General Mental Health Care Research Articles

Perspectives, Treatment Goals, and Approaches of Prevention-Specialist Mental Health Professionals in Working With Clients Attracted to Children.

The provision of effective mental health services to individuals attracted to children is rapidly expanding. However, these services have not yet been integrated into general mental healthcare systems and are mainly offered by organizations that predominantly provide services to child sexual abuse perpetrators. Little is known about the perspective, treatment goals, and approaches employed by prevention-specialist mental health professionals when working with clients attracted to children. To address this gap, we used purposive sampling to recruit 10 practitioners who had experience of working in prevention settings with clients attracted to children. After conducting semi-structured interviews and analyzing data through interpretative phenomenological analysis, we identified three main themes and four subthemes within the data. While most participants believed that attraction to minors is unmodifiable or doubted the possibility of modifiability, this belief did not necessarily manifest in their practice. Participants stressed the importance of finding safe alternatives for clients and highlighted the significance of accessing evidence-based information on alternative sexual outlets, such as sex dolls. One overarching theme that emerged across all themes and within participants' accounts was the concern of escalation, indicating a fear that pedophilic fantasies or alternative sexual outlets such as sex dolls could potentially lead to sexual offenses. The findings shed light on the approach of prevention-specialist mental health professionals in working with clients attracted to children and may be used to inform future intervention plans to facilitate service provision to this population.

Personality in individuals with mild intellectual disability to borderline intellectual functioning: a comparative study

PurposeThis study aims to investigate the distinctive personality traits and characteristics of individuals with borderline intellectual functioning (BIF) and mild intellectual disability (MID) within specialized centers for MID-BIF treatment and care compared with individuals without MID-BIF diagnosis gathered from general mental health care (GMH) settings.Design/methodology/approachPatients classified with MID-BIF (n = 58), most with comorbid psychopathology, were thoroughly interviewed by trained clinicians who afterward completed the Shedler–Westen Assessment Procedure (SWAP-200) about the patient. The authors compared SWAP-200 profiles of MID-BIF patients with profiles of GMH individuals. In addition, the authors have compared these profiles for the MID and BIF groups (differentiated based on previously known intelligence quotient scores).FindingsResults show significantly higher scores for the MID-BIF group than the GMH group on scales encompassing emotional instability, impulsivity and antagonism. On scales containing constraint and healthy traits, significantly lower scores were found for the MID-BIF group than for the GMH group. Importance of including SWAP-200 personality assessment for a more comprehensive understanding and treatment planning for individuals with MID-BIF is discussed.Originality/valueThis study offers insights into personality within individuals with an MID-BIF diagnosis, compared with individuals in a GMH setting.

The results of clinician-focused implementation strategies on uptake and outcomes of Measurement-Based Care (MBC) in general mental health care

BackgroundMeasurement-Based Care (MBC) is the routine administration of measures, clinicians’ review of the feedback and discussion of the feedback with their clients, and collaborative evaluation of the treatment plan. Although MBC is a promising way to improve outcomes in clinical practice, the implementation of MBC faces many barriers, and its uptake by clinicians is low. The purpose of this study was to investigate whether implementation strategies that were developed with clinicians and aimed at clinicians had an effect on (a) clinicians’ uptake of MBC and (b) clients’ outcomes of MBC.MethodsWe used an effectiveness-implementation hybrid design based on Grol and Wensing’s implementation framework to assess the impact of clinician-focused implementation strategies on both clinicians’ uptake of MBC and outcomes obtained with MBC for clients in general mental health care. We hereby focused on the first and second parts of MBC, i.e., the administration of measures and use of feedback. Primary outcome measures were questionnaire completion rate and discussion of the feedback with clients. Secondary outcomes were treatment outcome, treatment length, and satisfaction with treatment.ResultsThere was a significant effect of the MBC implementation strategies on questionnaire completion rate (one part of clinicians’ uptake), but no significant effect on the amount of discussion of the feedback (the other part of clinicians’ uptake). Neither was there a significant effect on clients’ outcomes (treatment outcome, treatment length, and satisfaction with treatment). Due to various study limitations, the results should be viewed as exploratory.ConclusionsEstablishing and sustaining MBC in real-world general mental health care is complex. This study helps to disentangle the effects of MBC implementation strategies on differential clinician uptake, but the effects of MBC implementation strategies on client outcomes need further examination.

Aggressive behaviour of psychiatric patients with mild and borderline intellectual disabilities in general mental health care.

Little is known about the associations between mild intellectual disability (MID), borderline intellectual functioning (BIF) and aggressive behaviour in general mental health care. The study aims to establish the association between aggressive behaviour and MID/BIF, analysing patient characteristics and diagnoses. 1174 out of 1565 consecutive in-and outpatients were screened for MID/BIF with the Screener for Intelligence and Learning Disabilities (SCIL) in general mental health care in The Netherlands. During treatment, aggressive behaviour was assessed with the Staff Observation Aggression Scale-Revised (SOAS-R). We calculated odds ratios and performed a logistic and poisson regression to calculate the associations of MID/ BIF, patient characteristics and diagnoses with the probability of aggression. Forty-one percent of participating patients were screened positive for MID/BIF. Patients with assumed MID/BIF showed significantly more aggression at the patient and sample level (odds ratio (OR) of 2.50 for aggression and 2.52 for engaging in outwardly directed physical aggression). The proportion of patients engaging in 2-5 repeated aggression incidents was higher in assumed MID (OR = 3.01, 95% CI 1.82-4.95) and MID/BIF (OR = 4.20, 95% CI 2.45-7.22). Logistic regression showed that patients who screened positive for BIF (OR 2,0 95% CL 1.26-3.17), MID (OR 2.89, 95% CI 1.87-4.46), had a bipolar disorder (OR 3.07, 95% CI 1.79-5.28), schizophrenia (OR 2.75, 95% CI 1.80-4.19), and younger age (OR 1.69, 95% CI 1.15-2.50), were more likely to have engaged in any aggression. Poisson regression underlined these findings, showing a SCIL of 15 and below (β = 0.61, p<0.001) was related to more incidents. We found an increased risk for aggression and physical aggression in patients with assumed MID/BIF. We recommend screening for intellectual functioning at the start of treatment and using measures to prevent and manage aggressive behaviour that fits patients with MID/BIF.

The Relevance of Trauma and Re-experiencing in PTSD, Mood, and Anxiety Disorders

How traumatic events (TEs) should be defined, and how specific TEs are for Post-traumatic Stress Disorder (PTSD) were examined in a general mental health care population. Three definitions of TEs were defined, according to the PTSD criteria of DSM-IV. Half of the sample reported any TE, with a high prevalence of TEs among non-PTSD disorders. Previous mental health care, female gender, and the likelihood of assigning PTSD were associated with more severe trauma definitions. Reexperiencing symptoms were especially common among mood disorders. The implications for treatment are discussed and an alternative, dimensional definition of trauma has been proposed.

Psychiatric symptoms influence the performance on the Screener Intelligence and Learning Disabilities in general mental health care in The Netherlands

PurposeA recently published study showed a 41% prevalence of mild intellectual disability (MID) and borderline intellectual functioning (BIF) in a large sample of Dutch psychiatric patients. This study aims to examine if the outcomes of the Screener for Intelligence and Learning Disabilities (SCIL) were affected by the severity of psychiatric symptoms during admission.Design/methodology/approachThe authors administered the SCIL and the Kennedy Axis V (domain psychological impairment) at two moments when patients were sufficiently stabilised and just before discharge.FindingsA total of 86% of the respondents had the same outcome regardless of the time of administration. The Kennedy score correlated modestly with changes in the SCIL scores, suggesting that the severity of psychiatric symptoms just modestly affected the performance.Practical implicationsRecognising MID/BIF in mental health care is essential but challenging for clinicians. The authors concluded that screening with the SCIL allows clinicians to identify patients with MID/BIF at an early stage of their admission, which helps to individualise treatment and reduce the risk of aggression, coercive measures and prolonged admissions. However, the authors prefer to assess all patients on cognitive impairment as early as possible after referral at a more stable moment in time.Originality/valueTo the best of the authors’ knowledge, there is no research concerning screening instruments on MID/BIF used at admission wards in Mental Health Care.

Dutch Forensic Flexible Assertive Community Treatment: Operating on the Interface Between General Mental Health Care and Forensic Psychiatric Care.

In the Netherlands, Forensic Flexible Assertive Community Treatment (ForFACT) is used as a specialized form of outpatient intensive treatment. This outreaching type of treatment is aimed at patients with severe and long lasting psychiatric problems that are at risk of engaging in criminal behavior. In addition, these patients often suffer from addiction and experience problems in different areas of their life (e.g., financial debt, unemployment, or lack of daytime activities). The aim of this exploratory study was to gain more insight into the characteristics of the ForFACT patient population. More knowledge about these patients may enhance the effectiveness of ForFACT and therefore (further) reduce the risk of recidivism. Data on 132 ForFACT patients were gathered by studying electronic patient records, criminal records, and by conducting semi-structured interviews with practitioners and patients. Additionally, as part of a cognitive screening, two screening instruments were conducted to gain insight into intelligence and possible mild cognitive impairments. This article gives a broad description of the ForFACT patient population, including demographic data and context variables, diagnostics, recidivism risk and offense history, and aspects related to care. Furthermore, several recommendations are given to further improve ForFACT. Based on the results it can be concluded that the ForFACT patient population shows a high degree of diversity in complex care needs and responsivity issues. Therefore, this article highlights the necessity for ForFACT to collaborate with other mental health institutions, as well as probation officers, and forensic or criminal justice institutions. Moreover, it is important to continually check the inclusion and exclusion criteria when admitting patients to ForFACT, and to examine whether ForFACT is still the most adequate care for patients or if they need to be referred. In addition, the results emphasize the importance of cognitive screening for forensic outpatients. Finally, this study zooms in on the interface between forensic psychiatric care and general mental health care.

Personality assessment with the Shedler-Westen assessment procedure 200 in a forensic sample: criterion validity and contribution to structured forensic clinical judgement

ABSTRACT Current investigation focused on the criterion validity in a forensic sample of the Dutch language version of the Shedler-Westen Assessment Procedure (SWAP-200-NL), a personality assessment instrument completed by the examiner. We inquired into two areas: a) possible differences between a forensic and general mental health care population for SWAP-200-NL Personality Syndromes (PS) and Trait Dimensions (TD;N = 68), and b) explore criterion validity of SWAP-200-NL PS and TD scales for data from criminal records (N = 114). An ANOVA showed significantly higher scores for the forensic group on antisocial-psychopathic PS and psychopathy TD and lower scores on dysphoric, obsessional, high functioning depressive and avoidant PS than those for the general population. Furthermore, antisocial-psychopathic PS and psychopathy TD correlate negative with the age of first sentenced offence and positive with the number of sentenced offences in the past. Also, for the number of sentenced offences in probationary period we found significant mean differences for antisocial-psychopathic PS, and psychopathy and narcissistic TD. In contrast, criminal data showed inverse associations with scales representing obsessional, avoidant and depressive tendencies. In conclusion, present results support the differential diagnostic potential of the SWAP-200-NL and its clinical utility in forensic settings.

Occupational performance problems in people with depression and anxiety

Background Depression and anxiety often reduce people’s ability to cope with everyday occupations. There is a lack of knowledge about such problems in people of working age with depression and anxiety. Aim To describe which problems people with depression or anxiety disorders experience when performing everyday occupations and which occupations are affected. Materials and methods Data based on the Canadian Occupational Performance Measure was used in this cross-sectional study. A total of 118 participants aged 18–65 years, with depression or anxiety, were recruited from primary healthcare and general mental healthcare services. The data were analysed with descriptive statistics and directed content analysis. Results The participants rated a low level of occupational performance, and their satisfaction with performance even lower. They described a great number of problems with their everyday occupations. The most frequent problem areas concerned household management, socialization and personal care. Detailed descriptions of which type of problem they experienced during everyday occupations are included. Conclusions This study provides knowledge of which problems people with depression and anxiety disorders experience in everyday occupations within self-care, productivity, as well as leisure. Furthermore, they rate performance and satisfaction with performance of the five occupations they find the most important to change in everyday life.

Clinical Ethics Support Services Are Not as Well-Established in Forensic Psychiatry as in General Psychiatry.

Background: Mental health care professionals deal with complex ethical dilemmas that involve the principles of autonomy, justice, beneficence, and non-maleficence. Such dilemmas are even more prominent in forensic mental health care, where the restriction of personal rights is legitimated not only by patient well-being but also by public safety interests. Little is known about either the use of formal ethics support services or specific ethical needs in forensic mental health care. Knowledge about the current structures and how they compare with those in general psychiatry would help to identify the most important ethical issues and to analyze whether there are unmet needs that might require specific ethics support.Methods: We performed a survey study in all general psychiatric and forensic psychiatric inpatient departments in Germany. The aims were to compare the availability and functioning of clinical ethics structures and to identify specific ethical needs in inpatient forensic and general mental health care.Results: Clinical ethics support was available in 74% of general psychiatric hospitals but in only 43% of all forensic psychiatric hospitals and 25% of those offering treatment for offenders with substance use disorders. Most ethics support services were interdisciplinary. The most frequently requested retrospective and prospective ethics consultations were on issues of omission and termination of treatment, coercive measures, and advance directives. Among the hospitals without access to ethics support, 71% indicated a need for training in ethics.Discussion: Our results show that ethics consultation is well established in general psychiatry, but less so in forensic psychiatry. Mental health care professionals in forensic psychiatry seem to have a need for ethics support and training in clinical ethics. We also found a difference in access to ethics structures between hospitals that treat mentally disordered offenders and those that treat offenders with substance use disorders. Further research should focus on how ethics support can be comprehensively implemented in forensic mental health care and how this might improve treatment quality and patient and staff well-being.

Crushed by the Belgian system: Lived experiences of forensic care trajectories by persons labelled as not criminally responsible

BackgroundCare trajectories of Persons labelled Not Criminally Responsible (PNCR) are often characterized by multiple transitions from one (forensic) mental health service to another and by long periods of admission. So far, little research has been conducted on forensic care trajectories, in particular on how PNCR perceive the trajectories they are subjected to. MethodData were obtained via semi-structured interviews (N = 23) with PNCR in various (forensic) mental health services in Belgium. A maximum variation sampling strategy was applied to recruit a heterogeneous group of PNCR and inductive thematic analysis adopted to analyse the data. ResultsPNCR's experiences about care trajectories in Belgium are marked by an absent voice and passive position in the decision-making process in addition to a lack of support during transitions. Barriers for admission in (forensic) mental health services and the indeterminate duration of care trajectories contribute to overall negative lived experiences. ConclusionAlthough some findings are interchangeable with general mental health care, PNCR's care trajectories differ by their undetermined nature, barriers for accessing care and power dynamics in compulsory forensic care. As concepts from prison sociology, such as tightness, power holders and pain of indeterminacy, seem to be equally relevant for the situation of PNCR, the balance between a criminal justice and mental health approach in forensic mental health care is questioned.

General and post-disaster mental health servicing in Vanuatu: A qualitative analysis

BackgroundNatural disasters contribute to the burden of mental illness, increased poverty and environmental degradation in developing Pacific countries. The aim of this study was to review the attitudes and opinions in relation to the delivery of post-disaster and general mental healthcare in Vanuatu. MethodThis qualitative study design applied semi-structured interviews to collect data from key informants. A total of 11 participants were involved in 11 interviews. The sample group consisted of; i) four government health representatives; ii) four non-government participants with knowledge of mental healthcare in Vanuatu; and iii) three community members from the village of Emua, Efate Island. NVivo qualitative data processing software assisted with thematic analysis of the transcribed data. ResultsThe key findings of this study were associated with mental healthcare in Vanuatu and exhibited themes including: i) low levels of mental health literacy; ii) a deficiency of general and post-disaster mental health services; iii) the increased prevalence of mental health disorders following a disaster; and iv) strategies to improve general and post-disaster mental healthcare. ConclusionFindings indicate a range of challenges impeding the provision of mental healthcare in Vanuatu. Future actions should aim to: i) enhance levels of mental health literacy to diminish the stigma associated with mental illness; and ii) facilitate decentralised mental healthcare to enable the development of community based services. Increased levels of mental health literacy and improved access to community services will assist the identification and treatment of mental health disorders in Vanuatu.

Lower versus higher frequency of sessions in starting outpatient mental health care and the risk of a chronic course; a naturalistic cohort study

BackgroundAn adequate frequency of treatment might be a prerequisite for a favorable outcome. Unfortunately, there is a diversity of factors that interfere with an adequate frequency of sessions. This occurs especially in the first phase of treatment, while the first phase seems vital for the rest of treatment. The aim of this naturalistic study was to explore the impact of the initial frequency of treatment sessions on treatment outcome in a diverse mental health care population.MethodsAnonymized data were analyzed from 2,634 patients allocated for anxiety disorders, depressive disorders, and personality disorders to outpatient treatment programs in a large general mental health care facility. Patients’ treatment outcome was routinely monitored with the Outcome Questionnaire-45 (OQ-45.2), every 12 weeks. Frequency of sessions was assessed for the first three months of treatment. Using Cox-proportional-hazard models, we explored the associations between initial frequency and improvement (reliable significant change) and recovery (reliable and clinically significant change).ResultsImprovement and recovery were associated with symptom severity and functional impairment at start of treatment, the year the treatment started, number of measurements, the treatment program (anxiety disorders, depressive disorders, and personality disorders) and receiving group therapy other than psychotherapy.In all diagnostic groups, both improvement and recovery were associated with a higher frequency of sessions during the first three months of treatment. For improvement, this effect diminished after three years in treatment; however, for recovery this association was sustained.ConclusionsIn addition to severity at start of treatment and other predictors of outcome, a low frequency of initial treatment sessions might lead to a less favorable outcome and a more chronic course of the mental disorder. This association seems not to be limited to a specific diagnostic group, but was found in a large group of patients with common mental disorders (depression and anxiety disorders) and patients with a personality disorder. Despite organizational obstacles, more effort should be made to start treatment quickly by an effective frequency of session.

The Instrument for Forensic Treatment Evaluation: Reliability, Factorial Structure, and Sensitivity to Measure Behavioral Changes

ABSTRACTRoutine Outcome Monitoring (ROM) is widely used in general mental health care but is still in its infancy in forensic psychiatry. As usable forensic ROM tools are lacking, the Instrument for Forensic Treatment Evaluation (IFTE) has been developed. The goal of this study is to assess the psychometric values of the IFTE and its ability to assess change. Therefore, multiple IFTE assessments of 218 male forensic inpatients were gathered, after which the interrater reliability, test–retest reliability, and internal consistency were assessed. Principal axis factoring was assessed to examine the clinically used factor structure. Patient scores were divided into low and high IFTE factor scores at T0 to examine changeability between T0 and T3. The results display moderate to good values for the interrater reliability, test–retest reliability, and internal consistency for most items. Factor analyses partly confirmed the original factor structure of the instrument. However, several items loaded on a fourth factor. The factor scores display a moderate to large change over time. These results mostly support the clinical use of the IFTE in treatment. However, sexually deviant behavior should be studied in a less structured setting. Future studies would have to assess the use of the IFTE in supporting treatment decisions and its use in individual treatment.

Increased All-Cause Mortality by Antipsychotic Drugs: Updated Review and Meta-Analysis in Dementia and General Mental Health Care.

It is almost ten years since the Banerjee 2009 report established that inappropriate prescribing of antipsychotics in the elderly was occurring in the UK and such patients had an 85% increased risk of adverse events and greater mortality. This report was a critical analysis addressing the outcomes of treatment practices for dementia in UK patients and globally, aimed at reducing prescribing of antipsychotic drugs for dementia. Since 2009, many significant studies worldwide (including several more recent large retrospective studies) provide more extensive longitudinal data for the adverse impacts of antipsychotic drugs in dementia. We have used the data in these studies including from over 380,000 dementia patients, with 85,069 prescribed antipsychotic agents as well as from 359,235 non-dementia antipsychotic drug users to provide an up-dated meta-analysis. This is the first meta-analysis to include evidence from general mental health studies showing that antipsychotic drugs precipitate excessive mortality across the spectrum. Prescribing of antipsychotic drugs for dementia or for other mental health care should be avoided and alternative means sought for handling behavioral disorders of such patients.

A Cost-Effectiveness Analysis to Evaluate a System Change in Mental Healthcare in the Netherlands for Patients with Depression or Anxiety

Over the last decade, the Dutch mental healthcare system has been subject to profound policy reforms, in order to achieve affordable, accessible, and high quality care. One of the adjustments was to substitute part of the specialized care for general mental healthcare. Using a quasi-experimental design, we compared the cost-effectiveness of patients in the new setting with comparable patients from specialized mental healthcare in the old setting. Results showed that for this group of patients the average cost of treatment was significantly reduced by, on average, €2132 (p < 0.001), with similar health outcomes as in the old system.

Addiction and Mental Health: The New Norm

Back to table of contents Next article EditorialNo AccessAddiction and Mental Health: The New NormCornel N. Stanciu, M.D.Cornel N. StanciuSearch for more papers by this author, M.D.Published Online:1 Dec 2017https://doi.org/10.1176/appi.ajp-rj.2017.121201AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail As a current addiction psychiatry fellow and editorial board member for several addiction-focused journals, I am thrilled to have the opportunity to serve as this month's Guest Editor for the American Journal of Psychiatry Residents' Journal. The aim of this special issue is to shine light on the impact of substance abuse on our health care system. As we have seen throughout training, substance use disorders are highly prevalent and morbid conditions that result in significant social, financial, and human costs. Their prevalence is highest in clinical populations, especially among those with mental illnesses. It is estimated that 25% of the U.S. hospital beds are occupied by individuals with active substance use disorders (1). Ongoing use of substances and lack of properly addressing behaviors that lead to substance abuse impede upon our ability to treat substance use disorders from psychiatric and medical standpoints.By 2020, substance use disorders are expected to surpass all physical diseases as the major cause of disability (2). Tobacco use is the current number-one worldwide cause of preventable death (3), with many of our patients with mental health conditions being tobacco users. To make matters worse, we as physicians tend to avoid implementing pharmacotherapies for tobacco use and alcohol use disorder, despite strong supportive evidence of the efficacy of such therapies. Looking at the broader picture, for the first time in history the average life expectancy in the United States is decreasing (4, 5), and the conditions responsible for this epidemic of earlier deaths are directly or indirectly related to addiction (for example, chronic obstructive pulmonary disease, lung cancer, hepatitis C, cirrhosis, and fatal overdoses) (4, 5). It is imperative for us and our health care system to start addressing addiction as a top priority. Early intervention following first identification of substance use targets such disorders at a less advanced phase and hence prevents progression. A report published in 2009 showed a significant cost-benefit ratio for early detection and treatment interventions (6). These reduced costs relate to health care, the adult and juvenile criminal justice systems, education, and work productivity (6).To date, significant emphasis has been placed on the need for more physicians trained in substance abuse to alleviate the treatment gap and increase system capacity (7). There is also an effort to increase the capacity of general mental health care providers to identify and treat high-risk individuals earlier, before referring them for specialty health care (7). This would reduce patients' health risks associated with substance use much sooner while at the same time reducing the burden placed on more costly health care specialties (7). It is in this latter role that trainees and general mental health providers can best have an impact on the care of patients with substance use disorders.Dr. Stanciu is an Addiction Psychiatry Fellow in the Department of Psychiatric Medicine, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, N.H. He is also the Guest Editor for this issue of the Residents' Journal.

Recovery of Offenders Formerly Labeled as Not Criminally Responsible: Uncovering the Ambiguity From First-Person Narratives.

The recovery paradigm is a widely accepted strength-based approach in general mental health care. Particular challenges arise when applying this paradigm in a forensic context. To address these issues, the present study examined recovery based on first-person narratives of offenders formerly labeled as not criminally responsible of whom the judicial measure was abrogated. Eleven in-depth interviews were conducted to obtain information on lived experiences and recovery resources of this hard-to-reach and understudied population. The interviews focused on recovery and elements that indicated a sense of progress in life. Key themes were derived from the collected data. Descriptions of recovery resources followed recurrent themes, including clinical, functional, social, and personal resources. Participants also reported ambiguous experiences related to features of the judicial trajectory. This was defined as forensic recovery and can be seen as an additional mechanism, besides more established recovery dimensions, that is unique to mentally ill offenders.

Understanding experiences of and preferences for service user and carer involvement in physical health care discussions within mental health care planning

BackgroundPeople with severe mental illness suffer more physical comorbidity than the general population, which can require a tailored approach to physical health care discussions within mental health care planning. Although evidence pertaining to service user and carer involvement in mental health care planning is accumulating, current understanding of how physical health is prioritised within this framework is limited. Understanding stakeholder experiences of physical health discussions within mental health care planning, and the key domains that underpin this phenomena is essential to improve quality of care. Our study aimed to explore service user, carer and professional experiences of and preferences for service user and carer involvement in physical health discussions within mental health care planning, and develop a conceptual framework of effective user-led involvement in this aspect of service provision.MethodsSix focus groups and four telephone interviews were carried out with twelve service users, nine carers, three service users with a dual service user and carer role, and ten mental health professionals recruited from one mental health Trust in the United Kingdom. Data was analysed utilising a thematic approach, analysed separately for each stakeholder group, and combined to aid comparisons.ResultsNo service users or carers recalled being explicitly involved in physical health discussions within mental health care planning. Six prerequisites for effective service user and carer involvement in physical care planning were identified. Three themes confirmed general mental health care planning requirements: tailoring a collaborative working relationship, maintaining a trusting relationship with a professional, and having access to and being able to edit a living document. Three themes were novel to feeling involved in physical health care planning discussions: valuing physical health equally with mental health; experiencing coordination of care between physical-mental health professionals, and having a physical health discussion that is personalised.ConclusionsHigh quality physical health care discussions within the care planning process demands action at multiple levels. A conceptual framework is presented which provides an evidence-based foundation for service level improvement. Further work is necessary to develop a new patient reported outcome measure to enable meaningful quantification of health care quality and patient experience.

Disparities in Psychiatric Care: Clinical and Cross-Cultural Perspectives

Back to table of contents Previous article Next article Book ReviewFull AccessDisparities in Psychiatric Care: Clinical and Cross-Cultural PerspectivesRosalie A. Torres Stone Ph.D.Rosalie A. Torres Stone Ph.D.Search for more papers by this authorPublished Online:1 Oct 2010https://doi.org/10.1176/ps.2010.61.10.1049AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The book Disparities in Psychiatric Care, edited by Pedro Ruiz and Annelle Primm, addresses the changes needed in the U.S. mental health system, including universal health care, full coverage and parity of mental health care with general medical care, improved quality of care, and more humane care. Dr. Ruiz is professor and interim chair of the Department of Psychiatry and Behavioral Services, University of Texas Medical School at Houston. The idea for this book evolved from Dr. Ruiz's efforts during his 2006–2007 tenure as President of the American Psychiatric Association (APA). Dr. Primm is deputy medical director and director of APA's Office of Minority and National Affairs. The book will inspire residents, medical students, physicians, administrators, researchers, and policy makers to take immediate action to improve mental health care services for vulnerable populations. The first two chapters address the importance of understanding the social and cultural context of individuals at every level of the service delivery system. Such understanding is the foundation for eliminating disparities in the American mental health system. The next 19 chapters provide a thorough overview of the complexities in understanding disparities in access to and quality of general mental health care of vulnerable populations (such as ethnic minority groups, the lesbian-gay-bisexual-transgender communities, immigrant and refugee groups, and addicted populations). These chapters demonstrate how psychiatric care for persons from racial and ethnic minority groups varies according to within- and between-group differences, including in gender, race, income, sexual orientation, linguistic barriers, and stigma.The authors conclude that in considering treatment for various groups, it is necessary to understand their biological as well and their social vulnerabilities, including poor communication in clinical therapeutic situations, linguistic barriers, poverty, discrimination, and racism. In support, Primm and William B. Lawson state in one of the chapters that "much of the recent psychiatric research has focused on identifying [a] genetic basis of mental disorders. Identifying risk genes for mental disorders does not preclude extragenetic factors."The next 12 chapters identify strategies to eliminate disparities in psychiatric care, including placing mental health on the public health priority agenda, developing culturally sensitive evaluations and therapeutic alliances, achieving cultural competence in quality assurance measures, conducting research in the integration of psychiatric and primary care, analyzing the financial impact of managed care, using complementary and alternative medicine, recognizing the role of religion and spirituality in healing and recovery, and conducting additional cost-effectiveness studies.Ruiz and Primm conclude with an urgent call for social action to eliminate disparities for the sake of all Americans: "The status quo is no longer viable. The current health/mental health care system of the country borders on being unethical." Similarly, contributors Robert Bransfield and Douglas Bransfield state, "Mental health parity is an equalization of mental health benefits and is an ethnic commitment to enhancing humane values, while lack of parity is an exploitation of human vulnerability that erodes our stature as a compassionate society with humanitarian priorities."The reviewer reports no competing interests.Dr. Stone is assistant professor, Department of Psychiatry, Center for Mental Health Services Research, University of Massachusetts Medical School, Worcester, Massachusetts. FiguresReferencesCited byDetailsCited byNone Volume 61Issue 10 October, 2010Pages 1049-1050PSYCHIATRIC SERVICES October 2010 Volume 61 Number 10 Metrics PDF download History Published online 1 October 2010 Published in print 1 October 2010