Factors associated with length of stay and readmission in acute psychiatric inpatient services in Portugal.

Assessing the factors that influence duration and number of hospitalizations may support mental health services planning and delivery. This study examines the factors associated with length of stay and readmission in Portuguese psychiatric inpatient services during 2002, 2007 and 2012. Data from all admissions were extracted from clinical files. Logistic regression models estimated the association between length of stay (<17 vs ≥17 days) and number of admissions per year (1 vs >1 admission) with sociodemographic, clinical, and contextual factors. Older age, a diagnosis of psychosis, and compulsory admission were associated with higher odds of longer length of stay. Being married, secondary education, suicide attempt, a diagnosis of substance use and "other mental disorders", being admitted in 2012, and two of the psychiatric inpatient services associated with lower odds of longer length of stay. Being retired (or others), a diagnosis of psychosis, compulsory admission, and psychiatric service were associated with increased odds of readmission. Older age, and secondary and higher education were associated with lower odds of readmission. The findings indicate that multiple factors influence length of stay and readmission. Identifying these factors provides useful evidence for clinicians and policy makers to design more targeted and cost-effective interventions.

Rethinking global mental health and its priorities.

Global mental health (GMH) seems to enjoy increasing visibility in the global health and development discourse. However, this visibility implies also the urgency of addressing few questions about new priority setting in the domains of policy, care delivery, service organisation and research. Even before trying to answer these questions, rethinking more deeply the notion and implications of GMH seems to be a useful collective exercise. Some unanswered questions should be at the core of this exercise: Is GMH really global or rather Western? Is GMH concerned enough with local context? Is GMH too unbalanced towards a biomedical model? What are the consequences of the predominant emphasis given by GMH on common mental disorders and primary care level on people with severe mental disabilities? GMH is not global but rather it is hegemonised by western institutions. It would be useful to have an independent and very inclusive think tank which should promote a global debate on these issues and offer an unbiased support to WHO.

Mapping actions to improve access to medicines for mental disorders in low and middle income countries.

AIMS: In recent years a number of intergovernmental initiatives have been activated in order to enhance the capacity of countries to improve access to essential medicines, particularly for mental disorders. In May 2013 the 66th World Health Assembly adopted the World Health Organization (WHO) Comprehensive Mental Health Action Plan 2013-2020, which builds upon the work of WHO's Mental Health Gap Action Programme. Within this programme, evidence-based guidelines for mental disorders were developed, including recommendations on appropriate use of medicines. Subsequently, the 67th World Health Assembly adopted a resolution on access to essential medicines, which urged Member States to improve national policies for the selection of essential medicines and to promote their availability, affordability and appropriate use. METHODS: Following the precedent set by these important initiatives, this article presents eleven actions for improving access and appropriate use of psychotropic medicines. RESULTS: A 4 × 4 framework mapping actions as a function of the four components of access - selection, availability, affordability and appropriate use - and across four different health care levels, three of which belong to the supply side and one to the demand side, was developed. The actions are: developing a medicine selection process; promoting information and education activities for staff and end-users; developing a medicine regulation process; implementing a reliable supply system; implementing a reliable quality-control system; developing a community-based system of mental health care and promoting help-seeking behaviours; developing international agreements on medicine affordability; developing pricing policies and a sustainable financing system; developing or adopting evidence-based guidelines; monitoring the use of psychotropic medicines; promoting training initiatives for staff and end-users on critical appraisal of scientific evidence and appropriate use of psychotropic medicines. CONCLUSIONS: Activating these actions offers an unique opportunity to address the broader issue of increasing access to treatments and care for mental disorders, as current lack of attention to mental disorders is a central barrier across all domains of the 4 × 4 access framework.

Reorganization of mental health services: from institutional to community-based models of care.

Mental health services in the Eastern Mediterranean Region are predominantly centralized and institutionalized, relying on scarce specialist manpower. This creates a major treatment gap for patients with common and disabling mental disorders and places an unnecessary burden on the individual, their family and society. Six steps for reorganization of mental health services in the Region can be outlined: (1) integrate delivery of interventions for priority mental disorders into primary health care and existing priority programmes; (2) systematically strengthen the capacity of non-specialized health personnel for providing mental health care; (3) scale up community-based services (community outreach teams for defined catchment, supported residential facilities, supported employment and family support); (4) establish mental health services in general hospitals for outpatient and acute inpatient care; (5) progressively reduce the number of long-stay beds in mental hospitals through restricting new admissions; and (6) provide transitional/bridge funding over a period of time to scale up community-based services and downsize mental institutions in parallel.

Reorganization of mental health services:from institutional to community-based models of care

Mental health services in the Eastern Mediterranean Region are predominantly centralized and institutionalized, relying on scarce specialist manpower. This creates a major treatment gap for patients with common and disabling mental disorders and places an unnecessary burden on the individual,their family and society. Six steps for reorganization of mental health services in the Region can be outlined: [1]integrate delivery of interventions for priority mental disorders into primary health care and existing priority programmes; [2]systematically strengthen the capacity of non-specialized health personnel for providing mental health care; [3]scale up community-based services [community outreach teams for defined catchment, supported residential facilities,supported employment and family support]; [4]establish mental health services in general hospitals for outpatient and acute inpatient care;[5]progressively reduce the number of long-stay beds in mental hospitals through restricting new admissions; and [6]provide transitional/bridge funding over a period of time to scale up community-based services and downsize mental institutions in parallel

Les services de santé mentale dans la Région de la Méditerranée orientale sont essentiellement centralisés et institutionnalisés.Ils reposent sur un personnel spécialisé qui est rare. Cette situation crée un large fossé thérapeutique pour les patients atteints de troubles mentaux courants et handicapants, et fait porter une charge inutile pour l'individu,sa famille et la société.Six étapes pour la réorganisation des services de santé mentale dans la Région peuvent être présentées de la manière suivante : 1]intégrer l'offre des interventions pour les troubles de santé mentale prioritaires dans les programmes de soins de santé primaires et les programmes prioritaires existants ; 2]renforcer systématiquement les capacités du personnel de santé non spécialisé à fournir des soins de santé mentale ; 3]intensifier les services communautaires [équipes communautaires de proximité pour une zone de desserte définie,établissements résidentiels bénéficiant d'assistance aide à l'emploi et soutien apporté à la famille]; 4]établir des services de soins de santé mentale dans des hôpitaux généraux pour les soins externes et les soins aigus chez le patient hospitalisé ; 5]réduire progressivement le nombre de lits de long séjour dans les hôpitaux de soins de santé mentale en diminuant le nombre des nouvelles admissions ; 6]fournir un financement de transition/provisoire pendant une certaine durée pour intensifier les services communautaires et parallèlement réduire la taille des institutions de santé mentale

[Mental health and public health: an essential bond]. / Santé mentate et sante publique: un lien incontournable.

The Mental Health domain is larger than psychiatry because it implies the establishment of strategies aiming at the promotion of the well-being of the population, the prevention of mental disorders and their treatment and care. Politicians, planners, users and families and society at large have a great expectations and this require health professionals to be able to provide public mental health knowledge. It is necessary to identify those specific public mental health actions to which general practitioners and specialist could contribute. To do so more knowledge in public mental health is needed and more training is necessary.

Trends in mortality from suicide, 1965-99.

OBJECTIVE: To analyse trends in mortality from suicide over the period 1965-99. METHOD: Data were derived from the WHO database, including data for 47 countries. RESULTS: In the European Union (EU), all age suicide mortality peaked at 16.1/100,000 in men in 1980-84, and declined thereafter to 14.4/100,000 in 1995-98. In females, the fall was 29% to reach 4.6/100,000. A similar pattern of trends was observed in several eastern European countries. In contrast, mortality from suicide rose substantially in the Russian Federation, from 37.7/100,000 in males in 1985-89 to 58.3/100,000 in 1995-98 (+55%), and to 9.5/100,000 (+12%) in females. In the USA and most other American countries providing data, no consistent pattern was evident for males, but falls were observed in females. Steady declines were registered for Japan, starting from the highest suicide rates worldwide in the late 1950s. Suicide rates were upwards in Ireland, Italy, Spain, the UK, Cuba, Australia and New Zealand. Substantial rises were observed in a few countries (Ireland, Cuba, Mexico, Australia and New Zealand) for young males. CONCLUSION: In spite of mixed trends, suicide remains a significant public health problem worldwide.

Mental health in EMRO: the future is now.

Recognizing the magnitude of the problem of mental health disorders globally, the World Health Organization has made mental health the focus of the year 2001. In this paper three priority areas for action in the Eastern Mediterranean Region are suggested, namely: human rights, mental hospitals and community care, drug abuse, and reconstruction of the health care system in Afghanistan.

Mental health in EMRO: the future is now

Recognizing the magnitude of the problem of mental health disorders globally, the World Health Organization has made mental health the focus of the year 2001. In this paper three priority areas for action in the Eastern Mediterranean Region are suggested, namely: human rights, mental hospitals and community care, drug abuse, and reconstruction of the health care system in Afghanistan

The Qualyop Project. 1: Monitoring the dismantlement of Italian public psychiatric hospitals. Characteristics of patients scheduled for discharge.

OBJECTIVES: Monitoring and evaluating the Italian psychiatric hospitals closure process, stated by the law to be concluded by 31 December 1996, and then postponed to 31 March 1998, identifying characteristics related to the possibility of discharge in 4493 patients living in twenty-two public psychiatric hospitals. METHOD: Sociodemographic and clinical data, information on impairment and functioning and plans for discharge in the subsequent twelve months of all patients were collected at baseline using a standard questionnaire. RESULTS: Discharge was planned within twelve months for 11% of the patients: 4% to other psychiatric or non-psychiatric institutions and 7% to community settings. Severely disabled patients and patients with some behavioural problems were more frequently scheduled to go to institutional settings. For both types of discharge, an adequate network of social relationships was an important determinant. Patients were more frequently planned for discharge if they resided in hospitals with a higher care providers/patients ratio, and in Emilia Romagna and Rome, than in Lombardy and Liguria. CONCLUSION: Frequency of planned discharge depended partly on the patients' personal characteristics related to independence and functioning, but the effect of these factors on frequency of planned discharge was influenced by characteristics of the hospitals where the patients lived.

QUALYOP project 2: monitoring the dismantling of Italian psychiatric hospitals. Psychotropic drug use in 1072 inpatients.

OBJECTIVE: This study describes the use of psychotropic drugs in a sample of eight Italian psychiatric hospitals. METHODS: A cross-sectional approach was used to collect information about sociodemographic and clinical characteristics of the inpatient population, and about medications prescribed. Prescribing behaviour in the hospitals was compared using three indicators: the number of patients taking psychotropic drugs, the use of high doses of neuroleptics and the use of multiple neuroleptics. RESULTS: More than a thousand patients were resident in the eight hospitals on the census day, 56% of them males. Half the population had an ICD-X diagnosis of schizophrenia, one third of mental retardation. Sixty-nine percent of the sample was on neuroleptic therapy, nearly 47% on benzodiazepines and 4% on antidepressants. Twenty percent of the sample did not take any psychotropic drug on the census day. After adjustment for sociodemographic and clinical variables, setting-related variables resulted as determinants of psychotropic drug use. CONCLUSIONS: These data call for continuing education in psychopharmacology towards a more rational use of drugs; longitudinal audits of clinical practice should be implemented to guide clinicians toward a more rational use of psychotropic drugs.