Objectives To describe models of integrated care used in the United States, assess how integration of mental health services into primary care settings or primary health care into specialty outpatient settings impacts patient outcomes and describe barriers to sustainable programs, use of health information technology (IT), and reimbursement structures of integrated care programs within the United States. Data sources MEDLINE, CINAHL, Cochrane databases, and PsychINFO databases, the internet, and expert consultants for relevant trials and other literature that does not traditionally appear in peer reviewed journals. Review methods Randomized controlled trials and high quality quasi-experimental design studies were reviewed for integrated care model design components. For trials of mental health services in primary care settings, levels of integration codes were constructed and assigned for provider integration, integrated processes of care, and their interaction. Forest plots of patient symptom severity, treatment response, and remission were constructed to examine associations between level of integration and outcomes. Results Integrated care programs have been tested for depression, anxiety, at-risk alcohol, and ADHD in primary care settings and for alcohol disorders and persons with severe mental illness in specialty care settings. Although most interventions in either setting are effective, there is no discernible effect of integration level, processes of care, or combination, on patient outcomes for mental health services in primary care settings. Organizational and financial barriers persist to successfully implement sustainable integrated care programs. Health IT remains a mostly undocumented but promising tool. No reimbursement system has been subjected to experiment; no evidence exists as to which reimbursement system may most effectively support integrated care. Case studies will add to our understanding of their implementation and sustainability. Conclusions In general, integrated care achieved positive outcomes. However, it is not possible to distinguish the effects of increased attention to mental health problems from the effects of specific strategies, evidenced by the lack of correlation between measures of integration or a systematic approach to care processes and the various outcomes. Efforts to implement integrated care will have to address financial barriers. There is a reasonably strong body of evidence to encourage integrated care, at least for depression. Encouragement can include removing obstacles, creating incentives, or mandating integrated care. Encouragement will likely differ between fee-for-service care and managed care. However, without evidence for a clearly superior model, there is legitimate reason to worry about premature orthodoxy.

Integration of Mental Health/Substance Abuse and Primary Care

ObjectiveTo assess the relationship between poverty and mental illness in order to stimulate debate on future international cooperation programs in mental healthMethodEpidemiological data in the international literature addressing the issue of material poverty as a risk factor for the development of mental illness and as a prognostic factor for the outcome of mental illness were reviewedResultsThe international literature reviewed supports the notion that material poverty is a risk factor for a negative outcome among mentally ill people In addition, preliminary epidemiological data suggest that service-related variables may be determinants of outcome of mental illnesses In our view, cooperation with developing countries is a great opportunity to evaluate mental health services in a natural settingConclusionsA new generation of programs for international cooperation in mental health is needed, in which knowledge and technology transfer is based on a service-research attitude Attention should be focus

Poverty and mental illness.

Trata-se de reflexao teorica sobre os determinantes e os elementos constitutivos do processo de trabalho da enfermagem no campo psiquiatrico e no campo psicossocial no contexto da Reforma Psiquiatrica brasileira. O objetivo e oferecer conteudo teorico-conceitual para orientar a acao reflexiva de trabalhadores em saude mental e, em particular, da enfermagem. A finalidade do artigo e preservar a memoria da pratica da enfermagem no campo psiquiatrico e promover sua necessaria superacao com vistas a construcao do campo psicossocial, subsidiando o ensino nos diversos campos de saber em saude.

/pdf/processo-de-trabalho-em-saude-mental-e-o-campo-psicossocial-302600t7he.pdf

Processo de trabalho em saúde mental e o campo psicossocial

The objective of this study was to validate the Self Report Questionnaire (SRQ-20) as a screening instrument to identify probable psychiatric cases in the general population in Nicaragua and to study the prevalence and identification of mental disorders in primary health care. In the general population 576 people were screened using SRQ-20. A subsample was further interviewed using the Present State Examination (PSE). In primary health care centers 781 patients were screened according to SRQ-20 and staff indicated whether a mental disorder was identified or not. In the general population study, 9/10 turned out an adequate cut-off for SRQ-20, identifying 23% as probable cases. Using the same cut-off, 47% of the primary health care patients were identified as probable cases. Among male probable cases only 7% were identified as cases by health care staff, and among female probable cases health care staff identified 13% as cases. When the results are compared with previous studies, it becomes evident that the general level of psycho-emotional complaints and accordingly the cut-off for caseness differ in different parts of the world. SRQ must be calibrated for each cultural setting. Among primary health care patients, mental disorders were overrepresented and frequently overlooked by the physicians. Educational programs with training in psychiatry should be implemented for primary health care staff.

Mental disorders among primary health care patients in Nicaragua.

Mental disorders are highly prevalent in Latin American countries and exact a serious emotional toll, yet investment in public mental health remains insufficient. Most countries of the region have developed national and local initiatives to improve delivery of mental health services over the last 22 years, following the technical leadership of the Pan American Health Organization/World Health Organization (PAHO/WHO). It is especially notable that PAHO/WHO facilitated the development of national policies and plans, as well as local programs, to deliver specialized community care for persons with severe mental disorders. Nevertheless, at present, the majority of Latin American countries maintain a model of services for severe mental disorders based primarily on psychiatric hospitals that consume most of the national mental health budget. To accelerate the pace of change, this article emphasizes the need to develop cross-country regional initiatives that promote mental health service development, focusing on severe mental disorders. As one specific example, the authors describe work with RedeAmericas, which has brought together an interdisciplinary group of international investigators to research regional approaches and train a new generation of leaders in public mental health. More generally, four regional strategies are proposed to complement the work of PAHO/WHO in Latin America: 1) to develop multi-country studies on community services, 2) to study new strategies and interventions in countries with more advanced mental health services, 3) to strengthen advocacy groups by cross-country interchange, and 4) to develop a network of well-trained leaders to catalyze progress across the region.

/pdf/community-mental-health-services-in-latin-america-for-people-4wywgognh3.pdf

Community Mental Health Services in Latin America for People with Severe Mental Disorders.

— Organization of services and patterns of psychiatric care were studied in Nicaragua in 1986, 7 years after the substantial changes in health policy launched after the revolution. The overall re-organization of the system is indicated by the progressive abandoning of the mental hospital as the center of psychiatric care and the creation of 15 community-based mental health centers now functioning throughout the country. Quality of care judged through analysis of a consecutive sample of 342 patients seen by services over a month confirmed the positive orientation of the system which seemed able to deliver good care following the new perspective of “de-institutionalization”. Some problems emerged to a large extent common to psychiatric care in industrialized countries looking at psychotropic drug use and at the relationship between primary health care and the psychiatric system especially when care delivered in urban and rural areas was compared.

Organization of services and pattern of psychiatric care in Nicaragua: Result of a survey in 1986

Manual de saúde mental: guia básico para atençäo primária

Cooperation in mental health: an Italian project in Nicaragua.

Laying foundations for improved care of the mentally ill.

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Organization of services and pattern of psychiatric care in Nicaragua: Result of a survey in 1986

Manual de saúde mental: guia básico para atençäo primária

Cooperation in mental health: an Italian project in Nicaragua.

Laying foundations for improved care of the mentally ill.