An empirical literature review of definitions of severe and persistent mental illness

Mapping of the health of the Nation Outcomes Scale (HoNOS) and Positive and Negative Symptom Scale (PANSS) to the EQ-5D-3L in psychosis patients using the PHAMOUS study

OBJECTIVES

When health outcomes relevant for economic evaluations are unavailable, algorithms can be developed to map utilities using available clinical outcome measures. This study aims to develop two mapping algorithms estimating EuroQol-5 dimension-3 level (EQ-5D-3 L) utilities using the clinician-rated Health of the Nation Outcome Scores (HoNOS) and Positive and Negative Syndrome Scale (PANNS).

METHODS

A dataset with 2,029 observations of patients with psychotic disorders included EQ-5D-3 L, HoNOS, PANSS item scores, and demographics. Correlations between instruments were evaluated. Least Absolute Shrinkage and Selection Operator (LASSO) regression and random forest (RF) algorithms with various predictor variable sets were applied. Model performance was cross-validated using R-squared and Root Mean Square Error (RMSE).

RESULTS

High ceiling effects were observed for EQ-5D-3 L, with weak to moderate negative correlations between EQ-5D and HoNOS (r = -0.34) and PANSS (r = -0.27). Overall, LASSO models outperformed RF models, with individual item models performing best for the HoNOS and PANSS, with the best observed RMSEs of 0.241 and 0.231, respectively.

CONCLUSIONS

The HoNOS and PANSS could be mapped onto EQ-5D-3 L utilities but lack accuracy for individual patient predictions. However, in the absence of alternatives, they could adequately predict population-based utility score differences for health economic evaluations.

Prevalence of harassment, abuse, and mental health among current and retired senior Swedish cheerleaders

This study examined the prevalence of non-accidental violence, focusing on experienced harassment and abuse (HA), and mental health among current and retired Swedish competitive cheerleaders. An online survey was distributed to current and retired athletes in the Swedish cheerleading federation. The survey assessed perceived coach-athlete relationship, sport psychological safety, resilience, mental health, and experienced HA within the cheerleading environment. A total of 284 athletes (men = 5; women = 278; gender not disclosed = 1; current athletes = 211; retired athletes = 73) completed the survey. Psychological abuse was the most frequently reported HA form (current athletes = 21.6%; retired athletes = 53.5%), followed by neglect (current athletes = 5.4%; retired athletes: 26.8%) and physical abuse (current athletes = 3.9%; retired athletes = 12.7%). A high-quality coach-athlete relationship was identified as a protective factor for HA. Additionally, 33.1% and 8.9% of participants displayed scores indicating anxiety and depression caseness, while 63.8% reported a high level of wellbeing. Anxiety/depression scores above clinical cut-off were linked to injury episodes and a high level of wellbeing to a mentally healthy environment. Resilience was found to protect mental health overall. The high occurrence of reported psychological abuse and indications of anxiety/depression related to injury episodes suggest a need of attention towards prevention and athlete protection strategies in cheerleading environments.

Effectiveness of Peer Support Programs for Severe Mental Illness: A Systematic Review and Meta-Analysis

(1) Background: While medication and various forms of psychotherapy are common treatments for severe mental illness, peer support programs have also proven to be effective in managing mental disorders. These programs, which involve individuals with similar experiences in navigating mental health challenges, aim to improve coping skills and foster supportive community networks. However, despite the prevalent mention of peer support programs, especially those with supervision, there has been no systematic review or meta-analysis of peer support supervision. This study aimed to systematically review and meta-analyze the forms and effectiveness of peer support programs for individuals with severe mental illnesses. (2) Methods: A literature search focusing on randomized controlled trials (RCTs) published between February 2003 and January 2024 was conducted. (3) Results: Sixteen RCTs meeting the inclusion criteria and involving a total of 4008 participants were reviewed. These studies utilized various peer support program strategies, with eight studies included in the qualitative analysis. The combined effect sizes for depressive symptoms (d = 0.12; 95% CI, -0.14, 0.37; p = 0.37), empowerment (d = 1.17; 95% CI, -0.81, 3.15; p = 0.25), quality of life (d = 0.70; 95% CI, -0.12, 1.52; p = 0.09), psychiatric symptoms (d = -0.05; 95% CI, -0.20, 0.10; p = 0.54), and self-efficacy (d = 0.20; 95% CI, 0.05, 0.36; p = 0.01) were assessed. (4) Conclusions: Our analysis emphasizes the need for further studies on peer support programs for individuals with severe mental illness, particularly those focused on self-efficacy outcomes across diverse geographic locations involving more countries and with larger scales to bolster the strength of the evidence.

Good psychiatric management for borderline personality disorder: A qualitative study of its implementation in a supported employment team

INTRODUCTION

People with borderline personality disorder have difficulties with work. The Individual Placement and Support model has shown its worldwide effectiveness in terms of vocational rehabilitation for individuals with psychiatric disorders. However, only a few recent studies have explored its results for people with personality disorders, and the findings were mitigated. Additionally, Individual Placement and Support job coaches reported difficulties in supporting this population. An evidence-based psychotherapeutic method, also applicable in a case management context, called Good Psychiatric Management for borderline personality disorder, could potentially overcome these obstacles. This study aimed to evaluate the initial integration of Good Psychiatric Management in Individual Placement and Support practice.

METHODS

Individual Placement and Support practitioners of Lausanne University Hospital, Switzerland, were trained in Good Psychiatric Management in January 2022. Five of them participated in a focus group to collect their impressions about the training, and six were interviewed 9 months later to assess the initial adoption of Good Psychiatric Management into their practice. Thematic analyses were conducted.

RESULTS

Job coaches were positive about this new tool. All of them found it useful and beneficial both for them and their patients. They were able to follow the main Good Psychiatric Management principles in their practice However, the findings also suggested some additional improvements in the implementation process.

CONCLUSIONS

Integrating Good Psychiatric Management in Individual Placement and Support seems feasible, and the team who appreciated it adopted it. The method offers new perspectives in community support for people living with borderline personality disorder.

Are probiotics effective in reducing the metabolic side effects of psychiatric medication? A scoping review of evidence from clinical studies

The psychopharmacological treatment of patients with schizophrenia or depression is often accompanied by serious side effects. In particular, the clinical findings of weight gain are worrying, as this side effect can lead to various medical sequelae in the future. However, the treatment of metabolic changes in psychiatric patients is often neglected or unsuccessful. An improved knowledge of possible therapeutic approaches is needed. The aim of this study was to provide an overview of the utilisation and effectiveness of probiotics in reducing weight gain in patients with severe mental illness. A scoping review of studies published until 15 June 2022 was conducted to identify studies using probiotics in people with schizophrenia or depression. We systematically searched the databases EMBASE, PubMed (MEDLINE), Web of Science and SCOPUS with a predefined search string. In addition, reference lists of relevant publications were examined for additional studies. The studies were assessed by two reviewers. The primary outcomes were weight-related measurements. The secondary outcomes were metabolic blood parameters and gut microbiota. Four studies ultimately met the inclusion criteria. Two studies in which probiotics were administered did not find significant effects on pharmacologically induced weight gain. The other two studies examined the effects of synbiotics (a combination of probiotics and prebiotics). Interestingly, less weight gain was observed in individuals with this combined intervention. Adjustments in diet can be helpful and are generally well-accepted interventions in the fight against pharmacologically induced weight gain. The clinical use of probiotics and prebiotics (or synbiotics) as dietary interventions may represent a promising additional strategy in this regard. However, the few studies available showed no clear conclusions.

Oral health primary preventive interventions for individuals with serious mental illness in low- and middle-income nations: Scoping review

Mental health disorders constitute a major global disease burden, especially in low and middle-income countries (LMICs). Due to issues related to access, hygiene, economic pressures, and communication, the oral health of individuals with serious mental illness (SMI) receives little attention. This scoping review comprehensively maps and synthesises the existing literature on oral health primary preventive interventions (OHPPIs) in LMICs, highlighting key strategies and challenges encountered in addressing oral health disparities in resource-constrained settings. We systematically searched Cochrane Library, Ovid (MEDLINE), PsycINFO and Embase. The search strategy included keywords and MeSH terms related to oral health, SMI interventions, and LMICs. We included all types of OHPPI, (preventive, promotive, behavioural, and educational approaches) implemented in LMICs. We identified three studies focused on OHPPI for SMI patients that met our inclusion criteria. The interventions included were: (I) educational interventions; (II) behavioural interventions combining motivational and educational elements, and (III) self-assessment interventions combining educational and physical elements. Multifaceted barriers and challenges to effective oral health interventions were identified covering limited access to dental services, and socio-economic disparities. This scoping review underscores the need to develop and test context-specific strategies, capacity building, and policy support to improve oral health outcomes in LMICs.

Socio-demographic and clinical characteristics associated with retention in care among adults living with HIV and severe mental illness and reasons for loss to follow-up in Uganda: a mixed-methods study

OBJECTIVE

This study aimed to determine the socio-demographic and clinical characteristics associated with retention in care and reasons for loss to follow-up (LTFU) among people living with HIV (PLWH) with a known diagnosis of severe mental illness (SMI).

DESIGN

We conducted a parallel convergent mixed-methods study. The quantitative study was used to determine the proportion and factors associated with retention in care among PLWH and SMI. The qualitative study explored reasons for LTFU.

SETTING

This study was conducted at two the HIV clinics of two tertiary hospitals in Uganda.

PARTICIPANTS

We reviewed records of 608 PLWH who started antiretroviral therapy (ART) and included participants who had a documented diagnosis of SMI.

OUTCOMES

The primary outcome was retention in care. Age, gender, religion, tuberculosis (TB) status, WHO clinical stage, functional status, cluster of differentiation 4 (CD4) cell count, viral load and SMI diagnosis were among the predictor variables.

RESULTS

We collected data from 328 participants. Retention at 6 months was 43.3% compared with 35.7% at 12 months. Having an unsuppressed viral load (≥1000 copies/mL) (adjusted incidence risk ratio (IRR)=1.54, 95% CI: 1.17 to 2.03), being 36 years and below (adjusted IRR=0.94, 95% CI: 0.94 to 0.95), initial presentation at outpatient department (adjusted IRR=0.74, 95% CI: 0.57 to 0.96), having TB signs and symptoms (adjusted IRR=0.98 95% CI: 0.97 to 0.99) and being in lower WHO stages (I and II) (adjusted IRR=1.08, 95% CI: 1.02 to 1.14) at ART initiation were significantly associated with retention in care at 6 and 12 months. Inadequate social support, long waiting hours at the clinic, perceived stigma and discrimination, competing life activities, low socioeconomic status and poor adherence to psychiatric medication were barriers to retention in care.

CONCLUSION

Twelve-month retention in care remains low at 35.7% far below the 90% WHO target. There is a need to design and implement targeted interventions to address barriers to retention in care among PLWH and SMI.

Development and Validation of a Risk Score for Predicting Non-Adherence to Antiretroviral Therapy

Several patient-related factors that influence adherence to antiretroviral therapy (ART) have been described. However, studies that propose a practical and simple tool to predict nonadherence after ART initiation are still scarce. In this study, we develop and validate a score to predict the risk of nonadherence in people starting ART. The model/score was developed and validated using a cohort of people living with HIV starting ART at the Hospital del Mar, Barcelona, between 2012 and 2015 (derivation cohort) and between 2016 and 2018 (validation cohort),. Adherence was evaluated every 2 months using both pharmacy refills and patient self-reports. Nonadherence was defined as taking <90% of the prescribed dose and/or ART interruption for more than 1 week. Predictive factors for nonadherence were identified by logistic regression. Beta coefficients were used to develop a predictive score. Optimal cutoffs were identified using the bootstrapping methodology, and performance was evaluated with the C statistic. Our study is based on 574 patients: 349 in the derivation cohort and 225 in the validation cohort. A total of 104 patients (29.8%) of the derivation cohort were nonadherent. Nonadherence predictors were patient prejudgment; previous medical appointment failures; cultural and/or idiomatic barriers; heavy alcohol use; substance abuse; unstable housing; and severe mental illness. The cutoff point (receiver operating characteristic curve) for nonadherence was 26.3 (sensitivity 0.87 and specificity 0.86). The C statistic (95% confidence interval) was 0.91 (0.87-0.94). These results were consistent with those predicted by the score in the validation cohort. This easy-to-use, highly sensitive, and specific tool could be easily used to identify patients at highest risk for nonadherence, thus allowing resource optimization and achieving optimal treatment goals.

Effectiveness of Illness Management and Recovery program on people with severe mental illnesses: a systematic review and meta-analysis

Background

The Illness Management and Recovery (IMR) program has been established in response to the challenges faced by people with severe mental illnesses (SMIs). The program emphasizes the self-management of mental health conditions and the achievement of personally meaningful goals. However, reviews on its efficacy remain scarce, especially in recent years.

Objective

This review aimed to examine the efficacy of IMR in improving personal-recovery outcomes among people with SMIs.

Methods

A search was conducted on seven databases (CINAHL, Embase, ProQuest, PsycINFO, PubMed, Scopus, and Web of Science) from inception to February 2022, without limits on the dates and types of publications. Studies were included if they had examined the efficacy of IMR in one or more outcomes, investigated at least one group of participants, and been published in English. The participants were adults (at least 16 years of age) with a formal diagnosis of at least one SMI.

Results

Fourteen studies were included in this review, and eight outcomes were examined: personal recovery, global functioning, social functioning, hope, perceived social support, quality of life, substance abuse, and knowledge of mental illness. There is limited evidence on the superiority of IMR to existing treatment plans or other interventions in improving the outcomes of interest among people with SMIs. However, the low attendance rates in many included studies suggest the presence of a threshold of exposure to IMR beyond which its treatment effects could be observed. Suggestions for future IMR implementation are discussed.

Conclusions

The IMR program may serve as an alternative or complementary intervention for people with SMIs, especially with enhanced program exposure and access to resource materials.

Systematic review registration

https://inplasy.com/inplasy-2022-10-0005/.

Examining Nutrition Knowledge, Skills, and Eating Behaviours in People with Severe Mental Illness: A Cross-Sectional Comparison among Psychiatric Inpatients, Outpatients, and Healthy Adults

Compared to the general population, people with severe mental illness (SMI) have an increased risk of weight gain and metabolic syndrome, but also of malnutrition, in part due to unhealthy lifestyle behaviours. The aim of this cross-sectional study was to identify barriers to healthy eating, including nutrition knowledge and skills in people with SMI. For this purpose, we compared the means of anthropometric data such as body mass index, waist-to-hip ratio, and interview data on nutrition knowledge and skills, health-related variables, eating behaviours, personality, motivation, and attitudes in 65 inpatients and 67 outpatients of the Psychiatric Hospital of the University of Zurich and 64 healthy adults using ANOVA and chi-squared tests. The results showed that patients with SMI had worse nutritional status and lifestyle compared to the healthy controls, including disordered (e.g., night eating) and unhealthy (e.g., high intake of sugary foods) eating habits. However, levels of nutrition knowledge, cooking and food skills, and motivation to eat healthily were not significantly lower in the psychiatric patients than in the healthy adults and were not associated with weight change. Based on our findings, nutritional support for people with SMI is urgently needed and should include not only educational but also behavioural and long-term approaches.

Policy Definitions for "Serious Mental Illness" Across 56 United States, Districts and Territories

The construct "serious/severe mental illness," or "SMI," is a priority within mental health initiatives in the United States. However, there is a lack of clarity regarding its operational definition in policy and practice settings. This study involved an evaluation of "SMI" policy definitions across the 50 United States, five territories, and Washington, D.C. via review of public legislation, department of health (DOH) websites and contacts. Policy definitions were available for 46 (82.2%) locations. Of those definitions, 32 (69.6%) were listed within legislation and 18 (39.1%) used pre-existing organizational or agency definitions. Only nine (19.6%) definitions indicated they were intended to determine eligibility for specific mental health services. Most locations (N = 38; 82.6%) mentioned functional impairment or disability as an eligibility criterion and suggested any psychiatric diagnosis could be considered SMI (N = 34; 73.9%). Results indicate substantial variability in SMI policy definitions across geographic locations with implications for service eligibility, delivery, and receipt.

(Cost)-effectiveness and implementation of integrated community-based care for patients with severe mental illness: a study protocol

BACKGROUND

As severe mental illness (SMI) is associated with a high disease burden and persistent nature, patients with SMI are often subjected to long-term mental healthcare and are in need of additional social support services. Community-based care and support services are organized via different providers and institutions, which are often lacking structural communication, resulting in a fragmented approach. To improve the efficiency of care provision and optimize patient wellbeing, an integrated multi-agency approach to community-based mental health and social services has been developed and implemented.

AIM

To present a research protocol describing the evaluation of flexible assertive community teams integrated with social services in terms of effectiveness, cost-effectiveness, and implementation.

METHODS/DESIGN

A quasi-experimental study will be conducted using prospective and retrospective observational data in patients with severe mental illness. Patients receiving care from three teams, consisting of flexible assertive community treatment and separately provided social support services (care as usual), will be compared to patients receiving care from two teams integrating these mental and social services into a single team. The study will consist of three parts: 1) an effectiveness evaluation, 2) a health-economic evaluation, and 3) a process implementation evaluation. To assess (cost-)effectiveness, both real-world aggregated and individual patient data will be collected using informed consent, and analysed using a longitudinal mixed model. The economic evaluation will consist of a cost-utility analysis and a cost-effectiveness analysis. For the process and implementation evaluation a mixed method design will be used to describe if the integrated teams have been implemented as planned, if its predefined goals are achieved, and what the experiences are of its team members.

DISCUSSION

The integration of health and social services is expected to allow for a more holistic and recovery oriented treatment approach, whilst improving the allocation of scarce resources. This study aims to identify and describe these effects using a mixed-method approach, and support decision-making in the structural implementation of integrating mental and social services.

Reliability of the Term "Serious Mental Illness": A Systematic Review

OBJECTIVE

The term "serious mental illness" (SMI) is widely used across research, practice, and policy settings. However, there is no consistent operational definition, and its reliability has not been systematically evaluated. The purpose of this review was to provide a comprehensive qualitative content analysis of "SMI" empirical research, including study and sample characteristics and SMI operational definitions. These data can provide important considerations for how stakeholders conceptualize SMI.

METHODS

Systematic review of PsycInfo, PsycArticles, and PubMed databases from January 1, 2015, to December 31, 2019, identified 788 original empirical studies that characterized the sample as having "SMI."

RESULTS

Descriptive content analysis indicated that most studies (85%) provided no operational definition for SMI. Only 15% defined the term, and an additional 26% provided examples of SMI that included only psychiatric diagnostic categories (e.g., SMI, such as schizophrenia). Of the 327 studies that provided any description of SMI, variability was noted regarding whether criteria included any mental health diagnosis (N=31) or only specified diagnoses (N=289), functional impairment (N=73), or any specified duration of symptoms (N=39). Across all studies that characterized samples as having SMI, substantial variability was noted regarding included diagnostic classifications.

CONCLUSIONS

Referencing "SMI" is second nature for many stakeholders. Findings suggest that evidence-based practice and policy efforts should weigh the level of research support indicating that the construct and the term "SMI" lacks generalizability. Researchers and stakeholders are encouraged to develop precise and agreed-upon diagnostic language in their efforts to support and advocate for people with mental illnesses.

A pilot randomized controlled trial of aquatic-based activities in a group occupational therapy program for adults living with serious mental illness in Spain

Although aquatic-based interventions are increasingly used in the psychiatric rehabilitation services, the effects of this type of community program as an adjuvant therapy for psychosocial problems of people with serious mental illness (SMI) have been under-explored. This research evaluated the feasibility and outcomes of an occupational therapy program consisting of aquatic-based activities (AA-OT program) in the community in Spain. This study is the first randomized controlled trial (RCT) on this topic. This pilot trial was conducted with a sample of 16 adults with SMI who were randomly allocated to the AA-OT program plus treatment as usual or treatment as usual alone (eight in each group). The AA-OT program included activation of daily living skills, warm-up, group activities/tasks, and relaxation. It consisted of two sessions per week over 12 weeks. Outcomes were evaluated at week 0 and 12. A total of 14 participants (87.5%) completed the trial. No adverse events or side-effects were noted. Comparisons between the two groups on change scores showed that participants in the intervention group showed significant improvements in several outcome measures: psychosocial problems (HoNOS), two health-related quality of life scales (SF-36: Physical Functioning and Mental Health), and performance of social activities (Activity and Social Relations scale). Satisfaction with the program was high. In conclusion, the results support the feasibility and potential benefits of this occupational therapy program. 12 weeks of aquatic-based activities in a group intervention may enhance the outcomes of psychiatric rehabilitation improving the severity of psychosocial problems, patient-reported health status, and social relations. This community-based program may be beneficial as a non-pharmacologic method in the illness management and recovery of people with SMI. The findings from this pilot trial need to be confirmed in a large, fully-powered RCT.

The health service contact patterns of people with psychotic and non-psychotic forms of severe mental illness in New South Wales, Australia: A record-linkage study

OBJECTIVE

To describe and compare the health profiles and health service use of people hospitalised with severe mental illness, with and without psychotic symptoms.

METHODS

We conducted a historical cohort study using linked administrative datasets, including data on public hospital admissions, emergency department presentations and ambulatory mental health service contacts in New South Wales, Australia. The study cohort comprised 169,306 individuals aged 12 years and over who were hospitalised at least once with a mental health diagnosis between 1 July 2002 and 31 December 2014. Of these, 63,110 had a recorded psychotic illness and 106,196 did not. Outcome measures were rates of hospital, emergency department and mental health ambulatory service utilisation, analysed using Poisson regression.

RESULTS

People with psychotic illnesses had higher rates of hospital admission (adjusted incidence rate ratio (IRR) 1.26; 95% confidence interval [1.23, 1.30]), emergency department presentation (adjusted IRR 1.17; 95% confidence interval [1.13, 1.20]) and ambulatory mental health treatment days (adjusted IRR 2.90; 95% confidence interval [2.82, 2.98]) than people without psychotic illnesses. The higher rate of hospitalisation among people with psychotic illnesses was driven by mental health admissions; while people with psychosis had over twice the rate of mental health admissions, people with other severe mental illnesses without psychosis (e.g. mood/affective, anxiety and personality disorders) had higher rates of physical health admissions, including for circulatory, musculoskeletal, genitourinary and respiratory disorders. Factors that predicted greater health service utilisation included psychosis, intellectual disability, greater medical comorbidity and previous hospitalisation.

CONCLUSION

Findings from this study support the need for (a) the development of processes to support the physical health of people with severe mental illness, including those without psychosis; (b) a focus in mental health policy and service provision on people with complex support needs, and (c) improved implementation and testing of integrated models of care to improve health outcomes for all people experiencing severe mental illness.

Identifying effective characteristics of behavioral weight management interventions for people with serious mental illness: A systematic review with a qualitative comparative analysis

People with serious mental illness (SMI) have identified barriers to engaging in behavioral weight management interventions (BWMIs). We assessed whether BWMIs that addressed these barriers were more effective. First, we systematically reviewed qualitative literature and used a thematic analysis to identify the characteristics of BWMIs that promote engagement for adults with SMI. Second, we systematically reviewed randomized controlled trials (RCTs) of BWMIs in adults with SMI. Data on the characteristics that promoted engagement and weight outcomes were extracted. We then used a crisp-set qualitative comparative analysis (CsQCA) to identify which characteristics were associated with weight loss. For the qualitative review, 20 studies in 515 people with SMI were analyzed and nine characteristics were reported to promote engagement in BWMIs. For the systematic review, 34 RCTs testing 36 interventions in 4305 participants were included. The active interventions resulted in more weight loss (mean = -4.37 to +1 kg at 6 weeks to 18 months follow-up) compared with controls (-1.64 to +3.08 kg). The CsQCA showed BWMIs that offered regular contact, tools to support enactment, and tailored materials were associated with effectiveness. As these are all supplementary strategies, it may be possible to augment BWMIs available for the general population to engage people with SMI.

COVID-19 and Psychosocial Support Services: Experiences of People Living with Enduring Mental Health Conditions

This paper uses secondary analysis to understand how COVID-19 shaped people's experiences with psychosocial support services in Australia. Data are drawn from questionnaires (n = 66) and semi-structured interviews (n = 62), conducted for a national service evaluation, with 121 people living with enduring mental health conditions and using psychosocial support services. Data relating to COVID-19 were inductively coded and analysed using constant comparative analysis. Most people's experiences included tele-support. While some people described minimal disruption to their support, many reported reduced engagement. People's wellbeing and engagement were influenced by: their location, living situation and pre-COVID lifestyles; physical health conditions; access to, comfort with, and support worker facilitation of technology; pre-COVID relationships with support workers; and communication from the organisation. The findings can help services prepare for future pandemics, adjust their services for a 'COVID-normal' world, and consider how learnings from COVID-19 could be incorporated into a flexible suite of service delivery options.

Correlates of Obtaining Employment among Veterans Receiving Treatment for Severe PTSD in Specialized Intensive Programs

Severe Post-Traumatic Stress Disorder (PTSD) has been identified as a significant impediment to employment. However, little is known about correlates of employment recovery after a period of not working among veterans with severe PTSD treated in specialized intensive treatment programs. This study examines rates and correlates of transitioning from not being employed at admission to working four months after discharge using national Veterans Health Administration (VHA) program evaluation data on veterans engaged in specialized intensive PTSD treatment (N = 27,339). Results suggest that only 5.68% of the sample made the transition to employment while 10.6% lost employment, 8.9% worked both at admission and following discharge, and 74.9%, did not work either at admission or following discharge. Multinomial regression analysis found that compared to other groups, veterans who became employed were younger, less likely to receive service-connected disability payments, and experienced a significantly greater reduction in PTSD symptoms. Findings from this study highlight that this distinct population has very poor employment outcomes and deserves more attention, and that reducing PTSD symptoms can lead to improved employment outcomes. Efforts to integrate evidence-based vocational rehabilitation practice into residential PTSD treatment targeting PTSD symptoms is encouraged.

Let's Talk About Mental Health and Mental Disorders in Elite Sports: A Narrative Review of Theoretical Perspectives

The objective of this article is to discuss: (a) the various theoretical perspectives on mental health and mental health disorders adopted in sport psychology, and (b) how the adoption of these various theoretical perspectives in studies might impact upon the interpretations and conclusions in research about the mental health of participants in elite sports. Well-being as a target construct, holistic models, the single continuum or stage models, and Keyes' dual-continuum model of mental health are described, together with a sports psychiatric view of mental health. The strengths and limitations of various mental health perspectives are discussed. We conclude that mental health is a complex construct and that the sport psychology literature, much like the clinical psychology literature, has struggled to reach a consensus regarding a definition or a feasible approach to investigating mental health. For the researcher, it becomes important to make explicit the underlying theoretical perspective adopted and the operationalization upon which conclusions about elite athletes' mental health are based so that an increased knowledge base with high scientific credibility can be established and consolidated over time.

A systematic review and meta-analysis of group peer support interventions for people experiencing mental health conditions

BACKGROUND

Peer support is being integrated within mental health services to further the development of a recovery approach. However, the most effective models and formats of intervention delivery are unknown. We conducted this systematic review and meta-analysis to determine the effectiveness of peer support for improving outcomes for people with lived experience of mental health conditions, when delivered as group interventions.

METHODS

Studies reporting randomised controlled trials of group peer support interventions for people experiencing mental health conditions were identified by searching MEDLINE, PsycINFO, Embase and Cochrane CENTRAL, from inception until July 12th 2019 and undertaking supplementary searches. Included studies were assessed for risk of bias and meta-analyses were conducted if three or more trials provided usable data.

RESULTS

Eight trials met eligibility criteria, providing data from 2131 participants. Six trials had either high or unclear risk of bias. Interventions were categorised as mutual support groups, or peer support groups, sub-categorised as anti-stigma or self-management interventions. Meta-analyses were only possible for peer support groups and five outcomes. We found evidence that group peer support may make small improvements to overall recovery but not hope or empowerment individually, or to clinical symptoms. Evidence for effectiveness for outcomes which could not be meta-analysed was mixed.

CONCLUSIONS

Findings from the few eligible trials suggest group peer support interventions may be specifically effective for supporting personal recovery and have a limited impact on other outcomes, though there were some risks of bias to study findings. Interventions were heterogeneous and most social outcomes were absent in the literature, highlighting further limitations to the current evidence-base. There is insufficient evidence available from trials of group peer support torecommend the routine implementation of these interventions across mainstream mental health services at present. More high-quality trials of peer-developed, group peer support interventions are needed in order tomake firm conclusions about intervention effectiveness.

The personal social network of psychiatric service users

BACKGROUND

For psychiatric service users, the personal social network offers resources such as behavioural guidance, social support, and coherence of care delivery. So far, most research on the subject has assessed the availability of these resources using size and composition measures. However, the availability of network resources also depends on the cohesion of the relationships between network members, a topic that is rarely addressed in the literature.

AIMS

In this article, we aim to describe the cohesion of psychiatric service users' networks.

METHOD

We carried out a personal network survey and collected data on the social networks of 380 service users recruited in outpatient and inpatient services in Belgium. We used an ego-network mapping technique. The data were analysed using several structural metrics describing size, composition, and cohesion. We carried out analysis of variance (ANOVA) in relation to residential status, level of education, psychiatric history, and psychosocial functioning and analysed three cohesion indicators (density, fragmentation, and centralisation) with regression analyses.

RESULTS

Personal social networks were small and not very cohesive. Most were composed of a dense subgroup as well as several isolated network members. The analyses revealed that highly educated psychiatric service users had more fragmented networks, while users living in independent accommodation had less dense networks. Density and fragmentation were not associated with the severity of psychosocial functioning, whereas centralisation was.

CONCLUSIONS

The low level of cohesion may indicate that service users aim to access multiple and diverse social resources and that better-off service users are more successful at doing so. On the whole, however, these personal social networks were fragile, because they contained a high number of isolated network members. Finally, it could be beneficial for professionals to pay special attention to the central persons within the networks of psychiatric service users.

Randomized Trial of a Mobile Personal Health Record for Behavioral Health Homes

OBJECTIVE

Behavioral health homes, which provide onsite primary medical care in mental health clinics, face challenges in integrating information across multiple health records. This study tested whether a mobile personal health record application improved quality of medical care for individuals treated in these settings.

METHODS

This randomized study enrolled 311 participants with a serious mental illness and one or more cardiometabolic risk factors across two behavioral health homes to receive a mobile personal health record application (N=156) or usual care (N=155). A secure mobile personal health record (mPHR) app provided participants in the intervention group with key information about diagnoses, medications, and laboratory test values and allowed them to track health goals. The primary study outcome was a chart-derived composite measure of quality of cardiometabolic and preventive services.

RESULTS

At 12-month follow-up, participants in the mPHR group maintained high quality of care (70% of indicated services at baseline and at 12-month follow-up), in contrast to a decline in quality for the usual-care group (71% at baseline and 67% at follow-up), resulting in a statistically significant but clinically modest differential impact between the groups. No differences between the study groups were found in secondary self-reported outcomes, including delivery of chronic illness care, patient activation, and quality of life related to mental or general medical health.

CONCLUSIONS

Use of a mPHR app was associated with a statistically significant but clinically modest differential benefit for quality of medical care among individuals with serious mental illness and comorbid cardiometabolic conditions.

Needs and care of migrants considered as severely mentally ill – cross-sectional and longitudinal studies of a Swedish sample

Purpose

Higher incidence of mental illnesses and less access to care is previously reported concerning migrants but few studies focus on the needs and care of migrant groups in psychiatry. The aim of this study was to compare differences in needs and care between migrant and nonmigrant groups of severely and persistently mentally ill (SMI) after the 1995 Swedish mental health care reform.

Methods

In a Swedish area, inventories were made in 2001 and 2006 of persons considered as SMI. These persons were interviewed and their needs were assessed. In a cross-sectional study in 2006, needs and care were compared between migrants and nonmigrants. In a longitudinal study, migrants and nonmigrants interviewed in both 2001 and 2006 were compared concerning the development of needs and care.

Results

The needs of the migrant group were less taken care of. In 2006, there were more unmet needs in this group concerning accommodation, physical health, psychological distress, basic education and economy.

Conclusion

The improvement of groups considered as SMI concerning functional disability and efforts of care found in the actual area did not seem to include the migrant group, at least not to the same degree.

Defining Severe and Persistent Mental Illness-A Pragmatic Utility Concept Analysis

The concept of severe and persistent mental illness (SPMI) lacks a consensual definition. Variations in definitions stem above all from different meanings about the constituent features of the concept and how to operationalize them. Our objective was to clarify the concept of SPMI and to explore the level of concept maturity through pragmatic utility (PU) concept analysis. Our findings suggest that SPMI is a partially mature concept that needs further clarification. We argue that the lack of a uniform definition is inherent to the problem: SPMI refers to a patient population rather than a disease entity, and the term has to be useful for different stakeholder purposes. Therefore, while an agreement on the principle three dimensions included in a definition may be possible (diagnosis, disability, and duration), their operationalization will have to be context-dependent and specific for the task at hand.

Delays to diagnosis among people with severe mental illness in rural Vietnam, a population-based cross-sectional survey

BACKGROUND

People with severe mental illness (SMI) living in low and middle-income countries can experience extended delays to diagnosis, which hinder access to medical treatment. The aims of this study were to describe the interval to diagnosis among these people in rural Vietnam and its associated factors.

METHODS

A population-based cross-sectional study was conducted among people with SMI in two provinces in Vietnam. The delay to diagnosis was defined as the time between the first abnormal behaviour being observed by family members and the formal diagnosis of psychosis. A multilevel linear regression was used to examine the factors associated with the delay to diagnosis.

RESULTS

Among 404 people with SMI from 370 households, the median delay to diagnosis was 11.5 months (IQR 0-168.0). Overall, 53.7% had a delay to diagnosis of less than one year (95% CI: 48.81-58.54). The financial burden of these people on their families was nearly USD 470/year. After adjusting for other factors at individual and household levels, living in a Northern province; older age, and having psychotic diagnosis before the implementation of the National Community Mental Health program (2003) were associated with a delay of more than twelve months to diagnosis.

CONCLUSIONS

These data indicate that the implementation of a national policy for community-based care has been effective in reducing the delay to diagnosis in rural Vietnam. Therefore, there is a need for strengthening the program and mental health policies, focusing on public communication to improve mental health literacy and reduce stigma against SMI.

Long-Term Severe Mental Disorders Preceding Behavioral Variant Frontotemporal Dementia: Frequency and Clinical Correlates in an Outpatient Sample

BACKGROUND

The behavioral variant frontotemporal dementia (bvFTD) shares some clinical features with severe mental disorders, such as bipolar affective disorder (BAD), schizophrenia (SCZ), and schizoaffective disorder (SZA), and at least for a small subgroup of patients, these conditions may share similar pathological genetic mutations.

OBJECTIVES

To investigate the frequency of a past medical history satisfying diagnostic criteria for BAD, SCZ, and SZA in a bvFTD outpatient sample, and to compare the clinical profile of patients with and without a positive history.

METHODS

Cross-sectional study in which participants were consecutively selected after receiving a diagnosis of probable bvFTD and had a caregiver interviewed with SCID-I. The sample was categorized into two groups: with (bvFTD+) or without (bvFTD-) prior medical history satisfying diagnostic criteria for BAD/SCZ/SZA. Subjects went through cognitive, functional, and neuropsychiatric evaluations.

RESULTS

Overall, 46 bvFTD patients were included; bvFTD+ patients accounted for 36.9% of the sample. The main nosology fulfilling criteria was BAD (76.5%). The groups differed in Neuropsychiatric Inventory scores (p = 0.01), use of antipsychotics (p = 0.01), family history of psychosis (p = 0.01), presence of primitive reflexes (p = 0.04), Frontal Assessment Battery performance (p = 0.01), Ekman's facial emotion recognition test (p = 0.03), frequency of apathy (p = 0.03), and stereotyped behavior (p = 0.01). All these parameters were more frequent/worse in the bvFTD+ group.

CONCLUSIONS

A prior medical history compatible with BAD/SCZ/SZA was found in more than 1/3 of this sample of bvFTD patients and was associated with subtle distinctive clinical features.

Reducing Self-Stigma in People with Severe Mental Illness Participating in a Regular Football League: An Exploratory Study

For the past 15 years, a regular indoor football competition has been taking place in Madrid (Spain) with 15 teams from different mental health services in the city, in which teams face off weekly as part of a competition lasting nine months of the year. We are not aware of whether a similar competition experience is offered in other cities. The purpose of the present study was to evaluate whether participating in this league, called Ligasame, has an influence on participants’ self-stigma. To do so, the Internalized Stigma of Mental Illness scale (ISMI) was adapted into Spanish and applied to 108 mental health patients, 40% of which participated in Ligasame, and the remainder of which did not. The results obtained reflect significant differences between those participating in Ligasame and those that did not in terms of two specific dimensions related to self-stigma (stereotype endorsement and stigma resistance) and total score. On the other hand, no significant differences were found in terms of other variables, such as patients’ prior diagnosis, age or belonging to different resources/associations. In this article, we discuss the importance of these results in relation to reducing self-stigma through participation in a regular yearly mental health football league.

Behavioral variant frontotemporal dementia in patients with previous severe mental illness: a systematic and critical review

ABSTRACT Objectives: To explore the relationship between severe/serious mental illness (SMI) and the behavioral variant of frontotemporal dementia (bvFTD), as the patterns of symptoms and cognitive performance that characterize both disorders share similarities. Methods: We performed a systematic review investigating what has already been published regarding the relationship between bvFTD and SMI. Studies were selected from PubMed and LILACS databases, including those published up to February 12, 2018. The search strategy included the following terms: “frontotemporal dementia” plus “bipolar”, OR “frontotemporal dementia” plus “schizophrenia”, OR “frontotemporal dementia” plus “schizoaffective”. Publications without abstracts, case reports with absent genetic or histopathological confirmation, reviews and non-English language papers were excluded across the search process. Results: The search on PubMed retrieved 186 articles, of which 42 met eligibility criteria. On the LILACS database, none met the requirements. Generally, three major research aims were identified: 1) to look for frontotemporal lobar degeneration-associated genetic abnormalities in patients with prior SMI; 2) to compare the cognitive profile between patients affected by neurodegenerative disorders and schizophrenic patients; 3) to highlight the association between bvFTD and preceding psychiatric conditions and/or distinguish them both. The investigated mutations were found infrequently in the studied SMI samples. Cross-sectional studies comparing cognitive performance between bvFTD and psychiatric disorders mostly found no remarkable differences. There were only a few case reports identifying definite frontotemporal lobar degeneration in patients with previous psychiatric diagnoses. Conclusions: The available evidence demonstrates how fragile the current understanding is regarding the association between bvFTD and prior SMI.

Social exclusion of people with severe mental illness in Switzerland: results from the Swiss Health Survey

AIMS

People with severe mental illness (SMI) have a high risk of living socially excluded from the mainstream society. Policy initiatives and health systems aim to improve the social situation of people who suffer from mental health disabilities. The aim of this study was to explore the extent of social exclusion (employment and income, social network and social activities, health problems) of people with SMI in Switzerland.

METHODS

Data from the Swiss Health Survey 2012 were used to compare the social exclusion magnitude of people with SMI with those suffering from severe physical illness, common mental illness and the general population.

RESULTS

With the exception of Instrumental Activities of Daily Living, we found a gradient of social exclusion that showed people with SMI to be more excluded than the comparison groups. Loneliness and poverty were widespread among people with SMI. Logistic regression analyses on each individual exclusion indicator revealed that people with SMI and people with severe physical illness were similarly excluded on many indicators, whereas people with common mental illness and the general population were much more socially included.

CONCLUSIONS

In contrast to political and health system goals, many people with SMI suffer from social exclusion. Social policy and clinical support should increase the efforts to counter exclusionary trends, especially in terms of loneliness and poverty.

Expanding Individual Placement and Support to Populations With Conditions and Disorders Other Than Serious Mental Illness

OBJECTIVE

A systematic review of studies of individual placement and support (IPS) for populations other than those with serious mental illness was conducted.

METHODS

The authors searched three electronic databases (PubMed, Web of Science, and Scopus) for studies of IPS and modified IPS. Eligibility criteria for the systematic review included randomized controlled trials with prospective data collection on competitive employment rate and at least 10 study participants from a well-defined population other than people with serious mental illness. Results were compiled for competitive employment rates, IPS fidelity, and other outcomes.

RESULTS

Three clinical groups other than people with serious mental illness have been studied: people with psychiatric disorders other than serious mental illness, people with substance use disorders, and people with musculoskeletal or neurological disorders. Nine controlled trials with a total of 2,902 participants included six trials with people who had psychiatric disorders other than serious mental illness, two with people who had substance use disorders, and one with people who had spinal cord injuries. In eight studies, results for competitive employment rates significantly favored IPS. Meta-analysis yielded an overall weighted odds ratio of 2.23 (95% confidence interval=1.53-3.24, p<.001). Findings for other employment outcomes also favored IPS, but findings on symptom reduction and quality of life were inconsistent. The strongest (and only replicated) findings were for veterans with posttraumatic stress disorder (PTSD). Methodological limitations included small samples, major modifications to IPS fidelity, and short follow-up periods.

CONCLUSIONS

IPS, often with modifications, is a promising employment intervention for several populations in addition to people with serious mental illnesses. The strongest evidence pertains to veterans with PTSD. IPS should be offered to these veterans. Research on other populations, including people with anxiety, depression, substance use disorder, musculoskeletal or neurological conditions, or pain syndromes, needs development, amplification, and replication.

Social support network and continuity of care: an ego-network study of psychiatric service users

PURPOSE

For severely mentally ill (SMI) users, continuity of care requires consistency between the supports provided by the members of their social support network. However, we know little about their network cohesion and its association with continuity of care. We set out to investigate this association and hypothesised that it would depend on the severity of the user's situation and on his/her living arrangements.

METHODS

We conducted face-to-face interviews with 380 SMI users recruited in outpatient and inpatient mental health services in three areas in Belgium. Data regarding users' social networks were collected using an ego-network mapping technique and analysed with social network analysis. The cohesion indicators were density (frequency of connections between network members), centralisation (having a small number of central people), and egobetweenness (the user's centrality in his/her own network). Participants' perception of continuity of care was measured by the Alberta Continuity of Services Scale.

RESULTS

Results show that cohesion indicators were associated with continuity of care only for users with high-severity problems, regardless of their living arrangements. The numbers of network members, professionals, and services in the network were all negatively associated with continuity of care for all the users.

CONCLUSIONS

Satisfactory continuity of care requires fewer professionals or services in a user's network and a dense network for users with the most severe problems. This implies that those providing care must not only be able to increase cohesion within a network, but also to adapt their interventions to support the transition to a different, individualised network structure when severity decreases.

Peer support for people with schizophrenia or other serious mental illness

BACKGROUND

Peer support provides the opportunity for peers with experiential knowledge of a mental illness to give emotional, appraisal and informational assistance to current service users, and is becoming an important recovery-oriented approach in healthcare for people with mental illness.

OBJECTIVES

To assess the effects of peer-support interventions for people with schizophrenia or other serious mental disorders, compared to standard care or other supportive or psychosocial interventions not from peers.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials on 27 July 2016 and 4 July 2017. There were no limitations regarding language, date, document type or publication status.

SELECTION CRITERIA

We selected all randomised controlled clinical studies involving people diagnosed with schizophrenia or other related serious mental illness that compared peer support to standard care or other psychosocial interventions and that did not involve 'peer' individual/group(s). We included studies that met our inclusion criteria and reported useable data. Our primary outcomes were service use and global state (relapse).

DATA COLLECTION AND ANALYSIS

The authors of this review complied with the Cochrane recommended standard of conduct for data screening and collection. Two review authors independently screened the studies, extracted data and assessed the risk of bias of the included studies. Any disagreement was resolved by discussion until the authors reached a consensus. We calculated the risk ratio (RR) and 95% confidence interval (CI) for binary data, and the mean difference and its 95% CI for continuous data. We used a random-effects model for analyses. We assessed the quality of evidence and created a 'Summary of findings' table using the GRADE approach.

MAIN RESULTS

This review included 13 studies with 2479 participants. All included studies compared peer support in addition to standard care with standard care alone. We had significant concern regarding risk of bias of included studies as over half had an unclear risk of bias for the majority of the risk domains (i.e. random sequence generation, allocation concealment, blinding, attrition and selective reporting). Additional concerns regarding blinding of participants and outcome assessment, attrition and selective reporting were especially serious, as about a quarter of the included studies were at high risk of bias for these domains.All included studies provided useable data for analyses but only two trials provided useable data for two of our main outcomes of interest, and there were no data for one of our primary outcomes, relapse. Peer support appeared to have little or no effect on hospital admission at medium term (RR 0.44, 95% CI 0.11 to 1.75; participants = 19; studies = 1, very low-quality evidence) or all-cause death in the long term (RR 1.52, 95% CI 0.43 to 5.31; participants = 555; studies = 1, very low-quality evidence). There were no useable data for our other prespecified important outcomes: days in hospital, clinically important change in global state (improvement), clinically important change in quality of life for peer supporter and service user, or increased cost to society.One trial compared peer support with clinician-led support but did not report any useable data for the above main outcomes.

AUTHORS' CONCLUSIONS

Currently, very limited data are available for the effects of peer support for people with schizophrenia. The risk of bias within trials is of concern and we were unable to use the majority of data reported in the included trials. In addition, the few that were available, were of very low quality. The current body of evidence is insufficient to either refute or support the use of peer-support interventions for people with schizophrenia and other mental illness.

Use of information and communication technologies among individuals with and without serious mental illness

Growing interest surrounds the use ofinformation and communication technologies (ICTs) for mental-health-related purposes, yet little is known about rates of ICT use among the psychiatric population and those with severe mental illness. This study examines ICT accessibility among the psychiatric population, focusing on serious and non-serious mental illness (SMI and non-SMI). Patients (N = 427) from all service branches of the Psychiatry Department at Emek Medical Centerwere recruited orally or through advertisement. Responders completed a self-report survey regarding accessibility and use of ICTs (i.e., computer, internet, Facebook, mobile phone, smartphone). Results revealed that 59.3% of respondents used computers, 77.3% used the internet, 92.7% owned a mobile phone, 67.9% owned a smartphone, and 63% used Facebook. Over half of participants who used ICTs reported doing so at least once per day. SMI and non-SMI respondents differed significantly in their use and access to a computer, the internet, Facebook, and smartphones. Results suggest that mental illness is not a barrier to using and accessing technology; however, when differentiating between SMI and non-SMI, illness severity is a barrier to potential ICT utilization. These results may encourage policy makers to design ICTs that suit the needs of individuals with SMI.

Longitudinal analysis of statistical and clinically significant psychosocial change following mental health rehabilitation

Purpose: With appropriate mental health rehabilitation, schizophrenia is increasingly associated with reports of recovery and stability. However, there is little empirical evidence evaluating the efficacy of services delivering this care. This study evaluated the effectiveness of rehabilitation for improving psychosocial function in consumers with schizophrenia.Methods: An electronic database of standardized assessment instruments mandated and maintained by the health service was retrospectively reviewed to extract ratings of psychosocial function, daily living skills, and mood state from consecutive admissions to an inpatient rehabilitation service. Outcomes were compared at admission, discharge, and one-year follow-up to identify statistically significant change. Individual reliable and clinically significant change was also assessed by comparison with a normative group of clients functioning independently in the community.Results: From admission to discharge the rehabilitation group made statistically significant gains in psychosocial function and daily living skills. Improvements were reliable and clinically significant in one-quarter to one-third of individual consumers. Approximately half sustained their improvements at follow-up, although this represented only a small fraction of the overall cohort. Consumers not demonstrating gains exhibited psychometric floor effects at admission.Conclusions: Rehabilitation can produce statistically and clinically significant immediate improvement in psychosocial function for a sub-set of consumers with elevated scores at admission. The durability of any gains is less clear, and strategies promoting longer-term maintenance are encouraged. Furthermore, currently mandated outcome measures are confounded by issues of sensitivity and reporting compliance, and exploration of alternative instruments for assessing recovery is recommended.Implications for RehabilitationRoutinely collected standardized outcome measures can be used to investigate the effectiveness of mental health rehabilitationIn addition to statistical significance, the clinical significance of outcomes should be evaluated to identify change that is individually meaningfulCurrently mandated outcomes instruments do not adequately evaluate many individuals' recovery journeyMental health service evaluation and quality improvement processes would likely benefit from adoption of recovery-oriented measures.

Optimal Network for Patients with Severe Mental Illness: A Social Network Analysis

It is still unclear what the optimal structure of mental health care networks should be. We examine whether certain types of network structure have been associated with improved continuity of care and greater social integration. A social network survey was carried out, covering 954 patients across 19 mental health networks in Belgium in 2014. We found continuity of care to be associated with large, centralized, and homophilous networks, whereas social integration was associated with smaller, centralized, and heterophilous networks. Two important goals of mental health service provision, continuity of care and social integration, are associated with different types of network. Further research is needed to ascertain the direction of this association.

Peer-Led Self-Management of General Medical Conditions for Patients With Serious Mental Illnesses: A Randomized Trial

OBJECTIVE

Individuals with serious mental illnesses have high rates of general medical comorbidity and challenges in managing these conditions. A growing workforce of certified peer specialists is available to help these individuals more effectively manage their health and health care. However, few studies have examined the effectiveness of peer-led programs for self-management of general medical conditions for this population.

METHODS

This randomized study enrolled 400 participants with a serious mental illness and one or more chronic general medical conditions across three community mental health clinics. Participants were randomly assigned to the Health and Recovery Peer (HARP) program, a self-management program for general medical conditions led by certified peer specialists (N=198), or to usual care (N=202). Assessments were conducted at baseline and three and six months.

RESULTS

At six months, participants in the intervention group demonstrated a significant differential improvement in the primary study outcome, health-related quality of life. Specifically, compared with the usual care group, intervention participants had greater improvement in the Short-Form Health Survey physical component summary (an increase of 2.7 versus 1.4 points, p=.046) and mental component summary (4.6 versus 2.5 points, p=.039). Significantly greater six-month improvements in mental health recovery were seen for the intervention group (p=.02), but no other between-group differences in secondary outcome measures were significant.

CONCLUSIONS

The HARP program was associated with improved physical health- and mental health-related quality of life among individuals with serious mental illness and comorbid general medical conditions, suggesting the potential benefits of more widespread dissemination of peer-led disease self-management in this population.

Pre-post, mixed-methods feasibility study of the WorkingWell mobile support tool for individuals with serious mental illness in the USA: a pilot study protocol

INTRODUCTION

Successful competitive employment has been found to be related to enhanced self-esteem, higher quality of life and reduced mental health service use for individuals living with serious mental illnesses (SMIs) including schizophrenia, bipolar disorder and major depression. The effectiveness of the individual placement and support model has been demonstrated in multiple randomised controlled trials in many countries. The management of stress, depression and anxiety in the workplace may be effectively enhanced through digital mental health interventions. The WorkingWell mobile support tool ('app') is specifically designed to meet the need for illness management support for individuals with SMI in the workplace, as an adjunct to professional treatment.

METHODS AND ANALYSIS

The WorkingWell app, grounded in evidence-based supported employment, is informed by user experience design. It will be tested in a pre-post design, mixed-methods pilot study to explore issues of feasibility, acceptability and usefulness, and to provide preliminary data on the impact of use. Putative mediators of improved job tenure and psychological well-being, including postintervention changes in social support, self-efficacy and work-related motivation, will be investigated. Forty individuals at least 18 years of age, meeting the eligibility requirements for supported employment services (ie, diagnosed with a mental illness meeting the criteria for severity, duration and treatment), working a minimum of 10 hours per week at study enrolment, and speaking, reading and writing in English will be recruited for the pilot study. Research staff will recruit individuals at community-based mental health agencies; provide orientation to the study, the study smartphones and the WorkingWell app; conduct research interviews including standardised measures as well as semistructured items; and provide technical assistance in telephone calls and inperson meetings. A sample of 10 agency staff will be recruited to obtain further information on the feasibility, acceptability and usefulness of WorkingWell.

ETHICS AND DISSEMINATION

The study design and procedures are approved by the Dartmouth-Hitchcock Medical Center Committee for the Protection of Human Subjects, the Massachusetts Department of Mental Health Central Office Research Review Committee and the Vermont Agency of Human Services Institutional Review Board. Study findings will be disseminated to agency partners, state agencies and funders, and to the research and technology development communities. Findings from the study will inform the design, data collection procedures and protocol for future full-scale randomised controlled trial testing of the effectiveness of the WorkingWell app, as well as investigations of work-related variables as mediators of psychological well-being and quality of life for individuals with SMI.

Novel technology as platform for interventions for caregivers and individuals with severe mental health illnesses: A systematic review

BACKGROUND

Severe mental illnesses (SMIs) have been found to be associated with both increases in morbidity-mortality, need for treatment care in patients themselves, and burden for relatives as caregivers. A growing number of web-based and mobile software applications have appeared that aim to address various barriers with respect to access to care. Our objective was to review and summarize recent advancements in such interventions for caregivers of individuals with a SMI.

METHODS

We conducted a systematic search for papers evaluating interactive mobile or web-based software (using no or only minimal support from a professional) specifically aimed at supporting informal caregivers. We also searched for those supporting patients with SMI so as to not to miss any which might include relatives.

RESULTS

Out of a total of 1673 initial hits, we identified 11 articles reporting on 9 different mobile or web-based software programs. The main result is that none of those studies focused on caregivers, and the ones we identified using mobile or web-based applications were just for patients and not their relatives.

LIMITATIONS

Differentiating between online and offline available software might not always have been totally reliable, and we might have therefore missed some studies.

CONCLUSIONS

In summary, the studies provided evidence that remotely accessible interventions for patients with SMI are feasible and acceptable to patients. No such empirically evaluated program was available for informal caregivers such as relatives. Keeping in mind the influential role of those informal caregivers in the process of treatment and self-management, this is highly relevant for public health. Supporting informal caregivers can improve well-being of both caregivers and patients.

Distribution of case-load in community mental health teams

Aims and Method

An audit project was carried out in a mental health trust in North-West London on two successive years to determine the average case-load size of defined severe mental illness for each professional discipline.

Results

The average case-load for non-consultants varied from 16 (for occupational therapists) through to 98 patients (for senior house officers). Community psychiatric nurses had an average case-load of 21 and consultants had an estimated average case-load of between 185 and 317 patients. The proportion of patients with severe mental illness ranged from 49% to 67%.

Clinical Implications

The case-loads of consultants in community health teams are too large to exercise the statutory duties of a responsible medical officer and, therefore, need revision.

Morbidity persistence and comorbidity of mood, anxiety, and eating disorders among preoperative bariatric patients

The current study investigates the patterns of disease persistence and comorbidity of psychiatric disorders among patients with class III obesity in pre-operative period. For 393 treatment-seeking patients with severe obesity recruited from a bariatric center, we ascertained their psychiatric diagnosis through Structured Clinical Interview for DSM-IV (SCID-I). Following, the frequency, persistence and comorbidity pattern of psychiatric disorders in this sample were determined. Current psychiatric disorders were observed in over half of patients during preoperative period, being anxiety disorders the most frequent diagnosis. For lifetime disorders, mood disorders were the most frequent diagnosis. Most of the sample presented 2 or more concurrent lifetime psychiatric disorders. While mood and eating disorders were frequent conditions, anxiety disorders were the most persistent conditions (the highest one month-to-lifetime prevalence ratio) and were significantly correlated with bipolar, depressive and eating disorders. Psychiatric disorders are frequent and enduring conditions among patients looking for bariatric surgery. Comorbid anxiety, mood, and eating disorders are remarkable features in treatment-seeking patients with obesity. Prognostic implications of preoperative psychiatric disorders on surgery outcome should be demonstrated prospectively in intervention studies.

Independent housing and support for people with severe mental illness: systematic review

OBJECTIVE

To systematically explore the outcomes of Independent Housing and Support (IHS) for people with severe mental disorders when compared to other residential settings.

METHOD

Systematic review of Randomised and Non-Randomised Controlled Trials of publications that analyse the outcomes of living in independent settings versus institutionalised accommodation. Risk of bias assessment was adapted from the Cochrane Collaboration's ACROBAT-Tool. The analysis was conducted separately for publications with homeless and non-homeless people.

RESULTS

Twenty-four publications from studies with homeless people and eight publications from studies with non-homeless people were included. Risk of bias was much lower in studies with the homeless. No RCT was found in the sample of publications with the non-homeless. Overall, results from Independent Housing and Support-settings are not inferior to results from institutionalised settings.

CONCLUSION

The results indicate that Independent Housing and Support-settings provide at least similar outcomes than residential care. We propose that clients' preferences should determine the choice of housing setting.

Prevalence and risk factors for HIV, hepatitis B, and hepatitis C in people with severe mental illness: a total population study of Sweden

BACKGROUND

Severe mental illness is associated with increased morbidity and mortality. The elevated risk of blood-borne viruses (BBVs) in people with severe mental illness is of concern, but the full extent of this problem is unclear. We aimed to determine the prevalence of and risk factors for BBVs in people with severe mental illness.

METHODS

In this nationwide, population-based, cross-sectional study, we estimated the point prevalence of HIV, hepatitis B (HBV), and hepatitis C (HCV) in people with severe mental illness, including the total adult (≥18 years) Swedish population. We defined severe mental illness as a clinical diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, or other psychotic illness according to the Swedish version of the International Statistical Classification of Diseases version 8, 9, or 10. We used multivariable logistic regression to determine the odds of BBVs in individuals with severe mental illness, relative to the general population, and to identify independent risk factors (age, sex, immigration status, socioeconomic status, education, and substance misuse) for BBV infection. We also did a sensitivity analysis excluding BBV diagnoses made before the introduction of the Register for Infection Disease Control (1997).

FINDINGS

Of 6 815 931 adults in Sweden, 97 797 (1·43%) individuals had a diagnosis of severe mental illness. Prevalence of BBVs was elevated in people with severe mental illness, of which 230 (0·24%) had HIV, 518 (0·53%) had HBV, and 4476 (4·58%) had HCV. After accounting for sociodemographic characteristics, the odds of HIV were 2·57 (95% CI 2·25-2·94, p<0·0001) times higher in people with severe mental illness than in the general population, whereas the odds of HBV were 2·29 (2·09-2·51, p<0·0001) times higher and the odds of HCV were 6·18 (5·98-6·39, p<0·0001) times higher. Substance misuse contributed most to the increased risk of BBV: after adjustment, odds ratios were 1·61 (1·40-1·85, p<0·0001) for HIV, 1·28 (1·16-1·41, p<0·0001) for HBV, and 1·72 (1·67-1·78, p<0·0001) for HCV.

INTERPRETATION

Our results highlight the need to address the issue of higher prevalence of BBVs in people with severe mental illness and identify interventions preventing infection. Targeting of comorbid substance misuse would have particular effect on reduction of BBV prevalence in this population.

FUNDING

Medical Research Council and Swedish Research Council.

Recent illicit drug use among psychiatric patients in Brazil: a national representative study

OBJECTIVE

To estimate factors associated to illicit drug use among patients with mental illness in Brazil according to gender.

METHODS

A cross-sectional representative sample of psychiatric patients (2,475 individuals) was randomly selected from 11 hospitals and 15 public mental health outpatient clinics. Data on self-reported illicit drug use and sociodemographic, clinical and behavioral characteristics were obtained from face-to-face interviews. Logistic regression was used to estimate associations with recent illicit drug use.

RESULTS

The prevalence of any recent illicit drug use was 11.4%. Men had higher prevalence than women for all substances (17.5% and 5.6%, respectively). Lower education, history of physical violence, and history of homelessness were associated with drug use among men only; not professing a religion was associated with drug use in women only. For both men and women, younger age, current hospitalization, alcohol and tobacco use, history of incarceration, younger age at sexual debut, and more than one sexual partner were statistically associated with illicit drug use.

CONCLUSIONS

Recent illicit drug use among psychiatric patients is higher than among the general Brazilian population and it is associated with multiple factors including markers of psychiatric severity. Our data indicate the need for the development of gender-based drug-use interventions among psychiatric patients in Brazil. Integration of substance use treatment strategies with mental health treatment should be a priority.

Gender differences and psychotropic polypharmacy in psychiatric patients in Brazil: a cross-sectional analysis of the PESSOAS Project

We aimed to estimate the prevalence and correlates of psychotropic polypharmacy in Brazilian psychiatric patients by gender. Sociodemographic, behavioral and clinical data were obtained through face-to-face interviews and medical charts of 2,475 patients. Psychotropic polypharmacy was defined as the use of two or more psychotropic drugs and occurred in 85.7% of men (95%CI: 83.6%-87.6%) and 84.9% of women (95%CI: 82.8%-86.8%; p > 0.05). The mean number of psychotropic drugs/patient was 2.98 ± 1.23 and most common combinations included antipsychotics. Multivariate analysis showed that for both genders, previous hospitalization, severe mental illness, multiple psychiatric diagnoses and an insufficient number of professionals in the health care unit was associated with psychotropic polypharmacy. However, other correlates such as inpatient care, use of non-psychotropic drugs, living in unstable conditions and current smoking vary among them. Psychotropic polypharmacy was a common practice in this national sample. The results highlighted the need for national guidelines to manage patients with mental illness, considering the difference among genders and disease severity, to reduce the burden of polyphamacy in this population.

Intensive case management for severe mental illness

BACKGROUND

Intensive Case Management (ICM) is a community-based package of care aiming to provide long-term care for severely mentally ill people who do not require immediate admission. Intensive Case Management evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (fewer than 20) and high-intensity input.

OBJECTIVES

To assess the effects of ICM as a means of caring for severely mentally ill people in the community in comparison with non-ICM (caseload greater than 20) and with standard community care. We did not distinguish between models of ICM. In addition, to assess whether the effect of ICM on hospitalisation (mean number of days per month in hospital) is influenced by the intervention's fidelity to the ACT model and by the rate of hospital use in the setting where the trial was conducted (baseline level of hospital use).

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (last update search 10 April 2015).

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community care setting, where ICM is compared to non-ICM or standard care.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, assessed quality, and extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect. We assessed overall quality for clinically important outcomes using the GRADE approach and investigated possible risk of bias within included trials.

MAIN RESULTS

The 2016 update included two more studies (n = 196) and more publications with additional data for four already included studies. The updated review therefore includes 7524 participants from 40 randomised controlled trials (RCTs). We found data relevant to two comparisons: ICM versus standard care, and ICM versus non-ICM. The majority of studies had a high risk of selective reporting. No studies provided data for relapse or important improvement in mental state.1. ICM versus standard careWhen ICM was compared with standard care for the outcome service use, ICM slightly reduced the number of days in hospital per month (n = 3595, 24 RCTs, MD -0.86, 95% CI -1.37 to -0.34,low-quality evidence). Similarly, for the outcome global state, ICM reduced the number of people leaving the trial early (n = 1798, 13 RCTs, RR 0.68, 95% CI 0.58 to 0.79, low-quality evidence). For the outcome adverse events, the evidence showed that ICM may make little or no difference in reducing death by suicide (n = 1456, 9 RCTs, RR 0.68, 95% CI 0.31 to 1.51, low-quality evidence). In addition, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment due to very low-quality evidence (n = 1129, 4 RCTs, RR 0.70, 95% CI 0.49 to 1.0, very low-quality evidence).2. ICM versus non-ICMWhen ICM was compared with non-ICM for the outcome service use, there was moderate-quality evidence that ICM probably makes little or no difference in the average number of days in hospital per month (n = 2220, 21 RCTs, MD -0.08, 95% CI -0.37 to 0.21, moderate-quality evidence) or in the average number of admissions (n = 678, 1 RCT, MD -0.18, 95% CI -0.41 to 0.05, moderate-quality evidence) compared to non-ICM. Similarly, the results showed that ICM may reduce the number of participants leaving the intervention early (n = 1970, 7 RCTs, RR 0.70, 95% CI 0.52 to 0.95,low-quality evidence) and that ICM may make little or no difference in reducing death by suicide (n = 1152, 3 RCTs, RR 0.88, 95% CI 0.27 to 2.84, low-quality evidence). Finally, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment as compared to non-ICM (n = 73, 1 RCT, RR 1.46, 95% CI 0.45 to 4.74, very low-quality evidence).3. Fidelity to ACTWithin the meta-regression we found that i.) the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36, 95% CI -0.66 to -0.07); and ii.) the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20, 95% CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but the 'baseline hospital use' result still significantly influences time in hospital (regression coefficient -0.18, 95% CI -0.29 to -0.07, P = 0.0027).

AUTHORS' CONCLUSIONS

Based on very low- to moderate-quality evidence, ICM is effective in ameliorating many outcomes relevant to people with severe mental illness. Compared to standard care, ICM may reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. Intensive Case Management is at least valuable to people with severe mental illnesses in the subgroup of those with a high level of hospitalisation (about four days per month in past two years). Intensive Case Management models with high fidelity to the original team organisation of ACT model were more effective at reducing time in hospital.However, it is unclear what overall gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, however we currently know of no review comparing non-ICM with standard care, and this should be undertaken.

Improving Physical Health in Patients With Chronic Mental Disorders: Twelve-Month Results From a Randomized Controlled Collaborative Care Trial

OBJECTIVE

Persons with chronic mental disorders are disproportionately burdened with physical health conditions. We determined whether Life Goals Collaborative Care compared to usual care improves physical health in patients with mental disorders within 12 months.

METHODS

This single-blind randomized controlled effectiveness study of a collaborative care model was conducted at a midwestern Veterans Affairs urban outpatient mental health clinic. Patients (N = 293 out of 474 eligible approached) with an ICD-9-CM diagnosis of schizophrenia, bipolar disorder, or major depressive disorder and at least 1 cardiovascular disease risk factor provided informed consent and were randomized (February 24, 2010, to April 29, 2015) to Life Goals (n = 146) or usual care (n = 147). A total of 287 completed baseline assessments, and 245 completed 12-month follow-up assessments. Life Goals included 5 weekly sessions that provided semistructured guidance on managing physical and mental health symptoms through healthy behavior changes, augmented by ongoing care coordination. The primary outcome was change in physical health-related quality of life score (Veterans RAND 12-item Short Form Health Survey [VR-12] physical health component score). Secondary outcomes included control of cardiovascular risk factors from baseline to 12 months (blood pressure, lipids, weight), mental health-related quality of life, and mental health symptoms.

RESULTS

Among patients completing baseline and 12-month outcomes assessments (N = 245), the mean age was 55.3 years (SD = 10.8; range, 25-78 years), and 15.4% were female. Intent-to-treat analysis revealed that compared to those in usual care, patients randomized to Life Goals had slightly increased VR-12 physical health scores (coefficient = 3.21; P = .01).

CONCLUSIONS

Patients with chronic mental disorders and cardiovascular disease risk who received Life Goals had improved physical health-related quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers: NCT01487668 and NCT01244854.

Medical comorbidities in patients with serious mental illness: a retrospective study of mental health patients attending an outpatient clinic in Qatar

BACKGROUND

The life span of individuals with serious mental illness (SMI) is shorter compared to the general population. This excess mortality is mainly due to physical illness. The aim of the study was to investigate the prevalence rates of different physical illnesses in individuals with SMI and to examine how these are being managed.

METHODS

The study was a cross-sectional retrospective chart review of a cohort of patients with SMI. A comprehensive electronic data extraction tool using SurveyMonkey^® was used to collect patient demographics, psychiatric and medical comorbidities, medications and all relevant physical assessments. Data were then first extrapolated into an Excel^® spreadsheet and later to SPSS^® for data analysis. A descriptive statistical approach was used to analyze the demographic and clinical data. Chi-square test for categorical variables and t-test for continuous variables were used to compare the demographic and clinical characteristics of the cohort.

RESULTS

A total of 336 patients with SMI were included for the retrospective chart review. The majority of these patients had a diagnosis of depression (50.3%), followed by schizophrenia (33.0%) and bipolar disorder (19.6%). Diabetes was the most frequent medical comorbidity, diagnosed in 16.1% of SMI patients, followed by hypertension (9.2%) and dyslipidemia (9.8%). Monitoring of comorbidity-associated risk factors and other relevant physical assessment parameters (such as blood pressure, weight, hemoglobin A1c [HbA1c], blood glucose and lipids) were documented in less than 50% of patients, and some parameters, such as smoking status, were not documented at all.

CONCLUSION

Both, the literature and our cohort provide evidence that individuals with SMI are less likely to receive standard levels of care for their medical comorbidities.

HIV prevention advice for people with serious mental illness

BACKGROUND

People with serious mental illness have rates of Human Immuno-deficiency Virus (HIV) infection higher than expected in the general population for the same demographic area. Despite this elevated prevalence, UK national strategies around sexual health and HIV prevention do not state that people with serious mental illness are a high risk group. However, a significant proportion in this group are sexually active and engage in HIV-risk behaviours including having multiple sexual partners, infrequent use of condoms and trading sex for money or drugs. Therefore we propose the provision of HIV prevention advice could enhance the physical and social well being of this population.

OBJECTIVES

To assess the effects of HIV prevention advice in reducing morbidity, mortality and preserving the quality of life in people with serious mental illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (24 January 2012; 4 July 2016).

SELECTION CRITERIA

We planned to include all randomised controlled trials focusing on HIV prevention advice versus standard care or comparing HIV prevention advice with other more focused methods of delivering care or information for people with serious mental illness.

DATA COLLECTION AND ANALYSIS

Review authors (NW, AC, AA, GT) independently screened search results and did not identify any studies that fulfilled the review's criteria.

MAIN RESULTS

We did not identify any randomised studies that evaluated advice regarding HIV for people with serious mental illness. The excluded studies illustrate that randomisation of packages of care relevant to both people with serious mental illness and HIV risk are possible.

AUTHORS' CONCLUSIONS

Policy makers, clinicians, researchers and service users need to collaborate to produce guidance on how best to provide advice for people with serious mental illness in preventing the spread of HIV infection. It is entirely feasible that this could be within the context of a well-designed simple large randomised study.

Oral health education (advice and training) for people with serious mental illness

BACKGROUND

People with serious mental illness not only experience an erosion of functioning in day-to-day life over a protracted period of time, but evidence also suggests that they have a greater risk of experiencing oral disease and greater oral treatment needs than the general population. Poor oral hygiene has been linked to coronary heart disease, diabetes, and respiratory disease and impacts on quality of life, affecting everyday functioning such as eating, comfort, appearance, social acceptance, and self esteem. Oral health, however, is often not seen as a priority in people suffering with serious mental illness.

OBJECTIVES

To review the effects of oral health education (advice and training) with or without monitoring for people with serious mental illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (5 November 2015), which is based on regular searches of MEDLINE, EMBASE, CINAHL, BIOSIS, AMED, PubMed, PsycINFO, and clinical trials registries. There are no language, date, document type, or publication status limitations for inclusion of records in the register.

SELECTION CRITERIA

All randomised clinical trials focusing on oral health education (advice and training) with or without monitoring for people with serious mental illness.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We employed a fixed-effect model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE.

MAIN RESULTS

We included three randomised controlled trials (RCTs) involving 1358 participants. None of the studies provided useable data for the key outcomes of not having seen a dentist in the past year, not brushing teeth twice a day, chronic pain, clinically important adverse events, and service use. Data for leaving the study early and change in plaque index scores were provided. Oral health education compared with standard careWhen 'oral health education' was compared with 'standard care', there was no clear difference between the groups for numbers leaving the study early (1 RCT, n = 50, RR 1.67, 95% CI 0.45 to 6.24, moderate-quality evidence), while for dental state: no clinically important change in plaque index, an effect was found. Although this was statistically significant and favoured the intervention group, it is unclear if it was clinically important (1 RCT, n = 40, MD - 0.50 95% CI - 0.62 to - 0.38, very low quality evidence).These limited data may have implications regarding improvement in oral hygiene. Motivational interview + oral health education compared with oral health educationSimilarly, when 'motivational interview + oral health education' was compared with 'oral health education', there was no clear difference for the outcome of leaving the study early (1 RCT, n = 60 RR 3.00, 95% CI 0.33 to 27.23, moderate-quality evidence), while for dental state: no clinically important change in plaque index, an effect favouring the intervention group was found (1 RCT, n = 56, MD - 0.60 95% CI - 1.02 to - 0.18 very low-quality evidence). These limited, clinically opaque data may or may not have implications regarding improvement in oral hygiene. Monitoring compared with no monitoringFor this comparison, only data for leaving the study early were available. We found a difference in numbers leaving early, favouring the 'no monitoring' group (1 RCT, n = 1682, RR 1.07, 95% CI 1.00 to 1.14, moderate-quality evidence). However, these data are problematic. The control denominator is implied and not clear, and follow-up did not depend only on individual participants, but also on professional caregivers and organisations - the latter changing frequently resulting in poor follow-up, but not a good reflection of the acceptability of the monitoring to patients. For this comparison, no data were available for 'no clinically important change in plaque index'.

AUTHORS' CONCLUSIONS

We found no evidence from trials that oral health advice helps people with serious mental illness in terms of clinically meaningful outcomes. It makes sense to follow guidelines and recommendations such as those put forward by the British Society for Disability and Oral Health working group until better evidence is generated. Pioneering trialists have shown that evaluative studies relevant to oral health advice for people with serious mental illness are possible.