The REFINEMENT Glossary of Terms: An International Terminology for Mental Health Systems Assessment

The Development of a New Approach for the Harmonized Multi-Sectoral and Multi-Country Cost Valuation of Services: The PECUNIA Reference Unit Cost (RUC) Templates

BACKGROUND

Increasing healthcare costs require evidence-based resource use allocation for which assessing costs rigorously and comparably is crucial. Harmonized cross-country costing methods for evaluating interventions from a societal perspective are lacking. This study presents the development process and content of the service costing templates developed as part of the European project PECUNIA.

METHODS

The six developmental steps towards technological readiness of the templates included (1) a common conceptual costing framework and review of methodological costing issues, (2) harmonization strategy formulation, (3) proof-of-concept with expert feedback, (4) piloting, (5) validation, and (6) demonstration in six European countries.

RESULTS

The PECUNIA Reference Unit Cost (RUC) Templates for service costing are three new self-completion tools to be used with secondary or primary data for top-down micro-costing or top-down gross-costing approaches. Complementary data collection and unit cost aggregation/weighting templates are available. The applications leading to the final versions including (4) piloting through calculation of 15-unit costs, (5) validation within a Health Technology Assessment framework, and (6) RUC calculations mostly based on secondary data demonstrated the templates' general feasibility, with feedback for improved usability incorporated and a supplementary user guide developed.

CONCLUSION

The validated PECUNIA RUC Templates for multi-sectoral and multi-country service costing allow for harmonized RUC development while incorporating flexibility and transparency in the choice of costing approaches, data sources and magnitude of remaining heterogeneity. The templates are expected to significantly improve the quality, comparability and availability of unit costs for economic evaluations, and promote the transferability of service cost information across Europe.

Assessment of care provision integration in a community-based mental health system: balanced care model implementation in Andalusia (Spain)

BACKGROUND

Andalusia is the second largest region in Spain, and it has developed a comprehensive mental health (MH) plan that encourages the consolidation of the balanced care model. However, its geographical and socioeconomic disparity is a great challenge for a community-based MH system. Both the assessment of the implementation of the MH plan and the development of new tools to support decision-making can be considered critical.

OBJECTIVES

The present study aims (i) to assess how the integration of different types of MH care may influence system performance and (ii) to check the performance evolution of the integration process geographically regarding the small MH areas of Andalusia.

METHODS

The performance of the Andalusian MH system was assessed by combining Monte Carlo simulation, fuzzy inference and data envelopment analysis. The relative technical efficiency was the main performance indicator.

RESULTS

A correct integration of appropriate types of MH care, according to population needs, increases the performance of the Andalusian MH system both from global and regional perspectives. The spatial representation (based on small MH areas) of the results highlights how the performance depends on specific geographical characteristics. By analyzing the identified spatial clusters, defined by different management patterns depending on user and socioeconomic characteristics, benchmark areas and areas for improvement can be studied to design evidence-informed policies and interventions.

CONCLUSIONS

A global analysis of MH system performance was carried out, including both the successive integration of different types of care and its spatial evolution. Although an appropriate integration of different types of MH care has a positive effect on the Andalusian MH system, this process has different profiles depending on specific geographically based user and socioeconomic characteristics. The balanced care model can be considered the paradigm for assessing the performance of a large and populated territory such as Andalusia, which has a community-based MH system. This methodological approach (performance assessment and spatial analysis) may be used as a guide for developing future evidence-informed policies and managerial interventions.

Patterns of service provision in child and adolescent mental health care in Australia

Standard description of local care provision is essential for evidence-informed planning. This study aimed to map and compare the availability and diversity of current mental health service provision for children and adolescents in Australia. We used a standardised service classification instrument, the Description and Evaluation of Services and DirectoriEs (DESDE) tool, to describe service availability in eight urban and two rural health districts in Australia. The pattern of care was compared with that available for other age groups in Australia. Outpatient care was found to be the most common type of service provision, comprising 212 (81.2%) of all services identified. Hospital care (acute and non-acute) was more available in urban than in rural areas (20 services [9.7%] vs 1 [1.8%]). The level of diversity in the types of care available for children and adolescents was lower than that for the general adult population, but slightly higher than that for older people in the same areas. Standardised comparison of the pattern of care across regions reduces ambiguity in service description and classification, enables gap analysis and can inform policy and planning.

Clarifying terminology and definitions in education services for mental health users: A disambiguation study

In the wake of the mental health crisis in children and adolescents, the coordination of education and mental health services has become a global priority. However, differing terminologies and classifications across sectors, hinder effective comparison. The classification in education focuses mainly on outputs like qualifications or throughputs like teaching programs. This proof-of-concept study tested the applicability of a standard classification of health services, the Description and Evaluation of Services and DirectoriEs (DESDE), to evaluate education services for mental health users in the context of Spain and The Netherlands. It was conducted alongside the PECUNIA project, that sought to develop methods for the assessment of mental health costs and outcomes in different sectors. The study followed an ontoterminology approach involving: 1) identification of services from a predefined list of 46 resource-use items, 2) disambiguation of identified services with the DESDE, and classifying them as accurate, ambiguous, vague or confuse; and 3) external validation by an expert panel. The analysis was conducted at the level of type of resource, target population and care provision. From the initial list, only ten of the resources could be categorized as services using DESDE, and not activities, interventions or professionals. Only four of them (8,65%) were accurate across all disambiguation categories. Experts were unaware of terminology problems in classification of service provision in the education sector. Classifications and glossaries can clarify service naming, description and costing allowing comparative effectiveness analysis and facilitating cross-sectoral planning. This should be grounded in common methodologies, tools, and units of analysis.

The transition towards community-based mental health care in the European Union: Current realities and prospects

The shift of mental health care from mental institutions to community-based services has been implemented differentially throughout the EU. However, because a comprehensive overview of the current mental health provision in member states is lacking, it is challenging to compare services across nations. This study investigates the extent of implementation of community-based mental health services within the EU using data collected from the WHO Mental Health Atlas. Results show that, although great cross-country variation exists in the implementation of community-based services, mental hospitals remain the prominent model of care in most countries. A few countries endorsed a balanced care model, with the co-occurrence of community services and mental hospitals. However, missing data, low quality of data and different service definitions hamper the possibility of a thorough analysis of the status on deinstitutionalization. Although policies on the closing and downsizing of mental institutions have been endorsed by the EU, the strong presence of mental hospitals slows down the shift towards community-based mental health care. This study highlights the need for an international consensus on definitions and a harmonization of indicators on mental health services. Together with the commitment of member states to improve the quality of data reporting, leadership must emerge to ensure quality monitoring of mental health-related data, which will help advance research, policies and practices.

Toward precision brain health: accurate prediction of a cognitive index trajectory using neuroimaging metrics

The goal of precision brain health is to accurately predict individuals' longitudinal patterns of brain change. We trained a machine learning model to predict changes in a cognitive index of brain health from neurophysiologic metrics. A total of 48 participants (ages 21-65) completed a sensorimotor task during 2 functional magnetic resonance imaging sessions 6 mo apart. Hemodynamic response functions (HRFs) were parameterized using traditional (amplitude, dispersion, latency) and novel (curvature, canonicality) metrics, serving as inputs to a neural network model that predicted gain on indices of brain health (cognitive factor scores) for each participant. The optimal neural network model successfully predicted substantial gain on the cognitive index of brain health with 90% accuracy (determined by 5-fold cross-validation) from 3 HRF parameters: amplitude change, dispersion change, and similarity to a canonical HRF shape at baseline. For individuals with canonical baseline HRFs, substantial gain in the index is overwhelmingly predicted by decreases in HRF amplitude. For individuals with non-canonical baseline HRFs, substantial gain in the index is predicted by congruent changes in both HRF amplitude and dispersion. Our results illustrate that neuroimaging measures can track cognitive indices in healthy states, and that machine learning approaches using novel metrics take important steps toward precision brain health.

Impact of the workforce allocation on the technical performance of mental health services: the collective case of Helsinki-Uusimaa (Finland)

BACKGROUND

Long-term mental health (MH) policies in Finland aimed at investing in community care and promoting reforms have led to a reduction in the number of psychiatric hospital beds. However, most resources are still allocated to hospital and community residential services due to various social, economic and political factors. Despite previous research focussing on the number and cost of these services, no study has evaluated the emerging patterns of use, their technical performance and the relationship with the workforce structure.

OBJECTIVE

The purpose of this study was to observe the patterns of use and their technical performance (efficiency) of the main types of care of MH services in the Helsinki-Uusimaa region (Finland), and to analyse the potential relationship between technical performance and the corresponding workforce structure.

METHODS

The sample included acute hospital residential care, non-hospital residential care and outpatient care services. The analysis was conducted using regression analysis, Monte Carlo simulation, fuzzy inference and data envelopment analysis.

RESULTS

The analysis showed a statistically significant linear relationship between the number of service users and the length of stay, number of beds in non-hospital residential care and number of contacts in outpatient care services. The three service types displayed a similar pattern of technical performance, with high relative technical efficiency on average and a low probability of being efficient. The most efficient acute hospital and outpatient care services integrated multidisciplinary teams, while psychiatrists and nurses characterized non-hospital residential care.

CONCLUSIONS

The results indicated that the number of resources and utilization variables were linearly related to the number of users and that the relative technical efficiency of the services was similar across all types. This suggests homogenous MH management with small variations based on workforce allocation. Therefore, the distribution of workforce capacity should be considered in the development of effective policies and interventions in the southern Finnish MH system.

The identification of economically relevant health and social care services for mental disorders in the PECUNIA project

BACKGROUND

Health economic research is still facing significant problems regarding the standardization and international comparability of health care services. As a result, comparative effectiveness studies and cost-effectiveness analyses are often not comparable. This study is part of the PECUNIA project, which aimed to improve the comparability of economic evaluations by developing instruments for the internationally standardized measurement and valuation of health care services for mental disorders. The aim of this study was to identify internationally relevant services in the health and social care sectors relevant for health economic studies for mental disorders.

METHODS

A systematic literature review on cost-of-illness studies and economic evaluations was conducted to identify relevant services, complemented by an additional grey literature search and a search of resource use measurement (RUM) questionnaires. A preliminary long-list of identified services was explored and reduced to a short-list by multiple consolidation rounds within the international research team and an external international expert survey in six European countries.

RESULTS

After duplicate removal, the systematic search yielded 15,218 hits. From these 295 potential services could be identified. The grey literature search led to 368 and the RUM search to 36 additional potential services. The consolidation process resulted in a preliminary list of 186 health and social care services which underwent an external expert survey. A final consolidation step led to a basic list of 56 services grouped into residential care, daycare, outpatient care, information for care, accessibility to care, and self-help and voluntary care.

CONCLUSIONS

The initial literature searches led to an extensive number of potential service items for health and social care. Many of these items turned out to be procedures, interventions or providing professionals rather than services and were removed from further analysis. The resulting list was used as a basis for typological coding, the development of RUM questionnaires and corresponding unit costs for international mental health economic studies in the PECUNIA project.

Reaching consensus on definitions for food and physical activity policies: experience from the Policy Evaluation Network

BACKGROUND

An upsurge in policy evaluation research within public health sciences has led to multi-disciplinary research networks like the 'Policy Evaluation Network' (PEN). This multi-disciplinary collaboration highlighted the need for consensus on clear, common terminology and definitions to facilitate the multi-disciplinary research. This article outlines the development process of the PEN definitions glossary tool, with a focus on the key domains of policy design, implementation and outcomes as they apply to physical activity, sedentary behaviour and dietary behaviours.

METHODS

A project specific participatory process was undertaken, involving PEN researchers (n = 48) from seven European countries across various disciplinary backgrounds. All involved researchers were invited to identify and collate definitions that were commonly used in their research field. Terms and definitions were discussed and debated during three online workshops. Subsequently, the definitions were discussed and refined until consensus was reached.

RESULTS

Consensus definitions for 93 terms related to the evaluation of policy design, implementation and outcomes are provided. Consensus was reached on a range of terms where the terms were understood and used differently across represented disciplines (e.g. 'Outcome' and 'Impact'). A conceptual 'Inter-relations in policy-related concepts' diagram was developed to enable navigation through an online database with key terms.

CONCLUSIONS

The definitions resulting from this participatory process has supported PEN researchers and practitioners across disciplines to reach a shared understanding of different terms related to policy evaluation. Thus, providing a platform for avoiding conflicting use of the same terms in differing contexts over the course of the PEN work programme, facilitating clear and consistent communication, and allowing for clarity within collaborative multi-disciplinary projects and in public-facing messages.

Magnitude of terminological bias in international health services research: a disambiguation analysis in mental health

AIMS

Health services research (HSR) is affected by a widespread problem related to service terminology including non-commensurability (using different units of analysis for comparisons) and terminological unclarity due to ambiguity and vagueness of terms. The aim of this study was to identify the magnitude of the terminological bias in health and social services research and health economics by applying an international classification system.

METHODS

This study, that was part of the PECUNIA project, followed an ontoterminology approach (disambiguation of technical and scientific terms using a taxonomy and a glossary of terms). A listing of 56 types of health and social services relevant for mental health was compiled from a systematic review of the literature and feedback provided by 29 experts in six European countries. The disambiguation of terms was performed using an ontology-based classification of services (Description and Evaluation of Services and DirectoriEs - DESDE), and its glossary of terms. The analysis focused on the commensurability and the clarity of definitions according to the reference classification system. Interrater reliability was analysed using κ.

RESULTS

The disambiguation revealed that only 13 terms (23%) of the 56 services selected were accurate. Six terms (11%) were confusing as they did not correspond to services as defined in the reference classification system (non-commensurability bias), 27 (48%) did not include a clear definition of the target population for which the service was intended, and the definition of types of services was unclear in 59% of the terms: 15 were ambiguous and 11 vague. The κ analyses were significant for agreements in unit of analysis and assignment of DESDE codes and very high in definition of target population.

CONCLUSIONS

Service terminology is a source of systematic bias in health service research, and certainly in mental healthcare. The magnitude of the problem is substantial. This finding has major implications for the international comparability of resource use in health economics, quality and equality research. The approach presented in this paper contributes to minimise differentiation between services by taking into account key features such as target population, care setting, main activities and type and number of professionals among others. This approach also contributes to support financial incentives for effective health promotion and disease prevention. A detailed analysis of services in terms of cost measurement for economic evaluations reveals the necessity and usefulness of defining services using a coding system and taxonomical criteria rather than by 'text-based descriptions'.

In Search for Comparability: The PECUNIA Reference Unit Costs for Health and Social Care Services in Europe

Improving the efficiency of mental healthcare service delivery by learning from international best-practice examples requires valid data, including robust unit costs, which currently often lack cross-country comparability. The European ProgrammE in Costing, resource use measurement and outcome valuation for Use in multi-sectoral National and International health economic evaluAtions (PECUNIA) aimed to harmonize the international unit cost development. This article presents the methodology and set of 36 externally validated, standardized reference unit costs (RUCs) for five health and social care services (general practitioner, dentist, help-line, day-care center, nursing home) in Austria, England, Germany, Hungary, The Netherlands, and Spain based on unambiguous service definitions using the extended DESDE PECUNIA coding framework. The resulting PECUNIA RUCs are largely comparable across countries, with any causes for deviations (e.g., country-specific scope of services) transparently documented. Even under standardized methods, notable limitations due to data-driven divergences in key costing parameters remain. Increased cross-country comparability by adopting a uniform methodology and definitions can advance the quality of evidence-based policy guidance derived from health economic evaluations. The PECUNIA RUCs are available free of charge and aim to significantly improve the quality and feasibility of future economic evaluations and their transferability across mental health systems.

Modelling the balance of care: Impact of an evidence-informed policy on a mental health ecosystem

Major efforts worldwide have been made to provide balanced Mental Health (MH) care. Any integrated MH ecosystem includes hospital and community-based care, highlighting the role of outpatient care in reducing relapses and readmissions. This study aimed (i) to identify potential expert-based causal relationships between inpatient and outpatient care variables, (ii) to assess them by using statistical procedures, and finally (iii) to assess the potential impact of a specific policy enhancing the MH care balance on real ecosystem performance. Causal relationships (Bayesian network) between inpatient and outpatient care variables were defined by expert knowledge and confirmed by using multivariate linear regression (generalized least squares). Based on the Bayesian network and regression results, a decision support system that combines data envelopment analysis, Monte Carlo simulation and fuzzy inference was used to assess the potential impact of the designed policy. As expected, there were strong statistical relationships between outpatient and inpatient care variables, which preliminarily confirmed their potential and a priori causal nature. The global impact of the proposed policy on the ecosystem was positive in terms of efficiency assessment, stability and entropy. To the best of our knowledge, this is the first study that formalized expert-based causal relationships between inpatient and outpatient care variables. These relationships, structured by a Bayesian network, can be used for designing evidence-informed policies trying to balance MH care provision. By integrating causal models and statistical analysis, decision support systems are useful tools to support evidence-informed planning and decision making, as they allow us to predict the potential impact of specific policies on the ecosystem prior to its real application, reducing the risk and considering the population’s needs and scientific findings.

Patterns of Service Provision in Older People's Mental Health Care in Australia

Australia has a population of around 4 million people aged 65 years and over, many of whom are at risk of developing cognitive decline, mental illness, and/or psychological problems associated with physical illnesses. The aim of this study was to describe the pattern of specialised mental healthcare provision (availability, placement capacity, balance of care and diversity) for this age group in urban and rural health districts in Australia. The Description and Evaluation of Services and DirectoriEs for Long Term Care (DESDE-LTC) tool was used in nine urban and two rural health districts of the thirty-one Primary Health Networks across Australia. For the most part service provision was limited to hospital and outpatient care across all study areas. The latter was mainly restricted to health-related outpatient care, and there was a relative lack of social outpatient care. While both acute and non-acute hospital care were available in urban areas, in rural areas hospital care was limited to acute care. Limited access to comprehensive mental health care, and the uniformity in provision across areas in spite of differences in demographic, socioeconomic and health characteristics raises issues of equity in regard to psychogeriatric care in this country. Comparing patterns of mental health service provision across the age span using the same classification method allows for a better understanding of care provision and gap analysis for evidence-informed policy.

Patterns of Mental Health Care in Remote Areas: Kimberley (Australia), Nunavik (Canada), and Lapland (Finland): Modèles de soins de santé mentale dans les régions éloignées: Kimberley (Australie), Nunavik (Canada) et Laponie (Finlande)

OBJECTIVE

Mental health (MH) care in remote areas is frequently scarce and fragmented and difficult to compare objectively with other areas even in the same country. This study aimed to analyze the adult MH service provision in 3 remote areas of Organization for Economic Cooperation and Development countries in the world.

METHODS

We used an internationally agreed set of systems indicators, terminology, and classification of services (Description and Evaluation of Services and DirectoriEs for Long Term Care). This instrument provided a standard description of MH care provision in the Kimberley region (Australia), Nunavik (Canada), and Lapland (Finland), areas characterized by an extremely low population density and high relative rates of Indigenous peoples.

RESULTS

All areas showed high rates of deprivation within their national contexts. MH services were mostly provided by the public sector supplemented by nonprofit organizations. This study found a higher provision per inhabitant of community residential care in Nunavik in relation to the other areas; higher provision of community outreach services in the Kimberley; and a lack of day services except in Lapland. Specific cultural-based services for the Indigenous population were identified only in the Kimberley. MH care in Lapland was self-sufficient, and its care pattern was similar to other Finnish areas, while the Kimberley and Nunavik differed from the standard pattern of care in their respective countries and relied partly on services located outside their boundaries for treating severe cases.

CONCLUSION

We found common challenges in these remote areas but a huge diversity in the patterns of MH care. The implementation of care interventions should be locally tailored considering both the environmental characteristics and the existing pattern of service provision.

The future of community psychiatry and community mental health services

PURPOSE OF REVIEW

The aim of this article is to provide a framework and analysis of a series of critical components to inform the future design, development, sustaining, and monitoring of community mental health services.

RECENT FINDINGS

Many mental health services remain too hospital-centric, often without adequate outreach services. On the basis of outcome evidence, we need to shift the balance of mental health services from hospital-centered with community outreach when convenient for staff, to community-centered and mobile, with in-reach to hospital only when necessary. Too few training programs those with emphasize the macroskills of public advocacy, working with service users, families, social movements, and the media to improve mental health and wellbeing of regional and local communities.

SUMMARY

We should adopt a health ecosystems approach to mental healthcare and training, encompassing nano to macrolevels of service in every region. Catchment mental health services should be rebuilt as community-centric mental health services, integrating all community and inpatient components, but led and integrated from community sites. Community psychiatrists and mental health professionals of the future will need to be well trained in the nano to macroskills required to take responsibility for the mental health and wellbeing of their catchment communities and to provide leadership in service-planning, management, and continuing revision on the basis of rigorous evaluation. These approaches should be the core of all training in psychiatry and all mental health professions prior to any subspecialization.

Predicting Patients' Readmission: Do Clinicians Outperform a Statistical Model? An Exploratory Study on Clinical Risk Judgment in Mental Health

This study explores whether clinicians or a statistical model can better identify patients at risk of early readmission and investigates variables potentially associated with clinicians' risk judgment. We focus on a total of 142 patients discharged from acute psychiatric wards in the Verona Mental Health Department (Italy). Psychiatrists assessed patients' risk of readmission at 30 and 90 days postdischarge, predicted their postdischarge compliance, and assessed their Global Assessment of Functioning (GAF) score at admission and discharge. Clinicians' judgment outperformed the statistical model, with the difference reaching statistical significance for 30-day readmission. Clinicians' readmission risk judgment, both for 30 and 90 days, was found to be statistically associated with predicted compliance with community treatment and GAF score at discharge. Clinicians' superior performance might be explained by their risk judgment depending on nonmeasurable factors, such as experience and intuition. Patients with a poorer GAF score at discharge and poor assumed compliance were predicted to have a higher risk of readmission.

Service availability and capacity in rural mental health in Australia: Analysing gaps using an Integrated Mental Health Atlas

OBJECTIVE

Access to services and workforce shortages are major challenges in rural areas worldwide. In order to improve access to mental health care, it is imperative to understand what services are available, what their capacity is and where existing funds might be spent to increase availability and accessibility. The aim of this study is to investigate mental health service provision in a selection of rural and remote areas across Australia by analysing service availability, placement capacity and diversity.

METHOD

This research studies the health regions of Western New South Wales and Country Western Australia and their nine health areas. Service provision was analysed using the DESDE-LTC system for long-term care service description and classification that allows international comparison. Rates per 100,000 inhabitants were calculated to compare the care availability and placement capacity for children and adolescents, adults and older adults.

RESULTS

The lowest diversity was found in northern Western Australia. Overall, Western New South Wales had a higher availability of non-acute outpatient services for adults, but hardly any acute outpatient services. In Country Western Australia, substantially fewer non-acute outpatient services were found, while acute services were much more common. Acute inpatient care services were more common in Western New South Wales, while sub-acute inpatient services and non-acute day care services were only found in Western New South Wales.

CONCLUSION

The number and span of services in the two regions showed discrepancies both within and between regions, raising issues on the equity of access to mental health care in Australia. The standard description of the local pattern of rural mental health care and its comparison across jurisdictions is critical for evidence-informed policy planning and resource allocation.

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.

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.

A decision support system for assessing management interventions in a mental health ecosystem: The case of Bizkaia (Basque Country, Spain)

Evidence-informed strategic planning is a top priority in Mental Health (MH) due to the burden associated with this group of disorders and its societal costs. However, MH systems are highly complex, and decision support tools should follow a systems thinking approach that incorporates expert knowledge. The aim of this paper is to introduce a new Decision Support System (DSS) to improve knowledge on the health ecosystem, resource allocation and management in regional MH planning. The Efficient Decision Support-Mental Health (EDeS-MH) is a DSS that integrates an operational model to assess the Relative Technical Efficiency (RTE) of small health areas, a Monte-Carlo simulation engine (that carries out the Monte-Carlo simulation technique), a fuzzy inference engine prototype and basic statistics as well as system stability and entropy indicators. The stability indicator assesses the sensitivity of the model results due to data variations (derived from structural changes). The entropy indicator assesses the inner uncertainty of the results. RTE is multidimensional, that is, it was evaluated by using 15 variable combinations called scenarios. Each scenario, designed by experts in MH planning, has its own meaning based on different types of care. Three management interventions on the MH system in Bizkaia were analysed using key performance indicators of the service availability, placement capacity in day care, health care workforce capacity, and resource utilisation data of hospital and community care. The potential impact of these interventions has been assessed at both local and system levels. The system reacts positively to the proposals by a slight increase in its efficiency and stability (and its corresponding decrease in the entropy). However, depending on the analysed scenario, RTE, stability and entropy statistics can have a positive, neutral or negative behaviour. Using this information, decision makers can design new specific interventions/policies. EDeS-MH has been tested and face-validated in a real management situation in the Bizkaia MH system.

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.

Integrated mapping of local mental health systems in Central Chile

OBJECTIVE

To describe the availability of local mental health (MH) services in small MH catchment areas in Central Chile, using a bottom-up approach.

METHODS

MH services of 19 small MH catchment areas in five health districts of Central Chile that provide health care to more than 4 million inhabitants were assessed using DESDE-LTC (Description and Evaluation of Services and Directories in Europe for Long-Term Care), a tool for standardized description and classification of LTC health services, in a study conducted in 2012 ("DESDE-Chile") designed to complement other studies conducted in 2004 and 2012 at the national and regional level using the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS). Key informants from national, regional, and local health authorities were contacted to compile a comprehensive list of MH services or facilities (health, social services, education, employment, and housing). The analysis of local care provision covered three criteria-service availability, placement capacity, and workforce capacity.

RESULTS

The study detected disparities in all three criteria (availability and placement and workforce capacity) across the five health districts, between urban and rural areas, and between neighboring urban areas. Analysis of service availability revealed differences in the weight of residential services versus day and outpatient care. The Talcahuano area could be considered a benchmark of MH care in Central Chile, based on its service provision patterns, and the criteria of the community care model. The list of MH services identified in this study differed from the one generated in the 2012 WHO-AIMS study.

CONCLUSIONS

This survey of local MH service provision in small catchment areas using the DESDE-LTC tool provided MH service provision data that complemented information collected in other studies conducted at the national/regional level using the WHO-AIMS tool. The bottom-up approach applied in this study would also be useful for the assessment of equity and accessibility and local planning.

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.