Structured communication methods for mental health consultations in primary care: a scoping review.

BACKGROUND: Majority of people with mental health problems attend primary care for support. Interventions that structure consultations have been found effective for physical health conditions and secondary mental health care. The aim of the review is to identify what tools or interventions exist to structure communication in primary care for appointments related to mental health problems and examine existing evidence for effectiveness for mental health and quality of life outcomes. METHODS: Quantitative and qualitative studies were eligible for inclusion if staff was based in a primary care setting and the intervention involved bi-directional communication with adult patients. Six databases were searched (MEDLINE, Web of Knowledge, EMBASE, PsycINFO, The Cochrane Library, CINAHL) with no time restriction. Search terms combined four concepts with key words such as "structured" and "interaction" and "mental illness" and "primary care". Reference lists of eligible studies were searched. RESULTS: After removing duplicates, 3578 records were found and underwent further screening. A total of 16 records were included, representing eight different interventions from five countries. The majority were delivered by primary care doctors and focused on patients experiencing psychological distress. Similarities across interventions' service delivery were that most were created for a broad patient population, used self-report assessments at the start and actions or plans as the end point, and employed group settings and didactic methods for training staff in the intervention. Booster and follow-up trainings were not offered in any of the interventions, and supervision was only part of the process for one. The evidence for effectiveness for mental health and quality of life outcomes was mixed with three out of five RCTs finding a positive effect. CONCLUSIONS: Although the idea of structuring communication for mental health consultations has been around since the 1980s, relatively few interventions have attempted to structure the conversations within the consultation, rather than modifying pre-visit events. As the evidence-base showed feasibility and acceptability for a number of interventions, there is scope for those interventions to be developed further and tested more rigorously.

How Should Long-Term Psychotherapy Address Ethical Questions During the Palliative Care of a Patient With Serious and Persistent Mental Illness?

This commentary on a case considers the course of a palliative approach to care of a patient with a serious and persistent mental illness. Supposing a psychiatrist and patient mutually agree that the patient's chronic refractory illness should be palliatively managed with long-term psychotherapy, the next step is to forecast possible ethical questions that can arise during the course of such care and to share decision making about how to respond to those questions.

[PSYCHIATRY - AN ERA OF CHANGES AND TRANSFORMATIONS].

INTRODUCTION: In this issue of Harefuah, we present several aspects of mental health during hospitalization and rehabilitation and in the community. Most mental health care is now in the community. This issue begins with a study of sleep monitoring in the community aiming to predict the development of depression; and continues with an interesting characterization of seasonality in presentation to the emergency room, noting the importance of family and community connections as a protective factor. The relevance of early diagnosis and treatment of post-traumatic syndrome is discussed using a multidimensional approach to assessment. Since many individuals with mental disorders have experienced sexual trauma, it is of utmost importance to raise the issue during intake.

Using big data and Population Health Management to assess care and costs for patients with severe mental disorders and move toward a value-based payment system.

BACKGROUND: Mental health (MH) care often exhibits uneven quality and poor coordination of physical and MH needs, especially for patients with severe mental disorders. This study tests a Population Health Management (PHM) approach to identify patients with severe mental disorders using administrative health databases in Italy and evaluate, manage and monitor care pathways and costs. A second objective explores the feasibility of changing the payment system from fee-for-service to a value-based system (e.g., increased care integration, bundled payments) to introduce performance measures and guide improvement in outcomes. METHODS: Since diagnosis alone may poorly predict condition severity and needs, we conducted a retrospective observational study on a 9,019-patient cohort assessed in 2018 (30.5% of 29,570 patients with SMDs from three Italian regions) using the Mental Health Clustering Tool (MHCT), developed in the United Kingdom, to stratify patients according to severity and needs, providing a basis for payment for episode of care. Patients were linked (blinded) with retrospective (2014-2017) physical and MH databases to map resource use, care pathways, and assess costs globally and by cluster. Two regions (3,525 patients) provided data for generalized linear model regression to explore determinants of cost variation among clusters and regions. RESULTS: Substantial heterogeneity was observed in care organization, resource use and costs across and within 3 Italian regions and 20 clusters. Annual mean costs per patient across regions was €3,925, ranging from €3,101 to €6,501 in the three regions. Some 70% of total costs were for MH services and medications, 37% incurred in dedicated mental health facilities, 33% for MH services and medications noted in physical healthcare databases, and 30% for other conditions. Regression analysis showed comorbidities, resident psychiatric services, and consumption noted in physical health databases have considerable impact on total costs. CONCLUSIONS: The current MH care system in Italy lacks evidence of coordination of physical and mental health and matching services to patient needs, with high variation between regions. Using available assessment tools and administrative data, implementation of an episodic approach to funding MH could account for differences in disease phase and physical health for patients with SMDs and introduce performance measurement to improve outcomes and provide oversight.

Characteristics of a Southern Intensive Trauma- and Psychiatric-Focused Recovery Program.

OBJECTIVES: Treatment of substance use disorders (SUDs) is complex, involving biological, psychological, and social factors to be considered when designing effective programs. Trauma-informed psychiatric care integrated with a developmentally appropriate intensive 12-step approach is being used at A Reprieve for Women (Reprieve), a long-term intensive residential recovery program for female emerging adults with SUDs located in Tuscaloosa, Alabama. The Reprieve treatment philosophy focuses on long-term intensive care, treatment of coexisting trauma and psychiatric disorders, and development of life skills. The purpose of this article is to outline Reprieve's programmatic features and report Reprieve's 1- and 2-year sobriety rates for women who completed the 6-month residential program and compare it with national sobriety rates for other residential SUD treatment programs. METHODS: Reprieve provided 1- and 2-year sobriety rates and duration of treatment from 110 deidentified participants who completed Reprieve's 6-month residential program between September 2016 and November 2020. The researchers defined sobriety as complete abstinence from any addictive substances. Reprieve staff contacted program graduates to determine sobriety status following completion of the program. This research, approved by the University of Alabama's institutional review board, involved usable data points from 68 of the 110 participants. RESULTS: We determined that Reprieve has a 75% 1-year sobriety rate and a 63% 2-year sobriety rate. The national average sobriety rate for people completing SUD treatment in residential programs is 40%. CONCLUSIONS: Reprieve's higher-than-national sobriety rates make it a valuable program to study. Its emphasis on the treatment of coexisting psychiatric problems and past traumas, development of life skills, and the unique needs of female emerging adults may contribute to the program's success. It is hoped that this program description and preliminary analysis of outcomes will provide valuable information for future SUD treatment program development. More rigorous study is needed to delineate the effects of specific programmatic features on sobriety.

Barriers and facilitators to the participation and engagement of primary care in shared-care arrangements with community mental health services for preventive care of people with serious mental illness: a scoping review.

BACKGROUND: People with serious mental illness die about 20 years earlier than the general population from preventable diseases. Shared-care arrangements between general practitioners and mental health services can improve consumers' access to preventive care, but implementing shared care is challenging. This scoping review sought to describe current evidence on the barriers and facilitators to the participation and engagement of primary care (specifically general practitioners) in shared-care arrangements with community mental health services for preventive health care of this population. METHODS: We searched Medline, Embase, CINAHL, Scopus, APA PsychINFO and EBM Reviews from 2010 to 2022. Data was extracted against a Microsoft Excel template developed for the review. Data was synthesised through tabulation and narrative methods. RESULTS: We identified 295 records. After eligibility screening and full-text review, seven studies were included. Facilitators of engagement included a good fit with organisation and practice and opportunities to increase collaboration, specific roles to promote communication and coordination and help patients to navigate appointments, multidisciplinary teams and teamwork, and access to shared medical/health records. Barriers included a lack of willingness and motivation on the part of providers and low levels of confidence with tasks, lack of physical structures to produce capacity, poor alignment of funding/incentives, inability to share patient information and challenges engaging people with severe mental illness in the service and with their care. CONCLUSION: Our results were consistent with other research on shared care and suggests that the broader literature is likely to be applicable to the context of general practitioner/mental health services shared care. Specific challenges relating to this cohort present difficulties for recruitment and retention in shared care programs. Sharing "goals and knowledge, mutual respect" and engaging in "frequent, timely, accurate, problem-solving communication", supported by structures such as shared information systems are likely to engage primary care in shared care arrangements more than the traditional focus on incentives, education, and guidelines.

Ethics and humanization of care: Reflections in the teaching of French institutional psychotherapy experience.

French institutional psychotherapy, developed by Jean Oury and his team at the Clinic de la Borde, has played a significant role in the evolution of psychotherapeutic practice, highlighting the importance of considering the institutional context as a determining factor in understanding and treating mental disorders. This innovative approach, based on recognition of asylums' pathogenic effects, has placed particular emphasis on the humanisation of treatment and the application of bioethical principles within psychiatric institutions. This article aims to investigate the key elements of French institutional psychotherapy, analysing its relationship with bioethics and its contribution to the humanisation of care.

Who am I? The identity crisis of mental health professionals living with mental illness.

WHAT IS KNOWN ON THE SUBJECT?: Large numbers of mental health professionals live with their own mental health challenges. Despite working in mental health care, they can experience stigma in the workplace. Mental health professionals with lived experience of mental illness can find it a challenge to integrate their identities as both mental health professional and mental health service user. There are currently limited options available to them. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is a personal reflection from a mental health nurse and lecturer, who lives with a severe and enduring mental illness. It offers a lived experience account of the identity struggles of a mental health professional living with a mental illness. This article attempts to redefine the identity of professionals with personal lived experience in a more positive manner. They can be valued and celebrated for their unique perspective on mental illness and mental health care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There remains a stigma attached to people living with mental health conditions. This article challenges some of this stigma. It will empower and encourage other health professionals with lived experience to embrace all aspects of their identity with authenticity and courage. ABSTRACT: There are growing numbers of mental health professionals with their own lived experience of mental illness. This is both in part due to increased visibility and openness, and students embarking on professional courses motivated by their own personal mental health history. The somewhat limited research in this area highlights the difficulty practitioners have in navigating this distinct identity. There are limited options, including a wounded healer, an impaired professional and professional survivor. All have their limitations. We need to revise the conceptualisation of mental health professionals with personal lived experience of mental illness. Our identity needs to be celebrated and valued, as are the roles of peer support worker and expert by experience. Through personal reflection, I describe my own challenges in negotiating my identity as a mental health nurse, lecturer, and service user. My solution is to embrace authenticity and have the courage to stand in vulnerability and strength, embracing all aspects of myself. I call for others to do the same.

Does employer involvement in primary health care enhance return to work for patients with stress-related mental disorders? a cluster randomized controlled trial.

BACKGROUND: Stress-related disorders have become a major challenge for society and are associated with rising levels of sick leave. The provision of support to facilitate the return to work (RTW) for this patient group is of great importance. The aim of the present study was to evaluate whether a new systematic procedure with collaboration between general practitioners (GPs), rehabilitation coordinators (RCs) and employers could reduce sick leave days for this patient group. METHOD: Employed patients with stress-related diagnoses seeking care at primary health care centres (PHCCs) were included in either the intervention group (n = 54), following the systematic intervention procedure, or the control group (n = 58), receiving treatment as usual (TAU). The intervention included a) a training day for participant GPs and RCs, b) a standardised procedure for GPs and RCs to follow after training, c) the opportunity to receive clinical advice from specialist physicians in the research group. Outcome measures for RTW were sick leave days. RESULTS: The median number of registered gross sick leave days was lower for the control group at six, 12 and 24 months after inclusion, but the difference was not statistically significant. The control group had significantly fewer net sick leave days at three months (p = 0.03) at six months (p = 0.00) and at 12-months follow-up (p = 0.01). At 24 months, this difference was no longer significant. CONCLUSIONS: The PRIMA intervention, which applied a standardized procedure for employer involvement in the rehabilitation process for patients with stress-related disorders, actually increased time to RTW compared to TAU. However, at 24 months, the benefit of TAU could no longer be confirmed. The study was registered on 16/01/2017 (ClinicalTrials.gov, NCT03022760).

Seasonal Trends in Emergency Department Visits for Mental and Behavioral Health Conditions Among Children and Adolescents Aged 5-17 Years - United States, January 2018-June 2023.

Mental and behavioral health conditions among school-aged children, including substance use disorders and overall emotional well-being, are a public health concern in the United States. Timely data on seasonal patterns in child and adolescent conditions can guide optimal timing of prevention and intervention strategies. CDC examined emergency department (ED) visit data from the National Syndromic Surveillance Program for 25 distinct conditions during January 2018-June 2023 among U.S. children and adolescents aged 5-17 years, stratified by age group. Each year, during 2018-2023, among persons aged 10-14 and 15-17 years, the number and proportion of weekly ED visits for eight conditions increased in the fall school semester and remained elevated throughout the spring semester; ED visits were up to twice as high during school semesters compared with the summer period. Among children aged 5-9 years, the number and proportion of visits increased for five mental and behavioral health conditions. Seasonal increases in ED visits for some conditions among school-aged children warrant enhanced awareness about mental distress symptoms and the challenges and stressors in the school environment. Systemic changes that prioritize protective factors (e.g., physical activity; nutrition; sleep; social, community, or faith-based support; and inclusive school and community environments) and incorporate preparedness for increases in conditions during back-to-school planning might improve child and adolescent mental health.

Widening participation - recruitment methods in mental health randomised controlled trials: a qualitative study.

BACKGROUND: Barriers to mental health research participation are well documented including distrust of services and research; and stigma surrounding mental health. They can contribute to a lack of diversity amongst participants in mental health research, which threatens the generalisability of knowledge. Given the recent widespread use of the internet in medical research, this study aimed to explore the perspectives of key partners on the use of online (e.g. social media) and offline (e.g. in-person) recruitment as an approach to improving diversity in mental health randomised controlled trials (RCTs). METHODS: Face-to-face and online interviews/focus groups with researchers working in mental health and Patient and Public Involvement partners in the United Kingdom. Recordings were transcribed and analysed using a combination of inductive and deductive thematic analysis. RESULTS: Three focus groups and three interviews were conducted with a total N = 23 participants. Four overarching themes were identified: (1) recruitment reach; (2) Demographic factors that affect selection of recruitment method; (3) safety of technology, and; (4) practical challenges. Five main factors were identified that affect the choice of recruitment method: age, complexity of mental health problem and stigma, cultural and ethnicity differences and digital divide. The use of online methods was considered more accessible to people who may feel stigmatised by their mental health condition and with a benefit of reaching a wider population. However, a common view amongst participants was that online methods require closer data monitoring for quality of responders, are not fully secure and less trustworthy compared to offline methods that enable participants to build relationships with health providers. Funding, staff time and experience, organisational support, and technical issues such as spam or phishing emails were highlighted as practical challenges facing online recruitment. All participants agreed that using a hybrid approach tailored to the population under study is paramount. CONCLUSIONS: This study highlighted the importance of offering a flexible and multifaceted recruitment approach by integrating online with offline methods to support inclusivity and widening participation in mental health research. The findings will be used to develop considerations for researchers designing RCTs to improve recruitment in mental health research.

Medicaid Value-Based Payments and Health Care Use for Patients With Mental Illness.

Importance: Medicaid patients with mental illness comprise one of the most high-need and complex patient populations. Value-based reforms aim to improve care, but their efficacy in the Medicaid program is unclear. Objective: To investigate if New York state's Medicaid value-based payment reform was associated with improved utilization patterns for patients with mental illness. Design, Setting, and Participants: This retrospective cohort study used a difference-in-differences analysis to compare changes in utilization between Medicaid beneficiaries whose outpatient practices participated in value-based payment reform and beneficiaries whose practices did not participate from before (July 1, 2013-June 30, 2015) to after reform (July 1, 2015-June 30, 2019). Participants were Medicaid beneficiaries in New York state aged 18 to 64 years with major depression disorder, bipolar disorder, and/or schizophrenia. Data analysis was performed from April 2021 to July 2023. Exposure: Beneficiaries were exposed to value-based payment reforms if their attributed outpatient practice participated in value-based payment reform at baseline (July 1, 2015). Main Outcomes and Measures: Primary outcomes were the number of outpatient primary care visits and the number of behavioral health visits per year. Secondary outcomes were the number of mental health emergency department visits and hospitalizations per year. Results: The analytic population comprised 306 290 individuals with depression (67.4% female; mean [SD] age, 38.6 [11.9] years), 85 105 patients with bipolar disorder (59.6% female; mean [SD] age, 38.0 [11.6] years), and 71 299 patients with schizophrenia (45.1% female; mean [SD] age, 40.3 [12.2] years). After adjustment, analyses estimated a statistically significant, positive association between value-based payments and behavioral health visits for patients with depression (0.91 visits; 95% CI, 0.51-1.30) and bipolar disorder (1.01 visits; 95% CI, 0.22-1.79). There was no statistically significant changes to primary care visits for patients with depression and bipolar disorder, but value-based payments were associated with reductions in primary care visits for patients with schizophrenia (-1.31 visits; 95% CI, -2.51 to -0.12). In every diagnostic population, value-based payment was associated with significant reductions in mental health emergency department visits (population with depression: -0.01 visits [95% CI, -0.02 to -0.002]; population with bipolar disorder: -0.02 visits [95% CI, -0.05 to -0.001]; population with schizophrenia: -0.04 visits [95% CI, -0.07 to -0.01]). Conclusions and Relevance: In this cohort study, Medicaid value-based payment reform was statistically significantly associated with an increase in behavioral health visits and a reduction in mental health emergency department visits for patients with mental illness. Medicaid value-based payment may be effective at altering health care utilization in patients with mental illness.

Repercussions imposed by the pandemic on the care for children with mental disorders in a pediatric unit.

OBJECTIVE: To understand the perceptions of nurses about the repercussions on the care for children with mental disorders in a pediatric inpatient unit amidst the COVID-19 pandemic. METHOD: Qualitative research conducted with 13 nurses in a general pediatrics unit in a large hospital in southern Brazil. Data were collected through semi-structured interviews and analyzed according to the Thematic Analysis. RESULTS: Respondents perceived repercussions on hospital routines due to the pandemic, such as restriction of recreation activities; enforcement of social distancing; limitation of family visits; mandatory use of personal protective equipment and difficulty in counter-referral of care. FINAL CONSIDERATIONS: The results characterized the moment experienced in the unit, providing the institution's managers with tools for the construction and implementation of new practices, making it possible to meet the demands of mental health care for children with mental disorders within the premises of psychosocial care.

The SOFIA pilot study: assessing feasibility and fidelity of coordinated care to reduce excess mortality and increase quality of life in patients with severe mental illness in a general practice setting; a cluster-randomised pilot trial.

OBJECTIVE: To evaluate the feasibility and fidelity of implementing and assessing the SOFIA coordinated care program aimed at lowering mortality and increasing quality of life in patients with severe mental illness by improving somatic health care in general practice. DESIGN: A cluster-randomised, non-blinded controlled pilot trial. SETTING: General Practice in Denmark. INTERVENTION: The SOFIA coordinated care program comprised extended structured consultations carried out by the GP, group-based training of GPs and staff, and a handbook with information on signposting patients to relevant municipal, health, and social initiatives. PATIENTS: Persons aged 18 years or older with a diagnosis of psychotic, bipolar, or severe depressive disorder. MAIN OUTCOME MEASURES: We collected quantitative data on the delivery, recruitment and retention rates of practices and patients, and response rates of questionnaires MMQ and EQ-5D-5 L. RESULTS: From November 2020 to March 2021, nine practices were enrolled and assigned in a 2:1 ratio to the intervention group (n = 6) or control group (n = 3). Intervention group practices included 64 patients and Control practices included 23. The extended consultations were delivered with a high level of fidelity in the general practices; however, thresholds for collecting outcome measures, and recruitment of practices and patients were not reached. CONCLUSION: Our findings suggest that delivering the coordinated care program in a fully powered trial in primary care is likely feasible. However, the recruitment methodology requires improvement to ensure sufficient recruitment and minimize selective inclusion. TRIAL REGISTRATION: The date of pilot trial protocol registration was 05/11/2020, and the registration number is NCT04618250.

The nurse-led GILL eHealth intervention for improving physical health and lifestyle behaviours in clients with severe mental illness: design of a cluster-randomised controlled trial.

BACKGROUND: Clients with severe mental illness (SMI) have overall poor physical health. SMI reduces life expectancy by 5-17 years, primarily due to physical comorbidity linked to cardiometabolic risks that are mainly driven by unhealthy lifestyle behaviours. To improve physical health in clients with SMI, key elements are systematic somatic screening and lifestyle promotion. The nurse-led GILL eHealth was developed for somatic screening and the implementation of lifestyle activities in clients with SMI. Aims of this study are to evaluate the effectiveness of the GILL eHealth intervention in clients with SMI compared to usual care, and to evaluate the implementation process, and the experiences of clients and healthcare providers with GILL eHealth. METHODS: The GILL study encompasses a cluster-randomised controlled trial in approximately 20 mental health care facilities in the Netherlands. The randomisation takes place at the team level, assigning clients to the eHealth intervention or the usual care group. The GILL eHealth intervention consists of two complementary modules for somatic screening and lifestyle promotion, resulting in personalised somatic treatment and lifestyle plans. Trained mental health nurses and nurse practitioners will implement the intervention within the multidisciplinary treatment context, and will guide and support the participants in promoting their physical health, including cardiometabolic risk management. Usual care includes treatment as currently delivered, with national guidelines as frame of reference. We aim to include 258 clients with SMI and a BMI of 27 or higher. Primary outcome is the metabolic syndrome severity score. Secondary outcomes are physical health measurements and participants' reports on physical activity, perceived lifestyle behaviours, quality of life, recovery, psychosocial functioning, and health-related self-efficacy. Measurements will be completed at baseline and at 6 and 12 months. A qualitative process evaluation will be conducted alongside, to evaluate the process of implementation and the experiences of clients and healthcare professionals with GILL eHealth. DISCUSSION: The GILL eHealth intervention is expected to be more effective than usual care in improving physical health and lifestyle behaviours among clients with SMI. It will also provide important information on implementation of GILL eHealth in mental health care. If proven effective, GILL eHealth offers a clinically useful tool to improve physical health and lifestyle behaviours. TRIAL REGISTRATION: Clinical trial registration NCT05533749, registration date: 8 September 2022.

Primary care physicians' experience of caring for children with parents with mental health illness: a qualitative study among French general practitioners and paediatricians.

BACKGROUND: Parental psychiatric disorders can have a significant impact on child development and the parent-infant bond, with a high risk of attachment disorders. Early identification of difficulties in the parent-child relationship is essential to prevent consequences for the child. Childcare practitioners have a major role to play in this early detection process, through regular mandatory consultations during the first two years of a child's life. Thus, the aim of this study was to collect the experience of private practitioners in their care of children of parents with a mental health illness. METHOD: This is a cross-sectional, observational, qualitative study. Data were collected by means of semi-structured interviews with eleven general practitioners and private paediatricians between February and July 2021 in Toulouse and its suburbs. We only included practitioners who had followed children of parents with a mental health illness. The interviews were recorded with the agreement of the participants, before being transcribed anonymously. The data were analysed with NVivo software using interpretative phenomenological analysis. RESULTS: Three main themes emerged from the results, which were further divided into several sub-themes. Addressing psychiatric disorders presents a risk for the therapeutic relationship. Practitioners express a need to preserve this relationship with the parent in joint care. Care is difficult and is permeated by the parents' emotional issues. Furthermore, practitioners face a conflict between their concerns for the parent-child bond and their desire not to stigmatise these families. They express a feeling of isolation in these follow-ups. This stressful care has a significant emotional impact on the doctors. Access to psychiatric training and multidisciplinary collaboration seem to be essential to improve the follow-up experience for practitioners, as these factors strengthen inter-professional connections. CONCLUSION: Practitioners describe a parent-doctor relationship at risk, which is underpinned by the fear of care placement. This study illustrates the need to strengthen multidisciplinary work by promoting interprofessional exchanges, in order to improve the experience of practitioners in this care process. Addressing practitioners' fear of discussing parental psychiatric illness is very important, so as not to delay the implementation of preventive actions that are likely to improve the developmental prognosis for children.