Ambulatory Mental Health Services Research Articles

Dropout from Mental Health Treatment Among Asylum-Seekers in Israel: A Retrospective Chart Study.

Dropout from psychiatric treatment and psychotherapy is common among asylum-seekers, even though they are at increased risk of emotional distress and psychiatric disorders. We aimed to define the associations between demographic and clinical variables and dropout among asylum-seekers in Israel. In this retrospective chart review we initially examined 271 files from Gesher (Bridge, in Hebrew), a government psychiatric clinic for asylum-seekers. All cases were considered eligible provided data were sufficient and asylum-seeker status could be ascertained. Of the 101 files included in the analysis, comparisons between patients who dropped out and patients who continued treatment were made, and logistic regression for dropout risk was conducted. In the study sample, 27 patients (26.7%) dropped out of treatment. Diagnosis of psychotic spectrum disorder and shorter time in Israel were significantly associated with dropout. Parenthood was significantly associated with dropout for men, but not for women. Defining factors associated with dropout and adherence to therapy for asylum-seekers may help improve ambulatory mental health services and the outcomes of treatment for this population.

Health service use for young males and females with a mental disorder is higher than their peers in a population-level matched cohort

BackgroundTo inform healthcare planning and resourcing, population-level information is required on the use of health services among young people with a mental disorder. This study aims to identify the health service use associated with mental disorders among young people using a population-level matched cohort.MethodA population-based matched case-comparison retrospective cohort study of young people aged ≤ 18 years hospitalised for a mental disorder during 2005–2018 in New South Wales, Australia was conducted using linked birth, health, and mortality records. The comparison cohort was matched on age, sex and residential postcode. Adjusted rate ratios (ARR) were calculated for key demographics and mental disorder type by sex.ResultsEmergency department visits, hospital admissions and ambulatory mental health service contacts were all higher for males and females with a mental disorder than matched peers. Further hospitalisation risk was over 10-fold higher for males with psychotic (ARR 13.69; 95%CI 8.95–20.94) and anxiety (ARR 11.44; 95%CI 8.70-15.04) disorders, and for both males and females with cognitive and behavioural delays (ARR 10.79; 95%CI 9.30-12.53 and ARR 14.62; 95%CI 11.20-19.08, respectively), intellectual disability (ARR 10.47; 95%CI 8.04–13.64 and ARR 11.35; 95%CI 7.83–16.45, respectively), and mood disorders (ARR 10.23; 95%CI 8.17–12.80 and ARR 10.12; 95%CI 8.58–11.93, respectively) compared to peers.ConclusionThe high healthcare utilisation of young people with mental disorder supports the need for the development of community and hospital-based services that both prevent unnecessary hospital admissions in childhood and adolescence that can potentially reduce the burden and loss arising from mental disorders in adult life.

Hospital service utilisation of people previously hospitalised with different subtypes of psychotic disorder: A record linkage study.

Little research has examined the physical and mental comorbidities, and health service use patterns, of people diagnosed with psychotic disorder subtypes other than schizophrenia spectrum disorders. This study aims to examine the physical and mental comorbidities, and subsequent hospital service use patterns, of individuals previously hospitalised with various psychotic disorder subtypes using linked health service data. We included individuals hospitalised with a psychotic disorder in New South Wales, Australia, between 1 July 2002 and 31 December 2014 (N = 63,110). We examined the demographic profile of the cohort and rates of subsequent acute hospital care and ambulatory mental health service use. We compared the rates of subsequent hospital admissions, emergency department presentations and ambulatory mental health treatment days of people hospitalised with different psychotic disorder subtypes to people hospitalised with schizophrenia spectrum disorders using Poisson regression. People most recently hospitalised with mood/affective disorders and psychotic symptoms had a higher rate of subsequent hospital admissions than those most recently hospitalised with schizophrenia spectrum and delusional disorders (adjusted incident rate ratio = 1.06; 95% confidence interval = [1.02, 1.10]), while people most recently hospitalised with drug-induced and other organic (adjusted incident rate ratio = 1.19; 95% confidence interval = [1.12, 1.27]) and acute psychotic disorders (adjusted incident rate ratio = 1.10; 95% confidence interval = [1.03, 1.18]) had more subsequent emergency department presentations than those most recently hospitalised with schizophrenia spectrum and delusional disorders. All three groups had fewer subsequent mental health ambulatory days than those most recently hospitalised with schizophrenia spectrum and delusional disorders (adjusted incident rate ratios = 0.85-0.91). The health profiles and subsequent hospital service use patterns of people previously hospitalised with different psychotic disorder subtypes are heterogeneous, and research is needed to develop targeted health policies to meet their specific health needs.

The health service contact patterns of people with psychotic and non-psychotic forms of severe mental illness in New South Wales, Australia: A record-linkage study.

To describe and compare the health profiles and health service use of people hospitalised with severe mental illness, with and without psychotic symptoms. We conducted a historical cohort study using linked administrative datasets, including data on public hospital admissions, emergency department presentations and ambulatory mental health service contacts in New South Wales, Australia. The study cohort comprised 169,306 individuals aged 12 years and over who were hospitalised at least once with a mental health diagnosis between 1 July 2002 and 31 December 2014. Of these, 63,110 had a recorded psychotic illness and 106,196 did not. Outcome measures were rates of hospital, emergency department and mental health ambulatory service utilisation, analysed using Poisson regression. People with psychotic illnesses had higher rates of hospital admission (adjusted incidence rate ratio (IRR) 1.26; 95% confidence interval [1.23, 1.30]), emergency department presentation (adjusted IRR 1.17; 95% confidence interval [1.13, 1.20]) and ambulatory mental health treatment days (adjusted IRR 2.90; 95% confidence interval [2.82, 2.98]) than people without psychotic illnesses. The higher rate of hospitalisation among people with psychotic illnesses was driven by mental health admissions; while people with psychosis had over twice the rate of mental health admissions, people with other severe mental illnesses without psychosis (e.g. mood/affective, anxiety and personality disorders) had higher rates of physical health admissions, including for circulatory, musculoskeletal, genitourinary and respiratory disorders. Factors that predicted greater health service utilisation included psychosis, intellectual disability, greater medical comorbidity and previous hospitalisation. Findings from this study support the need for (a) the development of processes to support the physical health of people with severe mental illness, including those without psychosis; (b) a focus in mental health policy and service provision on people with complex support needs, and (c) improved implementation and testing of integrated models of care to improve health outcomes for all people experiencing severe mental illness.

A randomized trial of permanent supportive housing for chronically homeless persons with high use of publicly funded services.

ObjectiveTo examine whether randomization to permanent supportive housing (PSH) versus usual care reduces the use of acute health care and other services among chronically homeless high users of county‐funded services.Data SourcesBetween 2015 and 2019, we assessed service use from Santa Clara County, CA, administrative claims data for all county‐funded health care, jail and shelter, and mortality.Study DesignWe conducted a randomized controlled trial among chronically homeless high users of multiple systems. We compared postrandomization outcomes from county‐funded systems using multivariate regression analysis.Data CollectionWe extracted encounter data from an integrated database capturing health care at county‐funded facilities, shelter and jails, county housing placement, and death certificates.Principal FindingsWe enrolled 423 participants (199 intervention; 224 control). Eighty‐six percent of those randomized to PSH received housing compared with 36 percent in usual care. On average, the 169 individuals housed by the PSH intervention have remained housed for 28.8 months (92.9 percent of the study follow‐up period). Intervention group members had lower rates of psychiatric ED visits IRR 0.62; 95% CI [0.43, 0.91] and shelter days IRR 0.30; 95% CI [0.17, 0.53], and higher rates of ambulatory mental health services use IRR 1.84; 95% CI [1.43, 2.37] compared to controls. We found no differences in total ED or inpatient use, or jail. Seventy (37 treatment; 33 control) participants died.ConclusionsThe intervention placed and retained frequent user, chronically homeless individuals in housing. It decreased psychiatric ED visits and shelter use, and increased outpatient mental health care, but not medical ED visits or hospitalizations. Limitations included more than one‐third of usual care participants received another form of subsidized housing, potentially biasing results to the null, and loss of power due to high death rates. PSH can house high‐risk individuals and reduce emergent psychiatric services and shelter use. Reductions in hospitalizations may be more difficult to realize.

Postpartum mental health service utilization in women with Human Immunodeficiency Virus (HIV): a population-based study

ABSTRACTWomen with HIV have higher rates of psychiatric disorders than HIV-negative women, yet little is known about their postpartum mental health and associated service use. The purpose of this study was to characterize HIV-positive women’s use of ambulatory and acute mental health services in the first year postpartum, relative to HIV-negative women. Using health administrative data, we identified 861,365 women who had a live birth delivery from April 1, 2002 to March 31, 2012 in Ontario, Canada, of whom 530 were identified to be HIV-positive. We described their use of mental health services, including outpatient mental health visits, psychiatric emergency department (ED) visits and hospitalizations using adjusted odds ratios (aORs) and 95% confidence intervals (CIs). HIV-positive women were more likely to access outpatient mental health services (31.5% vs. 21.0%, aOR, 1.26; 95% CI, 1.03–1.55), but more likely to remain engaged in psychiatrist services only (15.6% vs. 6.5%, aOR, 2.35; 95% CI, 1.41–3.72). They were also more likely to require a psychiatric ED visit or hospitalization (3.3% vs. 1.1%, aOR, 2.74; 95% CI, 1.72–4.12). Our findings highlight the importance of considering postpartum mental health as part of comprehensive reproductive health care for women with HIV.

Contact with mental health services after medically verified self-harm: A prospective data linkage study

IntroductionHigh rates of self-harm resulting in acute health service contact have been observed in adults released from prison. Contact with health services due to self-harm is a key intervention opportunity to prevent deleterious health outcomes. Little is known about subsequent mental health service contact after discharge from acute health services.
 Objectives and ApproachWe aimed to describe mental health service contact after discharge from acute health service contacts following self-harm in a representative sample of adults released from prison. Ambulance, emergency department (ED), hospital inpatient and ambulatory mental health service records were probabilistically linked to pre-release interview data. Self-harm events after release were identified from ICD codes and coded from case notes in ambulance, ED, and hospital records. We calculated the time between discharge from ambulance, ED, or hospital after self-harm and subsequent contact with mental health services. Factors predicting the likelihood of mental health service contact were examined using multivariate logistic regression.
 ResultsOf 1307 adults released from prison, 108 (8.3%) experienced 218 self-harm events resulting in acute health service use in the community. Of these presentations, 0%, 59%, and 50% of discharges from ambulance attendances, ED and hospital, respectively, had subsequent contact with a specialist mental health service within 7 days of that acute service contact. Mental health service contact within 7 days of acute service contact was positively associated with being female (adjusted odds ratio [AOR]: 3.27; 95%CI: 1.26-8.47) and being identified by prison staff as at risk for self-harm (AOR: 3.34; 95%CI: 1.29-8.62), and was negatively associated with dual diagnosis (AOR: 0.19: 95%CI: 0.06-0.61), substance use disorder only (AOR: 0.13; 95%CI: 0.04-0.48) and physical health functioning (AOR: 0.96; 95\%CI: 0.92-0.99).
 Conclusion/ImplicationsAlmost half of adults with a recent history of incarceration discharged from acute health service after self-harm did not receive timely specialist mental health care. Improved integration of acute health services and ambulatory mental health services could improve outcomes for adults who present with self-harm.

What is the current level of mental health service delivery and expenditure on infants, children, adolescents, and young people in Australia?

The study aim was to estimate the current level of ambulatory mental health service delivery to young people aged 0-24 years in Australia and associated government expenditure. Recognising the importance of the early years for the development of mental illness and socioeconomic outcomes, we were particularly interested in service access by infants and young children. We extracted information from government administrative datasets on the number of people who received mental health services, number of services and expenditure through the health sector for 2014-2015. Results are primarily reported by age groups 0-4, 5-11, 12-17 and 18-24 years. Less than 1% of 0- to 4-year-olds received a mental health service in any one service setting, whereas nearly 11% of 18- to 24-year-olds received a mental health service through the Medicare Benefits Schedule Better Access programme alone. Many more services were delivered to 12- to 24-year-olds (>4 million) than to 0- to 11-year-olds (552,000). Medicare Benefits Schedule Better Access delivers services to more children and youth than do state/territory community mental health services, although the latter provide more services per client. In 2013-2014, Australian Government expenditure on ambulatory mental health services for 0- to 24-year-olds was AUD428 million, similar to the AUD491 million spent by state/territory governments. The study provides a benchmark for data-driven service planning to ensure that the mental health needs of infants, children and young people are met. Our results indicate that the youngest age group are underserviced relative to need, even noting infants and children may receive services for behavioural/mental health issues from providers not captured in our study (such as paediatricians). The developmental origins of mental illness underlies the urgency of adequate provision by governments of perinatal, infant and child mental health services to avoid loss of life potential and reduce the pressures on the justice, child protection and welfare systems.

Mental Health Conditions and Symptoms in Pediatric Hospitalizations: A Single-Center Point Prevalence Study

BackgroundChildren and adolescents necessitating hospitalization for physical health conditions are at high risk for mental health conditions; however, the prevalence of mental health conditions and symptoms among hospitalized children and adolescents is uncertain. The objective of this study was to determine the proportion of hospitalized children and adolescents who have diagnosed mental health disorders or undiagnosed mental health problems. MethodsIn this single-center point prevalence study of hospitalized children between the ages of 4 and 21 years, patients or their parents reported known mental health diagnoses and use of services using the Services Assessment for Children and Adolescent, and they reported patient mental health symptoms using the Pediatric Symptom Checklist, 17-item form (PSC-17). ResultsOf 229 eligible patients, 119 agreed to participate. Demographic characteristics of patients who enrolled were not statistically significantly different from those of patients who declined to participate. Among participants, 26% (95% confidence interval [CI], 18%–35%) reported a known mental health diagnosis. On the PSC-17, 29% (95% CI, 21%–38%) of participants had a positive screen for mental health symptoms. Of those with a positive screen, 38% (95% CI, 21%–55%) had no known mental health diagnosis, and 26% (95% CI, 12%–43%) had not received ambulatory mental health services in the 12 months before hospitalization. ConclusionsMental health conditions and symptoms are common among patients hospitalized in a tertiary children's hospital, and many affected patients are not receiving ambulatory mental health services.

Ambulatory mental health data demonstrates the high needs of people with an intellectual disability: results from the New South Wales intellectual disability and mental health data linkage project.

To investigate the ambulatory mental health service profile of persons with intellectual disability (ID) in a representative sample of New South Wales (NSW). A statistical linkage key was used to link the Disability Services Minimum Data Set (DS-MDS) and a community mental health services dataset (MH-COM) for a representative area of NSW for the period 2005-2010. Linkage was undertaken in four NSW local health districts (LHDs), covering 36.7% of the NSW population. The mental health profiles and service use characteristics of people with an ID were compared to mental health service users without an ID. Of the 89,262 people in the MH-COM over this 6-year period, 1,459 people (1.6 %) were identified as having an ID. Compared to those without an ID, people with an ID were more likely to have psychotic disorders, developmental disorders and personality disorders, and more than twice as likely to have an 'unknown' diagnosis. Compared to those without an ID, people with an ID were less likely to have depressive disorders, adjustment disorders and other disorders. Service use profiles revealed that people with an ID had 1.6 times more face-to-face contacts, and a total face-to-face contact time which was 2.5 times longer than people without an ID. Ambulatory mental health data from NSW indicates that people with an ID receive care for a distinct range of mental disorders, and experience uncertainty regarding their diagnosis. People with an ID have higher service needs which require recognition and the allocation of specific resources. Such data provide a suitable baseline for future evaluation of the impact of ambulatory mental health reforms for people with an ID.

Evidence of system-based stigma in treatment of somatic and biomedical disorders in children with mental disorder: A population-based health utilization study

Objective: In this study we examine, across physician billing, ambulatory and inpatient/emergency datasets, the health care utilization of individuals under the age of 18 years for somatic disorders in relationship to the existence of a physician assigned psychiatric disorder [1]. Methods: Visit data for all cases receiving specialized ambulatory, emergency or inpatient (tertiary) mental health services was constructed and subsequently matched on age and sex with comparisons in a final ratio of 1:8. Comparisons were health care users who did not receive treatment in the specialized tertiary public mental health system. Based on approximately 10 million billing records, we compared the average number of visits per unique individual for “physical diagnoses” (non-psychiatric) and psychiatric diagnoses over the 16 year comparison groups. Results: We report among those with and without psychiatric disorders that physical disorders are significantly greater for with any psychiatric disorder over the 16 year study period in both physician billing and ambulatory datasets. This result differs in the inpatient/emergency dataset in that cases have about 1/3 the number of admissions for physical diagnoses. Discussion: It was unexpected that cases with a psychiatric diagnosis in the physician billing dataset had fewer physical disorder inpatient and emergency admissions. We suggest that this finding represents a form of system-based stigma [2]. Conclusion: System-Based stigma or treatment bias is a very serious issue that marginalizes the treatment of the biomedical disorders of children identified with Mental Disorder.

P-351 - Evidence of System-Based Stigma in the Hospital Reatment of Physical Disorders of Children and Adolescents with Psychiatric Disorders

In this study we examine, across physician billing, ambulatory and inpatient/emergency data sets, the relationship between physical health and mental health costs among those with and without psychiatric disorders under the age of 18 years on their index vist. Visit data for all cases receiving specialized ambulatory, emergency or inpatient (tertiary) mental health services was constructed and subsequently matched on age and sex with comparisons in a final ratio of 1:8. Comparisons were health care users who did not receive treatment in the specialized tertiary public mental health system). Based on approximately 10 Million billing records, we compared the average number of visits and average costs per unique individual for “physical diagnoses” (non-psychiatric) and psychiatric diagnoses over the 16 year study period across case and comparison groups. We report among those with and without psychiatric disorders that physical disorders are significantly greater for those with any psychiatric disorder over the 16 year study period in both physician billing and ambulatory datasets. This result differs in the inpatient / emergency dataset in that cases have about 1/3 the number of admissions for physical diagnoses. It was unexpected that cases with a psychiatric diagnosis in the physician billing dataset had fewer physical disorder inpatient and emergency admissions. We suggest that this finding represents a form of system-based stigma.

Homelessness and children's use of mental health services: A population-based study

This study examined whether children who become homeless differ from other low-income children in their mental health service use before and after their first homeless episode, and to what extent homelessness is associated with an increased likelihood of mental health service use. Differences between children with and without new onset of sheltered homelessness in the use of mental health services emerged following homelessness and widened over time. Sheltered homelessness and foster care placement history were associated with increased odds of receiving inpatient and ambulatory mental health services. Findings underscore the importance of collaborations between homeless assistance, foster care, and mental healthcare in efforts to mitigate family homelessness and collateral needs among homeless children.

Two views: Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America

Back to table of contents Previous article Next article Book ReviewsFull AccessTwo views: Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in AmericaRory P. Houghtalen, M.D.Rory P. HoughtalenSearch for more papers by this author, M.D.Published Online:1 Apr 2011https://doi.org/10.1176/ps.62.4.pss6204_0438aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in AmericaWhitakerRobert; New York, Crown Publishing, 2010, 416 pages, $26Will reading Robert Whitaker's Anatomy of an Epidemic interest you or make you angry? My guess: this book will do both. Whitaker is an investigative journalist best known for his writing on the treatment of the mentally ill population in America and the growing influence of the pharmaceutical industry in the practice of medicine and psychiatry. His latest book combines these topics. These intertwined issues deserve our attention and are generally good for provoking loud debates, if not genuine placard-carrying protests.I am unable to fully bridle my enthusiasm to point out the flaws in Whitaker's theories. His primary premise is that the reason so many more people are now on disability rolls for mental illness than was the case in the halcyon days of the 1950s is because they were exposed to psychotropic medication. There are a host of logical errors in his analysis that I painfully learned earning a B in Logic 101 as a college sophomore, most notably post hoc reasoning and the appealing slippery slope.Like a skillful prosecutor presenting a circumstantial case, Whitaker “connects the dots” to “expose” the pharmaceutical industry-American Psychiatric Association-National Institute of Mental Health-National Alliance on Mental Illness conspiracy (yes, even NAMI is a co-conspirator) to put every man, woman, and child on the planet on one psychotropic drug or another. The inclusion of heartbreaking stories of people mired in debilitating situations at the end of each chapter is a rather obvious ploy to appeal to emotion, increasing the likelihood of a conviction in the court of public opinion. Sadly, witnesses to the often life-improving, if not life-saving, benefits of properly applied medical treatments for mental illness barely find a voice in the transcript of this trial.This said, I cannot disagree with Prosecutor Whitaker that behaviors of the pharmaceutical industry and its speakers' bureaus, the practitioners of footloose diagnosis and fancy-free polypharmacy (especially for the young), the too cozy relationships between big pharma and big academia, and dare I say certain decisions the APA has made all provide enough evidence for an adverse verdict, especially by a lay reader. The author makes important points about overvalued theories, misplaced treatments, and bad behaviors of some engaged in the often messy, uncertain practice of medicine and psychiatry. Unfortunately, this book is more indictment than honest critique—an example of confirmation bias pretentiously devoid of any balance in the attack.This book provokes thought, discussion, and strong emotions. It will force you to reflect on the strength of the evidence for psychiatry's convictions about the nature and proper treatment of mental illness, to evaluate your personal professional practices, and to renew the oath that you as a physician once took to “first do no harm.” These are all good things. You should read this book; patients and their families will, and you should be ready with some answers to their questions. My copy is full of margin notes to prepare responses that I hope will not sound too defensive when delivered.Dr. Houghtalen is medical director of ambulatory mental health services and education, Department of Behavioral Health, Unity Health System, Rochester, New York.The reviewers report no competing interests. FiguresReferencesCited byDetailsCited byNone Volume 62Issue 4 April 2011Pages 438-439 Metrics PDF download History Published online 1 April 2011 Published in print 1 April 2011

Shared care in mental illness: A rapid review to inform implementation

BackgroundWhile integrated primary healthcare for the management of depression has been well researched, appropriate models of primary care for people with severe and persistent psychotic disorders are poorly understood. In 2010 the NSW (Australia) Health Department commissioned a review of the evidence on "shared care" models of ambulatory mental health services. This focussed on critical factors in the implementation of these models in clinical practice, with a view to providing policy direction. The review excluded evidence about dementia, substance use and personality disorders.MethodsA rapid review involving a search for systematic reviews on The Cochrane Database of Systematic Reviews and Database of s of Reviews of Effects (DARE). This was followed by a search for papers published since these systematic reviews on Medline and supplemented by limited iterative searching from reference lists.ResultsShared care trials report improved mental and physical health outcomes in some clinical settings with improved social function, self management skills, service acceptability and reduced hospitalisation. Other benefits include improved access to specialist care, better engagement with and acceptability of mental health services. Limited economic evaluation shows significant set up costs, reduced patient costs and service savings often realised by other providers. Nevertheless these findings are not evident across all clinical groups. Gains require substantial cross-organisational commitment, carefully designed and consistently delivered interventions, with attention to staff selection, training and supervision. Effective models incorporated linkages across various service levels, clinical monitoring within agreed treatment protocols, improved continuity and comprehensiveness of services.Conclusions"Shared Care" models of mental health service delivery require attention to multiple levels (from organisational to individual clinicians), and complex service re-design. Re-evaluation of the roles of specialist mental health staff is a critical requirement. As expected, no one model of "shared" care fits diverse clinical groups. On the basis of the available evidence, we recommended a local trial that examined the process of implementation of core principles of shared care within primary care and specialist mental health clinical services.

The Way Home

Back to table of contents Previous article Next article Book ReviewFull AccessThe Way HomeRory P. Houghtalen M.D.Rory P. Houghtalen M.D.Search for more papers by this authorPublished Online:1 Dec 2010https://doi.org/10.1176/ps.2010.61.12.1268aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail There's an old saying that "Every father should remember that one day his son will follow his example instead of his advice." Popular conversation about American culture has renewed an examination of the changing roles of men. What does manhood mean now in a world of rapidly changing mores? Many men find themselves more confused than ever about their roles, and there is nothing like the complex dynamics between father and son to shine a bright light on this predicament. With tight writing and an edgy tone, George Pelecanos, award-winning writer of the gritty television crime series "The Wire," has crafted a crime novel that mines the nuances of the psychology of manhood, codes of honor, and the dynamics of fathers and sons. Even though The Way Home will appeal to men and women, it is important to note that this is a manly story. Teen Chris Flynn faces a sentence at the Pinewood juvenile detention center after an escalating series of conduct problems, and his father's rescue attempts can no longer protect him. Unable to break his son of the demons that once inhabited his own character, Tom can only bear witness to Chris' inability to walk away from trouble and his fumbling attempts to define himself as his own man. Joining his father's business after his release, Chris begins to enjoy the new "working" relationship that finally seems to be narrowing the gap between them until a dramatic discovery on a job site threatens not only the budding relationship between father and son, but also Chris' life and those in his circle of family and friends. A harrowing rollercoaster ride of events ends in redemption and reconciliation that draws the family close again, and Chris learns that he and his father are not so very different, as he once believed. The book's title clearly telegraphs the book's ending, but the read is a journey well worth taking anyway. Dr. Houghtalen is medical director of Ambulatory Mental Health Services and Education, Unity Health System Department of Behavioral Health, Rochester, New York. FiguresReferencesCited byDetailsCited ByNone Volume 61Issue 12 December, 2010Pages 1268-1269PSYCHIATRIC SERVICES December 2010 Volume 61 Number 12 Metrics PDF download History Published online 1 December 2010 Published in print 1 December 2010

PW01-104 - Factors associated to use of ambulatory public mental health services among patients with schizophrenia in Spain. Case register study: RESMA

ObjectiveTo identify factors associated with visits by patients with schizophrenia and related disorders to community mental health services, under the Mental Health Department of Carlos Haya Hospital in Malaga, Spain.MethodsWe undertook a cross-sectional study. Data on demographic and clinical factors and service use were obtained from the public mental health services database and centralized in the “Malaga Schizophrenia Case Register (RESMA)”. The outcome measure, defined as the total number of outpatient consultations during one year, was analyzed by multilevel multivariate linear regression.ResultsThe analysis included 1097 patients with diagnoses of schizophrenia and related disorders (F20-F29, ICD-10).The adjusted model explained 46.35% of the variance. Patients who contacted both types of professional (nurses and psychiatrists) had a higher number of visits compared to patients who only contacted a psychiatrist (p< 0.001), and the individual psychiatrist attending the patients was also associated with the number of visits (p< 0.001).Clinical variables, such as a higher global level of severity (p< 0.001), a diagnosis of a persistent delusion disorder and having an inpatient episode (p< 0.001), were also associated with a higher number of visits. Patients who were receiving welfare benefits or who had no formal education or were illiterate had a higher number of visits. Patients living alone, living outside the study area and living in more rural municipalities was associated with fewer ambulatory contacts.ConclusionAmong all variables, the role of psychiatrists and nurses in organized outpatient settings present the strongest association with the number of visits by similar patients.

Systematic care for caregivers of people with dementia in the ambulatory mental health service: designing a multicentre, cluster, randomized, controlled trial

BackgroundCare for people with dementia and their informal caregivers is a challenging aim in healthcare. There is an urgent need for cost-effective support programs that prevent informal caregivers of people with dementia from becoming overburdened, which might result in a delay or decrease of patient institutionalization. For this reason, we have developed the Systematic Care Program for Dementia (SCPD). The SCPD consists of an assessment of caregiver's sense of competence and suggestions on how to deal with competence deficiencies. The efficiency of the SCPD will be evaluated in our study.Methods and designIn our ongoing, cluster, randomized, single-blind, controlled trial, the participants in six mental health services in four regions of the Netherlands have been randomized per service. Professionals of the ambulatory mental health services (psychologists and social psychiatric nurses) have been randomly allocated to either the intervention group or the control group. The study population consists of community-dwelling people with dementia and their informal caregivers (patient-caregiver dyads) coming into the health service. The dyads have been clustered to the professionals. The primary outcome measure is the patient's admission to a nursing home or home for the elderly at 12 months of follow-up. This measure is the most important variable for estimating cost differences between the intervention group and the control group. The secondary outcome measure is the quality of the patient's and caregiver's lives.DiscussionA novelty in the SCPD is the pro-active and systematic approach. The focus on the caregiver's sense of competence is relevant to economical healthcare, since this sense of competence is an important determinant of delay of institutionalization of people with dementia. The SCPD might be able to facilitate this with a relatively small cost investment for caregivers' support, which could result in a major decrease in costs in the management of dementia. Implementation on a national level will be started if the SCPD proves to be efficient.Trial RegistrationNCT00147693

Gender differences in health and health care utilisation in various ethnic groups in the Netherlands: a cross-sectional study

BackgroundTo determine gender differences in health and health care utilisation within and between various ethnic groups in the Netherlands.MethodsData from the second Dutch National Survey of General Practice (2000–2002) were used. A total of 7,789 persons from the indigenous population and 1,512 persons from the four largest migrant groups in the Netherlands – Morocco, Netherlands Antilles, Turkey and Surinam – aged 18 years and older were interviewed. Self-reported health outcomes studied were general health status and the presence of acute (past 14 days) and chronic conditions (past 12 months). And self-reported utilisation of the following health care services was analysed: having contacted a general practitioner (past 2 months), a medical specialist, physiotherapist or ambulatory mental health service (past 12 months), hospitalisation (past 12 months) and use of medication (past 14 days). Gender differences in these outcomes were examined within and between the ethnic groups, using logistic regression analyses.ResultsIn general, women showed poorer health than men; the largest differences were found for the Turkish respondents, followed by Moroccans, and Surinamese. Furthermore, women from Morocco and the Netherlands Antilles more often contacted a general practitioner than men from these countries. Women from Turkey were more hospitalised than Turkish men. Women from Morocco more often contacted ambulatory mental health care than men from this country, and women with an indigenous background more often used over the counter medication than men with an indigenous background.ConclusionIn general the self-reported health of women is worse compared to that of men, although the size of the gender differences may vary according to the particular health outcome and among the ethnic groups. This information might be helpful to develop policy to improve the health status of specific groups according to gender and ethnicity. In addition, in some ethnic groups, and for some types of health care services, the use by women is higher compared to that by men. More research is needed to explain these differences.

Modelling Candidate Effectiveness Indicators for Mental Health Services

Although Australia and the UK have both made efforts to systematize outcome measurement in mental health services, surprisingly little attention has been paid to how best to analyse routine outcome data in order to determine how services are performing. Outcome data collected in acute inpatient and ambulatory mental health services across Australia during the 2006-2007 financial year were used. three approaches to measuring effectiveness were explored: effect size (ES); the reliable change index (RCI); and standard error of measurement (SEM). The most conservative results were produced by the RCI and the least conservative by the medium ES statistic and the SEM. By way of example, only 38.0% of inpatient admission-discharge periods of care showed significant improvement for adults when the RCI was used, whereas 67.4% and 72.9% did so when the medium ES and the SEM statistics were used, respectively. In any routine outcome measurement exercise, the degree of effectiveness demonstrated by services will depend on the specific statistical indicator used to judge effectiveness. Routine outcome measurement has the potential to answer a range of crucial performance-related questions, but only if the same metric is used. Discussion of the appropriate statistical approach to take to facilitate cross-service, cross-area and even cross-national comparisons warrants attention.