New directions for psychiatric rehabilitation in the USA

When Distance Becomes Closeness: Distance Learning as a Meaningful Learning Opportunity During the COVID-19 Pandemic

The National School for Mental Health Rehabilitation, Integration, and Recovery in Israel developed responses to academic, pedagogical, and emotional needs that arose during the first wave of the COVID-19 pandemic. Despite reduced activity during the outbreak, the school continued all regular courses remotely and created new online workshops. In this article, we review the school's adjustment from being change agents on the frontal level to change agents on the virtual level, through descriptive and qualitative findings. We use the learning from success approach to examine development and implementation processes. The large number of participants who suddenly had access to distance learning and their highly positive responses indicated the creation of opportunities alongside the challenges we faced. To the best of our knowledge, this is the first description and analysis of the challenges, opportunities, and outcomes of a recovery-oriented online academic facility during a pandemic.

Psychiatric rehabilitation patterns in Italy: Results from the Italian Society of Psychosocial Rehabilitation (SIRP) survey

INTRODUCTION

Psychiatric rehabilitation can be considered a bidirectional technique, designed to allow patients to achieve their personal target, focusing on the individuals' strengths and challenges related to these targets and also on the community organizations in which they will live them out. Unfortunately, psychiatric rehabilitation is too often not considered a first line treatment. Moreover, rehabilitation has been confused with a generic and rough practice, consisting of extemporary actions and aimless entertainments designed to fill "the time passing".

METHODS

The aim of this study was to increase the knowledge and awareness about the state of the art of different systems of management and funding of psychosocial rehabilitation in the Italian "real-world" rehabilitative settings, using a specifically developed questionnaire.

RESULTS

The data obtained are positive for some aspects of the rehabilitation interventions, in particular for the use of validated tools for the evaluation and revision of projects and for the trend to work on a team, even though the scarcity of evidence-based rehabilitation interventions applied in Italian psychiatric services is less encouraging.

CONCLUSION

This survey presents, at least partially, the "real-world" of rehabilitation in Italy so that we can lay the foundations for the definition of an updated, validated and shared network of what is implemented in the context of psychiatric rehabilitation.

"Why I stay in community psychiatric rehabilitation": a semi-structured survey in persons with schizophrenia

AIMS

Although community psychiatric rehabilitation plays an important role in returning persons with schizophrenia to the society, many patients in China stay in rehabilitation centers for longer periods of time and subsequently fail to integrate. This study is aimed to explore the underlying causes of this trend and identify possible solutions.

METHODS

This study used a qualitative descriptive design to examine the persons with schizophrenia who stay in rehabilitation centers for longer periods of time. The researchers conducted semi-structured telephone interviews with the patients recruited through purposeful sampling. The audio-recorded interviews were transcribed in transcripts in Chinese. Thematic analysis was performed using Colaizzi's 7-step method.

RESULTS

Most patients believe that they have gained knowledge, improved skills, friendship and social circles through community mental rehabilitation, with the sense of belonging and enriched life strongly attracting them to the rehabilitation centers. They felt that the difficulty of further integration into society is mainly because of social prejudice and rejection. In addition, the activities of community mental rehabilitation meet the needs of social communication, which also hinder patients from further entering the society.

CONCLUSIONS

Persons with schizophrenia with long-term stay in community mental rehabilitation centers meet their friendship, sense of belonging and social needs by participating in rehabilitation activities. Providing special social opportunity for these patients can get them out of the rehabilitation center. Overall, it is possible for patients to gradually return to society in a collective form.

Contributions et défis de l’utilisation des technopédagogies à des fins de soutien à l’appropriation des meilleures pratiques en santé mentale

Contexte Malgré les ressources considérables consacrées et les efforts des nombreux acteurs concernés, l’écart entre la production de connaissances scientifiques et leur utilisation dans la pratique demeure un défi. L’utilisation des technologies de l’information et des communications (TICs) constitue un outil précieux pour réduire cet écart. Afin de relever ce défi, un projet de démonstration misant sur l’utilisation des technologies à des fins d’application des connaissances a été déployé auprès de 23 équipes de soutien dans la communauté de 5 régions du Québec (2016-2018). Plus de 324 professionnels de la santé mentale, chefs d’équipe et gestionnaires ont bénéficié de l’initiative À portée de main, les meilleures pratiques axées vers le rétablissement.

Objectif Cet article présente les résultats de l’étude de satisfaction effectuée auprès des chefs d’équipe responsables du soutien clinique dans les équipes de soutien dans la communauté à l’étude. L’objectif de cette étude consiste à enrichir la compréhension d’enjeux colligés en cours d’implantation et d’émettre des recommandations en vue d’une mise à l’échelle pérenne du programme d’application des connaissances mis en oeuvre.

Méthode Un devis qualitatif en recherche évaluative a été privilégié. Au terme du processus d’implantation du programme, 2 entrevues de groupe ont été effectuées avec les chefs d’équipe. Une analyse de contenu suivant une approche inductive à 3 niveaux de codification a été réalisée.

Résultats Les résultats montrent un décalage numérique important au sein du réseau de la santé et des services sociaux québécois comparativement à d’autres secteurs d’activités. Les participants soulignent l’importance de se doter de mécanismes d’échange et de transfert des connaissances intégrés aux pratiques organisationnelles (temps dédié, supervision clinique formelle, etc.) mettant à contribution les TICs.

Conclusion Malgré une importante mise à niveau technologique requise, les résultats confirment la pertinence d’utiliser les technopédagogies comme principal moyen pour soutenir l’application des connaissances et la transformation des pratiques. Les outils conçus et les modalités de soutien explorés semblent faciliter l’accès aux meilleures pratiques en santé mentale et favoriser leur adoption.

Applying Implementation Drivers to Scale-up Evidence-Based Practices in New York State

Mental health authorities in several states, often working with academic partners, have played important roles in disseminating evidence-based practices (EBPs) for adults diagnosed with serious mental illness. This work has been facilitated by intermediary organizations that work directly with providers to implement EBPs. This report uses two case studies to describe how the Center for Practice Innovations (CPI), an intermediary organization, has used the Active Implementation Research Network’s nine implementation drivers to successfully implement EBPs across the large state of New York. One case study focuses on supported employment and the second on integrated treatment for co-occurring mental health and substance use conditions. We provide these case studies to illustrate how intermediary organizations can use implementation science to organize and select effective support strategies to disseminate and implement a range of EBPs within a state system.

Impact of Supervisory Support on Turnover Intention: The Mediating Role of Burnout and Job Satisfaction in a Longitudinal Study

High rates of provider turnover are problematic for our mental health system. Research indicates that supervisory support could alleviate some turnover intention by decreasing emotional exhaustion (a key component of burnout) as well as by increasing job satisfaction. However, the potential mediation mechanisms have not been rigorously tested. Longitudinal data collected from 195 direct clinical care providers at two community mental health centers identified positive effects of supervisory support on reduced turnover intention through reduced emotional exhaustion. Job satisfaction was not a significant mediator. Supervisory support may help mitigate turnover intention through work-related stress reduction.

Evidence-Based Integrated Intervention in Patients with Schizophrenia: A Pilot Study of Feasibility and Effectiveness in a Real-World Rehabilitation Setting

Impairment in real-world functioning remains one of the most problematic challenges that people with schizophrenia have to face. Various psychosocial interventions have proven to be effective in promoting recovery and improving functioning in schizophrenia; however, their implementation and their effectiveness in routine rehabilitation practice are still objects of study. The present pilot study aimed to assess the feasibility and effectiveness on clinical and real-world outcomes of an integrated treatment protocol composed of stable pharmacological treatment, computer-assisted cognitive remediation and social skills training provided in a rehabilitation center. Predictors of functional improvement were also assessed. Seventy-two patients diagnosed with schizophrenia participated in the study. A significant (p < 0.001) improvement in positive, negative and total symptoms, as well as in global clinical severity and real-world functioning outcomes was observed, with a large effect size in positive and total symptoms, global clinical severity and real-world functioning, and a moderate effect size on negative symptoms. Improvement in total symptoms (p < 0.001) and in global clinical severity (p = 0.007) emerged as individual predictors of functional improvement. These findings, although preliminary, suggest that an integrated, evidence-based treatment program is feasible and effective in a real-world rehabilitation context, and that similar interventions should be further implemented in everyday clinical practice.

Persons with serious mental illness help relatives: rates and correlates of assistance

Background: Scant research has focused on assistance provided by persons with serious mental illness (SMI) to relatives.Aims: The objectives of the present study are to (1) describe and compare rates of assistance provided by persons with SMI to relatives and vice versa and (2) examine the extent to which factors are associated with assistance provided by persons with SMI.Methods: A cross-sectional survey design was employed. In 2014 and 2015, 573 adults with a relative with SMI completed an online survey. Multivariate logistic regression was computed.Results: Although persons with SMI were more likely to receive than provide assistance, 61% and 37% of persons with SMI provided relatives with assistance with activities of daily living (ADL) and financial assistance, respectively. Relationship type, co-residence and frequency of in-person contact were associated with providing assistance with ADL and financial assistance. Disability status and regular alcohol use were associated with assistance with ADL. Income was related to financial assistance.Conclusions: It is critical that researchers and practitioners acknowledge the help persons with SMI provide to relatives. Implications for research and practice are addressed.

The Design, Implementation, and Acceptability of a Telehealth Comprehensive Recovery Service for People With Complex Psychosis Living in NYC During the COVID-19 Crisis

INTRODUCTION

The COVID-19 crisis and subsequent stay-at-home orders have produced unprecedented challenges to the dissemination of recovery oriented behavioral health services (RS) that support the treatment of those with complex psychosis (CP).This population has typically been managed with in-person pharmacotherapy and/or RS, with the goals of relieving symptoms, improving life satisfaction and increasing community engagement. COVID-19 related social distancing measures have required rapid shifts in care management, while easing of telehealth regulations has allowed for flexibility to approach RS differently. It is essential to learn from the RS telemedicine implementation experience, so that RSs can maintain care for this vulnerable and needy population.

METHOD

This paper describes the successful telehealth conversion of a NYC-based, university affiliated RS that serves adults with severe mental illnesses (SMI; n = 64). Results focus on the telehealth acceptance rates of the subset of participants with CP (n = 23).

RESULTS

The RS continued providing services including intake, care coordination, group psychotherapies, skills training groups, individual skills coaching, and vocational/educational supports. The telehealth conversion rates of the CP subsample indicated that 90% of CP patients accepted telehealth sessions and maintained their specific treatment plans in the virtual format. Mean comparisons between session attendance and cancellations/no-shows during the six-week period before and after telehealth conversion showed no significant differences in service utilization.

DISCUSSION

RSs play an essential role in the treatment of CP and telehealth may prove to be a viable format of care delivery even after the COVID-19 crisis subsides. The multiple factors in the inner and outer treatment setting that contributed to successful conversion to telehealth will be considered along with the challenges that clinicians and patients encountered.

Psychosocial interventions for people with both severe mental illness and substance misuse

BACKGROUND

Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.

OBJECTIVES

To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care.

SEARCH METHODS

The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison.

MAIN RESULTS

Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence).

AUTHORS' CONCLUSIONS

We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.

Understanding consumers' initial expectations of community-based residential mental health rehabilitation in the context of past experiences of care: A mixed-methods pragmatic grounded theory analysis

This study explores how consumers expect community-based residential mental health rehabilitation to compare with previous experiences of care. Understanding what consumers hope to receive from mental health services, and listening to their perspectives about what has and has not worked in previous care settings, may illuminate pathways to improved service engagement and outcomes. A mixed-methods research design taking a pragmatic approach to grounded theory guided the analysis of 24 semi-structured interviews with consumers on commencement at three Community Care Units (CCUs) in Australia. Two of these CCUs were trialling a staffing model integrating peer support work with clinical care. All interviews were conducted by an independent interviewer within the first 6 weeks of the consumer's stay. All participants expected the CCU to offer an improvement on previous experiences of care. Comparisons were made to acute and subacute inpatient settings, supported accommodation, and outpatient care. Consumers expected differences in the people (staff and co-residents), the focus of care, physical environ, and rules and regulations. Participants from the integrated staffing model sites articulated the expected value of a less clinical approach to care. Overall, consumers' expectations aligned with the principles articulated in policy frameworks for recovery-oriented practice. However, their reflections on past care suggest that these services continue to face significant challenges realizing these principles in practice. Paying attention to the kind of working relationship consumers want to have with mental health services, such as the provision of choice and maintaining a practical and therapeutic supportive focus, could improve their engagement and outcomes.

Understanding Systems Change in Early Implementation of Housing First in Canadian Communities: An Examination of Facilitators/Barriers, Training/Technical Assistance, and Points of Leverage

We present interim findings of a cross-site case study of an initiative to expand Housing First (HF) in Canada through training and technical assistance (TTA). HF is an evidence-based practice designed to end chronic homelessness for consumers of mental health services. We draw upon concepts from implementation science and systems change theory to examine how early implementation occurs within a system. Case studies examining HF early implementation were conducted in six Canadian communities receiving HF TTA. The primary data are field notes gathered over 1.5 years and evaluations from site-specific training events (k = 5, n = 302) and regional network training events (k = 4, n = 276). We report findings related to: (a) the facilitators of and barriers to early implementation, (b) the influence of TTA on early implementation, and (c) the "levers" used to facilitate broader systems change. Systems change theory enabled us to understand how various "levers" created opportunities for change within the communities, including establishing system boundaries, understanding how systems components can function as causes of or solutions to a problem, and assessing and changing systems interactions. We conclude by arguing that systems theory adds value to existing implementation science frameworks and can be helpful in future research on the implementation of evidence-based practices such as HF which is a complex community intervention. Implications for community psychology are discussed.