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Public mental health: evidenced-based priorities

Este documento destaca aspectos de la salud mental de interés en salud pública según una reunión de profesionales. La prevención primaria (más factible en daño cerebral traumático, depresión por estrés sociolaboral o económico, conductas adictivas en jóvenes y trastornos de incidencia creciente) habría de completarse con prevención secundaria y terciaria. La vigilancia según el esquema de las enfermedades crónicas (estudios de encuestas, publicaciones científicas, etc.) priorizaría la depresión, el suicidio, las adicciones y las patologías del espectro autista, así como los pacientes crónicos complejos. Serian abordajes específicos:

• 1)

  El estudio de diagnósticos al alta hospitalaria y de causas de muerte para trastornos mayores, suicidios, tentativas de suicidio, nuevos pacientes psicóticos y trastornos de personalidad y de conducta alimentaria en adolescentes y jóvenes.

• 2)

  La identificación de una red clínica de salud mental de base poblacional capaz de revelar determinados eventos centinela: ejemplo de Italia.

• 3)

  La realización de encuestas sobre determinadas problemáticas en población asistida.

This document highlights aspects of mental health of interest in Public Health, as identified in a meeting of health professionals. Primary prevention (most feasible in traumatic brain injury, depression induced by socio-occupational or financial stress, addictive behaviours among adolescents and young adults, and disorders in which incidence is on the increase) would have to be completed with secondary and tertiary prevention. Surveillance patterned on that of chronic diseases (survey studies, scientific papers, etc.) would prioritise depression, suicide, addictions, autism spectrum disorders and complex chronic patients. This would entail specific approaches such as:

• 1)

  The study of hospital discharge diagnoses and causes of death for major disorders, suicides, attempted suicide, new psychotic patients, and personality and eating disorders among adolescents and youth.

• 2)

  The identification of a population-based, clinical mental-health networks capable of pinpointing certain sentinel events, as for example in Italy.

• 3)

  The undertaking of surveys of certain problem areas in the population requiring assistance.

Mental health policy in many countries is oriented around recovery, but the evidence base for service-level recovery-promotion interventions is lacking.

We did a cluster, randomised, controlled trial in two National Health Service Trusts in England. REFOCUS is a 1-year team-level intervention targeting staff behaviour to increase focus on values, preferences, strengths, and goals of patients with psychosis, and staff–patient relationships, through coaching and partnership. Between April, 2011, and May, 2012, community-based adult mental health teams were randomly allocated to provide usual treatment plus REFOCUS or usual treatment alone (control). Baseline and 1-year follow-up outcomes were assessed in randomly selected patients. The primary outcome was recovery and was assessed with the Questionnaire about Processes of Recovery (QPR). We also calculated overall service costs. We used multiple imputation to estimate missing data, and the imputation model captured clustering at the team level. Analysis was by intention to treat. This trial is registered, number ISRCTN02507940.

14 teams were included in the REFOCUS group and 13 in the control group. Outcomes were assessed in 403 patients (88% of the target sample) at baseline and in 297 at 1 year. Mean QPR total scores did not differ between the two groups (REFOCUS group 40·6 [SD 10·1] vs control 40·0 [10·2], adjusted difference 0·68, 95% CI −1·7 to 3·1, p=0·58). High team participation was associated with higher staff-rated scores for recovery-promotion behaviour change (adjusted difference −0·4, 95% CI −0·7 to −0·2, p=0·001) and patient-rated QPR interpersonal scores (−1·6, −2·7 to −0·5, p=0·005) at follow-up than low participation. Patients treated in the REFOCUS group incurred £1062 (95% CI −1103 to 3017) lower adjusted costs than those in the control group.

Although the primary endpoint was negative, supporting recovery might, from the staff perspective, improve functioning and reduce needs. Implementation of REFOCUS could increase staff recovery-promotion behaviours and improve patient-rated recovery.

National Institute for Health Research.