Symptomatic and functional remission and its associations with quality of life in patients with psychotic disorder in Assertive Community Treatment teams

Place-Based FACT: Treatment Outcomes and Patients' Experience with Integrated Neighborhood-Based Care

Locating specialized mental healthcare services in the neighborhood of people with severe mental illnesses (SMI) has been suggested as a way of improving treatment outcomes by increasing patient engagement and integration with the local care landscape. The current mixed methods study aimed to examine patient experience and treatment outcomes in three Flexible Assertive Community Treatment (FACT) teams that relocated to the neighborhood they served, compared to seven teams that continued to provide FACT as usual from a central office. Routine Outcome Measurement (ROM) and care use data were analyzed to compare change in treatment outcomes for patients in place-based FACT (n = 255) and FACT as usual (n = 833). Additionally, retrospective in-depth interviews were conducted with twenty patients about their experience with place-based FACT. Quantitative analysis showed mental health admission days decreased more in place-based than FACT as usual, although this difference was small. Both groups showed improved quality of life, psychosocial functioning, and symptomatic remission rates, and decreased unmet and overall needs for care. There was no change over time in met needs for care, employment, and daily activities. Qualitative analysis showed that patients experienced place-based FACT as more accessible, a better safety net, a more personal approach, better integrated with other forms of care, involving their social network, and embedded in their neighborhood and daily environment. This study showed that location and integration matter to patients, and the long term impact of place-based FACT on treatment outcomes should be explored.

Improvement in the quality of life of outpatients with severe mental illness in conjunction with intellectual disabilities and post-traumatic stress disorder

BACKGROUND

Elucidating the influence of mild intellectual disability (MID; IQ 50-70)/borderline intellectual functioning (BIF; IQ 70-85) and (comorbid) post-traumatic stress disorder (PTSD) on the quality of life of patients with serious mental illness (SMI) could improve their mental health care.

METHOD

This study comprises a prospective longitudinal cohort study using routine outcome monitoring data. The cohort comprised 601 patients who had undertaken at least one Manchester Short Assessment of Quality of Life (MANSA). The scores for screeners to detect MID/BIF and PTSD were analysed, and a repeated measures analysis of variance and a multi-level linear regression was performed on the MANSA scores.

RESULTS

The average quality of life for all patient groups increased significantly over time. A between-subject effect on quality of life was observed for PTSD, but not MID/BIF.

CONCLUSIONS

PTSD but not MID/BIF is associated with a lesser quality of life over time.

Psychopathology and health-related quality of life as patient-reported treatment outcomes: evaluation of concordance between the Brief Symptom Inventory (BSI) and the Short Form-36 (SF-36) in psychiatric outpatients

PURPOSE

Treatment outcome for common psychiatric disorders, such as mood and anxiety disorders, is usually assessed by self-report measures regarding psychopathology [e.g., via Brief Symptom Inventory (BSI)]. However, health-related quality of life [as measured by the 36-item Short-Form Health Survey (SF-36)] may be a useful supplementary outcome domain for routine outcome monitoring (ROM). To date, the assessment of both outcomes has become fairly commonplace with severe mental illness, but this is not yet the case for common psychiatric disorders. The present study examined among outpatients with common psychiatric disorders whether aggregate assessments of change across treatment regarding psychopathology and health-related quality of life yield similar results and effect sizes.

METHODS

We compared treatment outcome on the BSI and the SF-36 in a sample of 13,423 outpatients. The concordance of both instruments was assessed at various time points during treatment.

RESULTS

Scores on both instruments were associated, but not so strongly to suggest they measure the same underlying construct. The SF-36 scales presented a varied picture of treatment outcome: understandably, patients changed more on the mental component scales than on physical component scales. Outcome according to the BSI was quite similar to outcome according to scales of the SF-36 that showed the largest change.

CONCLUSIONS

Although (mental health) scores on both instruments are associated, adding the SF-36 in addition to the BSI in treatment evaluation research produces valuable information as the SF-36 measures a broader concept and contains physical/functional component scales, resulting in a more complete clinical picture of individual patients.

Symptomatic and Functional Remission in Young Adults with a Psychotic Disorder in a Rehabilitation Focused Team

The aim of this study is to assess symptomatic remission (SR) and functional remission (FR) in a rehabilitation focused program for young adults with a psychotic disorder in the Netherlands, and to investigate which individual and mental health care factors are associated with SR and/or FR, by using Routine Outcome Monitoring data and data on met needs and unmet needs for care. Data of 287 young adults were collected. Almost 40% achieved or maintained SR, 34% FR, and 26% achieved or maintained both. In addition to sociodemographic factors, living independently, paid employment, higher levels of compliance with treatment, and better fulfillment of unmet needs for care in relation to psychological distress, company and daytime activities were associated with better outcomes on SR and/or FR. Our findings underscore that to successfully improve and sustain remission in young adults with a psychotic disorder, it is needed to conduct specific research into the relationship between SR and FR.

Determinants of clinical, functional and personal recovery for people with schizophrenia and other severe mental illnesses: A cross-sectional analysis

OBJECTIVE

To analyze the relationships between insight, medication adherence, addiction, coping and social support-components of Illness Management and Recovery (IMR)-as determinants of clinical, functional and personal recovery in patients with schizophrenia and other severe mental illnesses. Our rationale lay in the interrelations between these concepts suggested in a conceptual framework of IMR.

METHODS

The cross-sectional design used baseline data of outpatient participants in a randomized clinical trial on IMR (N = 187). We used structural equation modeling (SEM) to describe pathways between degrees of insight, medication adherence, addiction, coping and social support, and degree of clinical, functional and personal recovery. We also explored whether clinical recovery mediated functional and personal recovery.

RESULTS

Our final model showed that coping was associated with clinical, functional and personal recovery. Direct associations between coping and functional and personal recovery were stronger than indirect associations via clinical recovery. Although SEM also showed a significant but weak direct pathway between social support and functional recovery, there were no significant pathways either between social support and clinical or personal recovery, or between insight, medication adherence, addiction and any type of recovery.

CONCLUSIONS

Coping may be a determinant of all three types of recovery, and social support a determinant of functional recovery. Clinical recovery appears not to be a prerequisite for functional or personal recovery. While our results also suggest the relevance of improving coping skills and of enhancing social support, they only partially support the conceptual framework of IMR.

Predictors and Prevalence of Recovery and Remission for Consumers Discharged from Mental Hospitals in a Chinese Society

This research study examines the 1 year rate of recovery and remissions for consumers recently discharging from mental hospitals and identifies factors predicting recovery and remissions in the Hong Kong context. By adopting a prospective longitudinal follow-up research design, a cohort of Chinese people discharged from the mental hospitals and participating in a community-based psychosocial program was followed for 1 year. These individuals were assessed by using standardized assessment scales at baseline, 6 months, and 12 months of follow-up. At 1 year follow up, the rates of recovery, functional and symptomatic remission were 8.0%, 23.0% and 79.3% respectively. Logistic regression analyses indicted that: current recovery was significantly predicted by baseline functioning level and achieving open employment, symptomatic remission was significantly predicted by previous symptom severity and having open employment at baseline, while functional remission was significantly predicted by previous functioning level and having open employment. Result indicates that it is more difficult to achieve functional remission and recovery than symptomatic remission for consumers recently discharging from mental hospitals. Also, symptomatic remission is found not a sufficient condition for recovery, while functional remission plays a vital role in recovery. Helping consumers to achieve open employment and improve social functioning are identified as the predicting factors for recovery and functional remission in the local context.

Rates and correlations of change in three dimensions of recovery within a recovery model oriented therapeutic community

This is a 10 year longitudinal study of recovery progress within a residential program based upon therapeutic community principles and a Seven Domains Enhanced Recovery Model (Young and Ensing, 1999). A broad suite of measures associated with one of three definitions of recovery (symptom, function, and personal focused recovery) were administered along three longitudinal courses. Normalized mean rates of change and mean shared variances for these scales were examined for three subgroups based on length of stay. Measures associated with the same definition of recovery correlated moderately to strongly but measures did not correlate between facets, suggesting relative independence between definition facets. The results of this analysis suggest the existence of qualitatively distinct subgroups with different change dynamics. The aggregate means of these facets showed correlated change, while individual recovery pathways did not, suggesting significant heterogeneity in individual pathways of recovery. These findings support the conceptualization of recovery as a complex, heterogeneous and multi-faceted process. Practically, these findings emphasize the need for holistic, flexible and individualized recovery supports and that research into these constructs should include at least these facets over a longitudinal time frame.

The motivation paradox: higher psychosocial problem levels in severely mentally ill patients are associated with less motivation for treatment

PURPOSE

Lack of motivation for treatment makes a subgroup of patients with severe mental illness (SMI) difficult to engage in psychiatric treatment. Such difficult-to-engage patients may also be the most in need of treatment. We hypothesized that the level of psychosocial problems would be inversely related to motivation for treatment.

METHODS

Cross-sectional study in two independent samples. The first sample (n = 294) included SMI patients who participated in a randomized controlled trial and were assessed using the Health of the Nation Outcome Scales (HoNOS) and self-rated and clinician-rated motivation-for-treatment scales. The second sample (n = 1,170) included SMI patients who were treated in Assertive Outreach Teams and were routinely assessed with the HoNOS and a motivation-for-treatment scale. In both samples, patients also self-rated their quality of life.

RESULTS

In both samples, patients with HoNOS scores of 16 and higher had lower motivation scores on all motivation scales than patients with lower HoNOS scores, and also a lower quality of life.

CONCLUSIONS

A motivation paradox seems inherent to this association between higher psychosocial problems levels, less motivation for treatment, and lower quality of life. Such a paradox has clinical relevance, as it may provide an ethical basis for outreach services which aim to engage marginally motivated SMI patients with severe psychosocial problems into mental health care.

Integrated care in patients with schizophrenia: results of trials published between 2011 and 2013 focusing on effectiveness and efficiency

PURPOSE OF REVIEW

Overview on integrated care trials focusing on effectiveness and efficiency published from 2011 to 2013.

RECENT FINDINGS

Eight randomized controlled trials (RCTs) and 21 non-RCT studies were published from 2011 to 2013. Studies differed in several methodological aspects such as study population, psychotherapeutic approaches used, outcome parameters, follow-up times, fidelities, and implementation of the integrated care model and the nation-specific healthcare context with different control conditions. This makes it difficult to draw firm conclusions. Most studies demonstrated relevant improvements regarding symptoms (P=0.001) and functioning (P=0.01), quality of life (P=0.01), adherence (P<.05) and patient's satisfaction (P=0.01), and reduction of caregiver's stress (P<0.05). Mean total costs were favoring or at least equalizing costs but with positive effects found on subjective health favoring integrated care models.

SUMMARY

There is an increasing interest in the effectiveness and efficiency of integrated care models in patients with mental disorders, specifically in those with severe and persistent mental illness. To increase generalizability, future trials should exactly describe rationales and content of integrated care model and control conditions.