Community-based Mental Health System Research Articles

Assessment of care provision integration in a community-based mental health system: balanced care model implementation in Andalusia (Spain).

Andalusia is the second largest region in Spain, and it has developed a comprehensive mental health (MH) plan that encourages the consolidation of the balanced care model. However, its geographical and socioeconomic disparity is a great challenge for a community-based MH system. Both the assessment of the implementation of the MH plan and the development of new tools to support decision-making can be considered critical. The present study aims (i) to assess how the integration of different types of MH care may influence system performance and (ii) to check the performance evolution of the integration process geographically regarding the small MH areas of Andalusia. The performance of the Andalusian MH system was assessed by combining Monte Carlo simulation, fuzzy inference and data envelopment analysis. The relative technical efficiency was the main performance indicator. A correct integration of appropriate types of MH care, according to population needs, increases the performance of the Andalusian MH system both from global and regional perspectives. The spatial representation (based on small MH areas) of the results highlights how the performance depends on specific geographical characteristics. By analyzing the identified spatial clusters, defined by different management patterns depending on user and socioeconomic characteristics, benchmark areas and areas for improvement can be studied to design evidence-informed policies and interventions. A global analysis of MH system performance was carried out, including both the successive integration of different types of care and its spatial evolution. Although an appropriate integration of different types of MH care has a positive effect on the Andalusian MH system, this process has different profiles depending on specific geographically based user and socioeconomic characteristics. The balanced care model can be considered the paradigm for assessing the performance of a large and populated territory such as Andalusia, which has a community-based MH system. This methodological approach (performance assessment and spatial analysis) may be used as a guide for developing future evidence-informed policies and managerial interventions.

Mental health care delivery and quality of service provision in Brazil

Public mental health system in Brazil is structured through “The Psychosocial Care Network (Rede de Atenção Psicossocial, RAPS)". This coordinated system comprises primary care, specialized mental health care, crisis management services, inpatient units, deinstitutionalization initiatives, and psychosocial rehabilitation programs. In this narrative review, we aim to provide an overview of mental health care delivery in Brazil by assessing three aspects of the RAPS: structure, operationalization, and current state. For reviewing its structure, we start by overviewing the public health system, then examining the psychiatric reform, as well as the law and policy that established the components of the community-based mental health system in the country. Regarding the operationalization, we review recommendations for how the different components of the system should be coordinated, as well as directions for practices at the assistance level. Finally, we review the results of the mental health system, including official data and academic publications assessing coverage, funding, and quality of care. Drawing on the results from this review, we highlight fragilities that indicate three future directions for strengthening the mental health provision in Brazil: establishing appropriate mechanisms for systematic assessment of the mental health system, improving the recommendations regarding the coordination and integration of services, and promoting evidence-based practices across the different levels of care provision.

Community Mental Health Services in Italy.

In 1978, in Italy, approval of Basaglia's reform law marked a shift from an asylum-based to a community-based mental health system. The main aim of the reform was to treat patients in the community and no longer in psychiatric hospitals. Following the Italian model, similar reforms of mental health care have been approved worldwide. The community-based model aims to promote integration and human rights for people with mental disorders on the basis of their freedom to choose treatment options. By 2000, all psychiatric hospitals had been closed and all patients discharged. Mental health care is organized through the Department of Mental Health, which is the umbrella organization responsible for specialist mental health care in the community; this includes psychiatric wards located in general hospitals, residential facilities, mental health centres, and day-hospital and day-care units. Approval of Law 180 led to a practical and ideological shift in the provision of care to patients with mental disorders. In particular, the reform highlighted the need to treat patients in the same way as any other patient, and mental health care moved from a custodialistic to a therapeutic model. Progressive consolidation of the community-based system of mental health care in Italy has been observed in the past 40 years. However, some reasons for concern still exist, including low staffing levels, potential use of community residential facilities as long-stay residential services, and a heterogeneity in the availability of resources for mental health throughout the country.

“They’ll Give You a Second Chance”: Perceptions of Youth and Caregivers Regarding Their Experiences in a Community-Based Mental Health System of Care

Child-and-family-centered systems of care and the inclusion of child, youth, and family voice represent an alternative to traditional, authoritarian approaches to children’s mental health treatment. Although much has been written about the centrality of child, youth, and family voice in creating responsive and effective mental health systems, the literature contains limited research highlighting the viewpoints of youth and caregivers themselves who have participated in systems of care. Our exploratory study seeks to narrow that gap. Utilizing eight semi-structured youth and caregiver interviews, we assessed the perceptions of youth and their caregivers participating in a community-based mental health system of care. Five primary themes emerged. The families we interviewed described negative previous experiences with mental health treatment and a strong sense of satisfaction with the care they received using a system of care approach. In addition, they expressed appreciation of the quality of relationships developed as a part of their treatment, felt individualized services made treatment more personally meaningful, and were empowered to act as active agents in obtaining future mental health treatment and achieving life goals. Implications for practice and future research are discussed, with the goal that the insights gleaned from our exploratory study can be used to inform future research and practice efforts seeking to incorporate child, youth, and family voice into children’s mental health services.

De “myth” ifying Mental Health – Findings from a Community University Research Alliance (CURA)

Many myths exist regarding mental illness and those with mental health issues. Under the auspices of a Community-University Research Alliance on Housing and Mental Health, a partnership between academics, community health and social service agencies and representatives of consumer-survivor groups, fourteen consumer-survivor and eight family member focus groups were held throughout Southwestern Ontario. Individual interviews were also conducted with 150 male and 150 female community-based mental health system consumer-survivors living in a variety of housing environments in London, Ontario. The findings dispute beliefs around four myths: that people with mental health problems are a homogenous population, which was highlighted by significant differences between men and women in frequency and length of psychiatric hospitalizations, primary diagnosis, problem severity, psychoactive drug use and sexual abuse, are unemployed because they are uneducated, are violent and dangerous and thus spend extended periods of time incarcerated and are unsupported by their families which then leads to housing problems. Challenging these and other equally erroneous myths is essential in responding to the oppression faced by mental-health consumer-survivors and in developing a national strategy for mental health.

Integrated mental health services in China: challenges and planning for the future.

Eager to build an integrated community-based mental health system, in 2004 China started the '686 Programme', whose purpose was to integrate hospital and community services for patients with serious mental illness. In 2015, the National Mental Health Working Plan (2015-2020) proposed an ambitious strategy for implementing this project. The goal of this review is to assess potential opportunities for and barriers to successful implementation of a community-based mental health system that integrates hospital and community mental health services into the general healthcare system. We examine 7066 sources in both English and Chinese: the academic peer-reviewed literature, the grey literature on mental health policies, and documents from government and policymaking agencies. Although China has proposed a number of innovative programmes to address its mental health burden, several of these proposals have yet to be fully activated, particularly those that focus on integrated care. Integrating mental health services into China's general healthcare system holds great promise for increased access to and quality improvement in mental health services, as well as decreased stigma and more effective management of physical and mental health comorbidities. This article examines the challenges to integrating mental health services into China's general healthcare system, especially in the primary care sphere, including: accurately estimating mental health needs, integrating mental and physical healthcare, increasing workforce development and training, resolving interprofessional issues, financing and funding, developing an affordable and sustainable mental health system, and delivering care to specific subpopulations to meet the needs of China's diverse populace. As China's political commitment to expanding its mental health system is rapidly evolving, we offer suggestions for future directions in addressing China's mental health needs.

Mental health law in Ghana.

In 2012 Ghana passed a new Mental Health Act, which aimed to create a new system of mental healthcare in Ghana. The Act includes provisions for the creation of a modern, community-based mental health system and for the protection of the rights of persons with mental disorders. This article discusses the implications of the Act and the progress which has been made towards its implementation.

Usual care for trauma-exposed youth: Are clinician-reported therapy techniques evidence-based?

Abstract The current study examined the extent to which usual care interventions targeting childhood traumatic stress involved the application of practice elements (Chorpita, Daleiden, & Weisz, 2005) represented among the evidenced-based treatments (EBTs) for trauma. Youth age and the presence of conduct problems at intake were examined as potential predictors of differences in the presence of elements from EBTs. Data were obtained from archival records from 814 youth who received services from a large, community-based mental health system. Results showed that usual care clinicians reported a variety of practices, only some of which were common to the evidence base for traumatic stress. ‘Exposure’ stood out as the most common practice element among EBTs for treating traumatic stress, but it was reported in fewer than a quarter of usual care cases. For youth receiving out-of-home services, a diagnosis of PTSD predicted that fewer practice elements from EBTs for trauma were reported. Also, as youth age increased, clinicians reported using more practice elements from the evidence base. These findings point to possible opportunities for service improvement in usual care settings for trauma-exposed youth and at the same time call into question whether aspects of the context or population warrant increased use of techniques not associated with EBTs for traumatic stress (cf. Brookman-Frazee, Haine, Baker-Ericzen, Zoffness, & Garland, 2010; Southam-Gerow, Chorpita, Miller, & Gleacher, 2008).

Who cares for it? How to provide psychosocial interventions in the community

Since the Mental Health Reform Law 1978/180, in Italy mental hospitals have been progressively closed and a community-centred psychiatric care oriented to rehabilitation began. After almost 35 years, the de-institutionalization process is now complete. However, psychosocial interventions in the community are provided only rarely, although a specific mental health professional, the psychiatric rehabilitation technician, has been established in Italy. Training courses and the education of psychosocial rehabilitation technicians have been analysed and the university degree has been described. Moreover, the practical and theoretical skills needed at the end of the training course have been discussed. Psychiatric rehabilitation technicians are trained to perform multidisciplinary rehabilitative and educational interventions for people with severe mental disorders and their carers. They represent an innovative professional workforce in mental health care, not yet established outside Italy, whose role and activities are essential in a community-based mental health system model. The skills needed for properly performing psychosocial interventions are not available in other mental health professionals and it is not possible that these interventions, which require in-depth training, are performed by professionals with a different background. It is advisable that psychiatric rehabilitation technicians become an integral and permanent component of an efficient community psychiatric staff.

Mental health system in China: history, recent service reform and future challenges

This paper summarizes the history of the development of Chinese mental health system; the current situation in the mental health field that China has to face in its effort to reform the system, including mental health burden, workforce and resources, as well as structural issues; the process of national mental health service reform, including how it was included into the national public health program, how it began as a training program and then became a treatment and intervention program, its unique training and capacity building model, and its outcomes and impacts; the barriers and challenges of the reform process; future suggestions for policy; and Chinese experiences as response to the international advocacy for the development of mental health.

Initiative to Build a Community-Based Mental Health System Including Assertive Community Treatment for People With Severe Mental Illness in Japan

In Japan, although the locus of care is still predominantly in psychiatric hospitals, a growing number of mental health service providers have become engaged in promoting community integration of people with severe mental illness. This paper describes an ongoing initiative to build a mental health and social services system, which is viewed as a model for other Japanese communities in creating support for people with severe mental illness. This initiative consists of two projects: development and evaluation of an assertive community treatment (ACT) team located in a suburb of Tokyo and a broader community support project in this same community. A pilot evaluation of consumer outcomes for the ACT team demonstrated that ACT is feasible and effective in the Japanese social and cultural context. The community support project was successful in start-up demonstration programs of case management, residential, and supported employment services. Challenges to the expansion of ACT and other community-based services...

Two States Buck Trend to Put MH Care on Chopping Block

Back to table of contents Previous article Next article Government NewsFull AccessTwo States Buck Trend to Put MH Care on Chopping BlockRich DalyRich DalySearch for more papers by this authorPublished Online:5 Jun 2009https://doi.org/10.1176/pn.44.11.0015aAmong the few states to enact major mental health legislation in the 2009 legislative session is West Virginia, which in April approved a statewide increase in expenditures for mental health care. The funding boost is part of a bid to stave off further court interventions on behalf of residents with psychiatric illnesses.The Mental Health Stabilization Act of 2009 (SB 672) aims to rebuild West Virginia's community-based mental health system by increasing reimbursement rates for a range of publicly funded mental health services provided at community mental health centers.“The state has been the subject of various court orders as result of the manner in which it dealt with people with mental health needs, and the legislature desires to be proactive and resolve issues surrounding mental illness without the intervention of the courts,” according to the legislation, which was sponsored by state Sen. Jeffrey Kessler (D).A report by a court-appointed “ombudsman for behavioral health” found that among the public mental health system's problems were serious overcrowding and understaffing at one of the state's two public psychiatric hospitals, Bateman Hospital. The report of the ombudsman, David Sudbeck, led to a West Virginia Supreme Court ruling in January that the ombudsman should conduct evidentiary hearings into conditions at Bateman Hospital and assess whether the state is providing sufficient care for traumatic brain injury and case-management services throughout the public system.Another recent marker of the decline of the state's mental health system came from the National Alliance on Mental Illness, which downgraded West Virginia's public mental health system from a “D” in 2006 to an“ F” in its recent “Grading the States 2009” report (Psychiatric News, May 1). That report concluded that needed reforms in the state included a redesigned Medicaid plan, increased use of evidence-based practices, and implementation of crisis-intervention, jail-diversion, and former-inmate reentry programs.The new law is designed to reverse some of these underperformance findings through funding expansions of the state's existing community mental health centers. Increased funding for prevention and treatment should cut current rates of involuntary mental health commitments and incarceration in jails and prisons of people with psychiatric illness, practices that use significant state resources, according to supporters of the measure.Sidney Lerfald, M.D., president of the West Virginia Psychiatric Association, told Psychiatric News that he hoped the new law would help reduce an overuse of involuntary commitment.“The [public] system poorly funds early interventions to prevent patients from getting to the point where they require hospitalization, which requires a crisis before someone can get treatment,” Lerfald said.The scope of the problem in West Virginia is significant. More than 37,000 people who need treatment for mental illness are placed in regional jails each year, advocates of the new law pointed out. They said that the funding burst should begin to return West Virginia to a position of national leadership in mental health as it was when it led national deinstitutionalization efforts in previous decades.Another statewide effort recently approved by a state legislature was a measure (HB 897) requiring a legislative study of the entire public mental health system in Mississippi. The legislation, advocated by the Mississippi Psychiatric Association (MPA) and signed into law in April, stemmed from growing concerns about poor access to mental health services throughout the state.The study will assess the availability of treatment for people with mental illness in various parts of the state, identify gaps in the ability to follow a patient from one facility to another, and examine what some describe as the trend of hiring nonpsychiatrists to oversee more functions at Mississippi's mental health facilities. Advocates of the study expect that its recommendations will provide impetus and direction for future legislatures in the state to reform mental health care.The law mandating this study stemmed from an MPA-sponsored forum for state legislators in December 2008 that sought to educate elected officials on mental health issues and the roles of clinicians, patients, and the state government in the provision of mental health care.The report and draft legislation to implement its recommendations are both due to the legislature by December 1.The Mental Health Stabilization Act of 2009 can be accessed at<www.legis.state.wv.us> by searching on the bill number, SB 672. The Mississippi mental health study measure can be accessed at<http://billstatus.ls.state.ms.us> by searching on the bill number, HB 897. ▪ ISSUES NewArchived

State Mental Health Policy: Mental Health Transformation: Moving Toward a Public Health, Early-Intervention Approach in Texas

State Mental Health Policy: Mental Health Transformation: Moving Toward a Public Health, Early-Intervention Approach in Texas

Criticism of Care Propels Study of Georgia's MH System

Back to table of contents Previous article Next article Government NewsFull AccessCriticism of Care Propels Study of Georgia's MH SystemRich DalyRich DalySearch for more papers by this authorPublished Online:5 Oct 2007https://doi.org/10.1176/pn.42.19.0013aGeorgia Gov. Sonny Perdue (R) ordered a study of state services for residents with mental illness in August. The effort follows critical media reports and the launch of a federal investigation.The study will be carried out by the state's Mental Health Service Delivery Commission, which will examine “conditions, needs, and issues associated with the services to those with mental illness and substance abuse,” according to a statement issued by his office.The commission will address long-standing concerns about “perceived or actual lack of sufficient funding, inadequate staffing and service delivery systems, overcrowding, treatment practices that unnecessarily separate consumers from their families, and the need for ongoing and effective advocacy on behalf of those children and adults living and receiving behavioral health services.”Creation of the commission in early August followed a Department of Justice announcement in July that it would inspect Georgia state psychiatric hospitals in September to see whether poor conditions violate patients' civil rights.“It is critical that we take a comprehensive look at Georgia's delivery of services to citizens who live with mental illnesses and substance abuse,” Perdue said.The commission also was appointed in the wake of media reports concluding that more than 100 state psychiatric hospital patients died under suspicious circumstances from 2002 to 2006, and nearly 200 other patients were physically or sexually abused.Earlier Perdue had vetoed a similar commission approved by the Georgia General Assembly because it did not include members of the executive branch, who oversee the state's hospitals and the mental health system. Supporters of the commission said they thought that including officials from the Department of Human Resources, which operates the state hospitals, would create a conflict of interest.Nora Haynes, president of the board of NAMI Georgia, met with Perdue in August to discuss the turmoil in Georgia's mental health care system.“Things have been pretty bad around here, and I don't think the governor realized how bad things were,” Haynes said in an interview with Psychiatric News.Mental health advocates have questioned the large number of state officials placed in charge of reviewing the problems and offering solutions, Haynes said, but they have withheld opposition in the hope that the governor's effort will improve the system.Among the leading problems in the state's publically funded mental health system, according to Haynes, is that the responsibility for the care of people with psychiatric conditions is split among many government departments.“There's a lot of money out there, but there's not a lot of coordination,” she said.The governor's commission will have the authority to recommend changes during next year's legislative session, and it is supposed to submit a final report by next June.The commission's charge includes identifying the “best use of public and private resources to relieve overcrowding in state facilities and to further consider methods to develop a full continuum of services and effective supports so that Georgia's citizens who live with mental illness and substance abuse may live and work when possible close to their families.”Haynes said she hopes the commission will address Georgia's lack of a community-based mental health system to offer alternatives to hospitals, jails, or homelessness.The public mental health system will never improve, she said, without better pay for its nurses and physicians. Better compensation is needed to raise Georgia's near-bottom rank as 44th nationally in state spending on mental health, according to NAMI.The order establishing the commission also directed it to report on the sufficiency of health insurance coverage for those with mental illness, including substance abuse.The panel's work will coincide with the Department of Justice investigation of the state hospitals. The federal inquiry is investigating allegations of civil rights violations at the seven state psychiatric hospitals.The state's human resources commissioner separately ordered a team of high-level government officials to take over management of the state psychiatric hospital in Atlanta in mid-August to reverse clinical problems that critics said have contributed to patients' deaths.The new management team's tasks includes setting new performance standards for employees, arranging for enhanced training and supervision, and creating methods to track progress.Information on the Mental Health Service Delivery Commission is posted at<www.gov.state.ga.us/press/2007/press1505.shtml>.▪ ISSUES NewArchived

Is Substance Abuse an Issue? Perceptions of Male and Female Community-Based Mental Health System Consumer-Survivors

Despite our increasing knowledge of the complexity of concurrent disorders the majority of research has involved either institutionalized or specific clinical populations and there have been limited opportunities to directly examine issues at the community level particularly if any differences exist between women and men. Using four standardized instruments, 150 male and 150 female community-based consumer-survivors in the London, Ontario area were interviewed. Eight focus group sessions including 65 individuals were also conducted. Differences between male and female respondents included primary diagnosis, history of family mental illness, family substance abuse, social supports and problematic parental substance abuse. While the overall level of functioning was similar for both sexes, men reported more problems with substance use while women reported a greater overall problem severity. Surprising was the lack of importance of substance abuse issues in respondents’ lives, particularly among focus group members as only four comments regarding substance abuse were made in over 10 h of dialogue. The findings support the belief that specific services by sex are required for this population though the likelihood of attending such programs would be increased if rudimentary income, housing and transportation needs were addressed.

Chronic mental illness and community treatment resistance

Objectives: The movement from institutional to community care has been a key component of national mental health reform in Australia. In Victoria, where a model of community care has been fully implemented, a specialized forensic hospital is the sole remaining stand-alone psychiatric inpatient facility and access to long-term inpatient beds is severely limited. Clinical experience suggests that some high-needs patients are not well serviced by this structure. These patients are placing an increasing burden on a wide range of community services outside mental health. This paper aims to define more clearly this patient group, explore the limitations of their management and outline potential pathways for service development.Conclusions: A population of complex patients with chronic mental illness are not effectively contained within a ‘good enough’ communitybased mental health system. Active debate is required regarding the com-munity's willingness to tolerate the risks and challenges that arise from the current approach. A collaborative care model involving case-based and incentive funding in combination with community-integrated complex care units may improve the care of these patients.

Chronic Mental Illness and Community Treatment Resistance

The movement from institutional to community care has been a key component of national mental health reform in Australia. In Victoria, where a model of community care has been fully implemented, a specialized forensic hospital is the sole remaining stand-alone psychiatric inpatient facility and access to long-term inpatient beds is severely limited. Clinical experience suggests that some high-needs patients are not well serviced by this structure. These patients are placing an increasing burden on a wide range of community services outside mental health. This paper aims to define more clearly this patient group, explore the limitations of their management and outline potential pathways for service development. A population of complex patients with chronic mental illness are not effectively contained within a 'good enough' community-based mental health system. Active debate is required regarding the community's willingness to tolerate the risks and challenges that arise from the current approach. A collaborative care model involving case-based and incentive funding in combination with community-integrated complex care units may improve the care of these patients.

The Case of Sam

Back to table of contents Previous article Next article LettersFull AccessThe Case of SamJeffrey L. Geller, M.D., M.P.H.Jeffrey L. GellerSearch for more papers by this author, M.D., M.P.H.Published Online:1 Apr 2002https://doi.org/10.1176/appi.ps.53.4.482AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In Reply: Drs. Moffic and Kuehn make many important and valid observations about what should be in place for an effective community-based mental health system. As they note, these elements include the following:• An accountable system of treatment and care• Clear and measurable treatment goals• Meaningful choices for persons being served that they can meaningfully make• Fewer intermediaries using funds that could otherwise be employed for direct services• Residential programs that are less isolated and better integrated into a community• Effective substituted judgment processes for persons who are incapable of making informed decisions for themselves• Medication trials that closely monitor side effects and optimize compliance• Community mental health centers that treat appropriately targeted populations of persons who have chronic, severe mental illnesses• Improved care and treatment at a lower costThe challenge for us remains how to achieve these ends. In the case of Sam, the system providing care and treatment sees all these objectives as its aims. It falls short, as does every system that currently exists. All too often a program description does not actually describe a program in practice. Compromises in the model are as frequent as adherence to the model. In some instances, the compromises reflect appropriate flexibility. In others, they are the result of bastardization of the model, a lack of resources, or personnel problems.We have begun to demonstrate the possibilities of effective, humane, compassionate care and treatment in communities of many types. Ahead of us are the tasks of not allowing our definitions of "community" to be narrowed, improving effectiveness and accountability, and not just settling for care but striving for true habilitation, rehabilitation, and treatment.Perhaps a banner for our efforts, one that Drs. Moffic and Kuehn could endorse, is "A job half done is a good beginning." FiguresReferencesCited byDetailsCited ByCommunity Mental Health Journal, Vol. 49, No. 1 Volume 53Issue 4 April 2002Pages 482-482 Metrics History Published online 1 April 2002 Published in print 1 April 2002

Accessibility and pathways to psychiatric care in a community-based mental health system.

The careful analysis of pathways to specialist mental health care, within the context of community-based services, is important because it allows a detailed understanding of the inter-relationship between the component parts of the whole system of care. Moreover, it permits a comparison of service functioning to made over time, and is one way to operationalise the measurement of accessibility to services. The aims of this study are to describe: (i) the pathways followed by patients with new episodes of care to community-based mental health services, (ii) the time intervals from onset of the problem to first contact with services, and then to onward referral to specialist care (accessibility), and (iii) to explore the short-term costs associated with different pathways. Using data from the South-Verona Psychiatric Case Register, all new patients referred to any of the facilities which are part of the South-Verona Community Psychiatric Service (CPS) over a 6-month period (November 1999 - May 2000) were eligible to enter the study. Patients were interviewed by telephone using the Italian translation of the WHO Encounter Form. The costs of care provided in the 3 months following the index contact were assessed for all patients. The most common route to mental health services is via a GP (40%), followed by a referral from a hospital doctor (26%) and self-referral (23%). The median interval from onset to direct contact with the South-Verona CPS (12 weeks) was shorter than the intervals from onset to direct contact with other service providers (the median interval for contact with GPs and hospital doctors was 24 weeks). The intervals varied considerably from 1 week (for attempted suicide), to 1.5 years (for disturbed behaviour). The results of backward regression modelling revealed a significant relationship between patients' characteristics and community costs or total psychiatric costs (44% and 53% of the variance explained respectively). When the results are compared with a directly comparable earlier study in South-Verona, it is apparent that between 1991 and 1999 an increasing proportion of patients with insomnia and somatic disorders presented first to GPs, while a decreasing proportion of patients over the years sought care directly from specialist care. An increase in the role of local GPs as gatekeepers has, therefore, emerged. A prompt assessment by the South-Verona CPS of the patients' presenting problems was also confirmed, and this can be explained by the 'drop-in' approach at the Mental Health Centre, where patients can seek specialist care directly, without previously attending GPs. This method of measuring time intervals along pathways is proposed as a way to operationalise accessibility to services in future.

State health care reform: the effects of program realignment on severely mentally ill persons in California's community-based mental health system.

State health care reform: the effects of program realignment on severely mentally ill persons in California's community-based mental health system.