In the 1980s a number of econometric analyses made use of cross sectional surveys to investigate the magnitude of demand response for ambulatory mentalhealth services, the services thought to be most responsive to cost sharing (McGuire, 1981; Horgan, 1986; Taube, Kessler and Burns, 1986; Watts, Scheffler and Jewell, 1986). 12 This first generation of econometric models focused on estimating the demand response of ambulatory mentalhealthcare use to differences in the cost-sharing provisions across private insurance plans. The empirical models of demand were built on simple assumptions about the price schedule and consumer expectations (Manning and Frank, 1992). Annual number of visits (or dollars) were assumed to be the relevant decision unit, consumers were assumed to face a constant price. Consumers formulated their demand at the beginning of the annual decision-period. Insurance coverage for mentalhealth is rarely described by a single price block, such as constant 50% coinsurance. Much more frequently there are two or even three blocks. Figure 4 shows a three-block schedule that would result from a deductible, a covered region and a limit on coverage. Empirical studies during the 1980s used an “average” price, and related this to quantity used. The block structure of pricing builds in a relation between use and average price unrelated to demand response (e.g., with a declining block price, average price and use are negatively correlated). In principle, instrumental variables might deal with this, but this is a highly imperfect way to address this measurement issue.
family intervention (Haddad, Brain and Scott, 2014) are suggested in the literature as a way to enhance medication adherence. On the pharmacological side, the literature suggests that drug treatment should be carefully design to suit the individual patient (Farooq and Naeem, 2014). More specifically, Farooq and Naeem (2014) suggest that GPs can simplify the treatment regime, switch when treatment is not effective, adjust doses, and treat side effects. However, authors claim the success of these strategies will depend on the degree of involvement of GPs in the treatment process. In particular, policies aiming to create incentives to treat mentalhealth patients and provide continuous care by GPs could engage physicians in the treatment process. Fleury et al. (2012) identify inappropriate GP payment model as a barrier to enhance GPs in managing mentalhealth disorders. GPs spend little time assessing and addressing the adherence problem. According to Farooq and Naeem (2014), clinicians need time and patience to keep patients engaged in treatment. Currently, Portugal has two types of primary healthcare centers: Personalised HealthCare Units (PHCU) and Family Health Units (FHU). The main difference between both units is the number of patients enrolled in a FHU, the payment mechanism of GPs working in FHU, and the voluntary creation of multidisciplinary teams in FHU (Sim˜ oes et al., 2017; Barros, Machado and Sim˜ oes, 2011). GPs are paid a salary in PHCUs but in FHUs, there are incentive mechanisms based on performance (Sim˜ oes et al., 2017; Barros, Machado and Sim˜ oes, 2011). However, there is only one mandatory indicator related to mentalhealth, “Percentage of patients aged 65 or older without being prescribed with AHS”. Therefore, additional indicators that could promote adherence should be implemented. Also, and as suggested by Fleury et al. (2012), the role of mentalhealthcare providers should be extended in order to enhance the ability of GPs to treat their patients with mental disorders and promote integrated care.
117 outcomes twelve months after acceptance for treatment for patients that are still in EIP care. Effects were strongest for waiting times longer than three months. Although effect sizes were small to moderate, we found the change in HoNOS to be reliable and clinically significant. Patients with shorter EIP treatment periods were not affected. Chapters 4 and 5 focused on the recently introduced EIP waiting time target and providers’ potential responses to it. Performance measures such as waiting time targets incentivise providers to improve the targeted outcome dimension. Even without direct financial penalties, providers may expect reputational damage from poor performance which makes them work towards an improved target performance. At the same time, being under pressure to serve a number of objectives, providers may also take unintended actions to make target performance look better than it actually is. For acute healthcare trusts, it has been shown that providers indeed respond to enforced waiting time targets in both intended and unintended ways. Mentalhealthcare trusts, however, comprise a different group of providers acting in different market structures and incentive systems (e.g. payment systems). Therefore, it is important to investigate whether the same changes in behaviour can be observed for mentalhealth trusts compared to acute physical health trusts. We looked at both, intended as well as unintended, effects of the EIP target policy. Since this is the first waiting time target that has ever been introduced for mentalhealth services, we provide novel evidence in this context.
We have never of course had a single metric before – nobody really believed that GDP was an adequate measure of how our society was doing. What is new is that a proper metric is now available – the metric of wellbeing. Questions like “Overall, how satisfied are you with your life nowadays?” have been asked for decades and they have become increasingly validated 2 . Increasingly, we are able to predict and explain people ’ s replies to the question. We can also use their replies to predict other things like a person ’ s life expectancy. And, most important, we have found areas in the brain where the objective electrical activity is well correlated with the subjective self-report 3 . So we should accept these self-reports as a valid proxy for what we care about.
care, general practitioners, in particular, will need to assign individuals to these broad categories without clear criteria of what exactly constitutes, for instance, a moderate versus a severe illness. This will result in wide variability of categorisation, both within and between PHNs, and ultimately disparate interventions recommended for those with the same sets of issues. Alternatively, other stepped-care models that focus on people with common single disorders, such as anxiety or depression, risk excluding people who have more complex needs. Our growing scientific understanding of the complex nature of mental ill health suggests that models that are either nonspecific or narrow are likely to result in the perpetuation of inadequate care provision for many consumers.
Non-maleficence Could involuntary commitment cause harm? Most inpatient psychiatric settings today are clean, safe, and therapeutic, a far cry from the kinds of institutions that existed in many states in the 1960’s and early 1970’s, when the first restrictive commitment laws were enacted. That said, seclusion and restraint continue to be used in inpatient commitment settings, and the experience can be highly traumatic for some patients, especially those who have been victims of sexual assault or other violence in the past (Zervakis et al., 2007). And, of course, persons committed to inpatient facilities today experience the same “massive curtailment of liberty” that the courts decried in the 1970’s, different from and far greater than the liberty restrictions occasioned by mandated treatment in the community. Thus, the more restrictive standards for inpatient commitment. So, the question becomes: whether the harms inevitably suffered by the committed inpatient are outweighed by the harms staved off. Predictable risks to the safety or well-being of the individual or others must be at stake, lest the harms facing the individual render commitment unjustifiable. Once commitment is ordered, moreover, every effort must be taken to minimize harm to the patient, including not only providing safe and effective care but promoting the patient’s autonomy to the greatest extent possible and assuring services in the least restrictive setting, with an eye toward release at the earliest opportunity.
Multiple studies conducted outside of the U.S. indicate the important role of mentalhealth literacy in mentalhealthcare including early recognition of mental illness, decreased stigma, positive attitudes toward help-seeking, and actual help-seeking as well as helping others with mental illness (Gabriel & Violato, 2010; Jorm, 2012; Kitchener & Jorm, 2006; Wright, Jorm, Harris, & McGorry, 2007). There are fewer studies in the U.S. that apply mentalhealth literacy and examine its role in mentalhealthcare. However, some studies yield similar findings that knowledge and beliefs are associated with mentalhealth service use (Mojtabai et al., 2011). For example, people who believe mental illness is a provisional problem not a chronic illness are likely to have negative view about professional help seeking (Wong, Tran, Kim, Van Horn Kerne, & Calfa, 2010). People believing benefits or effectiveness of mentalhealth treatment (e.g., antidepressants, counseling) are likely to be favorable or acceptable to seek mentalhealth services (Givens, Katz, Bellamy, & Holmes, 2007; Gonzalez, Alegria, Prihoda, Copeland, & Zeber, 2011). Moreover, studies consistently imply that a lack of knowledge about mental illness and treatment resources as well as not knowing how to access available services in the community deters people from using mentalhealth services (Cabassa & Zayas, 2007; Lee et al., 2009; Matthews et al., 2006; Roberts et al., 2008). Yet, many of these studies used a couple of items to measure certain aspects of mentalhealth
The introduction of new drugs has affected all payers, but Medicaid in particular, because a disproportionate fraction of Medicaid beneficiaries are treated for mentalhealth disorders. Low income children, for example, are 2 to 3 times more likely to have a serious mental disorder than other children (Glied et al. 1997). New mentalhealth drugs include new agents and new drug forms that are easier to administer, have simpler dosing schemes, reduce the likelihood of overdose or abuse, and offer fewer negative side effects (USDHHS 1999; Frank et al. 2005). All of this means that it is easier for clinicians to design mentalhealth treatment regimens and easier for patients to adhere to them. These newer drugs also have higher drug prices, due to their patent protections and lack of competition from generic drugs. At the same time, managed care incentives favor the use of prescription drugs over other therapies, while expanded Medicaid eligibility further increased spending.
Additionally regarding opinions for the promotion of exercise in the workplace, results showed that 75.70% did not sponsor any physical activity during the previous semester; 60.20% considers it very difficult to participate in any 61.30% said that there are similar initiatives on the 57.90% stated that their colleagues do not participate 62% said that such an initiative is valuable to them and 84.6% said they needed more between physical activity and 70.9% find their participation in 62.6% beneficial, 48.9% feasible, 74.1% 8.8% and 68.1% fun. Regarding their views on the main obstacles to the systematic application of exercise programs for people with mental disorders in open-ended questions variations and concerns about the mental state seem n promoting physical activity in work contexts results showed that 81% considered the lack of to implement such programs, 68.2% lack of knowledge relating to the planning, 64.7% equipment costs and 63.8% the lack of mobilization (motivation) of staff and patients. The absence of personal interest accounts for 47.4%, the lack of time for 39.9% and poor personal fitness for 29.4% .
The ethical dilemmas inherent in the context of older people necessitate the ability to balance different ethical demands in situations where a blend of principles, rules, virtues, paradigms and narratives is necessary to achieve practical wisdom 41 . We suggest that these features of ethical decision making must be located within the patient- practitioner relationship. This aspect of practical wisdom should be a continuing professional development aim for practitioners who currently base their ethical practice on Codes of Professional Conduct and legislation, as the ‘one size fits all’ approach (universalism) that could result from using such resources to guide decision making may not always result in the optimal care for an older person with mentalhealth problems (individualism). To know how to act ethically, healthcare practitioners must work towards understanding the other’s perspective and potential vulnerability 40.
Sen’s approach reiterates the importance of'needs' in deciding distributive justice and in this sense is an acceptable candidate for consideration in the health sector. However, translating capabilities into the functioning 'good health' is what one would be looking at in this sector and there is no guidance on how this is to be operationalised. In fact, the practicality of Sen’s account as a guide to social policy has been questioned by some as the range of possible functionings is very wide and he provides little guidance on how these different functionings are to be weighted in particular contexts. The challenges of applying his approach to health have resulted in calls to develop normative theory with an eye to empirical evidence (Alkire and Black 1997; Anand and Dolan 2005). The argument is that empirical evidence about social objectives is important and that if a theory purports to represent community values then these values must be elicited. Richardson and McKie (2005) argue that 'empirical ethics', an emerging approach in the health sector provides important lessons for overcoming the problems associated with the capability approach. They claim that it is an ethically defensible methodology and yields practical results that can assist policy makers in the allocation of resources. For example, results of several empirical studies (Nord 1993; Nord et al 1999; Pinto-Prades 1997; Menzel et al 1999; Ubel et al 1998) have shown that survey respondents generally express a strong preference for allocating resources to those with the worst health state and that large number of responses from the public conflict with the notion of health maximisation. One has to accept, however, that there is a wide range of ethical principles which according to members of the general public might be relevant in different circumstances and a number of attributes/contexts that are potentially relevant for decision-making. Fulfilling one principle can violate another and there is often the need for a trade-off.
In addition to the recruitment of high calibre students, the bedrock of mentalhealth nursing should be on attitudes and skills acquisition. A to an all graduate health in line with other disciplines like psychology should help to facilitate skill acquisition. Specific Cognitive Behavioural Therapy (CBT) and Motivational Interviewing techniques have the potential to benefit prospective nurses and improve patient care (Leahy, 2011). Over the past 10 years, various authorities have commented on the need to strengthen skills-based training/problem-based learning (PBL) with particular emphasis on these skills as they have a sound evidence base (Gournay et al. 2000; Rushworth and Happell 1998). Because of the shortcomings in current curriculum, anecdotal evidence suggest that when students do enter the mentalhealth setting, some are so overwhelmed by their clinical placement that their only goal is to survive the experience without any focus skills acquisition(Curtis 2007). There are many shortcomings to the current curriculum but one pertains to student support. Some students report that they often feel isolated and unsupported by some clinical staff and this lead to inadequate skills acquisition. In this regard, there is a need for greater involvement of clinical tutors in the practice area.
Acknowledgements We are very grateful to Seena Fazel (University of Oxford), Angela Hassiotis, and Gill Livingston (both University College London) for their contributions to the development of survey questions in their specialist areas (forensic psychiatry, older people, and intellectual disability, respectively), and to Dr Lade Smith for her help in promoting the survey, especially by making a video with the Mental Elf encouraging staff from Black and minority ethnic groups to partici- pate. We also thank the clinicians who took time to complete and feed- back on our pilot survey, and all participants for taking time from the pressures of the pandemic to respond to the survey. List of The COVID- 19 MentalHealth Policy Research Unit Group members: Andy Bell (Centre for MentalHealth, London, UK), Francesca Bentivegna (NIHR MentalHealth Policy Research Unit, Division of Psychiatry, Univer- sity College London, London, UK), Joseph Botham (NIHR MentalHealth Policy Research Unit, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK), Julian Edbrooke- Childs (Anna Freud Centre, London, UK), Lucy Goldsmith (Popu- lation Health Research Institute, St George’s, University of London, London, UK), Lisa Grünwald (NIHR MentalHealth Policy Research Unit, Division of Psychiatry, University College London, London, UK; North East London NHS Foundation Trust, London, UK), Jasmine Harju-Seppänen (NIHR MentalHealth Policy Research Unit, Divi- sion of Psychiatry, University College London, London, UK; Division of Psychology and Language Sciences, University College London, London, UK), Stephani Hatch (NIHR MentalHealth Policy Research Unit, Institute of Psychiatry, Psychology & Neuroscience, King’s Col- lege London, London, UK), Claire Henderson (NIHR MentalHealth Policy Research Unit, Institute of Psychiatry, Psychology & Neurosci- ence, King’s College London, London, UK), Louise Howard (NIHR MentalHealth
understanding of “integration of primary care and mentalhealth” requires that CCOs engage their partners, clinics, and providers in an open and transparent conversation about what is known and what is not known in order to facilitate a process through which they can collectively build a shared understanding of what integration means as well as identify desired outcomes and preferred strategies. The RMIC’s normative and functional enablers of integration offers a new approach to navigating these tensions, one that recognizes and allows for the simultaneous creation of what integration of primary care and mentalhealthcare means in practice as well as a broader understanding of what tools, resources, and information are needed to actually do the work of integration. This study’s findings suggest that CCOs can play an important role in developing normative and functional enablers of integration to bring stakeholders at multiple levels of the healthcare system together to engage in collective sensemaking.
Mentalhealth services appear to have been inade- quately incorporated into the primary healthcare in Zambia, a problem shared with many other low-income African countries [7-9]. Although there are psychiatric units within seven general hospitals across the country, and the mentalhealth policy in the country has made a commitment to integration, mentalhealth services in Zambia are largely delivered at Chainama Hospital in Lusaka, the only mentalhealth hospital in the country . According to MHaPP Country Report , about 2667 patients per 100,000 population are admitted to Chainama and psychiatric units around the country. The total number of beds in Chainama is 210 excluding 167 (floor beds) which are not officially recognised by the Ministry of Health. Primary healthcare units (health centres) do not have any mentalhealth plans, and are severely fragmented and unco-ordinated [12,13,10]. In these facilities, there are also inadequate psychotropic drugs, and the few staff that are available have either inadequate knowledge about mentalhealth or they are unable to cope with the inclusion of people with mentalhealth problems in their work schedule . It has been observed that mentalhealth referral services at the primary healthcare level have practically collapsed .
The decision to involve a specialist or agency in treatment means that the primary care clinician’s role will in- clude communicating with other care providers. The process is enhanced by conveying to the referral source the results of previous assessment and in- tervention efforts and openness to dis- cussion with the professional who will provide therapy. Although the HIPPA al- lows exchange of information among professionals involved in the care of a mutual patient, many mentalhealth professionals are reluctant to share information without express consent of the child and family. By obtaining written consent (or, for children in fos- ter care, enlisting the case worker’s help in obtaining written consent of the legal guardian) and sending it to the mentalhealth professional, the pri- mary care clinician can convey inter- est and facilitate communication. As with referrals for diagnostic assess- ment, it is critical that the practice track children who have been referred for spe- cialty treatment. If the family is unsuc- cessful in acquiring treatment in a timely way, the primary care clinician can offer to continue generic intervention efforts (as described in Algorithm A), initiate treatment, or make periodic telephone contacts to monitor for worsening or emergent problems. It may be necessary in some instances to use emergency pro- cedures to obtain needed services.
Piyasena was treated as mentally ill person when BasicNeeds first came into his village. However, now he has joined the volunteer committee which plays an active role in organizing communities in the programme. Equipped with a three wheeler and a loudspeaker, Piyasena is responsible for announcing in the neighbouring villages when we have events such as mentalhealth camps. About 30% of the membership of our volunteer committees are mentally ill people. The balance comprises carers and community members free from mental illness.
In Japan, the number of people with mental illness, especially depression and dementia, is growing. Although mentalhealthcare in Japan is in its transition phase from traditional hospital-based care to community-based in the recent decades, it has been characterized by orientation to large psychiatric institutions. This paper aims to provide recommendations for achieving well-balanced mentalhealthcare both in hospital and the community in Japan by reviewing facilitators and barriers of current mentalhealthcare system. A narrative literature review was conducted to identify facilitators and barriers to implementing community-based mentalhealthcare in Japan. The databases PsycInfo, Medline, Pubmed, CiNii and Google Scholar were searched in English and Japanese. 46 studies published from 1980 to 2016 were included in the review. The review identified six categories of mentalhealthcare services provided in the Japanese community: Outpatient clinics, Outreach services, Rehabilitation and Living support, Case management and public health centers, Community-based residential care, and Work and Occupation. The crosscutting themes of facilitators and barriers to implement these services in the community were funding, staff management, and collaboration among community resources. To further promote the transition to community mentalhealthcare in Japan, this paper recommends the following actions: to shift funding and human resources from inpatient to community care services, to strengthen a capacity building system and supportive environment for service providers in the community, and to set a clear policy and strategic framework integrating medical and social welfare services in the community.
Finally, I shed light on policy by simulating the effect of combining price transparency with high cost sharing insurance plans. One potential reason that current price trans- parency tools are not widely used even when they are available is that many consumers, especially those that pay a small coinsurance rate, have modest private gains from be- coming informed and price shopping. High cost sharing plans reduce moral hazard due to insurance, increasing consumers’ incentive to use the price transparency website. In counterfactual simulations, I find that high cost sharing, which I define as a 50 percent coinsurance rate, would lead to a 38 percent increase in the number of consumers using the website. In addition, consumers would have more incentive to choose a low cost provider once they had price information. For these reasons, equilibrium prices would be almost as low as the full information case without high cost sharing. Although this would result in higher out-of-pocket spending for consumers, overall healthcare spend- ing on medical imaging procedures would decline by 18 percent.
In addition, we have included individualized Patient Reported Outcome Measurement Information System (PROMIS) “General Quality of Life questionnaires, to enable primary care providers to recognize the extent to which an illness has affect psychosocial functioning and to determine to what extent their interventions, whether pharmacological or psychological, have helped during subsequent consultations.