Community-based Psychiatric Care Research Articles

Community-Based Psychiatric Care Provision in Hungary: Trends and Steps towards Progress.

Psychiatric care has undergone several cycles of profound changes in the past centuries all over the world. In Hungary, community-based outpatient care has been showing signs of evolution since the 1950s. Initially, the system centered on assertive outreach and family involvement, especially for those with serious mental health problems. Such services remain available throughout the country, but the emphasis in the past decades has shifted towards mass care provision. In many places, community-based services are no longer provided, and where they are the approach is biomedical and less asuming of recovery. In other centers, the services provided are conceived with the eventuality of rehabilitation in mind and in close cooperation with community-based care providers. Community-based services providers, as part of the social fabric, offer as many psychiatric and rehabilitation services as possible for those with mental disorders within their communities. The main objective of community-based care is to achieve community re-integration and recovery from mental disorders. Today in Hungary, deinstitutionalisation and the introduction of community-based psychiatric care have been adopted even by large inpatient institutions. The replacement of institutional bed space and the provision of subsidised housing further underscore the importance of community-based psychiatric care provision. There is the opinion that, as a further course of development, the emphasis needs to now shift towards the nurturing of a community of experienced experts and creastion of user-led programs. In this new paradigm, the ability of a person with a mental disorder to make decisions and the bolstering of that ability are seen as vital. In order to achieve these objectives, it is essential that health and social seervices professionals cooperate. Hands-on experience is key in the provision and development of such services.

PELATIHAN COMMUNITY MENTAL HEALTH NURSING (CMHN) BAGI PERAWAT DAPAT MENINGKATKAN PENANGANAN MASALAH KESEHATAN JIWA DI MASYARAKAT

Community-based psychiatric nursing care is a nursing approach to mental patients, which is carried out directly to patients and their families at home by health center nurses who have received previous training. Nurses who have been trained are expected to have competence, one of which is being able to provide nursing care to patients with mental disorders in the community, so that patients with mental disorders can be handled optimally. This research is to see the relationship between the Effectiveness of CMHN Training Implementation in 31 Public Health Centers in North Aceh District. The study was conducted at 31 Community Health Centers in North Aceh District. The research design used a correlational design with a total sampling technique. Data collection was carried out by distributing questionnaires online via the Google form to respondents in July 2022. Data analysis used the Chi Squere test with a 95% confidence interval. The research results obtained p value = 0.000, α = 0.05, p value ≤0.05, the statistical results are significant, meaning that there is a relationship between the effectiveness of implementing CMHN training on improving the handling of mental health problems in North Aceh District.

Intensive community care services for children and young people in psychiatric crisis: an expert opinion

BackgroundChildren and young people’s (CYP) mental health is worsening, and an increasing number are seeking psychiatric and mental health care. Whilst many CYPs with low-to-medium levels of psychiatric distress can be treated in outpatient services, CYPs in crisis often require inpatient hospital treatment. Although necessary in many cases, inpatient care can be distressing for CYPs and their families. Amongst other things, inpatient stays often isolate CYPs from their support networks and disrupt their education. In response to such limitations, and in order to effectively support CYPs with complex mental health needs, intensive community-based treatment models, which are known in this paper as intensive community care services (ICCS), have been developed. Although ICCS have been developed in a number of settings, there is, at present, little to no consensus of what ICCS entails.MethodsA group of child and adolescent mental health clinicians, researchers and academics convened in London in January 2023. They met to discuss and agree upon the minimum requirements of ICCS. The discussion was semi-structured and used the Dartmouth Assertive Community Treatment Fidelity Scale as a framework. Following the meeting, the agreed features of ICCS, as described in this paper, were written up.ResultsICCS was defined as a service which provides treatment primarily outside of hospital in community settings such as the school or home. Alongside this, ICCS should provide at least some out-of-hours support, and a minimum of 90% of CYPs should be supported at least twice per week. The maximum caseload should be approximately 5 clients per full time equivalent (FTE), and the minimum number of staff for an ICCS team should be 4 FTE. The group also confirmed the importance of supporting CYPs engagement with their communities and the need to remain flexible in treatment provision. Finally, the importance of robust evaluation utilising tools including the Children’s Global Assessment Scale were agreed.ConclusionsThis paper presents the agreed minimum requirements of intensive community-based psychiatric care. Using the parameters laid out herein, clinicians, academics, and related colleagues working in ICCS should seek to further develop the evidence base for this treatment model.

Models of community-based psychiatric care in Italy and England

Is to study and compare models of out-of-hospital psychiatric care in different countries-Italy and England.

Mental health outcome among psychiatric patients due to COVID 19 lockdown induced disruption of access to psychiatric services: A cross-sectional study

Background: COVID 19 lockdown has an impact on the mental health of the general population, COVID patients, and health professionals. However, knowledge about its impact on psychiatric patients is limited.Objectives: To assess the mental health outcomes among psychiatric patients due to disruption of access to psychiatric services caused by the COVID 19 lockdown.Materials and Methods: It was a single-center, cross-sectional, observational, pragmatic study conducted at a tertiary care psychiatric hospital. All consecutive psychiatric patients presented to review in the outpatient department for 3 weeks following the relaxation of lockdown were screened, and a total of 305 eligible patients were enrolled. A semi-structured questionnaire was applied to capture the mental health status of the patients.Results: More than three-fourths (78.3%) of patients were off medications during the lockdown. During lockdown, more than half (64.3%) of patients' mental health conditions worsened, and significantly more in those who were not on medications. More than half of patients who were doing well before lockdown showed re-emergence of symptoms, and it was more commonly seen in mood disorder patients, followed by schizophrenia and other psychotic disorder patients. Thirty-one (10.1%) patients reported self-harm ideas; six (1.9%) claimed to have made self-harm attempts during lockdown.Conclusions: COVID-19 lockdown has worsened the mental health status of psychiatric patients. Strengthening community-based psychiatric care in tie-up with telepsychiatry services and adopting new innovative measures may help face such eventualities in the future.

Community Psychiatry Care: An Urgent Need in Nigeria.

Nigeria’s mental health policy was formulated in 1991, but it did not make adequate provision for community-based psychiatric care. Since there are only seven government-owned psychiatry facilities in Nigeria and these are always overwhelmed, there is the need to overhaul the existing policy and emphasise the urgency of a shift from inpatient psychiatric mental healthcare towards a community-based multidisciplinary psychiatric healthcare system.

Features of Work of Psychologists with Different Age Groups

The Gulbenkian Global Mental Health Platform and the World Health Organization have jointly created a series of thematic papers on current mental health issues. The topics were identified by the Platform's advisory and oversight committees and identified priority ways to improve significantly the global mental health situation. The topic of this article is in one line with the four key objectives of the WHO 2020-2030 Mental Health Action Plan. The topic of the article concerns the following important issues: strategies that can be implemented through health care in order to promote mental health and prevent mental disorders; strategies based on the health care system for the organization and provision of integrated care for patients with mental disorders and other chronic health conditions; innovative methodologies for the transition from institutional to community-based psychiatric care.“Social Determinants of Mental Health” is the topic of this thematic report. It was chosen to deepen our knowledge of the many interacting forces that shape individual and collective levels of mental health and well-being. Moreover, it helps to understand and identify actions that can be taken to improve and protect our mental health. The article describes how a risk factor in the early stages can affect mental well-being or predisposition to mental disorder after many years or even decades. An important message is that actions and public policy to address existing mental health issues have to be universal and comprehensive, but at the same time proportionate to the need.

Unique Practice, Unique Place: Exploring Two Assertive Community Treatment Teams in Maine

ABSTRACTAssertive Community Treatment (ACT) is a model of care that provides comprehensive community-based psychiatric care for persons with serious mental illness. This model has been widely documented and has shown to be an evidence-based model of care for reducing hospitalizations for this targeted population. Critical ingredients of the ACT model are the holistic nature of their services, a team based approach to treatment and nurses who assist with illness management, medication monitoring, and provider collaboration. Although the model remains strong there are clear differences between urban and rural teams. This article describes present day practice in two disparate ACT programs in urban and rural Maine. It offers a new perspective on the evolving and innovative program of services that treat those with serious mental illness along with a review of literature pertinent to the ACT model and future recommendations for nursing practice. The success and longevity of these two ACT programs are testament to the quality of care and commitment of staff that work with seriously mentally ill consumers. Integrative care models such as these community-based treatment teams and nursing driven interventions are prime elements of this successful model.

Payment incentives for community-based psychiatric care in Ontario, Canada.

In September 2011, the government of Ontario implemented payment incentives to encourage the delivery of community-based psychiatric care to patients after discharge from a psychiatric hospital admission and to those with a recent suicide attempt. We evaluated whether these incentives affected supply of psychiatric services and access to care. We used administrative data to capture monthly observations for all psychiatrists who practised in Ontario between September 2009 and August 2014. We conducted interrupted time-series analyses of psychiatrist-level and patient-level data to evaluate whether the incentives affected the quantity of eligible outpatient services delivered and the likelihood of receiving follow-up care. Among 1921 psychiatrists evaluated, implementation of the incentive payments was not associated with increased provision of follow-up visits after discharge from a psychiatric hospital admission (mean change in visits per month per psychiatrist 0.0099, 95% confidence interval [CI] -0.0989 to 0.1206; change in trend 0.0032, 95% CI -0.0035 to 0.0095) or after a suicide attempt (mean change -0.0910, 95% CI -0.1885 to 0.0026; change in trend 0.0102, 95% CI 0.0045 to 0.0159). There was also no change in the probability that patients received follow-up care after discharge (change in level -0.0079, 95% CI -0.0223 to 0.0061; change in trend 0.0007, 95% CI -0.0003 to 0.0016) or after a suicide attempt (change in level 0.0074, 95% CI -0.0094 to 0.0366; change in trend 0.0006, 95% CI -0.0007 to 0.0022). Our results suggest that implementation of the incentives did not increase access to follow-up care for patients after discharge from a psychiatric hospital admission or after a suicide attempt, and the incentives had no effect on supply of psychiatric services. Further research to guide design and implementation of more effective incentives is warranted.

Current trends in the development of psychiatric care system

In this article, the authors summarize current trends in the development of domestic and foreign mental health services, results of the reforms of national psychiatric services, and the state of inpatient and community-based psychiatric care systems. Actual problems and prospects of development of system of psychiatric help are discussed.

Barriers and success factors in clinical pathways: transition process between psychiatric inpatient care and community care

Rationale, aims and objectives: This study examines the scope and limitations of clinical pathways to monitor patient-care management of a selected patient group during a specified time period. We aimed to identify (a) the factors that may obstruct the intended clinical care plan as devised by psychiatric hospital centres for implementation by community services and (b) the strategies which support the effective delivery of high quality care. Method: A qualitative design incorporating a descriptive approach was chosen. Seven focus groups with a total of 18 informants were convened. Data were analysed to identify condensed meaningful units, categories (sub-theme) and themes. Results: Three main themes emerged; Coordination, Clinical Care and Ethics. The main barriers were communication errors, lack of adherence to treatment due to disagreement on treatment and lack of competence. The main success factors were adequate direct communication and proper documentation systems between health personnel, patient participation in future plans and working hours of ambulant teams. Conclusions: This study suggests that clinical pathways are useful for securing key objectives at the interface between hospital and community-based psychiatric care. Improved information sharing in/between all care systems is imperative in order to strengthen patients’ participation in decision-making, ownership of the care plan and improve adherence to treatment.

Meaning in work and emerging work identities of housing support workers: A quest for a comprehensible plot

Work and employees are often marginalized in studies on community-based psychiatric care and support systems. This paper highlights the role of the worker at congregated supported housing for people with severe mental illness (SMI). Housing support workers (HSW) are a fairly new professional role and have developed as a result of major changes in Swedish mental health care and services. The development of new roles is not unproblematic and raises intriguing questions. The purpose of this article is to describe housing support workers' experiences of meaning in their work, and in addition illuminate how the work identity of HSWs can be negotiated and constructed. Four focus group interviews were conducted with a total of 25 participants. Additionally, three follow up sessions were conducted with the same participants. The material consists of employees from four different sites. The intepretation of the material was inspired by a constructionist approach. The analysis generated three themes: to do a good job, everyday needs and the formal role. The work identity for HSWs is complex and not easily interpreted. The experience of an unclear assignment affects the description of what is meaningful and important-the work identity and significant affiliations for HSWs. In the long run, this fragmented world can have negative implications for the HSW.

Decentralized outpatient teams in community-based psychiatric care

Decentralized outpatient teams in community-based psychiatric care

Prevalence of oral diseases and oral-health-related quality of life in people with severe mental illness undertaking community-based psychiatric care

To describe the prevalence of oral diseases and their impact on oral-health-related quality of life in people with severe mental illness undertaking community-based psychiatric care. A survey was conducted at eight outpatient psychiatric care clinics in Tower Hamlets, London, UK. One hundred and twelve consecutive patients with mental illness were invited to participate in this study. They were clinically examined and asked to complete the oral health impact profile (OHIP) questionnaire. The response rate was 79% (n = 89); 57 (64%) males and 58 persons over 45 years of age (65%) participated in this survey. Overall OHIP score was 25.4 (95% CI 23.3, 27.4), 70 (78%) were smokers and 45 (51%) had been to the dentist in the last two years. Forty-seven (53%) respondents had caries in at least one tooth, 60 (67%) had 21 teeth and more, and 14 (16%) used dentures. Advanced periodontal treatment was indicated in 42 (55%) of patients and 52.8% (n = 47) patients reported current pain. Overall, this survey found that oral health has a great impact on patients with severe mental illness being treated in the community setting and their oral health is poorer than the national adult general population. Future research should consider the causes that relate to the poorer oral health in this population and potential health promotion mechanisms in this population to encourage an upstream approach to health.

Summary of: Prevalence of oral diseases and oral-health-related quality of life in people with severe mental illness undertaking community-based psychiatric care

To describe the prevalence of oral diseases and their impact on oral-health-related quality of life in people with severe mental illness undertaking community-based psychiatric care. A survey was conducted at eight outpatient psychiatric care clinics in Tower Hamlets, London, UK. One hundred and twelve consecutive patients with mental illness were invited to participate in this study. They were clinically examined and asked to complete the oral health impact profile (OHIP) questionnaire. The response rate was 79% (n = 89); 57 (64%) males and 58 persons over 45 years of age (65%) participated in this survey. Overall OHIP score was 25.4 (95% CI 23.3, 27.4), 70 (78%) were smokers and 45 (51%) had been to the dentist in the last two years. Forty-seven (53%) respondents had caries in at least one tooth, 60 (67%) had 21 teeth and more, and 14 (16%) used dentures. Advanced periodontal treatment was indicated in 42 (55%) of patients and 52.8% (n = 47) patients reported current pain. Overall, this survey found that oral health has a great impact on patients with severe mental illness being treated in the community setting and their oral health is poorer than the national adult general population. Future research should consider the causes that relate to the poorer oral health in this population and potential health promotion mechanisms in this population to encourage an upstream approach to health.

A new mental health law to protect patients' autonomy could lead to drastic changes in the delivery of mental health services: is the risk too high to take?

A new mental health law to protect patients' autonomy could lead to drastic changes in the delivery of mental health services: is the risk too high to take?

Successful aging in individuals with schizophrenia dwelling in the community: A study on attitudes toward aging and preparing behavior for old age

'Successful aging' in individuals with schizophrenia has been attracting attention. We examined two forward-looking factors of successful aging among schizophrenia patients: 'attitude toward aging' and 'preparing behavior for old age'. Fifty-seven middle-aged and elderly schizophrenia patients with successful aging were identified using the Attitude toward Aging Scale, the Preparing Behavior for Old Age Scale, and assessments of their cognitive function, psychiatric symptoms, social functioning and quality of life. A multiple regression analysis was used to detect determinants of attitude toward aging/preparing behavior for old age at that time ('present': community dwelling). We also analyzed predictors of successful aging using demographic/clinical data assessed 3 years previously ('past': residential care). The multiple regression analysis revealed that quality of life was a significant determinant: a higher quality of life was related to a more positive attitude toward aging and less active preparing behavior. The significant predictors of preparing behavior were quality of life and the length of the hospital stay: a longer hospital stay and a higher quality of life were related to less active preparing behavior. Quality of life and the length of the hospital stay significantly contributed to forward-looking factors of successful aging. Avoiding long hospitalization periods for patients with schizophrenia may lead to more active preparing behavior, but the improvement of quality of life may not be a sufficient condition. As schizophrenia patients have an optimistic attitude and insufficient preparing behavior, support to prepare such individuals for old age is required as part of community-based psychiatric care strategies.

Suicide Risk: Navigating the Failure Modes

Suicide Risk: Navigating the Failure Modes

Mistakes to avoid in the implementation of community mental health care.

In this issue of the journal, we publish the first WPA guidance produced as part of the WPA Action Plan 2008-2011 1, 2, dealing with steps, obstacles and mistakes to avoid in the implementation of community mental health care. Two further documents are almost ready and will soon appear in the journal: the WPA guidance on how to combat stigmatization of psychiatry and psychiatrists, and the WPA guidance on mental health and mental health care in migrants. The guidance we present in this issue can be regarded as a “second-generation” document in the area of community mental health care, because it takes advantage of the experience of the countries in which the development of community care has been most active, to point out not only what should to be done to implement the process, but also the errors which should not be repeated. In this latter respect, the document contains several important statements, which I will now list and discuss briefly.

Letter.

Back to table of contents Previous article Next article LetterFull AccessLetterJeffrey L. Geller M.D., M.P.H.Jeffrey L. Geller M.D., M.P.H.Search for more papers by this authorPublished Online:1 May 2010https://doi.org/10.1176/ps.2010.61.5.529AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail A Case of Neutralized Findings?To the Editor: A funny thing happens on the way to determining whether an element of coercion is effective in some cases of outpatient treatment. No one wants to find out. The study by Phelan and colleagues ( 1 ) in the February issue is another example. It is beyond me why these excellent researchers would have used their time and New York State's scarce mental health resources to do this work. The study is particularly seductive because its elements appear to be the concrete in the foundation of evidence-based findings. The study compared outcomes of an experimental group treated under New York State's assisted outpatient treatment statute (Kendra's Law) and a control group discharged from a psychiatric hospital and attending the same outpatient facilities as the patients in the experimental group. The authors state that because assisted outpatient treatment includes not only coerced treatment but also enhanced services, "We cannot conclude which of these elements of the package deal contributed most to the generally positive outcomes for participants." However, the researchers knew this before they began the study. The study as designed had no possibility of evaluating coercion per se. The article's last sentence—"We therefore caution against using our results to justify an expansion of coercion in psychiatric treatment"—is disingenuous at best.More puzzling is the last sentence of the abstract, which goes even further: "As such, the results do not support the expansion of coercion in psychiatric treatment." But the results don't refute the expansion of coercion either, which the authors could just as easily have stated in their concluding sentence.Furthermore, the findings actually do, in some respects, support the use of coercion. The authors found that the patients who received assisted outpatient treatment were significantly less likely to engage in serious violent behavior, had a lower risk of suicide, and had better illness-related social functioning. There was also a trend for patients in this group to have a better quality of life. These findings could result from the coercion plus ancillary services. However, as a take-home message the authors offer their additional finding that the experimental group reported marginally less (p<.10) coercion and stigma than the control group. Thus some degree of coercion led to their experiencing less coercion and stigma. In and of itself, that is a profound argument for the benefits of the coercive component in assisted outpatient treatment. Currently, a debate is going on in New York State about whether to make Kendra's Law permanent. Despite the authors' gyrations to neutralize their own findings, their study provides data that supports Kendra's Law, and it provides absolutely no evidence that refutes the concept that a "tincture of coercion" ( 2 ), as used in assisted outpatient treatment, is an integral element in the treatment of a subset of patients in community-based psychiatric care. Dr. Geller is professor of psychiatry and director of public-sector psychiatry at University of Massachusetts Medical School, Worcester.