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Reilly S, Hobson-Merrett C, Gibbons B, Jones B, Richards D, Plappert H, Gibson J, Green M, Gask L, Huxley PJ, Druss BG, Planner CL. Collaborative care approaches for people with severe mental illness. Cochrane Database Syst Rev 2024; 5:CD009531. [PMID: 38712709 PMCID: PMC11075124 DOI: 10.1002/14651858.cd009531.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
BACKGROUND Collaborative care for severe mental illness (SMI) is a community-based intervention that promotes interdisciplinary working across primary and secondary care. Collaborative care interventions aim to improve the physical and/or mental health care of individuals with SMI. This is an update of a 2013 Cochrane review, based on new searches of the literature, which includes an additional seven studies. OBJECTIVES To assess the effectiveness of collaborative care approaches in comparison with standard care (or other non-collaborative care interventions) for people with diagnoses of SMI who are living in the community. SEARCH METHODS We searched the Cochrane Schizophrenia Study-Based Register of Trials (10 February 2021). We searched the Cochrane Common Mental Disorders (CCMD) controlled trials register (all available years to 6 June 2016). Subsequent searches on Ovid MEDLINE, Embase and PsycINFO together with the Cochrane Central Register of Controlled Trials (with an overlap) were run on 17 December 2021. SELECTION CRITERIA Randomised controlled trials (RCTs) where interventions described as 'collaborative care' were compared with 'standard care' for adults (18+ years) living in the community with a diagnosis of SMI. SMI was defined as schizophrenia, other types of schizophrenia-like psychosis or bipolar affective disorder. The primary outcomes of interest were: quality of life, mental state and psychiatric admissions at 12 months follow-up. DATA COLLECTION AND ANALYSIS Pairs of authors independently extracted data. We assessed the quality and certainty of the evidence using RoB 2 (for the primary outcomes) and GRADE. We compared treatment effects between collaborative care and standard care. We divided outcomes into short-term (up to six months), medium-term (seven to 12 months) and long-term (over 12 months). For dichotomous data we calculated the risk ratio (RR) and for continuous data we calculated the standardised mean difference (SMD), with 95% confidence intervals (CIs). We used random-effects meta-analyses due to substantial levels of heterogeneity across trials. We created a summary of findings table using GRADEpro. MAIN RESULTS Eight RCTs (1165 participants) are included in this review. Two met the criteria for type A collaborative care (intervention comprised of the four core components). The remaining six met the criteria for type B (described as collaborative care by the trialists, but not comprised of the four core components). The composition and purpose of the interventions varied across studies. For most outcomes there was low- or very low-certainty evidence. We found three studies that assessed the quality of life of participants at 12 months. Quality of life was measured using the SF-12 and the WHOQOL-BREF and the mean endpoint mental health component scores were reported at 12 months. Very low-certainty evidence did not show a difference in quality of life (mental health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.03, 95% CI -0.26 to 0.32; 3 RCTs, 227 participants). Very low-certainty evidence did not show a difference in quality of life (physical health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.08, 95% CI -0.18 to 0.33; 3 RCTs, 237 participants). Furthermore, in the medium term (at 12 months) low-certainty evidence did not show a difference between collaborative care and standard care in mental state (binary) (RR 0.99, 95% CI 0.77 to 1.28; 1 RCT, 253 participants) or in the risk of being admitted to a psychiatric hospital at 12 months (RR 5.15, 95% CI 0.67 to 39.57; 1 RCT, 253 participants). One study indicated an improvement in disability (proxy for social functioning) at 12 months in the collaborative care arm compared to usual care (RR 1.38, 95% CI 0.97 to 1.95; 1 RCT, 253 participants); we deemed this low-certainty evidence. Personal recovery and satisfaction/experience of care outcomes were not reported in any of the included studies. The data from one study indicated that the collaborative care treatment was more expensive than standard care (mean difference (MD) international dollars (Int$) 493.00, 95% CI 345.41 to 640.59) in the short term. Another study found the collaborative care intervention to be slightly less expensive at three years. AUTHORS' CONCLUSIONS This review does not provide evidence to indicate that collaborative care is more effective than standard care in the medium term (at 12 months) in relation to our primary outcomes (quality of life, mental state and psychiatric admissions). The evidence would be improved by better reporting, higher-quality RCTs and the assessment of underlying mechanisms of collaborative care. We advise caution in utilising the information in this review to assess the effectiveness of collaborative care.
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Affiliation(s)
- Siobhan Reilly
- Centre for Applied Dementia Studies, Faculty of Health Studies, University of Bradford, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
- Division of Health Research, Lancaster University, Lancaster, UK
| | - Charley Hobson-Merrett
- Primary Care Plymouth, University of Plymouth, Plymouth, UK
- National Institute for Health Research Applied Research Collaboration South West Peninsula, Plymouth, UK
| | | | - Ben Jones
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Debra Richards
- Primary Care Plymouth, University of Plymouth, Plymouth, UK
| | - Humera Plappert
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | | | - Maria Green
- Pennine Health Care NHS Foundation Trust, Bury, UK
| | - Linda Gask
- Health Sciences Research Group, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Peter J Huxley
- Centre for Mental Health and Society, School of Health Sciences, Bangor University, Bangor, UK
| | - Benjamin G Druss
- Department of Health Policy and Management, Emory University, Atlanta, USA
| | - Claire L Planner
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
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Martens N, Destoop M, Dom G. Physical Healthcare, Health-Related Quality of Life and Global Functioning of Persons with a Severe Mental Illness in Belgian Long-Term Mental Health Assertive Outreach Teams: A Cross-Sectional Self-Reported Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:5522. [PMID: 35564916 PMCID: PMC9100211 DOI: 10.3390/ijerph19095522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 02/01/2023]
Abstract
Research shows that care delivery regarding somatic health problems for patients with a severe mental illness (SMI) in community and mental health is difficult to establish. During the last decade, long term mental health outreach teams in Belgium were implemented to provide treatment and follow-up at home. This study aimed to map physical health status, care professionals, health related quality of life and global functioning in persons with SMI in Belgian long term outreach teams for mental health. Using a self-administered questionnaire, 173 persons, 58.1% female with a mean age of 48.3, were questioned. Our findings suggest an undertreatment of somatic comorbid conditions, with only half of physical health complaints being addressed. Although treatment rates for hypertension, when detected were high, treatment of respiratory complaints, pain and fatigue was lacking. Although the majority of respondents responded to have a GP or psychiatrist, contact rates were rather limited. Other disciplines, such as primary care nurses, when present, tend to have more contact with people with SMI. Notably, having regular contacts with GPs seems to improve physical health complaints and/or treatment. Being treated by an outreach team did not show significant correlations with physical health complaints and/or treatment suggesting a more proactive approach by outreach teams or primary care providers is desirable.
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Affiliation(s)
- Nicolaas Martens
- Multiversum Psychiatric Hospital, Brothers of Charity Belgium, 2530 Boechout, Belgium; (M.D.); (G.D.)
- Collaborative Antwerp Psychiatry Research Institute (CAPRI), University of Antwerp, 2610 Antwerp, Belgium
- Department of Nursing, Karel de Grote University of Applied Sciences, 2018 Antwerp, Belgium
| | - Marianne Destoop
- Multiversum Psychiatric Hospital, Brothers of Charity Belgium, 2530 Boechout, Belgium; (M.D.); (G.D.)
- Collaborative Antwerp Psychiatry Research Institute (CAPRI), University of Antwerp, 2610 Antwerp, Belgium
| | - Geert Dom
- Multiversum Psychiatric Hospital, Brothers of Charity Belgium, 2530 Boechout, Belgium; (M.D.); (G.D.)
- Collaborative Antwerp Psychiatry Research Institute (CAPRI), University of Antwerp, 2610 Antwerp, Belgium
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Grünwald LM, Duddy C, Byng R, Crellin N, Moncrieff J. The role of trust and hope in antipsychotic medication reviews between GPs and service users a realist review. BMC Psychiatry 2021; 21:390. [PMID: 34348680 PMCID: PMC8340528 DOI: 10.1186/s12888-021-03355-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/26/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Increasing number of service users diagnosed with schizophrenia and psychosis are being discharged from specialist secondary care services to primary care, many of whom are prescribed long-term antipsychotics. It is unclear if General Practitioners (GPs) have the confidence and experience to appropriately review and adjust doses of antipsychotic medication without secondary care support. AIM To explore barriers and facilitators of conducting antipsychotic medication reviews in primary care for individuals with no specialist mental health input. DESIGN & SETTING Realist review in general practice settings. METHOD A realist review has been conducted to synthesise evidence on antipsychotic medication reviews conducted in primary care with service users diagnosed with schizophrenia or psychosis. Following initial scoping searches and discussions with stakeholders, a systematic search and iterative secondary searches were conducted. Articles were systematically screened and analysed to develop a realist programme theory explaining the contexts (C) and mechanisms (M) which facilitate or prevent antipsychotic medication reviews (O) in primary care settings, and the potential outcomes of medication reviews. RESULTS Meaningful Antipsychotic medication reviews may not occur for individuals with only primary care medical input. Several, often mutually reinforcing, mechanisms have been identified as potential barriers to conducting such reviews, including low expectations of recovery for people with severe mental illness, a perceived lack of capability to understand and participate in medication reviews, linked with a lack of information shared in appointments between GPs and Service Users, perceived risk and uncertainty regarding antipsychotic medication and illness trajectory. CONCLUSIONS The review identified reciprocal and reinforcing stereotypes affecting both GPs and service users. Possible mechanisms to counteract these barriers are discussed, including realistic expectations of medication, and the need for increased information sharing and trust between GPs and service users.
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Affiliation(s)
- L M Grünwald
- Division of Psychiatry, University College London, 149 Tottenham Court Rd, Bloomsbury, London, W1T 7NF, UK.
- Comprehensive Clinical Trials Unit, 90 High Holborn, London, WC1V 6LJ, UK.
| | - C Duddy
- Nuffield Department of Primary Care Health Sciences, University of Oxford Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - R Byng
- Peninsula Medical School, University of Plymouth, Drake Circus, Plymouth, Devon, PL4 8AA, UK
| | - N Crellin
- Nuffield Trust, 59 New Cavendish Street, London, W1G 7LP, UK
| | - J Moncrieff
- Division of Psychiatry, University College London, 149 Tottenham Court Rd, Bloomsbury, London, W1T 7NF, UK
- Research and Development Department, North East London Foundation Trust, Maggie Lilley Suite, Goodmayes Hospital, Barley Lane, Ilford, Essex, IG3 8XJ, UK
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Myklebust LH, Lassemo E. The role of local inpatient psychiatric units and general practitioner on continuity of care in Northern Norway: A case-register study. Int J Methods Psychiatr Res 2021; 30:e1866. [PMID: 33248004 PMCID: PMC8170572 DOI: 10.1002/mpr.1866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The general practitioners' (GP) role in the care of mental health patients has received increased attention. The literature underlines the need for integration of primary and specialist services, but cross-boundary continuity for patients with severe conditions may be particularly poor. The aim of this study was to analyze the collaboration between primary care and different models of specialized psychiatric services for patients with severe conditions. METHODS We compared a local and a centralized model of mental health care. Service utilization over a 5-year period was studied. RESULTS Findings suggest that a local institution-based model of services positively affects the use of both GP and specialist outpatient care, with most inpatients utilizing both GP and specialist outpatient consultations. In the centralized model, a substantial proportion of inpatients only used GP outpatient care. Furthermore, inpatients that used both GP and specialist outpatient services received more of both services compared to those who did not enter specialist outpatient care at all. CONCLUSION Local inpatient units may positively affect continuity of care and collaboration between general practitioners and specialist psychiatric services compared to more traditional hospital units, probably because better functional integration of services, better facilitation of clinical alliances/relationships, or a more network-oriented treatment philosophy.
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Affiliation(s)
- Lars Henrik Myklebust
- Sykehuset Innlandet HF, Hamar, Norway.,Nord-Norsk Psykiatrisk Forskningssenter, Bodø, Norway
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Reilly S, McCabe C, Marchevsky N, Green M, Davies L, Ives N, Plappert H, Allard J, Rawcliffe T, Gibson J, Clark M, Pinfold V, Gask L, Huxley P, Byng R, Birchwood M. Status of primary and secondary mental healthcare of people with severe mental illness: an epidemiological study from the UK PARTNERS2 programme. BJPsych Open 2021; 7:e53. [PMID: 33583478 PMCID: PMC8058911 DOI: 10.1192/bjo.2021.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND There is global interest in the reconfiguration of community mental health services, including primary care, to improve clinical and cost effectiveness. AIMS This study seeks to describe patterns of service use, continuity of care, health risks, physical healthcare monitoring and the balance between primary and secondary mental healthcare for people with severe mental illness in receipt of secondary mental healthcare in the UK. METHOD We conducted an epidemiological medical records review in three UK sites. We identified 297 cases randomly selected from the three participating mental health services. Data were manually extracted from electronic patient medical records from both secondary and primary care, for a 2-year period (2012-2014). Continuous data were summarised by mean and s.d. or median and interquartile range (IQR). Categorical data were summarised as percentages. RESULTS The majority of care was from secondary care practitioners: of the 18 210 direct contacts recorded, 76% were from secondary care (median, 36.5; IQR, 14-68) and 24% were from primary care (median, 10; IQR, 5-20). There was evidence of poor longitudinal continuity: in primary care, 31% of people had poor longitudinal continuity (Modified Modified Continuity Index ≤0.5), and 43% had a single named care coordinator in secondary care services over the 2 years. CONCLUSIONS The study indicates scope for improvement in supporting mental health service delivery in primary care. Greater knowledge of how care is organised presents an opportunity to ensure some rebalancing of the care that all people with severe mental illness receive, when they need it. A future publication will examine differences between the three sites that participated in this study.
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Affiliation(s)
- Siobhan Reilly
- Division of Health Research, Lancaster University, UK; and Centre for Applied Dementia Studies, Faculty of Health Studies, University of Bradford, UK
| | | | | | - Maria Green
- Division of Health Research, Lancaster University, UK
| | - Linda Davies
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, UK
| | - Natalie Ives
- Birmingham Clinical Trials Unit, Birmingham University, UK
| | - Humera Plappert
- Institute for Mental Health, School of Psychology, University of Birmingham, UK
| | - Jon Allard
- Cornwall Partnership NHS Foundation Trust, UK; and Community and Primary Care Research Group, Faculty of Medicine, University of Plymouth, UK
| | - Tim Rawcliffe
- Division of Health Research, Lancaster University, UK
| | - John Gibson
- Institute for Mental Health, School of Psychology, University of Birmingham, UK
| | - Michael Clark
- London School of Economics and Political Science, UK
| | | | - Linda Gask
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, UK
| | - Peter Huxley
- Centre for Mental Health and Society, School of Health Sciences, Bangor University, UK
| | - Richard Byng
- Community and Primary Care Research Group, Faculty of Medicine, University of Plymouth, UK
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Collom JRD, Davidson J, Sweet D, Gillard S, Pinfold V, Henderson C. Development of a peer-led, network mapping intervention to improve the health of individuals with severe mental illnesses: protocol for a pilot study. BMJ Open 2019; 9:e023768. [PMID: 31256018 PMCID: PMC6609054 DOI: 10.1136/bmjopen-2018-023768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Adults with severe mental illness (SMI) have reduced life expectancy and many have comorbid physical health conditions. Primary care providers are experiencing increased demands for care for people with SMI. Barriers to accessing physical healthcare have been identified which negatively affect quality of care. We propose that peer support workers (PSWs) could deliver an intervention to service users to promote their physical health by drawing on existing social support. The aim of this research was to pilot a novel PSW-led intervention, including personal well-being network mapping, to improve access to primary care for physical health needs. METHODS AND ANALYSIS Twenty-four participants will be recruited from community-based mental health teams in two boroughs of London. Each participant will be offered a six-session intervention. Quantitative data will be collected before and after intervention (at 4-month follow-up). Qualitative interviews will be conducted with PSWs after completion of the intervention and with participants at a 4-month follow-up. Some intervention sessions will be observed by a member of the research team. This is a pilot study with a small sample aiming to assess acceptability and feasibility of an intervention. We aim to use the results to refine the existing theory of change and to optimise the intervention and its evaluation in a future randomised controlled trial. This study is strengthened by its potential clinical importance and origin in previous research where service users engaged with well-being network mapping. ETHICS AND DISSEMINATION This study has been approved by the London-Chelsea Regional Ethics Committee (ref: 17/LO/0585). The findings will be disseminated to participants, the National Health Service trusts that we recruited from, primary care mental health leads, commissioners and in peer-reviewed journals and academic conferences.
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Affiliation(s)
| | - Jonathan Davidson
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | | | - Steve Gillard
- Division of Population Health Sciences and Education, St George's University of London, London, UK
| | | | - Claire Henderson
- King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
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Wakida EK, Okello ES, Rukundo GZ, Akena D, Alele PE, Talib ZM, Obua C. Health system constraints in integrating mental health services into primary healthcare in rural Uganda: perspectives of primary care providers. Int J Ment Health Syst 2019; 13:16. [PMID: 30949234 PMCID: PMC6429816 DOI: 10.1186/s13033-019-0272-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/14/2019] [Indexed: 12/13/2022] Open
Abstract
Background The World Health Organization issued recommendations to guide the process of integrating mental health services into primary healthcare. However, there has been general as well as context specific shortcomings in the implementation of these recommendations. In Uganda, mental health services are intended to be decentralized and integrated into general healthcare, but, the services are still underutilized especially in rural areas. Purpose The purpose of this study was to explore the health systems constraints to the integration of mental health services into PHC in Uganda from the perspective of primary health care providers (PHCPs). Methods This was a cross sectional qualitative study guided by the Supporting the Use of Research Evidence (SURE) framework. We used a semi-structured interview guide to gain insight into the health systems constraints faced by PHCPs in integrating mental health services into PHC. Results Key health systems constraints to integrating mental health services into PHC identified included inadequate practical experience during training, patient flow processes, facilities, human resources, gender related factors and challenges with accessibility of care. Conclusion There is need to strengthen the training of healthcare providers as well as improving the health care system that supports health workers. This would include periodic mental healthcare in-service training for PHCPs; the provision of adequate processes for outreach, and receiving, referring and transferring patients with mental health problems; empowering PHCPs at all levels to manage and treat mental health problems and adequately provide the necessary medical supplies; and increase the distribution of health workers across the health facilities to address the issue of high workload and compromised quality of care provided. Electronic supplementary material The online version of this article (10.1186/s13033-019-0272-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Edith K Wakida
- 1Department of Psychiatry, Mbarara University of Science and Technology, P. O. Box 1410, Mbarara, Uganda
| | - Elialilia S Okello
- Mwanza Intervention Trials Unit, Tanzania National Institute for Medical, Mwanza Centre, Mwanza, Tanzania
| | - Godfrey Z Rukundo
- 1Department of Psychiatry, Mbarara University of Science and Technology, P. O. Box 1410, Mbarara, Uganda
| | - Dickens Akena
- 3Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Paul E Alele
- 4Department of Pharmacology and Therapeutics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Zohray M Talib
- Department of Medical Education, California University of Science and Medicine, San Bernardino, CA USA.,6Mbarara University of Science and Technology, Mbarara, Uganda
| | - Celestino Obua
- 7Department of Pharmacology and Therapeutics and Vice Chancellor, Mbarara University of Science and Technology, Mbarara, Uganda
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Baker E, Gwernan-Jones R, Britten N, Cox M, McCabe C, Retzer A, Gill L, Plappert H, Reilly S, Pinfold V, Gask L, Byng R, Birchwood M. Refining a model of collaborative care for people with a diagnosis of bipolar, schizophrenia or other psychoses in England: a qualitative formative evaluation. BMC Psychiatry 2019; 19:7. [PMID: 30616552 PMCID: PMC6323712 DOI: 10.1186/s12888-018-1997-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 12/20/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Many people diagnosed with schizophrenia, bipolar or other psychoses in England receive the majority of their healthcare from primary care. Primary care practitioners may not be well equipped to meet their needs and there is often poor communication with secondary care. Collaborative care is a promising alternative model but has not been trialled specifically with this service user group in England. Collaborative care for other mental health conditions has not been widely implemented despite evidence of its effectiveness. We carried out a formative evaluation of the PARTNERS model of collaborative care, with the aim of establishing barriers and facilitators to delivery, identifying implementation support requirements and testing the initial programme theory. METHODS The PARTNERS intervention was delivered on a small scale in three sites. Qualitative data was collected from primary and secondary care practitioners, service users and family carers, using semi-structured interviews, session recordings and tape-assisted recall. Deductive and inductive thematic analysis was carried out; themes were compared to the programme theory and used to inform an implementation support strategy. RESULTS Key components of the intervention that were not consistently delivered as intended were: interaction with primary care teams, the use of coaching, and supervision. Barriers and facilitators identified were related to service commitment, care partner skills, supervisor understanding and service user motivation. An implementation support strategy was developed, with researcher facilitation of communication and supervision and additional training for practitioners. Some components of the intervention were not experienced as intended; this appeared to reflect difficulties with operationalising the intervention. Analysis of data relating to the intended outcomes of the intervention indicated that the mechanisms proposed in the programme theory had operated as expected. CONCLUSIONS Additional implementation support is likely to be required for the PARTNERS model to be delivered; the effectiveness of such support may be affected by practitioner and service user readiness to change. There is also a need to test the programme theory more fully. These issues will be addressed in the process evaluation of our full trial. TRIAL REGISTRATION ISRCTN95702682 , 26 October 2017.
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Affiliation(s)
- Elina Baker
- Institute of Health Research, University of Exeter Medical School, St Luke's Campus, Exeter, UK.
| | - Ruth Gwernan-Jones
- 0000 0004 1936 8024grid.8391.3Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Nicky Britten
- 0000 0004 1936 8024grid.8391.3Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Maria Cox
- 0000 0000 8190 6402grid.9835.7Health Research, Lancaster University, Furness Building, Lancaster, UK
| | - Catherine McCabe
- 0000 0001 2219 0747grid.11201.33Community and Primary Care Research Group, University of Plymouth, Faculty of Medicine and Dentistry, Plymouth Science Park, Plymouth, UK
| | - Ameeta Retzer
- 0000 0004 1936 7486grid.6572.6Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Laura Gill
- 0000 0001 2219 0747grid.11201.33Community and Primary Care Research Group, University of Plymouth, Faculty of Medicine and Dentistry, Plymouth Science Park, Plymouth, UK
| | - Humera Plappert
- 0000 0004 1936 7486grid.6572.6Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Siobhan Reilly
- 0000 0000 8190 6402grid.9835.7Health Research, Lancaster University, Furness Building, Lancaster, UK
| | - Vanessa Pinfold
- grid.490917.2The McPin Foundation, 32-36 Loman Street, London, UK
| | - Linda Gask
- 0000000121662407grid.5379.8Centre for Primary Care research, University of Manchester, Oxford Road, Williamson Building, Manchester, UK
| | - Richard Byng
- 0000 0001 2219 0747grid.11201.33Community and Primary Care Research Group, University of Plymouth, Faculty of Medicine and Dentistry, Plymouth Science Park, Plymouth, UK
| | - Max Birchwood
- 0000 0000 8809 1613grid.7372.1Warwick Medical School, University of Warwick, Coventry, UK
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Wakida EK, Talib ZM, Akena D, Okello ES, Kinengyere A, Mindra A, Obua C. Barriers and facilitators to the integration of mental health services into primary health care: a systematic review. Syst Rev 2018; 7:211. [PMID: 30486900 PMCID: PMC6264616 DOI: 10.1186/s13643-018-0882-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 11/12/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The objective of the review was to synthesize evidence of barriers and facilitators to the integration of mental health services into PHC from existing literature. The structure of the review was guided by the SPIDER framework which involves the following: Sample or population of interest-primary care providers (PCPs); Phenomenon of Interest-integration of mental health services into primary health care (PHC); Design-influenced robustness and analysis of the study; Evaluation-outcomes included subjective outcomes (views and attitudes); and Research type-qualitative, quantitative, and mixed methods studies. METHODS Studies that described mental health integration in PHC settings, involved primary care providers, and presented barriers/facilitators of mental health integration into PHC were included in the review. The sources of information included PubMed, PsycINFO, Cochrane Central Register of Controlled trials, the WHO website, and OpenGrey. Assessment of bias and quality was done using two separate tools: the Critical Appraisal Skills Program (CASP) qualitative checklist and the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. RESULTS Twenty studies met the inclusion criteria out of the 3353 search results. The most frequently reported barriers to integration of mental health services into PHC were (i) attitudes regarding program acceptability, appropriateness, and credibility; (ii) knowledge and skills; (iii) motivation to change; (iv) management and/or leadership; and (v) financial resources. In order to come up with an actionable approach to addressing the barriers, these factors were further analyzed along a behavior change theory. DISCUSSION We have shown that the integration of mental health services into PHC has been carried out by various countries. The analysis from this review provides evidence to inform policy on the existing barriers and facilitators to the implementation of the mental health integration policy option. Not all databases may have been exhausted. SYSTEMATIC REVIEW REGISTRATION PROSPERO 2016 (Registration Number: CRD42016052000 ) and published in BMC Systematic Reviews August 2017.
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Affiliation(s)
- Edith K. Wakida
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Zohray M. Talib
- Department of Medical Education, California University of Science and Medicine, California, USA
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Dickens Akena
- Africa Center for Systematic Reviews and Knowledge Translation, College of Health Sciences Makerere University, Kampala, Uganda
- Department of Psychiatry, Makerere University, Kampala, Uganda
| | | | - Alison Kinengyere
- Department of Psychiatry, Makerere University, Kampala, Uganda
- Library, Africa Center for Systematic Reviews and Knowledge Translation, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Arnold Mindra
- Office of Research Administration, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Celestino Obua
- Department of Pharmacology and Therapeutics, Mbarara University of Science and Technology, Mbarara, Uganda
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Barriers and facilitators to the integration of mental health services into primary healthcare: a qualitative study among Ugandan primary care providers using the COM-B framework. BMC Health Serv Res 2018; 18:890. [PMID: 30477492 PMCID: PMC6258411 DOI: 10.1186/s12913-018-3684-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/05/2018] [Indexed: 12/20/2022] Open
Abstract
Background Uptake of clinical guideline recommendations into routine practice requires changes in attitudes and behaviors of the health care providers. The World Health Organization (WHO) has heavily invested in public health and health promotion globally by developing policy recommendations to guide clinical practice; however, clinical guidelines are often not applied. The success of the implementation of any guidelines depends on consideration of existing barriers and adequately addressing them. Therefore, exploring the context specific barriers and facilitators affecting the primary care providers (PCPs) in Mbarara district, Uganda may provide a practical way of addressing the identified barriers thus influence the PCPs action towards integration of mental healthcare services into PHC. Methods We adopted a theoretical model of behavior change; Capability, Opportunity and Motivation developed to understand behavior (COM-B). This was a cross-sectional study which involved using a semi-structured qualitative interview guide to conduct in-depth interviews with PCP’s (clinical officers, nurses and midwives). Results Capability - inadequacy in knowledge about mental disorders; more comfortable managing patients with a mental problem diagnosis than making a new one; knowledge about mental health was gained during pre-service training; no senior cadre to consultations in mental health; and burdensome to consult the Uganda Clinical Guidelines (UCG). Opportunity - limited supply of hard copies of the UCG; guidelines not practical for local setting; did not regularly deal with clients having mental illness to foster routine usage of the UCG; no sensitization about the UCG to the intended users; and no cues at the health centers to remind the PCPs to use UCG. Motivation - did not feel self-reliant; not seen the UCG at their health facilities; lack of trained mental health specialists; conflicting priorities; and no regulatory measures to encourage screening for mental health. Conclusions Efforts to achieve successful integration of mental health services into PHC need to fit in the context of the implementers; thus the need to adapt the UCG into local context, have cues to enforce implementation, and optimize the available expertize (mental healthcare providers) in the process. Electronic supplementary material The online version of this article (10.1186/s12913-018-3684-7) contains supplementary material, which is available to authorized users.
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11
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Young AS, Cohen AN, Chang ET, Flynn AWP, Hamilton AB, Oberman R, Vinzon M. A clustered controlled trial of the implementation and effectiveness of a medical home to improve health care of people with serious mental illness: study protocol. BMC Health Serv Res 2018; 18:428. [PMID: 29880047 PMCID: PMC5992687 DOI: 10.1186/s12913-018-3237-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 05/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND People with serious mental illness (SMI) die many years prematurely, with rates of premature mortality two to three times greater than the general population. Most premature deaths are due to "natural causes," especially cardiovascular disease and cancer. Often, people with SMI are not well engaged in primary care treatment and do not receive high-value preventative and medical services. There have been numerous efforts to improve this care, and few controlled trials, with inconsistent results. While people with SMI often do poorly with usual primary care arrangements, research suggests that integrated care and medical care management may improve treatment and outcomes, and reduce treatment costs. METHODS This hybrid implementation-effectiveness study is a prospective, cluster controlled trial of a medical home, the SMI Patient-Aligned Care Team (SMI PACT), to improve the healthcare of patients with SMI enrolled with the Veterans Health Administration. The SMI PACT team includes proactive medical nurse care management, and integrated mental health treatment through regular psychiatry consultation and a collaborative care model. Patients are recruited to receive primary care through SMI PACT based on having a serious mental illness that is manageable with treatment, and elevated risk for hospitalization or death. In a site-level prospective controlled trial, this project studies the effect, relative to usual care, of SMI PACT on provision of appropriate preventive and medical treatments, health-related quality of life, satisfaction with care, and medical and mental health treatment utilization and costs. Research includes mixed-methods formative evaluation of usual care and SMI PACT implementation to strengthen the intervention and assess barriers and facilitators. Investigators examine relationships among organizational context, intervention factors, and patient and clinician outcomes, and identify patient factors related to successful patient outcomes. DISCUSSION This will be one of the first controlled trials of the implementation and effectiveness of a patient centered medical home for people with serious mental illness. It will provide information regarding the value of this strategy, and processes and tools for implementing this model in community healthcare settings. TRIAL REGISTRATION ClinicalTrials.gov, NCT01668355 . Registered August 20, 2012.
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Affiliation(s)
- Alexander S. Young
- VA Greater Los Angeles Healthcare System, MIRECC, 11301 Wilshire Blvd., 210A, Los Angeles, CA 90073 USA
- Department of Psychiatry, Geffen School of Medicine, UCLA, 10920 Wilshire Blvd., Suite 300, Los Angeles, CA 90024 USA
| | - Amy N. Cohen
- VA Greater Los Angeles Healthcare System, MIRECC, 11301 Wilshire Blvd., 210A, Los Angeles, CA 90073 USA
- Department of Psychiatry, Geffen School of Medicine, UCLA, 10920 Wilshire Blvd., Suite 300, Los Angeles, CA 90024 USA
| | - Evelyn T. Chang
- VA Greater Los Angeles Healthcare System, MIRECC, 11301 Wilshire Blvd., 210A, Los Angeles, CA 90073 USA
- Department of Medicine, Geffen School of Medicine, UCLA, Los Angeles, CA 90095 USA
| | - Anthony W. P. Flynn
- VA Greater Los Angeles Healthcare System, MIRECC, 11301 Wilshire Blvd., 210A, Los Angeles, CA 90073 USA
- Department of Psychiatry, Geffen School of Medicine, UCLA, 10920 Wilshire Blvd., Suite 300, Los Angeles, CA 90024 USA
| | - Alison B. Hamilton
- VA Greater Los Angeles Healthcare System, MIRECC, 11301 Wilshire Blvd., 210A, Los Angeles, CA 90073 USA
| | - Rebecca Oberman
- VA Greater Los Angeles Healthcare System, MIRECC, 11301 Wilshire Blvd., 210A, Los Angeles, CA 90073 USA
| | - Merlyn Vinzon
- VA Greater Los Angeles Healthcare System, MIRECC, 11301 Wilshire Blvd., 210A, Los Angeles, CA 90073 USA
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Bhui K, Bhugra D. Communication with patients from other cultures: the place of explanatory models. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.10.6.474] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We discuss the complicated nature of communication between people from different cultural groups, perhaps using a second language. We focus on the fact that mental health practitioners and service users often have in common neither their cultural backgrounds nor their explanatory models of illness. Communication even in a shared language can be less than optimal as words carry multiple meanings. Consequently, consultations that involve culturally grounded explanatory models of illness challenge the professional. We give examples showing that reconciling different explanatory models during the consultation is a core task for psychiatrists and mental health practitioners working in multicultural settings.
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13
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Abstract
Shared care in mental health is now a policy imperative in England and Wales, yet its meaning, form and function are still open to debate. In this article, I discuss the benefits of and barriers to a shared care approach, explain how policy is currently driving practice in this area, discuss recent shared care initiatives and highlight some of the tensions inherent in the approach, particularly from the viewpoint of patients. I also give some of the key factors that need to be in place within a ‘whole systems' approach to ensure that shared care moves from the rhetoric of the statute book to everyday practice.
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Abstract
Over recent years early intervention in psychosis has fired the imagination of clinicians and researchers, following the publication of several studies linking a long duration of psychosis prior to receiving treatment with a poor treatment outcome: a relationship that has been cogently argued to be independent of illness factors (e.g. Scully et al, 1997). Most influential was Wyatt's (1991) review of 22 studies, in which relatively similar groups of patients suffering from schizophrenia were, or were not, given antipsychotic medication early in the course of their illness. This pointed towards an improved long-term course in schizophrenia with early treatment.
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15
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Wakida EK, Akena D, Okello ES, Kinengyere A, Kamoga R, Mindra A, Obua C, Talib ZM. Barriers and facilitators to the integration of mental health services into primary health care: a systematic review protocol. Syst Rev 2017; 6:171. [PMID: 28841908 PMCID: PMC6389192 DOI: 10.1186/s13643-017-0561-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 08/09/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Mental health is an integral part of health and well-being and yet health systems have not adequately responded to the burden of mental disorders. Integrating mental health services into primary health care (PHC) is the most viable way of closing the treatment gap and ensuring that people get the mental health care they need. PHC was formally adapted by the World Health Organization (WHO), and they have since invested enormous amounts of resources across the globe to ensure that integration of mental health services into PHC works. METHODS This review will use the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) framework approach to identify experiences of mental health integration into PHC; the findings will be reported using the "Best fit" framework synthesis. PubMed, EMBASE, PsycINFO, and Cochrane Central Register of Controlled trials (CENTRAL) will be searched including other sources like the WHO website and OpenGrey database. Assessment of bias and quality will be done at study level using two separate tools to check for the quality of evidence presented. Data synthesis will take on two synergistic approaches (qualitative and quantitative studies). Synthesizing evidence from countries across the globe will provide useful insights into the experiences of integrating mental health services into PHC and how the barriers and challenges have been handled. The findings will be useful to a wide array of stakeholders involved in the implementation of the mental health integration into PHC. DISCUSSION The SPIDER framework has been chosen for this review because of its suitable application to qualitative and mixed methods research and will be used as a guide when selecting articles for inclusion. Data extracted will be synthesized using the "Best fit" framework because it has been used before and proved its suitability in producing new conceptual models for explaining decision-making and possible behaviors. Synthesizing evidence from countries across the globe will provide useful insights into the experiences of integrating mental health services into PHC and how the barriers and challenges have been handled. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016052000.
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Affiliation(s)
- Edith K. Wakida
- Office of Research Administration, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Dickens Akena
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
- Africa Center for Systematic Reviews and Knowledge Translation, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Elialilia S. Okello
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Alison Kinengyere
- Africa Center for Systematic Reviews and Knowledge Translation, College of Health Sciences, Makerere University, Kampala, Uganda
- Library, Africa Center for Systematic Reviews and Knowledge Translation, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ronald Kamoga
- Department of Anatomy, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Arnold Mindra
- Office of Research Administration, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Celestino Obua
- Department of Pharmacology and Therapeutics and Vice Chancellor, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Zohray M. Talib
- Department of Medicine & of Health Policy, George Washington University, Washington DC, USA
- Mbarara University of Science and Technology, Mbarara, Uganda
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McCrone P, Wright S, Zala D, Radhakrishnan Kartha M, Koeser L, Ashworth M, Schofield P, Rose D, Corlett S, Patel A, Stewart R, Stahl D, Whitney D, Gannon J. Location of care for people with serious mental illness (LOCAPE): implications for service use and costs using a mixed-methods approach. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background
This study focuses on health care received by people with serious mental illness (SMI). The aim is to examine the economic implications of different locations of management of care and the views of service users and staff regarding services set up as alternatives to secondary care.
Objectives
Specific objectives are to (1) identify people with SMI managed in primary or secondary care; (2) identify those who could be potentially transferred to primary care; (3) compare the characteristics of these groups; (4) compare service use and costs; (5) generate models to estimate cost changes following transfer between settings; (6) identify characteristics associated with time to transition to secondary care; (7) investigate experiences of patients receiving support from community-based interventions; and (8) assess the economic impact of interventions to facilitate transfer of care management.
Methods
(1) Quantitative component – using linked primary and secondary care data we examined differences between those discharged to primary care (n = 1410) and those still in secondary care (n = 1629). Service use and costs were compared and predictors of costs were identified using regression models. (2) Qualitative component – interviews following a topic guide were conducted at two time points with 31 people using and 10 people working in services set up as alternatives to secondary care. (3) Economic modelling – an analysis of the health-care costs of the above services compared with usual care was conducted using decision modelling. Data were obtained from local services where possible, and the time horizon was 12 months.
Results
(1) Quantitative component – characteristics of those discharged to primary care (n = 1410) were similar to those still in secondary care (n = 1629). Costs for those discharged to primary care were 48% lower than for those remaining in secondary care. Other variables strongly associated with costs were a history of violence and a diagnosis of schizophrenia or bipolar disorder. Few patients in secondary care had a high probability of primary care management and, therefore, excess costs were only around £150,000 across the sample. (2) Qualitative component – service users’ views about a community options team and a primary care support service were positive and compared favourably to services used previously. Views about peer support were slightly less consistent. Staff had concerns with regard to caseload sizes and staff turnover. (3) Economic modelling – services to help transition had costs that were 40% of those for standard care. The results of this showed that triaging patients into these services would save £1578 over a 1-year period and that the results were robust to changes in most parameters.
Limitations
Analysis was hindered by the extent to which data were available. Qualitative analyses were limited by the fact that most of the participants did not have a SMI as usually defined and that many had been out of contact with secondary services for a long period of time.
Conclusions
Costs are substantially lower in primary care than secondary care, even after controlling for service-user patient differences. Generally, there is satisfaction with services to help facilitate primary care provision and these appear to be cost saving. Future work should continue the analysis of linked data and involve a more comprehensive evaluation of the specific services investigated here.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Paul McCrone
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Steve Wright
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Darshan Zala
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | | | - Leonardo Koeser
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Mark Ashworth
- Division of Health & Social Care Research, King’s College London, London, UK
| | - Peter Schofield
- Division of Health & Social Care Research, King’s College London, London, UK
| | - Diana Rose
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Sarah Corlett
- Lambeth and Southwark Public Health Department, London, UK
| | - Anita Patel
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Robert Stewart
- Psychiatric Epidemiology and Clinical Informatics, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Daniel Stahl
- Department of Biostatistics, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - David Whitney
- Division of Health & Social Care Research, King’s College London, London, UK
| | - Julia Gannon
- Contracts, South London and Maudsley NHS Foundation Trust, London, UK
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17
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van Rensburg AJ, Fourie P. Health policy and integrated mental health care in the SADC region: strategic clarification using the Rainbow Model. Int J Ment Health Syst 2016; 10:49. [PMID: 27453722 PMCID: PMC4957874 DOI: 10.1186/s13033-016-0081-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 07/14/2016] [Indexed: 11/17/2022] Open
Abstract
Background Mental illness is a well-known challenge to global development, particularly in low-to-middle income countries. A key health systems response to mental illness is different models of integrated health care, especially popular in the South African Development Community (SADC) region. This complex construct is often not well-defined in health policy, hampering implementation efforts. A key development in this vein has been the Rainbow Model of integrated care, a comprehensive framework and taxonomy of integrated care based on the integrative functions of primary care. The purpose of this study was to explore the nature and strategic forms of integrated mental health care in selected SADC countries, specifically how integrated care is outlined in state-driven policies. Methods Health policies from five SADC countries were analysed using the Rainbow Model as framework. Electronic copies of policy documents were transferred into NVivo 10, which aided in the framework analysis on the different types of integrated mental health care promoted in the countries assessed. Results Several Rainbow Model components were emphasised. Clinical integration strategies (coordination of person-focused care) such as centrality of client needs, case management and continuity were central considerations, while others such as patient education and client satisfaction were largely lacking. Professional integration (inter-professional partnerships) was mentioned in terms of agreements on interdisciplinary collaboration and performance management, while organisational integration (inter-organisational relationships) emerged under the guise of inter-organisational governance, population needs and interest management. Among others, available resources, population management and stakeholder management fed into system integration strategies (horizontally and vertically integrated systems), while functional integration strategies (financial, management and information system functions) included human resource, information and resource management. Normative integration (a common frame of reference) included collective attitude, sense of urgency, and linking cultures, though aspects such as conflict management, quality features of the informal collaboration, and trust were largely lacking. Conclusions Most countries stressed the importance of integrating mental health on primary healthcare level, though an absence of supporting strategies could prove to bar implementation. Inter-service collaboration emerged as a significant goal, though a lack of (especially) normative integration dimensions could prove to be a key omission. Despite the usefulness of the Rainbow Model, it failed to adequately frame regional governance aspects of integration, as the SADC Secretariat could play an important role in coordinating and supporting the development and strengthening of better mental health systems. Electronic supplementary material The online version of this article (doi:10.1186/s13033-016-0081-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- André Janse van Rensburg
- Health and Demographic Research Unit, Department of Sociology, Ghent University, Korte Meer 5, 9000 Ghent, Belgium ; Department of Political Science, Stellenbosch University, Corner Merriman and Ryneveld Street, Stellenbosch, 7602 South Africa ; Centre for Health Systems Research & Development, University of the Free State, Nelson Mandela Road, Bloemfontein, 9300 South Africa
| | - Pieter Fourie
- Department of Political Science, Stellenbosch University, Corner Merriman and Ryneveld Street, Stellenbosch, 7602 South Africa
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Rollins AL, Wright-Berryman J, Henry NH, Quash AM, Benbow K, Bonfils KA, Hedrick H, Miller AP, Firmin R, Salyers MP. Managing physical and mental health conditions: Consumer perspectives on integrated care. SOCIAL WORK IN MENTAL HEALTH 2016; 15:66-79. [PMID: 29308057 PMCID: PMC5754195 DOI: 10.1080/15332985.2016.1173160] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Despite the growing trend of integrating primary care and mental health services, little research has documented how consumers with severe mental illnesses manage comorbid conditions or view integrated services. OBJECTIVES We sought to better understand how consumers perceive and manage both mental and physical health conditions and their views of integrated services. METHODS We conducted semi-structured interviews with consumers receiving primary care services integrated in a community mental health setting. RESULTS Consumers described a range of strategies to deal with physical health conditions and generally viewed mental and physical health conditions as impacting one another. Consumers viewed integration of primary care and mental health services favorably, specifically its convenience, friendliness and knowledge of providers, and collaboration between providers. CONCLUSIONS Although integration was viewed positively, consumers with SMI may need a myriad of strategies and supports to both initiate and sustain lifestyle changes that address common physical health problems.
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Affiliation(s)
- Angela L Rollins
- Richard L. Roudebush VAMC Center for Health Information and Communication, ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology Department, Indianapolis, Indiana, USA
| | | | - Nancy H Henry
- ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology Department, Indianapolis, Indiana, USA
| | - Alicia M Quash
- ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology Department, Indianapolis, Indiana, USA
| | - Kyle Benbow
- ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology Department, Indianapolis, Indiana, USA
| | - Kelsey A Bonfils
- ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology Department, Indianapolis, Indiana, USA
| | - Heidi Hedrick
- ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology Department, Indianapolis, Indiana, USA
| | - Alex P Miller
- ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology Department, Indianapolis, Indiana, USA
| | - Ruthie Firmin
- ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology Department, Indianapolis, Indiana, USA
| | - Michelle P Salyers
- ACT Center of Indiana, Indiana University Purdue University Indianapolis, Psychology Department, Indianapolis, Indiana, USA
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Ruud T, Aarre TF, Boeskov B, le Husevåg PS, Klepp R, Kristiansen SA, Sandvik J. Satisfaction with primary care and mental health care among individuals with severe mental illness in a rural area: a seven-year follow-up study of a clinical cohort. Int J Ment Health Syst 2016; 10:33. [PMID: 27073414 PMCID: PMC4828811 DOI: 10.1186/s13033-016-0064-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 03/31/2016] [Indexed: 12/30/2022] Open
Abstract
Background Most studies of services for people with severe mental illness have been performed in cities. Our 7-year follow-up study aimed to investigate clinical course and satisfaction with services among individuals with severe mental illness who received community mental health services in a rural area. The services were provided by primary care and a community mental health center (CMHC), which worked in close collaboration and emphasized individually tailored case management, relationship-building and continuity of care. Methods All 57 patients with severe mental illness who were seen by the CMHC in 1992–1993 and were still alive in 1999 were asked to participate. Retrospective ratings were performed for the first month of contact in 1992–1993 based on patient records and detailed notes. A semi-structured interview was conducted in 1999–2000 with the 40 patients (70.2 %) who gave written consent to participate in the study. DSM-IV diagnoses were made using OPCRIT. The retrospective baseline ratings and the follow-up interview included assessments of symptoms and functioning using the following instruments: the Brief Psychiatric Rating Scale Expanded version 4 (BPRS-E), the Health of the Nation Outcome Scales (HoNOS), the Global Assessment of Functioning Scale (split version), and the Practical and Social Functioning Scale (PSF). Results The ratings revealed improvements in psychiatric problems and functioning. Patients with schizophrenia spectrum disorders improved primarily in psychotic symptoms, while patients with severe affective disorders improved primarily in affective symptoms. Large variations in the use of primary care and mental health services were observed, with more intensive specialized mental health services for individuals with schizophrenia spectrum disorders than severe affective disorders. Overall, the patients were satisfied with the provided services. They were most satisfied with GPs and more satisfied with local outpatient and inpatient services than with hospital inpatient services and medication. Conclusions Patients with severe mental illness in a rural area value local services that emphasize relationships and close collaborations among the CMHC, GPs and primary health and social care. Even in an area with a fairly well-staffed CMHC, the highest patient satisfaction was reported for GPs, indicating the potential key role of GPs for this patient group.
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Affiliation(s)
- Torleif Ruud
- Division of Mental Health Services, Akershus University Hospital, 1478 Lørenskog, Norway ; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Berit Boeskov
- Child and Adolescent Psychiatric Department, Center for Eating Disorders, Region Sjælland, Denmark
| | - Per Stå le Husevåg
- Nordfjord Psychiatric Center, Nordfjordeid, Norway ; Child Welfare, Gloppen, Norway
| | - Rigmor Klepp
- Nordfjord Psychiatric Center, Nordfjordeid, Norway
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20
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Myklebust LH, Sørgaard K, Wynn R. Local inpatient units may increase patients' utilization of outpatient services: a comparative cohort-study in Nordland County, Norway. Psychol Res Behav Manag 2015; 8:251-7. [PMID: 26604843 PMCID: PMC4630195 DOI: 10.2147/prbm.s94857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES In the last few decades, there has been a restructuring of the psychiatric services in many countries. The complexity of these systems may represent a challenge to patients that suffer from serious psychiatric disorders. We examined whether local integration of inpatient and outpatient services in contrast to centralized institutions strengthened continuity of care. METHODS Two different service-systems were compared. Service-utilization over a 4-year period for 690 inpatients was extracted from the patient registries. The results were controlled for demographic variables, model of service-system, central inpatient admission or local inpatient admission, diagnoses, and duration of inpatient stays. RESULTS The majority of inpatients in the area with local integration of inpatient and outpatient services used both types of care. In the area that did not have beds locally, many patients that had been hospitalized did not receive outpatient follow-up. Predictors of inpatients' use of outpatient psychiatric care were: Model of service-system (centralized vs decentralized), a diagnosis of affective disorder, central inpatient admission only, and duration of inpatient stays. CONCLUSION Psychiatric centers with local inpatient units may positively affect continuity of care for patients with severe psychiatric disorders, probably because of a high functional integration of inpatient and outpatient care.
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Affiliation(s)
| | - Knut Sørgaard
- Psychiatric Research Centre of North Norway, Nordland Hospital Trust, Bodø, Norway ; Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Rolf Wynn
- Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
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Akhavan S, Tillgren P. Client/patient perceptions of achieving equity in primary health care: a mixed methods study. Int J Equity Health 2015; 14:65. [PMID: 26265148 PMCID: PMC4533953 DOI: 10.1186/s12939-015-0196-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 07/28/2015] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION To provide health care on equal terms has become a challenge for the health system. As the front line in health services, primary care has a key role to play in developing equitable health care, responsive to the needs of different population groups. Reducing inequalities in care has been a central and recurring theme in Swedish health reforms. The aim of this study is to describe and assess client/patient experiences and perceptions of care in four primary health care units (PHCUs) involved in Sweden's national Care on Equal Terms project. METHODS Mixed Method Research (MMR) was chosen to describe and assess client/patient experiences and perceptions of health care with regard to equity. There was a focus group discussion, and individual interviews with 21 clients/patients and three representatives of patient associations. Data from the Swedish National Patient Survey (NPS), conducted in 2011 and followed up in 2013, were also used. RESULTS The interview data were divided into two main categories and three subcategories. The first category "Perception of equitable health care" had two subcategories, namely "Health care providers' perceptions" and "Fairness and participation". The second category "To achieve more equitable health care" had four subcategories: "Encounter", "Access", "Interpreters and bilingual/diverse health care providers" and "Time pressure and continuity". Results from the NPS showed that two of the PHCUs improved in some aspects of patient perceived quality of care (PPQC) while two were not so successful. CONCLUSIONS Clients/patients perceived health care providers' perceptions of their ethnic origin and mental health status as important for equitable health care. Discriminatory perceptions may lead to those in need of care refraining from seeking it. More equitable care means longer consultations, better accessibility in terms of longer opening hours, and ways of communicating other than just via voice mail. It also involves continuity in care and access to an interpreter if needed. Employing bilingual/diverse kinds of health providers is a way of providing more equitable primary health care.
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Affiliation(s)
- Sharareh Akhavan
- Public Health, School of Health, Care and Social Welfare, Mälardalen University, P.O. Box 883, Västerås, 72123, Sweden.
| | - Per Tillgren
- Public Health, School of Health, Care and Social Welfare, Mälardalen University, P.O. Box 883, Västerås, 72123, Sweden.
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Islam Z, Rabiee F, Singh SP. Black and Minority Ethnic Groups’ Perception and Experience of Early Intervention in Psychosis Services in the United Kingdom. JOURNAL OF CROSS-CULTURAL PSYCHOLOGY 2015. [DOI: 10.1177/0022022115575737] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In the United Kingdom, Black and minority ethnic (BME) service users experience adverse pathways into mental health care. Ethnic differences are evident even at first-episode psychosis; therefore, contributory factors must operate prior to first presentation to psychiatric services. This study examines the cultural appropriateness, accessibility, and acceptability of the Early Intervention (EI) for Psychosis Services in Birmingham (the United Kingdom) in improving the experience of care and outcomes for BME patients. Thirteen focus groups were conducted with EI service users ( n = 22), carers ( n = 11), community and voluntary sector organizations ( n = 6), service commissioners ( n = 10), EI professionals ( n = 9), and spiritual care representatives ( n = 8). Data were analyzed using a thematic approach and framework analysis. Findings suggest that service users and carers have multiple, competing, and contrasting explanatory models of illness. For many BME service users, help-seeking involves support from faith/spiritual healers, before seeking medical intervention. EI clinicians perceive that help-seeking from faith institutions in Asian service users might lead to treatment delays. The value of proactively including service user’s religious and spiritual perspectives and experiences in the initial assessment and therapy is recognized. However, clinicians acknowledge that they have limited spiritual/religious or cultural awareness training. There is little collaborative working between mental health services and voluntary and community organizations to meet cultural, spiritual, and individual needs. Mental health services need to develop innovative collaborative models to deliver holistic and person-centered care.
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Affiliation(s)
- Zoebia Islam
- Senior Research Fellow, Birmingham and Solihull Mental Health NHS Foundation Trust and LOROS, Hospice Care for Leicester, Leicestershire and Rutland; Honorary Lecturer and Research Fellow De Montfort University and Warwick University UK
| | - Fatemeh Rabiee
- Professor in Public Health promotion, Faculty of Health, Education and Life Sciences Birmingham City University (BCU), UK
| | - Swaran P. Singh
- Head of Division, Mental Health and Wellbeing Warwick Medical School University of Warwick CV4 7AL; Honorary Consultant Psychiatrist Birmingham and Solihull Mental Health Foundation Trust; Commissioner, Equality and Human Rights Commission
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Pinfold V, Sweet D, Porter I, Quinn C, Byng R, Griffiths C, Billsborough J, Enki DG, Chandler R, Webber M, Larsen J, Carpenter J, Huxley P. Improving community health networks for people with severe mental illness: a case study investigation. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03050] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
IntroductionPolicy drivers in mental health to address personal recovery, stigma and poor physical health indicate that new service solutions are required. This study aimed to understand how connections to people, places and activities were utilised by individuals with severe mental illness (SMI) to benefit health and wellbeing.MethodsA five-module mixed-methods design was undertaken in two study sites. Data were collected from 150 network-mapping interviews and 41 in-depth follow-up interviews with people with SMI; in-depth interviews with 30 organisation stakeholders and 12 organisation leaders; and 44 telephone interviews with practitioners. We undertook a three-stage synthesis process including independent lived experience feedback, and a patient and public involvement team participated in tool design, data collection, analysis and write-up.ResultsThree personal network types were found in our study using the community health network approach: diverse and active; family and stable; formal and sparse. Controlled for other factors we found only four variables significantly associated with which network type a participant had: living alone or not; housing status; formal education; long-term sickness or disability. Diagnosis was not a factor. These variables are challenging to address but they do point to potential for network change. The qualitative interviews with people with SMI provided further understanding of connection-building and resource utilisation. We explored individual agency across each network type, and identified recognition of the importance and value of social support and active connection management alongside the risks of isolation, even for those most affected by mental illness. We identified tensions in personal networks, be that relationships with practitioners or families, dealing with the impact of stigma, or frustrations of not being in employment, which all impact on network resources and well-being. The value of connectedness within personal networks of people, place and activity for supporting recovery was evident in shaping identity, providing meaning to life and sense of belonging, gaining access to new resources, structuring routines and helping individuals ‘move on’ in their recovery journey.Health-care practitioners recognised that social factors were important in recovery but reported system-level barriers (workload, administrative bureaucracy, limited contact time with clients) in addressing these issues fully. Even practitioners working in third-sector services whose remit involved increasing clients’ social connection faced restrictions due to being evaluated by outcome criteria that limited holistic recovery-focused practices. Service providers were keen to promote recovery-focused approaches. We found contrasts between recovery ideology within mental health policy and recovery practice on the ground. In particular, the social aspects of supporting people with SMI are often underprioritised in the health-care system. In a demanding and changing context, strategic multiagency working was seen as crucial but we found few examples of embedded multisector organisation partnerships.ConclusionWhile our exploratory study has limitations, findings suggest potential for people with SMI to be supported to become more active managers of their personal networks to support well-being regardless of current network type. The health and social care system does not currently deliver multiagency integrated solutions to support SMI and social recovery.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
| | | | - Ian Porter
- Primary Care Group, Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
| | - Cath Quinn
- Primary Care Group, Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
| | - Richard Byng
- Primary Care Group, Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
| | | | | | - Doyo Gragn Enki
- Primary Care Group, Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
| | - Ruth Chandler
- Sussex Partnership NHS Foundation Trust, West Sussex, UK
| | - Martin Webber
- International Centre for Mental Health Social Research, University of York, York, UK
| | | | - John Carpenter
- Department of Social Work and Applied Social Sciences, University of Bristol, Bristol, UK
| | - Peter Huxley
- Centre for Social Work and Social Care Research, University of Swansea, Swansea, UK
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Abstract
OBJECTIVES This study aims to assess the rate of six monthly communications between specialised psychiatric services and primary care and to determine factors which predict such communication. METHODS A retrospective review of the clinical records of all patients attending the relevant local psychiatric outpatient clinic was carried out by all members of the multidisciplinary team to identify patient demographic and clinical variables as well as to determine if there has been documentation of communication with primary care in the preceding six months. Letters were sent to the relevant primary care teams regarding progress on their patients in cases where it was identified that no communication had occurred in the preceding six months. RESULTS A total of 145 patients' charts were reviewed. Of these, 53.3% of the patients were females and 46.7% were males. The mean age was 47.9 years (SD = 14). Patients' diagnoses included; depression (41%), bipolar affective disorder (6.7%), schizophrenia/schizoaffective disorder (27.6%), anxiety disorders (6.7%), alcohol dependency syndrome (11%) and other disorders (7%). Overall, only 36% of patients' charts had a record of communication with primary care in the last six months. Only one variable, 'changes made to the patents medication in the last six months' was significantly associated with the likelihood that there had been communication with primary care with an odds ratio of 15 and a p-value of 0.00. CONCLUSION A six monthly review has a potential to improve the level of communication between specialised psychiatric services and primary care.
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Boydell J, Onwumere J, Dutta R, Bhavsar V, Hill N, Morgan C, Dazzan P, Morgan K, Pararajan M, Kuipers E, Jones P, Murray R, Fearon P. Caregiving in first-episode psychosis: social characteristics associated with perceived 'burden' and associations with compulsory treatment. Early Interv Psychiatry 2014; 8:122-9. [PMID: 23458284 DOI: 10.1111/eip.12041] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 01/06/2013] [Indexed: 01/03/2023]
Abstract
AIMS High incidence of psychosis and compulsory treatment within black and minority ethnic (BME) groups in the UK remain a concern. Psychosis has an impact on families and family involvement is important in predicting compulsory treatment. We therefore aimed to report the levels and predictors of caregiver burden in first-episode psychosis, in white British, and BME groups of carers, and investigate their relevance to compulsory treatment. METHODS A total of 124 caregivers were interviewed soon after the onset of psychosis using the General Health Questionnaire, GHQ-28, the Experience of Caregiving Inventory, the Personal and Psychiatric History Schedule, and the MRC Sociodemographic Schedule. RESULTS The overall level of distress as measured by GHQ-28 was high (mean 50, SD 11.4). Feelings of carer burden were also high (mean total negative score 72.5, SD 34.8), increased in men, and with carer age. Neither ethnicity nor social class nor social support was associated with distress or burden. Compulsory treatment was predicted by carer burden (as indicated by carer reports of 'problems with services' (OR 1.08; 95% CI 1.01, 1.15; P = 0.023)); this was particularly evident in the black Caribbean group of carers (OR 1.28; 95% CI 1.04, 1.57; P = 0.02) CONCLUSION: Carers of adults with first-episode psychosis experience considerable psychological distress and feelings of burden. There was a specific association between carer burden, specifically in terms of experience of services, and compulsory admission of service users, particularly in the black Caribbean group. Better ways of liaising with carers and targeted efforts to reduce carer burden at illness onset are needed.
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Affiliation(s)
- Jane Boydell
- King's College London, Institute of Psychiatry, London, UK
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Singh SP, Islam Z, Brown LJ, Gajwani R, Jasani R, Rabiee F, Parsons H. Ethnicity, detention and early intervention: reducing inequalities and improving outcomes for black and minority ethnic patients: the ENRICH programme, a mixed-methods study. PROGRAMME GRANTS FOR APPLIED RESEARCH 2013. [DOI: 10.3310/pgfar01030] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundBlack and minority ethnic (BME) service users experience adverse pathways into care. Ethnic differences are evident even at first-episode psychosis (FEP); therefore, contributory factors must operate before first presentation to psychiatric services. The ENRICH programme comprised three interlinked studies that aimed to understand ethnic and cultural determinants of help-seeking and pathways to care.Aims and objectivesStudy 1: to understand ethnic differences in pathways to care in FEP by exploring cultural determinants of illness recognition, attribution and help-seeking among different ethnic groups. Study 2: to evaluate the process of detention under the Mental Health Act (MHA) and determine predictors of detention. Study 3: to determine the appropriateness, accessibility and acceptability of generic early intervention services for different ethnic groups.MethodsStudy 1: We recruited a prospective cohort of FEP patients and their carers over a 2-year period and assessed the chronology of symptom emergence, attribution and help-seeking using semistructured tools: the Nottingham Onset Schedule (NOS), the Emerging Psychosis Attribution Schedule and the ENRICH Amended Encounter Form. A stratified subsample of user–carer NOS interviews was subjected to qualitative analyses. Study 2: Clinical and sociodemographic data including reasons for detention were collected for all MHA assessments conducted over 1 year (April 2009–March 2010). Five cases from each major ethnic group were randomly selected for a qualitative exploration of carer perceptions of the MHA assessment process, its outcomes and alternatives to detention. Study 3: Focus groups were conducted with service users, carers, health professionals, key stakeholders from voluntary sector and community groups, commissioners and representatives of spiritual care with regard to the question: ‘How appropriate and accessible are generic early intervention services for the specific ethnic and cultural needs of BME communities in Birmingham?’ResultsThere were no ethnic differences in duration of untreated psychosis (DUP) and duration of untreated illness in FEP. DUP was not related to illness attribution; long DUP was associated with patients being young (< 18 years) and living alone. Black patients had a greater risk of MHA detention, more criminal justice involvement and more crisis presentations than white and Asian groups. Asian carers and users were most likely to attribute symptoms to faith-based or supernatural explanations and to seek help from faith organisations. Faith-based help-seeking, although offering comfort and meaning, also risked delaying access to medical care and in some cases also resulted in financial exploitation of this vulnerable group. The BME excess in MHA detentions was not because of ethnicity per se; the main predictors of detention were a diagnosis of mental illness, presence of risk and low level of social support. Early intervention services were perceived to be accessible, supportive, acceptable and culturally appropriate. There was no demand or perceived need for separate services for BME groups or for ethnic matching between users and clinicians.ConclusionsStatutory health-care organisations need to work closely with community groups to improve pathways to care for BME service users. Rather than universal public education campaigns, researchers need to develop and evaluate public awareness programmes that are specifically focused on BME groups.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- SP Singh
- Division of Mental Health and Wellbeing, Warwick Medical School, Warwick University, Coventry, UK
- Research and Innovation Department, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Z Islam
- Division of Mental Health and Wellbeing, Warwick Medical School, Warwick University, Coventry, UK
- Research and Innovation Department, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - LJ Brown
- Division of Mental Health and Wellbeing, Warwick Medical School, Warwick University, Coventry, UK
- Research and Innovation Department, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - R Gajwani
- School of Psychology, University of Birmingham, Birmingham, UK
| | - R Jasani
- Humanitarian and Conflict Response Institute (HCRI), University of Manchester, Manchester, UK
| | - F Rabiee
- Centre for Health and Social Care Research, Faculty of Health, Birmingham City University, Birmingham, UK
| | - H Parsons
- Division of Health Sciences, Warwick Medical School, Warwick University, Coventry, UK
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Reilly S, Planner C, Gask L, Hann M, Knowles S, Druss B, Lester H. Collaborative care approaches for people with severe mental illness. Cochrane Database Syst Rev 2013:CD009531. [PMID: 24190251 DOI: 10.1002/14651858.cd009531.pub2] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Collaborative care for severe mental illness (SMI) is a community-based intervention, which typically consists of a number of components. The intervention aims to improve the physical and/or mental health care of individuals with SMI. OBJECTIVES To assess the effectiveness of collaborative care approaches in comparison with standard care for people with SMI who are living in the community. The primary outcome of interest was psychiatric admissions. SEARCH METHODS We searched the Cochrane Schizophrenia Group Specialised register in April 2011. The register is compiled from systematic searches of major databases, handsearches of relevant journals and conference proceedings. We also contacted 51 experts in the field of SMI and collaborative care. SELECTION CRITERIA Randomised controlled trials (RCTs) described as collaborative care by the trialists comparing any form of collaborative care with 'standard care' for adults (18+ years) living in the community with a diagnosis of SMI, defined as schizophrenia or other types of schizophrenia-like psychosis (e.g. schizophreniform and schizoaffective disorders), bipolar affective disorder or other types of psychosis. DATA COLLECTION AND ANALYSIS Two review authors worked independently to extract and quality assess data. For dichotomous data, we calculated the risk ratio (RR) with 95% confidence intervals (CIs) and we calculated mean differences (MD) with 95% CIs for continuous data. Risk of bias was assessed. MAIN RESULTS We included one RCT (306 participants; US veterans with bipolar disorder I or II) in this review. We did not find any trials meeting our inclusion criteria that included people with schizophrenia. The trial provided data for one comparison: collaborative care versus standard care. All results are 'low or very low quality evidence'.Data indicated that collaborative care reduced psychiatric admissions at year two in comparison to standard care (n = 306, 1 RCT, RR 0.75, 95% CI 0.57 to 0.99).The sensitivity analysis showed that the proportion of participants psychiatrically hospitalised was lower in the intervention group than the standard care group in year three: 28% compared to 38% (n = 330, 1 RCT, RR 0.72, 95% CI 0.53 to 0.99).In comparison to the standard care group, collaborative care significantly improved the Mental Health Component (MHC) of quality of life at the three-year follow-up, (n = 306, 1 RCT, MD 3.50, 95% CI 1.80 to 5.20). The Physical Health Component (PHC) of the quality of life measure at the three-year follow-up did not differ significantly between groups (n = 306, 1 RCT, MD 0.50, 95% CI 0.91 to 1.91).Direct intervention (all-treatment) costs of collaborative care at the three-year follow-up did not differ significantly from standard care (n = 306, 1 RCT, MD -$2981.00, 95% CI $16934.93 to $10972.93). The proportion of participants leaving the study early did not differ significantly between groups (n = 306, 1 RCT, RR 1.71, 95% CI 0.77 to 3.79). There is no trial-based information regarding the effect of collaborative care for people with schizophrenia.No statistically significant differences were found between groups for number of deaths by suicide at three years (n = 330, 1 RCT, RR 0.34, 95% CI 0.01 to 8.32), or the number of participants that died from all other causes at three years (n = 330, 1 RCT, RR 1.54, 95% CI 0.65 to 3.66). AUTHORS' CONCLUSIONS The review did not identify any studies relevant to care of people with schizophrenia and hence there is no evidence available to determine if collaborative care is effective for people suffering from schizophrenia or schizophreniform disorders. There was however one trial at high risk of bias that suggests that collaborative care for US veterans with bipolar disorder may reduce psychiatric admissions at two years and improves quality of life (mental health component) at three years, however, on its own it is not sufficient for us to make any recommendations regarding its effectiveness. More large, well designed, conducted and reported trials are required before any clinical or policy making decisions can be made.
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Affiliation(s)
- Siobhan Reilly
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, C07 Furness Building, Lancaster, UK, LA1 4YG
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Agyapong VIO, Jabbar F, Conway C. Shared care between specialised psychiatric services and primary care: the experiences and expectations of General Practitioners in Ireland. Int J Psychiatry Clin Pract 2012; 16:293-9. [PMID: 22509780 DOI: 10.3109/13651501.2012.667115] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective. The study aims to explore the views of General Practitioners in Ireland on shared care between specialised psychiatric services and primary care. Method. A self-administered questionnaire was designed and posted to 400 randomly selected General Practitioners working in Ireland. Results. Of the respondents, 189 (94%) reported that they would support a general policy on shared care between primary care and specialised psychiatric services for patients who are stable on their treatment. However, 124 (61.4%) reported that they foresaw difficulties for patients in implementing such a policy including: a concern that primary care is not adequately resourced with allied health professionals to support provision of psychiatric care (113, 53.2%); a concern this would result in increased financial burden on some patients (89, 48.8%); a lack of adequate cooperation between primary care and specialised mental health services (84, 41.8%); a concern that some patients may lack confidence in GP care (55, 27.4%); and that primary care providers are not adequately trained to provide psychiatric care (29, 14.4% ). Conclusion. The majority of GPs in Ireland would support a policy of shared care of psychiatric patients; however they raise significant concerns regarding practical implications of such a policy in Ireland.
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Agyapong VIO, Conway C, Guerandel A. Shared care between specialized psychiatric services and primary care: the experiences and expectations of consultant psychiatrists in Ireland. Int J Psychiatry Med 2012; 42:295-313. [PMID: 22439298 DOI: 10.2190/pm.42.3.e] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Internationally, there has been a growing interest in the pursuit of collaborative forms of care for patients with enduring mental health difficulties. OBJECTIVE The study aims to explore the views of consultant psychiatrists in Ireland on shared care between specialized psychiatric services and primary care for patients with mental health difficulties. METHOD A self-administered questionnaire was designed and posted to 470 consultant psychiatrists who are members of the College of Psychiatry of Ireland. Stamped self-addressed envelopes were included for the return of completed questionnaires. RESULTS Overall, 213 questionnaires were returned, giving a response rate of 45%. Of the respondents, 194 (91%) reported that they would support a general policy on shared care between primary care and specialized psychiatric services for patients who are stable on their treatment. However, 181 (85%) reported that they foresaw difficulties for patients in implementing such a policy including: increased financial burden on some patients (141, 66%); some patients may lack confidence in GP care (100, 47%); primary care is not adequately resourced with allied health professionals to support provision of psychiatric care (128, 60%); primary care providers are not adequately trained to provide psychiatric care (111, 52%); and lack of adequate cooperation between primary care and specialized mental health services (96, 45%). CONCLUSION The Irish government and the Colleges of General Practitioners and Psychiatrists in Ireland need to work together to remove the bottlenecks that hinder the active involvement of primary care in the management of patients with enduring mental health difficulties. Also, the health care systems need to be organized along a shared care model to facilitate effective collaboration between primary and specialized psychiatric services.
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Affiliation(s)
- Vincent I O Agyapong
- University of Dublin Trinity College and St. Patrick's University Hospital, Dublin, Ireland.
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Agyapong VIO. Continuing care for mentally stable psychiatric patients in primary care: patients' preferences and views. INTERNATIONAL JOURNAL OF FAMILY MEDICINE 2012; 2012:575381. [PMID: 22844590 PMCID: PMC3401536 DOI: 10.1155/2012/575381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 05/15/2012] [Accepted: 05/19/2012] [Indexed: 06/01/2023]
Abstract
Objective. To investigate the preferences of psychiatric patients regarding attendance for their continuing mental health care once stable from a primary care setting as opposed to a specialized psychiatric service setting. Methods. 150 consecutive psychiatric patients attending outpatient review in a community mental health centre in Dublin were approached and asked to complete a semistructured questionnaire designed to assess the objectives of the study. Results. 145 patients completed the questionnaire giving a response rate of 97%. Ninety-eight patients (68%) preferred attending a specialized psychiatry service even when stabilised on their treatment. The common reason given by patients in this category was fear of substandard quality of psychiatric care from their general practitioners (GPs) (67 patients, 68.4%). Twenty-nine patients (20%) preferred to attend their GP for continuing mental health care. The reasons given by these patients included confidence in GPs, providing same level of care as psychiatrist for mental illness (18 patients or 62%), and the advantage of managing both mental and physical health by GPs (13 patients, 45%). Conclusion. Most patients who attend specialised psychiatric services preferred to continue attending specialized psychiatric services even if they become mentally stable than primary care, with most reasons revolving around fears of inadequate psychiatric care from GPs.
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Affiliation(s)
- Vincent I. O. Agyapong
- Department of Psychiatry, The Trinity College, University of Dublin, Dublin, Ireland
- Department of Psychiatry, St. Patrick's University Hospital, James Street, Dublin 8, Ireland
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Hardy S. Training practice nurses to improve the physical health of patients with severe mental illness: effects on beliefs and attitudes. Int J Ment Health Nurs 2012; 21:259-65. [PMID: 22533333 DOI: 10.1111/j.1447-0349.2011.00800.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Annual health checks are recommended for patients with severe mental illness (SMI) as they are at high risk of cardiovascular disease. Ideally, these health checks should be carried out in primary care. Practice nurses are already competent in carrying out physical health checks, but might have misconceptions about mental illness, which is a barrier to offering the service. We used a mirror imaging study to establish the effectiveness of a training package for practice nurses that aims to address common misconceptions about the physical health of people with SMI. This 2-hour training package (Northampton Physical Health and Wellbeing Project) was delivered to eight practice nurses. Their misconceptions and beliefs were assessed before and after training. Motivation to work with community mental health workers was assessed after training. The practice nurses involved in the study rejected commonly held misconceptions about the physical health of people with SMI after training. Their attitudes towards their role in providing health checks appeared to be modified in a positive direction. Their motivation to work with community mental health workers also seemed to be enhanced. The Northampton Physical Health and Wellbeing Project training was effective in modifying practice nurses' misconceptions about physical health in people with SMI.
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Affiliation(s)
- Sheila Hardy
- Park Avenue Medical Centre, University of East Anglia, Northampton, UK.
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Reilly S, Planner C, Hann M, Reeves D, Nazareth I, Lester H. The role of primary care in service provision for people with severe mental illness in the United Kingdom. PLoS One 2012; 7:e36468. [PMID: 22615769 PMCID: PMC3352919 DOI: 10.1371/journal.pone.0036468] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 04/06/2012] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Severe mental illness is a serious and potentially life changing set of conditions. This paper describes and analyses patient characteristics and service usage over one year of a representative cohort of people with a diagnosis of severe mental illness across England, including contacts with primary and secondary care and continuity of care. METHODS AND FINDINGS Data were collected from primary care patient notes (n = 1150) by trained nurses from 64 practices in England, covering all service contacts from 1(st) April 2008 to 31st March 2009. The estimated national rate of patients seen only in primary care in the period was 31.1% (95% C.I. 27.2% to 35.3%) and the rates of schizophrenia and bipolar disorder were 56.8% (95% C.I. 52.3% to 61.2%) and 37.9% (95% C.I. 33.7% to 42.2%). In total, patients had 7,961 consultations within primary care and 1,993 contacts with mental health services (20% of the total). Unemployed individuals diagnosed more recently were more likely to have contact with secondary care. Of those seen in secondary care, 61% had at most two secondary care contacts in the period. Median annual consultation rates with GPs were lower than have been reported for previous years and were only slightly above the general population. Relational continuity in primary care was poor for 21% of patients (Modified Modified Continuity Index = <0.5), and for almost a third of new referrals to mental health services the primary care record contained no information on the referral outcome. CONCLUSIONS Primary care is centrally involved in the care of people with serious mental illness, but primary care and cross-boundary continuity is poor for a substantial proportion. Research is needed to determine the impact of poor continuity on patient outcomes, and above all, the impact of new collaborative ways of working at the primary/secondary care interface.
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Affiliation(s)
- Siobhan Reilly
- National Institute for Health Research School for Primary Care Research, Health Sciences Research Group, University of Manchester, Manchester, England, United Kingdom
| | - Claire Planner
- National Institute for Health Research School for Primary Care Research, Health Sciences Research Group, University of Manchester, Manchester, England, United Kingdom
| | - Mark Hann
- National Institute for Health Research School for Primary Care Research, Health Sciences Research Group, University of Manchester, Manchester, England, United Kingdom
| | - David Reeves
- National Institute for Health Research School for Primary Care Research, Health Sciences Research Group, University of Manchester, Manchester, England, United Kingdom
| | - Irwin Nazareth
- Department of Primary Care and Population Health, University College London School of Medicine, London, England, United Kingdom
| | - Helen Lester
- School of Health and Population Sciences, University of Birmingham, Birmingham, England, United Kingdom
- * E-mail:
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Reilly S, Planner C, Gask L, Hann M, Knowles S, Druss B, Lester H. Collaborative care approaches for people with severe mental illness. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009531] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Myklebust LH, Olstad R, Bjorbekkmo S, Eisemann M, Wynn R, Sørgaard K. Impact on continuity of care of decentralized versus partly centralized mental health care in Northern Norway. Int J Integr Care 2011; 11:e142. [PMID: 22359521 PMCID: PMC3280921 DOI: 10.5334/ijic.674] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 09/16/2011] [Accepted: 10/18/2011] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The issue of continuity of care is central in contemporary psychiatric services research. In Norway, inpatient admissions are mainly to take place locally, in a system of small bed-units that represent an alternative to traditional central psychiatric hospitals. This type of organization may be advantageous for accessibility and cooperation, but has been given little scientific attention. AIMS To study whether inpatients' utilization of outpatient services differ between an area with a decentralized care model in comparison to an adjacent area with a partly centralized model. METHOD The study was based on data from a one-year registered prevalence sample, drawing on routinely sampled data supplemented with data from medical records. Service-utilization for 247 inpatients was analyzed. The results were controlled for diagnosis, demographic variables, type of service system, localization of inpatient admissions, and length of hospitalization. RESULTS Most inpatients in the area with the decentralized care model also utilized outpatient consultations, whereas a considerable number of inpatients in the area with a partly centralized model did not enter outpatient care at all. Type of service system, localization of inpatient admission, and length of hospitalization predicted inpatients' utilization of outpatient consultations. The results are discussed in the light of systems integration, particularly management-arrangements and clinical bridging over the transitional phase from inpatient to outpatient care. CONCLUSION Inpatients' utilization of outpatient services differed between an area with a decentralized care model in comparison to an adjacent area with a partly centralized care model. In the areas studied, extensive decentralization of the psychiatric services positively affected coordination of inpatient and outpatient services for people with severe psychiatric disorders. Small, local-bed units may therefore represent a favourable alternative to traditional central psychiatric hospitals.
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Affiliation(s)
- Lars Henrik Myklebust
- Psychiatric Research Centre of North Norway, Nordland Hospital Trust, N-8092 Bodø, Norway
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Abstract
OBJECTIVES Primary care teams have the potential to deliver much of the care currently provided by specialist services. The aim of this review was to determine from patients' clinical records and multidisciplinary team discussions, those that may be suitable for discharge back into primary care. METHODS A retrospective review of the clinical notes of all patients attending a psychiatric outpatient clinic was carried out by all members of the multidisciplinary team to determine the appropriateness of continuing to provide psychiatric services in a specialised psychiatric clinic rather than in a primary care setting, taking into account the patients demographic and clinical variables. RESULTS It was recommended that 60% of all the patients needed to continue attending the local mental health service, 35.2% could be discharged back into primary care for continuing management whilst the remaining 4.8% could be managed jointly between primary care and the community mental health service. The bulk of the patients recommended for discharge into primary care had a diagnosis of anxiety disorder or depression and all of them had been stable on their treatment for more than six months. CONCLUSION Regular multidisciplinary team review has a potential to identify patients who could be discharged back into primary care.
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Bjertnaes OA, Nieland A, Damerell E, Garratt A. General practitioners' evaluation of community psychiatric services: responsiveness to change of the General Practitioner Experiences Questionnaire (GPEQ). BMC Health Serv Res 2010; 10:108. [PMID: 20433719 PMCID: PMC2874551 DOI: 10.1186/1472-6963-10-108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Accepted: 04/30/2010] [Indexed: 11/24/2022] Open
Abstract
Background Instruments have been developed to assess professional views of the quality of care but have rarely been tested for responsiveness to change. The objective of this study was to test the responsiveness of the General Practitioner Experiences Questionnaire (GPEQ) for the measurement of Community Mental Health Centres in Norway. Methods National surveys were conducted in Norway in 2006 (n = 2,415) and 2008 (n = 2,209) to measure general practitioners' evaluation of community mental health centres. GPs evaluated the centres by means of a postal questionnaire, consisting of questions focused on centre quality and cooperation with GPs. As part of the national surveys 75 GPs in 2006 and 66 GPs in 2008 evaluated Hamar community mental health centre. Between the surveys, several quality improvement initiatives were implemented which were directed at cooperation with and guidance for GPs in Stange municipality, one of eight municipalities in Hamar centre catchment area. The main outcome measures were changes in GPEQ scores from 2006 to 2008 for GPs evaluating Hamar community mental health centre from Stange municipality, and changes in scores for GPs in the other seven municipalities and nationally which were assessed for statistical significance. Results GPs in Stange municipality rated Hamar community mental health centre significantly better on the guidance scale in 2008 than in 2006; on a 0-100 scale where 100 represents the best possible experiences the score was 26.5 in 2006 and 58.3 in 2008 (p < 0.001). Apart from one item about workforce situation, none of the other scales and items showed significant changes. The control group from the other seven municipalities gave significantly poorer rating for the emergency situation scale, the workforce situation scale and seven items in 2008 than in 2006. The national results showed small differences between 2006 and 2008, even though several scales and items were significantly different. A question about changes in centre performance over the last 2-3 years showed that 82% of GPs from Stange municipality reported that Hamar community mental health centre had improved, compared to only 36% from the other seven municipalities and 40% nationally which was statistically significant. Conclusions Following the implementation of an initiative designed to enhance service quality, the GPEQ identified expected changes in the guidance scale for the intervention group, indicating that the instrument is responsive to change. The worsening of services for GPs in the control group evaluating Hamar centre warrants further study.
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Affiliation(s)
- Oyvind A Bjertnaes
- Department for Quality Measurement and Patient Safety, Norwegian Knowledge Centre for the Health Services, Oslo, Norway.
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Bjertnaes OA, Garratt A, Iversen H, Ruud T. The association between GP and patient ratings of quality of care at outpatient clinics. Fam Pract 2009; 26:384-90. [PMID: 19584122 PMCID: PMC2743734 DOI: 10.1093/fampra/cmp043] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND GPs and patients are frequently asked to evaluate mental health care, but studies including evaluations from both groups are rare. OBJECTIVE To assess the association between GPs' and patients' assessment of mental health outpatient clinic in Norway and identify important health care predictors for patient and GP satisfaction with the clinics. METHODS Two cross-sectional national surveys were carried out: survey of GPs in 2006 and patients in 2007 evaluating outpatient clinics at 69 community mental health centres in Norway. A total of 2009 GPs and 9001 outpatients assessed the clinics by means of a postal questionnaire. Main outcome measures were correlations between GP and patient ratings of the outpatient clinics at the clinic level and health care predictors for patient satisfaction and GP satisfaction with the clinics. RESULTS Clinic scores for GPs' and patients' assessment of waiting time were moderate to highly correlated (0.65), while clinic scores for GP and patient satisfaction had a lower but significant positive association (0.37). Significant positive correlations between clinic scores for GP and patients ratings were found for 38 of the 48 associations tested. The most important predictors for patient satisfaction with the clinics were interaction with the clinician (beta: 0.23) and being met with politeness and respect at the clinic (beta: 0.19), while the most important predictors for GP satisfaction with the clinics were perceived competence (beta: 0.25), rejection of referrals (beta: -0.17) and waiting time for patients (beta: -0.16). CONCLUSIONS A consistent positive association between GP and patient ratings at the clinic level was identified. Mental health services aiming at improving GP and patient satisfaction should be sensitive to the fact that the two groups prioritize different health care factors.
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Illness careers and continuity of care in mental health services: A qualitative study of service users and carers. Soc Sci Med 2009; 69:632-9. [DOI: 10.1016/j.socscimed.2009.06.015] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2008] [Indexed: 11/19/2022]
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Beecham J, Hallam A, Knapp M, Carpenter J, Cambridge P, Forrester-Jones R, Tate A, Wooff D, Coolen-Schrijner P. Twelve years on: Service use and costs for people with mental health problems who left psychiatric hospital. J Ment Health 2009. [DOI: 10.1080/09638230410001729816] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Lester H, Birchwood M, Freemantle N, Michail M, Tait L. REDIRECT: cluster randomised controlled trial of GP training in first-episode psychosis. Br J Gen Pract 2009; 59:e183-90. [PMID: 19520016 PMCID: PMC2688067 DOI: 10.3399/bjgp09x420851] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Revised: 07/22/2008] [Accepted: 10/15/2008] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Delays in accessing care for young people with a first episode of psychosis are significantly associated with poorer treatment response and higher relapse rates. AIM To assess the effect of an educational intervention for GPs on referral rates to early-intervention services and the duration of untreated psychosis for young people with first-episode psychosis. DESIGN OF STUDY Stratified cluster randomised controlled trial, clustered at practice level. SETTING Birmingham, England. METHOD Practices with access to the three early-intervention services in three inner-city primary care trusts in Birmingham were eligible for inclusion. Intervention practices received an educational intervention addressing GP knowledge, skills, and attitudes about first-episode psychosis. The primary outcome was the difference in the number of referrals to early-intervention services between practices. Secondary outcomes were duration of untreated psychosis, time to recovery, use of the Mental Health Act, and GP consultation rate during the developing illness. RESULTS A total of 110 of 135 eligible practices (81%) were recruited; 179 young people were referred, 97 from intervention and 82 from control practices. The relative risk of referral was not significant: 1.20 (95% confidence interval [CI] = 0.74 to 1.95; P = 0.48). No effect was observed on secondary outcomes except for 'delay in reaching early-intervention services', which was statistically significantly shorter in patients registered in intervention practices (95% CI = 83.5 to 360.5; P = 0.002). CONCLUSION GP training on first-episode psychosis is insufficient to alter referral rates to early-intervention services or reduce the duration of untreated psychosis; however, there is a suggestion that training facilitates access to the new specialist teams for early psychosis.
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Oud MJT, Meyboom-de Jong B. Somatic diseases in patients with schizophrenia in general practice: their prevalence and health care. BMC FAMILY PRACTICE 2009; 10:32. [PMID: 19426545 PMCID: PMC2688496 DOI: 10.1186/1471-2296-10-32] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Accepted: 05/09/2009] [Indexed: 11/10/2022]
Abstract
BACKGROUND Schizophrenia patients frequently develop somatic co-morbidity. Core tasks for GPs are the prevention and diagnosis of somatic diseases and the provision of care for patients with chronic diseases. Schizophrenia patients experience difficulties in recognizing and coping with their physical problems; however GPs have neither specific management policies nor guidelines for the diagnosis and treatment of somatic co-morbidity in schizophrenia patients. This paper systematically reviews the prevalence and treatment of somatic co-morbidity in schizophrenia patients in general practice. METHODS The MEDLINE, EMBASE, PsycINFO data-bases and the Cochrane Library were searched and original research articles on somatic diseases of schizophrenia patients and their treatment in the primary care setting were selected. RESULTS The results of this search show that the incidence of a wide range of diseases, such as diabetes mellitus, the metabolic syndrome, coronary heart diseases, and COPD is significantly higher in schizophrenia patients than in the normal population. The health of schizophrenic patients is less than optimal in several areas, partly due to their inadequate help-seeking behaviour. Current GP management of such patients appears not to take this fact into account. However, when schizophrenic patients seek the GP's help, they value the care provided. CONCLUSION Schizophrenia patients are at risk of undetected somatic co-morbidity. They present physical complaints at a late, more serious stage. GPs should take this into account by adopting proactive behaviour. The development of a set of guidelines with a clear description of the GP's responsibilities would facilitate the desired changes in the management of somatic diseases in these patients.
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Affiliation(s)
- Marian JT Oud
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Antonius Deusinglaan 1, 9713AV Groningen, The Netherlands
| | - Betty Meyboom-de Jong
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Antonius Deusinglaan 1, 9713AV Groningen, The Netherlands
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Burns T, Catty J, White S, Clement S, Ellis G, Jones IR, Lissouba P, McLaren S, Rose D, Wykes T. Continuity of care in mental health: understanding and measuring a complex phenomenon. Psychol Med 2009; 39:313-323. [PMID: 18570700 DOI: 10.1017/s0033291708003747] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Continuity of care is considered by patients and clinicians an essential feature of good quality care in long-term disorders, yet there is general agreement that it is a complex concept. Most policies emphasize it and encourage systems to promote it. Despite this, there is no accepted definition or measure against which to test policies or interventions designed to improve continuity. We aimed to operationalize a multi-axial model of continuity of care and to use factor analysis to determine its validity for severe mental illness. METHOD A multi-axial model of continuity of care comprising eight facets was operationalized for quantitative data collection from mental health service users using 32 variables. Of these variables, 22 were subsequently entered into a factor analysis as independent components, using data from a clinical population considered to require long-term consistent care. RESULTS Factor analysis produced seven independent continuity factors accounting for 62.5% of the total variance. These factors, Experience and Relationship, Regularity, Meeting Needs, Consolidation, Managed Transitions, Care Coordination and Supported Living, were close but not identical to the original theoretical model. CONCLUSIONS We confirmed that continuity of care is multi-factorial. Our seven factors are intuitively meaningful and appear to work in mental health. These factors should be used as a starting-point in research into the determinants and outcomes of continuity of care in long-term disorders.
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Affiliation(s)
- T Burns
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK.
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Ryan T, Hatfield B, Sharma I. Outcomes of referrals over a six-month period to a mental health gateway team. J Psychiatr Ment Health Nurs 2007; 14:527-34. [PMID: 17718724 DOI: 10.1111/j.1365-2850.2007.01122.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Mental health policy in recent years has prescribed the role, function and form for services in England. Evidence of their effectiveness post-policy implementation has been limited to date and minimal guidance has been available on how services should operate together as whole systems. This paper reports findings from a study of referrals and their outcomes in respect of specialist community mental health services following implementation of national policy and its interpretation and configuration at a local level. Findings highlight that gateway workers configured as a team operating between primary and secondary care can effectively shield community mental health teams from high numbers of referrals that they would deem inappropriate. The study also identified the triage role of this service as being crucial to the effectiveness of developing and maintaining care pathways and also in potentially supporting the mental health capability of primary care.
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Affiliation(s)
- T Ryan
- Tony Ryan Associates, UK.
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Abstract
This article explores some of the current issues in providing primary care for people with serious mental illness. In contrast to many patients in the United States, up to half of patients with serious mental illness in the United Kingdom are seen only by the primary care team. However many General Practitioners feel that the care of this patient group is beyond their remit. In the United Kingdom during the last decade, there have been a variety of policy initiatives, influenced by the generic principle of "partnership working" and the increasing recognition of the importance of patient choice, that have aimed to increase the role of primary care in the delivery of health care to people with serious mental illness. On the ground, these policy imperatives have been realised through different models of shared care and schemes to encourage better communication across the primary/secondary interface. Most recently, and perhaps most effectively, the introduction of a type of performance related pay into primary care may lead to changes to the way in which General Practitioners think and act in terms of their roles and responsibilities with this patient group. Theoretically, therefore the United Kingdom may be entering a new "golden age" of primary care based mental health services for people with serious mental illness, where holistic care, preventive care and health promotion are increasingly seen not as the gold standard, but the norm.
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Affiliation(s)
- Helen Lester
- Department of Primary Care, University of Birmingham, Edgbaston, UK.
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Paquette-Warren J, Vingilis E, Greenslade J, Newnam S. What do practitioners think? A qualitative study of a shared care mental health and nutrition primary care program. Int J Integr Care 2006; 6:e18. [PMID: 17041680 PMCID: PMC1602056 DOI: 10.5334/ijic.164] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2006] [Revised: 07/05/2006] [Accepted: 08/21/2006] [Indexed: 11/24/2022] Open
Abstract
Objective To develop an in-depth understanding of a shared care model from primary mental health and nutrition care practitioners with a focus on program goals, strengths, challenges and target population benefits. Design Qualitative method of focus groups. Setting/Participants The study involved fifty-three practitioners from the Hamilton Health Service Organization Mental Health and Nutrition Program located in Hamilton, Ontario, Canada. Method Six focus groups were conducted to obtain the perspective of practitioners belonging to various disciplines or health care teams. A qualitative approach using both an editing and template organization styles was taken followed by a basic content analysis. Main findings Themes revealed accessibility, interdisciplinary care, and complex care as the main goals of the program. Major program strengths included flexibility, communication/collaboration, educational opportunities, access to patient information, continuity of care, and maintenance of practitioner and patient satisfaction. Shared care was described as highly dependent on communication style, skill and expertise, availability, and attitudes toward shared care. Time constraint with respect to collaboration was noted as the main challenge. Conclusion Despite some challenges and variability among practices, the program was perceived as providing better patient care by the most appropriate practitioner in an accessible and comfortable setting.
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Affiliation(s)
- Jann Paquette-Warren
- Population and Community Health Unit, Family Medicine, Schulich School of Medicine and Dentistry, 2nd Floor-Dr. Don Rix Clinical Skills Facility, London, Ontario, Canada N6A 5C1.
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Craig B, Olsen A, Swadi H, Bobier C. Mood stabilizer prescribing in a Christchurch adolescent sample: does it comply with guidelines? Australas Psychiatry 2006; 14:304-9. [PMID: 16923044 DOI: 10.1080/j.1440-1665.2006.02298.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine the level of compliance with official guidelines for prescribing mood stabilizers among adolescents in Christchurch, New Zealand. METHODS A retrospective audit of clinical files of patients aged 13-19 years attending inpatient and outpatient services in the Child, Adolescent and Family Service in the Canterbury District catchment area was carried out against set criteria derived from the Ministry of Health Guidelines regarding the use of mood stabilizers (lithium and sodium valproate). A guideline compliance index was also created to measure overall compliance. RESULTS Over a period of 3 years beginning from January 2000, we identified 68 episodes of initiation among 58 adolescents. Of those, 91.2% were for indications set in the guidelines. More than half appeared to have been given no information about the medication, and only 61.8% had documented consent. Two-thirds had a full laboratory work-up before initiation. More than one-third had no evidence of communication with general practitioners about being initiated on a mood stabilizer. Overall, only 13.2% were 100% compliant and only 50% were 80% compliant. CONCLUSION In general, mood stabilizers were prescribed as indicated, but adherence to the guidelines beyond that appears to fall short of standards set by the guidelines.
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Affiliation(s)
- Brian Craig
- Youth Inpatient Unit, Princess Margaret Hospital, Christchurch, New Zealand.
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Woods K, McCollam A. Progress in the development of integrated mental health care in Scotland. Int J Integr Care 2006; 2:e21. [PMID: 16896397 PMCID: PMC1480385 DOI: 10.5334/ijic.59] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2001] [Revised: 04/25/2002] [Accepted: 05/14/2002] [Indexed: 11/30/2022] Open
Abstract
The development of integrated care through the promotion of ‘partnership working’ is a key policy objective of the Scottish Executive, the administration responsible for health services in Scotland. This paper considers the extent to which this goal is being achieved in mental health services, particularly those for people with severe and enduring mental illness. Distinguishing between the horizontal and vertical integration of services, exploratory research was conducted to assess progress towards this objective by examining how far a range of functional activities in Primary Care Trusts (PCTs) and their constituent Local Health Care Co-operatives (LHCCs) were themselves becoming increasingly integrated. All PCTs in Scotland were surveyed by postal questionnaire, and followed up by detailed telephone interviews. Six LHCC areas were selected for detailed case study analysis. A Reference Group was used to discuss and review emerging themes from the fieldwork. The report suggests that faster progress is being made in the horizontal integration of services between health and social care organisations than is the case for vertical integration between primary health care and specialist mental health care services; and that there are significant gaps in the extent to which functional activities within Trusts are changing to support the development of integrated care. A number of models are briefly considered, including the idea of ‘intermediate care’ that might speed the process of integration.
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Affiliation(s)
- Kevin Woods
- Department of Public Health, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ
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Verdoux H, Cougnard A, Grolleau S, Besson R, Delcroix F. How do general practitioners manage subjects with early schizophrenia and collaborate with mental health professionals? A postal survey in South-Western France. Soc Psychiatry Psychiatr Epidemiol 2005; 40:892-8. [PMID: 16205851 DOI: 10.1007/s00127-005-0975-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study was conducted to explore how general practitioners (GPs) manage subjects with early psychosis and collaborate with psychiatrists in the care of such patients. METHODS Survey questionnaires exploring practice in patients with early psychosis were mailed to all GPs in South-Western France (n=3,829). RESULTS The response rate was 23.6%. Half of GPs responding to the survey had actually diagnosed a possible case of schizophrenia during the previous year. In such cases, the most frequent decision was to refer the patient to a psychiatrist, despite the difficulties of convincing the patient and obtaining a rapid referral. According to GPs' answers, the relationships between primary care and the mental health team were characterised by a lack of communication: less than one out of three GPs had regular contact with a mental health team, and a large majority reported that they never or rarely had information about the diagnosis and treatment of subjects referred for early schizophrenia. Having regular contacts with mental health services had a major impact on GPs' management of subjects with early schizophrenia, in particular on reducing delays to obtain a psychiatric consultation and on level of information on diagnosis and treatment after referral. CONCLUSION Promotion of networking between primary care and mental health services is required to reduce delayed access to care in subjects with early schizophrenia.
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Affiliation(s)
- Hélène Verdoux
- Department of Adult Psychiatry, Université Victor Segalen Bordeaux 2, Bordeaux, France.
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Lester H, Tait L, Khera A, Birchwood M, Freemantle N, Patterson P. The development and implementation of an educational intervention on first episode psychosis for primary care. MEDICAL EDUCATION 2005; 39:1006-14. [PMID: 16178827 DOI: 10.1111/j.1365-2929.2005.02273.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
INTRODUCTION This paper describes the development and implementation of an educational intervention to help general practitioners (GPs) recognise young people with first episode psychosis. METHOD The Medical Research Council complex interventions framework was used to guide the development of the intervention. The theoretical phase included a literature review of previous educational interventions in primary care and consideration of the literature on attitude formation and change, and the relationship between attitudes and behaviour. The modelling phase included focus groups with GPs and service users, and a training needs analysis questionnaire administered to GPs. The 2-stage intervention consisted of a video featuring role-plays of primary care consultations, GP-led discussion and discussion with early intervention service users. The acceptability and utility of the educational programme was evaluated using a 5-point Likert scale questionnaire administered at the end of each session. RESULTS General practitioners from each of the 39 intervention practices participated in the initial session and from 27 practices in the booster session. Information about symptoms and signs of first episode psychosis was the most valued aspect of the initial session. The booster session was also well received, with GPs valuing the opportunity to gain insight into first episode psychosis from users. CONCLUSIONS This paper adds a pragmatic description to the literature on the development of educational interventions in primary care. The Medical Research Council framework helped to identify and clarify component parts of the intervention and how the active components may relate to the expected outcome of behaviour change.
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Affiliation(s)
- Helen Lester
- Department of Primary Care, University of Birmingham, Birmingham, UK.
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