alliance: Associations with Clinicians' Perceptions of Psychological Climate and Emotional Exhaustion

Despite increasing interest in supervision as a leverage point for bolstering public mental health services, the potential influence of supervisory alliance on organizations and direct service providers remains understudied, particularly in the context of supporting evidence-based treatment (EBT) use. This study examined agreement and discrepancy between supervisor and clinician ratings of alliance associated with clinicians' perceptions of psychological climate and emotional exhaustion. Results indicated that discrepancies in alliance ratings were common and associated with clinicians' perceptions of psychological climate. These findings have important implications for collaboration among supervisors and clinicians within a community mental health organizational context and the provision of EBTs.

Where do Peer Providers Fit into Newly Integrated Mental Health and Primary Care Teams? A Mixed Method Study

Little is known about the involvement of peer providers in integrated behavioral health teams. This study asks where peer providers fit within integrated care teams in Los Angeles County. Social network analysis combined with qualitative fieldwork was used to understand the network positions of peer providers in 14 integrated pilot programs. Four programs' peer providers were highly central, while 3 programs' were on the network's periphery. Positional variation appeared to be related to the peers' mental health status. Targeted efforts are needed to support the implementation of peer providers on integrated teams at the program and system levels.