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Mentally Disordered Offenders (MDOs) who have been declared not criminally responsible for their offense due to their mental condition should be admitted to settings with lowest possible level of security to support their social reintegration. In the context of the reorganization of care for MDOs in Belgium, we assessed the predictors and retrospective appropriateness of 3529 MDO admissions in 2017 according to security needs. Although there was a positive association between the security needs of MDOs and the level of security of the settings to which they were admitted, there was a gap between high and lower security levels. Medium-security settings made up 46% of all admissions, covering a variety of security need profiles. Half the sample of MDOs with high security needs was found in low- and medium-security settings, while a significant proportion of MDOs with low security needs was found in medium-security settings. Clinical characteristics predicted admissions more strongly than custodial characteristics. Decision-makers should refine criteria and procedures for MDOs’ care access. Indeed, the mixed results in relation to admission appropriateness in medium-security services may result from the lack of formal guidelines.

Background: Healthcare workers (HCWs) from COVID-19 hotspots worldwide have reported poor mental health outcomes since the pandemic's beginning. The virulence of the initial COVID-19 surge in Spain and the urgency for rapid evidence constrained early studies in their capacity to inform mental health programs accurately. Here, we used a qualitative research design to describe relevant mental health problems among frontline HCWs and explore their association with determinants and consequences and their implications for the design and implementation of mental health programs. Materials and methods: Following the Programme Design, Implementation, Monitoring, and Evaluation (DIME) protocol, we used a two-step qualitative research design to interview frontline HCWs, mental health experts, administrators, and service planners in Spain. We used Free List (FL) interviews to identify problems experienced by frontline HCWs and Key informant (KI) interviews to describe them and explore their determinants and consequences, as well as the strategies considered useful to overcome these problems. We used a thematic analysis approach to analyze the interview outputs and framed our results into a five-level social-ecological model (intrapersonal, interpersonal, organizational, community, and public health). Results: We recruited 75 FL and 22 KI interviewees, roughly balanced in age and gender. We detected 56 themes during the FL interviews and explored the following themes in the KI interviews: fear of infection, psychological distress, stress, moral distress, and interpersonal conflicts among coworkers. We found that interviewees reported perceived causes and consequences across problems at all levels (intrapersonal to public health). Although several mental health strategies were implemented (especially at an intrapersonal and interpersonal level), most mental health needs remained unmet, especially at the organizational, community, and public policy levels. Conclusions: In keeping

Background and aims: The coronavirus disease 2019 pandemic has challenged health services worldwide, with a worsening of healthcare workers’ mental health within initial pandemic hotspots. In early 2022, the Omicron variant is spreading rapidly around the world. This study explores the effectiveness and cost-effectiveness of a stepped-care programme of scalable, internet-based psychological interventions for distressed health workers on self-reported anxiety and depression symptoms. Methods: We present the study protocol for a multicentre (two sites), parallel-group (1:1 allocation ratio), analyst-blinded, superiority, randomised controlled trial. Healthcare workers with psychological distress will be allocated either to care as usual only or to care as usual plus a stepped-care programme that includes two scalable psychological interventions developed by the World Health Organization: A guided self-help stress management guide (Doing What Matters in Times of Stress)and a five-session cognitive behavioural intervention (Problem Management Plus). All participants will receive a single-session emotional support intervention, namely psychological first aid. We will include 212 participants. An intention-to-treat analysis using linear mixed models will be conducted to explore the programme’s effect on anxiety and depression symptoms, as measured by the Patient Health Questionnaire – Anxiety and Depression Scale summary score at 21 weeks from baseline. Secondary outcomes include post-traumatic stress disorder symptoms, resilience, quality of life, cost impact and cost-effectiveness. Conclusions: This study is the first randomised trial that combines two World Health Organization psychological interventions tailored for health workers into one stepped-care programme. Results will inform occupational and mental health prevention, treatment, and recovery strategies. Registration details: ClinicalTrials.gov Identifier: NCT04980326.

Background: For psychiatric service users suffering from severe mental disorders, the social support provided by personal social networks is essential for living a meaningful life within the community. However, the importance of the support received depend on the relations between the providers of social support. Yet this hasn’t been addressed in the literature so far for people with severe mental disorders. This article seeks to investigate how characteristics of service users with severe mental disorders, their social contacts, and the pattern of relationships between those contacts influence the distribution and provision of social support to people with severe mental disorders. Methods: We collected personal network data relating to 380 psychiatric service users from a random sample of health care providers in Belgium. We computed various measures of the structure of those networks and of the position of support persons within those networks. We conducted a multilevel analysis of the importance of the support provided by each support persons. Results: The results show that the more central a support person was in the network of a service user, the more important his or her support was considered to be by the service user. Also, the denser the network in which a support person was embedded, the less important was the support he or she offers, but only for hospitalised service users. Conclusion: These finding highlight the collective dimension of social support. We discuss the implications for the organisation of mental health care.

Introduction: De-institutionalization of psychiatric care has greatly increased the role of family members in the recovery pathways of Persons labeled as Not Criminally Responsible (PNCR). However, the role of family members in supporting PNCR in forensic psychiatric care remains understudied. Scarce evidence indicates that PNCR have to deal with stigma and endure specific burdens (i.e., symptom-specific, financial, social, and emotional). Recovery-focused research showed that recovery in both persons with a severe mental illness and family members develop in parallel with each other and are characterized by similar helpful principles (e.g., hope and coping skills). As such, the recovery pathways of PNCR often goes hand in hand with the recovery pathway of their family members. During the family recovery process, family members often experience not being listened to or being empowered by professionals or not being involved in the decision-making process in the care trajectory of their relative. Therefore, the aim of this study is to capture how family members experience the care trajectories of their relatives, more specifically by looking at family recovery aspects and personal advocacy of family members. Methods: Semi-structured interviews were conducted with 21 family members of PNCR from 14 families. A thematic analysis confirms that family members suffer from stigma and worry significantly about the future of their relative. Results: Regarding the care trajectory of PNCR, family members experienced barriers in multiple domains while trying to support their relative: involvement in care and information sharing, visiting procedures, transitions between wards, and the psychiatric and judicial reporting by professionals. In addition, family members emphasized the importance of (social) support for themselves during the forensic psychiatric care trajectories and of a shared partnership. Discussion: These findings tie in with procedural justice theory as a preconditi

The difficulty of implementing mental healthcare reforms owes much to the influence of stakeholders. So far, the endorsement of mental health policy reforms by stakeholder coalitions has received little attention. This study describes stakeholder coalitions formed around common mental health policy goals and highlights their central goals and oppositions. Data were collected on the policy priorities of 469 stakeholders (policymakers, service managers, clinicians, and user representatives)involved in the Belgian mental healthcare reform. Four coalitions of stakeholders endorsing different mental health policy goals were identified using a hierarchical cluster analysis on stakeholders’ policy priorities. A belief network analysis was performed to identify the central and peripheral policy goals within coalitions. Coalitions brought together stakeholders with similar professional functions. Disagreements were observed between service managers and policymakers around policy goals. The two coalitions composed of policymakers supported a comprehensive approach that combines the different goals and also supported the shortening of hospital stays, whereas the two coalitions composed of service managers emphasised the personal recovery of users and continuity of care. Regardless of the coalitions’ differing policy priorities, strengthening community care was a central goal while patient-centred goals were peripheral. The competing policy positions of the coalitions identified may explain the slow and inconsistent pace of the Belgian mental healthcare reform. Strengthening community care may be an essential part of reaching consensus across coalitions. Finally, special care must be taken to ensurethat patient-centred policy goals, such as social integration, are not set aside in favour of other goals

Background Despite an overall reduction in suicide, educational disparities in suicide have not decreased over the last decade. The mechanisms behind educational disparities in suicide, however, remain unclear: low educational status may increase the risk of suicide (“causation”) or low educational status and suicide may share confounders. This paper assesses whether educational disparities in suicide (EDS) are more likely to be due to causation. Method The DEMETRIQ study collected and harmonized register-based data on mortality follow-up from forty population censuses from twelve European populations. More than 102,000 suicides were registered over 392 million person-years. Three analyses were carried out. First, we applied an instrumental variable approach that exploits changes in the legislation on compulsory educational age to instrument educational status. Second, we analyzed EDS by age under the hypothesis that increasing EDS over the life cycle supports causation. Finally, we compared EDS in men and women under the assumption that greater EDS in women would support causation. Findings The instrumental variable analysis showed no evidence for causation between higher education and suicide, for men or women. The life-cycle analysis showed that the decrease of educational inequalities in suicide between the baseline 1991 period and the 2001 follow-up period was more pronounced and statistically significant in the first three younger age groups. The gender analysis indicated that EDS were systematic and greater in men than in women: the rate ratio of suicide for men with low level of education (RR = 2.51; 95%CI:2.44–2.58) was higher than the rate ratio in women (RR = 1.32; 95CI%:1.26–1.38). Interpretation Overall, there was little support for the causation hypothesis, suggesting that the association between education and suicide is confounded. Educational inequalities in suicide should be addressed in early life by early targeting of groups who struggle to comple

Background: The outbreak of the COVID-19 pandemic in 2020 and its associated measures led to high levels of mental distress in the general population. Previous research indicated that young people are especially vulnerable for a wide range of mental health problems during the pandemic, but little is known about the mechanisms. This study examined mental distress and its contributing factors among young Belgian people. Methods: An online survey was widely distributed in Belgium during the first wave of COVID-19 in March, and 16 to 25-year-olds were selected as a subsample. Mental distress was assessed using the 12-item General Health Questionnaire (GHQ-12), and a threshold of ≥ 4 was used to discriminate mental distress cases from non-cases. Bivariate and multivariable logistic regression analyses were performed to evaluate possible predictors of mental distress, including demographics, chronic condition, history of mental health problems, social support, exposure to COVID-19, and several changes in everyday activities. Results: A total of 2008 respondents were included, of which the majority was female (78.09%) and student (66.82%). The results indicate that about two thirds (65.49%) experienced mental distress. In the multivariable regression model, significant (p < .01) predictors of mental distress were female gender (OR = 1.78), low social support (OR = 2.17), loneliness (OR = 5.17), a small (OR = 1.63) or large (OR = 3.08) increase in social media use, a small (OR = 1.63) or large (OR = 2.17) decrease in going out for drinks or food, and a decrease in doing home activities (OR = 2.72). Conclusion: Young people experience high levels of mental distress during the COVID-19 pandemic. Our findings indicate that mental distress was highest among women, those experiencing loneliness or low social support and those whose usual everyday life is most affected. The psychological needs of young people, such as the need for peer interaction, should be more recognized and s

The Trinitarian model of therapeutic security is used to organize forensic mental health care in Ireland, England and Scotland. However, it remains unclear whether this model captures all significant factors for the organization of forensic mental health care delivery. In this case study, the Trinitarian model is applied to and tested on Belgian forensic mental health services. Relational security as a discriminative factor is debated and an extension of this institution-oriented model to the policy- and service users’ level is recommended. Finally, we propose to disentangle the concepts of therapeutic security, risk and care in forensic mental health.

Background: The COVID-19 pandemic and subsequent suppression measures have had health and social implications for billions of individuals. The aim of this paper is to investigate the risk of psychological distress associated with the COVID-19 pandemic and suppression measures during the early days of the lockdown. We compared the level of psychological distress at the beginning of that period with a pre-pandemic health survey and assessed the psychological effects of exposure to the COVID-19 pandemic and changes in social activity and support. Methods: An online survey was distributed to the general population in Belgium 3 days after the beginning of the lockdown. 20,792 respondents participated. The psychological distress of the population was measured using the GHQ-12 scale. Social activities and support were assessed using the Social Participation Measure, the Short Loneliness Scale, and the Oslo Social Support Scale. An index of subjective exposure to the COVID-19 pandemic was constructed, as well as a measure of change in occupational status. Measurements were compared to a representative sample of individuals extracted from the Belgian Health Interview Survey of 2018. Bootstrapping was performed and analyses were reweighted to match the Belgian population in order to control for survey selection bias. Results: Half of the respondents reported psychological distress in the early days of the lockdown. A longer period of confinement was associated with higher risk of distress. Women and younger age groups were more at risk than men and older age groups, as were respondents who had been exposed to COVID-19. Changes in occupational status and a decrease in social activity and support also increased the risk of psychological distress. Comparing the results with those of the 2018 Belgian Health Interview shows that the early period of the lockdown corresponded to a 2.3-fold increase in psychological distress (95% CI: 2.16–2.45). Conclusions: Psychological distress is

Background: Patients with severe mental illnesses (SMI) have low levels of social integration, which could be improved if they used social services. To our knowledge, however, the extent to which they use generic social services remains unknown. Aims: We assessed the extent to which patients with SMI use generic social services and the factors that may drive that usage. Methd: Study design: In 2014, we carried out a multi-setting clustered survey of patients with severe mental disorders (n=1019, participation rate=71%) and of services (n=517, participation rate=53%) in 19 networks of services, covering most of Belgium. On the one hand, we asked patients, amongst other, about their health condition, their social integration in the community, and their use of social services of different types. On the other hand, we asked each service to report on its relationships with other services in the services networks. Results: On average, patients’ use of generic social services within the previous six months was low (6-16%), with the exception of administrative services. There were few differences in usage according to the severity of patients’ symptoms, but some differences according to gender and age were observed. Social integration was improved when generic social services were more central in the networks. Conclusions: We suggest that generic social services should be more central in mental health services networks.

Purpose: Providing effective treatment for immigrants is an increasing challenge for mental health services across Europe. Yet, little is known as to whether current practice is associated with different outcomes in migrant and non-migrant patients.We compared outcomes of inpatient psychiatric treatment for migrants and non-migrants in a sample from five European countries. Methods: Patients with psychotic disorders, affective disorders or anxiety/somatisation disorders admitted to routine psychiatric inpatient treatment were assessed in hospitals in Belgium, Germany, Italy, Poland and the United Kingdom. Treatment outcomes were satisfaction with care during hospitalisation, length of stay, readmission to hospital (any and, specifically,involuntary re-hospitalisation), as well as untoward incidents in a 1-year follow-up period. Outcomes were compared between patients born inside (non-migrants) and outside (migrants) the country of treatment, through mixed regression models. Results Across all sites, 985 migrant patients and 6298 non-migrant patients were included. After accounting for the influence of confounding patient characteristics, migrants reported significantly lower treatment satisfaction, but there were no significant differences for length of stay and re-hospitalisations, in general and involuntary ones. Migrants had a lower rate of suicide attempts, but there was no significant difference in other types of untoward incidents in the year following the index admission. Conclusion The study suggests that migrants are less satisfied with their hospital treatment, there is no evidence that routine inpatient care as currently provided results overall in poorer objective outcomes for migrants than in non-migrant populations.

Background: Social support is a key dimension of personal recovery for patients with severe mental disorders. Although clinicians and health professionals should monitor the social support resources of patients in order to provide effective treatment, no specific tool or intervention exist for that purpose. Egonet is a computer-assisted intervention for health and social services that enables the mapping, assessment and fostering of patients’ social support networks. Aims: This paper describes the intervention and evaluates the appropriateness and acceptability of its implementation in a clinical setting. Method: We described the computer-assisted intervention. We used a questionnaire to assess how appropriate and acceptable clinicians found a preliminary version to be. We also collected patients’ level of satisfaction with their social support networks before and after the intervention and carried out qualitative interviews. Results: Egonet is made up of four components: (1) a computer-assisted interview for mapping social networks, (2) a remote data server, (3) a data-mining module and (4) a customisable reporting tool. Egonet was implemented for 232 patients by 91 clinicians from five services. The intervention was perceived by clinicians as appropriate and useful for clinical practice, although it was noted that considerable effort was required to obtain its benefits. Patients were slightly more satisfied with their social support after the intervention than before, and expressed the opinion that more attention should be paid to the social support network. Conclusions: EGONET is appropriate and acceptable for use in work related to the social support networks of patients with psychiatric disorders.

Aims: a core question in the debate about how to organise mental healthcare is whether in- and out-patient treatment should be provided by the same (personal continuity) or different psychiatrists (specialisation). The controversial debate drives costly organisational changes in several European countries, which have gone in opposing directions. The existing evidence is based on small and low-quality studies which tend to favour whatever the new experimental organisation is. We compared 1-year clinical outcomes of personal continuity and specialisation in routine care in a large scale study across five European countries. Methods: This is a 1-year prospective natural experiment conducted in Belgium, England, Germany, Italy and Poland. In all these countries, both personal continuity and specialisation exist in routine care. Eligible patients were admitted for psychiatric in-patient treatment (18 years of age), and clinically diagnosed with a psychotic, mood or anxiety/somatisation disorder.Outcomes were assessed 1 year after the index admission. The primary outcome was re-hospitalisation and analysed for the full sample and subgroups defined by country, and different socio-demographic and clinical criteria. Secondary outcomes were total number of inpatient days, involuntary re-admissions, adverse events and patients’ social situation. Outcomes were compared through mixed regression models in intention-to-treat analyses. The study is registered (ISRCTN40256812). Results: We consecutively recruited 7302 patients; 6369 (87.2%) were followed-up. No statistically significant differences were found in re-hospitalisation, neither overall (adjusted percentages: 38.9% in personal continuity, 37.1% in specialisation; odds ratio = 1.08; confidence interval 0.94–1.25; p = 0.28) nor for any of the considered subgroups. There were no significant differences in any of the secondary outcomes. Conclusions: Whether the same or different psychiatrists provide in- and out-patient treat

Most healthcare systems struggle to provide continuity of care for people with chronic conditions, such as patients with severe mental illness. In this study, we reviewed how system features in two national health systems (NHS) – England and Veneto (Italy) – and three regulated-market systems (RMS) – Germany,Belgium, and Poland –, were likely to affect continuing care delivery and we empirically assessed system performance. 6418 patients recruited from psychiatric hospitals were followed up one year after admission. We collected data on their use of services and contact with professionals and assessed care continuity using indicators on the gap between hospital discharge and outpatient care, access to services, number of contacts with care professionals, satisfaction with care continuity, and helping alliance. Multivariate regressions were used to control for patients’ characteristics. Important differences were found between healthcare systems. NHS countries had more effective longitudinal and cross-sectional care continuity than RMS countries, though Germany had similar results to England. Relational continuity seemed less affected by organisational mechanisms. This study provides straightforward empirical indicators for assessing healthcare system performance in care continuity. Despite systems’ complexity, findings suggest that stronger regulation of care provision and financing at a local level should be considered for effective care continuity.

Mental health and social care services networks aim to provide patients with continuity of care and support their recovery. There is, however, no conclusive evidence of their effectiveness. Since 2011, Belgium has been implementing a nation-wide reform of mental health care by commissioning service networks. Using a case–control design, we assessed the reform’s effectiveness for continuity of care, social integration, quality of life, and re-hospitalization for 1407 patients from 23 networks. Greater reform exposure was associated with a slight improvement in continuity of care, but not with other outcomes. We concluded that service networks alone do not affect patient-level outcomes.

Background: In Europe, at discharge from a psychiatric hospital, patients with severe mental illness may be exposed to one of two main care approaches: personal continuity, where one clinician is responsible for in- and outpatient care, and specialisation, where various clinicians are. Such exposure is decided through patient-clinician agreement or at the organisational level, depending on the country’s health system. Since personal continuity would be more suitable for patients with complex psychosocial needs,the aim of this study was to identify predictors of patients’ exposure to care approaches in different European countries. Methods: Data were collected on 7302 psychiatric hospitalised patients in 2015 in Germany, Poland, and Belgium (patient-level exposure); and in the UK and Italy (organisational-level exposure). At discharge,patients were exposed to one of the care approaches according to usual practice. Putative predictors of exposure at patients’ discharge were assessed in both groups of countries. Results: Socially disadvantaged patients were significantly more exposed to personal continuity. In all countries, the main predictor of exposure was the admission hospital, except in Germany, where having a diagnosis of psychosis and a higher education status were predictors of exposure to personal continuity. In the UK, hospitals practising personal continuity had a more socially disadvantaged patient population. Conclusion: Even in countries where exposure is decided through patient-clinician agreement, it was the admission hospital, not patient characteristics, that predicted exposure to care approaches. Nevertheless,organisational decisions in hospitals tend to expose socially disadvantaged patients to personal continuity.

Background: Patient satisfaction is a key indicator of inpatient care quality and is associated with clinical outcomes following admission. Different patient characteristics have been inconsistently linked with satisfaction. This study aims to overcome previous limitations by assessing which patient characteristics are associated with satisfaction within a large study of psychiatric inpatients conducted across five European countries. Methods: All patients with a diagnosis of psychotic (F2), affective (F3) or anxiety/somataform (F4) disorder admitted to 57 psychiatric inpatient units in Belgium, Germany, Italy, Poland and the UK were included. Data were collected from medical records and face-to-face interviews, with patients approached within 2 days of admission. Satisfaction with inpatient care was measured on the Client Assessment of Treatment Scale. Results: Higher satisfaction scores were associated with being older, employed, living with others, having a close friend, less severe illness and a first admission. In contrast, higher education levels, comorbid personality disorder and involuntary admission were associated with lower levels of satisfaction. Although the same patient characteristics predicted satisfaction within the five countries, there were significant differences in overall satisfaction scores across countries. Compared to other countries, patients in the UK were significantly less satisfied with their inpatient care. Conclusions: Having a better understanding of patient satisfaction may enable services to improve the quality of care provided as well as clinical outcomes for all patients. Across countries, the same patient characteristics predict satisfaction, suggesting that similar analytical frameworks can and should be used when assessing satisfaction both nationally and internationally.

Lancée en 2010 et généralisée en 2016, la " réforme 107 " a pour objectif de réorganiser l'offre de soins de santé mentale autour de l'usager en favorisant sa prise en charge dans son environnement de vie. La présente étude a pour objectif d'évaluer la mise en œuvre de cette réforme en région bruxelloise et de formuler des recommandations en conséquence. Le projet Parcours.Bruxelles, commandité par l'Observatoire de la Santé et du Social, a été mené par l'Institut de Recherche Santé et Société de l'Université catholique de Louvain. Il se distingue par la priorité donnée aux parcours des usagers des soins de santé mentale, afin d'y identifier les bifurcations principales. Les bifurcations identifiées ont ensuite guidé l'analyse de l'organisation, des collaborations et de la coordination du système de la santé mentale, afin de comprendre comment ces dimensions impactent le parcours des usagers. En vue de saisir les liens complexes entre les parcours des usagers et les aspects organisationnels du système, des méthodes qualitatives ont été utilisées, combinant des entretiens semi-directifs et des focus groups avec des professionnels et des usagers inclus et exclus des soins. Les 27 professionnels rencontrés représentent une diversité de secteurs, de services, de disciplines et de fonctions professionnelles, parmi lesquelles la coordination de réseaux, la gestion de services, et le travail de terrain. En vue d'inclure les expériences d'usagers présentant des difficultés d'accès aux soins souvent liées à la complexité et à la chronicité de leur situation, des entretiens ethnographiques ont également été réalisés dans des services à bas seuil d'accès. Au total, 29 rencontres auprès d'usagers issus de profils diversifiés ont été inclues dans cette recherche. Le rapport de recherche comprend deux parties principales. La première, " santé mentale et société ", présente les bifurcations principales observées dans le parcours des usagers dans et hors soin, qui interagissent ave

Het project Parcours.Brussel onderzoekt hoe het geestelijke gezondheidssysteem in het Brussels Hoofdstedelijk Gewest is georganiseerd aan de hand van de zorgtrajecten van personen die in contact staan of stonden met diensten voor geestelijke gezondheidszorg uit die regio. Wat het anders maakt dan andere projecten is de bewuste keuze om te vertrekken vanuit de ervaringen van personen die zorg krijgen of van zorg uitgesloten zijn en om bijzondere aandacht te schenken aan de sociale- en verzorgingsdimensie van de zorgtrajecten. De geestelijke gezondheid en de trajecten die erin worden afgelegd slagen of falen altijd binnen welbepaalde sociale omstandigheden die gekarakteriseerd worden door onder andere toegang of geen toegang tot adequate huisvesting, en doorheen interacties, met name op de werkvloer. Het project Parcours.Brussel conceptualiseert daarom de geestelijke gezondheid als een collectieve actie/onderneming die het domein van de zorg overstijgt. Dit vertaalt zich in het gebruik van de term “geestelijke gezondheidssysteem” in plaats van “geestelijke gezondheidszorgsysteem”.

Purpose: For severely mentally ill (SMI) users, continuity of care requires consistency between the supports provided by the members of their social support network. However, we know little about their network cohesion and its association with continuity of care. We set out to investigate this association and hypothesised that it would depend on the severity of the user’s situation and on his/her living arrangements. Methods: We conducted face-to-face interviews with 380 SMI users recruited in outpatient and inpatient mental health services in three areas in Belgium. Data regarding users’ social networks were collected using an ego-network mapping technique and analysed with social network analysis. The cohesion indicators were density (frequency of connections between network members), centralisation (having a small number of central people), and egobetweenness (the user’s centrality in his/her own network). Participants’ perception of continuity of care was measured by the Alberta Continuity of Services Scale. Results: Results show that cohesion indicators were associated with continuity of care only for users with high-severity problems, regardless of their living arrangements. The numbers of network members, professionals, and services in the network were all negatively associated with continuity of care for all the users. Conclusions: Satisfactory continuity of care requires fewer professionals or services in a user’s network and a dense network for users with the most severe problems. This implies that those providing care must not only be able to increase cohesion within a network, but also to adapt their interventions to support the transition to a different, individualised network structure when severity decreases.

Introduction: During the last decades, reforms in the organisation of mental health care (MHC) have been implemented in many countries. However, reforms are often partially implemented because of the resistance of stakeholders, especially in bottom-up and fragmented societies. So far, coalitions of stakeholders in the organisation of MHC has never been described. Objectives: The objective was to identify coalitions of stakeholders in relation to dimensions of the organisation of MHC. Methods: Using a national online survey in Belgium, data were collected on 469 stakeholders (policymakers, clinicians, managers, professional associations, user representatives). Seven dimensions of the MHC organisation were proposed to stakeholders: target group, geographical organisation of care, type of service provided, type of coordination, formalization of practice, provider payment mechanisms, and resource-pooling level. Classification was performed on stakeholders’ organisational choices with a non-metric cluster analysis. Results: Organisational choices of stakeholders in five clusters accounted for 50% of the variance. Coalitions have emerged around the following dimensions: geographical organisation of care, type of service provided, resource-pooling level and formalization of practices. Clusters composed of clinicians and professional associations favoured the autonomy of individual, specialised services while those composed of policymakers favoured generic services, the formalization of practice and integration at the network level in terms of provision, coordination, and funding of services. Conclusions: Coalitions that are composed of stakeholders with different backgrounds differ on the organisational dimensions that underlie issues of autonomy and identity of services. The definition of MHC policies and interventions should consider the impact of stakeholder coalitions.

Background: People with mental illness (MI) face issues of social integration such as finding a job and maintaining social relationships. In the past decades, many countries have developed specific social integration policies towards people with MI. Despite heterogeneous assessments of those policies, the social integration of people with MI and its improvement over time remains inconclusive. Aim: This study aimed to assess the evolution of the social integration of adults with moderate and severe MI in the general Belgian population between 1997 and 2013. Methods: Data on the general adult population were retrieved from the Belgian Health Interview Survey in five cross-sectional waves (1997, 2001, 2004, 2008 and 2013, n ≈ 10,000 per wave). Three degrees of MI severity were compared using the 12-item General Health Questionnaire (GHQ-12): no MI, moderate MI, and severe MI (score < 4, 4-7, and > 7). Indicators of social integration were the employment status, social contacts, and partnership situation. Adjusted prevalence of social integration indicators were estimated in the different periods. The evolution of prevalence was estimated with time-trend measures (absolute and relative change, and average annual percent chance). The association between social integration indicators and survey year was assessed with logistic regression models. Results: In 2013, the adjusted prevalence of social integration indicators of people without MI, with moderate MI, and with severe MI were respectively 26%, 35%, 56% for unemployment, 2%, 6%, 11% for low social contacts, and 14%, 18%, 32% for being single. For unemployment and low social contacts, the gap between people with severe MI and the other two groups increased over time. The probability of being unemployed decreased significantly in 2013 compared to 1997 for people without MI (AOR = 0.59, 95%CI = 0.53-0.65) and for people with moderate MI (AOR = 0.69, 95%CI = 0.51-0.97), but not for people with severe MI (AOR = 1.08, 95%CI

Most healthcare systems struggle to provide continuity of care for people with chronic conditions, such as patients with severe mental illness. In this study, we reviewed how system features in two national health systems (NHS) – England and Veneto (Italy) – and three regulated-market systems (RMS) – Germany, Belgium, and Poland –, were likely to affect continuing care delivery and we empirically assessed system performance. 6418 patients recruited from psychiatric hospitals were followed up one year after admission. We collected data on their use of services and contact with professionals and assessed care continuity using indicators on the gap between hospital discharge and outpatient care, access to services, number of contacts with care professionals, satisfaction with care continuity, and helping alliance. Multivariate regressions were used to control for patients' characteristics. Important differences were found between healthcare systems. NHS countries had more effective longitudinal and cross-sectional care continuity than RMS countries, though Germany had similar results to England. Relational continuity seemed less affected by organisational mechanisms. This study provides straightforward empirical indicators for assessing healthcare system performance in care continuity. Despite systems' complexity, findings suggest that stronger regulation of care provision and financing at a local level should be considered for effective care continuity.

Introduction. The social support network (SSN) of an individual is the set of people who interact with the individual and with each other to provide support to the individual. The SSN is a key element of the care for patients with long-term conditions, e.g. patients with severe mental illness (SMI), providing a variety of resources. It is well established that the size and the composition of the SSN influence patients' symptomatology, social functioning, and service utilisation. Recent studies also suggested that the network structure may affect patient's care outcomes, though these studies are inconclusive and considered only a limited number of structural indicators. In this context, the establishment of a typology of SSNs makes it possible to explore diverse structural indicators and their association, among themselves and with patient's outcomes. Recently, Bidart and colleagues established six types of ego-networks with distinctive structural shapes in the general population. Therefore, we sought to investigate the extent to which the SSN of SMI patients were fitting these network types. Method. We collected data on the SSNs of 380 SMI patients recruited in psychiatric services. We applied Bidart's typology, which is based on the combination of four structural indicators (betweenness centralisation, modularity, density, and diameter) to the patients' SSNs. Then, we assessed the differences found in our sample compared to Bidart's types. Results. Patients' SSN classification only fits partially Bidart's typology. A particular type, named 'regular dense' in Bidart's typology, appeared to be much more heterogeneous. A significant proportion of the networks in this category (81.7%) had a lower density than the median in Bidart’s typology (0.38). In addition, these networks were small (11 nodes on average), highly fragmented (69.4%), and had small components with many isolated nodes (5.5 components including 4.3 isolated nodes on average). Conclusion. Bidart's typolo

Mental health is a fundamental component of good health. The World Health Organization (WHO) defines mental health as ‘a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community’. Consequently, mental health problems range from the worries we all experience as part of everyday life to serious long-term conditions. The WHO pyramid Framework for mental health1 pleads for a comprehensive care offer and continuity of care. From a policy viewpoint every government needs to evaluate whether its mental health care system is effective and efficient and provides easy access for every civilian. Also for Belgium this exercise is important, especially in the light of recent social and political phenomena. In past decades the organisation of mental health care in Belgium underwent several reform waves with the main aim to further orient mental health care towards a reduction of residential hospital care in favour of recovery and reintegration treatment in the community. In order to attaint this objective, policies to promote five core foundations (i.e. deinstitutionalisation, inclusion, decategorisation, intensification, and consolidation)2 were developed. In 2016, the inter-cabinet working group (IKW – GTI) ‘task force on Mental Health care’ asked the KCE to look at the provision of mental health care services and the needs of the population. The current study focused on an in-depth analysis of the organisation of mental health services in Belgium with a need to clearly visualize the present care offer and to evaluate the organisation and continuity of care for the future decade. The objective of this study was to describe the Belgian mental health care offer in order to take into account possible gaps and overlaps between existing services and to assess the Belgian landscape against internationally defined framework

Background: For more than 30 years, drug consumption rooms (DCRs) have been implemented in Western countries. DCRs are supported by a large body of evidence about public safety and public health effectiveness. However, a political consensus has never been achieved in Belgium on amending the existing law that explicitly penalises the supply of a room for facilitating drug use. Despite this adverse legal and policy framework, a DCR opened in the city of Liège in 2018. In this case report, we applied the theoretical framework proposed by Shiffman and Smith for policy agenda setting, in order to describe and assess how political and legal barriers were overcome in the process of opening the DCR. Case presentation: For some years, fieldworkers and some city policymakers argued for DCR implementation in Belgium, but without gaining the support of the national authorities, mainly for ideological reasons. In order to address this debate, a feasibility study of DCR implementation in Belgian cities was commissioned. At the national level, an institutional debate took place about the political responsibility for DCRs as a public health intervention, as health care is mainly a matter of regional policy. The lack of consensus led to a situation of political deadlock. Meanwhile, the publication of the study report and the context of local elections offered an opportunity for Liège authorities to reignite the local debate on DCRs. At the local level, law enforcement, care professionals, residents, users, and the press were all involved in the implementation process. Therefore, a local consensus was formed and despite the absence of any national legal change, the DCR opened 1 month before the local elections. It has been working without major medical or legal incident since then. Incidentally, the mayor of Liège was re-elected. Conclusions: Although the lack of a legal framework may engender instability and affect longer-term effectiveness, the DCR implementation in Liège was succe

Aims: Treatment of patients with comorbidity of mental health problems and alcohol use disorder (AUD) constitutes a challenge in many countries. The article aimed at exploration of personal experiences of clinicians and patients with the comorbidity regarding its assessment, treatment and organization of care in Poland and the UK. Methods: Data were collected via in-depth, semi-structured interviews with clinicians (N = 28) and patients (N = 81) in both countries, according to a unified study protocol. Maximum variation sampling was applied to both study groups. All interviews’ transcripts were coded (CAQDA) and the consistency of coding across centres was assessed. Data analysis was performed according to the principles of thematic analysis. Results: Our data show that most patients with AUD admitted at the psychiatric wards—apart from assessment which is a standard procedure during admission—receive only minimal support during their hospital stay. This is the consequence of two factors: lack of trained staff prepared to help those patients and a priority given to self-referrals by AUD units. At the same time, it is recognized by clinicians and patients that more support is needed to encourage the utilization of AUD services and to prevent the drop-out. Conclusions: In order to improve the system response, the use of screening instruments in the process of the assessment of AUD and establishment of special procedures supporting motivation and adherence to treatment and preventing drop-out merits consideration. Moreover, the psychiatric wards and the AUD services could possibly profit from formalization of the collaboration between services.