Whose responsibility? Part 1 of 2: A scale to assess how stakeholders apportion responsibilities for addressing the needs of persons with mental health problems

Background Individuals with mental health problems have multiple, often inadequately met needs. Responsibility for meeting these needs frequently falls to patients, their families/caregivers, and governments. Little is known about stakeholders' views of who should be responsible for these needs and there are no measures to assess this construct. This study’s objectives were to present the newly designed Whose Responsibility Scale (WRS), which assesses how stakeholders apportion responsibility to persons with mental health problems, their families, and the government for addressing various needs of persons with mental health problems, and to report its psychometric properties. Methods The 22-item WRS asks respondents to assign relative responsibility to the government versus persons with mental health problems, government versus families, and families versus persons with mental health problems for seven support needs. The items were modelled on a World Values Survey item comparing the government’s and people’s responsibility for ensuring that everyone is provided for. We administered English, Tamil, and French versions to 57 patients, 60 family members, and 27 clinicians at two early psychosis programs in Chennai, India, and Montreal, Canada, evaluating test–retest reliability, internal consistency, and ease of use. Internal consistency estimates were also calculated for confirmatory purposes with the larger samples from the main comparative study. Results Test–retest reliability (intra-class correlation coefficients) generally ranged from excellent to fair across stakeholders (patients, families, and clinicians), settings (Montreal and Chennai), and languages (English, French, and Tamil). In the standardization and larger confirmatory samples, internal consistency estimates (Cronbach’s alphas) ranged from acceptable to excellent. The WRS scored average on ease of comprehension and completion. Scores were spread across the 1–10 range, suggesting that the scale captured variations in views on how responsibility for meeting needs should be distributed. On select items, scores at one end of the scale were never endorsed, but these reflected expected views about specific needs (e.g., Chennai patients never endorsed patients as being substantially more responsible for housing needs than families). Conclusions The WRS is a promising measure for use across geo-cultural contexts to inform mental health policies, and to foster dialogue and accountability among stakeholders about roles and responsibilities. It can help researchers study stakeholders’ views about responsibilities, and how these shape and are shaped by sociocultural contexts and mental healthcare systems.

Whose responsibility? Part 2 of 2: views of patients, families, and clinicians about responsibilities for addressing the needs of persons with mental health problems in Chennai, India and Montreal, Canada

Background Individuals with mental health problems have many insufficiently met support needs. Across sociocultural contexts, various parties (e.g., governments, families, persons with mental health problems) assume responsibility for meeting these needs. However, key stakeholders' opinions of the relative responsibilities of these parties for meeting support needs remain largely unexplored. This is a critical knowledge gap, as these perceptions may influence policy and caregiving decisions. Methods Patients with first-episode psychosis (n = 250), their family members (n = 228), and clinicians (n = 50) at two early intervention services in Chennai, India and Montreal, Canada were asked how much responsibility they thought the government versus persons with mental health problems; the government versus families; and families versus persons with mental health problems should bear for meeting seven support needs of persons with mental health problems (e.g., housing; help covering costs of substance use treatment; etc.). Two-way analyses of variance were conducted to examine differences in ratings of responsibility between sites (Chennai, Montreal); raters (patients, families, clinicians); and support needs. Results Across sites and raters, governments were held most responsible for meeting each support need and all needs together. Montreal raters assigned more responsibility to the government than did Chennai raters. Compared to those in Montreal, Chennai raters assigned more responsibility to families versus persons with mental health problems, except for the costs of substance use treatment. Family raters across sites assigned more responsibility to governments than did patient raters, and more responsibility to families versus persons with mental health problems than did patient and clinician raters. At both sites, governments were assigned less responsibility for addressing housing- and school/work reintegration-related needs compared to other needs. In Chennai, the government was seen as most responsible for stigma reduction and least for covering substance use services. Conclusions All stakeholders thought that governments should have substantial responsibility for meeting the needs of individuals with mental health problems, reinforcing calls for greater government investment in mental healthcare across contexts. The greater perceived responsibility of the government in Montreal and of families in Chennai may both reflect and influence differences in cultural norms and healthcare systems in India and Canada.

Pathways to mental health care in Nepal: a 14-center nationwide study

Background Pathways to care studies are feasible and tested means of finding the actual routes taken by patients before reaching proper care. In view of the predominance of nonprofessional service providers and the lack of previous large studies on pathways in Nepal, this multicenter study is needed. The aim of the study was to trace the various pathways and carers involved in mental health care; assess clinical variables such as the duration of untreated illness, clinical presentation and treatment; and compare geographically and culturally diverse landscapes. Methods This was a cross-sectional, convenience sampling study performed at 14 centers where new cases were being taken. The World Health Organization Study of the Pathways-to-Care Schedule was applied. The Nepali version of the encounter form was used. The data were collected between 17 September and 16 October 2020 and were analyzed using the Statistical Package for the Social Sciences (SPSS). Additionally, perspectives from local investigators were collected and discussed. Results Most of the first carers were native/religious faith healers (28.2%), followed by psychiatrists (26%). The median duration for the first psychiatric consultation was 3 weeks. The duration of untreated illness was 30.72 ± 80.34 (median: 4) weeks, and the time taken for this journey was 94.99 ± 274.58 (median: 30) min. The longest delay from the onset of illness to psychiatric care was for epilepsy {90.0 ± 199.0 (median: 25.5)} weeks, followed by neurotic illness {22.89 ± 73.45 (median: 2)} and psychotic illness {10.54 ± 18.28 (median: 2)} weeks. Overall, most patients with severe mental illnesses (SMIs) had their first contact with faithhealers (49%), then met with medical doctors (13%) or psychiatrists (28%). Marked differences in clinical presentation surfaced when hilly centers were compared with the Terai belt. Conclusions Faith healers, general practitioners and hospital doctors are major carers, and the means of educating them for proper referral can be considered. The investigators see several hindrances and opportunities in the studied pathways. The employment of more mental health professionals and better mental health advocacy, public awareness programs and school education are suggested strategies to improve proper mental health care.

Shifting North American drug markets and challenges for the system of care

Drug markets are dynamic systems which change based on demand, competition, legislation and revenue. Shifts that are not met with immediate and appropriate responses from the healthcare system can lead to public health crises with tragic levels of morbidity and mortality, as experienced Europe in the early 1990s and as is the case in North America currently. The major feature of the current drug market shift in North America is towards highly potent synthetic opioids such as fentanyl and fentanyl analogues. An additional spike in stimulant use further complicates this issue. Without understanding the ever-changing dynamics of drug markets and consequent patterns of drug use, the healthcare system will continue to be ineffective in its response, and morbidity and mortality will continue to increase. Economic perspectives are largely neglected in research and clinical contexts, but better treatment alternatives need to consider the large-scale macroeconomic conditions of drug markets as well as the behavioural economics of individual substance use. It is important for policy makers, health authorities, first responders and medical providers to be aware of the clinical implications of drug market changes in order to best serve people who use drugs. Only with significant clinical research, a comprehensive reorganization of the system of care across all sectors, and an evidence-driven governance, will we be successful in addressing the challenges brought on by the recent shifts in drug markets.

“A mismatch between what is happening on the inside and going on, on the outside”: a qualitative study of therapists’ perspectives on student mental health

Background Although a growing number of studies indicates a high prevalence of reported mental health problems in students and that the problems are growing in number and severity, less is known about the experiences of students facing mental health problems and personnel who interact with students that seek help for these problems. The aim of this study is to examine the perspectives of therapists working with students seeking therapy for mental health problems. Methods A qualitative study of 15 therapists’ perspectives. Data are collected with in-depth, semistructured and open-ended interviews, and analyzed using a reflexive thematic analysis. Results We developed four themes that summarize how the therapists viewed and understood the students’ experiences of mental health problems: (1) an agonizing mismatch between the inside and the outside, (2) conflicting needs for closeness and distance, (3) no room for pain, and (4) a major potential for ripple effects. Conclusions We relate our findings to the existing theory and research, and we discuss the implications for clinical practice and the limitations of the study. We argue that our findings demonstrate the need to provide students room to explore and make meaning of their difficulties and pain related to mental health problems, in addition to offer some symptom-reducing tools and techniques that can enhance performance and academic achievements. More research is needed to understand what student mental health problems might be related to and what students need.

Determinants of timely access to Specialized Mental Health Services and maintenance of a link with primary care: a cross-sectional study

Background Although access to specialized services is one of the main components of the study of paths to mental health care worldwide, the factors related to the continuity of the patient’s link with Primary Care after admission to a Specialized Mental Health Services still need to be explored in greater depth. Thus, this study aimed to evaluate the determinants of timely access to Specialized Mental Health Services (outcome 1) and maintenance of a link with Primary Care after patients’ admission (outcome 2). Methods This is a cross-sectional study, conducted with 341 users of Specialized Mental Health Services at outpatient and community level in a medium-sized city in Brazil between August and November 2019. Associations between the outcomes and the other variables were explored with the use of Poisson regression models with robust variance estimators. Results Factors positively associated with timely access were the diagnosis of psychosis or psychoactive substance misuse. The inversely associated factors with this outcome were higher income, having their need for mental health care identified in an appointment for general complaints, having been referred to the current service by Primary Care, having attended the current service for up to 3 years and delay until the first appointment (in a previous service). Regarding the maintenance of a link with Primary Care, factors positively associated were being referred to the current service by Primary Care or private service and receiving visits from Community Health Agents. The inversely associated factors with this outcome were male sex, being employed, having a diagnosis of psychosis or psychoactive substance misuse, and a greater perception of social support. Conclusions In addition to individual factors, factors related to the organization of services and the referral between them stood out in influencing both the access and maintenance of the patients’ link with Primary Care. Thus, this study reinforces the idea that integration between Primary Care and Specialized Mental Health Services should be strengthened, both to reduce waiting times for between-service referrals and benefit of care continuity.

Survey of non-conventional mental health care facilities in Côte d’Ivoire: first stage

Background Mental illnesses and disabilities as well as epileptic diseases remain an important public health issue. In Côte d’Ivoire, the provision of psychiatric care and specialised psychosocial facilities is almost non-existent. This study is based on the hypothesis that the care of people suffering from mental illness and epilepsy in Côte d’Ivoire is mainly in the hands of non-conventional mental health care facilities, including so-called ‘Prayer Camps’. These work according to traditional and spiritual principles and are mostly not registered or controlled by the Ivorian authorities. Methods This study is the first stage of a multi-stage study. For the first stage, a quantitative method with an exploratory and descriptive aim was chosen. 541 non-conventional mental health care facilities in Côte d’Ivoire were mapped, typologised according to their spiritual orientation and treatment methods, and examined according to some charactersitics. Semi-structured interviews with 435 facility leaders were conducted. Results The article provides a typology of four types of non-conventional mental health care facilities in Côte d’Ivoire including Christian Prayer Camps, Traditional Healing Centres, Phytotherapy Centres, and Roqya Centres. It explores their administrative embedding, the qualification of the facility leaders as well as their willingness, in principle, to cooperate with conventional mental health care centres. A considerable number of non-conventional expressed a desire or acceptance of cooperation with psychiatric organisations. Conclusions The next stage of this multi-stage study will be to assess the clinical and legal situation of the patients in these centres. The aim is to interview the patients in order to analyse their perceptions and to capture the concerns of relatives and staff in the centres as well as the human rights situation in a mixed-method study. The long-term objective is to establish future cooperation between conventional psychiatric care providers and suitable non-conventional mental health care facilities and to implement a community mental health care policy in Côte d’Ivoire.

Assessment of catatonia and inter-rater reliability of three instruments: a descriptive study

Background Clinical assessment of catatonia includes the use of diagnostic systems, such as the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) and the International Classification of Disease, Tenth Revision (ICD-10), or screening tools such as the Bush Francis Catatonia Screening Instrument (BFCSI)/Bush Francis Catatonia Rating Scale (BFCRS) and the Braunig Catatonia Rating Scale. In this study, we describe the inter-rater reliability (IRR), utilizing the BFCSI, BFCRS, and DSM-5 to screen for catatonia. Methods Data from 10 participants recruited as part of a larger prevalence study (of 135 participants) were used to determine the IRR by five assessors after they were trained in the application of the 14-item BFCSI, 23-item BFCRS, and DSM-5 to assess catatonia in new admissions. Krippendorff’s α was used to compute the IRR, and Spearman’s correlation was used to determine the concordance between screening tools. The study site was a 35-bed acute mental health unit in Dora Nginza Hospital, Nelson Mandela Bay Metro. Participants were mostly involuntary admissions under the Mental Health Care Act of 2002 and between the ages of 13 and 65 years. Results Of the 135 participants, 16 (11.9%) had catatonia. The majority (92 [68.1%]) were between 16 and 35 years old, with 126 (93.3%) of them being Black and 89 (66.4%) being male. The BFCRS (complete 23-item scale) had the greatest level of inter-rater agreement with α = 0.798, while the DSM-5 had the lowest level of inter-rater agreement with α = 0.565. The highest correlation coefficients were observed between the BFCRS and the BFCSI. Conclusion The prevalence rate of catatonia was 11.9%, with the BFCSI and BFCRS showing the highest pick-up rate and a high IRR with high correlation coefficients, while the DSM-5 had deficiencies in screening for catatonia with low IRR and the lowest correlation with the other two tools.

Exploring the perceived challenges and support needs of Indonesian mental health stakeholders: a qualitative study

Background Despite the large treatment gap in Indonesia, limited studies have attempted to explore both service users’ and providers’ evaluations of the current mental health system holistically. This study aims to explore the perceived challenges and support needs of Indonesian mental health stakeholders. Methods This qualitative study collected data from 17 participants from two mental health stakeholders in Yogyakarta (i.e., health professionals and service users) through a semi-structured interview. Thematic analysis was used to analyze the data. Results Findings reveal that service providers and users shared equally strong concerns regarding challenges and needs for improving mental health literacy, accessibility to services, and government support. However, a distinct emphasis was made in several areas—with service providers hinting more towards issues with interprofessional collaboration. In contrast, service users emphasized the negative attitude of health professionals and poor accessibility to service information. Conclusion The mental health service system is challenged by the lack of accessibility to service information, the limited spread of mental health practitioners, stigma, and lack of mental health literacy among both the public and professionals. A need for improvement in mental health promotion, accessibility, and quality of mental health workers is highlighted to satisfy the needs of both service users and providers.

How does context influence the delivery of mental health interventions for asylum seekers and refugees in low- and middle-income countries? A qualitative systematic review

Background Low- and middle-income countries (LMICs) host the majority of the world’s refugees. Evidence suggests that refugees and asylum seekers have high mental health needs compared to the host country population. However, they face many social, economic and culture barriers to receiving mental health care and benefitting from mental health interventions. This paper examines how these contextual factors affect the implementation of mental health interventions for refugees and asylum seekers in LMICs. Methods We conducted a qualitative systematic review searching 11 databases and 24 relevant government and non-governmental organisation (NGO) websites. We spoke with academic experts and NGO professionals for recommendations, and conducted forwards and backwards citation tracking. Results From 2055 records in abstract and title screening, and then 99 in full-text screening, 18 eligible studies were identified. Qualitative thematic synthesis was conducted on eligible papers. Three main thematic clusters were identified around: (1) support during a time of pressure and insecurity, and the need for intervention flexibility through facilitator and participant autonomy; (2) different cultural conceptions of mental health, and how interventions negotiated these differences; and (3) the importance of facilitator skills, knowledge, characteristics and relationships to intervention implementation. Conclusion Evidence suggests that intervention coordinators and developers should continue to: (1) think broadly about the range of social influences on mental health, addressing structural issues where possible; (2) offer flexibility with intervention style, content and timings; and (3) encourage building research capacity in LMICs while acknowledging pre-existing mental health knowledge and practice.