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.     

Predicting improvement in stroke patients referred for inpatient rehabilitation.

An historical prospective study of prediction of improvement and final disposition of 105 patients with a stroke was carried out over a 2-year period in the rehabilitation service of a hospital providing long-term care. Patients were referred a mean of 37.8 days after the stroke, and were evaluated for total function and for mental status, perception, communication and motor ability at the time of admission and every 2 to 3 weeks thereafter. At the time of admission 26% of the patients were able to care for themselves; at the time of discharge 59% were able to do so, but 44% of these could not return home, primarily because of unfavourable social and environmental circumstances. In contrast, 35% of the patients unable to care for themselves went home because their families were willing to provide extra care. Neither the total function score nor the neurologic subtest scores at the time of admission predicted improvement. The presence of sphincter control and a lower age were the only significant predictors of improvement.     

WPA guidance on the protection and promotion of mental health in children of persons with severe mental disorders

This guidance details the needs of children, and the qualities of parenting that meet those needs. Parental mental disorders can damage the foetus during pregnancy through the action of drugs, prescribed or abused. Pregnancy and the puerperium can exacerbate or initiate mental illness in susceptible women. After their birth, the children may suffer from the social disadvantage associated with severe mental illness. The parents (depending on the disorder, its severity and its persistence) may have intermittent or prolonged difficulties with parenting, which may sometimes result in childhood psychological disturbance or child maltreatment. This guidance considers ways of preventing, minimizing and remedying these effects. Our recommendations include: education of psychiatrists and related professions about the effect of parental mental illness on children; revision of psychiatric training to increase awareness of patients as caregivers, and to incorporate relevant assessment and intervention into their treatment and rehabilitation; the optimum use of pharmacological treatment during pregnancy; pre-birth planning when women with severe mental illness become pregnant; development of specialist services for pregnant and puerperal women, with assessment of their efficacy; community support for parenting by mothers and fathers with severe mental disorders; standards of good practice for the management of child maltreatment when parents suffer from mental illness; the importance of multi-disciplinary teamwork when helping these families, supporting their children and ensuring child protection; the development of child and adolescent mental health services worldwide.     

Community Resilience in Southern Appalachia: A Theoretical Framework and Three Case Studies

A fundamental assumption in nearly all research on social adaptation to environmental change is that there is a concomitant and inverse relationship between human communities’ dependence upon particular natural resources affected by environmental change and those communities or societies’ resilience to disturbances. However, recent theoretical and empirical developments suggest resilience is a dynamic social process determined, in part, by the ability of communities to act collectively and solve common problems. The interactional approach to community is utilized to develop a framework whereby various patterns of social interaction define the process of social resilience. Data come from multiple mixed methods case studies of forest dependent communities within Southern Appalachia. The findings reveal varied processes of social resilience can occur in communities with similar levels of resource dependence; a community’s composition of internal social ties and their cross-scale linkages to external agencies and organizations define these processes.     

Stigmatization in the long-term treatment of psychotic disorders

Stigma is linked to negative prejudices without examining whether there is any justification for such behaviour. Over time, various efforts have been made to reduce prejudice toward people with mental illness. Yet, the World Health Organization (WHO) World Health Report still describes stigma as one of the greatest obstacles to the treatment of mental illness. While schizophrenia, among other mental illnesses, is the most stigmatized even to the point that some want the name of the illness to be hidden or changed, patients with bipolar illness may also be exposed to stigma. The degree of stigmatization has been found to be positively associated with the severity of the mental disorder, and stigma is carried out not only by patients but also by their families in correlation with the severity. Tragically, people with mental illness themselves are as negative in their opinions about mental illness as is the general public, and concerns about stigma adversely affect self-esteem and adaptive social functioning. There are many programmes worldwide for the fight against stigmatization, and there is clear recognition of the fact that stigma can only be successfully eliminated if the programme becomes a normal part of health service rather than of campaigns of limited duration.     

Mental Health Help-Seeking Intentions and Preferences of Rural Chinese Adults

Purpose

We aimed to investigate mental health help-seeking intentions and preferences of rural Chinese adults and determine predictors of the intentions.

Methods

A total of 2052 representative rural residents aged 18–60 completed a cross-sectional survey by face-to-face interviews. The survey included seven questions asking about respondents’ help-seeking intentions and preferences, and a series of internationally validated instruments to assess self-perceived health status, depression, anxiety, alcohol abuse, mental health literacy, and attitudes towards mental illness.

Results

Nearly 80% of respondents were willing to seek psychological help if needed, and 72.4% preferred to get help from medical organizations, yet only 12% knew of any hospitals or clinics providing such help. A multivariate analysis of help-seeking intention revealed that being female, having lower education, higher social health, higher mental health knowledge, and physical causal attribution for depression were positive predictors of help-seeking intention.

Conclusion

A huge gap exists between the relatively higher intention for help-seeking and significantly lower knowledge of helpful resources. Predictors of help-seeking intention for mental problems in the current study are consistent with previous studies. Interventions to increase help-seeking for mental problems by Chinese rural adults may be best served by focusing on increasing public awareness of help sources, as well as improving residents’ mental health literacy and social health, with special focus on males and those more educated.     

Conceptualization of psychiatric illness and help-seeking behavior among Chinese

Problem conceptualizations of Chinese psychiatric patients were studied in relation to the patterns of help-seeking and ways of coping. Patients who conceptualized their initial problems in purely psychological terms were more likely to use self-directed psychological coping methods, delay initial professional consultation, and approach mental health professionals. Patients who used only somatic concepts were least likely to approach mental health professionals initially or any time during their previous consultation history, and tended to approach medical resources to cope with their problems. Patients who conceptualized their problems in mixed terms approached professional help early on and reached psychiatric resources soonest. These results provide a clearer perspective to understand the somatization tendency among Chinese patients.     

Needs for care from a demand led community psychiatric service: a study of patients with major mental illness.

OBJECTIVE--To measure needs for care of patients aged 18-65 years with major mental illness. DESIGN. Identification of everyone in one area seen by a health professional within the previous five years because of a psychotic disorder. Interview of a one in three sample of patients and their main carers with the cardinal needs schedule. SETTING--Hamilton, a socially deprived district of Scotland. SUBJECTS--71 subjects were interviewed from the original sample of 263 patients. MAIN OUTCOME MEASURES--"Cardinal problems" in seven clinical and eight social areas of functioning; these are defined as problems requiring action. "Needs"-cardinal problems for which suitable interventions exist but have not been tried recently. RESULTS--High levels of morbidity were found. 30 interviewed patients (42%; 95% confidence interval 31% to 54%) had one or more clinical needs. 35 (49%; 38% to 61%) had one or more social needs. Skills to deal with all but seven needs in the sample were available at the time of investigation. Patients not being seen by the community mental health team were similar in severity and levels of need to those who were on the community team''s caseload. Care was unequivocally and severely inadequate for four patients. Shortcomings in service delivery usually arose from failure to monitor some patients at home. Problems were not due to shortage of acute psychiatric beds nor the absence of an elaborate assertive community care team. CONCLUSIONS--Systematic assessment of needs with research instruments can give valuable insights into the successes and failures of community care of people with major mental illness. Most needs could be dealt with in these patients but in our area (and probably most other parts of the United Kingdom) this would entail diversion of resources from people with less severe disorders.     

Hui family migration in Northwest China: patterns,experiences and social capital

Based on an extensive questionnaire survey in three cities in Northwest China, this article identifies the factors influencing the sole, couple and family migration of Han and Hui. We find that Han migrants are more utility-oriented and tend to circulate among different places in order to maximize their utility. Hui migrants are more likely to seek opportunities to settle in destinations with their families. They rely on Hui communities and dedicate themselves to creating networks and accumulating social capital for their families. We suggest that the accumulation of bonding capital does not necessarily suggest the increase or decrease of bridging capital. Moreover, the ethnic community should be regarded neither in negative nor positive terms but rather as a coin with two sides, pro and con. The ethnic community is a vessel, which migrants can use for minimizing risks, improving livelihoods and fostering the settlement of families.     

Preventive Psychiatry: The Psychiatric Team as Consultant to the Public Health Nurse

Various forms of collaboration between the disciplines of public health and psychiatry are briefly reviewed and the 25-year-old mental health program of the Vancouver Health Department is described. The public health nurse has prime responsibility in all children with emotional disorders. She is supported by a psychiatric team which provides active treatment and educational and consultative help for the nurse and the school. During the year 1963, six social workers had 2357 contacts with nurses and school personnel but only 1049 treatment interviews. Of 401 children referred to the psychiatric team, 138 received active clinic treatment, 141 remained under supervision by the public health nurse, and 122 were referred elsewhere. In addition, 1330 children were identified as “mental hygiene cases” in the caseload of the 170 public health nurses in the community. By close co-ordination, the public health nurse and the psychiatric team can enhance each other''s contributions to community mental health.     

Female competition and male territorial behaviour influence female chimpanzees' ranging patterns

Current models of chimpanzee social structure differ in the extent to which females range with the males and are loyal to a particular social group. We tested these models by analysing 18 years of observational data on the Gombe chimpanzees to investigate the relationship between female space use patterns and both female feeding competition and changes in the male-defended range boundaries. Females at Gombe typically spend most of their time in small overlapping core areas within the community range. Most core areas clustered into two neighbourhoods, north and south. Most females maintained a high degree of site fidelity, but altered their space use patterns to stay within a male-defended boundary. This overall pattern supports the male-bonded model of the chimpanzee social system, over the bisexual or male-only community models, but there are many exceptions. Some females were very peripheral and may have associated simultaneously with two communities. Others switched communities as adults. Thus, different individual females displayed a variety of space use patterns. Different space use patterns of individual females were associated with differences in reproductive success. Members of the northern neighbourhood had higher reproductive success than those of the south, and peripheral individuals either did very well or very poorly. Females that moved from one community to another as adults produced the fewest surviving offspring. These results suggest that female ranging patterns are influenced by both feeding competition and male territorial behaviour.     

Community mental health care in the Asia‐Pacific region: using current best‐practice models to inform future policy

The reporting of child sexual abuse (CSA) and physician-patient sexual relationships (PPSR) are currently the focus of professional, legal and media attention in several countries. This paper briefly reviews mental health policies on these issues and reports on a WPA survey of them. While the WPA Madrid Declaration permits breaching confidentiality for mandatory reporting of CSA and clearly prohibits PPSR, it is not known how or to what extent these policies are implemented in WPA Member Societies’ countries. It is also not known whether policies or laws exist on these topics nationally or to what extent psychiatrists and the public are aware of them. Representatives of WPA Member Societies were e-mailed a survey about issues pertaining to CSA and PPSR. Fifty-one percent of 109 countries replied. All reporting countries had laws or policies regarding the reporting of CSA, but this was often voluntary (63%) and without protection for reporting psychiatrists either by law (29%) or by Member Societies (27%). A substantial number of psychiatric leaders did not know the law (27%) or their Society’s policy (11%) on these matters. With respect to PPSR, some reporting countries lacked laws or policies about PPSR with current (17%) or past (56%) patients. Fewer than half of responding representatives believed that their Society’s members or the public were well informed about the laws and policies pertaining to CSA or PPSR. There is clearly a wide range of laws, policies and practices about CSA and PPSR in WPA Member Societies’ countries. There is a need in some countries for laws or supplemental policies to facilitate the protection of vulnerable child and adult patients through clear, mandatory reporting policies for CSA and PPSR. Mechanisms to protect and support reporting psychiatrists should also be developed where they do not already exist. There is also a need in some countries to develop strategies to improve the education of psychiatrists, trainees, and the public on these issues.The Asia-Pacific region has close to half of the estimated 450 million people affected by mental illness globally 1.Based on international mental health care benchmarks, many Western health systems have established contemporary health policy and guidelines which include the provision of mental health care in the community. However, the delivery of quality and appropriate community mental health care remains an ongoing challenge for countries of both high and low socio-economic level. Difficulties and obstacles in implementation of comprehensive community service models include inadequate funding, availability of trained mental health workforce, integration with primary care services and community agencies, and collaboration between public and private health systems 2 - 3. As community mental health service system depends on sufficient workforce for service delivery, the critical shortage of adequately trained mental health staff continues to impede the progress of mental health reform.In response to such global trends, many countries in the Asia-Pacific region have begun to establish mental health policy and guidelines to move from institutional care to community mental health services. While these reforms are supported by recommendations from the World Health Organization (WHO) governing bodies, such as the Western Pacific Regional Mental Health Strategy 4, social, economic and cultural factors in Asia-Pacific countries often do not allow ready translation of Western community mental health models of care. Governments and service providers commonly face challenges in the development and implementation of locally appropriate community mental health care and services. Additionally, it would be unrealistic or undesirable to produce rigid recommendations for a singular community mental health care model, due to the diversity across the Asia-Pacific region. Hence, for constructive change to occur in the region, innovative, culturally appropriate and economically sustainable pathways for community treatment models need to be explored, developed and shared. Community mental health service reform appears to be gaining momentum in this region, despite the obstacles. Valuable lessons and inspiration for further development can be gained from both the successes and difficulties in reforming mental health systems and practices in the region.An emerging network of representatives from governments, peak bodies and key organizations is emerging in the Asia-Pacific region to build supportive relationships in order to facilitate the implementation of locally appropriate policy frameworks for community mental health service reform. The network is supported by the Asia-Pacific Community Mental Health Development (APCMHD) project, which involves 14 countries/regions in the Asia-Pacific region. Initiated in collaboration with the WHO Western Pacific Regional Office, the APCMHD project is led by Asia-Australia Mental Health, a consortium of the University of Melbourne Department of Psychiatry and Asialink, and St. Vincent’s Health, which is a part of the WHO Collaborating Centre for Mental Health (Melbourne). The project, which brought many key mental health organizations to work collaboratively, is consistent with the WHO Global Action Programme for Mental Health 5.The project aims are to promote best practice in community mental health care through exchange of knowledge and practical experience in the Asia-Pacific region. The key outcome is the documentation of the current status, strengths and needs of community mental health services in the region, in the hope to translate current understanding into practical changes in the future.     

Chronic illness and functional limitation in Ontario children: findings of the Ontario Child Health Study.

The Ontario Child Health Study (OCHS) was based on interviews of 1869 Ontario families who were selected by means of a stratified, multistaged sampling method from the 1981 census of Canada. Its primary purpose was to determine the prevalence and distribution of mental health problems in Ontario children aged 4 to 16 years and their families, but it also allowed an estimate of other significant medical conditions and provided an overview of these children''s use of health care, education and social services. Our results are based on questionnaire responses concerning 3294 children. Limitation of function without a chronic illness or medical condition was reported in 1.9%, the converse in 14.0%, and a chronic illness or medical condition with limitation of function in 3.7%. When the three groups are considered together, 19.6% of Ontario children had a chronic health problem. Children of lower socioeconomic status were much more likely to have chronic health problems. Overall, children with chronic health problems were more likely to use physician, special education, social and mental health services. These findings have implications for those who provide services for children, plan community programs or train professionals in caring for children.     

HIV,Embodied Secrets,and Intimate Labour in Northern Nigeria

ABSTRACT

This article explores how HIV-positive women manage secrets through the use of their bodies. Women conspicuously enhance their beauty in an attempt to defend themselves against the violence of social exclusion. Moreover, they do so in order to forge safe, loving, and prosperous relationships with their boyfriends, husbands, and families. My goal is to understand how intimacy, as a material, affective, psychological, and embodied state, characterises these women's corporeal and sartorial acts. Further, I question how these embodied practices become imbricated in exchange relations with family members, health workers, and the larger community. To describe these routinised toils and triumphs as women seek to care for themselves and others, I employ the term ‘intimate labour’. I demonstrate how women gain access to social and economic resources by attending to and capitalising on the sensual and bodily desires and needs of others.     

The Isis Centre: a counselling service within the National Health Service.

A new centre has been established to provide readily accessible counselling, consultation, and mental health information. People may refer themselves or are recommended to attend by general practitioners or other agencies. The counsellors have varied backgrounds in paramedical or counselling services, and they are supported by psychiatrists. Of a sample of 100 clients, four were referred to one of the team''s psychiatrists and 33 visited the centre only once. The centre''s staff aim to adopt a flexible approach to the client and his problems, and formal psychiatric categories have not been found useful. Provision is made for people who want to solve their problems by discussion rather than medication and those for whom the existing psychiatric services may have little time to spare. Consequently, the approach adopted by the Isis Centre, whereby many people benefit from psychotherapy yet the psychiatrist deals directly with only a few selected cases, contributes towards meeting the great need for psychiatric services and using the psychiatrist''s skills more effectively.     

Working with the Family Doctor: A Programme for Mental Health

A new type of assessment for mental health in four Scottish counties has been based on multidisciplinary teams comprising psychiatrists, psychiatric social worker, nursing administrator, and a secretary. Each team collaborated with 15 to 20 family doctors and they established four main patterns of contact: around an outpatient clinic; by informal availability; by administrative and teaching seminars; or by regular consultation sessions. This improved contact was found to help both the team and the family doctors and reduced the number of patients admitted to hospital and the length of their stay and the number of urgent referrals. It emphasizes the need for team work in mental health care and that the hospital needs to remain in touch with the outside community.     

Factors Influencing Patient Pathways for Receipt of Cancer Care at an NCI-Designated Comprehensive Cancer Center

Background

Within the field of oncology, increasing access to high quality care has been identified as a priority to reduce cancer disparities. Previous research reveals that the facilities where patients receive their cancer care have implications for cancer outcomes. However, there is little understanding of how patients decide where to seek cancer care. This study examined the factors that shape patients’ pathways to seek their cancer care at a National Cancer Institute-designated comprehensive cancer center (NCI-CCC), and differences in these factors by race, income and education.

Methods

In-depth interviews and survey questionnaires were administered to a random sample of 124 patients at one NCI-CCC in the Northeast US. In-depth interview data was first analyzed qualitatively to identify themes and patterns in patients’ pathways to receive their cancer care at an NCI-CCC. Logistic Regression was used to examine if these pathways varied by patient race, income, and education.

Results

Two themes emerged: following the recommendation of a physician and following advice from social network members. Quantitative data analysis shows that patient pathways to care at an NCI-CCC varied by education and income. Patients with lower income and education most commonly sought their cancer care at an NCI-CCC due to the recommendation of a physician. Patients with higher income and education most commonly cited referral by a specialist physician or the advice of a social network member. There were no statistically significant differences in pathways to care by race.

Conclusions

Our findings show that most patients relied on physician recommendations or advice from a social network member in deciding to seek their cancer care at an NCI-CCC. Due to the role of physicians in shaping patients’ pathways to the NCI-CCC, initiatives that strengthen partnerships between NCI-CCCs and community physicians who serve underserved communities may improve access to NCI-CCCs.     

Psychiatric morbidity of a long stay hospital population with chronic schizophrenia and implications for future community care.

In the United Kingdom there are plans to close most mental hospitals over the next 10 years. There is continuing uncertainty about the effectiveness of community psychiatric services that will be expected to cope with mental hospital inpatients after discharge, most of whom have schizophrenia. A survey was conducted to assess the severity of illness among such patients and implications for their future care. All 222 patients in non-psychogeriatric long stay wards of a mental hospital who met research diagnostic criteria for schizophrenia were interviewed by two psychiatrists with the comprehensive psychopathological rating scale to establish the prevalence of psychiatric symptomatology. A complete interview was not possible for 28 patients, mainly for reasons related to their schizophrenia. Despite energetic pharmacological and social treatments almost half of the 194 patients interviewed had enduring florid psychotic symptoms that presented as one or more delusions or auditory hallucinations, or both, and a sizable proportion showed behaviour that would set them apart in a community setting. The results illustrate a problem that is still imperfectly understood by policy makers and administrators in central and local government and in health authorities who are responsible for planning and implementing services for psychiatric care in the community.