Care gap: a comprehensive measure to quantify unmet needs in mental health.

AIM: Treatment gap refers to the percentage of individuals who require treatment in a country or a defined community but do not receive it due to various reasons. There is widespread acceptance of 'treatment gap' as a measure of unmet needs in mental health. However, the term 'treatment' carries a medical connotation and implies biomedical treatment (or lack of it) of mental illness and is often interpreted by policymakers, planners and researchers, as well as by non-professional stakeholders as exclusively referring to curative clinical psychiatric interventions. This common interpretation results in the exclusion of a range of effective psychosocial interventions available today. Treatment gap also does not include physical health services for persons with mental illness, a major concern due to the relative frequent yet highly unattended physical comorbidity and early mortality of persons with severe mental illness. METHODS & RESULTS: We, therefore, propose a more comprehensive measure of unmet needs.

Information for mental health systems: an instrument for policy-making and system service quality.

AIMS: Information is crucial in mental healthcare, yet it remains undervalued by stakeholders. Its absence undermines rationality in planning, makes it difficult to monitor service quality improvement, impedes accountability and human rights monitoring. For international organizations (e.g., WHO, OECD), information is indispensable for achieving better outcomes in mental health policies, services and programs. This article reviews the importance of developing system level information with reference to inputs, processes and outputs, analyzes available tools for collecting and summarizing information, highlights the various goals of information gathering, discusses implementation issues and charts the way forward. METHODS: Relevant publications and research were consulted, including WHO studies that purport to promote the use of information systems to upgrade mental health care in high- and low-middle income countries. RESULTS: Studies have shown that once information has been collected by relevant systems and analyzed through indicator schemes, it can be put to many uses. Monitoring mental health services, represents a first step in using information. In addition, studies have noted that information is a prime resource in many other areas such as evaluation of quality of care against evidence based standards of care. Services data may support health services research where it is possible to link mental health data with other health and non-health databases. Information systems are required to carefully monitor involuntary admissions, restrain and seclusion, to reduce human rights violations in care facilities. Information has been also found useful for policy makers, to monitor the implementation of policies, to evaluate their impact, to rationally allocate funding and to create new financing models. CONCLUSIONS: Despite its manifold applications, Information systems currently face many problems such as incomplete recording, poor data quality, lack of timely reporting and feedback, and limited application of information. Corrective action is needed to upgrade data collection in outpatient facilities, to improve data quality, to establish clear rules and norms, to access adequate information technology equipment and to train health care personnel in data collection. Moreover, it is necessary to shift from mere administrative data collection to analysis, dissemination and use by relevant stakeholders and to develop a "culture of information" to dismantle the culture of intuition and mere tradition. Clinical directors, mental health managers, patient and family representatives, as well as politicians should be educated to operate with information and not just intuition.

Perceived coercion in persons with mental disorder in India: A cross-sectional study.

BACKGROUND: Little is known about how patients in India perceive coercion in psychiatric care. AIMS: To assess perceived coercion in persons with mental disorder admitted involuntarily and correlate with sociodemographic factors and illness variables. MATERIALS AND METHODS: We administered the short MacArthur Admission Experience Interview Questionnaire to all consecutive involuntary psychiatric patients admitted in 2014 in Mysore, India. Multivariate linear regression was used. RESULTS: Three hundred and one patients participated. "Perceived coercion" subscale scores increased with female gender, nuclear family status, Muslim and Christian religion, lower income, and depressive disorder. It decreased with former coercion, forensic history, and longer illness duration. Drug use increased total scores; the extended family item decreased them. "Negative pressure" increased with male gender, extended family, lower income, forensic history, and longer illness duration. CONCLUSIONS: The study shows perceived coercion is a reality in India. Levels of perceived coercion and the populations affected are similar to high-income countries.

Staff and caregiver attitude to coercion in India.

OBJECTIVES: The objective of this study was to assess attitudes of Indian psychiatrists and caregivers toward coercion. MATERIALS AND: Methods: The study was conducted at the Department of Psychiatry, Krishna Rajendra Hospital, Mysore, India. Staff Attitude to Coercion Scale (SACS), a 15-item questionnaire, was administered to self-selected psychiatrists across India and caregivers from Mysore to measure attitudes on coercion. Data were analyzed using descriptive statistics and investigating differences in subgroups by means of Chi-square test, Student's t-test, and analysis of variance. Reliability of the SACS was tested in this Indian sample. RESULTS: A total of 210 psychiatrists and 210 caregivers participated in the study. Both groups agreed that coercion was related to scarce resources, security concerns, and harm reduction. Both groups agreed that coercion is necessary, but not as treatment. Older caregivers and male experienced psychiatrists considered coercion related to scarce resources to violate patient integrity. All participants considered coercion necessary for protection in dangerous situations. Professionals and caregivers significantly disagreed on most items. The reliability of the SACS was reasonable to good among the psychiatrists group, but not in the caregiver group (alpha 0.58 vs. 0.07). CONCLUSION: Caregivers and psychiatrists felt that the lack of resources is one of the reasons for coercion. Furthermore, they felt that the need on early identification of aggressive behavior, interventions to reduce aggressiveness, empowering patients, improving hospital resources, staff training in verbal de-escalation techniques is essential. There is an urgent need in the standardized operating procedure in the use of coercive measure in Indian mental health setting.

Public education for community care. A new approach.

BACKGROUND: The findings from a controlled study of the effect of a public education campaign on community attitudes to mentally ill people are presented. METHOD: A census of neighbours' attitudes toward mental illness was conducted in two areas before the opening of supported houses for the mentally ill. In one area an educational campaign was conducted. The attitude survey was then repeated in both areas and patients' social contact with neighbours was recorded. RESULTS: Respondents exposed to the didactic component of the campaign showed only a small increase in knowledge about mental illness but there was a lessening of fearful and rejecting attitudes in the experimental area and not in the control area. Neighbours in the experimental area were more likely to make social contact with both staff and patients. It was social contact which was directly associated with improved attitudes rather than education per se. Patients in the experimental area made contact and even friendships with neighbours whereas those in the control area did not. CONCLUSIONS: The public education campaign did not lead to significant change in neighbours' knowledge of mental illness. However, their attitudes improved and patients' social integration was enhanced.

Community attitudes to mental illness.

BACKGROUND: The baseline findings from a controlled study of the effect of a public education campaign on community attitudes to mental illness are presented. METHOD: A census of attitudes to mental illness was conducted in two areas, prior to the opening of supported houses for the mentally ill. Factor analysis of the Community Attitudes toward the Mentally Ill (CAMI) inventory revealed three components: Fear and Exclusion, Social Control and Goodwill. RESULTS: The only determinant of Fear and Exclusion was having children. The main determinants of Social Control were social class, ethnic origin, age, having suffered mental illness and having children. The main determinant of Goodwill was educational level. The attitude factors were predictive of respondents' behavioural intentions toward the mentally ill. Respondents with children and non-Caucasians were more likely to object to the mentally ill living in their neighbourhood. CONCLUSIONS: Any intervention aimed at changing attitudes to mentally ill people in the community should be targeted at people with children and non-Caucasians, as these groups are more likely to object.

Community knowledge of mental illness and reaction to mentally ill people.

BACKGROUND: We test the hypothesis that negative attitudes to mentally ill people may be fuelled by a lack of knowledge. METHOD: A census of knowledge of mental illness was conducted in two areas prior to the opening of long-stay supported houses for the mentally ill in each area. Three attitudinal factors (Fear and Exclusion, Social Control and Goodwill) which had been extracted by factor analysis of the Community Attitudes toward the Mentally Ill (CAMI) inventory (see previous paper) were analysed in respect of their associations with knowledge of mental illness. RESULTS: Most respondents (80%) knew of somebody who had a mental illness but a substantial proportion of respondents had little knowledge about mental illness. Social Control showed an association with knowledge of mental illness. Groups who showed more socially controlling attitudes (especially those over 50 years old, those of lower social class, and those of non-Caucasian ethnic origin) had less knowledge about mental illness. Regression analysis revealed that when knowledge was taken into account, age had no effect on Social Control, and the effect of social class and ethnic origin was diminished. Respondents with children, who showed more Fear and Exclusion, were not less knowledgeable about mental illness. CONCLUSIONS: The results support the hypothesis that negative attitudes, especially in older people, are fuelled by a lack of knowledge. Negative attitudes among people with children are not related to a lack of knowledge.

The Explanatory Model Interview Catalogue (EMIC). Contribution to cross-cultural research methods from a study of leprosy and mental health.

The Explanatory Model Interview Catalogue (EMIC) has been developed to elicit illness-related perceptions, beliefs, and practices in a cultural study of leprosy and mental health in Bombay. Leprosy is an especially appropriate disorder for studying the inter-relationship of culture, mental health and medical illness because of deeply rooted cultural meanings, the emotional burden, and underuse of effective therapy. Fifty per cent of 56 recently diagnosed leprosy out-patients, 37% of 19 controls with another stigmatised dermatological condition (vitiligo), but only 8% of 12 controls with a comparable non-stigmatised condition (tinea versicolor) met DSM-III-R criteria for an axis I depressive, anxiety or somatoform disorder. Belief in a humoral (traditional) cause of illness predicted better attendance at clinic.