Francesco Amaddeo

Comparing patterns and costs of schizophrenia care in five European countries: the EPSILON study

Objective: To compare service utilization and cost profiles of people with schizophrenia living in Europe in order to understand differences in treatment and care costs.

Provision of services for people with schizophrenia in five European regions.

Background: An increasing diversity of public, voluntary sector and private providers offer services for the mentally ill in the ongoing process of psychiatric reform. Good service description is one important prerequisite for mental health service research. Aims 1) To describe service provision for the mentally ill in five European centres using the European Service Mapping Schedule (ESMS); and 2) to discuss the use of the instrument in describing service provision. Methods: All services providing care for people with severe mental illness in five European catchment areas (in Amsterdam, the Netherlands; Copenhagen, Denmark; London, UK; Santander, Spain; Verona, Italy) were identified through various sources. The identified services were classified, and service provision was quantified in accordance with the ESMS manual. Descriptive information was obtained. Results: We identified from 10 to 45 different services for catchment areas of between 50,000 (Copenhagen) and 560,000 (Santander) population run by three to 16 providers. They varied in aims, staffing and functioning. Hospital and non-hospital residential services, community-based services, and social support agencies were available in all sites. There was substantial variation across centres in the range, number and activities of services. Collecting comparable data sets on all service types, particularly for day and structured activity services and outpatient and community services required substantial effort. Conclusion: Operationalised description of mental health services across Europe is possible but requires further refinement.

Burnout, compassion fatigue, and compassion satisfaction among staff in community-based mental health services

Providing care to individuals with complex mental health needs can be stressful. However, little research has focused on the emotional, cognitive, and physical consequences of providing mental health care. The aim of this study is to assess burnout (BO), compassion fatigue (CF) and compassion satisfaction (CS) among staff at the four community-based mental health services (CMHS) of Verona, Italy. All staff were asked to complete anonymously the Professional Quality of Life Scale, the General Health Questionnaire, and a socio-demographic questionnaire. In total 260 staff participated (a response rate of 84%). Psychiatrists and social workers were the professionals with the highest levels of BO and CF. Workers with psychological distress reported both higher BO and CF scores, and lower levels of CS. A significant increase in the BO and CF scores was also detected for each extra year spent working in a CMHS. A higher level of CF was associated with female and having been experienced one negative life event in the previous year. These findings are useful for health managers and team leaders to identify factors affecting the professional quality of life of mental healthcare staff, and can provide a rationale for detecting staff at risk for developing negative work-related outcomes.

Mortality and cause of death among psychiatric patients: a 20-year case-register study in an area with a community-based system of care

BACKGROUND Most mortality studies of psychiatric patients published to date have been conducted in hospital-based systems of care. This paper describes a study of the causes of death and associated risk factors among psychiatric patients who were followed up over a 20-year period in an area where psychiatric care is entirely provided by community-based psychiatric services. METHOD All subjects in contact with the South Verona Community-based Mental Health Service (CMHS) over a 20-year period with an ICD-10 psychiatric diagnosis were included. Of these 6956 patients, 938 died during the study period. Standardized mortality ratios (SMRs) and Poisson multiple regressions were used to assess the excess of mortality in the sample compared with the general population. RESULTS The overall SMR of the psychiatric patients was 1.88. Mortality was significantly high among out-patients [SMR 1.71, 95% confidence interval (CI) 1.6-1.8], and higher still following the first admission (SMR 2.61, 95% CI 2.4-2.9). The SMR for infectious diseases was higher among younger patients and extremely high in patients with diagnoses of drug addiction (216.40, 95% CI 142.5-328.6) and personality disorders (20.87, 95% CI 5.2-83.4). CONCLUSIONS This study found that psychiatric patients in contact with a CMHS have an almost twofold higher mortality rate than the general population. These findings demonstrate that, since the closure of long-stay psychiatric hospitals, the physical health care of people with mental health problems is often neglected and clearly requires greater attention by health-care policymakers, services and professionals.

Evaluating a community-based mental health service focusing on severe mental illness. The Verona experience.

Objective:  To describe the development of a community‐based mental health service, the patterns of care provided by this new service established in 1978 and its costs.

Collecting psychiatric resources utilisation data to calculate costs of care: a comparison between a service receipt interview and a case register.

Background: Economic assessment of interventions and policies is becoming increasingly common, in large measure because of the growing emphasis on cost containment within health care. Comprehensive and reliable outcome and cost data are required to advise policy makers and clinicians as to the best use of their limited resources. The process of costing can be broken down into three connected tasks: the collection of service receipt or utilisation data relative to individual clients or patients over a defined period; the costing of each of the services used; and the combination of these two sets of information in order to calculate individual costs. The aim of this study was to compare two methodologies of collecting data on individual service use – a customised interview schedule, ICAP, and the psychiatric case register (PCR) – and to calculate costs, testing the extent of agreement between them. Method: The agreement between the ICAP and the PCR costs measurement was evaluated using the concordance correlation coefficient ρc. From all patients (n = 543) who had atleast one contact with a psychiatrist or a psychologist during the period October–December 1996, 339 patients were interviewed using the ICAP. The overall number of patients in contact with the South-Verona CPS in the same period was 630. Results: The agreement between the two sources was very different for each diagnostic group and each professional category. However, the overall agreement on total costs was satisfactory (ρc < 0.95). This result is probably due to the effect of the good agreement observed on more costly services: inpatient care and sheltered accommodation. Conclusion: The results suggested practical implications for the use of the service receipt interview: interviewers should be trained in order to avoid misinterpretation of the definitions given in the form; the sources of information should be clearly defined to tease out all the items of services provided for the users; the professionals (i.e. psychiatrists) could influence the reliability of data collection by underestimating services provided by different professionals (nurses, social workers, etc.). The findings confirm that it is possible to use this approach when the aim is to estimate the whole cost of the services; however, the importance of adopting adequate procedures for analysing the complexity of cost components should be pointed out. Only a trained interviewer who thoroughly knows each component of the health and social services provided could guarantee an accurate data collection.

Off-label and non-classical prescriptions of antipsychotic agents in ordinary in-patient practice

Objective:  To estimate the proportion of off‐label prescriptions of antipsychotics (APs) in ordinary in‐patient practice.

Avoidable mortality of psychiatric patients in an area with a community-based system of mental health care.

Objective:  To ascertain the existence of an excess of avoidable mortality among psychiatric patients in an area with a community‐based system of care, to identify predictors of higher risk of avoidable mortality and to provide some possible indication to reduce avoidable mortality in modern psychiatric services.

Does Additional Care Provided by a Consumer Self-Help Group Improve Psychiatric Outcome? A Study in an Italian Community-based Psychiatric Service

This study compares the two-year clinical and social outcome, the use of services and the direct costs of patients of the South-Verona Community Psychiatric Service who were members of a self-help group, with those who were not. Use of services and costs in the two years before the baseline were compared with those occurring two years after the baseline. Self-help subjects decreased their use of hospital stay as to number of admissions and days in hospital, with a reduction of costs; they were more satisfied as to work/education while non self-help matches presented an increase of unmet needs. Clinical and social outcome showed no significant difference. The findings suggest that consumer participation may possibly enhance the effects of psychiatric treatment on outcome.

Financing mental health care in Europe

Background: Some of the most heated discussions about health policy concern financing and the funding base for services. How have west European countries approached the financing of their mental health systems? Aims: To describe the financing arrangements for mental health care in 17 European countries, and to identify the consequences for system efficiency, access and development. Method: A structured questionnaire was completed by partners in the Mental Health Economics European Network (MHEEN) to describe funding levels and financing arrangements in their countries. Responses were interpreted in the context of the wider literature on health care financing. Results: All participating countries are committed to collective pre-payment modes of financing of health care in general, and mental health care in particular. However, there is growing reliance on voluntary (private) health insurance, at the margins at least, with implications for targeting and equity. The movement of some support responsibilities into social care and housing sectors could further shift funding burdens onto individuals and families. Conclusions: Europes long-term commitment to social solidarity and mutuality must not be threatened by changes to funding arrangements that could undermine recent efficiency and equity achievements in mental health systems. Efforts to contain health care expenditure may have adverse consequences for mental health care access and utilization. Declarations of interest: The Mental Health Economics European Network Phase I was supported by a grant (SPC.2002397) from the European Commission, Health and Consumer Protection Directorate. There are no conflicts of interest.