Providing Behavioral Health Care in PACE - A Review of Federal and State Manual Regulations

OBJECTIVES

Present analysis of the federal and state regulations that guide The Program of All-Inclusive Care for the Elderly (PACE) operations and core clinical features for direction on behavioral health (BH).

DESIGN

Review and synthesize the federal (Centers for Medicare and Medicaid Services [CMS]) and all publicly available state manuals according to the BH-Serious Illness Care (SIC) model domains.

SETTING AND PARTICIPANTS

The 155 PACE organizations operating in 32 states and the District of Columbia.

METHODS

A multipronged search was conducted to identify official state and federal manuals guiding the implementation and functions of PACE organizations. The CMS PACE website was used to identify the federal PACE manual. State-level manuals for 32 states with PACE programs were identified through several sources, including official PACE websites, contacts through official websites, the National PACE Association (NPA), and public and academic search engines. The manuals were searched according to the BH-SIC model domains that pertain to integrating BH care with complex care individuals.

RESULTS

According to the CMS Manual, the interdisciplinary team is responsible for holistic care of PACE enrollees, but a BH specialist is not a required member. The CMS Manual includes information on BH clinical functions, BH workforce, and structures for outcome measurement, quality, and accountability. Eight of 32 PACE-participating states offer publicly available state PACE manuals; of which 3 offer information on BH clinical functions.

CONCLUSIONS AND IMPLICATIONS

Regarding BH, federal and state manual regulations establish limited guidance for comprehensive care service delivery at PACE organizations. The absence of clear directives weakens BH care delivery due to a limiting the ability to develop quality measures and accountability structures. This hinders incentivization and accountability to truly all-inclusive care. Clearer guidelines and regulatory parameters regarding BH care at federal and state levels may enable more PACE organizations to meet rising BH demands of aging communities.

A realist evaluation of an enhanced court-based liaison and diversion service for defendants with neurodevelopmental disorders

BACKGROUND

In England, court-based mental health liaison and diversion (L&D) services work across courts and police stations to support those with severe mental illness and other vulnerabilities. However, the evidence around how such services support those with neurodevelopmental disorders (NDs) is limited.

AIMS

This study aimed to evaluate, through the lens of court and clinical staff, the introduction of a L&D service for defendants with NDs, designed to complement the existing L&D service.

METHODS

A realist evaluation was undertaken involving multiple agencies based within an inner-city Magistrates' Court in London, England. We developed a logic model based on the initial programme theory focusing on component parts of the new enhanced service, specifically training, screening, signposting and interventions. We conducted semi-structured interviews with the court staff, judiciary and clinicians from the L&D service.

RESULTS

The L&D service for defendants with NDs was successful in identifying and supporting the needs of those defendants. Benefits of this service included knowledge sharing, awareness raising and promoting good practice such as making reasonable adjustments. However, there were challenges for the court practitioners and clinicians in finding and accessing local specialist community services.

CONCLUSION

A L&D service developed for defendants with NDs is feasible and beneficial to staff and clinicians who worked in the court setting leading to good practice being in place for the defendants. Going forward, a local care pathway would need to be agreed between commissioners and stakeholders including the judiciary to ensure timely and equitable access to local services by both defendants and practitioners working across diversion services for individuals with NDs.

Eating Disorders and Our Youth: Aggressive Action Must be Taken to Ensure Parity

Eating disorders are one of the most common chronic illnesses among adolescents. Yet, our current framework for mental health care provides limited education, access to care, and support for adolescents suffering from this disease. The enactment of key legislation and federal guidance such as the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is evidence that there are steps being taken to ensure the removal of barriers to care. However, eating disorders are often overlooked as a category of behavioral disorders. This paper analyzes the current legal and social framework for providing care and support to adolescents suffering from eating disorders. In doing so, it offers recommendations to develop stronger protective and responsive measures to ensure access, support, and care to these individuals.

[The Dutch Mandatory Mental Health Care Act allows more care for pregnant women under coercion]

Women with mental health issues may wish to get pregnant. In some situations a pregnancy is contra-indicated or not be in the best interests of the future child. This article analyses the way treating physicians may assist these women and, if needed, treat these women by using somatic of psychiatric care. This on the basis of the Dutch Patients' Rights Act and mental health legislation. The recent Dutch Mandatory Health Care Act provides physicians more opportunities to act in comparison with the previous situation.

California's Mental Health Services Act and Mortality Due to Suicide, Homicide, and Acute Effects of Alcohol: A Synthetic Control Application

California's Mental Health Services Act (MHSA) substantially expanded funding of county mental health services through a state tax, and led to broad prevention efforts and intensive services for individuals experiencing serious mental disorders. We estimated the associations between MHSA and mortality due to suicide, homicide, and acute effects of alcohol. Using annual cause-specific mortality data for each US state and the District of Columbia from 1976-2015, we used a generalization of the quasi-experimental synthetic control method to predict California's mortality rate for each outcome in the absence of MHSA using a weighted combination of comparison states. We calculated the association between MHSA and each outcome as the absolute difference and percentage difference between California's observed and predicted average annual rates over the postintervention years (2007-2015). MHSA was associated with modest decreases in average annual rates of homicide (-0.81/100,000 persons, corresponding to a 13% reduction) and mortality from acute alcohol effects (-0.35/100,000 persons, corresponding to a 12% reduction). Placebo test inference suggested that the associations were unlikely to be due to chance. MHSA was not associated with suicide. Protective associations with mortality due to homicide and acute alcohol effects provide evidence for modest health benefits of MHSA at the population level.

Impact of closure of the in-house psychiatric care unit on prehospital and emergency ward length of stay and disposition locations in patients who attempted suicide: A retrospective before-and-after cohort study at a community hospital in Japan

Suicide is an increasingly serious public health care concern worldwide. The impact of decreased in-house psychiatric resources on emergency care for suicidal patients has not been thoroughly examined. We evaluated the effects of closing an in-hospital psychiatric ward on the prehospital and emergency ward length of stay (LOS) and disposition location in patients who attempted suicide.This was a retrospective before-and-after study at a community emergency department (ED) in Japan. On March 31, 2014, the hospital closed its 50 psychiatric ward beds and outpatient consultation days were decreased from 5 to 2 days per week. Electronic health record data of suicidal patients who were brought to the ED were collected for 5 years before the decrease in in-hospital psychiatric services (April 1, 2009-March 31, 2014) and 5 years after the decrease (April 1, 2014-March 31, 2019). One-to-one propensity score matching was performed to compare prehospital and emergency ward LOS, and discharge location between the 2 groups.Of the 1083 eligible patients, 449 (41.5%) were brought to the ED after the closure of the psychiatric ward. Patients with older age, burns, and higher comorbidity index values, and those requiring endotracheal intubation, surgery, and emergency ward admission, were more likely to receive ED care after the psychiatric ward closure. In the propensity matched analysis with 418 pairs, the after-closure group showed a significant increase in median prehospital LOS (44.0 minutes vs 51.0 minutes, P < .001) and emergency ward LOS (3.0 days vs 4.0 days, P = .014) compared with the before-closure group. The rate of direct home return was significantly lower in the after-closure group compared with the before-closure group (87.1% vs 81.6%, odds ratio: 0.66; 95% confidence interval: 0.45-0.96).The prehospital and emergency ward LOS for patients who attempted suicide in the study site increased significantly after a decrease in hospital-based mental health services. Conversely, there was significant reduction in direct home discharge after the decrease in in-house psychiatric care. These results have important implications for future policy to address the increasing care needs of patients who attempt suicide.

Improving Access to Psychotherapy: Implications of Wit Versus United Behavioral Health

This column summarizes the verdict in the federal class action known as Wit v United Behavioral Health (UBH)/Optum, highlighting the verdict's implications for increasing access to care, implementing the mental health parity law, and reducing health disparities. Achieving these results requires recognition of the verdict as more than simply a nice news story, but as a decision that actually offers individual clinicians, their professional organizations, as well as patients, families, and their consumer organizations, a powerful tool for implementing change if they take up the task of learning how to use it. The verdict applies to outpatient treatment, including psychotherapy, along with 2 other levels of care: intensive outpatient programs and residential treatment.

Developing a Structure of Essential Services for a Child and Adolescent Mental Health System

Policy Points That child and adolescent mental health services needs are frequently unmet has been known for many decades, yet few systemic solutions have been sought and fewer have been implemented at scale. Key among the barriers to improving child and adolescent mental health services has been the lack of well-organized primary mental health care. Such care is a mutual but uncoordinated responsibility of multiple disciplines and agencies. Achieving consensus on the essential structures and processes of mental health services is a feasible first step toward creating an organized system.

Beyond the asylum and before the 'care in the community' model: exploring an overlooked early NHS mental health facility

This article discusses the Admission and Treatment Unit at Fair Mile Hospital, in Cholsey, near Wallingford, Berkshire (now Oxfordshire). This was the first new hospital to be completed in England following the launch of the National Health Service. The building was designed by Powell and Moya, one of the most important post-war English architectural practices, and was completed in 1956, but demolished in 2003. The article relates the commission of the building to landmark policy changes and argues for its historic significance in the context of the NHS and of the evolution of mental health care models and policies. It also argues for the need for further study of those early NHS facilities in view of current developments in mental health provision.

Mental health, mental capacity, ethics, and the law in the context of COVID-19 (coronavirus)

The emergence of the COVID-19 (coronavirus) pandemic in late 2019 and early 2020 presented new and urgent challenges to mental health services and legislators around the world. This special issue of the International Journal of Law and Psychiatry explores mental health law, mental capacity law, and medical and legal ethics in the context of COVID-19. Papers are drawn from India, Australia, the United Kingdom, Ireland, Germany, Portugal, and the United States. Together, these articles demonstrate the complexity of psychiatric and legal issues prompted by COVID-19 in terms of providing mental health care, protecting rights, exercising decision-making capacity, and a range of other topics. While further work is needed in many of these areas, these papers provide a strong framework for addressing key issues and meeting the challenges that COVID-19 and, possibly, other outbreaks are likely to present in the future.

Aligning dissemination and implementation science with health policies to improve children's mental health

The prevalence of mental health problems among children (ages 0-21) in the United States remains unacceptably high and, post-COVID-19, is expected to increase dramatically. Decades of psychological knowledge about effective treatments should inform the delivery of better services. Dissemination and implementation (D&I) science has been heralded as a solution to the persistent problem of poor quality services and has, to some extent, improved our understanding of the contexts of delivery systems that implement effective practices. However, there are few studies demonstrating clear, population-level impacts of psychological interventions on children. Momentum is growing among communities, cities, states, and some federal agencies to build "health in all policies" to address broad familial, social, and economic factors known to affect children's healthy development and mental health. These health policy initiatives offer a rare opportunity to repurpose D&I science, shifting it from a primary focus on evidence-based practice implementation, to a focus on policy development and implementation to support child and family health and well-being. This shift is critical as states develop policy responses to address the health and mental health impacts of the COVID-19 pandemic on already-vulnerable families. We provide a typology for building research on D&I and children's mental health policy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

"It's about how much we can do, and not how little we can get away with": Coronavirus-related legislative changes for social care in the United Kingdom

The coronavirus pandemic, referred to here as Covid-19, has brought into sharp focus the increasing divergence of devolved legislation and its implementation in the United Kingdom. One such instance is the emergency health and social care legislation and guidance introduced by the United Kingdom Central Government and the devolved Governments of Wales, Scotland and Northern Ireland in response to this pandemic. We provide a summary, comparison and discussion of these proposed and actual changes with a particular focus on the impact on adult social care and safeguarding of the rights of citizens. To begin, a summary and comparison of the relevant changes, or potential changes, to mental health, mental capacity and adult social care law across the four jurisdictions is provided. Next, we critique the suggested and actual changes and in so doing consider the immediate and longer term implications for adult social care, including mental health and mental capacity, at the time of publication.several core themes emerged: concerns around process and scrutiny; concerns about possible changes to the workforce and last, the possible threat on the ability to safeguard human rights. It has been shown that, ordinarily, legislative provisions across the jurisdictions of the UK are different, save for Wales (which shares most of its mental health law provisions with England). Such divergence is also mirrored in the way in which the suggested emergency changes could be implemented. Aside from this, there is also a wider concern about a lack of parity of esteem between social care and health care, a concern which is common to all. What is interesting is that the introduction of CVA 2020 forced a comparison to be made between the four UK nations which also shines a spotlight on how citizens can anticipate receipt of services.

Deciding to participate in mental health court: Exploring participant perspectives

As the number of mental health courts (MHC) expands across the United States, so does the body of research demonstrating its effectiveness in reducing criminal recidivism. While there has been considerable research conducted on MHC operations, less is known about how individuals decide to participate in MHCs. Data from in-depth interviews with 26 MHC participants from two MHCs in the United States were analyzed using grounded dimensional and thematic analyses. Results suggest that individuals participated in MHC to avoid incarceration and obtain treatment. Participants understood the court to function in four distinct ways: 1) to help through service provision, 2) to structure a judicial agreement allowing MHCs to make treatment decisions in exchange for community living, 3) to protect people from risks within the criminal justice system, and 4) to reward participants for treatment adherence. Findings can be used to guide the need for policy and practice for those referring to MHCs.

The impact of misdemeanor arrests on forensic mental health services: A state-wide review of Virginia sanity evaluations

OBJECTIVE

We examined the prevalence of criminal defendants facing only misdemeanor charges and referred for forensic mental health evaluations of legal sanity (criminal responsibility) in a state-wide sample of sanity reports. We sought to describe this population of defendants, particularly as compared to defendants facing felony charges and referred for evaluation of legal sanity.

HYPOTHESES

We hypothesized that, among those referred for sanity evaluations, defendants facing only misdemeanor charges would have higher rates of serious mental illness than would defendants charged with felonies, as evidenced by their mental status during the evaluation and at the time of alleged offenses. We also hypothesized that defendants charged with only misdemeanors would be more often opined insane, as compared to those charged with felonies.

METHOD

We reviewed a statewide sample of 926 court-ordered sanity evaluation reports in Virginia and coded numerous variables describing the defendants, sanity evaluation process, resulting reports, and legal opinions offered within the reports.

RESULTS

Approximately 22.3% of sanity evaluations involved defendants charged only with misdemeanor offenses. Defendants facing only misdemeanor charges were 1.82 times more likely to be opined insane than were defendants facing only felony charges, primarily due to their increased likelihood of experiencing psychotic symptoms at the time of the offense (1.83 times more likely than defendants facing felony charges).

CONCLUSIONS

The merits of pursuing the insanity defense in response to misdemeanor charges are questionable given the cost- and resource-intensive outcomes associated with insanity acquittals. Diversion strategies may be a more efficient response to those defendants with serious mental illness facing only misdemeanor charges. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Mental illness and the Lebanese criminal justice system: Practices and challenges

Forensic mental health services are a necessity for individuals involved in the criminal justice system. Such services involve two generally independent functions: assessment and treatment. A jurisdiction's legal system is a determinant of how such services are provided and to whom. In our study, we identified the Lebanese laws that address the rights and protections given to a mentally disordered defendant in the criminal justice system. We then analyzed how the Lebanese judicial system interprets and applies the written law in cases where the mental health of the defendant was brought up as an issue. We found that Lebanon's insanity test has a cognitive and a volitional component. However, there does not seem to be a uniform process regulating the use of the insanity defense: statutes do not address the procedural details and the cases we reviewed used various processes to reach their decisions. Based on our findings, we explored avenues for potential improvement in the Lebanese forensic mental health system.

Judicial perspectives on mental health courts: The role of psychiatric disorder and violence risk

OBJECTIVE

The extent to which psychiatric diagnosis, treatment compliance, and violence risk influenced judges perceived benefits of Mental Health Court ("MHC") for defendants with psychiatric disorders was examined.

METHOD

81 judges completed one vignette in which psychiatric diagnosis (Schizophrenia, Major Depressive Disorder, Posttraumatic Stress Disorder), treatment compliance (yes/no), and violence risk (high/low) were randomized. The online survey was distributed via email and following the vignette, judges answered a question about the appropriateness of MHC.

RESULTS

Judges assessed defendants with severe psychiatric disorders (Schizophrenia and Major Depressive Disorder) - compared to defendants with PTSD - as more likely to benefit from MHCs. If deemed at low treatment compliance and/or high violence risk, judges were unlikely to appraise MHCs as beneficial, regardless of psychiatric diagnosis.

IMPLICATIONS

Judges appear to consider relevant factors when determining whether MHC will benefit defendants with psychiatric disorders; however, future research should include more variables (e.g., addictions, history of violence) to examine the combined influence on judges' perception of MHC suitability.

Involuntarily and voluntarily admitted patients’ experiences of psychiatric admission and treatment—a comparison before and after changed legislation in Sweden

Objective

– The Swedish Compulsory Mental Care Act (LPT) of 1992 emphasises the participation of patients and relatives in the treatment of the patients. The purpose of this study was to compare patients' experiences under the LPT with patients' experiences under the previous law.

Method.

– Samples of 44 committed patients and 40 voluntarily admitted patients in 1991 and 49 committed and 49 voluntarily admitted patients in 1997/98 were interviewed at admission and at discharge, or after 3 weeks of care.

Results.

– There were similar proportions of committed and voluntarily admitted patients, respectively, in 1991 and 1997/98 who reported participation in treatment planning and participation of relatives and who reported deprivation of liberty, but more committed patients in 1997/98 reported coercive measures.

Conclusion.

– There were few differences of the patient's experiences between the study occasions. The fundamental aims of the legislation have not been fulfilled.

Trends in the use of the Italian Mental Health Act, 1979–1997

Italian statistics on psychiatric bed availability, voluntary and compulsory admissions were examined from 1979 to 1997. Although the number of psychiatric beds dropped by 62.5%, the absolute number of compulsory admissions has remained substantially stable. The proportion of all admissions that were compulsory decreased from 17.1% to 11%. This study shows that a shift to community care was not associated with an increase in compulsory admissions in Italy.

Service Provider Perspectives on Female Forensic Mental Health Services in Zimbabwe: An Interpretative Phenomenological Analysis

INTRODUCTION

Service providers' perspectives on female forensic mental health services have not been explored in Zimbabwe. This study examined how health service providers in forensic mental health in Zimbabwe understand and interpret rehabilitation of female forensic psychiatric patients.

METHODS

An interpretive phenomenological study was completed. Service provider participants were selected via purposive sampling from two main Special Institutions. Data were collected using audio-recorded semistructured interviews and subjected to interpretive phenomenological analysis.

FINDINGS

Two master themes evolved from interview data: (a) conflicting legal documents of care and management of female forensic psychiatric patients; and (b) the forensic mental health system's processes, procedures, and resources impacting female forensic psychiatric rehabilitation.

DISCUSSION

Findings of the study call for the need to balance between public safety interests and fulfilling clinical rehabilitation objectives.

The Policy Ecology of Behavioral Health Homes: Case Study of Maryland's Medicaid Health Home Program

Behavioral health homes, shown to improve receipt of evidence-based medical services among people with serious mental illness in randomized clinical trials, have had limited results in real-world settings; nonetheless, these programs are spreading rapidly. To date, no studies have considered what set of policies is needed to support effective implementation of these programs. As a first step toward identifying an optimal set of policies to support behavioral health home implementation, we use the policy ecology framework to map the policies surrounding Maryland's Medicaid behavioral health home program. Results suggest that existing policies fail to address important implementation barriers.

Conscience clauses and sexual and gender minority mental health care: A case study

Tennessee is one of the first states in the United States to have a law that enables counselors and therapists in independent practice to deny services to any client based on the practitioner's "sincerely held principles." This so-called "conscience clause" represents a critical moment in professional psychology, in which mental health care providers are on the frontlines of cultural and legal debates about religious freedom. Though the law's language is ambiguous, it was widely perceived to target sexual and gender minority (SGM) individuals. We interviewed 20 SGM people living in Tennessee to understand their experiences with mental health care in the state and their perceptions of the law. Our participants perceive the law as fundamentally discriminatory, though they overwhelmingly conceptualize the conscience clause as legalizing discrimination toward members of all stigmatized groups-not just SGM individuals. They described individual and societal consequences for the law, including an understanding of the conscience clause as harmful above and beyond any individual discrimination event it may engender. We situate these findings amid the research on structural stigma and suggest that counseling psychologists become actively engaged in combatting conscience clauses, which appear to have profound consequences on mental health care engagement, particularly for populations vulnerable to discrimination. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Putting Suicide Policy through the Wringer: Perspectives of Military Members Who Attempted to Kill Themselves

In response to the Air Force Surgeon General, Lieutenant General Mark Ediger's call for medical services to be guided by service members' values, preferences, and experiences within the medical system, we conducted an interpretive phenomenological analysis of transcripts in which service members shared their experiences of military mental health policy and practices after being identified as suicidal. Themes of their experiences underscore nuances as it relates to intersectionality of policy when faced with unique military contextual factors and power differentials; both of which were missing in available research literature. Their experiences also illuminate further the innate "Catch 22" which happens when accessing help. Catch 22 basically means if you know you need help than you are rational; but if you actually seek help, then you are crazy and not trustworthy to do your job. Themes presented center on the lack of confidentiality of Service Members in the Workplace, effects of Unit Members' Surveillance and Command Directed Evaluations, and experiences of Military Mental Health Services. Critical discussions of policy and taken for granted assumptions that often drive narrow responses to suicide, treatment, prevention, and stigma are presented. Particular attention is given to the lived experiences of service members when placed under the demands of circumstances created by policy that may inadvertently lead in some cases to further suffering. The paper closes with recommendations from participants and the authors for policy makers and future directions in research.

Discrimination against offenders with mental disorder

BACKGROUND

Mentally disordered offenders may suffer discrimination on the basis of mental disorder, or on the basis of being offenders, or both.

AIMS

The aim of this paper is to outline a framework for examining discrimination affecting mentally disordered offenders. It is argued that there should be systematic comparisons between offenders with mental disorder and nonoffenders with mental disorder in order to identify and characterise specific failures to ensure equivalence of mental health care; and systematic comparisons between offenders with mental disorder and offenders without mental disorder in order to identify how mental disorder may constitute a barrier to forms of support and constructive intervention available to other offenders.

METHODS

A critical review was conducted of official documents presenting criminal justice and mental health policy for England and Wales, principally since 2012, together with reports of inspectorate and oversight bodies and relevant research studies.

FINDINGS

There is evidence that offenders with mental disorder may not be able to access mental health care equivalent to that for nonoffenders with mental disorder. There is also evidence that they may not be able to access interventions available to other offenders. Further disadvantage may arise in the criminal courts since, in England and Wales, if inpatient care is required, the powers of criminal courts to effect hospital admission under Part III of mental health legislation are weakened by the statutory requirement of information that places are available. This is discriminatory against offenders with mental disorder insofar as forms of court disposal for other offenders are not prevented by the capacity of criminal justice agencies.

CONCLUSIONS AND IMPLICATIONS

The review supports the need for systematic comparisons to identify forms of disadvantage and discrimination experienced by mentally disordered offenders in relation to both mental health and criminal justice policies services.

[Open-door psychiatry and community mental health work]

In connection with the UN Convention on the Rights of Persons with Disabilities, mental healthcare concepts increasingly focus on the prevention of violence and coercion. Hospital care with an open-door policy is linked with a reduction in violence and coercive measures. The authors describe a specific therapeutic milieu aiming to promote social resources and to reduce institutional exclusion. Open-door policies can be extended to and tied in with outreach community mental health work. Model projects according to § 64b of the German Social Code (SGB V) on interdisciplinary care enable flexible needs-based care including home treatment for severe mental illness.

The use of 'tie down' in New Zealand prisons​-what is the role of the health sector?

We draw upon two recent reports from the Chief Ombudsman that describe the prison management of people assessed at risk of self-harm or suicide, as cruel, inhuman or degrading treatment or punishment. People were mechanically restrained on 'tie-down' beds by their legs, arms and chest or placed in waist restraints with their hands cuffed behind their backs over prolonged periods. These practices occurred at the direction of, or were approved by, health professionals. We highlight ethical issues for health professionals party to 'tie down' and examine the current guidance and regulatory framework for health professionals working in coercive environments. This article is timely in the context of current Government Inquiries into the criminal justice system and mental health and addictions, the review of the health and disability system, the Correction's Amendment Bill before parliament, and Government plans to expand Waikeria prison to include a 100-bed mental health facility. We call for the use of 'tie down' to be abolished in New Zealand prisons, and for all health professionals to refuse to participate in this practice. Government must make provision for sufficient forensic mental health capacity and capability in the health sector, and ensure timely, equitable access to high-quality, trauma-informed and culturally safe services.

Police detentions of 'mentally disordered persons': A multi-method investigation of section 136 use in Sussex

This research was conducted in response to governmental and public concern regarding the escalating use of section 136 of the Mental Health Act (1983) nationally and of the excessive use of police custody as a place of safety in Sussex in particular. A retrospective analysis of all detentions in Sussex during 2012 was combined with qualitative data from 37 people with lived experience of detention, as well as police, National Health Service (NHS) and allied staff and volunteers. Predominantly, police used s136 as suicide prevention (80%) when no other services or help were available. During the period of study (2013-2016), effective joint working strategies, such as the street triage pilot, were able to reduce the overall rates of s136 detentions and to increase access to NHS place of safety suites markedly. Although the research acknowledges idiosyncratic local factors which contribute to the high rate of detentions across Sussex, the results have wider implications for national policy and practice.

Screening for psychosocial distress among patients with cancer: implications for clinical practice, healthcare policy, and dissemination to enhance cancer survivorship

Accreditation standards are at the forefront of evolving healthcare systems, setting metrics for high-quality care. Healthcare outcomes (health, experience, cost, provider satisfaction/burn out) are becoming mutual goals of the patient, provider, payer, and healthcare system. Achieving high-quality outcomes in cancer care necessitates collaboration among interdisciplinary teams of clinical providers, administrators, patient advocates, caregivers, and researchers. Dissemination and implementation science provides necessary frameworks to organize the efforts of these implementation teams, inclusive of identifying facilitators and barriers to implementation of accreditation standards. Since 2015, cancer distress screening has been mandated for continued cancer center accreditation by the American College of Surgeon's Commission on Cancer. Cancer centers have thus become real world implementation laboratories. We present the current context of distress screening, highlighting prior research and key areas of future research. We consider multiple levels of cancer care delivery and the use of interdisciplinary teams to help cancer center teams adopt, implement, and maintain efficient distress screening programs. Finally, we present a case study to identify methods for successful implementation of distress screening at one cancer center and then describe efficiencies that can be introduced using elements from human factors engineering, e- and m-health screening platforms, and community partnerships.

PERSPECTIVES: Mental Health Policy in India: Seven Sets of Questions and Some Answers

BACKGROUND

This paper frames the state of mental health policy in India in terms of seven sets of questions, and seeks to provide at least partial answers to these questions, based on a meta-analysis of existing research. The context of the analysis is the arguably poor state of mental health care in India, as well as an unprecedented level of policy attention to the issue.

AIMS OF THE STUDY

In brief, the questions we pose pertain to (i) the provision of such care in hospitals, (ii) non-hospital provision, including by non-medical providers, (iii) issues of education and social acceptance, (iv) affordability, (v) within-country variation of care and possibilities for benchmarking, (vi) aggregate resource impacts of a concerted effort to change policies and improve care, and (vii) the shape of a more effective "continuum of care" for mental health issues.

METHODS

Given the complexity of the subject, this paper is meant to serve as a framing of issues for further research, but in doing so, to clarify what issues are most pressing, those that are most difficult and perhaps those that can be tackled more readily, to create some momentum in changing the relatively poor state of mental health care in India.

RESULTS

While new laws and policies being introduced in India propose ideas and changes that are groundbreaking for that country, leading to cautious optimism, there still are many gaps in the understanding of the challenges of the provision of increased access to, as well as better quality, mental health care in India. These challenges can be understood on two fronts: one is the psychiatric and medical aspect of the issues, and the other is the management and administration of the system.

DISCUSSION

Perhaps the highest priority in achieving the goals of greater access and better quality is to increase the number of trained personnel at all levels of specialization and skilling that are relevant. Further, while the new legal framework and policy identify the importance of information technology in rapid expansion of access to mental healthcare, more context-specific research and trials are needed. With respect to the administration and management needs of the public system, important challenges will be the need for significant organizational innovations in the education system, and cultural changes that allow specialized medical professionals to accept the use of software and less-qualified, more dispersed, frontline providers. A final area is the interface between the public and private sectors, including the role of non-profit organizations: challenges include information sharing, division of responsibilities, and resource allocation.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

Our analysis suggests that incorporating information technology, along with training professionals at a variety of skill levels in its use, may provide a resource-feasible approach to improving access to mental healthcare at reasonable cost and quality in the Indian context.

IMPLICATIONS FOR HEALTH POLICIES

India's mental health policies are already undergoing major changes, and our analysis emphasizes the need for translating these generic policies into specific and implementable versions that can be tested at the local level across different regional and social contexts in India.

IMPLICATIONS FOR FURTHER RESEARCH

The overall challenge is daunting, being the need to expand access and improve quality, while still managing costs, all within an overall healthcare system that is itself struggling to achieve these goals. Further research based on piloting and trials of assistive software and training programs will likely be useful.

India's Mental Healthcare Act, 2017: Content, context, controversy

India's new mental health legislation, the Mental Healthcare Act, 2017, was commenced on 29 May 2018 and seeks explicitly to comply with the United Nations Convention on the Rights of Persons with Disabilities. It grants a legally binding right to mental healthcare to over 1.3 billion people, one sixth of the planet's population. Key measures include (a) new definitions of 'mental illness' and 'mental health establishment'; (b) revised consideration of 'capacity' in relation to mental healthcare (c) 'advance directives' to permit persons with mental illness to direct future care; (d) 'nominated representatives', who need not be family members; (e) the right to mental healthcare and broad social rights for the mentally ill; (f) establishment of governmental authorities to oversee services; (g) Mental Health Review Boards to review admissions and other matters; (h) revised procedures for 'independent admission' (voluntary admission), 'supported admission' (admission and treatment without patient consent), and 'admission of minor'; (i) revised rules governing treatment, restraint and research; and (j) de facto decriminalization of suicide. Key challenges relate to resourcing both mental health services and the new structures proposed in the legislation, the appropriateness of apparently increasingly legalized approaches to care (especially the implications of potentially lengthy judicial proceedings), and possible paradoxical effects resulting in barriers to care (e.g. revised licensing requirements for general hospital psychiatry units). There is ongoing controversy about specific measures (e.g. the ban on electro-convulsive therapy without muscle relaxants and anaesthesia), reflecting a need for continued engagement with stakeholders including patients, families, the Indian Psychiatric Society and non-governmental organisations. Despite these challenges, the new legislation offers substantial potential benefits not only to India but, by example, to other countries that seek to align their laws with the United Nations' Convention on the Rights of Persons with Disabilities and improve the position of the mentally ill.

Trends in the number of restricted patients in England and Wales 2003-2016: Implications for forensic psychiatry services

This paper uses data produced by the Ministry of Justice to look for trends in the numbers of various categories of patients detained under the Mental Health Act in England and Wales between 2003 and 2016. Specifically, we have focussed on patients detained with Ministry of Justice restrictions in place. The number of 'restricted' patients, who are largely detained in secure psychiatric hospitals, has risen substantially during this period. If this trend continues, there will be the need for further expansion of secure psychiatric beds in the years ahead. Factors driving the increased number of restricted patients are discussed in this paper.

Contextual issues in the implementation of mental health legislation

Mental Health services in Victoria, Australia have seen major reform over the past 30 years. Rights based mental health legislation and major structural changes supported a reduction in bed based services and the development of a strong community mental health sector from the mid 1990's. Community Treatment Orders were established in the Mental Health Act (1986) and widely used across the State. Reformed legislation in 2014 brought greater emphasis on supported decision making and recovery orientation. Funding for mental health services did not keep pace with significant population growth, with consequent reduction in bed availability and intensity of community based services. This paper considers the impact of funding and service availability on the intended policy and practice directions of mental health legislation with particular consideration of the impact on the utilisation of Community Treatment Orders.

The right to aftercare: identifying the responsible bodies

In the second article on the right to aftercare under the Mental Health Act 1983 , section 117, Richard Griffith considers the identification of the body responsible and whether patients can be charged for their aftercare.

The right to aftercare: best endeavours

In this two-part article Richard Griffith, Senior Lecturer in Health Law at Swansea University, considers a detained mental health patient's right to aftercare under the Mental Health Act 1983, section 117.

Addressing Children’s Mental Health

(1) Untreated mental disorders and mental illness in children can lead to costly outcomes such as school dropout, substance use and suicide. (2) Half of lifetime cases of mental illness begin by age 14 and 75 percent of all lifetime cases present by age 24. (3) Early intervention and access to treatment may decrease the financial and health burdens associated with mental illness.

[Rights at 180. Forty years after the Basaglia law.]

On May 13, 1978 the Italian Mental health act [Law 180] was approved, better known as the Basaglia law, named after of the psychiatrist who inspired it. It represents the basis of the Italian mental health legislation: the outdated custodial care in psychiatric hospitals was shifted away from mental hospitals to community mental health centres. Alternative community care restored dignity and rights to locked up people. After forty years, it is time to make an assessment. Has the revolution begun by Franco Basaglia really ended? A journey through different Italian health centres has been performed, from Friuli-Venezia Giulia, where the Basaglia's experience started, to Piedmont, where - in the small town of Collegno - the largest psychiatric hospital in Italy was located. This paper collects memories of those who experienced this revolution, testimonies of young patients and former residents, stories of doctors involved in the daily care. A journey made of experiences, passions, hopes, disillusionments, but above all rights.

Department of Veterans Affairs. Definition of Domiciliary Care. Final rule

The Department of Veterans Affairs (VA) adopts as final, with no changes, a proposed rule amending the definition of domiciliary care to encompass VA's Mental Health Residential Rehabilitation Treatment Program (MH RRTP). This rule aligns regulations with VA's administrative decision in 2005 to designate MH RRTP as a type of domiciliary care. We also proposed clarifying that domiciliary care provides temporary, not permanent, residence to affected veterans. We provided a 60-day comment period on this proposed rule and received 4 comments, all of which were generally supportive of the proposed changes. We make no changes based on public comments and adopt the proposed rule as final.

Impacts of the Dependent Care Expansion on the Allocation of Mental Health Care

We examine the impact of insurance expansion under the Affordable Care Act's Dependent Care Expansion (DCE) on allocation of mental health care across illness severity, types of care and racial/ethnic groups. Evidence suggests that the increase in mental health care utilization resulting from the DCE was restricted to individuals with clinically significant mental health conditions. There is no evidence suggesting that the increase occurred disproportionately in medication-only treatment or that it increased racial/ethnic disparities. The DCE appears to have been successful in increasing utilization of mental health care among a high need group without lowering quality or increasing disparities.

Do coverage mandates affect direct-to-consumer advertising for pharmaceuticals? Evidence from parity laws

Direct-to-consumer advertising (DTCA) for prescription drugs is a relatively unique feature of the US health care system and a source of tens of billions of dollars in annual spending. It has also garnered the attention of researchers and policymakers interested in its implications for firm and consumer behavior. However, few economic studies have explored the DTCA response to public policies, especially those mandating coverage of these products. We use detailed advertising expenditure data to assess if pharmaceutical firms increase their marketing efforts after the implementation of relevant state and federal health insurance laws. We focus on mental health parity statutes and related drug therapies-a potentially ripe setting for inducing stronger consumer demand. We find no clear indication that firms expect greater value from DTCA after these regulatory changes. DTCA appears driven by other considerations (e.g., product debut); however, it remains a possibility that firms respond to these laws through other, unobserved channels (e.g., provider detailing).

The Mental Health Parity and Addiction Equity Act (MHPAEA) evaluation study: Did parity differentially affect substance use disorder and mental health benefits offered by behavioral healthcare carve-out and carve-in plans?

BACKGROUND

To assess whether implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA) was associated with: 1. Reduced differences in financial requirements (i.e., copayments and coinsurance) for substance use disorder (SUD) versus specialty mental health (MH) care and 2. Reductions in the level of cost-sharing for SUD-specific services.

METHODS

MH and SUD copayments and coinsurance, 2008-2013, were obtained from benefits databases for carve-in and carve-out plans from Optum®. Linear regression was used to estimate the association of MHPAEA with differences between MH and SUD care financial requirements among carve-in and carve-out plans. A two-part regression model investigated whether MHPAEA was associated with changes in the use or level of financial requirements for SUD-specific services among carve-out plans.

RESULTS

MHPAEA was not associated with significant changes in the difference between SUD and MH copayments or coinsurance levels among either carve-in or carve-out plans. MHPAEA was associated with decreases in the levels of inpatient (in-network: -$51.17; out-of-network: -$34.39) and outpatient (in-network: -$10.26) detox copayments, but increases in the levels of in-network outpatient detox coinsurance (6 percentage points) among all carve-out plans.

CONCLUSION

Even if SUD benefits had been historically less generous than MH benefits, SUD financial requirements were already at parity with MH financial requirements by the time MHPAEA was passed, among Optum® plans. MHPAEA's SUD parity mandate reduced cost-sharing for detox services via copayments, but, for outpatient detox, the law simultaneously increased cost-sharing via coinsurance.

Complete smokefree policies in mental health inpatient settings: results from a mixed-methods evaluation before and after implementing national guidance

BACKGROUND

Tobacco smoking is extremely prevalent in people with severe mental illness (SMI) and has been recognised as the main contributor to widening health inequalities in this population. Historically, smoking has been deeply entrenched in the culture of mental health settings in the UK, and until recently, smokefree policies tended to be only partially implemented. However, recent national guidance and the government's tobacco control plan now call for the implementation of complete smokefree policies. Many mental health Trusts across the UK are currently in the process of implementing the new guidance, but little is known about the impact of and experience with policy implementation.

METHODS

This paper reports findings from a mixed-methods evaluation of policy implementation across 12 wards in a large mental health Trust in England. Quantitative data were collected and compared before and after implementation of NICE guidance PH48 and referred to 1) identification and treatment of tobacco dependence, 2) smoking-related incident reporting, and 3) prescribing of psychotropic medication. A qualitative exploration of the experience of inpatients was also carried out. Descriptive statistical analyses were performed, and the feasibility of collecting relevant and complete data for each quantitative component was assessed. Qualitative data were analysed using thematic framework analysis.

RESULTS

Following implementation of the complete smokefree policy, increases in the numbers of patients offered smoking cessation advice (72% compared to 38%) were identified. While incident reports demonstrated a decrease in challenging behaviour during the post-PH48 period (6% compared to 23%), incidents relating to the concealment of smoking materials increased (10% compared to 2%). Patients reported encouraging changes in smoking behaviour and motivation to maintain change after discharge. However, implementation issues challenging full policy implementation, including covert facilitation of smoking by staff, were reported, and difficulties in collecting relevant and complete data for comprehensive evaluation purposes identified.

CONCLUSIONS

Overall, the implementation of complete smokefree policies in mental health settings may currently be undermined by partial support. Strategies to enhance support and the establishment of suitable data collection pathways to monitor progress are required.

Monitoring the correspondence of the mentally ill in Spanish psychiatric institutions: from care to censorship, 1852-1987

This article examines the legislation allowing confiscation of the correspondence of the mentally ill in psychiatric hospitals. Arguing a duty of care, patients' letters were read by physicians and administrators. A study was performed of the regulations governing this practice in different Spanish institutions from the nineteenth century on; the measure was implemented by staff members under orders from their superiors. This arbitrary decision meant that a great deal of correspondence remains in the archives of psychiatric establishments in different locations; nowadays, these letters can be used as valuable clinical documents that help us to understand daily life in those institutions and, obviously, mental health patients' subjective experience of their confinement.