Public Mental Health Care System Research Articles

A public early intervention approach to first-episode psychosis: Treated incidence over 7 years in the Emilia-Romagna region.

To estimate the treated incidence of individuals with first-episode psychosis (FEP) who contacted the Emilia-Romagna public mental healthcare system (Italy); to examine the variability of incidence and user characteristics across centres and years. We computed the raw treated incidence in 2013-2019, based on FEP users aged 18-35, seen within or outside the regional program for FEP. We modelled FEP incidence across 10 catchment areas and 7 years using Bayesian Poisson and Negative Binomial Generalized Linear Models of varying complexity. We explored associations between user characteristics, study centre and year comparing variables and socioclinical clusters of subjects. Thousand three hundred and eighteen individuals were treated for FEP (raw incidence: 25.3 / 100.000 inhabitant year, IQR: 15.3). A Negative Binomial location-scale model with area, population density and year as predictors found that incidence and its variability changed across centres (Bologna: 36.55; 95% CrI: 30.39-43.86; Imola: 3.07; 95% CrI: 1.61-4.99) but did not follow linear temporal trends or density. Centers were associated with different user age, gender, migrant status, occupation, living conditions and cluster distribution. Year was associated negatively with HoNOS score (R = -0.09, p < .001), duration of untreated psychosis (R = -0.12, p < .001) and referral type. The Emilia-Romagna region presents a relatively high but variable incidence of FEP across areas, but not in time. More granular information on social, ethnic and cultural factors may increase the level of explanation and prediction of FEP incidence and characteristics, shedding light on social and healthcare factors influencing FEP.

Individual placement and support in young people with severe mental illness: an Italian experience

IntroductionIndividual placement and support (IPS) has a considerable body of evidence for its effectiveness in helping people with mental disorder to obtain and maintain competitive jobs in the labour market. IPS closely follows 8 main principles (such as it aims to get people into competitive employment, it is open to all those who want to work, it tries to find jobs consistent with people’s preferences, it works quickly, it brings employment specialists into clinical teams, it provides time unlimited, individualised support, benefits counselling is included). However, little data in young adults are currently available, especially in Europe.ObjectivesAim of this study was to evaluate the beneficial effect of IPS in Italian young adults with severe mental illness, examining the main competitive employment outcomes and drop out rates during a 3-year follow-up period.Methods54 participants were recruited from patients receiving psychiatric treatment in adult Community Mental Health Centers of an Italian Department of Mental Health. Together with drop out rates, we examined job acquisition, job duration (total number of days worked), total hours per week worked and job tenure (weeks worked on the longest-held competitive job).ResultsA crude competitive employment rate of 40.7% and a crude drop out rate of 22.2% over the 3-year follow-up period were found. However, 66% of 42 clients who remained in the program over 3 years gained competitive employment at some time during the 3-year period.ConclusionsThis research shows the feasibility of an IPS intervention model in the public mental health care system in Italy, especially for a young adult target population.DisclosureNo significant relationships.

Poll: Michigan voters oppose privatization of MH services

A majority of voters are opposed to the privatization of mental health services in Michigan, according to a recent poll commissioned by the Community Mental Health Association of Michigan, the Huron Daily Tribune reported March 15. According to the results of the poll, 67% of voters prefer the public mental health system managed by public entities who specialized in mental health care versus turning the system over to private, for‐profit companies. Last year, Michigan Senate Majority Leader Mike Shirkey introduced Senate Bills 597 and 598, which would privatize all Medicaid mental health services by giving financial control and oversight to for‐profit insurance companies, a news release from Community Mental Health for Central Michigan (CMHCM). The EPIC‐MRA polling shows two out of three Michigan voters would not support that change. The poll was conducted in January among active and likely November 2022 general election voters. The poll found that 76% of voters are concerned that private, for‐profit health plans do not have a good track record in treating mental health needs and will make matters worse. In addition, 73% are concerned that the overhead costs and profits private insurance companies take out of the taxpayer‐funded Medicaid system will lead to fewer mental health services. Nearly four times as many voters are less likely to support their legislator if he/she supports privatization of mental health services for Medicaid patients than those who are likely to support that legislator, according to the poll. Fifty‐four percent think Gov. Gretchen Whitmer should veto the legislation if it comes to her desk. The CMHCM news release said that for the past 50 years, the mental health system in Michigan has been run and operated by county‐based government entities to serve Michiganders with complex mental health, emotional disturbance, intellectual and developmental disabilities, and substance use disorders. Each year, more than 325,000 Michiganders receive their services and care from the Michigan public mental health care system.

MENTAL HEALTH IN THE PANDEMIC TIMES

The primary aim of this paper is an attempt at the analysis of the prospective direct and indirect, short- and long-term consequences of COVID-19 pandemic for the individuals’ mental health. The secondary aim is to deconstruct the binarity of categories of “mental health” and “mental disorder” in the context of the global critical situation. The pandemic and its consequences such as isolation requirements as well as uncertainty in diverse aspects of life burden the individuals with the stress that results in the increase of anxiety and depressiveness, which challenges the public mental health care systems. Since the anxiety and depressive states are the reactions to a hazardous outside situation, the categories of “mental health” and “mental disorder” needs reconsideration. The theoretical framework of present analyses is determined by the theory of social (cultural) trauma. The method used for the present study is a meta-analysis of theoretical literature, the results of empirical research on COVID-19 pandemic published so far (mostly in medical journals), studies on psychosocial aspects of the previous pandemics (SARS and Ebola), and press publications selected on the basis of their content on mental health issues in the context of the coronavirus pandemic.

Implementation of Individual Placement and Support in Italy: The Reggio Emilia Experience.

Individual placement and support (IPS) is an evidence-based intervention helping people with mental illness to obtain competitive jobs. In the last decade, European mental health leaders were interested on its implementation. Aim of the study was to assess the IPS feasibility in Italian patients with moderate-to-severe mental illness. To date, no evaluation of IPS has been conducted exclusively in Italy. Participants (n = 95) were clients of community mental health centers of the Reggio Emilia Department of Mental Health. In addition to drop-out rates, we calculated job acquisition, job duration, and total hours per week worked. A crude competitive employment rate of 41.1% and a crude drop-out rate of 30.5% were found over 42-month follow-up period. Using a Kaplan-Meyer survival analysis, the cumulative employment rate increased up to 44% at 12months and 61% both at 24 and 42months. This study documents the feasibility of an implementation strategy for introducing the IPS model in the public mental health care system in Italy.

Prevalence and trends of mental disorders requiring inpatient care in the city of Porto Alegre: a citywide study including all inpatient admissions due to mental disorders in the public system from 2013-2017.

To investigate the 5-year prevalence of patients admitted to public inpatient care units due to a mental disorder, stratifying them by age group and diagnosis, and to assess trends of admissions over this time period in Porto Alegre. All admissions to the public mental health care system regulated by the city-owned electronic system Administração Geral dos Hospitais (AGHOS) were included in the analysis. The total population size was obtained by estimations of Fundação de Economia e Estatística (FEE). General information about 5-year prevalence of inpatient admissions, time-series trends e prevalence by age groups and diagnosis were presented. There were 32,608 admissions over the 5-year period analyzed. The overall prevalence of patients was 1.62% among the total population, 0.01% among children, 1.12% among adolescents, 2.28% among adults and 0.93% among the elderly. The most common diagnosis was drug-related, followed by mood, alcohol-related and psychotic disorders. There was a linear trend showing an increase in the number of admissions from 2013 to the midst of 2014, which dropped in 2015. Admissions due to mental disorders are relatively common, mainly among adults and related to drug use and mood disorders. Time trends varied slightly over the 5 years. Prevalence rates in real-world settings might be useful for policymakers interested in planning the public mental health system in large Brazilian cities.

Individual placement and support in Italian young adults with mental disorder: Findings from the Reggio Emilia experience.

Individual placement and support (IPS) has a considerable body of evidence for its effectiveness in helping people with mental disorder to achieve and maintain competitive jobs. However, little data in young adult populations are currently available, especially in Europe. Aim of this study was to assess the effect of IPS in Italian young adults with moderate-to-severe mental illness, examining the main competitive employment outcomes and drop out rates during a 3-year follow-up period. Participants (n = 54) were recruited from patients receiving psychiatric treatment in one of the seven adult Community Mental Health Centers of the Reggio Emilia Department of Mental Health. Together with drop out rates, we investigated job duration (total number of days worked), job acquisition (employment in the labour market for at least 1 day during the follow-up), total hours per week worked, and job tenure (weeks worked on the longest-held competitive job). A crude competitive employment rate of 40.7% and a crude drop out rate of 22.2% over the 3-year follow-up period were found. However, 66% of 42 clients who remained in the program over 3 years gained competitive employment at some time during the 3-year period. This research shows the feasibility of an IPS intervention model in the public mental health care system in Italy, especially for a young adult target population.

Adapting the Brief Coping Cat for Children with Anxiety to a Group Setting in the Spanish Public Mental Health System: a Hybrid Effectiveness-Implementation Pilot Study

Group therapy may offer a promising solution to reducing patient waiting lists for publicly funded mental health services. In this study, an individual brief cognitive behavioral therapy (BCBT) intervention was adapted for implementation in a group setting in the Spanish public mental health care system. The study was designed to test initial clinical effectiveness, acceptability, and feasibility of the group adaptation of BCBT for child anxiety. The study utilized an uncontrolled multiple-group design for 8 weeks (1 h per week). Inclusion criteria were (i) children and young adolescents between 8 and 15 years old, and (ii) a clinical diagnosis of general anxiety disorder, social phobia, and/or separation anxiety disorder. Five groups were completed (n = 33; mean age = 11 years; 42.4% females). A total of 31 (93.9%) participants completed at least 7 sessions, and follow-up data were collected for 84.9% (n = 28) of participants. Overall, anxiety symptoms were reduced after intervention on the Spence Children Anxiety Scale, Generalized Anxiety Disorder Questionnaire-IV, Social Anxiety Scale for Children-Revised, and Separation Anxiety Symptom Inventory. Our findings suggest that group BCBT was associated with beneficial treatment outcomes, was acceptable and feasible for children with anxiety in the Spanish public mental health system. Both participants and their caregivers reported satisfaction and feelings of safety with the intervention. Results underscore the need for a larger-scale hybrid effectiveness-implementation trial of BCBT in a group setting throughout more community mental health centers in different Spanish states. Such work could improve patient access to and benefit from an evidence-based treatment that works in community settings.

S254. IMPLEMENTATION OF A PROGRAM FOR EARLY INTERVENTION IN PSYCHOSIS ONSET: THE EXPERIENCE OF REGIONE EMILIA ROMAGNA, NORTHERN ITALY

BackgroundEarly interventions services (EIS) for psychosis are not uniformly available in the Italian public mental health care system. In 2012, Region Emilia Romagna funded the implementation of a comprehensive population based program to deliver EIS. These services provide a package of care including psychiatric consultation, family psychoeducation, case management, recovery oriented activities (e.g. supported employment, social inclusion), and physical health monitoring, consistent with international models but embedded within community mental health services (CMHS). We report feasibility, descriptors of enrolled samples, and clinical variables associated with remission.MethodsDemographic and clinical data of CMHS users that accepted EIS from January 1st, 2013 to December 31st, 2016 were acquired from paper and electronic health records in each province. Inclusion criteria were: residence in Regione Emilia Romagna, age 18–35, presence of non-organic, affective and non-affective psychotic symptoms within two years of onset. Exclusion criteria included severe intellectual disability and non-fluency in Italian. Remission was defined as a total score of 8 on the Health of Nation Outcome Scale (HoNOS) at 6 months after enrollment.ResultsSix hundred and eighty-nine patients accepted EIS. Median age was 22, 93% had diagnoses of non-affective psychosis, whereas 7% affective psychosis, with a median duration of untreated psychosis (DUP) of 6 months [IQR=10; 0–120], 41% had comorbid substance use disorders, 31.1% had personality disorders, and 39% had a previous hospitalization. The proportion of migrants (23%) was almost twice that of the entire Region (11.9%). Psychiatric visits represented 44% of total utilization, whereas only 14% received at least one case management visit, 79% a family session, 19% a recovery oriented activity, and 1% physical health monitoring.Of the sample, 460 subjects (67%) improved as presented with significant reduction in the 4 subscales scores of the follow up HoNOS, and 164 (35.7%) showed remission. Shorter DUP and lower HoNOS scores at baseline were associated with an increased likelihood of achieving remission (OR=1.03, p=0.0068, and OR=1.04, p=<0.0001, respectively), whereas the presence of personality disorder was associated with a reduced likelihood of remission (OR=0.48, p=0.0057).DiscussionEIS was acceptable to most eligible patients in regional CMHS. EIS enrollees evidenced significant clinical improvement in the first 6 months. Only a minority was diagnosed with bipolar disorder, suggesting a possible later onset of affective psychosis and reduced chance of accessing the Program.The correlation of comorbid personality disorder with worse outcomes, suggests the need to develop a targeted treatment. The EIS were also well accepted by the high proportion of migrants. Further work is required to understand possible social determinants of psychosis onset and pathways to care in these fragile communities. The high rate of concomitant substance use at intake must be considered for developing specific pharmacological and psychoeducational treatment.One in five patients needed admission to the inpatient unit in the first six months after onset, showing high levels of symptomatic distress. Moreover, referrals from hospital units show also possible barriers to access outpatient mental health facilities when users present with acute and urgent clinical conditions.This report establishes the feasibility of a regional network of EIS in Northern Italy with shared data elements that will lead to useful comparisons across EIS sites within the region, and also collaborative efforts to address specific gaps in access or outcomes.

Validity of police contacts as a performance indicator for the public mental health care system in Amsterdam: an open cohort study.

The Public Mental Health Care (PMHC) system is a network of public services and care- and support institutions financed from public funds. Performance indicators based on the registration of police contacts could be a reliable and useful source of information for the stakeholders of the PMHC system to monitor performance. This study aimed to provide evidence on the validity of using police contacts as a performance indicator to assess the continuity of care in the PMHC system. Data on services received, police contacts and detention periods of 1928 people that entered the PMHC system in the city of Amsterdam were collected over a period of 51 months. Continuity of care was defined as receiving more than 90 days of uninterrupted service. The associations between police contacts and continuity were analyzed with multilevel Poisson and multivariate linear regression modeling. Clients had on average 2.12 police contacts per person-year. Clients with police contacts were younger, more often single, male, and more often diagnosed with psychiatric or substance abuse disorders than clients without police contacts. Incidence rates of police contacts were significantly lower for clients receiving continuous care than for clients receiving discontinuous care. The number of police contacts of clients receiving PMHC coordination per month was found to be a significant predictor of the percentage of clients in continuous care. The number of police contacts of clients can be used as a performance indicator for an urban PMHC system to evaluate the continuity of care in the PMHC system.

Utilization of the Behavior Change Wheel framework to develop a model to improve cardiometabolic screening for people with severe mental illness

BackgroundIndividuals with severe mental illness (e.g., schizophrenia, bipolar disorder) die 10–25 years earlier than the general population, primarily from premature cardiovascular disease (CVD). Contributing factors are complex, but include systemic-related factors of poorly integrated primary care and mental health services. Although evidence-based models exist for integrating mental health care into primary care settings, the evidence base for integrating medical care into specialty mental health settings is limited. Such models are referred to as “reverse” integration. In this paper, we describe the application of an implementation science framework in designing a model to improve CVD outcomes for individuals with severe mental illness (SMI) who receive services in a community mental health setting.MethodsUsing principles from the theory of planned behavior, focus groups were conducted to understand stakeholder perspectives of barriers to CVD risk factor screening and treatment identify potential target behaviors. We then applied results to the overarching Behavior Change Wheel framework, a systematic and theory-driven approach that incorporates the COM-B model (capability, opportunity, motivation, and behavior), to build an intervention to improve CVD risk factor screening and treatment for people with SMI.ResultsFollowing a stepped approach from the Behavior Change Wheel framework, a model to deliver primary preventive care for people that use community mental health settings as their de facto health home was developed. The CRANIUM (cardiometabolic risk assessment and treatment through a novel integration model for underserved populations with mental illness) model focuses on engaging community psychiatrists to expand their scope of practice to become responsible for CVD risk, with significant clinical decision support.ConclusionThe CRANIUM model was designed by integrating behavioral change theory and implementation theory. CRANIUM is feasible to implement, is highly acceptable to, and targets provider behavior change, and is replicable and efficient for helping to integrate primary preventive care services in community mental health settings. CRANIUM can be scaled up to increase CVD preventive care delivery and ultimately improve health outcomes among people with SMI served within a public mental health care system.

Ending HIV, hepatitis B, and hepatitis C: what about people with severe mental illness?

Ending HIV, hepatitis B, and hepatitis C: what about people with severe mental illness?

Violent offenders as a target population for Public Mental Health Care

The study sought to specify which part of a population of young adult violent offenders in Amsterdam (mean age 24.9 years, sd = 8.2) were eligible for Public Mental Health Care (PMHC). The results of a semi-structured clinical interview were used (N = 454), which included the Self-Sufficiency Matrix (SSM-D). Using the SSM-D and two distinct definitions of what constitutes a need for PMHC, the size of the PMHC target population was determined twice. Depending on which definition was used, 35.9% (mathematical algorithm which put weights to single SSM-D domains) and 34.8% (problematic levels of self-sufficiency on a selection of domains) appeared to be eligible for entering the PMHC system. The study confirms that a substantial proportion of vulnerable people are among the forensic population.

Adolescents’ Rights: Better for Promoting Individual Rights or Public Health?

Background: This paper aims to consider whether adolescents’ rights differ from adults’ rights and whether applying a children’s rights framework is more helpful in pursuing a public health agenda for adolescents than promoting individual rights. Method: An overview of different types and categories of rights is provided. The need to balance rights and the relationships between mental health professionals’ roles and others’ reciprocal rights is discussed in order to aid consideration of the above questions. The context is healthcare provision for adolescents with mental health disorders and difficulties. The article is informed by practice in the public mental healthcare system in England, hence many examples are drawn from the English healthcare and legal literature, although international connections are made. Results: Adolescents’ rights differ from adults’ rights, especially because of the legal and political disabilities of childhood. Applying a rights framework offers one way of reasoning about ethical and legal challenges in adolescent mental health care. In England, however, having a Human Rights Act, with which all other law must be commensurate, has not resulted in significant promotion of the individual rights of adolescent minors who have capacity to consent. Pediatric professional organisations have met with some success in pursuing a public health agenda for adolescents by advocating for their human rights. Conclusion: Particularly given evidence that most lifetime psychiatric disorders have started by the end of adolescence, mental health professional organisations should strongly and actively advocate for human rights and global equity in healthcare provision for adolescents.

New frontiers

This final paper first summarises some of the major themes that previous authors have mentioned. The first theme is their endeavour to understand human beings in their ecological context. The second is that they also adhere to a (health) systems approach. The third theme refers to the proposed valuable research developments. This paper then elaborates on three ideas that deserve attention as potential ‘new frontiers’. The first is Network Mental Health, referring to the clinical staging model that may solve a range of problems: a new generation of epidemiological research that accommodates cultural expressions of distress, mitigates response bias, prevents outliers in prevalence rates, increases the cross cultural validity of psycho pathological constructs, opens venues to develop transdiagnostic treatments by non specialists, and that may help to bury the perennial universalism versus relativism debate.1 The second idea is referred to as Community Intervention Capital. Arguing that we need interventions, beneath the primary care level within communities, as the foundations of our public mental health care system and as the crucial source of universal prevention. In low and middle income countries, this involves a wide range of community resources including: healers, teachers, community leaders, extended families and organised religion. Additionally, concerted action of all players could achieve a great deal. The third idea is called Mental Health Mathematics. Mental health professionals are ill equipped for sophisticated mathematical modelling. We need a new generation of research to study causal pathways, robustness and redundancy of interventions in order to improve equity, access to care, life course research, complex health systems and/or stigma related to mental health.

The Use of the Dutch Self-Sufficiency Matrix (SSM-D) to Inform Allocation Decisions to Public Mental Health Care for Homeless People

The current study set out to develop a decision support tool based on the Self-Sufficiency Matrix (Dutch version; SSM-D) for the clinical decision to allocate homeless people to the public mental health care system at the central access point of public mental health care in Amsterdam, The Netherlands. Logistic regression and receiver operating characteristic-curve analyses were used to model professional decisions and establish four decision categories based on SSM-D scores from half of the research population (Total n = 612). The model and decision categories were found to be accurate and reliable in predicting professional decisions in the second half of the population. Results indicate that the decision support tool based on the SSM-D is useful and feasible. The method to develop the SSM-D as a decision support tool could be applied to decision-making processes in other systems and services where the SSM-D has been implemented, to further increase the utility of the instrument.

Mental health reform under policy mainstreaming: needed, but uncertain

October 2013 marks the 50th anniversary of President John F. Kennedy's message to the US Congress on the need to reform mental healthcare. Much has changed in that time. In 2006, Frank and Glied summarized these changes and the forces behind them, finding that the well-being of people with mental illness was 'better but not well.' They also conclude that most improvements have been due to 'mainstreaming,' the inclusion of those with mental illness in broad reforms such as Medicare, Medicaid and Social Security. With the gradual assimilation of mental health concerns, leadership and resources into mainstream programmes and agencies, future improvements will require that these programmes are accessible and oriented to people with mental illness. The passage of broad health reform legislation in 2010 (the Affordable Care Act) reinforces this change; several of its provisions attempt to make healthcare more relevant to the population with mental illness. In this editorial, I discuss a set of challenges which remain for the population with mental illness in the healthcare system, and the prospects for change. These challenges include: (1) improving basic mental healthcare in primary care, (2) improving mental healthcare for children, (3) earlier detection and treatment of psychotic illness, (4) disability and unemployment and (5) the challenge of sustaining an adequate, speciality public mental healthcare system under conditions of mainstreaming. In general, I conclude that the prospects for successful reform are uncertain. Establishing mental healthcare specialization in mainstream systems has not been notably successful to date.

Composing a Core Set of Performance Indicators for Public Mental Health Care: A Modified Delphi Procedure

Public mental health care (PMHC) systems are responsible for the wellbeing of vulnerable groups that cope with complex psychosocial problems. This article describes the development of a set of performance indicators that are feasible, meaningful, and useful to assess the quality of the PMHC system in Amsterdam, the Netherlands. Performance indicators were selected from an international inventory and presented to stakeholders of the PMHC system in a modified Delphi procedure. Characteristics of indicators were judged individually, before consensus on a core set was reached during a plenary discussion. Involving stakeholders at early stages of development increases support for quality assessment.

Bridging the gap in delivery of psychological treatments for posttraumatic stress disorder

Scientific understanding of and treatment for posttraumatic stress disorder (PTSD) have come long way in the past few decades. Not long ago, the diagnostic features and pathophysiology of what we now know as PTSD and previously knew as shell shock or battle fatigue were poorly understood and treatment was widely considered to be futile. Advancements in our understanding of the development, onset, classification, and treatment of PTSD over the last several decades now offer great promise to Veterans with PTSD returning from the conflicts in Iraq and Afghanistan, as well as to those who returned from conflict decades ago and non-Veteran trauma survivors. As the articles in this special issue of the Journal of Rehabilitation Research and Development illustrate, the current state of the science of and treatment for PTSD provide real and unprecedented opportunities for recovery for many individuals with PTSD. Among the significant advancements in PTSD research is the development of specialized treatments for PTSD, including specific trauma-focused psychotherapies, such as prolonged exposure therapy (PE) and cognitive processing therapy (CPT). Rigorous research, including randomized controlled efficacy trials and effectiveness research, have shown that PE and CPT are quite effective in similar degree [1-5] and often yield outcomes that are enduring [6]. Much of this research has focused on non-Veteran sexual trauma survivors, though recent spate of research has demonstrated the efficacy and effectiveness of these therapies with Veteran samples [3,5,7-10]. Based on the scientific evidence, CPT and PE are recommended in the Department of Veterans Affairs (VA)/Department of Defense (DOD) VA/ DOD Clinical Practice Guideline for Management of Post-Traumatic Stress for PTSD at the highest level, indicating a strong recommendation that the intervention is always indicated and acceptable. Although the research evidence would suggest that trauma-focused psychotherapies should be considered clinical mainstay for the treatment of PTSD, the clinical reality is that these and other evidence-based psychotherapies (EBPs) have largely languished in the laboratory for years and not made their way into therapy rooms in either private or public mental health care systems [11-12]. One survey of mental health professionals conducted in 2001 assessing the extent to which mental health providers provided evidence-based care for PTSD found that fewer than 10 percent of both generalist mental health providers and specialty PTSD mental health providers reported providing manualized psychotherapy for PTSD [12]. Among the key reasons identified in the literature for this science-to-practice gap are limited systematic training of providers in these therapies and lack of organizational support and infrastructures (e.g., the availability of 60-90 minute weekly sessions as these therapies require) to implement these treatments. As an integrated healthcare system that establishes its own policies and services, the Veterans Health Administration (VHA) supports PE and CPT as first-line treatments for PTSD when clinically indicated. In fact, national VHA policy requires that all Veterans with PTSD have access to CPT or PE as designed and shown to be effective. To promote the availability of these treatments, VA has been working over the last several years to nationally disseminate and implement these therapies as part of larger initiative to transform the VA mental health care delivery system [13]. This transformation process has led to both structural and process enhancements to mental health care delivery in VHA and to the addition of more than 7,000 staff to the mental health care workforce since 2005, bringing the current total to more than 20,000 staff. As part of its efforts to nationally disseminate PE, CPT, and other EBPs, VA has established national competency-based staff training programs in these and other psychotherapies. …

Shared decision making in public mental health care: Perspectives from consumers living with severe mental illness.

Most theoretical and empirical work regarding decision making in mental health suggests that mental health consumers have better outcomes when their preferences are integrated into quality of life decisions. A wealth of research, however, indicates that providers have difficulty predicting what their clients' priorities are. This study investigates consumer decision-making preferences and understanding of construction of decisions in community mental health. People living with severe mental illness being treated in the public mental health care system (N=16) participated in qualitative interviews regarding case management decision making as a part of a larger study investigating a decision support system to facilitate shared decision making. Interviews were transcribed, coded, and cross-case thematic analyses were conducted. Mental health consumers generally endorse a "shared" style of decision making. When asked what "shared" means, however, consumers describe a two-step process which first prioritizes autonomy, and if that is not possible, defers to case managers' judgment. Consumers also primarily focused on the relationship and affective components of decision making, rather than information-gathering or deliberating on options. Finally, when disagreements arose, consumers primarily indicated they handled them. Mental health consumers may have a different view of decision making than the literature on shared decision making suggests. Mental health consumers may consciously decide to at least verbally defer to their case managers, and remain silent about their preferences or wishes.