Demand For Mental Health Care Research Articles

Technological State of the Art of Electronic Mental Health Interventions for Major Depressive Disorder: Systematic Literature Review.

BackgroundElectronic mental (e-mental) health care for depression aims to overcome barriers to and limitations of face-to-face treatment. Owing to the high and growing demand for mental health care, a large number of such information and communication technology systems have been developed in recent years. Consequently, a diverse system landscape formed.ObjectiveThis literature review aims to give an overview of this landscape of e-mental health systems for the prevention and treatment of major depressive disorder, focusing on three main research questions: (1) What types of systems exist? (2) How technologically advanced are these systems? (3) How has the system landscape evolved between 2000 and 2017?MethodsPublications eligible for inclusion described e-mental health software for the prevention or treatment of major depressive disorder. Additionally, the software had to have been evaluated with end users and developed since 2000. After screening, 270 records remained for inclusion. We constructed a taxonomy concerning software systems, their functions, how technologized these were in their realization, and how systems were evaluated, and then, we extracted this information from the included records. We define here as functions any component of the system that delivers either treatment or adherence support to the user. For this coding process, an elaborate classification hierarchy for functions was developed yielding a total of 133 systems with 2163 functions. The systems and their functions were analyzed quantitatively, with a focus on technological realization.ResultsThere are various types of systems. However, most are delivered on the World Wide Web (76%), and most implement cognitive behavioral therapy techniques (85%). In terms of content, systems contain twice as many treatment functions as adherence support functions, on average. Furthermore, autonomous systems, those not including human guidance, are equally as technologized and have one-third less functions than guided ones. Therefore, lack of guidance is neither compensated with additional functions nor compensated by technologizing functions to a greater degree. Although several high-tech solutions could be found, the average system falls between a purely informational system and one that allows for data entry but without automatically processing these data. Moreover, no clear increase in the technological capabilities of systems showed in the field, between 2000 and 2017, despite a marked growth in system quantity. Finally, more sophisticated systems were evaluated less often in comparative trials than less sophisticated ones (OR 0.59).ConclusionsThe findings indicate that when developers create systems, there is a greater focus on implementing therapeutic treatment than adherence support. Although the field is very active, as evidenced by the growing number of systems developed per year, the technological possibilities explored are limited. In addition to allowing developers to compare their system with others, we anticipate that this review will help researchers identify opportunities in the field.

Moving towards universal health coverage for mental disorders in Ethiopia

BackgroundPeople with mental disorders in low-income countries are at risk of being left behind during efforts to expand universal health coverage.AimsTo propose context-relevant strategies for moving towards universal health coverage for people with mental disorders in Ethiopia.MethodsWe conducted a situational analysis to inform a SWOT analysis of coverage of mental health services and financial risk protection, health system characteristics and the macroeconomic and fiscal environment. In-depth interviews were conducted with five national experts on health financing and equity and analysed using a thematic approach. Findings from the situation analysis and qualitative study were used to develop recommended strategies for adequate, fair and sustainable financing of mental health care in Ethiopia.ResultsOpportunities for improved financing of mental health care identified from the situation analysis included: a significant mental health burden with evidence from strong local epidemiological data; political commitment to address that burden; a health system with mechanisms for integrating mental health into primary care; and a favourable macro-fiscal environment for investment in human capabilities. Balanced against this were constraints of low current general government health expenditure, low numbers of mental health specialists, weak capacity to plan and implement mental health programmes and low population demand for mental health care. All key informants referred to the under-investment in mental health care in Ethiopia. Respondents emphasised opportunities afforded by positive rates of economic growth in the country and the expansion of community-based health insurance, as well as the need to ensure full implementation of existing task-sharing programmes for mental health care, integrate mental health into other priority programmes and strengthen advocacy to ensure mental health is given due attention.ConclusionExpansion of public health insurance, leveraging resources from high-priority SDG-related programmes and implementing existing plans to support task-shared mental health care are key steps towards universal health coverage for mental disorders in Ethiopia. However, external donors also need to deliver on commitments to include mental health within development funding. Future researchers and planners can apply this approach to other countries of sub-Saharan Africa and identify common strategies for sustainable and equitable financing of mental health care.

Issues Faced by Aspiring Clinical Psychologists in India

15% of Indian adults are already in need of active intervention for one or more mental illness (National Mental Health Survey, 2015-2016). The increasing demand for mental health care needs to be met with an increased supply of trained professional. The generation that will soon bear the reins of this community needs to find practicing in India a lucrative option. Issues faced by aspiring clinicians at the start of their professional trajectory such as lax standards of licensure, inadequate training facilities, low remuneration, deficits in research funding and neglectful enforcement of code of conduct may dissuade them from practicing in India. This paper discusses challenges and recommendations keeping in mind the status of clinical psychology in other countries. A survey was conducted on practicing clinicians (N = 41) to integrate varying viewpoints.

APA Foundation Presents APA Staff, Member Donations to American Red Cross

Back to table of contents Previous article Next article Association NewsFull AccessAPA Foundation Presents APA Staff, Member Donations to American Red CrossRebecca GreenbergRebecca GreenbergSearch for more papers by this authorPublished Online:26 Dec 2017https://doi.org/10.1176/appi.pn.2018.1a22AbstractThe American Psychiatric Association (APA) Foundation donated a total of $30,000 to the American Red Cross (ARC) last month for disaster relief efforts in mainland United States and Puerto Rico. The generosity of APA members and staff along with matching funds from the APA Foundation made it possible to present a total of $30,000 to the American Red Cross last month for disaster relief efforts in mainland U.S. and Puerto Rico. Participating in the ceremony were (from left) Joshua Morganstein, M.D., a member of APA’s Committee on Psychiatric Dimensions of Disasters; Dan Gillison, executive director of the APA Foundation; Linda Mathes, CEO of the National Capital Region of the American Red Cross; and Saul Levin, M.D., M.P.A., APA CEO and medical director.David HathcoxOf that amount, $20,000 was earmarked for relief for recent disasters, including hurricanes Harvey, Irma, and Maria and the California wildfires; $10,000 was earmarked specifically for Hurricane Maria relief. The remaining amount raised—$3,000—is being donated to CrearConSalud, a newly formed nonprofit created by a group of Puerto Rican psychiatrists living in the United States. The group has made a series of trips to Puerto Rico since 2015, assessing community and mental health needs and organizing educational activities on the island.The funds were donated by APA members and staff to the APA Foundation’s Disaster Relief Fund and matched by the APA Foundation. Among those who donated were members of the APA Assembly, which held a special fund-raising event at its November meeting. The check presentation was held at the ARC’s national headquarters in Fairfax, Va. Participants included APA CEO and Medical Director Saul Levin, M.D., M.P.A.; APA Foundation Executive Director Daniel Gillison; Linda Mathes, CEO of the National Capital Region of the ARC; and Joshua Morganstein, M.D., a member of APA’s Committee on Psychiatric Dimensions of Disasters.The funds will help support the ARC’s mental health volunteer program, made up of 3,500 licensed professionals, including psychiatrists, social workers, counselors, marriage and family therapists, psychiatric nurses, psychologists, school counselors, and school psychologists, all of whom are trained in disaster mental health interventions. ARC program leaders, including Valerie Cole, Ph.D., who manages Disaster Health Services and Disaster Mental Health at ARC, explained during a presentation that followed the check-presentation ceremony that ARC’s mental health services operate on the assumption that most people are resilient; however, a significant minority may be at risk of developing new or aggravated psychological disorders after a disaster. Geoff DeLizzio shows APA attendees a real-time map in the American Red Cross’s Disaster Operations Coordination Center in Fairfax, Va. The map tracks analytics from single-family fires to widespread disasters such as Hurricane Maria.David HathcoxResponders provide disaster mental health interventions focused on basic care, support, and comfort for individuals experiencing disaster-related stress. Cole noted that volunteer services are meant to augment the community’s mental health resources, not replace them. In a year marked by historic hurricanes, wildfires, and other crises, the ARC deployed more than 56,000 disaster workers (92 percent of whom were volunteers) and facilitated twice as many overnight shelter stays than in the past four years combined. Workers provided 13.6 million meals; 7 million relief items such as bottled water, flashlights, and tarps; 267,000 health and mental health contacts; and financial recovery assistance for 624,000 households. Of each dollar donated to the ARC, 91 cents is spent directly on humanitarian services and programs, according to the ARC.Geoff DeLizzio, ARC’s chief development officer, took APA attendees on a tour of the ARC’s Disaster Operations Center, the ARC’s “nerve center” where ARC staff and volunteers map and monitor analytics for disasters as they occur and “pre-position” millions of supplies such as food, water, and cots for future events. In 2017 alone, ARC provided 76,000 households with recovery support after home fires and made 401,000 “home safety” visits to prevent future fires.After the tour, APA and ARC leaders gathered for discussion. APA representatives commented on the ongoing mental health challenges in areas like Puerto Rico and California wildfire zones where recovery has been slow. In addition to raising money to support humanitarian efforts, Brad Kieserman, ARC’s vice president of disaster operations and logistics, said, “We rely on the philanthropy of time. Demand for mental health care in particular often outstrips available resources.” ■Information for psychiatrists interested in becoming an ARC volunteer can be accessed here. ISSUES NewArchived

Temporal Trends in Mental Health Service Utilization across Outpatient and Acute Care Sectors: A Population-Based Study from 2006 to 2014.

Although evidence suggests that treatment seeking for mental illness has increased over time, little is known about how the health system is meeting the increasing demand for services. We examined trends in physician-based mental health service use across multiple sectors. In this population-based study, we used linked health-administrative databases to measure annual rates of mental health-related outpatient physician visits to family physicians and psychiatrists, emergency department visits, and hospitalizations in adults aged 16+ from 2006 to 2014. We examined absolute and relative changes in visit rates, number of patients, and frequency of visits per patient, and assessed temporal trends using linear regressions. Among approximately 11 million Ontario adults, age- and sex-standardized rates of mental health-related outpatient physician visits declined from 604.8 to 565.5 per 1000 population over the study period ( Ptrend = 0.04). Over time, the rate of visits to family physicians/general practitioners remained stable ( Ptrend = 0.12); the number of individuals served decreased, but the number of visits per patient increased. The rate of visits to psychiatrists declined ( Ptrend < 0.001); the number of individuals served increased, but the number of visits per patient decreased. Concurrently, visit rates to emergency departments and hospitals increased (16.1 to 19.7, Ptrend < 0.001 and 5.6 to 6.0, Ptrend = 0.01, per 1000 population, respectively). Increases in acute care service use were greatest for anxiety and addictions. The increasing acute care service use coupled with the reduction in outpatient visits suggest, overall, an increase in demand for mental health care that is not being met in ambulatory care settings.

Tratamiento psicológico grupal de sesión única para personas que sufren trastornos adaptativos. Programa y evaluación preliminar

The high demand for mental health care in the Public Health System of Andalusia requires to devise and imple­ment care proposals proportional to the severity of the disorders, while being agile and of quality. This paper presents a single-session group psychological treatment program to assist people with adjustment disorders, as well as the results of its preliminary evaluation. The objectives of the program are to help the psychological and emotional recovery of the participants and to prevent their relapse. It has been applied to 40 people, women and men, aged between 22 and 73 years, derived by their family doctors. The preliminary evaluation was carried out through a questionnaire of assessment and satisfaction with de treatment of own elaboration, indicators of care and the perception of professionals who indicated the derivation. In spite of the small number of people who are referred back within 12 months after the treatment, the discreetly positive scores obtained in the questionnaire and the favorable perception of the doctors who referred patients, the methodological limitations of this study oblige to continue assessing the opportunity and utility of the same in new controlled studies.

Psychotherapy Services in China: Current Provisions and Future Development

The current paper provides an overview of the history and development of mental health services with special emphasis on psychotherapy in China. Recent epidemiological surveys have revealed high prevalence rates of mental disorders that translate into a huge demand for mental health care. The Chinese government responds to such demand by increasing the number and types of mental health professionals in delivering mental health interventions, one of which is cognitive behavioural therapy (CBT). Due to unique Chinese cultural values, CBT needs to be adapted to these values so as to enhance its acceptability by Chinese people. Furthermore, training and supervision of Chinese therapists require some cultural adaptation in therapist’s training and supervision skills. This paper concludes by providing some specific recommendations on improving the quality and accessibility of CBT in China.

Maternal mental health in primary care in five low- and middle-income countries: a situational analysis.

BackgroundThe integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-income countries (LMICs). This study reports findings of a cross-country situation analysis on maternal mental health and services available in five LMICs, to inform the development of integrated maternal mental health services integrated into primary health care.MethodsThe situation analysis was conducted in five districts in Ethiopia, India, Nepal, South Africa and Uganda, as part of the Programme for Improving Mental Health Care (PRIME). The analysis reports secondary data on the prevalence and impact of priority maternal mental disorders (perinatal depression, alcohol use disorders during pregnancy and puerperal psychosis), existing policies, plans and services for maternal mental health, and other relevant contextual factors, such as explanatory models for mental illness.ResultsLimited data were available at the district level, although generalizable data from other sites was identified in most cases. Community and facility-based prevalences ranged widely across PRIME countries for perinatal depression (3–50 %) and alcohol consumption during pregnancy (5–51 %). Maternal mental health was included in mental health policies in South Africa, India and Ethiopia, and a mental health care plan was in the process of being implemented in South Africa. No district reported dedicated maternal mental health services, but referrals to specialised care in psychiatric units or general hospitals were possible. No information was available on coverage for maternal mental health care. Challenges to the provision of maternal mental health care included; limited evidence on feasible detection and treatment strategies for maternal mental disorders, lack of mental health specialists in the public health sector, lack of prescribing guidelines for pregnant and breastfeeding women, and stigmatising attitudes among primary health care staff and the community.ConclusionsIt is difficult to anticipate demand for mental health care at district level in the five countries, given the lack of evidence on the prevalence and treatment coverage of women with maternal mental disorders. Limited evidence on effective psychosocial interventions was also noted, and must be addressed for mental health programmes, such as PRIME, to implement feasible and effective services.

Students’ Perceptions of School Counselors: An Investigation of Two High Schools in Beijing, China

This study sought to examine students' perceptions of their school counselors in two high schools in Beijing, China. Independent t tests found that female students rated school counselors' availability significantly higher than male students did. Also, students who had received prior counseling services rated counselors significantly higher in the following areas than did students who had never received counseling services: knowledge of achievement tests, friendliness and approachability, understanding students' point of view, advocating for students, promptness in responding to requests, ability to explain things clearly, reliability to keep promises, availability, and overall effectiveness. A 2 × 2 between-subjects ANOVA found an interaction effect between gender and use or nonuse of counseling services. In general, students gave positive evaluations of school counselors and were satisfied with counseling services.Keywords: school counselors; counseling services; students' perceptions; high schools; Beijing, ChinaChina has been experiencing dramatic economic and social changes in the past 3 decades (Guthrie, 2012). During this time there has been increased attention to both mental health problems and student development (Cyranoski, 2010; Lim, Lim, Michael, Cai, & Schock, 2010; Xin & Zhang, 2009). It has been estimated that at least 17.5% of the Chinese population has some form of mental illness, one of the highest rates in the world (Phillips et al., 2009), accounting for about 20% of hospitalizations in the country (Fei, 2006). Facing significant mental health challenges, several authors have noted the need for more counseling professionals and mental health service providers (Cook, Lei, & Chiang, 2010; Davey & Zhao, 2012). In rural areas with fewer resources, the demand for mental health care is even greater (Ji, 2000).Given such great needs for mental health services, China has been making tremendous efforts in reforming its mental health service system (Tse, Ran, Huang, & Zhu, 2013). In 2004, China launched the 686 Project, a mental health reform initiative modeled on the World Health Organization's recommended framework for integrating hospital-based services with a community mental health service system (Ma, 2012). By the end of 2011, 1.83 million Chinese people with severe mental illness had been treated as a result of the project.While China has witnessed growth in the counseling profession, at the same time it has struggled to build national certification and licensing standards, and create comprehensive counselor training (Chang & Kleinman, 2002; Cook et al., 2010; Davey & Zhao, 2012; Ding, Kuo, & Van Dyke, 2008; Hou & Zhang, 2007). In 2002, China's National Counseling Licensing Board was formed, and there is currently a three-tier national licensing program. More than 30 locations throughout China offer the qualification exams for counselors, and recently a national exam to license school counselors was instituted (Lim et al, 2010). Results from a nationwide survey of professional training of mental health practitioners in China showed that quality of training and supervision were among common concerns (Gao et al., 2010). Also, more accredited professional training programs at the university or college level must be designed and established. Beijing Normal University, in collaboration with Rowan University in the United States, was reported to be the first university in China to offer a school counseling training program (Lim et al., 2010).Mental Health of Students in ChinaIncreased attention to student well-being has shown high prevalence of mental health problems among Chinese students (Cook et al, 2010; Wang & Miao, 2001). Common psychological problems among students included test anxiety, academic pressure, loneliness, social discomfort, video game addiction (Thomason & Qiong, 2008), Internet addiction, child obesity, self-centeredness and reclusion (Worrell, 2008). …

Is There a Place for PAs in Psychiatric Practice?

Is There a Place for PAs in Psychiatric Practice?

Incentives and disincentives for the treatment of depression and anxiety: a scoping review.

There is widespread support for primary care to help address growing mental health care demands. Incentives and disincentives are widely used in the design of health care systems to help steer toward desired goals. The absence of a conceptual model to help understand the range of factors that influence the provision of primary mental health care inspired a scoping review of the literature. Understanding the incentives that promote and the disincentives that deter treatment for depression and anxiety in the primary care context will help to achieve goals of greater access to mental health care. A review of the literature was conducted to answer the question, how are incentives and disincentives conceptualized in studies investigating the treatment of common mental disorders in primary care? A comprehensive search of MEDLINE, PsycINFO, CINAHL, and Google Scholar was undertaken using Arksey and O'Malley's 5-stage methodological framework for scoping reviews. We identified 27 studies. A range of incentives and disincentives influence the success of primary mental health care initiatives to treat depression and anxiety. Six types of incentives and disincentives can encourage or discourage treatment of depression and anxiety in primary care: attitudes and beliefs, training and core competencies, leadership, organizational, financial, and systemic. Understanding that there are 6 different types of incentives that influence treatment for anxiety and depression in primary care may help service planners who are trying to promote improved mental health care.

Mental healthcare in Germany--current situation and perspectives

For several years, there has been a significant increase of the utilization of health care due to mental disorders in Germany. Epidemiologic studies dealing with the prevalence of mental disorders show that the prevalence of mental disorders haven't increased. In consideration of the relative stable prevalence, currently there are only speculations about the reasons for the increasing service utilization. The capacity of psychiatric-psychosomatic-psychotherapeutic health care services is increasing. Despite the fact that capacity is increasing, in the outpatient and inpatient sector it comes apparent that there is an increasing burden, indicating that the demand for mental health care is not met by the capacity of psychiatric-psychosomatic-psychotherapeutic health care services. Health care provision by general practitioners and somatic disciplines predominate, going along with low cross-disciplinary and coordinated cooperation. So far, cooperative, intersectoral care models for mental disorders have been realized only in individual projects. Valid data are lacking, which need to reveal the causes and especially the consequences of this situation of mental health care provision and provide reference standards for an optimized, need-based care planning. For this reason, it is imperative to advance quality management for the care of mental disorders. With a view to the high rates of somatic comorbidity, an expansion of cooperative forms of mental health care appears essential.

Estratégia de Saúde da Família: recursos comunitários na atenção à saúde mental

OBJETIVO: Investigar a percepção de profissionais de estratégia de saúde da família sobre recursos existentes no território para atendimento de demandas em saúde mental. MÉTODOS: Estudo transversal, qualitativo realizado com 27 profissionais da saúde de serviços de atenção primária. Os dados foram coletados utilizando entrevistas, grupos focais e observação. Após a coleta, os dados foram transcritos e submetidos à análise à luz do conceito estruturalista. RESULTADOS: Os enfermeiros referiram dispositivos formais para apoio em saúde mental, enfatizando serviços de saúde. Os coordenadores mencionaram serviços de saúde, universidade e parcerias como conselho tutelar e promotoria pública. Os agentes comunitários demonstraram maior integração com o território e conhecimento abrangente de fontes de apoio social formal e informal. Na observação do território foram identificados recursos sociais não mencionados nas entrevistas. CONCLUSÃO: A percepção dos enfermeiros em relação aos recursos comunitários centrou-se em instituições formais relacionadas à saúde ou ao ensino de cursos na área da saúde. Os coordenadores identificaram outros serviços de saúde e dispositivos de proteção social. Os agentes comunitários têm a maior percepção dos recursos existentes em saúde mental.

The Long Road to Recovery: Environmental Health Impacts of Hurricane Sandy

Building contractor John Pierciey stands in the gutted interior of a 1950s-era home in Manasquan, New Jersey. Wallboard, two layers of wood flooring, a layer of felt—all of it had to be ripped out to rid the house of mold caused by Hurricane Sandy’s storm surge. “This is the sixth house I’ve gutted in a week,” Pierciey says. “Every one is different. You don’t know what you’re going to find until you take them apart.” Residents and volunteers keep warm by a fire barrel in the New Dorp Beach neighborhood of Staten Island, 5 November 2012. Power outages persisted through a cold snap that put temperatures in the single digits. So it is with the environmental health impacts of Hurricane Sandy. Every layer of society, every type of building, has felt the impact of the storm, which struck the U.S. East Coast on 29 October 2012. Incidences of death and illness, though small in number compared with some storms, have come in many forms, the effects still unfolding as time goes by.

A intersubjetividade no cuidado à Saúde Mental: narrativas de técnicos e auxiliares de enfermagem de um Centro de Atenção Psicossocial

Psychosocial Care Centers (Caps) were established as a result of the demand for Mental Health care and were an attempt to update psychiatric treatment for those afflicted with severe mental disorders. This article seeks to analyze subjective repercussions of work conducted in Caps on mid-level professionals and to contribute to healthcare planning. Two focal groups were conducted with workers of a Caps III. The methodology applied to the analysis was based on the critical hermeneutical approach proposed by Ricoeur and espoused by Gadamerian philosophy. Lack of appreciation in the workplace was revealed as being the main cause of suffering. Several themes stood out including the difficulty of obtaining the cooperation of users'; relatives, the tenuous interconnection between Caps and the health network, the attribution of responsibility for the night shift, controversies regarding overnight-stay patients and an excessive workload. Adequate structural planning and institutional organization is proposed when opening new Caps in order to reduce the workload of technicians and improve the clinical performance of the team.

Impact of a social and employment crisis on the demand for mental health care (Footwear Crisis, Elche 2004)

IntroductionBetween December 1999 and December 2004 the footwear manufacturing industry in Elche suffered a 24% fall in employment. In this context, it was decided to conduct study to detect possible changes in the demand for mental health care. Material and methodsThe first-time consultations between December 2001 and June 2002 were compared with those seen between October 2004 and April 2005. Differences were looked for in the percentage of referrals for work-related stress factors. The role of these work-related stress factors in the changes detected in the sociodemographic profile of the patients was also evaluated. Results and conclusionsChanges were detected in the sociodemographic profile (gender and education level), employment status and reason for consultation. First consultations increased in the following groups: males, with a higher education level, unemployed, on sick leave or pensioners, and also those with employment problems as the main reason for consultation or a worsening of other health conditions.

Rural mental health workforce difficulties: a management &#x0D; perspective

The recruitment, retention and training of mental health workers is of major concern in rural Australia, and the Gippsland region of Victoria is no exception. Previous studies have identified a number of common factors in these workforce difficulties, including rurality, difficulties of access to professional development and training, and professional and personal isolation. However, those previous studies have often focused on medicine and been based on the perspectives of practitioners, and have almost ignored the perspectives of managers of rural mental health services. The study reported in this article sought to contribute to the development of a more sustainable and effective regional mental health workforce by complementing earlier insights with those of leading administrators, managers and senior clinicians in the field. The study took a qualitative approach. It conducted semi-structured in-person interviews with 24 managers of health/mental-health services and senior administrators and clinicians working in organisations of varying sizes in the public and private sectors. Thematic content analysis of the transcribed interviews identified core difficulties these managers experienced in the recruitment, retention and training of employees. The study found that some of the issues commonly resulting in difficulties in recruiting, retaining and developing a trained workforce in rural areas, such as rurality (implying personal and professional isolation, distances to deliver service and small organisations) and a general shortage of trained personnel, are significant in Gippsland. Through its focus on the perspectives of leaders in the management of rural mental health services, however, the study found other key issues that contribute to workforce difficulties. Many, including the unattractive nature of mental health work, the fragmented administration of the mental health system, short-term and tied funding, and shortcomings in training are external to organisations. Interviewees indicated that these issues make it difficult for organisations to support personnel in ways that enhance personal and professional satisfaction and so retention and, in turn, the capacity to recruit new employees. Participants also highlighted issues internal to the organisation. The tensions that flow from the systemic forces require highly creative leadership to negotiate the numerous policy changes, diverse sources of funding, training regimens, worker cohorts and models of care. Managers must nurture the capacity of their own organisation to respond flexibly to the demands, by establishing a responsive culture and structure. They must also encourage the collaboration of their other organisations in their sub-regional grouping and the development of a regional sensibility. The approach taken by the study, particularly its focus on a management perspective, revealed that the difficulties experienced are the product of a core tension between a growing demand for mental health care, emerging specialities and technological advances in the field, and a diminished systemic capacity to support organisations in meeting the demand. Resolving this core tension is a key to the maintenance of a sustainable and effective workforce in Gippsland, and the role of management is crucial to that resolution.

Psychiatrists Protest Blues' New Coverage Requirements

Psychiatrists Protest Blues' New Coverage Requirements

Repliek

Response In our response to the three reviews of our book we focus on five critical points that were made, namely: the presumed absence of a central question and overall explanatory framework; the argument that the work is not a synthesis; the problem of the interplay between the supply of and demand for mental health care; the relation between the perspective of mental health experts and our interpretation of this in terms of cultural pessimism as well as social design; and the objection that our elaboration of the process of psychologisation is unclear. We would like to emphasise that we do indeed present a definition of a central problem in the introduction and that we discuss it extensively and systematically in our conclusion. We also explain what, in our view, a historical synthesis should aim for and that our approach is empirical-historical rather than theoreticalsociological. We believe that we maintain a considerable distance from the actor's perspective at that time and that the criticism of our description of psychologisation is based on a limited understanding of that term. This response is part of the discussion forum 'Verward van geest en ander ongerief' (H. Oosterhuis, M. Gijswijt-Hofstra).

Cultural Competence Reexamined: Critique and Directions for the Future

Cultural Competence Reexamined: Critique and Directions for the Future