The future of community psychiatry and community mental health services

The United Nations Convention on the Rights of Persons with Disabilities and its relevance to French mental health system

OBJECTIVES

The Convention on the Rights of Persons with Disabilities (CRPD) is a landmark international treaty which embeds the human rights of people with disabilities, including mental disabilities, into international law. We aim to demonstrate the relevance of the CRPD for the protection of human rights of people with mental illness in France. We begin with a broad overview of its development and implementation at the level of the international community, and then describe the situation in France.

CONCLUSION

Ratification of the CRPD by France in 2010 reflected the increasing recognition of human rights of people with disabilities. To date, the CRPD has inspired several initiatives in the field of mental health in France. As it is at the international level, in France, there remains significant room for advancement; particularly concerning the promotion and protection of economic, social and cultural rights, in addition to that of civil and political rights. Full realization of the principles of the CRPD requires input from all sectors of government and the whole of the community.

Clubhouse Partnerships with Clinical Services: Current Status and Barriers to Integration

The Clubhouse model of psychosocial rehabilitation has supported the recovery of people with serious mental illness for over 75 years, but many of the roughly 350 Clubhouses are not well-integrated into the larger health care system, limiting their reach. This article examines Clubhouses' and psychiatric providers' interactions and experiences to understand the nature of and barriers to partnerships. The directors of Clubhouses affiliated with Clubhouse International were surveyed, examining their attitudes and practices around collaboration with psychiatric providers. To provide context, psychiatric providers were also surveyed regarding their understanding of and experiences with Clubhouses. Findings reveal broad support among both Clubhouse directors and psychiatrists for enhancing partnerships, despite current barriers, limited interactions, and the need for greater mutual understanding. Key considerations that emerged include the importance of maintaining the Clubhouse model's distinct non-clinical, community-based, and member-directed identity in any integration efforts.

A Comparison of Behavioral Health Crisis Response Models in Meeting Behavioral Health Goals and Improving Criminal Legal Diversion

Various behavioral health crisis models have been developed to advance the shared goals of improving behavioral health outcomes and increasing diversion from criminal legal systems. The effectiveness of these models is promising, yet research is needed to understand their comparative advantages. This study compares the effectiveness of three community mental health response models-co-response, mobile response, and office-based response-and law enforcement-only response in addressing key behavioral health and diversion goals. These goals include improvements to follow-ups, service linkages to community resources, crisis de-escalation, and dispositions (i.e., decreasing hospitalizations and arrests). Five partner sites in Michigan provided administrative data on crisis cases and outcomes. The sample included crisis cases from one office-based model (n = 91), two mobile response models (n = 306), and two co-response models (n = 322), along with data from the partnering law enforcement agencies at each site (n = 669). Results show that model type is associated with all key outcomes. Mobile response effectively met all examined crisis response goals, including by resolving crises informally or without hospitalization, providing links to community services, and conducting follow-ups. Co-response showed some success in meeting goals, while the law enforcement-only model showed more limited results. Additionally, law enforcement presence during a mobile crisis response produced worse disposition outcomes, while contacting a CMH during law enforcement response produced better disposition outcomes. Overall, this study contributes to SAMHSA's (2020) crisis response vision to effectively meet the behavioral health needs of those in need of service by providing "someone to respond."

Roles and Dynamics within Community Mental Health Systems During the COVID-19 Pandemic: A Qualitative Systematic Review and Meta-Ethnography

Globally, COVID-19 had an immense impact on mental health systems, but research on how community mental health (CMH) systems and services contributed to the pandemic mental health response is limited. We conducted a systematic review and meta-ethnography to understand the roles of CMH services, determinants of the quality of CMH care, and dynamics within CMH systems during COVID-19. We searched and screened across five databases and appraised study quality using the CASP tool, which yielded 27 qualitative studies. Our meta-ethnographic process used Noblit and Hare's approach for synthesizing findings and applying interpretive analysis to original research. This identified several key themes. Firstly, CMH systems played the valuable pandemic role of safety nets and networks for the broader mental health ecosystem, while CMH service providers offered a continuous relationship of trust to service users amidst pandemic disruptions. Secondly, we found that the determinants of quality CMH care during COVID-19 included resourcing and capacity, connections across service providers, customized care options, ease of access, and human connection. Finally, we observed that power dynamics across the CMH landscape disproportionately excluded marginalized groups from mainstream CMH systems and services. Our findings suggest that while the pandemic role of CMH was clear, effectiveness was driven by the efforts of individual service providers to meet demand and service users' needs. To reprise its pandemic role in the future, a concerted effort is needed to make CMH systems a valuable part of countries' disaster mental health response and to invest in quality care, particularly for marginalized groups.

Mental Health Care Navigation Tools in Australia: Infoveillance Study

Background

In response to the well-documented fragmentation within its mental health system, Australia has witnessed recently rapid expansion in the availability of digital mental health care navigation tools. These tools focus on assisting consumers to identify and access appropriate mental health care services, the proliferation of such varied web-based resources risks perpetuating further fragmentation and confusion for consumers. There is a pressing need to systematically assess the characteristics, comprehensiveness, and validity of these navigation tools, especially as demand for digital resources continues to escalate.

Objective

This study aims to identify and describe the current landscape of Australian digital mental health care navigation tools, with a focus on assessing their comprehensiveness, identifying potential gaps, and the extent to which they meet the needs of various stakeholders.

Methods

A comprehensive infoveillance approach was used to identify Australian digital mental health care navigation tools. This process involved a systematic web-based search complemented by consultations with subject matter experts. Identified navigation tools were independently screened by 2 authors, while data extraction was conducted by 3 authors. Extracted data were mapped to key domains and subdomains relevant to navigation tools.

Results

From just a handful in 2020, by February 2024 this study identified 102 mental health care navigation tools across Australia. Primary Health Networks (n=37) and state or territory governments (n=21) were the predominant developers of these tools. While the majority of navigation tools were primarily designed for consumer use, many also included resources for health professionals and caregivers. Notably, no navigation tools were specifically designed for mental health care planners. Nearly all tools (except one) featured directories of mental health care services, although their functionalities varied: 27% (n=27) provided referral information, 20% (n=21) offered geolocated service maps, 12% (n=12) included diagnostic screening capabilities, and 7% (n=7) delineated care pathways.

Conclusions

The variability of navigation tools designed to facilitate consumer access to mental health services could paradoxically contribute to further confusion. Despite the significant expansion of digital navigation tools in recent years, substantial gaps and challenges remain. These include inconsistencies in tool formats, resulting in variable information quality and validity; a lack of regularly updated service information, including wait times and availability for new clients; insufficient details on program exclusion criteria; and limited accessibility and user-friendliness. Moreover, the inclusion of self-assessment screening tools is infrequent, further limiting the utility of these resources. To address these limitations, we propose the development of a national directory of mental health navigation tools as a centralized resource, alongside a system to guide users toward the most appropriate tool for their individual needs. Addressing these issues will enhance consumer confidence and contribute to the overall accessibility, reliability, and utility of digital navigation tools in Australia's mental health system.

Fair space for life: A dynamic care monitor working up to growth and flourishing for all

BACKGROUND

Mental health disparities persistently cause inequity and social exclusion. Extensive research underpins the need to embrace the social determinants of health and facilitate network learning at various ecosystem levels. Despite valuable quality frameworks and ratified conventions, local practices which counter health inequity are scarce.

METHODS

The Dutch HOP-TR study collected health and needs of Homeless Service Users (HSU) in a rights-based, transdiagnostic, recovery framework. We assessed the survival modes and conducted a socio-ecological analysis, exploring what happened in care pathways at three ecosystem levels: individual HSU, caregiver networks, society. While documenting vital conditions for growth and citizenship, we explore major opportunities to develop 'fair space for life'.

RESULTS

Under low distress levels, prosocial behavior is prominent (32.9%). High distress levels are found with an avoidant (42.0%) or aggressive mode (24.9%). Rising distress levels give more frictions in relations, psychiatric admissions, and police-justice contacts. The distress-induced descent in the social hierarchy causes social withdrawal, alienation, and marginalization. At society level, fair conditions for growth and citizenship are challenged by the cumulative impact of distress over the HSU' lives.

DISCUSSION

This care monitor uncovers the impact of distress on caregiver interactions. The care pathways reveal that the survival strategies reflect a systematic, pervasive neglect. Unfair representations hold HSU personally responsible of their situation, disregarding the cumulative impact of environmental conditions over their lives. The diverse sources of unfairness are intrinsic to the health care system and culture. Therefore, the survival modes ask for profound culture transformations in a whole-system-whole-society approach.

CONCLUSION

Given the need for action on health equity and the social determinants of health, this paper provides an example of a dynamic care monitor. The actionable data elicit dialogs and stimulate to enrich opportunities for inclusion and growth in communities and societies.

Epidemiological aspects of individuals with mental disorders in the referral system: the experience of a Community Mental Health Center in the northeast of Iran

BACKGROUND

Community Mental Health Centers (CMHCs) offer affordable mental health services in a less stigmatized environment, in a domiciliary setting. This study aimed to shed light on the epidemiological factors of patients attending CMHCs of Mashhad, their referral status, and treatment.

METHODS

This study was conducted over the medical records of patients seen by psychiatrists between January 2014 and December 2021 in Mashhad's CMHC, the northeast of Iran. A detailed questionnaire was used to extract data from medical records about the epidemiological characteristics, diagnosed mental illnesses, referral status, and how often they visited the psychiatrist. The association between epidemiological findings and patient referral (referral system or self-referral) as well as the association between epidemiological findings and the number of psychiatric revisits were examined using the Chi-square test.

RESULTS

Out of 662 patients, 472 (71%) were female and 190 (29%) were male, with an average age of 29 years. Among the 475 adult patients, 367 (77.3%) were married, with the majority being homemakers (56.4%). Major Depression Disorder (MDD) (32%) and Generalized Anxiety Disorder (GAD) (18.3%) were the most prevalent mental health conditions among patients. The majority of patients (74.9%) were referred to the CMHC of Mashhad from Primary Healthcare centers (PHCs) and psychiatric hospitals. Furthermore, female gender and patients with lower level of education were associated with more referral through from referral system. Of note, 431 patients (65.1%) did not return for a second visit, the ratio of treatment dropout was higher for patients with lower education levels.

CONCLUSIONS

Referral system should be more practical in Iran to enhance health services in CMHCs. It is recommended that PHCs undergo certain modifications to enhance the referral process for patients with mental health conditions, focusing on common mental disorders and individuals with low socioeconomic level.

Factors Influencing the Personal Recovery of Inpatients in a Forensic Psychiatric Hospital in South Korea

PURPOSE

This study aimed to identify the factors influencing the personal recovery of inpatients of a forensic psychiatric hospital.

METHODS

A descriptive study design was assigned. The participants were 136 inpatients in a forensic psychiatric hospital in South Korea. The data were analyzed using SPSS Statistics Version 26.0 with descriptive statistics, independent t test, analysis of variance, Pearson correlation coefficient, and multiple regression.

RESULTS

Perceived physical health status (β = 0.16, p = 0.034), perceived mental health status (β = 0.20, p = 0.023), perceived family support (β = 0.17, p = 0.013), duration of hospitalization (β = 0.25, p < 0.001), and recovery attitudes (β = 0.36, p < 0.001) were the significant factors explaining 42.6% of the variance in the personal recovery of participants.

CONCLUSION

The findings of this study indicate that recovery attitudes, health status, and personal support affect forensic mental health personal recovery. Personal recovery can be strengthened through nursing intervention and support to strengthen recovery attitudes and health status. It is necessary to get used to personal recovery through long-term and systematic education, and organizations and nurses need to make efforts to provide services centered on personal recovery.

Toward a Socioeconomic Equity in Combating Adolescent Substance Abuse: An Outreach and Drop-In Centre to Bridge the Gap

This paper describes a case study of an Outreach and Drop-in Centre (ODIC) established under the National Action Plan for Drug Demand Reduction, Ministry of Social Justice and Empowerment, Government of India. In the quantitative part, data were gathered from the ODIC office documents and analysed using MS Excel. Linear regression analysis demonstrated a relationship between the number of in-centre clients and the number of Community Outreach Programmes (COPs). Similarly, this study examined the relationship between the number of networks established and the number of participants in COPs. Hence, two regression lines were derived accordingly. In addition, qualitative data collected through key informant interviews corroborated the quantitative results. This case study highlights the importance of networks and COPs in increasing the reach of ODIC and ensuring the quality of services. Finally, in partnership with other government agencies, this ODIC sets a model for engaging marginalised adolescents in reducing substance abuse.

Effectiveness of Online and Remote Interventions for Mental Health in Children, Adolescents, and Young Adults After the Onset of the COVID-19 Pandemic: Systematic Review and Meta-Analysis

BACKGROUND

The prevalence of mental illness increased in children, adolescents, and young adults during the COVID-19 pandemic, while at the same time, access to treatment facilities has been restricted, resulting in a need for the quick implementation of remote or online interventions.

OBJECTIVE

This study aimed to give an overview of randomized controlled studies examining remote or online interventions for mental health in children, adolescents, and young adults and to explore the overall effectiveness of these interventions regarding different symptoms.

METHODS

A systematic literature search was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines using PubMed, PsycInfo, Psyndex, Embase, and Google Scholar. A meta-analysis was conducted using a random effects model to calculate overall effect sizes for interventions using standardized mean differences (SMDs) for postintervention scores.

RESULTS

We identified 17 articles with 8732 participants in the final sample, and 13 were included in the quantitative analysis. The studies examined different digital interventions for several outcomes, showing better outcomes than the control in some studies. Meta-analyses revealed significant medium overall effects for anxiety (SMD=0.44, 95% CI 0.20 to 0.67) and social functioning (SMD=0.42, 95% CI -0.68 to -0.17) and a large significant effect for depression (SMD=1.31, 95% CI 0.34 to 2.95). In contrast, no significant overall treatment effects for well-being, psychological distress, disordered eating, and COVID-19-related symptoms were found.

CONCLUSIONS

The qualitative and quantitative analyses of the included studies show promising results regarding the effectiveness of online interventions, especially for symptoms of anxiety and depression and for training of social functioning. However, the effectiveness needs to be further investigated for other groups of symptoms in the future. All in all, more research with high-quality studies is required.

Bringing together the World Health Organization's QualityRights initiative and the World Psychiatric Association's programme on implementing alternatives to coercion in mental healthcare: a common goal for action

BACKGROUND

Stakeholders worldwide increasingly acknowledge the need to address coercive practices in mental healthcare. Options have been described and evaluated in several countries, as noted recently in major policy documents from the World Health Organization (WHO) and World Psychiatric Association (WPA). The WHO's QualityRights initiative promotes human rights and quality of care for persons with mental health conditions and psychosocial disabilities. A position statement from the WPA calls for implementation of alternatives to coercion in mental healthcare.

AIMS

We describe the engagement of both the WHO and WPA in this work. We discuss their mutual aim to support countries in improving human rights and quality of care, as well as the differences between these two organisations in their stated goals related to coercion in mental healthcare: the WHO's approach to eliminate coercion and the WPA's goal to implement alternatives to coercion.

METHOD

We outline and critically analyse the common ground between the two organisations, which endorse a similar range of rights-based approaches to promoting non-coercive practices in service provision, including early intervention in prevention and care and other policy and practice changes.

RESULTS

Advocacy and action based on an agreed need to find practical solutions and advances in this area have the power to build consensus and unify key actors.

CONCLUSIONS

We conclude that persons with lived experience, families, mental health professionals and policy makers are now coming together in several parts of the world to work toward the common goals of improving quality, promoting human rights and addressing coercion in mental health services.

Patterns of mental health services and mood disorder disability pensions: a standard comparison of Finland's three largest hospital districts

INTRODUCTION

Mental disorders are one of the most common and disabling health conditions worldwide. There is however no consensus on the best practice of system level mental health services (MHS) provision, in order to prevent e.g. mood disorder disability pensions (DPs). We analyzed the MHS provision between Finland's three largest hospital districts Helsinki and Uusimaa (HUS), Southwest Finland and Pirkanmaa, with known differences in mood disorder DP risk but presumably equal rates of mood disorder prevalence.

METHODS

We used public MHS data analyzed with the standardized DEscription and Evaluation of Services and DirectoriEs for Long Term Care (DESDE-LTC) mapping tool, focusing on all MHS, outpatient care provision, local services without and with gatekeeping, and centralized services. We also collected demographic data based on the European Socio-Demographic Schedule (ESDS). As a novel approach, the Gini-Simpson Diversity Index (GSDI) was calculated for the districts.

RESULTS

Evident differences were observed regarding the districts' MHS factors. As the hospital district with lower DP risk, HUS was characterized by the highest level of regional socioeconomic prosperity as well as high service richness and diversity. With a nationally average DP risk, Southwest Finland had the highest number of MHS personnel in full-time equivalents (FTE) per 100 000 inhabitants. Pirkanmaa, with a higher DP risk, had overall the lowest service richness and the lowest FTE of the three districts in all MHS, outpatient care and local services with gatekeeping.

CONCLUSIONS

Our findings indicate that greater richness and diversity of MHS, especially in outpatient and community-based settings, may serve as indicators of a balanced, high-quality service system that is more effective in preventing mood disorder DP and meeting the different needs of the population. In addition, the need for sufficient resourcing in all MHS and outpatient services is indicated. We suggest using diversity indices to complement the measuring and reporting of regional service variation.

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.

The quality of mental health care for people with bipolar disorders in the Italian mental health system: the QUADIM project

BACKGROUND

The assessment of the quality of care pathways delivered to people with severe mental disorders in a community-based system remains uncommon, especially using healthcare utilization databases. The aim of the study was to evaluate the quality of care provided to people with bipolar disorders taken-in-care by mental health services of four Italian areas (Lombardy, Emilia-Romagna, Lazio, province of Palermo).

METHODS

Thirty-six quality indicators were implemented to assess quality of mental health care for patients with bipolar disorders, according to three dimensions (accessibility and appropriateness, continuity, and safety). Data were retrieved from healthcare utilization (HCU) databases, which contain data on mental health treatments, hospital admissions, outpatient interventions, laboratory tests and drug prescriptions.

RESULTS

29,242 prevalent and 752 incident cases taken-in-care by regional mental health services with a diagnosis of bipolar disorder in 2015 were identified. Age-standardized treated prevalence rate was 16.2 (per 10,000 adult residents) and treated incidence rate 1.3. In the year of evaluation, 97% of prevalent cases had ≥ 1 outpatient/day-care contacts and 88% had ≥ 1 psychiatric visits. The median of outpatient/day-care contacts was 9.3 interventions per-year. Psychoeducation was provided to 3.5% of patients and psychotherapy to 11.5%, with low intensity. 63% prevalent cases were treated with antipsychotics, 71.5% with mood stabilizers, 46.6% with antidepressants. Appropriate laboratory tests were conducted in less than one-third of prevalent patients with a prescription of antipsychotics; three quarters of those with a prescription of lithium. Lower proportions were observed for incident patients. In prevalent patients, the Standardized Mortality Ratio was 1.35 (95% CI: 1.26-1.44): 1.18 (1.07-1.29) in females, 1.60 (1.45-1.77) in males. Heterogeneity across areas was considerable in both cohorts.

CONCLUSIONS

We found a meaningful treatment gap in bipolar disorders in Italian mental health services, suggesting that the fact they are entirely community-based does not assure sufficient coverage by itself. Continuity of contacts was sufficient, but intensity of care was low, suggesting the risk of suboptimal treatment and low effectiveness. Care pathways were monitored and evaluated using administrative healthcare databases, adding evidence that such data may contribute to assess the quality of clinical pathways in mental health.

From Social Rejection to Welfare Oblivion: Health and Mental Health in Juvenile Justice in Brazil, Colombia and Spain

(1) Background: This study aims to examine and describe the policies of three Latin American countries: Colombia, Brazil, and Spain, and identify how they implement their support systems for health, mental health, mental health for children and adolescents, and juvenile justice systems that support judicial measures with treatment and/or therapeutic approaches specialized in mental health. (2) Methods: Google Scholar, Medline, and Scopus databases were searched to identify and synthesize of the literature. (3) Results: Three shared categories were extracted to construct the defining features of public policies on mental health care in juvenile justice: (i.) models of health and mental health care, (ii.) community-based child and adolescent mental health care, and (iii.) mental health care and treatment in juvenile justice. (4) Conclusions: Juvenile justice in these three countries lacks a specialized system to deal with this problem, nor have procedures been designed to specifically address these situations within the framework of children's rights.

Standardized Systematic Description of Provision of Care for Multiple Sclerosis at a Local Level: A Demonstration Study

BACKGROUND

This study evaluates and describes the pattern of services provided for people living with multiple sclerosis (MS) in a local area as a starting point for a more global assessment.

METHODS

A health care ecosystem approach has been followed using an internationally standardized service classification instrument-the Description and Evaluation of Services and DirectoriEs for Long Term Care (DESDE-LTC)-to identify and describe all services providing care to people with MS in the Australian Capital Territory, Australia. Available services were classified according to the target population into those specifically dedicated to people living with MS and those providing general neurologic services, both public and private, and across both social and health sectors.

RESULTS

A limited range of services was available. There were no local facilities providing or coordinating multidisciplinary integrated care specific to people with MS. Subspecialty services specific to MS were limited in number (6 of the 28 services), and use of specialist services provided in neighboring states was frequently reported. Overall, very few services were provided outside the core health sector (4%).

CONCLUSIONS

The provision of care to people living with MS in the Australian Capital Territory is fragmented and relies heavily on generic neurology services in the public and private sectors. More widespread use of the DESDE-LTC as a standardized method of service classification in MS will facilitate comparison with other local areas, allow monitoring of changes over time, and permit comparison with services provided for other health conditions (eg, dementia, mental disorders).

Per una salute mentale di comunità: la questione dei Servizi e dei modelli

La questione di quali Servizi siano necessari per una piena applicazione della riforma psichiatrica del 1978, costruendo un'alternativa istituzionale globale, viene discussa a partire dai modelli organizzativi e dai loro contesti applicativi, che definiscono l'offerta complessiva di cura. Nel realizzare la presa in carico vanno considerate non solo le evidenze scientifiche, ma anche un ancoraggio etico e valoriale che tenga conto delle esperienze e dei bisogni delle persone che usano i Servizi. Tra i princìpi-cardine sostenuti dall'Organizzazione Mondiale della Sanità spiccano la realizzazione dei diritti umani, con l'abbandono delle pratiche coercitive e dei trattamenti obbligatori routinari, l'empowerment dell'utenza e un approccio multisettoriale per una risposta ai determi-nanti sociali di salute. Dalla pratica discende una serie di indicazioni, dall'apertura sulle 24 ore alla continuità e non frammentazione delle cure. Si descrivono punti di orientamento e princìpi di fun-zionamento dei Servizi territoriali, e si delineano prospettive per un cambio di paradigma che riguardi gli esiti globali sulla vita delle persone.

Vital Needs of Dutch Homeless Service Users: Responsiveness of Local Services in the Light of Health Equity

BACKGROUND

Healthcare and social services aim to ensure health equity for all users. Despite ongoing efforts, marginalized populations remain underserved. The Dutch HOP-TR study intends to expand knowledge on how to enable the recovery of homeless service users.

METHODS

A naturalistic meta-snowball sampling resulted in a representative sample of homeless services (N = 16) and users (N = 436). Interviews collected health and needs from user and professional perspectives in a comprehensive, rights-based ecosystem strategy. We calculated the responsiveness to needs in four domains (mental health, physical health, paid work, and administration).

RESULTS

Most service users were males (81%) with a migration background (52%). In addition to physical (78%) and mental health needs (95%), the low education level (89%) and functional illiteracy (57%) resulted in needs related to paid work and administration support. Most had vital needs in three or four domains (77%). The availability of matching care was extremely low. For users with needs in two domains, met needs ranged from 0.6-13.1%. Combined needs (>2 domains) were hardly met.

CONCLUSIONS

Previous research demonstrated the interdependent character of health needs. This paper uncovers some causes of health inequity. The systematic failure of local services to meet integrating care needs demonstrates the urgency to expand recovery-oriented implementation strategies with health equity in mind.

Challenges to the provision of home care and support for people with severe mental illness: Experiences and perspectives of patients, caregivers, and healthcare providers in Dar es Salaam, Tanzania

A balance between hospital-based and community-based services is needed to effectively provide mental health services for people with mental illness. As an essential part of community mental health services, home-based care plays an important role in meeting patients' needs, and should, therefore, be appropriately provided. To achieve this, there is a need to understand the challenges faced and take relevant actions to address them. This study aimed to explore challenges to home care and support for people with mental illness in Temeke district, Dar es Salaam. We used a descriptive qualitative study approach to explore challenges to home care and support for people with mental illness among patients, their caregivers, and healthcare providers. The purposeful sampling method was used to recruit participants at Temeke hospital, data was collected using in-depth interviews and focus group discussions, and analysis was performed using a content analysis framework. Four main themes highlighting challenges encountered in the provision of home care and support for individuals with mental illness were revealed. They include poor understanding of mental illness, abandonment of patients' care responsibilities, disputes over preferred treatment, and lack of outreach services for mental health. Participants also provided suggestions to improve home care and support for people with mental illness. Home care for people with mental illness is affected by poor knowledge of the mental illness, social stigma, and lack of outreach visits. There is a need for the provision of health education regarding mental illness, stigma reduction programs, and funding and prioritization for outreach home visits to improve home care and support for people with mental illness. Further research is needed to determine the magnitude of these challenges and factors that can facilitate the provision of support in similar settings.

Patterns of mental healthcare provision in rural areas: A demonstration study in Australia and Europe

INTRODUCTION

Mental healthcare systems are primarily designed to urban populations. However, the specific characteristics of rural areas require specific strategies, resource allocation, and indicators which fit their local conditions. This planning process requires comparison with other rural areas. This demonstration study aimed to describe and compare specialized rural adult mental health services in Australia, Norway, and Spain; and to demonstrate the readiness of the healthcare ecosystem approach and the DESDE-LTC mapping tool (Description and Evaluation of Services and Directories of Long Term Care) for comparing rural care between countries and across areas.

METHODS

The study described and classified the services using the DESDE-LTC. The analyses included context analysis, care availability, placement capacity, balance of care, and diversity of care. Additionally, readiness (Technology Readiness Levels - TRL) and impact analyses (Adoption Impact Ladder - AIL) were also assessed by two independent raters.

RESULTS

The findings demonstrated the usability of the healthcare ecosystem approach and the DESDE-LTC to map and identify differences and similarities in the pattern of care of highly divergent rural areas. Day care had a greater weight in the European pattern of care, while it was replaced by social outpatient care in Australian areas. In contrast, care coordination was more common in Australia, pointing to a more fragmented system that requires navigation services. The share between hospital and community residential care showed no differences between the two regions, but there were differences between catchment areas. The healthcare ecosystem approach showed a TRL 8 (the tool has been demonstrated in a real-world environment and it is ready for release and general use) and an AIL of 5 (the target public agencies provided resources for its completion). Two experts evaluated the readiness of the use of DESDE-LTC in their respective regional studies. All of them were classified using the TRL.

DISCUSSION

In conclusion, this study strongly supports gathering data on the provision of care in rural areas using standardized methods to inform rural service planning. It provides information on context and service availability, capacity and balance of care that may improve, directly or through subsequent analyses, the management and planning of services in rural areas.

Analysis of the mental health service provision in Qatar: Progressing in community mental health in a Middle East country

Background

Qatari health planning in the last decade aimed to make the transition from the traditional hospital-based psychiatric care to a community-based care, building an integrated and comprehensive mental health system. The objective of this study was to explore the mental health service provision in Qatar in 2018 and 2022. This time span coincided with two mental health plans (2013-2018 and 2019-2022) and one health plan (2018-2022).

Methods

This study followed a healthcare ecosystem approach, including context analysis and the standard description and classification of mental health services. Service provision was studied applying DESDE-LTC system (Description and Evaluation of Services and DirectoriEs-Long Term Care), an internationally validated methodology to assess and describe mental health services. Service data were analyzed along with sociodemographic indicators from public statistics to know the care context.

Results

The availability of specialized mental health services increased for adults, although it remained the same for other age groups. The diversity of care and the weight of health-related care over social-related care also remained quite similar. It was noteworthy the development of new services for young adults, migrant workers, and female populations.

Conclusion

This was the first time that this service research methodology has been applied in a Middle East country to study its mental healthcare pattern. The analysis of the mental healthcare pattern in the study time period showed the continued progress toward community-based care in Qatar in the framework of three health plans and despite the unexpected COVID-19 world pandemic.

Innovations in community-based mental health care: an overview of meta-analyses

In the last four decades, mental health services for people with Severe Mental Illness (SMI) have seen asylums replaced by a balanced model of Community Mental Healthcare (CMH). Innovative approaches and strategies in the field of CMH have been extensively researched. However, this research has been hampered by issues limiting their capacity to inform clinicians and policymakers. We conducted an overview of meta-analyses of the effectiveness of innovative CMH models focussing on clinical and psychosocial outcomes in comparisons with standard care in adults with SMI. Based on the 12 eligible studies, we appraised, synthesised and graded the resulting evidence. There was moderate quality evidence that case management, Early Intervention Services (EIS) and caregiver-directed interventions were superior to standard care in reducing hospital admission. In relation to psychosocial outcomes, EIS showed high quality evidence of a small effect on global functioning. There was moderate quality evidence for a similar effect of Intensive Case Management, and for a large effect of family intervention. For quality of life, both EIS and self-management education had a small effect, with moderate quality. The level of research about effective CMH models is therefore substantial. However, several gaps related to innovative CMH not yet covered in meta-analytic synthesis, need to be filled.

Improving the mental health of Australians: A renewed call for primary care psychiatry

OBJECTIVE

To describe different ways to improve liaison between psychiatrists and general practitioners in Australia.

CONCLUSION

Strengthening the links between psychiatry and GPs in primary care is an effective approach to improve the mental health of Australians.

Co-leadership to co-design in mental health-care ecosystems: what does it mean to us?

PURPOSE

This study aims to demonstrate how service providers, service users and their families should be able to share the co-leadership, co-auspicing, co-ownership, and co-governance, of a the mental health-care ecosystem, at every level, as it develops upwards and wider, in a process of inclusivity, conviviality and polyphonic discourse, via the overlapping phases of co-creativity, codesign, co-production, co-delivery, co-evaluation, co-research and co-replication, to achieve outcomes of co-communal or organisational well-being.

DESIGN/METHODOLOGY/APPROACH

"Co-design" is shorthand code for encouraging multiple pathways and trajectories toward forming and sustaining a sparkling web or vibrant network of inclusive opportunities for stakeholder participation and a collaborative partnership in organizational development, in these circumstances, for more effective mental health services (MHSs).

FINDINGS

In a co-design framework, all partners should be entitled to expect and "to have and to hold" an ongoing equal stake, voice and power in the discourse from start to finish, in a bottom-up process which is fostered by an interdisciplinary leadership group, providing the strong foundation or nutrient-rich and well-watered soil and support from which a shared endeavor can grow, blossom and generate the desired fruit in ample quality and quantity.

ORIGINALITY/VALUE

The authors should be working toward co-design and co-production of contemporary MHSs in a mental health-care ecosystem.

Community-Based Psychiatric Treatment in Romania: Past, Present, Future

Community psychiatry has its origins in the West, in the 1950s, when many institutions for the mentally ill were closed down in an effort to shift the focus from hospital-based care to community-based. The aim of the current paper is to review the available literature on the community-based psychiatric treatment in Romania. The Romanian Ministry of Health is dedicated to promoting mental health education and to creating a mental health system that ensures that every patient has access to care and treatments designed for their own particular needs. Today, in Romania, as across the entirety of Central and Eastern Europe, mental health systems are transitioning from hospital-based care to community-based services. The RECOVER-E project, the SEE Mental Health Project, the "Horizons" project, among others, showcase Romania's mental healthcare system in terms of improving the chances of mental health patients' recovery. Community Psychiatry in Romania is a budding field that can greatly aid in the management and treatment of patients with mental disorders from both urban and rural areas. By applying the principles of deinstitutionalization and community health care at a systemic level, resources may be invested in the creation of a strong network of specialists that treat patients in their own living spaces.

Use of a decision support system for benchmarking analysis and organizational improvement of regional mental health care: Efficiency, stability and entropy assessment of the mental health ecosystem of Gipuzkoa (Basque Country, Spain)

Decision support systems are appropriate tools for guiding policymaking processes, especially in mental health (MH), where care provision should be delivered in a balanced and integrated way. This study aims to develop an analytical process for (i) assessing the performance of an MH ecosystem and (ii) identifying benchmark and target-for-improvement catchment areas. MH provision (inpatient, day and outpatient types of care) was analysed in the Mental Health Network of Gipuzkoa (Osakidetza, Basque Country, Spain) using a decision support system that integrated data envelopment analysis, Monte Carlo simulation and artificial intelligence. The unit of analysis was the 13 catchment areas defined by a reference MH centre. MH ecosystem performance was assessed by the following indicators: relative technical efficiency, stability and entropy to guide organizational interventions. Globally, the MH system of Gipuzkoa showed high efficiency scores in each main type of care (inpatient, day and outpatient), but it can be considered unstable (small changes can have relevant impacts on MH provision and performance). Both benchmark and target-for-improvement areas were identified and described. This article provides a guide for evidence-informed decision-making and policy design to improve the continuity of MH care after inpatient discharges. The findings show that it is crucial to design interventions and strategies (i) considering the characteristics of the area to be improved and (ii) assessing the potential impact on the performance of the global MH care ecosystem. For performance improvement, it is recommended to reduce admissions and readmissions for inpatient care, increase workforce capacity and utilization of day care services and increase the availability of outpatient care services.

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.

A new bottom-up method for the standard analysis and comparison of workforce capacity in mental healthcare planning: Demonstration study in the Australian Capital Territory

The aims of this study are to evaluate and describe mental health workforce and capacity, and to describe the relationship between workforce capacity and patterns of care in local areas. We conducted a comparative demonstration study of the applicability of an internationally validated standardised service classification instrument—the Description and Evaluation of Services and Directories—DESDE-LTC) using the emerging mental health ecosystems research (MHESR) approach. Using DESDE-LTC as the framework, and drawing from international occupation classifications, the workforce was classified according to characteristics including the type of care provided and professional background. Our reference area was the Australian Capital Territory, which we compared with two other urban districts in Australia (Sydney and South East Sydney) and three benchmark international health districts (Helsinki-Uusima (Finland), Verona (Italy) and Gipuzkoa (Spain)). We also compared our data with national level data where available. The Australian and Finnish regions had a larger and more highly skilled workforce than the southern European regions. The pattern of workforce availability and profile varied, even within the same country, at the local level. We found significant differences between regional rates of identified rates of psychiatrists and psychologists, and national averages. Using a standardised classification instrument at the local level, and our occupational groupings, we were able to assess the available workforce and provide information relevant to planners about the actual capacity of the system. Data obtained at local level is critical to providing planners with reliable data to inform their decision making.

A Comprehensive Assessment to Enable Recovery of the Homeless: The HOP-TR Study

Background: Homelessness is an increasing problem in Western European countries. In the Netherlands, policy reforms and austerity measures induced an urgent need for management information on local homeless citizens. Municipal authorities initiated cross-sectional reviews of Homeless Service (HS) users. The resulting Homeless People Treatment and Recovery (HOP-TR) study developed a health and needs assessment strategy over different domains to comprehensively assess individuals and care networks with the perspective on recovery.

Methods: Dutch HS users were selected using a naturalistic meta-snowball sampling. Semi-structured interviews provided the primary data source. The interview content was partly derived from the InterRAI Community Mental Health questionnaire and the “Homelessness Supplement.” Using the raw interview data, algorithmic summary scores were computed and integrating clinical parameters assessed. The data describe health and needs in a rights-based, recovery-oriented frame of reference. The mental health approach is transdiagnostic. The positive health framework is used for structuring health and needs aspects in relation to the symptomatic (physical and mental health), social (daily living, social participation), and personal (quality of life, meaning) dimensions of recovery.

Results: Recruitment (between 2015 and 2017) resulted in a saturated sample of 436 HS users in 16 facilities and seven cities. Most participants were long-term or intermittently homeless. The sample characteristics reveal the multi domain character of needs and the relevance of a broad, comprehensive approach. Local authorities used the reports to reflect and discuss needs, care provision, access, and network cooperation. These dialogs incited to improve the quality of care at various ecosystem levels.

Discussion: This paper describes new recruitment strategies and data collections of comprehensive data domains, to improve our knowledge in the field of homelessness. Traditional epidemiological literature on homelessness is often domain specific and relies on administrative sources. The HOP-TR study uses an analytical epidemiological approach. It shifts the assessment focus from problem-centered marginalization processes toward a comprehensive, three-dimensional recovery-oriented vision of health. Different perspectives are integrated to explore the interaction of homeless people with care networks.

Health Patterns Reveal Interdependent Needs of Dutch Homeless Service Users

Background: Homelessness is an increasing problem in Western European countries. Dutch local authorities initiated cross-sectional reviews to obtain accurate health and needs information on Homeless Service (HS) users. Methods: The Homeless People Treatment and Recovery (HOP-TR) study uses a comprehensive assessment strategy to obtain health data. Using a naturalistic meta-snowball sampling in 2015-2017, 436 Dutch HS users were assessed. The lived experience of HS users was the primary data source and was enriched with professional assessments. The InterRAI Community Mental Health questionnaire and "Homelessness Supplement" provided information in different areas of life. The approach for mental health assessments was transdiagnostic. Raw interview data were recoded to assess health and needs. The positive health framework structured symptomatic, social, and personal health domains relevant to recovery. Results: Most subjects were males, low educated, with a migration background. The majority were long-term or intermittently homeless. Concurrent health problems were present in two domains or more in most (95.0%) subjects. Almost all participants showed mental health problems (98.6%); for a significant share severe (72.5%). Frequent comorbid conditions were addiction (78%), chronic physical conditions (59.2%), and intellectual impairments (39.9%). Conclusion: The HOP-TR study reveals significant concurrent health problems among Dutch HS users. The interdependent character of different needs requires an integrated 3-D public health approach to comprehensively serve symptomatic, social, and personal dimensions, required to facilitate recovery.

International experiences of the active period of COVID-19 - Mental health care

AIM

To summarise commonalities and variations in the mental health response to COVID-19 across different sites and countries, with a view to better understanding key steps not only in crisis management, but for future systemic reform of mental health care.

METHOD

We conducted a Rapid Synthesis and Translation Process of lessons learned from an international panel of experts, collecting on the ground experiences of the pandemic as it evolved in real time. Digital conferencing and individual interviews were used to rapidly acquire knowledge on the COVID-19 outbreak across 16 locations in Australia, Denmark, Italy, Spain, Taiwan, the UK, and the USA.

RESULTS

COVID-19 has had massive impacts on mental health care internationally. Most systems were under-resourced and under-prepared, struggling to manage both existing and new clients. There were significant differences between sites, depending on the explosivity the pandemic and the readiness of the mental health system. Integrated, community mental health systems exhibited greater adaptability in contrast to services which depended on face-to-face and hospital-based care. COVID-19 has demonstrated the need for a new approach to rapid response to crisis in mental health. New decision support system tools are necessary to ensure local decision-makers can effectively respond to the enormous practical challenges posed in these circumstances.

CONCLUSIONS

The process we have undertaken has generated clear lessons for mental health policymakers worldwide, beyond pandemic planning and response to guide next steps in systemic mental health reform. Key here is achieving some balance between national leadership and local context adaptation of evidence.

Rapid response to crisis: Health system lessons from the active period of COVID-19

BACKGROUND

This paper outlines the need for a health systems approach and rapid response strategy for gathering information necessary for policy decisions during pandemics and similar crises. It suggests a new framework for assessing the phases of the pandemic.

METHOD

The paper draws its information and conclusions from a rapid synthesis and translation process (RSTP) of a series of webinars and online discussions from the Pandemic-Mental Health International Network (Pan-MHIN) - policy experts from across 16 locations in Australia, Denmark, Italy, Spain, Taiwan, the UK and the USA. While the initial focus of this research was on mental health, COVID-19 has raised much broader issues and questions for health planners.

RESULTS

We identified gaps affecting the capacity to respond effectively and quickly, including in relation to system indicators, the inadequacy of the prior classification of the phases of the pandemic, the absences of a healthcare ecosystem approach, and the quick shift to digital technologies. The strengths and weaknesses of COVID-19 responses across different systems, services, sites and countries been identified and compared, including both low and high impacted areas.

CONCLUSIONS

There is an urgent need for managerial epidemiology based on healthcare ecosystem research encompassing multidisciplinary teams, visualization tools and decision analytics for rapid response. Policy and healthcare context played a key role in the response to COVID-19. Its severity, the containment measures and the societal response varied greatly across sites and countries. Understanding this variation is vital to assess the impact of COVID-19 in specific areas such as ageing or mental health.