Continuum of Care
Introduction
Mental healthcare services are extremely beneficial for the continuum of care. Elevation of mental healthcare services and the treatment and diagnosis of mental disorders in the context of individuals and whole families are also important parts of the overall healthcare continuum.
Through internship and continuous medical training, family doctors are prepared to treat mental problems in patients of all ages. The stability of care innate in family medicine helps in the early diagnosis of possible mental health problems. Since family physicians are for whole families, they can diagnose the problems in a relatively more efficient manner as they can interfere in the family system. Family doctors are able to solve the problems of those individuals who do not want to go to traditional mental health clinics due to the social stigma linked with mental problems.
Mental health problems are mostly undiagnosed. Even if doctors diagnose properly, such problems do not receive the required amount of care and treatment. Proper diagnosis and treatment of mental disorders are important matters for primary care doctors as such matters have an impact on the overall continuum of healthcare.
Some factors that determine how successful an individual would be in his/her life and is the person leading a healthy life? Mental Health of the person is one of the factors in this criterion. Mental health plays a key role in the personal growth, development and success of an individual. Mental fitness helps a person doing his job efficiently, help in achieving his aims and only a mentally healthy person would aspire for more. Nevertheless, mental disorders are causing disabilities and untimely deaths all across the world. Nearly all in their life time encounter a mental problem. [1]
But America has left behind all the nations in this regard. According to a report of the President’s New Freedom Commission of Mental Health “Mental disorders are shockingly common.” “Achieving the Promise: Transforming Mental Health Care in America,”[2]
In the days of yore, it was really very difficult for the people to diagnose such illnesses, disorders were hard to detect and the treatment was even more complicated. Now with the advancement of medical science and new technologies being introduced every other day the diagnosis and the treatment are not too hard. But people usually feel hesitant in discussing their problems and in seeking the help of an expert. “Concerns about the cost of care – concerns made worse by the disparity in insurance coverage for mental disorders in contrast to other illnesses – are among the foremost reasons why people do not seek needed mental health care.”[3]
A brief description of the different services or programs in a continuum of care follows:
Office or outpatient clinic
Visits are usually under one hour. The number of visits per week depends on the youngster’s needs.
Intensive case management
Specially trained individuals coordinate or provide psychiatric, financial, legal, and medical services to help the child or adolescent live successfully at home and in the community.
Home-based treatment services
A team of specially trained staff go into a home and develop a treatment program to help the child and family.
Family support services
Services to help families care for their child such as parent training, parent support group, etc.
Day treatment program
This intensive treatment program provides psychiatric treatment with special education. The child usually attends five days per week.
Partial hospitalization (day hospital)
This provides all the treatment services of a psychiatric hospital, but the patients go home each evening.
Emergency/crisis services
24-hour-per-day services for emergencies (for example, hospital emergency room, mobile crisis team).
Respite care services
A patient stays briefly away from home with specially trained individuals.
Therapeutic group home or community residence
This therapeutic program usually includes 6 to 10 children or adolescents per home, and may be linked with a day treatment program or specialized educational program.
Crisis residence
This setting provides short-term (usually fewer than 15 days) crisis intervention and treatment. Patients receive 24-hour-per-day supervision
Residential treatment facility
Seriously disturbed patients receive intensive and comprehensive psychiatric treatment in a campus-like setting on a longer-term basis.
Hospital treatment
Patients receive comprehensive psychiatric treatment in a hospital. Treatment programs should be specifically designed for either children or adolescents. Length of treatment depends on different variables.
(All Family Resources, 1996)[4]
Diagnosis
A correct diagnosis is really very important for the further care and treatment of an individual. Today it has become very easy to diagnose the disorder with a high degree of reliability. Early intervention and diagnosis makes the further process like treatment, controlling symptoms comparatively easy. The treatment of mental diseases involves 3 most important steps pharmacotherapy, psychotherapy, and psychosocial rehabilitation.
Elements of a continuum
An incorporated continuum of mental health services has the potential to prevent many problems currently present in the current system. Such a continuum would let a patient to get treatment according to his health condition and not according to his financial condition. It offers transitional aftercare facilities to continue and improve therapeutic measures. By offering alternative treatment facilities, the healthcare continuum reduces the amount of time spent on other expensive treatment methods. The mental healthcare component provides services like the treatment of suicidal ideations, eating disorders, emotional problems, etc.
Emotional Problems
The mental healthcare component of the continuum also provides the treatment of emotional problems. “Some nine million children have serious emotional problems at any point in time. Yet, only 1 in 5 of these children are receiving appropriate treatment. When parents or teachers suspect that a child may have an emotional problem, they should seek a comprehensive evaluation by a mental health professional specifically trained to work with children and adolescents. Ongoing parental involvement and support are essential to the overall success of treatment. Depending on the nature of your child’s problems, it may also be important to involve the school, community agencies, and/or juvenile justice system.”[5]
Suicidal Behavior
A school counselor may send a depressed male student, who may be willing to commit suicide, to a mental healthcare provider. The provider may analyze that the boy’s problems are too serious to refer him for outpatient treatment so he may send the boy to a psychiatric hospital. After a few days, the boy’s insurance may exhaust so he may be moved to a state hospital if he is still depressed. After a few months, he is transferred to a residential treatment center. Eventually, the boy may come back to his home and visit a community clinic.
Example of Mental Healthcare in the Continuum of Care
Just take an example of a child, Tom, who took an overdose of a medicine that had devastative effects. Tom got admission in a hospital program and doctors found him too much depressed. Tom’s parents told the doctors that he had previously attempted suicide twice which came to their knowledge only through a therapist Tom had visited. The team of doctors decided to admit Tom for six months, as his conditions were severe. The doctors found out that Tom’s medical insurance allowed only three months of hospitalization. After 45 days of treatment, doctors analyzed Tom’s behavior and learned that he was still depressed and there were chances that he may still attempt suicide. His family had become extraordinarily engaged with him during his treatment. Doctors considered transitioning Tom to another component of the Healthcare continuum. After a thorough analysis, doctors shifted Tom to residential care with the condition that his parents would keep 24-hour supervision on him. Tom made some good progress and after 9 months, he got rid of suicidal ideations. Afterwards, doctors shifted him to outpatient care where he received therapy twice a week
Transitioning patients
Tom’s case depicts a number of factors including the treatment of suicidal ideations, a major service provided by the mental healthcare component. It also highlights a few aspects about the transition of a patient with mental disorders through different components of the healthcare continuum. Most transition decisions are based on doctoral judgments and case reviews. Transitions to less restraining components are normally made only if the patient has made significant positive progress within the present component.
Pharmacotherapy
This step includes the use of medicines and drugs. Psychotropic drugs have been divided into three types. Antipsychotic are used for all the psychotic symptoms, antidepressants for depression, and anti-epileptics for epilepsy and tranquillizers for anxiety. These drugs target the symptoms and not the disease. But these medicines are expensive and therefore out of the reach of poor people. The treatment of mental disorders requires a flexible approach of all the people to these medicines.
Psychotherapy
Psychotherapy involves intervention to improve the behaviour, mood, emotional status of the patient through verbal and non-verbal therapies. Usually communication adds a lot in the treatment of mentally suffering individuals. Psychotherapy does not require medicines, tests, and other biological means. “The techniques widely used in psychotherapy include behaviour therapy, cognitive therapy, interpersonal therapy, relaxation techniques and supportive therapy or counseling. The idea of Behaviour therapy has been driven from the principles of learning”.[6] In this therapy doctors use psychological facts and principles to treat clinical problems. Cognitive therapy involves the exercise of new ideas, thinking patterns to change the behaviours. Interpersonal therapy is a different sort of technique implied to work on the role dispute, role transition, unresolved anguish, and social scarcity. Relaxation technique involves a simple way of treating the mentally ill people and that is through aerobics, yoga, meditation and other forms of physical exercises. It aims to reduce the anxiety level of the patients. People accept this therapy without any apprehension.
Supportive therapy involves the councellung of the patient by the doctor. It includes advice, teaching, reassurance, suggestion. If supportive therapy is done properly then the chances of successful rehabilitation brighten.
All these therapies, techniques and modes of treatment have been successful in the management of co-occurring disorders, drug abuse, and psychotic complications like phobias, delusions and hallucinations. These psychotherapies maintain satisfaction among the suffering patients and thus contribute to minimize unemployment, less crowded hospitals and contended population.
Psychosocial Rehabilitation
Psychosocial rehabilitation aims to help those individuals, who face disabilities and impaired-ness due to a mental disorder to work as individuals without the minimum support of others. Psychosocial rehabilitation supports the handicapped people to prove their individuality and improves their socialization. It teaches them cooking, using transport services, house keeping and personal hygiene and empowers them.[7]
Vocational Rehabilitation and Employment
In the USA certain organizations and social workers provide psychiatric patients employments and trainings. These professional trainings help the patients to earn their bread easily. Some organizations also provide such people temporary jobs.
General Prevalence of Mental Health Disorders in Rural Areas
Mental disorders prevail among the people in the same way regardless of their residential area, locality or city. Although it is not decisive but national data available indicates that the ratio of mental health disorders among the adult rural and urban population is the same. Data collected from National Comorbidity Survey suggests that the 1 month prevalence of emotional, anxiety and other mental diseases are the same in urban and rural population.
In the rural population life long prevalence of affective mental disorders has been found comparatively lower as compared to the urban areas, while anxiety and other mental health problems prevail in the same ratio in the people either living in cities or in towns and villages. According to the National Household Survey on Drug Abuse the diagnosis of psychiatric disorders is also almost the same in the urban and rural population.
Mental health disorders are often followed by other problems and complications like drug abuse, addiction, violent acts etcetera. Experts suggest that in USA, about 70 percent patients treated substance abuses and rehabilitation have a life long history of mental illness, mostly depression. According to the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area study, persons with a mental disorder or substance abuse disorder can have co-occurring disorders more than anyone else.
It was concluded that 23 percent to 56 of those with a diagnosable Axis I mental disorder also have co-occurring disorders like substance abuse. The studies on mental health disorders, co-occurring disorders followed by substance abuse points out that these disorders occur in the rural areas as in the urban areas and the area of residence does not matter in the prevalence of such disorders. But it is assumed that due to lack of infrastructure, proper treatment and other commodities mental disorders usually o untreated in the rural areas.[8]
Experience of Patients and Caregivers:
“ In a Study the Department of Psychiatry, Yale University School of Medicine, New Haven examined the relationship between the use of health care services and treatable conditions among patients with Dementia. Ninety nine patient caregivers were interviewed. One year later patients’ VA records were reviewed to analyze the relationships between the study variables and three types of service use: inpatient medical stays, outpatient medical visits, and outpatient psychiatric visits. According to the results pain was positively associated with all types of service use. Depression was associated with outpatient psychiatric visits. Psychosis and aggression were not significantly associated with future use of health care services. The results confirmed that pain and depression are associated with increased use of health services. In another research done by the University the subjects were caregivers of 264 patients with bipolar disorder. Care giver mental and primary health care services were studied for a period of 7 months prior to inpatient or out patient admission of the patient results showed that caregiver burden increased the probability of health care services. It gives an idea that the burden experienced by the caregivers increase the use of care services and the cost also”.[9]
Mental Health Crisis
“According to Hunter McQuistion, M.D., an assistant clinical professor of psychiatry at Mt. Sinai School of Medicine and medical director of Project Renewal Inc., a nonprofit agency that provides services to homeless mentally ill and substance-abusing individuals, Patients with severe psychiatric disorders do not receive sufficient health care and services.” Patients occupy the hospitals and the doctors don’t have time to consider the state of one patient properly. They are the least concerned about the patients and their problems and act unprofessionally. They don’t take the psychiatric disorders as illness, for doctors mental disorders are insignificant issues. As psychiatrist Bert Pepper, M.D points out, “Once ER personnel or primary care doctors identify patients as having a mental illness; they often get less attention and not as complete a workup. There is an assumption that their problem is ‘psychiatric’ not ‘medical. But Mauger, clinical professor of psychiatry at Michigan State University defends the doctors and medical staff by stating that, generally the motives of physicians and ER doctors are not evil: They just don’t have the resources and time to make sense out of the patients with psychiatric illnesses especially when the patients’ communication is impaired.”
Experts say that despite of the past situation, scene has started to change now. Researchers have taken the issue seriously and scientific study has begun about the psychiatric disorders. Roger Kathol, M.D., a clinical professor of psychiatry and internal medicine at the University of Iowa, states “The focus of research funding for years has neglected issues at the psychiatry-medicine interface. While change has been slow, experts are now realizing the importance of medical care for patients with psychiatric illness.”
At present there are three man issues the whole country is facing as Psychiatric News has observed are:
· Psychiatric patients prematurely being discharged from ER labeled as ‘fit’.
· ER patients being sent to psychiatric wards (where they are not treated well) instead of the general wards.
· Primary care doctors not doing their jobs appropriately. They do not examine patients with mental disorders the way they examine the patients with other complications.
The unsatisfactory care of mentally ill individuals points out towards other problems as well, like the lack of education and training provided to the doctors about the treatment of psychiatric patients, physicians’ private clinics, lack of psychiatrists in the country and several other factors contribute in the inadequate care of the mentally suffering people.
Brian Coopper, director of consumer advocacy for the Mental Health America, presented another aspect. He said that some patients with serious mental disorders have no insurance and thus they do not get any compensation. If some have Medicaid then the amount paid is very low. [10]
Solutions
In America numbers of associations operate to work for the betterment of psychiatric patient, health care, access to the services and reimbursement. A group including the “American College of Physicians, and the American Society of Internal Medicine, coordinated by the Policy Committee of the Academy of Psychosomatic Medicine is working to effect regulatory and amend the legislative laws”.[11]
Besides all these associations the physicians should also ensure adequate medical services being provided to the patients. Psychiatrists must be made the active part of the hospitals. People should be educated about the mental disorders so that the stigma against the patients and mental disorders could be removed.
Doctors should be given special incentives. In this way they will be appreciated and students will be motivated to become a part of this field. In rural areas educational programs should be conducted regarding mental health disorders and care. The programs should be conducted in a way that the local people (of different ethnic groups) can understand it. State should develop the rural mental health services system. It can be done easily by developing community centers and community-oriented training. (“Not Available”)
With the growing American population rate of mental disorders is also increasing rapidly. State has to work in this area, but apart from the State associations also should work hand in hand with the government. Education about the mental problems needs to be conveyed, because people living in the rural areas still don’t know about mental health care. People even today don’t take mental disorders as diseases. These sort of people are to be educated especially community based health programs have been very successful in this regard. Until and unless people are informed any problem could not be solved. Health is a key to success as it is said that, “Health is Wealth.”
Conclusion
Although psychiatrists are important in the overall continuum of healthcare, most of the mental patients seek advice form primary care doctors. Patients want to get treatment from their family physicians or primary care doctors. Even those who visit psychiatrists want to keep in touch with primary care doctors during the treatment of their mental problems. To improve the scope of mental healthcare services in the scenario of the overall continuum of care, it is extremely important to improve the capabilities of primary care doctors with respect to the diagnosis and the treatment of mental health problems.
References
Achieving the Promise: Transforming Mental Health Care in America, New Freedom Commission on Mental Health, p. 1, 2003
Advocating For Your Child. No. 74; Updated Feburary 2000
http://www.aacap.org/page.ww?name=Advocating+For+Your+Child§ion=Facts+for+Families Accessed, April 24, 2007
All Family Resources: The Continuum Of Care For Children And Adolescents
Article #42 Updated 04/96
http://www.familymanagement.com/facts/english/facts42.html
Accessed, April 24, 2007
Bipolar Disord, 2005; 7(2): 126-35
Clinical & research news
http://www.psych.org/pnews/00-11-17/physical.html Accessed, April 17, 2007
KUNIK Mark E, CULLY Jeffrey A, SNOW A. Lynn , SOUCHEK Julie , SULLIVAN Greer and ASHTON Carol M. Treatable comorbid conditions and use of VA health care services among patients with dementia. Psychiatric services (Psychiatr. serv.) 2005, vol. 56, no1, pp. 70-75 [6 page(s) (article)] (35 ref.)
Mental Health: A Report of the Surgeon General, p. 23, 1999
Not Available
http://www.nrharural.org/advocacy/sub/issuepapers/ipaper14.htm Accessed, April 17, 2007
WHO | Chapter 3: Solving mental health problems
http://www.who.int/whr/2001/chapter3/en/index1.html Accessed, April 17, 2007
[1] Mental Health America, MHA
[2] New Freedom Commission on Mental Healths, 2003
[3] Mental Health: A Report of the Surgeon General,” 1999
[4] All Family Resources: The Continuum Of Care For Children And Adolescents
Article #42 Updated 04/96
[5] Advocating For Your Child. No. 74; Updated Feburary 2000
[6] WHO | Chapter 3: Solving mental health problems
[7] WHO | Chapter 3: Solving mental health problems
[8] Not available
[9] Bipolar Disord, 2005; 7(2): 126-35 and KUNIK Mark E, CULLY Jeffrey A, SNOW A. Lynn , SOUCHEK Julie , SULLIVAN Greer and ASHTON Carol M. Treatable comorbid conditions and use of VA health care services among patients with dementia. Psychiatric services (Psychiatr. serv.) 2005, vol. 56, no1, pp. 70-75 [6 page(s) (article)] (35 ref.)
[10] Clinical & research news
[11] Clinical & research news, op-cite
