This paper examines the sociomaterial dynamics of mental healthcare by following metaphors circulating among voluntary sector providers that they were becoming 'dumping grounds' within a system in crisis. In the United Kingdom, the voluntary sector has long been called upon to deliver flexible, community-based care that reduces pressure on primary and secondary services. Under chronic conditions of austerity, however, providers have been stretched beyond their capacity. Drawing on ethnographic research across three voluntary sector mental health sites in inner-city London, I analyse how providers made and maintained places of care while grappling with expanding and shifting demands. Taking a sociomaterial approach, I propose the analytic concept of 'threshold work' to complicate the dumping metaphor and to reconceptualise how material thresholds of place and immaterial thresholds of mental health need are co-constituted with care practices. I identify three interrelated modes of threshold work through which providers manage the limits of inclusion, revealing how diagnostic boundaries of need and spatial arrangements of care move together, shaping the terms and conditions of care in the city.
International journal of mental health nursingEuan Donley
For several decades crisis assessment and treatment teams (CATTs) have been an integral part of community mental health treatment. Since their implementation, however, there has been a significant shift in demand and complexity for the general community requiring acute mental health response. This change coincides with a worldwide mental health workforce shortage and a need to utilise more novice clinicians. This study aimed to examine any change in workload and complexity for the population the CATTs support. A total of 100 files were audited over a 7-year period examining caseload and scenarios associated with complexity in health. After coding, a clinically inspired formula was developed utilising theoretical principles to produce a total complexity score and examine any changes. Findings reveal that caseloads have increased, along with the level of complexity according to the formula index and risk CATTs respond to. With the likely limitation of increased resources through additional mental health clinicians, organisations need to consider how to support emerging clinicians-and the senior clinicians who might support them-while balancing increased caseload and complexity. The use of specialist consultants and relevant training may ease this burden while supporting people experiencing a mental health crisis. The complexity index may also be a useful starting point for measuring CATT complexity.
International journal of mental health nursingSamuel Ndoro, Guillermo Perez Algorta, Caroline Swarbrick
The significance of community mental health workers in coordinating hospital discharge of patients with diagnosed mental health conditions is globally recognised, yet research on their experiences is scarce. This study contributes to knowledge through a qualitative empirical intrinsic case study of community mental health workers' experiences. This study aimed to explore community mental health workers' experiences of care-coordinating patients diagnosed with mental health conditions discharged from the hospital into community mental health integrated services. Guided by constructivist inquiry, the qualitative study focused on co-constructing meaning to understand community mental health workers' experiences in care coordination. Two theoretical lenses informed the study: Ecological Systems Theory, to understand multi-level influences, and Normalisation Process Theory, to explore how care coordination practices are embedded in discharge processes. Fourteen community mental health workers aged 18 and above were recruited from one NHS Trust in Northwest England from October 2021 to June 2022. Data were collected through semi-structured interviews, audio-recorded, transcribed verbatim, and analysed using reflective thematic analysis, generating themes and subthemes. Analysis identified 13 subthemes grouped into four major themes: (1) Experiences of collaborative working; (2) Challenges and enablers to care coordination; (3) Experiences of organisational system and culture; and (4) Community Mental Health Workers' personal experiences of professional growth. Findings highlight poor communication, staff shortages, high caseloads, limited community mental health services, and challenges in care coordination. The study provides valuable insights for improving community mental health workers' clinical practice and informs future research and policy development in community mental health care.
Health expectations : an international journal of public participation in health care and health policyKarishma Jivraj, Iris Gault, Mary Chambers
BACKGROUND: A fundamental barrier to effective recovery outcomes for psychosis, is the lack of involvement of service users (SUs) in decisions made about their care. Despite policy recommendations, implementation of shared decision-making (SDM) is inconsistent, under-reported in mental health practice and thus requires further attention. This research aimed to explore SU and clinician experiences of SDM in community mental health care. DESIGN: Qualitative data from a cross-sectional mixed-method study is presented. A purposive sample of 18 participants (10 SUs experiencing psychosis, 8 psychiatrists) from one NHS community mental health service, took part in semi-structured interviews which underwent reflexive thematic analysis. RESULTS: Participants acknowledged SDM as integral to consultations, with overlaps and disparities in SU and clinician perceptions of the reality in practice. Three themes are reported: (1) knowledge and capacity for SDM, (2) relational dynamics; power and communication in SDM and (3) evaluating the realities of SDM in practice. SUs reported they needed to be in the right frame of mind while clinicians acknowledged they were struggling and it wasn't easy to take medication. SUs also wanted to be more engaged in decisions about their care, involving others in the process, with further clarification about options, and alluded to power asymmetry. Clinicians and SUs stressed that structural pressures (concerning time and resources) limited explanation of treatment options and clinicians reflected on stigma they faced. They questioned if SUs experienced the service they thought they were providing. DISCUSSION: SU and clinician perceptions often overlapped but at times misaligned, suggesting inconsistency in practicing SDM. Implications for practitioners and policy makers include revisiting how SDM is used in practice, with adequate structural and resource provision, potentially involving others to bridge the gap between experiential and medical knowledge. Limitations are reflected on, however, this research emphasises the importance of consistent use of SDM in community mental health. PATIENT OR PUBLIC CONTRIBUTION: Service users, academics, and clinicians from the Centre for Public Engagement, Kingston University participated in the research design, development of study materials and data analyses. The study would not be possible without this involvement.
Bundesgesundheitsblatt, Gesundheitsforschung, GesundheitsschutzMartin Lambert, Anja Zimmermann, Jürgen Gallinat
Severe mental illness (SMI) is associated with chronic courses, significant functional impairments, and increased mortality. At the same time, care for this population is characterized by fragmentation, lack of continuity, and insufficient coordination. Against this background, patient navigation has gained importance as an approach to improving the quality and efficiency of care. The aim of this narrative review is to present key evidence-based models of care for individuals with SMI, to analyze structural challenges in service provision, and to derive principles for effective patient navigation.The evidence shows that community-based, multidisciplinary, and continuous care approaches-such as assertive community treatment, crisis intervention, and early intervention programs-can improve clinical and functional outcomes, reduce hospitalizations, and enhance continuity of care. At the same time, it becomes clear that the isolated implementation of individual intervention models is insufficient to sustainably address structural deficits.Integrated and stepped care models enable the systematic linkage of evidence-based interventions along a continuous care pathway. Current findings indicate that such approaches can improve quality of care while being implementable without additional costs and may even generate cost savings. Patient navigation thus represents a key strategy to strengthen continuity of care, reduce fragmentation, and sustainably improve patient outcomes as well as resource efficiency.
PloS oneOpeyemi Atanda, Paula Reavey, Ben Wong, Ebony Baker, Jessica Collier, Thilipan Thaventhiran, Veronika Dobler, Ruth Woolhouse, Toby Zundel, Joe Clacey, Jovanka …
BACKGROUND: The quality of healthcare delivery relies heavily on building strong relationships between healthcare providers (HCPs) and clients. This study presents the results of a process evaluation for a Randomised Controlled Trial (RCT) examining the effectiveness of Intensive Community Care Service (ICCS) vs Treatment as Usual (TAU; inpatient or core community CAMHS). METHODS: Thirty-four semi-structured interviews were conducted with staff across various services, including 20 from ICCS and 14 other TAU services. A thematic decomposition analysis was conducted on the data, and specific themes relevant to staff experiences of young people's engagement with services and overall recovery. RESULTS: Three main themes were observed in the HCP data (1. Relational Ecologies: barriers and enablers to engagement, 2. flexibility of approach amidst systemic pressures and 3. the web of trust in the relationship-building process). HCPs highlighted the necessity of developing trust and rapport through non-clinical engagement strategies, such as informal visits and personalised interactions. HCPs emphasised that without trust, treatment effectiveness diminishes, necessitating a tailored approach rather than a one-size-fits-all model. The flexibility in duration of treatment and methods of engagement was noted as crucial in accommodating individual client needs and fostering an open, trusting environment necessary for long-term recovery. CONCLUSION: The findings highlight the vital importance of relational care models, especially ICCS, in addressing the complex needs of Children and Young People (CYP). Flexible, family-centred approaches improve trust, engagement, and long-term recovery outcomes. Recommendations include tackling systemic barriers and expanding relational care models within CAMHS to meet increasing mental health demands effectively. Further research should investigate scalable strategies for integrating these insights into wider mental health service frameworks.
JAMA health forumRuoxi Ding, Miaomiao Zhao, Yanshang Wang, Yiqi Xia, Xiaolong Guan, Zhenyu Shi, Ping He
IMPORTANCE: Schizophrenia imposes a substantial disease burden in resource-constrained settings such as China, yet rigorous evidence on the cost-effectiveness of community-based rehabilitation (CBR) remains limited. OBJECTIVE: To evaluate the cost-effectiveness of a group-based CBR intervention plus facility-based care (FBC) compared with FBC alone for adults with schizophrenia in China. DESIGN, SETTING, AND PARTICIPANTS: This prespecified secondary analysis evaluated a cluster randomized trial conducted across 18 urban and rural subdistricts in Weifang, Shandong Province, China, from March 2023 to October 2024. Participants were community-dwelling, clinically stable adults aged 18 to 59 years with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis of schizophrenia and illness duration of at least 12 months. INTERVENTION: The CBR program comprised 18 group sessions over 12 months (12 biweekly sessions, then 6 monthly sessions) covering psychoeducation, medication adherence, physical health promotion (including tai chi), life and social skills training, and caregiver support. FBC consisted of psychiatrist-led medication management and monthly consultations. MAIN OUTCOMES AND MEASURES: The main outcomes were incremental cost per quality-adjusted life-year (QALY) gained and per-unit improvement in symptom severity (Positive and Negative Syndrome Scale [PANSS]), social functioning (Personal and Social Performance Scale [PSP]), and caregiver burden (Burden Assessment Scale [BAS]), assessed from health care system, multipayer, and societal perspectives. RESULTS: A total of 334 participants were enrolled and randomized; 172 were randomized to CBR plus FBC and 162 to FBC alone. At 12 months, 161 participants (93.6%) and 154 participants (95.0%) were retained, respectively. Mean (SD) baseline age was 46.7 (9.3) years; 180 participants (53.9%) were male; 204 (61.1%) resided in rural areas. CBR was associated with significantly improved clinical outcomes and lower costs at 12 months. Incremental cost-effectiveness ratios indicated savings of $24 636 to $27 847 per QALY gained across perspectives, with $20.70 to $46.90 saved per unit improvement in PANSS, PSP, and BAS scores. The probability of cost-effectiveness ranged from 91.0% to 98.7% for QALYs and exceeded 95% for clinical outcomes at derived threshold values of $24.30 to $52.00 per unit. Sensitivity analyses confirmed robustness. CONCLUSIONS AND RELEVANCE: In this secondary analysis of a cluster randomized trial, group-based CBR for schizophrenia in China was associated with improved outcomes and a high probability of cost savings, supporting its scaled implementation in resource-constrained settings. TRIAL REGISTRATION: ChiCTR.org.cn Identifier: ChiCTR2200066945.
The Indian journal of medical researchJohnson-Pradeep Ruben, Supriya Shivashankar, Ramakrishna Goud Bhooma Goud, Aishwarya G V, Rajani Parthasarathy, Srinivasa G A, Girish Kumar, Prem Kumar Mony, S…
Background and objectives Accredited social health activists (ASHAs) play a key role in community mental health services in Karnataka; however, evidence on training interventions has not been systematically reviewed. We aimed to systematically synthesise evidence on mental health training interventions for ASHAs in Karnataka, focusing on provider competencies and service delivery outcomes. Methods Systematic search of databases, trial registries, and grey literature (October 2025-January 2026) included studies published between 2000 and 2025. Eligible studies involved ASHAs in Karnataka and evaluated mental health training interventions with outcomes related to provider competencies or service delivery. Due to heterogeneity, findings were synthesised narratively using SWiM guidelines for quantitative studies and GRADE-CERQual for qualitative. The risk of bias was assessed using RoB 2, ROBINS-I (v2), MMAT, and CASP. Results Of 648 records screened, 13 studies comprising 567 ASHAs met the inclusion criteria. Narrative synthesis showed improved provider competencies and service delivery outcomes from quantitative studies, while qualitative studies revealed moderate confidence. Overall, risk of bias was judged as 'low to some concerns'. Digital and hybrid models showed more sustained gains than standalone in-person training. Selected service delivery outcomes, including screening coverage, home visits and supervisory engagement, improved with structured support. However, the evidence was limited by pre-post designs, small sample size, reliance on self-reported outcomes, and heterogeneity in interventions and outcome measures. Interpretation and conclusion Structured training may improve ASHAs' mental health provider competencies and service delivery. Digital and hybrid models are promising, but evidence remains limited, highlighting the need for rigorous studies with standardised outcomes and long-term follow up.
Health expectations : an international journal of public participation in health care and health policySharon Lawn, Tessa-May Zirnsak, T J Spencer, Elaine Waddell, Jane Fischer, Tarmia Klass, Puneet Sansanwal, Edwina T Light, Vrinda Edan, Chris Maylea, Penelope …
BACKGROUND: Community Treatment Orders (CTOs) are contested practices in mental healthcare due to unresolved evidence of effectiveness and persistent human rights concerns. Despite this, Australia has high rates of CTO use internationally. Research from a lived and living experience (LLE) perspective remains limited. METHODS: This mixed methods research explored experiences of people with LLE of mental ill-health and being on a CTO ('consumers'). An online survey including Likert-rated, categorical and open-ended questions was disseminated across Australia in 2024 to consumers aged 18 years or over. Quantitative data were reported descriptively, and qualitative data were analysed using Latent Content Analysis. RESULTS: Forty-three people completed the survey; most identified as female (86%); 51.2% were aged 30-49 years; 7.2% were currently on a CTO; 40.5% had been on a CTO in the past 1-5 years; and 45.2% had been on a CTO more than once. Automated data contamination ('bot') infiltration hampered inclusion of further data. Participant responses included: (1) experiences prior to being on a CTO; (2) experiences whilst on a CTO; (3) attitudes towards CTOs; (4) family involvement; and (5) views on mental health services. While some consumers reported experiencing positive care, many rejected use of CTOs, reporting coercion, exclusion from decision-making and information, lack of alternative support options, and lack of compassion. CONCLUSIONS: Policy and practice reforms, including focus on recovery and human rights, appear to have failed to improve experiences of CTOs. Further work to close the policy-practice gap and translate policy into more inclusive, human rights-based care is indicated. LIVED EXPERIENCE OR PUBLIC CONTRIBUTIONS: This project has included considerable involvement and community engagement with people with lived and living experience ('LLE') of CTOs and/or mental health service use in all phases of the project. The project includes two Chief Investigators who identify as LLE leaders and researchers (VE and SL), and who have direct lived experience of CTOs, or as a family/caregiver of individuals who have direct lived experience of CTOs. The project manager (TZ) and some project staff (TS, TK, and PS) are LLE researchers, and the project is guided by a Lived Experience Advisory Panel (LEAP) with LLE experience of CTOs, including both service users and family/caregivers. We also have LLE experts on our project's international advisory panel. Together, their contributions have been vital in the project team's open and transparent reflections on their diverse perspectives and positioning which have grounded the project's focus on LLE perspectives.
Hu li za zhi The journal of nursingJhe-Jun Wu, Hsin-Pei Feng, Kai-Jo Chiang, Wen-Chii Tzeng
Mental health recovery, a core concept in contemporary mental health care, emphasizes that service users can pursue meaningful life goals by rebuilding hope, identity, and purpose even as related symptoms persist. As care has shifted from a biomedical focus on symptom control toward person-centered and community-oriented approaches, the mental health recovery process has presented challenges to traditional nursing roles and practices. Moreover, misperceptions of these approaches as psychiatric rehabilitation or illness management interventions have led to gaps between principles and practice. In this article, the relevant literature is reviewed to describe the meaning of recovery and its influencing factors, and measurement tools widely used to support nurses' understanding of recovery processes are summarized. In addition, the authors integrate their practical experiences in community psychiatric rehabilitation to reflect on challenges related to role positioning, intervention flexibility, and organizational support when implementing recovery-oriented care in practice.
Journal of community psychologyEmily Birdy, Christian Ryan, Clodagh Butler
Crisis helplines are a core component of community-based mental health support, yet volunteers' experiences of emotional labour, ethical responsibility, and role identity remain underexplored. This study aimed to examine how crisis helpline volunteers experience and make sense of their roles within contemporary service contexts. Semi-structured interviews were conducted with nine crisis helpline volunteers in Ireland. Data were analysed using inductive reflexive thematic analysis. The findings indicated that crisis helpline volunteering involves sustained emotional labour, ethical and risk-related uncertainty, and complex organisational ambiguity and demands. Volunteers described drawing on personal, relational, and supervisory coping strategies to manage emotional exposure, while developing a strong sense of purpose and helper identity. However, experiences of strain, vulnerability, and unrecognised professionalism were also evident, particularly in contexts characterised by inconsistent support and role ambiguity. Findings highlight the importance of supporting volunteer wellbeing across individual, relational, organisational, and systemic levels to sustain effective community-based crisis helpline services.
International journal of mental health nursingSuyoun Ahn, Eunmi Hwang
As community mental health services expand in scope and responsibility, mental health nurses are playing a central role in delivering integrated, recovery-oriented care. However, they face substantial challenges in adapting to community practice and sustaining professional development. Clinical supervision can mitigate these demands through its formative, normative, restorative functions. This study explored the supervision experiences of community mental health nurse specialists in South Korea to provide evidence for specifying the effective functions and operational systems of supervision using an exploratory qualitative design. Twelve community mental health nurse specialists participated in three focus group interviews conducted between June 2024 and July 2025. Data were analysed using reflexive thematic analysis. Four themes and 10 subthemes were generated: translating community mental health ideals into professional practice; serving as an anchor in unfamiliar terrain; supervision undermined by superficiality and disrespect; and competency development constrained by structural barriers. Supervision was perceived as a critical space for clarifying clinical direction, regulating emotional involvement and supporting professional adaptation. However, formalistic delivery and structural constraints limited its impact. These findings highlight the need for integrated and systematic supervision approaches aligned with the community mental health paradigm, supported by organisational and policy commitments to protected time, staffing, education and financial resources. Strengthening supervision under such conditions may enhance practitioner development and service user outcomes.
PloS oneRainer Mere, Merike Sisask, Peeter Värnik, Chantal Van Audenhove
BACKGROUND: Process evaluations are essential for understanding how community mental health interventions are implemented and why they succeed or fail. While numerous theoretical frameworks exist to guide such evaluations, the landscape of framework use in mental health contexts remains uncharted, limiting methodological guidance for researchers and practitioners. METHODS: Scoping review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Systematic searches of three databases (PubMed, Web of Science, EBSCOhost) identified 1,143 records, from which process evaluations of community mental health interventions published between 2006 and 2025 were selected. Data extraction captured framework characteristics, study context, and methodological features. Frameworks were inductively categorized into a hierarchical typology based on theoretical orientation and stated function. RESULTS: Eighty-three studies met inclusion criteria, employing 54 distinct primary frameworks organized into 14 categories. Implementation science frameworks dominated (39.8%), followed by process evaluation-specific frameworks (8.4%), behavior change theories (8.4%), and participatory approaches (6.0%). A marked temporal shift was observed: participatory and community-based frameworks characterized early publications (23.8% in 2006-2015) but were absent as primary frameworks after 2015, while implementation science frameworks rose from 14.3% to over 50% of studies. Geographic concentration in North America (54.2%) and high-income countries (83.1%) was pronounced. CONCLUSIONS: The field has undergone a paradigm shift from community-engaged to systematized evaluation approaches. While framework consolidation offers methodological consistency, the decline of participatory approaches raises questions about the role of community voice in evaluation design. We propose a typology to guide framework selection and identify priorities for methodological development in community mental health process evaluation.
PloS oneNatthapon Inta, Annmarie Grealish, Mary Leamy
INTRODUCTION: Strong community-based services and healthcare providers with a clear understanding and positive attitudes towards recovery, are central to delivering good quality mental health care in collaboration with service users. Although recovery has been explored in several Asian contexts, its interpretation remains diverse, and consensus on the definition and meaning of personal recovery in Thailand is limited. Further research is needed to explore how mental health service users, carers, and healthcare professionals understand and experience recovery and recovery support, in order to advance recovery-oriented practice within the local sociocultural context. AIM: To explore thoughts, perceptions, and experiences of mental health service users, carers, and healthcare professionals on mental health recovery and recovery support in Thailand. METHODS: A qualitative descriptive study using reflexive thematic analysis, which forms the experience gathering phase of an Experience Based Co-Design (EBCD) study. Thirty semi-structured interviews and two feedback workshops with three service users and eight healthcare professionals were conducted. RESULTS: Four themes were identified: (i) conceptions of mental health recovery, (ii) attitudes towards recovery, (iii) characteristics of a successful recovery journey, and (iv) factors impeding recovery. Participants viewed recovery as beginning with clinical and functional improvement, progressing to personal recovery characterised by hope, meaning, and social connectedness. Family support, community acceptance, and supportive healthcare relationships were central to recovery, while barriers operated at individual, family, service, and community levels. CONCLUSION: This study integrates the perspectives of mental health service users, carers, and healthcare professionals to generate new insights into personal recovery within Thai community mental health care. From these findings, we propose a culturally situated Recovery Support Model that foregrounds the interconnected roles of personal agency, family involvement, professional engagement, and community support as drivers of recovery-oriented practice within the Thai mental health system.
Frontiers in public healthFlora Cohen, Kevin Yau, Jane Kennedy, Hayley Saxby, Mozhgan Moarefizadeh
There are over 120 million forcibly displaced people in the world, with numbers steadily increasing. The majority of refugees and asylum seekers are displaced in urban settings with fragmented access to health services, and those living in countries without refugee protections face particularly dire circumstances. High rates of trauma exposure and related mental disorders persist alongside structural barriers to care, underscoring an urgent public health equity challenge. This community case study describes the Cope program, a refugee community-led mental health and psychosocial support (MHPSS) initiative implemented by the Refugees and Asylum Seekers Information Center (RAIC) in Jakarta, Indonesia. Using an apprenticeship model, community members transition from program participants to trained, supervised facilitators across three phases (n = 30 at baseline, n = 16 at endline). Pre- post-assessments using validated measures found significant reductions in depressive symptoms (52%), anxiety symptoms (50%), and Post-traumatic Stress Disorder (PTSD) symptoms (46%) from baseline to endline, with large effect sizes. These findings demonstrate that community-led, culturally grounded MHPSS programming can produce meaningful mental health gains among protractedly displaced populations in non-signatory countries. Beyond individual-level outcomes, the Cope model illustrates how Refugee-Led Organizations (RLOs) can serve as sustainable pillars of inclusive health system delivery-a critical consideration for governments, UNHCR, and global health actors working to advance universal health coverage for displaced populations.
BMC health services researchJo Day, Julia Frost, Alex Stirzaker, Debra Richards, John Gibson, Vanessa Pinfold, Richard Byng
INTRODUCTION: PARTNERS is a model of care that was co-designed with service users and carers to address the needs of people with severe mental illness to receive better support in primary care. Taking learning from a randomised controlled trial and process evaluation of this complex person-centred goal and coaching-based approach to care, our aim was to understand better the challenges of implementing PARTNERS in complex dynamic service delivery systems. METHODS: We identified two Integrated Care Systems that were interested in adopting the PARTNERS model of care. We trained practitioners to adopt PARTNERS to their local settings and provided meta-supervision (supervision of supervisors). We examined the implementation period that covered site engagement, training of staff and initial delivery of the new PARTNERS model of care, undertaking a qualitative realist evaluation informed by the Consolidated Framework for Implementation Research (CFIR). Data collection involved semi-structured interviews with 10 System Change Leads, Supervisors, and trained intervention practitioners or 'Care Partners'; augmented by observations of supervision and practice within the systems and collation of documents. Analysis was qualitative informed by a realist approach and the CFIR. RESULTS: Analysis identified complex overlapping configurations of teams and roles within them, leadership, and individual characteristics influenced the systems' ability to implement the PARTNERS model of care. The presence or absence of leadership was instrumental in providing clarity regarding where the delivery of PARTNERS sat within newly emerging systems and was an important indicator of successful implementation. Collaborative leadership and supervision, alongside training tailored to the needs of individual practitioners, increased or decreased perceived self-efficacy amongst individual practitioners and their confidence in delivering the PARTNERS model of care. CONCLUSIONS: We identified that both internal and external supervision and system leadership are crucial to the implementation of PARTNERS, backed up by training delivered by a clinician and people with lived experience, to ensure that this new model of care is embedded in everyday practice. It is likely that the absence of any one of these mechanisms could make implementation and sustainability of the PARTNERS model challenging. CLINICAL TRIAL NUMBER: Not applicable.
Clozapine is a pharmacological treatment with strong evidence for treatment-resistant schizophrenia (TRS), yet it continues to be under-prescribed, initiated late, and offered to a minority of eligible patients. This treatment gap is felt most acutely in early intervention in psychosis (EIP) services. The accompanying study by Conaty et al. examines the clinico-demographic correlates of community versus hospital clozapine initiation in a first-episode psychosis (FEP) population. Over half of clozapine treated patients were initiated in the community, and this was associated with substantially lower discontinuation rates. This commentary situates those findings within the wider barriers literature in first episode psychosis, considers the emerging role of virtual wards and remote monitoring in facilitating community-based initiation, and outlines implications for service design and future research.
BACKGROUND: Smartphone use has become an indispensable part of modern life. This study examined the associations between smartphone use, loneliness, and perceived social support among adults attending a Community Mental Health Center (CMHC). METHODS: This descriptive, cross-sectional study included 250 outpatients diagnosed with schizophrenia, psychotic disorder, or bipolar disorder. Data were collected between May and August 2023 using the Demographic and Smartphone-Use Questionnaire, the Multidimensional Scale of Perceived Social Support (MSPSS), and the UCLA Loneliness Scale. Descriptive statistics, correlation, and regression analyses were performed. RESULTS: Nearly all participants owned a smartphone (99.6%). Smartphones were used primarily for communication, followed by sharing and entertainment. Most participants reported checking their smartphones fewer than 30 times per day and using them for less than 2 h daily. The mean UCLA Loneliness Scale score was 55.8 ± 14.3, while the mean MSPSS total score was 44.9 ± 15.3. More frequent smartphone checking was associated with lower loneliness and higher perceived social support (p < .001). Loneliness was negatively correlated with perceived social support, with the strongest association observed for friend support. Perceived social support explained 46% of the variance in loneliness. CONCLUSION: Adults receiving community mental health services reported high loneliness and moderate perceived social support. More frequent smartphone use was associated with lower loneliness and higher perceived social support, while social support emerged as an important correlate of loneliness.
Journal of community psychologyTrine Natasja Sindahl, Carsten Stage, Matilde Nisbeth Brøgger
Frequent use of anonymous helplines is often framed as problematic from a service perspective. This study aims to explore how frequent users themselves perceive the helpfulness of repeated helpline contact and to examine tensions between user and staff understandings of effective helpline communication. The study draws on qualitative interviews with 31 frequent users across ten Danish helplines, covering telephone-, chat-, and SMS-based services. The analysis is conducted in dialogue with prior findings on helpline staff's communicative ideals, using a framework distinguishing between transformative, relational, and respectful communication. Frequent users experience helpline interactions as micro-transformative, providing immediate emotional regulation, relief from intrusive thoughts, and temporary containment of loneliness. Relational presence is experienced as meaningful change in the here-and-now. Frequent helpline use is best understood as a situated, relational community practice rather than an individual deficit, with important implications for community-based mental health support.
Early intervention in psychiatryJoséphine Caubel, Donia Bouchiba, Diane Fabre, Albane Mansoux, IJbrand Visser, Laurent Lecardeur
AIM: To develop and describe the implementation and early outcomes of a stepped, transdiagnostic early intervention service (FIPP) for individuals aged 17-30, and to evaluate changes in access, age profile, length of stay, diagnostic mix and community engagement between 2016 and 2024. METHODS: The Jean Wier outpatient centre is part of the public mental health hospital Érasme, which is part of the GHT PsySudParis group in the metropolis of greater Paris (France). Data and surveys showed a treatment gap in service delivery for young people with emerging psychiatric disorders. A comprehensive reorganisation of mental health services was initiated. Developmental aims were training professionals, service establishment and introducing standardised assessment. Evaluation aims were shifts in access, length of stay and diagnostic distribution. RESULTS: The results show an improved healthcare provision by better trained teams, increased community engagement, a diminished average age of service users, a decreased average length of stay and a diagnostic shift in the day-care program (CARE). Duration of untreated psychosis and disengagement have not yet been objectified. CONCLUSIONS: A proactive, structured and collaborative approach in public mental health care can enhance access to early psychiatric care for young adults in France.
Early intervention in psychiatryKevin E K Chai, Elvis Rapoo, Crystal M Y Lee, Peter M McEvoy, Kyran Graham-Schmidt, Daniel Rock, Kim S Betts, Suzanne Robinson, Mathew Coleman
INTRODUCTION: Psychosis is a debilitating condition and prompt treatment is a key prognostic factor. Early intervention services aim to provide timely care, but co-occurring substance use disorders (SUDs) complicate treatment, leading to poorer outcomes. This study examined the clinical journey of individuals with SUD who were subsequently diagnosed with a psychotic disorder, focusing on the interval between diagnoses to understand this issue. METHODS: Patient pathways were constructed using linked health data (2005-2022) from Western Australia for individuals aged ≥ 18 years with a diagnosis of SUD followed by a primary psychotic disorder. Service events across emergency departments (EDs), inpatient and community mental health services were analysed. Descriptive statistics and subgroup analyses examined variations based on the time between diagnoses, sex, remoteness and socioeconomic status. RESULTS: Analysis of 7568 patient pathways revealed a median diagnostic interval of 1.9 years. Initial SUD diagnoses occurred most frequently in inpatient settings (62%), whilst psychoses diagnoses were most common in EDs (46%). Common diagnostic pathways included inpatient to ED (28%) and inpatient to inpatient (24%). Subgroup analyses showed women had a 7-month longer diagnostic interval and six more mental health service events than men. Remoteness and socioeconomic disadvantage correlated with increased diagnosis in inpatient settings and decreased diagnosis in EDs. CONCLUSION: A significant delay between diagnoses is likely associated with poorer outcomes. Integrated service delivery, particularly between EDs and specialised mental health services, is important for early intervention. Patient demographics and geographic location influence diagnostic pathways, suggesting targeted interventions to improve access to prompt, appropriate care.
Information needs among people with dementia and their family carers remain often unmet, despite policy emphasis on information as the key enabler of choice, agency, and empowerment. An intervention to address these unmet information needs was co-designed and implemented in the North-East of England. This study is a realist process evaluation of the intervention's implementation through the local community mental health services for older people. The realist process evaluation drew on three strands of qualitative data: longitudinal interviews with the service manager of the implementing services, longitudinal group interviews with practitioners, and a focus group with the co-design working group. Thematic analysis used a deductive approach to identify implementation outcomes (Reach, Dose, Fidelity & Adaptation, Acceptability, Adoption, Appropriateness, Penetration, Feasibility, Sustainability), followed by a retroductive approach to interpret data through the realist framework of Context, Mechanisms, and Outcomes. Participants showed different strategies for offering the leaflet in clinical practice (Reach), but all appeared to offer it multiple times and at every opportunity (Dose). Some adaptation in implementation was identified. The intervention was successfully integrated into practice (Penetration, Feasibility) and well received by implementers (Acceptability, Adoption). The intervention was perceived as addressing a genuine need and as compatible with the implementation setting (Appropriateness), also in the longer term (Sustainability). Nine levels of contextual factors and eight mechanisms appeared to contribute to the observed outcomes. The study offers an in-depth understanding of how information-giving occurs at the level of the individual practitioner and identifies some variation in information-giving practice. Some participants' approach to information-giving was consistent with a person-centred, relational, and situated approach to care, while others embodied a rational approach to information which did not account for the circumstances of the information recipient. Policy and practice should acknowledge and address this variation to ensure that critical stances on information-giving are widely adopted.
Global health actionRosco Kasujja, Ronald Asiimwe, Barbra Makumbi, Cosmas Goodluck, Mariam Umugwaneza, Ibrahim Luberenga
Lay mental health workers play a central role in implementing and sustaining mental health interventions across East Africa. However, limited research exists on how these workers are trained and supervised, an important gap given their role in addressing the region's severe treatment shortage, where up to 85% of individuals with mental disorders receive little or no evidence-based care. Task-sharing, which involves training non-specialist workers to deliver psychological interventions under supervision, has become a key strategy over the past two decades. Yet, the processes that ensure LMHW competence, fidelity, and wellbeing, particularly training and supervision, remain underexplored. Guided by Arksey and O'Malley's five-stage framework, this scoping review maps and synthesizes literature on training and supervision practices for LMHWs delivering community-based mental health interventions in East Africa. Systematic searches of five databases (Web of Science, Embase, Scopus, PubMed, and ProQuest) yielded records that, after screening and eligibility assessment, resulted in 18 included studies from five of the seven East African countries. Data were charted and thematically analyzed to describe training methods, supervision strategies, outcomes, and implementation challenges. Findings revealed wide variations in training duration and pedagogy, from brief workshops to multi-module or apprenticeship models, and diverse supervision formats, including hierarchical, peer, hybrid, and digital approaches. Evidence showed improvements in client outcomes, provider competence, and service delivery, but highlighted persistent gaps in standardized supervision, sustainability, and workforce support. This review informs policy and implementation efforts to strengthen LMHW training and supervision systems, contributing to narrowing the mental health treatment gap in East Africa.
Frontiers in public healthJosephina Lin, Piper Derenoncourt, Rainelle Walker-White, Nancy Oriol, Daniel Palazuelos, Giuseppe Raviola, Stephanie L Smith, Mollie Williams
Mental health inequities persist in underserved communities due to systemic barriers to care. Healthy Roads, a mental wellness support program developed by the mobile clinic The Family Van, adapted the World Health Organization's Problem Management Plus (PM+) curriculum to address these disparities with support from Partners In Health. PM+ is a brief, evidence-based psychological intervention designed for trained non-specialists to deliver in low-resource settings. This community case study describes the adaptation, implementation, and early lessons learned from delivering PM+ with trained community health workers (CHWs) among racially and linguistically diverse communities in Boston, Massachusetts. Data were collected from 49 participants who engaged in 173 sessions between January 2021 and December 2023. Quantitative outcomes were measured using the Psychological Outcomes Profiles (PSYCHLOPS) tool, alongside qualitative insights from session notes and client feedback. Participants who completed the program experienced a 25.4% reduction in mental health distress 95% CI [13.1, 37.9%], with those attending at least one session experiencing an 11.4% reduction 95% CI [5.8, 17.0%]. This program also demonstrates how community-based mental health initiatives can contribute to broader systems of collaborative learning where frontline providers, participants, community members, and institutional partners jointly adapt and refine program delivery to inform equitable adaptation and dissemination of mental health practices. As the first adaptation of PM + in a community-based mobile clinic in the United States, Healthy Roads offers implementation insights for community health programs on building a mental health workforce reflective of the community, centering community expertise, adapting program delivery for cultural relevance, and ensuring proper staffing to sustain quality care.
Journal of health care for the poor and underservedEvelyn Vázquez, Arianna Zimmer, Martin Pallares Perez, Connie Marmolejo, Muriel Casamayor, Maria Pozar, Laysi Da Silva Zacarias, Ann Cheney
Low-income immigrant communities experience significant trauma and structural health inequities, particularly in mental health access, quality of care, and outcomes. This study evaluates the effects of restorative circles as a community-driven intervention for psychological trauma among low-income Latine and Pre-Columbian Indigenous immigrants in rural California. We conducted three focus groups (N=34), each representing a distinct immigrant community. Findings revealed diverse, community-specific challenges: Relocated immigrants (n=14) reported post-COVID-19 trauma, economic precarity, and the psychological toll of undocumented status. Farmworkers (n=10) identified school violence and substance abuse as key concerns. The Purépecha community (n=10), a Pre-Columbian Indigenous group, highlighted suicidality, mental health stigma, and severe resource scarcity. Across all groups, participants described discrimination and school-based bullying as persistent issues. These findings emphasize the urgent need for culturally responsive, community-based mental health interventions co-developed with rural immigrant populations.
Journal of health care for the poor and underservedKristine Namhee Kwon, Feygele Jacobs, Leighton Ku
Community health centers (CHCs) have significantly expanded behavioral health (BH) and social service delivery in recent years. Using 2020 and 2024 Uniform Data System data and the 2023-2024 Commonwealth Fund CHC Survey data, this study describes trends and challenges in care provision. From 2020 to 2024, CHC BH and social services staffing, utilization, and patient volume increased markedly. Most CHCs offered onsite counseling for mental health (70.4% for long-term, 88.0% for short-term), while substance use disorder services were less common (66.1% onsite, 53.4% telehealth). The BH challenges most often cited by CHCs were provider shortages (66.0%) and BH needs outpacing capacity (64.0%). While over half reported routinely screening for patients' social needs, difficulty connecting patients to services was high-especially for housing (30.3% reported "Extremely difficult"). These findings underscore that CHCs are delivering comprehensive, community-anchored care, but rising behavioral and social needs call for targeted policy and financial support.