Public Health Service System Research Articles

Educational Collaboration in Psychiatric Disability, Rehabilitation, and Recovery: Developing Transformative Solutions

This article describes an innovative statewide collaboration between schools of social work and public mental health departments to transform social work curriculum and address the workforce crisis in public mental health service systems. The collaborative partnership has fostered the development of a Mental Health Initiative that has developed a set of mental health competencies offered in each of the participating master's in social work (MSW) programs in California. These competencies identify critical skills and knowledge necessary to support recovery, resiliency, evidence-based practice, and psychosocial rehabilitation principles. A statewide stipend program to support final-year MSW students in their graduate study and a requirement for a year of employment payback in the public mental health system is also presented, as well as a brief discussion of the organizational and structural principles supporting the collaborative organization. Current successes, future challenges, and strategies for the partnership collaborative in their task of developing a workforce are addressed.

Shortage of health workers in the Malawian public health services system: how do parliamentarians perceive the problem?*

The quality and quantity of health care services delivered by the Malawi public health system is severely limited, due to, among other things the shortage of adequate numbers of trained health care workers. In order to suggest policy changes and implement corrective measures, there may be need to describe the perceptions of the legislature on how they perceive as the cause of the problem, which could be the solutions and an evaluation of those solution. In this paper, I present the finding from a qualitative study of Hansards (official verbatim record of parliamentary speeches) analysed by discourse analysis. Parliamentarians identified the shortage of health workers as resulting from death, retirement and brain drain to other countries mostly the UK, Saudi Arabia and South Africa. Training more health workers, training new but lower cadres of health workers not marketable to the outside world, improving the working conditions and remuneration of health workers are suggested as some of the solutions. Even without the brain drain of health workers to other countries, Malawi's health sector personnel numbers are not adequate to serve the needs of the country. Relying on training more health workers in the numbers normally produced from the prevailing training institutions is unlikely to remove the shortages.

Public-Academic Partnerships: Improving Care for Older Persons With Schizophrenia Through an Academic-Community Partnership

Translating evidence-based mental health interventions designed in research settings into community practice is a priority for multiple stakeholders. Partnerships between academic and public institutions can facilitate this translation. To improve care for middle-aged and older adults with schizophrenia, the authors developed a collaboration between a university research center and a public mental health service system using principles from community-based participatory research and cultural exchange theory. They describe the process that has led to a number of mutually beneficial products. Despite the challenges involved, building and maintaining academic-public collaborations will be essential for improving mental health care for persons with schizophrenia.

The Use of Public Mental Health Services by Older Californians and Complementary Service System Effects

Older adults with mental disorders are less likely to use specialty care than any other population group. In this study, we created a multisource secondary data file and examined the use of public mental health services by older adults across California's county-based community mental health systems. We specifically considered complementary service system effects relative to compositional effects representing individual service users and more general contextual effects. Service use was defined in terms of treated prevalence rates, repeat service use, and intensity of service use. Differences across 49 county-based systems were evaluated by regressing the 3 service use measures onto compositional characteristics including client age, diagnosis, and insurance status; variables reflecting complementary service systems including mental health, health, long-term care, and aging services; and other contextual effects such as the size of the county population and average education level. The analyses were adjusted statistically for regional, yearly, and seasonal differences, and for longitudinal clustering within the 49 counties over 12 quarters of observation. Results suggested that older adults' service use varied significantly from one county to the next, and differences were associated with both compositional and contextual effects. As the aging population continues to grow and place an increasing demand on public mental health service systems, this research may help policy makers and program administrators understand some of the critical elements that affect service use patterns among older adults.

One Year Clinical Evaluation of Two Different Types of Composite Resins in Posterior Teeth

The aim of this study was to assess the clinical performance of two adhesive restorative systems (Single Bond/Filtek P-60 and Single Bond/Filtek Z-250) in posterior teeth using a modified United States Public Health Service (USPHS) system. A total of 70 restorations were placed in molars and premolars in 30 patients (14 females and 16 males; 18-40 years) by one operator. All restorations were directly evaluated by two examiners at baseline, six months, and 12 months using the following modified USPHS rating criteria: marginal integrity, marginal discoloration, surface texture, contour, postoperative sensitivity, and recurrent caries. At six and 12 months all restorations were available for evaluation of marginal discoloration, surface texture, contour, postoperative sensitivity, and recurrent caries that remained with 100% Alpha-ratings at recalls for both restorative systems. Marginal integrity for P-60 was scored as 94.3% and 91.4% Alpha at six and 12 months, respectively, and rates for Z-250 were 100% and 97.1% Alpha at six and 12 months, respectively. Statistical analysis was completed with Fisher's exact and McNemar Chi-square tests at a significance level of 5% (P<0.05). All restorations were clinically satisfactory and no significant differences were found among them. Posterior resin composite restorations placed under appropriate conditions provide a satisfactory clinical performance.

A Typology of Advance Statements in Mental Health Care

A Typology of Advance Statements in Mental Health Care

Policy and practice implications of epidemiological surveys on co-occurring mental and substance use disorders

This article describes factors that influence national policy and practice, with particular focus on the implications of epidemiological survey research. Examples of areas of concern to policymakers include treatment-seeking patterns, access to care at points of service in public health and social service systems, evidence-based practices, workforce development, and the complexities of reimbursement. In responding to data on systemic barriers to care, the Substance Abuse and Mental Health Services Administration (SAMHSA) has sought to promote a no wrong door strategy to address the needs of persons with co-occurring disorders (CODs) involving their mental health and substance use. Examples of SAMHSA programs and policies addressing CODs discussed in this article include targeted partnerships with the states, mechanisms to enhance system infrastructure, technical assistance, and initiatives with special populations.

Reforming Mental Health Care in Victoria: A Decade Later

From 1994, the Australian State of Victoria began a major transformation of its public mental health service system. In June 2006, St Vincent's Mental Health hosted a conference to reflect on the changes and identify steps to be taken over the next decade. Participants came from Victoria's 21 adult mental health services, consumer and carer groups, and psychiatric disability rehabilitation and support organizations. They met in small groups, and discussed pre-set topics. Their observations were pooled in plenary sessions. Participants agreed the changes had had many positive outcomes. People most affected by mental illness had priority for treatment. Services were better structured to meet their needs, and staff were more familiar with community-based care. Negatives included restricted service access for some groups, insufficient resourcing to meet increased service demand and clinical staff not maintaining specialist skills. The conference enabled experiences to be shared and ideas exchanged about improvements.

Issues in Medicaid Policy and System Transformation: Recommendations From the President's Commission

Issues in Medicaid Policy and System Transformation: Recommendations From the President's Commission

Violence and Leveraged Community Treatment for Persons With Mental Disorders

Objective: This article explores the link between violence and the practice of legally mandating treatment in the community or leveraging benefits from the social welfare system, such as subsidized housing and disability income support, to ensure adherence to treatment. Method: Data are presented from a survey of 1,011 persons with psychiatric disorders receiving treatment in public mental health service systems in five U.S. cities. Multinomial logit analysis was used to examine the association between physically assaultive behavior and experience of social welfare leverage, legal leverage, or both types of leverage, with the analyses controlling for demographic and clinical characteristics. Results: Across study sites, 18% to 21% of participants reported having committed violent acts in the past 6 months; 3% to 9% reported having used or made threats with a lethal weapon, committed sexual assault, or caused injury. About three-quarters of subjects who reported such serious violence also reported having experienced some form of leveraged treatment, compared with about one-half of subjects who did not report serious violence. Demographic and clinical factors that were independently associated with the likelihood of experiencing both types of leverage included younger age, male gender, poorer clinical functioning, more years in treatment, more frequent hospitalizations, higher frequency of outpatient visits, and negative attitudes toward medication adherence. Among participants who did not voluntarily take psychotropic medication, even minor assaultiveness was associated with having experienced legal leverage. Conclusions: A combination of concerns about safety and treatment nonadherence may influence decisions by clinicians and judges to apply legal leverage.

Violence and Leveraged Community Treatment for Persons With Mental Disorders

This article explores the link between violence and the practice of legally mandating treatment in the community or leveraging benefits from the social welfare system, such as subsidized housing and disability income support, to ensure adherence to treatment. Data are presented from a survey of 1,011 persons with psychiatric disorders receiving treatment in public mental health service systems in five U.S. cities. Multinomial logit analysis was used to examine the association between physically assaultive behavior and experience of social welfare leverage, legal leverage, or both types of leverage, with the analyses controlling for demographic and clinical characteristics. Across study sites, 18% to 21% of participants reported having committed violent acts in the past 6 months; 3% to 9% reported having used or made threats with a lethal weapon, committed sexual assault, or caused injury. About three-quarters of subjects who reported such serious violence also reported having experienced some form of leveraged treatment, compared with about one-half of subjects who did not report serious violence. Demographic and clinical factors that were independently associated with the likelihood of experiencing both types of leverage included younger age, male gender, poorer clinical functioning, more years in treatment, more frequent hospitalizations, higher frequency of outpatient visits, and negative attitudes toward medication adherence. Among participants who did not voluntarily take psychotropic medication, even minor assaultiveness was associated with having experienced legal leverage. A combination of concerns about safety and treatment nonadherence may influence decisions by clinicians and judges to apply legal leverage.

Shortage of health workers in the Malawian public health services system: how do parliamentarians perceive the problem?

The quality and quantity of health care services delivered by the Malawi public health system is severely limited, due to, among other things the shortage of adequate numbers of trained health care workers. In order to suggest policy changes and implement corrective measures, there may be need to describe the perceptions of the legislature on how they perceive as the cause of the problem, which could be the solutions and an evaluation of those solution. In this paper, I present the finding from a qualitative study of Hansards (official verbatim record of parliamentary speeches) analysed by discourse analysis. Parliamentarians identified the shortage of health workers as resulting from death, retirement and brain drain to other countries mostly the UK, Saudi Arabia and South Africa. Training more health workers, training new but lower cadres of health workers not marketable to the outside world, improving the working conditions and remuneration of health workers are suggested as some of the solutions. Even without the brain drain of health workers to other countries, Malawi's health sector personnel numbers are not adequate to serve the needs of the country. Relying on training more health workers in the numbers normally produced from the prevailing training institutions is unlikely to remove the shortages. African Journal of Health Sciences Vol. 12(3-4) 2005: 101-107

Canada to Reform Troubled Mental Health Care System

Back to table of contents Previous article Next article Professional NewsFull AccessCanada to Reform Troubled Mental Health Care SystemJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:2 Dec 2005https://doi.org/10.1176/pn.40.23.0012Canadians are often thought to have a public health service system that is taking care of everyone, but that does not appear to be so, since only 30 percent of Canadians needing mental health services are receiving adequate care.So reported Wilbert Keon, M.D., at the annual Canadian Psychiatric Association meeting in Vancouver in November. In addition to being an innovator in cardiovascular surgery, Keon is a Canadian senator from Ontario and deputy chair of Canada's Standing Senate Committee on Social Affairs, Science, and Technology (known as the Kirby Committee). During the past several years, the Kirby Committee has been working on ways to reform Canada's mental health service delivery system (Psychiatric News, December 5, 2003).Keon underscored several specific mental health delivery problems facing Canada. For example, he said, “We are without a national mental health strategy.” Psychologists' and social workers' services are not covered by public health insurance, which may limit access to mental health treatment (Psychiatric News, October 21).A number of things need to be done to help the 70 percent of Canadians not receiving adequate mental health services gain access to them, Keon added.For instance, Canada has a good physician-hospital system, but not a good system for getting patients integrated back into the community after they have been treated.Patients need to have their mental health care needs met in a culturally sensitive manner, which is a huge challenge in Canada, with so many ethnic groups and native peoples.Severely mentally ill Canadians need to recover enough so that they can interact usefully in society, not just wander the streets or stay in jail.Currently, mental health services are fragmented—a maze of independent federal, provincial, community, public, and private programs.“ We have to find a way to integrate them,” Keon stressed. Mental health services also need to be better linked with police and emergency services.Private health insurance in Canada is viewed by many Canadians as a supplement to public health services. Most Canadians do not want to move to an essentially private health insurance system as in the United States. So the challenge is for the Canadian government and the private-insurance industry to work together “so the gap [between government coverage and private coverage] is closed.”There is a big advantage to having a single-payer universal health insurance system, such as Canada's, over a multipayer universal health insurance system, such as in Germany—and that is low overhead, he said. Nonetheless, competition can still play a role in the Canadian health system. The idea is to get away from service providers having monopolies, whether the providers operate on a public or private basis, Keon said.“We hope that with such strategies we can bring people suffering from mental illness and addiction into the [public/private mental health care] system,” Keon concluded.Meanwhile, he added, the Kirby Committee should be releasing its final report in mid-January, and the report should press Canadians to make a sobering decision: Will they continue with their inadequate mental health care delivery system, or will they make positive changes? ▪ ISSUES NewArchived

A Short Medical School Course on Responding to Bioterrorism and Other Disasters

The events of 9/11 highlighted the limitations of the United States health care system in responding to large-scale public health emergencies. The key for an effective response to any mass casualty event is preparedness; thus, the education of medical students has become a priority. The Association of American Medical Colleges (AAMC) recommended that the nation's medical schools should thoroughly educate students about the public health and emergency services systems to ensure coordinated responses to weapons of mass destruction or other public health threats. In response, The Texas A&M University System Health Science Center College of Medicine, partnering with the Defense Institute for Medical Operations (DIMO), developed a one-week block of required (but not graded) instruction, the "Leadership Course in Disaster Response," first given in 2003-04 to 72 second-year students and taught by six military experts from DIMO. The course goal is to (1) educate students on resources available for regional disaster response; (2) define principles of resource management in disaster response; (3) identify specific agents associated with bioterrorism; and (4) understand the psychosocial aspects of disasters. The course was well received, and the 2004-05 session was improved, based on student and faculty feedback. The authors describe the details of the course (specifically, how the course was tailored to fit the AAMC guidelines), changes in students' knowledge and attitudes, and how the course was improved.

Developing an HIV Intervention for Indigent Women Substance Abusers in the United States Virgin Islands

As the HIV/AIDS epidemic continues to expand and penetrate new communities around the globe, risk reduction intervention initiatives must continue to evolve and adapt to new challenges and populations. This is especially true in the Caribbean Basin, where the feminization of the HIV epidemic is tied to a cultural milieu characterized by pervasive gender inequality. HIV intervention programs in the Caribbean must treat women's risks as a function of the social context, standards, and meanings of sexual behaviors and practices in the local community. As such, this article describes an initiative to develop an HIV prevention-intervention protocol for the cultural context of substance abusing women in the US Virgin Islands. Through street-based survey research combined with focus groups and in-depth interviews with such "cultural insiders" as members of the substance-abusing target population, members of the local public health and social services system, and community leaders, a culturally sensitive HIV/AIDS protocol was developed which addresses the supports and barriers to risk reduction faced by substance abusing women in the Virgin Islands.

A need-based model for determining staffing needs for the public sector outpatient mental health service system

This article proposes a need-based model for determining staffing needs for regional or national public sector outpatient mental health services. It constitutes a spreadsheet method involving a sequence of calculations relating demographic variables, workers' productivity, anticipated demand, and standards pertaining to annual visits per client distributed among the core mental health professions. The authors demonstrate the application of the model to national planning of adult outpatient mental health services using standards based on both expert consensus and existing staffing patterns while they note the need for more rigorously derived and empirically based standards. It is suggested that by using clearly stated assumptions and quantifiable variables, the model can facilitate constructive negotiations among various agencies and community organizations involved in policymaking and in budget allocations.

Psychotropic medications prescribing patterns for children and adolescents in New York's public mental health system.

Breakthroughs in the development of effective medications for a number of psychiatric disorders have led to increased use of these compounds in the treatment of children. To understand the use of psychotropic medications in the treatment of children, a state-wide study was undertaken based on the data collected in a large planning study. DATA AND SETTING: A stratified random sample of 10 different program types in New York State produced data on children served in different specialty mental health services. Randomly selected cases were reviewed at a randomly selected sites to generate a sample of 1592 cases on which data were collected on clinical presentation and service use, including psychotropic medication prescriptions. The Child and Adolescent Needs and Strengths (CANS-MH) tool was used to provide a reliable review of clinical indicators. Psychotropic medication use is common in the children's public mental health service system in New York. Most children served in high intensity settings receive medication as a part of their treatment. It appears that most prescriptions for stimulants and antidepressants are consistent with either diagnostic or symptom indications. Many children with these indications are not on medications. On the other hand, a large number of children without evidence of psychosis receive antipsychotic medications. The evidence suggests that stimulant and antidepressant are not over-prescribed. However, the use of antipsychotic medications for other indications is a priority for further research.

Objectives and activities of the German Federal Working Group on migration and public health

The 53rd scientific congress of the Federal association of physicians and dentists in the public health services addressed the interdependence of migration and health under the motto "health unlimited" in May, 2003. Manifold interactions between migration and health contribute to the public health services' everyday experiences. Immigrants often encounter manifold obstacles to their access to health services in Germany. These barriers are often of communicative or administrative nature. The system of public health administration and services has, by its very nature, opportunities and assignment a special obligation to support the immigrant population. The public health services will increasingly become guarantors of equal health opportunities in times of cumulative migration and social inequalities. In cooperation with the German Federal Commissioner for Migration, Refugees and Integration the German Federal Working Group on Migration and Public Health acts as facilitator and advocate for health of immigrants to Germany since 1994. A very close co-operation with the public health services and an interdisciplinary, intercultural, population-oriented and health-promoting approach are core elements of the working group that is lobbying the health of a multinational population within the borders of Germany.

Clinicians and outcome measurement: what's the use?

The goal of this study was to learn more about clinicians' experiences with, and perceptions of the utility, validity, and feasibility of standardized outcome measures in practice. Fifty randomly selected clinicians from multiple disciplines and multiple service agencies in a large children's public mental health service system were interviewed individually (n = 30) or in focus groups (n = 20) using semistructured interviews. There was great variability across clinicians in attitudes about empirical methods of treatment evaluation. There was consensus regarding feasibility challenges of administering standardized measures, including time burden and literacy barriers. Although all participants had received scored assessment profiles for their clients, the vast majority reported that they did not use the scores in treatment planning or monitoring. Their suggestions for improved clinical utility of outcome measurement are included. With increased attention and resources devoted to performance outcome assessment, it is concerning that most clinicians perceive little clinical utility of outcome measurement.

Health technology assessment of the diagnosis of colorectal cancer in a public health service system

Abstract A Danish national health technology assessment (HTA) on diagnosis of colorectal cancer, which was done by a multidisciplinary group of experts, is reported. HTA is an applied, research-based systematic interdisciplinary assessment, a form of policy research, of relevant available knowledge of short- and long-term consequences of application of a health technology, a set of related technologies, or an issue related to technology. HTA as a field was developed internationally to assist decision-making by providing comprehensive, systematic assessments of the conditions for and the consequences of using health technology in the diagnostic, therapeutic, and preventive procedures and the pharmaceuticals, equipment, and devices used with the procedures. To fulfill their aim, the central problem statements in an HTA should meet the decision makers' (and their advisers') need for a documented basis for deciding whether or not to apply health technology and to what extent. The elements of the reported HTA were synthesized into a diagnostic strategy with organizational and economic consequences included in the synthesis. The link between HTA and policy is discussed. Several counties in Denmark are now implementing the diagnostic strategy. However, it is too early to establish the report's impact on policy. Copyright © 2002 by W.B. Saunders Company