BackgroundEvidence from the context of local health ecosystems is highly relevant for research and policymaking to understand geographical variations in outcomes of health care delivery. In mental health systems, the analysis of context presents particular challenges related to their complexity and to methodological difficulties. Method guidelines and standard recommendations for conducting context analysis of local mental health care are urgently needed. This scoping study reviews current methods of context analysis in mental health systems to establish the parameters of research activity examining availability and capacity of care at the local level, and to identify any gaps in the literature.MethodsA scoping review based on a systematic search of key databases was conducted for the period 2005–2016. A systems dynamics/complexity approach was adopted, using a modified version of Tansella and Thornicroft’s matrix model of mental health care as the conceptual framework for our analysis.ResultsThe lack of a specific terminology in the area meant that from 10,911 titles identified at the initial search, only 46 papers met inclusion criteria. Of these, 21 had serious methodological limitations. Fifteen papers did not use any kind of formal framework, and five of those did not describe their method. Units of analysis varied widely and across different levels of the system. Six instruments to describe service availability and capacity were identified, of which three had been psychometrically validated. A limitation was the exclusion of grey literature from the review. However, the imprecise nature of the terminology, and high number of initial results, makes the inclusion of grey literature not feasible.ConclusionWe identified that, in spite of its relevance, context studies in mental health services is a very limited research area. Few validated instruments are available. Methodological limitations in many papers mean that the particular challenges of mental health systems research such as system complexity, data availability and terminological variability are generally poorly addressed, presenting a barrier to valid system comparison. The modified Thornicroft and Tansella matrix and related ecological production of care model provide the main model for research within the area of health care ecosystems.
Objective To describe the availability of local mental health (MH) services in small MH catchment areas in Central Chile, using a bottom-up approach. Methods MH services of 19 small MH catchment areas in five health districts of Central Chile that provide health care to more than 4 million inhabitants were assessed using DESDE-LTC (Description and Evaluation of Services and Directories in Europe for Long-Term Care), a tool for standardized description and classification of LTC health services, in a study conducted in 2012 (“DESDE-Chile”) designed to complement other studies conducted in 2004 and 2012 at the national and regional level using the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS). Key informants from national, regional, and local health authorities were contacted to compile a comprehensive list of MH services or facilities (health, social services, education, employment, and housing). The analysis of local care provision covered three criteria—service availability, placement capacity, and workforce capacity. Results The study detected disparities in all three criteria (availability and placement and workforce capacity) across the five health districts, between urban and rural areas, and between neighboring urban areas. Analysis of service availability revealed differences in the weight of residential services versus day and outpatient care. The Talcahuano area could be considered a benchmark of MH care in Central Chile, based on its service provision patterns, and the criteria of the community care model. The list of MH services identified in this study differed from the one generated in the 2012 WHO-AIMS study. Conclusions This survey of local MH service provision in small catchment areas using the DESDE-LTC tool provided MH service provision data that complemented information collected in other studies conducted at the national/regional level using the WHO-AIMS tool. The bottom-up approach applied in this study would also be useful for the assessment of equity and accessibility and local planning.
Se presenta el caso de una estudiante que acude al Servicio de Atención Psicológica de la Universidad de Cádiz con diagnóstico de trastorno obsesivo compulsivo. Los contenidos de las obsesiones están relacionados principalmente con la duda. Las compulsiones más frecuentes son de limpieza, comprobación y orden. Las metas principales del tratamiento fueron reducir la aparición de obsesiones y compulsiones, modificando las creencias disfuncionales que las mantienen y disminuir el malestar asociado. La sintomatología obsesivo compulsiva se evalúa con los instrumentos Y-BOCS-Gravedad, OCI-R, ICO-R, INPIOS. Se planifica y se aplica una intervención de terapia cognitiva basada en el protocolo propuesto por Belloch, Cabedo y Carrió (2011) para el TOC de cuestionamiento de las creencias disfuncionales que mantienen las obsesiones de la paciente y las estrategias que utiliza para afrontarlas. Se han llevado a cabo18 sesiones semanales en formato online de 1 hora de duración. Para modificar las creencias obsesivas se utilizaron técnicas cognitivas (análisis de evidencias a favor y en contra, ventajas y desventajas, flecha descendente o estimación de probabilidades) y experimentos conductuales orientados al cuestionamiento de creencias. Se ha producido una disminución en la intensidad de las creencias disfuncionales así como de la sintomatología obsesiva y del malestar.
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