Access to inpatient mood management services after stroke in Australian acute and rehabilitation hospitals.

OBJECTIVE: Post-stroke mental health impairments are common, but under-assessed and under-treated. We aim to describe trends in the provision of mood management to patients with stroke, and describe factors associated with adoption of national mood management recommendations for stroke within Australian hospitals. DESIGN: Secondary analysis of cross-sectional data from the biennial Stroke Foundation Audit Program. SETTING: Participating acute (2011-2021) and rehabilitation hospitals (2012-2020) in Australia. PARTICIPANTS: In the acute audit, 22,937 stroke cases were included from 133 hospitals. In the rehabilitation audit, 15,891 stroke cases were included from 127 hospitals. MAIN MEASURES: Hospital- and patient-level mood management processes. RESULTS: Among 133 acute hospitals (22,937 stroke episodes), improvements were made between 2011 and 2021 in utilization of mood screening (17% [2011], 33% [2021]; p < 0.001) and access to psychologists during hospital stay (18% [2011], 45% [2021]; p < 0.001). There was no change in access to a psychologist among those with a mood impairment (p = 0.34). Among 127 rehabilitation hospitals (15,891 stroke episodes) improvements were observed for mood screening (35% [2012], 61% [2020]; p < 0.001), and access to a psychologist during hospital stay (38% [2012], 68% [2020]; p < 0.001) and among those with a mood-impairment (30% [2012], 50% [2020]; p < 0.001). Factors associated with receiving mood management processes included: younger age, not requiring an interpreter and longer length of stay. CONCLUSIONS: Adherence to mood management recommendations has improved over 10 years within Australian hospitals. Those aged over 65, requiring an interpreter, or with shorter hospital stays are at risk of missing out on appropriate mood management.

Perioperative Assessment of Cerebellar Masses and the Potential for Cerebellar Cognitive Affective Syndrome.

The cerebellum was long perceived to be a region of limited importance with primary functions in the regulation of motor control. A degree of its functional topography in motor modulation has been traditionally appreciated. However, an evolving body of evidence supports its role in a range of cognitive processes, including executive decision making, language, emotional processing, and working memory. To this end, numerous studies of cerebellar stroke syndromes as well as investigations with functional magnetic resonance imaging and diffusion tensor imaging have given clinicians a better model of the functional topography within the cerebellum and the essential lanes of communication with the cerebrum. With this deeper understanding, neurosurgeons should integrate these domains into the perioperative evaluation and postoperative rehabilitation of patients with cerebellar tumors. This review aims to discuss these understandings and identify valuable tools for implementation into clinical practice.

Cognitive Predictors of Work Among Social Security Disability Insurance Beneficiaries With Psychiatric Disorders Enrolled in IPS Supported Employment.

BACKGROUND: Impaired cognitive functioning is a significant predictor of work dysfunction in schizophrenia. Less is known, however about relationships of cognition and work in people with less severe disorders with relatively normal cognitive functioning. METHODS: This secondary analysis evaluated cognitive predictors of work in Social Security Disability Insurance (SSDI) beneficiaries with a recent work history who were randomized to receive mental health services, supported employment, and freedom from work disincentives over a 2-year study period in the Mental Health Treatment Study. Of the 1045 participants randomized to the treatment package, 945 (90.4%) received a cognitive assessment at study entry. Competitive work activity was evaluated using a computer-assisted timeline follow-back calendar at baseline and quarterly for 24 months. RESULTS: Mood disorders were the most common psychiatric diagnoses (64.9%), followed by schizophrenia or schizoaffective disorder (35.1%). Tobit regression analyses predicting the average number of hours worked per week, controlling for demographic characteristics, diagnosis, and work history indicated that the cognitive composite score (P < .01) and verbal learning subscale scores (P < .001) were associated with fewer hours of weekly work over the study period. CONCLUSIONS: Cognitive functioning predicted work over 2 years in SSDI beneficiaries with mood or schizophrenia-spectrum disorders who were receiving supported employment and mental health interventions, despite a relative absence of cognitive impairment in the study participants. The findings suggest cognitive functioning contributes to competitive work outcomes in persons with psychiatric disorders who have relatively unimpaired cognitive abilities, even under optimal conditions of treatment and vocational support.

Self-directed care: participants' service utilization and outcomes.

OBJECTIVE: Self-directed care (SDC) is a mental health service delivery model in which participants budget the state dollars allotted for their care to purchase the goods and services they deem most appropriate for achieving their recovery goals. This study examines the demographic characteristics, service utilization patterns, and outcomes of individuals enrolled in the Florida Self-Directed Care (FloridaSDC) program, which is the oldest and most established SDC program in the United States for individuals diagnosed with a severe and persistent mental illness. METHOD: This is a naturalistic descriptive study in which demographic, service utilization, and outcome data (i.e., Functional Assessment Rating Scale (FARS) scores, days in the community, days worked, monthly income, discharge status) were collected from the clinical and fiscal records of 136 FloridaSDC participants. RESULTS: Key findings suggest that FloridaSDC participants had very little income and largely utilized their budgets to subsidize their living expenses. Though most participants did not work or earn income and very few left the program due to employment, participants' FARS scores improved modestly and nearly all participants remained in the community throughout the study period. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Participants' service purchases were rational given the poverty in which they live, and their outcomes did not suffer when they controlled decisions regarding their service needs. These findings highlight the utility and value of the personalized budgeting and individualized planning components of SDC. Findings also point to the need for practitioners to implement innovative strategies to enhance participants' employment readiness and supported employment opportunities. (PsycINFO Database Record

Do comprehensive, coordinated, recovery-oriented services alter the pattern of use of treatment services? Mental health treatment study impacts on SSDI beneficiaries' use of inpatient, emergency, and crisis services.

Current arrangements for financing and delivering behavioral health services to U.S. working-age adults with severe and persistent mental disorders (SPMD) have major inadequacies in funding for and access to critical elements of a recovery-oriented, comprehensive, and coordinated package of community-based treatment and rehabilitation services. This study presents results from a nation-wide 2-year randomized trial, involving 2,238 SSDI beneficiaries with SPMD, of a comprehensive intervention including evidence-based treatment and employment services. Estimates of impacts of the MHTS service intervention package, from a variety of regression specifications, showed clearly significant treatment group reductions in four outcomes (hospital stays and days, ER visits for mental health problems, and psychiatric crisis visits); these estimates suggest annual inpatient hospital treatment cost savings in excess of approximately $900 to 1,400. Negative estimated MHTS effects on three other utilization outcomes (hospital stays and days for mental health problems, overall ER visits) generally did not achieve statistical significance. Possible study implications for cost offsets from further expansions/replications of the MHTS intervention model are considered within the context of health reform.

Evaluation of the short-term executive plus intervention for executive dysfunction after traumatic brain injury: a randomized controlled trial with minimization.

OBJECTIVE: To determine whether the Short-Term Executive Plus (STEP) cognitive rehabilitation program improves executive dysfunction after traumatic brain injury (TBI). DESIGN: Randomized, waitlist controlled trial with minimization and blinded outcome assessment. SETTING: Community. PARTICIPANTS: Participants with TBI and executive dysfunction (N=98; TBI severity 50% moderate/severe; mean time since injury ± SD, 12±14y; mean age ± SD, 45±14y; 62% women; 76% white). INTERVENTION: STEP program: 12 weeks (9h/wk) of group training in problem solving and emotional regulation and individual sessions of attention and compensatory strategies training. MAIN OUTCOME MEASURES: Factor analysis was used to create a composite executive function measure using the Problem Solving Inventory, Frontal Systems Behavior Scale, Behavioral Assessment of the Dysexecutive Syndrome, and Self-Awareness of Deficits Interview. Emotional regulation was assessed with the Difficulties in Emotion Regulation Scale. The primary attention measure was the Attention Rating and Monitoring Scale. Secondary measures included neuropsychological measures of executive function, attention, and memory and measures of affective distress, self-efficacy, social participation, and quality of life. RESULTS: Intention-to-treat mixed-effects analyses revealed significant treatment effects for the composite executive function measure (P=.008) and the Frontal Systems Behavior Scale (P=.049) and Problem Solving Inventory (P=.016). We found no between-group differences on the neuropsychological measures or on measures of attention, emotional regulation, self-awareness, affective distress, self-efficacy, participation, or quality of life. CONCLUSIONS: The STEP program is efficacious in improving self-reported post-TBI executive function and problem solving. Further research is needed to identify the roles of the different components of the intervention and its effectiveness with different TBI populations.

Women in medium secure care: tracking treatment progress for changes in risk profiles and treatment engagement.

The treatment and risk management programmes in a women's medium secure service are described. Changes in risk profiles and its relationship to treatment engagement are examined in a cohort of women during their stay in a medium secure service. Findings show that clinically significant reductions in risk behaviours were paralleled by increases in treatment engagement. The clinical healthcare implications of these findings are discussed along with the need for further research.

The Concord Centre for Mental Health's new 'phase of illness' model of care: are we on the right track?

OBJECTIVE: The aim of this study was to provide an overview of a new 'phase of illness' model of care after relocation of Rozelle Hospital to the new purpose built Concord Centre for Mental Health and discuss its implementation and progress thus far. METHOD: One year after relocation, staff were asked to provide feedback of their views of the new model of care in order to identify implementation barriers and ways forward. RESULTS: The new model has clear benefits for the consumer, but there are a number of practical challenges and dilemmas emerging that necessitate some refinement and evaluation. Feedback from staff provided a wide range of opinions indicating that some were quite cynical of the new model while others were very supportive and thought that patient care was enhanced. CONCLUSIONS: Further development and consolidation of the model is required, including more education sessions and a clear mission statement at unit, hospital and community levels. Further research is also required to assess the impact and ability of the new model to deliver better patient outcomes, especially in regard to continuity of care.

Criminal justice involvement, behavioral health service use, and costs of forensic assertive community treatment: a randomized trial.

Jail diversion and forensic community treatment programs have proliferated over the past decade, far outpacing evidence regarding their efficacy. The current study reports findings from a randomized clinical trial conducted in California for frequent jail users with serious mental illness that compares a forensic assertive community treatment (FACT) intervention with treatment as usual (TAU). Outcomes are reported at 12 and 24 months post-randomization for criminal justice outcomes, behavioral health services and costs. At 12 months, FACT vs. TAU participants had fewer jail bookings, greater outpatient contacts, and fewer hospital days than did TAU participants. Results of zero-inflated negative binomial regression found that FACT participants had a higher probability of avoiding jail, although once jailed, the number of jail days did not differ between groups. Increased outpatient costs resulting from FACT outpatient services were partially offset by decreased inpatient and jail costs. The findings for the 24 month period followed the same pattern. These findings provide additional support for the idea that providing appropriate behavioral health services can reduce criminal justice involvement.

[The regional psychiatry budget (RPB): a model for a new payment system of hospital based mental health care services]. / Das Regionale Psychiatriebudget (RPB): Ein Modell für das neue pauschalierende Entgeltsystem psychiatrischer Krankenhausleistungen?

OBJECTIVE: To analyze the impact of a capitated multi-sector-financing model for psychiatric care (RPB) on costs and effectiveness of care. METHODS: Patients with a diagnosis according to ICD-10 F10, F2 or F3 were interviewed in the model region (MR, n = 258) and a control region (CR, n = 244) financed according to the fee-for-service principle. At baseline, 1.5 years and 3.5 years follow-up patients were interviewed using measures of psychopathology (CGI-S, HoNOS, SCL-90R, PANSS, BRMAS / BRMES), functioning (GAF, SOFAS) and quality of life (WHOQOL-BREF, EQ-5D). Use of care was determined semi-annually. RESULTS: There were no significant differences in the development of psychopathology and quality of life between MR and CR. In the MR, functioning of patients with schizophrenia and affective disorders improved significantly more strongly. The development of total mental health care costs was not different between MR and CR. However, the costs of office based mental health care increased slightly more strongly in the MR, indicating a small cost-shift from the RPB to extrabudgetary financed services. CONCLUSIONS: The RPB showed slight advantages regarding the effectiveness of care and did not significantly change the total mental health care costs.

Estimating the changes in demand for public mental health services following changes in eligibility: analysis of national survey data.

BACKGROUND: Numerous national surveys have shown that the rate of use of mental health services in a population lags behind the prevalence rate of psychiatric disorder. The preparations to provide universal coverage in Israel require estimates of the utilization levels likely to be reached once mental health care becomes a legal right of each resident. AIMS: This paper aims to provide an estimate of the size of the population which not only will be eligible for specialty mental health care, but which will also demand ambulatory mental health specialty care from public providers METHODS: Data for this study were extracted from a national survey conducted during 2003-2004 in Israel as part of the WMH2000 initiative. Use and perceived need to use services among eligible respondents was used to estimate likely levels of demand. RESULTS: The estimates for future demands on public mental health clinics ranged between 1.2%--the size of the population that is eligible by law and is currently using public mental health services to 5.5%--the size of the eligible population that is currently using some type of service or perceives the need for care in mental health. DISCUSSION: The estimate of the expected use falls in the range of other universal access systems. CONCLUSIONS AND IMPLICATIONS FOR POLICY: The present study provides estimates that are much higher than the estimated size of the population currently using public mental health services, yet the upper limit of the range of estimates is close to those on which the new legislation is based.

Mental disorders as risk factors for later substance dependence: estimates of optimal prevention and treatment benefits.

BACKGROUND: Although mental disorders have been shown to predict subsequent substance disorders, it is not known whether substance disorders could be cost-effectively prevented by large-scale interventions aimed at prior mental disorders. Although experimental intervention is the only way to resolve this uncertainty, a logically prior question is whether the associations of mental disorders with subsequent substance disorders are strong enough to justify mounting such an intervention. We investigated this question in this study using simulations to estimate the number of substance disorders that might be prevented under several hypothetical intervention scenarios focused on mental disorders. METHOD: Data came from the National Comorbidity Survey Replication (NCS-R), a nationally representative US household survey that retrospectively assessed lifetime history and age of onset of DSM-IV mental and substance disorders. Survival analysis using retrospective age-of-onset reports was used to estimate associations of mental disorders with subsequent substance dependence. Simulations based on the models estimated effect sizes in several hypothetical intervention scenarios. RESULTS: Although successful intervention aimed at mental disorders might prevent some proportion of substance dependence, the number of cases of mental disorder that would have to be treated to prevent a single case of substance dependence is estimated to be so high that this would not be a cost-effective way to prevent substance dependence (in the range 76-177 for anxiety-mood disorders and 40-47 for externalizing disorders). CONCLUSIONS: Treatment of prior mental disorders would not be a cost-effective way to prevent substance dependence. However, prevention of substance dependence might be considered an important secondary outcome of interventions for early-onset mental disorders.

Outcomes of activity-based assessment (BIA) compared with standard assessment in occupational therapy.

This study was aimed at investigating the outcomes of an activity-based assessment (BIA) compared with standard assessment (SA) for evaluating clients undergoing psychiatric occupational therapy. Patients admitted to a psychiatric occupational therapy unit were randomized into the BIA or the SA assessment. The outcome indicators were (a) clients' satisfaction with the occupational therapy during the assessment period, (b) clients' awareness of capacities and occupational problems, (c) satisfaction with the assessment among the referring physicians, and (d) outcomes of the intervention following the assessment, in terms of changes in occupational performance and satisfaction. The groups did not differ in awareness of occupational problems, but the BIA group was more satisfied than the SA group with the support of their contact person and with the group leader during the period of assessment. Furthermore, physicians receiving feedback on patients in the BIA group were more satisfied than those receiving feedback on patients in the SA group. However, the groups did not differ concerning change during the treatment period in occupational performance or satisfaction. Thus, there was no difference between the assessment methods regarding the outcomes of the treatment following assessment. Minor advantages from the patients' perspective were found, in terms of better satisfaction in the BIA group, and from the referring physicians' perspective the BIA clearly seemed more satisfying than the SA. Thus, the findings showed that the BIA possessed better qualities than the SA regarding the indicators pertaining to satisfaction, but not concerning awareness of capacities and problems or the outcome of the subsequent treatment.

Working across boundaries: clinical outcomes for an integrated mental health service for people with intellectual disabilities.

BACKGROUND: The Mental Health Service for People with Learning Disabilities (MHSPLD) is a service development in keeping with UK government policy that promotes cross agency working and access to mainstream mental health services for people with intellectual disabilities. We aimed to show whether the service model brought about improvements in people's mental state and level of functioning. METHODS: Community and inpatient groups were compared across three time points using a range of clinical outcome measures that assessed psychiatric symptoms, risk, needs and level of functioning. RESULTS: Inpatients and community groups had similar mental health problems, but inpatients had higher unmet needs and lower functioning, and were at greater risk. There were significant improvements across the range of outcome measures in both groups. CONCLUSIONS: Working with mainstream mental health services and across health and social service boundaries delivers effective mental health care for people with intellectual disabilities.

Does additional care provided by a consumer self-help group improve psychiatric outcome? A study in an Italian community-based psychiatric service.

This study compares the two-year clinical and social outcome, the use of services and the direct costs of patients of the South-Verona Community Psychiatric Service who were members of a self-help group, with those who were not. Use of services and costs in the two years before the baseline were compared with those occurring two years after the baseline. Self-help subjects decreased their use of hospital stay as to number of admissions and days in hospital, with a reduction of costs; they were more satisfied as to work/education while non self-help matches presented an increase of unmet needs. Clinical and social outcome showed no significant difference. The findings suggest that consumer participation may possibly enhance the effects of psychiatric treatment on outcome.

An analysis of post-booking jail diversion programming for persons with co-occurring disorders.

For persons with co-occurring disorders, interaction with criminal justice systems is a frequent occurrence. As a result, a variety of diversionary programs have been developed nationwide. In this study, a total of 248 individuals with co-occurring disorders of serious mental illness and substance use disorders who had been arrested and booked on misdemeanor charges participated in a post-booking jail diversion program in two urban communities. A quasi-experimental design was used with individuals assigned to diversion or non-diversion status based upon the decision processes of the mental health-criminal justice systems. The effectiveness of the jail diversion program was evaluated from a variety of sources, including structured interviews, behavioral health service utilization patterns, and criminal justice recidivism patterns. Analyses revealed general main effects for time on many of the outcome variables, with few main effects or interaction effects detected on the basis of diversion status (diverted versus non-diverted). Across all measures assessing mental health and substance abuse, study participants displayed improvements over time, irrespective of their diversion status or program location. Participants generally displayed no significant changes in their rates of accessibility to, or frequency of use of, the various mental health, substance abuse, and other services, and few changes for diversion status were detected with regard to service utilization. Although a number of indicators of criminality and violence were reduced over time, these reductions were statistically insignificant, with changes for diversionary status or time identified at follow-up. These results are discussed in light of their implications for jail diversion programming and future research in this area.

[Analysis and comparative evaluations of the costs of supports and treatments of schizophrenia, affective psychosis, paranoia and neurosis]. / Analisi e valutazioni comparative dei costi dei trattamenti terapeutico-riabilitativi delle psicosi schizofreniche, delle psicosi affettive, della paranoia e dei disturbi nevrotici.

OBJECTIVE: The aim of the study was to show, trough the calculation of the direct costs of supports and treatments actually provided by a NHS Mental Health Department, the presence of associations between four diagnostic groups (schizophrenia, affective psychosis, paranoia and neurotic disorders) and their overall and items (community care, rehabilitation facilities and in-patients services) costs. SETTING: Mental Health Department and CSM "Scalo" (NHS Mental Centre), AUSL "Città di Bologna", Emilia-Romagna Region. DESIGN: Yearly direct costs were calculated for a sample (n = 75) of all patients (N = 745) who during 365 days had more than four contacts with CSM and also for four randomised diagnostic groups (n = 30 per group). MAIN OUTCOME MEASURES: We calculated unit costs of 15 types of services provided by CSM, selected according to the yearly number of services provided and the time spent by each health professional, and the in patient-cost per all days spent in a public or private sector hospital for psychiatric care. RESULTS: The statistic analysis, performed with the help of the Kruskal-Wallis test, showed significantly higher overall costs for the schizophrenic patients than the sample-group and the neurotic disorders-group; besides a significant difference in the item costs for rehabilitation facilities was found between the schizophrenic group and the paranoia, neurotic disorders groups and the sample one, whereas no significant differences in costs of inpatients services and drugs administration were tested between the groups. CONCLUSIONS: The results of our study allow to demonstrate that there are cost differences between the diagnosis (direct costs are highest for schizophrenic patients and lowest for those with neurotic disorders) and that the costs evaluation can be used to ensure appropriate provisions to Mental Health Department for support and treatment of a wide range of psychiatric disorders.

Use of the Disability Rating Scale Recovery curve as a predictor of psychosocial outcome following closed-head injury.

Rapid rate of recovery has been associated with better outcome following closed-head injuries, but few studies have compellingly demonstrated this. This study used growth curve analyses of Disability Rating Scale (DRS) scores at acute hospitalization discharge, 1, 3, and 6 months post injury in a sample of 55 patients with a closed-head injury. Six month post-injury outcome measures were taken from significant other (SO) responses on the NYU Head Injury Family Interview (NYU-HIFI) including severity and burden ratings of affective/neurobehavioral disturbance, cognitive deficits, and physical/dependency status. Rate of recovery (linear and curvilinear recovery curve components) was significantly related to the level of affective/neurobehavioral severity, and the severity and burden of SO-perceived cognitive deficits. Only the intercept of the DRS recovery curve was associated with the SO-perceived severity and burden of physical/dependency status. Growth curve modeling is a meaningful and powerful tool in predicting head injury outcome.

Service components of case management which reduce inpatient care use for persons with serious mental illness.

This is a study of two types of case management: case management (CM) which provided the service coordination functions, and Intensive Case Management (ICM) which consisted of both the coordination function and the provision of direct support to the client. Using secondary data on public clients, characteristics of mental health service use were analyzed for 80 ICM and 84 CM clients. The ICM clients had significantly fewer episodes per patient and less inpatient days per year than the CM clients. These findings suggest that direct support services make a significant difference in reducing annual hospital care.