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.     

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.     

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.     

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.     

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.     

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.     

Partnerships for better mental health worldwide: WPA recommendations on best practices in working with service users and family carers

WPA President M. Maj established the Task Force on Best Practice in Working with Service Users and Carers in 2008, chaired by H. Herrman. The Task Force had the remit to create recommendations for the international mental health community on how to develop successful partnership working. The work began with a review of literature on service user and carer involvement and partnership. This set out a range of considerations for good practice, including choice of appropriate terminology, clarifying the partnership process and identifying and reducing barriers to partnership working. Based on the literature review and on the shared knowledge in the Task Force, a set of ten recommendations for good practice was developed. These recommendations were the basis for a worldwide consultation of stakeholders with expertise as service users, families and carers, and the WPA Board and Council. The results showed a strong consensus across the international mental health community on the ten recommendations, with the strongest agreement coming from service users and carers. This general consensus gives a basis for Task Force plans to seek support for activities to promote shared work worldwide to identify best practice examples and create a resource to assist others to begin successful collaboration.     

Lessons learned in developing community mental health care in Latin American and Caribbean countries

This paper summarizes the findings for the Latin American and Caribbean countries of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. It presents an overview of the provision of mental health services in the region; describes key experiences in Argentina, Belize, Brazil, Chile, Cuba, Jamaica and Mexico; and discusses the lessons learned in developing community mental health care.     

Integration of mental health into primary care and community health working in Kenya: context, rationale, coverage and sustainability

Integration of mental health into primary care is essential to meet population needs yet faces many challenges if such projects are to achieve impact and be sustainable in low income countries alongside other competing priorities. This paper describes the rationale and progress of a collaborative project in Kenya to train primary care and community health workers about mental health and integrate mental health into their routine work, Within a health systems strengthening approach. So far 1877 health workers have been trained. The paper describes the multiple challenges faced by the project, and reviews the mechanisms deployed which have strengthened its impact and sustainability to date.     

Patient characteristics that may predict the likelihood of the presence of mental health problems in patients attending the general outpatient clinic of a tertiary hospital in South-South Nigeria

Background A considerable number of patients seen in general outpatient clinics (GOPC) are known to suffer from psychiatric rather than physical disorders. Studies have shown that doctors working in these clinics have difficulty in making accurate ratings of mental health problems in their patients and have poor knowledge of psychiatric diagnosis. Accurate recognition of psychiatric symptoms in a patient is essential for specific diagnosis and successful management. There is a need for the use of an easy tool such as the12-item General Health Questionnaire (GHQ-12) for screening and identification of psychopathologies especially in a busy clinic setting like the GOPC. Aside from psychometric screening tools, patients' sociodemographic characteristics such as gender, age, marital status, occupation, education etc. have been found to be of value in predicting those at risk.Objectives This study seeks to correlate GHQ 'caseness' with sociodemographic factors and to compare physician diagnosis with GHQ diagnosis.Subjects and method Three-hundred and twenty-two respondents were recruited for the study by a systematic random sampling method. Using a cut off score of three on both the English and Efik translation versions of the GHQ-12, 'cases' and 'non-cases' generated were compared with the same classification as identified by the GOPC doctors. Identification rates for both groups were calculated and the coefficients determined using a two-by-two contingency table. Sociodemographic correlates were determined by statistical comparison of the classifications in both groups.Results Statistically significant differences in sociodemographic characteristics of respondents were found for age (χ(2)=48.97; P <0.05) and education (χ(2)=45.64; P=0.05) using their GHQ-12 scores, and for occupation (χ(2)=37.90; P <0.05) among those seen by the GOPC doctors. A further comparison of identified 'cases' and 'non-cases' by doctors again revealed significant difference for age (χ(2)=7.151; P <0.05). Sex as a sociodemographic characteristic showed no statistically significant difference though a greater percentage of females (57.3%) were observed as 'high scorers' as compared to their male counterparts (42.7%). The GHQ-12 identified 46.6% 'cases' while the GOPC doctors identified 6.8% among the attendees with a diagnostic sensitivity of 8% and a specificity of 94%, respectively.Conclusion Belonging to the 18-39 years age group, being employed and having less than 12 years of education were the patients' characteristics that suggested the likelihood of the presence of mental health problems.This study also revealed that despite the high proportion of psychiatric morbidity (46.6%) in the GOPC of the University of Calabar Teaching Hospital (UCTH) rate of detection by the clinic doctors was low (6.8%).It is recommended that primary care doctors should be alerted to the possibility that clinically significant psychiatric morbidity may be present in GOPC attendees. The correlation between patients' sociodemographic parameters and presence of mental health problems could be informative and should be given adequate attention during consultation.     

Dream work with children: Perceptions and practices of school mental health professionals.

In this study, 49 public school mental health practitioners (school counselors, school psychologists, and school social workers) completed a survey about working with students’ dreams. The majority of these practitioners reported having at least one student bring up dreams during counseling, more frequently with troubling dreams and nightmares or when coping with grief. Results showed that practitioners were less likely to talk about dreams with students who had been identified with an adjustment disorder, psychosis, or eating disorder; those who were oppositional or ill; and those who struggled with substance abuse problems. Although most practitioners did not feel competent working with children’s dreams and reported minimal training in dream work, they were interested in learning more about children’s dreams and potential uses of dream work in supportive counseling. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Correlation between mental health co-morbidity screening scores and clinical response in collaborative care treatment for depression

The hypothesis for this paper is that adult patients who have higher screening scores for mental health co-morbidities and depression have a greater likelihood of not responding to treatment with collaborative care management (CCM) for their depression within six months.For the 334 patients in this study, the primary endpoints were if the patient was in remission at six months (PHQ-9 score <5) or if they were non-responsive (NR) (PHQ-9 >50% of baseline score). Initial evaluation included screening for alcoholism (AUDIT), anxiety (GAD-7) and bipolar disorders (MDQ).The differences in marital status, percentage of minority patients, gender, initial PHQ-9 and AUDIT scores were not statistically significant. Mood Disorders Questionnaire (MDQ) screening was more likely to be negative for the group in remission (96.2% vs 90.0%, P=0.049) and positive for the NR group (8.0% vs 2.1%, P=0.026). GAD-7 screening was significantly lower in the remission group (9.85) than in the NR group (11.53, P=0.009).Results of multiple logistic regression analysis demonstrated that age, gender, race, marital status, PHQ-9 score and AUDIT score were not related to the odds of being NR. A one-point higher GAD-7 score was associated with approximately 6% higher adjusted odds of being NR. Patients with a positive MDQ were associated with elevated odds of non-response (adjusted OR=3.4714, P=0.044) when controlling for all other variables.A higher initial screening score for anxiety or bipolar disorder is associated with a statistically significant increase in the relative risk of patients in CCM not responding to current treatments for depression within six months.     

Measuring and improving the quality of mental health care: a global perspective

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology‐based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient‐centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement‐based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.     

‘Can he have the test for bipolar,doctor? His dad's got it’: exploring the potential of general practitioners to work with children and young people presenting in primary care with common mental health problems – a clinical initiative

Background General practitioners (GPs) play a key role in assessing and managing adult mental health problems, but this input is not seen in their management of child and adolescent mental health. Mental health problems in 5–19-year-olds are common, yet detection rates in primary care are low. The symptoms of most adult diagnoses of mental health problems are present by mid-adolescence, yet the typical time from onset to diagnosis is 5–15 years. The role of general practice in this area has been underexplored.Aim This pilot study explores the potential of GPs to respond to common mental health problems in children and adolescents.Design Children and young people who would have ordinarily been referred to Child and Adolescent Mental Health Services (CAMHS) were seen in a GP setting. In a UK general practice surgery serving a disadvantaged population.Method Children and young people were seen for an initial biopsychosocial assessment and formulation of the presenting concerns. GP-based interventions were offered as appropriate or referred to CAMHS.Results Data from the first 50 children (2–19 years) are presented. Twenty younger children (10 years and under) and 30 older children (11 years and above) were seen. Eighteen referrals were made to CAMHS. GP interventions included watchful waiting, brief behavioural interventions, non-directive counselling, brief cognitive– behavioural therapy (CBT) and liaison with colleagues in education, CAMHS and the voluntary sector.Conclusion This clinical pilot demonstrates that with adequate time, access to supervision and practice support, children and young people experiencing emotional and behavioural problems associated with common mental health issues can be helped in primary care.     

Reducing the treatment gap for mental disorders: a WPA survey

The treatment gap for people with mental disorders exceeds 50% in all countries of the world, approaching astonishingly high rates of 90% in the least resourced countries. We report the findings of the first systematic survey of leaders of psychiatry in nearly 60 countries on the strategies for reducing the treatment gap. We sought to elicit the views of these representatives on the roles of different human resources and health care settings in delivering care and on the importance of a range of strategies to increase the coverage of evidence-based treatments for priority mental disorders for each demographic stage (childhood, adolescence, adulthood and old age). Our findings clearly indicate three strategies for reducing the treatment gap: increasing the numbers of psychiatrists and other mental health professionals; increasing the involvement of a range of appropriately trained non-specialist providers; and the active involvement of people affected by mental disorders. This is true for both high income and low/middle income countries, though relatively of more importance in the latter. We view this survey as a critically important first step in ascertaining the position of psychiatrists, one of the most influential stakeholder communities in global mental health, in addressing the global challenge of scaling up mental health services to reduce the treatment gap.