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Schindler A, Warkentin HF, Bierbrodt J, König H, Konnopka A, Pepic A, Peth J, Lambert M, Gallinat J, Karow A, König HH, Härter M, Schulz H, Rohenkohl A, Krog K, Biedermann SV, Schäfer I. Dialectical behavior therapy (DBT) in an assertive community treatment structure (ACT): testing integrated care borderline (ICB) in a randomized controlled trial (RECOVER). Borderline Personal Disord Emot Dysregul 2024; 11:18. [PMID: 39138537 PMCID: PMC11323610 DOI: 10.1186/s40479-024-00261-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 07/18/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND Though Dialectical Behavior Therapy (DBT) and other treatment models for individuals with Borderline Personality Disorder (BPD) have shown to be efficient in inpatient and outpatient settings, there is a general shortage of these treatments. In Germany, most resources are spent on inpatient treatments and unspecific crisis interventions, while it is difficult to implement the necessary team structures in an outpatient setting. This study is testing an alternative approach focussing on outpatient treatment: Integrated Care Borderline (ICB) provides DBT for persons with severe BPD within the structures of an Assertive Community Treatment (ACT). ICB is team-based, integrating psychiatric and social support as well as crisis interventions into a DBT-strategy. METHODS ICB was compared to TAU in a prospective, randomized controlled trial. This study is part of RECOVER, a comprehensive stepped care approach in Germany, which enrolled a total of 891 participants. 146 persons were diagnosed with BPD as main diagnosis. Of these, 100 were allocated to the highest level of severe mental illness (SMI) and randomly assigned to either ICB (n = 50) or TAU (n = 50). Data were collected at baseline and 12 months later. The main outcomes were psychosocial functioning (GAF), severity of BPD (BSL-23) and other mental symptoms (BSI, PHQ-9, GAD-7, self-harm), employment status (VILI), as well as hospital days and associated costs. RESULTS Data show a significant increase of psychosocial functioning and a significant decrease of BPD and other psychiatric symptoms in both groups (r = .28 - .64), without any significant differences between the groups. The proportion of self-harming persons decreased in both groups without statistical significance. Patients were significantly more likely to be employed after a year of treatment in ICB (p = .001), but not in the TAU group (p = .454). Analyses showed a significant difference between the groups (p = .032). Moreover, psychiatric hospital days were significantly reduced in ICB (-89%, p < .001, r = .61), but not in TAU (-41%, p = .276, r = .15), resulting in a significant difference between the groups (p = .016) and in lower annual hospital costs in ICB (5,546€ vs. 10,726€, -48%, p = .011) compared to TAU. CONCLUSION Our results replicate earlier studies, showing that DBT can be efficient in outpatient settings. Furthermore, they indicate additional effects on employment and hospital days. The ICB-approach seems to offer a viable framework for multiprofessional outpatient DBT-teams. Future research will have to test whether the additional effects are brought about by the additional features of ICB compared to standard outpatient DBT. TRIAL REGISTRATION Registration number with ClinicalTrials.gov (NCT03459664), RECOVER.
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Affiliation(s)
- Andreas Schindler
- Center for Psychosocial Medicine, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - H F Warkentin
- Center for Psychosocial Medicine, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Bierbrodt
- Center for Psychosocial Medicine, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H König
- Center for Psychosocial Medicine, Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Konnopka
- Center for Psychosocial Medicine, Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Pepic
- Center for Experimental Medicine, Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Peth
- Center for Psychosocial Medicine, Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Lambert
- Center for Psychosocial Medicine, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Gallinat
- Center for Psychosocial Medicine, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Karow
- Center for Psychosocial Medicine, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H-H König
- Center for Psychosocial Medicine, Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Härter
- Center for Psychosocial Medicine, Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H Schulz
- Center for Psychosocial Medicine, Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Rohenkohl
- Center for Psychosocial Medicine, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - K Krog
- Center for Psychosocial Medicine, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S V Biedermann
- Center for Psychosocial Medicine, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - I Schäfer
- Center for Psychosocial Medicine, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Zelko E, Korpar DC. The Impact of the Community Psychiatric Treatment Program on the User's Quality of Life - experience of the Study Participants. Mater Sociomed 2022; 34:296-300. [PMID: 36936889 PMCID: PMC10019875 DOI: 10.5455/msm.2022.34.296-300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 12/04/2022] [Indexed: 12/23/2022] Open
Abstract
Background Community psychiatric treatment (CPT) is a novelty in the primary health care system for the people with mental health problems. The service operates according to the Flexible Assertive Community Treatment (FACT) model. FACT is a rehabilitation-oriented clinical case management model based on the ACT model (Assertive Community Treatment). Objective This study aimed to assess how involvement in a community psychiatry program affects the quality of life of program participants. Methods Between December 2020 and March 2021 we conducted a qualitative study. To obtain information, semi-structured interviews with twelve patients treated in the Community Psychiatric Treatment program were conducted. All restriction regarding COVID pandemic were considered at the research. Content analysis of the text was used for data analysis, which means that we interpreted the analysed text and determine the meaning of individual parts of the text. Results Twelve persons participated in the interviews, six of which were women (50%) and six men (50%). All the participants were of Slovenian nationality. They were from 28 to 80 years old, with a mean age of 47 years. We identified twelve categories and four themes: treatment problems, principles of operating of CPT program, satisfaction with inclusion in the CPT and improvement of quality of life through inclusion in the program. Conclusion Quality of life is essential for every individual, as well as for people with mental health problems. In our study we have proved that the Community psychiatric programs could significantly impact the quality of life of people with mental health problems.
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Affiliation(s)
- Erika Zelko
- Faculty of Medicine University of Maribor, Maribor, Slovenia
- JKU Linz, Faculty of Medicine, Institut of Family Medicine, Linz, Austria
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The Psychiatric Nurse Care Coordinator on a Multi-disciplinary, Community Mental Health Treatment Team. Community Ment Health J 2022; 58:1354-1360. [PMID: 35169939 DOI: 10.1007/s10597-022-00945-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 01/18/2022] [Indexed: 11/03/2022]
Abstract
Community mental health nurses sometimes join multi-disciplinary teams, but the role has not been defined and studied carefully. This article describes the psychiatric Nurse Care Coordinator (NCC)-a unique position created to support care management, facilitate systematic medication management, and coordinate medical care in the Social Security Administration's 30-site Supported Employment Demonstration. The authors reviewed the study's NCC manual, supervised and consulted with the NCCs weekly over nearly three years, and reviewed data on NCC activities. Although the 984 participants assigned to NCCs experienced numerous mental health, substance use, and chronic medical conditions, only 59% completed intake assessments and engaged over time with NCCs. For those 581 participants, NCCs spent approximately 51% of their time helping with mental health issues, 35% on medical care, and 12% on substance use conditions. The NCC was critically important for complex, high-need individuals.
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Mueller-Stierlin AS, Dinc U, Herder K, Walendzik J, Schuetzwohl M, Becker T, Kilian R. The Cost-Effectiveness Analysis of an Integrated Mental Health Care Programme in Germany. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116814. [PMID: 35682397 PMCID: PMC9180080 DOI: 10.3390/ijerph19116814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/18/2022] [Accepted: 05/31/2022] [Indexed: 02/06/2023]
Abstract
The network for mental health (NWpG = Netzwerk psychische Gesundheit) is an umbrella association for non-medical community mental health care facilities across Germany which are enabled to provide multi-professional mental health care packages including medical and psychosocial services reimbursed by German statutory health insurances since 2009. The aim of this study is to analyse the cost-effectiveness of providing NWpG mental health care packages plus treatment as usual (NWpG) to treatment as usual alone (TAU) in Germany. In a prospective, multicenter, controlled trial over 18 months, a total of 511 patients (NWpG = 251; TAU = 260) were observed in five regions, four times at six-month intervals. The EQ-5D-3L and the Client Sociodemographic and Service Receipt Inventory (CSSRI) were used to estimate quality-adjusted life-years and total costs of illness. Propensity score-adjusted cost–utility analysis was applied using the net benefit approach. No significant differences in costs and QALYs between NWpG and TAU groups were identified. The probability of NWpG being cost-effective compared to TAU was estimated below 75% for maximum willingness to pay (MWTP) values between 0 and 125,000 EUR. The additional provision of the NWpG package is not cost-effective compared to TAU alone.
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Affiliation(s)
- Annabel Sandra Mueller-Stierlin
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, 89312 Günzburg, Germany
- Institute of Epidemiology and Medical Biometry, Ulm University, 89075 Ulm, Germany
| | - Uemmueguelsuem Dinc
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, 89312 Günzburg, Germany
| | - Katrin Herder
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, 89312 Günzburg, Germany
| | | | - Matthias Schuetzwohl
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, 01307 Dresden, Germany
| | - Thomas Becker
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, 89312 Günzburg, Germany
| | - Reinhold Kilian
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, 89312 Günzburg, Germany
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Marquant T, Van Nuffel M, Sabbe B, Goethals K. Substance Use Disorders as a Critical Element for Decision-Making in Forensic Assertive Community Treatment: A Systematic Review. Front Psychiatry 2021; 12:777141. [PMID: 34950071 PMCID: PMC8688775 DOI: 10.3389/fpsyt.2021.777141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/29/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction: The prevalence of substance use disorders in forensic populations is high. They are an important factor linked to negative outcomes in mentally ill offenders and are detrimental to forensic or non-forensic outcome measures. In contrast, substance use disorders are often underdiagnosed and undertreated, especially in forensic settings. Forensic Assertive Community Treatment is a forensic adaptation of regular assertive community treatment, combined with essential elements of forensic rehabilitation theories. Little is known however on the effectivity of forensic assertive community treatment when it comes to substance use disorders or what their exact role is on the outcome measures. In this paper, we explore how SUD is treated in Forensic assertive community treatment and how it relates to the forensic and non-forensic outcome measures. Methods: We performed a systematic review (PRISMA) of forensic Assertive community treatment teams that followed the main evidence-based principles of regular assertive community treatment and added basic elements of forensic rehabilitation. We analyzed articles the Psychinfo and Medline databases dating from 2005 to 2020. Fifteen studies fit the search criteria and were included in the analysis. The Quality of the studies was assessed using the Newcastle-Ottawa scale. Results: SUD was highly prevalent in all studies. Patients entered FACT through two pathways, either from a care continuum or directly from prison. The severity of SUD at intake emerges as a critical element when deciding which pathway to choose, as a high severity-score at the start of FACT follow-up was linked to recidivism. While differing in method all studies offered integrated SUD treatment. These included evidence-based techniques like CBT, therapeutic communities, and Substance Abuse Management Module. Though results on SUD outcomes were mixed 4 studies mentioned abstinence in 50-75%. The severity of SUD tended to increase initially and to stabilize afterwards. Conclusion: Severity of SUD at intake emerges as a decisive element in decision-making on entering FACT teams directly from prison or through a care-continuum. The ways to provide SUD treatment varied and outcomes for SUD were mixed. SUD was found to be detrimental to forensic and non-forensic outcome measures, such as recidivism or hospitalizations during FACT treatment.
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Affiliation(s)
- Thomas Marquant
- Department of Psychiatry, Collaborative Antwerp Psychiatric Research Institute, Antwerp, Belgium
- Department of Forensic Psychiatry, Fivoor, Rotterdam, Netherlands
- Department of Justice, Brussels, Belgium
| | | | - Bernard Sabbe
- Department of Psychiatry, Collaborative Antwerp Psychiatric Research Institute, Antwerp, Belgium
- Department of Psychiatry, Antwerp University, Antwerp, Belgium
- Department of Psychiatry, Antwerp University Hospital, Antwerp, Belgium
| | - Kris Goethals
- Department of Psychiatry, Collaborative Antwerp Psychiatric Research Institute, Antwerp, Belgium
- Department of Psychiatry, Antwerp University, Antwerp, Belgium
- Department of Psychiatry, Antwerp University Hospital, Antwerp, Belgium
- Department of Forensic Psychiatry, University Forensic Center, Antwerp, Belgium
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Nyttingnes O, Rugkåsa J. The Introduction of Medication-Free Mental Health Services in Norway: An Analysis of the Framing and Impact of Arguments From Different Standpoints. Front Psychiatry 2021; 12:685024. [PMID: 34366919 PMCID: PMC8340297 DOI: 10.3389/fpsyt.2021.685024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/14/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Debates about coercive practices have challenged a traditional biomedical hegemony in mental health care. The perspectives of service user organizations have gained considerable ground, such as in the development of the Convention on the Rights of Persons with Disabilities. Such changes are often contested, and might in practice be a result of (implicit) negotiation between stakeholders with different discursive positions. To improve understanding of such processes, and how discursive positions may manifest and interact, we analyzed texts published over a 10 year period related to the introduction of medication-free inpatient services in Norway. Methods: We conducted qualitative analyses of 36 policy documents related to the introduction of medication-free services and 75 opinion pieces from a subsequent debate. We examined discursive practices in these texts as expressions of what is perceived as legitimate knowledge upon which to base mental health care from the standpoints of government, user organizations and representatives of the psychiatric profession. We paid particular attention to how standpoints were framed in different discourse surrounding mental health care, and how these interacted and changed during the study period (2008-2018). Results: The analysis shows how elements from the discourse promoted by service user organizations-most notably the legitimacy of personal experiences as a legitimate source of knowledge-entered the mainstream by being incorporated into public policy. Strong reactions to this shift, firmly based in biomedical discourse, endorsed evidence-based medicine as the authoritative source of knowledge to ensure quality care, although accepting patient involvement. Involuntary medication, and how best to help those with non-response to antipsychotic medication represented a point at which discursive positions seemed irreconcilable. Conclusion: The relative authorities of different sources of knowledge remain an area of contention, and especially in determining how best to help patients who do not benefit from antipsychotics. Future non-inferiority trials of medication-free services may go some way to break this discursive deadlock.
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Affiliation(s)
- Olav Nyttingnes
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
- R&D Department Mental Health, Akershus University Hospital, Lørenskog, Norway
| | - Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
- Centre for Care Research, University of South-Eastern Norway, Porsgrunn, Norway
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Hogewind JWF, Nugter MA, Engelsbel F. Pilot Study of the Cost-Effectiveness of Youth F-ACT in the Netherlands. Community Ment Health J 2021; 57:701-710. [PMID: 33630227 DOI: 10.1007/s10597-021-00791-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 01/31/2021] [Indexed: 10/22/2022]
Abstract
Mental healthcare costs are rising. Community-based interventions often are being implemented without sufficient evidence for the effectiveness in terms of care and cost. In this pilot study, we evaluated the cost-effectiveness of youth Flexible Assertive Community Treatment (F-ACT) compared to treatment as usual (TAU). In total 28 adolescents (12-18 years) participated in F-ACT (N = 13) and TAU (N = 15). The outcome measures were the percentage of adolescents with a significant improvement in quality of life and Quality Adjusted Life Years (QALYs). Costs were measured using a retrospective cost-questionnaire. Outcomes were assessed at the start and after three months of care. Compared to TAU, F-ACT resulted in a significantly higher quality of life as reported by adolescents. There was no significant difference in quality of life reported by the parents. The incremental cost-effectiveness ratio (ICER) demonstrated that youth F-ACT is more effective but with higher costs. This study may help to make evidence-based decisions in terms of who benefits the most from youth F-ACT interventions.
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Affiliation(s)
- Johannes W F Hogewind
- Department of Child and Youth Psychiatry, Mental Health Service Organization GGZ Noord-Holland-Noord, PO Box 18, 1850 BA, Heiloo, The Netherlands. .,Department of Research and Monitoring, Mental Health Service Organization GGZ Noord-Holland-Noord, PO Box 18, 1850 BA, Heiloo, The Netherlands.
| | - M Annet Nugter
- Department of Research and Monitoring, Mental Health Service Organization GGZ Noord-Holland-Noord, PO Box 18, 1850 BA, Heiloo, The Netherlands
| | - Fabiana Engelsbel
- Department of Research and Monitoring, Mental Health Service Organization GGZ Noord-Holland-Noord, PO Box 18, 1850 BA, Heiloo, The Netherlands
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Ben-Zeev D, Buck B, Meller S, Hudenko WJ, Hallgren KA. Augmenting Evidence-Based Care With a Texting Mobile Interventionist: A Pilot Randomized Controlled Trial. Psychiatr Serv 2020; 71:1218-1224. [PMID: 32631130 PMCID: PMC7708508 DOI: 10.1176/appi.ps.202000239] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study aimed to evaluate the feasibility and clinical utility of training intensive psychiatric community care team members to serve as "mobile interventionists" who engage patients in recovery-oriented texting exchanges. METHODS A 3-month pilot randomized controlled trial was conducted to compare the mobile interventionist approach as an add-on to assertive community treatment (ACT) versus ACT alone. Participants were 49 individuals with serious mental illness (62% with schizophrenia/schizoaffective disorder, 24% with bipolar disorder, and 14% with depression). Clinical outcomes were evaluated at baseline, posttreatment, and 6-month follow-up, and satisfaction was evaluated posttreatment. RESULTS The intervention appeared feasible (95% of participants assigned to the mobile interventionist arm initiated the intervention, texting on 69% of possible days and averaging four messages per day), acceptable (91% reported satisfaction), and safe (no adverse events reported). Exploratory posttreatment clinical effect estimations suggested greater reductions in the severity of paranoid thoughts (Cohen's d=-0.61) and depression (d=-0.59) and improved illness management (d=0.31) and recovery (d=0.23) in the mobile interventionist group. CONCLUSIONS Augmentation of care with a texting mobile interventionist proved to be feasible, acceptable, safe, and clinically promising. The findings are encouraging given the relative ease of training practitioners to serve as mobile interventionists, the low burden placed on patients and practitioners, and the simplicity of the technology. The technical resources are widely accessible to patients and practitioners, boding well for potential intervention scalability. When pandemics such as COVID-19 block the possibility of in-person patient-provider contact, evidence-based texting interventions can serve a crucial role in supporting continuity of care.
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Affiliation(s)
- Dror Ben-Zeev
- Department of Psychiatry and Behavioral Sciences, BRiTE Center, University of Washington, Seattle (Ben-Zeev, Buck, Meller, Hallgren); Department of Psychological and Brain Sciences, Dartmouth College, and Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, New Hampshire (Hudenko)
| | - Benjamin Buck
- Department of Psychiatry and Behavioral Sciences, BRiTE Center, University of Washington, Seattle (Ben-Zeev, Buck, Meller, Hallgren); Department of Psychological and Brain Sciences, Dartmouth College, and Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, New Hampshire (Hudenko)
| | - Suzanne Meller
- Department of Psychiatry and Behavioral Sciences, BRiTE Center, University of Washington, Seattle (Ben-Zeev, Buck, Meller, Hallgren); Department of Psychological and Brain Sciences, Dartmouth College, and Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, New Hampshire (Hudenko)
| | - William J Hudenko
- Department of Psychiatry and Behavioral Sciences, BRiTE Center, University of Washington, Seattle (Ben-Zeev, Buck, Meller, Hallgren); Department of Psychological and Brain Sciences, Dartmouth College, and Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, New Hampshire (Hudenko)
| | - Kevin A Hallgren
- Department of Psychiatry and Behavioral Sciences, BRiTE Center, University of Washington, Seattle (Ben-Zeev, Buck, Meller, Hallgren); Department of Psychological and Brain Sciences, Dartmouth College, and Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, New Hampshire (Hudenko)
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O'Donnell R, Savaglio M, Fast D, Vincent A, Vicary D, Skouteris H. MyCare study: protocol for a controlled trial evaluating the effect of a community-based intervention on psychosocial, clinical outcomes and hospital admission rates for adults with severe mental illness. BMJ Open 2020; 10:e040610. [PMID: 33234646 PMCID: PMC7684817 DOI: 10.1136/bmjopen-2020-040610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION People with serious mental illness (SMI) often fail to receive adequate treatment. To provide a higher level of support, mental health systems have been reformed substantially to integrate mental healthcare into the community. MyCare is one such community-based mental health model of care. This paper describes the study protocol of a controlled trial examining the effect of MyCare on psychosocial and clinical outcomes and hospital admission and duration rates for adults with SMI. METHODS AND ANALYSIS This is a multisite non-randomised controlled trial with a 3, 6 and 12-month follow-up period. The study participants will be adults (18-64 years of age) with SMI recruited from Hobart, Launceston and the North-West of Tasmania. The treatment group will include adults who receive both the MyCare intervention and standard mental health support; the control group will include adults who receive only standard mental health support. The primary outcome includes psychosocial and clinical functioning and the secondary outcome will examine hospital admission rates and duration of stay. Mixed-effects models will be used to examine outcome improvements between intake and follow-up. This trial will generate the evidence needed to evaluate the effect of a community mental health support programme delivered in Tasmania, Australia. If MyCare results in sustained positive outcomes for adults with SMI, it could potentially be scaled up more broadly across Australia, addressing the inequity and lack of comprehensive treatment that many individuals with SMI experience. ETHICS AND DISSEMINATION This study has been approved by the Tasmanian Health and Medical Human Research Ethics Committee. The findings will be disseminated to participants and staff who delivered the intervention, submitted for publication in a peer-reviewed journal and shared at academic conferences. TRIAL REGISTRATION NUMBER ACTRN12620000673943.
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Affiliation(s)
- Renée O'Donnell
- Monash Centre for Health Research and Implementation, Monash University, Clayton, Victoria, Australia
| | - Melissa Savaglio
- Monash Centre for Health Research and Implementation, Monash University, Clayton, Victoria, Australia
| | | | | | | | - Helen Skouteris
- Monash Centre for Health Research and Implementation, Monash University, Clayton, Victoria, Australia
- Warwick Business School, University of Warwick, Coventry, West Midlands, UK
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Liljeholm U, Argentzell E, Bejerholm U. An integrated mental health and vocational intervention: A longitudinal study on mental health changes among young adults. Nurs Open 2020; 7:1755-1765. [PMID: 33072359 PMCID: PMC7544838 DOI: 10.1002/nop2.560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 05/26/2020] [Accepted: 06/16/2020] [Indexed: 01/17/2023] Open
Abstract
Aim This study aimed to investigate changes in mental health among young adults participating in an integrated mental health and vocational support intervention according to the Södertälje Supported Employment and Education model. Design A prospective longitudinal pre–post intervention study of 12 months. Methods Instruments on depressive symptoms, quality of life, empowerment, engagement in activities and sociodemographic characteristics were administered to 42 young adults aged 19–28 years with mood disorders. Wilcoxon signed rank tests were used to assess changes in mental health. Results Statistically significant positive changes between baseline and 12 months were noted for quality of life and engagement in activities. Difference in empowerment scores neared significance and a statistical trend towards lower depression scores was seen, corresponding to moderate depression at baseline and less severe depression at 12 months. Conclusions Integrated mental health and vocational services may support young adults' mental health and is suggested to be linked to their personal recovery and clinical recovery.
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Affiliation(s)
- Ulrika Liljeholm
- Department of Health Sciences/Mental Health, Activity and Participation Lund University Lund Sweden.,Centre for Evidence-based Psychosocial Interventions Lund University Lund Sweden
| | - Elisabeth Argentzell
- Department of Health Sciences/Mental Health, Activity and Participation Lund University Lund Sweden.,Centre for Evidence-based Psychosocial Interventions Lund University Lund Sweden
| | - Ulrika Bejerholm
- Department of Health Sciences/Mental Health, Activity and Participation Lund University Lund Sweden.,Centre for Evidence-based Psychosocial Interventions Lund University Lund Sweden
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Shields-Zeeman L, Petrea I, Smit F, Walters BH, Dedovic J, Kuzman MR, Nakov V, Nica R, Novotni A, Roth C, Tomcuk A, Wijnen BFM, Wensing M. Towards community-based and recovery-oriented care for severe mental disorders in Southern and Eastern Europe: aims and design of a multi-country implementation and evaluation study (RECOVER-E). Int J Ment Health Syst 2020; 14:30. [PMID: 32336984 PMCID: PMC7178587 DOI: 10.1186/s13033-020-00361-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 04/11/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Substantial strides have been made around the world in reforming mental health systems by shifting away from institutional care towards community-based services. Despite an extensive evidence base on what constitutes effective care for people with severe mental ill-health, many people in Europe do not have access to optimal mental health care. In an effort to consolidate previous efforts to improve community mental health care and support the complex transition from hospital-based to community-based care delivery, the RECOVER-E (LaRge-scalE implementation of COmmunity based mental health care for people with seVere and Enduring mental ill health in EuRopE) project aims to implement and evaluate multidisciplinary community mental health teams in five countries in Central and Eastern Europe. This paper provides a brief overview of the RECOVER-E project and its methods. METHODS Five implementation sites were selected (Sofia, Bulgaria; Zagreb, Croatia; Skopje, North Macedonia; Kotor, Montenegro; Siret-Suceava, Romania) where hospital-based mental health services are available (care as usual, CAU) for patients with severe mental disorders (severe depression, bipolar disorder, schizophrenia). The intervention consists of the introduction of a new service delivery model in each site, consisting of community-based recovery-oriented care delivered by trained multidisciplinary community mental health teams (including a peer worker with lived experience of a severe mental disorder). The implementation outcomes of the teams and the effect of the team's approach on patient and service utilisation outcomes will be evaluated using a mix of research methods. The study includes five planned hybrid implementation-effectiveness trials (1 per site) with patient-level randomization (n = 180, with patients randomised to either care as usual or intervention condition). Effectiveness is evaluated using a pragmatic non-blinded design with patients randomised into two parallel groups: receiving new community-based care or receiving usual care in the form of institutional, hospital-based mental health care. Trial-based health economic evaluation will be conducted; implementation outcomes will be evaluated, with data aligned with dimensions from the RE-AIM framework. Pathways to sustaining project results will be developed through policy dialogue sessions, which will be carried out in each country and through ongoing policy engagement activities at the European level. DISCUSSION The RECOVER-E project has been developed and conducted to demonstrate the impact of implementing an evidence-based service delivery model for people with severe mental illness in different contexts in middle-income countries in Central and Eastern Europe. It is expected that the results will contribute to the growing evidence-base on the health and economic benefits of recovery-oriented and community-based service models for health systems in transition.Trial registration Each trial was registered before participant enrolment in the clinicaltrials.gov database: Site-Croatia, Zagreb (Trial Reg. No. NCT03862209); Montenegro, Kotor (Trial Reg. No. NCT03837340); Romania, Suceava (Trial Reg. No. NCT03884933); Macedonia, Skopje (Trial Reg. No. NCT03892473); Bulgaria, Sofia (Trial Reg. No. NCT03922425).
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Affiliation(s)
- Laura Shields-Zeeman
- Trimbos Institute (Netherlands Institute of Mental Health and Addiction), P.O. Box 725, 3500 AS Utrecht, The Netherlands
- Department of Public Mental Health and Prevention, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands
| | - Ionela Petrea
- Trimbos Institute (Netherlands Institute of Mental Health and Addiction), P.O. Box 725, 3500 AS Utrecht, The Netherlands
| | - Filip Smit
- Centre for Economic Evaluation, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands
- Department of Public Mental Health and Prevention, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands
- Department of Biostatistics and Epidemiology and Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Bethany Hipple Walters
- Trimbos Institute (Netherlands Institute of Mental Health and Addiction), P.O. Box 725, 3500 AS Utrecht, The Netherlands
| | - Jovo Dedovic
- Special Psychiatric Hospital Dobrota, Kotor, Montenegro
| | | | - Vladimir Nakov
- National Center for Public Health Analyses, Sofia, Bulgaria
| | - Raluca Nica
- Romanian League for Mental Health, Bucharest, Romania
| | - Antoni Novotni
- University Clinic of Psychiatry, Skopje, North Macedonia
| | - Catharina Roth
- Department of General Practice and Health Service Research, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Ben F. M. Wijnen
- Centre for Economic Evaluation, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands
| | - Michel Wensing
- Department of General Practice and Health Service Research, University Hospital Heidelberg, Heidelberg, Germany
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Odden S, Landheim A, Clausen H, Stuen HK, Heiervang KS, Ruud T. Model fidelity and team members' experiences of assertive community treatment in Norway: a sequential mixed-methods study. Int J Ment Health Syst 2019; 13:65. [PMID: 31636700 PMCID: PMC6796407 DOI: 10.1186/s13033-019-0321-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 10/10/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Assertive community treatment (ACT) is an evidence-based treatment for people with severe mental illness, and this model is used widely throughout the world. Given the various adaptations in different contexts, we were interested in studying the implementation and adaptation of the ACT model in Norway. The first 12 Norwegian ACT teams were established between 2009 and 2011, and this study investigated the teams' model fidelity and the team members' experiences of working with ACT. METHODS To investigate implementation of the ACT model, fidelity assessments were performed 12 and 30 months after the teams started their work using the Tool for Measurement of Assertive Community Treatment (TMACT). Means and standard deviations were used to describe the ACT teams' fidelity scores. Cohen's effect size d was used to assess the changes in TMACT scores from the first to second assessment. Qualitative focus group interviews were conducted in the 12 teams after 30 months to investigate the team members' experiences of working with the ACT model. RESULTS The fidelity assessments of the Norwegian teams showed high implementation of the structural and organizational parts of the ACT model. The newer parts of the model, the recovery and evidence-based practices, were less implemented. Four of the six subscales in TMACT improved from the first to the second assessment. The team members experienced the ACT model to be a good service model for the target population: people with severe mental illness, significant functional impairment, and continuous high service needs. Team members perceived some parts of the model difficult to implement and that it was challenging to find effective ways to collaborate with existing health and social services. CONCLUSION The first 12 Norwegian ACT teams implemented the ACT model to a moderate degree. The ACT model could be implemented in Norway without extensive adaptations. Although the team members were satisfied with the ACT model, especially the results for their service users, inclusion of the ACT team to the existing service system was perceived as challenging.
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Affiliation(s)
- Sigrun Odden
- Norwegian National Advisory Unit On Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brumunddal, Norway
| | - Anne Landheim
- Norwegian National Advisory Unit On Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brumunddal, Norway
- Department of Public Health, Inland Norway University of Applied Sciences, Elverum, Norway
| | - Hanne Clausen
- Norwegian National Advisory Unit On Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brumunddal, Norway
- Dept. of Research & Development, Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Hanne Kilen Stuen
- Norwegian National Advisory Unit On Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brumunddal, Norway
| | - Kristin Sverdvik Heiervang
- Dept. of Research & Development, Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Torleif Ruud
- Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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13
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[Healthcare research in the living environment]. DER NERVENARZT 2019; 90:1093-1102. [PMID: 31482184 DOI: 10.1007/s00115-019-00793-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Healthcare research in the living environment is focused on the scientific investigation of care, which is delivered in the personal environment of those affected by diseases. OBJECTIVE Presentation of the healthcare policy starting position, content and evidence of forms of care by which treatment focuses on the living environment of affected persons. Presentation of the RECOVER model, by which these forms of care are integrated and coordinated in a care model. MATERIAL AND METHODS Literature search on "care or treatment models" and "psychiatric disease" over the last 10 years. RESULTS Many experts are calling for the introduction of integrated and coordinated care as well as the digitalization of the healthcare system as essential future solutions. Evidence-based forms of care, which have a main focus on the living environment of those concerned, play an important role here. These include, for example early diagnosis and treatment of psychoses (early psychosis services, EPS), crisis resolution team (CRT), assertive community treatment (ACT), supported employment (SE) and e‑mental health. With the exception of CRT, which can be financed as a hospital ward equivalent treatment according to §§ 39 and 115d (German Social Code V, SGB V), many of these treatment models are not yet part of standard care in Germany. In an integrated and coordinated care system these components work together in a meaningful and coordinated manner in defined care processes. This approach is currently being tested using the so-called RECOVER model, a severity level, evidence-based and cross-sectoral coordinated care model, where implementation, testing and transfer from 2017-2020 will be promoted by the Innovation Fund of the Joint Federal Committee (G-BA).
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14
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Schöttle D, Ruppelt F, Schimmelmann BG, Karow A, Bussopulos A, Gallinat J, Wiedemann K, Luedecke D, Rohenkohl AC, Huber CG, Bock T, Lambert M. Reduction of Involuntary Admissions in Patients With Severe Psychotic Disorders Treated in the ACCESS Integrated Care Model Including Therapeutic Assertive Community Treatment. Front Psychiatry 2019; 10:736. [PMID: 31708810 PMCID: PMC6822062 DOI: 10.3389/fpsyt.2019.00736] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 09/13/2019] [Indexed: 01/12/2023] Open
Abstract
Objective: The ACCESS treatment model offers assertive community treatment (ACT) embedded in an integrated care program to patients with severe psychotic disorders. Compared to standard care, it proved to be more effective in terms of service disengagement and other outcomes in patients with psychotic disorders over 12, 24, and 48 months. Many patients with severe mental disorders experience involuntary admissions which can be potentially traumatic. In this study, we assessed the effect of ACT on reducing involuntary admissions over an observation period of 4 years. Method: One hundred seventy-one patients treated in ACCESS were included in this study. The primary outcome was rate of involuntary admissions during 48 months. Secondary outcomes were differences between those with and without involuntary admissions in the 2 years prior to ACCESS regarding change of psychopathology, severity of illness, psychosocial functioning, quality of life, satisfaction with care, medication non-adherence, and service-disengagement. Results: Of 171 patients, 58 patients (33.9%) were involuntarily admitted to hospital in the past 2 years before entry. During the 4 years of treatment, 16 patients (9.4%) were involuntarily admitted to hospital which was a significantly lower rate compared to the 2 years before inclusion in ACCESS (p < .001). Comparing the two groups, larger improvements in severity of illness (p = .004) and functional status (p = .043) were detected in the group with no history of involuntary admissions. At 4-year follow-up, of the remaining patients, 69.2% (n = 81) were full adherent (p < .001), compared to 18.9% (n = 31) at baseline with no differences between the two groups over the study period (p = .25). Over 4 years, only 13 patients (13.2%) were service-disengaged due to non-practical reasons. Conclusions: In this long-term study, we were able to demonstrate a reduction in involuntary admissions in four treatment years compared to the 2 years prior to admission to the ACCESS model in patients with severe and mostly multiphase schizophrenia spectrum disorders and affective disorders with psychotic features. This may help prevent patients from suffering from a potentially traumatic experience during treatment in the psychiatric system. Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT01888627.
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Affiliation(s)
- Daniel Schöttle
- Psychosis Centre, Department of Psychiatry and Psychotherapy, University Centre of Psychosocial Medicine, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friederike Ruppelt
- Psychosis Centre, Department of Psychiatry and Psychotherapy, University Centre of Psychosocial Medicine, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benno G Schimmelmann
- University Hospital of Child and Adolescent Psychiatry, University of Bern, Bern, Switzerland.,University Hospital of Child and Adolescent Psychiatry, University Centre of Psychosocial Medicine, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Karow
- Psychosis Centre, Department of Psychiatry and Psychotherapy, University Centre of Psychosocial Medicine, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandra Bussopulos
- Psychosis Centre, Department of Psychiatry and Psychotherapy, University Centre of Psychosocial Medicine, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jürgen Gallinat
- Department of Adult Psychiatry, Universitäre Psychiatrische Kliniken Basel (UPK), University of Basel, Basel, Switzerland
| | - Klaus Wiedemann
- Department of Psychiatry and Psychotherapy, University Centre of Psychosocial Medicine, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Luedecke
- Psychosis Centre, Department of Psychiatry and Psychotherapy, University Centre of Psychosocial Medicine, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anja Christine Rohenkohl
- Psychosis Centre, Department of Psychiatry and Psychotherapy, University Centre of Psychosocial Medicine, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian G Huber
- Department of Adult Psychiatry, Universitäre Psychiatrische Kliniken Basel (UPK), University of Basel, Basel, Switzerland
| | - Thomas Bock
- Psychosis Centre, Department of Psychiatry and Psychotherapy, University Centre of Psychosocial Medicine, Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Lambert
- Psychosis Centre, Department of Psychiatry and Psychotherapy, University Centre of Psychosocial Medicine, Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Lofthus AM, Westerlund H, Bjørgen D, Lindstrøm JC, Lauveng A, Rose D, Ruud T, Heiervang K. Recovery concept in a Norwegian setting to be examined by the assertive community treatment model and mixed methods. Int J Ment Health Nurs 2018; 27:147-157. [PMID: 28026106 DOI: 10.1111/inm.12304] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2016] [Indexed: 11/26/2022]
Abstract
Recovery is a crucial concept in the mental health field. The research of recovery is split into the categories of personal, social and clinical recovery. The purpose of this study was to explore the fragmented concept of recovery in light of assertive community treatment (ACT) in Norway. The study has a mixed methods design with a pragmatic approach. The Questionnaire about the Process of Recovery and open-ended questions posed to 70 participants from 12 ACT teams in Norway, gathered by the "Users interview users" method, are combined with interviews or focus groups with eight of these participants. Surprisingly those under a community treatment order (CTO) report the highest degree of personal recovery. The qualitative material shows that the service users interpreted the concept of recovery differently than researchers and professionals. The ACT service users highlighted three important elements: flexible treatment, medication and access to a car. They emphasized the necessity for basic needs to be met in order to experience a meaningful recovery process, and these basic needs may be of even greater importance to those under CTOs. Their experiences should imply a greater emphasis on securing basic needs such as secure housing, sounder finances and access to the normal benefits offered by society.
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Affiliation(s)
- Ann-Mari Lofthus
- Division Mental Health Services, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, Regional Research Network in Psychotic Disorders, University of Oslo, Oslo, Norway
| | - Heidi Westerlund
- National Centre for Knowledge Through Experience in Mental Health, Skien, Norway
| | - Dagfinn Bjørgen
- National Centre for Knowledge Through Experience in Mental Health, Skien, Norway
| | | | - Arnhild Lauveng
- Division Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Diana Rose
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Torleif Ruud
- Division Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Kristin Heiervang
- Division Mental Health Services, Akershus University Hospital, Lørenskog, Norway
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Stergiopoulos V, Saab D, Francombe Pridham K, Aery A, Nakhost A. Building flexibility and managing complexity in community mental health: lessons learned in a large urban centre. BMC Psychiatry 2018; 18:20. [PMID: 29368586 PMCID: PMC5784615 DOI: 10.1186/s12888-018-1597-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 01/08/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Across many jurisdictions, adults with complex mental health and social needs face challenges accessing appropriate supports due to system fragmentation and strict eligibility criteria of existing services. To support this underserviced population, Toronto's local health authority launched two novel community mental health models in 2014, inspired by Flexible Assertive Community Team principles. This study explores service user and provider perspectives on the acceptability of these services, and lessons learned during early implementation. METHODS We purposively sampled 49 stakeholders (staff, physicians, service users, health systems stakeholders) and conducted 17 semi-structured qualitative interviews and 5 focus groups between October 23, 2014 and March 2, 2015, exploring stakeholder perspectives on the newly launched team based models, as well as activities and strategies employed to support early implementation. Interviews and focus groups were audio recorded, transcribed verbatim and analyzed using thematic analysis. RESULTS Findings revealed wide-ranging endorsement for the two team-based models' success in engaging the target population of adults with complex service needs. Implementation strengths included the broad recognition of existing service gaps, the use of interdisciplinary teams and experienced service providers, broad partnerships and collaboration among various service sectors, training and team building activities. Emerging challenges included lack of complementary support services such as suitable housing, organizational contexts reluctant to embrace change and risk associated with complexity, as well as limited service provider and organizational capacity to deliver evidence-based interventions. CONCLUSIONS Findings identified implementation drivers at the practitioner, program, and system levels, specific to the implementation of community mental health interventions for adults with complex health and social needs. These can inform future efforts to address the health and support needs of this vulnerable population.
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Affiliation(s)
- Vicky Stergiopoulos
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, Toronto, ON M5B 1W8 Canada
- Centre for Addiction and Mental Health, 100 Stokes Street, Toronto, ON M6J 1H4 Canada
- Department of Psychiatry, University of Toronto, 250 College Street, 8th Floor, Toronto, ON M5T 1R8 Canada
| | - Dima Saab
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, Toronto, ON M5B 1W8 Canada
| | - Kate Francombe Pridham
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, Toronto, ON M5B 1W8 Canada
| | - Anjana Aery
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 209 Victoria Street, Toronto, ON M5B 1W8 Canada
| | - Arash Nakhost
- Department of Psychiatry, University of Toronto, 250 College Street, 8th Floor, Toronto, ON M5T 1R8 Canada
- Mental Health Services, St. Michael’s Hospital, 30 Bond Street, Toronto, ON M5B 1W8 Canada
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17
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Suijkerbuijk YB, Schaafsma FG, van Mechelen JC, Ojajärvi A, Corbière M, Anema JR. Interventions for obtaining and maintaining employment in adults with severe mental illness, a network meta-analysis. Cochrane Database Syst Rev 2017; 9:CD011867. [PMID: 28898402 PMCID: PMC6483771 DOI: 10.1002/14651858.cd011867.pub2] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND People with severe mental illness show high rates of unemployment and work disability, however, they often have a desire to participate in employment. People with severe mental illness used to be placed in sheltered employment or were enrolled in prevocational training to facilitate transition to a competitive job. Now, there are also interventions focusing on rapid search for a competitive job, with ongoing support to keep the job, known as supported employment. Recently, there has been a growing interest in combining supported employment with other prevocational or psychiatric interventions. OBJECTIVES To assess the comparative effectiveness of various types of vocational rehabilitation interventions and to rank these interventions according to their effectiveness to facilitate competitive employment in adults with severe mental illness. SEARCH METHODS In November 2016 we searched CENTRAL, MEDLINE, Embase, PsychINFO, and CINAHL, and reference lists of articles for randomised controlled trials and systematic reviews. We identified systematic reviews from which to extract randomised controlled trials. SELECTION CRITERIA We included randomised controlled trials and cluster-randomised controlled trials evaluating the effect of interventions on obtaining competitive employment for adults with severe mental illness. We included trials with competitive employment outcomes. The main intervention groups were prevocational training programmes, transitional employment interventions, supported employment, supported employment augmented with other specific interventions, and psychiatric care only. DATA COLLECTION AND ANALYSIS Two authors independently identified trials, performed data extraction, including adverse events, and assessed trial quality. We performed direct meta-analyses and a network meta-analysis including measurements of the surface under the cumulative ranking curve (SUCRA). We assessed the quality of the evidence for outcomes within the network meta-analysis according to GRADE. MAIN RESULTS We included 48 randomised controlled trials involving 8743 participants. Of these, 30 studied supported employment, 13 augmented supported employment, 17 prevocational training, and 6 transitional employment. Psychiatric care only was the control condition in 13 studies. Direct comparison meta-analysis of obtaining competitive employmentWe could include 18 trials with short-term follow-up in a direct meta-analysis (N = 2291) of the following comparisons. Supported employment was more effective than prevocational training (RR 2.52, 95% CI 1.21 to 5.24) and transitional employment (RR 3.49, 95% CI 1.77 to 6.89) and prevocational training was more effective than psychiatric care only (RR 8.96, 95% CI 1.77 to 45.51) in obtaining competitive employment.For the long-term follow-up direct meta-analysis, we could include 22 trials (N = 5233). Augmented supported employment (RR 4.32, 95% CI 1.49 to 12.48), supported employment (RR 1.51, 95% CI 1.36 to 1.68) and prevocational training (RR 2.19, 95% CI 1.07 to 4.46) were more effective than psychiatric care only. Augmented supported employment was more effective than supported employment (RR 1.94, 95% CI 1.03 to 3.65), transitional employment (RR 2.45, 95% CI 1.69 to 3.55) and prevocational training (RR 5.42, 95% CI 1.08 to 27.11). Supported employment was more effective than transitional employment (RR 3.28, 95% CI 2.13 to 5.04) and prevocational training (RR 2.31, 95% CI 1.85 to 2.89). Network meta-analysis of obtaining competitive employmentWe could include 22 trials with long-term follow-up in a network meta-analysis.Augmented supported employment was the most effective intervention versus psychiatric care only in obtaining competitive employment (RR 3.81, 95% CI 1.99 to 7.31, SUCRA 98.5, moderate-quality evidence), followed by supported employment (RR 2.72 95% CI 1.55 to 4.76; SUCRA 76.5, low-quality evidence).Prevocational training (RR 1.26, 95% CI 0.73 to 2.19; SUCRA 40.3, very low-quality evidence) and transitional employment were not considerably different from psychiatric care only (RR 1.00,95% CI 0.51 to 1.96; SUCRA 17.2, low-quality evidence) in achieving competitive employment, but prevocational training stood out in the SUCRA value and rank.Augmented supported employment was slightly better than supported employment, but not significantly (RR 1.40, 95% CI 0.92 to 2.14). The SUCRA value and mean rank were higher for augmented supported employment.The results of the network meta-analysis of the intervention subgroups favoured augmented supported employment interventions, but also cognitive training. However, supported employment augmented with symptom-related skills training showed the best results (RR compared to psychiatric care only 3.61 with 95% CI 1.03 to 12.63, SUCRA 80.3).We graded the quality of the evidence of the network ranking as very low because of potential risk of bias in the included studies, inconsistency and publication bias. Direct meta-analysis of maintaining competitive employment Based on the direct meta-analysis of the short-term follow-up of maintaining employment, supported employment was more effective than: psychiatric care only, transitional employment, prevocational training, and augmented supported employment.In the long-term follow-up direct meta-analysis, augmented supported employment was more effective than prevocational training (MD 22.79 weeks, 95% CI 15.96 to 29.62) and supported employment (MD 10.09, 95% CI 0.32 to 19.85) in maintaining competitive employment. Participants receiving supported employment worked more weeks than those receiving transitional employment (MD 17.36, 95% CI 11.53 to 23.18) or prevocational training (MD 11.56, 95% CI 5.99 to 17.13).We did not find differences between interventions in the risk of dropouts or hospital admissions. AUTHORS' CONCLUSIONS Supported employment and augmented supported employment were the most effective interventions for people with severe mental illness in terms of obtaining and maintaining employment, based on both the direct comparison analysis and the network meta-analysis, without increasing the risk of adverse events. These results are based on moderate- to low-quality evidence, meaning that future studies with lower risk of bias could change these results. Augmented supported employment may be slightly more effective compared to supported employment alone. However, this difference was small, based on the direct comparison analysis, and further decreased with the network meta-analysis meaning that this difference should be interpreted cautiously. More studies on maintaining competitive employment are needed to get a better understanding of whether the costs and efforts are worthwhile in the long term for both the individual and society.
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Affiliation(s)
- Yvonne B Suijkerbuijk
- VU University Medical CenterDepartment of Public and Occupational Health, Amsterdam Public Health Research InstituteVan der Boechorststraat 7Postbus 7057AmsterdamNetherlands1007 MB
- AMC‐UMCG‐UWV‐VUmcResearch Centre for Insurance MedicineAmsterdamNetherlands
| | - Frederieke G Schaafsma
- VU University Medical CenterDepartment of Public and Occupational Health, Amsterdam Public Health Research InstituteVan der Boechorststraat 7Postbus 7057AmsterdamNetherlands1007 MB
- AMC‐UMCG‐UWV‐VUmcResearch Centre for Insurance MedicineAmsterdamNetherlands
| | - Joost C van Mechelen
- VU University Medical CenterDepartment of Public and Occupational Health, Amsterdam Public Health Research InstituteVan der Boechorststraat 7Postbus 7057AmsterdamNetherlands1007 MB
| | - Anneli Ojajärvi
- Finnish Institute of Occupational HealthTopeliuksenkatu 41 a AHelsinkiFinlandFI‐00250
| | - Marc Corbière
- Université du Québec à Montréal (UQAM)Department of Education and Pedagogy ‐ Career CounselingMontrealQCCanada
- Centre de recherche de l'Institut universitaire en santé mentale de Montréal (CR‐IUSMM)MontrealCanada
| | - Johannes R Anema
- VU University Medical CenterDepartment of Public and Occupational Health, Amsterdam Public Health Research InstituteVan der Boechorststraat 7Postbus 7057AmsterdamNetherlands1007 MB
- AMC‐UMCG‐UWV‐VUmcResearch Centre for Insurance MedicineAmsterdamNetherlands
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Mueller-Stierlin AS, Helmbrecht MJ, Herder K, Prinz S, Rosenfeld N, Walendzik J, Holzmann M, Dinc U, Schützwohl M, Becker T, Kilian R. Does one size really fit all? The effectiveness of a non-diagnosis-specific integrated mental health care program in Germany in a prospective, parallel-group controlled multi-centre trial. BMC Psychiatry 2017; 17:283. [PMID: 28764729 PMCID: PMC5539984 DOI: 10.1186/s12888-017-1441-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 07/24/2017] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The Network for Mental Health (NWpG-IC) is an integrated mental health care program implemented in 2009 by cooperation between health insurance companies and community mental health providers in Germany. Meanwhile about 10,000 patients have been enrolled. This is the first study evaluating the effectiveness of the program in comparison to standard mental health care in Germany. METHODS In a parallel-group controlled trial over 18 months conducted in five regions across Germany, a total of 260 patients enrolled in NWpG-IC and 251 patients in standard mental health care (TAU) were recruited between August 2013 and November 2014. The NWpG-IC patients had access to special services such as community-based multi-professional teams, case management, crisis intervention and family-oriented psychoeducation in addition to standard mental health care. The primary outcome empowerment (EPAS) and the secondary outcomes quality of life (WHO-QoL-BREF), satisfaction with psychiatric treatment (CSQ-8), psychosocial and clinical impairment (HoNOS) and information about mental health service needs (CAN) were measured four times at 6-month intervals. Linear mixed-effect regression models were used to estimate the main effects and interaction effects of treatment, time and primary diagnosis. Due to the non-randomised group assignment, propensity score adjustment was used to control the selection bias. RESULTS NWpG-IC and TAU groups did not differ with respect to most primary and secondary outcomes in our participating patients who showed a broad spectrum of psychiatric diagnoses and illness severities. However, a significant improvement in terms of patients' satisfaction with psychiatric care and their perception of treatment participation in favour of the NWpG-IC group was found. CONCLUSIONS Providing integrated mental health care for unspecific mentally ill target groups increases treatment participation and service satisfaction but seems not suitable to enhance the overall outcomes of mental health care in Germany. The implementation of strategies for ameliorating the needs orientation of the NWpG-IC should be considered. TRIAL REGISTRATION German Clinical Trial Register DRKS00005111 , registered 26 July 2013.
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Affiliation(s)
- Annabel Sandra Mueller-Stierlin
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Ulm, Germany
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | | | - Katrin Herder
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Ulm, Germany
| | - Stefanie Prinz
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Ulm, Germany
| | - Nadine Rosenfeld
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Ulm, Germany
| | - Julia Walendzik
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Marco Holzmann
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Uemmueguelsuem Dinc
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Ulm, Germany
| | - Matthias Schützwohl
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Thomas Becker
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Ulm, Germany
| | - Reinhold Kilian
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Ulm, Germany
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19
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Lerbaek B, Aagaard J, Andersen MB, Buus N. Assertive community treatment (ACT) case managers' professional identities: A focus group study. Int J Ment Health Nurs 2016; 25:579-587. [PMID: 26872034 DOI: 10.1111/inm.12211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 12/12/2015] [Accepted: 12/16/2015] [Indexed: 11/29/2022]
Abstract
Assertive community treatment (ACT) case managers provide healthcare services to people with severe and persistent mental illness. These case managers take on generic roles in multidisciplinary teams and provide all-around services in the clients' private homes. This focus group study aimed to gain insight into Danish ACT case managers' professional identity work by examining their discussions of ethical dilemmas and collaboration in their everyday practice. Data were collected during five focus groups at three ACT teams in the North Denmark Region and subjected to discourse analysis emphasizing how identity work was accomplished through talk. The findings indicated that the case managers constructed professional identities by actively positioning themselves and the particular ACT approach in relation to other mental healthcare professionals and clients. They represented themselves as achieving better client-related outcomes by being more assertive and persistent, and as responsible caregivers who provided the help that their clients needed when other services had failed to do so. They depicted their services as being focused on the clients' well-being, and their persistent efforts to establish and sustain interpersonal relationships with clients were an important part of their service. Basic nursing tasks were described as an important part of their everyday work, and even though such tasks were not distinctive for ACT case managers, the representations of their work seemed to give them a sense of worth as professionals and legitimized a unique role in the community mental healthcare services.
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Affiliation(s)
- Birgitte Lerbaek
- RN, MHS, Aalborg University Hospital, Psychiatric Hospital, Aalborg, Denmark
| | - Jørgen Aagaard
- Unit for Psychiatric Research and Department S, Aalborg University Hospital, Psychiatric Hospital, Aalborg, Denmark.,Unit for Psychiatric Research and Department M, Aarhus University Hospital, Risskov, Denmark
| | | | - Niels Buus
- Faculty of Nursing and Midwifery, University of Sydney, Australia and St. Vincent's Private Hospital Sydney, Sydney
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20
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Nugter MA, Engelsbel F, Bähler M, Keet R, van Veldhuizen R. Outcomes of FLEXIBLE Assertive Community Treatment (FACT) Implementation: A Prospective Real Life Study. Community Ment Health J 2016; 52:898-907. [PMID: 25648552 PMCID: PMC5108818 DOI: 10.1007/s10597-015-9831-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 01/17/2015] [Indexed: 11/30/2022]
Abstract
This study aimed to investigate social and clinical outcomes and use of care during and after implementation of FLEXIBLE Assertive Community Treatment (ACT). Three teams and 372 patients were involved. Model fidelity, clinical and social assessments were performed at baseline and after 1 and 2 years. Use of care was registered continuously. Model fidelity was good at the end of the study. Data showed much variation between patients in number and duration of ACT periods. Statistically significant improvements were found in compliance, unmet needs and quality of life. Improvement of quality of life and functioning was related to duration of ACT. The percentage of remissions increased with 9 %. The number of admissions, admission days and face to face contacts differed between ACT and non-ACT patients, but generally decreased. Findings suggest that implementation of FACT results in a more flexible adaptation of care to the needs of the patients.
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Affiliation(s)
- M Annet Nugter
- Department of Research and Monitoring, Mental Health Service Organization GGZ Noord-Holland-Noord, PO Box 18, 1850 BA, Heiloo, The Netherlands.
| | - Fabiana Engelsbel
- Department of Research and Monitoring, Mental Health Service Organization GGZ Noord-Holland-Noord, PO Box 18, 1850 BA, Heiloo, The Netherlands
| | - Michiel Bähler
- Department of Community Mental Health, Mental Health Service Organization GGZ Noord-Holland-Noord, PO Box 18, 1850 BA, Heiloo, The Netherlands
| | - René Keet
- Department of Community Mental Health, Mental Health Service Organization GGZ Noord-Holland-Noord, PO Box 18, 1850 BA, Heiloo, The Netherlands
| | - Remmers van Veldhuizen
- Centre for Certification ACT and FACT (CCAF), Praediniussingel 20/9, 9711 AG, Groningen, The Netherlands
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21
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"Sometimes What They Think is Helpful is Not Really Helpful": Understanding Engagement in the Program of Assertive Community Treatment (PACT). Community Ment Health J 2016; 52:882-890. [PMID: 26335712 DOI: 10.1007/s10597-015-9934-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 08/24/2015] [Indexed: 10/23/2022]
Abstract
This exploratory study recruited a purposive sample of twelve clinical staff from a Program of Assertive Community Treatment (PACT) team in central Virginia to understand the perceptions and experiences related to assertive engagement. The researchers coded the transcribed data initially as twenty-three sub-themes and further refined the data into four overarching themes: characteristics of assertive engagement, PACT engagement strategies and engagement strategies for difficult to engage clients. Further analysis emphasized that PACT team members emphasized the importance of the therapeutic relationship for engagement, which proves challenging for hard-to-engage clients.
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22
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Scholz SM, Andermatt P, Tobler BL, Spinnler D. Work Incapacity and Treatment Costs After Severe Accidents: Standard Versus Intensive Case Management in a 6-Year Randomized Controlled Trial. JOURNAL OF OCCUPATIONAL REHABILITATION 2016; 26:319-31. [PMID: 26687330 PMCID: PMC4967427 DOI: 10.1007/s10926-015-9615-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Purpose Case management is widely accepted as an effective method to support medical rehabilitation and vocational reintegration of accident victims with musculoskeletal injuries. This study investigates whether more intensive case management improves outcomes such as work incapacity and treatment costs for severely injured patients. Methods 8,050 patients were randomly allocated either to standard case management (SCM, administered by claims specialists) or intensive case management (ICM, administered by case managers). These study groups differ mainly by caseload, which was approximately 100 cases in SCM and 35 in ICM. The setting is equivalent to a prospective randomized controlled trial. A 6-year follow-up period was chosen in order to encompass both short-term insurance benefits and permanent disability costs. All data were extracted from administrative insurance databases. Results Average work incapacity over the 6-year follow-up, including contributions from daily allowances and permanent losses from disability, was slightly but insignificantly higher under ICM than under SCM (21.6 vs. 21.3 % of pre-accident work capacity). Remaining work incapacity after 6 years of follow-up showed no difference between ICM and SCM (8.9 vs. 8.8 % of pre-accident work incapacity). Treatment costs were 43,500 Swiss Francs (CHF) in ICM compared to 39,800 in SCM (+9.4 %, p = 0.01). The number of care providers involved in ICM was 10.5 compared to 10.0 in ICM (+5.0 %, p < 0.001). Conclusions Contrary to expectations, ICM did not reduce work incapacity as compared to SCM, but did increase healthcare consumption and treatment costs. It is concluded that the intensity of case management alone is not sufficient to improve rehabilitation and vocational reintegration of accident victims.
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Affiliation(s)
- Stefan M Scholz
- Suva (Swiss National Accident Insurance Fund), Lucerne, Switzerland.
| | - Peter Andermatt
- Suva (Swiss National Accident Insurance Fund), Lucerne, Switzerland
| | - Benno L Tobler
- Suva (Swiss National Accident Insurance Fund), Lucerne, Switzerland
| | - Dieter Spinnler
- Suva (Swiss National Accident Insurance Fund), Lucerne, Switzerland
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23
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Kawohl W, Wyss C, Roser P, Brüne M, Rössler W, Juckel G. [Social psychiatry and neurobiology : A long overdue convergence exemplified by schizophrenia]. DER NERVENARZT 2016; 88:510-519. [PMID: 27491537 DOI: 10.1007/s00115-016-0179-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The proliferation of biological psychiatry has greatly increased over the last two decades. With the possibility to carry out brain research using modern technical methods, it seemed that social influencing factors would lose importance in the development of mental diseases; however, in actual fact this does not seem to be justified. It is necessary to overcome this separation, in that social factors are incorporated into a conceptual framework in the development of mental diseases, which simultaneously also takes the results of current neurobiological research into consideration. OBJECTIVES AND METHODS The aims of this review article are to summarize the current state of sociopsychiatric research and to emphasize the perspectives of the biological principles and their validity with respect to the social dimensions of psychiatry, as exemplified by schizophrenic disorders. The article presents the options for a biosocial approach in social psychiatry and gives an overview of the currently available literature. RESULTS AND CONCLUSION There is an abundance of neurobiological research approaches, which are closely associated with sociopsychiatric topics, such as social cognition. Social psychiatry and biological psychiatry should no longer be considered as diametrically opposed subdisciplines. On the contrary, the options which could emerge from a synthesis must be used in research and clinical practice.
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Affiliation(s)
- W Kawohl
- Zentrum für Soziale Psychiatrie, Klinik für Psychiatrie, Psychotherapie und Psychosomatik, Psychiatrische Universitätsklinik Zürich, Militärstr. 8, Postfach 1930, 8021, Zürich, Schweiz. .,Universität Zürich, Zürich, Schweiz. .,Leuphana Universität Lüneburg, Lüneburg, Deutschland.
| | - C Wyss
- Zentrum für Soziale Psychiatrie, Klinik für Psychiatrie, Psychotherapie und Psychosomatik, Psychiatrische Universitätsklinik Zürich, Militärstr. 8, Postfach 1930, 8021, Zürich, Schweiz.,Universität Zürich, Zürich, Schweiz
| | - P Roser
- Klinik für Psychiatrie, Psychotherapie und Präventivmedizin, LWL-Universitätsklinik, Ruhr-Universität Bochum, Bochum, Deutschland
| | - M Brüne
- Klinik für Psychiatrie, Psychotherapie und Präventivmedizin, LWL-Universitätsklinik, Ruhr-Universität Bochum, Bochum, Deutschland.,Forschungsabteilung für Kognitive Neuropsychiatrie und Psychiatrische Präventivmedizin, LWL-Universitätsklinik, Ruhr-Universität Bochum, Bochum, Deutschland
| | - W Rössler
- Universität Zürich, Zürich, Schweiz.,Leuphana Universität Lüneburg, Lüneburg, Deutschland
| | - G Juckel
- Klinik für Psychiatrie, Psychotherapie und Präventivmedizin, LWL-Universitätsklinik, Ruhr-Universität Bochum, Bochum, Deutschland
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24
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Emmerink PMJ, Roeg DPK. Predictors of quality of life of people receiving intensive community-based care. Qual Life Res 2016; 25:457-464. [PMID: 26319948 PMCID: PMC4722070 DOI: 10.1007/s11136-015-1093-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Intensive community-based care (ICBC) is a home-treatment approach aiming to support people 'living in the community' with severe psychiatric and addiction problems. Although subjective quality of life (SQOL) is an increasingly important outcome measure in health care, little is known on ICBC clients' SQOL. METHODS Clients of three ICBC teams (N = 523) participated in the study. Upon intake, clients filled out a SQOL measure and indicated whether they had a good friend, partner, and children, as well as their experiences with crime. Professional caregivers filled in a measure on problem severity. RESULTS Regression was used to examine to what extent the included variables contributed to explaining variance in ICBC clients' SQOL. Determinants in the model significantly predicted client SQOL and explained 37 % of the variance. 'Symptomatology' (depressive symptoms) and 'social problems' (living conditions) negatively influenced the SQOL, while having a partner, a good friend, and an overall lower problem severity positively influenced SQOL. CONCLUSIONS SQOL among ICBC clients is related to psychopathology, in contrast to previous knowledge. It is dependent upon symptom specificity, living conditions, and social circumstances and therefore presumably on program characteristics. This study provides insight into well-being among ICBC clients and is therefore relevant to involved healthcare professionals.
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Affiliation(s)
- P. M. J. Emmerink
- Tranzo Department, Tilburg University, Warandelaan 2, 5000 LE Tilburg, The Netherlands
| | - D. P. K. Roeg
- Tranzo Department, Tilburg University, Warandelaan 2, 5000 LE Tilburg, The Netherlands
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25
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Hamilton I, Lloyd C, Bland JM, Savage Grainge A. The impact of assertive outreach teams on hospital admissions for psychosis: a time series analysis. J Psychiatr Ment Health Nurs 2015; 22:484-90. [PMID: 26118395 DOI: 10.1111/jpm.12239] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2015] [Indexed: 11/28/2022]
Abstract
Although the assertive outreach model was developed in the United States and imported to the United Kingdom to date, there is only limited evidence to support its wide-scale implementation within the United Kingdom. This is the first study to have combined a large dataset with this type of research method to explore the impact of assertive outreach teams on hospital admissions. The introduction and expansion of assertive outreach teams was associated with reducing hospital admissions for people with psychosis. This study found a consistent summer peak in hospital admissions which community and in-patient mental health nurses should take account of and plan for. Ever since the Mental Health Policy Implementation Policy Guide paved the way for the introduction of the Assertive Outreach Treatment (AOT) model in England, the impact of this approach has been the subject of considerable debate but limited evaluation. To date, most of the evidence supporting this model has originated from outside the United Kingdom. A central aim of the AOT was to reduce the need for in-patient treatment. We aimed to assess the impact of the AOT model on hospital admissions for people with psychosis in England. Interrupted time series analysis was used in this study to evaluate the impact of the policy change. Following the introduction of the AOT model, a statistically significant reduction in hospital admissions for psychosis was found. In addition, we observed a repeated, annual summer peak in admissions. This study adds to the international evidence which supports the effectiveness of the AOT model in reducing hospital admissions for people with severe mental health problems. We offer five suggested implications for mental health nurses and clients based on our findings.
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Affiliation(s)
- I Hamilton
- Health Sciences, University of York, York, UK
| | - C Lloyd
- Health Sciences, University of York, York, UK
| | - J M Bland
- Health Sciences, University of York, York, UK
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26
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Theodoridou A, Hengartner MP, Gairing SK, Jäger M, Ketteler D, Kawohl W, Lauber C, Rössler W. Evaluation of a new person-centered integrated care model in psychiatry. Psychiatr Q 2015; 86:153-68. [PMID: 25141779 DOI: 10.1007/s11126-014-9310-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The present study evaluated a new integrated treatment concept offering inpatient care, acute psychiatric day hospital and outpatient treatment by the same therapeutic team. 178 patients participated in this randomized controlled trial. Data on psychopathology, global and social functioning, patient satisfaction, continuity of care and administrative data was gathered on admission, throughout the course of treatment, upon discharge and at 1-year follow-up. In addition, the physicians in charge rated the therapeutic relationship. The data analysis consists of group-wise comparisons and regression analyses (cross-tabulations and χ(2) test statistics for categorical data and Mann-Whitney U tests for continuous data). Differences between groups over time were analyzed with a series of generalized linear mixed model. The integrated care group showed a significant reduction in psychopathological impairment (20.7%) and an improvement of psychosocial functioning (36.8%). The mean number of days before re-admission was higher in the control group when compared to the integrated care group (156.8 vs. 91.5). There was no difference in the number of re-admissions and days spent in psychiatric institutions. This new approach offers a treatment model, which facilitates continuity of care. Beside it improves psychopathological outcome measures and psychosocial functioning in patients with mental illness.
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Affiliation(s)
- Anastasia Theodoridou
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Lenggstrasse 31, 8032, Zurich, Switzerland,
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27
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Speyer H, Nørgaard HCB, Hjorthøj C, Madsen TA, Drivsholm S, Pisinger C, Gluud C, Mors O, Krogh J, Nordentoft M. Protocol for CHANGE: a randomized clinical trial assessing lifestyle coaching plus care coordination versus care coordination alone versus treatment as usual to reduce risks of cardiovascular disease in adults with schizophrenia and abdominal obesity. BMC Psychiatry 2015; 15:119. [PMID: 26001844 PMCID: PMC4460642 DOI: 10.1186/s12888-015-0465-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 03/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Life expectancy in patients with schizophrenia is reduced by 20 years for males and 15 years for females compared to the general population. About 60% of the excess mortality is due to physical illnesses, with cardiovascular disease being the single largest cause of death. METHODS/DESIGN The CHANGE trial is an investigator-initiated, independently funded, randomized, parallel-group, superiority, multi-centre trial with blinded outcome assessment. 450 patients aged 18 years or above, diagnosed with schizophrenia spectrum disorders and increased waist circumference, will be recruited and randomized 1:1:1 to 12-months interventions. We will compare the effects of 1) affiliation to the CHANGE team, offering a tailored, manual-based intervention targeting physical inactivity, unhealthy dietary habits, and smoking, and facilitating contact to their general practitioner to secure medical treatment of somatic comorbidity; versus 2) affiliation to a care coordinator who will secure guideline-concordant monitoring and treatment of somatic comorbidity by facilitating contact to their general practitioner; versus 3) treatment as usual to evaluate the potential add-on effects of lifestyle coaching plus care coordination or care coordination alone to treatment as usual. The primary outcome is the 10-year risks of cardiovascular disease assessed at 12 months after randomization. DISCUSSION The premature mortality observed in this vulnerable population has not formerly been addressed specifically by using composite surrogate outcomes for mortality. The CHANGE trial expands the evidence for interventions aiming to reduce the burden of metabolic disturbances with a view to increase life expectancy. Here, we present the trial design, describe the methodological concepts in detail, and discuss the rationale and challenges of the intermediate outcomes. TRIAL REGISTRATION Clinical Trials.gov NCT01585493 . Date of registration 27(th) of March 2012.
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Affiliation(s)
- Helene Speyer
- Mental Health Centre Copenhagen, Mental Health Services in the Capital Region, DK-2400, Copenhagen, Denmark.
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
| | | | - Carsten Hjorthøj
- Mental Health Centre Copenhagen, Mental Health Services in the Capital Region, DK-2400, Copenhagen, Denmark.
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Thomas Axel Madsen
- Mental Health Centre Copenhagen, Mental Health Services in the Capital Region, DK-2400, Copenhagen, Denmark.
| | - Søren Drivsholm
- Research Department P, Aarhus University Hospital, Risskov, Denmark.
| | - Charlotta Pisinger
- Research Centre for Prevention and Health, Department 84-85, Glostrup University Hospital, Glostrup, Denmark.
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Ole Mors
- Research Department P, Aarhus University Hospital, Risskov, Denmark.
| | - Jesper Krogh
- Mental Health Centre Copenhagen, Mental Health Services in the Capital Region, DK-2400, Copenhagen, Denmark.
| | - Merete Nordentoft
- Mental Health Centre Copenhagen, Mental Health Services in the Capital Region, DK-2400, Copenhagen, Denmark.
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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Karow A, Wittmann L, Schöttle D, Schäfer I, Lambert M. The assessment of quality of life in clinical practice in patients with schizophrenia. DIALOGUES IN CLINICAL NEUROSCIENCE 2015. [PMID: 25152657 PMCID: PMC4140512 DOI: 10.31887/dcns.2014.16.2/akarow] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of the present article is to review QoL scales used in studies investigating patients with schizophrenia over the past 5 years, and to summarize the results of QoL assessment in clinical practice in these patients. Literature available from January 2009 to December 2013 was identified in a PubMed search using the key words "quality of life" and "schizophrenia" and in a cross-reference search for articles that were particularly relevant. A total of n=432 studies used 35 different standardized generic and specific QoL scales in patients with schizophrenia. Affective symptoms were major obstacles for QoL improvement in patients with schizophrenia. Though positive symptoms, negative symptoms, and cognitive functioning may be seen as largely independent parameters from subjective QoL, especially in cross-sectional trials, long-term studies confirmed a critical impact of early QoL improvement on long-term symptomatic and functional remission, as well as of early symptomatic response on long-term QoL. Results of the present review suggest that QoL is a valid and useful outcome criterion in patients with schizophrenia. As such, it should be consistently applied in clinical trials. Understanding the relationship between symptoms and functioning with QoL is important because interventions that focus on symptoms of psychosis or functioning alone may fail to improve subjective QoL to the same level. However, the lack of consensus on QoL scales hampers research on its predictive validity. Future research needs to find a consensus on the concept and measures of QoL and to test whether QoL predicts better outcomes with respect to remission and recovery under consideration of different treatment approaches in patients with schizophrenia.
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Affiliation(s)
- Anne Karow
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linus Wittmann
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Schöttle
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ingo Schäfer
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Lambert
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Kayama M, Kido Y, Setoya N, Tsunoda A, Matsunaga A, Kikkawa T, Fukuda T, Noguchi M, Mishina K, Nishio M, Ito J. Community outreach for patients who have difficulties in maintaining contact with mental health services: longitudinal retrospective study of the Japanese outreach model project. BMC Psychiatry 2014; 14:311. [PMID: 25403680 PMCID: PMC4251924 DOI: 10.1186/s12888-014-0311-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 10/22/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Japan still has the highest ratio of beds devoted to psychiatric patients in the world. In 2011, in order to reduce re-hospitalization of patients who became disconnected from regular contact with outpatient medical services, the Japanese Ministry established the Japanese Outreach Model Project (JOMP). In this study, we will explicate the JOMP project protocol and investigate the rate and length of hospital admission, impairments of social function and problematic behavior at the follow-up period (6- and 12-month) and time of services provided by JOMP. METHOD This longitudinal retrospective study used survey data collected from 32 outreach teams of 21 prefectures in Japan during September 2011 to July 2013. The outcome variables were assessed at baseline, 6-month and 12-month as to whether or not participants had been admitted to the hospital. Data from 162 participants with mental illness who had difficulties in maintaining contact with mental health services were analyzed. Repeated measures analysis of variance provided a significant effect of the intervention over time. RESULTS The rate of hospital admission of JOMP participants was 24.1% at 6-months and 27.2% at the 12-month follow-up. The average length of hospital-stay at baseline and 12-months was 38.7 days (SD 84.7). Compared with the baseline, the average score of the Global Assessment Functioning and the Social Behavioral Schedule were significantly improved after the 6-month and 12-month follow-up. The activity log showed that among the most often delivered JOMP services were to "prevent exacerbation of somatic symptoms" and "care for families". CONCLUSION These results suggest that JOMP has a strong potential to both reduce readmission rates and the length of hospital stay compared with the Japanese regular outpatient care by public insurance, and improve social function and problematic behavior. The JOMP teams provided long-term support for families. As of April 2014 JOMP was included in the National Health Insurance program in a limited way therefore an evaluation of JOMP team fidelity on readmissions must be examined.
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Affiliation(s)
- Mami Kayama
- />Psychiatric and Mental Health Nursing, College of Nursing, St. Luke’s International University, 10-1 Akashi-cho, Chuo-ku, Tokyo 104-0044 Japan
| | - Yoshifumi Kido
- />Psychiatric and Mental Health Nursing, College of Nursing, St. Luke’s International University, 10-1 Akashi-cho, Chuo-ku, Tokyo 104-0044 Japan
- />Department of Psychiatric Nursing, The University of Tokyo, Tokyo, Japan
| | - Nozomi Setoya
- />Psychiatric and Mental Health Nursing, College of Nursing, St. Luke’s International University, 10-1 Akashi-cho, Chuo-ku, Tokyo 104-0044 Japan
| | - Aki Tsunoda
- />Psychiatric and Mental Health Nursing, College of Nursing, St. Luke’s International University, 10-1 Akashi-cho, Chuo-ku, Tokyo 104-0044 Japan
| | - Asami Matsunaga
- />Department of Psychiatric Nursing, The University of Tokyo, Tokyo, Japan
| | - Takahiro Kikkawa
- />Department of Nursing, School of Health Sciences, Tokai University, Kanagawa, Japan
| | | | | | - Keiko Mishina
- />Hanazono University, Clinical Psychology, Faculty of Social Welfare, Kyoto, Japan
| | - Masaaki Nishio
- />Tohoku Fukushi University, Social Welfare, Faculty of General Welfare, Miyagi, Japan
| | - Junichiro Ito
- />National Center of Neurology and Psychiatry, National Institute of Mental Health, Psychiatric Rehabilitation, Tokyo, Japan
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Roeg DPK, van de Goor IAM, Voogt MCM, van Assen MALM, Garretsen HFL. Effects of interferential care: a community-based care program for persons with severe problems on several life areas. Int J Soc Psychiatry 2014; 60:584-94. [PMID: 24221098 PMCID: PMC4230954 DOI: 10.1177/0020764013507247] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND AND AIMS Interferential care differs from the current community-based care programs in that it targets a larger, heterogeneous group and combines brokerage and full service elements in a multi-organizational care team. The team provides all the services itself, but with the aim to prepare clients within a few months for referral to regular (ambulant) healthcare services. The aim of this study was to assess the effectiveness of interferential care. METHODS In a multisite, pretest-posttest design, 523 patients of three interferential care teams were followed. Quality of life, problem severity, problems with referral and engagement were assessed at baseline, at referral and again after 6 months. Analyses were performed using linear mixed modeling. RESULTS Interferential care showed moderate to strong effects on quality of life and problem severity. These effects persisted (quality of life) or further improved (problem severity) until follow-up 6 months after referral to regular services. There were also small effects on both engagement and problems with referral. CONCLUSION Interferential care offers significant improvements in quality of life and problem severity in persons who have severe problems on several life areas and who are currently not reached by healthcare services. It is a promising community-based care program for healthcare systems in which regular care already contains many elements of home-based practice.
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Affiliation(s)
- Diana P K Roeg
- Tranzo Department, Tilburg University, Tilburg, The Netherlands Mental Health Care Institute GGz Eindhoven and the Kempen, Eindhoven, The Netherlands
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Stierlin AS, Herder K, Helmbrecht MJ, Prinz S, Walendzik J, Holzmann M, Becker T, Schützwohl M, Kilian R. Effectiveness and efficiency of integrated mental health care programmes in Germany: study protocol of an observational controlled trial. BMC Psychiatry 2014; 14:163. [PMID: 24894310 PMCID: PMC4057655 DOI: 10.1186/1471-244x-14-163] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 05/27/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Since 2009 some German health insurance companies have implemented integrated mental health care services along the principles of assertive community treatment in collaboration with local mental health service providers across Germany. Focus of this study is the analysis of effectiveness and cost-effectiveness of this integrated care programme compared to care as usual in routine care surroundings in five regions in Germany. METHODS In this 18-month multi-centre observational trial 250 patients enrolled in an integrated mental health care programme and 250 patients who receive treatment as usual from five catchment areas will be included. In addition, in each group about 125 relatives of the participating patients will be included. The primary outcome criterion is the improvement of empowerment; secondary outcomes are subjective quality of life, functional impairment and costs of illness. Data will be collected at baseline and three follow-ups after 6, 12 and 18 months. Data will be analysed by means of mixed effects regression models. Propensity score methods are used for selection bias control. DISCUSSION Study results are expected to provide information about how integrated care programmes in their present form contribute to the improvement of mental health care. In addition, the study will provide hints to weaknesses of the current integrated care programme and options to overcome them. The major strengths of this study are the real-world character of the study intervention with a simultaneous high level of academic rigour. However, the fact that patients are not randomised to study groups and that there is no blinding might limit the study. TRIAL REGISTRATION German Clinical Trial Register DRKS00005111.
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Affiliation(s)
| | - Katrin Herder
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Germany
| | | | - Stefanie Prinz
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Germany
| | - Julia Walendzik
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus Dresden, TU Dresden, Germany
| | - Marco Holzmann
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus Dresden, TU Dresden, Germany
| | - Thomas Becker
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Germany
| | - Matthias Schützwohl
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus Dresden, TU Dresden, Germany
| | - Reinhold Kilian
- Department of Psychiatry II, Ulm University, Bezirkskrankenhaus Günzburg, Germany
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Low L, Tan YY, Lim BL, Poon WC, Lee C. Effectiveness of Assertive Community Management in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2013. [DOI: 10.47102/annals-acadmedsg.v42n3p125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction: Assertive Community Treatment (ACT) was introduced in the 1970s as a comprehensive and assertive approach to community-based case management of patients with chronic and serious mental illness. Launched in Singapore in 2003, the Assertive Community Management (ACM) was modelled after the ACT, but with the main difference of 24 hour availability for the latter only. In line with the move towards de-institutionalisation of psychiatric patients, ACM was introduced to provide a mobile community-based multidisciplinary team approach to manage patients with severe chronic psychiatric illness. This article aims to evaluate and provide an update on this service programme in Singapore following an earlier study by Fam Johnson in 2007. Materials and Methods: A naturalistic and retrospective study was conducted. One hundred and fifty-five patients recruited into ACM from 1 September 2008 to 1 September 2009 and had completed 1 year of ACM were included in our study. Outcomes were defined as number of admissions (NOA) and length of stay (LOS) one year before and one year following induction into the programme. Baseline socio-demographic factors were also investigated to see if they predicted outcome with ACM. Results: The mean NOA was 1.9 pre-ACM and 0.6 post-ACM, with mean reduction in NOA of 1.3 (P <0.01). The mean LOS was 72.2 days pre-ACM and 17.1 days post ACM, mean reduction in LOS 55.1 days (P <0.01). In addition, it was found that gender, diagnoses and ethnicity were not predictive of the outcome measures of NOA or LOS. Conclusion: ACM in Singapore had been well established since its inception and continued to show effectiveness in reducing inpatient hospitalisation among the chronically mentally ill.
Key words: Assertive Community Treatment, Community Psychiatry, Length of stay, Number of admission, Global assessment of functioning
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Affiliation(s)
| | | | | | | | - Cheng Lee
- Institute of Mental Health, Singapore
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Gilburt H, Burns T, Copello A, Coulton S, Crawford M, Day E, Deluca P, Godfrey C, Parrott S, Rose AK, Sinclair JMA, Wright C, Drummond C. Assertive Community Treatment for alcohol dependence (ACTAD): study protocol for a randomised controlled trial. Trials 2012; 13:19. [PMID: 22348423 PMCID: PMC3305428 DOI: 10.1186/1745-6215-13-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2011] [Accepted: 02/20/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Alcohol dependence is a significant and costly problem in the UK yet only 6% of people a year receive treatment. Current service provision based on the treatment of acute episodes of illness and emphasising personal choice and motivation results in a small proportion of these patients engaging with alcohol treatment. There is a need for interventions targeted at the population of alcohol dependent patients who are hard to engage in conventional treatment. Assertive Community Treatment (ACT), a model of care based on assertive outreach, has been used for treating patients with severe mental illnesses and presents a promising avenue for engaging patients with primary alcohol dependence. So far there has been little research on this. METHODS/DESIGN In this single blind exploratory randomised controlled trial, a total of 90 alcohol dependent participants will be recruited from community addiction services. After completing a baseline assessment, they will be assigned to one of two conditions: (1) ACT plus care as usual, or (2) care as usual. Those allocated to the ACT plus care as usual will receive the same treatment that is routinely provided by services, plus a trained key worker who will provide ACT. ACT comprises intensive and assertive contact at least once a week, over 50% of contacts in the participant's home or local community, and comprehensive case management across social and health care, for a period of one year. All participants will be followed up at 6 months and 12 months to assess outcome post randomisation. The primary outcome measures will be alcohol consumption: mean drinks per drinking day and percentage of days abstinent measured by the Time Line Follow Back interview. Secondary outcome measures will include severity of alcohol dependence, alcohol related problems, motivation to change, social network involvement, quality of life, therapeutic relationship and service use. Other outcome variables are treatment engagement including completion of assessment, detoxification and aftercare. DISCUSSION Results of this trial will help clarify the potential beneficial effects of ACT for people with alcohol dependence and provide information to design a definitive trial. TRIAL REGISTRATION NUMBER ISRCTN: ISRCTN22775534.
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Affiliation(s)
- Helen Gilburt
- Department of Addictions, Institute of Psychiatry, Kings College London, London, UK
| | - Tom Burns
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Alex Copello
- School of Psychology, University of Birmingham, Birmingham, UK
| | - Simon Coulton
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | | | - Ed Day
- School of Psychiatry, University of Birmingham, Birmingham, UK
| | - Paolo Deluca
- Department of Addictions, Institute of Psychiatry, Kings College London, London, UK
| | | | - Steve Parrott
- Department of Health Sciences, University of York, York, UK
| | - Abigail K Rose
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | | | - Christine Wright
- Department of Mental Health, St George's, University of London, London, UK
| | - Colin Drummond
- Department of Addictions, Institute of Psychiatry, Kings College London, London, UK
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Stull LG, McGrew JH, Salyers MP. Processes underlying treatment success and failure in assertive community treatment. J Ment Health 2012; 21:49-56. [PMID: 22142361 PMCID: PMC4023683 DOI: 10.3109/09638237.2011.629239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Processes underlying success and failure in assertive community treatment (ACT), a widely investigated treatment model for persons with severe mental illness, are poorly understood. AIMS The purpose of the current study was to examine processes in ACT by (1) understanding how consumers and staff describe the processes underlying treatment success and failure and (2) comparing processes identified by staff and consumers. METHOD Investigators conducted semi-structured interviews with 25 staff and 23 consumers from four ACT teams. RESULTS Both staff and consumers identified aspects of the ACT team itself as the most critical in the process of consumer success. For failure, consumers identified consumer characteristics as most critical and staff identified lack of social relationships. Processes underlying failure were not viewed as merely the opposite of processes underlying success. In addition, there was notable disagreement between staff and consumers on important processes. CONCLUSIONS Findings overlap with critical ingredients identified in previous studies, including aspects of the ACT team, social involvement and employment. In contrast to prior studies, there was little emphasis on hospitalizations and greater emphasis on not abusing substances, obtaining wants and desires, and consumer characteristics.
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Affiliation(s)
- Laura G Stull
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA.
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Abstract
BACKGROUND People with schizophrenia from families that express high levels of criticism, hostility, or over involvement, have more frequent relapses than people with similar problems from families that tend to be less expressive of emotions. Forms of psychosocial intervention, designed to reduce these levels of expressed emotions within families, are now widely used. OBJECTIVES To estimate the effects of family psychosocial interventions in community settings for people with schizophrenia or schizophrenia-like conditions compared with standard care. SEARCH STRATEGY We updated previous searches by searching the Cochrane Schizophrenia Group Trials Register (September 2008). SELECTION CRITERIA We selected randomised or quasi-randomised studies focusing primarily on families of people with schizophrenia or schizoaffective disorder that compared community-orientated family-based psychosocial intervention with standard care. DATA COLLECTION AND ANALYSIS We independently extracted data and calculated fixed-effect relative risk (RR), the 95% confidence intervals (CI) for binary data, and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated mean differences (MD). MAIN RESULTS This 2009-10 update adds 21 additional studies, with a total of 53 randomised controlled trials included. Family intervention may decrease the frequency of relapse (n = 2981, 32 RCTs, RR 0.55 CI 0.5 to 0.6, NNT 7 CI 6 to 8), although some small but negative studies might not have been identified by the search. Family intervention may also reduce hospital admission (n = 481, 8 RCTs, RR 0.78 CI 0.6 to 1.0, NNT 8 CI 6 to 13) and encourage compliance with medication (n = 695, 10 RCTs, RR 0.60 CI 0.5 to 0.7, NNT 6 CI 5 to 9) but it does not obviously affect the tendency of individuals/families to leave care (n = 733, 10 RCTs, RR 0.74 CI 0.5 to 1.0). Family intervention also seems to improve general social impairment and the levels of expressed emotion within the family. We did not find data to suggest that family intervention either prevents or promotes suicide. AUTHORS' CONCLUSIONS Family intervention may reduce the number of relapse events and hospitalisations and would therefore be of interest to people with schizophrenia, clinicians and policy makers. However, the treatment effects of these trials may be overestimated due to the poor methodological quality. Further data from trials that describe the methods of randomisation, test the blindness of the study evaluators, and implement the CONSORT guidelines would enable greater confidence in these findings.
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Affiliation(s)
- Fiona Pharoah
- South West Community Mental Health Team, Oxford and Buckinghamshire Mental Health NHS Foundation Trust, High Wycombe, UK
| | - Jair Mari
- Departamento de Psiquiatria, UNIFESP, CEP 04023-900 Sao Paulo, Brazil
| | - John Rathbone
- HEDS, ScHARR, The University of Sheffield, Sheffield, UK
| | - Winson Wong
- Huddersfield Royal Infirmary, Huddersfield, UK
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Pharoah F, Mari J, Rathbone J, Wong W. Family intervention for schizophrenia. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [PMID: 21154340 DOI: 10.1002/14651858.cd000088.pub3.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND People with schizophrenia from families that express high levels of criticism, hostility, or over involvement, have more frequent relapses than people with similar problems from families that tend to be less expressive of emotions. Forms of psychosocial intervention, designed to reduce these levels of expressed emotions within families, are now widely used. OBJECTIVES To estimate the effects of family psychosocial interventions in community settings for people with schizophrenia or schizophrenia-like conditions compared with standard care. SEARCH STRATEGY We updated previous searches by searching the Cochrane Schizophrenia Group Trials Register (September 2008). SELECTION CRITERIA We selected randomised or quasi-randomised studies focusing primarily on families of people with schizophrenia or schizoaffective disorder that compared community-orientated family-based psychosocial intervention with standard care. DATA COLLECTION AND ANALYSIS We independently extracted data and calculated fixed-effect relative risk (RR), the 95% confidence intervals (CI) for binary data, and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated mean differences (MD). MAIN RESULTS This 2009-10 update adds 21 additional studies, with a total of 53 randomised controlled trials included. Family intervention may decrease the frequency of relapse (n = 2981, 32 RCTs, RR 0.55 CI 0.5 to 0.6, NNT 7 CI 6 to 8), although some small but negative studies might not have been identified by the search. Family intervention may also reduce hospital admission (n = 481, 8 RCTs, RR 0.78 CI 0.6 to 1.0, NNT 8 CI 6 to 13) and encourage compliance with medication (n = 695, 10 RCTs, RR 0.60 CI 0.5 to 0.7, NNT 6 CI 5 to 9) but it does not obviously affect the tendency of individuals/families to leave care (n = 733, 10 RCTs, RR 0.74 CI 0.5 to 1.0). Family intervention also seems to improve general social impairment and the levels of expressed emotion within the family. We did not find data to suggest that family intervention either prevents or promotes suicide. AUTHORS' CONCLUSIONS Family intervention may reduce the number of relapse events and hospitalisations and would therefore be of interest to people with schizophrenia, clinicians and policy makers. However, the treatment effects of these trials may be overestimated due to the poor methodological quality. Further data from trials that describe the methods of randomisation, test the blindness of the study evaluators, and implement the CONSORT guidelines would enable greater confidence in these findings.
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Affiliation(s)
- Fiona Pharoah
- South West Community Mental Health Team, Oxford and Buckinghamshire Mental Health NHS Foundation Trust, Apex 550 (Unit 5), The Valley Centre, Gordon Road, High Wycombe, Buckinghamshire, UK, HP13 6EQ
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Stobbe J, Mulder NCL, Roosenschoon BJ, Depla M, Kroon H. Assertive community treatment for elderly people with severe mental illness. BMC Psychiatry 2010; 10:84. [PMID: 20958958 PMCID: PMC2970585 DOI: 10.1186/1471-244x-10-84] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Accepted: 10/19/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adults aged 65 and older with severe mental illnesses are a growing segment of the Dutch population. Some of them have a range of serious problems and are also difficult to engage. While assertive community treatment is a common model for treating difficult to engage severe mental illnesses patients, no special form of it is available for the elderly. A special assertive community treatment team for the elderly is developed in Rotterdam, the Netherlands and tested for its effectiveness. METHODS We will use a randomized controlled trial design to compare the effects of assertive community treatment for the elderly with those of care as usual. Primary outcome measures will be the number of dropouts, the number of patients engaged in care and patient's psychiatric symptoms, somatic symptoms, and social functioning. Secondary outcome measures are the number of unmet needs, the subjective quality of life and patients' satisfaction. Other secondary outcomes include the number of crisis contacts, rates of voluntary and involuntary admission, and length of stay. Inclusion criteria are aged 65 plus, the presence of a mental disorder, a lack of motivation for treatment and at least four suspected problems with functioning (addiction, somatic problems, daily living activities, housing etc.). If patients meet the inclusion criteria, they will be randomly allocated to either assertive community treatment for the elderly or care as usual. Trained assessors will use mainly observational instruments at the following time points: at baseline, after 9 and 18 months. DISCUSSION This study will help establish whether assertive community treatment for the elderly produces better results than care as usual in elderly people with severe mental illnesses who are difficult to engage. When assertive community treatment for the elderly proves valuable in these respects, it can be tested and implemented more widely, and mechanisms for its effects investigated. TRIAL REGISTRATION The Netherlands National Trial Register NTR1620.
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Affiliation(s)
- Jolanda Stobbe
- Research Centre O3, Erasmus mc, University medical center, Department of Psychiatry, PO Box 2040 Dp-0122, 3000 CA Rotterdam, the Netherlands
- BavoEuropoort, Centre for Mental Health Care, Rotterdam, the Netherlands
| | - Niels CL Mulder
- Research Centre O3, Erasmus mc, University medical center, Department of Psychiatry, PO Box 2040 Dp-0122, 3000 CA Rotterdam, the Netherlands
- BavoEuropoort, Centre for Mental Health Care, Rotterdam, the Netherlands
- Municipal Public Health Service, Rotterdam Rijnmond Division of Public Mental Health Care, the Netherlands
| | | | - Marja Depla
- VU University Medical Centre Amsterdam, Institute for Research in Extramural Medicine, Department of Nursing-Home Nedicine, the Netherlands
| | - Hans Kroon
- Trimbos institute, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands
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Kortrijk HE, Mulder CL, Roosenschoon BJ, Wiersma D. Treatment outcome in patients receiving assertive community treatment. Community Ment Health J 2010; 46:330-6. [PMID: 19847646 PMCID: PMC2910892 DOI: 10.1007/s10597-009-9257-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Accepted: 10/02/2009] [Indexed: 11/30/2022]
Abstract
In an observational study of severely mentally ill patients treated in assertive community treatment (ACT) teams, we investigated how treatment outcome was associated with demographic factors, clinical factors, and motivation for treatment. To determine psychosocial outcome, patients were routinely assessed using the Health of the Nation Outcome Scales (HoNOS). Trends over time were analyzed using a mixed model with repeated measures. The HoNOS total score was modeled as a function of treatment duration and patient-dependent covariates. Data comprised 637 assessments of 139 patients; mean duration of follow-up was 27.4 months (SD = 5.4). Substance abuse, higher age, problems with motivation, and lower educational level were associated with higher HoNOS total scores (i.e., worse outcome). To improve treatment outcome, we recommend better implementation of ACT, and also the implementation of additional programs targeting subgroups which seem to benefit less from ACT.
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Affiliation(s)
- H E Kortrijk
- Parnassia Bavo Group, BavoEuropoort, Westersingel 94, 3015 LC, Rotterdam, The Netherlands.
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O'Brien A, Fahmy R, Singh SP. Disengagement from mental health services. A literature review. Soc Psychiatry Psychiatr Epidemiol 2009; 44:558-68. [PMID: 19037573 DOI: 10.1007/s00127-008-0476-0] [Citation(s) in RCA: 186] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Revised: 11/13/2008] [Indexed: 10/21/2022]
Abstract
This paper reviews the literature on disengagement from mental health services examining how the terms engagement and disengagement are defined, what proportion of patients disengage from services, and what sociodemographic variables predict disengagement. Both engagement and disengagement appear to be poorly conceptualised, with a lack of consensus on accepted and agreed definitions. Rates of disengagement from mental health services vary from 4 to 46%, depending on the study setting, service type and definition of engagement used. Sociodemographic and clinical predictors of disengagement also vary, with only a few consistent findings, suggesting that such associations are complex and multifaceted. Most commonly reported associations of disengagement appear to be with sociodemographic variables including young age, ethnicity and deprivation; clinical variables such as lack of insight, substance misuse and forensic history; and service level variables such as availability of assertive outreach provision. Given the importance of continuity of care in serious mental disorders, there is a need for a consensual, validated and reliable measure of engagement which can be used to explore associations between patient, illness and service related variables and can inform service provision for difficult to reach patients.
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Affiliation(s)
- Aileen O'Brien
- Division of Mental Health, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK.
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Killaspy H, Johnson S, Pierce B, Bebbington P, Pilling S, Nolan F, King M. Successful engagement: a mixed methods study of the approaches of assertive community treatment and community mental health teams in the REACT trial. Soc Psychiatry Psychiatr Epidemiol 2009; 44:532-40. [PMID: 19039510 DOI: 10.1007/s00127-008-0472-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2008] [Revised: 11/06/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND The only randomised trial of assertive community treatment (ACT) carried out in England (the "REACT" study: randomised evaluation of assertive community treatment in North London) found no clinically significant advantage over usual care from community mental health teams (CMHTs). However, ACT clients were more satisfied and better engaged with services. To understand these findings better, we investigated the content of care and interventions offered to study participants. METHOD Quantitative data were collected to compare team structures and processes. Qualitative interviews with care co-ordinators of 40 of the 251 REACT study participants (20 ACT, 20 CMHT clients) were carried out and thematic analysis was used to explore differences in the approaches of the two types of team. RESULTS CMHTs scored low for ACT model fidelity and ACTTs scored high or ACT-like. All staff cited client engagement as their primary aim, but ACT approaches were less formal, more frequent and more successful than CMHTs'. Two aspects of ACT appeared important for engagement: small case loads and the team approach. Successful client engagement appeared to be associated with greater staff satisfaction. CONCLUSIONS The findings from this study assist in understanding why the ACT approach is more acceptable to clients deemed by CMHTs as "hard to engage". The key elements of ACT that facilitate client engagement may not be easily replicated within CMHTs due to their larger, varied caseloads.
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Affiliation(s)
- Helen Killaspy
- Dept. of Mental Health Sciences, Royal Free Campus, University College London, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK.
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Rössler W, Theodoridou A. [Innovative care models for treating psychosis]. DER NERVENARZT 2007; 77 Suppl 2:S111-8; quiz S119. [PMID: 17072569 DOI: 10.1007/s00115-006-2192-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
It is generally accepted that modern mental health care gives community treatment priority over partial or full inpatient treatment. The requirements for community treatment of severely ill and chronic psychiatric patients are complex and, together with financing by the different social insurance providers, may lead to a rather problematic fragmentation of health service supply. Schizophrenia is considered the most expensive mental illness in Germany. It is estimated that indirect costs (expressed in financial terms) are five times higher than the direct costs of treatment and care. Innovative concepts of psychosocial intervention show that case management and assertive community treatment reduce the hospitalisation rate and duration of inpatient treatment, enhance social integration, and find the approval of most patients. However, there is no empirical evidence supporting this "psychiatry with no beds". Consideration should be given to psychosocial interventions as an alternative to inpatient hospital treatment such as day hospital care, crisis houses, or acute home treatment.
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Affiliation(s)
- W Rössler
- Klinik für Soziale Psychiatrie und Allgemeinpsychiatrie Zürich West, Psychiatrische Universitätsklinik, Zürich, Schweiz.
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Abstract
Assertive Community Treatment (ACT) is a well-defined service delivery model for the care and treatment of the most severely mentally ill in the community. We have opted for a Dutch version named 'Function' ACT or FACT. In a FACT team, ACT is one of the functions that the team can perform. For more stable long-term patients FACT provides coordinated multidisciplinary treatment and care by individual case management. Unstable patients at risk of relapse are followed with assertive outreach care by the same team, working with a shared caseload for this subgroup. This article describes the service model and everyday practice in FACT.
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Roder V, Mueller DR, Mueser KT, Brenner HD. Integrated psychological therapy (IPT) for schizophrenia: is it effective? Schizophr Bull 2006; 32 Suppl 1:S81-93. [PMID: 16916888 PMCID: PMC2632544 DOI: 10.1093/schbul/sbl021] [Citation(s) in RCA: 185] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Against the background of evidence-based treatments for schizophrenia, nowadays the implementation of specific cognitive and behavioral interventions becomes more important in the standard care of these patients. Over the past 25 years, research groups in 9 countries have carried out 30 independent evaluations of Integrated Psychological Therapy (IPT), a group program that combines neurocognitive and social cognitive interventions with social skills approaches for schizophrenic patients. The aim of the present study was to evaluate the effectiveness of IPT under varying treatment and research conditions in academic and nonacademic sites. In a first step, all 30 published IPT studies with the participation of 1393 schizophrenic patients were included in the meta-analysis. In a second step, only high-quality studies (HQS) (7 studies including 362 patients) were selected and analyzed to check whether they confirmed the results of the first step. Positive mean effect sizes favoring IPT over control groups (placebo-attention conditions, standard care) were found for all dependent variables, including symptoms, psychosocial functioning, and neurocognition. Moreover, the superiority of IPT continued to increase during an average follow-up period of 8.1 months. IPT obtained similarly favorable effects across the different outcome domains, assessment formats (expert ratings, self-reports, and psychological tests), settings (inpatient vs outpatient and academic vs nonacademic), and phases of treatment (acute vs chronic). The HQS confirmed the results of the complete sample. The analysis indicates that IPT is an effective rehabilitation approach for schizophrenia that is robust across a wide range of patients and treatment conditions.
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Affiliation(s)
- Volker Roder
- University Psychiatric Services, University Hospital of Psychiatry, Bolligenstrasse 111, 3000 Bern 60, Switzerland.
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Weinmann S, Gaebel W. [Care requirements for severe mental disorders. Scientific evidence for integration of clinical psychiatry and community psychiatry]. DER NERVENARZT 2005; 76:809-10, 812-6, 819-21. [PMID: 15580465 DOI: 10.1007/s00115-004-1851-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In Germany it is not clear which forms of community mental health care should be encouraged to meet the needs particularly of the severely mentally ill. We performed a literature review of systematic meta-analyses and controlled trials and show that a set of well-evaluated and effective psychiatric care systems is available, of which only a few are being implemented in Germany. It becomes obvious that in Germany organizational requirements for an integration of psychiatric services are not being adequately met, particularly in the case of schizophrenia. Team-based assertive community treatment, crisis intervention teams, community mental health teams, and modern job rehabilitation programs, which have been established primarily in English-speaking countries, could not be effectively adapted for German psychiatric care. At the same time many psychiatric care models have been poorly evaluated. Given the available scientific evidence we comment on future requisites and further developments in German psychiatry to meet the growing need of care for people with severe mental illnesses.
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Affiliation(s)
- S Weinmann
- Rheinische Kliniken Düsseldorf, Klinik und Poliklinik für Psychiatrie und Psychotherapie der Heinrich-Heine-Universität Düsseldorf.
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Wright C, Catty J, Watt H, Burns T. A systematic review of home treatment services--classification and sustainability. Soc Psychiatry Psychiatr Epidemiol 2004; 39:789-96. [PMID: 15669659 DOI: 10.1007/s00127-004-0818-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND In view of the plethora of different community-based mental health services, there is a clear need for a classification based on service components rather than labels. Moreover, the sustainability of experimental services beyond their research studies is rarely reported. METHODS As part of a systematic review of home treatment for mental health problems, authors of all included studies were followed up for data on service components and sustainability. Associations between components were explored. RESULTS There was evidence of a core group of components co-occurring in home treatment services: regularly visiting at home, taking responsibility for health and social care, having smaller caseloads, multidisciplinary teams, integrated psychiatrists and a high proportion of contacts at home. Fifty-four per cent of services no longer existed, of which almost half had ended by the study's publication date. There was a significant association between sustainability and the study's hospitalisation outcome. CONCLUSIONS Some of the related service components presented here were associated with reducing hospitalisation. This group cannot, however, be used to provide a new taxonomy of services. It is imperative that future studies prospectively record and report service components to enable better classification. It is of concern that policy is currently predicated on research findings regardless of whether or not the experimental service was sustainable.
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Affiliation(s)
- Christine Wright
- Dept of Mental Health, St George's Hospital Medical School, London SW17 ORE, UK.
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Ravelli DP, Buwalda VJA, Slooff CJAJ, Schrijvers AJP, van Engeland H. Do integrated mental healthcare organisations facilitate process quality in the treatment of people with schizophrenia and related psychoses? Int J Integr Care 2003; 3:e17. [PMID: 16896377 PMCID: PMC1483946 DOI: 10.5334/ijic.74] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2002] [Revised: 01/05/2003] [Accepted: 01/30/2003] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective of this study is to investigate the influence of mergers of ambulatory and mental healthcare organisations on the process quality of care for persons suffering from schizophrenia or related psychoses. THEORY On the basis of the theory of Donabedian we assume the relationships between three types of quality in healthcare: structure quality, process quality and outcome quality. This study focuses on the influences of structure quality, i.e. years since merger and catchment area size upon process quality. METHODS Criteria according to Tugwell for evaluating healthcare were used to describe the process quality of schizophrenia care, resulting in a process quality questionnaire with 6 subscales and 21 items. Leading psychiatrists of 31 Dutch mental healthcare organisations, covering 89% of the country, answered the questionnaire. Both programmes and documents from the responding institutions and schizophrenia projects were analysed. Correlations of two determinants, age of the merged organisation and catchment area size, were made with total scale scores and the sub scores of the questionnaire. RESULTS The response rate was 97% (31/32). Twenty-two organisations (71%) had a score of more than 50% on the used scale, 8 (29%) scored less. Two evidence-based interventions were implemented in more than 50% of the organisations, three in less than 50%. A low degree of implementation occurs in establishing care for people with schizophrenia from ethnic minorities, standardising diagnostic procedures and continuity of care. No significant relationship between the age of the merged organisation ('age') and the total process quality of schizophrenia care was found, however, the relationships between age and the subscales availability of interventions and integrated treatment were significant. No association was found between the size of the MHO's catchment area and any of the used subscales. CONCLUSIONS The age of integration of residential and ambulatory mental health institutions correlates significantly with two subscales of process quality of schizophrenia care, i.e. availability of interventions and treatment. Catchment area size is not significantly associated with process quality or any of the subscales. Despite the mentioned positive effects, the overall picture of schizophrenia care is not very positive. Additional forces other than merely integration of ambulatory and residential services are needed for the further implementation of evidence-based interventions, diagnostic standards and continuity of care. The development of a national 'schizophrenia standard' (like in other countries) in relation with implementation plans and strategies to evaluate care on a regional level is recommended as well as further research on patient outcomes in relation to mergers of mental healthcare organisations.
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Affiliation(s)
- D P Ravelli
- General Psychiatric Hospital Robert Fleury, Leidschendam, The Netherlands.
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