Effectiveness and cost-effectiveness of community-based mental health services for individuals with severe mental illness in Iran: a systematic review and meta-analysis.

BACKGROUND: Severe mental illness (SMI) imposes a substantial worldwide burden of disability, highlighting the need for comprehensive and adaptable mental health services. This study aims to assess the efficacy and cost-effectiveness of community-based mental health services (CBMHS) in reducing relapse and rehospitalization rates among individuals with SMI in Iran. METHOD: A systematic review and meta-analysis were conducted. Medline, EMBASE, ISI, SCOPUS, and ProQuest were searched until December 2022. We focused on randomized controlled trials, quasi-experimental studies, or economic studies related to individuals with SMI. Out of 127 articles, 17 were selected for a full-text review. The primary outcomes were the severity of psychopathology, rehospitalization rates, and the mental health of caregivers. We also examined community-based interventions and their impact on various outcomes. Data extraction and risk of bias assessment were performed, and critical appraisal was conducted using JBI checklists. Meta-analysis was carried out using STATA software. (PROSPERO registration. CRD42022332660). RESULT: Rehospitalization rates among patients who received CBMHS were significantly lower, with an odds ratio of 2.14 (95% CI: 1.44 to 3.19), indicating a 2.14 times lower likelihood than those who received treatment as usual. A reduction in psychopathology accompanied this, SMD: -0.31, 95% CI: -0.49 to -0.13, I2 = 40.23%). Moreover, there was a notable improvement in social skills (SMD: -0.7, 95% CI: -0.98 to -0.44, I2 = 0.00%). The burden on caregivers also decreased (SMD: -0.55, 95% CI: -0.99 to -0.1, I2 = 63.2). The Incremental Cost-Effectiveness Ratio (ICER) for QUALY was acceptable, albeit with a wide range of 613 to 8400 Dollars. CONCLUSION: CBMHS has demonstrated effectiveness and efficiency in Iran as a developing country. Additionally, it shows promise in mitigating the shortage of acute psychiatry beds. Using multiple data collection tools poses a limitation regarding data consolidation and conducting a meta-analysis.

Assertive community treatment for high-utilizing alcohol misuse patients: a before-and-after cohort study protocol.

BACKGROUND: The challenge posed by Alcohol-Related Frequent Attenders (ARFAs) in Emergency Departments (EDs) is growing in Singapore, marked by limited engagement with conventional addiction treatment pathways. Recognizing this gap, this study aims to explore the potential benefits of Assertive Community Treatment (ACT) - an innovative, community-centered, harm-reduction strategy-in mitigating the frequency of ED visits, curbing Emergency Medical Services (EMS) calls, and uplifting health outcomes across a quartet of Singaporean healthcare institutions. METHODS: Employing a prospective before-and-after cohort design, this investigation targeted ARFAs aged 21 years and above, fluent in English or Mandarin. Eligibility was determined by a history of at least five ED visits in the preceding year, with no fewer than two due to alcohol-related issues. The study contrasted health outcomes of patients integrated into the ACT care model versus their experiences under the exclusive provision of standard emergency care across Hospitals A, B, C and D. Following participants for half a year post-initial assessment, the evaluation metrics encompassed socio-demographic factors, ED, and EMS engagement frequencies, along with validated health assessment tools, namely Christo Inventory for Substance-misuse Services (CISS) scores, University of California, Los Angeles (UCLA) Loneliness scores, and Centre for Epidemiologic Studies Depression Scale Revised (CESD-R-10) scores. DISCUSSION: Confronted with intricate socio-economic and medical challenges, the ARFA cohort often grapples with heightened vulnerabilities in relation to alcohol misuse. Pioneering the exploration of ACT's efficacy with ARFAs in a Singaporean context, our research is anchored in a patient-centered approach, designed to comprehensively address these multifaceted clinical profiles. While challenges, like potential high attrition rates and sporadic data collection, are anticipated, the model's prospective contribution towards enhancing patient well-being and driving healthcare efficiencies in Singapore is substantial. Our findings have the potential to reshape healthcare strategies and policy recommendations. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04447079. Initiated on 25 June 2020.

Reliability and validity of the dynamic risk outcome scales-short version for clients with mild intellectual disabilities or borderline intellectual functioning.

INTRODUCTION: This study investigated the reliability and validity of the dynamic risk outcome scales-short version (DROS-SV). This instrument is developed to monitor treatment progress using dynamic risk factors in clients with mild intellectual disabilities or borderline intellectual functioning and behavioural and/or mental health problems. METHOD: Data were collected from 264 clients who received Flexible Assertive Community Treatment (FACT), a form of intensive outpatient treatment. RESULTS: A principal component analysis showed that there were six components explaining 73.9% of the variance. Furthermore, the DROS-SV showed good internal consistency of its subscales and total score (α > 0.78). Correlating the DROS-SV with the Historical and Clinical subscales of the Historical, Clinical and Future-30 indicated convergent and divergent validity. DISCUSSION: The DROS-SV has good psychometric properties for measuring dynamic risk factors in clients with mild intellectual disabilities or borderline intellectual functioning in FACT teams.

Uncertainty Work: Dealing with a Psychiatric Crisis in Two European Community Mental Health Teams.

The quest for how to deal with a crisis in a community setting, with the aim of deinstitutionalizing mental health care, and reducing hospitalization and coercion, is important. In this article, we argue that to understand how this can be done, we need to shift the attention from acute moments to daily uncertainty work conducted in community mental health teams. By drawing on an empirical ethics approach, we contrast the modes of caring of two teams in Utrecht and Trieste. Our analysis shows how temporality structures, such as watchful waiting, are important in dealing with the uncertainty of a crisis.

Routine Sensitive Enquiry of Adult Interpersonal Trauma in Community Mental Health Teams: An Audit of the Initial Assessment Tool.

This audit aimed to evaluate the utility of the Initial Assessment Tool (IAT) in documenting routine sensitive enquiry of adult interpersonal trauma within three Community Mental Health Teams (CMHTs) in North-East Glasgow. In addition, it sought to evaluate if disclosures informed patient risk assessments and if patients were signposted to additional support services. 57% of 90 IATs had evidence of routine sensitive enquiry. Of 51 casefiles with evidence of routine sensitive enquiry, 61% had evidence of the information informing their risk assessments and 14% had documented recommendations of support organisations. The IAT appeared able to assist clinicians with routine sensitive enquiry in adulthood. However, there may be advantage in supporting staff understanding of how to ask questions to specific populations and to use this information to inform treatment planning. Given the prevalence of adult interpersonal trauma experienced by patients presenting to CMHTs, trauma-informed approaches to care should be implemented.

First-contact patients with a community mental health service in rural Greece: A 3-year prospective study of treatment attendance and its co-relations.

BACKGROUND: Treatment continuation is essential for the optimal management of patients with mental disorders in the community, but treatment and outcome are often undermined by the high rates of service disengagement and treatment non-adherence across all psychiatric diagnoses. The phenomenon may be even more relevant in rural settings. AIMS: The aim of the present study was to explore attendance to treatment in first-contact patients in a community-based treatment setting in rural Greece and to explore the associations of treatment attendance with demographic and clinical factors. METHOD: Data were collected prospectively over a 3-year period, with 1-year follow-up interval. All first-contact cases with the Mobile Mental Health Unit of the prefectures of Ioannina and Thesprotia (MMHU I-T), Northwest Greece were considered, but only clinical cases were processed. RESULTS: The sample size consisted of 446 patients, with a mean age 65.4 ± 18.8 years. The rate of 12-month attendance to mental health treatment was 13.5% (60 out of 446 patients). Treatment attendance was found to be correlated with younger age, the diagnosis of schizophrenia-spectrum disorder, and patients' referral by other psychiatric services. First examination over the year 2019 had been significantly inversely associated with treatment engagement. CONCLUSION: Rates of subsequent attendance after initial assessment in a rural community mental healthcare setting were rather low in the present study. Several variables that have been previously associated with service engagement were found to be related in this study too, whereas other were not. Research on treatment engagement in rural treatment settings should be ongoing to reveal all associated factors.

Perceptions of community mental health services among culturally diverse adult Singaporeans with major depressive disorder: A descriptive qualitative study.

Persons with major depressive disorder (PMDDs) often experience pernicious ramifications on the biopsychosocial aspects of their health. While community mental health services (CMHSs) in Singapore are increasingly leveraged to meet the escalating demand for mental healthcare, shortcomings such as a substantial treatment gap and the lack of holistic, culturally sensitive care have been highlighted. Of note, the perspectives of the service users, which have hardly been studied in the literature, are crucial to our understanding of their needs to continuously improve CMHSs. Accordingly, this qualitative descriptive study explored the perceptions and experiences of community-dwelling adults with major depressive disorder in their use of CMHSs in Singapore. Seventeen adults with major depressive disorder purposefully sampled from a CMHS provider were interviewed through a semi-structured guide between October and November 2021. Data analysis via Braun and Clarke's six-step thematic framework yielded five themes corresponding to three different phases: pre-CMHS encounter ((i) procrastination to seek help and (ii) factors influencing CMHS utilization); intra-CMHS encounter ((iii) incongruous perceptions of the impacts on biopsychosocial health and (iv) differing perceptions and experiences of culturally sensitive care); and post-CMHS encounter ((v) enhancing CMHSs for PMDDs based on end-users' experiences). Our findings underscore the need to improve the delivery of personalized mental healthcare services, use of settings- and culturally-specific anti-stigma strategies, and nationwide mental health literacy in symptom recognition and awareness of help-seeking resources.

Exploring mental health consumer experiences of the strengths model of case management: A phenomenological study.

The strengths of model of case management is a recovery-oriented model of community mental health care that has been linked to positive consumer outcomes. The aim of this qualitative study was to explore the consumer perspective of the strengths model of case management using a descriptive phenomenological approach. Data were collected through in-depth, semi-structured interviews. In total, six consumers from a metropolitan community mental health service were interviewed. Interview transcripts were analysed using Colaizzi's phenomenological method. Three major themes were identified: the relationship between the consumer and the case manager is valuable, the strengths assessment supports identifying strengths and areas for action and the strengths model of case management promotes recovery and goal achievement. Implications for practice include an increased understanding of consumer preferences and promoting the consumer voice, thereby supporting the provision of higher quality evidence-based practice.

Culturally Adapted Cognitive Behaviour Therapy (CaCBT) to Improve Community Mental Health Services for Canadians of South Asian Origin: A Qualitative Study.

BACKGROUND: South Asian (SA) Canadians are disproportionately affected by higher rates of mood and anxiety disorders. SA Canadians with depression report significant barriers to accessing mental health care and the highest proportion of unmet mental health needs. The Mental Health Commission of Canada (MHCC) advocates for culturally and linguistically relevant services for SA Canadians. Culturally adapted cognitive behavior therapy (CaCBT) has shown to be more effective than standard cognitive behavior therapy (CBT). Adapting CBT for the growing SA population in Canada will ensure equitable access to effective, culturally-appropriate mental health interventions. METHOD: The study used a qualitative design to elicit stakeholder consultation via in-depth interviews. This study is reported using the criteria included in Consolidated Criteria for Reporting Qualitative Studies (COREQ). The analysis follows an ethnographic approach and was informed by the principles of emergent design. RESULTS: Five themes were identified from the analysis, (i) Awareness and preparation: factors that impact the individual's understanding of therapy and mental illness. (ii) Access and provision: SA Canadians' perception of barriers, facilitators, and access to treatment. (iii) Assessment and engagement: experiences of receiving helpful treatment. (iv) Adjustments to therapy: modifications and suggestions to standard CBT. (v) Ideology and ambiguity: racism, immigration, discrimination, and other socio-political factors. CONCLUSIONS: Mainstream mental health services need to be culturally appropriate to better serve SA Canadians experiencing depression and anxiety. Services must understand the family dynamics, cultural values and socio-political factors that impact SA Canadians to reduce attrition rates in therapy.

Assessing a pilot scheme of intensive support and assertive linkage in levels of engagement, retention, and recovery capital for people in recovery housing using quasi-experimental methods.

INTRODUCTION: Strong and ever-growing evidence highlights the effectiveness of recovery housing in supporting and sustaining substance use disorder (SUD) recovery, especially when augmented by intensive support that includes assertive linkages to community services. This study aims to evaluate a pilot intensive recovery support (IRS) intervention for individuals (n = 175) entering certified Level II and III recovery residences. These individuals met at least three out of five conditions (no health insurance; no driving license; substance use in the last 14 days; current unemployment; possession of less than $75 capital). The study assesses the impact of the IRS on engagement, retention, and changes in recovery capital, compared to the business-as-usual Standard Recovery Support (SRS) approach (n = 1758). METHODS: The study employed quasi-experimental techniques to create weighted and balanced counterfactual groups. These groups, derived from the Recovery Capital assessment tool (REC-CAP), enabled comparison of outcomes between people receiving IRS and those undergoing SRS. RESULTS: After reweighting for resident demographics, service needs, and barriers to recovery, those receiving IRS exhibited improved retention rates, reduced likelihood of disengagement, and growth in recovery capital after living in the residence for 6-9 months. CONCLUSION: The results from this pilot intervention indicate that intensive recovery support, which integrates assertive community linkages and enhanced recovery coaching, outperforms a balanced counterfactual group in engagement, length of stay, and recovery capital growth. We suggest that this model may be particularly beneficial to those entering Level II and Level III recovery housing with lower levels of recovery capital at admission.

Fatores associados à internação de usuários encaminhados 1 pela atenção primária para acompanhamento em Centros de Atenção Psicossociais do município de São Paulo, Brasil / Factors associated with the hospitalization of users referred from primary health care to follow-up in Psychosocial Care Centers in the city of São Paulo, Brazil

Avaliaram-se os fatores associados à internação relacionadas à saúde mental de pessoas em acompanhamento nos Centros de Atenção Psicossocial (CAPS) do município de São Paulo, encaminhadas pela atenção primária (APS). Pesquisa avaliativa com 297 pessoas em 24 CAPS Adulto. Analisaram-se as razões de prevalência (RP) e seus respectivos intervalos de confiança de 95% (IC), obtidas por meio da regressão de Poisson com variância robusta. Mostraram associação estatisticamente significativa com a internação durante o acompanhamento no CAPS: ter plano de saúde/convênio médico; tempo de espera entre diagnóstico e primeiro atendimento com profissional não médico maior que sete dias; não ter sido orientado sobre o tempo de uso da medicação; não receber prescrição de psicofármaco na APS; e ter histórico de ocorrência de internação por saúde mental. Os resultados alertam para a necessidade de ampliação do acesso à população com maior vulnerabilidade social, além de uma reestruturação dos serviços para a oferta de prática mais articuladas e inclusivas, voltadas às singularidades dos usuários.

Increasing chronic disease preventive care in community mental health services: clinician-generated strategies.

BACKGROUND: People with a mental health condition experience a high prevalence of chronic disease risk behaviours e.g., tobacco smoking and physical inactivity. Recommended 'preventive care' to address these risks is infrequently provided by community mental health services. This study aimed to elucidate, among community mental health managers and clinicians, suggestions for strategies to support provision of preventive care. METHODS: Three qualitative focus groups (n = 14 clinicians) were undertaken in one regional community mental health service to gather perspectives of barriers to preventive care provision, deductively coded against the domains of the Theoretical Domains Framework (TDF). Drawing on the learnings from the focus groups, individual interviews (n = 15 managers and clinicians) were conducted in two services to identify suggestions for strategies to increase preventive care. Strategies were inductively coded and mapped into TDF domains. RESULTS: Barriers were identified across a wide range of TDF domains, most notably knowledge and environmental context and resources. Nine strategies were identified across three themes: training, resources and systems changes; mapping to all 14 TDF domains. CONCLUSION: Future research seeking to increase implementation of preventive care may be guided by these findings. There is need for greater recognition and resourcing of preventive care as a priority and integral component of mental health treatment.

Riding the tides: Directions in mental health rehabilitation in NSW.

OBJECTIVE: This paper outlines the evolution of mental health rehabilitation in NSW, where allocation of health resources has repeatedly contradicted the policy intention to reorient services from inpatient to community-based services, leaving community rehabilitation the poor and disconnected cousin of inpatient services. The expanding role of community-managed organisations (CMOs) in psychosocial rehabilitation, the introduction of the National Disability Insurance Scheme (NDIS), and emerging service models have helped foster a maturing housing and social care environment, but present reality and the integration of health and social care services remains at a distance from best evidence practice. CONCLUSION: The challenge of the next decade of mental health reform is to embrace and consolidate greater service diversity and complexity. Understanding what factors influenced present reality is important in providing guardrails for the future, enabling the current wave of renewal and reinvestment in NSW to build on the strengths of past developments and steer a course around their weaknesses.

Evaluation of a mental health service reform program, the Pathways to Community Living Initiative, for people with severe mental illness and complex needs.

OBJECTIVE: The Pathways to Community Living Initiative (PCLI) aims to reform mental health care for people with severe and persistent mental illness (SPMI) and complex needs. This study reports independent evaluation findings on transitions from hospital and practice change in mental health services. METHODS: Data for this mixed-methods evaluation were obtained from administrative collections and semi-structured interviews with PCLI program managers, teams and executive leads; aged care managers; and leaders in inpatient, community and older people's mental health services. RESULTS: Between July 2015 and December 2020, 674 participants (67% of those eligible for the PCLI) were transitioned from hospital to community. Of those transitioned, 21 required subsequent long-stay admissions. The PCLI introduced resources, clearly defined processes, and state-wide networks to guide changes in practice which are becoming embedded in the operations and governance of mental health services across New South Wales. CONCLUSIONS: Severe and persistent mental illness and complex needs can be managed in community settings with highly individualised planning and care, supported by specialised clinical teams in partnership with mental health, aged care and disability services. Evaluation findings highlight the importance of continued investment in rehabilitation psychiatry.

Exploring gender impact on collaborative care planning: insights from a community mental health service study in Italy.

INTRODUCTION: Personal recovery is associated with socio-demographic and clinical factors, and gender seems to influence the recovery process. This study aimed to investigate: i) differences in the recovery goals of men and women users of a community mental health service in Italy; ii) any differences by gender in recovery over six months using the Mental Health Recovery Star (MHRS). METHODS: Service users and staff completed the MHRS together at recruitment and six months later to agree the recovery goals they wished to focus on. Socio-demographic and clinical characteristics and ratings of symptoms (BPRS), needs (CAN), functioning (FPS), and functional autonomy (MPR) were collected at recruitment and six months follow-up. Comparisons between men and women were made using t-tests. RESULTS: Ten women and 15 men completed the MHRS with 19 mental health professionals. Other than gender, men and women had similar socio-demographic, and clinical characteristics at recruitment. Women tended to choose recovery goals that focused on relationships whereas men tended to focus on work related goals. At follow-up, both men and women showed improvement in their recovery (MHRS) and women were less likely to focus on relationship related goals, perhaps because some had found romantic partners. There were also gains for both men and women in engagement with work related activities. Ratings of functional autonomy (MPR) improved for both men and women, and men also showed improvement in symptoms (BPRS) and functioning (FPS). CONCLUSIONS: Our findings suggest that collaborative care planning tools such as the MHRS can assist in identifying individualized recovery goals for men and women with severe mental health problems as part of their rehabilitation.