Reform of mental health services in Eastern Europe and former Soviet republics: progress and challenges since 2005.

For over a decade, concerted efforts have been made in Europe to reform mental health services and move away from institutions to community-based models of care, supported by international policy statements, good practice examples and research evidence. Progress has been uneven. So what is the status of mental healthcare across the World Health Organization European Region, and what factors support, or detract from, such progress?

The state of psychiatry in Europe: facing the challenges, developing consensus.

All European countries are facing the challenge to address the very high prevalence of mental disorders with limited mental health resources, resulting in a treatment gap. Countries have drafted mental health strategies, replacing institutions with community based models of care with the aim to offer good and decent care. Psychiatry across Europe is very diverse, whether one considers models of care, resources, ways of working or training. Variation within countries, due to regionalization, can be as large as across frontiers. Valid comparisons of service delivery and their outcomes is essential for identification and dissemination of effective and efficient practice, but hampered by widely used but poorly defined terminology such as 'primary care' and 'community services', or assumptions about common ways of working. There is also still a lack of standardisation of outcome indicators. The combination of high morbidity and low supply in the presence of effective interventions is a strong argument in favour of investment, especially at times of growing need. It is necessary to support this argument with consistent evidence of improved outcome. It is essential that international groups now accept the challenge to reach consensus in order to advocate for more mental health resources.

Scaling up in Europe: learning from diversity.

Over the past decade, attention has increasingly focused on the need to increase the capacity of mental health services. The World Health Report 2001 - Mental Health: New Understanding, New Hope (World Health Organization, 2001) set the agenda, advocating the development of community-based mental health services. The case for scaling up, inspired by the World Health Organization's vision of 'no health without mental health', was powerfully argued first in the Lancet series in 2007 (Prince et al, 2007) and again in the Lancet in 2011 (Eaton et al, 2011). The forthcoming Global Mental Health Action Plan, requested in a resolution by member states of the World Health Organization at the 2012 World Health Assembly, is a great opportunity to formulate objectives and targets for countries, and to analyse experiences from around the world. The forthcoming European Action Plan builds on this, customising actions for European countries.

Challenging times for mental health services.

We are living in significant and challenging times for mental health services across the world. On the one hand, many countries are in the middle of comprehensive reforms of their mental health systems, and these require funding (WHO Europe, 2008). On the other, they are affected by the global financial crisis as regional and national economic recessions threaten to herald a social crisis in many countries. Governments have had to come up with multi-billion-dollar rescue packages. At an individual level, debt status is already high in many countries, owing to falling house prices and high consumption levels, combined with rising commodity prices during the past few years, before the onset of the recession. At a public level, countries will be forced to make stringent cuts in public sector expenditure.

Focus on mental health care reforms in Europe. Mental health services in Europe: an overview.

Psychiatric services in Europe are experiencing a period of change, driven by political commitment at national and intergovernmental levels in response to the public health challenges posed by mental health problems. However, diversity among European countries makes any generalization speculative. Resources such as funding, workforce, and infrastructure vary dramatically, and new investment is limited. Some European countries can take pride in sophisticated service systems, whereas others continue to rely almost exclusively on asylums. Reforms are hampered by a lack of comparable information and a lack of research, particularly in less developed countries. However, many exciting local initiatives are emerging, even in the poorest countries. The challenge will be to translate good local practice into national policies and practice, supported by adequate resources.

Challenges for psychiatry: delivering the Mental Health Declaration for Europe.

Mental health care is in the process of transformation across the European Region, due to a combination of recognition of disease burden, poor treatment conditions and demand from clinicians and the public. This transformation affects the scope of mental health, increasingly including promotion and prevention, and the structure and process of care, shifting to community based delivery. Many psychiatrists are in leadership positions, able to influence policies and strategies. But their work is also seriously affected by the consequences of these policies. New roles and responsibilities of all members of a multi-disciplinary team need to be planned, and education and training have to be designed to prepare professionals to deal with expectations and demands. Psychiatrists face major challenges, since their complex roles are affected in multiple ways by the psychiatric and general health system. Some of these challenges can be addressed by the psychiatric profession and their partners, including patient and family organizations; others require wide ranging changes in attitude and system design.

The components of good community care for people with severe mental illnesses: views of stakeholders in five European countries.

Researchers and practitioners collaborated in a project across five European countries aimed at defining the characteristics of good community care for people with severe mental illnesses and to explore the values ofstakeholders in this debate (clients, families, professionals, policy makers, other citizens). In a concept mapping procedure all stakeholders gave highest priority to a trusting and stimulating relationship between clients and professionals. Secondly, good care was seen as effective treatment tailored to the individual needs. Accessibility of services came in the third place. Differences between the views of stakeholders are discussed.

Characteristics of teams, staff and patients: associations with outcomes of patients in assertive outreach.

BACKGROUND: Little is known about what characteristics of teams, staff and patients are associated with a favourable outcome of severe mental illness managed by assertive outreach. AIMS: To identify predictors of voluntary and compulsory admissions in routine assertive outreach services in the UK. METHOD: Nine features of team organisation and policy, five variables assessing staff satisfaction and burn-out and eleven patient characteristics taken from the baseline data of the Pan-London Assertive Outreach Study were tested as predictors of voluntary and compulsory admissions within a 9-month follow-up period. RESULTS: Weekend working, staff burn-out and lack of contact of the patient with out and lack of contact of the patient with other services were associated independently with a higher probability of both voluntary and compulsory admission. In addition, admissions in the past predicted further voluntary and compulsory admissions, and teams not working extended hours predicted compulsory admissions in the follow-up period. CONCLUSIONS: Characteristics of team working practice, staff burn-out and patients' history are associated independently with outcome. Patient contact with other services is a positive prognostic factor.

Assertive outreach teams in London: models of operation. Pan-London Assertive Outreach Study, part 1.

BACKGROUND: Assertive outreach teams have been introduced in the UK, based on the assertive community treatment (ACT) model. It is unclear how models of community care translate from one culture to another or the degree of adaptation that may result. AIMS: To characterise London assertive outreach teams and determine whether there are distinct groups within them. METHOD: Semi-structured interviews with team managers plus one month's prospective process of care data collection were used to test for 'model fidelity' to ACT and, by cluster analysis, to identify groupings. RESULTS: Fidelity varied widely, with four teams (out of 24 studied) rated 'high fidelity' and three teams rated 'low fidelity' by US standards and 17 rated 'ACT-like'. Three clusters were identified, with voluntary sector teams being the most distinct group. CONCLUSIONS: There is wide variation in the practice of assertive outreach in London. The role of the voluntary sector requires increased attention. Heterogeneity in practice is a clinical challenge but a research opportunity in distinguishing effective from redundant components of the approach.

Assertive outreach teams in London: staff experiences and perceptions. Pan-London Assertive Outreach Study, part 2.

BACKGROUND: The job satisfaction, burn-out and work experiences of assertive outreach team staff are likely to be important to the model's sustainability. AIMS: To describe self-reported views and work experiences of staff in London's 24 assertive outreach teams and to compare these with staff in community mental health teams (CMHTs) and between different types of assertive outreach team. METHOD: Confidential staff questionnaires in London's assertive outreach teams (n=187, response rate=89%) and nine randomly selected CMHTs (n=114, response rate=75%). RESULTS: Staff in assertive outreach teams and CMHTs were moderately satisfied with their jobs, with similar sources of satisfaction and stress. Mean scores were low or average for all sub-scales of the Maslach Burnout Inventory for the assertive outreach team and the CMHT staff, with some differences suggesting less burn-out in the assertive outreach teams. Nine of the 24 assertive outreach teams had team means in the high range for emotional exhaustion and there were significant differences between types of assertive outreach team in some components of burn-out and satisfaction. CONCLUSIONS: These findings are encouraging, but repeated investigation is needed when assertive outreach teams have been established for longer.

Assertive outreach teams in London: patient characteristics and outcomes. Pan-London Assertive Outreach Study, part 3.

BACKGROUND: Although the model of assertive outreach has been widely adopted, it is unclear who receives assertive outreach in practice and what outcomes can be expected under routine conditions. AIMS: To assess patient characteristics and outcome in routine assertive outreach services in the UK. METHOD: Patients (n=580) were sampled from 24 assertive outreach teams in London. Outcomes--days spent in hospital and compulsory hospitalisation--were assessed over a 9-month follow-up. RESULTS: The 6-month prevalence rate of substance misuse was 29%, and 35% of patients had been physically violent in the past 2 years. During follow-up, 39% were hospitalised and 25% compulsorily admitted. Outcome varied significantly between team types. These differences did not hold true when baseline differences in patient characteristics were controlled for. CONCLUSIONS: Routine assertive outreach serves a wide range of patients with significant rates of substance misuse and violent behaviour. Over a 9-month period an average of 25% of assertive outreach patients can be expected to be hospitalised compulsorily. Differences in outcome between team types can be explained by differences in patient characteristics.