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Williams TM, Smith GP. Laying new foundations for 21st century community mental health services: An Australian perspective. Int J Ment Health Nurs 2019; 28:1008-1014. [PMID: 30903646 DOI: 10.1111/inm.12590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2019] [Indexed: 11/30/2022]
Abstract
While there has been a significant increase in investment in community mental health in Australia since the advent of the National Mental Health Strategy in the early 1990s, there has been little guidance on service design and delivery. This has led to a growing diversity of approaches and concern about the adequacy of care with repeated calls for a system overhaul. Consumers and carers have very largely been absent from decision-making about service design and development which has led to a system primarily designed by healthcare professionals. However, with the emergence of recovery as a core principle in mental health, it is time for consumers and carers to be centrally engaged in co-designing services with service providers. This raises the question of whether dominant service delivery models - such as the growth of specialist teams/services, the changing balance between profession-specific and generic case management roles in multidisciplinary teams, and the separation of inpatient from community care - will prevail. Contentious issues in these three service delivery areas are outlined to stimulate debate and highlight the pressing need for national guidance on the configuration of community mental health services. Building on the lessons learned from the first National Mental Health Strategy, we outline a proposal for a co-designed National Framework for Community Mental Health Services to guide the delivery of care in a way which satisfies the aspirations of consumers, carers, and mental health professionals alike.
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Affiliation(s)
- Theresa Maureen Williams
- Research and Strategy, Office of the Chief Psychiatrist, Perth, Western Australia, Australia.,Division of Psychiatry, University of Western Australia, Perth, Western Australia, Australia
| | - Geoffrey Paul Smith
- Research and Strategy, Office of the Chief Psychiatrist, Perth, Western Australia, Australia.,Division of Psychiatry, University of Western Australia, Perth, Western Australia, Australia
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Muñoz JL, Gómez MCS, Vicario BP, Martín MÁF. Approach and treatment of suicidal behavior in the clinical practice of different groups of health professionals in Spain: results of the project euregena. Rev Esc Enferm USP 2015; 48 Spec No. 2:139-47. [PMID: 25830748 DOI: 10.1590/s0080-623420140000800021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 07/16/2014] [Indexed: 11/21/2022] Open
Abstract
According to the WHO (World Health Organization) and the European Union, suicide is considered to be a health problem of prime importance and to be one of the principal causes of unnatural death. In Spain, the number of suicides has increased 12% since 2005 . The Research Project "European Regions Enforcing Actions against Suicide (EUREGENAS), funded by the Health Program 2008-2013, has as main objective the description of an integrated model of Mental Health orientated to the prevention of suicide. The differences that allow distinguishing the meaning of prevention in suicide behavior are described and explained through a qualitative methodological strategy and through the creation of discussion groups formed by different groups of health professionals. The results highlight the existing differences between the diverse health professionals who come more in contact with this problem and it shows as well the coincidence of meaning that suicide has to be considered as a priority in the field of health.
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Affiliation(s)
- Juan Luis Muñoz
- Psychiatry Department of Zamora Virgen de la Concha Hospital, Zamora, Spain
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Hemmings C, Bouras N, Craig T. How should community mental health of intellectual disability services evolve? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2014; 11:8624-31. [PMID: 25158137 PMCID: PMC4198982 DOI: 10.3390/ijerph110908624] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 08/04/2014] [Accepted: 08/06/2014] [Indexed: 11/16/2022]
Abstract
Services for people with Intellectual Disability (ID) and coexisting mental health problems remain undeveloped; research into their effectiveness has been lacking. Three linked recent studies in the UK have provided evidence on essential service provision from staff, service users and carers. Interfaces with mainstream mental health services were seen as problematic: the area of crisis response was seen as a particular problem. Further services’ research is needed, focusing on service components rather than whole service configurations. There was not support for establishing more intensive mental health services for people with ID only. The way forward is in developing new ways of co-working with staff in “mainstream” mental health services. Mental health of ID staff might often be best situated directly within these services.
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Affiliation(s)
- Colin Hemmings
- Institute of Psychiatry, Kings College, London WC2R 2LS, UK.
| | - Nick Bouras
- Institute of Psychiatry, Kings College, London WC2R 2LS, UK.
| | - Tom Craig
- Institute of Psychiatry, Kings College, London WC2R 2LS, UK.
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Hunt IM, Rahman MS, While D, Windfuhr K, Shaw J, Appleby L, Kapur N. Safety of patients under the care of crisis resolution home treatment services in England: a retrospective analysis of suicide trends from 2003 to 2011. Lancet Psychiatry 2014; 1:135-41. [PMID: 26360577 DOI: 10.1016/s2215-0366(14)70250-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Community care provided by crisis resolution home treatment teams is used increasingly as an alternative to admission to psychiatric wards. No systematic analysis has been done of the safety of these teams in terms of rates of suicide. We aimed to compare the rate and number of suicides among patients under the care of crisis resolution home treatment teams with those of psychiatric inpatients. We also assessed the clinical features of individuals who died by suicide in both home and hospital settings. METHODS We did a retrospective longitudinal analysis between 2003 and 2011 of all adults (aged 18 years or older) treated by the National Health Service in England who died by suicide while under the care of crisis resolution home treatment services or as a psychiatric inpatient. We obtained data from the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness and from the Mental Health Minimum Dataset. FINDINGS 1256 deaths by suicide (12% of all patient suicides) were recorded among patients cared for under crisis resolution home treatment teams, an average of 140 deaths per year. Different denominators meant that direct comparison between groups was difficult, but the average rate of suicide under crisis resolution home treatment services (14·6 per 10 000 episodes under crisis care) seemed higher than the average rate of suicide among psychiatric inpatients (8·8 per 10 000 admissions). The number of suicides in patients under the care of crisis resolution home treatment teams increased from an average of 80 per year (in 2003 and 2004) to 163 per year (in 2010 and 2011) and were twice as frequent as inpatient suicides in the last few years of the study. However, because of the growing number of patients under the care of crisis resolution home treatment teams, the average rate of suicide fell by 18% between the first and last 2 years of the study. 548 (44%) patients who died by suicide under the care of crisis resolution home treatment teams lived alone and 594 (49%) had had a recent adverse life event. In a third of patients (n=428) under the care of crisis resolution home treatment teams, suicide happened within 3 months of discharge from psychiatric inpatient care. INTERPRETATION Although the number of suicides under the care of crisis resolution home treatment teams has risen since 2003, the rate has fallen. However, suicide rates remain high compared with the inpatient setting, and safety of individuals cared for by crisis resolution home treatment teams should be a priority for mental health services. For some vulnerable people who live alone or have adverse life circumstances, crisis resolution home treatment might not be the most appropriate care setting. Use of crisis resolution home treatment teams to facilitate early discharge could present a risk to some patients, which should be investigated further. FUNDING Healthcare Quality Improvement Partnership.
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Affiliation(s)
- Isabelle M Hunt
- National Confidential Inquiry into Suicide and Homicide, Centre for Suicide Prevention, Centre for Mental Health and Risk, University of Manchester, Manchester, UK.
| | - Mohammad Shaiyan Rahman
- National Confidential Inquiry into Suicide and Homicide, Centre for Suicide Prevention, Centre for Mental Health and Risk, University of Manchester, Manchester, UK
| | - David While
- National Confidential Inquiry into Suicide and Homicide, Centre for Suicide Prevention, Centre for Mental Health and Risk, University of Manchester, Manchester, UK
| | - Kirsten Windfuhr
- National Confidential Inquiry into Suicide and Homicide, Centre for Suicide Prevention, Centre for Mental Health and Risk, University of Manchester, Manchester, UK
| | - Jenny Shaw
- National Confidential Inquiry into Suicide and Homicide, Centre for Suicide Prevention, Centre for Mental Health and Risk, University of Manchester, Manchester, UK
| | - Louis Appleby
- National Confidential Inquiry into Suicide and Homicide, Centre for Suicide Prevention, Centre for Mental Health and Risk, University of Manchester, Manchester, UK
| | - Nav Kapur
- National Confidential Inquiry into Suicide and Homicide, Centre for Suicide Prevention, Centre for Mental Health and Risk, University of Manchester, Manchester, UK
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Abstract
The aim of this article was to put community psychiatry into a longitudinal and global perspective and to try to look into the future. Specifically, we set out the following nine proposals:1. Central and regional government should measure the treated percentage of people with mental illness (coverage) and set specific targets to increase coverage over set time periods.2. Health care services need to recognize the far lower life expectancy among people with mental disorders and develop and evaluate new methods to reduce this health disparity.3. Mental health services should provide specific modules to reduce stigma and discrimination experienced by people with mental illness.4. Mental health staff should provide care that service users (and their family members) find accessible and acceptable.5. Mental health care should consist of a careful balance of hospital and community care, with most care provided at or near people's homes.6. Mental health planners, both in times of economic growth and recession, should invest in treatments known to be effective and disinvest from treatments known to be ineffective or even harmful.7. Mental health staff and service users should develop and evaluate methods to improve shared decision making.8. Health care practitioners (of western and nonwestern traditions) should take practical steps to see each other as partners in an integrated system that increases the total amount of mental health care available, while ensuring that only effective and acceptable treatments are provided.9. Mental health services should develop dedicated programs for recovery: this implies that staff understand an individual's personal recovery goals and fully support his/her achievement.
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Botha UA, Koen L, Galal U, Jordaan E, Niehaus DJH. The rise of assertive community interventions in South Africa: a randomized control trial assessing the impact of a modified assertive intervention on readmission rates; a three year follow-up. BMC Psychiatry 2014; 14:56. [PMID: 24571621 PMCID: PMC3974055 DOI: 10.1186/1471-244x-14-56] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 02/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many countries have over the last few years incorporated mental health assertive interventions in an attempt to address the repercussions of deinstitutionalization. Recent publications have failed to duplicate the positive outcomes reported initially which has cast doubt on the future of these interventions. We previously reported on 29 patients from a developing country who completed 12 months in an assertive intervention which was a modified version of the international assertive community treatment model. We demonstrated reduction in readmission rates as well as improvements in social functioning compared to patients from the control group. The obvious question was, however, if these outcomes could be sustained for longer periods of time. This study aims to determine if modified assertive interventions in an under-resourced setting can successfully maintain reductions in hospitalizations. METHODS Patients suffering from schizophrenia who met a modified version of Weidens' high frequency criteria were randomized into two groups. One group received a modified assertive intervention based on the international assertive community treatment model. The other group received standard care according to the model of service delivery in this region. Data was collected after 36 months, comparing readmissions and days spent in hospital. RESULTS The results demonstrated significant differences between the groups. Patients in the intervention group had significantly less readmissions (p = 0.007) and spent less days in hospital compared to the patients in the control group (p = 0.013). CONCLUSION Modified assertive interventions may be successful in reducing readmissions and days spent in hospital in developing countries where standard care services are less comprehensive. These interventions can be tailored in such a way to meet service needs and still remain affordable and feasible within the context of an under-resourced setting.
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Affiliation(s)
- Ulla A Botha
- Department of Psychiatry, Faculty of Medicine and Health Sciences, University of Stellenbosch, PO Box 19063, Tygerberg 7505, South Africa.
| | - Liezl Koen
- Department of Psychiatry, Faculty of Medicine and Health Sciences, University of Stellenbosch, PO Box 19063, Tygerberg 7505, South Africa
| | - Ushma Galal
- Medical Research Council, Bellville, South Africa,Department of Statistical Sciences, University of Cape Town, Rondebosch, South Africa
| | - Esme Jordaan
- Medical Research Council, Bellville, South Africa
| | - Daniel JH Niehaus
- Department of Psychiatry, Faculty of Medicine and Health Sciences, University of Stellenbosch, PO Box 19063, Tygerberg 7505, South Africa
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Case management or assertive community treatment: are they really alternative approaches? ACTA ACUST UNITED AC 2011. [DOI: 10.1017/s1121189x0000275x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
AbstractThe 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.
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Cost-effectiveness of nidotherapy for comorbid personality disorder and severe mental illness: randomized controlled trial. ACTA ACUST UNITED AC 2011. [DOI: 10.1017/s1121189x00001019] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
SummaryAims – Nidotherapy is the systematic modification of the environment to create a better fit for people. This is the first randomized controlled trial of its efficacy in an assertive community team. Methods – Patients in an assertive outreach team with continued management problems together with comorbid personality disturbance and severe mental illness were randomized to nidotherapy enhanced assertive treatment (up to 12 sessions) or to continued assertive outreach care. Use of psychiatric beds over one years (primary outcome) and change from base-line in other health service resources, psychiatric symptoms, social functioning and engagement with services were measured at 6 and 12 months (secondary outcomes). Results – 52 patients were recruited over 13 months, with 49 and 37 assessed at 6 and 12 months. Patients referred to nidotherapy had a 63% reduction in hospital bed use after one year compared with control assertive care (P=0.13) and showed non-significant improvement in psychiatric symptoms, social functioning and engagement than the control group. The mean cost savings for each patient allocated to nidotherapy was £4,112 per year, mainly as a consequence of reduced psychiatric bed use. Conclusion – Nidotherapy may be a cost-effective option in the management of comorbid serious mental illness and personality disorder, but larger confirmatory trials are necessary.
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Botha UA, Koen L, Joska JA, Hering LM, Oosthuizen PP. Assessing the efficacy of a modified assertive community-based treatment programme in a developing country. BMC Psychiatry 2010; 10:73. [PMID: 20843301 PMCID: PMC2945974 DOI: 10.1186/1471-244x-10-73] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 09/15/2010] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND A number of recently published randomized controlled trials conducted in developed countries have reported no advantage for assertive interventions over standard care models. One possible explanation could be that so-called "standard care" has become more comprehensive in recent years, incorporating some of the salient aspects of assertive models in its modus operandi. Our study represents the first randomised controlled trial assessing the effect of a modified assertive treatment service on readmission rates and other measures of outcome in a developing country. METHODS High frequency service users were randomized into an intervention (n = 34) and a control (n = 26) group. The control group received standard community care and the active group an assertive intervention based on a modified version of the international model of assertive community treatment. Study visits were conducted at baseline and 12 months with demographic and illness information collected at visit 1 and readmission rates documented at study end. Symptomatology and functioning were measured at both visits using the PANSS, CDSS, ESRS, WHO-QOL and SOFAS. RESULTS At 12 month follow-up subjects receiving the assertive intervention had significantly lower total PANSS (p = 0.02) as well as positive (p < 0.01) and general psychopathology (p = 0.01) subscales' scores. The mean SOFAS score was also significantly higher (p = 0.02) and the mean number of psychiatric admissions significantly lower (p < 0.01) in the intervention group. CONCLUSIONS Our results indicate that assertive interventions in a developing setting where standard community mental services are often under resourced can produce significant outcomes. Furthermore, these interventions need not be as expensive and comprehensive as international, first-world models in order to reduce inpatient days, improve psychopathology and overall levels of functioning in patients with severe mental illness.
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Affiliation(s)
- Ulla A Botha
- Department of Psychiatry, University of Stellenbosch, Tygerberg, South Africa.
| | - Liezl Koen
- Department of Psychiatry, University of Stellenbosch, Tygerberg, South Africa
| | - John A Joska
- Department of Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Linda M Hering
- Associated Psychiatric Hospitals, Cape Town, South Africa
| | - Piet P Oosthuizen
- Department of Psychiatry, University of Stellenbosch, Tygerberg, South Africa
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Tseng KC, Chang CM, Liao SC, Chen YY, Lee MB. Factors of early suicide after discharge: a national linkage study for suicide victims in Taiwan. Suicide Life Threat Behav 2010; 40:353-68. [PMID: 20822362 DOI: 10.1521/suli.2010.40.4.353] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patients recently discharged from psychiatric inpatient care have a higher suicide rate. The study aimed to identify the characteristics associated with early suicide of those patients discharged from psychiatric wards in Taiwan. The results indicated that among 672 suicide victims who died within one year post-discharge from psychiatric wards in Taiwan between 2000 and 2004, diagnosis of schizophrenia, shorter disease duration, and co-morbidity with cancer were all significantly associated with suicide occurring within one month of discharge. Clinical diagnosis of psychiatric disorders, recent psychiatric diagnosis, and co-morbidity with severe physical illnesses should receive special monitoring for potential suicide after discharge.
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Affiliation(s)
- Kuan-Chiao Tseng
- National Taiwan University Hospital, Department of Psychiatry, Taipei City, Taiwan.
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