Is psychiatric residential facility discharge possible and predictable? A multivariate analytical approach applied to a prospective study in Italy

Moving from supported to independent living: what are the barriers and facilitators for individuals with psychosis?

PURPOSE

Living independently, as opposed to in sheltered housing or with caregivers, is an important aim in the recovery of individuals with psychosis, but the transition to independence can be challenging. This study aims to investigate how individuals with psychosis move between living arrangements and to identify the barriers and facilitators of moving towards independence.

METHODS

The living arrangements of 1119 individuals with non-affective psychosis from the Genetic Risk and Outcome of Psychosis study were assessed at baseline, at three- and six-year follow-ups and further categorized as either supported (sheltered housing or with parents) or independent (single or with partner/family). We estimated the probabilities of transitioning between the living statuses and investigated the influence of demographic characteristics, symptomatology, cognition, social support, and premorbid social adjustment on transition using Markov chain modelling.

RESULTS

The majority of individuals living in supported housing remained there during the six-year follow-up period (~ 60%). The likelihood of moving from supported to independent living was twice as high for participants who were younger, five-to-six times higher for women, twice as high for individuals with better overall cognition, and five times higher for those with a course of low positive symptoms.

CONCLUSION

This study highlights that a large group of individuals with psychosis in supported housing is unlikely to move to independent living. Older men with cognitive impairments and who show continuous severe positive symptoms are the least likely to move living independently. Tailored interventions for these at-risk individuals could increase their chances of moving to independent living.

Patterns of antipsychotic prescription and accelerometer-based physical activity levels in people with schizophrenia spectrum disorders: a multicenter, prospective study

Antipsychotic polypharmacy (APP) in patients with schizophrenia spectrum disorders (SSDs) is usually not recommended, though it is very common in clinical practice. Both APP and SSDs have been linked to worse health outcomes and decreased levels of physical activity, which in turn is an important risk factor for cardiovascular diseases and premature mortality. This real-world, observational study aimed to investigate antipsychotic prescribing patterns and physical activity in residential patients and outpatients with SSDs. A total of 620 patients and 114 healthy controls were recruited in 37 centers across Italy. Each participant underwent a comprehensive sociodemographic and clinical evaluation. Physical activity was monitored for seven consecutive days through accelerometer-based biosensors. High rates of APP were found in all patients, with residential patients receiving more APP than outpatients, probably because of greater psychopathological severity. Physical activity was lower in patients compared to controls. However, patients on APP showed trends of reduced sedentariness and higher levels of light physical activity than those in monopharmacy. Rehabilitation efforts in psychiatric residential treatment facilities were likely to result in improved physical activity performances in residential patients. Our findings may have important public health implications, as they indicate the importance of reducing APP and encouraging physical activity.

Quality of residential facilities in Italy: satisfaction and quality of life of residents with schizophrenia spectrum disorders

BACKGROUND

Recovery and human rights promotion for people with Schizophrenia Spectrum Disorders (SSDs) is fundamental to provide good care in Residential Facilities (RFs). However, there is a concern about rehabilitation ethos in RFs. This study aimed to investigate the care quality of Italian RFs, the quality of life (QoL) and care experience of residents with SSD.

METHODS

Fourty-eight RFs were assessed using a quality assessment tool (QuIRC-SA) and 161 residents with SSD were enrolled. Seventeen RFs provided high intensity rehabilitation (SRP1), 15 medium intensity (SRP2), and 16 medium-low level support (SRP3). Staff-rated tools measured psychiatric symptoms and psychosocial functioning; user-rated tools assessed QoL and satisfaction with services. RFs comparisons were made using ANOVA and Chi-squared.

RESULTS

Over two-thirds patients (41.5 y.o., SD 9.7) were male. Seventy-six were recruited from SRP1 services, 48 from SRP2, and 27 from SRP3. The lowest QuIRC-SA scoring was Recovery Based Practice (45.8%), and the highest was promotion of Human Rights (58.4%). SRP2 had the lowest QuIRC-SA ratings and SRP3 the highest. Residents had similar psychopathology (p = 0.140) and functioning (p = 0.537). SRP3 residents were more employed (18.9%) than SRP1 (7.9%) or SRP2 (2.2%) ones, and had less severe negative symptoms (p = 0.016) and better QoL (p = 0.020) than SRP2 residents. There were no differences in the RF therapeutic milieu and their satisfaction with care.

CONCLUSIONS

Residents of the lowest supported RFs in Italy had less severe negative symptoms, better QoL and more employment than others. The lowest ratings for Recovery Based Practice across all RFs suggest more work is needed to improve recovery.

Using Group Concept Mapping to Develop a Conceptual Model of Housing and Community-Based Residential Settings for Adults With Severe Mental Illness

BACKGROUND

Most existing conceptual models of residential environments and housing programs were developed over a decade ago or lack comprehensiveness. The attributes to be used to describe housing programs with adequate specification remain unclear including the attributes that mediate service user outcomes. In this study, group concept mapping was used to develop a conceptual model of housing and community-based residential settings for adults with severe mental illness based on stakeholder perceptions and values.

METHODS

Participants were selected through purposive sampling and included service users, family members, staff working in residential facilities, mental health workers and managers. Participants (n=221) generated 1,382 statements describing attributes of housing and community-based residential settings for adults with severe mental illness (99% saturation). Thematic content analysis was conducted to analyze the statements and create a list of 140 selected statements. Participants then rated (n=416) and sorted into categories (n=73) the selected statements. Descriptive statistics were computed for each statement relative importance. Multidimensional scaling and hierarchical cluster analysis were used to produce the conceptual model (maps). Stakeholders (n=12) were also involved in the interpretation of the maps.

RESULTS

The findings show overall concordance between stakeholders in relation to statements perceived importance (rating) and the statements inter-relationships (sorting). The stress value of 0.23 indicates that the two-dimensional solution of the multidimensional scaling analysis fits the data set (goodness of fit). The final conceptualization includes 12 clusters: (1) A balanced and healthy housing system; (2) Quality and management practices (facility/local level); (3) Physical external environment; (4) Services tailored to needs and preferences; (5) Services and interventions provided (linkage); (6) Equality, policies and availability of activities; (7) Organizational structure and staff qualities; (8) Services and interventions (learning skills); (9) Services and interventions (daily living support); (10) Personal space and right to privacy; (11) Physical interior environment; (12) Respect, functioning and atmosphere.

CONCLUSION

The results illustrate the multifaceted and multilevel nature of community-based residential settings through a visual representation. They articulate a number of attributes, clusters and dimensions that could be included in a common conceptual model of community-based residential settings and housing for adults with severe mental illness.

DAily time use, Physical Activity, quality of care and interpersonal relationships in patients with Schizophrenia spectrum disorders (DiAPASon): an Italian multicentre study

BACKGROUND

Schizophrenia spectrum disorders (SSD) are ranked among the leading causes of disabilities worldwide. Many people with SSD spend most of their daily time being inactive, and this is related to the severity of negative symptoms. Here, we present the 3-year DiAPAson project aimed at (1) evaluating the daily time use among patients with SSD living in Residential Facilities (RFs) compared to outpatients with SSD and to the general population (Study 1); (2) evaluating the quality of staff-patient relationships, its association with specific patient outcomes and the quality of care provided in RFs (Study 2); and (3) assessing daily activity patterns in residential patients, outpatients with SSD and healthy controls using real-time methodologies (Study 3).

METHODS

Study 1 will include 300 patients with SSD living in RFs and 300 outpatients; data obtained in these clinical populations will be compared with normative data obtained by the National Institute of Statistics (ISTAT) in the national survey on daily time use. Time use assessments will consist of daily diaries asking participants to retrospectively report time spent in different activities. In Study 2, a series of questionnaires will be administered to 300 residential patients (recruited for Study 1) to evaluate the quality of care and staff-patient relationships, level of well-being and burnout of RFs' staff, and quality of RFs using a European standardized questionnaire (QuIRC-SA). In Study 3, the daily time use will be evaluated in a subgroup of 50 residential patients, 50 outpatients and 50 healthy controls using the Experience Sampling Method approach (participants will complete a brief questionnaire -about time use, mood and perceived energy- on a smartphone 8 times a day for 1 week) to compare retrospective and real-time reports. Moreover, their level of physical activity, sleep patterns, and energy expenditure will be monitored through a multi-sensor device.

DISCUSSION

This project is highly innovative because it combines different types of assessments (i.e., retrospective and real-time reports; multi-sensor monitoring) to trace an accurate picture of daily time use and levels of physical activity that will help identify the best therapeutic options promoting daily activities and physical exercise in patients with SSD.

TRIAL REGISTRATION

ISRCTN registry ID ISRCTN21141466.

Community-care unit model of residential mental health rehabilitation services in Queensland, Australia: predicting outcomes of consumers 1-year post discharge

AIMS

Community care units (CCUs) are a model of residential psychiatric rehabilitation aiming to improve the independence and community functioning of people with severe and persistent mental illness. This study examined factors predicting improvement in outcomes among CCU consumers.

METHODS

Hierarchical regression using data from a retrospective cohort (N = 501) of all consumers admitted to five CCUs in Queensland, Australia between 2005 and 2014. The primary outcome was changed in mental health and social functioning (Health of the Nation Outcome Scale). Secondary outcomes were disability (Life Skills Profile-16), service use, accommodation instability, and involuntary treatment. Potential predictors covered service, consumer, and treatment characteristics. Group-level and individualised change were assessed between the year pre-admission and post-discharge. Where relevant and available, the reliable and clinically significant (RCS) change was assessed by comparison with a normative sample.

RESULTS

Group-level analyses showed statistically significant improvements in mental health and social functioning, and reductions in psychiatry-related bed-days, emergency department (ED) presentations and involuntary treatment. There were no significant changes in disability or accommodation instability. A total of 54.7% of consumers demonstrated reliable improvement in mental health and social functioning, and 43.0% showed RCS improvement. The majority (60.6%) showed a reliable improvement in psychiatry-related bed-use; a minority demonstrated reliable improvement in ED presentations (12.5%). Significant predictors of improvement included variables related to the CCU care (e.g. episode duration), consumer characteristics (e.g. primary diagnosis) and treatment variables (e.g. psychiatry-related bed-days pre-admission). Higher baseline impairment in mental health and social functioning (β = 1.12) and longer episodes of CCU care (β = 1.03) increased the likelihood of RCS improvement in mental health and social functioning.

CONCLUSIONS

CCU care was followed by reliable improvements in relevant outcomes for many consumers. Consumers with poorer mental health and social functioning, and a longer episode of CCU care were more likely to make RCS improvements in mental health and social functioning.

The Effectiveness of Mental Health Rehabilitation Services: A Systematic Review and Narrative Synthesis

Introduction: Mental health rehabilitation services provide essential support to people with complex and longer term mental health problems. They include inpatient services and community teams providing clinical input to people living in supported accommodation services. This systematic review included international studies evaluating the effectiveness of inpatient and community rehabilitation services. Methods: We searched six online databases for quantitative studies evaluating mental health rehabilitation services that reported on one or both of two outcomes: move-on to a more independent setting (i.e. discharge from an inpatient unit to the community or from a higher to lower level of supported accommodation); inpatient service use. The search was further expanded by screening references and citations of included studies. Heterogeneity between studies was too great to allow meta-analysis and therefore a narrative synthesis was carried out. Results: We included a total of 65 studies, grouped as: contemporary mental health rehabilitation services (n = 34); services for homeless people with severe mental health problems (n = 13); deinstitutionalization programmes (n = 18). The strongest evidence was for services for homeless people. Access to inpatient rehabilitation services was associated with a reduction in acute inpatient service use post discharge. Fewer than one half of people moved on from higher to lower levels of supported accommodation within expected timeframes. Conclusions: Inpatient and community rehabilitation services may reduce the need for inpatient service use over the long term but more high quality research of contemporary rehabilitation services with comparison groups is required. Review registration: This review was prospectively registered on PROSPERO (ID: CRD42019133579).

The importance of clinical normative data for conceptualizing neuropsychological deficits in people with schizophrenia spectrum disorders

OBJECTIVE

To create clinical normative data tables for Norwegian patients with schizophrenia spectrum disorders, to examine whether clinical normative data from Norway differs from similar normative data from Canada and the U.S., and to illustrate the usefulness of such data.

METHOD

A nationally representative sample of 335 patients from psychiatric hospitals in Bergen, Norway was included. Inclusion criteria were 18-39 years of age, Norwegian as first language, and symptoms of schizophrenia, psychosis, or hallucinations. Comorbid substance abuse was recorded in 134 (40.0%). All completed the Norwegian version of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS).

RESULTS

The average scores of patients with schizophrenia spectrum disorders were approximately one to two standard deviations below the mean for healthy adults. There were no significant differences in scores between patients with or without comorbid substance abuse. Men had higher scores than women. Clinical normative reference value look-up tables were created.

CONCLUSIONS

Clinical normative values were very similar to values from Canada and the U.S. Clinical normative data, as a supplement to standard healthy normative data, can be used to describe patients' cognitive performance in terms of expectation for their peer group which can be useful for multidisciplinary treatment planning.

Factors Associated with Long-Stays in an Italian Psychiatric Intensive Treatment Facility: 1-Year Retrospective Observational Analysis

Psychiatric Intensive Treatment Facilities (PITF) are health inpatient settings for patients affected by sub-acute psychiatric disorders with impaired personal and social functioning. The aim of this study is to analyse the demographic and clinical variables related to long-stays in an Italian PITF in order to highlight the risk factors for stay lengthening. We retrospectively collected the selected variables from all patients and their stays in a PITF from 1 to 11-2016 to 31-10-2017. We divided the stays according to the median of duration, ≤29 and > 29 days, to compare selected variables in the two groups of stay length. Patients hospitalized for >29 days more frequently presented "Self-neglect", nursing diagnosis NANDA-I, and needed economic social service support. Multiple linear regression revealed that the presence of some variables as "many medical consultations", "economic social service support", "clinical interviews extended to institutional figures" were statistically significantly associated with an increased stay duration, suggesting that both clinical severity and difficult economic conditions were associated with the lengthening of stay. The knowledge of these factors can contribute to improve psychiatric treatments, reducing potential risk conditions for patient institutional dependence.

Development and Validation of the Health of the Nation Outcome Scales-Residential Facility (HoNOS-RF)

The Health of the Nation Outcome Scale (HoNOS) (Lora et al. Epidemiol Psichiatr Soc 10(3):198-212, 2001) is widely used. However, clinicians have expressed concerns about its ability to describe severe mentally ill patients, as it does not consider some relevant clinical aspects. This study aims to develop and validate the HoNOS-Residential Facility (HoNOS-RF) in order to pursue a thorough assessment of patients admitted to psychiatric residential facilities (RFs). The final version of the HoNOS-RF was administered to 409 patients admitted to four RFs. Exploratory factor analysis, Cronbach' alpha (α), Intraclass Correlation Coefficients (ICC) were used to assess construct validity, internal consistency and reliability, respectively. Concurrent criterion validity was assessed through correlations with the Brief Psychiatric Rating Scale-Expanded Version (BPRS-E) (Roncone et al. Acta Psychiatric Scand 100(3):229-36, 1999), Personal and Social Performance Scale (PSP) (Morosini et al. Acta Psychiatric Scand 101(4): 323-29, 2000), and comparisons across diagnostic groups. The final version of the HoNOS-RF consisted of 31 items, grouped into the following eight factors (overall explaining 55% of the total variability): personal and interpersonal functioning; environment; behavior and burden of care; cognitive function; somatic problems; anxiety-depression symptoms; psychotic symptoms; and other psychiatric symptoms. The scale showed high internal consistency (α = .807), and the correlations with PSP and BPRS-E ranged from adequate to moderate. The ICCs were in the excellent range for almost all items. These findings support the validity and the reliability of the HoNOS-RF, thus it may be a useful tool for the assessment of patients admitted to RFs, as it addresses clinical aspects that were mostly not included in the original version.

Mental health supported accommodation services: a systematic review of mental health and psychosocial outcomes

BACKGROUND

Post-deinstitutionalisation, mental health supported accommodation services have been implemented widely. The available research evidence is heterogeneous in nature and resistant to synthesis attempts, leaving researchers and policy makers with no clear summary what works and for whom. In this context, we undertook a comprehensive systematic review of quantitative studies in order to synthesise the current evidence on mental health and psychosocial outcomes for individuals residing in mental health supported accommodation services.

METHODS

Using a combination of electronic database searches, hand searches, forward-backward snowballing and article recommendations from an expert panel, 115 papers were identified for review. Data extraction and quality assessments were conducted, and 33 articles were excluded due to low quality, leaving 82 papers in the final review. Variation in terminology and service characteristics made the comparison of service models unfeasible. As such, findings were presented according to the following sub-groups: 'Homeless', 'Deinstitutionalisation' and 'General Severe Mental Illness (SMI)'.

RESULTS

Results were mixed, reflecting the heterogeneity of the supported accommodation literature, in terms of research quality, experimental design, population, service types and outcomes assessed. There is some evidence that supported accommodation is effective across a range of psychosocial outcomes. The most robust evidence supports the effectiveness of the permanent supported accommodation model for homeless SMI in generating improvements in housing retention and stability, and appropriate use of clinical services over time, and for other forms of supported accommodation for deinstitutionalised populations in reducing hospitalisation rates and improving appropriate service use. The evidence base for general SMI populations is less developed, and requires further research.

CONCLUSIONS

A lack of high-quality experimental studies, definitional inconsistency and poor reporting continue to stymie our ability to identify effective supported accommodation models and practices. The authors recommend improved reporting standards and the prioritisation of experimental studies that compare outcomes across different service models.

Lessons from the past: Family involvement in patient admission and discharge, Beechworth Lunatic Asylum, 1900-1912

In this study, document analysis is used to examine case books from the Beechworth Lunatic Asylum with the aim of determining the extent of family involvement in patients' admission and discharge. There were 420 male and 278 female patients admitted in the study period, with over half transferred from other Victorian asylums. Next of kin were identified for 64% of male and 84% of female patients. Families were involved in the admission of 52 (12%) male and 50 (18%) female patients, usually by bringing patients to the asylum or providing evidence of behavioural changes. Approximately 25% of patients were discharged (101 men and 62 women) and of these, families were involved in discharge for 26% of male and 71% of female patients, mainly by taking responsibility for them during trial discharge. Occasionally families refused to do this, or sought to have patients detained because of fears of violence. The relevance of the study to contemporary practice is explored, particularly the need for dialogue between clinicians and families who identify behavioural changes in family members, appropriate support for family carers, and timely provision of community care following discharge from inpatient facilities.

What Works? Toward a New Classification System for Mental Health Supported Accommodation Services: The Simple Taxonomy for Supported Accommodation (STAX-SA)

Inconsistent terminology and variation in service models have made synthesis of the supported accommodation literature challenging. To overcome this, we developed a brief, categorical taxonomy that aimed to capture the defining features of different supported accommodation models: the simple taxonomy for supported accommodation (STAX-SA). Data from a previous review of existing classification systems were used to develop the taxonomy structure. After initial testing and amendments, the STAX-SA and an existing taxonomy were applied to 132 supported accommodation service descriptions drawn from two systematic reviews and their performance compared. To assess external validity, the STAX-SA was distributed to a sample of supported accommodation managers in England and they were asked to use it to classify their services. The final version of the STAX-SA comprised of five supported accommodation 'types', based on four domains; Staffing location; Level of support; Emphasis on move-on; and Physical setting. The STAX-SA accurately categorized 71.1% (n = 94) of service descriptions, outperforming the comparison tool, and was not affected by publication date or research design. The STAX-SA effectively discriminated between 'real world' service models in England and 53.2% (n = 17) of service managers indicated that the taxonomy was 'Very effective' or 'Extremely effective' in capturing key characteristics of their service. The STAX-SA is an effective tool for classifying supported accommodation models and represents a promising approach to synthesizing the extant effectiveness literature. The authors recommend the development of reporting guidelines for future supported accommodation publications to facilitate comparison between models.

Violent behavior of patients living in psychiatric residential facilities: a comparison of male patients with different violence histories

People with severe mental disorders and a history of violence are often seen as a difficult-to-manage segment of the population. In addition, this group is usually characterized by a high risk of crime recidivism, and poor compliance with community and aftercare programs. To investigate a sample of male patients living in Residential Facilities (RFs) with a history of violent behavior against people and to compare their characteristics with those of never-violent residents; to analyze the associations between aggressive behaviors in the last two years and a history of previous violence; and, to assess the predictors of aggressive behaviors. This study is part of a prospective observational cohort study which involved 23 RFs in Northern Italy. A comprehensive set of sociodemographic, clinical, and treatment-related information was gathered, and standardized assessments were administered to each participant. Also a detailed assessment of aggressive behaviors in the past two years was carried out. The study involved 268 males: 81 violent and 187 never-violent. Compared to never-violent patients, violent patients were younger, with a higher proportion of personality disorders, and have displayed an increased number of aggressive behaviors in the last two years. The presence of a history of violent behavior in the past significantly increases the probability of committing aggressive acts in the future.

Monitoring and evaluating the Italian mental health system: the "Progetto Residenze" study and beyond

Filling an alarming gap in evidence-based data on the post-1978 reformed Italian psychiatric system, two turn-of-millennium nationwide projects, Progetto Residenze (PROGRES) and PROGRES-Acute, provided detailed qualitative-quantitative information about care facilities. In 2000, there were 2.9 residential beds per 10,000 inhabitants, hospital care being delivered through small (15-bed) psychiatric units. Private inpatient facilities had proliferated, private inpatient beds per 10,000 inhabitants outnumbering public beds. In 2002, there were 1.7 acute inpatient beds per 10,000 inhabitants, one of Europe's lowest current ratios. The PROGRES and other subsequent projects showed marked nationwide variation in the provision of residential inpatient and outpatient care, grounds for concern about the quality of such care, and an uneven service use pattern. Although the Italian reform law produced a broad network of facilities to meet diverse mental health care needs, the present overview article confirms that further efforts are required to improve quality, balance public and private sectors, and coordinate resources and agencies.

The effect of service satisfaction and spiritual well-being on the quality of life of patients with schizophrenia

Quality of life (QOL) has been considered an important outcome measure in psychiatric research and determinants of QOL have been widely investigated. We aimed at detecting predictors of QOL at baseline and at testing the longitudinal interrelations of the baseline predictors with QOL scores at a 1-year follow-up in a sample of patients living in Residential Facilities (RFs). Logistic regression models were adopted to evaluate the association between WHOQoL-Bref scores and potential determinants of QOL. In addition, all variables significantly associated with QOL domains in the final logistic regression model were included by using the Structural Equation Modeling (SEM). We included 139 patients with a diagnosis of schizophrenia spectrum. In the final logistic regression model level of activity, social support, age, service satisfaction, spiritual well-being and symptoms' severity were identified as predictors of QOL scores at baseline. Longitudinal analyses carried out by SEM showed that 40% of QOL follow-up variability was explained by QOL at baseline, and significant indirect effects toward QOL at follow-up were found for satisfaction with services and for social support. Rehabilitation plans for people with schizophrenia living in RFs should also consider mediators of change in subjective QOL such as satisfaction with mental health services.