“Everyone is Hungry for Hignity”: A Qualitative Study of Parenting in a Community Mental Health Center in Brazil

State Mental Health Policy: Mending Missouri's Safety Net: Transforming Systems of Care by Integrating Primary and Behavioral Health Care

T the use of communication technologies to offer psychiatric services, has become a topic of great interest as a means of overcoming the effects of the shortage of psychiatrists in rural areas (1–4). The idea of using telecommunication in psychiatry is not new. In fact, examples can be found as far back as 1959, and the topic has been well reviewed (1,4–6). Although the technology has improved to the point of providing adequate audiovisual interactions, the cost-effectiveness of these interactions remains unassessed. Clearly, technological feasibility does not eliminate the need for economic practicality. Before relying on telepsychiatry as a solution to inadequate psychiatric services in rural areas, we need to consider economic variables such as the cost of the equipment, charges for maintaining connections, the volume of use, and reimbursement. We also need to consider its impact on existing systems of care into which it would be introduced. We studied the feasibility of implementing a telepsychiatry system to link psychiatrists at Michigan State University with patients at a community mental health center (CMHC) in rural Michigan. The target county we studied has a population of 58,000 and is approximately 75 miles from the university. The county is poor and demographically similar to many rural counties and is designated by the U.S. Department of Health and Human Services as an area with a shortage of mental health professionals. Many people lack transportation. Based on our feasibility study, this column examines the economics of setting up a telepsychiatry system through which care can be provided to a rural area. Moreover, we estimated the cost of delivering one type of patient care (medication management) via this system. The purpose of the paper is not to provide a technological discussion of designing a system. Rather, we offer an analysis of economic issues and systems problems encountered in setting up a very basic telepsychiatry installation at the low end of the cost range.

To provide a model to estimate human resource needs for community-based mental health services in South Africa. A situation analysis was conducted of current community-based mental health service provision in South Africa, which comprise outpatient and emergency services, residential care and day care. Service utilisation rates and staffing needs were estimated for two levels of service coverage, using data from the situation analysis, local epidemiological studies and consultation with key stakeholders. For a population of 100,000 people, 7.3-23.8 full-time equivalent staff would be required to provide services in outpatient services, 14.9-41.6 in day care and 11.5-23.0 in residential care at minimum and full coverage levels respectively. The model can facilitate rational planning by requiring transparency and accountability in the assumptions used. This method can be adapted to a range of countries, by entering relevant country data. The model fills a gap, particularly in low- and middle-income countries, where community-based mental health services are sparse, and decisions regarding allocations to them are hampered by a lack of good quality data. The results of the model are limited by the quality of data and the assumptions upon which the modelling are based.

The community mental health center (CMHC) movement, largely conceived by psychiatrists to improve standards of mental health care nationally, appears to be going through an evolutionary phase in which there is decreasing utilization of psychiatrists and increasing utilization of other mental health professionals. The author discusses some factors that may have influenced this trend. In order to counter it CMHCs must become a recognized, essential, and respectable part of a pluralistic system of mental health care, and psychiatrists must be willing to assume their responsibility for involvement in all segments of mental health care, including the private and public sectors, in both leadership and clinical positions.

In 2011, Türkiye restructured the mental health care system in community-based settings following the announcement of the National Mental Health Action Plan. Community mental health centers (CMHCs) are the major element of this approach. As of now, the total number of CMHC have reached 186, and the service users have almost reached 100.000.Mental health care system gained significant advantages through CMHCs, such as 1) improvement in the conditions of mental health services, 2) better follow-up of patients with chronic severe mental disorders, 3) capability of in-home services, 4) decrease in the number of hospitalizations, 5) increased social involvement of patients with severe mental disorder. CMHCs also played a significant role in promoting social rehabilitation, including employment status, development of social relationships, and redress of stigmatization. All these advantages were put into practice by community mental health teams comprising a psychiatrist, psychologists, nurses, social workers and ergotherapists, if available.Community mental health centers come with severe challenges and shortcomings despite their ameliorations. First, CMHCs need trained mental health professionals. However, only 52% of the CMHC teams completed the CMHC trainings currently. Second, standardized work flow algorithms should be developed for CMHCs. Third, there should be a strong relationship between CMHCs, primary health care system and inpatient units as a complementary part of essential mental health care. In addition, hospital administration should be trained in terms of CMHC policy since every CMHC is affiliated with a state hospital. For instance, the ongoing issue of defining quality standards for CMHCs contributes to a misconception, portraying these centers as profit-making units rather than dedicated rehabilitation facilities.In conclusion, community-based settings and CMHCs significantly advance mental health services despite the challenges confronted in practice. To optimize the effectiveness of community mental health care facilitated by CMHCs, it is imperative to review the implementation process with the active involvement and support of non-governmental organizations, including patient-driven organizations and national psychiatric associations.Disclosure of InterestNone Declared

Family Physicians' Experiences With Community Mental Health Centers: A Multilevel Analysis

In April 2003 the Alberta government integrated specialized mental health services, formerly organized independently, with the health regions, which are responsible for general health services. The objective of this article is to determine whether the transfer was associated with an increase or decrease in the share of resources in the region allocated to mental health care relative to total spending for health care. The measure of the share for mental health care is the total costs for mental health care resources as a percentage of total health care spending. Resources and spending examined were those that were actually or potentially under the regions' control. Annual costs for mental health services in the province were obtained for a seven-year period (fiscal year [FY] 2000 through FY 2006) from provincial utilization records for all residents in the province. Unit costs were assigned to each visit. The trend in the share measure was plotted for each year. The share for mental health care increased overall from FY 2000 (7.6%) to FY 2003 (8.2%), but returned to pre-FY 2003 levels in the three years after the transfer (7.6%). Despite concerns expressed before the transfer by federal and provincial reports over the level of expenditures devoted to mental health care, the integration of mental health services with other health services did not result in an increase of the share for mental health care.

We Need to Find Right Balance Between Telehealth, In-Person Care

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

This paper summarizes the findings for the European Region of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. The article presents a description of the region, an overview of mental health policies and legislation, a summary of relevant research in the region, a precis of community mental health services, a discussion of the key lessons learned, and some recommendations for the future.

Individuals with serious mental illnesses (SMI) face significant health disparities, also affecting physical health. While Community Mental Health (CMH) services primarily support mental recovery, their potential to address the physical health needs of this population remains insufficiently understood. In particular, little is known about how service users conceptualize health and evaluate support efforts - especially with regard to physical well-being. Gaining insight into these perspectives is essential for developing person-centered health promotion strategies that align with users' lived experiences and contribute to reducing persistent disparities.This qualitative study explored, how individuals with SMI understand health in everyday life, how they perceive the role of CMH professionals in supporting their health, and how they make sense of and respond to health promotion efforts - particularly those targeting physical well-being. Twenty-three qualitative interviews with users of CMH services in Germany were analyzed using a reconstructive, comparative approach that aimed to capture meaning-making processes embedded in everyday social practice.Participants expressed three distinct subjective health orientations: (a) agency-oriented, viewing health as the ability to shape one's life according to personal goals; (b) stability-oriented, emphasizing inner balance, emotional control, and predictability; and (c) functionality-oriented, focusing on the capacity to manage everyday tasks. These orientations were conceptually distinct and shaped participants' understanding of health, their attitudes toward CMH services, and their evaluation of health promotion. Health was understood as embedded in daily routines, relationships, and biographical experience. Psychological stability was seen as interconnected and essential for physical well-being. CMH professionals were seen as consistent and trusted partners who promote health through close, everyday relationships and hands-on support. Health promotion and support for physical health was strongly welcomed - if it was voluntary, respectful, and practically integrated into daily life.Health was defined not through symptoms, but as a lived, everyday experience shaped by stability, agency, and biographical context. Health promotion was broadly welcomed when it was voluntary, respectful, and practically embedded in daily life. Although CMH services are primarily focused on mental health, they offer a promising environment for addressing the physical health needs of individuals with SMI.

Editor's Note: In the commentary below, Francine Cournos, M.D., and Stephanie Le Melle, M.D., discuss the article on page 989, reprinted from the July 1981 issue of Hospital and Community Psychiatry. That article described a new group of chronic patients, young adults with poor social functioning who were draining the resources of public-sector programs. Drs. Cournos and Le Melle place the emergence of this patient group within a larger context of shifts in funding streams for social welfare programs and a lack of resources for community-based care. They describe studies published in this journal in the 1980s that examined many issues related to the treatment of young adult chronic patients—homelessness, outpatient commitment, and comorbid substance abuse—and they call on mental health professionals to advocate for more resources to improve patient care.

Back to table of contents Previous article Next article Professional NewsFull AccessBattles Over Money, Mission Limited CMHCs’ SuccessKate MulliganKate MulliganSearch for more papers by this authorPublished Online:6 Feb 2004https://doi.org/10.1176/pn.39.3.0007aThe concept of community mental health centers (CMHCs) has been an important part of discussions about how to provide mental health services at least since 1960, when the federal Joint Commission on Mental Illness and Health proposed one “fully staffed, full-time mental health clinic” for each 50,000 of population.In that year, the Democratic Party voted at its convention in favor of a plank in support of “greatly increased federal support for psychiatric research and training and community mental health programs to [help hospitalized mentally ill live in communities].”President John F. Kennedy attempted to fulfill that campaign promise with the appointment of a National Institute of Mental Health (NIMH) study group, which recommended “comprehensive” CMHCs offering inpatient, outpatient, and rehabilitative services, as well as education and public information.A coalition of mental health organizations supported a Kennedy proposal for CMHCs that would have provided funding for construction of CMHCs and limited staffing grants.Congress approved the construction costs but not the staffing grants until President Lyndon B. Johnson requested them with legislation, the Community Mental Health Centers Act Amendments, which passed in 1965.The NIMH mandated that CMHCs were to provide five essential mental health services: inpatient, emergency, partial hospitalization, outpatient, and education.Henry Foley, Ph.D., and Steven Sharfstein, M.D., wrote in Madness and Government (APPI, 1983), “In the beginning, then, CMHC services plus those of the state hospitals theoretically represented a balanced array, but the CMHC program alone did not. . . . The unanticipated consequence. . .was the failure of most CMHCs to develop even minimal rehabilitation and aftercare services for the mentally ill being discharged or diverted from state hospitals.”In 1972 President Richard M. Nixon argued that federal support for the CMHC program should be phased out and replaced with local support.Instead, in 1975 with new legislation, seven new services were added to the definition of “essential service.”“The enactment of PL 94-63 in July 1975 over a presidential veto climaxed a seven-year struggle for program survival, which included appropriation battles and impoundment suits,” wrote Foley and Sharfstein.By 1977, 650 CMHCs had been funded, covering 43 percent of the population and serving 1.9 million people that year. The $1.5 billion federal investment generated another $2.5 billion in other sources of funds.In 1977, however, the average length of stay for a patient in a state hospital was three weeks, down from six months in 1955.“The bold new CMHC approach had little time and too meager resources to test its mettle before being overtaken. . .by the urgent needs of patients with chronic mental illness,” wrote Foley and Sharfstein. In 1977, President Jimmy Carter established the President’s Commission on Mental Health, which ultimately made more than 100 major recommendations and findings.After considerable debate within the administration, Carter submitted the Mental Health Systems Act to Congress in 1979, where it was subjected again to much debate.“The primary mission of community mental health has been disputed since the beginning: the Systems Act forcefully restated each of three missions without resolving priorities,” according to Foley and Sharfstein.The missions are adequate clinical care, particularly for those with serious mental illness; supportive services; and prevention.President Ronald Reagan, who was elected in 1980, recommended that Congress cut the level of funding for the act by 25 percent and convert it into a block-grant program.In August 1981 he signed the Omnibus Budget Reconciliation Act, which “substantially repealed the Mental Health Services Act. . . . The federal government was entirely removed from the direction of the program and became a mere conduit of funds to the states.” ▪ ISSUES NewArchived

Background: The global burden of mental health conditions has led to the implementation of new models of care for persons with mental illness. Recent mental health reforms in Peru include the implementation of a community mental health model (CMHM) that, among its core objectives, aims to provide care in the community through specialized facilities, the community mental health centers (CMHCs). Community involvement is a key component of this model. This study aims to describe perceptions of community engagement activities in the current model of care in three CMHCs and identify barriers and potential solutions to implementation.Methods: A qualitative research study using in-depth semi-structured interviews with clinicians from three CMHCs and with policy-makers involved in the implementation of the mental health reforms was conducted in two regions of Peru. The interviews, conducted in Spanish, were digitally recorded with consent, transcribed and analyzed using principles of grounded theory applying a framework approach. Community engagement activities are described at different stages of patient care.Results: Twenty-five full-time employees (17 women, 8 men) were interviewed, of which 21 were clinicians (diverse health professions) from CMHCs, and 4 were policy-makers. Interviews elucidated community engagement activities currently being utilized including: (1) employing community mental health workers (CMHWs); (2) home visits; (3) psychosocial clubs; (4) mental health workshops and campaigns; and (5) peer support groups. Inadequate infrastructure and financial resources, lack of knowledge about the CMHM, poorly defined catchment areas, stigma, and inadequate productivity approach were identified as barriers to program implementation. Solutions suggested by participants included increasing knowledge and awareness about mental health and the new model, implementation of peer-training, and improving productivity evaluation and research initiatives.Conclusion: Community engagement activities are being conducted in Peru as part of a new model of care. However, their structure, frequency, and content are perceived by clinicians and policy-makers as highly variable due to a lack of consistent training and resources across CMHCs. Barriers to implementation should be quickly addressed and potential solutions executed, so that scale-up best optimizes the utilization of resources in the implementation process.

Back to table of contents Previous article Next article LettersFull AccessWhat Shaped My Career: In ReplyE. Fuller Torrey, M.D.E. Fuller TorreySearch for more papers by this author, M.D.Published Online:1 Nov 2019https://doi.org/10.1176/appi.ps.701106AboutSectionsView articleView PDFView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articleIN REPLY: I thank Dr. Sharfstein for his comments. He was one of the best of the “young, idealistic” mental health professionals at the National Institute of Mental Health (NIMH) to whom I referred in my personal account (1). His subsequent career has proven his dedication to providing services for persons with serious mental illness. Dr. Sharfstein tried to salvage the federal community mental health center (CMHC) program, but he inherited a program that was fatally flawed. One major mistake had been the selection and funding of centers directly by the National Institute of Mental Health (NIMH), completely bypassing the state mental health agencies that had had the primary responsibility for seriously mentally ill individuals for 150 years. Dr. Lucy Ozarin, who was a member of the 1963 CMHC planning task force, said that Dr. Robert H. Felix [first NIMH director] had made that decision even before the task force met (personal communication, interview with L. Ozarin, July 21, 2010).Editor's Note: Clearly, there are many perspectives, and I am pleased to use the Personal Accounts column as a way to elucidate the influences that have shaped our leaders.—L.B.D.Another major mistake was to not require the federally funded CMHCs to provide care for the patients being discharged from state hospitals. Most CMHCs therefore did not do so. As described in my 1988 book, Nowhere to Go, the longer a CMHC was in operation, the smaller was the percentage of its referrals from public mental hospitals. “In 1976, for example, CMHCs that had been operational for 1 to 2 years had 5.5 percent of their admissions referred from public mental hospitals, whereas CMHCs that had been operational for 6 to 7 years had only 2.6 percent of their admissions referred from public mental hospitals” (2). A 1979 NIMH report emphasized the problem: “The relationships between the CMHCs and public psychiatric hospitals are difficult at best, adversarial at worst” (2; emphasis in original). It has been widely claimed that President Reagan killed the federal CMHC program, but it can be equally argued that the program was stillborn.It is important not to conflate deinstitutionalization with the federal CMHC program. Driven by the availability of chlorpromazine, the emptying of state mental hospitals was inevitable and had begun in 1955. By the time that President Kennedy proposed his new program in 1963, the state hospitals had already been downsized by more than 54,000 patients, 10% of the total. Community psychiatry was also underway. A few good mental health centers existed prior to the federal program, such as the Prairie View Mental Health Center in Newton, Kansas, which opened in the 1940s. Similarly, the Fountain House Clubhouse in New York had opened in 1948. Thus, community psychiatry predates the federal CMHC program and has continued to thrive since the demise of that program.References1 Torrey EF: What shaped my career. Psychiatr Serv 70:961–962, 2019. https://ps.psychiatryonline.org/doi/10.1176/appi.ps.70901Google Scholar2 Torrey EF: Nowhere to Go: The Tragic Odyssey of the Homeless Mentally Ill. New York, Harper & Row, 1988Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 70Issue 11 November 01, 2019Pages 1074-1075 Metrics History Published online 1 November 2019 Published in print 1 November 2019