Mental Health Planning During the COVID-19 Crisis: A Systematic Review of Online International Strategies and Recommendations

Mental Health care systems have been dramatically affected by COVID-19. Containment measures have been imposed with negative consequences on population mental health. Therefore, an increase in both symptomatology and mental disorders incidence is expected. This research aims to identify, describe and assess the empirical background on online strategies and recommendations developed by international organizations and governments to cope with the psychological impact of COVID-1

Evolution of Mental Health Online Strategies from the Early Stage of the COVID-19 Pandemic to the Pre-Vaccination Period

Background: The COVID-19 outbreak and its consequent quarantines, containment measures and social distancing imposed by authorities worldwide has caused an increase of psychological responses such as depression, abuse use, insomnia, post-traumatic stress symptoms, anger, anxiety, grief or confusion. This situation has fostered the implementation of new strategies like remote therapy to maintain the continuity of mental health (MH) care. Several international organizations (World Health Organization, the United Nations and the American Psychiatric Association) are focused on addressing the recovery from the COVID-19 pandemic, ensuring availability of emergency MH services, strengthening social cohesion, reducing the isolation, and promoting psychological support, as well as protecting human rights. This research aims to assess the evolution of online MH strategies and recommendations to cope with psychological impact of COVID-19 since early stages of the pandemic to pre-vaccination period. Methods: A sample of 24 online documents was analysed to assess their structural evolution from April 2020 to June 2021. Each document was analysed separately by two researchers. The questionnaire, developed by Almeda et al. (2021), was used to assess the content of these documents. This instrument consists of 39 items organized in seven domains (D) D1) Symptoms, D2) Mental disorders, D3) COVID-19 general information, D4) MH strategies and MH topics, D5) MH strategies and MH-related topics, D6) MH recommendations and MH topics and D7) MH recommendations and MH-related topics. To assess the structural evolution of the document in the selected periods, a T-Student for related samples was used. Results: Statistically significant differences with a negligible effect size were found in D1+D2 domains (t(23) = 3, p = 0.006, d = 0.18). An increasing concern on bereavement, sleeping problems and loneliness symptoms has been highlighted together with a greater interest on schizophrenia, bipolar disorder, chronic pain and obsessivecompulsive disorder. Statistically significant differences with negligible size effect were also found when the questions related to COVID-19 have been analysed (D3-D7;t(23) = 2.24, p = 0.035, d = 0.19). All COVID-19 information items have increased (D3) as also happened in most of the MH strategies and MH-related topics (80%;D5). In D7, D4 and D6 domains, a small increase in the information provided is highlighted. From an international point of view, England, Australia, New Zealand and Mexico are the countries with the highest rate of improvement in their strategies, followed by Ireland and Spain with small improvements. Finally, the information in the online documents of the rest of the countries remains stable. Conclusions: Online MH strategies and recommendations have improved during the pandemic period only in specific countries, especially in Mexico. Due to the high rate of mortality, bereavement has played a key role in the set of symptoms included. Globally speaking, the analysed countries are making efforts to address MH remotely, as it is evidenced in their online strategies

Mental health planning at a very early stage of the COVID-19 crisis: a systematic review of online international strategies and recommendations

Background: Mental health care systems have been dramatically affected by COVID-19. Containment measures have been imposed, with negative consequences on population mental health. Therefore, an increase in both symptomatology and mental disorder incidence is expected. This research aims to identify, describe and assess the empirical background on online strategies and recommendations developed by international organizations and governments to cope with the psychological impact of COVID-19 at a very early stage of the pandemic. Methods: The PRISMA guidelines were adapted to review online documents. A new questionnaire was developed to identify the existence of common patterns in the selected documents. Questions were classified into three domains: COVID-19 information, mental health strategies and mental health recommendations. A two-step cluster analysis was carried out to highlight underlying behaviours in the data (patterns). The results are shown as spider graphs (pattern profiles) and conceptual maps (multidimensional links between questions). Results: Twenty-six documents were included in the review. The questionnaire analysed document complexity and identified their common key mental health characteristics (i.e., does the respondent have the tools for dealing with stress, depression and anxiety?). Cluster analysis highlighted patterns from the questionnaire domains. Strong relationships between questions were identified, such as psychological tips for maintaining good mental health and coping with COVID-19 (question n° 4), describing some psychological skills to help people cope with anxiety and worry about COVID-19 (question n° 6) and promoting social connection at home (question n° 8). Conclusions: When fast results are needed to develop health strategies and policies, rapid reviews associated with statistical and graphical methods are essential. The results obtained from the proposed analytical procedure can be relevant to a) classify documents according to their complexity in structuring the information provided on how to cope with the psychological impact of COVID-19, b) develop new documents according to specific objectives matching population needs, c) improve document design to face unforeseen events, and d) adapt new documents to local situations. In this framework, the relevance of adapting e-mental health procedures to community mental health care model principles was highlighted, although some problems related to the digital gap must be considered.Part of this study was funded by the Carlos III Health Institute (PI18/01521) and the Regional Government of Andalusia (PY18-RE-0022)

Assessment of Relative Technical Efficiency of Small Mental Health Areas in Bizkaia (Basque Country, Spain)

Mental disorders cause an enormous burden to society. Considering the current economic context, an efficient use of scarce inputs, with an appropriate outcome production, is crucial. This situation defines a classical Relative Technical Efficiency (RTE) problem. A well-known methodology to assess RTE is the Data Envelopment Analysis, although it presents some limitations. These may be overcome through a hybrid strategy that integrates Monte-Carlo simulation and artificial intelligence. This study aims to (1) design of a Decision Support System for the assessment of RTE of Small Mental Health Areas based on DEA; and (2) analyse 19 mental health areas of the Bizkaian Healthcare System (Spain) to classify them and to identify potential management improvements. The results have showed higher global RTE in the output-oriented orientation than in the input-oriented one. This suggests that a decision strategy based on improving the input management, within the ranges of the expert-driven model of community healthcare, could be appropriate. A future research line will focus our attention on the validation process through the analysis of micromanagement interventions and their potential impacts in the real system

Impact of the workforce allocation on the technical performance of mental health services: the collective case of Helsinki-Uusimaa (Finland)

Background Long-term mental health (MH) policies in Finland aimed at investing in community care and promoting reforms have led to a reduction in the number of psychiatric hospital beds. However, most resources are still allocated to hospital and community residential services due to various social, economic and political factors. Despite previous research focussing on the number and cost of these services, no study has evaluated the emerging patterns of use, their technical performance and the relationship with the workforce structure. Objective The purpose of this study was to observe the patterns of use and their technical performance (efciency) of the main types of care of MH services in the Helsinki-Uusimaa region (Finland), and to analyse the potential rela‑ tionship between technical performance and the corresponding workforce structure. Methods The sample included acute hospital residential care, non-hospital residential care and outpatient care services. The analysis was conducted using regression analysis, Monte Carlo simulation, fuzzy inference and data envelopment analysis. Results The analysis showed a statistically signifcant linear relationship between the number of service users and the length of stay, number of beds in non-hospital residential care and number of contacts in outpatient care services. The three service types displayed a similar pattern of technical performance, with high relative technical efciency on average and a low probability of being efcient. The most efcient acute hospital and outpatient care services integrated multidisciplinary teams, while psychiatrists and nurses characterized non-hospital residential care. Conclusions The results indicated that the number of resources and utilization variables were linearly related to the number of users and that the relative technical efciency of the services was similar across all types. This suggests homogenous MH management with small variations based on workforce allocation. Therefore, the distribution of workforce capacity should be considered in the development of efective policies and interventions in the southern Finnish MH system

Modelling mental healthcare improvement in highly integrated care systems: the case of the Basque Country (Spain)

Currently there is growing interest in providing integrated mental health care between hospital (acute residential care) and community-based services (… and other health systems). Mental health systems are complex due to the high disorder prevalence, socio-economic burden, stigma associated, and high gap of unmet population needs. Mental health can be considered an ecosystem related to, at least, physical health and social services ones. Decision support systems are robust tools for guiding and improving planning and management of health ecosystems by integrating methods like Bayesian networks. These models identify critical variables, domains and constructs and their corresponding causal relationships. The objective of this research is to design an integrated and integral theoretical Bayesian network for guiding mental health planning and management, and in consequence, improving mental health care delivery

On the roller coaster: An abridged history of mental health planning in Spain. SESPAS Report 2020

Effective mental health change in Spain started in 1985 with the Report of the Ministerial Commission for the Psychiatric Reform that recommended integrating psychiatric care into the general health system, providing care in the patient's context and for specific diagnoses. The SESPAS 2002 Report carried out an analysis of this reform and recommended the creation of a permanent ministerial commission, the design of a national map of socio-sanitary mental health services, the creation of a coordination and promotion agency for and carrying out a financial analysis of resource provision and research. Since 2004, the Technical Committee for the Mental Health Strategy boosted the elaboration of a theoretical and normative framework that unfortunately did not lead to a road map for the improvement of the system. After 2011, during the financial crisis, the Ministry of Health lost the opportunity to lead a second phase of change of the mental health care, which was evidence-based: no key technical reports were published nor was an action plan based on data developed. Currently, the 1985 community mental health model is still the general framework of mental health care with the addition of aspects related to the recovery model and the balance of care model. Significant progress has been made in developing care systems assessment methods and data-based models that could advance mental health planning. The gap between general health attention and mental health care has increased and the expected reform of the mental health system will not take place in the near future.El cambio efectivo de la salud mental en España se inició en 1985 con el Informe de la Comisión Ministe-rial para la Reforma Psiquiátrica, que recomendaba integrar la asistencia psiquiátrica dentro de sistema sanitario general, proveer una atención integral en el entorno del paciente y atender a grupos diagnósticos específicos. El Informe SESPAS 2002 analizó la reforma y recomendó crear una comisión ministerial permanente, diseñar un mapa nacional de servicios sociosanitarios de salud mental, crear una agencia de coordinación y de promoción de la salud mental, y analizar la financiación de los recursos y la investigación. Desde 2004, el Comité Técnico de la Estrategia de Salud Mental impulsó la elaboración de un marco teórico y normativo que desafortunadamente no se siguió de una hoja de ruta para la mejora del sistema. Después de 2011, el impulso inicial se disipó y el Ministerio de Sanidad declinó liderar la transformación del sistema partiendo de la evidencia informada. Actualmente, el modelo de salud mental comunitaria de1985 sigue vigente con la adición de algunas mejoras derivadas del modelo de la recuperación (Recovery) y en línea con el modelo del equilibrio de la atención (Balance of care). Asimismo, se ha avanzado en el desarrollo de métodos de evaluación de sistemas y de modelación basada en datos. Sin embargo, la brecha entre la atención general y la de salud mental ha vuelto a aumentar y no se ha avanzado en el desarrollo de una nueva estrategia de salud mental en España.© 2020 SESPAS. Publicado por Elsevier España, S.L.U

Use of a decision support system for benchmarking analysis and organizational improvement of regional mental health care:Efficiency, stability and entropy assessment of the mental health ecosystem of Gipuzkoa (Basque Country, Spain)

Decision support systems are appropriate tools for guiding policymaking processes, especially in mental health (MH), where care provision should be delivered in a balanced and integrated way. This study aims to develop an analytical process for (i) assessing the performance of an MH ecosystem and (ii) identifying benchmark and target-for-improvement catchment areas. MH provision (inpatient, day and outpatient types of care) was analysed in the Mental Health Network of Gipuzkoa (Osakidetza, Basque Country, Spain) using a decision support system that integrated data envelopment analysis, Monte Carlo simulation and artificial intelligence. The unit of analysis was the 13 catchment areas defined by a reference MH centre. MH ecosystem performance was assessed by the following indicators: relative technical efficiency, stability and entropy to guide organizational interventions. Globally, the MH system of Gipuzkoa showed high efficiency scores in each main type of care (inpatient, day and outpatient), but it can be considered unstable (small changes can have relevant impacts on MH provision and performance). Both benchmark and target-for-improvement areas were identified and described. This article provides a guide for evidence-informed decision-making and policy design to improve the continuity of MH care after inpatient discharges. The findings show that it is crucial to design interventions and strategies (i) considering the characteristics of the area to be improved and (ii) assessing the potential impact on the performance of the global MH care ecosystem. For performance improvement, it is recommended to reduce admissions and readmissions for inpatient care, increase workforce capacity and utilization of day care services and increase the availability of outpatient care services

Modelling the balance of care:Impact of an evidence-informed policy on a mental health ecosystem

Major efforts worldwide have been made to provide balanced Mental Health (MH) care. Any integrated MH ecosystem includes hospital and community-based care, highlighting the role of outpatient care in reducing relapses and readmissions. This study aimed (i) to identify potential expert-based causal relationships between inpatient and outpatient care variables, (ii) to assess them by using statistical procedures, and finally (iii) to assess the potential impact of a specific policy enhancing the MH care balance on real ecosystem performance. Causal relationships (Bayesian network) between inpatient and outpatient care variables were defined by expert knowledge and confirmed by using multivariate linear regression (generalized least squares). Based on the Bayesian network and regression results, a decision support system that combines data envelopment analysis, Monte Carlo simulation and fuzzy inference was used to assess the potential impact of the designed policy. As expected, there were strong statistical relationships between outpatient and inpatient care variables, which preliminarily confirmed their potential and a priori causal nature. The global impact of the proposed policy on the ecosystem was positive in terms of efficiency assessment, stability and entropy. To the best of our knowledge, this is the first study that formalized expert-based causal relationships between inpatient and outpatient care variables. These relationships, structured by a Bayesian network, can be used for designing evidence-informed policies trying to balance MH care provision. By integrating causal models and statistical analysis, decision support systems are useful tools to support evidence-informed planning and decision making, as they allow us to predict the potential impact of specific policies on the ecosystem prior to its real application, reducing the risk and considering the population’s needs and scientific findings

Bulimia Nervosa, Borderline Personality Disorder, and Executive Functions: Treatment and Follow-up in a Case Study

This study describes the clinical case of a 20-year-old woman diagnosed with bulimia nervosa (BN), borderline personality disorder (BPD), and impaired executive functioning. The objectives were to: 1) Determine the efficacy of cognitive-behavioral therapy (CBT) and dialectic behavioral therapy (DBT) in a case of BN and BPD comorbidity, evaluating the improvement of specific parameters related to eating disorders (BN) and aspects of BPD after treatment (posttreatment) and at 1-year follow-up; and 2) Determine whether the psychological intervention of choice for BN and BPD is also of benefit for alteration of executive functions. She was assessed at three time points: pretreatment, posttreatment, and at 12-month follow-up. The instruments used were EDI-3, SCL-90-R, MCMI-III, ring test, and WCST. CBT and DBT were applied for 11 months. The results at 1-year follow-up showed a decrease in the characteristic symptomatology of BN and BPD, whereas executive functioning impairments did not show any improvement. It was concluded that a specific unit on neuropsychological rehabilitation must be included in the treatment protocol for patients with these characteristics. However, more research is still necessary to provide an answer to the open debate on whether alterations of executive functions are previous to or consequences of ED