Coping strategies and distress reduction in psychological well-being? A structural equation modelling analysis using a national population sample

BACKGROUND

Little is understood about of the role of coping strategies in psychological well-being (PWB) and distress for the general population and different physical and psychiatric disease groups. A thorough examination of these relationships may provide evidence for the implementation of public mental health promotion and psychiatric disease prevention strategies aimed at improving the use of positive coping approaches or addressing the causes and maintainers of distress. The present study using a structural equation modelling (SEM) approach and nationally representative data on the Canadian population investigates the relationships among PWB, distress and coping strategies and identifies major factors related to PWB for both the general population and diverse-specific disease groups.

METHODS

Data examined were from the Canadian Community Health Survey of Mental Health and Well-being (CCHS 1.2), a large national survey (n = 36 984). We applied exploratory factor analysis (EFA), confirmatory factor analysis and SEM to build structural relationships among PWB, distress and coping strategies in the general population.

RESULTS

Both SEM measurement and structure models provided a good fit. Distress was positively related to negative coping and negatively related to positive coping. Positive coping indicated a higher level of PWB, whereas negative coping was associated with a lower level of PWB. PWB was negatively related to distress. These same relationships were also found in the population subgroups. For the population with diseases (both physical and psychiatric diseases, except agoraphobia), distress was the more important factor determining subjective PWB than the person's coping strategies, whereas, negative coping had a major impact on distress in the general population. Strengths and limitations were also discussed.

CONCLUSIONS

Our findings have practical implications for public psychiatric disease intervention and mental health promotion. As previously noted positive/adaptive coping increased the level of PWB, whereas negative/maladaptive coping was positively related to distress and negatively related to PWB. Distress decreased the level of PWB. Our findings identified major correlates of PWB in both the general population and population subgroups. Our results provide evidence for the differential use of intervention tactics among different target audiences. In order to improve the mental health of the general population public mental health promotion should focus on strategies that reduce negative coping at a population level, whereas clinicians treating individual clients should make the reduction of distress their primary target to maintain or improve patients' PWB.

Generalised anxiety disorder symptoms and utilisation of health care services. A cross-sectional study from the "Northern Finland 1966 Birth Cohort"

OBJECTIVE

To analyse the utilization of health care services of people who tested positive for GAD compared to those who tested negative.

SETTING

A cross-sectional study from the Northern Finland 1966 Birth Cohort.

SUBJECTS

A total of 10,282 members followed from birth in a longitudinal study were asked to participate in a follow-up survey at the age of 46. As part of this survey they filled in questionnaries concerning health care utilization and their illness history as well as the GAD-7 screening tool. Althogether 5,480 cohort members responded to the questionnaries.

MAIN OUTCOME MEASURES

Number of visits in different health care services among people who tested positive for GAD with the GAD-7 screening tool compared to those who tested negative.

RESULTS

People who tested positive for GAD had 112% more total health care visits, 74% more total physician visits, 115% more visits to health centres, 133% more health centre physician visits, 160% more visits to secondary care, and 775% more mental health care visits than those who tested negative.

CONCLUSION

People with GAD symptoms utilize health care services more than other people. Key Points Generalised anxiety disorder (GAD) is a common but poorly identified mental health problem in primary care. People who tested positive for GAD utilise more health care services than those who tested negative. About 58% of people who tested positive for GAD had visited their primary care physician during the past year. Only 29% of people who tested positive for GAD had used mental health services during the past year.

Delivering recovery focused mental health care in Ireland: implications for services and practice development

Introduction The recovery approach provides a key organising principle underlying mental health policy throughout the English speaking world with endorsement by agencies such as the World Health Organisation. In Ireland, personal recovery is one of the quality markers identified by users of mental health services and has become central to national mental health policy. Aim and objective The aim of this study was to explore the implications for mental health services and professional practice arising from a structured investigation of what personal recovery means for people using specialist mental health services and the extent to which services support their individual recovery.

METHOD

Ten service user participants in a service initiative were assessed using a novel measure based on an empirically based conceptual framework of recovery. The INSPIRE determines the level of recovery promoting support received from mental health staff and the quality of the supportive relationship as perceived by individual service users.

RESULTS

A consistent pattern of beliefs about recovery in keeping with national guidelines and the international literature was apparent. All respondents indicated that support by other people was an important part of their recovery with high levels of support received from mental health professionals. There was less consistent endorsement of the quality of relationships with professionals and recovery-oriented practice as perceived by participants.

CONCLUSION

The findings are highly relevant to the development of recovery focused, clinically excellent services. Further work is needed to improve the process of translating recovery guidance into mental health practice.

Mental Health Service Use Among Children and Youth in Ontario: Population-Based Trends Over Time

OBJECTIVE

Little is known about mental health service use among Canadian children and youth. Our objective was to examine temporal trends in mental health service use across different sectors of the health care system among children and youth living in Ontario.

METHODS

We conducted a population-based, repeated annual cross-sectional study of mental health service use, including mental health- and addictions-related emergency department (ED) visits, psychiatric hospitalizations, and mental health-related outpatient physician visits using linked health administrative databases. Subjects included Ontario residents between 10 and 24 years of age. We tested temporal trends between 2006 and 2011 using linear regression models.

RESULTS

Between 2006 and 2011, the relative increase in rates of mental health-related ED visits and hospitalizations were 32.5% and 53.7%, respectively. The absolute increase in anxiety disorders, the most common reason for ED visits, was 2.2 per 1000 population (P < 0.001) while mood and affective disorders, the most common reason for hospitalizations, showed an increase of 0.6 per 1000 population (P < 0.01). The overall relative increase in rates of outpatient visits was 15.8%, with the largest absolute increase found among family physician visits (28.7 per 1000 population, P = 0.01).

CONCLUSIONS

Mental health care use for children and youth is increasing over time in all sectors, but appears to be increasing at a greater rate in the acute care sector. Further research is required to understand whether the observed differences reflect difficulty with access to outpatient care.

Rich Country, Poor People: the challenges of providing psychiatric services in the public and the private sectors in Papua New Guinea

OBJECTIVE

To describe some of the challenges in the provision of psychiatric services in Papua New Guinea.

CONCLUSION

Many of the challenges faced when providing mental health care are not clinical in nature, but rather a combination of social, cultural, economic and infrastructural factors that hinder the adequate provision of, and access to, psychiatric services in Papua New Guinea.

Depression symptom and professional mental health service use

BACKGROUND

Despite the sharp rise in antidepressant use, the underutilization of mental healthcare services for depression remains a concern. We investigated factors associated with the underutilization of mental health services for potential depression symptoms in the Republic of Korea, using a nationally representative sample.

METHODS

Data were obtained from the Community Health Survey (2011-2012) conducted in the Republic of Korea. Participants comprised adults who reported potential depression symptoms during the year prior to the study (n = 21,644); information on professional mental healthcare use for their symptoms was obtained. The association of demographic, socioeconomic, and health-related factors with consultation use was analysed via multiple logistic regression. Adjusted odds ratio and 95% confidence intervals were estimated.

RESULTS

Among those reporting potential depression symptoms, only 17.4% had consulted a medical/mental health professional. Elderly individuals of both genders had significantly lower consultation rates compared to middle-aged individuals. Unmet healthcare needs and a history of diabetes mellitus were associated with lower consultation rates. After stratification by age, elderly individuals with the lowest education and income level were significantly less likely to seek professional mental health services. Married, separated, or divorced men had lower consultation rates compared to unmarried individuals, whereas married, separated, or divorced women had higher rates.

CONCLUSIONS

The results suggest that target strategies for vulnerable groups identified in this study--including elderly individuals--need to be established at the community level, including strengthening social networks and spreading awareness to reduce the social stigma of depression.

Recovery-based services in a psychiatric intensive care unit - the consumer perspective

OBJECTIVE

To describe the implementation of recovery-based practice into a psychiatric intensive care unit, and report change in seclusion rates over the period when these changes were introduced (2011-2013).

METHOD

Recovery-based practices including collaborative care, safety care plans, a comfort room, and debriefing after coercive interventions were introduced. A carer consultant was employed. A restraint and seclusion review committee, chaired by a peer worker, was established. A consumer exit interview was introduced and these data were collected, reviewed by staff and the peer worker and used to improve the ward environment. Rates of seclusion were measured during the period when recovery-based practices were introduced.

RESULTS

Consumer feedback indicated that positive aspects of the psychiatric intensive care unit included approachable, helpful staff and completion of a safety care plan. Negative aspects included lack of involvement in decisions about admission and about medications, the non-smoking policy, and being placed in seclusion or restraint. There was a significant reduction in the number of consumers secluded and the total number of seclusions.

CONCLUSIONS

Recovery principles can be successfully introduced in a psychiatric intensive care unit environment. Introduction of recovery based practice was associated with a reduction in seclusion.

Putting meaning into medicine: why context matters in psychiatry

Mainstream psychiatry emphasises controlling symptoms by taking medications. This approach ignores the role of context in shaping illness experiences and how people engage with mental health professionals. The focus on symptom control and medication management also narrows the function of the psychiatrist. This editorial argues that knowledge of patients' lives is important for providing empathic care that is oriented to the outcomes that matter to patients. In addition, care that attends to the person-in-context motivates and sustains mental health providers by putting meaning back into medicine. Truly patient-centred care demands pushing back against the reductionism of contemporary psychiatry to thoughtfully engage with the complexities of patients' lives.

Early intervention in psychosis: a feasibility study financed by the Italian Center on Control of Maladies

AIM

In November 2005 the Italian Center on Control of Maladies, a department operating under the Ministry of Health, financed a project aimed at evaluating the feasibility of a protocol of intervention based on the early intervention in psychosis (EIP) model within the Italian public mental health-care network.

METHODS

The study was carried out between March 2007 and December 2009. It involved five centres operating under the Departments of Mental Health of Milan (Programma 2000), Rome (area D), Grosseto, Salerno (Nocera) and Catanzaro (Soverato).

RESULTS

Enrolment lasted 12 months, at the end of which 43 patients were enrolled as first-episode psychosis (FEP), and 24 subjects as ultra high-risk (UHR) patients. Both FEP and UHR samples included a preponderance of male patients. A family history of psychosis was rarely reported in both samples. The FEP incidence rate was lower than expected on the basis of international estimates of the incidence of schizophrenia but within the expected figure for the estimated Italian rates in three centres out of five.

CONCLUSIONS

Overall, the study proved that an EIP centre can be established within the public Department of Mental Health to reach a good fraction of the cases in need of treatment. Since then, several studies have been set up to assess the feasibility of EIP in the Italian public mental health sector in Lombardy and Tuscany, and in 2012 the Emilia-Romagna Regional Authority started an educational plan aimed at implementing the EIP model in all the Mental Health Departments in the region.

An updated meta-analysis of randomized controlled evidence for the effectiveness of community treatment orders

OBJECTIVES

It is unclear whether community treatment orders (CTOs) for people with severe mental illnesses can reduce health service use, or improve clinical and social outcomes. Randomized controlled trials of CTOs are rare because of ethical and logistical concerns. This meta-analysis updates available evidence.

METHOD

A systematic literature search was performed of the Cochrane Schizophrenia Group Register, Science Citation Index, PubMed, MEDLINE, and Embase to November 2013. Inclusion criteria were studies comparing CTOs with standard care including those where control subjects received voluntary care, for most of the trial.

RESULTS

Three studies provided 749 subjects for the meta-analysis. Two compared compulsory treatment with entirely voluntary care, while the third had control subjects receiving voluntary treatment for the bulk of the time. Compared with control subjects, CTOs did not reduce readmissions (risk ratio 0.98, 95% CI 0.82 to 1.16) or bed days (mean difference [MD] -16.36; 95% CI -40.8 to 8.05) in the subsequent 12 months (n = 749). Moreover, there were no significant differences in psychiatric symptoms (standardized MD -0.03; 95% CI -0.25 to 0.19; n = 331) or the Global Assessment of Functioning (MD -1.36; 95% CI -4.07 to 1.35; n = 335). Only including the 2 studies that compared compulsory treatment with entirely voluntary care made no difference to the results.

CONCLUSIONS

CTOs may not lead to significant differences in readmission, social functioning, or symptomatology, compared with standard care. Their use should be kept under review.

Rasch analysis of the illness management and recovery scale-clinician version

RATIONALE, AIMS AND OBJECTIVES

The illness management and recovery scale-clinician version (IMRS-C) is a measure of outcomes thought to be important indicators of progress for consumers participating in illness management and recovery (IMR). Prior research has examined the psychometric properties of the IMRS-C; extant research supports certain aspects of the scale's reliability (test-retest) and validity (sensitivity to interventions). Analyses based on Rasch provide certain advantages and have not been applied to the IMRS-C.

METHOD

This study used an archival IMRS database including responses regarding 697 participants with severe mental illness from a variety of community-based settings. Rasch analyses were utilized to determine item functioning and utility of the IMRS-C.

RESULTS

Results of Rasch analyses using the IMRS-C as one unidimensional scale were problematic. Analyses grouping items into three separate scales measuring recovery, management and biological vulnerability were more promising, but the third scale had other limitations.

CONCLUSIONS

Results suggest that the items included in the IMRS-C can form two screeners, one for recovery and one for management; items regarding biological vulnerability were inadequate. The assessment could be supplemented by more refined measures of coping/self-management and recovery constructs.

Are there mental health differences between francophone and non-francophone populations in manitoba?

OBJECTIVE

Francophones may experience poorer health due to social status, cultural differences in lifestyle and attitudes, and language barriers to health care. Our study sought to compare mental health indicators between Francophones and non-Francophones living in the province of Manitoba.

METHODS

Two populations were used: one from administrative datasets housed at the Manitoba Centre for Health Policy and the other from representative survey samples. The administrative datasets contained data from physician billings, hospitalizations, prescription drug use, education, and social services use, and surveys included indicators on language variables and on self-rated health.

RESULTS

Outside urban areas, Francophones had lower rates of diagnosed substance use disorder (rate ratio [RR] = 0.80; 95% CI 0.68 to 0.95) and of suicide and suicide attempts (RR = 0.59; 95% CI 0.43 to 0.79), compared with non-Francophones, but no differences were found between the groups across the province in rates of diagnosed mood disorders, anxiety disorders, dementia, or any mental disorders after adjusting for age, sex, and geographic area. When surveyed, Francophones were less likely than non-Francophones to report that their mental health was excellent, very good, or good (66.9%, compared with 74.2%).

CONCLUSIONS

The discrepancy in how Francophones view their mental health and their rates of diagnosed mental disorders may be related to health seeking behaviours in the Francophone population. Community and government agencies should try to improve the mental health of this population through mental health promotion and by addressing language and cultural barriers to health services.

Is the effect of compulsory community treatment on preventable deaths from physical disorders mediated by better access to specialized medical procedures?

OBJECTIVES

Compulsory community treatment has been shown to reduce preventable deaths from physical disorders-these causes being up to 10 times more common than suicide in psychiatric patients. We investigated whether this was mediated by better access to specialized medical procedures.

METHOD

All patients on compulsory community treatment for over 11 years were compared with matched control subjects using linked administrative health data from Western Australia (state population of about 2.24 million). Outcomes were access to revascularization and other specialized procedures at 1-, 2-, and 3-year follow-up. Logistic regression was used to adjust for demographics, prior health service use, diagnosis, and length of psychiatric history.

RESULTS

There were 2757 patients and 2687 control subjects (total n = 5444). Sixty-five per cent were males (n = 3522), and the average age was 36 years (SD 13.2). Most had schizophrenia or other nonaffective psychoses (74%), followed by affective disorders (26%). At 2-year follow-up, 2% (n = 53) of patients and 2.6% (n = 69) of control subjects had undergone a specialized intervention. Compulsory community treatment did not result in greater access to specialized procedures at all 3 time points even after adjusting for potential confounders.

CONCLUSIONS

Greater access to specialized procedures does not explain the reduced mortality from preventable physical illness that had been reported in patients on community treatment orders. There must be other explanations for this finding, such as mental health staff facilitating access to chronic disease management in primary care. This warrants further research.

Psychiatric services in the community? The German public's opinion in 1990 and 2011

Background. During the last two decades, the change from custodial care provided by large institutions to community-focused services made considerable progress in Germany. However, nothing is known about how this is reflected in the public's acceptance of community psychiatry services. Methods. The study is based on data from two population surveys among German citizens aged 18 years and over, living in the 'old' German States. The first was conducted in 1990 (n = 3067), the second in 2011 (n = 2416). With the help of identical questions, respondents' attitudes towards psychiatric units at general hospitals and group homes for mentally ill people were assessed. Results. While the proportion of the public that explicitly welcomed establishing psychiatric units at general hospitals and opening group homes for mentally ill people decreased, the proportion of those who reacted with indifference increased. The proportion of the German population that explicitly rejected the implementation of these services remained unchanged. Conclusions. While community psychiatry services expanded considerably over the last few years, the public's attitude towards them has not changed substantially.

Social network intervention in patients with schizophrenia and marked social withdrawal: a randomized controlled study

OBJECTIVE

To evaluate the efficacy and feasibility of actions intended to implement or improve patients' social network within the Italian National Health Service community mental health services.

METHODS

We conducted a randomized clinical trial through a network of 47 community mental health services on patients with a diagnosis in the schizophrenia spectrum (F20 in the International Classification of Diseases, 10th Revision), who were young (aged younger than 45 years), and with a poor social network (less than 5 relationships). In addition to routine treatments, for the experimental group, the staff identified possible areas of interest for individual patients and proposed social activities taking place outside the services' resources and with members of the community. The main outcome was an improvement in the patients' social network; secondary end points were clinical outcome, abilities of daily living, and work.

RESULTS

One- and 2-year outcomes of 345 and 327, respectively, of the 357 patients randomized were analyzed by intention-to-treat. A social network improvement was observed at year 1 in 25% of the patients allocated to routine treatment and in 39.9% of those allocated to the experimental arm (OR 2.0, 95% CI 1.3 to 3.1; adjusted OR 2.4, 95% CI 1.4 to 3.9). The difference remained statistically significant at year 2. No significant differences emerged for any of the other end points. However, patients with 1 or more other areas of improvement at year 1 and 2 showed a statistically significant social network improvement.

CONCLUSIONS

The activation of social networks as an activity integrated with standard psychiatric care is practicable, without added economic and organizational costs, and appears to produce an effect persisting well beyond its implementation.

Improving services for people with personality disorders: views of experienced clinicians

People with personality disorders are frequent users of both inpatient and outpatient psychiatric services, representing a significantly large proportion of all mental health clients. Despite this, most services find it a challenge to offer the most appropriate and effective treatment models for people with personality disorders. This paper is a report of a study of clinician opinions about how organizations can improve the delivery of services to people with personality disorders. Data was collected from experienced clinicians attending a personality disorders clinical and scientific meeting who were asked to work together in groups and present solutions for how organizations can improve the services provided to people with personality disorders. Qualitative data was collected and thematically and semantically analyzed using Nvivo and Leximancer. The Nvivo analysis revealed five main areas in which clinicians believe organizations can improve services for people with personality disorders. These focused on: (i) more training and education for health professionals and carers; (ii) better support through supervision and leadership; (iii) adoption of a more consistent evidence-based approach to client management and treatment; (iv) clearer guidelines and protocols; and (v) changed attitudes about personality disorder to decrease stigma. The Leximancer analysis of responses indicated the identified themes were not distinct; rather they were interconnected and related to one another, semantically. In summary, clinicians across a large and diverse geographical area developed a consensus that mainstream management of personality disorder is largely poor and inadequate. The findings lend support to an integrative and collaborative whole-service approach that enhances evidence-based practice in the community.

The treatment outcome of psychotic disorders by traditional healers in central Sudan

BACKGROUND

Alternative and traditional healing methods are common and popular in Sudan, particularly for treating people with mental disorders, but little information is available about the outcome of theses traditional healing approaches.

OBJECTIVES

To study the outcome of treating patients with psychotic disorders by traditional healers, and to understand the type of services, interventions procedures and treatments methods used by traditional healers to manage patients with psychotic disorders.

METHOD

A prospective follow-up quantitative study of a cohort of inpatients with psychotic disorders was carried out from admission until discharge. Subjects were people with psychotic disorders undergoing treatment in traditional healer centres in central Sudan. The Mini International Neuropsychiatric Interview (MINI) was used to diagnose the psychotic disorders and the Positive and Negative Syndrome Scale (PANSS) was used to assess the severity of psychotic symptoms on admission and discharge from the traditional healer centre.

RESULTS

We interviewed 129 inpatients with psychotic disorders on admission and discharge from the traditional healers centres. There was a significant reduction in the PANSS score (p = .0001) after a mean period of stay of 4.5 months. The mean for the overall PANSS score was 118.36 on admission and 69.36 on discharge.

CONCLUSION

Although traditional-healing approaches produce a significant improvement in the signs and symptoms of psychotic disorders measured on the PANSS, they need to be further investigated, assessed and studied.

THERACOM: a systematic review of the evidence base for interventions to improve Therapeutic Communications between black and minority ethnic populations and staff in specialist mental health services

BACKGROUND

Black and Minority Ethnic (BME) groups in receipt of specialist mental health care have reported higher rates of detention under the mental health act, less use of psychological therapies, and more dissatisfaction. Although many explanations have been put forward to explain this, a failure of therapeutic communications may explain poorer satisfaction, disengagement from services and ethnic variations in access to less coercive care. Interventions that improve therapeutic communications may offer new approaches to tackle ethnic inequalities in experiences and outcomes.

METHODS

The THERACOM project is an HTA-funded evidence synthesis review of interventions to improve therapeutic communications between black and minority ethnic patients in contact with specialist mental health services and staff providing those services. This article sets out the protocol methods for a necessarily broad review topic, including appropriate search strategies, dilemmas for classifying different types of therapeutic communications and expectations of the types of interventions to improve them. The review methods will accommodate unexpected types of study and interventions. The findings will be reported in 2013, including a synthesis of the quantitative and grey literature.

DISCUSSION

A particular methodological challenge is to identify and rate the quality of many different study types, for example, randomised controlled trials, observational quantitative studies, qualitative studies and case studies, which comprise the full range of hierarchies of evidence. We discuss the preliminary methodological challenges and some solutions. (PROSPERO registration number: CRD42011001661).

Services provided by volunteer psychiatrists after 9/11 at the New York City family assistance center: September 12-November 20, 2001

OBJECTIVE

To characterize the experience of volunteer disaster psychiatrists who provided pro bono psychiatric services to 9/11 survivors in New York City, from September 12, 2001 to November 20, 2001.

METHOD

Disaster Psychiatry Outreach (DPO) is a non-profit organization founded in 1998 to provide volunteer psychiatric care to people affected by disasters and to promote education and research in support of this mission. Data for this study were collected from one-page clinical encounter forms completed by 268 DPO psychiatrists for 2 months after 9/11 concerning 848 patients served by the DPO 9/11 response program at the New York City Family Assistance Center.

RESULTS

In this endeavor, 268 psychiatrist volunteers evaluated 848 individuals and provided appropriate interventions. The most commonly recorded clinical impressions indicated stress-related and adjustment disorders, but other conditions such as bereavement, major depression, and substance abuse/dependence were also observed. Free samples were available for one sedative and one anxiolytic agent; not surprisingly, these were the most commonly prescribed medications. Nearly half of those evaluated received psychotropic medications.

CONCLUSIONS

In the acute aftermath of the attacks of September 11, 2001, volunteer psychiatrists were able to provide services in a disaster response setting, in which they were co-located with other disaster responders. These services included psychiatric assessment, provision of medication, psychological first aid, and referrals for ongoing care. Although systematic diagnoses could not be confirmed, the fact that most patients were perceived to have a psychiatric diagnosis and a substantial proportion received psychotropic medication suggests potential specific roles for psychiatrists that are unique and different from roles of other mental health professionals in the early post-disaster setting. In addition to further characterizing post-disaster mental health needs and patterns of service provision, future research should focus on the short- and long-term effects of psychiatric interventions, such as providing acute psychotropic medication services and assessing the effectiveness of traditional acute post-disaster interventions including crisis counseling and psychological first aid.

The cumulative needs for care monitor: a unique monitoring system in the south of the Netherlands

INTRODUCTION

Patients diagnosed with severe mental illness (SMI) have a complex combination of psychiatric, somatic and social needs for care, requiring an integrated, multidisciplinary health care approach. The present paper describes the methods of the cumulative needs for care monitor (CNCM), a monitoring system in operation in a geographically defined area.

METHODS

The CNCM provides information on need for care, functioning and other outcomes in SMI patients in the area. This information can be used not only to plan treatment at the individual level, but also to conduct health services research at the group level.

Steps, challenges and lessons in developing community mental health care

This paper summarises our own accumulated experience from developing community-orientated mental health services in England and Italy over the last 20-30 years. From this we have provisionally concluded that the following issues are central to the development of balanced mental health services: a) services need to reflect the priorities of service users and carers; b) evidence supports the need for both hospital and community services; c) services need to be provided close to home; d) some services need to be mobile rather than static; e) interventions need to address both symptoms and disabilities; and f) treatment has to be specific to individual needs. In this paper we consider ten key challenges that often face those trying to develop community-based mental health services: a) dealing with anxiety and uncertainty; b) compensating for a possible lack of structure in community services; c) learning how to initiate new developments; d) managing opposition to change within the mental health system; e) responding to opposition from neighbours; f) negotiating financial obstacles; g) avoiding system rigidities; h) bridging boundaries and barriers; i) maintaining staff morale; and j) creating locally relevant ser- vices rather than seeking "the right answer" from elsewhere.