From contact coverage to effective coverage of community care for patients with severe mental disorders: A real-world investigation from Italy

Abstract

Objectives: To measure the gap between contact and effective coverage of mental healthcare (MHC).

Materials and methods: 45,761 newly referred cases of depression, schizophrenia, bipolar disorder, and personality disorder from four Italian regions were included. A variant of the self-controlled case series method was adopted to estimate the incidence rate ratio (IRR) for the relationship between exposure (i.e., use of different types of MHC such as pharmacotherapy, generic contact with the outpatient services, psychosocial intervention, and psychotherapy) and relapse (emergency hospital admissions for mental illness).

Results: 11,500 relapses occurred. Relapse risk was reduced during periods covered by (i) psychotherapy for patients with depression (IRR 0.67; 95% CI: 0.49 to 0.91) and bipolar disorder (0.64; 0.29 to 0.99); (ii) psychosocial interventions for those with depression (0.74; 0.56 to 0.98), schizophrenia (0.83; 0.68 to 0.99), and bipolar disorder (0.55; 0.36 to 0.84), (iii) pharmacotherapy for patients with schizophrenia (0.58; 0.49 to 0.69), and bipolar disorder (0.59; 0.44 to 0.78). Coverage with generic care, in absence of psychosocial/psychotherapeutic interventions, did not affect risk of relapse.

Conclusion: This study ascertained the gap between contact and effective coverage of MHC and showed that administrative data can usefully contribute to assess the effectiveness of a mental health system.

Keywords: effective coverage; health service research; healthcare utilization database; mental healthcare; quality of healthcare.

FIGURE 1

Flow-chart of inclusion and exclusion criteria for patients with severe mental health disorders. QUADIM-MAP project, Italy, 2013–2018.

FIGURE 2

Monthly coverage rate of drug therapy from the first until the 64th month after diagnosis of depression, schizophrenia, bipolar disorder, and personality disorder. QUADIM-MAP project, Italy, 2013–2018.

FIGURE 3

Monthly coverage rate of contacts with the mental health service from the first until the 64th month after diagnosis of depression, schizophrenia, bipolar disorder, and personality disorder. Coverage was assigned to psychotherapy whether at least one psychotherapeutic session was performed, to psychosocial intervention whether at least any other psychosocial intervention was performed, to generic mental health care whether the patient attended the service without receiving neither psychosocial nor psychotherapeutic intervention. QUADIM-MAP project, Italy, 2013–2018.

FIGURE 4

Self-controlled case-referent series estimates of the incidence rate ratio of relapse episodes associated with categories of mental care, according with the main diagnosis of depression, schizophrenia, bipolar disorder, and personality disorder. QUADIM-MAP project, Italy, 2013–2018. Self-controlled case-referent series incidence rate ratio, and 95% confidence interval, estimated with Poisson regression contrasting within-patient incidence of relapse onset observed during mental care coverage and no coverage person-time. Relapse was emergency hospital admissions in a psychiatric ward. Estimates were obtained through the design shown in Supplementary Figure 1; please see the extensive footnote of Supplementary Figure 1 for details about the design. Time-windows with width of 180 and 90 days respectively prior and following the relapse onset were removed for mitigating the effect of incorrect allocate person-time of MHC coverage.