What are the ethics of care in mental health disorders?

Psychiatry is undergoing a major crisis, on both an institutional as well as a clinical level. Numerous players involved in psychiatry feel in difficulty and are increasingly raising questions as to what direction and meaning to give to their practice. It is in such a context that ethics can help us to progress, reflect and build the future together. It is high time to create the specific basis of ethics in psychiatry.     

The influence of state mental health perceptions and spending on an individual’s use of mental health services

Purpose

To explore the possible contextual effects of state-level mental health perceptions and public spending for mental health treatment on an individual’s use of mental health services, independent of the individual’s own perceptions.

Methods

Cross-sectional data from the 2007 Behavioral Risk Factor Surveillance System were used. A total of 216,514 participants from 35 states and the District of Columbia were included in the study. Logistic regression and multilevel modeling were used to estimate the effects of individual-level characteristics and three state-level factors—per capita spending on community mental health services, aggregated perceptions of the effectiveness of mental health treatment and the stigma of mental illness—on the individual’s current use of mental health services.

Results

Adjusting for the individual’s perceptions and characteristics, state-level perception of treatment effectiveness was positively associated with the use of mental health services [odds ratio (OR) for 5 % increase in the percentage perceiving effectiveness = 1.08; 95 % confidence interval (CI): 1.01, 1.16]. This association was strongest for individuals who experienced 1–4 days of mental distress in the past 30 days (OR = 1.17; 95 % CI 1.06, 1.29). State-level public spending on community mental health services was also positively associated with an individual’s use of mental health services (OR for a $40 increase in spending = 1.09; 95 % CI 1.01, 1.17); however, state-level perceptions of mental-illness stigma was not.

Conclusions

Our findings suggest there may be contextual effects of state-level perceptions of treatment effectiveness and state spending on community mental health services on the use of mental health services.     

The volume-quality relationship of mental health care: does practice make perfect?

OBJECTIVE: An extensive literature has demonstrated a relationship between hospital volume and outcomes for surgical care and other medical procedures. The authors examined whether an analogous association exists between the volume of mental health delivery and the quality of mental health care. METHOD: The study used data for the 384 health maintenance organizations participating in the Health Employer Data and Information Set (HEDIS), covering 73 million enrollees nationwide. Analyses examined the association between three measures of mental health volume (total annual ambulatory visits, inpatient discharges, and inpatient days) and the five HEDIS measures of mental health performance (two measures of follow-up after psychiatric hospitalization and three measures of outpatient antidepressant management), with adjustment for plan and enrollee characteristics. RESULTS: Plans in the lowest quartile of outpatient and inpatient mental health volume had an 8.45 (95% CI [confidence interval]=4.97-14.37) to 21.09 (95% CI=11.32-39.28) times increase in odds of poor 7- and 30-day follow-up after discharge from inpatient psychiatric hospitalization. Low-volume plans had a 3.49 (95% CI=2.15-5.67) to 5.42 (95% CI=3.21-9.15) times increase in odds of poor performance on the acute, continuation, and provider measures of antidepressant treatment. CONCLUSIONS: The large and consistent association between mental health volume and performance suggests parallels with the medical and surgical literature. As with that previous literature, further work is needed to better understand the mechanisms underlying this association and the potential implications for using volume as a criterion in plan choice.     

What do mental health professionals really think of family members of mental health patients?

Mental health professionals working at three rural public community mental health agencies were asked for their views on the families of mental health patients. Findings revealed themes that included families as supportive caregivers, as unsupportive agitators, as in pain, as uninformed, and as unequal partners. Implications for clinical intervention, education, and research are discussed.     

Delayed discharge—a solvable problem? The place of intermediate care in mental health care of older people

The National Service Framework for Older People envisages the development of intermediate care for older people. This study examined the possible role of intermediate care beds within mental health trusts. We interviewed senior clinicians in an inner city old age psychiatry service about the 91 current in-patients on the old age psychiatric wards. Sixty-five were classified as acute patients and the remaining 26 were continuing care patients. Structured instruments were used to collect information regarding neuropsychiatric symptoms, activities of daily living and current met and unmet needs. Where discharge was delayed an assessment was made regarding the appropriateness for an intermediate care setting according to the criteria set by the Department of Health guidelines. A total of 30 (46%) patients' discharges were delayed. Of these, 19 (29%) patients met the DOH criteria for intermediate care; 10 (53%) had dementia, five (26%) affective disorder, and four (21%) with schizophrenia. The 11 other delayed discharges were because of lack of availability of finance for placements. The study found that the prompt discharge of older patients from acute psychiatric care was a significant problem and many of those patients may benefit from the therapeutic and rehabilitative process afforded by intermediate care.     

Social services day care and health services day care in mental health: do they differ?

BACKGROUND: The difference between the services provided by day hospitals and day centres is far from clear. The supposition that day hospitals would provide an acute service, while day centres would offer social support for a more chronic population has been contentious and there is little evidence of how they are currently used. AIMS: We aimed to ascertain the differences between day hospitals (partial hospitalisation) and social service day centres in functions and roles, as perceived by staff, service users and referrers. METHODS: The views of service users and staff at two day hospitals and four day centres were ascertained through questionnaires and interviews, along with those of staff of eight Community Mental Health Teams, who constitute the sole pathway to the two services. RESULTS: Day hospitals were perceived by both referrers and clients to offer short-term, more intensive 'treatment' to more acutely ill people in need of mental health monitoring. Day centres were perceived to offer longer-term support, particularly social support, to people more likely to have longer-term and psychotic illnesses. CONCLUSION: There is currently a clear distinction between day centres and day hospitals, in key features of their services and client groups. It would be unwise to treat them as interchangeable.     

Architecture signifying social control: the restoration of asylumdom in mental health care?

Prior to the era of community care, the asylum has been an architectural manifestation of the power of psychiatry and the State. Asylumdom was a period in which custodial warehouses were used by the State to store sections of the population considered to be 'unreasonable'. There are signs, however, of a re-birth of asylumdom in both the UK and Australia. For example, there is a projected growth in the number of 'secure units' in the community, and a growing concern with issues of security and risk management in mental health care. Furthermore, new technologies for containment and surveillance are being installed in acute inpatient psychiatric units. Once again the asylum will symbolize emphatically the authority of the State (and its agencies of social control), and re-emphasize the exclusion of 'unreason' from the 'reasonable' society.     

Monitoring the impact of COVID-19 pandemic on mental health: a public health challenge? Reflection on Italian data

A recent Italian report on medicines use during COVID-19 epidemic outlined a non-significant increase in outpatient pharmaceutical antidepressant consumption in March and a significant increase in anxiolytic consumption. Along with this, an analysis of psychiatric hospitalizations in Lombardy revealed a reduction in voluntary admissions in the 40 days after the beginning of COVID-19 epidemic in Italy. Nevertheless, several studies reported a greater prevalence of depressive and anxiety symptoms in the Italian general population during the lockdown compared to before the pandemic. Furthermore, the request for psychological support by the Italian population appeared to be high during lockdown. Indeed, the Italian Ministry of Health declared that more than 50,000 calls to the telephone number for psychological support activated by the Ministry of Health and the Civil Protection because of the pandemic, with peaks during the lockdown. In addition, looking at Google Trends, the greatest searching activity for “psychological support” in recent years was detected the week of the 26th April 2020, followed by the week of the 22nd March 2020. We think that stronger indicators of mental health status and psychological well-being should be found to understand the long-term effects of the pandemic. The necessity of research for population-level and universal strategies is urgent, through repurposing, developing, and testing interventions to create evidence-based action plans for the entire population. Lastly, it is also essential to keep offering a psychological support suitable for all as done in past months to help individuals who have fewer opportunities to access care.

     

What drives changes in institutionalised mental health care? A qualitative study of the perspectives of professional experts

Background

Since 1990, the provision of mental healthcare has changed substantially across Western Europe. There are fewer psychiatric hospital beds and more places in forensic psychiatric hospitals and residential facilities. However, little research has investigated the drivers behind these changes. This study explored qualitatively the perspectives of mental health professional experts on what has driven the changes in Western Europe.

Methods

In-depth interviews were conducted with twenty-four mental health experts in England, Germany and Italy, who as professionals had personal experiences of the changes in their country. Interviewees were asked about drivers of changes in institutionalised mental health care from 1990 to 2010. The accounts were subjected to a thematic analysis.

Results

Four broad themes were revealed: the overall philosophy of de-institutionalisation, with the aim to overcome old-fashioned asylum style care; finances, with a pressure to limit expenditure and an interest of provider organisations to increase income; limitations of community mental health care in which most severely ill patients may be neglected; and emphasis on risk containment so that patients posing a risk may be cared for in institutions. Whilst all themes were mentioned in all three countries, there were also differences in emphasis and detail.

Conclusions

Distinct factors appear to have influenced changes in mental health care. Their precise influence may vary from country to country, and they have to be considered in the context of each country. The drivers may be influenced by professional groups to some extent, but also depend on the overall interest and attitudes in the society at large.

     

Correspondence of perceptions about centenarians’ mental health

Objectives: The goals of this study were to uncover the criteria by which centenarians, proxy/caregivers, and interviewers rated centenarians’ mental health. Often proxy and interviewer reports are obtained in studies of the oldest-old and become a primary source of information.

Methods: Data were from a population-based sample of mentally competent US centenarians in northern Georgia. The dependent variables were based on alternative reports for the centenarians’ mental or emotional health. Regression analysis was used to predict each source's rating of mental health separately with the same set of variables. These variables included information obtained from the centenarians and proxies about their distal experiences, demographics, and proximal resources including Mini-Mental Status Examination (MMSE), health, personality, socioeconomic resources, and coping behaviors.

Results: Examination of mean-level differences between sources revealed similarity across mental health ratings. For centenarians and proxies, perceived economic status was a very important predictor of mental health. For centenarians and interviewers, personality (neuroticism and extraversion) was an important common predictor. The interviewer and proxy mental health ratings were strongly associated with MMSE, but that was not the case for centenarians.

Conclusion: Mean-level findings and the comparative regression results provide corroborating evidence that centenarians’ self-reports of mental health are similar based on average ratings and presence of common associations with other raters (i.e., perceived economic status and personality). Implications of differences across rater pairs are discussed as guidance about the comparative value of substitution of proxies as informants for addressing specific influences on mental health.     

Coercion, involuntary treatment and quality of mental health care: is there any link?

PURPOSE OF REVIEW: This paper summarizes major results and debates in the field of coercive or involuntary treatment of the mentally ill and how these relate to the quality of care, as published in literature during 2002 and 2003. RECENT FINDINGS: Studies focus on four major issues: involuntary hospital placement and treatment of mentally ill patients, compulsory outpatient treatment, attitudes towards or perceived coercion, and ethics of coercive measures in mental health care. Studies suggest a complex correlation between the involuntary placement of mentally ill patients, coercive measures, and outcomes. Outcome indicators for the quality of mental health care are not standardized, but vary with the point of view of the individual or collective assessor. None of the results question the necessity or the legality of involuntary treatments or conclude to refrain from employing coercive measures in mental health care if these cannot be avoided. Many results of research on attitudes towards involuntary treatments or perceived coercion suggest an acceptance of the application of coercive measures, even by the persons concerned, if the legal conditions are clearly defined. Research standards or study designs may benefit from some improvement. Study samples usually are small and only in rare cases has their selection been representative. SUMMARY: Research activities are remarkably few in number, especially considering the frequency of involuntary measures and the controversial perception or discussion of these measures among the persons concerned, professionals, or a wider public. Many basic research questions still remain to be adequately addressed, such as the long-term effects of involuntary treatment.     

Is health care a right or a commodity? Implementing mental health reform in a recession

The Patient Protection and Affordable Care Act, signed into law by President Obama in March 2010, contains elements of two seemingly contradictory positions: health care as a commodity and as a right. The commodity argument posits that the marketplace should govern demand, supply, and costs of care. The law's establishment of state insurance exchanges reflects this position. The argument that health care is a right posits that it is a need, not a choice, and that government should regulate care standards that may be compromised as insurers attempt to minimize costs. The law's requirement for coverage of mental and substance use disorders reflects this position. This Open Forum examines these arguments in light of current state fiscal crises and impending reforms. Despite the federal government's interest in expanding prevention and treatment of mental illness, states may demonstrate varying levels of commitment, based in part on their perception of health care as a right or a commodity. The federal government should outline clear performance standards, with minimum services specified to maximize state commitments to services.