Discharged from a mental health admission ward: is it safe to go home? A review on the negative outcomes of psychiatric hospitalization

Associations between readmission and patient-reported measures in acute psychiatric inpatients: a multicenter prospective longitudinal study

PURPOSE

This study examined whether patient-reported measures (PRMs) addressing quality of life, personal agency, functional impairment, and treatment satisfaction at hospital discharge were associated with future readmission during a 12-month follow-up period. The study also examined whether readmission influenced changes in the same measures.

METHODS

A multicenter prospective cohort study was conducted at 21 psychiatric hospitals in Japan. Participants completed the EuroQol-five-dimensions-five-level (EQ-5D), the Five-item Subjective Personal Agency Scale, and the Sheehan Disability Scale (SDS) at the time of index admission (T1), discharge from index admission (T2), and 6 months (T3) and 12 months (T4) after discharge. Inpatient treatment satisfaction was assessed at T2. Readmission and variables potentially associated with hospitalization and PRMs were evaluated using mixed-effects logistic regression models and mixed models for repeated measures.

RESULTS

A total of 491 participants were followed for 12 months (attrition rate: 19.4%), and 480 were included in the EQ-5D analysis. The most common diagnoses were schizophrenia (59%), depression (14%), and bipolar disorder (13%). No patient-reported measures were significantly associated with readmission over the follow-up period. Interaction of readmission and time did not significantly affect changes in EQ-5D. Readmission did significantly influence SDS score changes between T2 and T3 (B = 1.78, 95% CI = 0.30-3.25, p = 0.018) and between T3 and T4 (B = 1.43, 95% CI = 0.14-2.72, p = 0.029). The same influence of readmission on SDS score changes was not observed in the model which adjusted for all potential covariates.

CONCLUSION

Readmission was potentially associated with changes in self-reported functional impairment. Findings highlight the potential role of intensive post-discharge services in preventing readmission, rather than relying on time-of-discharge PRMs in order to predict readmission risk.

TRIAL REGISTRATION

This study was registered in UMIN Clinical Trials Registry (UMIN000034220).

Proxy consultations for severe mental illnesses: An exploratory cross-sectional study from a tertiary care hospital

BACKGROUND

Non-adherence to medication leading to a break in continuity of care poses significant challenges in severe mental illness (SMI), leading to poor outcomes. In India, proxy consultation, wherein caregivers consult on behalf of patients, is a commonly adopted but insufficiently researched area to address these challenges.

AIMS

To explore the extent of proxy consultation in outpatient care of persons with SMI and investigate its sociodemographic and clinical correlates.

METHODOLOGY

In a tertiary care psychiatry outpatient setting, we conducted a cross-sectional study involving 374 caregivers of persons with SMI (Schizophrenia, Bipolar and related disorders). Descriptive statistics and univariate logistic regression were performed to examine correlates' relationships with proxy consultation.

RESULTS

Proxy consultation prevalence was 43% in the past 1 year. Compared with 18 to 30 years, middle-aged patients aged 31 to 40, 41 to 50 and 51 to 60 years had twofold, threefold and sixfold increased chances of proxy consultation, respectively. Being illiterate had six times higher odds than graduates, three times and two times if they studied till primary and secondary education. Early age of onset was associated with three times higher chances of proxy consultation compared to the onset of illness in adulthood. On the contrary, male gender and upper and middle socioeconomic status decreased the chances of proxy consultation by 40%. Financial difficulties (n = 72, 45%) and patients' unwillingness to visit outpatients (n = 44, 27.5%) were the most commonly cited reasons for proxy consultation.

CONCLUSION

Proxy consultations are relatively common, driven by many social, economic, patient-related, pragmatic and practical factors. In formulating community care policies for persons with SMI, the primary imperative should be to conduct additional research, deepening our understanding of proxy consultations. Additionally, it is essential to be mindful of the diverse issues associated with proxy consultations during the formulation process.

Prescriptive factors for intensive home treatment in acute psychiatry: a secondary analysis of a randomised controlled trial

BACKGROUND

Intensive home treatment (IHT) aims to prevent psychiatric hospitalisation. Although this intervention is well tested, it is still unknown for whom this intervention works best. Therefore, this study aims to explore prescriptive factors that moderate the effect of IHT compared to care as usual (CAU) on symptom severity.

METHODS

Using data from a randomised controlled trial, 198 participants that experience an exacerbation of acute psychiatric symptoms were included in this secondary analysis. In order to maximise clinical relevance, generally available environmental and clinical baseline factors were included as tentative moderators: age, gender, employment status, domestic situation, psychiatric disorders, psychological symptoms, psychosocial functioning, alcohol and other substance use. The outcome variable symptom severity was measured using the Brief Psychiatric Rating Scale (BPRS) and collected at 26 and 52 weeks post-randomisation. Multiple regression analysis was used to examine which participants' characteristics moderate the effect of IHT on the total BPRS score.

RESULTS

Our results suggest that being employed (B = 0.28, SE = 0.13, 95% CI = 0.03-0.53, p = 0.03) at baseline seems to have a moderation effect, which result in lower symptom severity scores at 26 weeks follow-up for patients who received IHT. This effect was not found at 52 weeks.

CONCLUSIONS

On the basis of the number of factors tested, there is no evidence for robust outcome moderators of the effect of IHT versus CAU. Our conclusion is therefore that IHT can be offered to a diverse target population with comparable clinical results.

TRIAL REGISTRATION

This trial is registered (date of registration: 2016-11-23) at the international clinical trials registry platform (NTR6151).

Preventing post-discharge suicides in psychiatric patients: insights from patients, lay healthcare supporters, and mental health professionals-a qualitative analysis

BACKGROUND

Discharged psychiatric patients are at higher risk of suicide due to various risk factors in their lives compared to the general population. However, specific problems and needs of these patients after discharge remain unclear. This research constitutes a segment of a broader implementation study designed to formulate an interventional strategy targeting post-discharge suicide among Chinese psychiatric patients. The present study seeks to qualitatively investigate the problems and needs from the perspectives of patients, their lay healthcare supporters (LHSs), and mental health professionals (MPs), aiming to enhance the efficacy of the interventional strategy.

METHODS

This study is part of a larger implementation study based on Shenzhen Kangning Hospital (SKH) in Shenzhen, Guangdong, China. Under the community-based participatory research framework, we recruited discharged psychiatric patients, their LHSs, and MPs as a collaborative community team, and we conducted individual in-depth interviews for patients and LSHs and focus group interviews with MPs. We utilized a thematic analysis approach to identify sub-themes and themes from interviews through systematically coding and analyzing the data.

RESULTS

A total of 45 participants were recruited for interviews, comprising 17 patients, 8 LHSs, and 20 MPs. We conducted 25 individual in-depth interviews and 3 focus group interviews. Through the interviews, we identified three themes of post-discharge problems: problems related to self, family-related problems, societal and community-related problems. We also identified four themes related to reducing post-discharge suicide: proactive self-management, multifunctional relatives, multifunctional MP group, and a warm society. The tangible support from LHSs and emotional support from MPs are strongly emphasized. Follow-up interventions were identified as the most significant way to addressing these unmet needs. Instrumental support from the community and a caring and non-discriminatory environment for individuals with mental disorders are essential for reducing suicide risk.

CONCLUSIONS

Establishing an integrated mental health care service network that connects psychiatric patients, LHSs, and MPs cross community and societal sectors, with patient-centered follow-up care at its core, is a practical approach to better address patients' needs and reduce post-discharge suicide.

TRIAL REGISTRATION

Registration number: NCT04907669. Date of registration: May 26th,2021.

Involuntary Treatment for Child and Adolescent Anorexia Nervosa-A Narrative Review and Possible Advances to Move Away from Coercion

BACKGROUND

Children and adolescents with psychiatric disorders frequently experience hospital treatment as coercive. In particular, for patients with severe anorexia nervosa (AN), clinical and ethical challenges often arise if they do not voluntarily agree to hospital admission, often due to the ego-syntonic nature of the disorder. In these cases, involuntary treatment (IVT) might be life-saving. However, coercion can cause patients to experience excruciating feelings of pressure and guilt and might have long-term consequences.

METHODS

This narrative review aimed to summarize the current empirical findings regarding IVT for child and adolescent AN. Furthermore, it aimed to present alternative treatment programs to find a collaborative method of treatment for young AN patients and their families.

RESULTS

Empirical data on IVT show that even though no inferiority of IVT has been reported regarding treatment outcomes, involuntary hospital treatment takes longer, and IVT patients seem to struggle significantly more with weight restoration. We argue that more patient- and family-oriented treatment options, such as home treatment, might offer a promising approach to shorten or even avoid involuntary hospital admissions and further IVT. Different home treatment approaches, either aiming at preventing hospitalization or at shortening hospital stays, and the results of pilot studies are summarized in this article.

Status after Hospital Discharge: An Observational Study of the Progression of Patients' Mental Health Symptoms Six Weeks after Hospital Discharge

(1) Background: Transitioning from mental health inpatient care to community care is often a vulnerable time in the treatment process where additional risks and anxiety may arise. We collected data for this study as part of a pragmatic cluster-randomized, longitudinal approach in Alberta. As the first phase of the ongoing innovative supportive program, this paper assessed the progression of mental health symptoms in patients six weeks after hospital discharge. Factors that may contribute to the presence or absence of anxiety and depression symptoms, as well as well-being, following return to the community were investigated. This provides evidence and baseline data for future phases of the project. (2) Methods: An observational study design was adopted for this study. Data on a variety of sociodemographic and clinical factors were collected at discharge and six weeks after via REDCap. Anxiety, depression, and well-being symptoms were assessed using the Generalized Anxiety Disorder (GAD-7) questionnaire, the Patient Health Questionnaire-9 (PHQ-9), and the World Health Organization-Five Well-Being Index (WHO-5), respectively. Descriptive, chi-square, independent t-tests, and multivariate regression analyses were conducted. (3) Result: The survey was completed by 88 out of 306 participants (28.8% response rate). The chi-square/Fisher exact test and independent t-test revealed no significant change in the mental health conditions from baseline to six weeks after discharge. It was found that the only significant factor predicting symptoms six weeks after discharge from inpatient treatment was the baseline symptoms in all three logistic regression models. It was four times more likely for those who experienced anxiety and depression at baseline to experience anxiety and depression symptoms six weeks after discharge (OR = 4.27; 95% CI: 1.38-13.20) (OR = 4.04; 95% CI: 1.25-13.05). Those with poor baseline well-being were almost 12 times more likely to experience poor well-being six weeks after discharge (OR = 11.75; 95% CI: 3.21-42.99). (4) Conclusions: Study results found no significant change in mental health conditions in the short term following hospital discharge. It is essential that researchers and policymakers collaborate in order to implement effective interventions to support and maintain the mental health conditions of patients following discharge.

Outcome of Involuntary Mental Health Assessment in a Psychiatric Department in Greece

Despite their controversiality, involuntary admissions in psychiatric departments remain a central issue in mental health care. The present study aims to identify demographic and clinical factors possibly associated with emergency involuntary psychiatric assessment and its outcome in Greece. This study was carried out in the psychiatric department of the University General Hospital of Alexandroupolis (UGHA) from 1 March 2018 to 28 February 2019. The sample included 191 individuals who had been psychiatrically assessed without their consent following a prosecutorial order. The majority of the involuntary assessments resulted in hospitalization (71%), with 51% of them resulting in involuntary hospitalization. Almost all patients diagnosed with "F20-29 schizophrenia, schizotypal and delusional disorders" were subsequently admitted to the psychiatric department of the UGHA (77 of 81, 66 of them involuntarily). Higher admission rates were recorded among those who had been referred from the Prosecutor's Office of regions that are located far from the psychiatric department of UGHA (Fisher's exact test, p-value = 0.045). In multivariate logistic regression, prior contact with psychiatric services and having an "F20-29 schizophrenia, schizotypal and delusional disorders" diagnosis was statistically significant with admission to the hospital as an outcome variable. Our study suggests an increased risk of involuntary admission among patients with psychosis, patients who had visited a psychiatric service prior to their assessment as well as those living further away from the main psychiatric services of the hospital. Better organization of community psychiatric services in remote places from hospital central services may lead to fewer prosecutorial referrals and coercive measures.

Technologically assisted intensive home treatment: feasibility study

Introduction

In recent year, many attempts have been made to provide patients with alternatives to psychiatric hospitalization during acute distress. Although several hospitalization alternatives have been offered, most of them still require patients to be distanced from their families, friends, and the social environment.

Methods

In this report we describe the implementation of a novel approach to psychiatric care termed "Technologically assisted Intensive Home Treatment", where patients arriving to emergency settings are directed to home care with technological aids that enable close monitoring and ongoing contact with their therapists.

Results

We describe the rationale and treatment principles of the treatment, and provide an elaborative description of the implementation process during the first year of implementation.

Discussion

Additional attention is given to factors associated with early dropout from the program, in order to inform readers of predictors to optimal care. Limitations and directions for future research and practice are discussed.Clinical Trial Registration: The study was registered in the database of clinical trials (registration number SHEBA-19-6555-MW-CTIL) and in the Ministry of Health (registration number MOH_2022-08-22_011992).

Profiles, correlates, and risk of death among patients with mental disorders hospitalized for psychiatric reasons

This study identified profiles of hospitalized patients with mental disorders (MD) based on their 3-year hospitalization patterns and clinical characteristics and compared sociodemographic profiles and other service use correlates as well as risk of death within 12 months after hospitalization. Quebec (Canada) medical administrative databases were used to investigate a 5-year cohort of 4,400 patients hospitalized for psychiatric reasons. Latent class analysis, chi-square tests and survival analysis were produced. Three profiles of hospitalized patients were identified based on hospitalization patterns and other patient characteristics. Profile 3 patients had multiple hospitalizations and early readmissions, worst health and social conditions, and used the most outpatient services. Profiles 2 and 1 patients had only one hospitalization, of brief duration in the case of Profile 2 patients, who had mainly common MD and made least use of psychiatric care. All Profile 1 patients were hospitalized for serious MD but received least continuity of physician care and fewest biopsychosocial interventions. Risk of death was higher for Profiles 3 and 2 versus Profile 1 patients. Interventions like early follow-up care after hospitalization for Profile 3, collaborative care between general practitioners and psychiatrists for Profile 2, and continuous biopsychosocial care for Profile 1 could be greatly improved.

Recovery-oriented daily care practice for community-based mental health service consumers in Japan: A grounded theory approach

Recovery, which is a non-linear, unique process allowing mental health service consumers to live autonomously, has become a prominent concept. However, adapting recovery-oriented practice to daily care is challenging. We explored recovery-oriented practice among mental health professionals in Japan via semi-structured interviews including nurses, occupational therapists, and psychiatric social workers (17 professionals in total). Data were analysed using grounded theory. Six categories emerged. The core category was 'Continuing to adjust care to meet consumers' needs for their unique lives'. The professionals stated that they practised in accordance with the service consumers' sincere hopes based on an equitable relationship because they believed that this approach would enhance consumers' personal agency, proactive behaviour, and self-choice. Despite negative consequences, the professionals did not view the consumers' choices as 'failures' and instead helped them to find meaning in their experiences. Although the therapeutic relationship tended to be paternalistic, participants described how concrete practices helped build an equitable relationship. In recovery-oriented practice, the provision of support centred on consumer values is important, without imposing own's own values. Care practices should also be aligned with consumers' hopes, needs and goals.

Short-term outcomes of physical activity counseling in in-patients with Major Depressive Disorder: Results from the PACINPAT randomized controlled trial

Introduction

A physical activity counseling intervention based on a motivation-volition model was developed and delivered to in-patients with Major Depressive Disorders with the aim of increasing lifestyle physical activity. The aim of this study is to evaluate the short-term outcomes of this intervention.

Methods

A multi-center randomized controlled trial was conducted in four Swiss psychiatric clinics. Adults who were initially insufficiently physically active and were diagnosed with Major Depressive Disorder according to ICD-10 were recruited. The sample consisted of 113 participants in the intervention group (M age = 42 years, 56% women) and 107 in the control group (M age = 40 years, 49% women). Motivation and volition determinants of physical activity were assessed with questionnaires. Implicit attitudes were assessed with an Implicit Association Test. Physical activity was self-reported and measured with hip-worn accelerometers over 7 consecutive days starting on the day following the data collection.

Results

According to accelerometer measures, step count decreased on average 1,323 steps less per day (95% CI = -2,215 to -431, p < 0.01) over time in the intervention group compared to the control group. A trend was recognized indicating that moderate-to-vigorous physical activity decreased on average 8.37 min less per day (95% CI = -16.98 to 0.23, p < 0.06) over time in the intervention group compared to the control group. The initial phase of the intervention does not seem to have affected motivational and volitional determinants of and implicit attitudes toward physical activity.

Conclusion

Physical activity counseling may be considered an important factor in the transition from in-patient treatment. Methods to optimize the intervention during this period could be further explored to fulfill the potential of this opportunity.

Clinical trial registration

https://www.isrctn.com/ISRCTN10469580, identifier ISRCTN10469580.

Everyday Life after the First Psychiatric Admission: A Portuguese Phenomenological Research

Returning to daily life after psychiatric admission can be difficult and complex. We aimed to explore, describe and interpret the lived experience of returning to everyday life after the first psychiatric admission. We designed this research as a qualitative study, using van Manen's phenomenology of practice. We collected experiential material through phenomenological interviews with 12 participants, from 5 June 2018 to 18 December 2018. From the thematic and hermeneutic analysis, we captured seven themes: (1) (un)veiling the imprint within the self; (2) the haunting memories within the self; (3) from disconnection to the assimilation of the medicated body in the self; (4) from recognition to overcoming the fragility within the self; (5) the relationship with health professionals: from expectation to response; (6) the relationship with others: reformulating the bonds of alterity; (7) the relationship with the world: reconnecting as a sense of self. The results allow us to establish the phenomenon as a difficult, complex, demanding and lengthily transitional event that calls into question the person's stability and ability for well-being and more-being. Thus, implementing structured transitional interventions by health services seems crucial. Mental health specialist nurses can present a pivotal role in establishing a helping relationship with recovery-oriented goals, coordinating patients' transitional care, and assuring continuity of care sensitive to the person's subjective experiences, volitions, and resources.

Pathway Home™ for High Utilizers of Psychiatric Inpatient Services: Impact on Inpatient Days and Outpatient Engagement

OBJECTIVE

This study examined the impact of Pathway Home™ (PH) transition services for high utilizers of psychiatric hospitalization on inpatient days and outpatient engagement post-hospital discharge.

METHODS

This case series study of forty PH graduates (5/22/2015-8/31/2018) used Medicaid claims to assess psychiatric inpatient days-per-month, average proportion of months with psychiatric emergency room, outpatient, and health home care management services. T-tests compared three time periods: the year prior, during, and after enrollment.

RESULTS

Graduates had significantly fewer psychiatric inpatient days/month during (M = 1.84, p < 0.001) and after PH enrollment (M = 1.88, p < 0.001) compared to prior to enrollment (M = 7.1), while emergency services were stable. Outpatient visits increased from 45% prior to 76% during enrollment (p < 0.001) and was sustained on follow-up (67%, p = 0.008). A similar pattern emerged for health home services (32%, 60%, and 50%).

CONCLUSION

PH is a promising approach for improving outcomes for high utilizers of psychiatric inpatient services, with sustained impact on follow-up.

Clinical Outcomes in Routine Evaluation Measures for Patients Discharged from Acute Psychiatric Care: Four-Arm Peer and Text Messaging Support Controlled Observational Study

Background: Peer support workers (PSW) and text messaging services (TxM) are supportive health services that are frequently examined in the field of mental health. Both interventions have positive outcomes, with TxM demonstrating clinical and economic effectiveness and PSW showing its utility within the recovery-oriented model. Objective: To evaluate the effectiveness of PSW and TxM in reducing psychological distress of recently discharged patients receiving psychiatric care. Methods: This is a prospective, rater-blinded, pilot-controlled observational study consisting of 181 patients discharged from acute psychiatric care. Patients were randomized into one of four conditions: daily supportive text messages only, peer support only, peer support plus daily text messages, or treatment as usual. Clinical Outcomes in Routine Evaluation—Outcome Measure (CORE-OM), a standardized measure of mental distress, was administered at four time points: baseline, six weeks, three months, and six months. MANCOVA was used to assess the impact of the interventions on participants’ scores on four CORE-OM subscales across the three follow-up time points. Recovery, clinical change, and reliable change in CORE-OM all-item analysis were examined across the four groups, and the prevalence of risk symptoms was measured. Results: A total of 63 patients completed assessments at each time point. The interaction between PSW and TxM was predictive of differences in scores on the CORE-OM functioning subscale with a medium effect size (F1,63 = 4.19; p = 0.045; ηp2 = 0.07). The PSW + TxM group consistently achieved higher rates of recovery and clinical and reliable improvement compared to the other study groups. Additionally, the text message group and the PSW + TxM group significantly reduced the prevalence of risk of self/other harm symptoms after six months of intervention, with 27.59% (χ2(1) = 4.42, p = 0.04) and 50% (χ2(1) = 9.03, p < 0.01) prevalence reduction, respectively. Conclusions: The combination of peer support and supportive text messaging is an impactful intervention with positive clinical outcomes for acute care patients. Adding the two interventions into routine psychiatric care for patients after discharge is highly recommended.

School Supports for Reintegration Following a Suicide-Related Crisis: A Mixed Methods Study Informing Hospital Recommendations for Schools During Discharge

The immediate period following psychiatric hospitalization is marked by increased risk for suicide behavior and rehospitalization. Because adolescents commonly return to school settings following hospital discharge, school-related stressors and supports are important considerations for psychiatric treatment and discharge planning. The current study aimed to inform recommendations provided by hospitals to schools to improve school reintegration practices by employing a concurrent, mixed-methods design. Specifically, we: (1) surveyed school professionals (n = 133) in schools varying in resource availability and populations in one southeastern state of the United States about supports and services provided to returning students; and (2) conducted in-depth interviews with a subset of these professionals (n = 19) regarding their perceptions of the hospital to school transition for youth recovering from suicide-related crises. Findings from survey responses indicated that, compared to schools located in urban and suburban areas, schools in rural areas were less likely to have school reintegration protocols for returning students. More generally, however, available interventions and modifications were relatively consistent across rural and urban/suburban schools, schools serving high and low poverty communities, and schools with predominantly white and predominantly ethnic and racial minoritized student bodies. Key themes across interviews signify the importance of communication between stakeholders, the type of information used to develop re-entry plans, available school-based services for returning youth, and the need to mitigate stigma associated with mental health crises. Findings inform recommendations that can be provided by hospitals to schools to support adolescent recovery as they return to school following psychiatric hospitalization.

Mental health service contact following release from prison or hospital discharge in those with psychosis

BACKGROUND

An association exists between psychosis and criminal offending, which evidence suggests can be reduced by effective mental health care for this vulnerable population. However mental health services often lose contact with people after diagnosis. The association between the first episode of psychosis and criminal offending highlights the need for effective mental health care for this vulnerable population.

AIMS

To investigate the association between the first diagnosis of psychosis (FDP) in prison or hospital and subsequent mental health service contact following release from prison or discharge from hospital.

MATERIALS AND METHODS

Individuals with a FDP either in prison (n = 492) or hospital setting (n = 24,910) between July 2006 and December 2011 in NSW (Australia), were followed post-release or discharge until their first mental health service contact in the community, the occurrence of an offence, death, or completion of the study period at the end of December 2012. Cox regression models were used to examine the predictors for the mental health service contacts following release or discharge.

RESULTS

Over 70% of those with a FDP in prison or hospital had a psychosis-related or any community-based mental health service contact following release or discharge between July 2006 and December 2012. Those with a FDP in prison were more likely to have no contact with mental health services than those in hospital with no prior offence record (hazard ratio, HR = 3.14, 95% CI: 2.66-3.72 and adjusted hazard ratio, aHR = 3.05, 95% CI: 2.56-3.63) within a median follow-up time of 25 days for the prison group and 26 days for hospital group. Males, individuals of Aboriginal heritage and individuals diagnosed with substance-related psychoses compared to those with schizophrenia and related psychoses were less likely to have a mental health service contact following release or discharge in both the univariable and multivariable analysis.

CONCLUSION

This study suggests that prior offending or a previous prison episode represents a barrier to mental health service contact in the community for those with a FDP. Effective rehabilitation planning while exiting prison and discharge planning from hospital are essential to the successful reintegration of these individuals with a FDP.

Discharge interventions from inpatient child and adolescent mental health care: a scoping review

The post-discharge period is an extremely vulnerable period for patients, particularly for those discharged from inpatient children and adolescent mental health services (CAMHS). Poor discharge practices and discontinuity of care can put children and youth at heightened risk for readmission, among other adverse outcomes. However, there is limited understanding of the structure and effectiveness of interventions to facilitate discharges from CAMHS. As such, a scoping review was conducted to identify the literature on discharge interventions. This scoping review aimed to describe key components, designs, and outcomes of existing discharge interventions from CAMHS. Nineteen documents were included in the final review. Discharge interventions were extracted and summarized for pre-discharge, post-discharge, and bridging elements. Results of this scoping review found that intervention elements included aspects of risk assessment, individualized care, discharge preparation, community linkage, psychoeducation, and follow-up support. Reported outcomes of discharge interventions were also extracted and included positive patient and caregiver satisfaction, improved patient health outcomes, and increased cost effectiveness. Literature on discharge interventions from inpatient CAMHS, while variable in structure, consistently underscore the role of such interventions in minimizing patient and family vulnerability post-discharge. However, findings are limited by inadequate reporting and heterogeneity across studies. There is a need for further research into the design, implementation, and evaluation of interventions to support successful discharges from inpatient child and adolescent mental health care.

Unpacking stigma: Meta-analyses of correlates and moderators of personal stigma in psychosis

Personal stigma entails perceived, experienced and internalised stigmatisation. Mental Health stigma has been widely researched across a range of countries and a meta-analysis of their associations and moderators in psychosis is timely. Meta-analyses were conducted examining the correlates and moderators of personal stigma in terms of: (1) demographic variables (2) illness related variables (3) symptoms/negative outcomes, and (4) aspects of wellbeing. Associations were obtained from a total of 216 records. Several demographic factors including age, economic status, employment, and rural residence had small associations with aspects of personal stigma (r's = 0.12 to -0.13). Personal stigma aspects were inversely related to medication adherence (r's = -0.20, -0.21), and positively associated with insight and number of hospitalisations (r's = 0.09-0.19). Most symptoms were positively associated with personal stigma (r's = 0.10-0.43), whereas inverse relations with wellbeing variables were identified (r's = -0.13 to -0.54). Moderator effects emerged including that of cultural setting and sex, age and education level, highlighting the role of cultural and demographic factors in shaping personal stigma aspects in psychosis. The present study also highlights the importance of recognizing the negative effect of actual stigma and discrimination experiences; particularly its detrimental impact on self-image and its complex role in shaping the internalisation of societal stigma.

Mitigating Suicide Risk for Children Discharged From a Psychiatric Hospital: A Treatment Intervention

The current article describes the work of an inpatient child psychiatric hospital in creating a treatment intervention in which parents learn about mitigating suicide risk for their child at home and are coached through the process of making changes in the home before the child's discharge. For simplicity, children and adolescents are referred to as children, the adults caring for children after discharge are referred to as parents, and the places children are discharged to are referred to as home. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

Suicide Risk and Addiction: The Impact of Alcohol and Opioid Use Disorders

Purpose of Review

Suicide is a major public health concern and a leading cause of death in the US. Alcohol and opioid use disorders (AUD/OUD) significantly increase risk for suicidal ideation, attempts, and death, and are the two most frequently implicated substances in suicide risk. We provide a brief overview of shared risk factors and pathways in the pathogenesis of AUD/OUD and suicidal thoughts and behaviors. We also review clinical recommendations on inpatient care, pharmacotherapy, and psychotherapeutic interventions for people with AUD/OUD and co-occurring suicidal ideation and behavior.

Recent Findings

Among people with an underlying vulnerability to risk-taking and impulsive behaviors, chronic alcohol intoxication can increase maladaptive coping behaviors and hinder self-regulation, thereby increasing the risk of suicide. Additionally, chronic opioid use can result in neurobiological changes that lead to increases in negative affective states, jointly contributing to suicide risk and continued opioid use. Despite significantly elevated suicide risk in individuals with AUD/OUD, there is a dearth of research on pharmacological and psychosocial interventions for co-occurring AUD/OUD and suicidal ideation and behavior.

Summary

Further research is needed to understand the effects of alcohol and opioid use on suicide risk, as well as address notable gaps in the literature on psychosocial and pharmacological interventions to lower risk for suicide among individuals with AUD/OUD.

Predictors of Intensive Treatment in Patients With Obsessive-Compulsive Disorder

Background: Few studies have investigated which patients with obsessive-compulsive disorder (OCD) do not recover through regular cognitive behavior therapy or pharmacotherapy and subsequently end up in intensive treatment like day treatment or inpatient treatment. Knowing the predictors of intensive treatment in these patients is significant because it could prevent intensive treatment. This study has identified predictors of intensive treatment in patients with OCD. Methods: Using 6-year longitudinal data of the Netherlands Obsessive Compulsive Disorder Association (NOCDA), potential predictors of intensive treatment were assessed in patients with OCD (n = 419). Intensive treatment was assessed using the Treatment Inventory Costs in Patients with Psychiatric Disorders (TIC-P). Examined potential predictors were: sociodemographics, and clinical and psychosocial characteristics. Logistic Generalized Estimating Equations was used to estimate to what extent the various characteristics (at baseline, 2- and 4-year assessment) predicted intensive treatment in the following 2 years, averaged over the three assessment periods. Results: Being single, more severe comorbid depression, use of psychotropic medication, and a low quality of life predicted intensive treatment in the following 2 years. Conclusions: Therapists should be aware that patients with OCD who are single, who have more severe comorbid depression, who use psychotropic medication, and who have a low quality of life or a drop in quality of life are at risk for intensive treatment. Intensive treatment might be prevented by focusing regular treatment not only on OCD symptoms but also on comorbid depression and on quality of life. Intensive treatment might be improved by providing extra support in treatment or by adjusting treatment to impairments due to comorbid depressive symptoms or a low quality of life.

Prevalence of Severe Mental Illness Dual Diagnosis Among Inpatients in a Psychiatric Hospital in Malaysia

The aim of this study was to determine the prevalence of alcohol or non-alcohol substance use dual diagnosis among inpatients with severe mental illness in a psychiatric institution in Malaysia. In addition, this study aimed to determine adverse outcomes between dual diagnosis versus single diagnosis. Methods: This was a cross-sectional study conducted in the inpatient ward using the Mini-International Neuropsychiatric Interview (MINI) to establish the diagnosis of severe mental illness and to screen for alcohol or non-alcohol substance use disorder comorbidity. Outcomes and severity of different domains among severe mental illness patients were assessed using the Addiction Severity Index (ASI). Results: Out of 152 patients who participated in this study, 51.3% (n = 78) had comorbid alcohol use disorder, and 29.6% (n = 45) had non-alcohol substance use disorder. Males with Kadazan ethnicity with severe mental illness and alcohol use disorder had a higher risk of having comorbid non-alcohol substance use disorder. Similarly, male Kadazan patients with severe mental illness and non-alcohol substance use disorder had a higher risk of having a comorbid alcohol use disorder. Dual diagnosis patients with alcohol and non-alcohol substance use disorder had higher rates of hospitalizations (p < .001 and p = .001). Family and social relationships were affected among the alcohol use disorder group as shown by the higher composite score for family status (FCOMP; p < .001). This group also showed more severe psychiatric status, as the composite score for psychiatric status (PCOMP) was high (p = .004). Suicidality was higher among patients with alcohol use disorder and severe mental illness (p < .001). Conclusions: The prevalence of severe mental illness dual diagnosis was high in this study with poorer outcomes, higher rates of admissions, and risk of suicidality. This highlights the importance of provisions for a more holistic treatment approach among patients with dual diagnosis.

An implementation evaluation of "Zero Suicide" using normalization process theory to support high-quality care for patients at risk of suicide

Background

Suicide rates continue to rise across the United States, galvanizing the need for increased suicide prevention and intervention efforts. The Zero Suicide (ZS) model was developed in response to this need and highlights four key clinical functions of high-quality health care for patients at risk of suicide. The goal of this quality improvement study was to understand how six large health care systems operationalized practices to support these functions-identification, engagement, treatment and care transitions.

Methods

Using a key informant interview guide and data collection template, researchers who were embedded in each health care system cataloged and summarized current and future practices supporting ZS, including, (1) the function addressed; (2) a description of practice intent and mechanism of intervention; (3) the target patient population and service setting; (4) when/how the practice was (or will be) implemented; and (5) whether/how the practice was documented and/or measured. Normalization process theory (NPT), an implementation evaluation framework, was applied to help understand how ZS had been operationalized in routine clinical practices and, specifically, what ZS practices were described by key informants (coherence), the current state of norms/conventions supporting these practices (cognitive participation), how health care teams performed these practices (collective action), and whether/how practices were measured when they occurred (reflexive monitoring).

Results

The most well-defined and consistently measured ZS practices (current and future) focused on the identification of patients at high risk of suicide. Stakeholders also described numerous engagement and treatment practices, and some practices intended to support care transitions. However, few engagement and transition practices were systematically measured, and few treatment practices were designed specifically for patients at risk of suicide.

Conclusions

The findings from this study will support large-scale evaluation of the effectiveness of ZS implementation and inform recommendations for implementation of high-quality suicide-related care in health care systems nationwide.

'If we would change things outside we wouldn't even need to go in…' supporting recovery via community-based actions: A focus group study on psychiatric rehospitalization

BACKGROUND

Psychiatric rehospitalization is a complex phenomenon in need of more person-centred approaches. The current paper aimed to explore how community-based actions and daily life influence mental health and rehospitalization.

DESIGN, SETTING AND PARTICIPANTS

The qualitative study included focus group data from six European countries including 59 participants. Data were thematically analysed following an inductive approach deriving themes and subthemes in relation to facilitators and barriers to mental health.

RESULTS

Barriers consisted of subthemes (financial difficulty, challenging family circumstances and stigma), and facilitators consisted of three subthemes (complementing services, signposting and recovery). The recovery subtheme consisted of a further five categories (family and friends, work and recreation, hope, using mental health experience and meaning).

DISCUSSION

Barriers to mental health largely related to social determinants of mental health, which may also have implications for psychiatric rehospitalization. Facilitators included community-based actions and aspects of daily life with ties to personal recovery. By articulating the value of these facilitators, we highlight benefits of a person-centred and recovery-focused approach also within the context of psychiatric rehospitalization.

CONCLUSIONS

This paper portrays how person-centred approaches and day-to-day community actions may impact psychiatric rehospitalization via barriers and facilitators, acknowledging the social determinants of mental health and personal recovery.

PATIENT OR PUBLIC CONTRIBUTION

The current study included participants with experience of psychiatric rehospitalization from six different European countries. Furthermore, transcripts were read by several of the focus group participants, and a service user representative participated in the entire research process in the original study.

Analysis of correlated data with feedback for time-dependent covariates in psychiatry research

In studies on psychiatry and neurodegenerative diseases, it is common to have data that are correlated due to the hierarchical structure in data collection or to repeated measures on the subject longitudinally. However, the feedback effect created due to time-dependent covariates in these studies is often overlooked and seldom modelled. This article reviews the methodological development of feedback effects with marginal models for longitudinal data and discusses their implementation.

Quality of life outcomes for people with serious mental illness living in supported accommodation: systematic review and meta-analysis

PURPOSE

To conduct a systematic review and meta-analysis of quality of life (QoL) outcomes for people with serious mental illness living in three types of supported accommodation.

METHODS

Studies were identified that described QoL outcomes for people with serious mental illness living in supported accommodation in six electronic databases. We applied a random-effects model to derive the meta-analytic results.

RESULTS

13 studies from 7 countries were included, with 3276 participants receiving high support (457), supported housing (1576) and floating outreach (1243). QoL outcomes related to wellbeing, living conditions and social functioning were compared between different supported accommodation types. Living condition outcomes were better for people living in supported housing ([Formula: see text]= - 0.31; CI = [- 0.47; - 0.16]) and floating outreach ([Formula: see text]= - 0.95; CI = [- 1.30; - 0.61]) compared to high-support accommodation, with a medium effect size for living condition outcomes between supported housing and floating outreach ([Formula: see text]= - 0.40; CI = [- 0.82; 0.03]), indicating that living conditions are better for people living in floating outreach. Social functioning outcomes were significant for people living in supported housing compared to high support ([Formula: see text] = - 0.37; CI = [- 0.65; - 0.09]), with wellbeing outcomes not significant between the three types of supported accommodation.

CONCLUSION

There is evidence that satisfaction with living conditions differs across supported accommodation types. The results suggest there is a need to focus on improving social functioning and wellbeing outcomes for people with serious mental illness across supported accommodation types.

Strengthening mental health systems in Zambia

BACKGROUND

Studies in mental health care for low resource settings indicate that providing services at primary care level would significantly improve provision and utilisation of mental health services. Challenges related to inadequate funding were noted as significant barriers to service provision, with the contribution of low knowledge of mental health conditions and stigma in the community. This study aimed to explore the barriers to the use of mental health services in Zambia, suggesting health systems thinking approaches to solving these challenges.

METHODS

Primary data were collected through individual interviews from 12 participants; primary caregivers, health workers from public health institutions that treat mental health conditions and policymakers and implementers. The digitally recorded responses were transcribed and analysed using thematic analysis.

RESULTS

Key barriers to care included inadequate funding, few human resources, poor infrastructure and stigma. Barriers to care at policy, facility and individual or community level could be alleviated by strengthening the mental health system. Engagement of community health workers and increasing efforts to sensitise the community about mental health would prove beneficial.

CONCLUSIONS

Strengthening the community health systems for mental health could improve access and increase utilisation of services.

Short stay unit for patients in acute mental health crisis: A case-control study of readmission rates

INTRODUCTION

Past evaluations of psychiatric short stay units have shown positive outcomes for patients, yet very little is known about the factors related to readmissions.

METHODS

A Short Stay Pathway (SSP) has been introduced on the Gold Coast, Australia, for patients in acute mental health crisis with admissions of up to 3 days. Rates of readmissions within 28 days were compared for SSP patients (N = 678), and a diagnosis-matched control group of patients from acute mental health beds (N = 1356). Demographic and clinical factors were considered as predictors of subsequent readmissions.

RESULTS

Average length of stay for SSP patients was 3.4 days, compared to 7.6 days in the control group. 10.6% of SSP patients and 18.4% of the control group were readmitted within 28 days (P < .001). For both groups, a 7-day follow up significantly reduced readmissions (P < .05). Indigenous patients on SSP had higher odds of readmissions than non-Indigenous patients (P < .05), and a diagnosis of a personality disorder increased readmission in the control group but not the SSP group (P < .001).

DISCUSSION

SSP reduced repeated hospitalizations for patients in acute crisis by 42%. An identification of factors related to future admissions can inform future tailoring of this model of care to subgroups of patients.

Internet-based aftercare for patients with personality disorders and trauma-related disorders: A pilot study

Preventing readmission after hospital discharge is a major issue with regard to the continuity of patients' recovery process and the financial burden on the healthcare system, but adequate aftercare services are lacking. Therefore, a pilot study was conducted to examine the feasibility and acceptability of an Internet-based aftercare program for patients with personality disorders (PD) and / or trauma-related disorders as well as to obtain a preliminary estimate of effects on symptomatology and readmission. Patients' satisfaction with the program and symptomatology (KPD-38, BDI-II) were assessed prior to hospital discharge (t1) and after three months of participation (t2). Log data on program utilization (i.e., logins, page hits, and chat use) were automatically assessed via server logs. N = 31 of 45 eligible patients consented to participate. 84% used the intervention at least once. The average duration of participation was 63 days (SD = 4.6). Patients attended on average 7.2 out of 12 group chat sessions (SD = 4.0). Findings indicate very high acceptance of and satisfaction with the intervention. Symptomatology on all outcomes was stable, no deteriorations could be observed. 20% reported readmission within the aftercare period. Efficacy and cost-effectiveness should be tested with a large-scale randomized controlled trial.

Feasibility and Preliminary Effects of Implementing Acceptance and Commitment Therapy for Inpatients With Psychotic-Spectrum Disorders in a Clinical Psychiatric Intensive Care Setting

The aim of this study was to adapt Acceptance and Commitment Therapy for Inpatients (ACT-IN) for implementation in a typical hospital setting to prepare for a larger clinical trial. The sample consisted of 26 inpatients diagnosed with psychotic-spectrum disorders. Using an open trial design, patients received individual and group ACT-IN sessions during their stay. We assessed the feasibility/acceptability of ACT-IN and preliminary changes on patient outcomes at baseline, discharge, and 4-month follow-up. We successfully recruited and retained participants as planned. Patients reported satisfaction with treatment, and routine hospital staff showed adoption and fidelity to the intervention. Relative to baseline, patients demonstrated significant improvements in symptoms and functioning across the 4-month follow-up. The current study shows that ACT-IN may be feasible and acceptable for inpatients with psychotic disorders in a psychiatric intensive care setting and should be tested in a future effectiveness-implementation trial.

Recent advances in understanding and managing self-harm in adolescents

Adolescent suicide is a serious public health problem, and non-suicidal self-injury (NSSI) is both highly comorbid with suicidality among adolescents and a significant predictor of suicide attempts (SAs) in adolescents. We will clarify extant definitions related to suicidality and NSSI and the important similarities and differences between these constructs. We will also review several significant risk factors for suicidality, evidence-based and evidence-informed safety management strategies, and evidence-based treatment for adolescent self-harming behaviors. Currently, dialectical behavior therapy (DBT) for adolescents is the first and only treatment meeting the threshold of a well-established treatment for self-harming adolescents at high risk for suicide. Areas in need of future study include processes underlying the association between NSSI and SAs, clarification of warning signs and risk factors that are both sensitive and specific enough to accurately predict who is at imminent risk for suicide, and further efforts to sustain the effects of DBT post-treatment. DBT is a time- and labor-intensive treatment that requires extensive training for therapists and a significant time commitment for families (generally 6 months). It will therefore be helpful to assess whether other less-intensive treatment options can be established as evidence-based treatment for suicidal adolescents.

Early discharge in acute mental health: A rapid literature review

Long psychiatric hospital stays are unpopular with services users, harmful, and costly. Economic pressures alongside a drive for recovery-orientated care in the least restrictive contexts have led to increasing pressure to discharge people from hospital early. Hospital discharge is, however, complex, stressful, and risky for service users and families. This rapid literature review aimed to assess what is known about early discharge in acute mental health. Searches were conducted in nine bibliographic databases, reference lists, and targeted grey literature sources. Fourteen included papers focused on early discharge in mental health, a population over 18 years with a mental health condition, and reported outcomes on therapeutic care or service delivery. Quality appraisal was undertaken using The Mixed Method Appraisal Tool. The meta-summary of the literature found that early discharge was neither provided to all inpatients nor limited to the Crisis Resolution and Home Treatment (CRHT) service model internationally. Early discharge interventions required collaborative working and discharge planning. It was not associated with unplanned readmissions and had a small effect on length of stay. Most studies reported service outcomes, whereas health outcomes were underreported. Professionals and service users were positive about early discharge and service users asked for peer support. Carers preferred hospital or day hospital care suggesting their need for respite. Limitations in the scope, detail, and quality of the evidence about early discharge leave an unclear picture of the components of early discharge as an intervention, its effectiveness, cost-effectiveness, or outcomes.

Outcomes and feasibility of the short transitional intervention in psychiatry in improving the transition from inpatient treatment to the community: A pilot study

Discharge from psychiatric inpatient care is frequently described as chaotic, stressful, and emotionally charged. Following discharge, service users are vulnerable to becoming overwhelmed by the challenges involved in readapting to their home environments, which could result in serious problems and lead to readmission. The short transitional intervention in psychiatry (STeP) is a bridging intervention that includes pre- and post-discharge sections. It aims to prepare patients for specific situations in the period immediately following discharge from a psychiatric hospital. We conducted a quasi-experimental pilot study to determine the feasibility of the intervention, and gain insight into the effects of the STeP. Two inpatient wards at a Swiss psychiatric hospital participated in the study, and represented the intervention and control arms. Patient recruitment and baseline assessment were performed 2 weeks prior to discharge. Follow-up data were collected 1 week subsequent to discharge. Questionnaires measured coping, admission and health-care usage, self-efficacy, working alliance, experience of transition, and the number of difficulties experienced following discharge. Fourteen and 15 patients completed the follow-up assessment in the control and intervention groups, respectively. The STeP did not affect primary or secondary outcomes; however, it was shown to be feasible, and patients' feedback highlighted the importance of post-discharge contact sessions. Further research is required to improve understanding of the discharge experience, identify relevant patient outcomes, and assess the effectiveness of the intervention in an adequately-powered randomized, controlled trial.

Introduction of a Psychosocial Post-Discharge Intervention Program Aimed at Reducing Psychiatric Rehospitalization Rates and at Improving Mental Health and Functioning

PURPOSE

Based on the premises of assertive community treatment and intensive case management, we designed a program delivered by social workers that is targeted at transition to community treatments and social support.

DESIGN AND METHODS

Narrative review and qualitative analysis of three patients who participated in the program.

FINDINGS

Case reports revealed that patients' social networks are small and their relationships are commonly conflictual and unstable.

PRACTICE IMPLICATIONS

Access to patients' social networks is a challenging task. Based on our preliminary experiences with the program, we suggest that more efforts should be made to enhance patients' social and interpersonal abilities.

Symptoms, functioning and quality of life after treatment in a residential sub-acute mental health service in Australia

The aim of this study was to assess clients' and service providers' perspectives on changes in mental health after an admission to a residential recovery-focused, sub-acute service, in Australia. Clients were either step-up clients, entering the service directly from the community, or step-down clients who were transitioning from an inpatient unit to home. During the 30-month period of data collection (August 2011 to January 2014) all clients (N = 102) were invited to participate in the longitudinal study and 41 clients consented to be involved (38% response rate). At admission and exit, participants completed the Behaviour and Symptom Identification Scale (Basis-32) and service providers completed the Life Skills Profile-16 and Health of the Nations Outcome Scales. Follow-up data 3 months after exit were available for 12 clients, including the Basis-32 and a self-report measure of quality of life (Assessment of Quality of Life 8-dimension). Both client groups reported positive improvements between admission and exit in the areas of relation to self and others, psychosis, daily living and presence of depression or anxiety symptoms. Service providers reported gains for clients in the areas of self-care, level of symptoms and presence of social problems. At 3 months, clients generally reported positive quality of life, although there was no significant change in symptoms and functioning. This study demonstrates that after an admission to a sub-acute service, step-up clients experience an improvement in their symptoms and functioning, have avoided a hospital admission and are well enough to return home. Step-down clients also experience further improvements in their symptoms and functioning, indicating that the service has assisted them in their transition to independent living after a hospital admission. Sub-acute residential units provide a continuation of care for inpatients preparing to return home, and people with a mental health problem living in the community who experience an escalation in symptoms and prefer an alternative to hospital.

An Improvement Program as a Way to Intensify Inter-Professional Collaboration in the Community for People with Mental Disabilities: A Follow-Up

The aim of the study was to follow up inter-professional experiences of improvement work one year after a completed CII improvement program aiming at improve health care and social services for people with mental disabilities living in ordinary housing. This study was performed with a qualitative descriptive approach which employed six focus group interviews followed by a thematic analysis. The results revealed four themes; Self-awareness and insights; Behavior and actions in daily practice; Organizational cultures and subcultures; and Organizational practices, using Ken Wilbers' integral theory of four quadrants of realities as a holistic frame in the discussion.

Hallucinogen Persisting Perception Disorder and Risk of Suicide

A 30-year-old male patient developed a hallucinogen persisting perception disorder (HPPD) after smoking cannabis laced with phencyclidine (PCP) or lysergic acid diethylamide (LSD) 10 years prior to hospital admission. Clinically, he reported seeing vivid, saturated colors and caricature-like objects. The patient described perceiving objects or people in motion as moving faster than normal. He reported living in a dream-like state and feeling numb and detached from other people and his surroundings. Upon pharmacotherapy initiation, facility transfer, and subsequent discharge from an acute psychiatry unit, he ultimately committed suicide. Although hallucinogen abuse is common in the United States, this case suggests that HPPD maybe significantly underdiagnosed and undertreated. In some cases, this oversight may perpetuate years of unnecessary patient suffering and can ultimately lead to severe depression and suicide.

Facilitators of recovery for step-up and step-down clients of a sub-acute residential mental health service

BACKGROUND

Sub-acute residential mental health services provide care for people who are not acutely unwell but require more support than generally available when living in the community. Little is known about how these services facilitate recovery and whether these facilitators differ for clients entering from the community (step-up) or from inpatient settings (step-down).

AIM

To identify features of a sub-acute residential service that have assisted step-up and step-down clients in their recovery.

METHOD

Semi-structured interviews were conducted with 16 step-up and 21 step-down clients. Interview transcripts were examined using an inductive, semantic content analysis approach.

RESULTS

Themes identified included the community context, personal support, the formal program offered and assistance in personal recovery processes, with the level of support for these themes differing for step-up and step-down clients.

CONCLUSIONS

Step-up and step-down clients have differing needs to be addressed in a sub-acute service. These services can better meet the needs of clients if they are aware of the setting the client has come from and tailor their services accordingly. Step-up clients prefer support in developing social skills and illness management techniques; step-down clients prefer a less structured environment with assistance in living skills and personal processes of recovery.