General Mental Health Services Research Articles

Mentalization based treatment for borderline personality disorder.

Mentalizing is the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes. It is a profoundly social construct in the sense that we are attentive to the mental states of those we are with, physically or psychologically. Given the generality of this definition, most mental disorders will inevitably involve some difficulties with mentalization, but it is the application of the concept to the treatment of borderline personality disorder (BPD), a common psychiatric condition with important implications for public health, that has received the most attention. Patients with BPD show reduced capacities to mentalize, which leads to problems with emotional regulation and difficulties in managing impulsivity, especially in the context of interpersonal interactions. Mentalization based treatment (MBT) is a time-limited treatment which structures interventions that promote the further development of mentalizing. It has been tested in research trials and found to be an effective treatment for BPD when delivered by mental health professionals given limited additional training and with moderate levels of supervision. This supports the general utility of MBT in the treatment of BPD within generic mental health services.

Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder

Objective: This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder. Method: Patients (N=134) consecutively referred to a specialist personality disorder treatment center and meeting selection criteria were randomly allocated to MBT or SCM. Eleven mental health professionals equal in years of experience and training served as therapists. Independent evaluators blind to treatment allocation conducted assessments every 6 months. The primary outcome was the occurrence of crisis events, a composite of suicidal and severe self-injurious behaviors and hospitalization. Secondary outcomes included social and interpersonal functioning and self-reported symptoms. Outcome measures, assessed at 6-month intervals, were analyzed using mixed effects logistic regressions for binary data, Poisson regression models for count data, and mixed effects linear growth curve models for self-report variables. Results: Substantial improvements were observed in both conditions across all outcome variables. Patients randomly assigned to MBT showed a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalization. Conclusions: Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required. (Reprinted with permission from American Journal of Psychiatry 2009; 166:1355–1364)

Impact of the Fast Track Prevention Program on Health Services Use by Conduct-Problem Youth

We tested the impact of the Fast Track conduct disorder prevention program on the use of pediatric, general health, and mental health services in adolescence. Participants were 891 public kindergarten boys and girls screened from a population of 9594 children and found to be at risk for conduct disorder. They were assigned randomly (by school) to intervention or control conditions and were followed for 12 years. Intervention lasted 10 years and included parent training, child social-cognitive skills training, reading tutoring, peer-relations enhancement, and classroom curricula and management. Service use was assessed through annual interviews of parents and youth. Youth assigned to preventive intervention had significantly reduced use of professional general health, pediatric, and emergency department services relative to control youth on the basis of parent-report data. For control-group youth, the odds of greater use of general health services for any reason and general health services use for mental health purposes were roughly 30% higher and 56% higher, respectively. On the basis of self-report data, the intervention reduced the likelihood of outpatient mental health services among older adolescents for whom odds of services use were more than 90% higher among control-group youth. No differences were found between intervention and control youth on the use of inpatient mental health services. Statistical models controlled for key study characteristics, and potential moderation of the intervention effect was assessed. Random assignment to the Fast Track prevention program is associated with reduced use of general health and outpatient mental health services in adolescents. Future studies should examine the mechanism of this impact and service use patterns as subjects reach young adulthood.

Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder

This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder. Patients (N=134) consecutively referred to a specialist personality disorder treatment center and meeting selection criteria were randomly allocated to MBT or SCM. Eleven mental health professionals equal in years of experience and training served as therapists. Independent evaluators blind to treatment allocation conducted assessments every 6 months. The primary outcome was the occurrence of crisis events, a composite of suicidal and severe self-injurious behaviors and hospitalization. Secondary outcomes included social and interpersonal functioning and self-reported symptoms. Outcome measures, assessed at 6-month intervals, were analyzed using mixed effects logistic regressions for binary data, Poisson regression models for count data, and mixed effects linear growth curve models for self-report variables. Substantial improvements were observed in both conditions across all outcome variables. Patients randomly assigned to MBT showed a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalization. Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required.

Providing mental health services to adult offenders in Victoria, Australia: Overcoming barriers

PurposeTo illustrate the development of the interface between general and forensic mental health services in Victoria, Australia. MethodDeveloping effective cooperation between the general and forensic mental health services requires overcoming a number of barriers. The attitude of general services that antisocial behaviour was none of their business was tackled through ongoing workshops and education days over several years. The resistance to providing care to those disabled by severe personality disorders or substance abuse was reduced by presenting and promoting models of care developed in forensic community and inpatient services which prioritised these areas. The reluctance of general services to accept offenders was reduced by involving general services in court liaison clinics and in prisoner release plans. Cooperation was enhanced by the provision of risk assessments, the sharing of responsibility for troublesome patients, and a problem behaviours clinic to support general services in coping with stalkers, sex offenders and threateners. ConclusionsActive engagement with general services was promoted at the level of providing education, specialised assessments and a referral source for difficult patients. This generated a positive interface between forensic and general mental health services, which improved the quality of care delivered to mentally abnormal offenders.

The Relationship Between General Population Suicide Rates and Mental Health Funding, Service Provision and National Policy: a Cross-National Study

The main aims were to examine the relationship between general population suicide rates and the presence of national policies on mental health, funding for mental health, and measures of mental health service provision. Data on general population suicide rates for both genders were obtained from the World Health Organization (WHO) databank available on the WHO website. Data on the presence of national policies on mental health, funding for mental health and measures of mental health service provision were obtained from the Mental Health Atlas 2005, also available on the WHO website. The main findings were: (i) there was no relationship between suicide rates in both genders and different measures of mental health policy, except they were increased in countries with mental health legislation; (ii) there was a significant positive correlation between suicide rates in both genders and the percentage of the total health budget spent on mental health; and (iii) suicide rates in both genders were higher in countries with greater provision of mental health services, including the number of psychiatric beds, psychiatrists and psychiatric nurses, and the availability of training in mental health for primary care professionals. Cross-national ecological studies using national-level aggregate data are not helpful in establishing a causal relationship (and the direction of this relationship) between suicide rates and mental health funding, service provision and national policies. The impact of introducing national policies on mental health, increasing funding for mental health services and increasing mental health service provision on suicide rates requires further examination in longitudinal within-country studies.

Perceived Need for Mental Health Care and Service Use Among Adults in Western Europe: Results of the ESEMeD Project

Perceived Need for Mental Health Care and Service Use Among Adults in Western Europe: Results of the ESEMeD Project

Case: Liability for general practitioners and mental health services for the acts of their patients

Case: Liability for general practitioners and mental health services for the acts of their patients

Annotation: New research into general psychiatric services for adults with intellectual disability and mental illness

There are a variety of models for the mental health care of adults with comorbid intellectual disability (ID) and mental illness. There has been a long-running debate as to whether this should be provided by general psychiatric or specialised ID services. A previous review concluded that there was no clear evidence to support either model with research being often of a poor quality, lacking replication, and outcome measures were often inappropriate or varied between studies. This review aims assess differences in outcome for patients with ID and mental disorders treated in general or specialised ID mental health services. A literature review was conducted using electronic databases and websites of ID and mental health organisations to locate all references where people with ID receive mental health care in general psychiatric services from 2003. No meta-analysis was attempted because of the divergent nature of the studies. People with ID (especially severe ID) have reduced access to general psychiatric services. General psychiatric inpatient care is unpopular especially with carers but can be improved by providing specially trained staff and in-reach from community ID teams. Opportunities may exist to enhance the care of people with borderline intellectual functioning within general psychiatric services. Although no new randomised controlled trials have been published, the weight of research is accumulating to suggest that provision of general psychiatric services without extra help is not sufficient to meet the needs of people with ID.

Recent and lifetime utilization of health care services by children and adolescent suicide victims: A case-control study

Objective In the present paper we describe a case-control study on the utilization of health care services prior to suicide (across different time periods) among children and adolescents aged 11 to 18 years in the Province of Quebec, Canada and matched healthy controls. Method Utilization of services (i.e., contact with general practitioners, mental health professionals, psychiatrists and/or youth protection groups) was examined at different time periods in 55 child and adolescent suicide victims and 54 matched community controls using proxy-based interviews and questionnaires. In addition, we examined the rates of detection of psychopathology by health care professionals, the use of psychotropic medications and the subjects' compliance with treatment. Results Although more than 90% of child and adolescent suicide completers in our sample suffered from mental disorders, a significant proportion of them were left without appropriate healthcare support (including psychiatric consultation) in the period preceding their suicide. Also, 20% of suicide completers and no control subject made prior suicide attempts. More specifically, over two-thirds of suicide completers had no treatment contact within the month prior to the completion, while only 12.7% ( n = 7) of them were in contact with psychiatric services during that same period. Moreover, 56.4% ( n = 31) of the suicide completers had not been diagnosed as having a mental disorder at the time of their death, and 54.5% of the subjects' that received treatment (12 out of 22) were considered poorly compliant or not compliant at all according to their medical/psychosocial records. Finally, we also found that females seemed to have more psychiatric and mental health service contacts in the past month, that subjects with depressive and anxious disorders received more psychiatric and general mental health services in the past year, and that past month hospitalization was more often associated with alcohol abuse and psychosis. Limitations Relatively small sample size, and cross-sectional design. Conclusions Our findings indicate the need for an overall increase in the rates of healthcare services delivered to young subjects at risk for suicide, as well as better training of health professionals in detecting and treating youth psychopathology.

Psychiatric intensive care and low secure units: where are we now?

SummaryThe last decade has seen clinicians and policy makers develop psychiatric intensive care units and low secure units from the so-called ‘special care wards’ of the 1980s and 1990s. Psychiatric intensive care units are for short-term care, while low secure units are for care for up to about 2 years. Department of Health standards have been set for these units. A national survey has shown that there are two main patient groups in the low secure units: patients on forensic sections coming down from medium secure units and those on civil sections who are transferred from general psychiatric facilities. Recent clinical opinion has emphasised the important role both psychiatric intensive care units and low secure units play in providing a bridge between forensic and general mental health services.

Psychiatric service use and psychiatric disorders in adults with intellectual disability

UK policies aim to facilitate access to general psychiatric services for adults with intellectual disability (ID). If this is to be achieved, it is important to have a clear idea of the characteristics and proportion of people with ID who currently access specialist psychiatric services and the nature and extent of psychiatric disorders in this population. A cross-sectional study was carried out on all adults with ID using specialist services in Leicestershire and Rutland, UK, between 2001 and 2006. Characteristics of individuals seen by psychiatric services and the nature and prevalence of psychiatric disorders were investigated. Of 2711 adults identified, 1244 (45.9%) accessed specialist psychiatric services at least once during the study period. Individuals attending psychiatric services were more likely to be older and to live in residential settings; they were less likely to be south Asian or to have mild/moderate ID. The prevalence of psychiatric disorders among the total study population was 33.8%; the most common disorders were behaviour disorder (19.8%) and autistic spectrum disorders (8.8%). Epilepsy was highly prevalent (60.8%) among those attending psychiatric services without a mental health diagnosis. Behaviour disorders and autistic spectrum disorders were more common in men and in adults with severe/profound ID, whereas schizophrenia and organic disorders were more common in women and in adults with mild/moderate ID. Depression was also more common in women with ID. Psychiatric disorders and specialist health problems are common among adults with ID and the profile of psychiatric disorders differs from that found in general psychiatry. Close collaboration between general and specialist service providers is needed if the current move towards use of general psychiatric services in this population is to be achieved. The measures should include a clear care pathway for people with ID and mental health problems to facilitate the smooth transfer of patients between specialist and generic mental health services and arrangements for joint working where input from both services is required. The commissioning framework for such processes should be in place with appropriate pooling of resources.

A comparison of patients with intellectual disability receiving specialised and general services in Ontario's psychiatric hospitals

Over the years, the closure of institutions has meant that individuals with intellectual disabilities (IDs) must access mainstream (i.e. general) mental health services. However, concern that general services may not adequately meet the needs of patients with ID and mental illness has led to the development and implementation of more specialised programmes. This study compares patients with ID receiving specialised services to patients with ID receiving general services in Ontario's tertiary mental healthcare system in terms of demographics, symptom profile, strengths and resources and clinical service needs. A secondary analysis of Colorado Client Assessment Record data collected from all tertiary psychiatric hospitals in the province was completed for all 371 inpatients with ID, from both specialised and general programmes. Inpatients in specialised programmes were more likely to have a diagnosis of mood disorder and were less likely to have a substance abuse or psychotic disorder. Individuals receiving specialised services had higher ratings of challenging behaviour than those in more general programmes. The two groups did not differ significantly in terms of recommended level of care, although more inpatients from specialised programmes were rated as requiring Level 4 care than inpatients from general programmes. In Ontario, inpatients in specialised and general programmes have similar overall levels of need but unique clinical profiles that should be taken into consideration when designing interventions for them.

Improving efficiency and access to mental health care: combining integrated care and advanced access

Objective To provide an example of implementation of a new program that enhances access to mental health care in primary care. Method A general and specialized mental health service was redesigned to introduce open access to comprehensive mental health care in a primary care clinic. Key variables measured before and after implementation of the clinic included numbers of completed referrals, waiting time for appointments and clinic productivity. Workload and pre/post-implementation waiting time data were gathered through a computerized electronic monitoring system. Results Waiting time for new appointments was shortened from a mean of 33 days to 19 min. Clinician productivity and evaluations of new referrals more than doubled. These improvements have been sustained for 4 years. Conclusion Moving mental health services into primary care, initiating open access and increasing use of technological aids led to dramatic improvements in access to mental health care and efficient use of resources. Implementation and sustainability of the program were enhanced by using a quality improvement approach.

Improving Integrated General Medical and Mental Health Services in Community-based Practices

The historical fragmentation of physical and mental health services has impeded efforts to improve quality and outcomes of care for persons with mental disorders. However, there is little information on effective strategies that might reduce fragmentation and improve integrated services within non-academic, community-based healthcare settings. Twenty-three practices from across the U.S. participated in a learning community meeting designed to identify barriers to integrated care and strategies for reducing such barriers. Barriers were initially identified based on a quantitative survey of organizational factors. Focus groups were used to elaborate on barriers to integrated care and to identify strategies for reducing barriers that are feasible in community-based settings. Participants identified key barriers, including administrative (e.g., lack of common medical records for mental health and general medical conditions), financial (e.g., lack of reimbursement codes to bill for mental health and general medical care in the same setting), and clinical (e.g., lack of an integrated care protocol). Top strategies recommended by participants included templates (i.e., for memoranda of understanding) to allow providers to work across practice settings, increased medical record security to enable a common medical record between mental health and general medical care, working with state Medicaid agencies to establish integrated care reimbursement codes, and guidance in establishing workflows between different providers (i.e., avoid duplication of tasks). Strategies to overcome barriers to integrated care may require cooperation across different organizational levels, including administrators, providers, and health care payers in order for integrated care to be established and sustained over time.

No evidence for restrictive care practices in Māori admitted to a New Zealand psychiatric inpatient unit: do specialist cultural teams have a role?

To ascertain the presence, and describe the pattern and extent, of restrictive care practices in the treatment of mental health inpatients in a rural New Zealand unit. Retrospective data was anonymously extracted from patient records at Rotorua Hospital (Rotorua, New Zealand). Data sets were compiled from 300 consecutive patient admissions between January 2000 and December 2001. The demographic and diagnostic characteristics extracted were gender, age, ethnicity (Măori or non-Măori classification only), primary diagnosis, length of hospital stay, seclusion, medication on discharge, dosage of antipsychotic medication if given, referral to psychotherapy, voluntary/involuntary status on admission, and readmission rates. After controlling for other clinical variables, ethnicity was not associated with specific diagnoses, increased use of seclusion, and involuntary status on admission or higher readmission rates. Măori patients were more likely to receive antipsychotic medication and at higher doses than non-Măori. Măori were less likely to be referred to psychotherapy services and had shorter lengths of stay. There was no evidence of widespread restrictive care practices against Măori, although the disparities in antipsychotic prescription and psychotherapy referral suggest some restrictive care practices do exist. The use of specialist cultural teams in general mental health services may prevent restrictive care practices.

Patient and Staff Perspectives on the Use of Seclusion

This paper investigates the perceptions and experience of patients and staff on the use of seclusion in psychiatric services. A purpose designed questionnaire was distributed to staff and patients in a general adult mental health service. Staff and patients both attributed more negative than positive feelings to patients' experience of seclusion. Monitoring and evaluation of the use of seclusion may be insufficient to prevent or ameliorate its emotional impact. More comfortable alternatives to seclusion need to be utilized whenever possible.

Community rehabilitation for severe enduring mental illness: a naturalistic, observational study

Dear Editor, The development of rehabilitation and recovery services forms a key element of national mental health policy in Ireland [1]. Over the past 10 years, mental health services in Monaghan and Cavan have developed Assertive Outreach Teams (AOT) as part of Community Rehabilitation Teams (CRT), with the aim of providing individualised care programmes for clients with severe and enduring mental illness and their carers, based on identified needs and implemented as much as possible in a non-institutional settings. The CRT provides specialised services for people disadvantaged by a range of problems that can develop with severe mental illness, and which cannot be adequately met by generic mental health services. This approach helps to optimise social inclusion, reduce the need for repeated admissions and increase patient satisfaction and quality of life. On 1 July 2006, 24 patients were selected from the case-load of the CRT in Cavan; these patients were receiving intensive community treatment for psychiatric symptoms at that time. This naturalistic, observational study aimed to determine the benefits of the CRT in terms of (1) the health and social needs that the CRT was addressing, and (2) the number and duration of hospital admissions before and after intervention by the CRT. The CRT reviewed the cases of each of the 24 patients being treated by the CRT on 1 July 2006 and used the Camberwell Assessment of Need (CAN) [2] to determine the areas of health and social need in which each patient was receiving assistance (see Table 1). Case notes were reviewed to determine the number and duration of hospital admissions before and after intervention by the CRT. Patients were receiving treatment and assistance from the CRT in all 16 areas of health and social need, most commonly psychotic symptoms, psychological distress and information about illness (Table 1). Prior to intervention by the CRT, these 24 patients had an average of 0.93 admissions per year (standard deviation [SD] 0.63); in the 3 years following intervention by the CRT, they had an average of 0.18 admissions per year (SD 0.39) (Z = -3.94; P \ 0.001). Prior to intervention by the CRT, these 24 patients spent an average of 49.53 days in hospital per year (SD 69.12); in the 3 years following intervention by the CRT, they spent an average of 3.37 days in hospital per year (SD 7.04) (Z = -4.17; P \ 0.001). The introduction of the CRT has resulted in (1) interventions aimed a broad range of medical and social needs and (2) a reduction in the number and duration of hospital admissions in patients with severe, enduring mental illness. This is an observational study without a comparison group and was primarily aimed at establishing the effects of the CRT in a ‘‘real life’’ setting. These naturalistic data support research findings [3] that community rehabilitation programmes are valuable in reducing need for admission, optimising provision of individualised care and improving quality of life for patients with enduring mental illness in community settings. A. Niazi B. D. Kelly (&) Department of Adult Psychiatry, University College Dublin, Mater Misericordiae University Hospital, 62/63 Eccles Street, Dublin 7, Ireland e-mail: brendankelly35@gmail.com

Clinical effectiveness of treatments for anorexia nervosa in adolescents

Treatment guidelines identify few adequately powered trials to guide recommendations for anorexia nervosa. To evaluate the effectiveness of three readily available National Health Service treatments for adolescents (aged 12-18 years) with anorexia nervosa. Multicentre randomised controlled trial of 167 young people comparing in-patient, specialist out-patient and general child and adolescent mental health service (CAMHS) treatment. Each group made considerable progress at 1 year, with further improvement by 2 years. Full recovery rates were poor (33% at 2 years, 27% still with anorexia nervosa). Adherence to in-patient treatment was only 50%. Neither in-patient nor specialist out-patient therapy demonstrated advantages over general CAMHS treatment by intention to treat, although some CAMHS out-patients were subsequently admitted on clinical grounds. In-patient treatment (randomised or after out-patient transfer) predicted poor outcomes. First-line in-patient psychiatric treatment does not provide advantages over out-patient management. Out-patient treatment failures do very poorly on transfer to in-patient facilities.

Needs‐based cognitive‐behavioural family intervention for patients suffering from schizophrenia: 5‐year follow‐up of a randomized controlled effectiveness trial

To determine whether a 24-week, needs-based cognitive-behaviourally oriented family intervention for patients suffering from schizophrenia led to improved relapse profiles over a 5-year follow-up period. The case notes of 60 patients who had participated in a randomized, controlled effectiveness trial were examined to determine relapse rates over a 5-year period. Patients were less likely to relapse over the 5-year follow-up when they received the needs-based family intervention, especially in relation to exacerbations of symptoms not requiring inpatient admissions: 86.7% of control participants relapsed compared with 53.3% (P = 0.01). Survival analysis indicated that the relapse risk was 2.5 times higher for patients receiving routine care, compared with those receiving family intervention. A similar trend was observed for the final 4 years of follow-up. The present study provides some tentative support for the long-term effectiveness of family-based interventions for the management of schizophrenia in general mental health services.