Economic approaches to improving access to evidence-based and recovery-oriented services for people with severe mental illness

Individualized strategies for depression: narrative review of clinical profiles responsive to vortioxetine

BACKGROUND

Depression is a highly heterogeneous disorder, often resulting in suboptimal response and remission rates. This underscores the need for more nuanced clinical characterization of patients to tailor individualized treatment plans. Emerging evidence highlights the critical role of cognitive and emotional dysfunction in major depression, prompting the exploration of novel therapeutic interventions that target these specific symptom domains.

MAIN TEXT

Vortioxetine, a multimodal antidepressant, enhances serotonergic activity while also modulating several other neurotransmitter systems involved in depressive symptoms such as emotional blunting, anhedonia, and cognitive dysfunction. Numerous randomized, placebo-controlled trials have demonstrated vortioxetine's efficacy and safety in treating depression, particularly in specific subgroups of depressed patients, including those with cognitive deficits and comorbid anxiety symptoms or disorders. Although not randomized or placebo-controlled, studies have also shown vortioxetine's efficacy in depressed patients with emotional blunting or anhedonia. Vortioxetine's ability to effectively treat a range of depressive symptoms, including anhedonia, emotional blunting, anxiety, and cognitive dysfunction, provides an individualized treatment solution for depressed individuals suffering from these symptoms. The purpose of this paper is to identify clinical profiles of patients who may benefit from vortioxetine, with the goal of optimizing therapeutic outcomes.

CONCLUSION

Vortioxetine has been shown to be effective for patients with depression and symptoms such as anhedonia, emotional blunting, anxiety, and cognitive dysfunction. Tailoring treatment plans to individual needs and personalizing treatment choices based on the specific symptoms presented by depressed patients improve treatment outcomes.

Experiencing (Shared) Decision Making: Results from a Qualitative Study of People with Mental Illness and Their Family Members

(1) Background: There is a fundamental shift in healthcare toward shared decision making (SDM). This study explores SDM from the perspective of individuals affected by mental illness and their family members and investigates factors which promote and hinder the process. (2) Methods: We conducted N = 15 telephone interviews (n = 4 adults affected by mental illness, n = 5 family members, n = 6 both applicable, the majority reporting experiences with affective and anxiety disorders). Data were recorded, transcribed, and analyzed according to procedures established by Mayring. (3) Results: Individuals affected by mental illness and their family members have a strong desire to be involved in treatment decisions and to participate in finding a diagnosis. Often these stakeholders are denied the opportunity to participate; sometimes enabling behaviors impede participation. The stigmatization of mental illnesses is a major barrier. There are also structural barriers to SDM within the healthcare system. Peer support, self-help associations, and psychosocial counseling services are important to empowering individuals and promoting SDM. (4) Conclusions: SDM has the potential to improve the quality of mental healthcare. Barriers can be mitigated and new approaches for interventions in the psychiatric sector have been identified. This study has also shown the importance of understanding SDM as a process that should begin at the diagnostic phase.

Shared decision-making interventions for people with mental health conditions

BACKGROUND

One person in every four will suffer from a diagnosable mental health condition during their life. Such conditions can have a devastating impact on the lives of the individual and their family, as well as society.  International healthcare policy makers have increasingly advocated and enshrined partnership models of mental health care. Shared decision-making (SDM) is one such partnership approach. Shared decision-making is a form of service user-provider communication where both parties are acknowledged to bring expertise to the process and work in partnership to make a decision.  This review assesses whether SDM interventions improve a range of outcomes. This is the first update of this Cochrane Review, first published in 2010.

OBJECTIVES

To assess the effects of SDM interventions for people of all ages with mental health conditions, directed at people with mental health conditions, carers, or healthcare professionals, on a range of outcomes including: clinical outcomes, participation/involvement in decision-making process (observations on the process of SDM; user-reported, SDM-specific outcomes of encounters), recovery, satisfaction, knowledge, treatment/medication continuation, health service outcomes, and adverse outcomes.

SEARCH METHODS

We ran searches in January 2020 in CENTRAL, MEDLINE, Embase, and PsycINFO (2009 to January 2020). We also searched trial registers and the bibliographies of relevant papers, and contacted authors of included studies.  We updated the searches in February 2022. When we identified studies as potentially relevant, we labelled these as studies awaiting classification.

SELECTION CRITERIA

Randomised controlled trials (RCTs), including cluster-randomised controlled trials, of SDM interventions in people with mental health conditions (by Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

This updated review included 13 new studies, for a total of 15 RCTs. Most participants were adults with severe mental illnesses such as schizophrenia, depression, and bipolar disorder, in higher-income countries. None of the studies included children or adolescents.  Primary outcomes We are uncertain whether SDM interventions improve clinical outcomes, such as psychiatric symptoms, depression, anxiety, and readmission, compared with control due to very low-certainty evidence. For readmission, we conducted subgroup analysis between studies that used usual care and those that used cognitive training in the control group. There were no subgroup differences. Regarding participation (by the person with the mental health condition) or level of involvement in the decision-making process, we are uncertain if SDM interventions improve observations on the process of SDM compared with no intervention due to very low-certainty evidence. On the other hand, SDM interventions may improve SDM-specific user-reported outcomes from encounters immediately after intervention compared with no intervention (standardised mean difference (SMD) 0.63, 95% confidence interval (CI) 0.26 to 1.01; 3 studies, 534 participants; low-certainty evidence). However, there was insufficient evidence for sustained participation or involvement in the decision-making processes. Secondary outcomes We are uncertain whether SDM interventions improve recovery compared with no intervention due to very low-certainty evidence. We are uncertain if SDM interventions improve users' overall satisfaction. However, one study (241 participants) showed that SDM interventions probably improve some aspects of users' satisfaction with received information compared with no intervention: information given was rated as helpful (risk ratio (RR) 1.33, 95% CI 1.08 to 1.65); participants expressed a strong desire to receive information this way for other treatment decisions (RR 1.35, 95% CI 1.08 to 1.68); and strongly recommended the information be shared with others in this way (RR 1.32, 95% CI 1.11 to 1.58). The evidence was of moderate certainty for these outcomes. However, this same study reported there may be little or no effect on amount or clarity of information, while another small study reported there may be little or no change in carer satisfaction with the SDM intervention. The effects of healthcare professional satisfaction were mixed: SDM interventions may have little or no effect on healthcare professional satisfaction when measured continuously, but probably improve healthcare professional satisfaction when assessed categorically. We are uncertain whether SDM interventions improve knowledge, treatment continuation assessed through clinic visits, medication continuation, carer participation, and the relationship between users and healthcare professionals because of very low-certainty evidence. Regarding length of consultation, SDM interventions probably have little or no effect compared with no intervention (SDM 0.09, 95% CI -0.24 to 0.41; 2 studies, 282 participants; moderate-certainty evidence). On the other hand, we are uncertain whether SDM interventions improve length of hospital stay due to very low-certainty evidence. There were no adverse effects on health outcomes and no other adverse events reported.

AUTHORS' CONCLUSIONS

This review update suggests that people exposed to SDM interventions may perceive greater levels of involvement immediately after an encounter compared with those in control groups. Moreover, SDM interventions probably have little or no effect on the length of consultations.  Overall we found that most evidence was of low or very low certainty, meaning there is a generally low level of certainty about the effects of SDM interventions based on the studies assembled thus far. There is a need for further research in this area.

Shared decision making for adults with severe mental illness: A concept analysis

AIM

Shared decision making for adults with severe mental illness has increasingly attracted attention. However, this concept has not been comprehensively clarified. This review aimed to clarify a concept of shared decision making for adults with severe mental illness such as schizophrenia, depression, and bipolar disorder, and propose an adequate definition.

METHODS

Rodgers' evolutionary concept analysis was used. MEDLINE, PsychINFO, and CINAHL were searched for articles written in English and published between 2010 and November 2019. The search terms were "psychiatr*" or "mental" or "schizophren*" or "depression" or "bipolar disorder", combined with "shared decision making". In total, 70 articles met the inclusion criteria. An inductive approach was used to identify themes and sub-themes related to shared decision making for adults with severe mental illness. Surrogate terms and a definition of the concept were also described.

RESULTS

Four key attributes were identified: user-professional relationship, communication process, user-friendly visualization, and broader stakeholder approach. Communication process was the densest attribute, which consisted of five phases: goal sharing, information sharing, deliberation, mutual agreement, and follow-up. The antecedents as prominent predisposing factors were long-term complex illness, power imbalance, global trend, users' desire, concerns, and stigma. The consequences included decision-related outcomes, users' changes, professionals' changes, and enhanced relationship.

CONCLUSIONS

Shared decision making for adults with severe mental illness is a communication process, involving both user-friendly visualization techniques and broader stakeholders. The process may overcome traditional power imbalance and encourage changes among both users and professionals that could enhance the dyadic relationship.

Barriers and facilitators to employment for young adults with mental illness: a scoping review

OBJECTIVES

The issue of gaining employment for those with mental illness is a growing global concern. For many in the young adult population, who are at a transitional age, employment is a central goal. In response, we conducted a scoping review to answer the question, 'What are the barriers and facilitators to employment for young adults with mental illness?'

DESIGN

We conducted a scoping review in accordance to the Arksey and O'Malley framework. We performed a thorough search of Medline, EMBASE, CINAHL, ABI/INFORM, PsycINFO and Cochrane. We included studies that considered young adults aged 15-29 years of age with a mental health diagnosis, who were seeking employment or were included in an employment intervention.

RESULTS

Our search resulted in 24 research articles that focused on employment for young adults with mental illness. Four main themes were extracted from the literature: (1) integrated health and social services, (2) age-exposure to employment supports, (3) self-awareness and autonomy and (4) sustained support over the career trajectory.

CONCLUSIONS

Our review suggests that consistent youth-centred employment interventions, in addition to usual mental health treatment, can facilitate young adults with mental illness to achieve their employment goals. Aligning the mental health and employment priorities of young adults may result in improved health and social outcomes for this population while promoting greater engagement of young adults in care.

Protocol for a mixed studies systematic review on the implementation of the recovery approach in adult mental health services

INTRODUCTION

Recovery is integral to mental health planning in G-8 countries including Canada. A recovery-oriented approach to care aims to promote personal empowerment, illness self-management and a life beyond services for people with serious mental illness (SMI), while reducing the financial burden associated with mental illness. Although there is a growing body of literature on recovery, no synthesis of research on the implementation of recovery into mental health services exists.

OBJECTIVES

The objective is to conduct a mixed studies systematic review on the operationalisation of recovery into mental health services for adults with SMI. It will inform the transformation of Canadian services to a recovery orientation, but may be applicable to other countries.

METHODS AND ANALYSIS

Seven databases including PubMed, Ovid Medline, Ovid Embase, Ovid PsycInfo, CINAHL, the Cochrane Library and Scopus will be searched for peer-reviewed empirical studies published from 1998 to December 2016. Systematic reviews and studies using quantitative, qualitative and mixed methodologies will be included. Secondary searches will be conducted in reference lists of all selected full text articles. Handsearches will also be performed in the tables of contents of three recovery-focused journals for the last 5 years. International experts in the field will be contacted for comments and advice. Data extraction will include identification and methodological synthesis of each study; definition of recovery; information on recovery implementation; facilitators and barriers and study outcomes. A quality assessment will be conducted on each study. The data will be synthesised and a stepwise thematic analysis performed.

ETHICS AND DISSEMINATION

Ethics approval is not required for this knowledge synthesis. Findings will be disseminated through knowledge translation activities including: (1) a 1-day symposium; (2) presentations in national and international conferences and to local stakeholders; (3) publications in peer-reviewed journals; (4) posts on the organisational websites.

Treatment of Cognition in the Schizophrenia Spectrum: The Context of Psychiatric Rehabilitation

Evidence-based approaches and modalities for targeting and treating the cognitive impairments of schizophrenia have proliferated over the past 15 years. The impairments targeted are distributed across the cognitive spectrum, from elemental perception, attention, and memory, to complex executive and social-cognitive functioning. Cognitive treatment is most beneficial when embedded in comprehensive programs of psychiatric rehabilitation. To personalize comprehensive treatment and rehabilitation of schizophrenia spectrum disorders, practitioners and participants must select from a rapidly expanding array of particular modalities and apply them in the broad context of the participant's overall recovery. At present, no particular treatment, cognitive or otherwise, can be considered more important or primary than the context in which it is applied. Persistent difficulty in dissemination of new technology for severe and disabling mental illness compounds the significance of the context created by a full treatment array. In this article, a case-study of a mental health service system is described, showing the broad-ranging effects of degrading the rehabilitative context of treatments, obviating the benefits of cognitive treatment and other modalities. To realize the promise of cognitive treatment, the problems that prevent dissemination and maintenance of complete psychiatric rehabilitation programs have to be addressed.

Community mental health care in the future: nine proposals

The aim of this article was to put community psychiatry into a longitudinal and global perspective and to try to look into the future. Specifically, we set out the following nine proposals:1. Central and regional government should measure the treated percentage of people with mental illness (coverage) and set specific targets to increase coverage over set time periods.2. Health care services need to recognize the far lower life expectancy among people with mental disorders and develop and evaluate new methods to reduce this health disparity.3. Mental health services should provide specific modules to reduce stigma and discrimination experienced by people with mental illness.4. Mental health staff should provide care that service users (and their family members) find accessible and acceptable.5. Mental health care should consist of a careful balance of hospital and community care, with most care provided at or near people's homes.6. Mental health planners, both in times of economic growth and recession, should invest in treatments known to be effective and disinvest from treatments known to be ineffective or even harmful.7. Mental health staff and service users should develop and evaluate methods to improve shared decision making.8. Health care practitioners (of western and nonwestern traditions) should take practical steps to see each other as partners in an integrated system that increases the total amount of mental health care available, while ensuring that only effective and acceptable treatments are provided.9. Mental health services should develop dedicated programs for recovery: this implies that staff understand an individual's personal recovery goals and fully support his/her achievement.

Implementing a continuum of evidence-based psychosocial interventions for people with severe mental illness: part 2-review of critical implementation issues

OBJECTIVE

In North America and internationally, efforts have been made to reduce the gaps between knowledge of psychosocial evidence-based practices (EBPs) and the delivery of such services in routine mental health practice. Part 2 of this review identifies key issues for stakeholders to consider when implementing comprehensive psychosocial EBPs for people with severe mental illness (SMI).

METHOD

A rapid review of the literature was conducted. Searches were carried out in MEDLINE and PsycINFO for reports published between 1990 and 2012 using key words related to SMI, and psychosocial practices and implementation. The Consolidated Framework for Implementation Research (CFIR) was used to structure findings according to key domains and constructs known to influence the implementation process.

RESULTS

The CFIR allowed us to identify 17 issues reflecting more than 30 constructs of the framework that were viewed as influential to the process of implementing evidence-based psychosocial interventions for people with SMI. Issues arising at different levels of influence (intervention, individual, organizational, and system) and at all phases of the implementation process (planning, engagement, execution, and evaluation) were found to play important roles in implementation.

CONCLUSION

The issues identified in this review should be taken into consideration by stakeholders when engaging in efforts to promote uptake of new psychosocial EBPs and to widen the range of effective psychosocial services available in routine mental health care.

Perceived stops to suicidal thoughts, plans, and actions in persons experiencing psychosis

BACKGROUND

Suicide has been conceived as involving a continuum, whereby suicidal plans and acts emerge from thoughts about suicide. Suicide prevention strategies need to determine whether different responses are needed at these points on the continuum.

AIMS

This study investigates factors that were perceived to counter suicidal ideation, plans, and acts.

METHOD

The 36 participants, all of whom had had experiences of psychosis and some level of suicidality, were presented with a vignette describing a protagonist with psychotic symptoms. They were asked to indicate what would counter the suicidal thoughts, plans, and acts of the protagonist described in the vignette. Qualitative techniques were first used to code these free responses into themes/categories. Correspondence analysis was then applied to the frequency of responses in each of these categories.

RESULTS

Social support was identified as a strong counter to suicidal ideation but not as a counter to suicidal plans or acts. Help from health professionals was strongly related to the cessation of suicidal plans as were the opinions of the protagonist's children. Changing cognitions and strengthening psychological resources were more weakly associated with the cessation of suicidal ideation and plans. The protagonist's children were considered potentially helpful in addressing suicidal acts.

CONCLUSION

These results suggest that both overlapping and nonoverlapping factors need to be considered in understanding suicide prevention, dependent on whether individuals are thinking about, planning, or attempting suicide.

Distinctive trajectory groups of mental health functioning among assertive community treatment clients: an application of growth mixture modelling analysis

OBJECTIVE

Assertive community treatment (ACT) studies that have used conventional, statistical growth modelling methods have not examined different trajectories of outcomes or covariates that could influence different trajectories, even though heterogeneity in outcomes has been established in other research on severe mental illness. The purpose of our study was to examine the general trend in mental health functioning of ACT clients over a 2-year follow-up time period, to discover groups of ACT clients with distinctive longitudinal trajectories of mental health functioning, and to examine if some of the key sociodemographic and illness-related factors influence group membership.

METHOD

A 2-year, prospective, within-subjects study of 216 ACT clients within southern Ontario, collected functional outcome data at baseline and 12 and 24 months using the Colorado Client Assessment Record. Baseline covariates included sex, primary diagnosis, number of comorbidities, hospitalization history, and duration of illness. Growth mixture modelling (GMM) was used to examine trajectories.

RESULTS

Clinical staff assessments of ACT clients showed a statistically significant improvement in functioning and 84% achieved successful community tenure. GMM analysis identified 2 classes of ACT clients: class 1 (79.63% of clients) experienced lower and stable overall functioning, and class 2 (20.37%) showed a better baseline functioning score and improvement in the overall functioning over time. Class membership was predicted by the number of comorbidities and diagnosis.

CONCLUSIONS

Our study suggests general stability in overall functioning for the sampled ACT clients over 2 years, but significant heterogeneity in trajectories of functioning.