9.5 Examples of mental health services research studies
9.5.2 Studies using primary data collection
be studied. Epidemiological studies could deal with these disadvantages, helping, with the information obtained, to document service use and unmet need for treatment.
China Lebanon Nigeria Japan Ukraine Mexico South-Africa Colombia Germany France Netherlands Italy Israel New Zealand Spain USA Belgium
severe moderate mild none
0 10 20 30 40 50 60 70 80 90 100
Fig 9.8 Use of mental health services by severity of mental disorders and country. Own elaboration with data extracted from Wang PSet al. (2007) Use of mental health services for anxiety, mood and substance disorders in 17 countries in the WHO world mental health surveys.The Lancet,370, 841–850 [35].
are objectively in need of treatment), and not a
‘subjective’ approach (based on what people feel they need). So the data should be interpreted with caution.
The subjective approach in the assessment of needs is exemplified by the work analysing patient needs using the Camberwell Assessment of Need (CAN) inventory. For example, Ochoa et al. [37]
conducted a study which evaluated 231 people with schizophrenia living in the city of Barcelona and its surroundings. The CAN instrument is useful in help- ing professionals to design treatment plans for their individual patients, but also in studying the perfor- mance of mental health services. The CAN evaluates the presence of need in 22 areas: accommodation, food, house upkeep, self-care, daytime activities, physical health, psychotic symptoms, information, psychological distress, risk to self, risk to others, alco- hol, drugs, company, intimate relationships, sexual expression, child care, education, telephone, trans- port, money and benefits. For each of these areas, the CAN determines, if a need is detected, whether it is met, who provides the care (formal or informal care) and whether the help provided is appropriate.
The questionnaire is completed independently by the staff and the patient. This double assessment allows the comparison of normative needs with felt needs. Briefly, this study pointed out that staff detected more needs than patients did (staff mean=6.6 (SD=3.17) vs. patients mean=5.36 (SD=2.71);p<0.0001). The most frequent detected needs by patients were: psychotic symptoms, house upkeep, food and information. Staff detected needs in the areas of psychotic symptoms, company, day- time activities, house upkeep, food and information.
With regard to who gave the required help, results showed that patients received more informal than formal help (75% of participants with met needs received informal help while, on the other hand, less than 50% received formal help). Regarding unmet needs, they also found that staff rated more areas as unmet needs than patients did (staff mean=1.38 (SD=1.75) vs. patients mean=1.82(SD=1.98);
p<0.0001). Most frequent unmet need expressed by patients included: companionship, intimate relation- ship, sexual expression and daytime activities. The same areas were detected by staff. It is important to note that in most of the unmet areas, the participant
reported that they received help; although this was not considered sufficient to meet their need.
So far we have reviewed examples describing or comparing data. These kinds of studies are usual in Mental HSR and are useful for analysing and plan- ning the needs of a given community. But Mental HSR is also interested in assessing the performance of programs or interventions focused on mental or emotional problems. One example of such studies is the UK 700 case management trial [38]. This study was carried out in four centres, three in London and one in Manchester, which obtained, in 1993, fund- ing from the National Health Service (NHS) for a randomised, controlled trial of intensive case man- agement (ICM). Investigators aimed to investigate the cost-effectiveness of ICM (case-load size 10–15) compared with standard case management (SCM) (case-load size 30–35) for patients with severe psy- chosis. A total of 708 patients with psychosis and a history of repeated hospital admissions were ran- domly allocated to ICM or SCM and assessed at baseline, 12 and 24 months by researchers indepen- dent of those providing clinical care. They did not find any differences in terms of days in hospital for psychiatric problems over 24 months, or in the scores of the Comprehensive Psychiatric Rating Scale, in the Quality of Life, in the assessment of unmet needs, in the mean Disability Assessment Schedule total score or in patient satisfaction. Nor did they find differ- ences between ICM and CSM in the total 2-year costs of care per patient. As neither form of case management was better than the other, the authors conclude that formal cost-effectiveness analyses were not required. This study had a clear policy implica- tion: it contradicted the policy of advocating ICM for patients with severe psychosis, as their study showed no beneficial effects of ICM on costs, clinical outcomes or cost-effectiveness.
Another example is the paper by Bellonet al. [39]
carried out in a primary care setting aiming to assess the effectiveness of general practitioner intervention to reduce frequent-attendee consultation. This study was carried out by a multidisciplinary team formed by general practitioners, statisticians and psychiatrists. The interest of this study from a Mental HSR standpoint is that, typically, frequent- attendee consultations are sought by people affected by emotional problems or mental disorders. The
authors designed a randomised, controlled trial with frequent attendees divided into an intervention group (N=66) and two control groups (CG1, N=71; and CG2, patients who consulted the same general practitioners (GPs) as the intervention group, N=72). A total of six GPs participated in the study.
GPs on the control groups were blind to which patients were selected to be acting as controls. They used two different control groups, CG1 absolutely na¨ıve to the intervention, and CG2 formed by those GPs also in the intervention group aiming to study if intervention was interiorised. The setting was a primary health care centre in southern Spain.
Authors identified the sample of frequent- attendees with reference to mean annual consultation rates (before intervention) at the health centre, strat- ified by sex and age. Frequent attendees were considered to be those patients who had an annual rate of consultation at least twice as high as the sex- and-age-related mean for the health centre; that is, nearly the 90th percentile of the overall distribution.
The intervention aiming to reduce frequent- attendee visits was called by the investigators, the ‘seven hypotheses + team’ intervention. The three GPs in the intervention group underwent an interactive workshop training session (15 hours). Briefly, this intervention encourages GPs to select, from a list of seven possible hypotheses, a reason why the patient is a frequent attendee:
biological, psychological, social, family, cultural, administrative–organisational or related to the doctor–patient relationship. After this, GPs share their analysis with other GPs regarding the hypoth- esis and the plans derived from it (this is the team component of the intervention).
The frequent-attendees’ mean consultations by group at baseline and 1-year after intervention with GPs are detailed in Figure 9.9.
At the end of the follow-up it was observed that the intervention group had significantly fewer vis- its than control group 1 (p<0.001) and control group 2 (p<0.001). Moreover, CG2 (those patients whose GPs form part of the control and intervention groups) also showed a reduction between visits at baseline and 1 year later (p<0.001). All the results were adjusted by covariates such as chronic diseases and self-reported health, provider-use interface vari- ables (such as traveling time to the health centre
and satisfaction with the GP), sociodemographic and psychosocial variables. Pending further evidence, the intervention showed a significant and relevant reduction in frequent-attendee consultations. This study could be seen as an example of a patient- process study.