Barriers and errors in the implementation of community psychiatry in Slovenia

Background Slovenian psychiatry is predominantly hospital based. A programme for the development of general community psychiatric services was proposed to improve access to and quality and comprehensiveness of psychiatric care according to the modern standards of delivery of psychiatric services.Aim The aim of the paper is to present the programme for developing community services that was proposed to the Slovenian government, and to describe the barriers to its implementation that were encountered, as well as the errors made by the programme authors, that contributed to the rejection of the programme last year.Conclusions There are historical, political, professional and service organisation characteristics that impede the development of community psychiatry in Slovenia. These are to be addressed through coordinated action involving primary care professionals, non-government organisations with service users and carers, the Health Insurance Agency and politicians involved in the planning of health services.     

Community-based mental health care in Africa: mental health workers’ views

The World Health Organization (WHO) has for long proposed the development of community-based mental health services worldwide. However, the progress toward community mental health care in most African countries is still hampered by a lack of resources, with specialist psychiatric care essentially based in large, centrally located mental hospitals. It is again time to reconsider the direction of mental health care in Africa. Based on a small inquiry to a number of experienced mental health professionals in sub-Saharan Africa, we discuss what a community concept of mental health care might mean in Africa. There is a general agreement that mental health services should be integrated in primary health care. A critical issue for success of this model is perceived to be provision of appropriate supervision and continuing education for primary care workers. The importance of collaboration between modern medicine and traditional healers is stressed and the paper ends in a plea for WHO to take the initiative and develop mental health services according to the special needs and the socio-cultural conditions prevailing in sub-Saharan Africa.     

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.     

Steps,challenges and lessons in developing community mental health care

This paper summarises our own accumulated experience from developing community-orientated mental health services in England and Italy over the last 20-30 years. From this we have provisionally concluded that the following issues are central to the development of balanced mental health services: a) services need to reflect the priorities of service users and carers; b) evidence supports the need for both hospital and community services; c) services need to be provided close to home; d) some services need to be mobile rather than static; e) interventions need to address both symptoms and disabilities; and f) treatment has to be specific to individual needs. In this paper we consider ten key challenges that often face those trying to develop community-based mental health services: a) dealing with anxiety and uncertainty; b) compensating for a possible lack of structure in community services; c) learning how to initiate new developments; d) managing opposition to change within the mental health system; e) responding to opposition from neighbours; f) negotiating financial obstacles; g) avoiding system rigidities; h) bridging boundaries and barriers; i) maintaining staff morale; and j) creating locally relevant ser- vices rather than seeking “the right answer” from elsewhere.     

Reform of mental health care in Serbia: ten steps plus one

Disastrous events in the country and the region caused a 13.5% increase in the prevalence of mental and behavioral disorders in Serbia in the last few years, thus making them the second largest public health problem. Due to prolonged adversities, the health system has deteriorated and is facing specific challenges. However, the reform of mental health care has been initiated, with a lot of positive movements such as the preparation of a national policy for mental health care and a law for protection of mentally ill individuals. The transformation of mental health services has started, with an accent on community care, antistigma campaigns and continuing education. Based on an assessment carried out by the National Committee on Mental Health, service provision, number of professionals working in services, funding arrangements, pathways into care, user/carer involvement and other specific issues are reported.     

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.     

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.     

Task-shifting in HIV care: a case study of nurse-centered community-based care in Rural Haiti

Introduction

At least 36 countries are suffering from severe shortages of healthcare workers and this crisis of human resources in developing countries is a major obstacle to scale-up of HIV care. We performed a case study to evaluate a health service delivery model where a task-shifting approach to HIV care had been undertaken with tasks shifted from doctors to nurses and community health workers in rural Haiti.

Methods

Data were collected using mixed quantitative and qualitative methods at three clinics in rural Haiti. Distribution of tasks for HIV services delivery; types of tasks performed by different cadres of healthcare workers; HIV program outcomes; access to HIV care and acceptability of the model to staff were measured.

Results

A shift of tasks occurred from doctors to nurses and to community health workers compared to a traditional doctor-based model of care. Nurses performed most HIV-related tasks except initiation of TB therapy for smear-negative suspects with HIV. Community health workers were involved in over half of HIV-related tasks. HIV services were rapidly scaled-up in the areas served; loss to follow-up of patients living with HIV was less than 5% at 24 months and staff were satisfied with the model of care.

Conclusion

Task-shifting using a community-based, nurse-centered model of HIV care in rural Haiti is an effective model for scale-up of HIV services with good clinical and program outcomes. Community health workers can provide essential health services that are otherwise unavailable particularly in rural, poor areas.     

Low-intensity workers: lessons learned from supervising primary care mental health workers and dilemmas associated with such roles

The UK government's latest primary care mental health initiative, Improving Access to Psychological Therapies (IAPT), seeks to achieve its aims partly through the extensive use of low-intensity workers (LIWs). As clinical supervisors to teams of primary care mental health workers (PCMHWs) already offering brief, evidence-based interventions in primary care mental health services, we draw on the growing body of literature and our own experience to discuss dilemmas associated with the roles of such workers. These concern clinical governance, training, supervision and integration into existing services. We discuss how IAPT service characteristics may provide solutions to some of these dilemmas. We argue that it is unlikely they will be completely resolved and that IAPT services, in addressing future challenges, could benefit from lessons learned from the PCMHW role.     

WPA guidance on steps,obstacles and mistakes to avoid in the implementation of community mental health care

This paper provides guidance on the steps, obstacles and mistakes to avoid in the implementation of community mental health care. The document is intended to be of practical use and interest to psychiatrists worldwide regarding the development of community mental health care for adults with mental illness. The main recommendations are presented in relation to: the need for coordinated policies, plans and programmes, the requirement to scale up services for whole populations, the importance of promoting community awareness about mental illness to increase levels of help-seeking, the need to establish effective financial and budgetary provisions to directly support services provided in the community. The paper concludes by setting out a series of lessons learned from the accumulated practice of community mental health care to date worldwide, with a particular focus on the social and governmental measures that are required at the national level, the key steps to take in the organization of the local mental health system, lessons learned by professionals and practitioners, and how to most effectively harness the experience of users, families, and other advocates.     

Collaboration between general practitioners (GPs) and mental healthcare professionals within the context of reforms in Quebec

Background In the context of the high prevalence and impact of mental disorders worldwide, and less than optimal utilisation of services and adequacy of care, strengthening primary mental healthcare should be a leading priority. This article assesses the state of collaboration among general practitioners (GPs), psychiatrists and psychosocial mental healthcare professionals, factors that enable and hinder shared care, and GPs’ perceptions of best practices in the management of mental disorders. A collaboration model is also developed.Methods The study employs a mixed-method approach, with emphasis on qualitative investigation. Drawing from a previous survey representative of the Quebec GP population, 60 GPs were selected for further investigation.Results Globally, GPs managed mental healthcare patients in solo practice in parallel or sequential follow-up with mental healthcare professionals. GPs cited psychologists and psychiatrists as their main partners. Numerous hindering factors associated with shared care were found: lack of resources (either professionals or services); long waiting times; lack of training, time and incentives for collaboration; and inappropriate GP payment modes. The ideal practice model includes GPs working in multidisciplinary group practice in their own settings. GPs recommended expanding psychosocial services and shared care to increase overall access and quality of care for these patients.Conclusion As increasing attention is devoted worldwide to the development of optimal integrated primary care, this article contributes to the discussion on mental healthcare service planning. A culture of collaboration has to be encouraged as comprehensive services and continuity of care are key recovery factors of patients with mental disorders.     

Integration of child mental health services to primary care: challenges and opportunities

In the first decade of this new millennium, health professionals are faced with a rapidly increasing need for child mental health services and changing models of service provision. This gives us a unique opportunity to make provision for services where it has not been available before, or to improve upon the existing services. This paper examines the challenges and opportunities while attempting to integrate child mental health services to primary care.     

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.     

Exploring core competencies for mental health and addictions work within a Family Health Team setting

Approximately 200 Family Health Teams (FHTs) have been implemented in Ontario to improve access to primary healthcare, including mental health and addiction. The objectives of this project were to examine, through a focus group and qualitative methodology with three FHTs, the profile of patients'' mental health and addiction-related needs and to identify the implications for the development of core competencies in these innovative organisations. A spectrum of needs and service trajectories was identified, as well as the importance of a wide range of clinical skills and knowledge. The results indicate that ‘core’ competencies for mental health work in the context of an FHT go well beyond those required for an embedded mental health ‘programme’ or specialised mental health counsellors, but rather they relate to the core and discipline-specific competencies of members of the entire team. In addition to specific knowledge and skills, competencies include common attitudes and values relating to teamwork, good communication and collaboration. Challenges were noted with regard to working with some community service providers, especially addiction services. Implications for core competencies at the individual and organisational level were identified.     

OMA's Continuing Education Program

Confronted with the inability to offer access to trained mental health personnel to their remote rural community, a private medical group practice in California recruited and integrated psychiatric social workers in their clinic. The rapid acceptance of these newer mental health professionals by community members of all economic levels and by group physicians confirms the success of this program, now in its fourth year, and rising community interest in mental health services.The group practice prototype affords a unique opportunity for innovation in community health care delivery in outlying areas with their traditional difficulties in attracting health care professionals.     

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.     

Impact of a one-week intensive ‘training of trainers’ workshop for community health workers in south-west Nigeria

Background There is a huge unmet need for mental health services in low- and middle-in-come countries such as Nigeria. It has been suggested that one way of bridging the service gap is to plan for the effective integration of mental health services into primary care. We present the impact of a one-week training workshop on attitudes to and knowledge of mental health issues among the tutors of community health workers.Method An intensive one-week training workshop was organised for 24 trainers of community health officers from eight Nigerian states. The package was designed for the training of primary care workers in low-income countries by one of the authors (RJ). Participants completed a questionnaire designed to assess knowledge of and attitudes to mental health issues before and on completion of the training.Results There were 24 participants with a mean age of 47 years (SD ± 4.89). Eighteen (75%) of the participants were female. The overall assessment of knowledge of mental health issues increased from a mean score of 60.4% before training to a mean score of 73.7% after the training (t-test = 4.48, P = 0.001).Conclusion We reported a significant improvement in the knowledge and attitudes of tutors of community health workers following an intensive one-week training workshop. This, we believe, should improve the quality of pre-service mental health training for community health workers and hopefully impact on mental health service delivery at the primary healthcare level.     

Beyond the Biomedical: Community Resources for Mental Health Care in Rural Ethiopia

BackgroundThe focus of discussion in addressing the treatment gap is often on biomedical services. However, community resources can benefit health service scale-up in resource-constrained settings. These assets can be captured systematically through resource mapping, a method used in social action research. Resource mapping can be informative in developing complex mental health interventions, particularly in settings with limited formal mental health resources.MethodWe employed resource mapping within the Programme for Improving Mental Health Care (PRIME), to systematically gather information on community assets that can support integration of mental healthcare into primary care in rural Ethiopia. A semi-structured instrument was administered to key informants. Community resources were identified for all 58 sub-districts of the study district. The potential utility of these resources for the provision of mental healthcare in the district was considered.ResultsThe district is rich in community resources: There are over 150 traditional healers, 164 churches and mosques, and 401 religious groups. There were on average 5 eddir groups (traditional funeral associations) per sub-district. Social associations and 51 micro-finance institutions were also identified. On average, two traditional bars were found in each sub-district. The eight health centres and 58 satellite clinics staffed by Health Extension Workers (HEWs) represented all the biomedical health services in the district. In addition the Health Development Army (HDA) are community volunteers who support health promotion and prevention activities.DiscussionThe plan for mental healthcare integration in this district was informed by the resource mapping. Community and religious leaders, HEWs, and HDA may have roles in awareness-raising, detection and referral of people with mental illness, improving access to medical care, supporting treatment adherence, and protecting human rights. The diversity of community structures will be used to support rehabilitation and social reintegration. Alcohol use was identified as a target disorder for community-level intervention.