Clinical Mental Health Services Research Articles

Reflections from Learning Disability Child and Adolescent Mental Health Service clinicians: Designing and delivering a pilot ‘understanding emotions’ group

Authors describe the process of delivering a pilot ‘understanding emotions’ group to young people attending a special educational needs (SEN) school. The group was designed to provide early intervention with a preventative focus. Reflections and ideas for future groups are discussed.

Chinese label for people at risk for psychosis.

With the movement of early detection and intervention for people at risk for psychosis, there is a growing need for a uniform terminology to describe the condition. A diagnostic label that can adapt into local culture and value may have positive effect in minimizing stigma. This study explored the preference of Chinese label for people at risk of psychosis and its associated stigma in Hong Kong. A total of 149 individuals from the general public and 51 health-care professionals were recruited between March 2013 and May 2014. The condition of at risk for psychosis was described in a vignette. Participants' preference of label and perceived stigma of the condition and their basic demographics were collected by self-administered questionnaires. The most preferred Chinese label was 'yun-niang-qi' (developing period, 45%), followed by 'qian-qu-qi' (precursor period, 19%), 'feng-xian-qi' (risky period, 18%), 'zao-xian-qi' (early sign period, 16%) and 'gao-wei-qi' (high risk period, 4%). Gender, age, occupation and previous contact with mental health were not associated with preference of any Chinese label. The process in searching for this potential and locally accepted label for people at risk for psychosis has raised the awareness among the professionals. A proper label may help promote future clinical research and mental health services in Hong Kong.

Is Housing First for Mental Health Community Support Possible During a Housing Shortage?

AbstractSupported housing programmes for people with chronic mental health needs have shifted towards approaches that rely on housing first, which prioritizes access to a permanent home in the community. How do support programmes with this assumption manage the market constraints of a shortage of affordable housing? The article examines empirical mixed method data (interviews and programme data) about the experience of managing this problem in the Mental Health Housing and Accommodation Support Initiative (HASI) in New South Wales, Australia. HASI provides clinical mental health services, housing support and housing if needed, for people who are not yet living independently in the community.It found that the housing shortage affected the ability of the providers to implement the intended programme design at three early steps in the support: determining eligibility; prioritizing access between people with and without housing; and managing entry to the programme when they did not have housing. As a result, some otherwise suitable applicants were not prioritized for entry into the programme or their entry was delayed until they were housed.The providers adjusted the programme to the housing market realities, which compromised the programme intentions. The policy lessons are that programmes need strategies to provide housing for people who require it; assist people to find or apply for housing; and support people while they wait for housing. These approaches enhance the coherence of programmes, build on integration mechanisms and respond to the housing context.

Exploring the meaning of recovery-oriented care: an action-research study.

The present study describes participants' perspectives of the meaning of recovery-oriented care in developing services for people with psychosocial disability associated with mental illness. Participants were involved in a 12-month cooperative inquiry action-research group from August 2012 to July 2013, with six consumers, four clinicians, and a carer. A major finding was the importance of the facilitation of dialogue that acknowledged the asymmetrical power differences between participants. Thematically-analysed data identified an overarching global theme: 'I want services to hear me'. The theme reflected a shared view that participation is important in service development. Actions included mapping the integration of consumer participation within a mental health service and developing workshops to support change. Addressing the asymmetrical power relationship inherent in traditional mental health design is important. Using participatory processes, structural discrimination is revealed, and tensions associated with clinical mental health services and psychiatric practice can be discussed. A partnership approach to service development enables the social determinants of health to be addressed more effectively, as well as supporting individual recovery. These approaches create the potential for genuine transformational change. Approaches that support coproduction and codesign have the potential to enable solutions.

Implementing family involvement in the treatment of patients with psychosis: a systematic review of facilitating and hindering factors

ObjectiveTo synthesise the evidence on implementing family involvement in the treatment of patients with psychosis with a focus on barriers, problems and facilitating factors.DesignSystematic review of studies evaluating the involvement...

Holy psychopathology Batman: The pedagogical use of comic books in the teaching of abnormal psychology

Many undergraduate psychology students eventually choose a career providing clinical mental health services. A background in abnormal psychology (psychopathology) is helpful and requisite in these graduate academic and future professional venues. The creativity needed to adequately teach the complex material covered in most abnormal psychology courses may be best conjured from the theory of pedagogical constructivism. Using constructivist theory, the present pilot study evaluates the efficacy of using comic books to supplement undergraduate abnormal psychology course material. Students who completed a diagnostic evaluation of a comic book character (N=29) performed significantly better on an abnormal psychology ‘pop quiz’ than students who received lecture–style instruction exclusively (N=15). These preliminary results add to the existing and expansive library of constructivist-inspired activities used in the instruction of abnormal psychology.

Maternal postpartum morbidity in Marrakech: what women feel what doctors diagnose?

BackgroundInformation about postpartum maternal morbidity in developing countries is limited and often based on information obtained from hospitals. As a result, the reports do not usually reflect the true magnitude of obstetric complications and poor management at delivery. In Morocco, little is known about obstetric maternal morbidity. Our aim was to measure and identify the causes of postpartum morbidity 6 weeks after delivery and to compare women’s perception of their health during this period to their medical diagnoses.MethodsWe did a cross-sectional study of all women, independent of place of delivery, in Al Massira district, Marrakech, from December 2010 to March 2012. All women were clinically examined 6 to 8 weeks postpartum for delivery-related morbidities. We coupled a clinical examination with a questionnaire and laboratory tests (hemoglobin).ResultsDuring postpartum consultation, 44% of women expressed at least one complaint. Complaints related to mental health were most often reported (10%), followed by genital infections (8%). Only 9% of women sought treatment for their symptoms before the postpartum visit. Women who were aged ≥30 years, employed, belonged to highest socioeconomic class, and had obstetric complications during birth or delivered in a private facility or at home were more likely to report a complaint. Overall, 60% of women received a medical diagnosis related to their complaint, most of which were related to gynecological problems (22%), followed by laboratory-confirmed anemia (19%). Problems related to mental health represented only 5% of the diagnoses. The comparative analysis between perceived and diagnosed morbidity highlighted discrepancies between complaints that women expressed during their postpartum consultation and those they received from a physician.ConclusionsA better understanding of postpartum complaints is one of the de facto essential elements to ensuring quality of care for women. Sensitizing and training clinicians in mental health services is important to respond to women’s needs and improve the quality of maternal care.

Disconfirmed expectations of therapy and young people’s clinical outcome, help-seeking intentions, and mental health service use

Objective: Disconfirmed client expectations of therapy have been linked with poorer clinical outcomes and higher premature termination of therapy for adult clients, however, research with young people has been lacking. The present study aimed to address this gap by examining the effects of disconfirmed expectations in relation to roles, outcomes, and processes of therapy on young people’s clinical outcome, mental health service use, and future help-seeking intentions. Age and gender differences were also examined. Method: Participants included 102 young people aged 12–25 years who completed an initial questionnaire on contact with a youth mental health care service, which was targetted at mild to moderate early presentations of mental health problems, and a follow-up questionnaire 2 months later. Results: Findings showed that young people who experienced negatively disconfirmed expectations related to their role as a client or the processes of therapy had a poorer clinical outcome and attended fewer sessions. Furthermore, young people who had a negative experience of their role as a client or the therapist’s role attended fewer sessions and those who had a negative experience of their outcome expectations had a poorer clinical outcome. No age or gender differences were found. Conclusions: The potentially detrimental effect of having a worse therapy experience than expected on outcomes and engagement for young people indicate a need for clinicians to help young consumers to have realistic expectations as well as a positive experience of therapy.

Clinical Characteristics and Outpatient Mental Health Service Use of Transition-Age Youth in the USA

This study examines diagnostic and service utilization patterns of transition-age youth in outpatient care derived from the 2007 nationally representative Client/Patient Sample Survey. Comparisons between 16-17, 18-21, and 22-25 year olds are highlighted. Among transition-age outpatients, the oldest youth had the highest rates of depression and bipolar disorder and co-occurring medical and substance use problems. Controlling for sociodemographic and clinical characteristics, 18-21 year olds were less likely to receive individual therapy than 16-17 year olds, but there were no age group differences in receipt of specialized therapy or psychotropic medication. Female gender and Hispanic ethnicity were positively associated with the number of services received and specialized service use, respectively; youth with private insurance were more likely than those with public insurance to receive psychotropic medication. Implications are discussed regarding access to and adequacy of services provided for young people in the critical transition to adulthood, especially with the implementation of the 2010 Affordable Care Act.

Disconfirmed expectations of therapy and young people’s clinical outcome, help-seeking intentions, and mental health service use

Objective: Disconfirmed client expectations of therapy have been linked with poorer clinical outcomes and higher premature termination of therapy for adult clients, however, research with young people has been lacking. The present study aimed to address this gap by examining the effects of disconfirmed expectations in relation to roles, outcomes, and processes of therapy on young people’s clinical outcome, mental health service use, and future help-seeking intentions. Age and gender differences were also examined. Method: Participants included 102 young people aged 12–25 years who completed an initial questionnaire on contact with a youth mental health care service, which was targetted at mild to moderate early presentations of mental health problems, and a follow-up questionnaire 2 months later. Results: Findings showed that young people who experienced negatively disconfirmed expectations related to their role as a client or the processes of therapy had a poorer clinical outcome and attended fewer sessions. Furthermore, young people who had a negative experience of their role as a client or the therapist’s role attended fewer sessions and those who had a negative experience of their outcome expectations had a poorer clinical outcome. No age or gender differences were found. Conclusions: The potentially detrimental effect of having a worse therapy experience than expected on outcomes and engagement for young people indicate a need for clinicians to help young consumers to have realistic expectations as well as a positive experience of therapy.

Traditional Anishinabe Healing in a Clinical Setting: The Development of an Aboriginal Interdisciplinary Approach to Community-based Aboriginal Mental Health Care

Traditional medicine has been practiced by Aboriginal people for thousands of years at the community level. It is still practiced today outside of the mainstream health system by many Aboriginal people. However, providing this type of care in a clinical, health centre setting and in co-operation with western treatment methods is new, and requires a merging of traditional Aboriginal and western medical world views in order to develop protocols for service delivery that ensure the integrity of both systems. The groundwork required to ensure the safety of clients, providers, and organizations within the new integrated system is still largely undocumented. To address this gap, we studied factors that support the successful integration of traditional Aboriginal healing and western mental health care approaches, and document the experiences of clients and providers. To accomplish this we contextualize 10 years of experience of traditional healing services development with in-depth interviews and focus groups with 17 community service providers and 23 clients. We found that the development of traditional healing protocols, inter-professional education for providers and community members and a focus on client access to traditional Anishinabe health services provide the basis for the integration of western and traditional healing practices in the model under study. Our findings show integrated care resulted in positive experiences for clients and providers. We conclude that traditional healing approaches can be successfully integrated with clinical mental health services. Further research is necessary to improve our understanding of client experiences with this integrated approach and the impact on wholistic health and well-being.

Sociocultural context of suicidal behaviour in the sundarban region of India.

The role of mental illness in nonfatal deliberate self-harm (DSH) is controversial, especially in Asian countries. This prospective study examined the role of psychiatric disorders, underlying social and situational problems, and triggers of DSH in a sample of 89 patients hospitalised in primary care hospitals of the Sundarban Delta, India. Data were collected by using a specially designed DSH register, Explanatory Model Interview Catalogue (EMIC), and clinical interview. Psychiatric diagnosis was made following the DSM-IV guidelines. The majority of subjects were young females (74.2%) and married (65.2%). Most of them (69.7%) were uncertain about their “intention to die,” and pesticide poisoning was the commonest method (95.5%). Significant male-female differences were found with respect to education level, occupation, and venue of the DSH attempt. Typical stressors were conflict with spouse, guardians, or in-laws, extramarital affairs, chronic physical illness, and failed love affairs. The major depressive disorder (14.6%) was the commonest psychiatric diagnosis followed by adjustment disorder (6.7%); however 60.7% of the cases had no psychiatric illness. Stressful life situations coupled with easy access to lethal pesticides stood as the risk factor. The sociocultural dynamics behind suicidal behaviour and community-specific social stressors merit detailed assessment and timely psychosocial intervention. These findings will be helpful to design community-based mental health clinical services and community action in the region.

Determining mental health research priorities in a Queensland region: An inclusive and iterative approach with mental health service clinicians, consumers and carers

Australia has national and state mental health plans that guide service development and promote quality in its public mental health system. Interestingly though, Australia still lacks a well-managed, priority-driven program of research in the mental health sector. This lack is perhaps indicative of the historical relative lack of funding for mental health research compared with other areas of health, at a national level. As a result, approaches to research tend to be ad hoc and reactive to emergent problems. In 2009–2010, a participatory action research study using elements of the consensus oriented Delphi method was implemented in a Queensland regional public mental health service. The aims of the study were to identify and prioritise research questions of importance to the local public mental health service and its members, to compare local priorities with national and state research agendas, and to identify needs relating to research capacity. Data were collected using a modified Delphi technique, three rounds of surveys, field notes and research team reflection.The study reached consensus, with all three cohorts of participants agreed that emotional well-being was the most important research area. The second most important research area was service quality and accountability. The equal third most important research areas were family involvement in the care of their relative and personal (that is, consumer) involvement in their own care.

Planning estimates for the mental health community support sector

To describe the approach undertaken to derive planning estimates for the mental health community support sector in Queensland, Australia. We quantified the needs for services by calculating the prevalence of mental illness in Queensland and by stratifying mental illness by severity. A taxonomy of services in the mental health community support sector was developed and target groups for services identified. Resource targets were set based on a review of the academic and grey literature, expert opinion and consultation with the funding body. To provide adequate supported accommodation, 88 beds per 100,000 population are required, with 33.6 full-time equivalents (FTEs) per 100,000 population of attached personalised support. An additional 12.7 FTEs per 100,000 population of personalised support is required for individuals living independently in the community. We estimated that 6.9 FTEs per 100,000 population would be required for the provision of group support services. We estimated that a target of 1.6% of total mental health community support sector budget should be allocated to mutual support and self-help and 5% to community development. The mental health community support sector is now a major provider of services for people with mental illness, and is likely to continue to grow. When compared to public sector clinical mental health services, the mental health community support sector has lacked clarity surrounding what services are provided, and the quantity of resources required to provide these services. In the absence of other planning information for the community mental health support sector, the estimates described here provide a first step to guide governments and policymakers. Further research and testing in the real world by mental health community support sector practitioners is required to increase the evidence base and refine resource targets.

Determining mental health research priorities in a Queensland region: An inclusive and iterative approach with mental health service clinicians, consumers and carers

Australia has national and state mental health plans that guide service development and promote quality in its public mental health system. Interestingly though, Australia still lacks a well-managed, priority-driven program of research in the mental health sector. This lack is perhaps indicative of the historical relative lack of funding for mental health research compared with other areas of health, at a national level. As a result, approaches to research tend to be ad hoc and reactive to emergent problems. In 2009–2010, a participatory action research study using elements of the consensus oriented Delphi method was implemented in a Queensland regional public mental health service. The aims of the study were to identify and prioritise research questions of importance to the local public mental health service and its members, to compare local priorities with national and state research agendas, and to identify needs relating to research capacity. Data were collected using a modified Delphi technique, three rounds of surveys, field notes and research team reflection.The study reached consensus, with all three cohorts of participants agreed that emotional well-being was the most important research area. The second most important research area was service quality and accountability. The equal third most important research areas were family involvement in the care of their relative and personal (that is, consumer) involvement in their own care.

The Evolution of a Community-Based Telepsychiatry Program in Rural Alabama: Lessons Learned—A Brief Report

The purpose of this paper is to describe the partnership between a community-based rural mental health clinic and an academic health center to provide telepsychiatry services in rural Alabama. The partnership was developed to meet the needs of a clinic that serves an underserved rural population with limited psychiatric services. This paper offers valuable lessons learned for mental health practitioners who may be considering the benefits and challenges of forming community-based partnerships in use of telepsychiatry to build capacity to deliver clinical mental health services to rural mental health shortage areas.

Emergency Treatment of Deliberate Self-harm

Although concern exists over the quality of emergency mental health services, little is known about the mental health care of adults who are admitted to emergency departments for deliberately harming themselves and then discharged to the community. To describe the predictors of emergency department discharge, the emergency mental health assessments, and the follow-up outpatient mental health care of adult Medicaid beneficiaries treated for deliberate self-harm. A retrospective longitudinal cohort analysis. National Medicaid claims data supplemented with county-level sociodemographic variables and Medicaid state policy survey data. Adults aged 21 to 64 years who were treated in emergency departments for 7355 episodes of deliberate self-harm, focusing on those who were discharged to the community (4595 episodes). Rates and adjusted risk ratios (ARRs) of discharge to the community, mental health assessments in the emergency department, and outpatient mental health visits during the 30 days following the emergency department visit. Most patients (62.5%) were discharged to the community. Emergency department discharge was directly related to younger patient age (21-31 years vs 45-64 years) (ARR, 1.18 [99% confidence interval {CI}, 1.10-1.25]) and self-harm by cutting (ARR, 1.18 [99% CI, 1.12-1.24]) and inversely related to poisoning (ARR, 0.84 [99% CI, 0.80-0.89]) and recent psychiatric hospitalization (ARR, 0.74 [99% CI, 0.67-0.81]). Approximately one-half of discharged patients (47.5%) received a mental health assessment in the emergency department, and a similar percentage of discharged patients (52.4%) received a follow-up outpatient mental health visit within 30 days. Follow-up mental health care was directly related to recent outpatient mental health care (ARR, 2.30 [99% CI, 2.11-2.50]) and treatment in a state with Medicaid coverage of mental health clinic services (ARR, 1.13 [99% CI, 1.05-1.22]) and inversely related to African American (ARR, 0.86 [99% CI, 0.75-0.96]) and Hispanic (ARR, 0.86 [99% CI, 0.75-0.99]) race/ethnicity. Most adult Medicaid beneficiaries who present for emergency care for deliberate self-harm are discharged to the community, and many do not receive emergency mental health assessments or follow-up outpatient mental health care.

Shared care in mental illness: A rapid review to inform implementation

BackgroundWhile integrated primary healthcare for the management of depression has been well researched, appropriate models of primary care for people with severe and persistent psychotic disorders are poorly understood. In 2010 the NSW (Australia) Health Department commissioned a review of the evidence on "shared care" models of ambulatory mental health services. This focussed on critical factors in the implementation of these models in clinical practice, with a view to providing policy direction. The review excluded evidence about dementia, substance use and personality disorders.MethodsA rapid review involving a search for systematic reviews on The Cochrane Database of Systematic Reviews and Database of s of Reviews of Effects (DARE). This was followed by a search for papers published since these systematic reviews on Medline and supplemented by limited iterative searching from reference lists.ResultsShared care trials report improved mental and physical health outcomes in some clinical settings with improved social function, self management skills, service acceptability and reduced hospitalisation. Other benefits include improved access to specialist care, better engagement with and acceptability of mental health services. Limited economic evaluation shows significant set up costs, reduced patient costs and service savings often realised by other providers. Nevertheless these findings are not evident across all clinical groups. Gains require substantial cross-organisational commitment, carefully designed and consistently delivered interventions, with attention to staff selection, training and supervision. Effective models incorporated linkages across various service levels, clinical monitoring within agreed treatment protocols, improved continuity and comprehensiveness of services.Conclusions"Shared Care" models of mental health service delivery require attention to multiple levels (from organisational to individual clinicians), and complex service re-design. Re-evaluation of the roles of specialist mental health staff is a critical requirement. As expected, no one model of "shared" care fits diverse clinical groups. On the basis of the available evidence, we recommended a local trial that examined the process of implementation of core principles of shared care within primary care and specialist mental health clinical services.

Clinician experiences of employing the AmpliChip® CYP450 test in routine psychiatric practice

These findings are from a qualitative study examining clinician experiences of employing the AmpliChip® CYP450 test in psychiatric practice. One hundred tests were made available to secondary care mental health service clinicians commencing patient treatment with risperidone across three District Health Boards within New Zealand. Feedback was sought on clinicians' (n = 33) experiences of ordering the test and receiving results, utilization of results, and perceived advantages and disadvantages. Difficulties were reported regarding ordering the test and receiving the results; however, real or perceived advantages of employing the test results in practice were widely reported. Analysis of the ways in which the test results were reportedly utilized revealed that they generally played a supporting role with regard to dosing decisions, rather than being the main influence on clinician behaviour. The test itself, and subsequent results, was viewed as potentially useful in facilitating the development of the doctor-patient relationship. Reported disadvantages of the test included potential over-reliance at the expense of clinical wisdom, cost, and challenges inherent in introducing a new clinical procedure into routine practice. These findings indicate that psychiatric clinicians are receptive to employing this test as a clinical support tool if its implementation is carefully considered and economically justifiable.

FC04-01 Development of an instrument to measure the level of evidence-based practice in clinical mental health services

Introduction:While systems of care are identifying the need to employ evidence-based modes of treatment, there are to date few instruments designed to measure the degree to which clinicians apply evidence-based interventions. The interventions survey was designed to tap each clinicians’ understanding of evidence-based interventions and the degree to which they identify theory in relation to evidence-based intervention and diagnosis.Method:A literature review was conducted to identify evidence-based interventions. Search strategies included meta-analyses that focused on systematic review of a range of databases. Emphasis in the survey's design was placed on linking evidence-based interventions, diagnosis and theoretical orientations. Clinicians (n = 118) could select among a range of options including evidence-based interventions for specific diagnoses. In addition to mapping evidence to interventions by diagnosis, results include a report of index modal interventions used by staff by type (individual, group, family) and diagnosis. The higher the index reported (range 0-1) the greater the variation of interventions by diagnoses.Results:Forty percent of clinical staff favored more that one type of family therapy for different diagnoses, and 35% of staff favored more than one type of group therapy for different diagnoses, whereas about 30% of staff varied their choice of individual intervention as a function of diagnosis.Conclusions:The results indicate that the survey is able to tap a range of clinicians’ theoretical orientations and knowledge of evidence-based practices related to child and adolescent mental health interventions.