Implementing shared decision making in routine mental health care

Shared decision making (SDM) in mental health care involves clinicians and patients working together to make decisions. The key elements of SDM have been identified, decision support tools have been developed, and SDM has been recommended in mental health at policy level. Yet implementation remains limited. Two justifications are typically advanced in support of SDM. The clinical justification is that SDM leads to improved outcome, yet the available empirical evidence base is inconclusive. The ethical justification is that SDM is a right, but clinicians need to balance the biomedical ethical principles of autonomy and justice with beneficence and non‐maleficence. It is argued that SDM is “polyvalent”, a sociological concept which describes an idea commanding superficial but not deep agreement between disparate stakeholders. Implementing SDM in routine mental health services is as much a cultural as a technical problem. Three challenges are identified: creating widespread access to high‐quality decision support tools; integrating SDM with other recovery‐supporting interventions; and responding to cultural changes as patients develop the normal expectations of citizenship. Two approaches which may inform responses in the mental health system to these cultural changes – social marketing and the hospitality industry – are identified.     

Detecting mental disorders in primary care

Managing mental health problems of people around the world is a major challenge for health workers as well as for policy makers. It is a particular problem for low- and middle-income countries for many reasons, especially due to lack of recourses.A computer-assisted interview, the GMHAT/PC (Global Mental Health Assessment Tool - Primary Care) has been developed to assist general practitioners and other health professionals to make a quick, convenient, and comprehensive, standardised mental health assessment. It has proved to be a reliable and valid tool in various studies. Its use by other health professionals may help in detecting and managing mental disorders in primary care and general health settings more effectively. The article outlines the development and potential use of the GMHAT/PC.     

Public mental health: the time is ripe for translation of evidence into practice

Public mental health deals with mental health promotion, prevention of mental disorders and suicide, reducing mental health inequalities, and governance and organization of mental health service provision. The full impact of mental health is largely unrecognized within the public health sphere, despite the increasing burden of disease attributable to mental and behavioral disorders. Modern public mental health policies aim at improving psychosocial health by addressing determinants of mental health in all public policy areas. Stigmatization of mental disorders is a widespread phenomenon that constitutes a barrier for help-seeking and for the development of health care services, and is thus a core issue in public mental health actions. Lately, there has been heightened interest in the promotion of positive mental health and wellbeing. Effective programmes have been developed for promoting mental health in everyday settings such as families, schools and workplaces. New evidence indicates that many mental disorders and suicides are preventable by public mental health interventions. Available evidence favours the population approach over high-risk approaches. Public mental health emphasizes the role of primary care in the provision of mental health services to the population. The convincing evidence base for population-based mental health interventions asks for actions for putting evidence into practice.     

Barriers in the mind: promoting an economic case for mental health in low- and middle-income countries

In recent years, policy makers in high-income countries have placed an increasing emphasis on the value of maintaining good mental health, recognizing the contribution that this makes to quality of life, whilst ever more mindful of the socio-economic consequences of poor mental health. The picture in many other parts of the world is much less encouraging; policy attention and resources are still directed largely at communicable diseases. We reflect on some of the challenges faced in these countries and outline the role that economic evidence could play in strengthening the policy case for investment in mental health. Clearly this should include assessment of the economic impact of strategies implemented outside, as well as within the health sector. The ways in which mental health services are delivered is also of critical importance. Non-governmental organizations (NGOs) have long been shown to be key stakeholders in the funding, coordination and delivery of these services in high-income countries. Their role in low- and middle-income countries, where infrastructure and policy focus on mental health are more limited, can be even more vital in overcoming some of the barriers to the development of mental health policy and practice.     

Recession, debt and mental health: challenges and solutions

Background During the economic downturn, the link between recession and health has featured in many countries' media, political, and medical debate. This paper focuses on the previously neglected relationship between personal debt and mental health.Aims Using the UK as a case study, this paper considers the public health challenges presented by debt to mental health. We then propose solutions identified in workshops held during the UK Government's Foresight Review of Mental Capital and Wellbeing.Results Within their respective sectors, health professionals should receive basic 'debt first aid' training, whilst all UK financial sector codes of practice should - as a minimum - recognise the existence of customers with mental health problems. Further longitudinal research is also needed to 'unpack' the relationship between debt and mental health. Across sectors, a lack of co-ordinated activity across health, money advice, and creditor organisations remains a weakness. A renewed emphasis on co-ordinated 'debt care pathways' and better communication between local health and advice services is needed.Discussion The relationship between debt and mental health presents a contemporary public health challenge. Solutions exist, but will require action and investment at a time of competition for funds.     

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.     

Economics and mental health: the current scenario

Economics and mental health are intertwined. Apart from the accumulating evidence of the huge economic impacts of mental ill‐health, and the growing recognition of the effects that economic circumstances can exert on mental health, governments and other budget‐holders are putting increasing emphasis on economic data to support their decisions. Here we consider how economic evaluation (including cost‐effectiveness analysis, cost‐utility analysis and related techniques) can contribute evidence to inform the development of mental health policy strategies, and to identify some consequences at the treatment or care level that are of relevance to service providers and funding bodies. We provide an update and reflection on economic evidence relating to mental health using a lifespan perspective, analyzing costs and outcomes to shed light on a range of pressing issues. The past 30 years have witnessed a rapid growth in mental health economics, but major knowledge gaps remain. Across the lifespan, clearer evidence exists in the areas of perinatal depression identification‐plus‐treatment; risk‐reduction of mental health problems in childhood and adolescence; scaling up treatment, particularly psychotherapy, for depression; community‐based early intervention and employment support for psychosis; and cognitive stimulation and multicomponent carer interventions for dementia. From this discussion, we pull out the main challenges that are faced when trying to take evidence from research and translating it into policy or practice recommendations, and from there to actual implementation in terms of better treatment and care.     

Too unwell to trust? The effect of mental health on social trust in Europe

Social trust is often thought to be adversely affected by mental health problems. However, rigorous causal evidence required to substantiate this thought is scarce. Here I examine the causal effect of individuals’ mental health on social trust using data from the European Social Survey. Estimating the causal effect, however, is a formidable task since the relationship between mental health and social trust is endogenous due to reverse causality and unmeasured confounding. I circumvent these difficulties by using a recently developed econometric technique that does not rely on valid exclusion restriction for identification. I find strong evidence that mental ill health has a significant negative effect on social trust. Further, I provide suggestive evidence which shows that the adverse effect of mental ill health on social trust arises due to reductions in individuals’ level of optimism and hope, and participation in social networks caused by mental ill health. Overall, the results suggest that for achieving a durable increase in social trust – which often is one of the fundamental objectives of policy makers – interventions to promote mental health of individuals could be extremely useful.     

New trends in assessing the outcomes of mental health interventions

Assessing the outcomes of interventions in mental health care is both important and challenging. The aim of this paper is to advance the field of outcomes research by proposing a taxonomy of the decisions that clinicians and researchers need to consider when evaluating outcomes. Our taxonomy has eight components, framed as decisions: Whose outcome will be considered? Which scientific stage is being investigated? What outcome domain(s) matter? What level of assessment will be used? Will clinical and/or recovery outcomes be assessed? Whose perspective will be considered? Will deficits and/or strengths be the focus? Will invariant or individualized measures be preferred? We propose a future focus on understanding what matters most to people using mental health services, and on the use of measures rated by service users as the primary approach to evaluating outcome.     

Uses and abuses of recovery: implementing recovery‐oriented practices in mental health systems

An understanding of recovery as a personal and subjective experience has emerged within mental health systems. This meaning of recovery now underpins mental health policy in many countries. Developing a focus on this type of recovery will involve transformation within mental health systems. Human systems do not easily transform. In this paper, we identify seven mis‐uses (“abuses”) of the concept of recovery: recovery is the latest model; recovery does not apply to “my” patients; services can make people recover through effective treatment; compulsory detention and treatment aid recovery; a recovery orientation means closing services; recovery is about making people independent and normal; and contributing to society happens only after the person is recovered. We then identify ten empirically‐validated interventions which support recovery, by targeting key recovery processes of connectedness, hope, identity, meaning and empowerment (the CHIME framework). The ten interventions are peer support workers, advance directives, wellness recovery action planning, illness management and recovery, REFOCUS, strengths model, recovery colleges or recovery education programs, individual placement and support, supported housing, and mental health trialogues. Finally, three scientific challenges are identified: broadening cultural understandings of recovery, implementing organizational transformation, and promoting citizenship.     

The needs of primary care mental health service users: a Q-sort study

Background Within scientific and policy literature, the broader needs and preferences of the service user are usually described as being relatively homogenous for any particular condition. Additionally, despite common adult mental health problems being a huge burden to primary care services, there has been little research into the client's perspective of their needs regarding such difficulties. The aim of this research was thus to uncover the issues and preferences for this sample.Method The attitudes of 28 service users were explored through use of a Q-methodology approach. This procedure involves statistical analysis of the order that participants rank pertinent statements associated with the area of study.Results Five independent factors (clusters of preferences) were identified. These differed over issues associated with: relationships with service providers, access/barriers associated with services, information provision, stigma, choices associated with therapy and the care pathway, medication and complementary approaches, as well as social support.Discussion The study suggests that differing individual needs exist within diagnostic categories which, unless considered, may impede service engagement. Issues associated with the implications for service delivery for these differing clusters of perceived needs and viewpoints are outlined.     

Integrating mental health into primary care in Sverdlovsk

Introduction Mental disorders occur as frequently in Russia as elsewhere, but the common mental disorders, especially depression, have gone largely unrecognised and undiagnosed by policlinic staff and area doctors.Methods This paper describes the impact and sustainability of a multi-component programme to facilitate the integration of mental health into primary care, by situation appraisal, policy dialogue, development of educational materials, provision of a training programme and the publication of standards and good practice guidelines to improve the primary care of mental disorders in the Sverdlovsk region of the Russian Federation.Results The multi-component programme has resulted in sustainable training about common mental disorders, not only of family doctors but also of other cadres and levels of professionals, and it has been well integrated with Sverdlovsk's overall programme of health sector reforms.Conclusion It is possible to facilitate the sustainable integration of mental health into primary care within the Russian context. While careful adaptation will be needed, the approach adopted here may also hold useful lessons for policy makers seeking to integrate mental health within primary care in other contexts and settings.     

Clinical utility of ICD‐11 diagnostic guidelines for high‐burden mental disorders: results from mental health settings in 13 countries

In this paper we report the clinical utility of the diagnostic guidelines for ICD‐11 mental, behavioural and neurodevelopmental disorders as assessed by 339 clinicians in 1,806 patients in 28 mental health settings in 13 countries. Clinician raters applied the guidelines for schizophrenia and other primary psychotic disorders, mood disorders (depressive and bipolar disorders), anxiety and fear‐related disorders, and disorders specifically associated with stress. Clinician ratings of the clinical utility of the proposed ICD‐11 diagnostic guidelines were very positive overall. The guidelines were perceived as easy to use, corresponding accurately to patients’ presentations (i.e., goodness of fit), clear and understandable, providing an appropriate level of detail, taking about the same or less time than clinicians’ usual practice, and providing useful guidance about distinguishing disorder from normality and from other disorders. Clinicians evaluated the guidelines as less useful for treatment selection and assessing prognosis than for communicating with other health professionals, though the former ratings were still positive overall. Field studies that assess perceived clinical utility of the proposed ICD‐11 diagnostic guidelines among their intended users have very important implications. Classification is the interface between health encounters and health information; if clinicians do not find that a new diagnostic system provides clinically useful information, they are unlikely to apply it consistently and faithfully. This would have a major impact on the validity of aggregated health encounter data used for health policy and decision making. Overall, the results of this study provide considerable reason to be optimistic about the perceived clinical utility of the ICD‐11 among global clinicians.     

Investigating mental health risk assessment in primary care and the potential role of a structured decision support tool,GRiST

Aim To explore current risk assessment processes in general practice and Improving Access to Psychological Therapies (IAPT) services, and to consider whether the Galatean Risk and Safety Tool (GRiST) can help support improved patient care.Background Much has been written about risk assessment practice in secondary mental health care, but little is known about how it is undertaken at the beginning of patients'' care pathways, within general practice and IAPT services.Methods Interviews with eight general practice and eight IAPT clinicians from two primary care trusts in the West Midlands, UK, and eight service users from the same region. Interviews explored current practice and participants'' views and experiences of mental health risk assessment. Two focus groups were also carried out, one with general practice and one with IAPT clinicians, to review interview findings and to elicit views about GRiST from a demonstration of its functionality. Data were analysed using thematic analysis.Findings Variable approaches to mental health risk assessment were observed. Clinicians were anxious that important risk information was being missed, and risk communication was undermined. Patients felt uninvolved in the process, and both clinicians and patients expressed anxiety about risk assessment skills. Clinicians were positive about the potential for GRiST to provide solutions to these problems.Conclusions A more structured and systematic approach to risk assessment in general practice and IAPT services is needed, to ensure important risk information is captured and communicated across the care pathway. GRiST has the functionality to support this aspect of practice.     

What does mental health have to do with well-being?

Positive mental health involves not the absence of mental disorder but rather the presence of certain mental goods. Institutions, practitioners, and theorists often identify positive mental health with well-being. There are strong reasons, however, to keep the concepts of well-being and positive mental health separate. Someone with high positive mental health can have low well-being, someone with high well-being can have low positive mental health, and well-being and positive mental health sometimes conflict. But, while positive mental health and well-being are not identical, there is an informative conceptual connection between them. Positive mental health usually contributes instrumentally to the living of a good human life, where a good human life includes (but is not limited to) well-being.     

Lessons learned in developing community mental health care in Africa

This paper summarizes the findings for the African Region of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. We present an overview of mental health policies, plans and programmes in the African region; a summary of relevant research and studies; a critical appraisal of community mental health service components; a discussion of the key challenges, obstacles and lessons learned, and some recommendations for the development of community mental health services in the African region.