Evaluation Of Mental Health Services Research Articles

Using feedback from patient-reported outcome measures in mental health services: a scoping study and typology.

Routine evaluation of mental health services has become widespread, and the use of patient-reported outcome measures (PROMs) as clinical aids or discussion tools has been receiving increasing attention. The purpose of this scoping study was to provide a typology of the diverse ways in which studies reporting on PROM use in mental health services have utilized PROMs. Iterative scoping searches of the literature identified articles reporting on the use of PROM feedback in mental health settings, which were then categorized to develop a typology along a dimension of intensity of use of PROM feedback, ranging from no feedback to patient and clinician to clinician-patient discussion that followed a formalized structure. Of the 172 studies that were identified, 27 were grouped into five categories, ranging from studies in which there was no PROM feedback to clinician or patient to studies in which a formalized structure was available by which PROM feedback could be discussed between clinician and patient. Of the 11 studies in the category with formalized feedback, nine reported some significant effects of feedback compared with a control condition, and two reported partial significant effects. The proposed procedural typology helps explain the diversity of results from studies reporting on the effects of PROM feedback, by highlighting that PROM feedback appears to be more effective when integrated in a formalized and structured manner. Future work is required to isolate these effects from common procedural correlates, such as monitoring of the therapeutic alliance.

Using social bonding theory to examine 'recovery' in a forensic mental health hospital: A qualitative study.

For people living with mental illness, recovery involves learning to overcome and manage their symptoms and striving to live fulfilling lives. The literature on achieving recovery emphasises the importance of social connections and positive role models. Hirschi's social bonding theory posits that an individual's attachment to others, belief in social norms, and their commitment and involvement in conventional activities are the major contributors to normalising social behaviour. The aim of this study is to understand the qualities of service identified by patients in a forensic hospital as being important and meaningful to recovery. Semi-structured interviews with 30 inpatients in a forensic mental health hospital in British Columbia, Canada, were audio recorded, and the transcriptions were analysed using thematic analysis. Five themes emerged: involvement in programmes, belief in rules and social norms, attachment to supportive individuals, commitment to work-related activities and concern about indeterminacy of stay. The first four themes map closely onto Hirschi's criminologically derived social bonding theory; however, indeterminacy of stay also arose as a common theme. In addition, the theory was too simple in its separation of elements; our data suggested the complex integration of themes. Our findings may be useful for informing evaluation of forensic mental health services.

Involvement of users and relatives in mental health service evaluation.

Although Italian mental health (MH) services are community based, user and relative participation in service evaluation lagged behind until lately. We here review three recent studies involving stakeholder participation in service evaluation: two were quantitative studies, one on 204 users in an MH service in Pistoia (Central Italy) and the other on 2259 relatives, conducted with the National Union of Associations for Mental Health. The third (supported by The Centro per il Controllo delle Malattie, the ministerial Center for Disease Control) was a qualitative study in seven MH services, involving users, relatives, and professionals together, which collected interviews from 136 users, 119 relatives, and 79 professionals. In the quantitative studies, positive evaluations outnumbered negative ones. The qualitative study explored negative aspects in greater depth. Common findings were insufficient information, underinvolvement of users-relatives in planning, no choice of clinician, psychiatrist domination, and limited helpfulness of interventions. With stakeholder participation in service evaluation, the present medical framework will need reshaping.

Integralidade e humanização em saúde mental: experiências de usuários em dois centros de atenção psicossocial

A implementacao de politicas publicas de saude mental na conjuntura do Sistema Unico de Saude, baseada nos preceitos da Reforma Psiquiatrica, enseja novos desafios para a area, tais como a producao de redes substitutivas e territoriais que visem a superacao do modelo hospitalocentrico, a conquista de cidadania e a criacao de um novo lugar social para a experiencia do sofrimento psiquico. Para garantir a materialidade dessas mudancas, faz-se necessaria a participacao efetiva dos usuarios na avaliacao de servicos e programas de saude mental. Destarte, esta investigacao objetiva compreender as experiencias de usuarios em dois Centros de Atencao Psicossocial (CAPS) de Fortaleza-Ceara, no que concerne a assistencia conferida pelos profissionais, exprimindo destaque as dimensoes integralidade e humanizacao do cuidado em saude. A escolha da abordagem qualitativa como metodologia desta pesquisa esta relacionada a natureza ontologica do objeto em foco, visto que esta e permeada de significados que os usuarios atribuem as suas experiencias nos servicos de saude mental e a maneira como compreendem e interpretam as praticas assistenciais. As tecnicas utilizadas para a obtencao do material empirico foram a entrevista em profundidade e a observacao nao estruturada, nos meses de julho a dezembro de 2011. Os dados foram analisados e interpretados sob a optica da Hermeneutica-critica gadameriana, cujo metodo assume a intersubjetividade na interconexao com a materialidade a que se vincula de maneira dialetica. Os resultados evidenciaram tres temas centrais que constituiram a Rede de Significados: A) Experiencias dos itinerarios terapeuticos; B) Percepcao dos usuarios sobre o servico; e C) Qualidade do cuidado. Destaca-se o impacto dos diferentes modelos asilar e psicossocial na experiencia vivida dos usuarios dos distintos CAPS. Observou-se, tambem, que os usuarios percebem o acolhimento, a resolubilidade, a ambiencia, a boa interacao dos profissionais-usuarios, o agenciamento de medicamentos e a humanizacao como os principais aspectos concernentes ao atendimento de qualidade em saude mental - embora tais questoes, em alguns momentos, tenham se revelado de maneira singular nos dois dispositivos desta pesquisa. Conclui-se que, apesar de alguns entraves, os aspectos da assistencia apontados pelos usuarios dos distintos CAPS corroboram os ideais da Reforma Psiquiatrica e sinalizam que a reorientacao do modelo de atencao em saude mental ja se capilariza no cotidiano das praticas de cuidado.

Perceptions of behavioral health care among veterans with substance use disorders: Results from a national evaluation of mental health services in the Veterans Health Administration

Understanding patients' perceptions of care is essential for health care systems. We examined predictors of perceptions of behavioral health care (satisfaction with care, helpfulness of care, and perceived improvement) among veterans with substance use disorders (SUD; n=1,581) who participated in a phone survey as part of a national evaluation of mental health services in the U.S. Veterans Health Administration. In multivariate analyses, SUD specialty care utilization and higher mental health functioning were associated positively with all perceptions of care, and comorbid schizophrenia, bipolar, and PTSD were associated positively with multiple perceptions of care. Perceived helpfulness of care was associated with receipt of SUD specialty care in the prior 12months (adjusted OR=1.77, p<.001). Controlling for patient characteristics, satisfaction with care exhibited strong associations with perceptions of staff as supportive and empathic, whereas perceived improvement was strongly linked to the perception that staff helped patients develop goals beyond symptom management. Survey responses that account for variation in SUD patients' perceptions of care could inform and guide quality improvement efforts with this population.

Mental health service delivery: a profile of mental health non-government organisations in south-east Queensland, Australia

Non-government organisations make a substantial contribution to the provision of mental health services; despite this, there has been little research and evaluation targeted at understanding the role played by these services within the community mental health sector. The aim of the present study was to examine the depth and breadth of services offered by these organisations in south-east Queensland, Australia, across five key aspects of reach and delivery. Representatives from 52 purposively targeted non-government organisations providing mental health services to individuals with significant mental health challenges were interviewed regarding their approach to mental health service provision. The findings indicated a diverse pattern of service frameworks across the sector. The results also suggested a positive approach to the inclusion of consumer participation within the organisations, with most services reporting, at the very least, some form of consumer advocacy within their processes and as part of their services. This paper offers an important first look at the nature of non-government service provision within the mental health sector and highlights the importance of these organisations within the community sector. What is known about the topic? Non-government organisations make a substantial contribution to the multisectorial provision of services to mental health consumers in community settings. Non-government organisations in Australia are well established, with 79.9% of them being in operation for over 10 years. There is an increasing expectation that consumers influence the development, delivery and evaluation of mental health services, especially in the community sector. What does this paper add? This paper provides a profile of non-government organisations in one state in Australia with respect to the services they provide, the consumers they target, the practice frameworks they use, the use of peer workers and consumer participation, the success they have had with obtaining funding and the extent to which they collaborate with other services. What are the implications for practitioners? This paper provides readers with an understanding of the non-government organisations and the services they provide to people with mental health conditions. In addition, the findings provide an opportunity to learn from the experience of non-government organisations in implementing consumer participation initiatives.

EPA-1030 – The greek version of the camberwell assessment of need: psychometric properties and associations with quality of life and social disability in schizophrenia

Needs assessment has been highlighted as a crucial factor in the development, organisation and evaluation of mental health services. Moreover, meeting self-reported needs is of prime importance for ensuring quality of life and reducing social disability for people with severe mental disorders. Service evaluation based on patients’ need assessments has never taken place in Greece. Furthermore there are no standardized needs assessment instruments. Given the underfunding of psychiatric services due to the current economic crisis, systematic need assessment is expected to contribute to the efficient use of their limited resources. To examine the concurrent validity, inter-rater and test-retest reliability of the Greek research version of the Camberwell Assessment of Need (CAN-R). Fifty-three schizophrenia patient–staff pairs were interviewed twice to test the inter-rater and test-retest reliability of the CAN-R (Greek version). The WHOQOL-BREF and WHODAS 2.0 were administered to the patients to examine concurrent validity. The inter-rater and test-retest reliability of patient and staff interviews for the 22 individual items and the eight summary scores of the instrument's four sections were good to excellent. Significant correlations emerged between CAN scores and the WHOQOL-BREF and WHODAS 2.0 domains for patient and staff ratings, indicating good concurrent validity. Our results suggest that the Greek version of the CAN-R is a reliable instrument for assessing mental health patients’ needs. This is the first CAN-R validity study with satisfactory results using WHOQOL-BREF and WHODAS 2.0 as criterion variables.

Retention of Children and Their Families in the Longitudinal Outcome Study of the Comprehensive Community Mental Health Services for Children and Their Families Program

Predictors of retention of participants in a longitudinal study and heterogeneity between communities were investigated using a multilevel logistic regression model. Data from the longitudinal outcome study of the national evaluation of the Comprehensive Community Mental Health Services for Children and Their Families program and information on communities participating in the evaluation were used to examine retention of participants at 6-, 12-, 18-, and 24-month follow-up interviews. Findings revealed that both child and family characteristics and community characteristics significantly influenced participation for up to 24-month follow-up. Specifically, behavioral and emotional problems at intake, referral source, proportion of total staff devoted to interviewers, and total amount of incentive paid out at baseline influenced retention of participants. In addition, significant random effects at both Level 2 and Level 3 indicated that retention varied significantly between communities and among children even after controlling for child and family characteristics.

Measuring the needs of mental health patients in Greece: Reliability and validity of the Greek version of the Camberwell Assessment of Need

Evaluation of mental health services based on patients' needs assessments has never taken place in Greece, although it is a crucial factor for the efficient use of their limited resources. To examine the inter-rater and test-retest reliability and the concurrent/convergent validity of the Greek research version of the Camberwell Assessment of Need-Research (CAN-R). A total of 53 schizophrenic patient-staff pairs were interviewed twice to test the inter-rater and test-retest reliability of the Greek version of the CAN-R. The World Health Organization Quality of Life-Brief Form (WHOQOL-BREF) and World Health Organization Disability Assessment Schedule-2.0 (WHODAS-2.0) were administered to the patients to examine concurrent validity. The inter-rater and test-retest reliability of patient and staff interviews for the 22 individual items and the eight summary scores of the instrument's four sections were good to excellent. Significant correlations emerged between CAN scores and the WHOQOL-BREF and WHODAS-2.0 domains for both patient and staff ratings, indicating good concurrent validity. Our results suggest that the Greek version of the CAN-R is a reliable instrument for assessing mental health patients' needs. Moreover, it is the first CAN-R validity study with satisfactory results using WHOQOL-BREF and WHODAS-2.0 as criterion variables.

Qualitative evaluation of mental health services for clients with limited English proficiency

BackgroundTo meet federal requirements under Title VI of the Civil Rights Act, the state of California instituted policies requiring that comprehensive mental health services in native languages be made available to limited English proficiency (LEP) populations when concentrations exceed “threshold” levels.MethodsThis paper builds on promising results from quantitative evaluations by reporting on qualitative interviews with Latino and Vietnamese LEP clients in mental health services (N = 20) to examine the awareness, impact, and implications of these threshold language policies.ResultsResults suggest that, while individuals are often not aware of the policies themselves, the language-related services they receive that are prompted by the policies are critical to treatment initiation and retention. Results also convey the complexities of using interpreters for sensitive psychological topics, and suggest that, for LEP individuals seeking mental health treatment, providers who speak their native languages are generally preferred.ConclusionsAccess to language-appropriate services seems to be an important part of why LEP populations seek mental health treatment. However, there are multiple variables that factor into the usage and usefulness of such services.

Patient satisfaction with specialized mental health service for obsessive-compulsive disorder

BackgroundPatient satisfaction is an important outcome variable that is increasingly used in mental health service evaluation. There are no results available for patients with obsessive-compulsive disorder (OCD) yet.MethodsUsing the Verona Service Satisfaction Scale, patient satisfaction with a specialized mental health service was examined in patients with OCD.ResultsOCD patients were overall satisfied with the professional help provided, whereas satisfaction with the professional involvement of relatives within the treatment and health care process was found to be quite low. Patients with more severe OCD, as measured by the Yale-Brown Obsessive-Compulsive Scale, as well as chronically ill and more disabled patients were more likely to be dissatisfied with the overall care they received. Patient satisfaction plays an important role in the long-term course of an illness such OCD. This seems to be decreased so longer illness is not or badly treated. There is a stronger need for involvement of family members in the treatment and health care of patients with OCD.ConclusionsMore OCD-specific treatment offers have to be established for patients with this long-term illness such as psychotherapy in groups.

Pilot Testing of a Questionnaire for the Evaluation of Mental Health Services in Family Health Team Clinics in Ontario

Family health teams (FHTs), regarded today as a premier model of provision of primary care services in North America, were introduced in 2004 to improve traditionally fragmented primary healthcare in Ontario. Physicians and healthcare providers from various disciplines team up under the same roof in FHTs to provide and coordinate care and to ensure adequate access to and continuity of care. Because many Canadians with mental health problems consult family physicians in primary care, routine evaluation of the delivery of primary mental health care services in FHTs is becoming important. The authors' goal was to develop and test an evaluation tool (containing a questionnaire for patients and a questionnaire for providers) for mental health services provided in FHTs with a focus on accessibility, availability, quality, continuity of care and coordination of services. They developed and pilot tested an English-French tailored evaluation instrument in several FHTs in South East, Champlain and North East Local Health Integration Networks across Ontario. A convenience sample of English- and French-speaking healthcare providers and patients using mental health services was recruited. Provider and patient questionnaires were developed and pilot-tested with 12 providers and 10 clients. Patient reviewers rated the patient questionnaire consistently as "good" or "very good." Provider reviewers found the provider questionnaire to be important and timely and the questions to be adequate and interesting. This instrument evaluates, from both the patient and provider perspectives, whether mental health services are structured to meet expectations set for FHTs, and enables healthcare providers, administrators and policy makers to learn about the benefits and the deficiencies of mental health care delivered through these clinics. This instrument can also be used to enhance future research and evaluation of FHTs. Further validation effort will be required to establish its validity and reliability.

Back to the basics: identifying positive youth development as the theoretical framework for a youth drug prevention program in rural Saskatchewan, Canada amidst a program evaluation.

BackgroundDespite endorsement by the Saskatchewan government to apply empirically-based approaches to youth drug prevention services in the province, programs are sometimes delivered prior to the establishment of evidence-informed goals and objectives. This paper shares the 'preptory’ outcomes of our team’s program evaluation of the Prince Albert Parkland Health Region Mental Health and Addiction Services’ Outreach Worker Service (OWS) in eight rural, community schools three years following its implementation. Before our independent evaluation team could assess whether expectations of the OWS were being met, we had to assist with establishing its overarching program goals and objectives and 'at-risk’ student population, alongside its alliance with an empirically-informed theoretical framework.MethodsA mixed-methods approach was applied, beginning with in-depth focus groups with the OWS staff to identify the program’s goals and objectives and targeted student population. These were supplemented with OWS and school administrator interviews and focus groups with school staff. Alignment with a theoretical focus was determined though a review of the OWS’s work to date and explored in focus groups between our evaluation team and the OWS staff and validated with the school staff and OWS and school administration.ResultsWith improved understanding of the OWS’s goals and objectives, our evaluation team and the OWS staff aligned the program with the Positive Youth Development theoretical evidence-base, emphasizing the program’s universality, systems focus, strength base, and promotion of assets. Together we also gained clarity about the OWS’s definition of and engagement with its 'at-risk’ student population.ConclusionsIt is important to draw on expert knowledge to develop youth drug prevention programming, but attention must also be paid to aligning professional health care services with a theoretically informed evidence-base for evaluation purposes. If time does not permit for the establishment of evidence-informed goals and objectives at the start-up of a program, obtaining insight and expertise from program personnel and school staff and administrators can bring the program to a point where this can still be achieved and theoretical linkages made after a program has been implemented. This is a necessary foundation for measuring an intervention’s success.

Pilot of Te Tomo mai, a child and adolescent mental health service evaluation tool for an indigenous rangatahi (youth) population

The acceptability of Child and Adolescent Mental Health Services (CAMHS) to indigenous rangatahi (12–19-year-olds) requires investigation. Evaluation tools able to take account of the more holistic approach to the attainment of mental health that characterises Māori, the indigenous population of Aotearoa (New Zealand) with specificity to the rangatahi population are critical to this examination. The study aims were to: (1) develop an instrument and establish its psychometric properties; and (2) use the measure to establish rangatahi views on desirable CAMHS characteristics. A kaupapa Māori (Māori-driven) research paradigm, based on the traditional Pōwhiri process of engagement and participation, particularly the components of karanga, mihimihi, whaikōrero and koha guided this quantitative research approach. These components are essential to positive contact and commitment to the study processes by researchers and participants. A self-administered survey, Te Tomo mai, was developed by modifying a North American questionnaire, the Youth Services Survey for Youth. The intent of the tool was to record rangatahi experiences and views on service acceptability. The Te Tomo mai survey incorporates questions designed to examine CAMHS delivery in the light of the Whare Tapa Whā, a Māori comprehensive model of health with a focus on culturally responsive services. This survey was completed by a cohort of 69 Māori rangatahi who were referred to six CAMHS District Health Boards in Aotearoa. The Te Tomo mai instrument factor structure, specifically the cultural factor, had similarity to the North American questionnaire from which it had been derived. This work confirms the concept that Māori desire therapeutic methods consistent with the Whare Tapa Whā, such as the importance of culture and spirituality. It further identified issues relevant to Māori rangatahi acceptability with CAMHS such as access, satisfaction and appropriateness. The participants were generally positive about the services they received from the CAMHS, which shows good acceptability of CAMHS for Māori. The Te Tomo mai instrument can prove useful if applied in Aotearoa or other similar cultural settings. It is a means of determining the cultural acceptability which will contribute to improving CAMHS delivery to rangatahi from indigenous populations.

‘Show me the money’: improving the economic evaluation of mental health services

Compared with the United Kingdom, mental health services in Ireland are under-funded and under-developed. This may be partly due to the neglect of economic analyses concerning mental health services in Ireland, as few policy makers would invest in the sector without evidence that such investment represents 'value-for-money' economically. Aim The aim of this paper is to highlight how mental health services can conduct economic service evaluations that ultimately will drive the policy-making agenda and future governmental investment. A guide to the economic evaluation of mental health services, based on a narrative review of relevant policy documents and papers, in an Irish context. Three types of economic analyses that can be undertaken within mental health services are outlined: (a) cost-benefit analysis, (b) cost-utility analysis and (c) cost-minimisation analysis. In addition, a newly formulated questionnaire (i.e. the 'EcoPsy 12') is presented. Economic evaluations of mental health services can provide re-assurances to policy-makers that (much-needed) investment in such services is economically viable.

System-level change in mental health services in North Wales: An observational study using systems thinking

To describe changes to mental health services using systems thinking. Structured standardized quality of life assessment (Manchester Short Quality of Life Assessment: MANSA) was used to establish service user priorities for changes to service provision (part of a process known as check in systems thinking). Current service performance in these priority areas was identified, and changes to service arrangements were planned, implemented and monitored by task and finish (T&F) groups (making use of a process known as flow in systems thinking). 81 MANSA assessments were completed at the check stage (by NM). Work finances and leisure activities emerged as service user priority areas for change, and T&F groups were established with representation of all sectors and service users. Ways to make improvements were observed, planned and implemented by T&F groups (the flow stage). The systems approach reveals how services and quality of life have been changed for patients in Wrexham. Further generalizable research is needed into the potential benefits of using systems thinking in mental health service evaluation.

Psychotropic Medication Use and Clinical Outcomes Among Children and Adolescents Receiving System of Care Services

Few studies of psychotropic medication use among children and adolescents address the effectiveness of this medication, as it is typically used in naturalistic treatment settings. The objective of this study was to investigate psychotropic medication use among children and adolescents treated in system of care communities, to identify subject characteristics associated with psychotropic medication use, and determine whether psychotropic medication use is associated with reduced symptom severity. Data were collected through the National Evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program. For this evaluation, 27 system of care communities reported data on medication use and clinical ratings at intake and 6-month follow-up on children and adolescents 6-18 years of age receiving mental health services between 2006 and 2009. We used mixed-effects logistic regression to determine associations between patient characteristics and medication use, and mixed-effects linear regression to determine whether subjects taking medication and those not taking medication experienced different changes in symptom severity between intake and 6 months. Subject characteristics associated with psychotropic medication use, when controlling for other characteristics, included having more severe emotional and behavioral symptoms at intake, having more co-occurring diagnoses, and receiving more than one type of service. Those both taking and not taking medication showed symptom reduction at 6 months, although symptom severity among subjects taking medication remained in the clinical range. When controlling for covariates, symptom reduction was associated with medication use. Taking psychotropic medication was more strongly associated with measures of illness severity-greater symptom severity at intake, more co-occurring diagnoses, and more service intensity-than with other demographic characteristics. Subjects who took medication showed more symptom reduction at 6 months than those not taking medication, although this reduction was not sufficient to normalize symptoms among those taking medication.

Telephone survey of service‐user experiences of a telephone‐based mental health triage service

The participation of service users in all aspects of mental health service delivery including policy development, service planning and evaluation is increasingly an expectation of contemporary mental health care. Although there are a growing number of publications reporting service-user perspectives in the evaluation of mental health services, little attention has been paid to the views of service users about mental health triage services. The purpose of the study reported here was to examine service-users' (consumers and informal carers) experiences of a telephone-based mental health triage service. Using a framework developed from the World Health Organisation's elements of responsiveness, we conducted structured telephone interviews with service users who had contacted a telephone-based mental health triage service in regional Victoria, Australia. The main findings of the study were that consumers experienced more difficulty than carers in accessing the service and that, although most participants were satisfied, only a minority reported being involved in decision-making. Further work is needed to improve accessibility of mental health triage services and to investigate barriers to consumer self-referral. Professional development and practice support systems should be established to support mental health triage nurses in the development of collaborative, consumer-focused care.

A small-scale service evaluation of Warwickshire Child and Adolescent Mental Health Services’ systemic family therapy

A small-scale service evaluation of Warwickshire Child and Adolescent Mental Health Services’ systemic family therapy

Setting Priorities for Mental Health Research in Brazil

The main aim of this study is to review the agenda for research priorities of mental health in Brazil. The first step was to gather 28 experts (22 researchers, five policy makers, and the coordinator) representing all mental health fields from different geographical areas of the country. Participants were asked to list what they considered to be the most relevant mental health research questions for the country to address in the next 10 years. Seventeen participants answered this question; after redundancies were excluded, a total of 110 responses were collected. As the second step, participants were asked to rank which questions were the 35 most significant. The final step was to score 15 items for each of the 35 selected questions to determine whether it would be a) answerable, b) effective, c) deliverable, d) equitable, and e) effective at reducing the burden of mental health. The ten highest ranked questions were then selected. There were four questions addressing primary care with respect to a) the effectiveness of interventions, b) "matrix support", c) comparisons of different models of stepped care, and d) interventions to enhance identification and treatment of common mental disorders at the Family Health Program. The other questions were related to the evaluation of mental health services for adults and children/adolescents to clarify barriers to treatment in primary care, drug addiction, and severe mental disorders; to investigate the cost-benefit relationship of anti-psychotics; to design interventions to decrease alcohol consumption; and to apply new technologies (telemedicine) for education and supervision of non-specialists. This priority-setting research exercise highlighted a need for implementing investments at the primary-care level, particularly in the family health program; the urgent need to evaluate services; and policies to improve equity by increasing accessibility to services and testing interventions to reduce barriers for seeking mental health treatment.