Acta Psychiatr Scand 2000: 102: 366375 Printed in UK.

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Copyright # Munksgaard 2000

ACTA PSYCHIATRICA SCANDINAVICA ISSN 0001-690X

The perception of needs for care in staff and patients in community-based mental health services. The South-Verona Outcome Project 3
Lasalvia A, Ruggeri M, Mazzi MA, Dall'Agnola RB. The perception of needs for care in staff and patients in community-based mental health services. The South-Verona Outcome Project 3. Acta Psychiatr Scand 2000: 102: 366375. # Munksgaard 2000. Objective: The present study aims to assess needs for care rated by patients and staff and their agreement on needs assessment in a community-based mental health service by using the Camberwell Assessment of Need (CAN). Method: The Italian version of the CAN was used in a sample of 247 patientstaff pairs. Results: Patients and staff showed poor agreement on both the presence of a need and on whether need had been met or not. Higher disability predicted a higher number of patient-rated needs, while higher disability, higher number of service contacts and patient unemployment predicted a higher number of staff-rated needs. Lower global functioning predicted higher disagreement in patients and staff ratings of needs. Conclusion: Patients and staff show different perceptions of needs for care and therefore multiple perspectives should be taken into account for planning and providing effective needs-led mental health care.

Antonio Lasalvia, Mirella Ruggeri, Maria Angela Mazzi, Rosa Bruna Dall'Agnola
Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Italy

Key words: needs assessment; community mental health care; health services research Dr Mirella Ruggeri, Dipartimento di Medicina e Sanita Pubblica, Sezione di Psichiatria, Ospedale Policlinico, via delle Menegone, 10, 37134 Verona, Italy Accepted for publication May 31, 2000

Introduction

In recent years, the concept of needs for care has been proposed as a new paradigm in planning mental health service interventions (1). Unfortunately, there is no consensus on how needs should be dened or who should dene them. On the basis of the distinctions made by Bredshaw (2) between `normative', `felt', `expressed' and `comparative' need, two main approaches to needs assessment have been developed. In a normative model, needs occur when the clinical or the social functioning of an individual falls (or threatens to fall) below a specied level because of a potentially remediable cause (3). In such a view needs assessment should be based on the judgement of an expert, performed on the basis of his own competence and of the shared knowledge of the scientic community. In a negotiated model, needs are not a xed concept that can be objectively measured, but are best viewed as a dynamic and relative concept that can be inuenced by a range of contextual factors and on which there 366

is no single correct perspective (46). In this context, needs assessment should therefore include both staff and patients' perceptions. The Camberwell Assessment of Need (CAN) is a reliable needs assessment tool (7) that includes a comprehensive range of health and social needs and allows one to assess both staff and patients' perceptions. In a negotiated approach, it is important to assess differences between staff and users' perceptions of needs for care. If the differences are insignicant and predictable, it will be sufcient to take into account either staff or patients' perceptions, thus allowing for a simpler and quicker assessment. If, on the contrary, the differences between staff and users are signicant and unpredictable, it will then be necessary to consider both sets of perceptions. Two studies (8, 9) comparing staff and patients' perceptions of needs, as measured by the CAN, conducted in Great Britain in 49 and 137 subjects suffering from functional psychosis, reported low

Perception of needs for care patientstaff agreement on needs assessment, particularly on unmet needs. The authors pointed out the importance of assessing the discrepancies between staff and patients' points of view, suggesting that any improvement in patientstaff agreement would be associated with improved outcomes in terms of compliance with treatment, engagement and satisfaction with services, and resource utilization (9). A comparison between an `objective' assessment of needs (made using the MRC Needs for Care Assessment Schedule) (3) and `subjective' assessment of needs (made using the CAN), conducted in Holland in 50 subjects suffering from functional psychosis, conrmed the lack of agreement between staff and patients, particularly on unmet needs (10). Another study conducted on a group of 45 psychotic patients referred for a housing support programme and their key workers revealed a generally low level of agreement on the presence of needs (11). Recently Slade et al. (12) found that, in an epidemiologically repre-sentative sample of 133 psychotic patients, patient ratings of unmet need were more reliable than ratings made by staff. This indicates that the patient's perspective on their difculties (especially their unmet needs) must be central to mental health care. The aim of this paper is to evaluate needs for care, in a larger sample of patients with a wide range of psychiatric disorders which is representative of all those in contact with a community-based service. Specically we assess: 1) the pattern of needs for care as perceived by staff and patients, 2) the agreement between patient and staff perceptions of needs, and 3) the predictors of needs according to staff and patients' views.
Subjects

Data used in this paper are part of the larger South-Verona Outcome Project (SVOP), a naturalistic and longitudinal study that was started in 1994 and is still running, in which all patients attending the South-Verona CMHS are assessed routinely with a set of standardized instruments. Fuller details on the SVOP are given elsewhere (15). For the present study, data collection was performed in OctoberDecember 1996.
Measures

Material and methods Research setting

South-Verona is a predominantly urban area on the southern outskirts of Verona with a total population of approximately 75 000 inhabitants. Ethnic minorities are a negligible percentage of the population. Data were collected in the SouthVerona community-based mental health service (CMHS), which serves the South-Verona catchment area. The South-Verona CMHS offers a range of comprehensive and well-integrated programmes including in-patient, day, rehabilitation and out-patient care, home visits, a 24-hour emergency service and residential facilities (three apartments and one hostel) for long-term patients (13). A Psychiatric Case Register (PCR) covers the same geographic area. Full details on the South-Verona PCR are reported elsewhere (14).

Needs for care were measured using the Camberwell Assessment of Need (CAN) (7). The CAN is a structured interview for evaluating the clinical and social needs of patients with serious mental illness. It was developed for staff (CANstaff) and patient (CAN-patient) use. It is divided into 22 areas: accommodation, food, looking after the home, self-care, daytime activities, physical health, psychotic symptoms, information about condition and treatment, psychological distress, safety to self, safety to others, alcohol, drugs, company, intimate relationships, sexual expression, childcare, basic education, telephone, transport, money and social benets. Clinical and research versions of the CAN have been developed. The CAN clinical version has three sections. Section 1 assesses a problem that is currently present using a three-point scale, where serious problem=`2', no problem/moderate problem due to the help given=`1', no problem=`0'. According to the authors (9), a rating of `1' is considered to represent a met need, while a rating of `2' represents an unmet need. A need is considered to be met when the patient or staff judges that there is no problem in a specic domain because of the help provided, but that a problem would exist if no help was provided. A need is considered to be unmet when the patient or staff considers a problem in a specic domain to be currently present, regardless of any help provided. Section 2 and Section 3 of the CAN clinical version assess, respectively, the informal help received and the formal help received and needed from local services, using a four-point scale on which high help=`3', moderate help=`2', low help=`1', and no help=`0'. In each CAN section a rating of `9' is also used for not known. In this study, for the purpose of analysis, ratings `0' and `9' were combined according to Slade et al. (8). In the present study the Italian version of the CAN was used. The reliability of the Italian translation of the CAN was investigated in a sample of patients attending the South-Verona 367

Lasalvia et al. CMHS (16) and found to be consistent with the results of the reliability study conducted with the English version (7). Psychopathology was measured by using the Brief Psychiatric Rating Scale (BPRS, `expanded version') (17), which rates 24 items on a 17 severity scale (1=no symptoms; 7=very severe symptoms). Disability was assessed using the section on Social Roles of the Disability Assessment Schedule (DAS II) (18), which rates eight items on a ve-point Likert scale (0=no disability; 5=maximum disability). Global functioning was measured using the Global Assessment of Functioning Scale (GAF) (19), which measures overall psychological functioning on a scale from 0 to 90, where 0 indicates the lowest functioning and 90 the highest.
Statistical analysis

total mean score. Sociodemographic characteristics and service utilization data were extracted from the South-Verona PCR; BPRS, GAF and DAS scores were assessed at the same time as needs in the wider frame of SVOP. The nal set of predictors was selected by stepwise regression, retaining only those variables that showed signicant partial correlation with the dependent variables: the signicance levels for variable entry and removal were, respectively, 0.05 and 0.20, according to Draper and Smith (22). Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) for Windows release 7.5 (23) and STATA Statistical Software, Release 5.0 (24).
Results

Univariate statistics using summary indexes and bivariate statistics (chi-squared test, paired sample t-tests, one-way ANOVA) where appropriate were performed. In order to assess the applicability of ANOVA (i.e. normality and homoschedasticity in the ratings' distribution), non-parametric chisquared tests were applied to empirical frequencies. Total percentage agreement and Cohen's weighted kappa (20) using linear weights, based on ratings of `0', `1' or `2' in Section 1 of each individual area of the CAN, were calculated to give a measure of agreement on the level of need. The weighted index takes into account the degree to which disagreements concern neighbouring categories. Particular attention was paid to the marginal distribution of the ratings in order to avoid the paradox of discordance between percentage agreement and kappa (21). Three multiple regression analyses were nally performed using in turn as dependent variables: 1) mean total number of needs rated by staff, 2) mean total number of needs rated by patients and 3) the difference in needs between staff and patients. A set of sociodemographic, service utilization and clinical characteristics were used as explanatory variables. In order to avoid multicollinearity, correlation among variables was checked. In detail, the sociodemographic characteristics included in the model were: sex, age, marital status (married or not), living situation (with family or not), education (basic or above), and employment status (employed or not); the service utilization variables included were: number of contacts and admissions during the last 3 months, number of contacts and admissions during the last year and time since rst contact; the clinical variables included were: diagnosis, GAF total mean score, BPRS total mean score and DAS 368

The needs of 365 patients were assessed by their own key professionals who completed the CAN-staff. Of these, 118 (32.3%) did not complete the CANpatient due to a series of reasons including patient's refusal to participate or to complete the interview, severity of psychopathology, failure to locate the subjects, and various other practical reasons. Two hundred and forty-seven patients consented and were interviewed by research workers using the CAN-patient. The characteristics of the 247 patients for whom both the CAN-staff and CAN-patient were completed are shown in Table 1. Diagnosis was made according to ICD-10 codes (25) and collapsed into four larger groups according to the classication system used in the South-Verona Psychiatric Case Register (26). These 247 patients were similar to those who were assessed with the CAN-staff alone, with respect to sociodemographic (gender, marital status, living arrangements, educational attainment, employment status, age) and clinical (ICD10 diagnosis, GAF, DAS, BPRS) characteristics, except that the patients assessed with both versions had lower duration of contact with service (4.95 years, 95% CI 4.205.71 vs. 7.29 years, 95% CI 6.068.51; t-test: P<0.01).
Total, met and unmet needs as rated by patients and staff

Overall, ratings of `9' (not known) occurred very rarely, with the exception of the areas concerning intimate relationships (n=24) and sexual expression (n=55) for staff-rated scores, and sexual expression (n=22) for patient-rated scores. Of the 247 subjects interviewed, 84% (n=207), according to the CAN-patient, and 88% (n=218), according to the CAN-staff, had at least one need. The mean total number of needs reported by patients was 3.34 (95% CI 2.973.70), consisting of 2.03 (95% CI 1.782.29) met needs and 1.30 (95% CI 1.041.56) unmet needs. The mean total number of

Perception of needs for care

Table 1. Sociodemographic and clinical characteristics of the patients assessed by using both CAN-staff and CAN-patient (n=247) n Male Female Single, widowed, divorced Married Living alone Living with family or relatives Living in hospital, hostel, community Elementary/junior high school Secondary school/university degree Employed Unemployed Housewife, student, retired Psychosis1 Neurosis2 Personality disorder3 Other No diagnosis Age (years) Admissions last 3 months Admissions last year Contacts last 3 months Contacts last year Time since rst contact (years) GAF score (0=very low functioning; 90=very high functioning) BPRS (1=no symptom; 7=very severe symptom) DAS (0=no disability; 5=maximun disability)
1 2

% 35.6 64.4 58.7 41.3 15.4 80.6 4.0 73.7 26.3 36.8 14.2 49.0 35.6 49.0 4.9 8.1 2.4 S.D. 15.37 0.49 1.26 27.23 93.21 6.03 15.76 0.48 0.95

88 159 145 102 38 199 10 182 65 91 35 121 88 121 12 20 6 Mean 45.30 0.16 0.40 10.18 34.93 4.95 58.68 1.51 0.63

Includes the following ICD-10 diagnoses: F20, F21, F22, F23, F24, F25, F28, F29, F30, F31, F32.2, F33.3, F84. Includes the following ICD-10 diagnoses: F32(0.0, 0.1, 0.2, 0.8, 0.9), F33( 0.0, 0.1, 0.2, 0.8, 0.9), F34.1, F40, F41 (0.0, 0.1, 0.2, 0.3, 0.8, 0.9), F42, F43 (0.20, 0.21, 22), F44, F45, F48, F54. 3 Includes the following ICD-10 diagnoses: F34, F52, F60, F61, F62, F63, F64, F65, F66, F68, F69.

needs rated by staff was 3.26 (95% CI 2.873.65), consisting of 2.36 (95% CI 2.062.64) met needs and 0.90 (95% CI 0.71.10) unmet needs. On the basis of the paired sample t-test, the mean difference between patient and staff assessment of total needs was not signicant (0.07, 95% CI x0.310.46), while the difference was signicant both for met needs (x0.34, 95% CI x0.64x0.04, P<0.05), with higher ratings among staff, and for unmet needs (0.41, 95% CI 0.120.69, P<0.01), with higher ratings among patients. Table 2 shows the mean number of total, met and unmet needs in the 22 CAN areas grouped, according to Slade et al. (9), into ve main aggregated domains of needs (health, basic, social, services and functioning). Signicant discrepancies between patients and staff were found in health and services aggregated domains. In the health domain, staff identied a signicantly higher number of total needs and met needs (specically in the areas of physical health and psychological distress), but a signicantly lower number of unmet needs (specically in the areas of physical health, safety to self, safety to others and psychological distress). In the services domain, staff identied a signicantly lower

number of total and unmet needs (specically in the areas of information and benets), while no signicant difference between patients and staff was found in the number of met needs. No signicant differences were found in the remaining aggregated domains. Table 3 compares the ve aggregated needs domains in the four ICD-10 diagnostic groups (patients with psychosis, neurosis, personality disorders and other diagnosis). As shown in the bottom of Table 3, patients with personality disorders or psychosis reported a higher overall number of total needs; the same was true for met needs, while no signicant difference in unmet needs was found among the diagnostic groups. Staff rated a signicantly higher number of total, met, and unmet needs in patients with personality disorder or psychosis. With regard to the ve aggregated domains, patients with personality disorder reported a signicantly higher number of total needs and of met needs in the basic, social and functioning domains (P<0.05, Bonferroni multiple comparison test). Staff rated a signicantly higher number of total needs in patients with personality disorder or psychosis in all domains. According to the staff, 369

Lasalvia et al.
Table 2. Staff and patient aggregated ratings of total, met, and unmet needs (mean number of needs and 95% CI; paired samples t-test) Total needs Patients Aggregated domain Health (maximum 7) Physical health, psychotic symptoms, drugs, alcohol, safety to self, safety to others and psychological distress Basic (maximum 3) Accommodation, food, daytime activities Social (maximum 3) Sexual expression, company, intimate relationships Services (maximum 4) Information, telephone, transport, benets Functioning (maximum 5) Education, money, childcare, self-care, looking after the home Staff P Patients Met needs Staff P Patients Unmet needs Staff P

Mean 95% CI Mean 95% CI

Mean 95% CI Mean 95% CI

Mean 95% CI Mean 95% CI

1.30 1.161.42 1.51 1.381.64 0.01 0.81 0.700.90 1.26 1.141.38 <0.01 0.50 0.380.6

0.26 0.180.33 <0.01

0.47 0.380.58 0.42 0.320.52 0.33 0.33 0.250.41 0.28 0.200.35

0.21 0.15 0.090.2

0.15 0.090.20

0.91

0.73 0.610.85 0.67 0.560.78 0.34 0.33 0.250.41 0.29 0.220.35

0.46 0.41 0.300.5

0.38 0.300.48

0.62

0.34 0.280.44 0.23 0.170.31 0.01 0.21 0.150.27 0.18 0.120.24

0.44 0.14 0.090.20 0.05 0.090.2

0.04

0.47 0.380.57 0.41 0.300.51 0.26 0.36 0.280.44 0.35 0.250.45

0.88 0.11 0.060.16 0.05 0.020.09

0.06

Table 3. Staff and patient aggregated ratings of total, met, and unmet needs in the various ICD-10 diagnostic groupings shown in Table 1 (mean number of needs; one-way ANOVA) Aggregated domain Health (maximum 7) Level of need Met Unmet Total Met Unmet Total Met Unmet Total Met Unmet Total Met Unmet Total Met Unmet Total Met Unmet Total Met Unmet Total Met Unmet Total Met Unmet Total Met Unmet Total Met Unmet Total Group Patient Psychosis (n=88) 0.70 0.56 1.26 1.38 0.44 1.81 0.43 0.20 0.64 0.47 0.28 0.75 0.28 0.49 0.77 0.35 0.52 0.87 0.26 0.16 0.42 0.26 0.09 0.35 0.47 0.15 0.61 0.57 0.11 0.68 2.08 1.56 3.64 3.05 1.46 4.50 Neurosis (n=121) 0.83 0.49 1.31 1.11 0.14 1.25 0.22 0.14 0.36 0.12 0.05 0.16 0.27 0.35 0.62 0.22 0.26 0.49 0.17 0.13 0.30 0.14 0.03 0.17 0.28 0.09 0.37 0.15 0.01 0.16 1.78 1.20 2.97 1.74 0.50 2.24 Personality d. (n=18) 1.11 0.50 1.61 1.89 0.22 2.11 0.84 0.05 0.89 0.61 0.33 0.94 0.94 0.56 1.50 0.39 0.67 1.05 0.22 0.17 0.39 0.22 0.05 0.27 0.61 0.22 0.83 0.78 0.11 0.89 3.72 1.50 5.22 3.89 1.39 5.28 Other (n=20) 0.85 0.25 1.10 1.10 0.20 1.30 0.10 0.00 0.10 0.10 0.00 0.10 0.30 0.30 0.60 0.30 0.25 0.55 0.15 0.10 0.25 0.05 0.05 0.10 0.15 0.00 0.15 0.25 0.00 0.25 1.55 0.65 2.20 1.80 0.50 2.30 P 0.25 0.59 0.46 <0.01 <0.01 <0.01 <0.01 0.24 <0.01 <0.01 <0.01 <0.01 <0.01 0.52 <0.01 0.30 <0.05 <0.01 0.44 0.88 0.40 0.15 0.43 0.08 <0.05 0.28 <0.01 <0.01 <0.05 <0.01 <0.01 0.29 <0.01 <0.01 <0.01 <0.01

Staff

Basic (maximum 3)

Patient

Staff

Social (maximum 3)

Patient

Staff

Services (maximum 4)

Patient

Staff

Functioning (maximum 5)

Patient

Staff

Overall (maximum 22)

Patient

Staff

370

Perception of needs for care

Table 4. Number of needs (ratings `1' or `2') identied by patients, staff and patientstaff pairs and total percentage agreement for each individual area of the CAN Patient identifying a need No. (%) Health Physical health Psychotic symptoms Drugs Alcohol Safety to self Safety to others Psychological distress Basic Accommodation Food Daytime activities Social Sexual expression Company Intimate relationships Services Information Telephone Transport Benets Functioning Basic education Money Childcare Self-care Looking after the home Staff identifying a need No. (%) Patient/staff pairs identifying a need No. (%) Total percentage agreement %

70 (28.3) 52 (21.1) 5 (2.0) 9 (3.6) 34 (13.8) 18 (7.3) 132 (53.4) 27 (10.9) 44 (17.8) 47 (19.0) 49 (19.9) 66 (26.8) 66 (26.8) 25 11 30 23 (10.1) (4.5) (12.1) (9.3)

78 (31.6) 69 (27.9) 6 (2.4) 12 (4.9) 20 (8.1) 7 (2.8) 182 (73.7) 19 (7.7) 30 (12.1) 56 (22.7) 37 (15.0) 77 (31.2) 52 (21.1) 25 (10.1) 2 (0.8) 22 (8.9) 10 (4.0) 3 (1.2) 19 (7.7) 5 (2.0) 31 (12.6) 43 (17.4)

36 (15) 27 (11) 0 (0) 3 (1.2) 4 (2) 2 (0.8) 105 (43) 9 (4) 15 (6) 24 (10) 16 (7) 34 (14) 27 (11) 2 1 7 4 (0.8) (0.4) (2.8) (2.0)

63 70 95* 92 80 90* 42 88 80 73 53 64 69 84 95* 84 89 93* 87 97* 82 78

15 (6.1) 29 (11.7) 1 (0.4) 25 (10.1) 47 (19)

1 (0.4) 9 (4.0) 0 (0) 8 (3.2) 19 (9)

* In this area the percentage agreement on the presence of a need is <1% (indicating that a very limited number of pairs agreed on the presence of a need, while most staff patient pairs agreed on the absence of a need).

these two diagnostic groups also had a signicantly higher number of met needs in the health, basic, and functioning domains and a signicantly higher number of unmet needs in those same three domains plus the social domain (P<0.05, Bonferroni multiple comparison test).
Agreement of patientstaff pairs

The number of needs identied in each CAN area (ratings `1' or `2'), respectively, by patient alone, staff alone and by the patientstaff pairs is shown in the rst three columns of Table 4. In all cases the needs that were most frequently identied by both patients and staff were related to the health and social domains and specically to the areas of psychological distress, physical health, company, psychotic symptoms and intimate relationships. The individual areas of need mentioned most frequently by both patients and staff were psychotic symptoms and psychological distress in subjects with a diagnosis of psychosis, psychological distress and physical health in subjects with a diagnosis of neurosis and psychological distress and company in subjects with personality disorders.

Overall, the patientstaff pairs agreed on a number of areas ranging from a minimum of 6 to a maximum of 22, with 75% of the pairs agreeing on more than 15 CAN areas. Their agreement on the full range of possible scores (`0', `1' and `2') was explored in each of the 22 CAN areas. Both the simple agreement rate and the kappa statistic were computed. The latter represents a more severe index of agreement because it controls for random agreement. The total percentage agreement of patientstaff pairs in each individual CAN area is shown in the fourth column of Table 4. According to House et al. (27), percentage agreement is considered good if it is o90% and adequate if it is between 80 and 90%. In our sample, the agreement was good (range 9097) in six areas: safety to others, drugs, alcohol, basic education, childcare and telephone; adequate (range 8089) in eight areas: accommodation, food, self-care, safety to self, information, money, transport and benets; and poor (range 4278) in the remaining eight areas. In this last group we found an agreement between 60% and 80% in six areas (looking after the home, daytime activities, psychotic symptoms, intimate relationships, company, physical health) and below 60% in the remaining two areas (sexual expression and psychological distress). 371

Lasalvia et al. In order to adjust for the agreement due to chance, a weighted kappa coefcient was calculated for each individual CAN area. According to Landis and Koch (28), the agreement indicated by a kappa coefcient can be slight (up to 0.2), fair (0.210.4), moderate (0.410.6), substantial (0.610.8) and almost perfect (0.811.0). Due to insufciently spread data, kappa was applicable (interquartile range o1) in only ve areas: physical health, psychotic symptoms, psychological distress, company and intimate relations. In these ve areas, where a poor percentage agreement was found, patientstaff agreement indicated by weighted kappa was also low, ranging from slight (psychological distress 0.14; intimate relations 0.19) to fair (physical health 0.21; psychotic symptoms 0.21; company 0.23). In order to explore which needs tend to be perceived more frequently either by patients or by staff in those patientstaff pairs who disagree on the presence of a need, we calculated in each CAN area the ratio between the number of needs identied by patients and the number of needs identied by staff. Table 5 shows the patient/staff ratio in those patientstaff pairs who disagree, with a patient/ staff ratio >1 indicating that the patients have the tendency to identify more needs than the staff. As reported in Table 5, patients tended to perceive more needs than staff in telephone, basic education, safety to others, benets and money, while staff tended to identify more needs than patients in childcare, psychological distress and psychotic symptoms.
Predictors of need
Table 5. Direction of disagreement for each CAN area in those patientstaff pairs who disagree on the presence of a need Need identied by patient only No. Health Physical health Psychotic symptoms Drugs Alcohol Safety to self Safety to others Psychological distress Basic Accommodation Food Daytime activities Social Sexual expression Company Intimate relationships Services Information Telephone Transport Benets Functioning Basic education Money Childcare Self-care Looking after the home Need identied by staff only No.

Patient/ staff ratio

34 25 5 6 30 16 27 18 29 32 33 32 39 23 10 23 18 14 20 1 17 28

42 42 6 9 16 5 77 10 15 32 21 43 25 23 1 15 6 2 10 5 23 24

0.8 0.6 0.8 0.7 1.9 3.2 0.3 1.8 1.9 0.7 1.6 0.7 1.6 1.0 10.0 1.5 3.0 7.0 2.0 0.2 0.7 1.2

Three multiple regression analyses were performed to explore the relative inuence of sociodemographic, service utilization and clinical variables on: 1) the mean total number of needs rated by patients; 2) the mean total number of needs rated by staff, and 3) on the difference between patientstaff ratings.

As shown in Table 6, a higher number of patientrated needs was predicted by patient disability, but the model explains only 13% of the variance. A higher number of staff-rated needs was predicted by patient disability, number of contacts with service and being unemployed, with 54% of variance explained by the model. A higher disagreement between patient and staff ratings was predicted by lower patient global functioning, but the model explains only 15% of the variance.

Table 6. Multiple regression analyses of the effect of sociodemographic, service utilization and clinical variables on: 1) mean total number of needs as rated by patients; 2) mean total number of needs as rated by staff; and 3) difference between patient and staff ratings of needs (n=247). Only factors with signicant effect (P<0.05) were retained in the model 1 Needs rated by patients Independent variable1 DAS GAF Number of contacts in the last year Employment status (1=employed; 0=unemployed) Constant R2 adjusted
1

2 Needs rated by staff t 6.0 b 1.78 0.62 x1.27 2.33 0.54 SE 0.15 0.11 0.29 0.21 t 11.7 5.6 x4.43 11.3 x0.07 b

3 D needs SE t

b 1.09

SE 0.18

0.01

x6.58

2.6 0.13

0.21

12.8

4.31 0.15

0.69

6.2

Independent variables which did not enter in any model are omitted from the table.

372

Perception of needs for care

Discussion

To our knowledge this is the rst study in the literature to assess needs for care according to both patient and staff perspectives in a sample of patients that includes the full spectrum of diagnoses of mental disorder. Moreover, this is the rst study to assess the needs for care in patients attending a wellresearched Italian community-based psychiatric service.
Total, met and unmet needs

ional's judgement may result in better compliance which may in turn increase the uptake of interventions being offered.
Agreement between patientstaff pairs

Patients and staff identied approximately the same number of overall needs (respectively, 3.34 and 3.26). The number of total needs reported in this sample is lower than in a roughly similar diagnostic sample of Swedish psychiatric inpatients and out-patients (29), which reported values of total needs of approximately 5. According to patients and staff, the higher number of needs belonged to the health and social domains. The CAN areas most frequently mentioned by the patients are consistent with the results of a Swedish study (29), in which a higher number of needs was found in psychological distress, psychotic symptoms, physical health, company and intimate relationships. Staff identied a signicantly higher number of total needs in the health domain (physical health, psychotic symptoms, drugs, alcohol, safety to self, safety to others and psychological distress) while patients reported a signicantly higher mean number of total needs in the service domain (information, telephone, transport and benets). The latter nding is consistent with results reported by Slade et al. (9). Patients rated a signicantly higher mean number of unmet needs in the health and services domains, and specically in the areas of physical health, psychological distress, safety to self, safety to others, information and benets. Surprisingly, we found that staff identied a signicantly higher number of met needs in physical health and psychological distress, which are two of the areas where the patients had reported the higher number of unmet needs. Overall, these ndings are of interest, since they suggest that staff tend to perceive needs in the health domain more frequently than the patient. In the staff view, these needs are usually met; on the contrary, the patients, when they perceive needs in this domain, tend to consider them mostly unmet. This discrepancy is likely to reect different opinions of patients and staff on the effectiveness of the interventions provided. Negotiating care goals on the basis of both the subjective views of the patient and the profess-

On the whole, our results indicate that in most of the CAN areas staff and patients have different perceptions both on the presence of a need and on whether or not needs have been met. Psychological distress, physical health, psychotic symptoms, intimate relationships, company and sexual expression were the CAN areas with the poorest agreement, as indicated by low values of both total percentage agreement and weighted kappa. The high percentage agreement found in drugs, safety to others, telephone, childcare and basic education occurred in those CAN areas where most patient staff pairs agreed on the absence of a need, while few pairs agreed in identifying the presence of a need. Disagreement between staff and patients on unmet needs can be due to different factors in the various CAN areas (9). For example, lack of knowledge of the patient's problems by the staff may apply particularly to CAN areas such as sexual expression or intimate relations. Different expectations about what constitutes a problem, as a result of sociocultural, educational and professional background, may apply to some CAN health-related areas. On the other hand, agreement tends to be higher in those CAN areas that assess well-dened service responses (such as supported housing, telephone card provision or benets entitlement). Such results are consistent with the ndings from previous studies (8, 9), in which good agreement was found only in the areas where a specic service intervention had been provided and for which the type and extent of problems had already been negotiated. When staffpatient pairs disagree, patients tend to identify more needs in areas of everyday life such as use of the telephone, basic education and benets, while staff seems to be more sensitive to medical issues such as psychological distress and psychotic symptoms. Therefore, a standardized needs assessment may be extremely useful in mental health care because it forces staff members to evaluate systematically all areas of potential needs.
Needs and diagnosis

For subjects with a diagnosis of personality disorder or psychosis, both staff and patients reported a signicantly higher number of total and met needs; in these groups a higher number of unmet needs was also rated by staff. The subsample of psychotic 373

Lasalvia et al. patients assessed in this study rated a number of needs (mean 3.64) that was similar to that reported in a Dutch sample of psychotic patients (mean 2.9) (10), but much lower than was found in a British sample (mean: 6.7) (9). Moreover, in a previous pilot study, Slade et al. (8) found that psychiatric patients rated an even higher mean number of total needs (mean 7.9). This difference could be due to the more difcult living conditions in deprived metropolitan areas such as London compared to a medium-size wealthy city such as Verona. According to the staff's point of view, it seems that patients who are suffering from the more severe mental disorders, such as psychosis and personality disorders, tend to constitute a broader and quite homogeneous category of subjects based on their level of needs, regardless of their specic ICD-10 diagnosis. These very difcult and problematic patients deserve specic attention from mental health services in terms of long-term and comprehensive interventions.
Needs, sociodemographic, service utilization and clinical variables

whether a need had been met or not was poor in most CAN areas. In general, staff tended to identify more needs in areas related to medical issues, while patients tended to report more needs in areas of everyday life. Therefore, in order to plan and provide effective needs-led mental health care it is not sufcient to assess staff or patient views alone, but it is necessary to take multiple perspectives into account. In this context, further research is needed in order to examine the relationships between needs for care, as assessed by both patients and staff, and users' sociodemographic characteristics, service utilization and other outcome variables, such as psychopathology, quality of life, satisfaction with the services and family burden (31). Furthermore, longitudinal studies are also needed in order to explore whether improvements in the various outcome measures are associated with a reduction of unmet needs for care and to evaluate whether high patientstaff agreement may be used as a reliable predictor of an increase of the proportion of met needs in the medium or long term.
Acknowledgements
This study was supported by the Cassa di Risparmio di Verona, Vicenza, Belluno e Ancona Foundation, Progetto Sanita 19961997 (grant to Prof. Michele Tansella). The authors thank Laura Fontecedro, Paola Bonizzato, Maurizio Galletta, Nazario Santolini, Paola Pacati, Tommaso Maniscalco, Manuela Benetollo for their contribution in the data collection, Doriana Cristofalo for assistance in data management and Giulia Bisof for her comments on statistical analyses.

The ndings of our regression analyses should be taken with caution due to the not optimal subjectsto-variables ratio (30) and need further conrmation in a larger sample. However, they seem to suggest that subjects which are unemployed, which have had a high number of service contacts in the previous year and have severe disability in social roles tend to show a higher number of total needs, regardless of diagnosis. Both service contact and unemployment may be viewed as proxy measures of patient's severity from the staff point of view. So, it is not surprising that staff members tend to rate higher number of needs (and specically healthrelated needs) in those patients which they consider more seriously ill. Nevertheless, the more serious the patient's clinical condition, the more difcult it was for staff to perceive what kind of needs were important for the patient. In fact, as shown by the results of the multivariate analysis, the difference between needs rated by staff and by patients tends to increase when the global functioning of the patients assessed decreases. For this reason, especially in severely ill patients, a thorough needs assessment should take into account the patient's point of view by means of a structured interview that explicitly elicits the patient's opinion. In conclusion, our ndings conrm that disagreement between patients and expert/staff opinion seems to be the rule rather than the exception (10, p. 56), especially when provision of individualized mental health care in concerned. The agreement between patientstaff pairs on the presence of a need and on 374

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