9.5 Examples of mental health services research studies
9.5.1 Administrative data
ENVIRONMENT
Health care system External environment
POPULATION CHARACTERISTICS Predisposing
characteristics
Enabling resources
Need
OUTCOMES
(satisfaction with treatment, perceived or/and evaluated health status, quality of life…)
HEALTH BEHAVIOUR
Personal health practices Use of Health Services
Fig 9.1 Behavioral Model and Access to Medical Care by Ronald M. Andersen. Adapted from: Andersen RM (1995) Revisiting the behavioral model and access to medical care: does it matter?Journal of Health and Social Behavior,36, 1–10 [27].
Using his model of access to care, Andersen defines equitable access as occurring when demographic and need variables account for most of the variance in utilisation, whereas inequitable access occurs when social structure (for instance ethnicity), health beliefs or enabling resources (income) determine who gets medical care [27].
9.5 Examples of mental health
hospital care consistently decreased, whereas outpa- tient care, home visits and day-hospital increased.
Specifically, hospital rates decreased from almost 350 patients per 100 000 adult South Verona resi- dents in 1979, to just 50 patients per 100 000 South Verona residents in 2003. On the other hand, out- patient/community care increased from nearly 25 patients per 100 000 residents in 1979 to more than 250 per 100 000 in 2003. Twenty-five years after the reform (from 1978 to 2003) there was a 29% decrease of inpatient admissions, with a 56%
decrease in compulsory admissions. The mean num- ber of occupied beds per day decreased over time, falling by 81% between 1977 and 2003. Figure 9.2 shows the patterns of inpatient admissions from 1977 to 2004. This study could be seen as evidence of the achievement of one of the main objectives of psychi- atric reform. These kinds of studies could be useful in monitoring and evaluating the implementation of a programme or a new policy.
One of the main studies in Mental HSR is the World Health Organization (WHO)Mental Health Atlas. Following Thornicroft and Tansella’s matrix, this study is an example of a country-input study, as it is comparing resources devoted to mental health (inputs) in different countries that are grouped into wide regions. This project was initiated in 2000 with the objectives of collecting, compiling and disseminating global information on mental health resources and services in each country [30].
With this information, WHO aims to show both
public and professionals the inadequacies of existing resources and services devoted to mental health, and the large inequities in their distribution at national and global level.
In 2005 this information was updated in a second edition of theAtlas. Information was obtained from the Ministry of Health of each country and triangu- lated with results of an exhaustive literature search and with other kind of documents submitted and collected by WHO Regional Offices staff. Informa- tion was also checked with experts and members of the World Psychiatric Association.
The 192 WHO member states and the 11 asso- ciated members are represented in the Atlas. This represents nearly 99% of the world’s population.
As an example, Table 9.3 shows a comparison of the median number of different mental health profes- sionals per 100 000 inhabitants, according to WHO Regions. As can be observed, there is a large variation in the number of professionals from region to region.
For instance, there are nearly 1800 psychiatrists for 702 million people in the African Region, compared with more than 89 000 psychiatrists for 879 million people in the European Region. It points out not just the lack of resources but also the high inequities in resource distribution.
Such information has potential value for planning mental health services both at national and interna- tional level. Moreover, as information is updated, comparisons and changes in resources devoted to mental health can be monitored, indicating whether
0 100 200 300 400 500 600
1977 1979 1983 1987
Compulsory To state mental hospital (voluntary) To public care
To private care TOTAL 1991 1995 1999 2003
Fig 9.2 Patterns of in-patient admissions from 1977 to 2003 in South Verona (ratios per 100 000 residents). Own elaboration with data obtained from: Tansella M, Amaddeo F, Burti L, Lasalvia A and Ruggeri M (2006) Evaluating a community- based mental health service focusing on severe mental illness. The Verona experience.Acta Psychiatrica Scandinavica,113, 90–94 [29].
Table 9.3 Median number of mental health professionals by WHO regions.
Africa Americas Eastern Europe South-East Western World
Mediterranean Asia Pacific
Psychiatrists 0.04 2.00 0.95 9.80 0.20 0.32 1.20
Psychiatric nurses 0.20 2.60 1.25 24.8 0.10 0.50 2.00
Neurologists 0.02 0.70 0.30 4.00 0.05 0.00 0.30
Neurosurgeons 0.01 0.40 0.20 1.00 0.03 0.00 0.20
Psychologists working in mental health
0.05 2.80 0.60 3.10 0.03 0.03 0.60
Social workers working in mental health
0.05 1.00 0.40 1.50 0.04 0.05 0.40
Own elaboration with data obtained from: World Health Organization (2005) Mental Health Atlas, World Health Organization, Geneva [30].
specific policies aimed at improving resources have been effective. For instance, comparisons of data collected in 2001 and updated in 2004 show an increase in the quantity of mental health profes- sionals in the world, the number of psychologists and social workers showing the greatest increases (with increases in median of 0.2 points and 0.1 points per 100 000 inhabitants respectively). There were no major changes in the median number of other professionals.
Comparisons between large regions are interesting from a macro/international standpoint. Nevertheless, it would be interesting to complete and compare these results with data obtained at a meso-level, that is with data gathered in municipalities, health areas or districts, as it may diverge from data aggregated at higher levels (i.e. countries). The meso-level compar- ison of mental health service availability is related to the study of SAV in medical procedures.
One of the major difficulties when comparing availability of services in different areas (even within the same countries) is the different names that ser- vices are given. Moreover, the name they receive may or may not describe its main activity, which can make comparisons difficult. To deal with this barrier, in 1994 a group of investigators named the Euro- pean Psychiatric Care Assessment Team (EPCAT) group began to work towards the establishment of a standardised methodology for the description and assessment of the care received by people suffering from mental disorders. They developed theEuropean Service Mapping Schedule(ESMS). The ESMS is an instrument that serves three purposes: (i) to com- pile the adult mental health services of a catchment
area; (ii) to describe and compare the structures and types of mental health services between catchment areas and (iii) to measure and compare the levels of provision of major types of mental health services between catchment areas. The ESMS uses atheoret- ical descriptors based on the main types of care:
(i) residential care; (ii) day care and (iii) outpatient and communiy care. By choosing these terms, the ESMS avoid using culturally laden words (such as rehabilitation) or common names designing different types of care (day-centre). Moreover, each type of care is divided according to whether patients stays overnight at the service, receives care in a day-care facility or has face-to-face contact with the profes- sional. Secondary and tertiary subdivisions are made on the basis of other characteristics such as: inten- sity, time of stay and mobility [31]. Graphically, the ESMS can be seen as a ‘service tree’ (Figure 9.3).
Salvador-Carulla et al. [32] used the ESMS to make a meso-level comparison of mental health service availability and use in Chile and Spain. They selected small areas (catchment areas) with marked differences regarding organisation and provision of services. The areas selected in Spain were: Gav `a (Catalonia, in the north-east), Granada-Norte (Andalusia, South) and Rochapea (Navarre, North).
The three areas differed in the socioeconomic, dis- tribution and organisation models for their mental health services. It is also important to note that in Spain the responsibilities of the National Health System and Social Services have been gradually transferred to each of the 17 autonomous regions that comprise Spain. The three small Spanish areas selected are from different autonomous regions, with
Mental Health Services ResidentialDay & structured activityOut-patient & communitySelf-help & non-professional Secure Generic acute Non-acute Hospital Non-hospital
Hospital Non-hospital
Time limited Indefinite stay
24-h support Daily support 24-h support Daily support Time limited Indefinite stay
24-h support Daily support 24-h support Daily support
Acute Non-acute High intensity Low intensity
Work Work related activity Other structured activity Social support Work Work related activity Other structured activity Social support
Emergency careContinuing care Mobile Non-mobile
Mobile Non-mobile
24 h Limited hours 24 h Limited hours
High intensity Moderate intensity Low intensity High intensity Moderate intensity Low intensity Fig9.3TheESMSservicetree.Modifiedfrom:JohnsonS,KuhlmannRandtheEPCATgroup(2000)TheEuropeanServiceMappingSchedule(ESMS): ofaninstrumentforthedescriptionandclassificationofmentalhealthservices.ActaPsychiatricaScandinavica,102,14–23[31].
different mental health services and objectives. The Chilean areas were: Concepcion and Talcahuano. On the one hand, the organisation of services in Concep- cion is more traditional (dating from the 1960s). On the other hand, provision of mental health services in Talcahuano was reorganised during the 1990s.
Briefly, the procedure for data collection for the ESMS began in each area with a face-to-face inter- view with the head of the community mental-health centre and the reference hospital setting. A map of the services and the main local administrative data source were identified. Figures 9.4–9.7 show the utilisation rates of the main types of care in the five small health areas per 100 000 inhabitants. This study showed that there were differences in the use of residential and day-care facilities between Span- ish and Chilean areas. However, if we look data in detail, the rate of continuous outpatient care in Chilean areas was closer to that of the Rochapea area than the other two Spanish areas. This could be related to the greater availability of these kinds of services in these areas which could have an impact on demand as well as the clinical pattern. This study also showed the lack of availability of day-care ser- vices and acute care. It demonstrated that patterns of hospital residential care in Chile and Spain were more similar than expected. In fact, the poorest Span- ish studied area (Granada) was very similar to the Chilean ones. Combining data from the WHOMen- tal Health Atlaswith meso-level data offers a more accurate picture of the use of mental health services.
Another example of the use of the ESMS could be found in the study by Pirkolaet al. in Finland [33],
0 5 10 15 20 25 30
Hospital acute
Hospital non-acute:total
Nonhospital:
total
Rochapea Gavà Granada Norte Concepcion Talchuano
Fig 9.4 Comparison of mental health services in five small areas. Residential care (beds occupied per month per 100 000 population). Own elaboration with data obtained from Salvador-Carulla L, Sladivia S, Mart´ınez-Leal R, Vicente B, Garc´ıa- Alonso C, Grandon P and Haro JM (2008) Meso-level comparison of mental health services availability and use in Chile and Spain.Psychiatric Services,59, 421–428 [32].
which aimed to investigate the relation between sui- cide risk and different ways of organising mental health services in the 428 municipalities that make up Finland. Each of these municipalities has nearly 5000 inhabitants. The provision of mental health care has been transferred to these municipalities, so management structure and procedures vary widely among them. Again, following the mental health matrix, this study could be seen as an example of meso-level comparison, but in this case the authors compare outcomes (suicide) rather than inputs. The authors obtained ESMS data by means of interviews with the 20 mainland Finnish hospital districts, and from health care and social-care officers. Data on suicide was obtained from Statistics Finland. Find- ings from this study suggested that, after controlling for socioeconomic factors, those municipalities with a predominance of outpatient services had a low sui- cide rate (relative risk (RR) 0.94, 95% CI 0.90–0.98).
In spite of the cross-sectional design of the study that precluded causal implications, results were consis- tent with results of a meta-analysis that suggested that patients treated by community mental-health teams are less likely to kill themselves.
Studies made with administrative data have some advantages: they are readily available, nor- mally they are inexpensive to acquire, they are computer-based and typically have a big sample size. Nevertheless, when compared with studies using primary data, some limitations have to been acknowledged. The main disadvantage is that, in most cases, sociodemographic information is scarce.
Moreover, with administrative data, the study of unmet needs from the general population can not
0.00 20.00 40.00 60.00 80.00 100.00 120.00
Day-care (users per months per 100 000 population)
Rochapea Gavà Granada Norte Concepcion Talchuano
Fig 9.5 Comparison of mental health services in five small areas. Day care (day and structured activities). Own elaboration with data obtained from Salvador-Carulla L, Sladivia S, Mart´ınez-Leal R, Vicente B, Garc´ıa-Alonso C, Grandon P and Haro JM (2008) Meso-level comparison of mental health services availability and use in Chile and Spain.Psychiatric Services,59, 421–428 [32].
0 50 100 150 200 250
Emergency
Rochapea Gavà Granada Norte Concepcion Talchuano
Fig 9.6 Comparison of mental health services in five small areas. Outpatient and ambulatory care I (contacts per month per 100 000 population). Own elaboration with data obtained from Salvador-Carulla L, Sladivia S, Mart´ınez-Leal R, Vicente B, Garc´ıa-Alonso C, Grandon P and Haro JM (2008) Meso-level comparison of mental health services availability and use in Chile and Spain.Psychiatric Services,59, 421–428 [32].
0 500 1000 1500 2000 2500 3000
Continuing care
Rochapea Gavà Granada Norte Concepcion Talchuano
Fig 9.7 Comparison of mental health services in five small areas. Outpatient and ambulatory care II (services users per month per 100 000 population). Own elaboration with data obtained from Salvador-Carulla L, Sladivia S, Mart´ınez-Leal R, Vicente B, Garc´ıa-Alonso C, Grandon P and Haro JM (2008) Meso-level comparison of mental health services availability and use in Chile and Spain.Psychiatric Services,59, 421–428 [32].
be studied. Epidemiological studies could deal with these disadvantages, helping, with the information obtained, to document service use and unmet need for treatment.