Latent structure and factor reliability of the National Health Service Community Mental Health Service User Questionnaire.

BACKGROUND: National Health Service use the Community Mental Health Service User Questionnaire (NHS-CMH) to assess care quality. However, its reliability and internal validity is uncertain. AIMS: To test the NHS-CMH structure, reliability and item-level characteristics. METHODS: We used data from 11,373 participants who answered the 2017 NHS-CMH survey. First, we estimated the NHS-CMH structure using Exploratory Factor Analysis (EFA) in half of the dataset. Second, we tested the best EFA-derived model with Confirmatory Factor Analysis (CFA). We tested the internal validity, construct reliability (omega - ω), explained common variance of each factor (ECV), and item thresholds. RESULTS: EFA suggested a 4-factor solution. The structure derived from the EFA was confirmed, demonstrating good reliability for the four correlated dimensions: "Relationship with Staff" (ω = 0.952, ECV = 40.1%), "Organizing Care" (ω = 0.855, ECV = 21.4%), "Medication and Treatments" (ω = 0.837, ECV = 13.3%), and "Support and Well-being" (ω = 0.928, ECV = 25.3%). A second-order model with a high-order domain of "Quality of Care" is also supported. CONCLUSIONS: The NHS-CMH can be used to reliably assess four user-informed dimensions of mental health care quality. This model offers an alternative for its current use (item-level and untested sum scores analysis).

Direct healthcare costs and their relationships with age at start of drug use and current pattern of use: a cross-sectional study.

BACKGROUND: It is well known that early start of drug use can lead users to psychosocial problems in adulthood, but its relationship with users' direct healthcare costs has not been well established. OBJECTIVES: To estimate the direct healthcare costs of drug dependency treated at a community mental health service, and to ascertain whether early start of drug use and current drug use pattern may exert influences on these costs. DESIGN AND SETTING: Retrospective cross-sectional study conducted at a community mental health service in a municipality in the state of São Paulo, Brazil. METHODS: The relationships between direct healthcare costs from the perspective of the public healthcare system, age at start of drug use and drug use pattern were investigated in a sample of 105 individuals. A gamma-distribution generalized linear model was used to identify the cost drivers of direct costs. RESULTS: The mean monthly direct healthcare costs per capita for early-start drug users in 2020 were 1,181.31 Brazilian reais (BRL) (274.72 United State dollars (USD) according to purchasing power parity (PPP)) and 1,355.78 BRL (315.29 USD PPP) for late-start users. Early start of drug use predicted greater severity of cannabis use and use of multiple drugs. The highest direct costs were due to drug dependence combined with alcohol abuse, and due to late start of drug use. CONCLUSIONS: Preventive measures should be prioritized in public policies, in terms of strengthening protective factors before an early start of drug use.

Community-based mental health services in Brazil.

Introduction: The shift from the hospital-based model of care to community-based mental health services began three decades ago and is still an ongoing process in Brazil. Objectives: To update data on the development of the community mental health services network in Brazil in relation to service availability and structure, manpower, pattern of service use, financing, epidemiological studies and the burden of mental disorders, research and national mental health policy. Methods: Searches were constructed to collect data on indexed databases (Medline, Scielo), as well as governmental,NGOs and medical council sources, reports and the grey literature up until 30th March, 2019. Results: Community mental health services are unevenly distributed in the country. Brazil leads the world in terms of the prevalence of anxiety disorders, ranking fifth for depression prevalence. Violence and suicide rates are two growing factors which exacerbate the prevalence of mental disorders prevalence. An increased reduction of the number of psychiatric beds in the country, in addition to the unbalanced growth of services in the community, has resulted in treatment gaps and the underutilization of services and barriers to treating people with the most severe psychosis. Investment in mental healthcare is still scarce. However, mental health funding is not addressed according to the population´s needs and scientific evidence, resulting in a waste of resources and inefficiency. Programmes and service interruptions are common according to each government mandate. Conclusion: Successive changes in ideological perspectives have led to the introduction of policies which have caused fragmentation in the mental health system and services. A lack of evaluation and transparency of services and costs are the main barriers to integrating multiple services and planning long-term developmental phases.

Accommodation and Health Costs of Deinstitutionalized People with Mental Illness Living in Residential Services in Brazil.

BACKGROUND: Health costs are the main hindrances for expanding community mental health services. Exploring patient profiles and cost predictors may be useful for optimising financial resources. However, the deinstitutionalisation process may burden health budgets in terms of supporting multiple community services based on varying levels of need. OBJECTIVE: This study assessed accommodation and health service costs, quality of life and clinical and psychosocial profiles among individuals receiving mental healthcare through residential services. Specific accommodation cost predictors were also verified. METHODS: Health costs were assessed from the perspective of a public health provider using a microcosting bottom-up approach at 20 residential services in São Paulo, Brazil. Instruments used to assess health costs and patient profiles included the Brazilian version of the Client Socio-demographic and Service Receipt Inventory (CSSRI), the Mini International Neuropsychiatric Interview (MINI), the Clinical Global Impression-Severity Scale (CGI-S), the Independent Living Skills Survey (ILLS), the Social Behaviour Scale (SBS) and the Quality of Life Scale (QLS). RESULTS: One hundred and forty-seven residents, predominantly experiencing psychotic disorders, were interviewed. The geographical region and length of time spent living in residential services or in a psychiatric hospital predicted 66% of the variance in accommodation costs. The CGI-S and ILLS scores and years of education explained 52.7% of the variance in quality of life. CONCLUSION: Accommodation costs were not driven by patient profile variables, while region and time spent in a hospital or in residential services were the main cost predictors. Semi-staffed homes may be an alternative for resource optimisation among individuals with mild impairment, particularly if strategies for psychosocial rehabilitation and improving quality of life are implemented.

Cost of a community mental health service: a retrospective study on a psychosocial care center for alcohol and drug users in São Paulo.

BACKGROUND: Psychosocial care centers for alcohol and drug users (CAPS-ad) are reference services for treatment of drug users within the Brazilian National Health System. Knowledge of their total costs within the evidence-based decision-making process for public-resource allocation is essential. The aims here were to estimate the total costs of a CAPS-ad and the costs of packages of care (according to intensity of care); to ascertain the ratio between total CAPS-ad costs and the federal funding allocated; and to describe the methods for estimating unit costs for each CAPS-ad cost component. DESIGN AND SETTING: Retrospective study conducted in a public community mental health service. METHODS: This was a retrospective cost description study on a CAPS-ad located in a city in the state of São Paulo, using a public healthcare provider perspective and a top-down approach, conducted over a 180-day period from March 1 to August 30, 2015. RESULTS: The total mean monthly costs of the CAPS-ad were BRL 64,017.54. Healthcare staff accounted for 56.5% of total costs. The mean costs per capita and per month for intensive and non-intensive care packages were, respectively, BRL 668.34 and BRL 37.12. CONCLUSIONS: The federal budget allocation covered 62.1% of the CAPS-ad costs and the remaining 37.9% end up funded by the municipal government. The cost of the intensive package of care was 18 times greater than the non-intensive package. Developing criteria for using services and different packages of care based on patients' needs, and optimizing human resources according to specific actions, may improve people's mental health and avoid wasted resources.

The Adaption of the Client Sociodemographic and Service Receipt Inventory for Costing Mental Health Services in Brazil.

BACKGROUND: There is a scarcity of tested instruments for measuring mental health services and costs. The Client Sociodemographic Service Receipt Inventory (CSSRI) is the most used tool in economic evaluation in mental health in Europe; it was translated into five languages, and it was mainly used to evaluate deinstitutionalisation process in mental health system reform. AIMS OF THE STUDY: To translate and adapt to the Brazilian healthcare system, and to test its inter-rater reliability, validity and its feasibility in a deinstitutionalized sample of psychiatric hospital living in residential facilities. METHOD: The translation and adaptation of CSSRI to Brazilian context was done by a focus group with eight experts on public mental health services, covering all the available Brazilian healthcare services. Decisions on the extent of conceptual overlap between British and Brazilian version were discussed until reaching expert consensus. The inter-rater reliability and applicability of this version, called ``Inventário Sociodemográfico de Uso e Custos de Serviços - ISDUCS'', was tested in a sample of 30 subjects with moderate to severe mental disorders living in residential facilities. Because the lack of medical record or another source, ISDUCS's validity was assessed using Kappa coefficient agreement to compare between resident`s answers and their professional carers`answers. RESULTS: The same structure of the original instrument was kept, with an additional list of items for costing consumable services. The main modifications were on items related to education, occupational status and on detailed descriptions of public health services. The agreement between two mental health raters was good to excellent for the majority of items, with Kappa coefficient ranged from 0.6 to 1.0. Because 43% of the sample was unable to answer questions about regularly taken medications and consultations with health professionals, an exploratory analysis was done to identify potentially related variables. Greater severity of psychiatric symptoms and lower independent living skills were related to the inability to answer these questions. Agreement between residents and carers was good to excellent for socio and demographic variables, living situation and occupational status, income, visits to a psychologist, occupational therapists and social workers. CONCLUSION: ISDUCS is the first tool for economic evaluation including mental health services translated and adapted to Brazilian context. Despite the widespread use of CRSSI among people with schizophrenia in Europe, this study found that greater severity of symptoms led to high rate of missing responses. Inter-rater reliability was excellent as a whole. Small sample size didn't allow generalisation of results of this preliminary testing. IMPLICATIONS FOR HEALTH PROVISION AND USE: ISDUCS may be suitable for people with mental illness but requires additional sources of information such as carers and medical records. ISDUCS could be used for monitoring health service use in general practice. IMPLICATIONS FOR HEALTH POLICIES: Despite some limitations, this instrument was used to measure mental health service costs in three Brazilian studies, generating data for supporting local mental health policies, for boosting empirical research in the country and for supporting modelling studies. IMPLICATIONS FOR FURTHER RESEARCH: It should be tested further in other health settings and samples.

Cost variation of antipsychotics in the public health system in Brazil: the implication for health resource use / A variação de custos de antipsicóticos no sistema público de saúde do Brasil: as implicações para o uso de recursos

Objective: This study aimed to verify the variation on antipsychotics costs according to four unit costs paid by public health providers in Brazil. Methods: This cross-sectional study used the health provider perspective and bottom-up approach to evaluate 134 subjects with mental disorders, in regular use of antipsychotics, and living in 20 residential services in the city of Sao Paulo between 2011 and 2012. They were assessed for psychiatric diagnosis, the severity of symptoms, quality of life, independent living skills, pattern of health service use and treatments. The Brazilian version of Client Socio-demographic Services Receipt Inventory (ISDUCS) was used to assess health service and medication use. Four different values of unit costs for each antipsychotic were extracted from Medication Price Database (Banco de Preços de Saúde) by the Ministry of Health, Brazil. Results: Variability on the unit costs for chlorpromazine was found by 25,600 fold to the lowest values. Similarly, mean costs of chlorpromazine use per capita per diem varied between BRL 0.55 and BRL 357.87, that is, a difference by 650 fold to the lowest value. Conclusion: The great variability in the unit costs paid by public health providers for all antipsychotics hinders any guideline recommendation for the best cost-saving choice of antipsychotics. It is paramount to proceed cost-effectiveness studies verifying acceptable thresholds for treatments according to the national budget. Yet, monitoring public resource use on the antipsychotic purchasing is imperative to avoid waste of public resources.

Objetivo: Este estudo verificou a variação de custos do antipsicóticos de acordo com quatro valores de unidade de custos pagas pelos provedores públicos no Brasil. Métodos: Estudo transversal utilizou a perspectiva dos provedores públicos de saúde e abordagem bottom-up para avaliar 134 indivíduos com transtornos mentais em uso regular de antipsicóticos, residindo em 20 residências terapêuticas na cidade de São Paulo entre 2011 e 2012. Foram mensurados os diagnósticos psiquiátricos, a gravidade dos sintomas, a qualidade de vida, habilidades de vida independente. O Inventário Sociodemográfico de Utilização de Serviços e Custos ­ ISDUCS (versão do Client Socio-demographic Service Receipt Inventory) foi utilizado para mensurar a frequência de utilização de serviços e de medicamentos. Quatro valores de unidades de custo para os antipsicóticos foram extraídos do Banco de Preços de Saúde do Ministério da Saúde do Brasil. Resultados: A variabilidade entre as unidades de custo para a clorpromazina foi de 25.600 vezes comparada com o menor valor, e o custo médio da clorpromazina per capita por dia variou de R$ 0,55 a R$ 357,87, uma diferença de 650 vezes o menor valor. Conclusão: A grande variabilidade entre as unidades de custos pagas pelo provedor público de saúde dificulta as recomendações dos guias clínicos em termos de escolher o antipsicótico menos custoso como primeira linha, sendo necessários estudos de custo-efetividade para verificar o limite máximo aceitável para a unidade de custo compatível com o orçamento nacional. O monitoramento do uso de recursos públicos para a aquisição de antipsicóticos é imperativo para impedir o desperdício de recursos públicos.

Culture-bound syndromes in Spanish speaking Latin America: the case of Nervios, Susto and Ataques de Nervios

Abstract Background Cultural issues are important for diagnostic validity between different countries; little has been addressed from Latin America and Caribbean countries (LAC). Objective To identify LAC studies on culture-bound syndromes (CBS) and extract potential empirical evidence about Susto,Nervios and Ataques de Nervios. Methods Search strategies were carried out in Medline, Embase, Lilacs, ISI and PsycINFO, covering 1992 to 2015. Inclusion criteria studies on CBS conducted on populations residing in LAC, LAC articles on diagnostic classification and culture, where LAC has been included. Exclusion criteria studies on Latin American migrants outside LAC. Content analysis used the system proposed by Guarnaccia and Rogler (1999): epidemiological, ethnographic and socio-demographic data and identification of comorbidities with other psychiatric disorders. Results Thirty one articles were selected out of 1.090. These CBS were selected out of 1aphic data and identification of comorbidities with other ps proposed by Guarnaccia diagnostic classification and cun panic disorders and post-traumatic stress disorder and presented more psychosocial vulnerability. Discussion Analysis showed that Nervios, Susto andAtaques de Nervios are important idioms of distress, associated with socio-economically vulnerable populations and comorbidities with other psychiatric conditions, particularly post-traumatic stress disorder. More studies are needed on their relation with stress and in more LAC countries.

The impact of antipsychotic polytherapy costs in the public health care in Sao Paulo, Brazil.

INTRODUCTION: Guidelines for the treatment of psychoses recommend antipsychotic monotherapy. However, the rate of antipsychotic polytherapy has increased over the last decade, reaching up to 60% in some settings. Studies evaluating the costs and impact of antipsychotic polytherapy in the health system are scarce. OBJECTIVE: To estimate the costs of antipsychotic polytherapy and its impact on public health costs in a sample of subjects with psychotic disorders living in residential facilities in the city of Sao Paulo, Brazil. METHOD: A cross-sectional study that used a bottom-up approach for collecting costs data in a public health provider's perspective. Subjects with psychosis living in 20 fully-staffed residential facilities in the city of Sao Paulo were assessed for clinical and psychosocial profile, severity of symptoms, quality of life, use of health services and pharmacological treatment. The impact of polytherapy on total direct costs was evaluated. RESULTS: 147 subjects were included, 134 used antipsychotics regularly and 38% were in use of antipsychotic polytherapy. There were no significant differences in clinical and psychosocial characteristics between polytherapy and monotherapy groups. Four variables explained 30% of direct costs: the number of antipsychotics, location of the residential facility, time living in the facility and use of olanzapine. The costs of antipsychotics corresponded to 94.4% of the total psychotropic costs and to 49.5% of all health services use when excluding accommodation costs. Olanzapine costs corresponded to 51% of all psychotropic costs. CONCLUSION: Antipsychotic polytherapy is a huge economic burden to public health service, despite the lack of evidence supporting this practice. Great variations on antipsychotic costs explicit the need of establishing protocols for rational antipsychotic prescriptions and consequently optimising resource allocation. Cost-effectiveness studies are necessary to estimate the best value for money among antipsychotics, especially in low and middle income countries.

Setting priorities for mental health research in Brazil / Agenda de prioridades de pesquisa para saúde mental no Brasil

BACKGROUND: The main aim of this study is to review the agenda for research priorities of mental health in Brazil. METHODOLOGY: The first step was to gather 28 experts (22 researchers, five policy makers, and the coordinator) representing all mental health fields from different geographical areas of the country. Participants were asked to list what they considered to be the most relevant mental health research questions for the country to address in the next 10 years. Seventeen participants answered this question; after redundancies were excluded, a total of 110 responses were collected. As the second step, participants were asked to rank which questions were the 35 most significant. The final step was to score 15 items for each of the 35 selected questions to determine whether it would be a) answerable, b) effective, c) deliverable, d) equitable, and e) effective at reducing the burden of mental health. The ten highest ranked questions were then selected. RESULTS: There were four questions addressing primary care with respect to a) the effectiveness of interventions, b) "matrix support", c) comparisons of different models of stepped care, and d) interventions to enhance identification and treatment of common mental disorders at the Family Health Program. The other questions were related to the evaluation of mental health services for adults and children/adolescents to clarify barriers to treatment in primary care, drug addiction, and severe mental disorders; to investigate the cost-benefit relationship of anti-psychotics; to design interventions to decrease alcohol consumption; and to apply new technologies (telemedicine) for education and supervision of non-specialists. CONCLUSION: This priority-setting research exercise highlighted a need for implementing investments at the primary-care level, particularly in the family health program; the urgent need to evaluate services; and policies to improve equity by increasing accessibility to services and testing interventions to reduce barriers for seeking mental health treatment.

INTRODUÇÃO: O principal objetivo desse estudo foi revisar a agenda de prioridades em pesquisa em saúde mental no Brasil. MÉTODO: Foram selecionados 28 especialistas (22 pesquisadores, cinco legisladores e o coordenador) de diferentes regiões. Responderam ao que consideravam mais relevante em pesquisa para a saúde mental para os próximos 10 anos. Dezessete responderam e configuraram 110 questões, que foram reavaliadas por eles, com atribuição de escore, a partir de 15 itens distribuídos segundo grau de responsividade, eficácia, aplicabilidade, equidade e impacto na redução da carga da doença mental. 35 questões, e dentre elas as 10 mais bem pontuadas, foram destacadas. RESULTADOS: Prevaleceram indicações para estudos de efetividade das intervenções, matriciamento, comparação entre modelos de intervenção e detecção e tratamento de transtornos mais prevalentes na Estratégia da Saúde da Família. Avaliação de serviços quanto às barreiras ao tratamento; custo-efetividade dos antipsicóticos, intervenções contra efeitos do álcool e outras drogas, e aplicação de tecnologias (telemedicina) para educação e supervisão dos generalistas foram outros. CONCLUSÃO: Apontou-se para necessidade de investimentos na saúde mental na atenção primária à saúde; avaliação do sistema de serviços de cuidados de saúde mental, e pesquisas para romper barreiras ao acesso e à equidade no tratamento dos transtornos mentais.

Lessons learned in developing community mental health care in Latin American and Caribbean countries.

This paper summarizes the findings for the Latin American and Caribbean countries of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. It presents an overview of the provision of mental health services in the region; describes key experiences in Argentina, Belize, Brazil, Chile, Cuba, Jamaica and Mexico; and discusses the lessons learned in developing community mental health care.

Strategies for the treatment of antipsychotic-induced sexual dysfunction and/or hyperprolactinemia among patients of the schizophrenia spectrum: a review.

There is limited evidence for the management of sexual dysfunction and/or hyperprolactinemia resulting from use of antipsychotics in patients with schizophrenia and spectrum. The aim of this study was to review and describe the strategies for the treatment of antipsychotic-induced sexual dysfunctions and/or hyperprolactinemia. The research was carried out through Medline/PubMed, Cochrane, Lilacs, Embase, and PsycINFO, and it included open labels or randomized clinical trials. The authors found 31 studies: 25 open-label noncontrolled studies and 6 randomized controlled clinical trials. The randomized, double-blind controlled studies that were conducted with adjunctive treatment that showed improvement of sexual dysfunction and/or decrease of prolactin levels were sildenafil and aripiprazole. The medication selegiline and cyproheptadine did not improve sexual function. The switch to quetiapine was demonstrated in 2 randomized controlled studies: 1 showed improvement in the primary outcome and the other did not. This reviewed data have suggested that further well-designed randomized controlled trials are needed to provide evidence for the effects of different strategies to manage sexual dysfunction and/or hyperprolactinaemia resulting from antipsychotics. These trials are necessary in order to have a better compliance and reduce the distress among patients with schizophrenia.