Patterns of mental health service utilisation in Italy and Spain--an investigation using the European Service Mapping Schedule

Are patients improving during and after a psychiatric hospitalisation? Continuity of care outcomes of compulsory and voluntary admissions to an Italian psychiatric ward

Background: To compare the characteristics of compulsory admissions (CAs) and voluntary admissions (VAs) in a General Hospital Psychiatric Unit (GHPU), and to assess whether CA and VA patients’ outcomes improved during hospitalisation and followup in mental health services (MHS) based on community continuity of care.

Design and methods: Observational longitudinal study comparing 19 CAs and 83 VAs consecutively admitted to GHPU of Udine, Italy, and followed-up for six-months by MHS. Five psychometric scales assessed psychosocial and clinical characteristics for each patient at admission (T0), discharge (T1) and follow-up (T2). Statistical analyses were performed using: multivariate logistic regression for comparing CA and VA; Friedman χ2 and Mann-Whitney tests for outcomes’ improvement.

Results: Being hospitalised for a psychotic crisis was the most significant predictor of CA (OR = 5.07). An outcomes’ improvement was observed from T0 to T1 in almost all psychometric tests, while from T1 to T2 only for PSP-A (useful social activities), CGI-S (severity of illness) and CGI-EI (drug’s efficacy related to side effects). CA was associated to lower performances in all scales at T0, in GAF and CGI-S at T1, while no difference with VA was observed at T2.

Conclusions: CA and VA patients improved to a same extent during hospitalisation and follow-up, particularly in relation to social functioning. This fosters the hypothesis that communitybased MHS using a longitudinal continuity of care model might achieve recovery in a long-term perspective. Future research may benefit by considering patients’ subjective experiences and assessing long-term improvement in those who received personcentred interventions.

A Method to Compare the Delivery of Psychiatric Care for People with Treatment-Resistant Schizophrenia

INTRODUCTION

Community services are gaining ground when it comes to attention to patients with psychiatric diseases. Regarding patients with treatment-resistant schizophrenia (TRS), the use of information and communication technology (ICT) could help to shift the focus from hospital-centered attention to community services. This study compares the differences in mental health services provided for patients with TRS in Budapest (Hungary), Tel-Aviv (Israel) and Catalonia (Spain) by means of a method for the quick appraisal of gaps among the three places, for a potential implementation of the same ICT tool in these regions.

METHODS

An adapted version of the Description and Standardised Evaluation of Services and Directories in Europe for Long Term Care (DESDE-LTC) instrument was made by researchers in Semmelweis University (Budapest, Hungary), Gertner Institute (Tel-Aviv, Israel) and Hospital de la Santa Creu I Sant Pau and Parc Sanitari Sant Joan de Déu (Catalonia, Spain).

RESULTS

Two types of outpatient care services were available in the three regions. Only one type of day-care facility was common in the whole study area. Two residential care services, one for acute and the other for non-acute patients were available in every region. Finally, two self-care and volunteer-care facilities were available in the three places.

CONCLUSION

Although the availability of services was different in each region, most of the services provided were sufficiently similar to allow the implementation of the same ICT solution in the three places.

[On the roller coaster: An abridged history of mental health planning in Spain. SESPAS Report 2020]

Effective mental health change in Spain started in 1985 with the Report of the Ministerial Commission for the Psychiatric Reform that recommended integrating psychiatric care into the general health system, providing care in the patient's context and for specific diagnoses. The SESPAS 2002 Report carried out an analysis of this reform and recommended the creation of a permanent ministerial commission, the design of a national map of socio-sanitary mental health services, the creation of a coordination and promotion agency for and carrying out a financial analysis of resource provision and research. Since 2004, the Technical Committee for the Mental Health Strategy boosted the elaboration of a theoretical and normative framework that unfortunately did not lead to a road map for the improvement of the system. After 2011, during the financial crisis, the Ministry of Health lost the opportunity to lead a second phase of change of the mental health care, which was evidence-based: no key technical reports were published nor was an action plan based on data developed. Currently, the 1985 community mental health model is still the general framework of mental health care with the addition of aspects related to the recovery model and the balance of care model. Significant progress has been made in developing care systems assessment methods and data-based models that could advance mental health planning. The gap between general health attention and mental health care has increased and the expected reform of the mental health system will not take place in the near future.

Individual Health Budgets in Mental Health: Results of Its Implementation in the Friuli Venezia Giulia Region, Italy

Background: Individual Health Budget (IHB) is an intervention for recovery in mental health services, providing personalized care for subjects with severe disorders and complex needs. Little is known on its effectiveness and on the criteria for its delivery. Methods: A total of 67 IHB beneficiaries and 61 comparators were recruited among service users of the Mental Health Department of the Trieste Healthcare Agency, Italy. Data included sociodemographic and clinical variables, type of IHB, and Health of the Nation Outcome Scale (HoNOS) scores. Results: A comparison between groups showed significant differences in several socioeconomic and clinical characteristics. Multivariate logistic regression showed that IHB was positively associated to the 20–49 age group, single status, unemployment, low family support, cohabitation with relatives or friends, diagnosis of personality disorder, and a higher number of hospitalizations. The IHB group was at a higher risk of severe problems related to aggressive or agitated behaviors (OR = 1.4), hallucinations and delusions (OR = 1.5), and impairment in everyday life activities (OR = 2.1). Conclusions: IHB was used in patients with severe clinical and social problems. More resources, however, may be aimed at the working and social axes. More research is needed to better assess clinical and social outcomes of IHB and to adjust their intensity in a longitudinal perspective in order to enhance cost-effectiveness.

Mental health care in Italy: Basaglia's ashes in the wind of the crisis of the last decade

BACKGROUND AND AIMS

The purpose is to highlight the legal and ethical principles that inspired the reform of mental health care in Italy, the only country to have closed its psychiatric hospitals. The article will also try to verify some macro-indicators of the quality of care and discuss the crisis that the mental health care system in Italy is experiencing.

METHODS

Narrative review.

RESULTS

The principal changes in the legislation on mental health care in Italy assumed an important role in the evolution of morals and common sense of the civil society of that country. We describe three critical points: first, the differences in implementation in the different Italian regions; second, the progressive lack of resources that cannot be totally attributed to the economic crisis and which has compromised application of the law; and finally, the scarce attention given to measurement of change with scientific methods.

CONCLUSION

Italy created a revolutionary approach to mental health care in a historical framework in which it produced impressive cultural expressions in many fields. At that time, people were accustomed to 'believing and doing' rather than questioning results and producing research, and this led to underestimating the importance of a scientific approach. With its economic and cultural crisis, Italy has lost creativity as well as interest in mental health, which has been guiltily neglected. Any future humanitarian approach to mental health must take the Italian experience into account, but must not forget that verification is the basis for any transformation in health care culture.

Comparison of Elixhauser and Charlson Methods for Discriminative Performance in Mortality Risk in Patients with Schizophrenic Disorders

Although Charlson Comorbidity Index scores (CCIS) and Elixhauser comorbidity index scores (ECIS) have been used to assess comorbidity in patients with schizophrenia, only CCIS, not ECIS, have been used to predict mortality in this population. This nationwide retrospective study investigated discriminative performance of mortality of these two scales in patients with schizophrenia. Exploiting Taiwan's National Health Insurance Research Database (NHRID), we identified patients diagnosed with schizophrenia discharged from hospitals between Jan 1, 1996 and Dec 31, 2007. They were followed up for subsequent death. Comorbidities presented one year prior to hospital admissions were identified and adapted to the CCIS and ECIS. Discriminatory ability was evaluated using the adjusted hazard ratio and Akaike information criterion (AIC) and Harrell's C-statistic. We identified 58,771 discharged patients with schizophrenic disorders and followed them for a mean of 10.4 years, 16.6% of whom had died. Both ECIS and CCIS were significantly associated with mortality, but ECIS had superior discriminatory ability by a lower AIC and higher Harrell's C-statistic (201231 vs. 201400; 0.856 vs. 0.854, respectively). ECIS had better discriminative performance in mortality risk than CCIS in patients with schizophrenic disorders. Its use may be encouraged for risk adjustment in this population.

Standardised description of health and social care: A systematic review of use of the ESMS/DESDE (European Service Mapping Schedule/Description and Evaluation of Services and DirectoriEs)

BACKGROUND

Evidence-informed planning and interpretation of research results both require standardised description of local care delivery context. Such context analysis descriptions should be comparable across regions and countries to allow benchmarking and organizational learning, and for research findings to be interpreted in context. The European Service Mapping Schedule (ESMS) is a classification of adult mental health services that was later adapted for the assessment of health and social systems research (Description and Evaluation of Services and DirectoriEs - DESDE). The aim of the study was to review the diffusion and use of the ESMS/DESDE system in health and social care and its impact in health policy and decision-making.

METHOD

We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (1997-2018).

RESULTS

Out of 155 papers mentioning ESMS/DESDE, 71 have used it for service research and planning. The classification has been translated into eight languages and has been used by seven international research networks. Since 2000, it has originated 11 instruments for health system research with extensive analysis of their metric properties. The ESMS/DESDE coding system has been used in 585 catchment areas in 34 countries for description of services delivery at local, regional and national levels.

CONCLUSIONS

The ESMS/DESDE system provides a common terminology, a classification of care services, and a set of tools allowing a variety of aims to be addressed in healthcare and health systems research. It facilitates comparisons across and within countries for evidence-informed planning.

Standard comparison of local mental health care systems in eight European countries

AIMS

There is a need of more quantitative standardised data to compare local Mental Health Systems (MHSs) across international jurisdictions. Problems related to terminological variability and commensurability in the evaluation of services hamper like-with-like comparisons and hinder the development of work in this area. This study was aimed to provide standard assessment and comparison of MHS in selected local areas in Europe, contributing to a better understanding of MHS and related allocation of resources at local level and to lessen the scarcity in standard service comparison in Europe. This study is part of the Seventh Framework programme REFINEMENT (Research on Financing Systems' Effect on the Quality of Mental Health Care in Europe) project.

METHODS

A total of eight study areas from European countries with different systems of care (Austria, England, Finland, France, Italy, Norway, Romania, Spain) were analysed using a standard open-access classification system (Description and Evaluation of Services for Long Term Care in Europe, DESDE-LTC). All publicly funded services universally accessible to adults (≥18 years) with a psychiatric disorder were coded. Care availability, diversity and capacity were compared across these eight local MHS.

RESULTS

The comparison of MHS revealed more community-oriented delivery systems in the areas of England (Hampshire) and Southern European countries (Verona - Italy and Girona - Spain). Community-oriented systems with a higher proportion of hospital care were identified in Austria (Industrieviertel) and Scandinavian countries (Sør-Trøndelag in Norway and Helsinki-Uusimaa in Finland), while Loiret (France) was considered as a predominantly hospital-based system. The MHS in Suceava (Romania) was still in transition to community care.

CONCLUSIONS

There is a significant variation in care availability and capacity across MHS of local areas in Europe. This information is relevant for understanding the process of implementation of community-oriented mental health care in local areas. Standard comparison of care provision in local areas is important for context analysis and policy planning.

Healthcare ecosystems research in mental health: a scoping review of methods to describe the context of local care delivery

BACKGROUND

Evidence from the context of local health ecosystems is highly relevant for research and policymaking to understand geographical variations in outcomes of health care delivery. In mental health systems, the analysis of context presents particular challenges related to their complexity and to methodological difficulties. Method guidelines and standard recommendations for conducting context analysis of local mental health care are urgently needed. This scoping study reviews current methods of context analysis in mental health systems to establish the parameters of research activity examining availability and capacity of care at the local level, and to identify any gaps in the literature.

METHODS

A scoping review based on a systematic search of key databases was conducted for the period 2005-2016. A systems dynamics/complexity approach was adopted, using a modified version of Tansella and Thornicroft's matrix model of mental health care as the conceptual framework for our analysis.

RESULTS

The lack of a specific terminology in the area meant that from 10,911 titles identified at the initial search, only 46 papers met inclusion criteria. Of these, 21 had serious methodological limitations. Fifteen papers did not use any kind of formal framework, and five of those did not describe their method. Units of analysis varied widely and across different levels of the system. Six instruments to describe service availability and capacity were identified, of which three had been psychometrically validated. A limitation was the exclusion of grey literature from the review. However, the imprecise nature of the terminology, and high number of initial results, makes the inclusion of grey literature not feasible.

CONCLUSION

We identified that, in spite of its relevance, context studies in mental health services is a very limited research area. Few validated instruments are available. Methodological limitations in many papers mean that the particular challenges of mental health systems research such as system complexity, data availability and terminological variability are generally poorly addressed, presenting a barrier to valid system comparison. The modified Thornicroft and Tansella matrix and related ecological production of care model provide the main model for research within the area of health care ecosystems.

Causal Modelling for Supporting Planning and Management of Mental Health Services and Systems: A Systematic Review

Mental health services and systems (MHSS) are characterized by their complexity. Causal modelling is a tool for decision-making based on identifying critical variables and their causal relationships. In the last two decades, great efforts have been made to provide integrated and balanced mental health care, but there is no a clear systematization of causal links among MHSS variables. This study aims to review the empirical background of causal modelling applications (Bayesian networks and structural equation modelling) for MHSS management. The study followed the PRISMA guidelines (PROSPERO: CRD42018102518). The quality of the studies was assessed by using a new checklist based on MHSS structure, target population, resources, outcomes, and methodology. Seven out of 1847 studies fulfilled the inclusion criteria. After the review, the selected papers showed very different objectives and subjects of study. This finding seems to indicate that causal modelling has potential to be relevant for decision-making. The main findings provided information about the complexity of the analyzed systems, distinguishing whether they analyzed a single MHSS or a group of MHSSs. The discriminative power of the checklist for quality assessment was evaluated, with positive results. This review identified relevant strategies for policy-making. Causal modelling can be used for better understanding the MHSS behavior, identifying service performance factors, and improving evidence-informed policy-making.

The balance of adult mental health care: provision of core health versus other types of care in eight European countries

AIMS

Although many mental health care systems provide care interventions that are not related to direct health care, little is known about the interfaces between the latter and core health care. 'Core health care' refers to services whose explicit aim is direct clinical treatment which is usually provided by health professionals, i.e., physicians, nurses, psychologists. 'Other care' is typically provided by other staff and includes accommodation, training, promotion of independence, employment support and social skills. In such a definition, 'other care' does not necessarily mean being funded or governed differently. The aims of the study were: (1) using a standard classification system (Description and Evaluation of Services and Directories in Europe for Long Term Care, DESDE-LTC) to identify 'core health' and 'other care' services provided to adults with mental health problems; and (2) to investigate the balance of care by analysing the types and characteristics of core health and other care services.

METHODS

The study was conducted in eight selected local areas in eight European countries with different mental health systems. All publicly funded mental health services, regardless of the funding agency, for people over 18 years old were identified and coded. The availability, capacity and the workforce of the local mental health services were described using their functional main activity or 'Main Types of Care' (MTC) as the standard for international comparison, following the DESDE-LTC system.

RESULTS

In these European study areas, 822 MTCs were identified as providing core health care and 448 provided other types of care. Even though one-third of mental health services in the selected study areas provided interventions that were coded as 'other care', significant variation was found in the typology and characteristics of these services across the eight study areas.

CONCLUSIONS

The functional distinction between core health and other care overcomes the traditional division between 'health' and 'social' sectors based on governance and funding. The overall balance between core health and other care services varied significantly across the European sites. Mental health systems cannot be understood or planned without taking into account the availability and capacity of all services specifically available for this target population, including those outside the health sector.

A Comparison of Mental Health Care Systems in Northern and Southern Europe: A Service Mapping Study

Mental health services (MHS) have gone through vast changes during the last decades, shifting from hospital to community-based care. Developing the optimal balance and use of resources requires standard comparisons of mental health care systems across countries. This study aimed to compare the structure, personnel resource allocation, and the productivity of the MHS in two benchmark health districts in a Nordic welfare state and a southern European, family-centered country. The study is part of the REFINEMENT (Research on Financing Systems' Effect on the Quality of Mental Health Care) project. The study areas were the Helsinki and Uusimaa region in Finland and the Girona region in Spain. The MHS were mapped by using the DESDE-LTC (Description and Evaluation of Services and Directories for Long Term Care) tool. There were 6.7 times more personnel resources in the MHS in Helsinki and Uusimaa than in Girona. The resource allocation was more residential-service-oriented in Helsinki and Uusimaa. The difference in mental health personnel resources is not explained by the respective differences in the need for MHS among the population. It is important to make a standard comparison of the MHS for supporting policymaking and to ensure equal access to care across European countries.

Identifying Local and Centralized Mental Health Services-The Development of a New Categorizing Variable

The challenges of mental health and substance abuse services (MHS) require shifting of the balance of resources from institutional care to community care. In order to track progress, an instrument that can describe these attributes of MHS is needed. We created a coding variable in the European Service Mapping Schedule-Revised (ESMS-R) mapping tool using a modified Delphi panel that classified MHS into centralized, local services with gatekeeping and local services without gatekeeping. For feasibility and validity, we tested the variable on a dataset comprising MHS in Southern Finland, covering a population of 2.3 million people. There were differences in the characteristics of services between our study regions. In our data, 41% were classified as centralized, 37% as local without gatekeeping and 22% as local services with gatekeeping. The proportion of resources allocated to local services varied from 20% to 43%. Reclassifying ESMS-R is an easy way to compare the important local vs. centralized balance of MHS systems globally, where such data exists. Further international studies comparing systems and validating this approach are needed.

Regional Correlates of Psychiatric Inpatient Treatment

Current reforms of mental health and substance abuse services (MHS) emphasize community-based care and the downsizing of psychiatric hospitals. Reductions in acute and semi-acute hospital beds are achieved through shortened stays or by avoiding hospitalization. Understanding the factors that drive the current inpatient treatment provision is essential. We investigated how the MHS service structure (diversity of services and balance of personnel resources) and indicators of service need (mental health index, education, single household, and alcohol sales) correlated with acute and semi-acute inpatient treatment provision. The European Service Mapping Schedule-Revised (ESMS-R) tool was used to classify the adult MHS structure in southern Finland (population 1.8 million, 18+ years). The diversity of MHS in terms of range of outpatient and day care services or the overall personnel resourcing in inpatient or outpatient services was not associated with the inpatient treatment provision. In the univariate analyses, sold alcohol was associated with the inpatient treatment provision, while in the multivariate modeling, only a general index for mental health needs was associated with greater hospitalization. In the dehospitalization process, direct resource re-allocation and substituting of inpatient treatment with outpatient care per se is likely insufficient, since inpatient treatment is linked to contextual factors in the population and the health care system. Mental health services reforms require both strategic planning of service system as a whole and detailed understanding of effects of societal components.

How size matters: exploring the association between quality of mental health services and catchment area size

BACKGROUND

The diversity of mental health and substance abuse services (MHS) available to service users is seen as an indicator of the quality of the service system. In most countries MHS are provided by a mix of public, private and third sector providers. In Finland, officially, the municipalities are responsible for organizing the services needed, but the real extent and roles of private and third sector service providers are not known. Our previous study showed that the catchment area population size was strongly associated with diversity of mental health services. It is not known whether this was due to some types of services or some provider types being more sensitive to the size effect than others. The aim of this study was to investigate the association between area population size and diversity of mental health services, i.e. which types of services and which service providers' contributions are sensitive to population size.

METHODS

To map and classify services, we used the ESMS-R. The diversity of services was defined as the count of main types of care. Providers were classified as public, private or third sectors.

RESULTS

The diversity of outpatient, residential and voluntary services correlated positively with catchment area population size. The strongest positive correlation between the size of population and services available was found in third sector activities followed by public providers, but no correlation was found for diversity of private services. The third sector and public corporations each provided 44 % of the service units. Third sector providers produced all self-help services and most of the day care services. Third sector and private companies provided a significant part (59 %) of the residential care service units.

CONCLUSIONS

Significant positive correlations were found between size of catchment area population and diversity of residential, outpatient and voluntary services, indicating that these services concentrate on areas with larger population bases. The third sector seems to significantly complement the public sector in providing different services. Thus the third sector be needs to be functionally integrated with other MHS services to achieve a diversified and integrated service system.

Does primary care mental health resourcing affect the use and costs of secondary psychiatric services?

Collaborative care models for treatment of depression and anxiety disorders in primary care have been shown to be effective. The aim of this study was to investigate at the municipal level to what extent investment in mental health personnel at primary care health centres in the study area is reflected in the costs and use of secondary psychiatric services. Furthermore, we analysed whether the service provision and use of secondary psychiatric care correlates with the socioeconomic indicators of need. We found significant variation in the amount of mental health personnel provided at the health centres, uncorrelated with the indicators of need nor with the costs of secondary psychiatric care. The amount of mental health nurses at the health centres correlated inversely with the number of secondary psychiatric outpatient visits, whereas its relation to inpatient days and admission was positive. The costs of secondary psychiatric care correlated with level of psychiatric morbidity and socioeconomic indicators of need. The results suggest that when aiming at equal access of care and cost-efficiency, the primary and secondary care should be organized and planned with integrative collaboration.

Size matters - determinants of modern, community-oriented mental health services

Governances, structures and contents of mental health services are being reformed across countries. There is a need for data to support those changes. The aim of this study was to explore the quality, i.e., diversity and community orientation, and quantity, i.e., personnel resources, of mental health and substance abuse services (MHS) and evaluate correlation between population needs and quality and quantity of MHS. The European Service Mapping Schedule—Revised (ESMS-R) was used to classify mental health and substance abuse services in southern Finland. Municipal-level aggregate data, local data on unemployment rate, length of education, age of retirement, proportion of single households, alcohol sales and a composite mental health index were used as indicators of population mental health needs. Population size correlated strongly with service diversity, explaining 84% of the variance. Personnel resources did not associate with diversity or community orientation. The indicators of mental health services need did not have the expected association with quality and quantity of services. In terms of service organization, the results may support larger population bases, at least 150,000 adult inhabitants, when aiming for higher diversity.

Availability of mental health service providers and suicide rates in Slovenia: a nationwide ecological study

AIM

To investigate the influence of socioeconomic factors, mental health service availability, and prevalence of mental disorders on regional differences in the suicide rate in Slovenia.

METHODS

The effects of different socioeconomic factors, mental health service availability, and mental disorders factors on suicide rates from 2000-2009 were analyzed using a general linear mixed model (GLMM). Pearson correlations were used to explore the direction and magnitude of associations.

RESULTS

Among socioeconomic factors, unemployment rate ranked as the most powerful predictor of suicide and an increase of one unit in the unemployment rate increased regional suicide rate by 2.21 (β=2.21, 95% confidence intervals [CI]=1.87-2.54, P<0.001). On the other hand, higher marriage/divorce ratio was negatively related to the suicide rate and an increase of one unit in marriage/divorce ratio reduced regional suicide rate by 1.16 (β=-1.16, 95% CI=-2.20 to -0.13, P<0.031). The most influential mental health service availability parameter was higher psychiatrist availability (4 psychiatrists and more working at outpatient clinics per 100 000 inhabitants), which was negatively correlated with the suicide rate and reduced regional suicide rate by 2.95 (β=-2.95, 95% CI=-4.60 to -1.31, P=0.002). Another negatively correlated factor was the antidepressant/anxiolytic ratio higher than 0.5, which reduced the regional suicide rate by 2.32 (β=-2.32, 95% CI=-3.75 to -0.89, P=0.003). Among mental health disorders, only the prevalence of alcohol use disorders was significantly related to the regional suicide rates and an increase of one unit in the prevalence of alcohol use disorders per 1000 inhabitants increased the regional suicide rate by 0.02 (β=0.02, 95% CI=0.01- 0.03, P=0.008).

CONCLUSIONS

Besides unemployment, which was a very strong predictor of suicide rates, unequal availability of mental health services and quality of depressive disorder treatment may contribute to variations in suicide rates in different regions.

Evaluation of an integrated system for classification, assessment and comparison of services for long-term care in Europe: the eDESDE-LTC study

Background

The harmonization of European health systems brings with it a need for tools to allow the standardized collection of information about medical care. A common coding system and standards for the description of services are needed to allow local data to be incorporated into evidence-informed policy, and to permit equity and mobility to be assessed. The aim of this project has been to design such a classification and a related tool for the coding of services for Long Term Care (DESDE-LTC), based on the European Service Mapping Schedule (ESMS).

Methods

The development of DESDE-LTC followed an iterative process using nominal groups in 6 European countries. 54 researchers and stakeholders in health and social services contributed to this process. In order to classify services, we use the minimal organization unit or “Basic Stable Input of Care” (BSIC), coded by its principal function or “Main Type of Care” (MTC). The evaluation of the tool included an analysis of feasibility, consistency, ontology, inter-rater reliability, Boolean Factor Analysis, and a preliminary impact analysis (screening, scoping and appraisal).

Results

DESDE-LTC includes an alpha-numerical coding system, a glossary and an assessment instrument for mapping and counting LTC. It shows high feasibility, consistency, inter-rater reliability and face, content and construct validity. DESDE-LTC is ontologically consistent. It is regarded by experts as useful and relevant for evidence-informed decision making.

Conclusion

DESDE-LTC contributes to establishing a common terminology, taxonomy and coding of LTC services in a European context, and a standard procedure for data collection and international comparison.

Number of prior episodes and the presence of depressive symptoms are associated with longer length of stay for patients with acute manic episodes

BACKGROUND

Few studies have analyzed predictors of length of stay (LOS) in patients admitted due to acute bipolar manic episodes. The purpose of the present study was to estimate LOS and to determine the potential sociodemographic and clinical risk factors associated with a longer hospitalization. Such information could be useful to identify those patients at high risk for long LOS and to allocate them to special treatments, with the aim of optimizing their hospital management.

METHODS

This was a cross-sectional study recruiting adult patients with a diagnosis of bipolar disorder (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) criteria) who had been hospitalized due to an acute manic episode with a Young Mania Rating Scale total score greater than 20. Bivariate correlational and multiple linear regression analyses were performed to identify independent predictors of LOS.

RESULTS

A total of 235 patients from 44 centers were included in the study. The only factors that were significantly associated to LOS in the regression model were the number of previous episodes and the Montgomery-Åsberg Depression Rating Scale (MADRS) total score at admission (P < 0.05).

CONCLUSIONS

Patients with a high number of previous episodes and those with depressive symptoms during mania are more likely to stay longer in hospital. Patients with severe depressive symptoms may have a more severe or treatment-resistant course of the acute bipolar manic episode.

Factors associated with use of community mental health services by schizophrenia patients using multilevel analysis

Background

Persons with schizophrenia and related disorders may be particularly sensitive to a number of determinants of service use, including those related with illness, socio-demographic characteristics and organizational factors. The objective of this study is to identify factors associated with outpatient contacts at community mental health services of patients with schizophrenia or related disorders.

Methods

This cross-sectional study analyzed 1097 patients. The main outcome measure was the total number of outpatient consultations during one year. Independent variables were related to socio-demographic, clinical and use of service factors. Data were collected from clinical records.

Results

The multilevel linear regression model explained 46.35% of the variance. Patients with significantly more contacts with ambulatory services were not working and were receiving welfare benefits (p = 0.02), had no formal education (p = 0.02), had a global level of severity of two or three (four being the most severe) (p < 0.001), with one or more inpatient admissions (p < 0.001), and in contact with both types of professional (nurses and psychiatrists) (p < 0.001). The patients with the fewest ambulatory contacts were those with diagnoses of persistent delusional disorders (p = 0.04) and those who were attended by four of the 13 psychiatrists (p < 0.001).

Conclusions

As expected, the variables that explained the use of community service could be viewed as proxies for severity of illness. The most surprising finding, however, was that a group of four psychiatrists was also independently associated with use of ambulatory services by patients with schizophrenia or related disorders. More research is needed to carefully examine how professional support networks interact to affect use of mental health.

Costs of depression in Catalonia (Spain)

OBJECTIVE

To estimate the cost of depression for the adult population in Catalonia (Spain) for 2006.

METHOD

The total adult population of Catalonia for the reference year was close to 6 million. A cross-design synthesis study was conducted, combining "top-down" and "bottom-up" data from secondary data sources, as well as expert opinion (nominal groups). A societal perspective was adopted. Estimates included direct health costs (hospital, primary, specialised and pharmacological care) and the indirect costs derived from the productivity lost due to morbidity and mortality. Sensitivity analyses were carried out for primary and specialised care resource utilisation. A Monte Carlo simulation model was developed to handle the uncertainty of the unit costs of primary care, specialised care and hospital visits.

RESULTS

The total annual cost of depression in Catalonia for 2006 was 735.4 million Euros. Of this figure, 21.2% corresponded to direct costs, including 41 million Euros in primary care (5.6%), 8.1 million Euros in mental health specialised care (1.1%), 5.6 million Euros due to hospitalisation (0.8%) and 101.1 million Euros due to pharmacological care (13.7%); and 78.8% to indirect costs due to productivity loss. 3.7 million work days were lost to temporary disability for depression with a cost of 199.6 million Euros (27.1%), and 353.3 million Euros due to permanent disability (48%). Mortality attributed to suicide accounted for 26.9 million Euros (3.7%). The average annual cost of an adult with depression was close to 1800 Euros.

LIMITATIONS

The heterogeneity of the data sources, the uncertainty in several estimates (i.e. proportion of psychotropic expenditure attributed to the treatment of depression, suicide rate attributed to depression), and the difficulty in disaggregating anxiety and depressive disorders in a number of databases are study limitations.

CONCLUSIONS

The burden of depression for the Catalan public health system and society as a whole due to the consumption of resources and, more importantly, the loss of productivity is significant. Inefficiencies may be found in the overuse of pharmaceuticals and in the eligibility criteria of disability for work.

So what shall we do about assertive community treatment?

The usefulness of Assertive Community Treatment (ACT) in European countries with well-developed community care systems has been disputed, despite considerable relevant literature. This paper aims to assess reasons for and against implementing ACT in such countries. ACT may not be useful where generic community mental health teams are not yet well-developed, where admission rates are already low, or where an alternative model based on close integration of a full range of types of care is in place. Good reasons for introducing ACT include listening to patients' preferences, being able to monitor a high risk group of patients more successfully, good staff satisfaction, and the potential for using ACT teams as a platform for delivering interventions for difficult to treat psychosis. The ACT model is more likely to thrive in future if a recovery orientation can be adopted.

Physical disease in schizophrenia: a population-based analysis in Spain

Background

Physical disease remains a challenge in patients with schizophrenia. Our objective was to determine the epidemiological characteristics and burden of physical disease in hospitalized patients with schizophrenia.

Methods

We analyzed the 2004 Spanish National Hospital Discharge Registry, identified records coded for schizophrenia (295.xx) and characterized the physical diseases using the ICD-9 system and the Charlson Index. We also calculated standardized mortality ratios (SMRs) versus the general population adjusted by age and calendar time.

Results

A total of 16, 776 cases (mean age: 43 years, 65% males) were considered for analysis. Overall, 61% of cases had at least one ICD-9 physical code and 32% had more than one ICD-9 code. The Charlson index indicated that 20% of cases had a physical disease of known clinical impact and prognostic significance. Physical disease appeared early in life (50% of cases were 15-31 years of age) and increased rapidly in incidence with age. Thus, for patients aged 53 years or more, 84% had at least one physical ICD-9 code. Apart from substance abuse and addiction, the most prevalent diseases were endocrine (16%), circulatory (15%), respiratory (15%), injury-poisoning (11%), and digestive (10%). There were gender-related differences in disease burden and type of disease. In-hospital mortality significantly correlated with age, the Charlson Index and several ICD-9 groups of physical disease. Physical disease was associated with an overall 3.6-fold increase in SMRs compared with the general population.

Conclusions

This study provides the first nationally representative estimate of the prevalence and characteristics of physical disease in hospitalized patients with schizophrenia in Spain. Our results indicate that schizophrenia is associated with a substantial burden of physical comorbidities; that these comorbidities appear early in life; and that they have a substantial impact on mortality. This information raises concerns about the consequences and causes of physical disorders in patients with schizophrenia. Additionally, it will help to guide the design and implementation of preventive and therapeutic programs from the viewpoint of clinical care and in terms of health-care service planning.

Community mental-health services and suicide rate in Finland: a nationwide small-area analysis

BACKGROUND

In many countries, psychiatric services have been reformed by reducing the size of hospitals and developing community mental-health services. We investigated this reform by assessing the relation between suicide risk and different ways of organising mental-health services.

METHODS

We did a nationwide comprehensive survey of Finnish adult mental-health service units between Sept 1, 2004, and March 31, 2005. From health-care or social-care officers of 428 municipalities, we asked for information, classified according to the European service mapping schedule, about adult mental-health services. For each municipality, we measured age-adjusted and sex-adjusted suicide risk, pooled between 2000 and 2004, and then adjusted for register-derived socioeconomic factors.

FINDINGS

A wide variety of outpatient services (relative risk [RR] 0.92, 95% CI 0.87-0.96), prominence of outpatient versus inpatient services (0.93, 0.89-0.97), and 24-h emergency services (0.84, 0.75-0.92) were associated with decreased death rates from suicide. However, after adjustment for socioeconomic factors, only the prominence of outpatient services was associated with low suicide rate (0.94, 0.90-0.98). We replicated this finding even after adjustment for organisational changes and inpatient treatment.

INTERPRETATION

Well-developed community mental-health services are associated with lower suicide rates than are services oriented towards inpatient treatment provision. These data are consistent with the idea that population mental health can be improved by use of multifaceted, community-based, specialised mental-health services.

FUNDING

Academy of Finland.

Development and spatial representation of synthetic indexes of outpatient mental health care in Andalusia (Spain)

INTRODUCTION

There is a need to develop composite indicators to monitor mental health care in countries such as Spain, where there is wide variability of care systems in 17 different regions. The aim of this study is to generate and to test the usability of synthetic indexes in Andalusia (Southern Spain).

METHOD

Seven mental health indicators were selected by expert opinion from a previous list of simple indicators used to compare mental health care systems across Spain (Psicost-74). A Geographical Information Systems (GIS) was used to delineate 71 sectors based on the catchment areas of the mental health centers in Andalusia. Synthetic indexes were obtained through linear combinations of simple indicators via Principal Components Analysis (PCA), using activity data from the Mental Health Information System of Andalusia (SISMA). Maps of these indexes were drawn for 71 catchment areas.

RESULTS

Two synthetic indexes were obtained and showed high consistency in the PCA. The Care Load Index (component 1) related to population size and total outpatient care provided within the area. The Case Load Index (component 2) related to assisted morbidity in relation to the population size. The care load index was higher in populated urban areas, whereas the case load was higher in rural areas.

DISCUSSION

Care and case load indexes show a different pattern in urban and rural areas. This may be related to a different underlying model of care related to the degree of urbanisation. Geographical Information Systems (GIS) improved recognition and assessment of the spatial phenomena related to the mental health care system, and support policy decision making process in mental health.

Leitos hospitalares e reforma psiquiátrica no Brasil

O objetivo do trabalho é estimar o número de leitos psiquiátricos ocupados por Unidade da Federação e o valor pago pelo Sistema Único de Saúde (SUS) nas internações por serviços hospitalares, serviços profissionais, exames e medicamentos no Brasil em 2004. O número médio de leitos psiquiátricos ocupados, estimado a partir do total de dias de permanência no ano, e o valor pago pelo SUS foram obtidos a partir das Autorizações de Internação Hospitalar (AIH). O número de leitos psiquiátricos ocupados pelo SUS era de 45 mil em 2004. O valor total pago pelo SUS para internações de pacientes com transtornos mentais atingiu R$ 487 milhões em 2004. Os hospitais privados eram responsáveis por 78,8% do total de leitos psiquiátricos ocupados pelo SUS. Ainda que a desativação de estimados 15 mil leitos asilares possa gerar anualmente R$ 162 milhões ao ano passíveis de serem realocados para serviços psiquiátricos extra-hospitalares, o planejamento e a execução da Reforma Psiquiátrica têm sido muito tímidos. A precária rede extra-hospitalar tem sido utilizada como impedimento à desativação dos leitos psiquiátricos, embora esta gere os recursos necessários para a ampliação daquela.

Spatial analysis to identify hotspots of prevalence of schizophrenia

INTRODUCTION

The geographical distribution of mental health disorders is useful information for epidemiological research and health services planning.

OBJECTIVE

To determine the existence of geographical hotspots with a high prevalence of schizophrenia in a mental health area in Spain.

METHOD

The study included 774 patients with schizophrenia who were users of the community mental health care service in the area of South Granada. Spatial analysis (Kernel estimation) and Bayesian relative risks were used to locate potential hotspots. Availability and accessibility were both rated in each zone and spatial algebra was applied to identify hotspots in a particular zone.

RESULTS

The age-corrected prevalence rate of schizophrenia was 2.86 per 1,000 population in the South Granada area. Bayesian analysis showed a relative risk varying from 0.43 to 2.33. The area analysed had a non-uniform spatial distribution of schizophrenia, with one main hotspot (zone S2). This zone had poor accessibility to and availability of mental health services.

CONCLUSION

A municipality-based variation exists in the prevalence of schizophrenia and related disorders in the study area. Spatial analysis techniques are useful tools to analyse the heterogeneous distribution of a variable and to explain genetic/environmental factors in hotspots related with a lack of easy availability of and accessibility to adequate health care services.

Patterns of mental health service utilization in a general hospital and outpatient mental health facilities: analysis of 365,262 psychiatric consultations

PURPOSE

Mental health is one of the priorities of the European Commission. Studies of the use and cost of mental health facilities are needed in order to improve the planning and efficiey of mental health resources. We analyze the patterns of mental health service use in multiple clinical settings to identify factors associated with high cost.

SUBJECTS AND METHODS

22,859 patients received psychiatric care in the catchment area of a Spanish hospital (2000-2004). They had 365,262 psychiatric consultations in multiple settings. Two groups were selected that generated 80% of total costs: the medium cost group (N = 4,212; 50% of costs), and the high cost group (N = 236; 30% of costs). Statistical analyses were performed using univariate and multivariate techniques. Significant variables in univariate analyses were introduced as independent variables in a logistic regression analysis using "high cost" (>7,263$) as dependent variable.

RESULTS

Costs were not evenly distributed throughout the sample. 19.4% of patients generated 80% of costs. The variables associated with high cost were: age group 1 (0-14 years) at the first evaluation, permanent disability, and ICD-10 diagnoses: Organic, including symptomatic, mental disorders; Mental and behavioural disorders due to psychoactive substance use; Schizophrenia, schizotypal and delusional disorders; Behavioural syndromes associated with physiological disturbances and physical factors; External causes of morbidity and mortality; and Factors influencing health status and contact with health services.

DISCUSSION

Mental healthcare costs were not evenly distributed throughout the patient population. The highest costs are associated with early onset of the mental disorder, permanent disability, organic mental disorders, substance-related disorders, psychotic disorders, and external factors that influence the health status and contact with health services or cause morbidity and mortality.

CONCLUSION

Variables related to psychiatric diagnoses and sociodemographic factors have influence on the cost of mental healthcare.

Social predictors of out-patient mental health contact in schizophrenia patients

INTRODUCTION

Since community-based health care was introduced, the use of mental health services by patients with serious mental disorders has been an issue of much interest. However, our knowledge of intervening factors is both scarce and partial.

OBJECTIVE

To study socio-demographic variables which may predict time-lapse (in days) between each out-patient contact among a cohort of schizophrenia patients.

METHOD

Data comes from the South Granada Schizophrenia Case Register. We used Cox's regression analysis to study the influence of the socio-demographic variables in the time lapsed between out-patient contacts.

RESULTS

After adjusting for all other socio-demographic variables included, we found that to live in a rural area and being younger independently predicted a longer time-lapse between out-patient contacts while being retired predicted a shorter interval between such contacts. Other variables such as sex, educational level and marital status did not determine such length between out-patients contacts.

CONCLUSION

Socio-demographic variables, and not only psychopathological ones, determine mental health out-patient service use.

A framework for evidence-based mental health care and policy

OBJECTIVE

Care planning integrates a growing number of disciplines, research fields and analysis techniques. A framework of the main areas of interest with regard to evidence-based health care in mental health is provided here.

METHOD

The framework is based on the experience of working with data analysts and health and social decision makers at the PSICOST/RIRAG network, a Spanish research association which includes psychiatrists, health economists and health policy experts, as well as on a review of the literature.

RESULTS

Three main areas have been identified and described here: outcomes management, knowledge discovery from data, and decision support systems. Their use in mental health care is reviewed.

CONCLUSION

It is important to promote bridging strategies among these new fields in order to enhance communication and information transfer between the different parts involved in mental health decision making: i) clinicians and epidemiologists, ii) data analysts, iii) care policy makers and other end-users.

Development and usefulness of an instrument for the standard description and comparison of services for disabilities (DESDE)

OBJECTIVE

Mental health research has made significant progress in international comparison and instrument development. This study reports the adaptation of the European Service Mapping Schedule (ESMS) to the assessment of services for persons with disabilities.

METHOD

Qualitative groups were used to develop the Description and Evaluation of Services for Disabilities in Europe (DESDE). The psychometric analysis of DESDE covered: feasibility, inter-rater reliability, descriptive validity and internal validity. A demonstration study was also carried out.

RESULTS

Compared to the original ESMS, a new main branch and several sub-branches were added. We identified 826 services for persons with disabilities, which provided 1284 main types of care. The feasibility and reliability was good for the majority of codes. Only 6% of services were not properly classified. The Boolean factor analysis supported the internal validity of DESDE.

CONCLUSION

DESDE is a useful and reliable instrument for the assessment of services for persons with disabilities.

The current state of mental health care in Italy: problems, perspectives, and lessons to learn

After legislative changes in 1978, Italian psychiatry underwent a thorough overhaul, with the gradual closure of all Mental Hospitals. A nation-wide network of Departments of Mental Health now deliver outpatient and inpatient care, but also run semi-residential and residential facilities (the latter with 2.9 beds per 10,000 inhabitants). Hospital care is delivered through small psychiatric units (with no more than 15 beds). There are also many private inpatient facilities operating in Italy, and the number of private inpatient beds per 10,000 inhabitants exceeds the number of public beds; overall there are 1.7 acute beds per 10,000 inhabitants - one of Europe's currently lowest numbers. There is marked quanti- and qualitative variation in the provision of out- and inpatient care throughout the country, and service utilization patterns are similarly uneven. Studies examining quality of life report a fairly high degree of patient satisfaction, whereas patients' families frequently bear a heavy burden. In conclusion, the Italian reform law led to the establishment of a broad network of facilities to meet diverse care needs. Further efforts are required to improve quality of care and to develop a more effectively integrated system. Greater attention must be paid to topics such as quality of care and outcomes, public and private sector balance, and the coordination of various resources and agencies.

The Barents project in psychiatry: a systematic comparative mental health services study between Northern Norway and Archangelsk County

BACKGROUND

There is virtually no readily accessible systematically recorded evidence on how the organization of mental health services in Europe's largest country, Russia, may differ from other national systems. This study systematically compares the mental health services in Archangelsk County and Northern Norway using instruments developed for trans-cultural use.

METHODS

The European Service Mapping Schedule (ESMS) and The International Classification of Mental Health Care (ICMHC) were used to describe: (i) resources, organisation and utilisation of the services; (ii) their decentralisation and differentiation; (iii) some interventions delivered by the mental health service units (n = 132) in both regions.

RESULTS

The Norwegian services are more decentralised and differentiated, while the Russian services are largely hospital-based. The GPs are of considerable importance to the Norwegian services, functioning as gatekeepers-both centrally and peripherally. In contrast, the GP model is still poorly established in Archangelsk County. There are more units for long term stay in the Russian services than in Norway. General health care and taking over daily living activities are more organised in Archangelsk County, while psychopharmacological treatment and psychosocial interventions are more developed in Norway.

CONCLUSION

The study has revealed several differences in resources, organisation and utilisation of the mental health services between the two compared areas. The very large variations indicate that underlying local patterns of service delivering must be further investigated and taken into account in the planning of the services development.

[Social deprivation and mental health. Replicability and applicability in the Italian context of the resource allocation methods developed in the United Kingdom]

AIMS

Most of the available evidence on the relationship between socioeconomic indicators of social deprivation and patterns of use of mental health services has been produced in the United Kingdom, where the Ministry of Health has developed a resource allocation formula based upon the results of those studies. The main aim of the paper is to evaluate the replicability in the Italian context of such research, and of the resulting allocation strategies.

METHODS

Detailed description of the resource allocation method currently adopted in the United Kingdom, whose main purpose consists in reaching the best balance between available funding and patterns of need. Detailed description of resource allocation processes in Italy; discussion of the main methodological and statistical limitations restraining the replicability of the British formula in the Italian context.

CONCLUSIONS

There is a growing interest in Italy towards the introduction of evidence-based methods in health decision making, in order to correct the overwhelming influence of political issues. What is needed is a better understanding of the relationship between higher levels of equity in health services access, and their effects in terms of better outcomes.

Assessment of service use patterns in out-patients with schizophrenia: a Spanish study

OBJECTIVE

The objective is to describe and characterize patterns of service use by out-patients with schizophrenia in Spain.

METHOD

A representative treated prevalence sample of cases with schizophrenia was selected from four Spanish health areas. The evaluation included health service use, clinical severity, functioning and disability. Statistical analysis was based on hierarchical clustering methods.

RESULTS

A total of 356 patients were included in the analysis. Five patterns of health service use were defined: heavy out-patient mental health users; mental health and general health service users; heavy hospital service users; nursing service users; low users of mental health services. Patients in each group showed differences in clinical and disability status. Patterns of health service use showed consistency, but also variability, among the geographical areas.

CONCLUSION

Development and organization of mental health services should take into account the combinations of services patients most frequently use.