Mental health-related structural stigma and discrimination in health and social policies in Nepal: A scoping review and synthesis.

AIMS: National policies can be used to reveal structural stigma and discrimination in relation to mental health. This review assesses how structural stigma and discrimination are manifested in the policies and legislations of Government of Nepal. METHODS: Scoping review methodology was followed to review policy documents (acts of parliament, legislation, policies, strategies, guidelines and official directives) drafted or amended after 2010. RESULTS: Eighty-nine policies were identified related to health, social welfare, development and regulations which were relevant to people with psychosocial and mental disabilities or have addressed the mental health agendas. Several critical policy failings and gaps are revealed, such as the use of stigmatizing language (e.g., 'insane' or 'lunatic'), inconsistencies within and between policies, deviation from international protocols defining legal capacity and consent, lack of inclusion of the mental health agenda in larger development policies and lack of cost-effective interventions and identification of financing mechanisms. Provisions for people living with mental health conditions included adequate standard of living; attaining standard mental health; the right to exercise legal capacity, liberty and security; freedom from torture or discrimination; and right to live independently. However, other policies contradicted these rights, such as prohibiting marriage, candidacy for and retention of positions of authority and vulnerability to imprisonment. CONCLUSION: Mental health-related structural stigma and discrimination in Nepal can be identified through the use of discriminator language and provisions in the policies. The structural stigma and discrimination may be addressed through revision of the discriminating policies, integrating the mental health agenda into larger national and provincial policies, and streamlining policies to comply with national and international protocols.

EPA guidance on the quality of mental health services: A systematic meta-review and update of recommendations focusing on care coordination.

BACKGROUND: The quality of mental health services is crucial for the effectiveness and efficiency of mental healthcare systems, symptom reduction, and quality of life improvements in persons with mental illness. In recent years, particularly care coordination (i.e., the integration of care across different providers and treatment settings) has received increased attention and has been put into practice. Thus, we focused on care coordination in this update of a previous European Psychiatric Association (EPA) guidance on the quality of mental health services. METHODS: We conducted a systematic meta-review of systematic reviews, meta-analyses, and evidence-based clinical guidelines focusing on care coordination for persons with mental illness in three literature databases. RESULTS: We identified 23 relevant documents covering the following topics: case management, integrated care, home treatment, crisis intervention services, transition from inpatient to outpatient care and vice versa, integrating general and mental healthcare, technology in care coordination and self-management, quality indicators, and economic evaluation. Based on the available evidence, we developed 15 recommendations for care coordination in European mental healthcare. CONCLUSIONS: Although evidence is limited, some concepts of care coordination seem to improve the effectiveness and efficiency of mental health services and outcomes on patient level. Further evidence is needed to better understand the advantages and disadvantages of different care coordination models.

Impact of integrated district level mental health care on clinical and social outcomes of people with severe mental illness in rural Ethiopia: an intervention cohort study.

AIM: There is limited evidence of the safety and impact of task-shared care for people with severe mental illnesses (SMI; psychotic disorders and bipolar disorder) in low-income countries. The aim of this study was to evaluate the safety and impact of a district-level plan for task-shared mental health care on 6 and 12-month clinical and social outcomes of people with SMI in rural southern Ethiopia. METHODS: In the Programme for Improving Mental health carE, we conducted an intervention cohort study. Trained primary healthcare (PHC) workers assessed community referrals, diagnosed SMI and initiated treatment, with independent research diagnostic assessments by psychiatric nurses. Primary outcomes were symptom severity and disability. Secondary outcomes included discrimination and restraint. RESULTS: Almost all (94.5%) PHC worker diagnoses of SMI were verified by psychiatric nurses. All prescribing was within recommended dose limits. A total of 245 (81.7%) people with SMI were re-assessed at 12 months. Minimally adequate treatment was received by 29.8%. All clinical and social outcomes improved significantly. The impact on disability (standardised mean difference 0.50; 95% confidence interval (CI) 0.35-0.65) was greater than impact on symptom severity (standardised mean difference 0.28; 95% CI 0.13-0.44). Being restrained in the previous 12 months reduced from 25.3 to 10.6%, and discrimination scores reduced significantly. CONCLUSIONS: An integrated district level mental health care plan employing task-sharing safely addressed the large treatment gap for people with SMI in a rural, low-income country setting. Randomised controlled trials of differing models of task-shared care for people with SMI are warranted.

Feasibility of WHO mhGAP-intervention guide in reducing experienced discrimination in people with mental disorders: a pilot study in a rural Kenyan setting.

AimsStigma can have a negative impact on help-seeking behaviour, treatment adherence and recovery of people with mental disorders. This study aimed to determine the feasibility of the WHO Mental Health Treatment Gap Interventions Guidelines (mhGAP-IG) to reduce stigma in face-to-face contacts during interventions for specific DSM-IV/ICD 10 diagnoses over a 6-month period. METHODS: This study was conducted in 20 health facilities across Makueni County in southeast Kenya which has one of the poorest economies in the country and has no psychiatrist or clinical psychologist. We recruited 2305 participants from the health facilities catchment areas that had already been exposed to community mental health services. We measured stigma using DISC-12 at baseline, followed by training to the health professionals on intervention using the WHO mhGAP-IG and then conducted a follow-up DISC-12 assessment after 6 months. Proper management of the patients by the trained professionals would contribute to the reduction of stigma in the patients. RESULTS: There was 59.5% follow-up at 6 months. Overall, there was a significant decline in 'reported/experienced discrimination' following the interventions. A multivariate linear mixed model regression indicated that better outcomes of 'unfair treatment' scores were associated with: being married, low education, being young, being self-employed, higher wealth index and being diagnosed with depression. For 'stopping self' domain, better outcomes were associated with being female, married, employed, young, lower wealth index and a depression diagnosis. In regards to 'overcoming stigma' domain; being male, being educated, employed, higher wealth index and being diagnosed with depression was associated with better outcomes. CONCLUSIONS: The statistically significant (p < 0.05) reduction of discrimination following the interventions by trained health professionals suggest that the mhGAP-IG may be a useful tool for reduction of discrimination in rural settings in low-income countries.

Interventions at the Transition from Prison to the Community for Prisoners with Mental Illness: A Systematic Review.

Prisoners have high rates of mental illness and the transition from prison to the community is a problematic time for the provision of mental health services and a range of negative outcomes have been identified in this period. A systematic review was conducted to identify interventions for prisoners with diagnosed mental health conditions that targeted this transition period. Fourteen papers from 13 research studies were included. The interventions identified in this review were targeted at different stages of release from prison and their content differed, ranging from Medicaid enrolment schemes to assertive community treatment. It was found that insurance coverage, and contact with mental health and other services can be improved by interventions in this period but the impact on reoffending and reincarceration is complex and interventions may lead to increased return to prison. There is a developing evidence base that suggests targeting this period can improve contact with community mental health and other health services but further high quality evidence with comparable outcomes is needed to provide more definitive conclusions. The impact of programmes on return to prison should be evaluated further to establish the effect of interventions on clinical outcomes and to clarify the role of interventions on reincarceration.

Evaluating capacity-building for mental health system strengthening in low- and middle-income countries for service users and caregivers, service planners and researchers.

Efforts to support the scale-up of integrated mental health care in low- and middle-income countries (LMICs) need to focus on building human resource capacity in health system strengthening, as well as in the direct provision of mental health care. In a companion editorial, we describe a range of capacity-building activities that are being implemented by a multi-country research consortium (Emerald: Emerging mental health systems in low- and middle-income countries) for (1) service users and caregivers, (2) service planners and policy-makers and (3) researchers in six LMICs (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda). In this paper, we focus on the methodology being used to evaluate the impact of capacity-building in these three target groups. We first review the evidence base for approaches to evaluation of capacity-building, highlighting the gaps in this area. We then describe the adaptation of best practice for the Emerald capacity-building evaluation. The resulting mixed method evaluation framework was tailored to each target group and to each country context. We identified a need to expand the evidence base on indicators of successful capacity-building across the different target groups. To address this, we developed an evaluation plan to measure the adequacy and usefulness of quantitative capacity-building indicators when compared with qualitative evaluation. We argue that evaluation needs to be an integral part of capacity-building activities and that expertise needs to be built in methods of evaluation. The Emerald evaluation provides a potential model for capacity-building evaluation across key stakeholder groups and promises to extend understanding of useful indicators of success.

Socio-economic variations in the mental health treatment gap for people with anxiety, mood, and substance use disorders: results from the WHO World Mental Health (WMH) surveys.

BACKGROUND: The treatment gap between the number of people with mental disorders and the number treated represents a major public health challenge. We examine this gap by socio-economic status (SES; indicated by family income and respondent education) and service sector in a cross-national analysis of community epidemiological survey data. METHODS: Data come from 16 753 respondents with 12-month DSM-IV disorders from community surveys in 25 countries in the WHO World Mental Health Survey Initiative. DSM-IV anxiety, mood, or substance disorders and treatment of these disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI). RESULTS: Only 13.7% of 12-month DSM-IV/CIDI cases in lower-middle-income countries, 22.0% in upper-middle-income countries, and 36.8% in high-income countries received treatment. Highest-SES respondents were somewhat more likely to receive treatment, but this was true mostly for specialty mental health treatment, where the association was positive with education (highest treatment among respondents with the highest education and a weak association of education with treatment among other respondents) but non-monotonic with income (somewhat lower treatment rates among middle-income respondents and equivalent among those with high and low incomes). CONCLUSIONS: The modest, but nonetheless stronger, an association of education than income with treatment raises questions about a financial barriers interpretation of the inverse association of SES with treatment, although future within-country analyses that consider contextual factors might document other important specifications. While beyond the scope of this report, such an expanded analysis could have important implications for designing interventions aimed at increasing mental disorder treatment among socio-economically disadvantaged people.

Service user and caregiver involvement in mental health system strengthening in low- and middle-income countries: a cross-country qualitative study.

AIMS: The aims of this paper are to: (i) explore the experiences of involvement of mental health service users, their caregivers, mental health centre heads and policy makers in mental health system strengthening in three low- and middle-income countries (LMICs) (Ethiopia, Nepal and Nigeria); (ii) analyse the potential benefits and barriers of such involvement; and (iii) identify strategies required to achieve greater service user and caregiver participation. METHODS: A cross-country qualitative study was conducted, interviewing 83 stakeholders of mental health services. RESULTS: Our analysis showed that service user and caregiver involvement in the health system strengthening process was an alien concept for most participants. They reported very limited access to direct participation. Stigma and poverty were described as the main barriers for involvement. Several strategies were identified by participants to overcome existing hurdles to facilitate service user and caregiver involvement in the mental health system strengthening process, such as support to access treatment, mental health promotion and empowerment of service users. This study suggests that capacity building for service users, and strengthening of user groups would equip them to contribute meaningfully to policy development from informed perspectives. CONCLUSION: Involvement of service users and their caregivers in mental health decision-making is still in its infancy in LMICs. Effective strategies are required to overcome existing barriers, for example making funding more widely available for Ph.D. studies in participatory research with service users and caregivers to develop, implement and evaluate approaches to involvement that are locally and culturally acceptable in LMICs.

Scaling-up services for psychosis, depression and epilepsy in sub-Saharan Africa and South Asia: development and application of a mental health systems planning tool (OneHealth).

BACKGROUND: Although financing represents a critical component of health system strengthening and also a defining concern of efforts to move towards universal health coverage, many countries lack the tools and capacity to plan effectively for service scale-up. As part of a multi-country collaborative study (the Emerald project), we set out to develop, test and apply a fully integrated health systems resource planning and health impact tool for mental, neurological and substance use (MNS) disorders. METHODS: A new module of the existing UN strategic planning OneHealth Tool was developed, which identifies health system resources required to scale-up a range of specified interventions for MNS disorders and also projects expected health gains at the population level. We conducted local capacity-building in its use, as well as stakeholder consultations, then tested and calibrated all model parameters, and applied the tool to three priority mental and neurological disorders (psychosis, depression and epilepsy) in six low- and middle-income countries. RESULTS: Resource needs for scaling-up mental health services to reach desired coverage goals are substantial compared with the current allocation of resources in the six represented countries but are not large in absolute terms. In four of the Emerald study countries (Ethiopia, India, Nepal and Uganda), the cost of delivering key interventions for psychosis, depression and epilepsy at existing treatment coverage is estimated at US$ 0.06-0.33 per capita of total population per year (in Nigeria and South Africa it is US$ 1.36-1.92). By comparison, the projected cost per capita at target levels of coverage approaches US$ 5 per capita in Nigeria and South Africa, and ranges from US$ 0.14-1.27 in the other four countries. Implementation of such a package of care at target levels of coverage is expected to yield between 291 and 947 healthy life years per one million populations, which represents a substantial health gain for the currently neglected and underserved sub-populations suffering from psychosis, depression and epilepsy. CONCLUSIONS: This newly developed and validated module of OneHealth tool can be used, especially within the context of integrated health planning at the national level, to generate contextualised estimates of the resource needs, costs and health impacts of scaled-up mental health service delivery.

Type 2 diabetes mellitus in people with severe mental illness: inequalities by ethnicity and age. Cross-sectional analysis of 588 408 records from the UK.

AIMS: To investigate whether the association of severe mental illness with Type 2 diabetes varies by ethnicity and age. METHODS: We conducted a cross-sectional analysis of data from an ethnically diverse sample of 588 408 individuals aged ≥18 years, registered to 98% of general practices (primary care) in London, UK. The outcome of interest was prevalent Type 2 diabetes. RESULTS: Relative to people without severe mental illness, the relative risk of Type 2 diabetes in people with severe mental illness was greatest in the youngest age groups. In the white British group the relative risks were 9.99 (95% CI 5.34, 18.69) in those aged 18-34 years, 2.89 (95% CI 2.43, 3.45) in those aged 35-54 years and 1.16 (95% CI 1.04, 1.30) in those aged ≥55 years, with similar trends across all ethnic minority groups. Additional adjustment for anti-psychotic prescriptions only marginally attenuated the associations. Assessment of estimated prevalence of Type 2 diabetes in severe mental illness by ethnicity (absolute measures of effect) indicated that the association between severe mental illness and Type 2 diabetes was more marked in ethnic minorities than in the white British group with severe mental illness, especially for Indian, Pakistani and Bangladeshi individuals with severe mental illness. CONCLUSIONS: The relative risk of Type 2 diabetes is elevated in younger populations. Most associations persisted despite adjustment for anti-psychotic prescriptions. Ethnic minority groups had a higher prevalence of Type 2 diabetes in the presence of severe mental illness. Future research and policy, particularly with respect to screening and clinical care for Type 2 diabetes in populations with severe mental illness, should take these findings into account.

The economic costs of mental health-related discrimination.

OBJECTIVE: To estimate and compare the economic costs of mental health-related discrimination in the domains of health care, relationships and participation in leisure activities in England between 2011 and 2014. METHOD: A subsample of the Viewpoint survey was interviewed using the Costs of Discrimination Assessment Questionnaire in 2011 and 2014. Information on the impact of discrimination on healthcare use, help seeking from family and friends and participation in leisure activities was recorded. Pattern of contacts, costs and predictor of costs were examined. RESULTS: Our findings showed higher costs of health service use for individuals who reported experiences of discrimination in healthcare settings in 2011 compared with those who did not (mean difference £625, P-value 0.019). Individuals who reported experiences of discrimination in relationships in 2014 had higher healthcare costs than those who did not (mean difference £418, P -value 0.034). There was some evidence of a reduction in overall levels of healthcare use, leisure activities and support from families over time. Discrimination did not significantly affect help seeking from family/friends or leisure activities. CONCLUSION: There is some evidence that discrimination is related to increased healthcare costs. A prospective study is needed to better understand the consequences of these effects.

Ethnicity and cardiovascular health inequalities in people with severe mental illnesses: protocol for the E-CHASM study.

PURPOSE: People with severe mental illnesses (SMI) experience a 17- to 20-year reduction in life expectancy. One-third of deaths are due to cardiovascular disease. This study will establish the relationship of SMI with cardiovascular disease in ethnic minority groups (Indian, Pakistani, Bangladeshi, black Caribbean, black African and Irish), in the UK. METHODS: E-CHASM is a mixed methods study utilising data from 1.25 million electronic patient records. Secondary analysis of routine patient records will establish if differences in cause-specific mortality, cardiovascular disease prevalence and disparities in accessing healthcare for ethnic minority people living with SMI exist. A nested qualitative study will be used to assess barriers to accessing healthcare, both from the perspectives of service users and providers. RESULTS: In primary care, 993,116 individuals, aged 18+, provided data from 186/189 (98 %) practices in four inner-city boroughs (local government areas) in London. Prevalence of SMI according to primary care records, ranged from 1.3-1.7 %, across boroughs. The primary care sample included Bangladeshi [n = 94,643 (10 %)], Indian [n = 6086 (6 %)], Pakistani [n = 35,596 (4 %)], black Caribbean [n = 45,013 (5 %)], black African [n = 75,454 (8 %)] and Irish people [n = 13,745 (1 %)]. In the secondary care database, 12,432 individuals with SMI over 2007-2013 contributed information; prevalent diagnoses were schizophrenia [n = 6805 (55 %)], schizoaffective disorders [n = 1438 (12 %)] and bipolar affective disorder [n = 4112 (33 %)]. Largest ethnic minority groups in this sample were black Caribbean [1432 (12 %)] and black African (1393 (11 %)). CONCLUSIONS: There is a dearth of research examining cardiovascular disease in minority ethnic groups with severe mental illnesses. The E-CHASM study will address this knowledge gap.

Developing mental health research in sub-Saharan Africa: capacity building in the AFFIRM project.

BACKGROUND: There remains a large disparity in the quantity, quality and impact of mental health research carried out in sub-Saharan Africa, relative to both the burden and the amount of research carried out in other regions. We lack evidence on the capacity-building activities that are effective in achieving desired aims and appropriate methodologies for evaluating success. METHODS: AFFIRM was an NIMH-funded hub project including a capacity-building program with three components open to participants across six countries: (a) fellowships for an M.Phil. program; (b) funding for Ph.D. students conducting research nested within AFFIRM trials; (c) short courses in specialist research skills. We present findings on progression and outputs from the M.Phil. and Ph.D. programs, self-perceived impact of short courses, qualitative data on student experience, and reflections on experiences and lessons learnt from AFFIRM consortium members. RESULTS: AFFIRM delivered funded research training opportunities to 25 mental health professionals, 90 researchers and five Ph.D. students across 6 countries over a period of 5 years. A number of challenges were identified and suggestions for improving the capacity-building activities explored. CONCLUSIONS: Having protected time for research is a barrier to carrying out research activities for busy clinicians. Funders could support sustainability of capacity-building initiatives through funds for travel and study leave. Adoption of a train-the-trainers model for specialist skills training and strategies for improving the rigor of evaluation of capacity-building activities should be considered.

How does a decision aid help people decide whether to disclose a mental health problem to employers? Qualitative interview study.

Background Decisions about whether to disclose mental health problems to employers are complex, with potential personal, employment and legal implications. Decision aids are evidence based tools, designed to help individuals make specific choices between treatment options. We previously developed a decision aid-Conceal Or ReveAL (CORAL)-to assist service users with decisions about disclosure to employers. As part of a mixed methods exploratory RCT, which demonstrated that the CORAL decision aid was effective in reducing decisional conflict, we aimed to explore its mechanism of action and to optimise the intervention for a future full scale trial. Methods In depth interviews were conducted with individuals receiving vocational support from a mental health trust and participating in the intervention arm of the pilot trial. Thematic analysis was conducted to identify the main themes relating to participants' perceptions of the CORAL decision aid. Results Thirteen participants were interviewed and five main themes were identified: sense of self and values; sense of control; anticipation of disclosure; experience of disclosure; and mechanism of action of the decision aid. Conclusions Data from our 13 participants suggest that the CORAL decision aid acts on several dimensions of decisional conflict: clarifying the pros and cons of different choices; increasing knowledge; structuring the decision making process; and clarifying needs and values. The current study indicated that it would be most effective when delivered by a professional well versed in employment and mental health matters such as a vocational adviser. The need for employers and policymakers to reduce the negative impact of disclosure is also highlighted.

How much does mental health discrimination cost: valuing experienced discrimination in relation to healthcare care costs and community participation.

AIMS: This study builds on existing research on the prevalence and consequences of mental illness discrimination by investigating and quantifying the relationships between experienced discrimination and costs of healthcare and leisure activities/social participation among secondary mental health service users in England. METHODS: We use data from the Mental Illness-Related Investigations on Discrimination (MIRIAD) study (n = 202) and a subsample of the Viewpoint study (n = 190). We examine experiences of discrimination due to mental illness in the domains of personal relationships, community activities, and health care, and how such experienced discrimination relates to patterns of service use and engagement in leisure activities. RESULTS: Our findings show that the cost of health services used for individuals who reported previous experiences of discrimination in a healthcare setting was almost twice as high as for those who did not report any discrimination during the last 12 months (Relative Risk: 1.73; 95% Confidence Interval (CI): 1.39, 2.17) and this was maintained after controlling for symptoms and functioning. Experienced discrimination in healthcare (Relative Risk: 0.83; 95% CI: 0.81, 0.84) or in relationships (Relative Risk: 0.89; 95% CI: 0.87, 0.91), however, was associated with lower participation in, and hence lower costs of, leisure activities. Individuals who reported any discrimination in a healthcare setting had, on average, £434 higher costs associated with health service use while reported discrimination in the community was associated with increased leisure costs of £32. CONCLUSIONS: These findings make an important initial step towards understanding the magnitude of the costs of mental health-related discrimination.

Randomized controlled trial of computerized cognitive behavioural therapy for depressive symptoms: effectiveness and costs of a workplace intervention.

BACKGROUND: Depression and anxiety are major causes of absence from work and underperformance in the workplace. Cognitive behavioural therapy (CBT) can be effective in treating such problems and online versions offer many practical advantages. The aim of the study was to investigate the effectiveness of a computerized CBT intervention (MoodGYM) in a workplace context. METHOD: The study was a phase III two-arm, parallel randomized controlled trial whose main outcome was total score on the Work and Social Adjustment Scale (WSAS). Depression, anxiety, psychological functioning, costs and acceptability of the online process were also measured. Most data were collected online for 637 participants at baseline, 359 at 6 weeks marking the end of the intervention and 251 participants at 12 weeks post-baseline. RESULTS: In both experimental and control groups depression scores improved over 6 weeks but attrition was high. There was no evidence for a difference in the average treatment effect of MoodGYM on the WSAS, nor for a difference in any of the secondary outcomes. CONCLUSIONS: This study found no evidence that MoodGYM was superior to informational websites in terms of psychological outcomes or service use, although improvement to subthreshold levels of depression was seen in nearly half the patients in both groups.

Greek mental health reform: views and perceptions of professionals and service users.

The Greek mental health system has been undergoing radical reforms for over the past twenty years. In congruence with trends and practices in other European countries, Greek mental health reforms were designed to develop a community-based mental health service system. The implementation of an extensive transformation became possible through the "Psychargos" program, a national strategic and operational plan, which was developed by the Ministry of Health and Social Solidarity. The Psychargos program was jointly funded by the European Union by 75% of the cost over a period of 5 years and the Greek State. After the period of 5 years, the entire cost of the new services became the responsibility of the Greek National Budget. Over the years the Psychargos program became almost synonymous with the deinstitutionalisation of long term psychiatric patients with the development of a wide range of community mental health services. The Psychargos program ended in December 2009. This article presents the views of service providers and service users as part an ex-post evaluation of the Psychargos program carried out in 2010. Data derived for this part of the evaluation are from the application of the qualitative method of focus groups. The outcomes of the study identified several positive and noteworthy achievements by the reforms of the Greek mental health system as well as weaknesses. There was considerable similarity of the views expressed by both focus groups. In addition the service users' focus group emphasized more issues related to improving their mental health wellbeing and living a satisfying, hopeful, and contributing life.

The balanced care model for global mental health.

BACKGROUND: For too long there have been heated debates between those who believe that mental health care should be largely or solely provided from hospitals and those who adhere to the view that community care should fully replace hospitals. The aim of this study was to propose a conceptual model relevant for mental health service development in low-, medium- and high-resource settings worldwide. Method We conducted a review of the relevant peer-reviewed evidence and a series of surveys including more than 170 individual experts with direct experience of mental health system change worldwide. We integrated data from these multiple sources to develop the balanced care model (BCM), framed in three sequential steps relevant to different resource settings. RESULTS: Low-resource settings need to focus on improving the recognition and treatment of people with mental illnesses in primary care. Medium-resource settings in addition can develop 'general adult mental health services', namely (i) out-patient clinics, (ii) community mental health teams (CMHTs), (iii) acute in-patient services, (iv) community residential care and (v) work/occupation. High-resource settings, in addition to primary care and general adult mental health services, can also provide specialized services in these same five categories. CONCLUSIONS: The BCM refers both to a balance between hospital and community care and to a balance between all of the service components (e.g. clinical teams) that are present in any system, whether this is in low-, medium- or high-resource settings. The BCM therefore indicates that a comprehensive mental health system includes both community- and hospital-based components of care.

Development of the ITHACA Toolkit for monitoring human rights and general health care in psychiatric and social care institutions.

Background. Human rights violations are commonly experienced by people in psychiatric and social care institutions. States and private organizations providing such health and social services must comply with international human rights law. Monitoring of such compliance is increasingly recognized as a vital component in ensuring that rights are respected and violations are brought out in the open, remedied and prevented. Aims. The Institutional Treatment, Human Rights and Care Assessment (ITHACA) project produced a method to document violations and good practice with the aim of preventing human rights violations and improving general health care practice in psychiatric and social care institutions (www.ithacastudy.eu). Methods. A methodological and implementation study conducted across 15 European countries developed and assessed the ITHACA Toolkit in monitoring visits to 87 mental health organizations. Results. The toolkit is available in 13 European languages and has demonstrated applicability in a range of contexts and conditions. The information gathered through monitoring visits can document both good practice and areas for improvement. Conclusions. The ITHACA Toolkit is an acceptable and feasible method for the systematic monitoring of human rights and general health care in psychiatric and social care institutions that explicitly calls for the participation of service users in the monitoring of human rights violations and general health care practice.

Identification and management of prisoners with severe psychiatric illness by specialist mental health services.

BACKGROUND: The prevalence of mental disorders among prisoners is considerably higher than in the general population. This is an important public health issue as the vast majority of prisoners stay in custody for less than 9 months and, when not in prison, offenders' lifestyles are frequently chaotic, characterized by social exclusion, instability and unemployment. Multi-disciplinary mental health inreach services were introduced to target care towards prisoners with severe mental illness (SMI) in a similar way to that provided by Community Mental Health Teams outside prison. The aim was to establish the proportion of prisoners with SMI who were assessed and managed by prison mental health inreach services. Method A two-phase prevalence survey in six prisons in England measured SMI upon reception into custody. Case-note review established the proportion of those with SMI subsequently assessed and treated by inreach services. RESULTS: Of 3492 prisoners screened, 23% had SMI. Inreach teams assessed only 25% of these unwell prisoners, and accepted just 13% onto their caseloads. CONCLUSIONS: Inreach teams identified and managed only a small proportion of prisoners with SMI. Prison-based services need to improve screening procedures and develop effective care pathways to ensure access to appropriate services. Improved identification of mental illness is needed in both the community and the Criminal Justice System to better engage with socially transient individuals who have chaotic lifestyles and complex needs.