Profane Mysteries: the Otherworldly in Caricature and Satire of the Russian Fin de Siècle

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.

Service provision in psychiatric and social care is increasingly guided by recovery principles. However, little is known about the degree of consensus among stakeholders in diverse contexts on the components of care that most promote recovery. This study aimed to identify specific items of care that key stakeholders regard as most important in promoting recovery for people with longer-term mental health problems in institutional care, to measure consensus between and across stakeholder groups and countries, and to develop a conceptual framework of the most important domains of care. Ten European countries in various stages of deinstitutionalization participated in a series of conventional three-round iterative Delphi exercises. In each country individuals in four separate expert groups (service users, mental health professionals, caregivers, and advocates) identified components of care that they considered important to recovery and then rated their group's suggestions in terms of importance. Median and consensus ratings were measured. High-ranking items were grouped into domains. A total of 4,098 separate items of care were proposed by the 40 participating groups. Eleven broad domains of care important for recovery were identified: social policy and human rights, social inclusion, self-management and autonomy, therapeutic interventions, governance, staffing, staff attitudes, institutional environment, postdischarge care, caregivers, and physical health care. Consensus between groups and countries was generally high, but some modest differences in priorities were noted. The most consistently highly rated consensus domain was therapeutic interventions. Domains and components of care related to recovery principles were also viewed as important across stakeholder groups.

Recent Changes in Medicaid Policy and Their Possible Effects on Mental Health Services

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

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.

Opportunities in mental health services research.

Back to table of contents Previous article Next article LetterFull AccessLetterLarry Davidson Ph.D.Larry Davidson Ph.D.Search for more papers by this authorPublished Online:1 Apr 2010https://doi.org/10.1176/ps.2010.61.4.418AboutSectionsView articleView PDFView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articleRecovery and the Medical Model in Institutional CareTo the Editor: The March issue included an article by Turton and colleagues ( 1 ) describing a process that assessed stakeholder views on the most important treatment components in promoting recovery of people receiving institutional care in the European Union. The authors expressed surprise that aspects of care that were ranked as being most important were "therapeutic interventions" and other domains of "a more conventional" medical model. They contrasted these domains to ones that they considered more reflective of a "recovery" orientation—such as "autonomy and self-management, social inclusion, dignity, hope"—and inferred from these findings that the recovery vision might need to be tempered a bit by giving more importance to medical aspects of care and less value to such "broader recovery principles" as autonomy and dignity. Given that the study was limited to asking stakeholders about institutional care and that participants were chosen based on their belief that "the institutional setting [is] an environment that supports people in moving back into the community," the only thing that surprised me was that the authors were surprised by this largely tautologous finding. Thus I find the conclusions they draw from their findings concerning. Turton and colleagues readily acknowledge that these findings might be due to the fact that therapeutic interventions and medical care "form the very basis and raison d'être of health care." What they perhaps have not taken fully into account is that therapeutic interventions and medical care form the very justification for institutional care in particular. The question they asked participants was, "In your view, what most helps recovery for people with long-term mental health problems in institutional care?" It would be hard to argue that autonomy or social inclusion are the most helpful aspects of care for people in institutions when these are the same aspects of care that are most compromised in institutional settings. In fact, how could institutional care promote autonomy or social inclusion when by its very function it serves to supervise and segregate? A very different answer to this question could have been "What would most help recovery is for these people to be discharged to community-based care in natural settings." It does not seem that this answer was considered as a possibility.Rather than interpreting these data to suggest that the recovery orientation needs to be counterbalanced by the medical model, I take these findings, along with the focus of the study on institutional care, to indicate the stage at which the participating countries are at this time in history. It is hard to move beyond the authors' acknowledgment that their results "inevitably reflect[ed] the selected orientation and affiliations of our participants." The results would likely have been different had they recruited stakeholders with experiences of systems that no longer use institutional care. It is worth noting, for example, that advocates and service users in Italy, where institutional care has been prohibited since 1978, did not endorse this "medical" domain at all. What the results suggest to me, therefore, is that many stakeholders remain tied to a predominantly medical model of care carried out within institutional settings. But this is precisely why a transformation of mental health care is needed to begin with.Dr. Davidson is affiliated with the Department of Psychiatry, Yale University, New Haven, Connecticut.Reference1. Turton P, Wright C, White S, et al: Promoting recovery in long-term institutional mental health care: an international Delphi study. Psychiatric Services 61:293–299, 2010Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 61Issue 4 April, 2010Pages 418-418PSYCHIATRIC SERVICES April 2010 Volume 61 Number 4 Metrics History Published online 1 April 2010 Published in print 1 April 2010

Medical Clinic Characteristics and Access to Behavioral Health Services for Persons With HIV

In 2004, the American Academy of Pediatrics (AAP) Board of Directors formed the Task Force on Mental Health and charged it with developing strategies to improve the quality of child and adolescent mental health* services in primary care. The task force acknowledged early in its deliberations that enhancing the mental health care that pediatricians and other primary care clinicians† provide to children and adolescents will require systemic interventions at the national, state, and community levels to improve the financing of mental health care and access to mental health specialty resources. Systemic strategies toward achieving these improvements are the subject of other publications of the task force: “ Strategies for System Change in Children's Mental Health: A Chapter Action Kit ” (chapter action kit),1 “Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration,”2 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3 The task force also recognized that enhanced mental health practice will require competencies not currently achieved by many primary care clinicians; in the policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,”4 the task force collaborated with the AAP Committee on Psychosocial Aspects of Child and Family Health to outline these competencies and propose strategies for achieving them. This report offers strategies for preparing the primary care practice itself for provision of enhanced mental health care services. The task force proposes incrementally applying chronic care principles to the care of children with mental health and substance abuse problems as primary care clinicians apply them to the care of children with chronic medical conditions such as asthma. Most primary care clinicians will find that significant gaps exist between their current practice and the proposed ideal. The task force offers guidance in … Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy{at}wfubmc.edu

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 International NewsFull AccessWHO Annual Report Devoted To Mental Health IssuesJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:2 Nov 2001https://doi.org/10.1176/pn.36.21.0001aThe World Health Organization has done something unprecedented this year—it has devoted both its World Health Day and its World Health Report to a single topic.WHO dedicated its World Health Day on April 7 to mental health, with the goal that it would galvanize leaders and policymakers around the world to improve care for people with mental illness (Psychiatric News, February 2). And now WHO has devoted its World Health Report 2001 to mental health as well.The report contains five chapters. Chapter one discusses mental health in general and explains why it is as important as physical health to the overall well-being of individuals, families, communities, and societies.Neuropsychiatric disorders account for 31 percent of the world’s disabilities.Chapter two addresses the treatment gap as one of the most important issues in mental health today. It states that throughout the world, mental and neurological disorders account for 12 percent of the total disability-adjusted life years lost due to all diseases and injuries, yet only a small minority of people receive any treatment.Chapter three is concerned with shifting from institutionalized care to care in the community. In practice, community care implies the development of a wide range of services within local settings. This process, which has not yet begun in many regions and countries, aims to ensure that some of the protective functions of the asylum are fully provided and that the negative aspects of the institutions are not perpetuated. However, this chapter warns against closing mental hospitals without community alternatives and, conversely, creating community alternatives without closing mental hospitals. Both have to occur at the same time, in a well-coordinated, incremental way.Chapter four deals with mental health policy and service provision. “Governments, as the ultimate stewards of mental health, need to assume the responsibility for ensuring that these complex activities are carried out,” the report states. “People should be protected from catastrophic financial risk, which means minimizing out-of-pocket payments in favor of prepayment methods, whether via general taxation, mandatory social insurance, or voluntary private insurance. The healthy should subsidize the sick through prepayment mechanisms, and a good financing system will also mean that the well-off subsidize the poor, at least to some extent.”This chapter also points out that the public mental health budget in many countries is mainly spent on institutional care, with few resources being made available for more effective community services. The chapter also notes that in most countries mental health services need to be reevaluated and reformed to provide the best available treatment.Finally, chapter five contains recommendations and three scenarios for action. These are among the report’s recommendations:• Provide treatment for mental disorders in primary care settings. The management and treatment of mental disorders in primary care is a fundamental step that enables the largest number of people to get easier and faster access to services—it needs to be recognized that many are already seeking help at this level.• Make psychotropic drugs available at all levels of health care. These medicines should be included in every country’s essential-drugs list, and the best drugs to treat conditions should be made available whenever possible. In some countries, this may require enabling legislation changes.• Provide mental health care through community-based services. Community care has a better effect than institutional treatment on the outcome and quality of life of individuals with chronic mental disorders.• Educate the public about mental illnesses. The main goal is to reduce barriers to treatment and care by increasing awareness of the frequency of mental disorders, their treatability, the recovery process, and the human rights of people with mental disorders.• Involve communities, families, and consumers in the development of mental health services. Such involvement should lead to services being better tailored to people’s needs and better used.• Establish mental health policies, programs, and legislation for sustained action. Most countries need to increase their budgets for mental health programs from current low levels.• Develop mental health resources. Most developing countries need to increase and improve training of mental health professionals, who will provide specialized care as well as support the primary health care programs.• Get sectors such as education, labor, welfare, and law involved in improving the mental health of communities. • Monitor community mental health by including mental health indicators in health information and reporting systems.• Support more research into the biological and psychosocial aspects of mental health to increase the understanding of mental disorders and to develop more effective interventions.The first scenario for action—Scenario A—applies to economically poorer countries where resources are absent or very limited: They should train personnel, make essential drugs available at all health facilities, and move the mentally ill out of prisons.Scenario B applies to countries with modest resources: They should close custodial mental hospitals and integrate mental health care into general health care.Scenario C applies to countries with the most resources: They should improve the management of mental disorders in primary health care, ease access to newer drugs, and have community care facilities offer a full range of mental health services.Darrel Regier, M.D., director of APA’s Office of Research and executive director of the American Psychiatric Institute for Research and Education, was involved in the preparation of the report as an adviser to WHO and as a consultant on the report. WHO also sought the input of other leading psychiatrists and mental health professionals around the world in preparing the report.The report is being sent to all 190 WHO member states, the hundreds of nongovernmental organizations that have an official relationship with WHO, the international media, all WHO collaborating centers, the public health community, and anyone from the general public who asks for it.What kind of influence might the report have on world mental health? Psychiatric News asked this question of Reshma Prakash, a WHO information officer in Geneva, Switzerland, as well as of Regier. Prakash said that WHO is hoping the report will “update governments, policymakers, and the general public on the latest data on mental health and bring home to governments the importance of putting more resources into mental health and formulating the right kind of policies to address the mental health needs of their people.”Said Regier, “I hope that the report will have the same impact on a global basis that we have had from the surgeon general’s mental health report on a national basis, which is to really raise the level of appreciation of the importance of mental health as a fundamental component of any health care program. For instance, in many countries around the world mental health remains much more separate from the rest of medicine than it does even here in the United States. I would like to see the report correct that situation—that is, get people in various countries to integrate mental health care into the mainstream of health care.”“The World Health Report 2001—Mental Health: New Understanding, New Hope” can be accessed on the Web at www.who.int/whr/ by clicking on “contents.” ▪ ISSUES NewArchived

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

Focus on Transformation: A Public Health Model of Mental Health for the 21st Century

This policy analysis provides insight into the ongoing process of mental health reform and the difficulty of sustaining such reform in post-conflict areas. It is based on experiences in Bosnia Herzegovina and Kosovo in the former Yugoslavia. This could be the first health policy analysis specifically on the subject of mental health reform in post-conflict areas. Mental health reforms started in 1995 in Bosnia Herzegovina and in Kosovo in 1999, immediately following the end of armed conflict in these regions. As a result, there are now sufficient literature studies and experience available in both areas to make an initial evaluation and policy analysis. Both areas were studied during various stages of the implementation of mental health reform, and because of this provided insight into the different phases of this ongoing process. The insights provided by this study could have implications for things such as the development of strategies for improving the sustainability of mental health reform in similar situations in future. Mental health problems account for five of the 10 leading causes of disability worldwide, which amounts to 12% of the total global burden of disease.1 In general, war-related disabilities (physical injuries) and mental disorders have an increasing impact on the global burden of disease. Projections for 2020 rank unipolar major depression and war-related disabilities in first and eighth place, respectively, in their impact on the global burden of diseases; in 1990 they ranked fourth and sixteenth.1 Mental health reform refers to a shift from institutional mental health care towards community mental health and mental health care. The WHO's World Health Report 2001 showed worldwide interest in community mental health care, considered to be more cost-effective than institutional care. Care of this kind makes it possible to intervene early when mental disorders are developing, and to limit the …

Mental Health in the Context of Health Disparities