Rural Community Mental Health Research Articles

Pattern of general practitioners' referrals to a rural community mental health centre: a 3-year analysis

Community mental health centres (CMHCs) represent a major trend towards developing locally based community psychiatric services. The Beaconfield Centre described here is an example of a rural project which aims to provide comprehensive and accessible psychiatric services to the population of the town of Grantham, in south Lincolnshire. The rate and pattern of referrals to the Beaconfield Centre over a period of 3 years are examined. It was found that the bulk of the general practitioners' (GPs) referrals were directed mainly to Community Psychiatric Nurses (CPNs), 49%, followed by the Consultant Psychiatrists, 42%. GPs considered the nature of the patient's problem to be responsible for nearly 20% of the total referrals. More work is required to test the appropriateness of these referrals and assess the degree of congruence between the GPs' and the mental health team's perception. The paper also highlights the need to assess regional variations in the function of these centres and their relationship to both primary health care and traditional psychiatric services. The future composition and the policy of referrals to the Community Mental Health Team (CMHT) need to be reviewed, particularly in relation to the growing number of fund holding general practices. The future role of all mental health professionals working in community settings urgently needs to be redefined with reference to the role of the CPNs vis a vis day care nurses.

New York state case manager survey: Urban and rural differences in Job activities, job stress, and job satisfaction

The impact of stress in the workplace on employees' well-being and effectiveness has been increasingly recognized in recent years. The purpose of this research was to study the quality of working life of case managers in urban and rural community mental health programs in New York State. The objectives were to describe specific job activities and examine differences in the perceptions of job stress and job satisfaction. Urban case managers attributed greater job stress intensity and frequency than did rural workers to stressors relating to collaborating and coordinating services. Urban case managers reported higher levels of perceived job stress due to organizational support deficits than did rural workers. No differences were found for the 2 groups on job pressure stressors. The significance of the findings for mental health agencies is discussed.

Rural community mental health nursing: a grounded theory account of sole practice.

This paper examines community mental health in rural and remote settings, characterized as sole practice. Using a grounded theory approach, the research reported here explored how meanings of health and health care are advanced within the context of rural mental health care, dominated and in the main led by nurses. Five different practice sites in rural New South Wales were involved. The study articulated a model of therapeutics that foregrounds a relationship of intense professional intimacy and trust against a context of geographical disadvantage and professional isolation. The meanings of the relationship are elaborated in terms of unusually high levels of responsibility, professional ingenuity, powerlessness and the independent and risky character of life in the bush.

At 3 am who the Hell do you Call? Case Management Issues in Sole Practice as a Rural Community Mental Health Nurse

Objective: This paper presents a section of data from a larger study into the sole practice of rural community mental health nurses, highlighting the uniqueness of the therapeutic model and the stresses associated with sole practice.Method: A grounded theory method was used that involved interviews with senior community mental health nurses from five rural and remote sites in New South Wales.Results: Rural mental health nurses engage community structures in a unique way, strategically as therapeutic tools supporting recovery or maintenance of an independent lifestyle. Findings also highlight the current strain that sole practice places on nurses, such as the insecurity of bearing responsibility beyond which nurses are formally authorised, in the absence of formal mentoring or professional development.Conclusions: Suggestions for resolving these tensions include virtual teams and Nurse Practitioner roles.

The program of assertive community treatment: Implementation and dissemination of an evidence-based model of community-based care for persons with severe and persistent mental illness

The Program of Assertive Community Treatment (PACT), a multidisciplinary team approach, delivers integrated community-based treatment, rehabilitation, and support services to help persons with severe and persistent mental illness to avoid psychiatric hospitalization and to live independently in natural community settings. Twenty-five randomized clinical trials of PACT and its close adaptations, conducted over the past 30 years in several countries, demonstrate its effectiveness for this population in reducing use of inpatient psychiatric services and sustaining tenure in normalized housing. Programs based on the PACT model now operate in many countries and most states. Several states have disseminated these programs statewide using a mix of standards, financial incentives, monitoring of program performance, and expert training and consultation. However, despite the strong evidence base for PACT, most states have neither committed the resources nor implemented fidelity assurance methods necessary to widely disseminate PACT and/or its close variants. For the PACT model, we offer our hypotheses about behavioral change processes underlying its approach, describe its major operational structure and process elements, briefly review the research evidence of its effectiveness, and summarize statewide dissemination efforts and factors facilitating effective dissemination. Lastly, as a case study of implementation and dissemination, we report our difficulties in implementing PACT in a rural South Carolina community mental health center (1995–2000), discuss how supervision and consultation by national PACT experts prevented a collapse of our project and turned it into a success, and outline our present plans, supported with a federal grant, to disseminate an integrated PACT and supported employment service in South Carolina's community mental health center system.

What do mental health professionals really think of family members of mental health patients?

Mental health professionals working at three rural public community mental health agencies were asked for their views on the families of mental health patients. Findings revealed themes that included families as supportive caregivers, as unsupportive agitators, as in pain, as uninformed, and as unequal partners. Implications for clinical intervention, education, and research are discussed.

Dissociative Spectrum Disorders in the Primary Care Setting

Dissociative disorders have a lifetime prevalence of about 10%. Dissociative symptoms may occur in acute stress disorder, posttraumatic stress disorder, somatization disorder, substance abuse, trance and possession trance, Ganser's syndrome, and dissociative identity disorder, as well as in mood disorders, psychoses, and personality disorders. Dissociative symptoms and disorders are observed frequently among patients attending our rural South Carolina community mental health center. Given the prevalence of mental illness in primary care settings and the diagnostic difficulties encountered with dissociative disorders, such illness may be undiagnosed or misdiagnosed in primary care settings. We developed an intervention model that may be applicable to primary care settings or helpful to primary care physicians. Key points of the intervention are identification of dissociative symptoms, patient and family education, review of the origin of the symptoms as a method of coping with trauma, and supportive reinforcement of cognitive and relaxation skills during follow-up visits. Symptom recognition, Education of the family, Learning new skills, and Follow-up may be remembered by the mnemonic device SELF. We present several cases to illustrate dissociative symptoms and our intervention. Physicians and other professionals using the 4 steps and behavioral approaches will be able to better recognize and triage patients with dissociative symptoms. Behaviors previously thought to be secondary to psychosis or personality disorders may be seen in a new frame of reference, strengthening the therapeutic alliance while reducing distress and acting-out behaviors.

The Assaulted Staff Action Program (ASAP) and declines in rates of assault: mixed replicated findings.

The Assaulted Staff Action Program (ASAP) is a crisis intervention program that has been associated with providing both needed support for employee victims of patient assault and declines in rates of assaults in traditional state hospital and community mental health settings. This study examined the possible role of ASAP and declines in rates of assault in three community-based services impacted by privatization and managed care approaches: community residences, an acute care rural community mental health center, and an urban intermediate/extended care facility. ASAP was associated with a statistically significant decline in the rate of assault in the intermediate/extended care facility. The community residence program was not a true test because of structural issues associated with managed care. The community mental health center appeared to be a true failed replication. The extended care facility's decline in the rate of assault was interrupted by the aftermath of one serious clinical incident during one month and then continued to decline. The implications are discussed.

A satisfaction study of general practitioners, and community mental health workers in rural and remote areas with the use of telemedicine for managing their psychiatric patients

Aim: To study the satisfaction with the use of Telemedicine by the service providers of Mental Health Services in the rural and remote areas, using the primary care psychiatry concept.Method: 28 Rural General Practitioners (RGP) and 30 Rural Community Mental Health Workers (RMHW) were administered a specially developed questionnaire studying the satisfaction with the Telemedicine service and its use for assessment and management of psychiatric patients in the country. These questionnaires were completed after the service providers used the Telemedicine service for getting specialist assessment and management for their rural psychiatric patients.Results: There was high satisfaction scores recorded by both the RGP and RMHW with the Telemedicine service, the assessment and the management of rural psychiatric patients. The RMHWs had higher satisfaction with the psychological management, social management and confidential issues than the RGPs. The RGP expressed highest satisfaction with the biological componen...

Initial treatment engagement in a rural community mental health center.

The charts of patients who received an initial assessment at a rural mental health center were reviewed to identify patient, system, and clinical characteristics that predicted return to the center for at least one treatment visit in the following three months. Among 112 patients, the overall rate of return was 46 percent. Patients who were seen for assessment within one week of their initial request for services were significantly more likely to return, as were those who had lower scores on the Global Assessment of Functioning scale. Patients referred for assessment by agencies of social control were the least likely to return for treatment.

Rural telepsychiatry is economically unsupportable: the Concorde crashes in a cornfield.

T the use of communication technologies to offer psychiatric services, has become a topic of great interest as a means of overcoming the effects of the shortage of psychiatrists in rural areas (1–4). The idea of using telecommunication in psychiatry is not new. In fact, examples can be found as far back as 1959, and the topic has been well reviewed (1,4–6). Although the technology has improved to the point of providing adequate audiovisual interactions, the cost-effectiveness of these interactions remains unassessed. Clearly, technological feasibility does not eliminate the need for economic practicality. Before relying on telepsychiatry as a solution to inadequate psychiatric services in rural areas, we need to consider economic variables such as the cost of the equipment, charges for maintaining connections, the volume of use, and reimbursement. We also need to consider its impact on existing systems of care into which it would be introduced. We studied the feasibility of implementing a telepsychiatry system to link psychiatrists at Michigan State University with patients at a community mental health center (CMHC) in rural Michigan. The target county we studied has a population of 58,000 and is approximately 75 miles from the university. The county is poor and demographically similar to many rural counties and is designated by the U.S. Department of Health and Human Services as an area with a shortage of mental health professionals. Many people lack transportation. Based on our feasibility study, this column examines the economics of setting up a telepsychiatry system through which care can be provided to a rural area. Moreover, we estimated the cost of delivering one type of patient care (medication management) via this system. The purpose of the paper is not to provide a technological discussion of designing a system. Rather, we offer an analysis of economic issues and systems problems encountered in setting up a very basic telepsychiatry installation at the low end of the cost range.

Cost-effectiveness of clozapine therapy for severe psychosis.

The cost-effectiveness of using the atypical antipsychotic medication clozapine for severe psychosis was examined in a rural public-sector community mental health setting in Virginia. Based on a sample of 20 patients, use of clozapine resulted in estimated cost savings of between $3,000 and $9,000 per patient per year, including the costs of dropouts from treatment. Savings were mainly due to a decline in hospitalization from 47.7+/-59.8 days per patient in the year before clozapine treatment to 4.6+/-11.3 days in the year after. Although this study had methodological limitations, the results suggest that clozapine may be cost-effective in this setting.

Capacity of rural community mental health centers to treat serious mental illness.

This study evaluates the capacity of rural community mental health center staff to treat persons with serious mental illness (SMI). A 20-item survey was mailed to 720 providers in 34 community mental health centers (CMHCs) in Iowa. Responses were received from 285/680 persons in 32/34 centers. The confidence and interest in receiving additional training in tasks necessary for the care of persons with SMI was assessed for staff members of various disciplines and both confidence and training interest was found to vary by discipline. Recommendations to enhance CMHC capacity to treat persons with SMI are discussed.

Administrative update: utilization of services. III. Factors affecting emergency service utilization at a rural community mental health center.

Various factors may contribute to cyclical fluctuations in mental health emergency service utilization. Information regarding service utilization patterns would assist the planning and administration of such programs. Five years of data on emergency service contacts at a rural community mental health center were analyzed retrospectively in order to clarify which of an array of potential factors actually affect the utilization of emergency services. One way analyses of variance (ANOVA) or analogous nonparametric tests were performed. Furthermore analyses of significant group differences were performed by means of multiple comparison tests and confidence intervals. Significant associations with number of emergency contacts were found for season, day of week, holidays, school vacations and weather conditions. This study helps to elucidate those factors affecting psychiatric emergency service utilization at a rural community mental health center. Such factors may differ from those affecting other indicators of psychopathology.

Student Ratings of Outpatient Learning Favor Rural Community Mental Health Centers

All students (N = 185) in 8 consecutive rotations within a private Southern schools multisite, inpatient-based psychiatry clerkship completed a survey of perceived educational experiences while assigned to 1 of 5 part-time outpatient services (usable response rate 82%). The rural community mental health center (CMHC) students reported increased 1) appreciation for the nature and implications of psychiatric disorders; 2) appreciation for treatment effectiveness; 3) interest, enjoyment, and hopefulness; 4) firsthand experience with patient evaluation and treatment; 5) community treatment resource information; and 6) teaching model helpfulness. The rural CMHC and Veterans Affairs Medical Center students reported a learning model based on experience. The rural CMHC and university student mental health service better exemplified the biopsycho-social treatment approach.

Case manager follow-up to failed appointments and subsequent service utilization.

Case manager responses to failed appointments were monitored for 83 seriously mentally ill persons in a rural community mental health center. Case manager actions taken were grouped into four categories of follow-up from most intensive to least intensive: home visit, phone call, letter, and no follow-up. On the whole, case managers most frequently did not follow-up missed appointments (56.7%), followed up by letters (21.3%), and telephone calls (18.7%), and home visits (3.3%). Analyses revealed that home visits were most intensive and all clients who were visited following failed appointments did not fail the subsequent appointment. Clients who received telephone calls or letters were about equally likely to fail the subsequent appointment, but were much more likely to attend the subsequent appointment than were clients who received no follow-up to the failed appointment. Interestingly, clients who failed appointments and received no follow-up were much more likely to need emergency services rather than a regular appointment as their next contact with the clinic.

Characteristics and service use of seriously mentally ill persons living in rural areas.

Data from a cross-sectional survey of 210 current or former inpatients at Mississippi State Hospital and 197 informants, usually patients' family members, were used to compare the demographic, clinical, and service use characteristics of patients living in rural areas with those of patients living in nonrural areas. All subjects completed structured face-to-face interviews. Information on recent use of community mental health center (CMHC) services was obtained from CMHC records. Characteristics of rural patients (N = 107) and nonrural patients (N = 103) were compared using chi square and t tests. Rural patients were less likely to have completed high school and more likely to be living with family members. Although rural and nonrural subjects were clinically similar, rural subjects were less likely to have received certain community mental health services such as case management and day treatment and were more likely to have used physical health services and to have been involved with the criminal justice system. Differences between rural and nonrural patients in patterns of service use are most likely a reflection of less availability or accessibility of mental health services in rural areas, resulting in spillover into physical health and criminal justice sectors. Rural community mental health centers need to formally incorporate families, local medical providers, and law enforcement officials into their network of care.

The treatment of persons with dual diagnoses in a rural community.

Persons with dual diagnoses of psychiatric illness and substance abuse represent a large subpopulation within the mental health system, but mental health service delivery systems typically do not adequately address their special needs. The literature on dual diagnoses is marked by the paucity of information on such persons in rural settings. This paper describes the characteristics of a rural community mental health system, which illustrate the difficulties in treating persons with dual diagnoses in rural communities. These problems include a fragmented system of services, centralized services in a large geographic area, overly restrictive regulations, conceptual differences in treatment approaches, confidentiality and stigma in a rural culture, and the academic and professional isolation of mental health workers, leading to high turnover and a shortage of staff having sufficient training and experience to work with persons with dual diagnoses. Some recommendations to address these problems and to improve the delivery of services to persons with dual diagnoses are suggested.

A community ability scale for chronically mentally ill consumers: Part II. Applications.

The authors describe uses for a 17-item instrument that efficiently measures the functioning level of chronically mentally ill persons living in the community. The Multnomah Community Ability Scale is designed to be completed by case managers who work with chronically mentally ill consumers. The instrument is sensitive to differences among individuals within this special population of consumers and is easy to complete. Community mental health program staff can be trained to use the scale reliably. The scale has been used to compare levels of severity between urban and rural community mental health program clients. The authors discuss the application of the Multnomah Community Ability Scale to a capitated payment system for severely mentally ill, involuntary clients.

Racial matching and service utilization among seriously mentally Ill consumers in the rural south

The authors examined racial matching between case manager and client for 677 seriously mentally ill consumers served through a rural community mental health center in the southeastern United States. Nonparametric statistics indicated that client-case manager dyads were more likely to be of the same race than of different races. Same-race dyads tended to have greater service utilization as indicated by a greater number of made appointments over the study period. An interaction was found for failed appointments where African Americans in same-race dyads were more likely to fail appointments, while caucasian consumers in same-race dyads were less likely to fail appointments.