Does staff-patient agreement on needs for care predict a better mental health outcome? A 4-year follow-up in a community service

Development and preliminary validation of the treatment adherence rating scale

BACKGROUND AND OBJECTIVES

Patient adherence to treatment is an important barrier to the implementation of evidence-based psychological treatments (EBPTs). There is a need for simple and deployable measures of patient adherence to treatment for use across EBPTs. The Treatment Adherence Rating Scale (TARS) was developed and validated in two samples.

METHODS

This study includes two samples: adults with Major Depressive Disorder who received Cognitive Therapy for depression (Sample 1; N = 48, mean age = 44.27 years), and at-risk adolescents who received either the Transdiagnostic Sleep and Circadian Intervention or Psychoeducation (Sample 2; N = 176, mean age = 14.77 years). Factor structure of the TARS scores was examined via Exploratory Factor Analyses (EFA) in Sample 1 and Confirmatory Factor Analyses (CFA) in Sample 2. Internal consistency, predictive validity, and construct validity of the TARS scores were examined.

RESULTS

Results from EFA in Sample 1 supported a one-factor model. Results from CFA in Sample 2 suggested that a two-factor model (i.e., agreement and compliance) fit better than a one-factor model. TARS scores from both samples demonstrated adequate predictive validity with primary clinical outcomes and construct validity with treatment expectations.

LIMITATIONS

The sample was small with two specific populations. Future research should focus on other patient populations, a larger population, and other EBPTs. Future research examining patient ratings of these items are needed for further validation of the TARS.

CONCLUSIONS

Preliminary findings support the use of a two-factor model and highlight the potential utility of a simple measure of patient adherence to treatment across age and diagnostic groups.

Needs for care of residents with schizophrenia spectrum disorders and association with daily activities and mood monitored with experience sampling method: the DIAPASON study

AIMS

Care needs represent an essential paradigm in planning residential facility (RF) interventions. However, possible disagreements between users and staff are critical issues in service delivery. The Experience Sampling Method (ESM) tracks experiences in the real world and real time. This study aimed to evaluate the care needs of patients with schizophrenia spectrum disorder (SSD) in RFs and its association with daily activities and mood monitored using the ESM.

METHODS

As part of the DIAPASON project, 313 residents with SSD were recruited from 99 Italian RFs. Sociodemographic and clinical characteristics were recorded. Care needs, the severity of symptomatology and negative symptoms were assessed. Fifty-six residents were also assessed for 7 consecutive days using the mobile ESM. Descriptive, agreement, predictor and moderator analyses were conducted.

RESULTS

The staff rated a higher number of total and met needs than service users (p < 0.001). Only a slight agreement between users and staff on unmet needs was found in self-care (k = 0.106) and information (k = 0.100) needs, while a moderate agreement was found in accommodation (k = 0.484), food (k = 0.406), childcare (k = 0.530), physical health (k = 0.470), telephone (k = 0.458) and transport (k = 0.425) needs. Older age (-0.15; p < 0.01), longer SSD diagnosis (-0.16; p < 0.01), higher collaboration (-0.16; p < 0.01) and lower symptomatology (-0.16; p < 0.01) decreased the number of unmet needs, while being a female (0.27; p < 0.05) and a shorter length of stay in an RF (0.54; p < 0.001) increased the number of unmet needs. A higher number of unmet needs was associated with a lower amount of time spent in leisure activities or reporting a positive mood: on the contrary, more unmet needs were associated with a greater amount of time spent in religious or non-productive activities. The associations between unmet needs rated by staff and users and momentary mood as assessed using the ESM were not moderated by the severity of symptomatology.

CONCLUSIONS

Although care needs are fundamental in planning residential activities aimed at recovery-oriented rehabilitation, RF interventions did not fully meet users' needs, and some disagreements on unmet needs between users and staff were reported. Further efforts are necessary to overcome Italian RF limits in delivering rehabilitative interventions defined by real users' needs to facilitate users' productivity and progress towards personal recovery.

Patient-reported needs predict perceived psychosocial disability and quality of life beyond symptom severity in schizophrenia

PURPOSE

We examined whether patient-rated or clinician-rated needs are more strongly associated with perceived psychosocial disability (PPD) and subjective quality of life (SQOL) of schizophrenia patients, beyond symptom severity.

METHODS

Hierarchical regression analyses were computed to test patient and clinician-rated unmet and met needs (estimated by eighty-two patient-clinician pairs) as predictors of PPD and SQOL above and beyond demographics and psychopathology. Needs, symptomatology, PPD and SQOL were estimated using Camberwell Assessment of Need (CAN), PANSS, WHODAS 2.0 and WHOQOL-BREF respectively.

RESULTS

Needs were significantly associated with all WHODAS 2.0 and WHOQOL-BREF domains above and beyond demographics and PANSS variables. Clinician-rated needs were better predictors of only one WHODAS 2.0 domain, while patient-rated needs were better predictors of all other WHODAS 2.0 and WHOQOL-BREF domains. Patient-rated unmet needs were more strongly than met needs associated with the most WHODAS 2.0 and WHOQOL-BREF subscores.

CONCLUSION

This study offers the first evidence that patient-rated needs, especially unmet needs, are strongly associated, above and beyond symptomatology, with global and domain-specific PPD of schizophrenia patients. Accordingly, strong relations of patient-rated needs with SQOL emerged. Identifying and addressing patient-reported needs could facilitate PPD and SQOL improvement more effectively than interventions confined solely to symptom remission.IMPLICATIONS FOR REHABILITATIONSchizophrenia is associated with poor rehabilitation and recovery outcomes, i.e., perceived psychosocial disability (PPD) and subjective quality of life (SQOL).Assessment of patients' needs constitutes the basis of determining treatment goals and planning tailor-made interventions to achieve crucial rehabilitative outcomes.Higher levels of patient-reported unmet needs are associated with poorer SQOL and higher global and domain-specific PPD of schizophrenia patients, above and beyond symptom severity.Addressing patient-reported needs through personalized interventions can facilitate more effectively PPD and SQOL improvement, than treatment confined to symptomatic alleviation.

What if children with psychiatric problems disagree with their clinicians on the need for care? Factors explaining discordance and clinical directions

BACKGROUND

Children and adolescents in mental healthcare often perceive their care needs and necessary treatment differently from their clinicians. As such discordance between young patients and clinicians may obstruct treatment adherence and compromise treatment outcomes, it is important to understand the factors associated with it. We therefore investigated the factors associated with patient-clinician discordance with regard to care needs in various areas of functioning.

METHODS

A cross-sectional study involving 244 children/adolescents aged 6-18 participating with their clinicians in treatment at a specialized mental healthcare center. As a previous study conducted by our research group had found the greatest patient-clinician discordance in three CANSAS care needs-"mental health problems," "information regarding diagnosis and/or treatment," and "making and/or keeping friends"-we used univariable and multivariable statistics to investigate the factors associated with discordance regarding these three care needs.

RESULTS

patient-clinician discordance on the three CANSAS items was associated with child, parent, and family/social-context factors. Three variables were significant in each of the three final multivariable models: dangerous behavior towards self (child level); severity of psychiatric problems of the parent (parent level); and growing up in a single-parent household (family/social-context level).

CONCLUSIONS

To deliver treatment most effectively and to prevent drop-out, it is important during diagnostic assessment and treatment planning to address the patient's care needs at all three levels: child, parent and family/social context.

The clinical characterization of the patient with primary psychosis aimed at personalization of management

The current management of patients with primary psychosis worldwide is often remarkably stereotyped. In almost all cases an antipsychotic medica-tion is prescribed, with second-generation antipsychotics usually preferred to first-generation ones. Cognitive behavioral therapy is rarely used in the vast majority of countries, although there is evidence to support its efficacy. Psychosocial interventions are often provided, especially in chronic cases, but those applied are frequently not validated by research. Evidence-based family interventions and supported employment programs are seldom implemented in ordinary practice. Although the notion that patients with primary psychosis are at increased risk for cardiovascular diseases and diabetes mellitus is widely shared, it is not frequent that appropriate measures be implemented to address this problem. The view that the management of the patient with primary psychosis should be personalized is endorsed by the vast majority of clinicians, but this personalization is lacking or inadequate in most clinical contexts. Although many mental health services would declare themselves "recovery-oriented", it is not common that a focus on empowerment, identity, meaning and resilience is ensured in ordinary practice. The present paper aims to address this situation. It describes systematically the salient domains that should be considered in the characterization of the individual patient with primary psychosis aimed at personalization of management. These include positive and negative symptom dimensions, other psychopathological components, onset and course, neurocognition and social cognition, neurodevelopmental indicators; social functioning, quality of life and unmet needs; clinical staging, antecedent and concomitant psychiatric conditions, physical comorbidities, family history, history of obstetric complications, early and recent environmental exposures, protective factors and resilience, and internalized stigma. For each domain, simple assessment instruments are identified that could be considered for use in clinical practice and included in standardized decision tools. A management of primary psychosis is encouraged which takes into account all the available treatment modalities whose efficacy is supported by research evidence, selects and modulates them in the individual patient on the basis of the clinical characterization, addresses the patient's needs in terms of employment, housing, self-care, social relationships and education, and offers a focus on identity, meaning and resilience.

Agreement between patients and mental healthcare providers on unmet care needs in child and adolescent psychiatry

PURPOSE

In mental health care, patients and their care providers may conceptualize the nature of the disorder and appropriate action in profoundly different ways. This may lead to dropout and lack of compliance with the treatments being provided, in particular in young patients with more severe disorders. This study provides detailed information about patient-provider (dis)agreement regarding the care needs of children and adolescents.

METHODS

We used the Camberwell Assessment of Need (CANSAS) to assess the met and unmet needs of 244 patients aged between 6 and 18 years. These needs were assessed from the perspectives of both patients and their care providers. Our primary outcome measure was agreement between the patient and care provider on unmet need. By comparing a general outpatient sample (n = 123) with a youth-ACT sample (n = 121), we were able to assess the influence of severity of psychiatric and psychosocial problems on the extent of agreement on patient's unmet care needs.

RESULTS

In general, patients reported unmet care needs less often than care providers did. Patients and care providers had the lowest extents of agreement on unmet needs with regard to "mental health problems" (k = 0.113) and "information regarding diagnosis/treatment" (k = 0.171). Comparison of the two mental healthcare settings highlighted differences for three-quarters of the unmet care needs that were examined. Agreement was lower in the youth-ACT setting.

CONCLUSIONS

Clarification of different views on patients' unmet needs may help reduce nonattendance of appointments, noncompliance, or dropout. Routine assessment of patients' and care providers' perceptions of patients' unmet care needs may also help provide information on areas of disagreement.

European Psychiatric Association (EPA) guidance on quality assurance in mental healthcare

Purpose:

To advance the quality of mental healthcare in Europe by developing guidance on implementing quality assurance.

Methods:

We performed a systematic literature search on quality assurance in mental healthcare and the 522 retrieved documents were evaluated by two independent reviewers (B.J. and J.Z.). Based on these evaluations, evidence tables were generated. As it was found that these did not cover all areas of mental healthcare, supplementary hand searches were performed for selected additional areas. Based on these findings, fifteen graded recommendations were developed and consented by the authors. Review by the EPA Guidance Committee and EPA Board led to two additional recommendations (on immigrant mental healthcare and parity of mental and physical healthcare funding).

Results:

Although quality assurance (measures to keep a certain degree of quality), quality control and monitoring (applying quality indicators to the current degree of quality), and quality management (coordinated measures and activities with regard to quality) are conceptually distinct, in practice they are frequently used as if identical and hardly separable. There is a dearth of controlled trials addressing ways to optimize quality assurance in mental healthcare. Altogether, seventeen recommendations were developed addressing a range of aspects of quality assurance in mental healthcare, which appear usable across Europe. These were divided into recommendations about structures, processes and outcomes. Each recommendation was assigned to a hierarchical level of analysis (macro-, meso- and micro-level).

Discussion:

There was a lack of evidence retrievable by a systematic literature search about quality assurance of mental healthcare. Therefore, only after further topics and search had been added it was possible to develop recommendations with mostly medium evidence levels.

Conclusion:

Evidence-based graded recommendations for quality assurance in mental healthcare were developed which should next be implemented and evaluated for feasibility and validity in some European countries. Due to the small evidence base identified corresponding to the practical obscurity of the concept and methods, a European research initiative is called for by the stakeholders represented in this Guidance to improve the educational, methodological and empirical basis for a future broad implementation of measures for quality assurance in European mental healthcare.

Profiles of Service Users with Severe Mental Disorders Based on Adequacy of Help

This study has for aims to develop a typology describing adequacy of help based on socio-demographic, clinical and service utilization variables for 204 service users with severe mental disorders treated in the community. Study participants were recruited in an urban area of Quebec (Canada). Adequacy of help was assessed with the Montreal Assessment of Needs Questionnaire. A cluster analysis identified five profiles of service users. Adequacy of help was mainly related to continuity of care, help given by services, seriousness of needs and, to some extent, quality of life (QOL). Adequacy of help was highest among Class 3 participants, described as older individuals with mood disorders, who lived in autonomous housing and enjoyed good QOL. They received substantial help from both relatives and services. Adequacy of help was lowest for Class 5, which included individuals affected by co-occurring mental disorders but who also lived autonomously. Health service utilization was more strongly related to adequacy of help for this sample than were the socio-demographic and clinical factors tested.

Satisfaction of psychiatric inpatients in China: clinical and institutional correlates in a national sample

BACKGROUND

Surveying patients' satisfaction is essential to improve patient-centered care, however, studies on satisfaction and their correlates among psychiatric inpatients are rare in China. This study aimed to measure satisfaction levels of psychiatric inpatients in a national sample and to examine individual and institutional correlates.

METHODS

As part of the National Survey for the Evaluation of Psychiatric Hospital Performance, psychiatric inpatients from 32 tertiary psychiatric hospitals in 29 Chinese provinces were interviewed on the day of discharge by trained research staff. Satisfaction was assessed using a five-item questionnaire. Patients' sociodemographic and clinical information were manually retrieved from medical records and institutional data were provided by participating hospitals. Multilevel linear regression was used to assess factors associated with level of satisfaction.

RESULTS

Among 1663 inpatients, the reported satisfaction levels were high, with a mean score of 23.3 ± 2.4 out of 25. Education level was positively associated with global satisfaction, satisfaction with costs, and satisfaction with privacy protection. Treatment response was associated with global satisfaction and with the doctor-patient communication subscore. The number of psychotherapy sessions was positively associated with the privacy protection subscore (coefficient = 0.0, P = 0.046). The Global Assessment of Function score was positively associated with the doctor-patient communication subscore (coefficient = 0.0, P = 0.003). Total satisfaction scores and all five subscores were positively associated with hospital-level factors, and patients discharged from hospitals with better staffing and resources reported significantly higher levels of satisfaction.

CONCLUSION

Overall, psychiatric inpatients in China were satisfied with the services they received. To further improve patient satisfaction, mental health professionals should optimize their patients' treatment response as much as possible before discharge and provide more psychological treatment during the hospitalization. The government should also provide more resources to increase the number of mental health professionals (nurses, psychologists, and psychiatrists) working in psychiatric hospitals.

Treatment agreement, adherence, and outcome in cognitive behavioral treatments for insomnia

BACKGROUND

Patient adherence has been identified as an important barrier to the implementation of evidence-based psychological treatments.

OBJECTIVE

In cognitive behavioral treatments (CBT) for insomnia, the current study examined (a) the validity of therapist ratings of patient agreement and adherence against an established behavioral measure of adherence, and (b) the relationship between treatment agreement, adherence, and outcome.

METHOD

Participants were 188 adults meeting DSM-IV-TR criteria for chronic insomnia who were randomized to receive behavior therapy, cognitive therapy, or CBT for insomnia. Treatment agreement/adherence was measured by (a) weekly therapist ratings of patient agreement and homework completion, and (b) adherence to behavioral strategies (ABS) derived from patient-reported sleep diary. Outcome measures were Insomnia Severity Index and insomnia remission (Insomnia Severity Index <8).

RESULTS

Therapist ratings of patient agreement as well as homework completion were significantly associated with sleep diary-derived global ABS. Therapist-rated patient agreement and homework completion as well as global ABS predicted greater insomnia symptoms reduction from pretreatment to posttreatment. Patient agreement also predicted insomnia symptoms reduction from pretreatment to 6-month follow-up. Patient agreement, adherence, and ABS measures during treatment significantly predicted insomnia remission at posttreatment, and all but therapist rating of homework completion predicted remission at 6-month follow-up.

CONCLUSIONS

Greater patient agreement and adherence (therapist ratings and ABS) during treatment predicted better treatment outcome. Therapist-rated treatment agreement and adherence correspond well with patient-reported sleep diary-derived adherence measure. These simple, deployable therapist-rated patient agreement and adherence can potentially be useful for treatments for other disorders. (PsycINFO Database Record

Complex needs survey: informing the development of a community recovery and rehabilitation team

Aims and method

To inform the development of a new, recovery-oriented rehabilitation service, identify local needs and create a pathway for appropriate referrals, accelerating the build up of case-load. We surveyed 1353 secondary service users using a purpose-made needs assessment and case identification questionnaire, completed by nominated care coordinators.

Results

Significant unmet need for rehabilitation and recovery-oriented interventions was found. The results were used to invite referrals, create a case-load of 150 and allocate the appropriate resources for the new team.

Clinical implications

The results highlight the untapped recovery potential among users of mainstream secondary mental health services and support investment in rehabilitation at a time of resource restriction. This work also supports a similar, evidence-based approach to targeting appropriate referrals during the development and the early stages of rehabilitation services.

Mediation analysis of severity of needs, service performance and outcomes for patients with mental disorders

BACKGROUND

Needs and service performance assessment are key components in improving recovery among individuals with mental disorders.

AIMS

To test the role of service performance as a mediating factor between severity of patients' needs and outcomes.

METHOD

A total of 339 adults with mental disorders were interviewed. A mediation analysis between severity of needs, service performance (adequacy of help, continuity of care and recovery orientation of services) and outcomes (personal recovery and quality of life) was carried out using structural equation modelling.

RESULTS

The structural equation model provided a good fit with the data. An increase in needs was associated with lower service performance and worse outcomes, whereas higher service performance was associated with better outcomes. Service performance partially mediated the effect of patient needs on outcomes.

CONCLUSIONS

Poorer service performance has a negative impact on outcomes for patients with the highest needs. Ensuring more efficient services for patients with high needs may help improve their recovery and quality of life.

A pilot cluster randomised trial to assess the effect of a structured communication approach on quality of life in secure mental health settings: The Comquol Study

BACKGROUND

There is a lack of research in forensic settings examining therapeutic relationships. A structured communication approach, placing patients' perspectives at the heart of discussions about their care, was used to improve patients' quality of life in secure settings. The objectives were to: • Establish the feasibility of the trial design • Determine the variability of the outcomes of interest • Estimate the costs of the intervention • If necessary, refine the intervention METHODS: A pilot cluster randomised controlled trial was conducted. Data was collected from July 2012 to January 2015 from participants in 6 medium secure in-patient services in London and Southern England. 55 patients and 47 nurses were in the intervention group with 57 patients and 45 nurses in the control group. The intervention comprised 6 nurse-patient meetings over a 6 month period. Patients rated their satisfaction with a range of domains followed by discussions on improving patient identified problems. Assessments took place at baseline, 6 months, and 12 months. Participants were not blind to their allocated group. The primary outcome was self-reported quality of life collected by a researcher blind to participants' allocation status.

RESULTS

The randomisation procedures and intervention approach functioned well. The measures used were understood by the participants and gave relevant outcome information. The response rates were good with low patient withdrawal rates. The quality of life estimated treatment effect was 0.2 (95 % CI: -0.4 to 0.8) at 6 months and 0.4 (95 % CI: -0.3 to 1.1) indicating the likely extreme boundaries of effect in the main trial. The estimated treatment effect of the primary outcome is clinically important, and a positive effect of the intervention is not ruled out. The estimate of the ICC for the primary outcome at 6 and 12 months was 0.04 (0.00 to 0.17) and 0.05 (0.00 to 0.18). The cost of the intervention was £529 per patient.

CONCLUSIONS

The trial design was viable as the basis for a full-scale trial. A full trial is justified to estimate the effect of the intervention with greater certainty. The variability of the outcomes could be used to calculate numbers needed for a full-scale trial. Ratings of need for therapeutic security may be useful in any future study.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN34145189 . Retrospectively registered 22 June 2012.

Ecological Interventionist Causal Models in Psychosis: Targeting Psychological Mechanisms in Daily Life

Integrated models of psychotic disorders have posited a number of putative psychological mechanisms that may contribute to the development of psychotic symptoms, but it is only recently that a modest amount of experience sampling research has provided evidence on their role in daily life, outside the research laboratory. A number of methodological challenges remain in evaluating specificity of potential causal links between a given psychological mechanism and psychosis outcomes in a systematic fashion, capitalizing on longitudinal data to investigate temporal ordering. In this article, we argue for testing ecological interventionist causal models that draw on real world and real-time delivered, ecological momentary interventions for generating evidence on several causal criteria (association, time order, and direction/sole plausibility) under real-world conditions, while maximizing generalizability to social contexts and experiences in heterogeneous populations. Specifically, this approach tests whether ecological momentary interventions can (1) modify a putative mechanism and (2) produce changes in the mechanism that lead to sustainable changes in intended psychosis outcomes in individuals' daily lives. Future research using this approach will provide translational evidence on the active ingredients of mobile health and in-person interventions that promote sustained effectiveness of ecological momentary interventions and, thereby, contribute to ongoing efforts that seek to enhance effectiveness of psychological interventions under real-world conditions.

Self-reported patient psychosocial needs in integrated primary health care: A role for social work in interdisciplinary teams

Despite being identified as significant determinants of health, depression and anxiety continue to be underdiagnosed and undertreated in primary care settings. This study examined the psychosocial health needs of patients at four urban interdisciplinary primary health teams. Quantitative analysis revealed that nearly 80% of patients reported anxiety and/or depression. Self-reported anxiety and depression was correlated with poor social relationships, compromised health status and underdeveloped problem-solving skills. These findings suggest that social workers have a vital role to play within interdisciplinary primary health teams in the amelioration of factors associated with anxiety and depression.

Mental health and social service needs for mental health service users in Japan: a cross-sectional survey of client- and staff-perceived needs

Background

The appropriate utilization of community services by people with mental health difficulties is becoming increasingly important in Japan. The aim of the present study was to describe service needs, as perceived by people with mental health difficulties living in the community and their service providers. We analyzed the difference between two necessity ratings using paired data in order to determine implications related to needs assessment for mental health services.

Methods

This cross-sectional study used two self-reported questionnaires, with one questionnaire administered to mental health service users living in the community and another questionnaire to staff members providing services to those users at community service facilities. The study was conducted in psychiatric social rehabilitation facilities for people with mental health difficulties in Japan. The paired client and staff responses rated needs for each kind of mental health and social service independently. The 19 services listed in the questionnaire included counseling and healthcare, housing, renting, daily living, and employment. Overall, 246 individuals with mental health difficulties were asked to participate in this study, and after excluding invalid responses, 188 client-staff response dyads (76.4% of recruited people, 83.6% of people who gave consent) were analyzed in this study. A Wilcoxon matched-pairs signed rank test was used to compare the perceived needs, and weighted and unweighted Kappa statistics were calculated to assess rating agreement within client-staff dyads.

Results

Over 75% of participants in our study, who were people with mental health difficulties living in the community, regarded each type of mental health service as “somewhat necessary,” or “absolutely necessary” to live in their community. Most clients and staff rated healthcare facilities with 24/7 crisis consultation services as necessary. Agreement between client and staff ratings of perceived needs for services was low (Kappa = .02 to .26). Services regarding housing, renting a place to live, and advocacy had the same tendency in that clients perceived a higher need when compared to staff perceptions (p < .01).

Conclusions

It is essential for the service providers to identify the services that each user needs, engage in dialogue, and involve clients in service planning and development.

Electronic supplementary material

The online version of this article (doi:10.1186/s13033-015-0009-7) contains supplementary material, which is available to authorized users.

Exploring the Response Shift Effect on the Quality of Life of Patients with Schizophrenia

Background. Interpretation of quality of life (QoL) scores over time can be difficult because of possible changes in internal standards, values, and conceptualization of QoL by individuals. This effect is called a response shift (RS). The purpose of this study was to examine whether an RS effect occurred over a 24-mo period in patients who were suffering from schizophrenia. Methods. The random forest method was applied to detect any RS reprioritization in a multicenter cohort study. QoL was recorded using a generic questionnaire (SF36) at baseline (T0), 12 mo (T12), and 24 mo (T24). Patients were categorized into 3 groups based on psychotic symptoms and relapse (stable, improved, and worsened groups) from their clinical profiles. The random forest method was performed to predict the General Health score of the SF36 from the other QoL domain scores of the SF36. We estimated the average variable importance of the QoL domain for each of the 3 groups. Results. A total of 124 (53.2%) patients were defined as stable, 59 (25.3%) as improved, and 50 (21.5%) as worsened. Among the stable group, the Social Functioning domain became more important over time. Of those classified as improved, the Mental Health domain became more important over time, while the Vitality domain became less important. Among those in the group who worsened, the Mental Health domain became less important while the Vitality and Bodily Pain domains became more important. Conclusions. Our study identified differential RS reprioritization among patients with different clinical profiles. Further work is needed to determine whether RS should be interpreted as a measurement bias or as an effect integrated in a true change.

Determinants of patient satisfaction with hospital health care in psychiatry: results based on the SATISPSY-22 questionnaire

BACKGROUND

The aim of our study was to identify patient- and care-related factors that are associated with patients' satisfaction with psychiatric hospital care, using a specific, self-administered questionnaire based exclusively on the patient's point of view: the Satisfaction with Psychiatry Care Questionnaire-22 (SATISPSY-22).

METHODS

This cross-sectional study was conducted in the psychiatric departments of two French public university teaching hospitals. The data collected included sociodemographic information, clinical characteristics, care characteristics, and the SATISPSY-22. A multivariate analysis using multiple linear regressions was performed to determine the variables potentially associated with satisfaction levels.

RESULTS

Two hundred seventy patients were enrolled in our study. Only one moderate association was found between satisfaction and sociodemographic characteristics: the personal experience dimension with age (β=0.15). Clinical improvement was moderately associated with higher global satisfaction (β=-0.15), higher satisfaction with quality of care (β=-0.19), and higher satisfaction with food (β=-0.18). Stronger associations with satisfaction were found for care characteristics, particularly the therapeutic alliance with all of the satisfaction dimensions (β, 0.20-0.43) except food, and for seclusion with global satisfaction (β=-0.33) and personal experience (β=-0.32). Patients with previous hospitalization also had a higher level of satisfaction with quality of care compared with patients who were admitted for the first time (β=-0.15).

CONCLUSION

This study has identified a number of potential determinants of satisfaction. The therapeutic relationship and seclusion were the most important features associated with a patient's satisfaction. These factors might be amenable through intervention, which, in turn, might be expected to improve satisfaction, patients' management, and health outcomes in psychiatric hospitals.

Living in supportive housing for people with serious mental illness: a paradoxical everyday life

Since the closure of large psychiatric institutions, various types of community-based supportive housing for people with serious mental illness (SMI) have been developed. There is currently limited knowledge about users' experiences of living in supportive housing. The aim of the present study was to describe user experiences of living in supportive housing for people with SMI. Twenty-nine people living in such facilities participated in open, qualitative interviews. Data were subjected to latent content analysis. Three main themes emerged from this analysis: (i) having a nest, which included the subthemes of a place to rest and having someone to attach to; (ii) being part of a group, with the subthemes of being brought together and a community spirit; and (iii) leading an oppressive life, including the subthemes of questioning one's identity, sense of inequality, and a life of gloom. It could be concluded that user experiences of living in supportive housing are complex and paradoxical. In order to provide supportive housing, staff need to recognize and work within social group processes, and perform continual and structural evaluations of users' social and emotional needs.

Utility of the Montreal assessment of need questionnaire for community mental health planning

Needs assessment facilitates mental health services planning, provision, and evaluation. This study aimed to (a) validate a new instrument, the Montreal Assessment of Needs Questionnaire (MANQ), and (b) use this to assess variations and predictors of need (number and seriousness) in 297 individuals with severe mental disorders for 18 months, during implementation of the Quebec Mental Health Action Plan. MANQ internal and external validations were adequate. Variables significantly associated with need number and seriousness variations were used to build multiple linear regression models. Autonomous housing, not receiving welfare, not having consulted a health educator, higher level of help from services, Alcohol Use Disorders Identification Test total score, and social support were associated with decreasing need number and seriousness over time. Having a higher education was also associated with decreasing need number. In a reform context, the MANQ's unique ability to detect rapid improvement in patient needs has usefulness for Quebec mental health planning.

Outcomes from Italian community psychiatric services studies

Outcome measurement, to be valid, reliable, and useful to both program planning and evaluation of interventions, should be based on the principle of multiaxiality (i.e., considering the perspectives of all those involved in the care process, including clinicians, patients, caregivers, users' representatives, third-party payers) and of multidimensionality (i.e., considering an intervention's effect on various dimensions of patients' life, including clinical outcomes such as psychopathology, disability, and needs for care and self-perceived outcomes such as quality of life and service satisfaction). Unfortunately, in Italy, this methodology has not been applied on a large scale. However, some Italian centers with a long-lasting tradition in the area of psychiatric epidemiology have provided evidence that outcome assessment in routine practice is not only sustainable but also advantageous in the medium- and long-term. This article summarizes the results obtained in some of these studies, including three longitudinal studies on the outcome of community psychiatric care promoted by the research group of South Verona, such as the South Verona Outcome Project, the Psychosis Incident Cohort Outcome Study, and the Genetics Endophenotypes and Treatment: Understanding early Psychosis - &bullet; Psychosis: early Intervention and Assessment of Needs and Outcome trial.Implementation of routine outcome assessment can lead-and to a certain extent has already led-to a cultural change among Italian mental health service staff members, to facilitate a) the establishment of a revision-of-practice process, b) greater acceptance of the importance of evidence, and a predisposition to put it into practice.

Lessons from community mental health to drive implementation in health care systems for people with long-term conditions

This paper aims to identify which lessons learned from the evidence and the experiences accruing from the transformation in mental health services in recent decades may have relevance for the future development of healthcare for people with long-term physical conditions. First, nine principles are discussed which we first identified to guide mental health service organisation, and all of which can be potentially applied to long term care as well (autonomy, continuity, effectiveness, accessibility, comprehensiveness, equity, accountability, co-ordination, and efficiency). Second, we have outlined innovative operational aspects of service user participation, many of which were first initiated and consolidated in the mental health field, and some of which are now also being implemented in long term care (including case management, and crisis plans). We conclude that long term conditions, whether mental or physical, deserve a long-term commitment from the relevant health services, and indeed where continuity and co-ordination are properly funded implemented, this can ensure that the symptomatic course is more stable, quality of life is enhanced, and the clinical outcomes are more favourable. Innovations such as self-management for long-term conditions (intended to promote autonomy and empowerment) need to be subjected to the same level of rigorous scientific scrutiny as any other treatment or service interventions.

Effects of the two-way communication checklist (2-COM): a one-year cluster randomized study in a group of severely mentally ill persons

BACKGROUND

In a health-care service with the emphasis on improvement related to functioning and well-being, the communication process between patient and professionals is essential. There is a lack of research on this matter.

AIM

The aim was to investigate, in a group of severely mentally ill persons, whether the use of a simple communication tool could influence the sense of empowerment, satisfaction with care, therapeutic alliance and unmet needs.

METHOD

The study had a cluster randomized design. The intervention was a communication tool (2-COM) applied in two teams during one year. In a comparison group of two other teams, the treatment was as usual. At baseline, after six months, and after one year, assessments were made.

RESULTS

After one year the 2-COM groups seemed to have a larger reduction in unmet needs compared to the treatment-as-usual group. However, there were large problems with attrition in the study, and it was not possible to draw relevant conclusions.

CONCLUSIONS

The methodological problems were substantial, and the study may be considered as a pilot study. In a main study the researchers ought to take control over the selection of patients on the basis of the experiences from this study.

The validity of patient- and clinician-rated measures of needs and the therapeutic relationship in psychosis: a pooled analysis

Measuring outcomes of treatments for psychosis such as needs and the quality of the therapeutic relationship is important in research and routine care. However, evidence on the validity of existing outcome measures is limited. We aimed to test the convergent, discriminant, and predictive validity of two widely used patient- and clinician-rated measures of needs and the therapeutic relationship. Multitrait-multimethod (MTMM) analysis was conducted on the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS) and the Helping Alliance Scale (HAS), both the clinician (CANSAS-C, HAS-C) and patient (CANSAS-P, HAS-P) versions, in a pooled sample of 605 psychotic patients and their clinicians. CANSAS-C and CANSAS-P items loaded substantially into one common unmet needs factor. By comparison, substantial factor loadings were found for HAS-C and HAS-P items on two separate clinician- and patient-rated therapeutic relationship factors. Common unmet needs and clinician-rated therapeutic relationship factors significantly predicted reduced psychiatric in-patient days. Our findings support the convergent validity of the CANSAS, discriminant validity of the HAS, and predictive validity of CANSAS and HAS-C. The findings may inform the use of CANSAS and HAS as psychosis outcome measures in research and routine care.

Study to assess the effect of a structured communication approach on quality of life in secure mental health settings (Comquol): study protocol for a pilot cluster randomized trial

Background

Forensic mental health services have largely ignored examining patients’ views on the nature of the services offered to them. A structured communication approach (DIALOG) has been developed with the aim of placing the patient’s perspective on their care at the heart of the discussions between patients and clinicians. The effectiveness of the structured communication approach in community mental health services has been demonstrated, but no trial has taken place in a secure psychiatric setting. This pilot study is evaluating a 6-month intervention combining DIALOG with principles of solution-focused therapy on quality of life in medium-secure settings.

Methods and design

A cluster randomized controlled trial design is being employed to conduct a 36-month pilot study. Participants are recruited from six medium-secure inpatient services, with 48 patients in the intervention group and 48 in the control group. The intervention uses a structured communication approach. It comprises six meetings between patient and nurse held monthly over a 6-month period. During each meeting, patients rate their satisfaction with a range of life and treatment domains with responses displayed on a tablet. The rating is followed by a discussion of how to improve the current situation in those domains identified by the patient. Assessments take place prior to the intervention (baseline), at 6 months (postintervention) and at 12 months (follow-up). The primary outcome is the patient’s self-reported quality of life.

Discussion

This study aims to (1) establish the feasibility of the trial design as the basis for determining the viability of a large full-scale trial, (2) determine the variability of the outcomes of interest (quality of life, levels of satisfaction, disturbance, ward climate and engagement with services), (3) estimate the costs of the intervention and (4) refine the intervention following the outcome of the study based upon the experiences of the nurses and patients. The intervention allows patients to have a greater say in how they are treated and targets care in areas that patients identify as important to them. It is intended to establish systems that support meaningful patient and caregiver involvement and participation.

Trial registration

Current Controlled Trials, ISRCTN34145189

[Development and validation of the Inventory of Needs in Memory Impairment (BIG-65): illness-related needs in people with cognitive impairment and dementia]

BACKGROUND

There is growing evidence that individuals with cognitive impairment and dementia require systematic assessment of needs for the selection of optimal treatments. Currently no valid instrument is applicable for illness-related need assessment in this growing population.

METHOD

The purpose of this study was to develop and validate a new instrument ("Bedürfnisinventar bei Gedächtnisstörungen", BIG-65) that systematically assesses illness-related needs. The development was based on an adequate theoretical framework and standardised procedural guidelines and validated to an appropriate sample of individuals attending a Swiss memory clinic (n = 83).

RESULTS

The BIG-65 provides a comprehensive range of biopsychosocial and environmental needs items and offers a dementia-friendly structure for the assessment of illness-related needs. The BIG-65 has high face validity and very high test-retest reliability (rtt = 0,916). On average 3.5 (SD = 3.7) unmet needs were assessed. Most frequently mentioned needs were: "forget less" (50%), "better concentration" (23.2%), "information on illness" (20.7%), "information on treatments" (17.1%), "less worry", "less irritable", "improve mood", "improve orientation" (13.4% each). Needs profiles differed between patients with preclinical (subjective cognitive impairment, mild cognitive impairment) and clinical (dementia) diagnosis.

DISCUSSION

The BIG-65 reliably assesses illness-related needs in individuals with moderate dementia. With decreasing cognitive functions or an MMSE <20 points, additional methods such as observation of the emotional expression may be applied. According to our results, individuals with cognitive impairment and dementia pursue individual strategies to stabilize their quality of life level. In addition to the assessment of objective illness symptoms the selection of optimal treatments may profit from a systematic needs assessment to optimally support patients in their individual quality of life strategies.

Measuring patient-reported outcomes in psychosis: conceptual and methodological review

BACKGROUND

There are calls to use patient-reported outcomes (PROs) routinely across mental health services. However, the use of PROs in patients with psychosis has been questioned.

AIMS

To examine the concepts and measures of four widely used PROs: treatment satisfaction, subjective quality of life, needs for care and the quality of the therapeutic relationship.

METHOD

We conducted a literature search of academic databases on concepts, characteristics and psychometric properties of the four PROs in patients with psychosis.

RESULTS

Although numerous concepts and measures have been published, evidence on the methodological quality of existing PROs is limited. Measures designed to assess distinct PROs showed a considerable conceptual, operational and empirical overlap, and some of them also included specific aspects. The impact of symptoms and cognitive deficits appears unlikely to be of clinical significance.

CONCLUSIONS

The popularity of PROs has not been matched with progress in their conceptualisation and measurement. Based on current evidence, some recommendations can be made. Distinct and short measures with clinical relevance and sufficient psychometric properties should be preferred. Future research should optimise the validity and measurement precision of PROs, while reducing assessment burden.

Secluded/restrained patients' perceptions of their treatment: validity and reliability of a new questionnaire

AIM

To develop a standardized self-reporting questionnaire to evaluate patients' perceptions of their overall treatment in specific relation to the use of seclusion and/or restraint (SR) measures as part of the treatment program.

METHODS

A 17-item self-rating questionnaire was given to 56 patients with experience of SR-related treatment to develop a new scale, the Secluded/Restrained Patients' Perceptions of their Treatment (SR-PPT). Concurrent validity was examined against the Client Satisfaction Questionnaire-8 Japanese Version (CSQ-8J). In addition, Patient burden induced by answering the SR-PPT was evaluated.

RESULTS

On factor analysis, two factors named as Cooperation with Staff (nine items) and Perceptions of SR (two items) were derived. Cronbach's coefficient alphas were 0.928 and 0.887, and correlation coefficients against the CSQ-8J were 0.838 and 0.609, respectively. Answering the SR-PPT was found to induce little burden on the patients.

CONCLUSION

Adequate internal consistency and concurrent validity of the final version of the SR-PPT, which consists of 11 items, indicate that it is acceptable as a measurement scale. Use of this questionnaire will add the patient's view to the assessment of overall treatment involving SR.

Multiple perspectives on mental health outcome: needs for care and service satisfaction assessed by staff, patients and family members

PURPOSE

Community-based mental health care requires the involvement of staff, patients, and their family members when both planning intervention programmes and evaluating mental health outcomes. The present study aimed to compare the perceptions of these three groups on two important subjective mental health outcome measures--needs for care and service satisfaction--to identify potential areas of discrepancy.

METHODS

The sample consisted of patients with a DSM diagnosis of psychosis and attending either outpatient or day centres operating in a community-based care system. Staff, patients and family members were assessed by using the CAN and the VSSS to evaluate, respectively, needs for care and service satisfaction. Kappa statistics were computed to assess agreement in the three groups.

RESULTS

Patients identified significantly fewer basic (e.g. daytime activities, food, accommodation) and functioning needs (e.g. self-care, looking after home, etc.) than staff or family members. Only fair levels of agreement were found in the three groups (average kappa was 0.48 for staff and patients, 0.54 for staff and family members, and 0.45 for patients and relatives), with patients and family members showing more areas of discrepancies in both needs and service satisfaction.

CONCLUSIONS

These findings provide further support for the idea that mental health services should routinely involve patients and their relatives when planning and evaluating psychiatric intervention and that this policy is a premise for developing a partnership care model.

Instruments for comprehensive needs assessment in individuals with cognitive complaints, mild cognitive impairment or dementia: a systematic review

OBJECTIVE

In recent years, it has become more common to complement the objective assessment of symptoms with an assessment of individual needs patterns that are created by the individual pattern of symptoms. However, little is known on needs patterns in individuals with subjective cognitive impairment, mild cognitive impairment and dementia. Thus, on the basis of an analysis of the development of needs in the course of cognitive decline, we provide an overview of the existing needs assessment instruments with respect to feasibility, validity and reliability.

METHOD

We conducted a literature search in PsycINFO and PubMed including all publications up to September 2009. We included needs assessment instruments for use in older individuals with mental or cognitive disorders and dementia.

RESULTS

We identified 17 needs assessment instruments for individuals with mental disorders, cognitive impairment or dementia. The analysis of selected articles demonstrated a wide range of needs indicators within different subgroups. Validity and reliability range between moderate and good.

CONCLUSIONS

Even though a wide range of needs assessment instruments is available, most instruments assess the needs of individuals with subjective cognitive impairment, mild cognitive impairment and dementia on a general level rather than on a more concrete level that may serve better to inform interventions for this growing population. In addition, we suggest basing the development of instruments firmly on an adequate theoretical framework and standardised procedural guidelines.

Collaborative Care for patients with severe borderline and NOS personality disorders: a comparative multiple case study on processes and outcomes

BACKGROUND

Structured psychotherapy is recommended as the preferred treatment of personality disorders. A substantial group of patients, however, has no access to these therapies or does not benefit. For those patients who have no (longer) access to psychotherapy a Collaborative Care Program (CCP) is developed. Collaborative Care originated in somatic health care to increase shared decision making and to enhance self management skills of chronic patients. Nurses have a prominent position in CCP's as they are responsible for optimal continuity and coordination of care. The aim of the CCP is to improve quality of life and self management skills, and reduce destructive behaviour and other manifestations of the personality disorder.

METHODS/DESIGN

Quantitative and qualitative data are combined in a comparative multiple case study. This makes it possible to test the feasibility of the CCP, and also provides insight into the preliminary outcomes of CCP. Two treatment conditions will be compared, one in which the CCP is provided, the other in which Care as Usual is offered. In both conditions 16 patients will be included. The perspectives of patients, their informal carers and nurses are integrated in this study. Data (questionnaires, documents, and interviews) will be collected among these three groups of participants. The process of treatment and care within both research conditions is described with qualitative research methods. Additional quantitative data provide insight in the preliminary results of the CCP compared to CAU. With a stepped analysis plan the 'black box' of the application of the program will be revealed in order to understand which characteristics and influencing factors are indicative for positive or negative outcomes.

DISCUSSION

The present study is, as to the best of our knowledge, the first to examine Collaborative Care for patients with severe personality disorders receiving outpatient mental health care. With the chosen design we want to examine how and which elements of the CC Program could contribute to a better quality of life for the patients.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR2763.

What makes community psychiatric nurses label non-psychotic chronic patients as 'difficult': patient, professional, treatment and social variables

PURPOSE

To determine which patient, professional, treatment and/or social variables make community psychiatric nurses (CPNs) label non-psychotic chronic patients as 'difficult'.

METHODS

A questionnaire was designed and administered to 1,946 CPNs in the Netherlands. Logistic regression was used to design models that most accurately described the variables that contributed to perceived difficulty.

RESULTS

Six variables were retained in the final logistic model. Perception-related variables (feeling powerless, feeling that the patient is able but unwilling to change, and pessimism about the patient's change potential) dominated treatment-related variables (number of contacts per week and admission to a locked ward in the last year) and social variables (number of psychosocial problems).

CONCLUSION

This research shows that perceived difficulty is related to complex treatment situations, not so much to individual patient characteristics. If the constructed model has good predictive qualities, which remains to be tested in longitudinal research, it may be possible to accurately predict perceived patient difficulty. When used as a screening tool, such a model could improve treatment outcomes.

Self-assessment of need for help in patients undergoing psychiatric treatment

Needs assessment for patients in mental health care is an important tool. When used systematically, needs assessment can improve the quality of care and facilitate a process of 'shared decision making' in service provision. A self-report questionnaire, the Needs Assessment Scale (NAS), was developed for use in larger survey samples. The perceived problems of patients and their associated need for help were assessed in 22 life areas similar to those of the Camberwell Assessment of Need (CAN) interview. In this article, we explore the validity and utility of the NAS. For this purpose 305 psychiatric patients completed the NAS in a postal survey. The factor structure of the scale shows four subscales. Two domains are measured: problem assessment and needs assessment. Patients reported a mean number of 4.0 (S.D. 3.5) problem areas and a mean number of 2.4 (S.D. 3.6) unmet need areas. Differences between various subgroups (e.g. diagnostic categories, treatment setting) and concurrent validity with the CAN are discussed. The NAS seems to be sensitive to the perceived needs of patients, although those with psychotic disorders tend to under-report unmet need. We conclude that the NAS is a useful and feasible instrument in the assessment of patients' need for help at a population level.

Addressing mental health disparities through clinical competence not just cultural competence: the need for assessment of sociocultural issues in the delivery of evidence-based psychosocial rehabilitation services

Recognition of ethnic/racial disparities in mental health services has not directly resulted in the development of culturally responsive psychosocial interventions. There remains a fundamental need for assessment of sociocultural issues that have been linked with the expectations, needs, and goals of culturally diverse consumers with severe and persistent mental illness. The authors posit that embedding the assessment of sociocultural issues into psychosocial rehabilitation practice is one step in designing culturally relevant empirically supported practices. It becomes a foundation on which practitioners can examine the relevance of their interventions to the diversity encountered in everyday practice. This paper provides an overview of the need for culturally and clinically relevant assessment practices and asserts that by improving the assessment of sociocultural issues the clinical competence of service providers is enhanced. The authors offer a conceptual framework for linking clinical assessment of sociocultural issues to consumer outcomes and introduce an assessment tool adapted to facilitate the process in psychosocial rehabilitation settings. Emphasizing competent clinical assessment skills will ultimately offer a strategy to address disparities in treatment outcomes for understudied populations of culturally diverse consumers with severe and persistent mental illness.

Who Stays in Treatment? Child and Family Predictors of Youth Client Retention in a Public Mental Health Agency

The present study examined possible predictors of youth client retention in therapy in a large community-based sample. We used several conceptualizations of retention, including (a) "intake retention" (i.e., returned to treatment after intake session); (b) "mutual termination" (i.e., termination agreed upon by family and therapist), (c) "mean treatment duration" (i.e., completing the mean number of sessions in the agency), and (d) "total treatment duration" (i.e., total number of sessions). Archival data from over 400 children and adolescents who sought treatment at a large public mental health clinic were analyzed using regression analyses. Although different predictors were identified across the various conceptualizations, a few robust predictors emerged including ethnicity and client symptom severity. Clinical implications and future research directions are discussed.