Managing Managed Care: Habitus, Hysteresis and the End(s) of Psychotherapy

In this paper we examine how clinicians at acommunity mental health center are respondingto the beginnings of changes in the health caredelivery system, changes that are designatedunder the rubric of ``managed care.' Wedescribe how clinicians' attitudes about goodmental health care are embodied in whatsociologist Pierre Bourdieu calls theirhabitus, i.e., their professional habits andsense of good practice. Viewed in this light,their moral outrage and sense of threat, aswell as their strategic attempts to resist orsubvert the dictates of managed care agencies,become a function of what Bourdieu terms thehysteresis effect. The paper is based onethnographic fieldwork conducted by a team ofresearchers at the mental health and substanceabuse service of a hospital-affiliated,storefront clinic which serves residents ofseveral neighborhoods in a large northeasterncity. Data consist primarily of observationsof meetings and interviews with staff members. We describe four aspects of the clinicians'professional habitus: a focus on cases asnarratives of character and relationship, animperative of authenticity, a distinctiveorientation towards time, and an ethic ofambiguity. We then chronicle practices thathave emerged in response to the limits on careimposed by managed care protocols, which areexperienced by clinicians as violating theintegrity of their work. These are discussedin relation to the concept of hysteresis.     

Designing and scaling up integrated youth mental health care

Mental ill‐health represents the main threat to the health, survival and future potential of young people around the world. There are indications that this is a rising tide of vulnerability and need for care, a trend that has been augmented by the COVID‐19 pandemic. It represents a global public health crisis, which not only demands a deep and sophisticated understanding of possible targets for prevention, but also urgent reform and investment in the provision of developmentally appropriate clinical care. Despite having the greatest level of need, and potential to benefit, adolescents and emerging adults have the worst access to timely and quality mental health care. How is this global crisis to be addressed? Since the start of the century, a range of co‐designed youth mental health strategies and innovations have emerged. These range from digital platforms, through to new models of primary care to new services for potentially severe mental illness, which must be locally adapted according to the availability of resources, workforce, cultural factors and health financing patterns. The fulcrum of this progress is the advent of broad‐spectrum, integrated primary youth mental health care services. They represent a blueprint and beach‐head for an overdue global system reform. While resources will vary across settings, the mental health needs of young people are largely universal, and underpin a set of fundamental principles and design features. These include establishing an accessible, “soft entry” youth primary care platform with digital support, where young people are valued and essential partners in the design, operation, management and evaluation of the service. Global progress achieved to date in implementing integrated youth mental health care has highlighted that these services are being accessed by young people with genuine and substantial mental health needs, that they are benefiting from them, and that both these young people and their families are highly satisfied with the services they receive. However, we are still at base camp and these primary care platforms need to be scaled up across the globe, complemented by prevention, digital platforms and, crucially, more specialized care for complex and persistent conditions, aligned to this transitional age range (from approximately 12 to 25 years). The rising tide of mental ill‐health in young people globally demands that this focus be elevated to a top priority in global health.     

Confronting utilization review in New Mexico's Medicaid mental health system: the critical role of "medical necessity"

The insertion of managed care into Medicaid services for the mentally ill has created contention about clinical decision making. At the center of this debate is the matter of what constitutes a medical necessity. Employing ethnographic methodology, this study examines utilization review (UR), the context in which decisions concerning the authorization of mental health care services are made. Interviews carried out in the study contrast ideological underpinnings of providers and advocates of the mentally ill, on the one hand, with employees and administrators of managed care institutions, on the other. The result is an exploration into the ways discourses surrounding the mental health care needs of New Mexico's Medicaid population are being constructed and are determining the actual care they receive.     

The role of the primary care clinician in the management of erectile dysfunction

Although many medical problems commonly seen in the primary care clinician's office are associated with ED, the majority of men do not discuss sexual difficulties and activities with their clinician. Patients are, however, appreciative of the clinician's willingness to listen and initiate discussions. Often a new level of patient-doctor relationship is thereby reached, which provides for comanagement of sexual and other disorders. The acronym "ALLOW" defines a 5-step proactive management plan for the primary care clinician to follow in order to improve his or her flexibility and sensitivity of response to the patient's ED; at the same time, "ALLOW" helps the clinician to recognize possible limitations in managing sexual health problems. More overall communication has been related to greater patient satisfaction, which in turn results in patients who are more involved in following through on their care, who have increased confidence in their clinician, and who continue to see one physician for their health care needs.     

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

Background

Individuals 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.

Methods

Using 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.

Results

Following 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.

Conclusion

The 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.

     

Transforming the Safety Net: Responses to Medicaid Managed Care in, Rural and Urban New Mexico

In this article we examine the impact of Medicaid managed care on safety net organizations in New Mexico and their ability to maintain their traditional mission of charity care. We address two particular areas of concern that have arisen in the literature on Medicaid managed care. First, analysts have debated under what circumstances safety net organizations are better positioned to survive under market competition without abandoning their social orientation. Second, analysts have suggested that populations in rural areas may be more disadvantaged under Medicaid managed care due to its intensification of already-existent barriers to access. By comparing the differential ability of safety net organizations in rural and urban New Mexico to buffer their patients from potentially harmful effects of Medicaid managed care, we identify factors that place these safety nets particularly at risk. We find that a rural location, lack of affiliation with a larger organization, and lack of recourse to charitable funding are "risk factors" determining who sinks—and who floats—in this new competitive health care system, [privatization of health care, Medicaid safety net organizations, managed care, resistance, ruralurban]     

Collaborative Care for Depression in Primary Care: How Psychiatry Could “Troubleshoot” Current Treatments and Practices

The bulk of mental health services for people with depression are provided in primary care settings. Primary care providers prescribe 79 percent of antidepressant medications and see 60 percent of people being treated for depression in the United States, and they do that with little support from specialist services. Depression is not effectively managed in the primary care setting. Collaborative care based on a team approach, a population health perspective, and measurement-based care has been proven to treat depression more effectively than care as usual in a variety of settings and for different populations, and it increases people’s access to medications and behavioral therapies. Psychiatry has the responsibility of supporting the primary care sector in delivering mental health services by disseminating collaborative care approaches under recent initiatives and opportunities made possible by the Affordable Care Act (ACA).     

Community mental health care in the Asia‐Pacific region: using current best‐practice models to inform future policy

The reporting of child sexual abuse (CSA) and physician-patient sexual relationships (PPSR) are currently the focus of professional, legal and media attention in several countries. This paper briefly reviews mental health policies on these issues and reports on a WPA survey of them. While the WPA Madrid Declaration permits breaching confidentiality for mandatory reporting of CSA and clearly prohibits PPSR, it is not known how or to what extent these policies are implemented in WPA Member Societies’ countries. It is also not known whether policies or laws exist on these topics nationally or to what extent psychiatrists and the public are aware of them. Representatives of WPA Member Societies were e-mailed a survey about issues pertaining to CSA and PPSR. Fifty-one percent of 109 countries replied. All reporting countries had laws or policies regarding the reporting of CSA, but this was often voluntary (63%) and without protection for reporting psychiatrists either by law (29%) or by Member Societies (27%). A substantial number of psychiatric leaders did not know the law (27%) or their Society’s policy (11%) on these matters. With respect to PPSR, some reporting countries lacked laws or policies about PPSR with current (17%) or past (56%) patients. Fewer than half of responding representatives believed that their Society’s members or the public were well informed about the laws and policies pertaining to CSA or PPSR. There is clearly a wide range of laws, policies and practices about CSA and PPSR in WPA Member Societies’ countries. There is a need in some countries for laws or supplemental policies to facilitate the protection of vulnerable child and adult patients through clear, mandatory reporting policies for CSA and PPSR. Mechanisms to protect and support reporting psychiatrists should also be developed where they do not already exist. There is also a need in some countries to develop strategies to improve the education of psychiatrists, trainees, and the public on these issues.The Asia-Pacific region has close to half of the estimated 450 million people affected by mental illness globally 1.Based on international mental health care benchmarks, many Western health systems have established contemporary health policy and guidelines which include the provision of mental health care in the community. However, the delivery of quality and appropriate community mental health care remains an ongoing challenge for countries of both high and low socio-economic level. Difficulties and obstacles in implementation of comprehensive community service models include inadequate funding, availability of trained mental health workforce, integration with primary care services and community agencies, and collaboration between public and private health systems 2 - 3. As community mental health service system depends on sufficient workforce for service delivery, the critical shortage of adequately trained mental health staff continues to impede the progress of mental health reform.In response to such global trends, many countries in the Asia-Pacific region have begun to establish mental health policy and guidelines to move from institutional care to community mental health services. While these reforms are supported by recommendations from the World Health Organization (WHO) governing bodies, such as the Western Pacific Regional Mental Health Strategy 4, social, economic and cultural factors in Asia-Pacific countries often do not allow ready translation of Western community mental health models of care. Governments and service providers commonly face challenges in the development and implementation of locally appropriate community mental health care and services. Additionally, it would be unrealistic or undesirable to produce rigid recommendations for a singular community mental health care model, due to the diversity across the Asia-Pacific region. Hence, for constructive change to occur in the region, innovative, culturally appropriate and economically sustainable pathways for community treatment models need to be explored, developed and shared. Community mental health service reform appears to be gaining momentum in this region, despite the obstacles. Valuable lessons and inspiration for further development can be gained from both the successes and difficulties in reforming mental health systems and practices in the region.An emerging network of representatives from governments, peak bodies and key organizations is emerging in the Asia-Pacific region to build supportive relationships in order to facilitate the implementation of locally appropriate policy frameworks for community mental health service reform. The network is supported by the Asia-Pacific Community Mental Health Development (APCMHD) project, which involves 14 countries/regions in the Asia-Pacific region. Initiated in collaboration with the WHO Western Pacific Regional Office, the APCMHD project is led by Asia-Australia Mental Health, a consortium of the University of Melbourne Department of Psychiatry and Asialink, and St. Vincent’s Health, which is a part of the WHO Collaborating Centre for Mental Health (Melbourne). The project, which brought many key mental health organizations to work collaboratively, is consistent with the WHO Global Action Programme for Mental Health 5.The project aims are to promote best practice in community mental health care through exchange of knowledge and practical experience in the Asia-Pacific region. The key outcome is the documentation of the current status, strengths and needs of community mental health services in the region, in the hope to translate current understanding into practical changes in the future.     

Power, blame, and accountability: Medicaid managed care for mental health services in New Mexico

I examine the provision of mental health services to Medicaid recipients in New Mexico to illustrate how managed care accountability models subvert the allocation of responsibility for delivering, monitoring, and improving care for the poor. The downward transfer of responsibility is a phenomenon emergent in this hierarchically organized system. I offer three examples to clarify the implications of accountability discourse. First, I problematize the public-private "partnership" between the state and its managed care contractors to illuminate the complexities of exacting state oversight in a medically underserved, rural setting. Second, I discuss the strategic deployment of accountability discourse by members of this partnership to limit use of expensive services by Medicaid recipients. Third, I focus on transportation for Medicaid recipients to show how market triumphalism drives patient care decisions. Providers and patients with the least amount of formal authority and power are typically blamed for system deficiencies.     

Functional ability of the elderly in institutional and non-institutional care in Croatia

Gerontology-public health indicators of functional ability of the elderly in institutional and non-institutional health care in Croatia were determined by use of expert methodology developed at Department of Gerontology, Dr. Andrija Stampar Institute of Public Health in Zagreb, with the aim to upgrade the Program of Health Care Measures and Procedures in Health Care of the Elderly. Comparison of functional ability between the users of selected Old People's Homes (institutional care; N = 5030) and Gerontology Centers (non-institutional care; N = 2112) yielded highest between-group difference in the proportion of "fully movable" and "fully independent" categories in favor of the latter, thus steering the program of health care for the elderly accordingly. In addition, study results showed greater difference in the proportion of categories describing mental status of institutional and non-institutional care users as compared with the categories describing their physical status, suggesting that mental status plays a more important role than physical status in the geriatric user's stay in non-institutional care versus institutional care. This issue requires additional studies. The results obtained by this indicator analysis pointed to the preventive and geroprophylactic measures to ensure efficient health care for the elderly and to develop the program of mental health promotion and preservation. According to 2007 estimate, there were 759,318 (16.9%) persons aged > or = 65 in Croatia. Data collected at gerontology database kept at Department of Gerontology, Dr. Andrija Stampar Institute of Public Health (September 2008) showed 2% of the elderly (N = 14807) to be accommodated at Old People's Homes, which is below the European average of 4%.     

Behavioral health care integration in obstetrics and gynecology

Depression, anxiety, and somatoform disorders are 2 to 3 times more prevalent in women than in men. Since the advent of managed care and other pressures on the healthcare delivery system in the United States, there has been a notable diminishment of services and service funding for treatment of mental health conditions, whether they are temporary, transitional, or chronic. As a result of this trend, we have seen an increase in the number of patients seeking help for emotional and mental health concerns from their family doctors or, in the case of women, from their obstetrician-gynecologists. We have also found that emotional and mental health problems are often converted into physical symptomatology that carries fewer stigmas and is often viewed as easier to treat. Many women use their obstetrician-gynecologists for primary care, particularly during their reproductive years. Provision of behavioral healthcare is critical to health maintenance for many of these women. Barriers to the integration of behavioral healthcare into obstetrics and gynecology practice need to be understood and systemically addressed.     

The organizational social context of mental health services and clinician attitudes toward evidence-based practice: a United States national study

ABSTRACT: BACKGROUND: Evidence-based practices have not been routinely adopted in community mental health organizations despite the support of scientific evidence and in some cases even legislative or regulatory action. We examined the association of clinician attitudes toward evidence-based practice with organizational culture, climate, and other characteristics in a nationally representative sample of mental health organizations in the United States. METHODS: In-person, group-administered surveys were conducted with a sample of 1,112 mental health service providers in a nationwide sample of 100 mental health service institutions in 26 states in the United States. The study examines these associations with a two-level Hierarchical Linear Modeling (HLM) analysis of responses to the Evidence-Based Practice Attitude Scale (EBPAS) at the individual clinician level as a function of the Organizational Social Context (OSC) measure at the organizational level, controlling for other organization and clinician characteristics. RESULTS: We found that more proficient organizational cultures and more engaged and less stressful organizational climates were associated with positive clinician attitudes toward adopting evidence-based practice. CONCLUSIONS: The findings suggest that organizational intervention strategies for improving the organizational social context of mental health services may contribute to the success of evidence-based practice dissemination and implementation efforts by influencing clinician attitudes.     

Common mental health problems in immigrants and refugees: general approach in primary care

Background:

Recognizing and appropriately treating mental health problems among new immigrants and refugees in primary care poses a challenge because of differences in language and culture and because of specific stressors associated with migration and resettlement. We aimed to identify risk factors and strategies in the approach to mental health assessment and to prevention and treatment of common mental health problems for immigrants in primary care.

Methods:

We searched and compiled literature on prevalence and risk factors for common mental health problems related to migration, the effect of cultural influences on health and illness, and clinical strategies to improve mental health care for immigrants and refugees. Publications were selected on the basis of relevance, use of recent data and quality in consultation with experts in immigrant and refugee mental health.

Results:

The migration trajectory can be divided into three components: premigration, migration and postmigration resettlement. Each phase is associated with specific risks and exposures. The prevalence of specific types of mental health problems is influenced by the nature of the migration experience, in terms of adversity experienced before, during and after resettlement. Specific challenges in migrant mental health include communication difficulties because of language and cultural differences; the effect of cultural shaping of symptoms and illness behaviour on diagnosis, coping and treatment; differences in family structure and process affecting adaptation, acculturation and intergenerational conflict; and aspects of acceptance by the receiving society that affect employment, social status and integration. These issues can be addressed through specific inquiry, the use of trained interpreters and culture brokers, meetings with families, and consultation with community organizations.

Interpretation:

Systematic inquiry into patients’ migration trajectory and subsequent follow-up on culturally appropriate indicators of social, vocational and family functioning over time will allow clinicians to recognize problems in adaptation and undertake mental health promotion, disease prevention or treatment interventions in a timely way.Changing patterns of migration to Canada pose new challenges to the delivery of mental health services in primary care. For the first 100 years of Canada’s existence, most immigrants came from Europe; since the 1960s, there has been a marked shift, with greater immigration from Asia, Africa, and Central and South America.¹ The mix differs across the provinces, although nearly all immigrants settle in Canada’s largest cities.² The task of preventing, recognizing and appropriately treating common mental health problems in primary care is complicated for immigrants and refugees because of differences in language, culture, patterns of seeking help and ways of coping.^3–6In consultation with experts in immigrant and refugee mental health, we reviewed the literature to determine associated risks and clinical considerations for primary care practitioners in the approach to common mental health problems among new immigrant or refugee patients.^7–10 In this paper, we review the effect of migration on mental health, use of health care and barriers to care. We outline basic clinical strategies for primary mental health care of migrants including the use of interpreters, family interaction and assessment, and working with community resources.     

Lowering Cardiovascular Disease Risk for People with Severe Mental Illnesses in Primary Care: A Focus Group Study

Background

People with severe mental illnesses die early from cardiovascular disease. Evidence is lacking regarding effective primary care based interventions to tackle this problem.

Aim

To identify current procedures for, barriers to, and facilitators of the delivery of primary care based interventions for lowering cardiovascular risk for people with severe mental illnesses.

Method

75 GPs, practice nurses, service users, community mental health staff and carers in UK GP practice or community mental health settings were interviewed in 14 focus groups which were audio-recorded, transcribed and analysed using Framework Analysis.

Results

Five barriers to delivering primary care based interventions for lowering cardiovascular risk in people with severe mental illnesses were identified by the groups: negative perceptions of people with severe mental illnesses amongst some health professionals, difficulties accessing GP and community-based services, difficulties in managing a healthy lifestyle, not attending appointments, and a lack of awareness of increased cardiovascular risk in people with severe mental illnesses by some health professionals. Identified facilitators included involving supportive others, improving patient engagement with services, continuity of care, providing positive feedback in consultations and goal setting.

Conclusion

We identified a range of factors which can be incorporated in to the design, delivery and evaluation of services to reduce cardiovascular risk for people with severe mental illnesses in primary care. The next step is determining the clinical and cost effectiveness of primary care based interventions for lowering cardiovascular risk in people with severe mental illnesses, and evaluating the most important components of such interventions.     

Population‐based analysis of health care contacts among suicide decedents: identifying opportunities for more targeted suicide prevention strategies

The objective of this study was to detail the nature and correlates of mental health and non‐mental health care contacts prior to suicide death. We conducted a systematic extraction of data from records at the Office of the Chief Coroner of Ontario of each person who died by suicide in the city of Toronto from 1998 to 2011. Data on 2,835 suicide deaths were linked with provincial health administrative data to identify health care contacts during the 12 months prior to suicide. Sub‐populations of suicide decedents based on the presence and type of mental health care contact were described and compared across socio‐demographic, clinical and suicide‐specific variables. Time periods from last mental health contact to date of death were calculated and a Cox proportional hazards model examined covariates. Among suicide decedents, 91.7% had some type of past‐year health care contact prior to death, 66.4% had a mental health care contact, and 25.3% had only non‐mental health contacts. The most common type of mental health contact was an outpatient primary care visit (54.0%), followed by an outpatient psychiatric visit (39.8%), an emergency department visit (31.1%), and a psychiatric hospitalization (21.0%). The median time from last mental health contact to death was 18 days (interquartile range 5‐63). Mental health contact was significantly associated with female gender, age 25‐64, absence of a psychosocial stressor, diagnosis of schizophrenia or bipolar disorder, past suicide attempt, self‐poisoning method and absence of a suicide note. Significant differences between sub‐populations of suicide decedents based on the presence and nature of their health care contacts suggest the need for targeting of community and clinical‐based suicide prevention strategies. The predominance of ambulatory mental health care contacts, often close to the time of death, reinforce the importance of concentrating efforts on embedding risk assessment and care pathways into all routine primary and specialty clinical care, and not only acute care settings.     

Delivering the WISE (Whole Systems Informing Self-Management Engagement) training package in primary care: learning from formative evaluation

Background

Several studies document disparities in access to care and quality of care for depression for African Americans. Research suggests that patient attitudes and clinician communication behaviors may contribute to these disparities. Evidence links patient-centered care to improvements in mental health outcomes; therefore, quality improvement interventions that enhance this dimension of care are promising strategies to improve treatment and outcomes of depression among African Americans. This paper describes the design of the BRIDGE (Blacks Receiving Interventions for Depression and Gaining Empowerment) Study. The goal of the study is to compare the effectiveness of two interventions for African-American patients with depression--a standard quality improvement program and a patient-centered quality improvement program. The main hypothesis is that patients in the patient-centered group will have a greater reduction in their depression symptoms, higher rates of depression remission, and greater improvements in mental health functioning at six, twelve, and eighteen months than patients in the standard group. The study also examines patient ratings of care and receipt of guideline-concordant treatment for depression.

Methods/Design

A total of 36 primary care clinicians and 132 of their African-American patients with major depressive disorder were recruited into a cluster randomized trial. The study uses intent-to-treat analyses to compare the effectiveness of standard quality improvement interventions (academic detailing about depression guidelines for clinicians and disease-oriented care management for their patients) and patient-centered quality improvement interventions (communication skills training to enhance participatory decision-making for clinicians and care management focused on explanatory models, socio-cultural barriers, and treatment preferences for their patients) for improving outcomes over 12 months of follow-up.

Discussion

The BRIDGE Study includes clinicians and African-American patients in under-resourced community-based practices who have not been well-represented in clinical trials to improve depression care. The patient-centered and culturally targeted approach to depression care is a relatively new one that has not been tested in most previous studies. The study will provide evidence about whether patient-centered accommodations improve quality of care and outcomes to a greater extent than standard quality improvement strategies for African Americans with depression.

Trial Registration

ClinicalTrials.gov NCT00243425     

Caring for mentally ill people.

Despite legislation to harmonise mental health practice throughout Europe and convergence in systems of training there remains an extraordinary diversity in psychiatric practice in Europe. Approaches to tackling substance misuse vary among nations; statistics on psychiatric morbidity are affected by different approaches to diagnosis and treatment of psychiatric disorders; attitudes towards mental illness show definite international differences. Everywhere, though, mental health care for patients with psychotic illnesses is a "cinderella service," and there is a general move towards care falling increasingly on the family and the community.     

Needs for care from a demand led community psychiatric service: a study of patients with major mental illness.

OBJECTIVE--To measure needs for care of patients aged 18-65 years with major mental illness. DESIGN. Identification of everyone in one area seen by a health professional within the previous five years because of a psychotic disorder. Interview of a one in three sample of patients and their main carers with the cardinal needs schedule. SETTING--Hamilton, a socially deprived district of Scotland. SUBJECTS--71 subjects were interviewed from the original sample of 263 patients. MAIN OUTCOME MEASURES--"Cardinal problems" in seven clinical and eight social areas of functioning; these are defined as problems requiring action. "Needs"-cardinal problems for which suitable interventions exist but have not been tried recently. RESULTS--High levels of morbidity were found. 30 interviewed patients (42%; 95% confidence interval 31% to 54%) had one or more clinical needs. 35 (49%; 38% to 61%) had one or more social needs. Skills to deal with all but seven needs in the sample were available at the time of investigation. Patients not being seen by the community mental health team were similar in severity and levels of need to those who were on the community team''s caseload. Care was unequivocally and severely inadequate for four patients. Shortcomings in service delivery usually arose from failure to monitor some patients at home. Problems were not due to shortage of acute psychiatric beds nor the absence of an elaborate assertive community care team. CONCLUSIONS--Systematic assessment of needs with research instruments can give valuable insights into the successes and failures of community care of people with major mental illness. Most needs could be dealt with in these patients but in our area (and probably most other parts of the United Kingdom) this would entail diversion of resources from people with less severe disorders.     

Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level

Physical disorders are, compared to the general population, more prevalent in people with severe mental illness (SMI). Although this excess morbidity and mortality is largely due to modifiable lifestyle risk factors, the screening and assessment of physical health aspects remains poor, even in developed countries. Moreover, specific patient, provider, treatment and system factors act as barriers to the recognition and to the management of physical diseases in people with SMI. Psychiatrists can play a pivotal role in the improvement of the physical health of these patients by expanding their task from clinical psychiatric care to the monitoring and treatment of crucial physical parameters. At a system level, actions are not easy to realize, especially for developing countries. However, at an individual level, even simple and very basic monitoring and treatment actions, undertaken by the treating clinician, can already improve the problem of suboptimal medical care in this population. Adhering to monitoring and treatment guidelines will result in a substantial enhancement of physical health outcomes. Furthermore, psychiatrists can help educate and motivate people with SMI to address their suboptimal lifestyle, including smoking, unhealthy diet and lack of exercise. The adoption of the recommendations presented in this paper across health care systems throughout the world will contribute to a significant improvement in the medical and related psychiatric health outcomes of patients with SMI.