Effects of a culturally adapted counselling service for low-income ethnic minorities experiencing mental distress: a pragmatic randomised clinical trial

BACKGROUND

Culturally competent early mental health interventions for ethnic minorities (EMs) with no formal diagnoses are needed.

OBJECTIVES

To determine whether 8-12 weeks culturally adapted counselling (CAC) is better than waiting (waitlist (WL) group) to reduce depressive and anxiety symptoms and stress levels among EMs with elevated mental distress.

METHODS

Hong Kong EMs with mild and above-mild mental distress were randomly assigned to CAC or WL in this pragmatic, randomised, WL-controlled trial. The CAC group received the intervention after randomisation and the WL group received the intervention after 8-12 weeks (T1). The prespecified primary outcomes were depressive and anxiety symptoms and stress levels measured by the Depression, Anxiety and Stress subscales of the Depression, Anxiety and Stress Scale (DASS-D, DASS-A and DASS-S, respectively) at postintervention (T1, 8-12 weeks).

FINDINGS

A total of 120 participants were randomly assigned to either CAC (n=60) or WL (n=60), of whom 110 provided primary outcome data. At T1, CAC led to significantly lower depressive and anxiety symptom severity and stress levels compared with waiting, with unstandardised regression coefficients of -8.91 DASS-D points (95% CI -12.57 to -5.25; d=-0.90),-6.33 DASS-A points (95% CI -9.81 to -2.86; d=-0.68) and -8.60 DASS-S points (95% CI -12.14 to -5.06; d=-0.90).

CONCLUSIONS

CAC clinically outperformed WL for mild and above-mild levels of mental distress in EMs.

CLINICAL IMPLICATIONS

Making CAC routinely available for EMs in community settings can reduce healthcare burden.

TRIAL REGISTRATION NUMBER

NCT04811170.

Employment Trends in Rhode Island From 2011 to 2017 for Adults With Intellectual Disability and Developmental Disabilities

This study reports on state-level data in Rhode Island on employment and non-work activities of adults with intellectual and developmental disabilities receiving services between 2011 and 2017. The goal was to examine the complex patterns of change over time in individual-level employment outcomes and the potential short-term impacts of a consent decree entered into by the state of Rhode Island to address integrated employment outcomes. Findings suggest that policy initiatives such as the consent decree can lead to reductions in reliance on facility-based work, but also highlight the importance of planning for the transition to competitive, integrated employment and not simply a shift toward non-work activities. Further, the data support the notion that the best predictor of integrated employment over time is previous experiences in integrated employment (not facility-based or other work or non-work activities), suggesting the role of ongoing supported employment and transition services that create and support the maintenance of integrated employment.

Changes in community mental health services availability and suicide mortality in the US: a retrospective study

BACKGROUND

Despite the fact that the overwhelming majority of mental health services are delivered in outpatient settings, the effect of changes in non-hospital-based mental health care on increased suicide rates is largely unknown. This study examines the association between changes in community mental health center (CMHC) supply and suicide mortality in the United States.

METHODS

Retrospective analysis was performed using data from National Mental Health Services Survey (N-MHSS) and the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) (2014-2017). Population-weighted multiple linear regressions were used to examine within-state associations between CMHCs per capita and suicide mortality. Models controlled for state-level characteristics (i.e., number of hospital psychiatric units per capita, number of mental health professionals per capita, age, race, and percent low-income), year and state.

RESULTS

From 2014 to 2017, the number of CMHCs decreased by 14% nationally (from 3406 to 2920). Suicide increased by 9.7% (from 15.4 to 16.9 per 100,000) in the same time period. We find a small but negative association between the number of CMHCs and suicide deaths (- 0.52, 95% CI - 1.08 to 0.03; p = 0.066). Declines in the number of CMHCs from 2014 to 2017 may be associated with approximately 6% of the national increase in suicide, representing 263 additional suicide deaths.

CONCLUSIONS

State governments should avoid the declining number of CMHCs and the services these facilities provide, which may be an important component of suicide prevention efforts.

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 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.

Atmiyata, a community-led intervention to address common mental disorders: Study protocol for a stepped wedge cluster randomized controlled trial in rural Gujarat, India

BACKGROUND

While lay-health worker models for mental health care have proven to be effective in controlled trials, there is limited evidence on the effectiveness and scalability of these models in rural communities in low- and middle-income countries (LMICs). Atmiyata is a rural community-led intervention using local community volunteers, called Champions, to identify and provide a package of community-based interventions for mental health, including evidence-based counseling for persons with common mental disorders (CMD).

METHODS

The impact of the Atmiyata intervention is evaluated through a stepped wedge cluster randomized controlled trial (SW-CRCT) with a nested economic evaluation. The trial is implemented across 10 sub-blocks (645 villages) in Mehsana district in the state of Gujarat, with a catchment area of 1.52 million rural adults. There are 56 primary health centers (PHCs) in Mehsana district and villages covered under these PHCs are equally divided into four groups of clusters of 14 PHCs each. The intervention is rolled out in a staggered manner in these groups of villages at an interval of 5 months. The primary outcome is symptomatic improvement measured through the GHQ-12 at a 3-month follow-up. Secondary outcomes include: quality of life using the EURO-QoL (EQ- 5D), symptom improvement measured by the Self-Reporting Questionnaire-20 (SRQ-20), functioning using the World Health Organization's Disability Assessment Scale (WHO-DAS-12), depression symptoms using the Patient Health Questionnaire (PHQ-9), anxiety symptoms using Generalized Anxiety Disorder Questionnaire (GAD-7), and social participation using the Social Participation Scale (SPS). Generalized linear mixed effects model is employed for binary outcomes and linear mixed effects model for continuous outcomes. A Return on Investment (ROI) analysis of the intervention will be conducted to understand whether the intervention generates any return on financial investments made into the project.

DISCUSSION

Stepped wedge designs are increasingly used a design to evaluate the real-life effectiveness of interventions. To the best of our knowledge, this is the first SW-CRCT in a low- and middle-income country evaluating the impact of the implementation of a community mental health intervention. The results of this study will contribute to the evidence on scaling-up lay health worker models for mental health interventions and contribute to the SW-CRCT literature in low- and middle-income countries.

TRIAL REGISTRATION

The trial is registered prospectively with the Clinical Trial Registry in India and the Clinical Trial Registry number- CTRI/2017/03/008139. URL http://ctri.nic.in/Clinicaltrials/regtrial.php?modid=1&compid=19&EncHid=70845.17209. Date of registration- 20/03/2017.

Improving the process of zoning in a community mental health team

Introduction

A zoning system is used to ensure that service users receive appropriate levels of support while they are using community mental health team (CMHT) services. Patients are split into red, amber and green zones and are discussed in a daily morning meeting to ensure management plans are in place. We identified that the meeting was an area for improvement as initial feedback indicated that the meeting was repetitive, newcomers to the team found that they did not understand why patients were in different zones and discussions were not being documented. Our three aims for the project were to improve staff-rated satisfaction by 25%, to improve weekly documentation of discussions to 100% and to improve the quality of information handed over by 25% over 4 months.

Methods

We used the Model for Improvement and "plan, do, study, act" (PDSA) cycles to test change ideas such as having someone chair the meeting, use of a ‘situation, background, assessment, recommendation, decision’ (SBARD) format to handover, introduction of a blue zone for inpatients and documentation in a specific part of the electronic notes at a specific time.

Results

We did not find our PDSA cycles led to a consistent change in satisfaction, quality and efficiency. We found an improvement of SBARD use up to 100% although this was not always consistent and an improvement in documentation to 100% for 3 weeks however this was not sustained.

Conclusion

On examining barriers to change, we found the key to sustaining improvement is in ensuring multidisciplinary team member involvement at all stages of the Quality Improvement project.

Association between health behaviors and mood disorders among the elderly: a community-based cohort study

BACKGROUND

According to a WHO report, nearly 15% of adults aged 60 and over suffer from a mental disorder, constituting 6.6% of the total disability for this age group. Taipei City faces rapid transformation towards an aging society, with the proportion of elderly in the total population rising from 12% in 2008 to 16% in 2016. The aim of this study is to identify the prevalence of mental disorders among the elderly in Taipei City and to elucidate risk factors contributing to mental disorders.

METHODS

The elderly health examination database was obtained from the Department of Health, Taipei City government, from 2005 to 2012. A total of 86,061 people underwent publicly funded health examinations, with 348,067 visits. Each year, there are around 43,000 elderly persons in Taipei City using this service. We used a mental health questionnaire including five questions to estimated relative risks among potential risk factors with the generalized estimating equations (GEE) model to measure the mental health status of the elderly. Mood disorders were measured with the Brief Symptom Rating Scale (BSRS-5) questionnaire. Age, education level, gender, marital status, living alone, drinking milk, eating vegetables and fruits, long-term medication, smoking status, frequency of alcohol consumption, frequency of physical activity, BMI, and number of chronic diseases were included as covariates.

RESULTS

The results show that being male (odds ratio (OR) 0.57; 95% CI = 0.56, 0.59), higher education (OR 0.88; 95% CI = 0.82, 0.95), no long-term medication (OR 0.57; 95% CI = 0.56, 0.58), and exercising three or more times per week (OR 0.94; 95% CI = 0.91, 0.98) were all positively correlated with better emotional status. However, being divorced (OR = 1.22, 95% CI = 1.09, 1.36), not drinking milk (OR = 1.12, 95% CI = 1.09, 1.14), not eating enough vegetables and fruits every day (OR = 1.78, 95% CI = 1.73, 1.83), daily smoking (OR = 1.15, 95% CI = 1.01, 1.32), and having more chronic diseases (OR = 1.02, 95% CI = 1.01, 1.03) were all correlated with poor mental status among the elderly.

CONCLUSIONS

The findings of this research can both estimate the prevalence of mood disorders at the community level, and identify risk factors of mood disorders at the personal level.

A systematic review of service models and evidence relating to the clinically operated community-based residential mental health rehabilitation for adults with severe and persisting mental illness in Australia

BACKGROUND

Clinically operated community-based residential rehabilitation units (Community Rehabilitation Units) are resource intensive services supporting a small proportion of the people with severe and persisting mental illness who experience difficulties living in the community. Most consumers who engage with these services will be diagnosed with schizophrenia or a related disorder. This review seeks to: generate a typology of service models, describe the characteristics of the consumers accessing these services, and synthesise available evidence about consumers' service experiences and outcomes.

METHOD

A systematic review was undertaken to identify studies describing Community Rehabilitation Units in Australia, consumer characteristics, and evidence about consumer experiences and outcomes. Search strings were applied to multiple databases; additional records were identified through snowballing. Records presenting unique empirical research were subject to quality appraisal.

RESULTS

The typology defined two service types, Community-Based Residential Care (C-BRC), which emerged in the context of de-institutionalisation, and the more recent Transitional Residential Rehabilitation (TRR) approach. Key differentiating features were the focus on transitional care and 'recovery' under TRR. Schizophrenia spectrum disorders were the most common primary diagnosis under both service types. TRR consumers were more likely to be male, referred from community settings, and less likely to be subject to involuntary treatment. Regarding outcomes, the limited quantitative evidence (4 records, 2 poor quality) indicated C-BRC was successful in supporting the majority of consumers transferred from long-term inpatient care to remain out of hospital. All qualitative research conducted in C-BRC settings was assessed to be of poor quality (3 records). No methodologically sound quantitative evidence on the outcomes of TRR was identified. Qualitative research undertaken in these settings was of mixed quality (9 records), and the four records exploring consumer perspectives identified them as valuing the service provided.

CONCLUSIONS

While there is qualitative evidence to suggest consumers value the support provided by Community Rehabilitation Units, there is an absence of methodologically sound quantitative research about the consumer outcomes achieved by these services. Given the ongoing and increasing investment in these facilities within the Australian context, there is an urgent need for high-quality research examining their efficiency and effectiveness.

TRIAL REGISTRATION

PROSPERO ( CRD42018097326 ).

Community-, facility-, and individual-level outcomes of a district mental healthcare plan in a low-resource setting in Nepal: A population-based evaluation

BACKGROUND

In low-income countries, care for people with mental, neurological, and substance use (MNS) disorders is largely absent, especially in rural settings. To increase treatment coverage, integration of mental health services into community and primary healthcare settings is recommended. While this strategy is being rolled out globally, rigorous evaluation of outcomes at each stage of the service delivery pathway from detection to treatment initiation to individual outcomes of care has been missing.

METHODS AND FINDINGS

A combination of methods were employed to evaluate the impact of a district mental healthcare plan for depression, psychosis, alcohol use disorder (AUD), and epilepsy as part of the Programme for Improving Mental Health Care (PRIME) in Chitwan District, Nepal. We evaluated 4 components of the service delivery pathway: (1) contact coverage of primary care mental health services, evaluated through a community study (N = 3,482 combined for all waves of community surveys) and through service utilisation data (N = 727); (2) detection of mental illness among participants presenting in primary care facilities, evaluated through a facility study (N = 3,627 combined for all waves of facility surveys); (3) initiation of minimally adequate treatment after diagnosis, evaluated through the same facility study; and (4) treatment outcomes of patients receiving primary-care-based mental health services, evaluated through cohort studies (total N = 449 depression, N = 137; AUD, N = 175; psychosis, N = 95; epilepsy, N = 42). The lack of structured diagnostic assessments (instead of screening tools), the relatively small sample size for some study components, and the uncontrolled nature of the study are among the limitations to be noted. All data collection took place between 15 January 2013 and 15 February 2017. Contact coverage increased 7.5% for AUD (from 0% at baseline), 12.2% for depression (from 0%), 11.7% for epilepsy (from 1.3%), and 50.2% for psychosis (from 3.2%) when using service utilisation data over 12 months; community survey results did not reveal significant changes over time. Health worker detection of depression increased by 15.7% (from 8.9% to 24.6%) 6 months after training, and 10.3% (from 8.9% to 19.2%) 24 months after training; for AUD the increase was 58.9% (from 1.1% to 60.0%) and 11.0% (from 1.1% to 12.1%) for 6 months and 24 months, respectively. Provision of minimally adequate treatment subsequent to diagnosis for depression was 93.9% at 6 months and 66.7% at 24 months; for AUD these values were 95.1% and 75.0%, respectively. Changes in treatment outcomes demonstrated small to moderate effect sizes (9.7-point reduction [d = 0.34] in AUD symptoms, 6.4-point reduction [d = 0.43] in psychosis symptoms, 7.2-point reduction [d = 0.58] in depression symptoms) at 12 months post-treatment.

CONCLUSIONS

These combined results make a promising case for the feasibility and impact of community- and primary-care-based services delivered through an integrated district mental healthcare plan in reducing the treatment gap and increasing effective coverage for MNS disorders. While the integrated mental healthcare approach does lead to apparent benefits in most of the outcome metrics, there are still significant areas that require further attention (e.g., no change in community-level contact coverage, attrition in AUD detection rates over time, and relatively low detection rates for depression).

Sibling Aggression Among Clinic-Referred Children and Adolescents

Aggression against siblings has been associated with a number of negative outcomes within community samples of children and adolescents, but little is known about this phenomenon within clinical samples. The current study empirically identified subtypes of sibling aggression, assessed prevalence within a clinic-referred sample of children and adolescents, and described risk factors associated with sibling aggression. Surveys were administered as part of the intake procedures at a community mental health center serving children and adolescents. The current study analyzed reports of sibling-directed aggression and mother-to-child aggression, as well as symptom counts, from a sample of 346 matched pairs of mothers and children or adolescents. Ages of child/adolescent participants ranged from 7 to 18 (M = 12.92, SD = 2.82) and were 55.8% male. The sample was primarily Caucasian (90.2%), were lower income, and resided in a semirural midwestern county. Sibling-directed aggression was reported by 93.1% of mothers and 82.4% of children. Principal components analyses identified two subtypes of sibling aggression, mild and severe. Mother and child/adolescent reports of sibling aggression demonstrated only moderate agreement. Mother-to-child verbal aggression and corporal punishment were more predictive of sibling aggression than more severe maternal aggression, and externalizing symptoms were also associated with sibling aggression. Sibling-directed aggression is very common among clinic-referred children and adolescents and may be an important target for treatment. Using multiple reports of sibling aggression could increase the chances of detection, as would awareness of other risk factors associated with sibling aggression.

Community-Based Providers' Selection of Practices for Children and Adolescents With Comorbid Mental Health Problems

The goal of this study is to explore providers' patterns of implementation by investigating how community mental health providers selected therapy practice modules from a flexible, modular evidence-based treatment working with youths with comorbid mental health problems. Data were obtained from 57 youths, 5-15 years old, presenting with anxiety, depressive, and/or conduct problems and their 27 providers during their participation in an effectiveness trial involving a modular evidence-based treatment. Although all youths evidenced clinically elevated symptomatology in at least two problem areas, providers targeted youths' comorbid problems with only about half of their study cases. Practice modules indicated for youths' comorbid problems were typically used less frequently and with less depth relative to practice modules indicated for youths' principal clinical problem and were often transdiagnostic in nature (i.e., designed to target more than one problem area). To determine whether providers' decisions to target youths' comorbid problems were systematic, multilevel, logistic regression analyses were conducted and revealed that youths' pretreatment characteristics and time in therapy influenced providers' patterns of module selection. Providers tend to use, but not exploit, the flexibility allowed by modular EBTs and to focus treatment on youths' principal presenting problem. In addition, providers appear to make these practice choices in a systematic and rational manner, and whether and which choices are associated with improved outcomes is an important area of future study.

Commentary on Community Mental Health and the Common Good

This article comments on the core question addressed by this Special Issue: "What's good about public sector mental health?" Theoretical, empirical, and programmatic insights derived from the Issue's six article contributions guide the overall commentary. Several points of thematic overlap are featured in these preliminary observations, and these themes are suggestive for directing future research (e.g., citizenship studies) in the field of community mental health. Copyright © 2017 John Wiley & Sons, Ltd.

Consumer providers' experiences of recovery and concerns as members of a psychiatric multidisciplinary outreach team: A qualitative descriptive study from the Japan Outreach Model Project 2011-2014

Objective

The objective of this study was to clarify consumer providers (CPs) subjective experiences as members of a psychiatric multidisciplinary outreach team that provided services to individuals with a mental illness living in the community.

Methods

A qualitative descriptive study was conducted through semi-structured interviews. Participants were clients hired as CPs in the Japanese Outreach Model Project from September 2011 until March 2014. Of the seventeen CPs, nine participated in this study. We looked at the CPs' subjective experiences of fulfillment and difficulty.

Results

In the process of providing services, CPs experienced both achievements and concerns. They had a sense of achievement by caring for their clients and they experienced that they themselves were recovering. They were also concerned about having inadequate knowledge and skills to provide psychiatric services to their clients. Further, there were concerns about their dual role on the multidisciplinary team and being support staff while they were still using mental health services themselves.

Conclusion

The results show that the activities of CPs included fulfillment, recovery, and dilemmas. Clarifications will likely contribute to an increase in understanding and cooperation between CPs and other professionals with whom they work. Further studies are needed to investigate policies related to mental health consumers who are also providers of mental health services.

An analysis of the federal funding for mental health care in Brazil

This article analyzes spending on mental health by the Brazilian Ministry of Health between 2001 and 2014. It is documental research of the Brazilian Ministry of Health's databases. It analyzes the data using descriptive statistical analysis. Total spending on mental health for the period 2001 to 2014 shows a percentage increase in resources destined for outpatient care, but this increase is a reallocation from hospital services to community-based services and total resources for the mental health program remain at an average of 2.54% of the total health budget. Within outpatient expenditure, spending on medications remains high. Professionals committed to psychiatric reform fight to guarantee that a small fraction of the surplus appropriated by the state is directed towards social policies.

Clinical Community Psychology: Reflections on the Decades Following Swampscott

The Swampscott report was foundational, but in some ways reflected divisions within community psychology that have continued into the present. Community psychologists trained in the 1970s and, especially, the 1980s confronted a period where the original focus of community mental health began to have less influence in the mental health field due to a variety of public policies, and the growth of third party payments as a significant source of health care funding. Programs that engaged communities and provided a base for prevention interventions were greatly curtailed because of changes in federal legislation and limited opportunities for state and local funding, although prevention interventions found growing interest from research funders. Clinical and community psychologists who trained in this period increasingly looked to a variety of areas outside of mental health. Consequently, the field of community psychology has become more applied and less academic, with increased attention to advocacy, theory, and global perspectives. The sweep of these changes and their implications for the future of the field are discussed here.

Commentary on the Future of Community Psychology: Perspective of a Research Community Psychologist

Community psychology is commented upon from the perspective of a community psychologist who was trained in the Community Psychology Program at the University of Michigan in Ann Arbor. Her background and training are reviewed. A brief survey of research on homelessness as a frame for community psychology research is presented. Concluding remarks are provided on the future of research in community psychology.

Reflections on a Community Psychology Setting and the Future of the Field

The 50th anniversary of the Swampscott Conference offers an opportunity to reflect on a community psychology setting, The Consultation Center at Yale, that was formed in response to the 1963 Community Mental Health Act and the 1965 Swampscott Conference. The Center has flourished as a community psychology setting for practice, research, and training for 39 of the 50 years since Swampscott. Its creation and existence over this period offers an opportunity for reflection on the types of settings needed to sustain the field into the future.

[Art, mental health, and public healthcare: profile of a care culture in the history of São Paulo city]

By studying the inclusion of artistic and cultural activities in the care provided throughout the history of public mental healthcare in greater São Paulo, Brazil, we can better understand and characterize the practices adopted in the Psychosocial Care Centers in the city today. Experiments carried out between the 1920s and 1990s are investigated, based on bibliographic research. The contemporary data were obtained from research undertaken at 126 workshops at 21 Psychosocial Care Centers in the same city between April 2007 and April 2008. The findings indicate that the current trend in mental healthcare, whose clinical perspective spans the realms of art and mental health and has territorial ramifications, has maintained some of the features encountered in earlier mental healthcare experiments.

[Practice of Community Psychiatry for the Treatment of Depression]

The practice in the psychiatric division of Kitasato University East Hospital and Kitasato University Hospital has been emphasizing community psychiatry. The problems and proposed solutions are discussed. 1. Both hospitals are core hospitals located in Sagamihara City (Kanagawa Prefecture), which has no municipal hospital. 2. Kitasato University East Hospital has 94 beds in two closed wards and is one of the hospitals designated for psychiatric emergencies in Kanagawa Prefecture. 3. Over the last 10 years aroud Sagamihara City, cooperation between psychiatric hospitals and outpatient clinics, the treatment of patients with mental and physical diseases, improvement of the quality of psychiatric practice, emergency psychiatry, and imbalances in the incomes and workloads of psychiatrists have been problematic. 4. Problems that need to be solved in practice to treat depression involve inappropriate pharmacotherapy, disease mongering (the practice of widening the diagnostic boundaries of illnesses in order to expand the markets for drug treatment), clinical skills of psychiatrists, profitability, and medical institutions which cannot cope with regular patients in an emergency. 5. Up to now, we have established a consulting service ("Second opinion" clinic) at Sagamihara Mental Health and Welfare Center (Municipal institution), recommended patients' consultation with family pharmacists, and increased the frequency of conferences for doctors without the support of pharmaceutical companies. 6. In order to develop community psychiatric services for patients with depression, the author is preparing a community-based critical path for depression as well as community-based treatment network in the Sagamihara area. 7. The author believes that the urgent issue necessitates transparency and the increased visibility of psychiatric services.

[Fifty years of public service for Quebec community psychiatry services. Part I]

This essay comprises 2 parts. It aims to recognize the public service of psychiatrists of the Département de psychiatrie de l'Université de Montréal who served at the provincial level of the Ministry of Health and Social Services for deinstitutionalisation of policies and organisation of services, at the service of people with severe mental disorders. First with Dr. Camille Laurin post-face of the 1962 book Les fous crient au secours! (Mentally ill patients cry for help); then the insight on the latest phase of differentiated specialised clinics by Dr. Denis Lazure, who participated in 1962 to the Bédard, Lazure, Roberts commission that launched community psychiatry, but who will also be Social Affairs Minister in the late '70 s; Dr. Arthur Amyot will sail through the budgetary issues when in the beginning of the '80s the mental health directorate was under Social Affairs; Dr. Luc Blanchet will be associated to a rich production of interdisciplinary reports by the advisory Mental Health Committee until its dismissal in 2003; and finally, Dr. André Delorme, who probably has the record of longevity at the head of the mental health directorate, transferred in 2003 under the deputy minister for medical and university affairs.The essay will propose since the beginning a grid or referential of four health services analysis. First; the arguments for community care by British and Italian psychiatrists and researchers, Thornicroft and Tansella. Second; system issues of mental health reforms proposed by Canadian psychiatric nurse and researcher Paula Goering. Third; the model of socio-political regulation of health system proposed by the Université de Montréal' health administration researcher Dr. André-Pierre Contandriopoulos; and Fourth; the structural tension between the medical and social sector signaled by the American medical sociologist, Leutz.The same phases of deinstitutionalization in other countries as UK, took place as followed: a) the asylum phase (before 1960); b) the psychiatry community (1960-2000); and c) the differentiated system (since 2000). The essay will evidence the long march towards hospitals without walls, interdisciplinary work, tension between cure and rehabilitation and a relative decreasing budget. This in conjunction with vulnerability in organisation and leadership, attributed to tension or burn out has revealed system deficits like the trans-institution towards homelessness or towards the judiciary system. The essay will conclude with a discussion on the opportunities and challenges of the very new Law 10 that reforms the general governance of the provincial and regional health and social services and hopes for a more balanced mental health care system in Quebec.

[The changes in values and beliefs through the first 50 years of the department of Psychiatry at the University of Montreal]

This essay attempts to describe and discuss the major changes in values and fundamental beliefs related to clinical practice within the Département de psychiatrie de l'Université de Montréal since its creation fifty years ago.Being an essay, the methods include shared recollections, discussions with colleagues, especially between the co-authors, and the study of some documents related to the practice of psychiatry 40 to 50 years ago.Five major axes of change are proposed: 1- From psychoanalysis to brain diseases, 2- From "Can a non-physician practice psychoanalysis?" to "Can a psychiatrist still perform psychotherapy?" 3- From continuity of care to episodes of treatment, 4- From treatment first to repeated assessments of patients, 5- From love that can heal and repair to a taboo of love.Finally it is suggested that the increasing emphasis on psychopharmacology and on DSM classifications has contributed to a shift from attempts to understand the intimate nature of symptoms and suffering to a priority given to rather mechanical clinical assessments in search of "objective" criteria.

How should community mental health of intellectual disability services evolve?

Services for people with Intellectual Disability (ID) and coexisting mental health problems remain undeveloped; research into their effectiveness has been lacking. Three linked recent studies in the UK have provided evidence on essential service provision from staff, service users and carers. Interfaces with mainstream mental health services were seen as problematic: the area of crisis response was seen as a particular problem. Further services’ research is needed, focusing on service components rather than whole service configurations. There was not support for establishing more intensive mental health services for people with ID only. The way forward is in developing new ways of co-working with staff in “mainstream” mental health services. Mental health of ID staff might often be best situated directly within these services.

[Survey of actual condition of outreach activity of multi-disciplinary team in Japan]

In Japan, some agencies have begun to provide a multi-disciplinary outreach team for people with severe mental illnesses. A medical fee system specially designed for the outreach team has not been developed, so existing fees cannot cover all activities of the team. This undeveloped legal system for the outreach team and inadequate finances are the main obstacles to dissemination in Japan. In order to plan and realize a valid medical fee system for the multi-disciplinary outreach team, we described the financial conditions of such activities in Japan.

[Models of community care for people with severe mental illness: an evaluation of assertive community treatment]

Today's psychiatric treatment system in Japan is hospital-based. It is supported by mental hospitals established after 1960. However, the psychiatric treatment system has already changed to community-based treatment in other developed countries. So, we need to change to the community-based system for those who are suffering from severe mental illness such as schizophrenia to realize deinstitutionalization. Assertive Community Treatment (ACT) is one of the effective community support programs to improve this situation. It is important to develop a program like "ACT" for clinical and cost effectiveness.

Learning and change in a community mental health setting

This article offers methodological reflections and lessons learned from a three-year university-community partnership that used participatory action research methods to develop and evaluate a model for learning and change. Communities of practice were used to facilitate the translation of recovery-oriented and evidence-based programs into everyday practice at a community mental health agency. Four lessons were drawn from this project. First, the processes of learning and organizational change are complex, slow, and multifaceted. Second, development of leaders and champions is vital to sustained implementation in an era of restricted resources. Third, it is important to have the agency's values, mission, policies, and procedures align with the principles and practices of recovery and integrated treatment. And fourth, effective learning of evidence-based practices is influenced by organizational culture and climate. These four lessons are expanded upon and situated within the broader literature and implications for future research are discussed.

Audit to identify the number of patients with multiple diagnoses in a community mental health team in Bedford, England

BACKGROUND

Patients with 'simple' mental health problems should be able to be managed exclusively in primary care. It is therefore anticipated that only the more complex cases would be referred to secondary care. In order to test this hypothesis, the number of patients registered with a community mental health team (CMHT) in Bedford, United Kingdom, who had received multiple psychiatric diagnoses in 2010, 2011 and 2013, was determined and analysed.

METHOD

Using a secure and anonymised Microsoft Excel® database that contains all patient data, the proportions of patients with more than one diagnosis were audited and thus determined for the months of August 2010, June 2011 and February 2013. The total number of patients registered was also determined for comprehensiveness. We had established the basic audit standard that every patient should have only one mental health diagnosis if this was possible.

RESULTS

Many patients were indeed found to have received multiple diagnoses. Furthermore, an increase in the proportion of patients with multiple diagnoses was observed; from 23.2% in 2010 to 25.2% in 2011 to 34.3% in 2013.

DISCUSSION

Several psychiatric conditions have been shown to be associated with particular psychiatric co-morbidities, which may be one reason why many of the Bedford CMHT's patients receive multiple diagnoses. Furthermore, the trend observed may reflect improving mental healthcare in primary care and therefore fewer referrals of patients with 'simple' mental health conditions to secondary care, thus causing the CMHT's caseload to become increasingly complex. It may also reflect improving communication between primary and secondary care, which may also lead to fewer referrals. Finally, the trend may merely reflect better use of the available database.

CONCLUSION

We have found that numerous patients received multiple diagnoses. We have also observed an increase in the proportion of such patients over three years, which may reflect improved management of mental health problems in primary care. Our results may therefore provide an incentive to establish formal shared care of psychiatric patients between primary and secondary care to improve patient management even further. Furthermore, our results reflect the complexity of the cases referred to secondary care, which are far more difficult to treat than those exclusively managed in primary care.

The role of community rehabilitation providers in employment for persons with intellectual and developmental disabilities: results of the 2010-2011 National Survey

Based on the 2010-2011 National Survey of Community Rehabilitation Providers, findings are presented on people with all disabilities and people with intellectual and developmental disabilities (IDD) who are served in employment and nonwork settings by community rehabilitation providers. Findings suggest little change over the past eight years in participation in integrated employment. Overall, 28% of all individuals and 19% of individuals with IDD were reported to receive individual integrated employment services. The results suggest that 15% of individuals with IDD work in individual integrated jobs for pay. Group supported employment continues to play a smaller but significant role in employment supports, with almost 10% of individuals with IDD participating in enclaves or mobile work crews. Data do reflect a decline in participation in facility-based work for individuals with IDD, from 41% to 27.5% and a concurrent growth in participation in nonwork services to 43% of all purchased services.

[ACT and the trends of psychiatric community care]

Bleuler has said that we have to provide community care for people with schizophrenia. In Japan, the process of modernization already ended by the miraculously swift growth of the economy in the postwar era. So it will be difficult to maintain facilities such as psychiatric hospital because the maintenance costs are too high. The core of mental health system should be community care in the future. The deinstitutionalization is essential to realize community care. Assertive community treatment (ACT) is the effective support system for people with severe mental illness (SMI). A characteristic of ACT is multidisciplinary team consisting of specialists in welfare and in medical service (ex. nurse, psychiatric social worker, occupational therapist, doctor, etc.) providing care for people with SMI. The following are detailed explanations of ACT.

Deinstitutionalization? Where have all the people gone?

Although there is broad consensus that the state psychiatric hospital population drastically declined over the past five decades, the destination and well-being of people with serious mental illness (SMI) have been in greater doubt. In this article, we examine the aftermath of the deinstitutionalization movement. We begin with a brief historical overview of the move away from state hospitals, followed by an examination of where people with SMI currently reside and receive treatment. Next, we review recent trends reflecting access to treatment and level of community integration among this population. Evidence suggests the current decentralized mental health care system has generally benefited middle-class individuals with less severe disorders; those with serious and persistent mental illness, with the greatest need, often fare the worst. We conclude with several questions warranting further attention, including how deinstitutionalization can be defined and how barriers to community integration may be addressed.

Intentional collaboration: addressing transitions in care for people with severe and persistent mental illnesses

This commentary explores transitions in care for people who have severe and persistent mental illnesses and reside in long-term care communities. Challenges and historical approaches as well as barriers to successful transitions are examined. Recent policy changes in North Carolina are discussed and contextualized in emerging evidence-based practices that emphasize intentional collaborative efforts.

[Community care in home-visit nursing for drug-dependent people--questionnaire survey of home-visit nursing stations]

The present study aimed to clarify the present status of home-visit nursing for drug-dependent people and awareness among their caretakers. A questionnaire was sent to 279 stations that provide home-visit psychiatric nursing care. Among the 89 stations that responded, 24 (26.9%) are currently providing home-visit nursing for drug-dependent patients, while 36 (40.4%) had experience doing so in the past. Although many stations recognized that drug-dependent patients need home-visit nursing, their practices tended to be based on trial and error due to insufficient knowledge about the actual conditions and recovery processes of drug dependence. Compared to stations that had experience with home-visit nursing for drug-dependent patients, stations without such experience were more concerned about the safety of caretakers and their insufficient specialist knowledge about drug dependence.

Psychotherapy dropouts: differences by modality, license, and DSM-IV diagnosis

Dropouts are frequent in mental health care. Several client factors have been identified as dropout predictors, including ethnic minority status, race, low SES, and more severe symptoms. Research on therapist and process variables is less common, and findings are inconsistent. This study used administrative data for 434,317 patients from CIGNA Behavioral Health (CIGNA) to examine dropout rates by profession of provider, therapy modality, and DSM-IV diagnosis. Results indicate that among the providers, MFTs have the lowest dropout rates in the CIGNA network. Of the therapy modalities, individual therapy is associated with lower dropout rates than family therapy. Mood and anxiety disorders have lower dropout rates than other diagnosis categories, while schizophrenia, psychotic, and substance use disorders have the highest dropout rates.

Community-based partnered research: new directions in mental health services research

OBJECTIVE

Community-based participatory research has the potential to improve implementation of best practices to reduce disparities but has seldom been applied in mental health services research. This article presents the content and lessons learned from a national conference designed to stimulate such an application.

DESIGN

Mental health program developers collaborated in hosting a two-day conference that included plenary and break-out sessions, sharing approaches to community-academic partnership development, and preliminary findings from partnered research studies. Sessions were audiotaped, transcribed and analyzed by teams of academic and community conference participants to identify themes about best practices, challenges faced in partnered research, and recommendations for development of the field. Themes were illustrated with selections from project descriptions at the conference.

SETTING AND PARTICIPANTS

Participants, representing 9 academic institutions and 12 community-based agencies from four US census regions, were academic and community partners from five research centers funded by the National Institute of Mental Health, and also included staff from federal and non-profit funding agencies.

RESULTS

Five themes emerged: 1) Partnership Building; 2) Implementing and Supporting Partnered Research; 3) Developing Creative Dissemination Strategies; 4) Evaluating Impact; and 5) Training.

CONCLUSIONS

Emerging knowledge of the factors in the partnership process can enhance uptake of new interventions in mental health services. Conference proceedings suggested that further development of this field may hold promise for improved approaches to address the mental health services quality chasm and service disparities.

Change what? Identifying quality improvement targets by investigating usual mental health care

Efforts to improve community-based children’s mental health care should be based on valid information about effective practices and current routine practices. Emerging research on routine care practices and outcomes has identified discrepancies between evidence-based practices and “usual care.” These discrepancies highlight potentially potent quality improvement interventions. This article reviews existing research on routine or “usual care” practice, identifies strengths and weaknesses in routine psychotherapeutic care, as well as gaps in knowledge, and proposes quality improvement recommendations based on existing data to improve the effectiveness of children’s mental health care. The two broad recommendations for bridging the research-practice gap are to implement valid, feasible measurement feedback systems and clinician training in common elements of evidence-based practice.

An impetus to move the field forward: a look at child and adolescent mental health services participants' views of the prospects for change

In September 2009 key stakeholders convened for the invitation-only Child and Adolescent Mental Health Services (CAMHS): Issues and Solutions conference. This paper provides a brief synopsis of the key high points and issues in children's mental health (CMH) and describes the process by which participants collectively brainstormed the priorities and distilled the four key foci for the new action agenda, and summarizes the key outcomes. In addition, this paper offers participants' perspectives on the conference. Based on observation notes and post-conference qualitative interviews, this paper reports conference participants' feedback on the event, their views on the prospects for change generated by the conference and suggestions for follow-up.