Fragmented Mental Health Research Articles

Dedicated Pediatric Behavioral Health Unit

Pediatric mental health emergencies are an increasing part of emergency medical practice because emergency departments have become the safety net for a fragmented mental health infrastructure that is experiencing critical shortages in services in all sectors. The emergency services for behavioral health unit at Akron Children's Hospital is an innovative model for delivering care to pediatric patients with mental health emergencies. A multidisciplinary team using the expertise of emergency services, psychiatry, social work, parent advisory counsel, security services, and engineering/architecture developed the emergency services for behavioral health unit blueprint, process, and staffing model.

Mental health care practices in the family health strategy: a review of possibilities and limit for na integrated care

The implementation of Mental Health actions in the Family Health Strategy (ESF) still represents a challenge for professionals and health managers, although several experiences of practice are known in Brazil. Based on a literature review, we aimed to systematize the main elements of the facilities and difficulties in the insertion of mental health in the context of ESF. If it is possible to identify similarities between the characteristics reported in the literature, we found that the relationship between professionals and community, the knowledge about the reality of the communities and the proposed actions for prevention and health promotion will facilitate the development of mental health actions in the ESF. Still, the lack of professional training, the medicalized and fragmented mental health design, the lack of a support network for the actions of professionals and the prejudice against mental disorders are factors that make the implementation of health care difficult, what must be focus of technical actions and policies to subsidize the construction of mental health care, focused on deinstitutionalization.

Psychiatric remuneration systems in Europe: an overview

SummaryNew forms of psychiatric remuneration linked to levels of activity undoubtedly will have an increasing role to play in mental health systems right across Europe. Potentially they can be more efficient and promote choice, but valid concerns have been raised about their impact on the sustainability and nature of psychiatric care. This article looks in particular at recent developments in England and the Netherlands and reflects on how remuneration mechanisms may need to develop further both to improve efficiency and quality within the context of an ever more fragmented and multi-sectoral mental health system. Any introduction of activity- based reimbursement should be introduced gradually. This should be accompanied by investment in adequate information systems to help better understand service utilisation patterns, transitional funding safeguards to reduce the risk of financial instability and incentives/ contractual measures to ensure that services strive to offer services of the highest possible quality that meet the needs of service users.

A-Visions: A Scripps supported employment program

This expository paper describes an innovative Scripps designed supported employment program, using an evidence- based practice model based on recovery by Scripps Behavioral Health Services staff to fill a gap in the continuum of care for Behavioral Health Services. The A-Visions Program was also developed to increase offerings to mental health consumers (typically those with serious and persistent mental illness) struggling to find help in an under funded, fragmented mental health system of care. The program has grown since its inception and has received commendations from external stakeholders. This paper reviews the prevalence of mental illness in the United States, a review of the classic and recent evidence-based literature, a comprehensive description of the program (including analyses of outcome measures), a plan to spread this innovation across the Scripps enterprise, and conclusions. Due to the success of the program in providing essential services to individuals with serious mental illness, the authors recommend replication in other Scripps facilities. The author makes a strong case for the spread of this innovation, as these services typically are not a part of the mental health care continuum. These program development strategies are replicable in other mental health programs.

Mental Health Services in New Nepal – Observations, Objections and Outlooks for the Future

It has been over a decade since the government of Nepal adopted the National Mental Health Policy (NMHP) in 1997. This article analyses the current provision of fragmented mental health services in Nepal through case scenarios from Jumla in northwest and Janakpur in southeast Nepal, criticises the proposed mental health Act, discusses the reasons why the NMHP has not been implemented and suggests future models of delivering mental health services in the wider community. Absence of a mental health section within the department of health, insufficient budget, chronic shortage of trained manpower, and unplanned growth of private medical institutions appear to be the issues deserving urgent attention. Setting up specialist psychiatric facilities in all developmental regions or future states, developing community mental health programmes and integration of mental health into general health care are the ways forward to meet the needs and expectations of the new federal Nepal.

A Rural Perspective on Perinatal Depression: Prevalence, Correlates, and Implications for Help‐Seeking Among Low‐Income Women

CONTEXT/PURPOSE: To examine a low-income sample of women in the rural Midwest (N = 1,086) who were screened for perinatal depression through the outreach and education activities within a Healthy Start Initiative project. Specifically, we describe the frequency and severity of depressive symptoms, explore social and demographic correlates of depression, and examine help-seeking through patterns of self-referral to a Healthy Start perinatal depression project in a rural, medically underserved community. Depression screening data using the Primary Care Evaluation of Mental Disorders (PRIME-MD) as well as intake records from the project were analyzed in a retrospective analysis to identify important demographic and psychosocial characteristics associated with elevated levels of depressive symptoms and help-seeking patterns. Thirty-six percent of screened women met criteria for major, minor, or subthreshold depression, with 13% meeting diagnostic criteria for major depression alone. Less than 8% were currently receiving any type of mental health services or treatment at screening. The most significant correlate of self-referral to the Healthy Start project was meeting symptom criteria for major depression, although minor depression, subthreshold depression, and status as low-income/Temporary Aid to Needy Families (TANF)-eligible were all significantly associated with self-referral. The findings from this study highlight the potential significance of identifying and addressing the unmet mental health needs of low-income rural women during and around pregnancy. In addition, the study illustrates that low income, in addition to depressive symptoms, impacts mental health service delivery in this rural community with a fragmented mental health service infrastructure.

Personal Accounts: Could Noah's Life Have Been Saved? Confronting Dual Diagnosis and a Fragmented Mental Health System

Personal Accounts: Could Noah's Life Have Been Saved? Confronting Dual Diagnosis and a Fragmented Mental Health System

Personal Accounts: Could Noah's Life Have Been Saved? Confronting Dual Diagnosis and a Fragmented Mental Health System

Personal Accounts: Could Noah's Life Have Been Saved? Confronting Dual Diagnosis and a Fragmented Mental Health System

Mental Health Policy and Services Five Years After the President's Commission Report: An Interview With Michael F. Hogan

Mental Health Policy and Services Five Years After the President's Commission Report: An Interview With Michael F. Hogan

Physician attitude toward depression care interventions: Implications for implementation of quality improvement initiatives

BackgroundFew individuals with depression treated in the primary care setting receive care consistent with clinical treatment guidelines. Interventions based on the chronic care model (CCM) have been promoted to address barriers and improve the quality of care. A current understanding of barriers to depression care and an awareness of whether physicians believe interventions effectively address those barriers is needed to enhance the success of future implementation.MethodsWe conducted semi-structured interviews with 23 primary care physicians across the US regarding their experience treating patients with depression, barriers to care, and commonly promoted CCM-based interventions. Themes were identified from interview transcripts using a grounded theory approach.ResultsSix barriers emerged from the interviews: difficulty diagnosing depression, patient resistance, fragmented mental health system, insurance coverage, lack of expertise, and competing demands and other responsibilities as a primary care provider. A number of interventions were seen as helpful in addressing these barriers – including care managers, mental health integration, and education – while others received mixed reviews. Mental health consultation models received the least endorsement. Two systems-related barriers, the fragmented mental health system and insurance coverage limitations, appeared incompletely addressed by the interventions.ConclusionCCM-based interventions, which include care managers, mental health integration, and patient education, are most likely to be implemented successfully because they effectively address several important barriers to care and are endorsed by physicians. Practices considering the adoption of interventions that received less support should educate physicians about the benefit of the interventions and attend to physician concerns prior to implementation. A focus on interventions that address systems-related barriers is needed to overcome all barriers to care.

Needs-oriented discharge planning and monitoring for high utilisers of psychiatric services (NODPAM): Design and methods

BackgroundAttempts to reduce high utilisation of psychiatric inpatient care by targeting the critical time of hospital discharge have been rare.MethodsThis paper presents design and methods of the study "Effectiveness and Cost-Effectiveness of Needs-Oriented Discharge Planning and Monitoring for High Utilisers of Psychiatric Services" (NODPAM), a multicentre RCT conducted in five psychiatric hospitals in Germany. Inclusion criteria are receipt of inpatient psychiatric care, adult age, diagnosis of schizophrenia or affective disorder, defined high utilisation of psychiatric care during two years prior to the current admission, and given informed consent. Consecutive recruitment started in April 2006. Since then, during a period of 18 months, comprehensive outcome data of 490 participants is being collected at baseline and during three follow-up measurement points.The manualised intervention applies principles of needs-led care and focuses on the inpatient-outpatient transition. A trained intervention worker provides two intervention sessions: (a) Discharge planning: Just before discharge with the patient and responsible clinician at the inpatient service; (b) Monitoring: Three months after discharge with the patient and outpatient clinician. A written treatment plan is signed by all participants after each session.Primary endpoints are whether participants in the intervention group will show fewer hospital days and readmissions to hospital. Secondary endpoints are better compliance with aftercare, better clinical outcome and quality of life, as well as cost-effectiveness and cost-utility.DiscussionIf a needs-oriented discharge planning and monitoring proves to be successful in this RCT, a tool will be at hand to improve patient outcome and reduce costs via harmonising fragmented mental health service provision.Trial RegistrationISRCTN59603527

Mortality and Medical Comorbidity Among Patients With Serious Mental Illness

Objectives: This study examined mortality and medical comorbidity among patients with serious mental illness in Ohio. Methods: Data for 20,018 patients admitted to an Ohio public mental health hospital between 1998 and 2002 were matched against state death records, and 608 deaths were identified. Leading causes of death and medical comorbidities, years of potential life lost (YPLL), and standardized mortality ratios were calculated for this population. Results: Heart disease (126 persons, or 21 percent) and suicides (108 persons, or 18 percent) were the leading causes of death. The mean ± SD number of YPLL was 32.0 ± 12.6 years. The highest cause-specific mean YPLL was for suicides (41.7 ± 10.3 years). Deaths from unnatural causes had higher mean YPLL than deaths from any other causes. Cause-specific mean YPLL were higher for women than for men, except for homicides, pneumonia and influenza, and heart disease. The aggregated standardized mortality ratio from all causes of death was 3.2, corresponding to 417 excess deaths (p < .001). Obesity (144 persons, or 24 percent) and hypertension (136 persons, or 22 percent) were the most prevalent medical comorbidities. Conclusions: This study demonstrated excess mortality among patients in Ohio with serious mental illness. Results highlight the need to integrate delivery of currently fragmented mental and physical health services and to target interventions that improve quality-of-life outcomes for this population. (Reprinted with permission by Psychiatric Services 2006; 57:1482–1487)

Understanding and Preventing Criminal Recidivism Among Adults With Psychotic Disorders

The high prevalence of adults with psychotic disorders in the criminal justice system has received much attention recently, but our understanding of this problem is marked by diverging opinions. Mental health professionals point to deinstitutionalization and our fragmented mental health system as primary causes. Criminologists minimize the role of mental illness and contend that persons with and without mental illness are arrested for the same reasons. Meanwhile, practice guidelines offer little guidance to clinicians about how to address the problem. Drawing upon contemporary crime prevention principles as well as current knowledge of psychotic disorders and their treatment, this article presents a conceptual framework for understanding and preventing criminal recidivism. The framework highlights the importance of individual and service-system risk variables and emphasizes the central role of treatment nonadherence as a mediator between modifiable risk variables and recidivism. On the basis of the conceptual framework described in this article, three necessary elements of intervention are presented for preventing recidivism among adults with psychotic disorders: competent care, access to services, and legal leverage. Research is needed to further define and test these intervention elements as foundations for future service delivery efforts.

An observational, “real life” trial of the introduction of assertive community treatment in a geographically defined area using clinical rather than service use outcome criteria

Assertive outreach methods of service delivery hold promise, but have been evaluated mostly in the context of short-lived experiments of limited sustainability and a focus on service use outcomes. The aim of the current investigation was to conduct an observational, "real life", pre-post comparison of the introduction of assertive outreach in a geographically defined area using clinical rather than service use outcome criteria. Assertive outreach was implemented in 2002 in a catchment area of 250,000, where cumulative routine outcome measurements had been in place since 1998. Clinical outcome, defined as making a transition to meeting the recently introduced remission criterion, was compared for two non-overlapping cohorts of patients treated in the period 1998-2001 and in the period 2002-2005. The proportion of patients that made the transition to remission increased from 19% in the period before the introduction of assertive outreach, to 31% in the period after (OR = 2.21, 95% CI 1.03-4.78). Assertive outreach in real life routine clinical practice brings about detectable changes in clinical outcome. ACT may bring improvement to the lives of patients living in countries characterised by fragmented and hospital-based mental health services.

Mortality and Medical Comorbidity Among Patients With Serious Mental Illness

This study examined mortality and medical comorbidity among patients with serious mental illness in Ohio. Data for 20,018 patients admitted to an Ohio public mental health hospital between 1998 and 2002 were matched against state death records, and 608 deaths were identified. Leading causes of death and medical comorbidities, years of potential life lost (YPLL), and standardized mortality ratios were calculated for this population. Heart disease (126 persons, or 21 percent) and suicides (108 persons, or 18 percent) were the leading causes of death. The mean+/-SD number of YPLL was 32.0+/-12.6 years. The highest cause-specific mean YPLL was for suicides (41.7+/-10.3 years). Deaths from unnatural causes had higher mean YPLL than deaths from any other causes. Cause-specific mean YPLL were higher for women than for men, except for homicides, pneumonia and influenza, and heart disease. The aggregated standardized mortality ratio from all causes of death was 3.2, corresponding to 417 excess deaths (p<.001). Obesity (144 persons, or 24 percent) and hypertension (136 persons, or 22 percent) were the most prevalent medical comorbidities. This study demonstrated excess mortality among patients in Ohio with serious mental illness. Results highlight the need to integrate delivery of currently fragmented mental and physical health services and to target interventions that improve quality-of-life outcomes for this population.

Pediatric Mental Health Emergencies in the Emergency Medical Services System

Emergency departments (EDs) are vital in the management of pediatric patients with mental health emergencies (MHE). Pediatric MHE are an increasing part of emergency medical practice because EDs have become the safety net for a fragmented mental health infrastructure which is experiencing critical shortages in services in all sectors. EDs must safely, humanely, and in a culturally and developmentally appropriate manner manage pediatric patients with undiagnosed and known mental illnesses including those with mental retardation, autistic spectrum disorders, attention deficit hyperactivity disorder (ADHD), and those experiencing a behavioral crisis. EDs also manage patients with suicidal ideation, depression, escalating aggression, substance abuse, post traumatic stress disorder, maltreatment, and those exposed to violence and unexpected deaths. EDs must address not only the physical but also the mental health needs of patients during and after mass casualty incidents and disasters. The American Academy of Pediatrics and the American College of Emergency Physicians support the following actions: advocacy for increased mental health resources, including improved pediatric mental health tools for the ED, increased mental health insurance coverage, adequate reimbursement at all levels; acknowledgment of the importance of the child's medical home, and promotion of education and research for mental health emergencies.

Pediatric Mental Health Emergencies in the Emergency Medical Services System

Emergency departments are vital in the management of pediatric patients with mental health emergencies. Pediatric mental health emergencies are an increasing part of emergency medical practice because emergency departments have become the safety net for a fragmented mental health infrastructure that is experiencing critical shortages in services in all sectors. Emergency departments must safely, humanely, and in a culturally and developmentally appropriate manner manage pediatric patients with undiagnosed and known mental illnesses, including those with mental retardation, autistic spectrum disorders, and attention-deficit/hyperactivity disorder and those experiencing a behavioral crisis. Emergency departments also manage patients with suicidal ideation, depression, escalating aggression, substance abuse, posttraumatic stress disorder, and maltreatment and those exposed to violence and unexpected deaths. Emergency departments must address not only the physical but also the mental health needs of patients during and after mass-casualty incidents and disasters. The American Academy of Pediatrics and the American College of Emergency Physicians support advocacy for increased mental health resources, including improved pediatric mental health tools for the emergency department, increased mental health insurance coverage, and adequate reimbursement at all levels; acknowledgment of the importance of the child's medical home; and promotion of education and research for mental health emergencies.

Burden of Illness: Costs and Consequences of Our Fragmented Mental Health Care System

OBJECTIVE: To discuss the treatment, barriers, and successful strategies to treat depression in a primary care setting. SUMMARY: Historical, conceptual, and individual barriers hinder the treatment of depression. Additionally, a lack of clarity about whether the responsibility for care lies with primary care or behavioral health providers further leads to fragmented and uncoordinated systems. Depression is a chronic illness, not unlike diabetes, heart failure, and asthma. Therefore, disease models used to treat these chronic illnesses can also be applied to successfully treat depression. CONCLUSION: Appropriately managing patients with depression and other behavioral health conditions will require changing the entire health care system. Future strategies should include developing a continual quality improvement process, developing bridges between behavioral health and primary care, eliminating clinical and financial barriers between systems, and viewing the mind and body as a whole.

Mental Healthcare in Rural Communities: The Once and Future Role of Primary Care

he provision of mental healthcare in rural communities has been a vexing challenge for clinicians and patients for many years. There is a chronic shortage of specialty mental health providers, particularly psychiatrists and psychologists, which has shifted much of the burden of care to primary care. Primary care clinicians have historically lacked the training and time within their busy practices to feel comfortable providing mental healthcare, particularly since the shortage of specialty mental health clinicians deprives them of consultation and referral sources. People who live in rural areas must often overcome significant travel distances, stigma, and lack of insurance and other resources to access the scarce mental health services that do exist. 1 Despite this difficult picture, rural primary care and specialty mental health clinicians have persevered to provide some level of mental healthcare to people in rural areas. Over the last decade, improvements in clinical screening tools, treatment protocols and guidelines, and information technology have significantly enhanced the potential to increase access to and improve the quality of mental health services in rural communities, particularly to underserved populations. Recent policy initiatives hold much promise to provide the structural and financial support necessary to help rural communities realize these improvements. In this commentary, we first present a general discussion of the issues related to the delivery of mental health services in the United States with particular attention to how these issues complicate the delivery of services in rural areas. Next we describe the renewed call for integrating primary care and mental health in rural areas (hence “the once and future role of primary care” in our title) and related clinical and policy support to do so. We close by briefly describing the policy interventions and resources needed to further these integration efforts and to improve access to services for rural underserved populations. Our Fragmented Mental Health Delivery System The mental health delivery system in the United States is characterized by a fragmentation of services, separation of funding streams and delivery systems, poor reimbursement, inadequate access to specialty mental health providers, and the mal-distribution of existing resources. These issues greatly complicate the delivery of services in rural areas. The United States mental health system is not a coordinated system of specialty mental health services but, rather, a fragmented collection of services and providers that has come to be known as

Promises, promises

Promises, promises