Introduction – There is a need to develop composite indicators to monitor mental health care in countries such as Spain, where there is wide variability of care systems in 17 different regions. The aim of this study is to generate and to test the usability of synthetic indexes in Andalusia (Southern Spain). Method – Seven mental health indicators were selected by expert opinion from a previous list of simple indicators used to compare mental health care systems across Spain (Psicost-74). A Geographical Information Systems (GIS) was used to delineate 71 sectors based on the catchment areas of the mental health centers in Andalusia. Synthetic indexes were obtained through linear combinations of simple indicators via Principal Components Analysis (PCA), using activity data from the Mental Health Information System of Andalusia (SISMA). Maps of these indexes were drawn for 71 catchment areas. Results – Two synthetic indexes were obtained and showed high consistency in the PCA. The Care Load Index (component 1) related to population size and total outpatient care provided within the area. The Case Load Index (component 2) related to assisted morbidity in relation to the population size. The care load index was higher in populated urban areas, whereas the case load was higher in rural areas. Discussion – Care and case load indexes show a different pattern in urban and rural areas. This may be related to a different underlying model of care related to the degree of urbanisation. Geographical Information Systems (GIS) improved recognition and assessment of the spatial phenomena related to the mental health care system, and support policy decision making process in mental health.

Declaration of Interest: None.

To what extent does previous and existing health economics research directly address key health system financing issues facing mental health services in developing countries? By mapping WHO's health systems framework onto mental health, three key financing questions for mental health are identified: the sufficiency of resources for mental health; the protection of individuals or households against the economic consequences of mental ill-health; and the efficient use of available resources for mental health. Research efforts to date have mainly focused on the evaluation of intervention costs in relation to mental health outcomes (the efficiency question). There is a need to achieve a greater balance between economic analysis (aimed at identifying best buys) versus financial planning (scaling up the delivery or implementation of interventions shown to be cost-effective). In addition, a better understanding and clearer articulation of the negative impact of mental disorders at the household level is needed, together with ways of alleviating financial burden via appropriate and affordable pre-payment financing mechanisms.

Aims - A systematic review of the studies on use of alternative and complementary medicine by mental health services' users to investigate the prevalence and motivations of CAM used to treat mental disorders. Methods - This paper shows a part of the results of a literature review, limited to studies between 1966 and 2005, was carried out using Ovid Medline, PsycINFO and EBM Reviews databases. This was supplemented by hand searching of reference lists. Results - Ninety-one studies on CAM's use by psychiatric patients were analyzed. In this paper the twenty-five articles about the CAM's prevalence and use's motivations are described. The use of complementary and alternative medicine (CAM) varies across countries: data suggest that from 50% to 80% of people suffering of mental disorders use CAM. Heterogeneous methods, samples and results characterizing the studies make generalizations results difficult. Patients motivations of CAM's use were poorly investigated by research, however it seems that persons affected by mental disorders use MAC prevalently because they are dissatisfied with conventional medicine and/or because these alternatives approaches are congruent with their own values, beliefs and philosophical orientation toward health care. Conclusions - The review emphasize the importance of a best physicians' education and information about CAM to improve the management of non-conventional and orthodox medicine relationship. The motivations of CAM's use underline the relevance of patient's holistic conception and the therapeutic role of a patient-physician relationship based on emphaty. Besides it seems important to investigate furtherly patients' psychological and social aspects that influence their choise to use CAM.

Aims – To evaluate the quality of psychiatric care during the acute psychotic episode and the early post-acute period. Methods – Data concerning 24 indicators, drawn from NICE recommendations, were collected in 19 Departments of Mental Health, in the frame of the SIEP-DIRECT's Project to evaluate the implementation of NICE recommendations in Italian Mental Health Services. Results – The treatment of the acute episode in the Italian Mental Health Services is not based only on admissions in Psychiatric Ward in General Hospitals, but also on intensive home based care. The utilization of day hospital facilities for treating acute episodes is less frequent, as the presence of home based follow up after discharge. About of Departments of Mental Health did not have clinical guidelines concerning the pharmacological treatment in this area. However usually the standard practices followed NICE recommendations in terms of prescribed dosages, monitoring side effects and rationale for shifting to atypical antipsychotic drugs. Antipsychotic drugs, atypical or conventional, were frequently prescribed concurrently, while utilization of atypical antipsychotic drugs was increasing. Conclusions – The results show critical points concerning on one hand the scarce diffusion of clinical guidelines, on other hand the connection between standard practices, clinical guidelines and marketing of atypical antipsychotic drugs. It should be reinforced the role of the community and particularly at service level the capacity of community mental health teams to treat the acute patients.

Declaration of Interest: none.

Aim – To review studies conducted to establish the risk of spontaneous abortion (SA) in women exposed to anti-depressant drugs (ADs) during early pregnancy. Methods – By using different search terms, PubMed, Toxline, EMBASE, PsychINFO, and the Cochrane library databases were searched from January 1980 to March 2008, to identify studies assessing the risk of SA in women exposed to different classes of ADs during the first trimester of pregnancy. Results – Ten studies over 21 identified were selected for the analysis. All were performed prospectively and included as control group unexposed women, or exposed to non-teratogenic drugs or to placebo. In seven studies a depressive episode was specified as the reason for which the drug was prescribed, while the time of exposure was in nine. Conclusions – Only three studies over ten selected reported a significant association between an increased rate of SAs and early pregnancy exposure to some ADs. Many methodological flaws in the study design were found in all studies considered. Given this background and a lack of strong evidence on this issue, further prospective and better designed studies are needed to assess the risk of SA in pregnant women exposed to ADs against the risk of an untreated maternal depression.

Declaration of Interest: None.

Although long-acting antipsychotics are widely used in individuals with psychotic disorders, it is unclear which long-acting preparation should be considered as first-line treatment in clinical practice. In this commentary, the main strengths and weaknesses of a recently published pragmatic randomised study comparing long-acting paliperidone palmitate v. long-acting haloperidol decanoate are briefly analysed.

Activation likelihood estimation (ALE) meta-analyses allow investigators to integrate the results of multiple neuroimaging studies, potentially yielding novel results that may not have been evident in the individual studies. Here, we provide a brief, introductory description of ALE methods for readers without extensive expertise in neuroimaging.

Objective – The assessment of outcome for any purpose is not undertaken routinely in European mental health services. This paper discusses the merits of using outcome data to inform the planning of mental health care for individual patients, and provides practical advice to support the implementation of this new approach to working. Method – The use of outcomes in North America and Europe is briefly reviewed. A conceptual basis is proposed for routine outcome assessment – the ongoing measurement and use of outcome data to inform decisions about whether to continue, change or curtail treatment. A cognitive psychology model is developed which indicates that the routine use of outcomes will improve mental health care. Perceived problems with routine outcome assessment are discussed, and principles for implementation are identified. Results – Outcomes are used mainly for generating local-level (rather than patient-level) data in North America, and rarely used in Europe. The use of outcome data routinely may facilitate reflective clinical practice, a model of decision-making which leads to a higher quality of clinical care than automated problem-solving. One issue relates to the use of standardised assessments designed for research purposes in clinical settings, and this is being addressed through the development of a new generation of outcome measures which are explicitly designed for clinical use. However, most clinicians remain unconvinced of the benefits of routine outcome assessment, and relevant research is currently underway across Europe which will address this concern. Scientific principles to maximise quality and pragmatic principles to maximise the chances of successful implementation are identified. Conclusions – The routine use of outcomes will become increasingly prominent in European mental health services. This provides clinicians with an opportunity to improve the quality of clinical care offered to patients.

Aims – To date only a few studies investigated the clinical reasons supporting and explaining non-classical antipsychotic prescriptions. The present study was carried out to develop concepts which help understand this phenomenon in a natural setting, giving emphasis to views of clinicians according to quali – quantitative research methodologies. Subjects – From the South-Verona Psychiatric Case Register all antipsychotic prescriptions issued during 2005 were extracted. Concurrent prescribing of two or more antipsychotics, prescribing antipsychotic drugs outside the licensed indications, and outside the licensed ranges of doses reported in the Italian National Formulary, were considered non-classical prescriptions. Reasons for non-classical prescriptions were collected by means of brainstorming sessions with clinicians. Non-classical prescriptions and the corresponding reasons were grouped according to whether they were “clinically sound” or “clinically not sound”. Results – During 2005 a total of 259 patients received 376 non-classical prescriptions. The most frequently reported reasons for non-classical prescribing were that prescriptions were inherited from another clinician with or without benefit, and that prescriptions were motivated by the need of reducing psychotic symptoms. More than 60% of these non-classical prescriptions were categorised as “clinically sound”. Clinically not sound prescriptions were related with negative clinicians’ views and opinions about the patient/clinician relationship. Conclusion – Clinically not sound prescriptions appeared just a reflection of a problematic doctor/patient relationship, where no individual treatment plan existed and psychiatric visits had the only goal of monitoring ongoing prescriptions.

Declaration of Interest: This study received no funding. We have no conflicts of interest.

Effective health information systems are essential to the delivery of high-quality community-based care for chronic disease which will be needed to address the changing healthcare needs of populations in low and middle-income country settings. Health management information systems (health service data collected at facility level) and electronic health records (data organised by individual patients) may support the measurement-based, collaborative approach that is central to the chronic care model, which has been adopted as the basis for task-shared models of care for mental health and non-communicable disease. We used the performance of routine information systems management to guide our commentary on the evidence-base about information systems to support chronic care. We found that, despite an appetite for using the information to support decision-making around service planning, this rarely happens in practice, reasons include that data is not perceived to be of good quality or fit for purpose. There is often a mismatch between technology design and the availability of specialised knowledge and infrastructure. However, when data collection is designed in collaboration with local stakeholders, there is some evidence of success, demonstrated by completion and accuracy of data forms. Whilst there are global targets for the development of health information systems and progress on these is undoubtedly being made, indicators for chronic disease are seldom prioritised by national governments and there is insufficient decentralisation to facilitate local data-driven decision-making. Our recommendations for future research and development, therefore, focus upon the need to integrate context into the design of information systems: through building strong multisectoral partnerships, ensuring newly developed indicators are well aligned to service models and using technology that is a good fit with local infrastructure. This approach will be necessary if information systems are to deliver on their potential to drive improvements in care for chronic disease.