Mental Health Delivery System Research Articles

Marcia Kraft Goin, M.D., 130th President, 2003-2004

Marcia Kraft Goin, M.D., 130th President, 2003-2004

Marcia Kraft Goin, M.D., 130th President, 2003–2004

Marcia Kraft Goin, M.D., 130th President, 2003–2004

Talbott and Financing Policy: Reducing Fragmentation

Talbott and Financing Policy: Reducing Fragmentation

Poor Endure Access Problems In All Regions of U.S.

Back to table of contents Previous article Next article Professional NewsFull AccessPoor Endure Access Problems In All Regions of U.S.Kate MulliganKate MulliganSearch for more papers by this authorPublished Online:6 Aug 2004https://doi.org/10.1176/pn.39.15.0390015Serious problems with access to mental health services have surfaced in one of the periodic analyses by the Center for Studying Health System Change (HSC) about the viability of the “safety net.”Every two years HSC researchers visit 12 nationally representative metropolitan communities to track changes in local health care markets. The communities are Boston, Cleveland, Greenville, S.C., Indianapolis, Lansing, Mich., Little Rock, Ark., Miami, northern New Jersey, Orange County, Calif., Phoenix, Seattle, and Syracuse, N.Y.The researchers interview individuals who are involved directly or indirectly in providing safety-net services to low-income people.The issue brief, “Health Care Access for Low-Income People: Significant Safety Net Gaps Remain,” published in June, reports on interviews that occurred in 2002-03.Comments such as “the mental health delivery system is in shambles” expressed the extent of these problems, according to researchers Laurie E. Felland, Suzanne Feit-Lisk, and Megan McHugh.Access to mental health services surfaced as a significant problem in eight of the 12 communities, although Felland told Psychiatric News that it should not be assumed that access was not a challenge in all the communities.“We are hearing that more and more patients are showing up at community health clinics and other places that provide primary care with serious mental health problems that have not been treated,” she said.HSC researchers typically have not interviewed individuals directly involved in providing mental health services, so these reports of problems suggest that mental health access issues are being manifested in the primary health care system.Felland said that their respondents also reported that more people with psychiatric emergencies are showing up in emergency rooms, a trend that has been documented in other research (Psychiatric News, June 18).One positive development has been the addition of mental health and substance abuse treatment services to community health centers through the use of federal grants from a program begun in 2002 by President Bush to expand and improve services at those centers.Felland and colleagues wrote, “State and local policymakers are aware of the access problems for specialty, mental health, and dental services, but communities have been more active in addressing the issue.”They continued by noting that budget constraints have hampered states' ability to allocate funds over the last few years.Felland said that although some states had increased Medicaid provider rates, those rates often were still much lower than private insurer rates.In addition, the HSC analysis was based on 2002-03 interviews before the deepest cuts to Medicaid had begun.The researchers concluded, “Across communities, low-income and uninsured people face long-standing, and sometimes worsening, difficulties in obtaining specialty, dental, and mental health services.... Safety net providers are not equipped to meet the wide range of health care needs of all low-income people, and access to private practitioners remains limited.”They identify low payment rates as a major barrier to access.“Health Care Access for Low-Income People: Significant Safety Net Gaps Remain” is posted online at<www.hschange.com/CONTENT/682/>.▪ ISSUES NewArchived

The systemic neglect of New York's young adults with mental illness.

The systemic neglect of New York's young adults with mental illness.

Datapoints: detecting depression in VA primary care clinics.

Back to table of contents Previous article Next article ColumnsFull AccessDatapoints: Detecting Depression in VA Primary Care ClinicsJoAnn E. Kirchner, M.D., Geoffrey M. Curran, Ph.D., and James Aikens, M.S.JoAnn E. KirchnerSearch for more papers by this author, M.D., Geoffrey M. CurranSearch for more papers by this author, Ph.D., and James AikensSearch for more papers by this author, M.S.Published Online:1 Apr 2004https://doi.org/10.1176/appi.ps.55.4.350AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The treatment of depression largely falls to providers in primary care settings, which have been identified as the de facto mental health delivery system (1). Systemwide programs to improve depression care have been initiated in the Department of Veterans Affairs (VA) and in other health care organizations (2,3). One such VA initiative is screening for depression as part of the Prevention Index, which was mandated in 1998 as an annual screening tool for all primary care patients. Our study investigated diagnosis patterns of depressive disorders in VA primary care clinics over a five-year period. Specifically, we wanted to determine whether primary care service use data indicated that implementing and monitoring the mandated depression screening affected depression diagnosis rates.Data on all primary care visits were gathered from the VA's national outpatient service use database for fiscal years 1997 to 2001. In the database, all primary care visits carry a primary diagnosis that indicates the main reason for and the presenting problem at the visit as well as up to ten secondary diagnoses.Overall, the frequency with which depression was diagnosed, as well as the percentage of the primary care population who received a diagnosis of depression, increased across the study years. As can be seen in Figure 1, the rates of primary diagnosis of depression remained unchanged in our study.Despite the overall increase in the diagnosis of depression in the primary care setting, it is important to note that among veterans with a primary care diagnosis of depression, the average number of primary care visits for which a primary diagnosis of depression was noted did not vary across the study period (1.4 or 1.3 visits) and falls well below guideline recommendations for the treatment of depression in this population (4).AcknowledgmentsThis work was supported by grant NMH98-001 from the Department of Veterans Affairs Mental Health Quality Enhancement Research Initiative and by grant IIR-98086-3 from the Department of Veterans Affairs Health Services Research and Development Service.Dr. Kirchner and Dr. Curran are affiliated with the Department of Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center, 2200 Fort Roots Drive, Building 58, North Little Rock, Arkansas 72114 (e-mail, [email protected]). All of the authors are with the Department of Veterans Affairs Mental Health Quality Enhancement Research Initiative. Harold Alan Pincus, M.D., and Terri L. Tanielian, M.A., are editors of this column.Figure 1. Patients with a diagnosis of depressive disorder among veterans in Department ofVeterans Affairs (VA) primary care clinics, from the VA national outpatient serviceuse database for fiscal years 1997 to 2001aa Yearly changes significant at p<.001

The International Consortium on Mental Health Policy and Services: objectives, design and project implementation

The concept of the burden of disease, introduced and estimated for a broad range of diseases in the World Bank report of 1993 illustrated that mental and neurological disorders not only entail a higher burden than cancer, but are responsible, in developed and developing countries, for more than 15% of the total burden of all diseases. As a consequence, over the past decade, mental disorders have ranked increasingly highly on the international agenda for health. However, the fact that mental health and nervous system disorders are now high on the international health agenda is by no means a guarantee that the fate of patients suffering from these disorders in developing countries will improve. In most developing countries the treatment gap for mental and neurological disorders is still unacceptably high. To address this problem, an international network of collaborating institutions in low-income countries has been set up. The establishment and the achievements of this network—the International Consortium on Mental Health Policy and Services—are reported. Sixteen institutions in developing countries collaborate (supported by a small number of scientific resource centres in industrialized nations) in projects on applied mental health systems research. Over a two-year period, the network produced the key elements of a national mental health policy; provided tools and methods for assessing a country's current mental health status (context, needs and demands, programmes, services and care and outcomes); established a global network of expertise, i.e., institutions and experts, for use by countries wishing to reform their mental health policy, services and care; and generated guidelines and examples for upgrading mental health policy with due regard to the existing mental health delivery system and demographic, cultural and economic factors.

Promises, promises

Promises, promises

Managing Mental Health Sector in Gujarat: An Overview of Strategic Priorities

Mental health disorders are actually much more prevalent than is apparent on the surface. Health sector, in general, and mental health sector, in particular, faces a number of challenges which include: shortage of trained mental health professionals inadequate training capacity absence of multidisciplinary approach nearly non-existent linkages between the community and hospital-based care weak institutional framework. Many of these problems flow from meagre financial resources, both governmental and non-governmental. This paper is based on several studies relating to socio-economic determinants of mental disorders; mental health delivery systems in the public, private, and the voluntary sector; the cost of mental health services; framework for financing mental health sector; issues relating to human resource development; management issues in the mental health sector; gender and mental health; role of ethics in mental health; issues relating to destigmatization of mental health; and interface of law and mental health in the context of Gujarat. It provides a broad canvas of strategies which need to be pursued to address issues facing this sector. The strategies discussed here should form part of the mental health programme of the government. Of late, there is a growing recognition of the fact that something needs to be done in this sector. The inclusion of mental aspects of health was reflected, for the first time, in the Ninth Five-Year Plan when a separate scheme for ‘Strengthening of Mental Health Services’ was included. The Tenth Five-Year Plan envisages continuation of this emphasis; in particular, it aims to ‘integrate mental health with rural health care and provide special care for mental disorders of all types by scientific surveillance and identification.’ Enhancement of mental health requires improved provision of preventive, curative, and rehabilitative services. Given the resource availability and social dimensions of the problem, appropriate community-based and cost-effective interventions need to be developed. Besides, there are also many ethical and legal concerns that need to be taken into account. A large number of cases of mental disorder currently go untreated as competent professional help is not available easily. This would need augmentation of capacities and competencies of large number of professionals and health workers working in the government, NGOs, and the private organizations. This paper suggests a series of priorities in laying out 12 strategic directions and a comprehensive set of short-term implementation modalities for the immediate two to three years. The strategic directions are: resource mobilization and allocation strengthening of ethics of care addressing of stigma strengthening of public mental health system strengthening of role of caregivers promotion of private sector human resources and capacity strengthening at various levels strengthening of the role of NGOs integration of mental health with other fields strengthening of the interface with law strengthening of the institutional mechanisms stimulation of mental health research.

Commentary: New Models for School-Based Mental Health Services

The potential of school-based delivery systems to dramatically improve access to and positive impact of mental health prevention and intervention services cannot be underestimated (Hoagwood & Erwin, 1997). Particularly when they involve coordinated collaboration with community-based agencies and stakeholders, school-based delivery systems can provide the backbone for accessible services that are integrated across the developmental spectrum from preschool through adolescence, and that span the continuum of service need, from mental health promotion and risk reduction to intensive intervention (Weissberg & Greenberg, 1998). As noted by Atkins and his colleagues (Atkins, Graczyk, Frazier, & Abdul-Adil, 2003), however, this potential cannot be realized without innovative models for school-based delivery system design and programmatic evaluation research. Three critical challenges for the design of effective school-based mental health delivery systems include: (a) supporting the high-fidelity implementation of empirically based practices, (b) sustaining effective programming over time, and (c) fostering local adaptations that enhance cultural and community fit and ownership (Biglan, Mrazek, Carnine, & Flay, 2003; Wandersman & Florin, 2003; Weissberg, Kumpfer & Seligman, 2003). Atkins et al. (2003) provide illustrative examples of how these challenges can be addressed in ways that can significantly increase children's access to empirically supported interventions (the PALS program), integrate programming into existing school leadership structures to support long-term sustainability (the use of Key Opinion Leaders), and foster close coordination and collaboration between school-based and community-based mental health services (the SOC-C mechanism). These models are best termed promising at this time, as empirical data on theft outcome effectiveness is not yet available, but the work of Atkins et al. (2003) suggests that they are each feasible and attractive models for schools and community partners. This commentary will focus on three complementary issues: (a) school-community adaptations of empirically based programs, (b) providing a continuum of care, and (c) researching sustainability. School-Community Adaptations of Empirically Based Programs One particular strength of the new models of Atkins et al. (2003) is the innovative use of indigenous resources and school-community partnerships to expand the responsiveness of programs to community values and priorities, thus enhancing parent engagement and community support. Debate exists concerning the optimal role for community members in prevention and intervention program design. For example, in the context of prevention design, Weissberg and Greenberg (1998) contrast the assumptions underlying the Prevention Science model and the Collaborative Community Action Research model. In the former model, program designs are based primarily upon research documenting the risk and protective factors associated with targeted mental health problems, combined with randomized-controlled efficacy trials that document the positive impact of specific intervention strategies on those outcomes. In this model, the dissemination challenge is to move the empirically validated procedures into the field. In contrast, the Collaborative Community Action Research model is based on an ecological perspective that emphasizes the critical involvement of community members in partnership with researchers in all phases of program development and design, assuming that effective program design requires local wisdom and engagement for success. Weissberg and Greenberg (1998) argue compellingly for the need to combine the strengths of these two approaches, developing program design and delivery strategies that involve community leaders and participants in all phases of decision making but that also make maximal use of available research regarding developmental patterns, risk and protective factors, and empirically proven intervention strategies (see also the Conduct Problems Prevention Research Group [CPPRG], 2002). …

The Commission's report and its implications for psychiatry.

The Commission's report and its implications for psychiatry.

The Campaign for Mental Health Reform: a new advocacy partnership.

The Campaign for Mental Health Reform: a new advocacy partnership.

Child mental health in Latin America: present and future epidemiologic research.

This report reviews population studies of child and adolescent mental health carried out in Latin America over the past 15 years. Also considered is the issue of how to meet the needs of children and adolescents who may present mental health problems in Latin America, given that most of them live in poverty in economies that are underdeveloped, providing limited resources. Ten studies from six different countries were identified that employed some form of randomized sampling method and used standardized instruments for assessment. The authors present a summary of the main characteristics of these studies, highlighting methodological features that may account for differences in the rates obtained. Overall, a similar pattern of prevalence and risk factors for mental health problems in children and adolescents in Latin American countries emerged. Moreover, rates of disorders in these children are similar to the 15 to 20% found in other countries. These findings are similar to those observed when adult mental health problems are considered. Prevention and treatment strategies are discussed and the peculiarities of the delivery of mental health services for children and adolescents are explored. Future research needs to focus on understanding of resilience and formal and informal mental health delivery systems of care available in different Latin American countries. Such research has high potential for ameliorating the prevention and treatment of child and adolescent mental health problems in this region of the world.

Providing Culturally Relevant Mental Health Services: Collaboration between Psychology and the African American Church

Many African American psychologists are concerned about the delivery of culturally relevant mental health services to their community. Recognizing the limitations of traditional psychotherapies and traditional mental health delivery systems, psychologists have developed African-centered models of therapy that emphasize spiritual development. Using African-centered therapies as a conceptual framework, the African American Counseling Team (AACT) was formed to overcome the limitations of traditional mental health systems. AACT provides mental health services to African Americans by integrating clinical assistance into a support system (the African American church) that, historically, African Americans have trusted, embraced, and used for a variety of personal, social, and spiritual needs. Specifically, AACT provides individual, group, and couples counseling. It offers life skills workshops and consults with mental health and other organizations to enhance the delivery of culturally relevant services by these organizations.

Towards an Integrated Approach to a Family Intervention for Co‐occurring Substance Abuse and Schizophrenia

Comorbid substance abuse and schizophrenia is a major cause for concern from clinical, economic and health care systems perspectives. Existing treatment strategies are frequently inadequate, partly due to a lack of research into the unique problems facing this dually diagnosed population. These individuals commonly place a disproportionate burden on the mental health delivery system. In addition, their families are left with the onerous task of caring for them. This paper reviews the literature on family interventions for both substance abuse and schizophrenia and postulates that a composite model of family therapy might be appropriate.

RESEARCH PRIORITIES IN MENTAL HEALTH NURSING

This study determined nursing research priorities that focused on mental health nursing in the published literature from 1990 to 1996. Determination of which priorities were related to mental health was completed using 18 sources (experts, organizations, and individual research projects). A content analysis of the 18 sources was completed, and 56 mental health related research priorities were identified. Six categories emerged from the data analysis: support, holism, mental health nursing practice, quality care outcomes, mental health etiology, and mental health delivery systems. As mental health nursing embraces evidenced-based practice, the need for clear research priorities is imperative for knowledge development in the field.

Florida's Medicaid mental health carve-out: lessons from the first years of implementation.

Florida, like many other states, has embarked on an experiment with managed mental health care for Medicaid enrollees. Under a 1915(b) waiver, the state's Medicaid agency began a mental health carve-out demonstration in March 1996 in the Tampa Bay area. This qualitative case study seeks to ascertain the impact of the carve-out (and, by comparison, HMO arrangements) on the public mental health sector. Findings suggest that the carve-out demonstration has succeeded in creating a fully integrated mental health delivery system with financial and administrative mechanisms that support a shared clinical model. However, other findings raise concerns about the HMO model in terms of stability, access to care, efficiency, and more generally about the shifting of risk and public responsibility "downstream" to private organizations without sufficient governmental oversight. These findings may offer guidance for other states implementing major managed care policy initiative for disabled Medicaid enrollees.

MEXICAN AMERICAN CLIENTS' PERCEPTIONS OF SERVICES IN AN OUTPATIENT MENTAL HEALTH FACILITY IN A BORDER CITY

This descriptive-exploratory pilot study analyzed the perceptions of services in an outpatient mental health facility located in a border city in southwest Texas among Mexican American clientele with chronic mental illness. Face-to-face interviews using structured questionnaires were conducted with high functioning mentally ill clients. The questionnaire, with both English and Spanish versions, consisted of items on sociodemographics, support networks, illness experiences, reasons for seeking health services, reactions to being visited in the home setting for follow-up care, receiving care from a mental health professional with a similar cultural background, satisfactions, problems encountered in the mental health delivery system, and suggestions for improving health services. Data from 56 respondents yielded generally highly favorable and positive ratings of services received in the facility. Overall, these baseline data present challenges and implications for delivering culturally competent mental health care to Mexican American clients with chronic mental illness.

Psychiatric home health: The Newest kid on the block

What is psychiatric home health care? Psychiatric home health care is a clinical specialty of home health services in which psychiatric nurses, social workers, home health aides, and occupational therapists visit the patient with a primary psychiatric diagnosis in the patient's own home. This service has been acknowledged in the Home Health Agency Manual for at least a decade but only recently has received widespread attention from home health providers. In fact, beginning in May 1996, the Health Care Financing Administration has broadened the service capacity by allowing all physicians, not just psychiatrists, to sign a Medicare psychiatric plan of care. This new standard is consistent with already recognized trends of primary care physicians treating psychiatric patients. The mental health literature is increasingly giving recognition to alternatives to traditional continuum of care models that favor psychiatric hospitalization. Addition of in-home interventions to psychiatric delivery systems has resulted in significant reduction in both hospitalization admission and recidivism rates. The models tested have, unfortunately, not used psychiatric home health care, but as more awareness and programs come into existence, psychiatric home health care can play a significant role in the mental health delivery system, particularly in a managed care environment.

Acute and chronic psychiatric care: establishing boundaries.

Despite advances in psychiatry, a proportion of those with mental illness have episodes of severe illness, and a few of these patients may attain only partial recovery. In this respect, mental illness is similar to physical illness and systems of acute and chronic care are essential. As mental health care financing and delivery systems undergo further flux and reform, we will require clear, consensually developed definitions of levels of care, especially because of the complexities created by a legacy of a 2-tiered, public and private mental health system. This paper first will offer definitions and examples of acute and chronic illness and care. We will also address certain problems inherent to such a classification. We will then consider principles of and potential plans for a system of financing and care for the chronically mentally ill. Two existing plans will be reviewed as illustrations of innovations in chronic care. As health reform changes the financing and delivery of care for the mentally ill, an opportunity exists to integrate public and private monies and services and to improve upon the care of the acutely and chronically mentally ill.