The impact of the organisation of mental health services on the quality of assessment provided to older patients with depression

Variations in structures, processes and outcomes of community mental health teams for older people: a systematic review of the literature

OBJECTIVES

In the UK and elsewhere, specialist community mental health teams (CMHTs) are central to the provision of comprehensive services for older people with mental ill health. Recent guidance documents suggest a core set of attributes that such teams should encompass. This article reports on a systematic literature review undertaken to collate existing evidence regarding the structures and processes of CMHTs for older people and to evaluate evidence linking approaches to effectiveness.

METHOD

Relevant publications were identified via systematic searches, both electronic and manual. Searches were limited to the UK for descriptions of organisation and practice but included international literature where comparisons between different CMHT arrangements were evaluated. Empirical, peer-reviewed studies from 1989 onward were included, extended to non peer-reviewed nationally or regionally representative reports, published after 1998, for the descriptive element.

RESULTS

Forty-five studies met inclusion criteria of which seven provided comparative outcome data. All but one were UK based. The most robust evidence related to research conducted in exemplar teams. Limited evidence was found regarding the effectiveness of many of the core attributes recommended in policy directives although their presence was reported in much of the literature.

CONCLUSIONS

The contrast between presentation and evaluation of attributes is stark. Whilst some gaps can be filled from related fields, further research is required that moves beyond description to evaluation of the impact of team design on service user outcomes in order to inform future policy directives and practice guidance. A framework for an evidence-based model of CMHTs for older people is provided.

An examination of the needs of older patients with chronic mental illness in public mental health services

OBJECTIVES

To describe the needs of patients aged 50 years and over with chronic mental illness being case managed within a public mental health service, and to determine factors that influence these needs.

METHOD

Patients were recruited from community-based Adult Mental Health (AMH) teams and Specialist Mental Health Services for Older People (SMHSOP) teams. Eligibility criteria included a diagnosis of schizophrenia or mood disorder. Patient, carer and key worker interviews were carried out using the Camberwell Assessment of Need for the Elderly (CANE).

RESULTS

Of 183 eligible patients, 97 (mean age of 66.4 years) participated, of whom 63 were managed by AMH teams and 34 by SMHSOP teams. The majority (52%) had a diagnosis of schizophrenia, particularly those managed by AMH (71%). Patients self-rated fewer needs overall on the CANE than their key workers or the researcher, and also rated a higher proportion of their needs being met (83%) than the key worker (77%) or researcher (76%). From each perspective, over 80% of psychiatric and around 95% of identified medical needs were being met. The majority of social needs were unmet, with patients reporting only 42%, and key workers only 33%, met needs. The key unmet social needs were company, daily activities and having a close confidant. Key workers, patients and researchers rated SMHSOP service delivery to have significantly less unmet needs.

CONCLUSIONS

The social needs of older patients with chronic mental illness require greater attention by public mental health services.

A survey of publicly funded aged psychiatry services in Australia and New Zealand

OBJECTIVE

To map the size and distribution of publicly funded aged psychiatry (psychogeriatric) services in Australia and New Zealand in 2003.

METHOD

Services were tracked exhaustively through personal, professional and academic contacts, electronic searches and word-of-mouth. Directors or managers of services were asked to complete a brief questionnaire concerning their locality, services, staff profile and patient contacts.

RESULTS

Services varied widely with respect to their numbers, size and community outreach. Victoria was the only Australian state to provide specialist, multidisciplinary aged psychiatry teams with community, acute inpatient and residential arms in all its major cities. New South Wales, the state with the largest aged population, performed relatively poorly on most indicators. New Zealand performed relatively well despite its small size and widely dispersed population.

CONCLUSIONS

Publicly funded aged mental health services are effective and reach frail, multiply disabled old people who cannot access private psychiatrists and are often overlooked by services for younger adults. At the time of our survey, such services were distributed in Australia in a highly inequitable fashion.

A methodology for timing reviews of inpatient hospital stay

OBJECTIVE

This paper aims to describe a methodology to inform decisions about the optimal time to schedule reviews of a patient's hospital stay and to provide an example of its implementation.

METHOD

Length of hospital stay was assessed in 1227 consecutive inpatient admissions. Data were transformed to reflect the probability of discharge from hospital in the following 7 days.

RESULTS

The resulting data reflected the points at which the conditional probability of being discharged were declining, revealing the potentially efficient times to conduct reviews of inpatient admissions.

CONCLUSIONS

The methodology outlined appears useful in assisting psychiatrists responsible for inpatient care to decide upon optimal times to review a patient's stay in hospital.

Outcomes for depressed and anxious inpatients discharged before or after group cognitive behavior therapy: a naturalistic comparison

Treatment outcomes for psychiatric inpatients with a primary diagnosis of a depressive or anxiety disorder who completed a cognitive behavior therapy (CBT) program while inpatients or when discharged were examined. Of 340 inpatients, 197 had been discharged to day patient status before the end of the CBT program, and 143 remained as inpatients. Data were collected before and after the CBT program and at 3-month follow-up. There was a significant improvement by posttreatment in self-esteem, locus of control, anxiety, depression, and stress, and these gains were maintained at 3-month follow-up. In addition, anxious, but not depressed, patients who completed CBT as day patients demonstrated greater improvements from after the CBT program to follow-up than those treated as inpatients. Possible reasons for the beneficial effects of completing the CBT as a day patient rather than an inpatient are discussed, and threats to the validity of this naturalistic study are considered.

Improving community-based services for older patients with depression: the benefits of an educational and service initiative

OBJECTIVE

The objective of this study was to report a quality improvement project for older patients with depression. The initiative focused on both clinical practice changes (improvement of medical, neurocognitive and behavioural assessment) and service development (greater continuity of care).

METHOD

After initial identification of key deficits, implementation of a service and educational initiative took place within a district mental health service. The service consisted of an inpatient unit, a specialized psychogeriatric service and two adult community mental health services. Mental health staff received education regarding the specific needs of older patients with depression and were provided with assessment materials, patient education and treatment aids. General practitioners participated in shared long-term management.

RESULTS

Following graded implementation, the management of 44 subjects (mean age = 65.4 years, 91% female) recruited over an 8-month period was reviewed. Compared with 99 subjects (mean age = 68.9 years, 69% female) from the earlier 12-month assessment phase, there were significant improvements in medical (43% to 92%), neurocognitive (37% to 84%) and behavioural (e.g. suicidal ideation: 78% to 100%) assessments. Similarly, relevant laboratory investigations (neuroimaging: 21% to 67%) and communication with general practitioners (73% to 97%) improved. The most change occurred in the adult community-based treatment services.

CONCLUSIONS

A coordinated management and educational initiative resulted in marked improvement in basic medical and psychiatric assessment and more integrated care. These changes did not require expansion of specialist services.

Clinical ethics revisited: responses

This series of responses was commissioned to accompany the article by Singer et al , which can be found at . If you would like to comment on the article by Singer et al or any of the responses, please email us on editorial@biomedcentral.com .