Successful engagement: a mixed methods study of the approaches of assertive community treatment and community mental health teams in the REACT trial

Open Dialogue services around the world: a scoping survey exploring organizational characteristics in the implementation of the Open Dialogue approach in mental health services

Objective

This cross-sectional study investigates the characteristics and practices of mental health care services implementing Open Dialogue (OD) globally.

Methods

A structured questionnaire including a self-assessment scale to measure teams' adherence to Open Dialogue principles was developed. Data were collected from OD teams in various countries. Confirmatory Composite Analysis was employed to assess the validity and reliability of the OD self-assessment measurement. Partial Least Square multiple regression analysis was used to explore characteristics and practices which represent facilitating and hindering factors in OD implementation.

Results

The survey revealed steady growth in the number of OD services worldwide, with 142 teams across 24 countries by 2022, primarily located in Europe. Referrals predominantly came from general practitioners, hospitals, and self-referrals. A wide range of diagnostic profiles was treated with OD, with psychotic disorders being the most common. OD teams comprised professionals from diverse backgrounds with varying levels of OD training. Factors positively associated with OD self-assessment included a high percentage of staff with OD training, periodic supervisions, research capacity, multi-professional teams, self-referrals, outpatient services, younger client groups, and the involvement of experts by experience in periodic supervision.

Conclusion

The findings provide valuable insights into the characteristics and practices of OD teams globally, highlighting the need for increased training opportunities, supervision, and research engagement. Future research should follow the development of OD implementation over time, complement self-assessment with rigorous observations and external evaluations, focus on involving different stakeholders in the OD-self-assessment and investigate the long-term outcomes of OD in different contexts.

Patients' experiences with coercive mental health treatment in Flexible Assertive Community Treatment: a qualitative study

BACKGROUND

Flexible Assertive Community Treatment (FACT) teams have been implemented in Norwegian health and social services over the last years, partly aiming to reduce coercive mental health treatment. We need knowledge about how service users experience coercion within the FACT context. The aim of this paper is to explore service user experiences of coercive mental health treatment in the context of FACT and other treatment contexts they have experienced. Are experiences of coercion different in FACT than in other treatment contexts? If this is the case, which elements of FACT lead to a different experience?

METHOD

Within a participatory approach, 24 qualitative interviews with service users in five different FACT teams were analyzed with thematic analysis.

RESULTS

Participants described negative experiences with formal and informal coercion. Three patterns of experiences with coercion in FACT were identified: FACT as clearly a change for the better, making the best of FACT, and finding that coercion is just as bad in FACT as it was before. Safety, improved quality of treatment, and increased participation were described as mechanisms that can prevent coercion.

CONCLUSION

Results from this study support the argument that coercion is at odds with human rights and therefore should be avoided as far as possible. Results suggest that elements of the FACT model may prevent the use of coercion by promoting safety, improved quality of treatment and increased participation.

Feasibility of implementing Extubation Advisor, a clinical decision support tool to improve extubation decision-making in the ICU: a mixed-methods observational study

OBJECTIVES

Although spontaneous breathing trials (SBTs) are standard of care to extubation readiness, no tool exists that optimises prediction and standardises assessment. In this study, we evaluated the feasibility and clinical impressions of Extubation Advisor (EA), a comprehensive clinical extubation decision support (CDS) tool.

DESIGN

Phase I mixed-methods observational study.

SETTING

Two Canadian intensive care units (ICUs).

PARTICIPANTS

We included patients on mechanical ventilation for ≥24 hours and clinicians (respiratory therapists and intensivists) responsible for extubation decisions.

INTERVENTIONS

Components included a predictive model assessment, feasibility evaluation, questionnaires and interviews with clinicians.

RESULTS

We enrolled 117 patients, totalling 151 SBTs and 80 extubations. The incidence of extubation failure was 11% in low-risk patients and 21% in high-risk patients stratified by the predictive model; 38% failed extubation when both the model and clinical impression were at high risk. The tool was well rated: 94% and 75% rated the data entry and EA report as average or better, respectively. Interviews (n=15) revealed favourable impressions regarding its user interface and functionality, but unexpectedly, also concerns regarding EA's potential impact on respiratory therapists' job security.

CONCLUSIONS

EA implementation was feasible, and users perceived it to have potential to support extubation decision-making. This study helps to understand bedside implementation of CDS tools in a multidisciplinary ICU.

TRIAL REGISTRATION NUMBER

NCT02988167.

A Qualitative Study on the Implementation of Flexible Assertive Community Treatment - an Integrated Community-based Treatment Model for Patients with Severe Mental Illness

Introduction

Flexible Assertive Community Treatment (FACT) is a model of integrated care aiming to increase continuity of care for individuals with severe mental illness. FACT teams have been implemented in many countries by merging Assertive Community Treatment (ACT) and standard care from Community Mental Health teams (CMHTs). However, there has been little research on how practitioners experienced the fusion of these teams.

Aim

This study explores how former ACT and CMHT practitioners perceived the implementation of FACT.

Method

Perceptions of the FACT model, implementation strategies and adaptations of the model were investigated through 17 semi-structured interviews with FACT practitioners.

Results

Perceived positive contributions of FACT included the recognition that FACT addressed a service gap for a group of patients who could benefit from increased support and improved integration of outpatient and hospital care. Perceived disadvantages of FACT included the experience that FACT drew away resources from ACT patients with the highest psychiatric needs. The findings also describe barriers to implementation, such as lack of perceived benefit of FACT, the maintenance of traditional work culture and insufficient organisational capacity. These challenges required the negotiation of local implementation strategies and adaptations.

Conclusion

FACT increases access to intensive care for a broader group of patients with severe mental illness. However, findings from this study also suggest that the increased caseload in FACT compared with ACT and a changed mindset may not reflect the needs of the smaller group of patients who find it difficult to engage with mental health care services.

Mental health practitioner experiences of engaging with service users in community mental health settings: A systematic review and thematic synthesis of qualitative evidence

WHAT IS KNOWN ON THE SUBJECT?: Engagement is regarded as important and beneficial for service users and mental health services A universal definition of engagement is not yet fully agreed upon. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Based upon their experience, mental health staff use varied engagement approaches to fit with the changeable and unique needs of people who use services (service users). Mental health staff demonstrate qualities such as persistence and adaptability to successfully engage with service users. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Irrespective of professional background, the role of community mental health staff is not restricted to any single approach. Practical help and social support are as seen as important as clinical treatment to establish successful engagement. Little is known about the engagement experiences of mental health staff working in early intervention settings as most studies in this review focused on the perspectives of staff based in assertive outreach or community mental health teams. There is a need to further understand staff experiences of engagement with service users in early intervention settings. Role descriptions and expectations of community mental health workers should account for the wide-ranging flexible approach required in order to deliver appropriate interventions. This may involve a focus on engagement in training programmes. ABSTRACT: Introduction Effective mental health care is dependent on engaging service users, but some individuals do not actively attend appointments, and may stop engaging with mental health services. Quantitative studies reveal some salient factors that seem to predict engagement, but these studies miss the nuances of good clinical practice in this area. A number of qualitative studies of health professionals' experiences and understanding of effective engagement have been published. Aim This review aimed to systematically identify, evaluate and synthesize results from these studies with a view to informing effective practice in this area. Methods Electronic databases MEDLINE, EMBASE, CINAHL, PsychINFO and AMED were searched (PROSPERO systematic review protocol registry (www.crd.york.ac.uk/prospero/; ID CRD42017083976). Of 799 records, ten papers met the inclusion criteria. All papers were subjected to quality appraisal based on the CASP checklist and data systematically extracted. A thematic synthesis of included studies examining mental health practitioners' experiences of engagement in community mental health settings was conducted. Results Mental health practitioners see engaging service users as depending upon complex, multi-dimensional phenomena which should include individualized person-centred approaches as well as practical, social and clinical support. Mental health practitioners demonstrate qualities such as determination and adaptability to establish and maintain engagement with service users. Implications for practice As a core aspect of nurse education, registered mental health nurses and other professionals would benefit from systematic guidance regarding engagement strategies. Most studies in this review focused on assertive outreach or community mental health teams, more clarification is needed of practitioner's engagement experiences in early intervention settings.

Engagement in specialized early intervention services for psychosis as an interplay between personal agency and critical structures: A qualitative study

BACKGROUND

Specialized early intervention programs for individuals experiencing a first episode of psychosis prioritize service engagement, generally operationalized as attendance, treatment completion, therapeutic alliance, and treatment adherence. However, there are critical theoretical and methodological gaps in understanding how service users experience and define their engagement with the service.

OBJECTIVES

This study aimed to explore how current and former service users define their engagement with a specialized early intervention program.

DESIGN

A qualitative descriptive approach was used to explore service users' decisions to use, remain involved with, and/or leave early intervention services.

SETTING

This study took place in an early intervention service for psychosis in Montreal, Canada.

PARTICIPANTS

Twenty-four participants who had experienced a first episode of psychosis and had been engaged in the service to varying degrees (fully engaged, partially engaged, disengaged) took part in in-depth interviews.

METHODS

In-depth interviews were employed to collect rich insights into participants' experiences and perceptions. The interviews were transcribed and analysed using thematic analysis, beginning with an inductive approach and completing the analysis using a theoretical approach. During the analysis, our original notions of engagement and disengagement were challenged by theorizing engagement in terms of agency and structure. Researchers engaged in reflexive practices to maintain and promote research rigor and trustworthiness.

RESULTS

Participants' narratives were thematically analyzed and organized into three themes: fluidity and temporality of engagement and disengagement; engagement as an ongoing negotiation; and critical structures and agency. Participants described engagement in a variety of ways, some of which were broader than service use and focused on self-care and commitment to recovery. These conceptions were subject to change as the individuals' perceptions of their needs changed. As needs changed, individuals also negotiated and renegotiated their care needs with themselves and with their treatment team. These exercises of agency were constrained by key structures: the treatment team, family and friends, and societal conceptions of mental health.

CONCLUSIONS

Our study findings argue for an expanded definition of engagement which prioritizes individuals' experience and acknowledges the steps towards recovery that they may make outside of the purview of the service. It also underlines the importance of a treatment structure which aligns with individuals' needs for both support and autonomy.

Safewards Impact in Inpatient Mental Health Units in Victoria, Australia: Staff Perspectives

Introduction: Mental health professionals working in acute inpatient mental health wards are involved in a complex interplay between an espoused commitment by government and organizational policy to be recovery-oriented and a persistent culture of risk management and tolerance of restrictive practices. This tension is overlain on their own professional drive to deliver person-centered care and the challenging environment of inpatient wards. Safewards is designed to reduce conflict and containment through the implementation of 10 interventions that serve to improve the relationship between staff and consumers. The aim of the current study was to understand the impact of Safewards from the perspectives of the staff. Methods: One hundred and three staff from 14 inpatient mental health wards completed a survey 12 months after the implementation of Safewards. Staff represented four service settings: adolescent, adult, and aged acute and secure extended care units. Results: Quantitative results from the survey indicate that staff believed there to be a reduction in physical and verbal aggression since the introduction of Safewards. Staff were more positive about being part of the ward and felt safer and more connected with consumers. Qualitative data highlight four key themes regarding the model and interventions: structured and relevant; conflict prevention and reducing restrictive practices; ward culture change; and promotes recovery principles. Discussion: This study found that from the perspective of staff, Safewards contributes to a reduction in conflict events and is an acceptable practice change intervention. Staff perspectives concur with those of consumers regarding an equalizing of staff consumer relationships and the promotion of more recovery-oriented care in acute inpatient mental health services.

Responsibilities with conflicting priorities: a qualitative study of ACT providers' experiences with community treatment orders

Background

Patients with severe mental illness may be subjected to Community Treatment Orders (CTOs) in order to secure that the patients adhere to treatment. Few studies have investigated the use of CTOs within an Assertive Community Treatment (ACT) setting, and little is known about how the tension between the patients’ autonomy and the clinicians’ responsibility to act in the patients’ best interest are resolved in practice. The aim of this study was to explore the service providers’ experiences with CTOs within an ACT setting.

Methods

The study was based on reviews of case files of 15 patients, eight individual qualitative in depth interviews and four focus group interviews with service providers involved in ACT and decisions related to CTOs. A modified grounded theory approach was used to analyze the data.

Results

The main theme ‘responsibility with conflicting priorities’ emerged from data analysis (case file reviews, individual interviews and focus group interviews). The balance between coercive approaches and the emphasis on promoting patient autonomy was seen as problematic. The participants saw few alternatives to CTOs as long-term measures to secure ongoing treatment for some of the patients. However, participants perceived the ACT model’s comprehensive scope as an opportunity to build rapport with patients and thereby better meet their needs. The team approach, the ACT providers’ commitment to establish supportive relationships and the frequent meetings with patients in their home environment were highlighted. The ACT approach gave them insight into patients’ everyday lives and, in some cases a greater sense of security when considering whether to take patients off CTOs.

Conclusions

Many of the participants viewed CTOs as helpful in securing long-term treatment for patients. CTO decision-making was described as challenging and complex and presented the providers with many dilemmas. The ACT approach was considered as helpful in that it afforded comprehensive, patient-centered support and opportunities to build rapport.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3097-7) contains supplementary material, which is available to authorized users.

Can "Model Projects of Need-Adapted Care" Reduce Involuntary Hospital Treatment and the Use of Coercive Measures?

Intensive outpatient models of need-adapted psychiatric care have been shown to reduce the length of hospital stays and to improve retention in care for people with severe mental illnesses. In contrast, evidence regarding the impact of such models on involuntary hospital treatment and other coercive measures in inpatient settings is still sparse, although these represent important indicators of the patients' wellbeing. In Germany, intensive models of care still have not been routinely implemented, and their effectiveness within the German psychiatric system is only studied in a few pioneering regions. An innovative model of flexible, assertive, need-adapted care established in Berlin, Germany, in 2014, treating unselected 14% of the catchment area's patients, was evaluated on the basis of routine clinical data. Records of n = 302 patients diagnosed with severe mental disorders, who had been hospitalized at least once during a 4-year-observational period, were analyzed in a retrospective individual mirror-image design, comparing the 2 years before and after inclusion in the model project regarding the time spent in hospital, the number and duration of involuntary hospital treatments and the use of direct coercive interventions like restraint or isolation. After inclusion to the project, patients spent significantly less time in hospital. Among patients treated on acute wards and patients with a diagnosis of psychosis, the number of patients subjected to provisional detention due to acute endangerment of self or others decreased significantly, as did the time spent under involuntary hospital treatment. The number of patients subjected to mechanical restraint, but not to isolation, on the ward decreased significantly, while the total number of coercive interventions remained unchanged. Findings suggest some potential of intensive models of need-adapted care to reduce coercive interventions in psychiatry. However, results must be substantiated by evidence from randomized-controlled trials and longer observation periods.

The replacement of assertive outreach services by reinforcing local community teams: a replication study reporting comparative outcomes and patient reported experience

BACKGROUND

This is the third in a series of papers on patient outcomes and other consequences of the withdrawal of specialist assertive outreach (AO) teams. We previously reported positive outcomes for patients receiving a less intensive service at up to four years, but had not systematically interviewed patients.

AIMS

To test the generalizability of earlier findings through replication in another service. To complement the analysis of service utilisation with patient reported experience between the two treatment models.

METHODS

Service level evaluation 12 months pre and post service change for 55 eligible AO patients. Thirty three consenting patients answered validated questionnaires.

RESULTS

There were no statistically significant changes in hospital bed use comparing the year before and the year after the change (850-712 bed days, median 34-20). No significant change in crisis activity occurred despite a highly significant reduction in face to face contacts from a mean of 90-40. There were no significant changes in patient reported experience.

CONCLUSIONS

Results are consistent with earlier studies. Reinforcing community mental health teams can provide an integrated service model that is clinically effective and equally acceptable to patients, making this a viable and affordable alternative to orthodox AO teams.

Facilitating Social Integration for People With Severe Mental Illness Served by Assertive Community Treatment

PURPOSE

This article explores the experience of workers on Assertive Community Treatment (ACT) teams surrounding their efforts to facilitate social integration for their clients.

DESIGN AND METHODS

Sixteen workers were individually interviewed and eight additional workers participated in two focus groups.

FINDINGS

The formation of caring relationships between worker and client was an important first step towards social integration for ACT clients. Community activities offer opportunities for social interaction.

PRACTICE IMPLICATIONS

The frequency of community based activities should be increased. Social integration should be a targeted focus of service by structurally embedding a social integration specialist onto the ACT model.

Are Users Satisfied with Assertive Community Treatment in Spite of Personal Restrictions?

The purpose of this explorative study was to examine satisfaction among 70 users of 12 Norwegian Assertive Community Treatment teams. The study was carried out among a group of 70 service users, and reveals generally high levels of satisfaction with the service, with satisfaction also being high in comparison to other ACT satisfaction studies. Users under a Community Treatment Order were more satisfied, while users with an alcohol use disorder were less satisfied. Younger service users were less positive than older users. There was no difference in satisfaction between the genders. This study's positive result may reflect the ACT model's focus on user involvement, recovery and building relationships, and the fact that this service has a more holistic approach than previous services that users have experienced.

Treatment engagement of individuals experiencing mental illness: review and update

Individuals living with serious mental illness are often difficult to engage in ongoing treatment, with high dropout rates. Poor engagement may lead to worse clinical outcomes, with symptom relapse and rehospitalization. Numerous variables may affect level of treatment engagement, including therapeutic alliance, accessibility of care, and a client's trust that the treatment will address his/her own unique goals. As such, we have found that the concept of recovery-oriented care, which prioritizes autonomy, empowerment and respect for the person receiving services, is a helpful framework in which to view tools and techniques to enhance treatment engagement. Specifically, person-centered care, including shared decision making, is a treatment approach that focuses on an individual's unique goals and life circumstances. Use of person-centered care in mental health treatment models has promising outcomes for engagement. Particular populations of people have historically been difficult to engage, such as young adults experiencing a first episode of psychosis, individuals with coexisting psychotic and substance use disorders, and those who are homeless. We review these populations and outline how various evidence-based, recovery-oriented treatment techniques have been shown to enhance engagement. Our review then turns to emerging treatment strategies that may improve engagement. We focus on use of electronics and Internet, involvement of peer providers in mental health treatment, and incorporation of the Cultural Formulation Interview to provide culturally competent, person-centered care. Treatment engagement is complex and multifaceted, but optimizing recovery-oriented skills and attitudes is essential in delivery of services to those with serious mental illness.

Engaging consumers in the Australian emergency mental health context: a qualitative perspective from clinicians working in the community

Successfully engaging with consumers is seen as an essential component of mental healthcare, yet doing so can be challenging and little is understood about the unique engagement skills and attributes employed by mental health clinicians working in the emergency community context. Consequently, this qualitative study explored the engagement experiences of clinicians to identify the attributes used when engaging with consumers in this unique setting. We conducted two semi-structured focus groups in July and August 2011 with 16 clinicians employed at one metropolitan mental health organisation in South Australia. Using thematic analysis, we identified two key themes pertaining to the skills and attributes used for successful consumer engagement: (i) building trust, through communication style, an honest approach, facilitating choice and locating trust networks; and (ii) portraying genuine care, through showing respect, offering practical assistance and taking the least restrictive pathway. These findings highlight the unique nature of engagement in the emergency community mental health setting, as well as the flexibility and resourcefulness required to facilitate it.

Engagement in assertive community treatment as experienced by recovering clients with severe mental illness and concurrent substance use

BACKGROUND

Clients with severe mental illness (SMI) who use substances are less engaged in treatment than those who do not use substances, and assertive community treatment (ACT) engages and retains clients with SMI and concurrent substance use at a higher rate compared with traditional treatment. This qualitative study aimed to explore the experiences of being recruited to, and remaining in, ACT among recovering clients diagnosed with SMI and concurrent substance use.

METHODS

Twenty semi-structured interviews were undertaken among 11 clients with SMI and concurrent substance use who were included in ACT teams. The inclusion criteria were SMI and concurrent substance use and improvement after a minimum of 12 months in treatment regarding one or several of the following parameters: quality of life, general functioning and substance use. Systematic text condensation was applied in the analyses.

RESULTS

The experiences of building trust through enduring involvement and receiving benefits were most important for the acceptance of ACT by clients. A feeling of exclusiveness, perceiving ACT as a safety net and the clients' own personal responsibility for taking part in the treatment were stated as the most important factors for remaining in treatment.

CONCLUSIONS

The implications of the results of the present study are that service providers have to prove that they can be trusted in the initial phase of the clients' contact with the team. The feeling by clients with SMI and concurrent substance use that service providers in ACT believe they can improve their client's quality of life, is of importance for feeling exclusive, having hope for the future and remaining in treatment.

Ten year outcomes of participants in the REACT (Randomised Evaluation of Assertive Community Treatment in North London) study

BACKGROUND

A previous randomised controlled trial that investigated Assertive Community Treatment (ACT) in the UK (the REACT Study) found no clinical advantage over usual care delivered by Community Mental Health Teams (CMHTs) at 18 and 36 month follow-ups. No studies have investigated long term clinical and social outcomes for patients receiving ACT.

METHOD

We investigated inpatient service use, social outcomes, service contact and adverse events for the 251 REACT study participants 10 years after randomisation through case note review. Data were analysed using regression models adjusted for original treatment group allocation and changes in treatment group.

RESULTS

We found no statistically significant differences in outcomes by original treatment group over the 10 years. Those whose care remained with ACT, or transferred to ACT or forensic services, had more inpatient days over the 10 years (coefficient 223, 95% CI 83 to 363, p = 0.002) than those whose care remained with the CMHTs or were discharged to primary care. Being subject to a Community Treatment Order was associated with a greater chance of being under ACT at 10 year follow-up (OR 6.39, 95% CI 2.98 to 13.70, p <0.001).

CONCLUSIONS

The ACT teams in this study showed no clinical advantage over usual care provided by CMHTs at 10 year follow-up. We also found that the ACT teams accrued patients from the original study sample who had more complex needs than those who remained with or transferred to the CMHTs or primary care during this period. Further well conducted trials are needed to identify the most cost-effective approaches to supporting successful community living and optimum long term outcomes for this group.

Avaliando a fidelidade de intervenções psicossociais: uma revisão sistemática da literatura

Objetivo Intervenções psicossociais têm tido impacto positivo na vida das pessoas com transtorno mental grave, porém tais intervenções devem ser implementadas fielmente ao protocolo. A fidelidade refere-se à medida que uma intervenção adere ao modelo original e sua avaliação é essencial para que os desfechos possam ser creditados à intervenção. O objetivo deste estudo foi realizar uma revisão sistemática da literatura mundial das intervenções psicossociais destinadas a pacientes com transtornos mentais que possuem um instrumento ou método de avaliação de fidelidade ao modelo original. Métodos Pesquisas bibliográficas sistemáticas foram realizadas para encontrar estudos relevantes ao tema nas seguintes bases de dados: Embase, Medline, Scopus e SciELO. Foram incluídos estudos de intervenções psicossociais, realizados na comunidade, dirigidos a pacientes diagnosticados com transtornos mentais. Intervenções de comparação poderiam incluir tanto o tratamento-padrão como uma intervenção de comparação ativa. A qualidade dos estudos foi avaliada de forma independente por dois revisores, utilizando critérios adaptados de instrumentos validados. Resultados Trinta estudos preencheram os critérios de inclusão. Os estudos mostraram a eficácia da avaliação da fidelidade em diferenciar diferentes modelos de tratamento, sua validade preditiva para os desfechos e a confiabilidade dos instrumentos utilizados, bem como os fatores facilitadores e os obstáculos para a obtenção de alta fidelidade nas intervenções avaliadas. Conclusão Além de documentar a adesão ao modelo original, a fidelidade fornece informações relativas à população-alvo e aos desfechos esperados, o que contribui para que seja alcançada excelência no processo de implementação das intervenções psicossociais.

Measuring the evidence: reviewing the literature of the measurement of therapeutic engagement in acute mental health inpatient wards

Quality nursing plays a central role in the delivery of contemporary health and social care, with a positive correlation being demonstrated between patient satisfaction and the quality of nursing care received. One way to ensure such quality is to develop metrics that measure the effectiveness of various aspects of care across a variety of settings. Effective mental health nursing is predicated on understanding the lived experiences of service users in order to provide sensitively-attuned nursing care. To achieve this, mental health nurses need to establish the all-important therapeutic relationship, showing compassion and creating a dialogue whereby service users feel comfortable to share their experiences that help contextualize their distress. Indeed, service users value positive attitudes, being listened to, and being able to trust those who provide care, while mental health nurses value their ability to relate through talking, listening, and expressing empathy. However, the literature suggests that within mental health practice, a disproportionate amount of time is taken up by other activities, with little time being spent listening and talking to service users. The present study discusses the evidence relating to the therapeutic relationship in acute mental health wards and explores why, after five decades, it is not recognized as a fundamental metric of mental health nursing.

The availability and quality across Europe of outpatient care for difficult-to-engage patients with severe mental illness: a survey among experts

BACKGROUND

As many patients with severe mental illness (SMI) who have complex needs are difficult to engage, outreach mental health services are needed to engage them into treatment. The extent to which these services exist in large European cities is unknown.

METHODS

Experts in 29 European countries were sent a structured questionnaire containing two case vignettes of difficult-to-engage patients (a first-episode psychosis patient and a homeless chronic schizophrenia patient). The type and quality of outpatient care was assessed and related to several national indices.

RESULTS

The questionnaire was returned by experts from 22 countries (76%) representing 92% of the EU population. Six countries (21%) had a systematic method for detecting difficult-to-engage patients. The most important route whereby such patients entered the mental health system was through informal care; the most important reasons for entering it were the level of psychiatric symptoms, nuisance and violence. Assertive outreach was available in nine countries (41%), with coverage ranging from a few teams (sometimes for a specific target group) to most of the country. The case vignettes showed that outpatient care for these difficult-to-engage patients varied widely. In seven (30%) of the 22 countries, a hospital would take no action if such patients who had been admitted voluntarily discharged themselves prematurely. On a scale of 0-10, the experts' mean scores regarding the quality of outpatient care for patients with SMI in general were 5.2 (SD = 1.9) and 3.2 (SD = 2.2) in difficult-to-engage ones. Explorative analyses showed that the quality of outpatient care for difficult-to-engage patients was associated with gross national income and the number of psychiatrists per capita.

CONCLUSIONS

Outpatient mental health services for difficult-to-engage SMI patients varied widely among European countries; experts judged their overall quality to be poor. It is now important to achieve consensus on a minimum European standard for the quality of care for such patients.

The effectiveness of assertive community treatment for elderly patients with severe mental illness: a randomized controlled trial

BACKGROUND

Due to fragmented mental, somatic, and social healthcare services, it can be hard to engage into care older patients with severe mental illness (SMI). In adult mental health care, assertive community treatment (ACT) is an organizational model of care for treating patients with SMI who are difficult to engage. So far all outcome studies of assertive community treatment have been conducted in adults.

METHODS

In a randomized controlled trial design we compared the effectiveness of ACT for elderly patients with that of treatment as usual (TAU). Sixty-two outpatients (60 years and older) with SMI who were difficult to engage in psychiatric treatment were randomly assigned to the intervention or control group (32 to ACT for elderly patients and 30 to TAU). Primary outcomes included number of patients who had a first treatment contact within 3 months, the number of dropouts (i.e. those discharged from care due to refusing care or those who unintentionally lost contact with the service over a period of at least 3 months); and patients' psychosocial functioning (HoNOS65+ scores) during 18 months follow-up. Secondary outcomes included the number of unmet needs and mental health care use. Analyses were based on intention-to-treat.

RESULTS

Of the 62 patients who were randomized, 26 were lost to follow-up (10 patients in ACT for elderly patients and 16 in TAU). Relative to patients with TAU, more patients allocated to ACT had a first contact within three months (96.9 versus 66.7%; X2 (df = 1) = 9.68, p = 0.002). ACT for elderly patients also had fewer dropouts from treatment (18.8% of assertive community treatment for elderly patients versus 50% of TAU patients; X2 (df = 1) = 6.75, p = 0.009). There were no differences in the other primary and secondary outcome variables.

CONCLUSIONS

These findings suggest that ACT for elderly patients with SMI engaged patients in treatment more successfully.

TRIAL REGISTRATION

NTR1620.

A mixed methods multiple case study of implementation as usual in children's social service organizations: study protocol

BACKGROUND

Improving quality in children's mental health and social service settings will require implementation strategies capable of moving effective treatments and other innovations (e.g., assessment tools) into routine care. It is likely that efforts to identify, develop, and refine implementation strategies will be more successful if they are informed by relevant stakeholders and are responsive to the strengths and limitations of the contexts and implementation processes identified in usual care settings. This study will describe: the types of implementation strategies used; how organizational leaders make decisions about what to implement and how to approach the implementation process; organizational stakeholders' perceptions of different implementation strategies; and the potential influence of organizational culture and climate on implementation strategy selection, implementation decision-making, and stakeholders' perceptions of implementation strategies.

METHODS/DESIGN

This study is a mixed methods multiple case study of seven children's social service organizations in one Midwestern city in the United States that compose the control group of a larger randomized controlled trial. Qualitative data will include semi-structured interviews with organizational leaders (e.g., CEOs/directors, clinical directors, program managers) and a review of documents (e.g., implementation and quality improvement plans, program manuals, etc.) that will shed light on implementation decision-making and specific implementation strategies that are used to implement new programs and practices. Additionally, focus groups with clinicians will explore their perceptions of a range of implementation strategies. This qualitative work will inform the development of a Web-based survey that will assess the perceived effectiveness, relative importance, acceptability, feasibility, and appropriateness of implementation strategies from the perspective of both clinicians and organizational leaders. Finally, the Organizational Social Context measure will be used to assess organizational culture and climate. Qualitative, quantitative, and mixed methods data will be analyzed and interpreted at the case level as well as across cases in order to highlight meaningful similarities, differences, and site-specific experiences.

DISCUSSION

This study is designed to inform efforts to develop more effective implementation strategies by fully describing the implementation experiences of a sample of community-based organizations that provide mental health services to youth in one Midwestern city.

A dismantling study of assertive outreach services: comparing activity and outcomes following replacement with the FACT model

PURPOSE

Financial constraints and some disappointing research evaluations have seen English assertive outreach (AO) teams subject to remodelling, decommissioning and integration into standard care. We tested a specific alternative model of integrating the AO function from two AO teams into six standard community mental health teams (CMHT). The Flexible Assertive Community Treatment model (FACT) was adopted from the Netherlands (Van Veldhuizen, Commun Mental Health J 43(4):421-433, 2007; Bond and Drake, Commun Mental Health J 43(4):435-438, 2007). We aimed to demonstrate non-inferiority in clinical effectiveness and thereby show cost efficiencies associated with FACT.

METHODS

Outcomes were compared in a mirror-image study of the 12 months periods pre- and post-service change with eligible individuals from the AO teams' caseloads (n = 112) acting as their own controls. We also conducted a cost-consequence analysis of the changes. Outcome data regarding admissions, use of crisis and home treatment, frequency of contact and DNA rate were extracted from the electronic patient record.

RESULTS

The results show AO patients (n = 112) transferred to standard CMHTs with FACT had significantly fewer admissions and a halving of bed use (21 fewer admission and 2,394 fewer occupied bed days) whilst being in receipt of a less intensive service (2,979 fewer contacts). This was offset by significantly poorer engagement but not by increased use of crisis and home treatment services.

CONCLUSIONS

Enhancing multi-disciplinary CMHTs with FACT provides a clinically effective alternative to AO teams. FACT offers a cost-effective model compared to AO.

Psychosocial interventions in people with severe mental illness: a Bleulerian perspective

BACKGROUND

Eugen Bleuler, in his book Dementia praecox oder Gruppe der Schizophrenien, discussed issues of social psychiatry, and he considered complex interventions pivotal in the care for people with schizophrenia. Bleuler emphasised the potential of therapeutic communities in providing care, the drawbacks of extended hospitalisation and the therapeutic potential of planned 'early discharge' and job integration.

METHODS

Some of the current evidence on therapeutic communities, planned early hospital discharge, alternatives to inpatient care and job integration in people with severe mental illness are reviewed.

RESULTS

(i) Current evidence suggests that therapeutic communities (and new forms of milieu therapy, e.g. Soteria) are an effective ingredient of care; (ii) the evidence on planned early discharge suggests that there is scope for early discharge if continuity of care is ensured, and (iii) the evidence on supported employment suggests that there is scope for early job placement/supported employment among people with schizophrenia with little risk to clinical stability.

CONCLUSION

Eugen Bleuler was a far-sighted social psychiatrist who concentrated on treatment issues and complex interventions that are considered cornerstones of care for people with severe mental illness one hundred years later.

Implementation of assertive community treatment in Australia: model fidelity, patient characteristics and staff experiences

The impact of variable implementation of the Assertive Community Treatment (ACT) model on patient outcomes is increasingly recognised. We conducted the first study of four established Australian ACT teams, examining team composition, processes and model fidelity, using previously validated questionnaires. Demographic and clinical details of patients and their own experiences of ACT were gathered from staff. Associations between burnout and work experiences were examined. All teams were ACT-like (mean DACTS score = 3.7, SD = 0.3) with few significant patient differences between teams, except diagnosis (schizophrenia 61-93%, co-morbid substance abuse 16-33%) and proportion living alone (23-72%). Clinicians were fairly satisfied, but inter-team differences in staffing profile and experience emerged and one team scored highly on emotional exhaustion. Increased burnout was associated with greater stress due to taking a team approach. Inter-team differences suggested that attention to effective team working and leadership, as well as model fidelity, may be warranted.

Does engagement with an intensive outreach service predict better treatment outcomes in 'high-risk' youth?

AIM

Engagement is critical in ensuring that the most 'at risk' clients receive care from psychiatric services, but the relationship between engagement and treatment outcomes remains unclear. This study investigated possible improvements in client engagement and the relationship between engagement and treatment outcomes in a group of difficult-to-engage, 'high-risk' young people seen by the Intensive Mobile Youth Outreach Service (IMYOS) in Western Metropolitan Melbourne, Australia.

METHODS

Data from standardized outcome measures on client engagement, suicidality, hostility, well-being and functioning obtained at referral, after initial assessment and at discharge, were analysed retrospectively.

RESULTS

Improved engagement was achieved after initial assessment and remained steady at discharge. All outcome measures showed significant improvement at discharge. Higher overall engagement following assessment was associated with decreased hostility risk and greater well-being and functioning at discharge. The engagement dimensions 'collaboration', 'perceived usefulness' and 'client-therapist interaction' were most consistently associated with better treatment outcomes.

CONCLUSION

Engagement at an early stage of treatment can be a useful predictor for later hostility risk, well-being and functioning. To promote better outcomes for difficult-to-engage youth, service delivery needs to focus on collaborative client involvement, the development of a 'strong' therapeutic alliance and individualization of treatment in regard to client needs.

The impact of organizational stress and burnout on client engagement

This article explores the impact of organizational attributes on client engagement within substance abuse treatment. Previous research has identified organizational features, including small size, accreditation, and workplace practices, that impact client engagement (K. M. Broome, P. M. Flynn, D. K. Knight, & D. D. Simpson, 2007). This study sought to explore how aspects of the work environment impact client engagement. The sample included 89 programs located in 9 states across the United States. Work environment measures included counselor perceptions of stress, burnout, and work satisfaction at each program, whereas engagement measures included client ratings of participation, counseling rapport, and treatment satisfaction. Using multiple regression, tests of moderation and mediation revealed that staff stress negatively predicted client participation in treatment. Burnout was related to stress but was not related to participation. Two additional organizational measures--workload and influence--moderated the positive relationship between staff stress and burnout. Implications for drug treatment programs are discussed.

Lessons learned in developing community mental health care in Europe

This paper summarizes the findings for the European Region of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. The article presents a description of the region, an overview of mental health policies and legislation, a summary of relevant research in the region, a precis of community mental health services, a discussion of the key lessons learned, and some recommendations for the future.

A comparison of the implementation of assertive community treatment in Melbourne, Australia and London, England

AIMS

The efficacy of Assertive Community Treatment (ACT) is well established in the USA, and to a lesser extent in Australia, whereas UK studies suggest little advantage for ACT over usual care. Implementation of ACT varies and these differences may explain variability in reported efficacy. We aimed to investigate differences in ACT implementation between Melbourne, Australia and London, UK.

METHODS

In a cross-sectional survey, we investigated team organisation, staff and client characteristics from four Melbourne ACT teams using almost identical methods to the Pan London Assertive Outreach studies of 24 ACT teams.

RESULTS

Client characteristics, staff satisfaction and burnout were very similar. Three of four Melbourne teams made over 70% of client contacts 'in vivo' compared to only one-third of comparable London teams, although all teams were rated as 'ACT-like'. Melbourne teams scored more highly on team approach. Three quarters of clients were admitted in the preceding 2 years but Melbourne clients had shorter stays.

CONCLUSIONS

Differences in the implementation of 'active components' of home treatment models that have been associated with better client outcomes (home visiting, team approach) may explain international differences in ACT efficacy. Existing fidelity measures may not adequately weight these important elements of the model.

Practitioner attributes as predictors of restrictive practices in assertive community treatment

BACKGROUND

Practitioners variably use restrictive practices with assertive community treatment (ACT) consumers. Little is known about practitioner attributes, such as pessimistic attitudes and lack of advanced education, which may predict greater use of restrictive practices.

OBJECTIVES

To describe the frequency of restrictive practices in ACT and examine the relationship between practitioner attributes, particularly pessimistic attitudes and education, and the frequency with which restrictive practices are reportedly used in daily treatment of adults with severe mental illness.

DESIGN

A cross-sectional study of 122 ACT practitioners in one state.

RESULTS

More restrictive practices were rarely reported by practitioners. Pessimistic attitudes and lack of graduate-level training were associated with self-reported higher use of restrictive practices, even when controlling for select consumer caseload variables and ACT program fidelity.

CONCLUSIONS

This study indicates the need to identify practitioner-related factors that may contribute to the high use of restrictive practices, and develop and implement relevant staff training.

Is the implementation of assertive community treatment in a low-income country feasible? The experience of Tbilisi, Georgia

BACKGROUND

In Georgia, difficult socioeconomic conditions have resulted in a drastic decrease in government financing for the health sector. State mental hospitals continue to be the main solution for the mentally ill, due to the severe lack of community-based services, and mental health services are inadequate to meet the needs of patients.

METHODS

An experimental intervention of assertive community care was implemented with the aim to engage socially isolated patients who lacked contact with outpatient services and to answer their different social and psychological needs. The intervention lasted 10 months and consisted of outpatient visits, visits at home, meetings outside and telephone calls to the services' facilities; all services were provided by a multidisciplinary team. The intervention was conducted in a psychiatric dispensary in the district of Tbilisi, Georgia.

RESULTS

This pilot study showed the economic sustainability of community care and its effectiveness to facilitate continuity of care and to improve clinical and social outcomes.

CONCLUSIONS

High-quality community care costs less than usual treatment and inpatient care and seems to be effective to improve clinical and social outcomes; for these reasons, policymakers should consider, in their future mental health reforms, allocating more resources to community-based care.

Randomised evaluation of assertive community treatment: 3-year outcomes

The only randomised controlled trial to test high-fidelity assertive community treatment (ACT) in the UK (the Randomised Evaluation of Assertive Community Treatment (REACT) study) found no advantage over usual care from community mental health teams in reducing the need for in-patient care and in other clinical outcomes, but participants found ACT more acceptable and engaged better with it. One possible reason for the lack of efficacy of ACT might be the short period of follow-up (18 months in the REACT study). This paper reports on participants' service contact, in-patient service use and adverse events 36 months after randomisation.