Mental Health Care Organizations Research Articles

Implementing and up-scaling evidence-based eMental health in Europe: The study protocol for the MasterMind project

BackgroundDepressive disorder is a major societal challenge. Despite the availability of clinically and cost-effective treatments including Internet interventions, the number of patients receiving treatment is limited. Evidence-based Internet interventions promise wide availability and high efficiency of treatments. However, these interventions often do not enter routine mental healthcare delivery at a large scale. The MasterMind project aims to provide insight into the factors that promote or hinder the uptake and implementation of evidence-based Internet interventions by mental healthcare practice. Internet-based Cognitive Behaviour Therapy (iCBT) and videoconferencing facilitating collaborative care (ccVC) will be implemented in routine mental healthcare. The services will be offered to 5230 depressed adults in 15 European regions. The current paper describes the evaluation protocol for this large-scale implementation project. DesignCurrent summative evaluation study follows a naturalistic one-group pretest–posttest design and assesses three distinct stakeholders: patients, mental healthcare professionals, and mental healthcare organisations. The Model for Assessment of Telemedicine applications (MAST) will be employed to structure the implementation and evaluation study. The primary focal points of interest are reach, clinical effect, acceptability, appropriateness, implementation costs, and sustainability of the interventions in practice. Mixed-methods are used to provide an understanding of what (quantitative) the implementation projects have achieved and their meaning to various stakeholders (qualitative). DiscussionThe use of Internet interventions in routine practice is limited. MasterMind attempts to bridge the gap between routine practice and effectiveness research by evaluating the implementation of evidence-based Internet interventions for depressive disorders in routine mental healthcare settings in Europe.

A case study of the organisation of research knowledge by systematic reviews within the mental health care field

Our aim was to explore how systematic reviews of the effects of complex interventions within the field of organisation of mental health care organised research knowledge. We looked up references included in 14 mental health care reviews in the database Epistemonikos to examine overlap between reviews. We classified topic concordance between study reports and reviews as similar, narrower, broader or other topic to indicate how well the research knowledge was organised. We examined 182 comparisons between the theme of study reports and reviews. In 100 (55%) of the 182 comparisons, the review had a broader theme, 18 (10%) narrower, 34 (19%) similar and in 30 (16%), the review's theme was classified as 'other'. The content analysis indicated that there existed (inconsistent) overlapping of study reports between different topics. Within the field organisation of mental health care, there exists some unclear and inconsistent organisation of current knowledge. This may diminish the validity and reliability of systematic reviews. It is important that review authors take care in defining the review question precisely, conduct thorough literature searches, consider each study's hypothesis, disciplinary tradition and context, and if necessary, examine which other reviews have included a study in question.

Effectiveness of the Comprehensive Approach to Rehabilitation (CARe) methodology: design of a cluster randomized controlled trial.

BackgroundThere is an increasing amount of evidence for the effectiveness of rehabilitation interventions for people with severe mental illness (SMI). In the Netherlands, a rehabilitation methodology that is well known and often applied is the Comprehensive Approach to Rehabilitation (CARe) methodology. The overall goal of the CARe methodology is to improve the client’s quality of life by supporting the client in realizing his/her goals and wishes, handling his/her vulnerability and improving the quality of his/her social environment. The methodology is strongly influenced by the concept of ‘personal recovery’ and the ‘strengths case management model’. No controlled effect studies have been conducted hitherto regarding the CARe methodology.Methods/designThis study is a two-armed cluster randomized controlled trial (RCT) that will be executed in teams from three organizations for sheltered and supported housing, which provide services to people with long-term severe mental illness. Teams in the intervention group will receive the multiple-day CARe methodology training from a specialized institute and start working according the CARe Methodology guideline. Teams in the control group will continue working in their usual way. Standardized questionnaires will be completed at baseline (T0), and 10 (T1) and 20 months (T2) post baseline. Primary outcomes are recovery, social functioning and quality of life. The model fidelity of the CARe methodology will be assessed at T1 and T2.DiscussionThis study is the first controlled effect study on the CARe methodology and one of the few RCTs on a broad rehabilitation method or strength-based approach. This study is relevant because mental health care organizations have become increasingly interested in recovery and rehabilitation-oriented care.Trial registrationThe trial registration number is ISRCTN77355880.

Mental health problems of undocumented migrants in the Netherlands: A qualitative exploration of recognition, recording, and treatment by general practitioners

Objective. To explore the views and experiences of general practitioners (GPs) in relation to recognition, recording, and treatment of mental health problems of undocumented migrants (UMs), and to gain insight in the reasons for under-registration of mental health problems in the electronic medical records. Design. Qualitative study design with semi-structured interviews using a topic guide. Subjects and setting. Sixteen GPs in the Netherlands with clinical expertise in the care of UMs. Results. GPs recognized many mental health problems in UMs. Barriers that prevented them from recording these problems and from delivering appropriate care were their low consultation rates, physical presentation of mental health problems, high number of other problems, the UM’s lack of trust towards health care professionals, and cultural differences in health beliefs and language barriers. Referrals to mental health care organizations were often seen as problematic by GPs. To overcome these barriers, GPs provided personalized care as far as possible, referred to other primary care professionals such as social workers or mental health care nurses in their practice, and were a little less restrictive in prescribing psychotropics than guidelines recommended. Conclusions. GPs experienced a variety of barriers in engaging with UMs when identifying or suspecting mental health problems. This explains why there is a gap between the high recognition of mental health problems and the low recording of these problems in general practice files. It is recommended that GPs address mental health problems more actively, strive for continuity of care in order to gain trust of the UMs, and look for opportunities to provide mental care that is accessible and acceptable for UMs.

Changing the obesogenic environment of severe mentally ill residential patients: ELIPS, a cluster randomised study design.

BackgroundSevere mentally ill (SMI) patients have a reduced life expectancy of 13–30 years compared to the general population, largely due to an increased risk of cardiovascular mortality. Unhealthy lifestyle behaviours in SMI patients contribute to this increased risk. The obesogenic living environment of patients in residential facilities may even pose an extra risk. Although several studies have shown positive effects of lifestyle interventions on SMI patients’ weight status, studies including residential patients and their obesogenic environment are scarce. This paper describes the Effectiveness of Lifestyle Interventions in PSychiatry trial (ELIPS). The goal of this trial is to improve cardiometabolic health in severe mentally ill residential patients by addressing the obesogenic environment.Methods/designThe ELIPS study is a multi-site cluster randomised controlled trial (RCT) based on the principles of a pragmatic RCT. All residential and long-term clinical care teams of two large mental health care organisations in the North of the Netherlands serving SMI patients are invited to participate. The intervention is aimed at team level. Lifestyle coaches first develop a team specific lifestyle plan that tailors the ELIPS goals and protocol and then train teams on how to create a healthy environment and stimulate healthy behaviours in patients. After three months, teams take over the intervention after they have set out goals to achieve in the following nine months. In this phase, adherence to the lifestyle plan and pre-set goals is monitored. Patients in the control arm receive care as usual. Primary outcome measure is waist circumference at three and 12 months after baseline.DiscussionELIPS is different from previously published lifestyle intervention studies in three ways. First, it follows the principles of a pragmatic design, which enables the examination of effects in everyday practice. Second, by implementing the intervention at team level, we expect lifestyle activities to be maintained when interventionists leave. Last, by targeting the obesogenic environment we create a prerequisite for any sustainable health improvement, as patients can only make healthy choices in a healthy living environment.Trial registrationNederlands Trialregister NTR2720 (Dutch Trial Register, www.trialregister.nl). Registered 27 January 2011.

Organization and financing of the zemstvo health care in the Kazan province

«The Statute on the provincial and district local government» (1864) started a significant social and economic changes in the country. Before the introduction of zemstvo self-government the organization of health care was administered by various departments. So there was no unified system of health care provision. With the introduction of the territorials authority in the area of «national health» were divided between governmental and territorial authorities. State management covered issues of sanitary improvement and anti-epidemic measures. The task of medical care organizing was on the territorial self-government, although they did not have sufficient administrative permissions. Throughout the whole period of activity the territorials created various administrative authorities for the organization of the effective system of management: the provincial and district councils of public health, provincial and district committees of public health, medical boards. Financing of the health care system was negligible in the early years of territorials. It was carried out from the provincial and district territorial budgets, with major financial expenses fell on the county local governments. They paid for the costs of the medical personnel and medical facilities, carrying out sanitary measures. Most of the funds were spent on treatment measures. The organization of an emergency anti-epidemic measures in case of the threat of spreading epidemics as well as the organization of mental health care and provision of the provincial hospital and paramedic school were funded from the provincial budget. The amount of financing of the territorial health care increased almost annually, reflecting the strategic importance of the health care sector for territorial self-government.

Continuity across inpatient and outpatient mental health care or specialisation of teams? A systematic review

BackgroundA central question for the organisation of mental health care is whether the same clinicians should be responsible for a patient's care across inpatient and outpatient settings (continuity of care) or if there should be separate teams (specialisation). Current reforms in Europe are inconsistent on which to favour, and are based on little research evidence. This review is the first systematic appraisal of the existing evidence comparing continuity of care and specialisation across inpatient and outpatient mental health care. MethodA systematic search for studies of any design comparing mental health care systems based on continuity or specialisation of care was performed. Differences in clinical, social and cost-effective outcomes, and the views and experiences of patients and staff were assessed using narrative synthesis. ResultsSeventeen studies met the inclusion criteria. All studies had methodological shortcomings, but findings point towards reduced length and number of hospitalisations, and faster or more flexible transitions between services in continuity systems. Survey and qualitative findings suggest advantages of both systems, whilst patients and staff appear to prefer a continuity system. ConclusionThe evidence base suggests better outcomes and stakeholder preferences for continuity of care systems, but the quality of existing studies is insufficient to draw definitive conclusions. Higher quality comparative studies across various settings and population groups are urgently needed.

Recovery-oriented care in older-adult acute inpatient mental health settings in Australia: an exploratory study.

Recovery-oriented care acknowledges the unique journey that consumers lead with the aim of regaining control of their lives in order to live a good life. Recovery has become a dominant policy-directed model of many mental health care organizations, but in older-adult acute mental health inpatient settings, nurses do not have a clear description of how to be recovery-oriented. The aims of this study were to determine the extent to which elements of existing nursing practice resemble the domains of recovery-oriented care and provide a baseline understanding of practice in preparation for transformation to recovery-oriented mental health care provision. An exploratory, qualitative research design was used to meet the research aims. A purposive sample of mental health nurses (N = 12) participated in focus groups in three older-adult inpatient settings in Australia. A general inductive approach was used to analyze the qualitative data. The mental health nurses in this study readily discussed aspects of their current practice within the recovery domains. They described pragmatic ways to promote a culture of hope, collaborative partnerships, meaningful engagement, autonomy and self-determination, and community participation and citizenship. Nurses also discussed challenges and barriers to recovery-oriented care in older-adult acute mental health settings. This study identified a reasonable baseline understanding of practice in preparation for transformation to recovery-oriented older-adult mental healthcare provision. A concerted drive focused on recovery education is required to effectively embed a recovery-orientated paradigm into older-adult mental health settings.

Investigation into coordinating dependencies between care pathways within mental healthcare: A qualitative case study and pilot testing of a new theoretical framework

Introduction Aiming to improve quality of care and reduce costs, mental healthcare organizations implemented care pathways. These pathways have mostly been evaluated as single entities. However, evidence suggests that improvements in individual pathways do not necessarily lead to better performance within the whole care process due to dependencies between pathways. Limited empirical research has been devoted to this theme. The aim of this study was to examine how departments coordinate dependencies between pathways, to discern types of coordination used and to construct a theoretical framework. Methods In a comparative case study of three departments within two mental healthcare organizations, 27 employees were interviewed on the subject of coordination of pathways. A document review was performed to gain general insights into the departments and their pathways. Interviews were transcribed and analyzed using content analysis, based on criteria derived from the theoretical framework. The cases were compared through pattern analysis. Results Findings indicate a lack of awareness among team members regarding the theoretical pathway structure within their department and that all departments deployed a function or system to monitor coordination practices. Within the departments, flow dependencies were found. Although departments coordinated pathways differently, these mostly were horizontal and programmed in nature. Discussion The findings suggest more explicit and structured communication about pathways can be helpful in organizations. Also, outcomes were better if coordination was monitored. Further research is warranted to verify and evaluate the preference for horizontal and programmed ways of coordinating pathway dependencies within mental healthcare.

Psychiatric Hospital Aesthetics Affect Seclusion, Restraint Use

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessPsychiatric Hospital Aesthetics Affect Seclusion, Restraint UseVabren WattsVabren WattsSearch for more papers by this authorPublished Online:5 Aug 2014https://doi.org/10.1176/appi.pn.2014.9a5AbstractAn initiative that involved redecoration of a psychiatric facility’s physical environment is credited with reducing the need for seclusion or restraint over the long term.More than a decade ago, a team of mental health professionals initiated a study that would eventually show that an 82 percent reduction in a psychiatric hospital’s rates for seclusion and restraint use could be achieved within a relatively short time, simply by making the physical environment more aesthetically pleasing.In a report published July 15 in Psychiatric Services in Advance, the researchers updated their data to show whether their intervention method can sustain such a reduction in use of seclusion and restraint over an extended period of time. In the first decade of this century, there was a major effort to lessen the use of seclusion and restraint for patients in mental health facilities. Government health agencies and mental health care organizations—including APA—were heavily involved in these efforts to curb seclusion and restraint use, stressing that these practices can be countertherapeutic for patients (Psychiatric News, 2003). Alok Madan, Ph.D., M.P.H., and Susan Hardesty, M.D., found that the physical appearance of a psychiatric facility can reduce rates of seclusion and restraint over a decade.“While several calls were made to reduce seclusion and restraint within inpatient settings, there was not a lot of research out there about how this [reduction] could be achieved,” commented the study’s lead author Alok Madan, Ph.D., M.P.H., an associate professor of psychiatry at the Menninger Clinic, during an interview with Psychiatric News. A former research fellow at the Institute of Psychiatry (IOP) at the Medical University of South Carolina, Madan was part of the earlier study whose findings were published in Psychiatric Services in 2011. That study involved the implementation of a multicomponent intervention plan to minimize seclusion and restraint use at the IOP. Findings from that study showed that changes to the physical environment—such as repainting walls with warm colors, using decorative rugs, and restructuring furniture in common areas—were the only interventions associated with a significant drop in the rates of seclusion and restraint from the beginning of 2005 to mid-2008, whereas interventions such as increased trauma-informed training for hospital staff and shared decision making practices did not lead to a similar result. In their current study, the researchers expanded upon these findings to assess whether the reduced rates of seclusion and restraint associated with modification of the physical atmosphere could be sustained beyond 2008. To answer that question, Madan and colleagues gathered information on seclusion and restraint rates at the IOP over multiple time periods: baseline, which included no prior modification to the facility’s physical environment (January 2003 to December 2004); the implementation period in which modifications were made to the physical environment (January 2005 to March 2008); an initial follow-up period (April 2008 to June 2008); and an extended follow-up period in which concerted efforts to further reduce seclusion and restraint were no longer being tried (July 2008 to December 2012). The results showed that rates of seclusion and restraint were reduced during the initial follow-up period and that this reduction was sustained throughout the extended follow-up period. “We are the first group to look at sustained results in this format,” said Susan Hardesty, M.D., medical director and a senior vice president at Menninger. She explained to Psychiatric News that though she and her colleagues left the IOP within the 10-year period studied, the reduction in seclusion and restraint practices as a result of improvements to the facility’s physical environment proved to be long lasting—even in the midst of an administration shift. Hardesty added that not only does an aesthetically pleasing environment benefit the mental health of patients, but it may also benefit that of faculty and staff. “People like coming to work in a presentable environment.”The researchers did note, however, that there may be some limits to the benefits of environmental improvements, since no further reduction in seclusion and restraint use was observed between the initial follow-up period and the extended follow-up. They concluded that future research should focus more on pinpointing the specific environmental and design features that may directly deter seclusion and restraint use. The study was funded by the Menninger Foundation and the McNair Medical Institute. ■An abstract of “Efforts to Reduce Seclusion and Restraint Use in a State Psychiatric Hospital: A Ten-Year Perspective” can be accessed here. ISSUES NewArchived

The role of academic psychiatry in leading health policy reform.

The authors discuss the current state of mental health care reform and the opportunity for academic psychiatry to emerge in a leadership role in the organization and delivery of mental health care.

The patient's perspective on "providing structure" in psychiatric inpatient care: an interview study.

To gain insight into the patients' experiences on providing structure (PS) as a nursing intervention during psychiatric inpatient care. Interviews were conducted with patients (n = 17) from two inpatient wards within a mental healthcare organization. For data analysis, a qualitative coding process was followed. The patients' expectations for PS were described. One expectation seemed to reflect key concern: the need to maintain autonomy. The study reveals the patients' views about PS. When the importance of PS is mentioned, nurses can refer to our description of PS. We were able to further stipulate the required activities of PS and provide for an adapted definition of PS.

Outsourcing mental health care services? The practice and potential of community-based farms in psychiatric rehabilitation.

Psychiatric rehabilitation supports individuals with mental disorders to acquire the skills needed for independent lives in communities. This article assesses the potential of outsourcing psychiatric rehabilitation by analysing care farm services in the Netherlands. Service characteristics were analysed across 214 care farms retrieved from a national database. Qualitative insights were provided by five case descriptions, selected from 34 interviews. Institutional care farms were significantly larger and older than private care farms (comprising 88.8% of all care farms). Private, independent care farms provide real-life work conditions to users who are relatively less impaired. Private, contracted care farms tailor the work activities to their capacities and employ professional supervisors. Institutional care farms accommodate for the most vulnerable users. We conclude that collaborations with independent, contracted and institutional care farms would provide mental health care organizations with a diversity in services, enhanced community integration and a better match with users' rehabilitation needs.

FRI0173 Reduced Hypothalamic-Pituitary-Adrenal Axis Activity in Chronic Widespread Pain: Partly Masked by Depressive and Anxiety Disorders

BackgroundResults of studies on hypothalamic-pituitary-adrenal axis (HPA-axis) function amongst patients with chronic widespread pain (CWP) are equivocal and well-controlled cohort studies are rare in this field.ObjectivesThe goal of our study...

AB0044 Basal Inflammation and Innate Immune Response in Chronic Widespread Pain

BackgroundDysregulation of the immune system may play a role in chronic widespread pain (CWP)1–3 although study findings so far are inconsistent.ObjectivesThis cross-sectional study examined whether basal inflammatory markers and the...

Non-professional-help-seeking among young people with depression: a qualitative study.

BackgroundAdolescents and young adults often suffer from depression, but tend to avoid seeking professional help. The aim of this study was to explore the reasons for non-professional-help-seeking in a sample of young adults resident in Catalonia with depressive symptoms through a qualitative study. In addition, the subjects were invited to offer their recommendations for making mental health care services more accessible.MethodsWe recruited 105 young persons (17–21 years of age) who had participated in a national survey on adolescents. The sample was divided into thirds, with 37 who had a previous diagnosis of depression, 33 who had self-perceived emotional distress, and 35 controls. The participants were interviewed in depth about their reasons for avoiding professional mental health care services, and the interview results were analyzed using both qualitative and cultural domain techniques and corroborated through comparison with the results of three focus groups.ResultsParticipants’ reasons for avoidance varied both by gender and according to prior experience with health services. Male study participants and female controls mainly understood depressive symptoms as normal and therefore not requiring treatment. Female participants with self-perceived distress were more likely to cite problems of access to treatment and fear of speaking to an unknown person about their problems. Females with a diagnosis expressed lack of trust in the benefits of treatment and fear of the social consequences of help-seeking. In their recommendations for best practices, the study participants suggested educational initiatives, as well as changes in the organization of mental health care services.ConclusionsA better understanding of the views of young people and a greater effort to involve them as active participants is important for facilitating help-seeking in this age group, and for adapting mental health care services to adolescent users and their social context.

Effectiveness and predictors of outcome in routine out-patient mental health care for older adults.

ABSTRACT Background: Meta-analyses show efficacy of several psychological and pharmacological interventions for late-life psychiatric disorders, but generalization of effects to routine mental health care for older people remains unknown. Aim of this study is to investigate the improvement of functioning within one year of referral to an outpatient mental health clinic for older adults. Methods: Pre-post measurement of the Health of Nations Outcome Scale 65+ (HoNOS 65+) in 704 older people referred for psychiatric problems (no dementia) to any of the seven participating mental health care organizations. Results: The pre-post-test Cohen's d effect size was 1.08 in the total group and 1.23 in depressed patients, the largest subgroup. Linear regression identified better functioning at baseline, comorbid personality disorder, somatic comorbidity and life events during treatment as determinants of a worse outcome. Conclusions: Functioning of older persons with psychiatric problems largely improves after treatment in routine mental health care.

Advocates Urge More Cooperation Among MH Organizations

Back to table of contents Previous article Professional NewsFull AccessAdvocates Urge More Cooperation Among MH OrganizationsVabren WattsVabren WattsSearch for more papers by this authorPublished Online:14 Apr 2014https://doi.org/10.1176/appi.pn.2014.4b7AbstractMultiple benefits accrue to patients with psychiatric disorders when the many organizations in the mental health field pool their advocacy efforts to improve care and insurance coverage.The African proverb “it takes a village to raise a child” may apply in the context of treating people with mental illness. Debbie Plotnick, M.S.S., M.L.S.P., discussed the importance of caring for those with mental illness outside of mental health care facilities.On February 28, Debbie Plotnick, M.S.S, M.L.S.P., senior director of state policy at the advocacy organization Mental Health America, spoke at the 2014 Intensive Winter Institute sponsored by the American Nurses Association (ANA) and the APA Minority Fellowship Program to discuss the importance of caring for those with mental illness in the community and collaboration among mental health care organizations.Mental health professionals are often located in the facilities in which people are being treated for their mental illness, Plotnick said, but “we should often go into the community to ensure that there are resources available concerning mental illness, so that people will know how to obtain help if they or a loved one is struggling with mental illness.”Plotnick emphasized that the community-based outreach concept can also be applied to help individuals recover from mental illness. “As we explore what we need [to improve] quality, we should consider more than clinical quality,” Plotnick said, explaining that mental health facilities often see patients when they are seriously ill and do not see those patients when they are well. “We need to know how they are doing . . . whether they’re back to a fulfilling life with a safe place to live and with meaningful work.”In an interview with Psychiatric News, Plotnick said that she has had personal experiences with the integration of mental health treatment and community outreach practices. “My daughter struggled with serious mental illness as an adolescent, and she was able to find community resources to keep her in school and help her take control of her illness. She is now a successful young woman who is a nurse.”In light of the multiple recent changes reshaping the health care system, Plotnick emphasized that it is especially important to advocate for both public and private insurance plans that will guarantee coverage of prevention efforts, peer-counseling services, and wellness programs, in addition to community inclusion services—that is, intervention services that guide those with psychiatric disabilities back into society to live a functional life. Plotnick said that this goal will be achieved only through a collaborative advocacy effort from all mental health organizations. She added that by making the needs of patients the primary focus of interdisciplinary meetings by organizations in the mental health field, mental health professionals will become more effective—benefitting patients in all stages of treatment and recovery.Annelle Primm, M.D., said that, “When mental health care organizations work collaboratively, it can only mean great things for the field of mental health.”Annelle Primm, M.D., M.P.H., APA deputy medical director and director of the Division of Diversity and Health Equity, agreed. “I think it is important for mental health care professionals to learn about the great benefits of team-based care, particularly in the context of the Affordable Care Act, which values interdisciplinary work,” she said.Primm noted that this is the first year that that APA and the ANA have co-sponsored the Intensive Winter Institute—usually it is hosted solely by the ANA. “Hopefully, there will be some sustained contact and opportunity for research and joint policy work,” said Primm. “When mental health care organizations work collaboratively, it can only mean great things for the field of mental health and for mental health care delivery. People are now equipped with the knowledge that they need to be on top of cutting-edge issues in today’s changing health care environment.” ■ ISSUES NewArchived

Are there gender differences in service use for mental disorders across countries in the European Union? Results from the EU-World Mental Health survey

BackgroundWomen are more likely than men to use mental healthcare (MHC) due to differences in the types of problems and help-seeking behaviours. The consistency of this relationship across European countries,...

Creative Use of Community MH Resources Saves Money, Improves Care

Back to table of contents Previous article Next article Full AccessCreative Use of Community MH Resources Saves Money, Improves CareAaron Levin, Aaron LevinSearch for more papers by this author, Published Online:2 Jan 2014https://doi.org/10.1176/appi.pn.2014.1a7AbstractMental health experts call for multilevel strategies to build and improve community-based mental health options.Community involvement is the key to better, more efficient, less costly mental health care in the United States as parity and the Affordable Care Act take hold, said speakers at a briefing in Washington, D.C., last November.The final parity rule, issued in November 2013, “brings mental health out of the closet” and symbolizes the field’s inclusion in the greater health care system, said Michael Fitzpatrick, outgoing executive director of the National Alliance on Mental Illness (NAMI) at the briefing. The briefing was held to introduce Connect 4 Mental Health (C4MH), an initiative to build support for mental health care using “locally driven strategies that aim to help individuals with serious mental illness, their families, and the communities in which they live.”“The parity rule is potentially revolutionary, but it will take years of effort to implement,” he said.People with serious mental illness need more than insurance reform, said others. “They rarely need just one service provided excellently,” said Paul Barry, M.Ed., executive director of MHA Village in Long Beach, Calif. “True, housing first is an improvement over hospitalization first, but you have to consider myriad factors that go into comprehensive wrap-around services.” For instance, since work is a primary source of individual identity, the Village offers its residents a variety of employment from day labor to agency-run businesses (like a cookie shop) where people on the way to recovery can build skills and demonstrate that they are assets in the working world.One critical element in any jurisdiction is reversing the trend toward locking up people with mental illness for minor offenses or leaving them homeless rather than directing them to care, said Leon Evans, president and CEO of the Center for Health Care Services in Bexar County, Texas. Eventually, under a federal grant, the county was able to divert 16,000 people a month from the criminal justice system to treatment services.Leon Evans (left), of the Center for Health Care Services, says that a variety of community-based diversion and treatment programs can save money and improve outcomes for people with mental illness. At right is Bruce Bird, Ph.D., of Vinfen.Connect 4 Mental Health“You need a community collaboration,” said Evans. The “black-robe effect” helps a lot—putting a judge in charge of convening consumers, families, law enforcement officials, hospitals, and the medical system. “We need to learn to speak each other’s languages and build trust,” he said. However, merely articulating mental health needs to legislators who hold the purse strings isn’t enough. “You also have to sell the system as ‘saving money’ and promoting ‘public safety,’ and you need the data to back that up,” said the Village’s Barry.But sharing clinical outcomes information and cost savings is just the start, Barry noted. Agencies were not always good at stopping practices that were not very helpful for people with mental illness. “So you also have to challenge providers to do their work better and differently,” he said.That challenge applies to others in the system too.In the first crisis-intervention training in Bexar County, police officers were skeptical of “hug-a-thug” deescalation techniques emphasizing the use of verbal interventions before resorting to force. However, by the end of the course they were believers, said Evans. The county also built a 24-hour crisis center to which the police can take people with severe psychiatric symptoms instead of to jail. The Restoration Center offers detoxification and substance abuse services as well. These diversion programs eliminated the need for a proposed new 1,000-bed jail.Finally, technology may offer another adjunct to the spectrum of community-based care, said Bruce Bird, Ph.D., president and CEO of Vinfen, in Cambridge, Mass. Bird’s company and several Massachusetts mental health care organizations have a Centers for Medicare and Medicaid Services grant to test the Health Buddy, a small electronic device that prompts patients with individualized questions about physical and mental health issues. Nurses at a central location can monitor the daily reports and intervene if the patient seems to need help.C4MH is a project of NAMI and the National Council for Behavioral Health, in conjunction with Otsuka America Pharmaceutical and Lundbeck. The initiative seeks to encourage deeper discussions about mental illness and promote changes in the approach to mental health services in local communities, with an emphasis on “early intervention, creative use of technology, service integration, and enhanced continuity of care.” ■Information about the Connect 4 Mental Health (C4MH) is posted at http://connect4mentalhealth.com. ISSUES NewArchived