Needs For Care Assessment Research Articles

Assessing needs for psychiatric treatment in prisoners: 2. Met and unmet need

BackgroundIn a companion paper, we established high levels of psychiatric morbidity in prisoners (Bebbington et al. Soc Psychiatry Psychiatr Epidemiol, 2016). In the current report, we evaluate how this morbidity translates into specific needs for treatment and the consequent implications for services. Mental health treatment needs and the extent to which they had been met were assessed in a representative sample of prisoners in a male and a female prison in London (Pentonville and Holloway).MethodsPrisoners were sampled at random in a sequential procedure based on the Local Inmate Data System. We targeted equal numbers of male remand, male sentenced, female remand, and female sentenced prisoners. Following structured assessment of psychosis, common mental disorders, PTSD, personality disorders and disorders of abuse, we used the MRC Needs for Care Assessment (NFCAS) to establish whether potential needs for care in ten areas of mental health functioning were met, unmet, or incapable of being met by services.ResultsData on treatment experience were provided by 360 inmates. Eighty percent of females and 70% of males had at least one need for treatment. Over half (53.7%) of the needs of female prisoners were met, but only one third (36.5%) in males. Needs for medication were unmet in 32% of cases, while those for psychological treatment were unmet in 51%.ConclusionsUnmet needs for mental health treatment and care were common in the two prisons. This has adverse consequences both for individual prisoners and for the effective functioning of the criminal justice system.

Needs of people with severe mental illness

This study reviews conceptual and methodological issues of needs for care among people with severe mental illness (SMI) and presents data on their prevalence, correlates and consequences for mental health care. Focus is on the definition of the concept of need as what people can benefit from and its measurement by means of two instruments, the Needs for Care Assessment (NCA) and the Camberwell Assessment of Needs (CAN). The prevalence of needs among patients with SMI varies between 4 and 10, which appears to be rather unrelated to gender, age or education, but not to severity of symptoms, diagnosis or treatment setting. Important is the perspective of the beholder: patient and professional differ significantly from each other in the assessment of number of needs and their adequate fulfillment. One of two to four needs are unmet, in particular in the area of psychological distress, daily activities, social contacts and psychotic symptoms. Prevalence of unmet needs seems to be related to the system of mental health care and to socioeconomic circumstances as well: the less integrated and continuous care and the poorer the life situation, the more unmet needs. Unmet needs are a strong predictor of less favourable health perceptions and a lower quality of life. Needs are to a certain extent changeable, and thus amenable by treatment or mental health interventions. The prevalence of (un)met needs should be an outcome criterion for the evaluation of mental health service systems and for cross-cultural comparison.

Needs for mental health treatment among general practice attenders

No study has directly assessed the need for mental health care among those consulting in general practice. To make a direct assessment of the needs for mental health care in people with non-psychotic disorders consulting their general practitioner. In a two-phase study design, consecutive general practice attenders aged 17-65 years were interviewed using the Structured Clinical Interview for DSM-IV Axis I Disorders. Needs for care were assessed using the community version of the Medical Research Council Needs for Care Assessment Schedule. Three hundred and thirty-six people were interviewed. The overall prevalence of need was 27.3%. More than half of the consulters (59.6%) had unmet needs and a further 6.2% had partially met needs. Needs were met in 28.1% and unmeetable in 6.2%. The prevalence of unmet need in those with anxiety disorders was 13.9% and depressive disorders 9.5%. The unmet need for mental health treatment in primary care attenders is high.

Needs for care of chronic schizophrenic patients in long-term community treatment.

Specific problems of long-term community care of chronic schizophrenic patients are an under-researched area interesting for the provision of regional mental health care. This study focuses on a 4 1/2-year prospective assessment of normative needs for care in a cohort (initially N = 115) living in the Dresden care region (Germany). At six time-points, normative needs for care were assessed with the Needs for Care Assessment (NFCAS). The total number of problems did not change significantly over the study period. The average number of met needs was lower at the longer-term follow-up assessments,due particularly to a decrease in the social section. This trend is also demonstrated for the average number of unmet needs. In contrast, the mean number of "unmeetable needs" increased. Consistently, 70-80% of the patients exhibit problems in positive psychotic and negative symptoms, household affairs and recreational activities. Communication, occupation and recreational activities constitute a trio of social needs not met for nearly one-third of the patients disabled in these respects. Logistic analyses of regression could not identify a predictive model for the total needs development within the 4 1/2-year community treatment. The rather stable pattern of needs for care seems to define clear long-lasting tasks for community mental health services. For chronic schizophrenic patients, services should especially focus on social skills training and psychoeducational approaches. Due to a wide range of possible factors of influence, however, planning long-term context-dependent processes of care in the community lacks a clear evidence base.

Suicidality of Chronic Schizophrenic Patients in Long-Term Community Care

In the provision of mental health care for chronic schizophrenic patients, the specific problems and requirements of long-term community care of suicidal behavior is an area of research not yet fully explored. This study focuses on a 4 1/2-year prospective assessment of normative and subjective needs for care related to this specific area for a cohort living in the Dresden region (Germany). One significant result of this study shows the constant high level of needs for care in the area of suicidal behavior imposed on community services by 30-40% of this diagnostic group. Furthermore, the study identified a special high-risk subgroup for suicides as well as specific needs for care. This subgroup is characterized by clinical reasons for the index hospitalization (suicidal risk or attempt) as well as by psychopathological features (suicidal thoughts and higher levels of anxiety/depression) 1 month after release from index hospitalization. Four items of care were rated as potentially effective for addressing suicidality in the community setting: clinical assessment, increased supervision or systematic recording of (suicidal) behavior, medication, and a sheltered environment. Because these care measures are provided, the percentage of unmet normative needs for the area of suicidal behavior was rather low. Due to limitations of the instrument used for assessment of normative needs, the Needs for Care Assessment (NFCAS), the care measures most frequently provided do not define a quality standard of community care for this problem. A subjective needs assessment differing from the normative approach has to be integrated in establishing guidelines for effective community care.

Normative needs for community-based psychiatric care of patients with schizophrenia in different residential settings

This study aims to assess the extent of needs for mental health care of patients with schizophrenia living in different residential settings and to evaluate the quality of care in these types of complementary services recently established in the East German region of Dresden. Survey data from the first wave of a longitudinal study of five patient subgroups ( N=244) living in (1) a psychiatric nursing home, (2) social therapeutic hostels, (3) sheltered community residential care, (4) at home in the family and (5) alone in one's own home are reported. Normative individual needs for care were assessed using the needs for care assessment (NCA). The patient groups show clear differences in the extent of needs for care, especially in the social NCA section. Patients in the psychiatric nursing home and in the social therapeutic hostels exhibit the highest numbers of areas of need. Positive psychotic symptoms, negative symptoms and neuroleptic side effects are the most prominent clinical areas of need in all subgroups. Patients are most frequently socially disabled in terms of managing household affairs, recreational activities and household chores. Deficits in the need status could be found in the NCA areas of ‘negative symptoms,’ ‘recreational activities,’ and ‘communication.’ The basic needs for mental health care of patients with schizophrenia are met in the established sheltered residential settings. Current deficiencies in providing psychological and educational interventions focusing on coping strategies and social skills training should be minimised in order to decrease the identified deficits in the need status.

Aftercare of depressed inpatients--service delivery and unmet needs.

In contrast to acute treatment, delivery of aftercare to depressed patients has not been well studied. Poor care may contribute to poor outcomes for treated depression. One hundred and two patients discharged from hospital with unipolar depression were followed up 18 months later and were interviewed in detail regarding aftercare and treatment received. Unmet needs were assessed on the community version of the MRC Needs for Care Assessment. In the first month after discharge approximately 70 % of subjects received contacts with mental health services and in the first 3 months over 80 % received at least one contact. About 40 % were in contact with mental health services at 18 months. Needs assessment found comparatively low unmet needs, reaching highest levels (around 25 % in any 6-month period) for medication. Two-thirds of unmet needs for medication and psychotherapy were due to patient refusal or non-compliance. Aftercare levels were higher in those with more previous admissions and were unrelated to presence of personality disorder. There were some deficiencies in service aftercare for depressed patients in a British NHS setting, although unmet need was not high. Some aftercare failures reflect patient reluctance to receive further treatment, representing a challenge to overcome in patients entitled to autonomous choices.

Prevalence of psychiatric disorder and the need for psychiatric care in Northern Ireland. Population study in the District of Derry.

This is the first report on the epidemiology of psychiatric disorders and needs for psychiatric treatment in the District of Derry, Northern Ireland. To assess the prevalence of psychiatric disorder and the needs for treatment in the general population of Derry. The sample was drawn at random with a two-phase design using the General Health Questionnaire (GHQ-28) during the first phase, and the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) with the Needs for Care Assessment (NFCAS-C) in the second phase. The second phase (n=307) gave a weighted 1-month prevalence of hierarchically ordered ICD-10 psychiatric disorders of 7.5% and a 1-year prevalence of 12.2%. The equivalent prevalences for depressive disorders were 2.4% and 6.0%, respectively, and those for anxiety states were 3.5% and 3.7%. Only a quarter of needs for treatment were met, with the situation being better for depression than for anxiety. The rates of psychiatric disorder in Derry were even higher than those reported by a similar survey in inner London. This almost certainly reflects the very high levels of social deprivation in the District. Needs for treatment were often unmet.

Rehabilitation concepts of schizophrenic patients treated in community psychiatry

In a cohort of patients with chronic schizophrenic disorders (n = 115) characterized by many social deficits and a high level of psychopathology, suggestions concerning rehabilitation were examined in an exploratory way and analysed referring to their relevance for community psychiatric care. The schizophrenic patients were followed up 1 and 12 months after discharge from hospital using an extensive array of instruments (among others: Needs for Care Assessment, Berlin Inventory of Care Needs). Included was a guided interview focusing on patients' subjective views relevant for the course of the disorder and for therapeutical procedures. Using a content analysis of the verbal material received at both points of study, the following main defining elements of the term rehabilitation (or reintegration, resp.) could be identified from the patients' perspective: vocational reintegration, independent residential setting, recovery of normality, and acceptance of responsibility. The rate of individualized confirmation in each category established after the first interview was between 75% and 93% 1 year after discharge from hospital.--Results from multiple and logistic regression analyses demonstrate that a higher degree of differentiation concerning individual rehabilitation suggestions exerts influence on the extent of subjective and normative needs for (psychiatric) care at the first point of study and moreover can be identified as a predictor of the decrease in the normative needs for care during the study period. To differentiate schizophrenic patients' suggestions referring to this subject can therefore be declared a therapeutical task. Furthermore it is a must to adjust individualized expert-based and subjective suggestions concentrating especially on the patients' main point of emphasis, i.e. vocational rehabilitation.

Gemeindepsychiatrischer Versorgungsbedarf schizophren Erkrankter: Ein brauchbares Konzept für die regionale Psychiatrieplanung?

One step in a public health research project focuses on the analysis of the individual (expert-based) normative needs for mental health care of chronic schizophrenic patients (n = 115) in the Dresden Region during the first year post hospital release and the extent to which this can be met by the current established level of complementary care. It is an exemplary contribution to the evaluation of community psychiatry as restructured in the Free State of Saxony following German reunification. The results of the study can be condensed to the following interpreting essential statements. Schizophrenics' normative needs for care are not a statistical issue. The single case analysis corroborates a high rate of relevant fluctuations, above all within the clinical sector (e.g. concerning "dyskinesias and other side effects"), that pose a particular challenge to the flexibility of a system of community psychiatry. This includes that the consequence for the practice of care implies then that when diagnosing course, attention must be paid to shifts in the content of the needs for mental health care (e.g. increasing importance of factors, which contain impairments of basic social competences) in order to orient to them any health care measures already initiated.--With the aid of the used research instrument (Needs for Care Assessment) deficits in meeting the needs for care can be identified. In the Dresden Region considerable deficits persist apparently in the subsections recreational activities and occupational and communication skills, which can be ascribed to the lack of appropriate institutions of care in the area.--The normative needs for care of schizophrenic patients cannot be determined simply on the basis of a few, quickly identifiable markers. Rather it demands individualized analysis incorporating variables pertaining to psychopathology, subjective coping, social competence and the course of the disorder. The development of the needs for care over the period of one year can apparently be predicted by trends in the social sector that are already visible within the first months. With regard to aspects of care planning this finding illustrates the limited ability of cross-section surveys to make definitive statements, as well as the predominance of social disabilities over the entire spectrum of the normative needs for psychiatric care.

The treatment of psychiatric disorder in the community: Report from the Camberwell Needs for Care Survey

Although the estimation of needs for treatment is a prime function of community psychiatric surveys, none has so far measured need directly. The Camberwell Needs for Care Survey is the first such attempt. Needs for treatment were identified in a random population sample from a catchment area in inner South London. Information obtained through SCAN, the Social Role Performance Schedule, the Life Events and Difficulties Schedule and a treatment inventory was assessed by a rating panel in relation to an explicit model of care by using the Needs for Care Assessment- Community Version. Subjects with psychotic disorders received good care and treatment. Subjects with depression often rejected the idea of treatment. Treatment was mainly pharmacological and needs were often unmet, particularly for cognitive or supportive psychotherapy. Subjects with anxiety disorders were less likely to reject treatment but still had a high proportion of needs unmet, as was the case for other disorders.

A pilot study of needs assessment in acute psychiatric inpatients.

The needs of acute psychiatric patients have been less studied than those of long-term patients. A pilot study of needs assessment using the MRC Needs for Care Assessment Schedule is reported in 35 consecutive acute inpatients who had been in hospital for 1 month or more. Unmet clinical needs included treatment of drug side effects and dangerous and socially embarrassing behaviour. Unmet social needs were widespread and included household shopping, cooking meals, occupation and money management. Although the MRC Needs for Care Assessment was found unsuitable for assessing needs in very acutely ill patients whose mental status was rapidly changing, we did find it a useful instrument in more stable acute patients, both on an individual basis and for identifying service underprovision.

The need for psychiatric treatment in the general population: the Camberwell Needs for Care Survey.

This paper presents the first results of a two-stage psychiatric population survey, which uses a new method of directly evaluating needs for specific psychiatric treatment and the extent to which they have been met. The sample was drawn at random from the population of an area of inner south London with high levels of deprivation. Seven hundred and sixty subjects aged 18-65 completed the GHQ-28. All those scoring > 5 and half of the rest were invited to take part in the second stage, comprising measures of mental state (SCAN), social role performance (SRPS), life events and difficulties (LEDS) and a Treatment Inventory. This information was used to rate the community version of the Needs for Care Assessment (NFCAS-C). In all, 408 subjects were interviewed in the second stage. The weighted 1 month prevalence of hierarchically ordered ICD-10 psychiatric disorders was 9.8%, the 1 year prevalence 12.3%. The equivalent prevalences for depressive episode were 3.1% and 5.3% respectively, while those for anxiety states were both 2.8%. At interview nearly 10% of the population were identified as having a need for the treatment of a psychiatric condition. This rose to 10.4% if the whole of the preceding year was assessed. Less than half of all potentially meetable needs were met. There was only partial overlap between diagnosis and an adjudged need for treatment. A majority of people with mental health problems do not have proper treatment; given more resources and greater public and medical awareness, most could be treated by family doctors.

The needs for care of the chronic mentally ill relocating from psychiatric hospital to the community: A pilot study

A pilot study is reported of non-hospital residential care for people with chronic mental illness. The Needs for Care Assessment (NFCA) was used to ascertain the clinical and social functioning of six patients who transferred from a long-term psychiatric ward to a high-support community hostel. Standardised interviews were conducted with patients and care-staff before re-location, during the settling-in period and one year later. Results indicate improvements in social and clinical functioning. Unmeetable needs in the hospital became meetable in the hostel. Residents expressed a preference for hostel accommodation.Staff and participants’ opinions regarding improvements in functioning appeared to differ. This study provided a first step to further explorative, but empirically-based analyses concerning hostel accommodation for people with chronic psychiatric disabilities.

The needs for care assessment – a longitudinal approach

This report describes the use of the needs for care assessment (NFCA) in measuring symptom and social function in patients with long-term mental Illness. The schedule recommends specific care interventions and these were implemented where appropriate. The problem status of the patients was reassessed using the needs for care schedule after the interventions had been offered and tried. The recommended care items were within the compass of our rehabilitation service, were rarely refused by the patients and there was an improvement in symptom and social function. These findings provide some validation for the concept of unmet need.

The reliability of the community version of the MRC Needs for Care Assessment.

One hundred and nine adults were screened in the community using the abridged version of the CIDI (CIDIS). The subjects comprised DSM-III-R current cases (N = 48), lifetime cases (N = 31) and non-cases (N = 30). The interviews with the 109 subjects were conducted by one of two pairs of clinicians and videotaped. Each interviewer-pair included a psychiatrist and a clinical psychologist. They rated the community version of the Needs for Care (NFCAS-C) by consensus. The other pair of judges then viewed the video and rated the NFCAS-C independently. The agreement on overall needs was excellent (kappa = 0.75), and very good for four of the seven specific sections (from kappa = 0.61 to 0.81). One section could not be rated because of low prevalence, and agreement was less good for the remaining two sections. Agreement was good on specific interventions (medication, kappa = 0.60; specific psychotherapy, kappa = 0.55), but poor on non-specific interventions. The majority of disagreements were due to differences in clinical judgement rather than to technical errors. A new instruction manual has been produced and should help training as well as stabilizing reliability. In devising reliable and valid instruments based on clinical judgement, a balance must be achieved between enhancing reliability with more precise rules and constraining clinical judgement so tightly that validity is lost.

How important is the assessment of social skills in current long-stay in-patients? An evaluation of clinical response to needs for assessment, treatment, and care in a long-stay psychiatric in-patient population.

Service response to problems in 20 clinical and social competence areas was assessed in 156 long-stay in-patients, using the Needs for Care Assessment (NFC). Although there were few unmet needs for treatment, over 200 instances of unmet needs for the assessment of social skills were found, and reasons for this are discussed, as is the importance of social-skills assessment in this group. In around a third of the sample most of the social-skill areas in the NFC were not applicable.

Can we measure need in the homeless mentally ill? Using the MRC Needs for Care Assessment in hostels for the homeless.

Hostels for the homeless contain many who are disabled by chronic mental illness but have little access to rehabilitation services. One approach to solving this problem might be to measure the needs of hostel residents in a standardized way and use this information as a basis for planning interventions. This study attempted to use the MRC Needs for Care Assessment Schedule to measure the needs of 46 mentally ill residents of Oxford hostels. It aimed to determine if a standardized assessment could be used in these difficult settings and if the needs it identified could form a useful basis for planning future interventions. Although it was possible to use the schedule, and although the pattern of need identified appeared broadly to reflect conditions in the hostels, it was not felt that the information produced was of sufficient quality to assist in planning services. The authors postulate that underlying this deficiency is the failure of the schedule to take sufficient account of the views of staff and residents.

The Nature and Severity of Disabilities in Long-Stay Psychiatric In-patients in South Glamorgan

Long-stay psychiatric in-patients in South Glamorgan were reviewed using the MRC Needs for Care assessment. The majority were middle aged or elderly and were severely disabled, with problems encompassing symptoms/behavioural difficulties, social skills, and physical health. In most, long-standing psychiatric illness was compounded by physical illness and cognitive deficits as age advanced, producing care needs that were greater than existing community services could meet.