Exploring service users experiences of remotely delivered CBT interventions in primary care during COVID-19: An interpretative phenomenological analysis.

Primary Care Mental Health Services (PMHCS) aim to provide accessible and effective psychological interventions. However, there is a scarcity of qualitative research focused on patients’ experiences. Service users’ experience can inform development of accessible, high-quality mental health services. Nine semi-structured interviews were analysed from Primary Care Mental Health users in Northern Scotland using Interpretative Phenomenological Analysis (IPA). Four superordinate themes were generated: Orientating to treatment, Intervention features, Change enablers, and Impact. The results identified both facilitators and barriers associated with access and psychological change; and narratives around CBT acceptability, outcomes and remote delivery. The role of GPs emerged as a key determinant of access to PMHCS. The therapeutic relationship contributed to person-centred care provision, idiosyncratic change processes and self-empowerment. A personal commitment to engage with homework was described as a crucial change enabler. Findings are discussed in relation to existing literature, practical implications and suggestions for future research.

Primary care mental health services play a crucial role in public mental health by providing local and accessible psychological interventions that meet individuals' needs. Despite growing research investigating service users' perspectives of psychological interventions, a qualitative systematic review in this context is not available. The present meta-synthesis collates the existing articles and gives a thematic synthesis of qualitative studies on service users' experience of psychological interventions in primary care. Multiple databases (CINAHL, EMBASE, PsychINFO, MEDLINE, and Cochrane Library) were searched for published qualitative studies of service users' experiences of psychological interventions delivered in primary care. Articles were included if they met inclusion criteria. Study quality was assessed using the Critical Appraisal Skills Programme tool. All types of psychological interventions were considered across model and delivery format (e.g., face-to-face, computerised programmes, and group). NVIVO was used to code the dataset and themes were extracted following thematic synthesis. Twenty-two studies were included. Four analytical themes and 10 subthemes emerged. The identified themes were as follows: (1) 'Access and Acceptability: facilitators and barriers', (2) 'Structural aspects'; (3) 'Therapeutic process' and (4) 'Outcomes'. A model of interrelationships between themes is proposed. Findings suggest several 'essential ingredients' across psychological interventions and modalities. The crucial role of relational factors, the importance of assessing service users' perceptions of treatment features (e.g., remote delivery) and of tailoring the intervention to their needs were emphasised. Results also suggest involving service users more in discussions and decisions about psychological interventions offered might enhance access, acceptability, and engagement. Recommendations for practice and research are provided.

Current health policy in Ireland, as articulated in the HSE’s Transformation Programme (2007-2010), has a focus on the health and wellbeing of the whole population and demands a shift from the hospital system to the primary care setting as the central locus of service delivery.1 The main vehicle for this change is the Primary Care Strategy (2001) which recommended the establishment across the country of primary care multidisciplinary teams (PCTs) supported by specialist services in primary care networks (PCNs).2 The Primary Care Strategy and Transformation Programme documents both emphasise that successful implementation depends on close liaison and integration between PCTs and networks and secondary care services so that the patient journey from one service to the next is “seamless and delay free”.1 Consistent with the broad thrust of the national health strategy, the Vision for Change (2006) policy framework for mental health services makes the ambitious statement that it is not enough for a comprehensive mental health policy to make recommendations relating solely to specialist mental health services – it must also deliver mental health activities capable of improving the wellbeing of the population as a whole.3 However, while Vision for Change recommends that links between specialist mental health and primary care services should be enhanced and formalised, most of its recommendations relate specifically to specialist mental health service provision. It envisaged that multidisciplinary community mental health teams (CMHTs) occupy community mental health centres in proximity to other community services, but did not go as far as to recommend the actual co-location of CMHTs and PCTs. In a significant recent development, the HSE has now committed to the provision of physical space to accommodate community mental health teams (CMHTs) and day hospital services within all primary care health centres as the Primary Care Strategy is rolled out nationally. This decision represents a potential milestone in the evolution of mental health service delivery. It presents particular challenges to the historic relationship between primary care and specialist mental health services both of which have been relatively underdeveloped in Ireland, have evolved separately and between which deficiencies in communication and collaboration have been reported by service users and providers alike.4,5 While the health strategy documents describe overall structures designed to increase primary care capacity and improve integration between primary care and secondary care services, other than the inclusion of a clinical psychologist in the envisaged networks, no detailed working arrangements are described. The Vision for Change document identifies the need to build mental healthcare capacity within primary care through enhanced primary care mental health resources, as well as through education and training initiatives, and it recommends the consultation-liaison model in order to achieve greater integration with specialist mental health services. However, at present there is no specific guidance available to either the newly formed PCTs or to existing mental health services in how to pursue these goals. In a worsening economic climate both services can be seen as entering unknown territory without a road-map and both services may have an understandable anxiety as to whether the goal of improved mental health for the population as a whole can be delivered without compromising the quality of service provided to society’s most vulnerable individuals.6

Managed care organizational complexity and access to high-quality mental health services: Perspective of U.S. primary care physicians

The integration of mental health services into primary care is a globally acclaimed strategy to close the treatment gap for mental disorders, but it has also been criticised for encouraging the medicalisation of everyday life. In Chile, this strategy has gained support and spread quickly in the last decades, and today, all primary public care centres have incorporated a mental health service. However, although some reports highlight problems that have arisen with integrated primary care, the critical social analysis of its impact on services, teams and communities is scarce. This article aims to analyse how primary public mental healthcare services (PPMHSs) in Chile could be contributing to medicalise life. Health policies, reports, evidence from research on local public health issues and the author’s experience are examined to develop the arguments. It is suggested that issues with the universal health access and integrated primary public care policies and the institutionalised use of standard classifications of mental disorders support the survival of a reductionist biomedical disease model and a trend to psychopathologise life. We conclude that these factors underpin the medicalisation of everyday life in primary public mental healthcare services in Chile. Critical engagement with daily practice is necessary to prevent PPMHSs from disempowering people and communities by providing them with medicalised solutions, instead of generating agency in their everyday problem-solving behaviours.

A reflection of the current status of the mental healthcare system in South Africa

This article draws on an environmental scan and interviews with visible minority immigrants in a small urban Atlantic community to report on gaps and opportunities for improving access to information about primary mental health care services and barriers to utilization of these services. Information about services was limited and did not specifically address the complex health-related concerns of immigrants with diverse religious and cultural backgrounds. Accessing information about mental health care services was challenging for some visible minority immigrants because of physical and financial constraints and limited computer and language literacy. The major barriers to the utilization of primary mental health care services were lack of information, language and literacy issues, a mistrust of primary mental health care services, the stigma associated with mental illness, long wait times, lack of finances, and religious and cultural differences and insensitivity. A list of nine recommendations, which may be of interest to mental health decision-makers and service providers in small urban centers with limited ethno-cultural diversity, is provided.

our years ago, when the Mental Health Review last focused on primary care, we took a ‘swift journey over the extensive ground of primary care and mental health’ (Pidd & McArthur, 2000). That review was written when only the 17 first-wave PCTs were in existence, most PCGs were still moving towards PCT status, and much of the landscape that has become familiar since the publication of Shifting the Balance of Power (Department of Health, 2001) had yet to develop. At that time, taking an overview of the key challenges facing primary care organisations in respect of mental health services and how those issues were being addressed, we felt cautiously hopeful. We recognised the continuing cultural differences between primary and secondary care mental health services and that considerable work was needed on several fronts to develop consistent and effective primary mental health care. Primary care organisations were still establishing themselves and shaping up to their role, and were frequently hampered by limited person power. Nonetheless, we cautiously acknowledged a period of new opportunities to re-engineer care, while recognising that it might be some time before PCTs would be in a position to drive forward the primary mental health care agenda. Where are we now? The intervening period has seen further relentless modernisation in primary care and in mental health services. For the NHS as a whole, we have probably reached the closest approach, however imperfect, to a ‘primary care-led NHS’ that we have yet seen. Are we still travelling hopefully toward a bright future for primary mental health care? Or has conservatism ‘in the system’ (and consequently, cynicism) inevitably set in? To a degree the wealth of material within this issue answers the question. The articles attest to a wide range of developmental work in primary mental health care, F contributing to the improvement of services and to better practice. They also illustrate the increasing profile of primary mental health care. It is no longer the poor relation, rarely getting attention and airspace, but is now firmly on the agenda and part of the mainstream discourse. A brief look at developing primary mental health care, and at PCT commissioning of mental health services, should help to determine how far we have travelled and how promising the current ‘state of the nation’ is.

Evolution of Child Mental Health Services in Primary Care

Improving the management of depression in primary careWith the overarching aim of making the management of depression easier, Lewisham PCT have implemented a multifaceted programme to develop primary health care workers' skills, knowledge and resources so as to improve their service to patients with depression. Now in its second year, the programme has, and still is, constantly evolving. This article outlines the programme's key messages and components during its first year, and briefly refers to its expansion and future aims.Primary care mental health services for 16‐19 year oldsStudies suggest that many young people who would benefit from accessing mental health services do not do so, as they fall into the gap between child and adult services. This report outlines the results of a project carried out within Bury Mental Health Services to establish what young people want from primary care mental health services and whether current service provision meets their needs. Copyright © 2007 Wiley Interface Ltd

Mental health services worldwide, including in the UK, face significant constraints that necessitate effective resource planning for delivering high-quality care. The application of analytics in healthcare offers the potential to enhance efficiency and improve care quality. However, achieving this vision is particularly challenging in the context of mental healthcare. This paper focuses on the evaluation and redesign of a Primary Care Mental Health (PCMH) service located in Kent, UK. To address this problem, we propose an analytics-driven approach that integrates the three stages of descriptive, predictive, and prescriptive analytics with an optimization model. Through a comprehensive case study, we illustrate how this integrated approach serves as a valuable tool for experimentation within the PCMH service. We explicitly detail how data analysis and stakeholder engagement informed model development. The findings of our novel multi-skill multi-location model demonstrate the benefits of utilising optimised workforce planning to reduce unmet demand while ensuring equitable workload distribution among clinicians. We also discuss the adaptability of the analytics approach and the potential applicability of the optimization model in mental health and other care settings.

BackgroundIntegration of mental health services into primary healthcare is proliferating in low-resource countries. We aimed to evaluate the impact of different compositions of primary care mental health services for depression and alcohol use disorder (AUD), when compared to usual primary care services.MethodsWe conducted a non-randomized controlled study in rural Nepal. We compared treatment outcomes among patients screening positive and receiving: (a) primary care mental health services without a psychological treatment component (TG); (b) the same services including a psychological treatment (TG + P); and (c) primary care treatment as usual (TAU). Primary outcomes included change in depression and AUD symptoms, as well as disability. Disability was measured using the 12-item WHO Disability Assessment Schedule. Symptom severity was assessed using the 9-item Patient Health Questionnaire for depression, the 10-item Alcohol Use Disorders Identification Test for AUD. We used negative binomial regression models for the analysis.ResultsFor depression, when combining both treatment groups (TG, n = 77 and TG + P, n = 60) compared to TAU (n = 72), there were no significant improvements. When only comparing the psychological treatment group (TG + P) with TAU, there were significant improvements for symptoms and disability (aβ = − 2.64; 95%CI − 4.55 to − 0.74, p = 0.007; aβ = − 12.20; 95%CI − 19.79 to − 4.62; p = 0.002, respectively). For AUD, when combining both treatment groups (TG, n = 92 and TG + P, n = 80) compared to TAU (n = 57), there were significant improvements in AUD symptoms and disability (aβ = − 15.13; 95%CI − 18.63 to − 11.63, p < 0.001; aβ = − 9.26; 95%CI − 16.41 to − 2.12, p = 0.011; respectively). For AUD, there were no differences between TG and TG + P. Patients’ perceptions of health workers’ skills in common psychological factors were associated with improvement in depression patient outcomes (β = − 0.36; 95%CI − 0.55 to − 0.18; p < 0.001) but not for AUD patients.ConclusionPrimary care mental health services for depression may only be effective when psychological treatments are included. Health workers’ competencies as perceived by patients may be an important indicator for treatment effect. AUD treatment in primary care appears to be beneficial even without additional psychological services.

Continued engagement with primary mental health services has been associated with the prevention of subsequent suicidal behaviour; however, there are few studies that identify determinants of treatment disengagement among those at risk of suicide in primary care settings. This study investigated determinants of treatment disengagement of those at risk of suicide who were referred to primary mental health care services in Western Sydney, Australia. This study used routinely collected data of those referred for suicide prevention services provided through primary mental health care services between July 2012 and June 2018. Associations between sociodemographic, diagnostic, referral- and service-level factors and treatment non-attendance and early treatment cessation were investigated using a series of multivariable generalised estimation equations. There were 1654 suicidal referrals for 1444 people during the study period. Those identified with a risk of suicide were less likely to never attend treatments (16.14% vs 19.77%), but were more likely to disengage earlier from subsequent service sessions (16.02% vs 12.41%), compared to those with no risk of suicide. A higher likelihood of non-attendance to any primary mental health care service sessions was associated with those aged 25-44, lower socioeconomic status, a presentation for substance use and a referral from acute care (either emergency department or hospital). Among those who attended an initial treatment session, younger age (18-24 years) and a longer waiting time for an initial follow-up appointment were associated with a higher likelihood of early treatment cessation from primary mental health care services. These findings can inform potential strategies in routine primary mental health care practice to improve treatment engagement among those at risk of suicidal behaviour. Youth-specific interventions, behavioural engagement strategies and prompt access to services are policy and service priorities.

Primary process: why psychiatry and general practice should collaborate

Mental Health Care Reforms in Latin America: Child and Adolescent Mental Health Services in Mexico