Reaching the Unreachable: Intensive Mobile Treatment, an Innovative Model of Community Mental Health Engagement and Treatment

In this paper we introduce the Intensive Mobile Treatment (IMT) model, which arose from a 2016 New York City initiative to engage individuals who were "falling through the cracks" of the mental health, housing, and criminal justice systems. People who are referred to IMT often have extensive histories of trauma. They experience structural racism and discrimination within systems and thus can present as distrustful of treatment teams. We detail the structure of the program as we practice it at our non-profit agency and outline the psychodynamic concepts that inform our work with challenging populations. We acknowledge IMT's role in engaging in advocacy and addressing social justice in our work. We also discuss how through this model we are able to both mitigate and tolerate risk in participants with difficult-to-manage behaviors. This is typically a long-term, non-linear process. We address how this impacts the team dynamic as a whole and explain how with long-term, trusting therapeutic relationships, participants can change and grow over time. We also explain the ways in which our non-billing model plays an integral role in the treatment we are able to provide and identify several challenges and areas for program growth. In outlining our model and its methodology, we hope to empower other practitioners to adapt IMT to other settings beyond the New York City area.

Difficult-to-Engage Patients with Severe Mental Illness in Rural Community Settings: Results of the Greek Hybrid Assertive Community Treatment Model of Mental Healthcare

Background: Modified Assertive Community Treatment (ACT) in rural settings may be effective in the care of patients with severe mental illness (SMI) that are difficult to engage in community care. The objective of the present study was to explore the impact of the care by a hybrid ACT team on SMI patients' hospitalizations, length of hospital stay, symptomatology and functioning in a rural community treatment setting in Greece. Methods: The hybrid ACT team is an expansion of the services of the well-established generic Mobile Mental Health Unit in a rural area of Northwest Greece, and delivers home-based care for patients with SMI. This was a 3-year prospective, mirror image, pre-post observational study. Patients' symptomatology, functioning and general outcome were measured with the use of the Brief Psychiatric Rating Scale (BPRS), the Global Assessment of Functioning Scale (GAF), and the Health of the Nation Outcome Scale (HοNOS). Results: The mean age of the 23 enrolled patients was 52.4 years and the mean age of disease onset was 23.5 years, with a mean number of hospitalizations 10.74. Over the 16-month follow-up patients' hospitalizations, both voluntary and involuntary, had been significantly reduced by almost 80%. Length of hospital stay had been significantly reduced by 87%, whereas patients' functioning and symptomatology had been significantly improved, by 17% and 14.5%, respectively. Conclusions: The model of hybrid ACT in rural areas in Greece may be effective in the treatment of difficult-to-engage patients with SMI and may improve patients' outcomes.

Evidence-based psychosocial interventions in schizophrenia: a critical review

PURPOSE OF REVIEW

Schizophrenia Spectrum Disorders (SSD) are severe conditions that frequently produce significant impairment in cognitive performance, social skills and psychosocial functioning. As pharmacological treatment alone often provides only limited improvements on these outcomes, several psychosocial interventions are employed in psychiatric rehabilitation practice to improve of real-world outcomes of people living with SSD: the present review aims to provide a critical overview of these treatments, focusing on those that show consistent evidence of effectiveness.

RECENT FINDINGS

Several recent systematic reviews and meta-analyses have investigated in detail the acceptability, the effectiveness on several specific outcomes and moderators of response of different psychosocial interventions, and several individual studies have provided novel insight on their implementation and combination in rehabilitation practice.

SUMMARY

Cognitive remediation, metacognitive training, social skills training, psychoeducation, family interventions, cognitive behavioral therapy, physical exercise and lifestyle interventions, supported employment and some other interventions can be fully considered as evidence-based treatments in SSD. Psychosocial interventions could be of particular usefulness in the context of early intervention services. Future research should focus on developing newer interventions, on better understanding the barriers and the facilitators of their implementation in clinical practice, and exploring the opportunities provided by novel technologies.

Impact of the Pandemic was Minor Compared to Systemic Decrease in Fidelity of Assertive Community Treatment Services- A Provincial Study in Ontario, Canada

Assertive Community Treatment (ACT) model is the gold standard in community psychiatry serving people with severe mental illness. With its outreach-based design, the pandemic has profoundly affected the operations and functioning of ACT. The Dartmouth ACT Scale (DACTS) provides a standardized comprehensive and quantitative way to evaluate ACT quality. Results could inform nature of impact and identify areas for improvement. Current online survey used DACTS during the pandemic in April-May 2021. Clinical and administrative leadership of the 80 ACT teams in Ontario, Canada cross-sectionally rated ACT quality one-year pre-Covid (2018-2019) and one-year post the start of Covid (2020-2021). The overall pre-Covid Ontario ACT DACTS fidelity was 3.65. The pandemic led to decreases in all domains of DACTS (Human Resources: -4.92%, p < 0.001, 95% CI [0.08-0.27]; Organizational Boundary: -1.03%, p < 0.013,95%CI [0.01-0.07]; and Nature of Services: -6.18%, p < 0.001, 95%CI [0.16-0.26]). These changes were accounted by expected lower face-to-face encounters, time spent with clients, reduction in psychosocial services, less interactions with hospitals and diminished workforces. The magnitude of change was modest (-3.84%, p < 0.001, 95%CI [0.09-0.19]). However, the Ontario ACT pre-Covid DACTS was substantially lower (-13.5%) when compared to that from a similar survey 15 years ago (4.22), suggestive of insidious systemic level loss of fidelity. Quantitative fidelity evaluation helped to ascertain specific pandemic impact. Changes were significant and specific, but overall relatively modest when compared to the larger system level drop over the last decade. There is both evidence for model adaptability and resilience during Covid disruption, and concerns over larger downward drift in ACT fidelity and quality.

'ALL ABOUT MY IDEAL MENTAL HEALTH SERVICE': Users, family members and experts by experience discussing a co-designed service

INTRODUCTION

Many studies have investigated patients' understandings of how to optimise mental health services. However, only a few studies in the Italian context have involved experts by experience (EbEs), who can be ex-users, family members of ex-users or current service collaborators. Their role is crucial in implementing collaborative service quality assessment projects.

METHOD

The study investigated the experience of 35 EbEs,  users, and family members who carried out a 9-month fortnightly project aimed at imagining an 'ideal service'. The facilitators of the discussion groups (two EbEs) were interviewed; written reports of each meeting were produced with relevant comments, notes and specific suggestions; and content analysis was applied.

RESULTS

The most important result concerns the effectiveness of the project management method and group leadership carried out by the two EbEs. This approach allowed for complete autonomy of the work, without professional gaze or power imbalance. Also, the ideas and specific contents focused on by the two groups offer strategies to facilitate users' entry and reception in health care centres, to reduce the stigma of mental illness, to improve the centres' physical environment, to improve organisational aspects, to keep family members actively involved and to network mental health services with other territorial services.

CONCLUSIONS

EbEs have proven to be key figures in ensuring equity of role in the service co-design process. This also concerns a context, the Italian one, where their role has not yet been recognised and legalised. Their contribution and ideas to improve services could be fundamental not only in mental health centres, but also in other health facilities, and could concern the entire service delivery process rather than being limited to quality assurance, according to a virtuous circle based on active participation and transformation of the role of users.

PATIENT OR PUBLIC CONTRIBUTION

This work resulted from close collaboration between the two EbEs who conducted the groups, users and family members, the university, and the psychiatrist in charge of the service. All of them contributed to the research. The EbEs, researchers and psychiatrist participated in the interpretation of the data and are the co-authors of this paper.

Evaluation of a flexible assertive community treatment (FACT) program for patients with severe mental illness: an observational study in Salzburg, Austria

BACKGROUND

Inpatient treatment of severe mentally ill patients binds substantial resources and creates the dilemma of "revolving-door hospitalizations". Evidence suggests that these patients benefit more from an assertive outreach community psychiatric treatment. This descriptive study evaluates the implementation of a new treatment program for severe mentally ill patients provided by a flexible assertive community treatment (FACT) team.

METHODS

An uncontrolled design with routine data was used to measure the total length of stays, readmission rates and number of contacts one year prior to the implementation of the FACT program and the following first three years of treatment.

RESULTS

A continuous decrease of hospitalization among patients with severe mental illness was observed with the implementation of the FACT program with declines in total length of stays and readmission rates and accompanied with a decreasing number of contacts per year.

CONCLUSION

Our findings indicate that this program may create effects in stabilizing patients with severe mental illness and may be highly relevant also for other patient groups.

Perceptions of ACT Team Members on the Implementation of Physical Health Services: A Qualitative Study

BACKGROUND

Adults with severe mental illnesses have mortality rates 2.5 to 3 times higher than the general population, largely due to medical illnesses. Those with the most profound mental illnesses are served by assertive community treatment (ACT) teams that provide intensive mental health care; however, there are no clearly established models to integrate physical health treatment into ACT and this is a critical gap in the literature.

AIMS

To describe perceptions of ACT team members regarding services provided for their clients to treat physical health, how those services can be improved, and what implementation strategies would likely be needed to promote uptake and sustainability of those services on ACT teams.

METHOD

Qualitative interviews were conducted via Zoom using a semistructured interview guide with 19 employees from three ACT teams in a southeastern state. Interview transcripts were analyzed, using manifest content analysis, a form of qualitative analysis, to identify key themes in the interview transcripts.

RESULTS

ACT team members described limited physical health services for their clients. They reported (1) system-level barriers to improving physical health care, such as inadequate tools and training; and (2) patient-level barriers, such as limited awareness of physical care needs. ACT team members reported the need for additional medical staff and strengthened relationships with primary care providers. They also recommended changes in policy, education, and quality monitoring to implement new physical health care services.

CONCLUSIONS

Findings suggest intervention components and implementation strategies for improving physical health care of ACT consumers.

Service users' perceptions of relevant and helpful components of an integrated care concept (ACCESS) for psychosis

Introduction

Psychotic disorders have a significant impact on patients' lives and their families, and long-term treatment with individually tailored multimodal combinations of therapies is often required. Integrated care (IC) concepts such as the "Hamburg Model (ACCESS)" with a focus on psychotic disorders, includes different (therapeutic) components with pharmaco- and psychotherapy, family involvement, home treatment and the option of using a 24/7 crisis hotline. All components are offered by a therapeutically-oriented assertive community treatment (TACT) team in a need-adapted manner. So far, however, little is known about which specific components are regarded as especially relevant and helpful by the users of IC.

Methods

Patients currently participating in IC completed a questionnaire as part of the continuous quality assurance study (ACCESS II) in which they were asked to rate the different components of treatment according to their relevance and helpfulness, considering the individual's unique experiences with IC and needs in mental health care. Furthermore, they were asked to make suggestions regarding additional helpful components of treatment.

Results

Fifty patients participated in this survey (23% of the patients currently participating in the IC concept). For participants, the most helpful and important factors were having the same therapist in the long-term and the 24/7 crisis telephone. Additional components suggested by patients included more addiction-specific therapies and increased focus on vocational rehabilitation and integration.

Conclusion

From the perspective of the users of IC, long-term care from a trusted therapist with whom there is a therapeutic relationship and the possibility to reach someone they already know from the TACT team 24/7 serves as the best basis for effective care, fostering trust, understanding, and open communication. In contrast, home treatment remains a relevant aspect of evidence-based care for people with severe mental illness, but perhaps surprisingly, is not viewed as the most important issue.

Cost structure in specialist mental healthcare: what are the main drivers of the most expensive episodes?

BACKGROUND

Mental disorders are one of the costliest conditions to treat in Norway, and research into the costs of specialist mental healthcare are needed. The purpose of this article is to present a cost structure and to investigate the variables that have the greatest impact on high-cost episodes.

METHODS

Patient-level cost data and clinic information during 2018-2021 were analyzed (N = 180,220). Cost structure was examined using two accounting approaches. A generalized linear model was used to explain major cost drivers of the 1%, 5%, and 10% most expensive episodes, adjusting for patients' demographic characteristics [gender, age], clinical factors [length of stay (LOS), admission type, care type, diagnosis], and administrative information [number of planned consultations, first hospital visits, interval between two hospital episode].

RESULTS

One percent of episodes utilized 57% of total resources. Labor costs accounted for 87% of total costs. The more expensive an episode was, the greater the ratio of the inpatient (ward) cost was. Among the top-10%, 5%, and 1% most expensive groups, ward costs accounted for, respectively, 89%, 93%, and 99% of the total cost, whereas the overall average was 67%. Longer LOS, ambulatory services, surgical interventions, organic disorders, and schizophrenia were identified as the major cost drivers of the total cost, in general. In particular, LOS, ambulatory services, and schizophrenia were the factors that increased costs in expensive subgroups. The "first hospital visit" and "a very short hospital re-visit" were associated with a cost increase, whereas "the number of planned consultations" was associated with a cost decrease.

CONCLUSIONS

The specialist mental healthcare division has a unique cost structure. Given that resources are utilized intensively at the early stage of care, improving the initial flow of hospital care can contribute to efficient resource utilization. Our study found empirical evidence that planned outpatient consultations may be associated with a reduced health care burden in the long-term.

"They Just Helped Save My Life:" Client Perspectives on the Los Angeles County Full Service Partnership (FSP) Program for Serious Mental Illness

The purpose of this qualitative study was to elicit client perspectives on the Los Angeles County Full Service Partnership (FSP) program - an adaptation of Assertive Community Treatment (ACT). Semi-structured interviews were conducted with 20 FSP clients. Qualitative data were analyzed using thematic analysis. Two major themes were identified from the interview data: (1) Clients' acknowledgement of the material benefits of the FSP program; and (2) FSP's impact on restoring and stabilizing clients' social and treatment relationships. Interviewees greatly valued the material (i.e., basic needs, housing assistance) and relational (i.e., relationships with providers, restored personal relationships) aspects of the program, but did not ascribe the same degree of value to mental health treatment. Interviewees' emphases on material and relational aspects reflect the status of assertive mental health treatment as an intervention on intermediary determinants of health in the lives of persons diagnosed with serious mental illness.

Identifying Unique Subgroups of High-Cost Patients With Schizophrenia: A Population-Based Study Using Latent Class Analysis

Schizophrenia does not present uniformly among patients and as a result this patient population is characterized by a diversity in the type and amount of healthcare supports needed for daily functioning. Despite this, little work has been completed to understand the heterogeneity that exists among these patients. In this work we used a data-driven approach to identify subgroups of high-cost patients with schizophrenia to identify potentially actionable interventions for the improvement of outcomes and to inform conversations on how to most efficiently allocate resources in an already strained system. Administrative health data was used to conduct a retrospective analysis of "high-cost" adult patients with schizophrenia residing in Alberta, Canada in 2017. Costs were derived from inpatient encounters, outpatient primary care and specialist encounters, emergency department encounters, and drug costs. Latent class analysis was used to group patients based on their unique clinical profiles. Latent class analysis of 1659 patients revealed the following patient groups: (1) young, high-needs males early in their disease course; (2) actively managed middle-aged patients; (3) elderly patients with multiple chronic conditions and polypharmacy; (4) unstably housed males with low treatment rates; (5) unstably housed females with high acute care use and low treatment rates. This taxonomy may be used to inform policy, including the identification of interventions most likely to improve care and reduce health spending for each subgroup.

Impact of COVID-19 on the lives of people with severe mental illness-front-line community psychiatry workers observation from a provincial survey of assertive community treatment teams in Ontario, Canada

Using an online survey distributed to members of the provincial organization that represents the 88 Assertive Community Treatment (ACT) and Flexible ACT teams in Ontario, Canada, this descriptive study relied on the unique vantage points and observations of the front-line community psychiatry workers who maintained contact with patients through outreach and telecommunication during the height of COVID-19. The patients who suffer from serious mental illness (SMI) were uniquely affected by COVID-19 due to the changes, reduction or shut down of many essential clinical and community support services. Thematic and quantitative analyses of the workers' observations highlighted 6 main areas of note, including significant social isolation and loneliness, clinical course deterioration and life disruption, increased hospital and ER use, police and legal contacts, and substance abuse and related deaths. There were also encouraging signs of positive adaptations in terms of independence and resilience. Reflections of these impacts and potential ameliorating approaches are further discussed.

Affordability of Forensic Assertive Community Treatment Programs: A Return-on-Investment Analysis

OBJECTIVE

In this study, the authors assessed return on investment (ROI) associated with a forensic assertive community treatment (FACT) program.

METHODS

A retrospective secondary data analysis of a randomized controlled trial comprising 70 legal-involved patients with severe mental illness was conducted in Rochester, New York. Patients were randomly assigned to receive either FACT or outpatient psychiatric treatment including intensive case management. Unit of service costs associated with psychiatric emergency department visits, psychiatric inpatient days, and days in jail were obtained from records of New York State Medicaid and the Department of Corrections. The total dollar value difference between the two trial arms calculated on a per-patient-per-year (PPPY) basis constituted the return from the FACT intervention. The FACT investment cost was defined by the total additional PPPY cost associated with FACT implementation relative to the control group. ROI was calculated by dividing the return by the investment cost.

RESULTS

The estimated return from FACT was $27,588 PPPY (in 2019 dollars; 95% confidence interval [CI]=$3,262-$51,913), which was driven largely by reductions in psychiatric inpatient days, and the estimated investment cost was $18,440 PPPY (95% CI=$15,215-$21,665), implying an ROI of 1.50 (95% CI=0.35-2.97) for FACT.

CONCLUSIONS

The Rochester FACT program was associated with approximately $1.50 return for every $1 spent on its implementation, even without considering potential returns from other sources, including reductions in acute medical care, crime-related damages, and public safety costs. ROI estimates were highly dependent on context-specific factors, particularly Medicaid reimbursement rates for assertive community treatment and hospital stays.

Evaluation of disparities in impact of mental health intensive case management on 6-month symptoms, functioning, and quality of life between black and white veterans diagnosed with schizophrenia

BACKGROUND

Substantial health disparities have been reported between Black and White Americans diagnosed with schizophrenia. The nature and extent of these disparities among individuals receiving services in an equal-access health care system remains understudied.

PURPOSE AND AIMS

The purpose of this study was to examine disparities in enrollment characteristics, service delivery and clinical outcomes between Black and White veterans diagnosed with schizophrenia who received care in the Veterans Health Administration (VHA), an equal-access health care system.

METHODS

National program evaluation data from the VHA Intensive Community Mental Health Recovery (ICMHR) program were used to evaluate disparities between 2436 Black and 3565 White veterans who enrolled between 1999 and 2013. Veterans and case managers completed measures of sociodemographic factors, clinical history, clinical characteristics, and justice system involvement at enrollment and six months. Chi square and ANOVAs were used to evaluate enrollment and service delivery differences. Six-month changes were evaluated using multiple regression controlling for potentially confounding baseline characteristics. Effect sizes were evaluated with Cohen's d.

RESULTS

Results indicated differences between Black and White veterans in clinical history, justice system involvement, and clinical characteristics at enrollment. Minimal differences in service delivery were noted and longitudinal analyses revealed no significant differences between Black and White veterans on the majority of outcomes.

CONCLUSION

Fewer racial disparities in service use and outcomes were observed in ICMHR than in standard non-VA clinic settings. This study demonstrates that disparities may emerge more strongly from systemic rather than individual-level differences.

Carer involvement in the assessment of personal recovery: A naturalistic study of assertive community treatment in Norway

Background

The user and carer movements have come a long way in becoming embedded in mainstream mental health services for individuals with serious mental illness. However, implementing recovery-oriented practice continues to be plagued by an individualistic clinical focus. The carers do not feel integrated despite policies and best intentions. The implementation of Assertive Community Treatment (ACT) provided an opportunity to involve the carers and compare their assessment of personal recovery with the users.

Aims

The aims of this study were to examine (i) how family carers and users differed in their assessment of personal recovery, (ii) whether familial and personal relationships influenced how carers assess personal recovery of users, and (iii) if the experience of family carers with the ACT team was associated with personal recovery.

Methods

The naturalistic, explorative study recruited 69 users and 36 family carers from 12 Norwegian ACT teams. The users and carers assessed the user's personal recovery. Family carers also reported their experience and satisfaction with the ACT teams. Analyses included independent and paired sample T-tests and correlation analysis.

Results

Family carers were significantly more conservative than the users' assessment of the intrapsychic and interpersonal subscales of personal recovery. The pattern held true whether the family carers were matched to the users or part of the total sample. Lastly, there was a significant negative correlation between the family carer's experience of cooperation with the ACT team and their assessment of the user's intrapersonal process of recovery.

Conclusions

The results of our study were consistent with previous research on carer involvement in MHS. However, it is the first study that engaged carers and assessed personal recovery of the users of ACT services. Discrepancy between carers and users is the rule. Clinicians are encouraged to embrace the discrepancy and diversity carers bring and learn the methodology of multi-informant assessments. There also is a need to address, update, and integrate the personal, familial, and relational aspects of recovery. Modification of recovery measures such as QPR and their creative use with carers has the potential to generate valuable third-party information and to involve them meaningfully in mental health services.

Advancing research on teams and team effectiveness in implementation science: An application of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework

Background

Effective teams are essential to high-quality healthcare. However, teams, team-level constructs, and team effectiveness strategies are poorly delineated in implementation science theories, models, and frameworks (TMFs), hindering our understanding of how teams may influence implementation. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework is a flexible and accommodating framework that can facilitate the application of team effectiveness approaches in implementation science.

Main Text

We define teams and provide an overview of key constructs in team effectiveness research. We describe ways to conceptualize different types of teams and team constructs relevant to implementation within the EPIS framework. Three case examples illustrate the application of EPIS to implementation studies involving teams. Within each study, we describe the structure of the team and how team constructs influenced implementation processes and outcomes.

Conclusions

Integrating teams and team constructs into the EPIS framework demonstrates how TMFs can be applied to advance our understanding of teams and implementation. Implementation strategies that target team effectiveness may improve implementation outcomes in team-based settings. Incorporation of teams into implementation TMFs is necessary to facilitate application of team effectiveness research in implementation science.

Current insights of community mental healthcare for people with severe mental illness: A scoping review

Background

For the last four decades, there has been a shift in mental healthcare toward more rehabilitation and following a more humanistic and comprehensive vision on recovery for persons with severe mental illness (SMI). Consequently, many community-based mental healthcare programs and services have been developed internationally. Currently, community mental healthcare is still under development, with a focus on further inclusion of persons with enduring mental health problems. In this review, we aim to provide a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision on the ingredients of community mental healthcare.

Methods

We conducted a scoping review by systematically searching four databases, supplemented with the results of Research Rabbit, a hand-search in reference lists and 10 volumes of two leading journals. We included studies on adults with SMI focusing on stimulating independent living, integrated care, recovery, and social inclusion published in English between January 2011 and December 2022 in peer-reviewed journals.

Results

The search resulted in 56 papers that met the inclusion criteria. Thematic analysis revealed ingredients in 12 areas: multidisciplinary teams; collaboration within and outside the organization; attention to several aspects of health; supporting full citizenship; attention to the recovery of daily life; collaboration with the social network; tailored support; well-trained staff; using digital technologies; housing and living environment; sustainable policies and funding; and reciprocity in relationships.

Conclusion

We found 12 areas of ingredients, including some innovative topics about reciprocity and sustainable policies and funding. There is much attention to individual ingredients for good community-based mental healthcare, but very little is known about their integration and implementation in contemporary, fragmented mental healthcare services. For future studies, we recommend more empirical research on community mental healthcare, as well as further investigation(s) from the social service perspective, and solid research on general terminology about SMI and outpatient support.

The Impact of Mental Health Intensive Case Management on Functioning and Clinical Outcomes of Older Black and White Veterans With Serious Mental Illness

OBJECTIVES

To examine differences in service delivery, functioning, and clinical outcomes between older Black and White veterans participating in a national Veterans Health Administration (VHA) program of intensive case management.

DESIGN

Secondary analysis of national program evaluation data.

SETTING

VHA Intensive Community Mental Health Recovery (ICMHR) program.

PARTICIPANTS

Black (n = 1327) and White (n = 4402) veterans age 55 and older who enrolled in ICMHR between 2000-2013.

MEASUREMENTS

Measures evaluated sociodemographic factors, service delivery, functioning, and clinical outcomes. ANOVA and chi-squares were used to evaluate differences in enrollment characteristics and service delivery between Black and White veterans. Regression analyses were used to examine changes in outcomes over 6 months controlling for confounding baseline differences and service delivery. Cohen's d of .20 was used as a threshold for a clinically meaningful effect.

RESULTS

Black veterans were more likely to be diagnosed with schizophrenia, alcohol use disorder, and drug use disorder. Although case managers spent significantly less time with Black veterans, there was no difference in the frequency of contacts. Medication management and substance use treatment were more often provided to Black veterans. Black veterans experienced substantially greater improvement in anxiety/depression than White veterans with a small effect size (Cohen's d =-0.25). Changes in all other outcome measures did not meet criteria for clinically meaningful differences.

CONCLUSIONS

Black veterans experienced meaningfully greater improvements than White veterans on anxiety/depression but not on other measures. Provision of high-intensity services in an equal-access setting may reduce health disparities between Black and White older adults with serious mental illness.

A Recovery-Oriented Intervention for People With Psychosis: A Pilot Randomized Controlled Trial

OBJECTIVE

This pilot randomized controlled trial evaluated the effectiveness of critical time intervention-task shifting (CTI-TS) for people with psychosis in Santiago, Chile, and Rio de Janeiro. CTI-TS is a 9-month intervention involving peer support workers and is designed to maintain treatment effects up to 18 months.

METHODS

A total of 110 people with psychosis were recruited when they enrolled in community mental health clinics (Santiago, N=60; Rio de Janeiro, N=50). Participants within each city were randomly assigned to either CTI-TS or usual care for 9 months. Primary outcomes were quality of life, measured with the World Health Organization Quality of Life Assessment-Brief Version (WHOQOL-BREF), and unmet needs, measured with the Camberwell Assessment of Need (CAN), at 18-month follow-up. Results were analyzed according to intention-to-treat guidelines. Generalized estimating equations, with observations clustered within cities, and multiple imputation for missing data were used.

RESULTS

At 18 months, both groups showed improved primary outcomes. In both unadjusted and fully adjusted analyses, no significant differences between CTI-TS and usual care (WHOQOL-BREF question on quality of life and CAN mean number of unmet needs) were found.

CONCLUSIONS

Three factors might explain the lack of difference between CTI-TS and usual care: first-contact enrollment precluded rapport prior to randomization, a minority of patients were uncomfortable with peers being on the treatment team, and primary outcome measures may not have been sensitive enough to capture the effects of a recovery-oriented intervention. The results have implications for the design of transitional services for people with psychosis, especially in Latin America.

The design and process of a family and community-based intervention for relapse prevention in people living with schizophrenia in Iran

BACKGROUND

People living with schizophrenia (PLS) suffer frequent relapse accompanied by emergency room visits, premature mortality, lower quality of life and a substantial social and economic burden on families and health systems. There is a dearth of community-based relapse prevention interventions (RPIs) in Iran.

AIMS

To determine an ideal model for a community-based RPIs for PLS.

METHODS

A qualitative study with 27 experts in Iran was carried out to understand the ideal RPIs for PLS and the key components of such interventions.

RESULTS

In 16 semi-structured interviews and 8 group-discussions, the participants identified six major stages of family and community-based RPIs including preparation, social mobilization, local team formation, design an RPI, implementing the RPI, participatory monitoring, and evaluation of the RPI.

CONCLUSIONS

Given the suboptimal healthcare systems and lack of professionals and services, PLS in Iran may benefit from family and community-based RPIs. Our findings warrant pilot testing of such initiatives across developing communities like Iran to improve health outcomes of PLS.

Psychiatric patients' experience in receiving services provided by non-specialist community nurses, southern Thailand

BACKGROUND

Psychiatric problems have been a growing and significant public health challenge. Community-based psychiatric services have been shown to contribute to the improvement of health and social-related outcomes, but with limited specialists in this field. Consequently, Thailand has integrated these services into the primary care system delivered by community nurses working in primary care units (PCUs).

AIM

To describe the experiences of psychiatric patients in receiving services provided by non-specialist community nurses.

METHOD

A phenomenological approach was used. Eleven psychiatric patients with 10 major depressive disorders and 1 with schizophrenia were interviewed. The results were evaluated using thematic content analysis.

RESULTS

The results revealed two main themes as barriers and facilitators experienced in receiving services from community nurses.

CONCLUSION

Community-based services should be concerned about developing psychiatric nursing competency for community nurses to extend basic services to patients in communities and to assist family members.

Social integration of people with non-psychotic mental illness over the last 2 decades: the widening gap in the adult population in Belgium

PURPOSE

Social integration is poor among people with mental illness (MI). In recent decades, many countries have developed policies to address this issue. It remains unclear, however, whether their social integration has improved over time. This study aimed to assess the evolution of the social integration of adults with moderate and severe non-psychotic MI compared to the general population without MI between 1997 and 2018 in Belgium.

METHODS

Data on the general adult population were retrieved from the Belgian Health Interview Survey in six cross-sectional waves from 1997 to 2018. Three degrees of non-psychotic MI severity were compared using the 12-items General Health Questionnaire: no MI, moderate MI, and severe MI (score < 4, 4-7, and > 7). Social integration was measured using indicators relating to employment, income, social contacts, and partnership.

RESULTS

Since 1997, the probability of being unemployed, having limited social contacts, and living on less than 60% of the median national income has been increasing among people with severe non-psychotic MI. Between 1997 and 2018, social integration increased among the general population without MI and among people with moderate non-psychotic MI, but decreased among people with severe non-psychotic MI.

CONCLUSION

The gap between the social integration of people with severe non-psychotic MI and people with moderate or no MI has widened over time, despite major reforms of mental health care and policies. Policymakers and clinical practitioners should pay more attention to supporting the social integration of people with more severe MI, particularly in relation to employability and social support.

An observational comparison of FACT and ACT in the Netherlands and the US

Assertive Community Treatment (ACT) is a well-defined service delivery model for the care and treatment of the most severely mentally ill in the community with American origins. The Dutch have adapted the model in order to accommodate a broader range of needs and allow more flexible implementation. Functional Assertive Community Treatment (FACT) provides the intensity of care needed to help participants sustain life in the community as well as continuity of care over time for many vulnerable client populations.

Functional Rehabilitation: An Integrated Treatment Model for Patients With Complex Physical and Psychiatric Conditions

The health care delivery system in the United States, structured to provide single-disease care, presents unique challenges for patients with complex physical and psychiatric comorbidities. Patients in these populations are often referred to multiple specialty clinics, encounter little continuity of care or collaboration among their providers, incur high health care costs, and experience poor treatment outcomes. Given these barriers, questions remain about the extent to which siloed and fragmented care, as opposed to the complex nature of the illnesses themselves, contribute to poor outcomes. If given the opportunity to receive well-integrated, consistent, and personalized care, can patients with historically difficult-to-treat comorbid medical and mental illnesses make progress? This article describes an innovative model of care called functional rehabilitation that is designed to address existing barriers in treatment. The functional rehabilitation program seeks to disrupt the escalating effects of interacting comorbidities by offering highly collaborative treatment from a small team of clinicians, personalized interventions using a shared decision-making framework, multipronged treatment options, colocation in a large hospital system, and significant 1:1 time with patients. The article includes a case example with longitudinal outcome data that illustrates how progress can be made with appropriate programmatic supports. Future research should examine the cost-effectiveness of this model of care.

Effectiveness of a community health worker-led case management programme to improve outcomes for people with psychotic disorders in Thailand: a one-year prospective cohort study

BACKGROUND

Intensive case management (ICM) programmes for psychotic patients are effective in improving outcomes, but often unfeasible in resource-poor settings, as they typically require extensive human resources and expertise. We developed and evaluated the effectiveness of a less intensive case management program (LICM), led by community health workers, on one-year social functioning and service use.

METHODS

A prospective cohort study was conducted on patients aged 18 and above residing in a hospital catchment area. Outcomes were compared between LICM (n = 64) and non-LICM participants (n = 485). A counterfactual framework approach was applied to assess causal effects of the LICM on outcomes. The programme effectiveness was analyzed by augmented-inverse probability of treatment weighting (AIPW) to estimate potential outcome mean (POM) and average treatment effect (ATE). Outcomes were employment status and use of emergency, inpatient and outpatient services. Analyses were stratified by the number of previous psychotic relapse (≤ 1, > 1) to assess heterogeneity of treatment effect on those in an early and later stages of psychotic illness.

RESULTS

In the early-stage cohort, the likelihood of being employed at one year post-baseline was significantly greater in LICM participants than non-LICM participants (ATE 0.10, 95%CI 0.05-0.14, p < 0.001), whereas service use of all types, except outpatient, was not significantly different between the two groups. In the later-stage cohort, the likelihoods of employment between the two groups at post-baseline were similar (ATE -0.02, 95%CI -0.19-0.15, p = 0.826), whereas service use of all types was significantly higher in LICM participants.

CONCLUSION

LICM in a setting where community mental services are scarce may benefit those at an early stage of psychotic illness, by leading to better social functioning and no higher use of unscheduled services at the end of the programme, possibly through their better prognosis and medication adherence. A more intensive case management model may be appropriate for those in a later stage of the illness.

PRISM: A Shelter-Based Partnership for People Experiencing Homelessness and Severe Mental Illness

PRISM (Projet Réaffiliation Itinérance Santé Mentale [Homelessness Mental Health Reaffiliation Project]) is a clinical service developed through partnerships between shelters and the publicly funded Canadian health care system to address the needs of individuals experiencing homelessness and severe mental illness in Montreal. It provides inpatient treatment in a shelter setting for 2-3 months while helping clients find housing and appropriate longer-term support services. From program inception in November 2013 to May 2019, 52% of the 579 PRISM clients were in permanent housing after program discharge, 11% were in temporary housing, and 21% were not housed (homeless or incarcerated). In addition, 16% were transferred to inpatient treatment or rehabilitation services, and 85% were referred to and engaged in outpatient or community services.

Care at door-steps for persons with severe mental disorders: A pilot experience from Karnataka district mental health program

BACKGROUND

Public funded outreach services for persons with severe mental disorders (SMDs), a norm in developed nations, is non-existent in India. We share our pilot experience with an indigenous model named 'Care at Doorsteps' (CADs) for persons with SMDs who dropped out from clinical care of District Mental Health Program (DMHP) at three sites of Karnataka, a south Indian state.

AIM

The objectives of this study were to identify the reasons for drop outs from routine care and to assess the burden of illness and disability after the intervention.

METHODOLOGY

Six-month prospective observational study on patients aged 18-60 years, diagnosed as Schizophrenia or bipolar disorder was conducted. Three home visits were made by the team and provided medications, also offered brief psychoeducation and counselling. Care-givers were interviewed to identify the reasons for drop outs and their expectations from the treating team. Patients were also assessed using the Clinical Global Impression Scale (CGI), Indian Disability Evaluation and Assessment Scale (IDEAS) and Burden Assessment Schedule (BAS) during each visit.

RESULTS

Ninety-six patients (50 males and 46 females) were followed up, of which 85 had a diagnosis of schizophrenia and 11 with bipolar illness. Common reasons for drop out were: single caregiver (breadwinner) unable to accompany the patient, loss of faith in medical treatment and financial constraints. Symptomatic improvement and restoration of productive work were the priority expectations. Over the course, the mean CGI-S showed significant reduction (4.81 ± 1.57, 4.46 ± 1.32 and 4.11 ± 1.39 respectively; p = 0.001). Mean score on BAS showed a significant reduction (85.76 ± 12.15, 83.46 ± 11.30, 84.27 ± 11.82; p = 0.04). Mean total IDEAS scores did not show significant change (13.27 ± 4.78, 12.82 ± 4.24, 13.17 ± 4.40; p = 0.16).

CONCLUSION

Meaningful assertive outreach care is feasible in India and is found to be useful for persons with SMDs by utilising the already existing public sector resources.

Substance Use Disorders as a Critical Element for Decision-Making in Forensic Assertive Community Treatment: A Systematic Review

Introduction: The prevalence of substance use disorders in forensic populations is high. They are an important factor linked to negative outcomes in mentally ill offenders and are detrimental to forensic or non-forensic outcome measures. In contrast, substance use disorders are often underdiagnosed and undertreated, especially in forensic settings. Forensic Assertive Community Treatment is a forensic adaptation of regular assertive community treatment, combined with essential elements of forensic rehabilitation theories. Little is known however on the effectivity of forensic assertive community treatment when it comes to substance use disorders or what their exact role is on the outcome measures. In this paper, we explore how SUD is treated in Forensic assertive community treatment and how it relates to the forensic and non-forensic outcome measures. Methods: We performed a systematic review (PRISMA) of forensic Assertive community treatment teams that followed the main evidence-based principles of regular assertive community treatment and added basic elements of forensic rehabilitation. We analyzed articles the Psychinfo and Medline databases dating from 2005 to 2020. Fifteen studies fit the search criteria and were included in the analysis. The Quality of the studies was assessed using the Newcastle-Ottawa scale. Results: SUD was highly prevalent in all studies. Patients entered FACT through two pathways, either from a care continuum or directly from prison. The severity of SUD at intake emerges as a critical element when deciding which pathway to choose, as a high severity-score at the start of FACT follow-up was linked to recidivism. While differing in method all studies offered integrated SUD treatment. These included evidence-based techniques like CBT, therapeutic communities, and Substance Abuse Management Module. Though results on SUD outcomes were mixed 4 studies mentioned abstinence in 50-75%. The severity of SUD tended to increase initially and to stabilize afterwards. Conclusion: Severity of SUD at intake emerges as a decisive element in decision-making on entering FACT teams directly from prison or through a care-continuum. The ways to provide SUD treatment varied and outcomes for SUD were mixed. SUD was found to be detrimental to forensic and non-forensic outcome measures, such as recidivism or hospitalizations during FACT treatment.

Experiences of healthcare staff providing community-based mental healthcare as a multidisciplinary community mental health team in Central and Eastern Europe findings from the RECOVER-E project: an observational intervention study

BACKGROUND

Community Mental Health Teams (CMHTs) deliver healthcare that supports the recovery of people with mental illness. The aim of this paper was to explore to what extent team members of five CMHTs newly implemented in five countries perceived that they had introduced aspects of the recovery-oriented, strength-based approach into care after a training week on recovery-oriented practice. In addition, it evaluated what the team members' perceptions on their care roles and their level of confidence with this role were.

METHOD

An observational intervention study using a quantitative survey that was administered among 52 health professionals (21 Nurses, 13 Psychiatrists, 9 Psychologists, 8 Social Workers) and 14 peer workers including the Recovery Self-Assessment Tool Provider Version (RSA-P), the Team Member Self-Assessment Tool (TMSA), and demographic questions was conducted. The measures were self-reported. Descriptive statistics were used to calculate the means and standard deviations for continuous variables and frequencies and percentages for categorical variables (TMSA tool and demographic data). The standard technique to calculate scale scores for each subscale of the RSA-P was used. Bivariate linear regression analyses were applied to explore the impact of predictors on the subscales of the RSA-P. Predictors with significant effects were included in multiple regression models.

RESULT

The RSA-P showed that all teams had the perception that they provide recovery-oriented practice to a moderately high degree after a training week on recovery-oriented care (mean scores between 3.85-4.46). Health professionals with fewer years of professional experience perceived more frequently that they operated in a recovery-oriented way (p = 0.036, B = - 0.268). Nurses and peer workers did not feel confident or responsible to fulfil specific roles.

CONCLUSION

The findings suggest that a one-week training session on community-based practices and collaborative teamwork may enhance recovery-oriented practice, but the role of nurses and peer workers needs further attention.

TRIAL REGISTRATION

Each trial was registered before participant enrolment in the clinicaltrials.gov database: Croatia, Zagreb (Trial Reg. No. NCT03862209 ); Montenegro, Kotor (Trial Reg. No. NCT03837340 ); Romania, Suceava (Trial Reg. No. NCT03884933 ); Macedonia, Skopje (Trial Reg. No. NCT03892473 ); Bulgaria, Sofia (Trial Reg. No. NCT03922425 ).

Automated quality assessment of cognitive behavioral therapy sessions through highly contextualized language representations

During a psychotherapy session, the counselor typically adopts techniques which are codified along specific dimensions (e.g., 'displays warmth and confidence', or 'attempts to set up collaboration') to facilitate the evaluation of the session. Those constructs, traditionally scored by trained human raters, reflect the complex nature of psychotherapy and highly depend on the context of the interaction. Recent advances in deep contextualized language models offer an avenue for accurate in-domain linguistic representations which can lead to robust recognition and scoring of such psychotherapy-relevant behavioral constructs, and support quality assurance and supervision. In this work, we propose a BERT-based model for automatic behavioral scoring of a specific type of psychotherapy, called Cognitive Behavioral Therapy (CBT), where prior work is limited to frequency-based language features and/or short text excerpts which do not capture the unique elements involved in a spontaneous long conversational interaction. The model focuses on the classification of therapy sessions with respect to the overall score achieved on the widely-used Cognitive Therapy Rating Scale (CTRS), but is trained in a multi-task manner in order to achieve higher interpretability. BERT-based representations are further augmented with available therapy metadata, providing relevant non-linguistic context and leading to consistent performance improvements. We train and evaluate our models on a set of 1,118 real-world therapy sessions, recorded and automatically transcribed. Our best model achieves an F1 score equal to 72.61% on the binary classification task of low vs. high total CTRS.

Dutch Forensic Flexible Assertive Community Treatment: Operating on the Interface Between General Mental Health Care and Forensic Psychiatric Care

In the Netherlands, Forensic Flexible Assertive Community Treatment (ForFACT) is used as a specialized form of outpatient intensive treatment. This outreaching type of treatment is aimed at patients with severe and long lasting psychiatric problems that are at risk of engaging in criminal behavior. In addition, these patients often suffer from addiction and experience problems in different areas of their life (e.g., financial debt, unemployment, or lack of daytime activities). The aim of this exploratory study was to gain more insight into the characteristics of the ForFACT patient population. More knowledge about these patients may enhance the effectiveness of ForFACT and therefore (further) reduce the risk of recidivism. Data on 132 ForFACT patients were gathered by studying electronic patient records, criminal records, and by conducting semi-structured interviews with practitioners and patients. Additionally, as part of a cognitive screening, two screening instruments were conducted to gain insight into intelligence and possible mild cognitive impairments. This article gives a broad description of the ForFACT patient population, including demographic data and context variables, diagnostics, recidivism risk and offense history, and aspects related to care. Furthermore, several recommendations are given to further improve ForFACT. Based on the results it can be concluded that the ForFACT patient population shows a high degree of diversity in complex care needs and responsivity issues. Therefore, this article highlights the necessity for ForFACT to collaborate with other mental health institutions, as well as probation officers, and forensic or criminal justice institutions. Moreover, it is important to continually check the inclusion and exclusion criteria when admitting patients to ForFACT, and to examine whether ForFACT is still the most adequate care for patients or if they need to be referred. In addition, the results emphasize the importance of cognitive screening for forensic outpatients. Finally, this study zooms in on the interface between forensic psychiatric care and general mental health care.

A retrospective records study of patterns in mental health and criminal justice service use by people found not criminally responsible on account of mental disorder

BACKGROUND

While the presence or absence of previous healthcare and criminal justice system (CJS) contacts in the histories of mentally ill offenders has been well-studied, the frequency of these contacts and when they occur in the period leading up to an index criminal event has received less research attention.

AIMS

To explore patterns of healthcare and CJS use in the year prior to a criminal act leading to a Not Criminally Responsible on Account of Mental Disorder (NCRMD) finding in Canada.

METHODS

In this 3-year retrospective records study, the case files of all patients newly admitted to the British Columbia forensic psychiatric system after a finding of NCRMD between 1st July 2012 and 31st July 2015 were reviewed. Data were extracted on healthcare and CJS use for the 12 months before the act leading to the NCRMD finding. Time-based descriptive statistics and two-step cluster analysis were used to investigate service use patterns.

RESULTS

Among 94 eligible patients, only four had no service contacts in the year leading up to the index event, leaving 90 in the cohort for further analysis. On average, these 90 patients had seven contacts with health or criminal justice services in the year prior to the index offence. Cluster analysis revealed a high healthcare pathway group who had had many healthcare and few CJS contacts; a limited service user group who had had few contacts of any kind and a heavy service user group who had had a high volume of contacts with both types of service providers.

CONCLUSIONS

The different patterns of patient contact prior to the index event imply that each practitioner-type has distinct and temporally relevant opportunities to provide preventative interventions to their patients or user groups.

The Psychometric Properties of the Assertive Community Treatment Transition Readiness Scale (ATR)

Assertive community treatment (ACT) is an evidence-based practice for individuals living with severe mental illnesses. Originally conceptualized as a lifetime service, there is a need for standardized measures to help ACT teams identify clients who are potentially ready for a transition to less intensive services. Here, to address this gap in the literature, the psychometric properties of the Assertive Community Treatment Transition Readiness Scale (ATR) were examined. Data on the ATR were collected from ACT staff from across the country who had experience transitioning ACT clients to less intensive services. Results from an exploratory factor analysis suggested a one-factor solution and that items on the ATR demonstrated excellent internal consistency reliability as well as predictive criterion validity and known-groups validity. The ATR is an easy-to-use, 18-item measure that has the potential, in combination with clinical judgment and practice wisdom, to be a useful tool for identifying ACT clients who could transition to a less intensive level of care.

The Work Ability of People with Mental Illnesses: A Conceptual Analysis

Continuous employment is an important goal for many people with mental illnesses. However, job retention and absenteeism remain significant problems that deter their attempts at gaining financial independence, expanding interpersonal relationships, and developing self-esteem. Although there is consensus on the necessity of their proactive treatment and social participation, such support is currently underwhelming. Therefore, this study analyzes the conceptual framework for work ability of people with mental illnesses. We performed our investigations using Rodgers' evolutionary conceptual analysis, targeting literature published from 1978 to 2020. Our search yielded 1420 articles in the Scopus inventory and 199 in PubMed. After exclusions, 13 articles remained. Using the same keywords in Google Scholar, we included 31 articles in our analysis. The attributes of work ability included the ability to self-manage, adaptability, the ability to dedicate oneself to work, and the ability to formulate plans. These were developed through a reiterative process. This study notes the importance of adjusting the work environment according to the patients' condition. Therefore, the ability to cope with stress and workload, as well as active self-adjustment, are crucial skills that nurses can help develop after assessing the patient's daily life. Furthermore, they can foster multidisciplinary collaboration and follow-up systems after employment.

The Effect of a Housing First Intervention on Acute Health Care Utilization among Homeless Adults with Mental Illness: Long-term Outcomes of the At Home/Chez-Soi Randomized Pragmatic Trial

We assessed the effects of the Toronto Site Housing First (HF) intervention on hospitalizations and emergency department (ED) visits among homeless adults with mental illness over 7 years of follow-up. The Toronto Site is part of an unblinded multi-site randomized pragmatic trial of HF for homeless adults with mental illness in Canada, which followed participants up to 7 years. Five hundred seventy-five participants were recruited and classified as having high (HN) or moderate need (MN) for mental health support services. Each group was randomized into intervention (HF) and treatment as usual groups, and 567 (98.6%) consented to link their data to health administrative databases. HF participants received a monthly rent supplement of $600 (Canadian) and assertive community treatment (ACT) support or intensive care management (ICM) support based on need level. Treatment as usual (TAU) participants had access to social, housing, and health services generally available in the community. Outcomes included all-cause and mental health-specific hospitalization, number of days in hospital, and ED visit. We used GEE models to estimate ratio of rate ratios (RRR). The results showed HF with ACT had no significant effect on hospitalization rates among HN participants, but reduced the number of days in hospital (RRR = 0.32, 95% CI 0.16-0.63) and number of ED visits (RRR = 0.57, 95% CI 0.34-0.95). HF with ICM resulted in an increase in the number of hospitalizations (RRR = 1.69, 95% CI 1.09-2.60) and ED visit rates (RRR = 1.42, 95% CI 1.01-2.01) but had no effect in days in hospital for MN participants. Addressing the health needs of this population and reducing acute care utilization remain system priorities. Trial registration: http://www.isrctn.com/identifier: ISRCTN42520374.

Appropriateness of psychiatric advance directives facilitated by peer support specialists and clinicians on Assertive Community Treatment teams

BACKGROUND

Psychiatric advance directives (PADs) are used to document a person's treatment preferences for a future mental health crisis. Peer support specialists have been proposed to facilitate PADs, but little is known about the quality of peer versus clinician facilitated PADs.

AIMS

This study examined whether PAD documents facilitated by peer specialists and non-peer clinicians differed in the mix of treatment requests and refusals and expert ratings of feasibility and consistency.

METHODS

Analyses were conducted of content and expert ratings of 72 PAD documents from a randomized trial of PAD facilitation by peers and clinicians on Assertive Community Treatment (ACT) teams. A count of treatment refusals and requests was used to classify documents as predominantly prescriptive, proscriptive, or balanced. Regression was used to estimate relationships between PAD facilitator type and content.

RESULTS

Peer-facilitated PADs were significantly more likely to be predominantly prescriptive than were PADs facilitated by non-peer clinicians. Prescriptive PADs were more likely to receive expert ratings of high feasibility and consistency.

CONCLUSIONS

Results should alleviate some clinicians' apprehensions regarding the appropriateness of peer-facilitated PADs, such as the concern that people with lived experience with mental illness might encourage other consumers to use their PAD primarily for treatment refusals.

Essential Elements of Forensic Assertive Community Treatment

LEARNING OBJECTIVE

After participating in this activity, learners should be better able to:• Assess characteristics of forensic assertive community treatment programs.

ABSTRACT

Forensic assertive community treatment (FACT) has emerged internationally as an intervention strategy for people with serious mental disorders who are involved with the criminal justice system. Studies to date have shown marked variability, however, in FACT program design and operation. Based upon a literature review and relevant experience, the authors present their perspective on the essential elements of FACT. Given that FACT is an adaptation of the evidence-based assertive community treatment (ACT) model, it is recommended that FACT programs maintain a high-fidelity ACT component. FACT programs should also have both mental health and criminal justice admission criteria because service recipients are involved in both service systems. For optimal effectiveness, FACT team clinicians must partner with criminal justice agencies that provide community-based supervision to their patients. Prospective FACT enrollees should receive a clear explanation of the program, including how their respective mental health and criminal justice service providers will work collaboratively with them to prevent incarceration. FACT programs should also use risk/need assessment to inform treatment planning, evidence-based mental health and community correctional practices to promote both wellness and public safety, and shared training to promote effective collaboration. Additional elements to consider include housing, medical care, and transitional services. These elements are presented and discussed, including a rationale and evidence to support each component. The article concludes with introduction of a FACT fidelity scale, the Rochester Forensic Assertive Community Treatment Scale (R-FACTS). By operationalizing essential FACT elements, the R-FACTS is designed to support FACT program development, implementation, and dissemination in a more consistent and measurable manner.

The Use of Clozapine in the Serious Mental Illness Patients Enrolled in an Assertive Community Treatment Program

Introduction Health care cost is projected to reach 20% of the nation's gross national product (GNP) by 2016. 6.2% of this is from mental health. The National Institute of Mental Health (NIMH) estimates the prevalence of serious mental illness (SMI) at 13.1 million or 5.2% of American adults age 18 or over. Hence, mental health care cost for this patient population is significant. Patients with SMI involved in an Assertive Community Treatment (ACT) program are individuals who experience the most intractable symptoms and the greatest level of dysfunction from their mental illness. These individuals typically are institutionalized in a long-term facility such as the state hospital. Clozapine has shown superior efficacy over first- and most second-generation antipsychotics in both treating treatment-resistant and non-treatment-resistant schizophrenia which has been supported by several large trials. There is also evidence of its efficacy in suicidality, aggression and substance misuse. In fact, clozapine has been approved by the FDA for use in refractory schizophrenia and suicidality in schizoaffective disorder. Due to the risk of agranulocytosis, clozapine is underutilized. The purpose of this study is to conduct a retrospective cohort study through chart review to analyze whether the addition of clozapine to ACT treatment of SMI patients in a community hospital from 2008 to 2018 led to decreased frequency of hospitalizations and increased clinical stability. Materials and methods A retrospective study using electronic medical record (EMR) of patients ages 20 and above who were enrolled in the ACT program at a community hospital from December 1, 2008 to December 31, 2018. Variables were collected from the EMR and de-identified during data collation. Analysis was performed using SPSS software package. Results A total of 179 patients enrolled in the ACT program and their data was extracted from the EMR. Twenty-five (62.5%) of these patient enrollments were on clozapine. They were made up of 53.6% male, 81.9% White/Asian, 18.1% Black; 44.1% ages between 36 to 50 years old, 30.2% were aged 18 to 35 years old, and 25.7% greater than 50 years old. There was no difference in age, sex, race, ethnicity, and insurance type in ACT program between those using clozapine and those not on clozapine. There was a higher proportion of psychiatric hospitalizations among clozapine users compared with the non-clozapine user group (62.5% vs 41.5%, p = 0.019). However, the two groups did not differ from one another in terms of psychiatric emergency visits (p = 0.128) or frequency of ACT visits (p = 0.002). Conclusion Effective treatment that will reduce hospitalizations and the burden of chronic disability in patients with SMI would greatly reduce mental health care cost. Clozapine remains the gold standard in the treatment of refractory schizophrenia. But due to the risk of agranulocytosis, clozapine is underutilized. It was hoped that this study will support the use of clozapine in SMI patients. Disappointingly, the use of clozapine did not prevent relapses and hospitalizations in this patient population and patients on clozapine seemed to have increased hospitalizations, compared to those who were not on clozapine. Perhaps, a different outcome would have occurred if the focus was limited to the patients themselves who were on Clozapine and ascertain what the rate of hospitalization was before the start of clozapine vs after the use of clozapine.

Strategies for Psychiatric Rehabilitation and their Cognitive Outcomes in Schizophrenia: Review of Last Five-year Studies

BACKGROUND

Cognitive deficits are core features of Schizophrenia, showing poor response to antipsychotic treatment, therefore non-pharmacological rehabilitative approaches to such a symptom domain need to be identified. However, since not all patients with Schizophrenia exhibit the same cognitive impairment profile, individualized rehabilitative approaches should be set up.

OBJECTIVES

We explored the last five-year literature addressing the issue of cognitive dysfunction response to rehabilitative methodologies in Schizophrenia to identify possible predictors of response and individualized strategies to treat such a dysfunction.

CONCLUSION

A total of 76 studies were reviewed. Possible predictors of cognitive rehabilitation outcome were identified among patient-specific and approach-specific variables and a general overview of rehabilitative strategies used in the last five years has been depicted. Studies suggest the existence of multifaced and multi-domain variables that could significantly predict pro-cognitive effects of cognitive rehabilitation, which could also be useful for identifying individual-specific rehabilitation trajectories over time.An individualized rehabilitative approach to cognitive impairment in Schizophrenia is possible if taking into account both patient and approach specific predictors of outcomes.

The Use of Long-Acting Injectable Antipsychotics (LAI) in the Serious Mental Illness (SMI) Patients Enrolled in an Assertive Community Treatment (ACT) Program

Introduction

Patients with serious mental illness (SMI) experience highly intractable symptoms and great levels of dysfunction from their mental illness. Relapse prevention is critical as psychopathology, social and occupational functioning worsen with repeated psychotic episodes. Poor medication adherence is a strong predictor of relapse. Use of long-acting injectable antipsychotics (LAI) is among the most effective treatment specially in the context of non-adherence and yet remains underutilized. This single center retrospective study conducted using the electronic medical record (EMR) of patients enrolled in an Assertive Community Treatment (ACT) program at a community hospital was analyzed as to whether use of LAI among these patients reduce the frequency of emergency room visits and hospitalizations.

Materials and methods

Single center retrospective study using EMR of patients ages 20 and above who were enrolled at the ACT program at a community hospital from December 1, 2008 to December 31, 2018. Variables were collected from the EMR and de-identified into an Excel spreadsheet for data collation. Analysis was performed using SPSS software package.

Results

A total of 179 patients enrolled in the ACT program and their hospitalizations were extracted from the EMR. Seventy-six (42.5%) of these hospitalizations had patients on LAI. The hospitalizations were made up of 53.6% male, 81.9% White/Asian, 18.1% Black; 44.1% ages between 36 and 50 years old, 30.2% ages between 18 and 35 years old, and 25.7% greater than 50 years old. There was no difference in age, sex, race, ethnicity, insurance type and time spent in ACT program between those using LAI and those not on LAI. There was a higher proportion of psychiatric hospitalizations among LAI users compared with the non-LAI user group (57.9% vs 37.4%, p = 0.007). However, the two groups did not differ from one another in terms of psychiatric emergency visits (p = 0.266) or frequency of ACT visits (p = 0.062).

Conclusion

To date, all of the new-generation antipsychotic LAI have demonstrated a statistically and clinically significant decrease of relapse rates over placebo. Despite this, LAIs are not widely prescribed for a variety of reasons, including the reservations of patients, clinicians and payers. It would seem, though, that our patient population at the ACT program do not seem to benefit from use of LAI in relapse prevention. These results are counterintuitive in that one would expect that patients with serious mental illness would benefit from use of LAI. Perhaps, individuals with SMI are a different subset of population and they do not respond as well to LAI.

Societal Reentry of Prison Inmates With Mental Illness: Obstacles, Programs, and Best Practices

Societal reentry from prison presents a wide array of extreme challenges to inmates attempting to reintegrate with society. This process is significantly more daunting for inmates suffering from mental illness for several reasons. This paper examines the reentry process for inmates with mental illness. Three sample reentry programs (Forensic Assertive Community Treatment, Critical Time Intervention, and Thresholds' Prison Aftercare Program) that were developed for inmates with mental illness are discussed along with research testifying to the effectiveness of these programs. Finally, components that would comprise an ideal prison reentry program for mentally ill inmates are outlined, which include a three-phase structure and a focus on preparing both inmates and communities for the reentry process.

Individual factors associated with recidivism among mental health court program clients

There is growing evidence that diversion to a mental health court program (MHC) can reduce recidivism rates and improve the quality of life of clients. However, there is less known about MHC client characteristics and factors associated with recidivism. Yet, this information would be useful to increase the effectiveness of these programs. Cross-sectional quantitative data were collected on MHC clients in three consecutive years. Of the 155 program clients that were successfully interviewed, only 154 were included in the analysis due to one non-consent to collect further data from their case manager. The purpose of this secondary analysis was to examine "What individual factors are associated with recidivism among MHC program clients?" This analysis specifically explored the association of sex, age, low functional ability, homelessness, court site, and criminal history. From the multiple logistic regression results, the increased risk of recidivism was found to be significantly associated with younger clients and a prior criminal history. The results of this study suggest programs tailored to young adults and repeat offenders may be areas that MHCs could potentially focus on to increase their effectiveness.

Adaptations and Innovations to Minimize Service Disruption for Patients with Severe Mental Illness during COVID-19: Perspectives and Reflections from an Assertive Community Psychiatry Program

Changes to community psychiatry during COVID-19 are unprecedented and without clear guidelines. Minimizing disruption, ensuring quality care to the already vulnerable people with serious mental illness is crucial. We describe and reflect our adaptations and innovations at one community psychiatry program, based on three key principles. In (i) Defining and maintaining essential services while limiting risk of contagion, we discuss such strategies and ways to assess risks, implement infection control, and other creative solutions. In (ii) Promoting health and mitigating physical and mental health impacts, we reflect on prioritizing vulnerable patients, dealing with loss of community resources, adapting group programs, and providing psychoeducation, among others. In (iii) Promoting staff resilience and wellness, we describe building on strength of the staff early, addressing staff morale and avoiding moral injury, and valuing responsive leadership. We also identify limitations and potential further improvements, mindful that COVID-19 and similar crises are likely recurring realities.

Qualitative study of the implementation of the Continuity of Care and Rehabilitation Program for people with severe mental disorders in Peru

Objective.

Describe the implementation of the Continuity of Care and Rehabilitation Program (PCC-R) in community mental health centers (CSMCs, Spanish acronym) in Peru.

Methods.

Qualitative study of the implementation of the PCC-R in four CSMCs in Lima and La Libertad, Peru. Forty-two individual semi-structured interviews were conducted, as well as a focus group with five participants, for a total of 47 informants, including users, family members, and professionals involved in the design, implementation, and monitoring of the program.

Results.

The PCC-R is a key program for community mental health services in Peru and it enjoys broad acceptability. Providers and users report satisfaction with its results; however, the program lacks a policy document specifying its objectives, organization, and activities. This would explain the variability in its implementation. The PCC-R has limitations in terms of management of financial and human resources, and it is necessary to improve training and supervision. There is consensus on the need, usefulness, and viability of developing a system to monitor the PCC-R. Good practices and suggestions are presented with a view to addressing these challenges.

Conclusions.

The PCC-R is a flagship program for the CSMCs and for mental health reform in Peru. It has achieved broad acceptability among providers and users. Its implementation combines successes and difficulties, with pending tasks that include developing a policy document, improving resource management, strengthening training and supervision, and implementing a monitoring system for continuous improvement of the program.

[Qualitative study of the implementation of the Continuity of Care and Rehabilitation Program for people with severe mental disorders in PeruEstudo qualitativo sobre a implementação do Programa de Continuidade de Cuidados e Rehabilitação para pessoas com transtornos mentais graves no Peru]

Objetivo.

Describir la implementación del Programa de continuidad de cuidados y rehabilitación (PCC-R) en centros de salud mental comunitaria (CSMC) del Perú.

Métodos.

Estudio cualitativo sobre la implementación del PCC-R en cuatro CSMC de Lima y La Libertad, Perú. Se realizaron 42 entrevistas semiestructuradas individuales y un grupo focal con cinco participantes, para un total de 47 informantes entre usuarios, familiares y profesionales vinculados al diseño, la implementación y el monitoreo del PCC-R.

Resultados.

El PCC-R es un programa central de los servicios de salud mental comunitaria en Perú, goza de amplia aceptación y los prestadores y usuarios refieren estar satisfechos con sus resultados. Sin embargo, el programa carece de un documento normativo que detalle sus objetivos, organización y actividades, lo que explicaría la variabilidad en su aplicación. Existen limitaciones en la gestión de recursos financieros y humanos del PCC-R y necesidades de capacitación y supervisión, que deben ser mejoradas. Existe consenso sobre la necesidad, la utilidad y la viabilidad de desarrollar un sistema de monitoreo del PCC-R. Se recogen buenas prácticas y sugerencias para enfrentar estos retos.

Conclusiones.

El PCC-R es un programa insignia de los CSMC y de la reforma de la salud mental en Perú, y ha logrado amplia aceptación entre los prestadores y usuarios. Su implementación combina aciertos y dificultades, y revela tareas pendientes como desarrollar un documento normativo, mejorar la gestión de recursos, fortalecer la capacitación y acompañamiento, y aplicar un sistema de monitoreo para favorecer la mejora continua del programa.

Augmenting Evidence-Based Care With a Texting Mobile Interventionist: A Pilot Randomized Controlled Trial

OBJECTIVE

This study aimed to evaluate the feasibility and clinical utility of training intensive psychiatric community care team members to serve as "mobile interventionists" who engage patients in recovery-oriented texting exchanges.

METHODS

A 3-month pilot randomized controlled trial was conducted to compare the mobile interventionist approach as an add-on to assertive community treatment (ACT) versus ACT alone. Participants were 49 individuals with serious mental illness (62% with schizophrenia/schizoaffective disorder, 24% with bipolar disorder, and 14% with depression). Clinical outcomes were evaluated at baseline, posttreatment, and 6-month follow-up, and satisfaction was evaluated posttreatment.

RESULTS

The intervention appeared feasible (95% of participants assigned to the mobile interventionist arm initiated the intervention, texting on 69% of possible days and averaging four messages per day), acceptable (91% reported satisfaction), and safe (no adverse events reported). Exploratory posttreatment clinical effect estimations suggested greater reductions in the severity of paranoid thoughts (Cohen's d=-0.61) and depression (d=-0.59) and improved illness management (d=0.31) and recovery (d=0.23) in the mobile interventionist group.

CONCLUSIONS

Augmentation of care with a texting mobile interventionist proved to be feasible, acceptable, safe, and clinically promising. The findings are encouraging given the relative ease of training practitioners to serve as mobile interventionists, the low burden placed on patients and practitioners, and the simplicity of the technology. The technical resources are widely accessible to patients and practitioners, boding well for potential intervention scalability. When pandemics such as COVID-19 block the possibility of in-person patient-provider contact, evidence-based texting interventions can serve a crucial role in supporting continuity of care.

Psychosocial interventions in schizophrenia: Focus on guidelines

BACKGROUND

Schizophrenia is a lifelong condition with acute exacerbations and varying degrees of functional disability. Acute and long-term treatments are based on antipsychotic drugs, even if some domains of personal and social functioning are not addressed by psychopharmacotherapy. In fact, psychosocial interventions show a positive impact on patient's functioning and clinical outcome. In addition, psychosocial interventions are significantly associated with a lower number of relapses and hospitalizations in schizophrenia.

METHODS

An analytical review of the International Guidelines on Psychosocial Interventions in Schizophrenia has been performed; we included the National Institute for Health and Care Excellence (NICE) guidelines, the Scottish Intercollegiate Guidelines Network (SIGN) guidelines, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) guidelines, the Schizophrenia Patient Outcomes Research Team (PORT) guidelines and the American Psychiatric Association (APA) guidelines.

RESULTS

The international guidelines recommend psychosocial interventions as supportive treatments alongside pharmaceutical or psychotherapeutic ones.

CONCLUSION

More research studies need to be conducted and included in the updated version of the international guidelines to confirm the effectiveness of psychosocial interventions in the long-term outcome of schizophrenia.

Finding Common Ground for Diverging Policies for Persons with Severe Mental Illness

Two diametrically opposed positions predominate discourse for the care and treatment of persons with severe mental illness: anti-deinstitutionalization and anti-institutionalization. Both share the same goal of ensuring best quality of life for those with severe psychiatric disorders, but pathways to achieving this goal are very different and have resulted in much contention. Supporters of each position espouse a different belief system regarding people with psychiatric disorders and their presumed capabilities, placing varying emphasis on maximizing protection of the community versus protection of individual rights, and result in contrasting mental health policies and practice orientations. The authors delineate the history from which these positions evolved, consequent views, and policies and practices that emerged from these differing attitudes. The article culminates in a proposed practice approach that offers a more balanced approach to serving adults with mental illness -navigating risk management by preserving freedom and opportunities of risk while affording mutually satisfactory "risk control."

Umsetzung von Behandlungskontinuität im Versorgungsalltag – ein Vergleich zwischen zwei psychiatrischen Kliniken 1

Ziel der Studie Die starre Trennung von ambulanter und stationärer Versorgung im deutschen Gesundheitssystem verhindert eine Behandlungskontinuität, obwohl sie sich für psychiatrische Patienten als sehr wichtig erwiesen hat. Die vorliegende Studie analysiert die Behandlungskontinuität einer Modellklinik mit einem Gesamtbudget nach § 64b SGB V und konstantem Behandlungspersonal über alle Settings hinweg im Vergleich zu einer Kontrollklinik mit Regelfinanzierung ohne ein solches Team.

Methodik In einer prospektiven Kohortenstudie mit einem Beobachtungszeitraum von 20 Monaten wurden Daten zur Behandlungskontinuität von 220 Patienten der Modellklinik und 215 Patienten der Kontrollklinik erhoben.

Ergebnisse Die Modellklinik erreichte eine signifikant höhere Behandlungskontinuität als die Kontrollklinik, sowohl während der stationären Behandlung zum Zeitpunkt der Rekrutierung als auch in allen Settings während des Beobachtungszeitraums.

Schlussfolgerung Ein Gesamtbudget kann die notwendigen Voraussetzungen für eine flexiblere psychiatrische Versorgung und eine bessere Umsetzung der Behandlungskontinuität schaffen.