Systematic assessments of need and care planning in severe mental illness: cluster randomised controlled trial

Effectiveness of a Community-Based Intensive Case Management Model on Reducing Hospitalization for People With Severe Mental Illness in Seoul

OBJECTIVE

To overcome the limited effectiveness of standard case management services, the Seoul Intensive Case Management program (S-ICM) for patients with serious mental illnesses was introduced in 2017. This study aimed to evaluate its effectiveness in reducing the length of hospital stay.

METHODS

Monitoring data from April 2019 to March 2020 were retrieved from the Seoul Mental Health Welfare Center. A total of 759 participants with serious mental illnesses were included. The average length of admission per month was compared between the pre-ICM (previous year) and during-ICM periods. For post-ICM observation subgroup, average length of admission per month was compared between pre-ICM, during-ICM, and post-ICM periods. To determine the relative contributions of risk factors for during-ICM and post-ICM admission, multivariate logistic regression analyses were performed.

RESULTS

The average admission stay for pre-ICM period was significantly longer than that for during-ICM period (1.47 vs. 0.26 days). Among the predictors for during-ICM admission, pre-ICM psychiatric admission was the most important risk factor, followed by medical aid beneficiary and suicidal behavior. In the subgroup analysis of the post-ICM observation period, the pre-ICM, during-ICM, and post-ICM average admission stays were 1.45, 0.29, and 0.57 days/month, respectively. There was a significant difference in the average length of stay between the pre-ICM and during-ICM periods and between the pre-ICM and post-ICM periods. Post-ICM admission risks included pre-ICM admission, S-ICM duration <3 months, and chronic unstable symptoms.

CONCLUSION

The results suggest that the S-ICM effectively reduces psychiatric hospitalization duration, at least over a short-term period.

Encounter-based randomization did not result in contamination in a shared decision-making trial: a secondary analysis

OBJECTIVES

To estimate the level of contamination in an encounter-randomized trial evaluating a shared decision-making (SDM) tool.

STUDY DESIGN AND SETTING

We assessed contamination at three levels: (1) tool contamination (whether the tool was physically present in the usual care encounter), (2) functional contamination (whether components of the SDM tool were recreated in the usual care encounters without directly accessing the tool), and (3) learned contamination (whether clinicians "got better at SDM" in the usual care encounters as assessed by the OPTION-12 score). For functional and learned contamination, the interaction with the number of exposures to the tool was assessed.

RESULTS

We recorded and analyzed 830 of 922 randomized encounters. Of the 411 recorded encounters randomized to usual care, the SDM tool was used in nine (2.2%) encounters. Clinicians discussed at least one patient-important issue in 377 usual care encounters (92%) and the risk of stroke in 214 encounters (52%). We found no significant interaction between number of times the SDM tool was used and subsequent functional or learned contamination.

CONCLUSION

Despite randomly assigning clinicians to use an SDM tool in some and not other encounters, we found no evidence of contamination in usual care encounters.

Cohort study comparison of Mental Health and Wellbeing Services delivered by The Royal Flying Doctor Service, across Far North and Central West Queensland

Background

Understanding cultural differences between geographical regions is essential in delivering culturally appropriate healthcare. We aimed to describe the characteristics and outcomes of diverse clients using the Far North Mental Health and Wellbeing Service (FNS) and the Central West Health and Wellbeing Service (CWS).

Methods

We conducted a cohort study within Queensland, Australia, on all clients who received a mental health therapy session at either the FNS or the CWS. Patient data was prospective data collected form July 2019 to December 2020.

Findings

There were1202 clients, with a median number of individual contacts per-client of 3.0 (IQR 2.0-6.0). There was 428 (35.6% 95% CI 32.90-38.39) males and 772 (64.2% 95% CI 61.44-66.94) females with a median age across the genders of 38.0 (IQR 28.0-51.0). There was 505 (42.0% 95% CI 39.20-44.86) identifying as Indigenous and 697 (58.0% 95% CI 55.14-60.80) as non-Indigenous Australians. The FNS had a significantly higher proportion of Indigenous clients (n=484; 54.8% 95% CI 51.46-58.13) as compared to the CWS (n=21; 6.6% 95% CI 4.12-9.89). Of the 1202 clients, 946 (78.7% 95% CI 76.28-80.99) had a socio-economic classification of ‘most disadvantaged’, consisting of 740 (83.8%) clients from the FNS and 206 (64.6%) clients from the CWS. The majority of presentations were for neurotic, stress-related and somatoform disorders (n=568; 47.3%), followed by mood affective disorders (n=310; 25.8%). The overall number of treatments strategies employed was 10798, equalling a median of 6.0 (IQR 4.0-9.0) strategies per-client, with the leading strategies being counselling/psychosocial (n=1394; 12.9%), reflective listening (n=1191; 11.0%), and strengths based reasoning (n=1116; 10.3%). There were 511 (42.5%) clients who completed the Kessler Psychological Distress Scale (K10/K5), with 493 (41.0%) clients not offered as deemed not culturally appropriate by the treating team. The mean initial K10/K5 score was 23.7 (SD 9.4) which significantly decreased (p<0.001) to 18.0 (SD 10.0) at final consultation.

Interpretation

This study highlighted client socioeconomic differences between two geographically remote mental health services. It is essential that services are regionally co-designed to ensure cultural appropriateness.

Funding

No funding to declare.

Decision Making in Psychiatric Patients: A Qualitative Study with Focus Groups

INTRODUCTION

It has been said that mental illnesses are characterised by poor decision making; there is some neuroscientific evidence of specific alterations in performance in decision making tests, but little is known about how patients make choices about their own treatments.

METHODS

Focus groups with patients from two psychiatric clinics, with discourse analysis.

RESULTS

Five deductive categories (tools, capacity, therapeutic relationship, method and family and network), plus one additional category from the analysis (stigma), and 35 inductive (posterior) categories were considered. The categories are analysed and the findings presented.

CONCLUSIONS

Patients express a need for greater participation in decisions about their treatment, and a more symmetrical psychiatrist-patient relationship, involving families. Decisions may be changed due to stigma, barriers to treatment access, and previous experiences.

Treating mental health crises at home: Patient satisfaction with home nursing care

WHAT IS KNOWN ON THE SUBJECT?: Most studies have focused on whether hospital admissions have been reduced by the introduction of crisis services, rather than focusing on how these services are employed. Research has also shown that home assistance decreases costs and increases the level of patient satisfaction, thereby being more efficient in terms of the cost/effectiveness ratio than is traditional hospital care. Patient satisfaction with nursing care has long been identified as a key element of quality of care; however, satisfaction with nursing care among patients and families receiving crisis resolution at home has not been studied yet. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: There is limited research on patient satisfaction with CRHTTs. This study provides new insights and data including that on relationships between patient satisfaction and the teams' attention to person-centred mental health care. The difference between this study and other studies on patient satisfaction with crisis resolution home treatment teams is that this study focused on patients' and families' satisfaction with the nursing care provided by crisis resolution home treatment teams rather than with the general service provided. This study is the first of its kind with such a focus. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This research has both academic and clinical implications. Patients' and their families' satisfaction with nursing care is an integral aspect for evaluating mental health services, and this is especially important regarding services provided by crisis resolution home treatment teams because such teams are currently being introduced in countries such as Spain. Closely examining patients and families' satisfaction with nursing care can also foster improvements in current practices. Nurses in crisis teams might need to focus on equalizing power relations, which the data gathered in this study suggests is most important to patient satisfaction. ABSTRACT: Introduction Crisis resolution home treatment teams (CRHTT) provide short-term, intensive home treatment to people experiencing mental health crises. Patient satisfaction has long been identified as a key element of quality of care; however, satisfaction with nursing care as part of this service has not been studied yet. Aim To assess patients' and their families' satisfaction with the nursing care provided through a home care program offered by a hospital in Catalonia which administers person-centred care. Method A mixed methods research design was conducted. A cross-sectional study including quantitative survey data and qualitative interview data with a phenomenological focus was conducted. Results Twenty interviews were conducted. Patients and relatives reported high satisfaction that seems to be related to the person-centred nature of the care. Discussion The findings provide new insights, including how home treatment tends to equalize power relations between nurses and patients/the patient's family members, and how nurses increase sensitivity when focusing on service users' needs and priorities, leading to high patient and family satisfaction. Implications for practice This research has both academic and clinical implications. It highlights what mental health patients and their families value most about home care and interactions with nurses, and also drives improvements in current practices.

A scoping review of the problems and solutions associated with contamination in trials of complex interventions in mental health

Background

In a randomised controlled trial, contamination is defined as the receipt of active intervention amongst participants in the control arm. This review assessed the processes leading to contamination, its typical quantity, methods used to mitigate it, and impact of use of cluster randomisation to prevent it on study findings in trials of complex interventions in mental health.

Methods

This is a scoping review of trial design approaches and methods of study conduct to address contamination. Studies included were randomised controlled trials of complex interventions in mental health that described the process leading to, amount of, or solution used to counter contamination. The Medline, Embase, and PsycInfo databases were searched for trials published between 2000 and 2015. Risk of bias was assessed using the Jadad score and domains recommended by Cochrane plus some relevant to cluster randomised trials.

Results

Two hundred and thirty-four articles were included in the review. The main processes that led to contamination were health professionals delivering both active and comparator treatments and communication among clinicians and participants from the different trial arms. Twenty-three trials (10%) measured binary treatment receipt in the control arm with median 13% of participants found to be contaminated (IQR 5–33%). The most common design approach for dealing with contamination was the use of cluster randomisation (n = 93). In addition, many researchers used simple trial conduct methods to minimise contamination due to suspected contamination processes, such as organising for each clinician to provide only one treatment and separating trial arms spatially or temporally. There was little evidence for a relationship between cluster randomisation to avoid contamination and size of treatment effect estimate.

Conclusion

There was some evidence of modest levels of treatment contamination with a large range, although a minority of studies reported the amount of contamination. A limitation was that many trials described the problem in little detail. Overall there is a need for greater measurement and reporting of treatment receipt in the control arm of trials. Researchers should be aware of trial conduct methods that can be used to minimise contamination without resorting to cluster randomisation.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0646-z) contains supplementary material, which is available to authorized users.

Traditions of research in community mental health care planning and care coordination: A systematic meta-narrative review of the literature

CONTEXT

In response to political and social factors over the last sixty years mental health systems internationally have endeavoured to transfer the delivery of care from hospitals into community settings. As a result, there has been increased emphasis on the need for better quality care planning and care coordination between hospital services, community services and patients and their informal carers. The aim of this systematic review of international research is to explore which interventions have proved more or less effective in promoting personalized, recovery oriented care planning and coordination for community mental health service users.

METHODS

A systematic meta-narrative review of research from 1990 to the present was undertaken. From an initial return of 3940 papers a total of 50 research articles fulfilled the inclusion criteria, including research from the UK, Australia and the USA.

FINDINGS

Three research traditions are identified consisting of (a) research that evaluates the effects of government policies on the organization, management and delivery of services; (b) evaluations of attempts to improve organizational and service delivery efficiency; (c) service-users and carers experiences of community mental health care coordination and planning and their involvement in research. The review found no seminal papers in terms of high citation rates, or papers that were consistently cited over time. The traditions of research in this topic area have formed reactively in response to frequent and often unpredictable policy changes, rather than proactively as a result of intrinsic academic or intellectual activity. This may explain the absence of seminal literature within the subject field. As a result, the research tradition within this specific area of mental health service delivery has a relatively short history, with no one dominant researcher or researchers, tradition or seminal studies amongst or across the three traditions identified.

CONCLUSIONS

The research findings reviewed suggests a gap has existed internationally over several decades between policy aspirations and service level interventions aimed at improving personalised care planning and coordination and the realities of everyday practices and experiences of service users and carers. Substantial barriers to involvement are created through poor information exchange and insufficient opportunities for care negotiation.

Feedback from Outcome Measures and Treatment Effectiveness, Treatment Efficiency, and Collaborative Practice: A Systematic Review

Due to recent increases in the use of feedback from outcome measures in mental health settings, we systematically reviewed evidence regarding the impact of feedback from outcome measures on treatment effectiveness, treatment efficiency, and collaborative practice. In over half of 32 studies reviewed, the feedback condition had significantly higher levels of treatment effectiveness on at least one treatment outcome variable. Feedback was particularly effective for not-on-track patients or when it was provided to both clinicians and patients. The findings for treatment efficiency and collaborative practice were less consistent. Given the heterogeneity of studies, more research is needed to determine when and for whom feedback is most effective.

Cross-national comparative mixed-methods case study of recovery-focused mental health care planning and co-ordination: Collaborative Care Planning Project (COCAPP)

Background

Concerns about fragmented community mental health care have led to the development of the care programme approach in England and care and treatment planning in Wales. These systems require those people receiving mental health services to have a care co-ordinator, a written care plan and regular reviews of their care. Care planning and co-ordination should be recovery-focused and personalised, with people taking more control over their own support and treatment.

Objective(s)

We aimed to obtain the views and experiences of various stakeholders involved in community mental health care; to identify factors that facilitated, or acted as barriers to, personalised, collaborative and recovery-focused care planning and co-ordination; and to make suggestions for future research.

Design

A cross-national comparative mixed-methods study involving six NHS sites in England and Wales, including a meta-narrative synthesis of relevant policies and literature; a survey of recovery, empowerment and therapeutic relationships in service users (n = 449) and recovery in care co-ordinators (n = 201); embedded case studies involving interviews with service providers, service users and carers (n = 117); and a review of care plans (n = 33).

Review methods

A meta-narrative mapping method.

Results

Quantitative and qualitative data were analysed within and across sites using inferential statistics, correlations and the framework method. Our study found significant differences for scores on therapeutic relationships related to positive collaboration and clinician input. We also found significant differences between sites on recovery scores for care co-ordinators related to diversity of treatment options and life goals. This suggests that perceptions relating to how recovery-focused care planning works in practice are variable across sites. Interviews found great variance in the experiences of care planning and the understanding of recovery and personalisation within and across sites, with some differences between England and Wales. Care plans were seen as largely irrelevant by service users, who rarely consulted them. Care co-ordinators saw them as both useful records and also an inflexible administrative burden that restricted time with service users. Service users valued their relationships with care co-ordinators and saw this as being central to their recovery. Carers reported varying levels of involvement in care planning. Risk was a significant concern for workers but this appeared to be rarely discussed with service users, who were often unaware of the content of risk assessments.

Limitations

Limitations include a relatively low response rate of between 9% and 19% for the survey and a moderate level of missing data on one measure. For the interviews, there may have been an element of self-selection or inherent biases that were not immediately apparent to the researchers.

Conclusions

The administrative elements of care co-ordination reduce opportunities for recovery-focused and personalised work. There were few shared understandings of recovery, which may limit shared goals. Conversations on risk appeared to be neglected and assessments kept from service users. A reluctance to engage in dialogue about risk management may work against opportunities for positive risk-taking as part of recovery-focused work.

Future work

Research should be commissioned to investigate innovative approaches to maximising staff contact time with service users and carers; enabling shared decision-making in risk assessments; and promoting training designed to enable personalised, recovery-focused care co-ordination.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The effects of motivation feedback in patients with severe mental illness: a cluster randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of providing clinicians with regular feedback on the patient's motivation for treatment in increasing treatment engagement in patients with severe mental illness.

DESIGN

cluster randomized controlled trial (Dutch Trials Registry NTR2968).

PARTICIPANTS

adult outpatients with a primary diagnosis of a psychotic disorder or a personality disorder and their clinicians, treated in 12 community mental health teams (the clusters) of two mental health institutions in the Netherlands.

INTERVENTIONS

monthly motivation feedback (MF) generated by clinicians additional to treatment as usual (TAU) and TAU by the community mental health teams.

PRIMARY OUTCOME

treatment engagement at patient level, assessed at 12 months by clinicians.

RANDOMIZATION

teams were allocated to MF or TAU by a computerized randomization program that randomized each team to a single treatment by blocks of varying size. All participants within these teams received similar treatment. Clinicians and patients were not blind to treatment allocation at the 12-month assessment.

RESULTS

The 294 randomized patients (148 MF, 146 TAU) and 57 clinicians (29 MF, 28 TAU) of 12 teams (6 MF, 6 TAU) were analyzed according to the intention-to-treat principle. No statistically significant differences between treatment groups on treatment engagement were found (adjusted mean difference =0.1, 95% confidence interval =-2.2 to 2.3, P=0.96, d=0). Preplanned ancillary analyses showed statistically significant interaction effects between treatment group and primary diagnosis on treatment motivation and quality of life (secondary outcomes), which were beneficial for patients with a primary diagnosis of a personality disorder but not for those with a psychotic disorder. There were no reports of adverse events.

CONCLUSION

The current findings imply that monitoring and discussing the patient's motivation is insufficient to improve motivation and treatment engagement, and suggests that more elaborate interventions for severe mental illness patients are needed.

Implementing an aim-based outcome measure in a psychoanalytic child psychotherapy service: insights, experiences and evidence

In this paper, we describe the use of an aim-based outcome measure used in routine outcome monitoring of child and adolescent psychotherapy within a child and adolescent mental health service. We aim to explore the clinical feasibility and implications of the routine use of this measure. We argue that use of the measure provides a simple and useful way of clarifying the focus of the clinical work and reflecting its progress, while also having the potential to illuminate the clinical picture by contributing an additional source of clinical information from a collaborative process with the patient, parents or both. We argue that while there are some cases where use of the measure may be impossible, or even perverse, in general it enhances rather than detracts from clinical work.

Motivation and treatment engagement intervention trial (MotivaTe-IT): the effects of motivation feedback to clinicians on treatment engagement in patients with severe mental illness

BACKGROUND

Treatment disengagement and non-completion poses a major problem for the successful treatment of patients with severe mental illness. Motivation for treatment has long been proposed as a major determinant of treatment engagement, but exact mechanisms remain unclear. This current study serves three purposes: 1) to determine whether a feedback intervention based on the patients' motivation for treatment is effective at improving treatment engagement (TE) of severe mentally ill patients in outpatient psychiatric treatment, 2) to gather insight into motivational processes and possible mechanisms regarding treatment motivation (TM) and TE in this patient population and 3) to determine which of three theories of motivation is most plausible for the dynamics of TM and TE in this population.

METHODS/DESIGN

The Motivation and Treatment Engagement Intervention Trial (MotivaTe-IT) is a multi-center cluster randomized trial investigating the effectiveness of feedback generated by clinicians regarding their patients' treatment motivation upon the patients' TE. The primary outcome is the patients' TE. Secondary outcomes are TM, psychosocial functioning and quality of life. Patients whose clinicians generate monthly motivation feedback (additional to treatment as usual) will be compared to patients who receive treatment as usual. An estimated 350 patients, aged 18 to 65 years, with psychotic disorders and/or severe personality disorders will be recruited from outpatient community mental health care. The randomization will be performed by a computerized randomization program, with an allocation ratio of 1:1 (team vs. team or clinician vs. clinician) and patients, but not clinicians, will be blind to treatment allocation at baseline assessment. Due to the nature of the trial, follow-up assessment can not be blinded.

DISCUSSION

The current study can provide important insights regarding motivational processes and the way in which motivation influences the treatment engagement and clinical outcomes. The identification of possible mechanisms through which changes in the outcomes occur, offers a tool for the development of more effective future interventions to improve TM and TE.

TRIAL REGISTRATION

Current Controlled Trials NTR2968.

Routine outcome monitoring and feedback on physical or mental health status: evidence and theory

OBJECTIVES

Routine Outcome Monitoring (ROM) is an important quality tool for measuring outcome of treatment in health care. The objective of this article is to summarize the evidence base that supports the provision of feedback on ROM results to (mental) health care professionals and patients. Also, some relevant theoretical aspects are considered.

METHODS

Literature study (Pubmed, Medline, PsychINFO, Embase Psychiatry, 1975-2009) concerning randomized controlled trials (RTC's) of ROM and feedback on physical or mental health status of patients of all ages. Main search terms were routine outcome monitoring/measurement, feedback, health status measurement, patient reported outcome measures.

RESULTS

Included were 52 RCT's concerning ROM and feedback with adult or older patients: of these seven RCT's were exclusively focused on physical health and 45 RCT's (also) on the mental health of the patient, although not always in a mental health care setting or as primary outcome measure. There appears to be a positive impact of ROM on diagnosis and monitoring of treatment, and on communication between patient and therapist. Other results were less clear. There were no published RCT's on this topic with children or adolescents.

CONCLUSIONS

ROM appears especially effective for the monitoring of patients who are not doing well in therapy. Further research into this topic and the clinical-and cost-effectiveness of ROM is recommended, especially in mental health care for both adults and children. Also, more theory-driven research is needed with relevant conceptualizations such as Feedback Intervention Theory, Therapeutic Assessment.

An evaluation of the implementation of the FACE Health and Social Assessment in routine psychiatric practice

BACKGROUND

Systematic assessment of patients is seen as an important aspect of mental health care. As yet few UK services have successfully implemented outcome measures.

AIMS

To examine the feasibility of using FACE Health and Social Assessment in everyday practice and explore issues raised for staff.

METHOD

This comprised a feasibility questionnaire completed by 52 staff, 3 focus groups involving 18 staff and an analysis of patient scores on routinely collected FACE data.

RESULT

The questionnaire findings were positive yet only just over half of the patients on Assertive Outreach (AO) teams had some part of FACE completed in the previous year. The focus groups drew attention to many other calls on staff time and the importance of ongoing support. Staff were uncertain about the benefits of FACE for measuring change but believed that it promoted reflective practice. FACE subscores showed some ability to discriminate between patients on Rehabilitation and Recovery and AO teams but there were no significant differences for AO patients over time.

CONCLUSIONS

Although competing demands and low priority may underpin the failure to implement FACE it is perhaps clinical staffs lack of conviction in its contribution to improving mental health care that is the fundamental issue.

Does monitoring need for care in patients diagnosed with severe mental illness impact on Psychiatric Service Use? Comparison of monitored patients with matched controls

BACKGROUND

Effectiveness of services for patients diagnosed with severe mental illness (SMI) may improve when treatment plans are needs based. A regional Cumulative Needs for Care Monitor (CNCM) introduced diagnostic and evaluative tools, allowing clinicians to explicitly assess patients' needs and negotiate treatment with the patient. We hypothesized that this would change care consumption patterns.

METHODS

Psychiatric Case Registers (PCR) register all in-patient and out-patient care in the region. We matched patients in the South-Limburg PCR, where CNCM was in place, with patients from the PCR in the North of the Netherlands (NN), where no CNCM was available. Matching was accomplished using propensity scoring including, amongst others, total care consumption and out-patient care consumption. Date of the CNCM assessment was copied to the matched controls as a hypothetical index date had the CNCM been in place in NN. The difference in care consumption after and before this date (after minus before) was analysed.

RESULTS

Compared with the control region, out-patient care consumption in the CNCM region was significantly higher after the CNCM index date regardless of treatment status at baseline (new, new episode, persistent), whereas a decrease in in-patient care consumption could not be shown.

CONCLUSIONS

Monitoring patients may result in different patterns of care by flexibly adjusting level of out-patient care in response to early signs of clinical deterioration.

Effect of feedback of treatment outcome in specialist mental healthcare: meta-analysis

BACKGROUND

Feedback of treatment outcome during the course of therapy (outcome management) is increasingly considered to be beneficial for improving the quality of mental healthcare.

AIMS

To review the impact of feedback of outcome to practitioners and/or patients in specialist mental health services.

METHOD

A systematic search and meta-analysis of controlled trials using outcome management in mental health services published in English or German language.

RESULTS

Twelve studies met inclusion criteria. Feeding back outcome showed a small, but significant (d = 0.10; 95% CI 0.01-0.19) positive short-term effect on the mental health of individuals that did not prevail in the long run. Subgroup analysis revealed no significant differences regarding feedback modalities. Outcome management did not contribute to a reduction of treatment duration.

CONCLUSIONS

Evidence on the effects of outcome management in mental healthcare is promising. More targeted research is needed in order to identify the effective ingredients of outcome feedback and to assess its cost-effectiveness.

Patient health outcomes in psychiatric mental health nursing

This integrative literature review examined evidence concerning the relationship between psychiatric mental health nursing interventions and patient-focused outcomes. Empirical studies, published between 1997 and 2007, were identified and gathered by searching relevant databases and specific data sources. Although 156 articles were critically appraised, only 25 of them met the inclusion criteria. Findings from this review showed that the most frequently used outcome instruments assessed psychiatric symptom severity. Most of the instruments targeted two symptom categories: altered thoughts/perceptions and altered mood. Other outcome instruments were categorized in the following domains: self-care, functioning, quality of life and satisfaction. The most important finding of this review is the lack of consistently strong evidence to support decisions concerning which outcome instrument or combination of instruments to recommend for routine use in practice. Based on this review, additional research to conceptualize, measure and examine the feasibility of outcome instruments sensitive to psychiatric mental health nursing interventions is recommended.

Predictors of changes in needs for care in patients receiving community psychiatric treatment: a 4-year follow-up study

OBJECTIVE

This study aimed to investigate changes and predictors of change in needs for care, as assessed by both patients and mental health professionals, in a sample of subjects receiving community-based psychiatric care.

METHOD

The study was conducted using a 4-year prospective longitudinal design. A cohort of patients from the South-Verona Community Mental Health Service (CMHS) was assessed at baseline and follow-up using the Camberwell Assessment of Need, both staff and patient versions. Predictors of changes in needs were explored using block-stratified multiple regression analyses.

RESULTS

An overall stability for both patient-rated and staff-rated needs was found over time; however, significant changes in some specific need domains were found, such as self-rated health needs (improvement), self-rated social needs (deterioration) and staff-rated health needs (deterioration). Changes over time in self-rated and staff-rated needs are influenced by different and specific set of predictors, thus indicating that the two measures are not overlapping and convey different types of information.

CONCLUSION

Our data support the adoption of a negotiated approach in which both staff and users' views should be given equal weight when planning and providing needs-led mental health care.

Structured patient-clinician communication and 1-year outcome in community mental healthcare: cluster randomised controlled trial

BACKGROUND

Patient-clinician communication is central to mental healthcare but neglected in research.

AIMS

To test a new computer-mediated intervention structuring patient-clinician dialogue (DIALOG) focusing on patients' quality of life and needs for care.

METHOD

In a cluster randomised controlled trial, 134 keyworkers in six countries were allocated to DIALOG or treatment as usual; 507 people with schizophrenia or related disorders were included. Every 2 months for 1 year, clinicians asked patients to rate satisfaction with quality of life and treatment, and request additional or different support. Responses were fed back immediately in screen displays, compared with previous ratings and discussed. Primary outcome was subjective quality of life, and secondary outcomes were unmet needs and treatment satisfaction.

RESULTS

Of 507 patients, 56 were lost to follow-up and 451 were included in intention-to-treat analyses. Patients receiving the DIALOG intervention had better subjective quality of life, fewer unmet needs and higher treatment satisfaction after 12 months.

CONCLUSIONS

Structuring patient-clinician dialogue to focus on patients' views positively influenced quality of life, needs for care and treatment satisfaction.

Systematic review of interventions delivered by UK mental health nurses

The effectiveness of mental health nurse interventions has not been generally established in the literature. In this systematic review, randomised controlled trials (RCTs) were identified, undertaken in the United Kingdom, where mental health interventions delivered by mental health nurses had been evaluated. The main online literature databases were searched, key journals were hand searched and contact was made with key authors, resulting in a total of 52 studies, involving at least 7172 service users. Data were extracted and then all identified trials were assessed for inclusion by two reviewers. The results showed that in the UK, mental health nurses are involved in the delivery of a wide range of interventions in a variety of clinical health settings, with broadly positive results.

Psychometric properties of the BASIS-24© (Behaviour and Symptom Identification Scale-Revised) Mental Health Outcome Measure

Objective. Outcome measurement in mental health services is an area of considerable clinical interest and policy priority. This study sought to assess the Behaviour and Symptom Identification Scale-24 (BASIS-24©), a brief, patient self-reported measure of psychopathology and functioning, in a UK sample, including establishing population norms for comparative purposes. Methods. Participants were 588 adults recruited from psychiatric inpatient, outpatient and primary care settings; and 630 adults randomly sampled from primary care lists who completed the BASIS-24©, and the Brief Symptom Inventory (BSI) at two time points. Results. BASIS-24© demonstrated adequate reliability (coefficient α values for combined clinical sample across subscales ranged from 0.75 to 0.91), validity and responsiveness to change (effect size for change of the BASIS-24© was 0.56 compared with 0.48 for BSI Global Severity Index). Population norms were established for the general population and adult in-patients (at in-take). The scale proved straightforward to complete across clinical settings. Variable rates of questionnaire distribution across clinical settings highlighted the ongoing challenge of incorporating outcome measures in clinical settings. Conclusion. BASIS-24© is a brief, easily administered, self-complete measure of mental well-being and functioning that adequately meets the requirements of reliability, validity and responsiveness to change required of an outcome measure.

A Population-based Needs Assessment for Mental Health Services

A needs assessment was done to objectively evaluate client need and determine gaps between these needs and the services provided by mental health services. The services included were standard case management, assertive case management and residential care across the Fraser Health Region in British Columbia, Canada. Assessments involved collection of data on current symptoms, functioning, and service use and needs. Results showed many specific areas where client needs were under met. A level-of-care planning model was applied to the data and results suggest that a high percentage of clients may be in fact receiving too high or too low a level of care for their needs. This method of performing a population-based needs assessment provided findings that have proved useful for planning purposes in order to ensure that community mental health services better match client need.

Use of standardised outcome measures in adult mental health services: randomised controlled trial

BACKGROUND

Routine use of standardised outcome measures is not universal.

AIMS

To evaluate the effectiveness of standardised outcome assessment.

METHOD

A randomised controlled trial, involving 160 representative adult mental health patients and paired staff (ISRCTN16971059). The intervention group (n=101) (a) completed monthly postal questionnaires assessing needs, quality of life, mental health problem severity and therapeutic alliance, and (b) received 3-monthly feedback. The control group (n=59) received treatment as usual.

RESULTS

The intervention did not improve primary outcomes of patient-rated unmet need and of quality of life. Other subjective secondary outcome measures were also not improved. The intervention reduced psychiatric inpatient days (3.5 v.16.4 mean days, bootstrapped 95% CI1.6-25.7), and hence service use costs were 2586 UK pounds (95% CI 102-5391) less for intervention-group patients. Net benefit analysis indicated that the intervention was cost-effective.

CONCLUSIONS

Routine use of outcome measures as implemented in this study did not improve subjective outcomes, but was associated with reduced psychiatric inpatient admissions.