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.     

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.     

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.     

What should prompt an urgent referral to a community mental health team?

Background There is often little guidance to advise general practitioners on whether a referral to a community mental health team should be classified as 'urgent' or not.Aims (1) To identify the proportion and appropriateness of referrals considered urgent by the referrer; (2) To develop a set of criteria to guide what should constitute an 'urgent' referral.Methods One hundred consecutive referral letters to a community mental health team were analysed to determine the proportion that were considered urgent by the referrer compared to a consensus panel of psychiatrists. A Delphi group was then used to develop a set of criteria to guide referrers as to what should be regarded as an urgent referral.Results Thirty-three percent of referrals were deemed urgent by the referrer, compared to 17% by the psychiatric consensus panel, with little agreement between the two (kappa = 0.021, P = 0.013). Referrals that were made using a single assessment process (SAP) form were significantly more likely to be inappropriately marked as being urgent (P < 0.001). A set of 12 criteria was developed using the Delphi technique.Conclusions There was significant disagreement between the referrers and the assessing team as to which referrals required urgent attention. The findings justified the creation of guidelines, and this paper outlines a set of 12 criteria to guide what should prompt an urgent referral.     

Factors predicting drop‐out in community mental health centres

This study aimed to identify treatment, therapist and patient factors associated with dropping out of treatment in four outpatient mental health services. The experimental group comprised all 789 individuals who attended for the first time the mental health services during one year and dropped out of treatment in the same year or during the two following ones. The control group consisted of the same number of individuals, chosen at random from patients who, in the same year, attended for the first time the services and did not subsequently drop out of treatment. The overall drop-out rate was 33.2%. According to logistic regression analysis, the predictive factors of dropping out were: being treated in a particular centre, the involvement of more than one therapist in treatment, having no previous history of psychiatric disorders, being young and being male.     

论实施医改的有效路径——兼议安徽省基层医药卫生体制综合改革思路

为解决群众看病贵的问题,安徽省以实行药品零差率销售为着力点,实施基层医疗卫生机构的综合改革,建立起全新、高效的管理体制、运行机制和经费保障机制,真正使医疗卫生事业回归公益性。介绍了安徽省基层医药卫生体制基层综合改革的基本框架、改革措施的创新性及成效,分析了当前需要重视的几个问题。     

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.     

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.     

艺术体操运动员及场馆运动设备的真菌群落组成多样性及关联分析

体操运动员及运动设备的真菌群落组成的多样性,及安全风险研究是涉及公共安全及健康的重要课题。本研究在某体育学院37名平均年龄为19.5岁的艺术体操运动员进行训练后,现场采集手掌、脚跟、运动员的脚尖鞋腔、球、圈、把杆及地毯样本,基于rDNA-ITS的高通量测序,对上述各样本进行了真菌群落组成差异、α-多样性、各样本间共存属及独特属的分布以及样本与物种间的关联分析。结果表明,供试样本的分类单元涉及子囊菌门Ascomycota、担子菌门Basidiomycota、壶菌门Chytridiomycota和接合菌门Zygomycota共4门22纲57目。所测样本中,手掌的优势属为网孢盘菌属Aleuria,相对多度为84.9%;鞋腔的优势属为念珠菌属Candida,相对多度为17.55%;地毯的优势属为交链孢属Alternaria,相对多度为50.9%;把杆的优势属为小大卫霉科Davidiellaceae中的未定属;球（E）和圈（F）群落组成的相对多度分布则较均匀。α-多样性分析结果表明把杆（G）的真菌多样性最高（3.54）,其次为鞋腔（D）（3.18）,再其次为圈（F）（3.13）。样本间共存属及独特属的Venn图解析表明,手掌（A）、脚跟（B）、地毯（C）、鞋腔（D）、球（E）及把杆（G）6个样本上只有一个共存属,即小大卫霉科的一未定属。两个样本间的共存属中,G+D和G+E（分别为27和24个属）比较多。在独特种上,把杆（G）最高,鞋腔（D）和球（E）次之,其余独特属的数量均未超过10个。样本及物种间的关联分析表明,把杆（G）在3个中心度的测度中都处于最高值：度中心度（degree centrality）,0.793;接近中心度（closeness centrality）,0.715;中介中心度（betweenness centrality）,0.754。在体操房运动员与器械构成的网络中,把杆是处于网络中心;随后是器械球（E）和运动员的鞋腔（D）,在度中心度和中介中心度最低的是样本手掌（A）和地毯（C）,其测度分别仅为0.077和0.048;0.053和0.001。研究结论为：（1）测试样本间真菌群落组成差异十分明显,其中把杆、鞋腔、球和圈的群落组成丰富,而地毯和手掌则相对贫乏;（2）把杆的真菌组成种类较多,含有多种潜在的人体病原真菌;（3）艺术体操场馆中地毯、把杆是多种潜在病原真菌的共同载体,它们涉及的公共卫生安全,值得高度关注。     

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.     

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.     

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.     

我国二级及以上医疗机构开展公共卫生工作现况分析

目的 对二级以上医疗机构疾病预防控制等公共卫生工作现况进行评估。方法 对全国10个省163家医院进行二级以上医疗机构公共卫生工作开展基本情况调查和人员基本情况调查的问卷调查;对全国34个省、自治区、直辖市和新疆生产建设兵团进行函调以及对浙江、河南、辽宁和甘肃4个省进行实地调研。结果（1）医疗机构应承担的公共卫生职能与落实情况相差甚远。（2）医疗机构从事公共卫生工作积极性不高。（3）医疗机构在公共卫生工作中接受多个部门管理,但在工作中缺乏协调。结论（1）弥合临床医疗服务体系与公共卫生体系的割裂状态。（2）增强医疗机构从事公共卫生工作积极性。（3）加强督察考核,促进公共卫生工作的落实。     

长江口潮间带大型底栖动物群落演替

2006年1月在崇明岛西端的潮间带湿地进行了一项生态工程,经过土方工程的区域被选为大型底栖动物群落演替区,因为其中的大型底栖动物群落受到了较大破坏,在其周边未受干扰区设立对照样点。试图通过群落重建群的研究分析3个问题：（1）在群落恢复过程中不同的生态学指标如何变化？（2）群落演替过程中什么先增长,生物量还是复杂性？（3）是否可以选择生态学指标以利于演替过程中3类不同增长模式（生物量、网络结构和信息量）的识别？多变量分析用于检验被干扰区群落是否已经得到恢复。Shannon-Wiener指数、Margalef指数、Pielou均匀度指数、能质（exergy）和结构能质（Specificexergy）用于分析演替过程中群落状态的变化。结果显示物种随时间的更替与群落结构变化密切相关。物种丰富度增长迅速,而且对照区和演替区的物种组成非常相似。演替进行1个月左右之后,演替区的生物多样性已经超过了对照区。能质和结构能质提供了群落结构发展的有用信息,但仍然缺乏鉴别系统所处信息状态的能力。多样性分析结果可以从中度干扰假说（Intermediate Disturbance Hypothesis）得到很好地解释。总体而言,干扰的空间尺度决定了群落的恢复特征,如果干扰区域明显小于周边未受干扰的区域,那么群落的复杂性（信息量和网络结构）将先于生物量得到恢复。     

鼎湖山格木群落的生物量和光能利用效率

研究了鼎湖山南亚热带常绿阔叶林的生物量,发现其中格木（Ｅｒｙｔｈｒｏｐｈｌｅｕｍ ｆｏｒｄｉｉ）群落的生物量为５６８．１７２ｔ／ｈｍ＾２,叶面积指数为２７．８０２５ｍ＾２／ｍ＾２,均高于大面积分布的厚壳桂（Ｃｒｙｐｔｏｃａｒｙａ ｃｈｉｎｅｎｘｓｉｓ）群落。用红外线ＣＯ２气体分析法,分层测定了格木群落主要植物的光合速率和呼吸速度,计算了嫩落的生产力和光能利用率。结果表明,格木群落的总生产力为２７９