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PubMed1996

Emerging issues in international mental health services research.

In developed nations, interest in mental health services research is increasing, which parallels an increased appreciation of the social and financial costs of mental illness and a growing need to identify cost-effective patterns of care. This paper examines common challenges in mental health services research, such as adjudicating between competing mental health priorities, designing research to better understand key elements in successful interventions, defining treatment outcomes more broadly to reflect consumer and family preference and quality of life, and linking services to improve community care. Using the assertive community treatment model as an example, the paper focuses on some of the differences between services research and controlled clinical investigations and the difficulties of looking inside the "black box" of effective interventions.

Community Mental Health Services↗
PubMed1998

Measurement of risk for mental disorders and competence in a psychiatric epidemiologic community survey: the National Institute of Mental Health Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study.

This paper describes the implementation of the National Institute of Mental Health Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study's goals of measuring risk factors and competence. The emphasis is on the development and testing of the measures. Relevant constructs for measurement of risk and competence in relation to psychopathology were selected and pilot tested prior to the field trials. A structured interview was developed and field tested using lay interviewers. Using the full sample from the field trials (n = 1285 caretaker-youth pairs), sample means, standard deviations, internal consistencies, parent-youth agreement, and associations with childhood disorder were computed. Descriptive statistics reveal a range of scores and means consistent with norming samples, when available, Internal consistencies were moderate to high. Parent-youth agreement on factual items was excellent and on scales was consistent with the literature. Several strong associations were found between risk factors and disorder, although most were related to disorder in general and not specific to a diagnostic category. This instrument provides a means of obtaining data that will be useful to researchers conducting epidemiologic and clinical studies designed to contribute to the understanding of mental disorders in children and adolescents, including nosology, risk factors, context, adaptive functioning, and treatment.

Adolescent↗
PubMed1993

Elderly patients' preferences concerning life-support treatment.

The preferences of 118 elderly patients, aged from 70 to 97 years, concerning the institution of artificial ventilation in the event of an overwhelming illness, were investigated using a questionnaire. Most patients wanted treatment if the outcome was likely to be good, but in approximately half, the desire for treatment declined as anticipated quality of life or chances of recovery fell. Forty percent wanted to make the decision about institution of artificial ventilation themselves if mentally competent and 24% wanted to use some form of advance directive if mentally incompetent.

Advance Directives↗
PubMed2006

How is the collaborative-practice competency operationalized by mental health workers?

The recovery-focused competencies currently endorsed in policy emphasize collaborative relationships between mental health workers, service users, families and communities. Based on a qualitative research methodology, multi-disciplined practitioners shared their perceptions as to how mental health workers could operationalize collaborative relationships. Two community mental health centres were the setting for three focus groups, where 16 voluntary participants contributed to focused discussions. Participants discussed the pragmatics of how they work collaboratively; identifying knowledge and attitudes that underpin their practice, and elaborating on environmental influences that impact on a collaborative approach. Findings from the study recommend the practitioner role as one of advocacy and facilitation. The collaborative approach, which is inextricably related to the quality of the practitioner-service user relationship, aids sense-making for service users of their mental health experience. This requires of practitioners the qualities of openness, expression of hope, genuineness and people-first attitude that supports the building of knowledge rather than communicating it.

Clinical Competence↗
PubMed1984

Competence to proceed: a functional and context-determinative decision.

Legally, the defendant's competence at any stage of criminal proceedings is defined in terms of the test set forth in Dusky v. United States, a test establishing minimum rationality as the basis for determining mental competence. A number of investigators have attempted to devise testing instruments to assist clinicians in applying this test to individual defendants being examined for competence. Competence, however, is both context-determinative and functional in nature. The evaluator must insist on being given specific information relating to the functions that the defendant is expected to perform. The evaluator must then assess the defendant's measurable skills in the light of those specified functions and articulate his findings to the court in terms of the skills and functions rather than in terms of conclusory legal labels. Competence is then best determined by the court as a legal, not a mental, health decision under the somewhat nebulous but nonetheless appropriate criterion of "fundamental fairness" in the light of the defendant's mental state.

Expert Testimony↗
PubMed1998

Problems with managed mental health care for multicultural populations.

Managed mental health care has developed a system of care-giving that does not recognize that acceptable and effective services must acknowledge individual differences and cultural or racial identities. This approach is unacceptable in an era when a psychology of differences is necessary to provide services for nearly one-third of the population. This paper suggests that the adequacy of contemporary psychoparmacological and psychological interventions for multicultural populations is either unknown or unsatisfactory. Historically, interventions in the United States were designed primarily for Euro-Americans and thus were culture-specific in derivation. Managed care has reduced the availability and quality of these interventions for all patients and further limited the range of possible options. Culturally competent mental health services are described and related to quality of care. A societal agenda for implementing cultural competence is suggested.

Community Mental Health Services↗
PubMed1988

The psychiatrist's role in determining competency to consent in the general hospital.

In the general hospital, consultation-liaison psychiatrists are frequently consulted regarding issues of competency to consent to medical and surgical procedures and treatments. It is necessary that psychiatrists practicing in this setting have a thorough awareness of both the legal aspects of competency and consent and the clinical situations which can arise. In this paper we discuss the legal basis for consent and various definitions proposed for mental competency to consent to treatment. We describe a number of typical situations which lead to psychiatric consultation and suggest an appropriate approach to their resolution.

Forensic Psychiatry↗
PubMed1987

Avila v. New York Health and Hospitals Corporation, 22 July 1987.

The Supreme Court of New York held that an institution receiving federal funds and performing sterilizations may not arbitrarily prevent a mentally competent person and freely consenting individual from being sterilized. The plaintiff was a thirty-seven year old woman who, although mildly retarded, was not mentally incompetent under federal law.

Americas↗
PubMed2001

Sexual Abuse of the Mentally Retarded Patient: Medical and Legal Analysis for the Primary Care Physician.

The primary care physician has a vital role in documenting and preventing sexual abuse among the mentally retarded populations in our community. Since the current national trend is to integrate citizens with mental retardation into the community away from institutionalized care, it is essential that all physicians have a basic understanding of the unique medical and legal ramifications of their clinical diagnoses. As the legal arena is currently revising laws concerning rights of sexual consent among the mentally retarded, it is essential that determinations of mental competency follow national standards in order to delineate clearly any instance of sexual abuse. Clinical documentation of sexual abuse and sexually transmitted disease is an important part of a routine examination since many such individuals are indeed sexually active. Legal codes adjudicating sexual abuse cases of the mentally retarded often offer scant protection and vague terminology. Thus, medical documentation and physician competency rulings form a solid foundation for future work toward legal recourse for the abused.

Journal Article↗
PubMed1992

Do-not-resuscitate orders for depressed psychiatric inpatients.

Many patients, especially those who are elderly and who have chronic medical illnesses, choose to forgo cardiopulmonary resuscitation (CPR) in case of cardiac arrest. The right of mentally competent patients to refuse CPR is supported by ethicists, the courts, and medical associations. Psychiatrists are increasingly presented with dilemmas about resuscitation preferences of elderly psychiatric inpatients whose decision-making capacity may be impaired because of mental illness such as depression. The authors discuss justifications for patients' refusing resuscitation, the role of advance directives in communicating patients' preferences, and the use of do-not-resuscitate orders for depressed psychiatric inpatients. Survival rates after CPR among elderly patients with chronic medical illnesses are low. Patients and their families need accurate information about the risks and benefits of CPR and about the consequences of refusing the procedure.

Aged↗
PubMed1989

Life-sustaining treatment for patients with AIDS.

Physicians increasingly are being called upon to make difficult decisions about intensive care for patients with the acquired immunodeficiency syndrome (AIDS). AIDS patients who require intensive care have a poor prognosis; the in-hospital mortality rate of those receiving mechanical ventilation for P carinii pneumonia is 86-100 percent in most studies. However, in the past year, two studies documenting improved outcome have been published. Physicians should understand these outcome data and use well-established ethical principles to allow informed competent patients with AIDS to express their preferences regarding intensive care. Patients should be encouraged to provide advanced directives regarding life-sustaining treatments or to designate surrogate decision-makers to be consulted should they lose mental competence. The health care system should provide alternatives to the ICU for compassionate terminal care. However, arbitrary policies denying intensive care to AIDS patients for whom it is medically indicated and desired are not warranted.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Mexican American clients' perceptions of services in an outpatient mental health facility in a border city.

This descriptive-exploratory pilot study analyzed the perceptions of services in an outpatient mental health facility located in a border city in southwest Texas among Mexican American clientele with chronic mental illness. Face-to-face interviews using structured questionnaires were conducted with high functioning mentally ill clients. The questionnaire, with both English and Spanish versions, consisted of items on sociodemographics, support networks, illness experiences, reasons for seeking health services, reactions to being visited in the home setting for follow-up care, receiving care from a mental health professional with a similar cultural background, satisfactions, problems encountered in the mental health delivery system, and suggestions for improving health services. Data from 56 respondents yielded generally highly favorable and positive ratings of services received in the facility. Overall, these baseline data present challenges and implications for delivering culturally competent mental health care to Mexican American clients with chronic mental illness.

Adult↗
PubMed2003

Stability of preferences regarding life-sustaining treatment: a two-year prospective study of nursing home residents.

BACKGROUND: The use of advance directives is based on the consensus that physicians should respect preferences expressed by competent patients about future treatments. Patient preferences are, however, subject to change and may be influenced by a number of factors. The purpose of our study was to evaluate the durability over time of decisions made regarding terminal care of mentally intact nursing home patients and the influence of such factors as intervening illness, loss of significant others, and cognitive, emotional and functional decline. METHODS: We undertook a longitudinal prospective cohort study in which 65 mentally competent nursing home patients were interviewed at three intervals (at baseline and after one and two years). For each patient, demographic, medical and socioeconomic data were collected and assessment of mood, function, cognition and preference for life-sustaining therapies (including cardiopulmonary resuscitation and parenteral and enteral nutrition) was obtained. RESULTS: Preferences regarding cardiopulmonary resuscitation and parenteral and enteral nutrition changed over both the 12- and 24-month study periods. Only degree of change in cognitive status proved to be predictive of changes in decision. Gender, presence or absence of depression, change in level of functional abilities and intercurrent illness or stressor did not influence change regarding life-sustaining therapy. CONCLUSIONS: In light of our findings, we suggest that periodic re-evaluation of these advance directives be performed and that ongoing discussions be initiated with their patients by health care professionals.

Advance Directives↗
PubMed1999

When is a mental health professional competent to assess a person's decision to hasten death?

As the country continues to debate the legality of aid-in-dying, it appears inevitable that at some point there will be a need for mental health professionals to be involved in assessments of individuals asking for a hastened death. I designed this article to provide a set of guidelines that will allow both mental health professionals and potential consultees to determine if a professional has the training and expertise necessary to be a competent consultant.

Attitude to Death↗