Evidence in Mental Health Care

Opportunities in mental health services research.

Policy Recommendations to Promote Integrated Mental Health Care for Children and Youth.

No service is an island: towards an ecosystem approach to mental health service evaluation.

The future of mental health in the UK: an election manifesto

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.

The literature on psychopathology among children in family foster care published in the last 20 years was reviewed to estimate prevalence and types of psychopathology in this population. A comprehensive computerized database was searched for the period 1974 through 1994, with emphasis on recent literature. Available evidence suggests that the prevalence of psychopathology among children in family foster care is higher than would be expected from normative data, even when this population is compared with children who have backgrounds of similar deprivation. As for the types of psychopathology in this population, the only apparent trend is the predominance of externalizing disorders, such as disruptive behavior disorders. A combination of social, psychological, and biological factors may render children in family foster care highly vulnerable to psychopathology.

A Global Call for Action to Prioritize Healthcare Worker Suicide Prevention During the COVID-19 Pandemic and Beyond.

Back to table of contents Next article Taking IssueFull AccessHealth Care Reform and Mental Health Care DeliveryVidhya Alakeson M.Sc.,Richard G. Frank Ph.D.,Vidhya Alakeson M.Sc.Search for more papers by this author,Richard G. Frank Ph.D.Search for more papers by this author,Published Online:1 Nov 2010AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Three articles in this issue of the journal review economic and policy implications for mental health delivery of the Patient Protection and Affordable Care Act, referred to as the ACA. The authors highlight opportunities for great improvement, as well as challenges, in the financing and delivery of mental health care in the United States. The ACA incrementally expands existing insurance, and it also creates and encourages the development and diffusion of important new institutions and organizational forms that will govern insurance markets and service provision. Garfield and colleagues describe these expansions. McGuire and Sinaiko explain the role of health insurance exchanges in restructuring the individual and small-group markets. Druss and Mauer explain the potential of new organizational forms to promote integration of mental health and other medical care, along with improved approaches to specialty care delivery.In each case, important potential gains in social welfare are noted, with an emphasis on key choices that must be made by those implementing the blueprint set out in the ACA. Gains in coverage among people with mental and substance use disorders are intertwined with the problems of poverty, illiteracy, and social isolation. Special efforts will be required to engage and enroll this deprived and frequently costly population. McGuire and Sinaiko explain that competitive insurance markets have functioned especially poorly in providing coverage to people at elevated risk of mental health and substance use problems. They review measures that might be adopted by new health insurance exchanges to mitigate historical failures in private insurance. The analysis presented by Garfield and colleagues highlights that gaps in services will remain despite coverage expansion, particularly for social supports that are not likely to be covered by private health insurance. Funding for wraparound services will continue to be important. Finally, Druss and Mauer suggest improvements in the infrastructure to promote improved mental health care within newly created medical homes and accountable care organizations. They call for development of a broader range of quality measures in mental health and the use of information technology by specialty providers.The ACA reinforces the place of mental health and substance use disorder care in the health care mainstream, building on the 2010 implementation of parity requirements for coverage of behavioral health care in private health insurance. Even though the field may have entered the mainstream of health care reform, it is still important to recognize and address the unique challenges to the health care system posed by individuals with mental and substance use disorders. The government and other stakeholders must redouble their commitments to craft policies that account for the sometimes exceptional circumstances presented by mental health care delivery.Nuffield TrustOffice of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services FiguresReferencesCited byDetailsCited ByNavigating a Complex Health System: the Perceptions of Psychiatric Residents in Addressing Sexual and Reproductive Health of Women with Severe Mental Illness21 February 2020 | Academic Psychiatry, Vol. 44, No. 4Behavioral Health's Integration Within a Care Network and Health Care Utilization30 May 2018 | Health Services Research, Vol. 53, No. 6The Role of Health Plans in Supporting Behavioral Health Integration23 June 2017 | Administration and Policy in Mental Health and Mental Health Services Research, Vol. 44, No. 6How Health Reform is Recasting Public PsychiatryPsychiatric Clinics of North America, Vol. 38, No. 3Administration and Policy in Mental Health and Mental Health Services Research, Vol. 42, No. 3 Volume 61Issue 11 November, 2010Pages 1063-1063PSYCHIATRIC SERVICES November 2010 Volume 61 Number 11 Metrics PDF download History Published online 1 November 2010 Published in print 1 November 2010

Back to table of contents Next article Taking IssueFull AccessHealth Care Reform and Mental Health Care DeliveryVidhya Alakeson M.Sc.,Richard G. Frank Ph.D.,Vidhya Alakeson M.Sc.Search for more papers by this author,Richard G. Frank Ph.D.Search for more papers by this author,Published Online:1 Nov 2010AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Three articles in this issue of the journal review economic and policy implications for mental health delivery of the Patient Protection and Affordable Care Act, referred to as the ACA. The authors highlight opportunities for great improvement, as well as challenges, in the financing and delivery of mental health care in the United States. The ACA incrementally expands existing insurance, and it also creates and encourages the development and diffusion of important new institutions and organizational forms that will govern insurance markets and service provision. Garfield and colleagues describe these expansions. McGuire and Sinaiko explain the role of health insurance exchanges in restructuring the individual and small-group markets. Druss and Mauer explain the potential of new organizational forms to promote integration of mental health and other medical care, along with improved approaches to specialty care delivery.In each case, important potential gains in social welfare are noted, with an emphasis on key choices that must be made by those implementing the blueprint set out in the ACA. Gains in coverage among people with mental and substance use disorders are intertwined with the problems of poverty, illiteracy, and social isolation. Special efforts will be required to engage and enroll this deprived and frequently costly population. McGuire and Sinaiko explain that competitive insurance markets have functioned especially poorly in providing coverage to people at elevated risk of mental health and substance use problems. They review measures that might be adopted by new health insurance exchanges to mitigate historical failures in private insurance. The analysis presented by Garfield and colleagues highlights that gaps in services will remain despite coverage expansion, particularly for social supports that are not likely to be covered by private health insurance. Funding for wraparound services will continue to be important. Finally, Druss and Mauer suggest improvements in the infrastructure to promote improved mental health care within newly created medical homes and accountable care organizations. They call for development of a broader range of quality measures in mental health and the use of information technology by specialty providers.The ACA reinforces the place of mental health and substance use disorder care in the health care mainstream, building on the 2010 implementation of parity requirements for coverage of behavioral health care in private health insurance. Even though the field may have entered the mainstream of health care reform, it is still important to recognize and address the unique challenges to the health care system posed by individuals with mental and substance use disorders. The government and other stakeholders must redouble their commitments to craft policies that account for the sometimes exceptional circumstances presented by mental health care delivery.Nuffield TrustOffice of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services FiguresReferencesCited byDetailsCited byNavigating a Complex Health System: the Perceptions of Psychiatric Residents in Addressing Sexual and Reproductive Health of Women with Severe Mental Illness21 February 2020 | Academic Psychiatry, Vol. 44, No. 4Behavioral Health's Integration Within a Care Network and Health Care Utilization30 May 2018 | Health Services Research, Vol. 53, No. 6The Role of Health Plans in Supporting Behavioral Health Integration23 June 2017 | Administration and Policy in Mental Health and Mental Health Services Research, Vol. 44, No. 6How Health Reform is Recasting Public PsychiatryPsychiatric Clinics of North America, Vol. 38, No. 3Administration and Policy in Mental Health and Mental Health Services Research, Vol. 42, No. 3 Volume 61Issue 11 November, 2010Pages 1063-1063PSYCHIATRIC SERVICES November 2010 Volume 61 Number 11 Metrics PDF download History Published online 1 November 2010 Published in print 1 November 2010

Photo by 168502358© Designer491|Dreamstime.com ABSTRACT Psychiatric Advance Directives (PADs) can protect the autonomy of those living with severe mental illness (SMI) and improve their treatment outcomes. However, their uptake is low for several documented reasons. Attempts to increase patient uptake of PADs can circumvent risks of undue provider influence in the facilitation process and promote optimal mental health outcomes with a peer-support model, thereby protecting patient autonomy in accordance with the principle of beneficence. Moreover, policymakers and mental health organizations should devote sufficient resources toward establishing peer-support specialist networks to mitigate the inequities those with SMI face. Capability theory can guide state leaders and directors in justifying the distribution of scarce resources to achieve these outcomes. INTRODUCTION Since the mid-twentieth century, scholars have increasingly rejected a strong paternalistic relationship between physician and patient, emphasizing the right of patients to accept or decline medical treatment.[1] With this greater emphasis on patient autonomy, a healthcare model of shared decision-making ascended in the 1980s.[2] Considering limitations in a patient’s capacity to make informed decisions in their treatment, the US Congress passed the Patient Self-Determination Act in 1990.[3] The act legally obliged hospitals and other care facilities that participate in Medicare and Medicaid to ask patients if they have an advance directive. In the absence of such a directive, these institutions are to ask if patients would like to complete one and to abide by it if presented by the patient.[4] These directives give patients control of future medical decisions in three key areas: entrusting an individual to act as a medical decision-making proxy, preferences for and consent to future treatment, and a statement of overall personal values and preferences to help inform future medical decisions by providers.[5] Although professionals initially crafted the law with end-of-life care in mind, 27 states now have mental health-specific provisions included in advance directive statutes.[6] As a subset of advance directives, psychiatric advance directives (PADs) are meant to protect patient autonomy during the treatment of psychiatric episodes when competence is compromised. Despite their promise and protection, PADs are underutilized by those with serious mental illness (SMI). In a survey of psychiatric patients, only 4-13 percent of respondents across multiple US sites reported having completed a PAD.[7] The same study indicated that 66-77 percent of respondents were interested in completing one if given assistance.[8] Having recognized the gap between patient interest and uptake, researchers have explored the possible reasons for this disparity. Several barriers have been identified and characterized at the system, health-professional, and service-user levels.[9] Although exploring interventions targeted at each level individually may be worthwhile, several barriers may be effectively overcome with one cross-level intervention. Specifically, a network of peer-support facilitators may be able to mitigate resource concerns of the system level, provider fears, reluctance, and lack of knowledge of PADs at the health-professional level, and a lack of trust and support among those with SMI within the service-user level.[10] Although the Patient Self-Determination Act mandated protections for patient autonomy, the law did not provide a sufficient mechanism to ensure the broad use of those protections. Much of the logistical burden falls on those living with SMI to educate themselves and initiate the completion of a PAD.[11] However, many of those living with SMI already face additional burdens that prevent their successful navigation of a complex healthcare system, including poverty, marginal housing, and food insecurity.[12] In addition, individuals with SMI tend to be more socially isolated, with few others to trust besides their providers.[13] Efforts to promote the uptake of PADs by those living with SMI that neglect these additional burdens risk exacerbating health inequities faced by those with SMI. Attempts to increase patient uptake of PADs should circumvent risks of undue provider influence in the facilitation process and promote optimal mental health outcomes with a peer-support model, thereby protecting patient autonomy per the principle of beneficence. Additionally, policymakers and mental health organizations should devote sufficient resources toward establishing peer-support specialist networks to mitigate the inequities those with SMI face. Capability theory can guide state leaders and directors in justifying the distribution of scarce resources to achieve these outcomes. I. System-Level Barriers to Psychiatric Advanced Directive Uptake At least three barriers to PAD uptake exist at the system level. Still, only one can be effectively addressed by peer-support specialists: resource implications to providers and administrators.[14] In one study, 71 percent of administrators and 52 percent of clinicians believed that a shortage of time would prevent adequate facilitation of PAD completion among those with SMI.[15] Logistical difficulties, such as incorporation into routine documentation and making them easily accessible, were mentioned by 25 percent of respondents in another study.[16] Professionals should take clinical burdens seriously since they can impact care and patient outcomes. Shifting to a peer-support model would alleviate these constraints on providers, who could then focus on other aspects of patient care. II. Health Professional-Level Barriers to Psychiatric Advance Directive Uptake Barriers at the health-professional level, which include a lack of knowledge and training, fear of complete treatment refusals, and a reluctance to facilitate PAD creation, keep patient uptake of PADs low.[17] Among these barriers is a need for more knowledge and training among healthcare professionals. In one study, 55 percent of health professionals had never heard of PADs; only 11 percent claimed they were "very familiar" with PADs.[18] In a survey of professionals, 45 percent voiced concern that the potential disadvantages such as the use of PADs to refuse medications could outweigh the benefits.[19] The reluctance of providers to assist service users in completing a PAD stemmed from concerns over time constraints and the providers’ ability to facilitate the completion of a PAD without bias.[20] These concerns are serious and hint at the asymmetrical power dynamic between providers and patients. By removing the responsibility of unbiased communication from the provider and placing it with peer-support facilitators, the risk to patient autonomy would be significantly lessened. III. Service User-Level Barriers to Psychiatric Advance Directive Uptake Several barriers exist at the service-user level that prevent the widespread adoption of PADs. These include a lack of trust, support, and knowledge of PADs, as well as a lack of understanding in completing a PAD.[21] Concerning trust, one study found that 43 percent of patients did not feel they had someone they could trust to help them complete their PAD.[22] Other studies indicated that patients had limited trust in their healthcare professionals.[23] Regarding the lack of support, one survey found that 94 percent of respondents would be unable to complete a PAD without assistance or without a facilitator.[24] Many patients lack knowledge and awareness of PADs, how to complete, and what to include in them.[25] Due to their complex legal nature, over half of the respondents in one survey indicated that they had problems understanding the PAD.[26] Similarly, 79 percent of clients interviewed in one study felt that PADs posed too much of a burden.[27] Through their shared lived experience, peer-support facilitators would be in a greater position to foster trust with patients and create the environment necessary for patients to explore their values and preferences through this process. IV. Circumventing Undue Provider Influence on Patient Autonomy The risk to patient autonomy is pervasive because of the advanced nature of medical practice and the dependence of patients to providers. In their delineation of bioethical principles, Beauchamp and Childress state: "To respect autonomous agents is to acknowledge their right to hold views, to make choices, and to take actions based on their values and beliefs."[28] This duty extends through a respectful attitude toward the patient and respectful action toward the patient.[29] On average, patients with SMI take 14.6 minutes to complete a PAD, which is well within the 30-minute time limit imposed by insurance reimbursement schedules.[30] However, as other researchers have indicated, this time of completion does not take into account the time required to inform and discuss the implications of future treatment decisions adequately.[31] Given that those living with SMI are often affected by cognitive deficits, the ability of a provider to relay complex health and legal information promptly may be further hamstrung.[32] By offloading the burden of providing efficient and practical education to patients with various levels of cognitive impairment, peer-support specialists could provide the necessary space and time to obtain informed consent and protect patient autonomy. Much of the moral force behind advance directives is the respect for patient autonomy, which has been a focus of researchers over the past several years.[33] Because psychiatric episodes severely limit the ability of a patient to make well-informed treatment decisions in a crisis, PADs are a way to protect the patient from paternalistic interventions. This takes on greater weight in treating patients experiencing a psychiatric episode when the threat and use of coercive treatment o

Datapoints: Psychotropic Drug Prescriptions by Medical Specialty

1167 T important role of general practitioners in prescribing antidepressant medications and treating depression has been documented. However, the extent to which general practitioners are prescribing other types of psychotropic medications has received less emphasis. This study used data from August 2006 to July 2007 from the National Prescription Audit (NPA) Plus database of IMS to examine this question. IMS collects transaction information each month from approximately 36,000 retail pharmacies, representing about 70% of all retail pharmacies, which when weighted represent all prescriptions filled in retail outlets in the United States. Using a separate sample of retail pharmacy transactions that includes the physician’s Drug Enforcement Administration number, IMS assigns physician specialty information to obtain an estimate of the total number of prescriptions filled in retail pharmacies by medical specialty. As shown Figure 1, of the 472 million prescriptions for psychotropic medications, 59% were written by general practitioners, 23% by psychiatrists, and 19% by other physicians and nonphysician providers. General practitioners wrote prescriptions for 65% of the anxiolytics in the sample, 62% of the antidepressants, 52% of the stimulants, 37% of the antipsychotics, and 22% of the antimania medications. Conversely, psychiatrists and addiction specialists wrote prescriptions for 66% of the antimania medications, 49% of the antipsychotics, 34% of the stimulants, 21% of the antidepressants, and 13% of the anxiolytics. Pediatricians were included as general practitioners and wrote 25% of all stimulant prescriptions but only 3% of all other types of psychotropic medications (data not shown). Prescribing of psychotropic medications by nonpsychiatrists improves access to treatment. However, concerns remain about whether patients treated in the general medical setting are receiving treatment concordant with evidence-based guidelines, psychotherapy, adequate medication monitoring, and appropriate intensity of treatment. Psychotropic Drug Prescriptions by Medical Specialty

The NHS: what are the UK's political parties promising?

Meso-level Comparison of Mental Health Service Availability and Use in Chile and Spain

Seventeen definitions of the severely and persistently mentally ill have appeared in the literature over the past decade. These definitions have been used by 13 authors to formulate service programs and to estimate the prevalence of serious mental illness in the population. To test the applicability of these definitions, the authors operationalized each definition and applied it to a representative sample of 222 patients receiving services in one of Philadelphia's inner-city neighborhoods. The analysis showed estimates of prevalence of serious mental illness ranging from 4% to 88% of the treated population, depending on the definition applied. The NIMH (1987) definition was representative of the middle-range estimates of 45% to 55% arrived at by eight authors.