Clinician experiences of managed mental health care: a rereading of the threat

The threat mental health professionals perceive in managed care, as indicated by their writings on the subject, is re-examined in light of evidence from an ethnographic study. Fieldwork focusing on clinician experiences of managed care was carried out at an urban community mental health center. Existing explanations of "the threat"—the possibility of deprofessionalization and the potential for deterioration in the quality of care—proved inadequate to account for the power it wielded at this site, perhaps because its full impact had yet to be felt at the time of data collection. A "rereading " suggests the meaning of managed care for this group of clinicians lies in the prospect of being gradually, unknowingly, and unwillingly reprofessionalized from critics into proponents simply by virtue of continuing to practice in a managed care context, and in losing a moral vision of good mental health treatment in the process, [clinician experience, mental health, managed care, medical anthropology]     

WPA guidance on mental health and mental health care in migrants

The purpose of this guidance is to review currently available evidence on mental health problems in migrants and to present advice to clinicians and policy makers on how to provide migrants with appropriate and accessible mental health services. The three phases of the process of migration and the relevant implications for mental health are outlined, as well as the specific problems of groups such as women, children and adolescents, the elderly, refugees and asylum seekers, and lesbian, gay, bisexual and transgender individuals. The concepts of cultural bereavement, cultural identity and cultural congruity are discussed. The epidemiology of mental disorders in migrants is described. A series of recommendations to policy makers, service providers and clinicians aimed to improve mental health care in migrants are provided, covering the special needs of migrants concerning pharmacotherapies and psychotherapies.     

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.     

The growing field of digital psychiatry: current evidence and the future of apps,social media,chatbots, and virtual reality

As the COVID‐19 pandemic has largely increased the utilization of telehealth, mobile mental health technologies – such as smartphone apps, vir­tual reality, chatbots, and social media – have also gained attention. These digital health technologies offer the potential of accessible and scalable interventions that can augment traditional care. In this paper, we provide a comprehensive update on the overall field of digital psychiatry, covering three areas. First, we outline the relevance of recent technological advances to mental health research and care, by detailing how smartphones, social media, artificial intelligence and virtual reality present new opportunities for “digital phenotyping” and remote intervention. Second, we review the current evidence for the use of these new technological approaches across different mental health contexts, covering their emerging efficacy in self‐management of psychological well‐being and early intervention, along with more nascent research supporting their use in clinical management of long‐term psychiatric conditions – including major depression; anxiety, bipolar and psychotic disorders; and eating and substance use disorders – as well as in child and adolescent mental health care. Third, we discuss the most pressing challenges and opportunities towards real‐world implementation, using the Integrated Promoting Action on Research Implementation in Health Services (i‐PARIHS) framework to explain how the innovations themselves, the recipients of these innovations, and the context surrounding innovations all must be considered to facilitate their adoption and use in mental health care systems. We conclude that the new technological capabilities of smartphones, artificial intelligence, social media and virtual reality are already changing mental health care in unforeseen and exciting ways, each accompanied by an early but promising evidence base. We point out that further efforts towards strengthening implementation are needed, and detail the key issues at the patient, provider and policy levels which must now be addressed for digital health technologies to truly improve mental health research and treatment in the future.     

Including Ethnic Minorities in Mental Health Intervention Research: A Practical Approach to a Long-Standing Problem

This paper examines a controversy that arose while developing a supplement to Mental Health: A Report of the Surgeon General that was focused on ethnic minority mental health. The controversy involved whether and how to make recommendations about ethnic minorities seeking mental health care. We found that few studies provided information on outcomes of mental health care for ethnic minorities. In this paper, we discuss outcomes of mental health care for ethnic minorities and how to proceed in developing an evidence base for understanding mental health care and minorities. We conclude that entering representative (based on population) numbers of ethnic minorities in efficacy trials is unlikely to produce useful information on outcomes of care because the numbers will be too small to produce reliable findings. We also conclude that while conducting randomized efficacy trials for all mental health interventions for each ethnic group would be impractical, innovative and theoretically informed studies that focus on specific cultural groups are needed to advance the knowledge base. We call for theory-driven research focused on mental health disparities that has the potential for understanding disparities and improving outcomes for ethnic minority populations.     

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.     

Anatomy of health care reform proposals.

The current proliferation of proposals for health care reform makes it difficult to sort out the differences among plans and the likely outcome of different approaches to reform. The current health care system has two basic features. The first, enrollment and eligibility functions, includes how people get into the system and gain coverage for health care services. We describe 4 models, ranging from an individual, voluntary approach to a universal, tax-based model. The second, the provision of health care, includes how physician services are organized, how they are paid for, what mechanisms are in place for quality assurance, and the degree of organization and oversight of the health care system. We describe 7 models of the organization component, including the current fee-for-service system with no national health budget, managed care, salaried providers under a budget, and managed competition with and without a national health budget. These 2 components provide the building blocks for health care plans, presented as a matrix. We also evaluate several reform proposals by how they combine these 2 elements.     

Futility in the practice of community psychiatry

The experience of futility among frontline clinicians in community psychiatry is produced by the temporal structuring of their work. All health care providers share the disposition to intervene in the course of disease. Specific notions about the course of severe mental illness are woven into the mission of Assertive Community Treatment (ACT) as well as the treatment plan, a key paperwork tool used to stage daily activities. The treatment plan demands a narrative of progress that ACT workers often find impossible to supply. The gap between the ideal of progress and the realities of practice produce distinctive kinds of demoralization. Drawing from an ethnography of a single ACT team in the United States, this article explores how clinicians encounter, articulate, and attempt to resolve such experiences of futility. It explores their practical strategies to reframe the time horizons of work and thereby restore the sense of their own therapeutic power.     

Community mental health care worldwide: current status and further developments

This paper aims to give an overview of the key issues facing those who are in a position to influence the planning and provision of mental health systems, and who need to address questions of which staff, services and sectors to invest in, and for which patients. The paper considers in turn: a) definitions of community mental health care; b) a conceptual framework to use when evaluating the need for hospital and community mental health care; c) the potential for wider platforms, outside the health service, for mental health improvement, including schools and the workplace; d) data on how far community mental health services have been developed across different regions of the world; e) the need to develop in more detail models of community mental health services for low‐ and middle‐income countries which are directly based upon evidence for those countries; f) how to incorporate mental health practice within integrated models to identify and treat people with comorbid long‐term conditions; g) possible adverse effects of deinstitutionalization. We then present a series of ten recommendations for the future strengthening of health systems to support and treat people with mental illness.     

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.     

Pharmacogenetics in Primary Care: The Promise of Personalized Medicine and the Reality of Racial Profiling

Many anticipate that expanding knowledge of genetic variations associated with disease risk and medication response will revolutionize clinical medicine, making possible genetically based Personalized Medicine where health care can be tailored to individuals, based on their genome scans. Pharmacogenetics has received especially strong interest, with many pharmaceutical developers avidly working to identify genetic variations associated with individual differences in drug response. While clinical applications of emerging genetic knowledge are becoming increasingly available, genetic tests for drug selection are not as yet widely accessible, and many primary care clinicians are unprepared to interpret genetic information. We conducted interviews with 58 primary care clinicians, exploring how they integrate emerging pharmacogenetic concepts into their practices. We found that in their current practices, pharmacogenetic innovations have not led to individually tailored treatment, but instead have encouraged use of essentialized racial/ethnic identity as a proxy for genetic heritage. Current manifestations of Personalized Medicine appear to be reinforcing entrenched notions of inherent biological differences between racial groups, and promoting the belief that racial profiling in health care is supported by cutting-edge scientific authority. Our findings raise concern for how pharmacogenetic innovations will actually affect diverse populations, and how unbiased treatment can be assured.     

Perinatal mental health: a review of progress and challenges

Perinatal mental health has become a significant focus of interest in recent years, with investment in new specialist mental health services in some high‐income countries, and inpatient psychiatric mother and baby units in diverse settings. In this paper, we summarize and critically examine the epidemiology and impact of perinatal mental disorders, including emerging evidence of an increase of their prevalence in young pregnant women. Perinatal mental disorders are among the commonest morbidities of pregnancy, and make an important contribution to maternal mortality, as well as to adverse neonatal, infant and child outcomes. We then review the current evidence base on interventions, including individual level and public health ones, as well as service delivery models. Randomized controlled trials provide evidence on the effectiveness of psychological and psychosocial interventions at the individual level, though it is not yet clear which women with perinatal mental disorders also need additional support for parenting. The evidence base on psychotropic use in pregnancy is almost exclusively observational. There is little research on the full range of perinatal mental disorders, on how to improve access to treatment for women with psychosocial difficulties, and on the effectiveness of different service delivery models. We conclude with research and clinical implications, which, we argue, highlight the need for an extension of generic psychiatric services to include preconception care, and further investment into public health interventions, in addition to perinatal mental health services, potentially for women and men, to reduce maternal and child morbidity and mortality.     

Opportunities in Reform: Bioethics and Mental Health Ethics

Last year marks the first year of implementation for both the Patient Protection and Affordable Care Act and the Mental Health Parity and Addiction Equity Act in the United States. As a result, healthcare reform is moving in the direction of integrating care for physical and mental illness, nudging clinicians to consider medical and psychiatric comorbidity as the expectation rather than the exception. Understanding the intersections of physical and mental illness with autonomy and self‐determination in a system realigning its values so fundamentally therefore becomes a top priority for clinicians. Yet Bioethics has missed opportunities to help guide clinicians through one of medicine's most ethically rich and challenging fields. Bioethics' distancing from mental illness is perhaps best explained by two overarching themes: 1) An intrinsic opposition between approaches to personhood rooted in Bioethics' early efforts to protect the competent individual from abuses in the research setting; and 2) Structural forces, such as deinstitutionalization, the Patient Rights Movement, and managed care. These two themes help explain Bioethics' relationship to mental health ethics and may also guide opportunities for rapprochement. The potential role for Bioethics may have the greatest implications for international human rights if bioethicists can re‐energize an understanding of autonomy as not only free from abusive intrusions but also with rights to treatment and other fundamental necessities for restoring freedom of choice and self‐determination. Bioethics thus has a great opportunity amid healthcare reform to strengthen the important role of the virtuous and humanistic care provider.     

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]     

Balint groups as 'shared care' in the area of mental health in primary medicine

This paper describes how Balint groups can be effective for primary care doctors and how leaders of these groups can act as role models in the interdisciplinary, experiential learning experience. The paper describes the way Balint activity helps the facilitation of a dialogue between mental health professionals and primary care physicians. While these groups have been found to improve the sensitivity of doctors in their interaction with patients, Balint groups, with the joint leadership of professionals from different disciplines, can be seen as an effective method to improve primary care and mental health cooperation. These issues are discussed and appropriate examples outlined offering an uncommon perspective on an interesting topic to promote an integrated, shared model of care.     

Trauma and Humanitarian Translation in Liberia: The Tale of Open Mole

The focus of this paper is the intercultural process through which Open Mole and trauma-related mental illnesses are brought together in the postconflict mental health encounter. In this paper, I explore the historical dimension of this process by reviewing the history of Open Mole, and the ways in which it has been interpreted, acted on, and objectified by external observers over the last half-century. Moving into Liberia’s recent war and postconflict period, I examine the process by which Open Mole is transformed from a culture-bound disorder into a local idiom of trauma, and how it has become a gateway diagnosis of PTSD-related mental illnesses, and consider how it is produced as an objectified experience of psychiatric disorder in clinical humanitarian contexts. By studying how Open Mole is transformed in the humanitarian encounter, I address the structure and teleology of the humanitarian encounter and challenge some of the foundational assumptions about cultural sensitivity and community-based mental health care in postconflict settings that are prevalent in scholarship and practice today.     

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.     

The Cultural Construction of Mental Illness in Prison: A Perfect Storm of Pathology

Large numbers of individuals in U.S. prisons meet DSM criteria for severe psychiatric disorder. These individuals also have co-occurring personality and substance abuse disorders, medical conditions, and histories of exposure to social pathologies. Based on nine months of ethnographic fieldwork in a U.S. prison, focusing on staff narratives, I utilize interpretivist and constructivist perspectives to analyze how mental health clinicians construct psychiatric disorder among inmates. Discrete categorization of disorders may be confounded by the clinical co-morbidities of inmates and the prison context. Incarcerated individuals’ responses to the institutional context substantially inform mental health staffs’ illness construction and the prison itself is identified as an etiological agent for disordered behaviors. In addition, diagnostic processes are found to be indeterminate, contested, and shaped by interactions with staff. Analysis of illness construction reveals that what is at stake for clinicians is not only provision of appropriate treatment, but also mandates for the safety and security of the institution. Enmeshed in these mandates, prison mental health becomes a particular local form of psychiatric knowledge. This paper contributes to anthropological approaches to mental disorder by demonstrating how local contexts mediate psychiatric knowledge and contribute to the limited ethnographic record of prisons.     

Insuring Care: Paperwork,Insurance Rules,and Clinical Labor at a U.S. Transgender Clinic

What is a clinician to do when people needing medical care do not have access to consistent or sufficient health insurance coverage and cannot pay for care privately? Analyzing ethnographically how clinicians at a university-based transgender clinic in the United States responded to this challenge, I examine the U.S. health insurance system, insurance paperwork, and administrative procedures that shape transgender care delivery. To buffer the impact of the system’s failure to provide sufficient health insurance coverage for transgender care, clinicians blended administrative routines with psychological therapy, counseled people’s minds and finances, and leveraged the prestige of their clinic in attempts to create space for gender nonconforming embodiments in gender conservative insurance policies. My analysis demonstrates that in a market-based health insurance system with multiple payers and gender binary insurance rules, health care may be unaffordable, or remain financially challenging, even for transgender people with health insurance. Moreover, insurance carriers’ “reliance” on clinicians’ insurance-related labor is problematic as it exacerbates existing insurance barriers to the accessibility and affordability of transgender care and obscures the workings of a financial payment model that prioritizes economic expediency over gender nonconforming health.     

Confidentiality for mental health concerns in adolescent primary care

Guidelines from several national professional groups and a patchwork of state laws support the option to provide confidential mental healthcare for adolescents as a way to reduce barriers to treatment. These guidelines do not, however, help doctors decide when and to what extent confidentiality might be appropriate. We propose a set of practical considerations that clinicians can use to develop and justify confidentiality and family involvement in individual cases. Use of this framework may increase clinician comfort in discussing confidentiality and mental health topics with adolescents, and thus reduce barriers to the management of mental health problems in adolescent primary care.