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.     

Implications of caring for an aging parent.

The burden of care for the aged often falls on their adult children, who are themselves stressed by the developmental tasks of middle age. These people are frequently unprepared for the role of caregiver, in which they become parents to their own parents. The author describes the potentially turbulent effect of this role and discusses the origin of the stresses that the caregiver may experience. Doctors need to recognize and deal with the negative feelings, such as resentment, anger, frustration, ambivalence, guilt and demoralization, that may arise in adult children who care for their parents. These emotions must be put into proper context if the mental and physical health of the caregivers as well as the vital support they provide for their elderly parents are to be maintained.     

First seven years of a new NHS mental handicap service 1974-81.

A new community-focused mental handicap service was started in a single-district area health authority in 1974. Almost 90% of all the severely mentally handicapped people in a population of 250,000 are now known to the service. Although two-thirds of long stay inpatients originally admitted with major behavioural problems have had them resolved, the remaining one-third with persisting problems are noted to have spent many years in large understaffed wards before transfer. Specialist services to mentally handicapped people are not synonymous with beds. The learning opportunities during the waking hours of a mentally handicapped person are where professional help must be concentrated, and extensive support services for those caring for the mentally handicapped at home must be set up. Absence of shared philosophies, policies, and planning among the health and local authorities has produced the problems and frustrations familiar to many professionals in mental handicap. Future developments must be based on clearly defined and declared principles.     

Are elderly people living alone an at risk group?

OBJECTIVE--To test the hypothesis that elderly people living alone are an at risk group with a high level of morbidity that makes high demands on health and social services. DESIGN--Secondary analysis of data from a community survey of 239 people aged 75 and over, identified from general practitioners'' age-sex registers. SETTING--Nine practices in the London boroughs of Brent and Islington. MAIN OUTCOME MEASURES--Scores on the mini-mental state examination; stated satisfaction with life; assessment of mobility; numbers of diagnoses of major physical problems; numbers of prescribed drugs taken; urinary incontinence; alcohol consumption; contacts with general practitioners and hospital outpatient and inpatient services; contact with community health and social services. RESULTS--There were significantly more women among those living alone (93/120 (78%) v 63/119 (53%); p < 0.0005) and the median age of elderly people living alone was higher (81 v 80; p < 0.04). Those living alone and those living with others showed no significant differences in measures of cognitive impairment, numbers of major physical diagnoses, impaired mobility, or use of general practitioner or hospital services. Stated satisfaction with life was somewhat higher in those living alone. Elderly people living alone were significantly more likely to have contact with chiropody, home help, and meals on wheels services and less likely to have someone they could contact in an emergency or at night. Living alone increased the likelihood of contact with one or more community health professionals (district nurses, health visitors, or chiropodists) considered as a group and also increased the likelihood of contact with social services as a whole. There was a tendency for more of those living alone than those living with others to have home visits from their general practitioners, but there were no significant differences in contact with hospital services between the two groups. CONCLUSIONS--Elderly people living alone do not have an excess of morbidity compared with those living with others and do not seem to be an at risk group requiring specifically targeted assessments. More help is needed to provide elderly people living alone with a point of contact in case of emergency.     

Perceptions About Oral Health and Utilization of Oral Health Care Services Among Urban Finnish Elderly1

A representative sample of urban elderly living at home were studied for their perceived problems of oral health, treatment need felt for these problems, and their utilization of oral health care services. The majority of these elderly were denture wearers. Nearly all of the denture-wearing elderly had problems with their dentures, and about half of the dentate elderly had problems with their remaining teeth. The number of problems perceived increased with deteriorating health and decreasing income. Half of the elderly with denture problems and two-thirds of those who had problems with remaining teeth felt they needed dental treatment. Multivariate analyses found the number of perceived problems, having some natural teeth, and perceived general health to be the most important determinants of their perceived treatment need. Although two-thirds of the studied elderly felt no barriers to seeking treatment, only half of them had made their last dental visit less than five years ago. Having some teeth remaining, oral health education experiences, and income were found to be the best predictors of service utilization. Altogether, affective and cognitive factors rather than socio-demographic differences appeared to determine the elderly's perceptions about treatment need and their actual utilization of dental services, emphasizing the necessity of oral health education approaches designed for the elderly.     

The Mental Health Consequences of the Recession: Economic Hardship and Employment of People with Mental Health Problems in 27 European Countries

Objectives

A period of economic recession may be particularly difficult for people with mental health problems as they may be at higher risk of losing their jobs, and more competitive labour markets can also make it more difficult to find a new job. This study assesses unemployment rates among individuals with mental health problems before and during the current economic recession.

Methods

Using individual and aggregate level data collected from 27 EU countries in the Eurobarometer surveys of 2006 and 2010, we examined changes in unemployment rates over this period among individuals with and without mental health problems.

Results

Following the onset of the recession, the gap in unemployment rates between individuals with and without mental health problems significantly widened (odds ratio: 1.12, 95% confidence interval: 1.03, 1.34). This disparity became even greater for males, and individuals with low levels of education. Individuals with mental health problems living in countries with higher levels of stigmatizing attitudes regarding dangerousness of people with mental illness were more vulnerable to unemployment in 2010, but not 2006. Greater agreement that people with mental health problems have themselves to blame, was associated with lower likelihood of unemployment for individuals with and without mental health problems.

Conclusion

These findings study suggest that times of economic hardship may intensify social exclusion of people with mental health problems, especially males and individuals with lower education. Interventions to combat economic exclusion and to promote social participation of individuals with mental health problems are even more important during times of economic crisis, and these efforts should target support to the most vulnerable groups.     

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.     

Patterns of dental caries and treatment experience in elderly Lithuanians

Objective: The aim of the study was to evaluate patterns of caries experience in a representative sample of Lithuanians, aged 65‐74. Methods: This cross‐sectional study included 301 participants (response rate 54%). Information was obtained from a clinical examination (caries experience, stimulated salivary flow rates and oral hygiene levels) and a questionnaire. The questionnaire comprised questions about oral, general, physical, mental and social health and about background, knowledge, attitudes and lifestyle. The study had a multidimensional approach to negative consequences of disease and positive aspects of health. For bivariate testing, t‐test, ANOVA and Spearman's correlation were used. Factor analysis was combined with linear multiple regression for a multivariate study of caries experience patterns. Results: Elderly Lithuanians were found to have lower levels of edentulousness (range 11‐15%) than elderly people in other European countries. The mean number of missing teeth was also lower than in any of the neighbouring countries. A comparison of dentate and edentulous groups did not show any major differences. Those who reported that they had general disease had higher levels of oral health maintenance. In dentate elderly, caries experience differed according to place of residence, fluoride content in the drinking water, socio‐economic status, gender, lifestyle, and many other factors. The multivariate approach explained 52%. 61% and 55% of the variation in the number of filled or sound teeth (FS‐T), delayed (DT) and missing teeth (MT) respectively. Conclusion: Levels of oral health maintenance and caries experience show substantial variation among elderly Lithuanians, according to many health‐related characteristics. These elderly people require appropriate oral care, just as much as people in other population sub‐groups.     

The aged: medical and social aspects

Physical health is affected by physiological aging that impacts on all tissues and organs, notably sensorial systems (hearing, sight), the locomotory and the immunological systems (lowering of resistance to infections). There is an increase with age in the incidence of many cancers (particularly breast, prostate, and colon cancers) and cardiovascular diseases. Regular check-ups are useful in order to take appropriate measures in time. It is important that people maintain regular physical activity and a balanced diet even up to an advanced age and the elderly must learn to adapt themselves to the ever-changing abilities of their organism. It is possible to slow down the aging process through good hygiene and often to maintain autonomy until the end of life. Mental health is threatened by impairment of mental functions, depressive tendencies, and the risk of senile dementia that cannot be foreseen or avoided. It appears that keeping intellectually active and having a good level of education impact favorably on mental aging. Social health depends, for a large part, on the way society accepts and treats the elderly. They must be kept integrated into society and allowed to live at home for as long as possible. Any measures of rejection, discrimination, and exclusion should be opposed. The dignity of the elderly must be respected and activities giving them a feeling of usefulness should be encouraged. It is important to help families who care for their parents at home, to develop and evaluate healthcare networks, and encourage medical professionals and social services to work together. The change in the demographic structure of France is a considerable phenomenon requiring a long-term strategy and not only superficial and cosmetic measures.     

The health of Indians in Canadian cities: a challenge to the health care system

It is well known that Canadian native people living on reserves have high morbidity and mortality rates, but less is known about the health of those who migrated to urban centres. Several studies have shown that these people have high rates of mental health problems, specific diseases, injuries, infant death and hospital admission. In addition, there is evidence that cultural differences create barriers to their use of health care facilities. The low socioeconomic status, cultural differences and discrimination that they find in cities are identified as the primary blocks to good health and adequate health care. More epidemiologic studies need to be done to identify health problems, needs and barriers to health care. Federal, provincial and civic governments along with the appropriate departments of faculties of medicine should begin working with native organizations to improve the health of native people living in Canada''s cities.     

Mental health and coping in a war situation: the case of Bosnia and Herzegovina

The latter part of the twentieth century has seen an increased concern for the implications of war for civilian populations, and more attention has been given to psychosocial impacts of uprooting and displacement. 'Loss of place', acute and chronic trauma, family disruption and problems of family reunification have become issues of concern. The war in Bosnia was characterized by massive displacement, disruption and loss of life, relatives and property. Health and psychosocial well-being were affected in a number of ways. There was an overwhelming loss of perceived power and self-esteem. Over 25%, of displaced people, for example, said they no longer felt they were able to play a useful role; even in non-displaced populations approximately 11% of those interviewed said that they had lost a sense of worth. Widespread depression and feelings of fatigue and listlessness were common and may have prevented people from taking steps to improve their situation. Almost a quarter of internally displaced people had a high startle capacity and said they were constantly nervous. Most adverse psychosocial responses increased with age and in a population that includes many elderly people this poses serious problems. The findings point to major challenges with respect to repatriation and reconstruction. They highlight the importance of family reunification and the facilitating of decision-making by affected people themselves. The findings also shed light on potential problems associated with over-dependence on external assistance and hence the need for people to be given the means of using their skills and knowledge to control their day-to-day lives.     

Acute psychiatric care: approaches to increasing the range of services and improving access and quality of care

Acute services for mental health crises are very important to service users and their supporters, and consume a substantial share of mental health resources in many countries. However, acute care is often unpopular and sometimes coercive, and the evidence on which models are best for patient experience and outcomes remains surprisingly limited, in part reflecting challenges in conducting studies with people in crisis. Evidence on best ap­proaches to initial assessment and immediate management is particularly lacking, but some innovative models involving extended assessment, brief interventions, and diversifying settings and strategies for providing support are potentially helpful. Acute wards continue to be central in the intensive treatment phase following a crisis, but new approaches need to be developed, evaluated and implemented to reducing coercion, addressing trauma, diversifying treatments and the inpatient workforce, and making decision‐making and care collaborative. Intensive home treatment services, acute day units, and community crisis services have supporting evidence in diverting some service users from hospital admission: a greater understanding of how best to implement them in a wide range of contexts and what works best for which service users would be valuable. Approaches to crisis management in the voluntary sector are more flexible and informal: such services have potential to complement and provide valuable learning for statutory sector services, especially for groups who tend to be underserved or disengaged. Such approaches often involve staff with personal experience of mental health crises, who have important potential roles in improving quality of acute care across sectors. Large gaps exist in many low‐ and middle‐income countries, fuelled by poor access to quality mental health care. Responses need to build on a foundation of existing community responses and contextually relevant evidence. The necessity of moving outside formal systems in low‐resource settings may lead to wider learning from locally embedded strategies.     

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.     

Towards remote monitoring and remotely supervised training

The growing number of elderly and people with chronic disorders in our western society puts such a pressure on our healthcare system that innovative approaches are required to make our health care more effective and more efficient. One way of innovating healthcare can be obtained by introducing new services that support and enable these elderly and people with chronic disorders in a more independent living and in self management with respect to their disorders. Examples of such services are remote monitoring and remotely supervised training (together RMT). Remote monitoring focuses on continuous monitoring of the health status with the assurance of assistance whenever required. Remotely supervised training focuses on efficient and effective individually tailored training anywhere and anytime with intensity not feasible in an intramural setting. It is expected that services of remote monitoring and remotely supervised treatment will become important for at least patients (safety, more in control, convenience), health care insurances (efficiency, cost reduction) and healthcare service providers (more effective care).RMT systems are in general quite complex distributed Information and Communication Technology (ICT) systems. RMT systems integrate ambulant sensing to measure relevant biosignals and (possibly) subject’s context information, secure data transport and storage, appropriate decisions support systems to assist in both technical and clinical decision making but also feedback on information to both patients and care providers. Feedback is essential for patients to make them aware of their health status, to give them a feeling of safety and to motivate and enable them to change/improve their health status. Feedback of information to healthcare professionals enables them in making appropriate decisions and to monitor changes/improvements in a patient’s health status.Despite this apparent complexity, these systems must be very dependable to be accepted and used in a healthcare setting. During the past years knowledge and experience has been gained with the development of the building blocks of RMT systems. In parallel, experience has been gained with respect to the challenges involved when using RMT systems in a clinical environment. Examples are: activity monitoring in low back pain, monitoring of spasticity, myofeedback in subjects with neck shoulder and lower back pain and post rehabilitation home training. Until now, the main focus has been on the technical realization of the sensing and transportation part of it. The development of intelligent decision support systems is still in its infancy and clinical validation studies and models how to implement these services and how to make them profitable are largely lacking.In conclusion, the combination of Biomedical Engineering with Information and Communication Technology has opened a new extensive area of research and development with a high potential to have substantial impact on our future healthcare.     

Self-Assessed General Health and Dental Status Among the Elderly in a Swedish County

A random sample of non-institutionalized elderly people in Örebro County, Sweden, has been examined. The present paper reports on the general health conditions obtained from interviews in this population and on the relation between general health and dental status. Eighty-one percent of the clinically examined subjects considered that they were healthy or fairly healthy. A higher percentage of women as compared to men regarded themselves to be moderately or very ill. Women also used more drugs than men did. Only 6% did not feel strong enough for extensive dental treatment. Physically handicapped people used dental services less than the rest of the population did. Otherwise, general health seemed to have limited influence on the use of dental services. Subjects with better dental status reported less frequent illness, chronic diseases, and medication as compared to subjects with poorer dental status. The self-assessed general health, also in the presence of age, sex, and residence variables, showed significant correlation with the dental status but not if socio-economic variables were also included in a regression model.     

Effects of preventive home visits to elderly people.

OBJECTIVES--To assess the effect of preventive home visits by public health nurses on the state of health of and use of services by elderly people living at home. DESIGN--Randomised controlled trial. SETTING--General population of elderly people in one of the southern regions of the Netherlands. SUBJECTS--580 subjects aged between 75 and 84 years randomly allocated to intervention (292) or control (288) group. INTERVENTIONS--Four visits a year over three years in intervention group. Control group received no home visits. MAIN OUTCOME MEASURES--Self rated health, functional state, well being, loneliness, aspects of the mental state (depressive complaints, memory disturbances), and mortality. Use of services and costs. RESULTS--Visits had no effect on the health of the subjects. In the group visited no higher scores were seen on health related measures, fewer died (42 (14%) v 50 (17%)), and community care increased slightly. In the control group more were referred to outpatient clinics (166 (66%) v 132 (55%)), and they had a 40% increased risk of admission (incidence rate ratio 1.4; 90% confidence interval 1.2 to 1.6). No differences were found in long term institutional care, and overall expenditure per person in the intervention group exceeded that in the control group by 4%. Additional analyses showed that visits were effective for subjects who initially rated their health as poor. CONCLUSIONS--Preventive home visits are not beneficial for the general population of elderly people living at home but might be effective when restricted to subjects with poor health.     

The elderly mentally ill--whose responsibility?

The elderly mentally ill make considerable demands on health and social services. To evaluate the need for these services a one-day census of all people aged 65 and over was carried out in an area containing 220 000 people (40 000 over 65). Data were obtained on the nursing needs and psychiatric state of the 2162 elderly people in hospital or local authority residential homes for the elderly, or living at home receiving care from the community nursing service. One-third were classified as having psychiatric problems, more than half of them being outside hospital. Residential homes and community nurses play a significant part in caring for the elderly mentally ill, and an integrated but flexible manpower policy is important.     

Physical healthcare of people with severe mental illness: everybody's business!

Aim People with severe mental illness are at higher risk of physical health problems. Guidelines recommend annual monitoring. An audit cycle was completed on individuals with severe mental illness under the care of an early interventions in psychosis (EIP) service to evaluate and improve physical health monitoring practice.Methods The number of patients who had undergone a physical health check in the previous year, and those having a record of it in their EIP notes, was examined. Interventions made between baseline audit and re-audit included improving awareness within the multidisciplinary EIP mental health team about the importance of physical health monitoring of people with severe mental illness and liaison with primary care health services.Results The number of patients undergoing at least one annual physical health check increased from 20% to 58%. Among patients who had undergone a physical health check at re-audit, a record of some or all the checks was available in the notes for 75% of patients.Clinical implications There is a need to improve awareness among mental health professionals about the importance of the physical health of people with severe mental illness and to make appropriate organisational changes.     

MENTAL HEALTH PROGRAMS—The Role of the Health Officer

Traditionally the treatment of mental illness has been a responsibility of state governments, but they have been unable to solve the problem with any degree of success.In spite of rationalizations as to why a health department should not become involved in this field, more and more local health departments in California and across the nation are initiating various services in mental health.With the widespread interest in mental health at national and state levels and in local citizens'' groups, local health officers must involve themselves in this most difficult effort.While the treatment of the emotionally disturbed and the psychotic is demanded most aggressively by the public which seeks outpatient, inpatient, and rehabilitation services on the local level, two services—consultation and education-information services—offer more hope in the promotion of mental health as contrasted with the treatment of mental illness.     

Mental health services--the user's view.

The needs of people with serious mental illnesses have dominated much of the debate on reforming community care. In this article Peter Campbell, who has used mental health services many times in the past, explains how the reforms could affect people like him. He welcomes the thinking behind the changes, particularly the idea that people who use community care should take part in planning services, but he warns that implementing the new philosophy might prove very difficult. Mr Campbell is secretary of a voluntary organisation for users of mental health services called Survivors Speak Out. The views he expresses here are his own, and do not necessarily reflect those of Survivors Speak Out.