Integrated versus non-integrated management and care for clients with co-occurring mental health and substance use disorders: a qualitative systematic review of randomised controlled trials

The purpose of this paper is to conduct a qualitative review of randomised controlled trials in relation to the treatment of adults with co-occurring mental health and substance use disorder (MH/SUD). In particular, integrated approaches are compared with non-integrated approaches to treatment. Ten articles were identified for inclusion in the review. The findings are equivocal with regard to the superior efficacy of integrated approaches to treatment, although the many limitations of the studies need to be considered in our understanding of this finding. Clearly, this is an extremely challenging client group to engage and maintain in intervention research, and the complexity and variability of the problems render control particularly difficult. The lack of available evidence to support the superiority of integration is discussed in relation to these challenges. Much remains to be investigated with regard to integrated management and care for people with co-occurring and MH/SUD, particularly for specific combinations of dual diagnosis and giving consideration to the level of inter-relatedness between the disorders. (C) 2004 Elsevier Ltd. All rights reserved.

Suicide in developing countries (3) Prevention efforts

Until now, suicide prevention efforts have been limited in developing countries, although there are pockets of excellent achievement. Various universal, selective, and indicated interventions have been implemented, many of which target a different pattern of risk factors to those in developed countries. In the absence of sufficient mental health services, developing countries rely heavily on nongovemment organizations (NGOs) to provide crisis interventions for suicidal individuals, as well as proactive interventions aimed at raising community awareness and building resilience. Often these NGOs work within a social and public health framework, collaborating with others to provide nested suicide prevention programs that are responsive to local community needs. There is a clear need to develop appropriate, relevant and effective national suicide prevention plans in developing countries, since, to date, only Sri Lanka has done so. These plans should focus on a range of priority areas, specify the actions necessary to achieve positive change in these priority areas, consider the range of collaborators required to implement these actions, and structure their efforts at national, regional, and local levels. The plans should also promote the collection of accurate data on completed and attempted suicide, and should foster evaluation efforts.

General practitioner, specialist providers case conferences in palliative care: Lessons learned from 56 case conferences

OBJECTIVE: To describe the utility and acceptability to general practitioners and palliative care staff of case conferences in palliative care. METHOD: Research focussed on case conferences conducted between GPs and staff of three specialist palliative care units (in an inner urban, outer metropolitan and regional setting), at the time of referral of patients to the service. Telephone interviews were conducted with all GPs who participated in a case conference, and focus groups were conducted with palliative care staff. RESULTS: For most GPs, case conferences by teleconference were a time effective and immediate means of information transfer. The best instances for a conference were at time of patient referral, time of discharge to the community, or where the case was complex. General practitioners appreciated access to multiple professionals simultaneously. Workload pressures were a drawback of participation for both GPs and specialists. Palliative care team members thought case conferences gave GPs an appreciation of a team approach, and reduced professional isolation. The usefulness of the case conferences depended on the willingness of the GP to participate. General practitioners would participate again provided they did not have to organise the case conference. Specialist staff were concerned by the financial cost of organising case conferences. DISCUSSION: Case conferences provide useful information exchange between GPs and specialist staff, and are acceptable to both parties. Much depends on the individual GPs attitude toward participation, as well as the timing of the conferences in the course of the patient's illness. Organisation needs to be a task of the specialist units, who would need administrative support to organise them. (author abstract)

Differences in sharing knowledge interpersonally and via databases: The role of evaluation apprehension and perceived benefits

Knowledge sharing is an essential component of effective knowledge management. However, evaluation apprehension, or the fear that your work may be critiqued, can inhibit knowledge sharing. Using the general framework of social exchange theory, we examined the effects of evaluation apprehension and perceived benefit of knowledge sharing ( such as enhanced reputation) on employees' knowledge sharing intentions in two contexts: interpersonal (i.e., by direct contact between two employees) and database (i.e., via repositories). Evaluation apprehension was negatively associated with knowledge sharing intentions in both contexts while perceived bene. it was only positively associated with knowledge sharing intentions in the database context. Moreover, compared to the interpersonal context, evaluation apprehension was higher and knowledge sharing lower in the database context. Finally, the negative effects of evaluation apprehension upon knowledge sharing intentions were worse when perceived benefits were low compared to when perceived benefits were high.

Effect of conditional release from hospitalization on mortality risk

Objectives: This study considered the protective value provided by conditional release. It assessed the contribution of conditional release to mortality risk among patients with mental disorders severe enough to require psychiatric hospitalization during a mental health treatment span of 13.5 years in Victoria, Australia. Methods: Death records were obtained from the Australian National Death Index for a sample of 24,973 Victorian Psychiatric Case Register patients with a history of psychiatric hospitalizations: 8,879 had experienced at least one conditional release during community care intervals and 16,094 had not. Risk of death was assessed with standardized mortality ratios of the general population of Victoria. Relative risk of death among patients with and without past experience of conditional release was computed with risk and odds ratios. The contribution of conditional release to mortality, taking into account use of community care services, age, gender, inpatient experience, and diagnosis, as well as other controls, was assessed with logistic regression. Results: Patients who had been hospitalized showed higher mortality risk than the general population. Sixteen percent ( 4,034) died. Patients exposed to conditional release, however, had a 14 percent reduction in probability of noninjury-related death and a 24 percent reduction per day on orders in the probability of death from injury compared with those not offered such oversight throughout their mental health treatment, all other factors taken into account. Conclusions: Conditional release can offer protective oversight for those considered dangerous to self or others and appears to reduce mortality risk among those with disorders severe enough to require psychiatric hospitalization.

Impact of Australia's Better Outcomes in Mental Health Care program on psychologists

The aim of this paper was to consider the impact on psychologists of one component of the Australian Government's Better Outcomes in Mental Health Care (BOiMHC) program, namely the Access to Allied Psychological Services (ATAPS) component. This supports psychologists and general practitioners (GPs) to work together to provide optimal mental health care, via 102 projects being conducted by Divisions of General Practice. The paper was informed by data from five sources: a project-based minimum dataset; local project evaluation reports; a forum; a survey of projects: and a survey of Australian Psychological Society (APS) members. Taken together, the data from these sources showed that a significant number of psychologists are providing services through the projects, and the majority are finding it a positive and professionally rewarding experience. There is considerable variability regarding models of retaining, locating and referring to psychologists, and there are pros and cons associated with each. The major problem identified by psychologists is the level of remuneration. BOiMHC is currently moving into a new phase of continuation and expansion, and consideration was given to whether the data point to any changes that could be made to the ATAPS projects during this period of transition. In the main, the data suggest that the status quo should be retained, but the issue of remuneration must be addressed.

Models of psychological service provision under Australia's better outcomes in mental health care program

The Access to Allied Psychological Services component of Australia's Better Outcomes in Mental Health Care program enables eligible general practitioners to refer consumers to allied health professionals for affordable, evidence-based mental health care, via 108 projects conducted by Divisions of General Practice. The current study profiled the models of service delivery across these projects, and examined whether particular models were associated with differential levels of access to services. We found: 76% of projects were retaining their allied health professionals under contract, 28% via direct employment, and 7% some other way; Allied health professionals were providing services from GPs' rooms in 63% of projects, from their own rooms in 63%, from a third location in 42%; and The referral mechanism of choice was direct referral in 51% of projects, a voucher system in 27%, a brokerage system in 24%, and a register system in 25%. Many of these models were being used in combination. No model was predictive of differential levels of access, suggesting that the approach of adapting models to the local context is proving successful.

The National Mental Health Strategy and Geographical Access to Mental Health Services: Some empirical results

In 1992 the Australian Government adopted the National Mental Health Strategy in an attempt to improve the provision of mental health services. A component was to improve geographical access to hospital-based mental health services. This paper is concerned with determining if this objective has been achieved. Time-series data on patients (at a regional level) with mental illness in the State of Queensland are available for the years from 1968-69 to 2002-03. A change in regional classification by the Australian Bureau of Statistics complicates the analysis by precluding certain empirical tests such as converging utilisation rates by region. To overcome this problem, it was decided to apply concepts of concentration and equality that are commonly employed in industrial economics to the regional data. The empirical results show no evidence of improving regional access following the National Mental Health Strategy: in fact the statistical results show the opposite, i.e. declining regional access.

Some economic dimensions of the mental health jigsaw in Australia

The purpose of this paper is to demonstrate that, although there are some unique features associated with mental illness, such special features do not preclude economic analysis. As a mechanism for understanding how individual economic studies fit into the mental health sector, a conceptual framework of the components of mental health service provision is outlined. Emphasis is placed on, not simply institutional and market resources, but also on the services provided by relatives, self-help groups, etc. Australian data on parts of the mental health sector are employed to illustrate that some (and different) economic analyses can be undertaken in mental health. First, time-series data on public psychiatric hospitals are employed to demonstrate trends associated with deinstitutionalisation. Other data (for Queensland alone) indicate that there are state-based differences in the provision of such services. Second, attention is then directed to the analysis of time-series data on private fee-for-service psychiatric services. Various concepts and measures from industrial economics are applied to analyse the relative size of this service industry, the pricing behaviour of the profession, the service-mix of "the psychiatry firms" operating in Australia.

Stakeholder concerns about Australia's mental health care system

There is growing community and professional concern that the Australian mental health care system requires substantial reform. In response to these concerns, a Senate Select Committee on Mental Health has been commissioned to conduct an inquiry into the provision of mental health services. The current study involved a content analysis of 725 submissions received by the Committee, and highlighted significant areas for reform. People with mental illness face difficulties in accessing mental health care, the care they do receive is of varying quality and poorly coordinated, and necessary services from other sectors, such as housing, are lacking. These problems may be exacerbated for particular groups with complex needs or heightened levels of vulnerability. The system requires reorienting towards the consumers and carers it is designed to serve, and needs stronger governance, higher levels of accountability and improved monitoring of quality. These findings are discussed in the context of the recent acknowledgement of mental health as an issue by the Council of Australian Governments (COAG), which has called for an action plan to be prepared for its consideration by June 2006.

Health care professionals' views of paediatric outpatient non-attendance:implications for general practice

Background. Non-attendance at paediatric hospital outpatient appointments poses potential risks to children's health and welfare. Prevention and management of missed appointments depends on the perceptions of clinicians and decision makers from both primary and secondary care, including general practitioners (GPs) who are integral to non-attendance follow-up. Objectives. To examine the views of clinical, managerial and executive health care staff regarding occurrence and management of non-attendance at general paediatric outpatient clinics. Methods. A qualitative study using individual semi-structured interviews was carried out at three English Primary Care Trusts and a nearby children's hospital. Interviews were conducted with 37 staff, including GPs, hospital doctors, other health care professionals, managers, executives and commissioners. Participants were recruited through purposive and 'snowball' sampling methods. Data were analysed following a thematic framework approach. Results. GPs focused on situational difficulties for families, while hospital-based staff emphasized the influence of parents' beliefs on attendance. Managers, executives and commissioners presented a broad overview of both factors, but with less detailed views. All groups discussed sociodemographic factors, with non-attendance thought to be more likely in 'chaotic families'. Hospital interviewees emphasized child protection issues and the need for thorough follow-up of missed appointments. However, GPs were reluctant to interfere with parental responsibilities. Conclusion. Parental motivation and practical and social barriers should be considered. Responsibilities regarding missed appointments are not clear across health care sectors, but GPs are uniquely placed to address non-attendance issues and are central to child safeguarding. Primary care policies and strategies could be introduced to reduce non-attendance and ensure children receive the care they require. © The Author 2013.

"Customer" knowledge management in healthcare

This paper reports on a work-in-progress project on the management of patient knowledge in a UK general hospital. Greater involvement of patients is generally seen as crucial to the effective provision of healthcare in the future. However, this presents many challenges, especially in the light of the ageing population in most developed countries and the consequent increasing demand for healthcare. In the UK, there have been many attempts to increase patient involvement by the systematisation of patient feedback, but typically they have not been open to academic scrutiny or formal evaluation, nor have they used any knowledge management principles. The theoretical foundations for this project come first from service management and thence from customer knowledge management. Service management stresses the importance of the customer perspective. Healthcare clearly meets the definitions of a service even though it may also include some tangible elements such as surgery and provision of medication. Although regarding hospital patients purely as "customers" is a viewpoint that needs to be used with care, application of the theory offers potential benefits in healthcare. The two main elements we propose to use from the theory are the type of customer knowledge and its relationship to attributes of the quality of the service provided. The project is concerned with investigating various knowledge management systems (KMS) that are currently in use (or proposed) to systematise patient feedback in an NHS Trust hospital, to manage knowledge from and to a lesser extent about patients. The study is a mixed methods (quantitative and qualitative) action research investigation intended to answer the following three research questions: • How can a KMS be used as a mechanism to capture and evaluate patient experiences to provoke patient service change • How can the KMS assist in providing a mechanism for systematising patient engagement? • How can patient feedback be used to stimulate improvements in care, quality and safety?

Integrating service user and practitioner expertise within a web-based system for collaborative mental-health risk and safety management

Objectives: To develop a decision support system (DSS), myGRaCE, that integrates service user (SU) and practitioner expertise about mental health and associated risks of suicide, self-harm, harm to others, self-neglect, and vulnerability. The intention is to help SUs assess and manage their own mental health collaboratively with practitioners. Methods: An iterative process involving interviews, focus groups, and agile software development with 115 SUs, to elicit and implement myGRaCE requirements. Results: Findings highlight shared understanding of mental health risk between SUs and practitioners that can be integrated within a single model. However, important differences were revealed in SUs' preferred process of assessing risks and safety, which are reflected in the distinctive interface, navigation, tool functionality and language developed for myGRaCE. A challenge was how to provide flexible access without overwhelming and confusing users. Conclusion: The methods show that practitioner expertise can be reformulated in a format that simultaneously captures SU expertise, to provide a tool highly valued by SUs. A stepped process adds necessary structure to the assessment, each step with its own feedback and guidance. Practice Implications: The GRiST web-based DSS (www.egrist.org) links and integrates myGRaCE self-assessments with GRiST practitioner assessments for supporting collaborative and self-managed healthcare.