Resource Group Assertive Community Treatment (RACT) as a Tool of Empowerment for Clients with Severe Mental Illness: A Meta-Analysis

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.

Health and Social Case Management for the Inclusion of People Living with a Schizophrenic Disorder: The PASSVers Experience

The way the social protection system in France is organized frequently leads to coordination difficulties between the social and healthcare sectors. A health and social program has been implemented in a French medical-psychological center to optimize the coherence of the pathway for people living with schizophrenia. This study evaluated the way users and professionals perceive this program so as to assess the relevance of double case management. Semi-structured interviews were conducted with users (N = 21) and professionals (N = 11) of this program and then analyzed with Alceste software. The results highlight the overall satisfaction of the participants with the program, and the double case management was shown to be beneficial in supporting people living with schizophrenia in their life project. These results indicate that this program enabled the emergence of a collective empowerment, which could assist with the recovery process of schizophrenia.

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.

How a point-of-care dashboard facilitates co-production of health care and health for and with individuals with psychotic disorders: a mixed-methods case study

BACKGROUND

Individuals with psychotic disorders experience widespread treatment failures and risk early death. Sweden's largest department specializing in psychotic disorders sought to improve patients' health by developing a point-of-care dashboard to support joint planning and co-production of care. The dashboard was tested for 18 months and included more than 400 patients at two outpatient clinics.

METHODS

This study evaluates the dashboard by addressing two questions: 1) Can differences in health-related outcome measures be attributed to the use of the dashboard? 2) How did the case managers experience the accessibility, use, and usefulness of the dashboard for co-producing care with individuals with psychotic disorders? This mixed-method case study used both Patient-Reported Outcome Measures (PROM) and data from a focus group interview with case managers. Data collection and analysis were framed by the Clinical Adoption Meta Model (CAMM) phases: i) accessibility, ii) system use, iii) behavior, and iv) clinical outcomes. The PROM used was the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0), which assesses functional impairment and disability. Patients at clinics using the dashboard were matched with patients at clinics not using the dashboard. PROM data were compared using non-parametric statistics due to skewness in distribution. The focus group included five case managers who had experience using the dashboard with patients.

RESULTS

Compared to patients from clinics that did not use the dashboard, patients from clinics that did use the dashboard improved significantly overall (p = 0.045) and in the domain self-care (p = 0.041). Focus group participants reported that the dashboard supported data feedback-informed care and a proactive stance related to changes in patients' health. The dashboard helped users identify critical changes and enabled joint planning and evaluation.

CONCLUSION

Dashboard use was related to better patient health (WHODAS scores) when compared with matched patients from clinics that did not use the dashboard. In addition, case managers had a positive experience using the dashboard. Dashboard use might have lowered the risk for missing critical changes in patients' health while increasing the ability to proactively address needs. Future studies should investigate how to enhance patient co-production through use of supportive technologies.

Non-pharmacological interventions for schizophrenia—analysis of treatment guidelines and implementation in 12 Southeast European countries

This study aimed to analyze treatment guidelines of 12 SEE countries to identify non-pharmacological interventions recommended for schizophrenia, explore the evidence base supporting recommendations, and assess the implementation of recommended interventions. Desk and content analysis were employed to analyze the guidelines. Experts were surveyed across the 12 countries to assess availability of non-pharmacological treatments in leading mental health institutions, staff training, and inclusion in the official service price list. Most SEE countries have published treatment guidelines for schizophrenia focused on pharmacotherapy. Nine countries—Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Greece, Moldova, Montenegro, North Macedonia, and Serbia—included non-pharmacological interventions. The remaining three countries—Kosovo (UN Resolution), Romania, and Slovenia—have not published such treatment guidelines, however they are on offer in leading institutions. The median number of recommended interventions was seven (range 5–11). Family therapy and psychoeducation were recommended in most treatment guidelines. The majority of recommended interventions have a negative or mixed randomized controlled trial evidence base. A small proportion of leading mental health institutions includes these interventions in their official service price list. The interventions recommended in the treatment guidelines seem to be rarely implemented within mental health services in the SEE countries.

[Inpatient equivalent home-treatment: an overview]

Inpatient equivalent home-treatment (IEHT) was implemented in Germany in 2018. Persons with a mental disorder can be admitted to acute multiprofessional IEHT to avoid or shorten inpatient hospital treatment. Exclusion criteria are amongst others lack of consent of cohabitants or endangerment of self and others. Advantages of IEHT include normalization and reduction of stigma. Nevertheless, administrative requirements are high. While there is international evidence for home treatment and crisis resolution teams, there is still a lack of evidence for the concept of IEHT, although specific studies are currently being carried out (e.g. AktiV study financed by the Innovation Fund). Overall, IEHT is important for mental health services and should be further developed.

[Characteristics of psychoses in adolescence-Longitudinal data of integrated care]

BACKGROUND

Integrated care according to the Hamburg model combines therapeutic assertive community treatment (TACT) with initiatives for early detection and early treatment of schizophrenia and affective psychoses. The aim of this study was to identify the clinical characteristics of adolescents in comparison to adult patients and to derive knowledge for transition-specific treatment approaches.

METHODOLOGY

Sociodemographic and clinical variables as well as treatment performance and clinical outcome were investigated over a period of 12 months in 167 patients with psychoses (16-25 years, n = 88; and >25 years, n = 79).

RESULTS

Patients with psychosis in adolescence had significantly more outpatient treatment contacts (3.5/week vs. 1.6/week; p < 0.001), while adults were hospitalized for twice as long (10 days vs. 21 days; p = 0.003). The duration of untreated psychoses was significantly shorter in the adolescent group than in adults (122 weeks vs. 208 weeks; p = 0.002). The proportion of comorbid mental disorders was significantly higher in the adolescent group (87% vs. 63%; p < 0.001). In addition, the adolescence patients already showed greater impairment of daily functions and a higher severity of illness at the start of treatment.

DISCUSSION

The treatment of psychoses in adolescence was characterized by a particularly high need for flexibility across all sectors and support systems, taking comorbid problem areas into account. Care models for adolescents and young adults with psychoses should therefore combine treatment approaches for severely ill patients with transition psychiatric interventions to avoid breaks in care and to meet the complex requirements of young patients with severe mental illnesses.

Risk Factors for Relapse in People with Severe Mental Disorders during the COVID-19 Pandemic: A Multicenter Retrospective Study

Background: Evidence suggests that different variables associated with the COVID-19 pandemic may increase the risk of relapse in people with Severe Mental Disorders (SMDs). However, no studies have yet looked closely at the different risk factors involved to determine their influence on the worsening of these patients’ illnesses. Objective: To analyze which variables related to the COVID-19 pandemic have increased the risk of relapse in patients with SMDs. Method: A multicenter retrospective cohort study in which data were collected from 270 patients with mental disorders who had been under follow-up in day hospitals during the year 2020. Results: The proportion of full mental health inpatient admissions was significantly higher in those who lost their employment (40.7% vs. 18.1%; p = 0.01), in those who were not receiving psychotherapy interventions (33.9% vs. 16.6%; p = 0.006), and in those who were not receiving occupational therapy (25.7% vs. 13.6%: p = 0.013). Significant associations were detected between urgent mental health consultations, the number of COVID-19 symptoms (B = 0.274; p = 0.02), and the low-income group (1.2424 vs. 0.4583; p = 0.018). Conclusions: COVID-19 symptoms and certain consequences of the pandemic, such as loss of employment, economic hardship, and loss of interventions, have brought about clinical worsening in people with SMDs. Knowledge of these factors is important for health-related decision-making in future outbreaks or pandemics.

The Greek Hybrid Version of the Assertive Community Treatment Model: A Perspective View between Challenges and Limitations

The Assertive Community Treatment (ACT) model of care has been long considered to be effective in the management of patients with severe mental illness (SMI) in most Western countries. The implementation of the original ACT model may be particularly challenging in rural and remote communities with small and dispersed populations and lack of adequate mental health services. Rural programs may have to adapt the model and modify the ACT fidelity standards to accommodate these limitations, and this is the rationale for the introduction of more flexible, hybrid ACT models. In rural Greece, the so called Mobile Mental Health Units (MMHUs) are well-established community mental health services. For patients with SMI that have difficulties engaging with treatment services, the new hybrid ACT model has been recently launched. The objective of this manuscript is to present the recently launched hybrid ACT model in rural areas in Greece and to explore the challenges and limitations in its implementation from the experience of a team of mental health professionals with ACT experience. Referral criteria have not been strictly set, but the number of previous relapses and hospitalizations is taken under consideration, as well as the history of poor treatment adherence and disengagement from mental health services. The main limitation in the implementation of the hybrid ACT service is that it has been introduced in several areas in the absence of a pre-existing community mental health service. This may impact referrals and limit focus on the difficult cases of patients with SMI, thus making the evaluation of the model inapplicable.

Effectiveness of Resource Groups for Improving Empowerment, Quality of Life, and Functioning of People With Severe Mental Illness: A Randomized Clinical Trial

Importance

Although the importance of recovery-oriented care for people with severe mental illness (SMI) is widely acknowledged, essential elements such as personalization and involvement of significant others are not adequately implemented in practice.

Objective

To determine whether using resource groups (RGs) within flexible assertive community treatment (FACT) has favorable effects on empowerment and recovery-related outcomes in people with SMI.

Design, Setting, and Participants

This assessor-blind, multisite randomized clinical trial was conducted from September 1, 2017, to September 30, 2020, with follow-up at 9 and 18 months. A total of 158 participants aged 18 to 65 years meeting the criteria for SMI were randomly allocated to FACT plus RG vs FACT as usual (1:1) in 20 FACT teams throughout the Netherlands. Data were analyzed from September 1, 2020, to January 31, 2021. The study was prespecified in the trial protocol and data from the intent-to-treat population were analyzed.

Interventions

In the FACT plus RG condition, patients chose members from their informal and formal networks to form an RG that meets quarterly to discuss self-formulated recovery goals. The RG was integrated into the multidisciplinary support provided by the FACT team. In the FACT as-usual condition, empowerment (defined as overcoming powerlessness and gaining control of one's life) and involvement of significant others was also part of the provided care, but without the structure of the RG.

Main Outcomes and Measures

The primary outcome was self-reported empowerment, measured with the Netherlands Empowerment List.

Results

A total of 158 participants with SMI (median age, 38 [median absolute deviation, 13] years; 93 men [58.9%]) were randomized to FACT plus RG (n = 80) or FACT as usual (n = 78) care. Intention-to-treat analyses showed that randomization to the RG condition was associated with a clinically significant increase in empowerment (Cohen d, 0.54; 95% CI, 0.21-0.86) and improved outcomes with small to medium effect sizes in terms of quality of life (Cohen d, 0.25; 95% CI, -0.07 to 0.56), personal recovery (Cohen d, 0.38; 95% CI, 0.06-0.69), quality of social contact (Cohen d, 0.24; 95% CI, -0.07 to 0.56), disability (Cohen d, 0.29; 95% CI, -0.03 to 0.60), general functioning (Cohen d, 0.30; 95% CI, -0.01 to 0.62), and social functioning (Cohen d, 0.28; 95% CI, -0.04 to 0.59). No differences between conditions were found regarding psychopathological symptoms, attachment, frequency of social contact, and employment. Compared with FACT as usual, participants who stayed with the assigned treatment in the RG condition were more satisfied with treatment at 9 (Cohen d = 0.45; t135 = -2.62; P = .009) and 18 (Cohen d = 0.41; t116 = -2.22; P = .02) months.

Conclusions and Relevance

These findings show that working with RGs improves empowerment and other mental health outcomes in people with SMI who receive community-based mental health services. This method of network-oriented care empowers people with SMI within their own environment.

Trial Registration

Netherlands Trial Register Identifier: NL6548.

Relatives' Experiences of Mental Health Care, Family Burden and Family Stigma: Does Participation in Patient-Appointed Resource Group Assertive Community Treatment (RACT) Make a Difference?

The aim of this exploratory cross-sectional study was to investigate the experiences of relatives of individuals with severe mental illness with and without participation in patient-appointed Resource Group Assertive Community Treatment (RACT). A total of 139 relatives (79 with and 60 without RACT) completed the Family Involvement and Alienation Questionnaire, the Burden Inventory for Relatives of Persons with Psychotic Disturbances, and the family version of the Inventory of Stigmatizing Experiences. We found that relatives participating in RACT experienced a more positive approach from the healthcare professionals, as well as a lower degree of alienation from the provision of care. Relatives who did not participate in RACT were more afraid that their ill next of kin would hurt someone. No other differences in family burden were found. Experiences of family stigmatization were similar in both groups. In conclusion, participating in patient-appointed RACT may contribute to a higher level of satisfaction for relatives in their encounter with healthcare professionals and a more positive alliance. Implementation of RACT in new settings would require adaptation to local conditions to facilitate cooperation between healthcare staff and other relevant services. Staff training focuses on the case manager function and needs assessment, as well as how to create an alliance with the patient and his/her relatives.

[Evidence on the effects of crisis resolution teams, home treatment and assertive outreach for people with mental disorders in Germany, Austria and Switzerland - a systematic review]

BACKGROUND

Based on international randomized controlled trials (RCT) the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) recommends acute treatment in the domestic environment (AHU) and intensive outreach treatment (IAB) with the highest level of evidence; however, due to large differences in national healthcare systems the transference of results from international studies to the healthcare systems in Germany, Austria and Switzerland could be limited.

OBJECTIVE

Evaluation of studies on outreach psychiatric treatment forms in Germany, Austria and Switzerland and discussion of the results in the light of international evidence.

MATERIAL AND METHODS

A systematic literature search for clinical trials on outreach community treatment from Germany, Austria and Switzerland was conducted in the PubMed database.

RESULTS

A total of 19 publications were identified which could be assigned to 5 publications on 4 studies with 2857 patients on AHU and 14 publications on 10 studies with 3207 patients on IAB. The studies on AHU showed this treatment form to be superior regarding the duration of inpatient stay and healthcare costs. The studies on IAB showed more positive outcomes in comparison to controls regarding symptoms, severity of illness, substance abuse, functioning level, remission, satisfaction with treatment, quality of life, healthcare costs, work and housing situations.

CONCLUSION

The studies from Germany, Austria, and Switzerland suggest that outreach community treatment is superior regarding several outcome parameters. Thus, there are no indications suggesting that international evidence could not be valid for these countries. Additionally, with one RCT for AHU and one for IAB the requirements for an evidence level of 1b for outreach community treatment in the healthcare systems in question are fulfilled.

Interpersonal Relations Within the Context of Resource Groups for People With Severe Mental Illness: A Narrative Approach

Objective: The resource group method intends to promote patients' agency and self-management and to organize meaningful partnerships between patients and their informal and formal support systems. The aim of this study was to enhance the understanding of interpersonal dynamics that arise within resource groups for people with severe mental illness. Insight into these unfolding processes would enable improved implementation of the resource group method so that it contributes to establishing a positive social environment, which can lead to more enduring recovery. Methodology: We performed a narrative analysis of transcripts and field notes obtained in a longitudinal, qualitative study on the resource group method. The stories of four different resource groups were reconstructed and analyzed in depth. Data included a total of 36 interviews (with patients, significant others, and mental health professionals) and 18 observations of resource group meetings. Results: The degree to which the resource group method actually contributes to recovery was based on the extent to which the existing roles of and patterns between the patient and his/her resource group members were altered. Breaking through old patterns of inequality and the joint search for a new balance in relationships proved to be crucial processes for establishing an empowering resource group. The four cases showed that it takes time, patience, and small steps back and forth to overcome the struggles and fears related to finding new ways of relating to each other. An honest and reflective atmosphere in which all participants are encouraged to participate and be curious about themselves and each other is essential for changes in interpersonal dynamics to emerge. Such changes pave the way for individuals with SMI to find their own voices and pursue their unique recovery journeys. Conclusions: The functioning of the resource group and the ability of the involved members to respond in new ways are important when working toward the patient's recovery goals. The resource group method should therefore not be considered an intervention to organize informal support for the patient, but a platform to expose and adjust the functioning of the patient's social network as a whole.

Decrease of hospitalizations and length of hospital stay in patients with schizophrenia spectrum disorders treated in a community mental health service in rural Greece

BACKGROUND

The treatment of severe and chronic mental disorders, such as schizophrenia and related syndromes, is largely based on community mental health services.

AIMS

The objective of the present study was to assess hospital admissions and length of hospital stay in patients with schizophrenia and related disorders, who are engaged to treatment with a Mobile Mental Health Unit (MMHU I-T) in a defined rural catchment area in Greece.

METHOD

Data were retrieved retrospectively for 76 patients with schizophrenia and related disorders. For each patient, comparison was made for the same interval prior and after engagement to treatment with the MMHU I-T.

RESULTS

The average age of patients was 56 years and the mean illness duration was 28 years. The mean follow-up duration was 5.3 years. There was a statistically significant decrease in the annual average of the number of voluntary and involuntary hospitalizations and on days of hospital stay after treatment engagement with the MMHU I-T.

CONCLUSIONS

Treatment of schizophrenia spectrum disorders in rural residents by the MMHUs may contribute to the reduction of patients' admissions and length of hospital stay. Future research should address the cost-effectiveness of such interventions.

Functioning in community-dwelling patients with schizophrenia spectrum disorders in rural Greece

BACKGROUND

There is a dearth of studies on functioning in patients with psychotic disorders in rural areas.

AIM

The objective of this study was to assess functioning in a population-based sample of patients with psychotic disorders who live in rural, remote and deprived areas in Greece, and to explore the differences in functioning across ages.

METHODS

The sample consisted of 61 patients with psychotic disorders that were engaged to treatment with a community mental health service. The mean age of patients was 54.2 years, and the mean illness duration was 26.5 years.

RESULTS

A total of 23 patients (37.7%) had score in the Global Assessment of Functioning scale >60, and were rated as adequately functioning, and 18 patients (29.5%) had score in Clinical Global Impression scale-Schizophrenia ⩽3 and could be rated as mildly or minimally ill. Functioning was found to be inversely related to the patients' symptomatology. No correlation with age was found.

CONCLUSION

This study suggests that a large proportion of patients with psychotic disorders in rural Greece may achieve a satisfactory level of functioning in the long-term, across the whole age range despite the not completely remitted symptomatology. More research is needed to clarify the factors associated with rural residency that may account for patients' functioning.

Embracing the Social Nature of Recovery: A Qualitative Study on the Resource Group Method for People With Severe Mental Illness

Objective: The resource group method for people with severe mental illness might provide a useful framework to facilitate patient's empowerment and systematically engage significant others. However, no research has explored the perspectives and experiences of patients and their significant others. This is crucial for better adjustment to the needs of the people using the method. The aim of this study was to develop a useful framework for a deeper understanding of the resource group method and its outcomes. Method: The study used a longitudinal, qualitative multiple case-study design based on grounded theory methodology. During a period of 2 years, the developments and processes in eight resource groups were explored by conducting a total of 74 interviews (e.g., with patients, significant others, and mental health professionals) and 26 observations of resource group meetings. Results: Analysis showed that a well-functioning resource group set the stage for five processes to unfold: (i) experience of support; (ii) acknowledgment of significant others; (iii) activation; (iv) openness; and (v) integration. These processes facilitated recovery both in terms of an arousing curiosity within the patient as well as increasing reciprocity and equality in their social relations. In addition, the method emphasized the uniqueness of each recovery journey, thereby providing a framework to shape recovery-oriented care. The analysis also revealed three hindering factors: (i) embedding and implementation issues; (ii) predominant network; and (iii) tensions inherent in the resource group setting. Conclusion: Working according to the resource group method involves that the person's recovery work becomes a social process that takes place in relation to the social environment and everyday life in which it is important to acknowledge and integrate the needs of significant others in treatment and care. This study provides a first step toward a multidimensional comprehension of the resource group method, the working mechanisms and its influence on recovery for people with severe mental illness.

Joining forces to improve psychosocial care for people with cognitive deficits across diagnoses: social health as a common framework

Cognitive deficits such as memory problems have a major impact on independence in daily life and participation in society in several populations, such as people with dementia, brain injury (i.e. stroke) or a severe mental illness such as schizophrenia. Similarities in the impact on participation and well-being have resulted in the development of comparable psychosocial interventions across populations, aiming to support people to adapt to cognitive deficits or by adapting the environment. These interventions are developed separately, without using the expertise in other fields. We argue that each of the fields and the field of psychosocial care in general would benefit from closer collaboration on development and evaluation of innovative psychosocial interventions. Collaboration has been complicated by the use of different care models and theoretical frameworks, each with their own terminology. The concept of social health - the ability to participate in work or other meaningful activities and to feel healthy despite a condition - translates to the leading care models within the fields of dementia, brain injury and severe mental illness. The concept of social health provides a common language and framework. In this paper, we elaborate on strategies for collaboration using examples of interventions to improve social health.

Recovery for all in the community; position paper on principles and key elements of community-based mental health care

BACKGROUND

Service providers throughout Europe have identified the need to define how high-quality community-based mental health care looks to organize their own services and to inform governments, commissioners and funders. In 2016, representatives of mental health care service providers, networks, umbrella organizations and knowledge institutes in Europe came together to establish the European Community Mental Health Services Provider (EUCOMS) Network. This network developed a shared vision on the principles and key elements of community mental health care in different contexts. The result is a comprehensive consensus paper, of which this position paper is an outline. With this paper the network wants to contribute to the discussion on how to improve structures in mental healthcare, and to narrow the gap between evidence, policy and practice in Europe.

MAIN TEXT

The development of the consensus paper started with an expert workshop in April 2016. An assigned writing group representing the workshop participants built upon the outcomes of this meeting and developed the consensus paper with the input from 100 European counterparts through two additional work groups, and two structured feedback rounds via email. High quality community-based mental health care: 1) protects human rights; 2) has a public health focus; 3) supports service users in their recovery journey; 4) makes use of effective interventions based on evidence and client goals; 5) promotes a wide network of support in the community and; 6) makes use of peer expertise in service design and delivery. Each principle is illustrated with good practices from European service providers that are members of the EUCOMS Network.

CONCLUSIONS

Discussion among EUCOMS network members resulted in a blueprint for a regional model of integrated mental health care based upon six principles.

The resource group method in severe mental illness: study protocol for a randomized controlled trial and a qualitative multiple case study

BACKGROUND

The resource group method provides a structure to facilitate patients' empowerment and recovery processes, and to systematically engage significant others in treatment and care. A patient chooses members of a resource group (RG) that will work together on fulfilling patients' recovery plan. By adopting shared decision-making processes and stimulating collaboration of different support systems, a broad and continuous support of patients' chosen goals and wishes is preserved and problem solving and communication skills of the RG members are addressed.

OBJECTIVE

The objectives of this study are (1) to establish the effectiveness of the RG method in increasing empowerment in patients with severe mental illnesses (SMI) in the Netherlands; (2) to investigate the cost-effectiveness and cost utility of the RG method; and (3) to qualitatively explore its dynamics and processes.

METHODS/DESIGN

This multisite randomized controlled trial will compare the effects of the RG-method integrated in Flexible Assertive Community Treatment (FACT) (90 patients) with those of standard FACT (90 patients). Baseline assessments and 9-month and 18-month follow-up assessments will be conducted in face-to-face home visits. The primary outcome measure, empowerment, will be assessed using the Netherlands Empowerment List (NEL). The secondary outcomes will be quality of life (MANSA); personal, community and clinical recovery (I.ROC); general, social and community functioning (WHODAS 2.0); general psychopathological signs and symptoms (BSI-18); and societal costs (TiC-P). An economic evaluation of the cost-effectiveness and cost utility of the RG method will also be conducted. A qualitative multiple case-study will be added to collect patients', RG members' and professionals' perspectives by in-depth interviews, observations and focus groups.

DISCUSSION

This trial will be the first to study the effects of the RG method on empowerment in patients with SMI. By combining clinical-effectiveness data with an economic evaluation and in-depth qualitative information from primary stakeholders, it will provide a detailed overview of the RG method as a mean of improving care for patients with SMI.Trial registration The study has been registered in the Dutch Trial Register, identifier: NTR6737, September 2017.

Nursing and the Emergence of Egoless Care: A Discussion on Social Engineering in Mental Health

The narrowing of the diverse fields of psychiatry to just the single dimension of the biomedical model has resulted in a situation where professions with a focus on curing (psychiatrists and psychologists) are favoured over those with a focus on caring and encouraging near communities to care for each other (nurses). The social engineering of mental problems leads to a state of helplessness. This paper contributes to an understanding of the barriers to utilise the social resources of people with mental health problems and argues for forms of "indirect social engineering" and "egoless care," and, ultimately, a rediscovery of nursing, using the mental health care in the Netherlands as a case study.

Early detection and integrated care for adolescents and young adults with severe psychotic disorders: rationales and design of the Integrated Care in Early Psychosis Study (ACCESS III)

AIM

The Integrated Care in Early Psychosis (ACCESS III) Study examined the efficacy and cost-effectiveness of a combined intervention consisting of strategies to improve early detection and quality of care (integrated care including therapeutic assertive community treatment) in adolescents and young adults in the early phase of a severe psychotic disorder from 2011 to 2014.

METHODS

This is a prospective, single-centre, 1-year cohort study comparing an intervention condition (early detection plus integrated care, n = 120) to the historical control condition (standard care, SC, n = 105) for adolescents and young adults aged 12-29 years suffering from a severe, early-phase psychotic disorder (i.e. within 2 years of treatment).

RESULTS

Primary outcome is the rate of combined symptomatic (i.e. Positive and Negative Syndrome Scale (PANSS) criteria) and functional (i.e. Global Assessment of Functioning scale (GAF) ≥ 60 points criterion) remission over at least 6 months at study endpoint. Secondary outcome comprises the comparison of the reduction in the duration of untreated psychosis within the 4-year study duration between integrated care and SC, course of psychopathology, functioning, quality of life, satisfaction with care, cost and quality-adjusted life years (QALYs) in comparison to a historical control group.

CONCLUSION

To the authors' knowledge, this is the first study assessing the efficacy and cost-effectiveness of a combined intervention consisting of early detection strategies and strategies to improve quality of care in both adolescents and young adults with early-phase psychosis. The results will be published in 2016.

Family Group Conferencing as a Catalyst for Recovery and Ownership in Mental Health

BACKGROUND

Recovery is a journey not only of personal change but also of social reengagement. It underlines the essence of social environments that are supportive to the recovery of people with ongoing mental health issues. The process of recovery also affects other actors, and likewise these actors exert their influence on the recovery of their family member or friend.

OBJECTIVE

Since 2009, we have been studying whether the decision-making model called family group conferencing (FGC) helps mental health clients increase their self-reliance. The essence of FGC is that individuals who experience problems have the opportunity to develop a plan together with people from their social network. Clients in mental health have to deal with different forms of disempowerment, especially when they are threatened with compulsory measures. It is an aim to help them regain ownership over their problems as well as over the potential solutions.

METHOD

From 2011 to 2013, we evaluated 41 family group conferences that were organized for clients in a public mental health care setting in the north of the Netherlands. Each conference was analyzed in a qualitative case study framework.

RESULTS

This article highlights two case portraits. It gives insight into how ownership was restored and what this meant regarding clients' recovery process.

CONCLUSION

FGC seems a promising tool to shift the attention from disorders and inabilities to capacities and the rediscovery of social resources.

Does one size really fit all? The effectiveness of a non-diagnosis-specific integrated mental health care program in Germany in a prospective, parallel-group controlled multi-centre trial

BACKGROUND

The Network for Mental Health (NWpG-IC) is an integrated mental health care program implemented in 2009 by cooperation between health insurance companies and community mental health providers in Germany. Meanwhile about 10,000 patients have been enrolled. This is the first study evaluating the effectiveness of the program in comparison to standard mental health care in Germany.

METHODS

In a parallel-group controlled trial over 18 months conducted in five regions across Germany, a total of 260 patients enrolled in NWpG-IC and 251 patients in standard mental health care (TAU) were recruited between August 2013 and November 2014. The NWpG-IC patients had access to special services such as community-based multi-professional teams, case management, crisis intervention and family-oriented psychoeducation in addition to standard mental health care. The primary outcome empowerment (EPAS) and the secondary outcomes quality of life (WHO-QoL-BREF), satisfaction with psychiatric treatment (CSQ-8), psychosocial and clinical impairment (HoNOS) and information about mental health service needs (CAN) were measured four times at 6-month intervals. Linear mixed-effect regression models were used to estimate the main effects and interaction effects of treatment, time and primary diagnosis. Due to the non-randomised group assignment, propensity score adjustment was used to control the selection bias.

RESULTS

NWpG-IC and TAU groups did not differ with respect to most primary and secondary outcomes in our participating patients who showed a broad spectrum of psychiatric diagnoses and illness severities. However, a significant improvement in terms of patients' satisfaction with psychiatric care and their perception of treatment participation in favour of the NWpG-IC group was found.

CONCLUSIONS

Providing integrated mental health care for unspecific mentally ill target groups increases treatment participation and service satisfaction but seems not suitable to enhance the overall outcomes of mental health care in Germany. The implementation of strategies for ameliorating the needs orientation of the NWpG-IC should be considered.

TRIAL REGISTRATION

German Clinical Trial Register DRKS00005111 , registered 26 July 2013.

Family Group Conferencing-Its Added Value in Mental Health Care

Worldwide, there is a growing emphasis on reducing coercion and involving social networks in the care of mental health clients. Nurses should encourage their clients to regain control over their lives, preferably with less coercion and with help from their social network. During four years, a Dutch evaluation study was deployed to determine the applicability of mobilising help from social networks of people with psychiatric problems. Specifically the potential of Family Group Conferencing was examined. In this discursive article the question, 'what Family Group Conferencing adds to the existing methods that aim to reduce coercion in mental health care and promote inclusion' is addressed.

Effects of assisted outpatient treatment and health care services on psychotic symptoms

RATIONALE

An ongoing debate concerns acceptability, benefits, and shortcomings of coercive treatment such as assisted outpatient treatment (AOT). The hypothesis that involuntary commitment to outpatient treatment may lead to a better clinical outcome for a subgroup of persons with severe mental illness (SMI) is controversial. Nonetheless, positive effects of AOT may be mediated by an increased availability of healthcare resources or increased service use.

OBJECTIVE

The purpose of the present study is to evaluate the course of delusions, hallucinations, and negative symptoms among patients with SMI receiving AOT compared to patients receiving non-compulsory treatment (NCT). Moreover, we assessed if the effects of AOT on psychotic symptoms were mediated by increased healthcare service use.

METHODS

This study used a quasi-experimental design to examine the effect of AOT and the use of healthcare services on psychotic symptoms. In total, 76 (41.3%) participants with SMI received AOT, and 108 (58.7%) received NCT. The participants were interviewed at baseline every 3 months up to 1 year. Propensity score matching was used to control for group differences.

RESULTS

In the basic model, AOT was associated with lower severity of psychotic symptoms over all follow-up points. In the model including healthcare service use, the frequency of case manager visits predicted a reduction in severity of all psychotic symptoms. The frequency of visits to the outpatient clinics, frequency of emergency room, and psychiatrist visits were independently associated with lower levels of delusional symptoms. Psychiatrist visits were related to a decrease in negative symptoms.

CONCLUSION

Results indicate that the treatment benefits of AOT are enhanced with the increased use of mental healthcare services, suggesting that the positive effect of AOT on psychotic symptoms is related to the availability of mental healthcare service use. Coercive outpatient treatment might be more effective through greater use of intensive services.

Schizophrenia in the Netherlands: Continuity of Care with Better Quality of Care for Less Medical Costs

Background

Patients with schizophrenia need continuous elective medical care which includes psychiatric treatment, antipsychotic medication and somatic health care. The objective of this study is to assess whether continuous elective psychiatric is associated with less health care costs due to less inpatient treatment.

Methods

Data concerning antipsychotic medication and psychiatric and somatic health care of patients with schizophrenia in the claims data of Agis Health Insurance were collected over 2008–2011 in the Netherlands. Included were 7,392 patients under 70 years of age with schizophrenia in 2008, insured during the whole period. We assessed the relationship between continuous elective psychiatric care and the outcome measures: acute treatment events, psychiatric hospitalization, somatic care and health care costs.

Results

Continuous elective psychiatric care was accessed by 73% of the patients during the entire three year follow-up period. These patients received mostly outpatient care and accessed more somatic care, at a total cost of €36,485 in three years, than those without continuous care. In the groups accessing fewer or no years of elective care 34%-68% had inpatient care and acute treatment events, while accessing less somatic care at average total costs of medical care from €33,284 to €64,509.

Conclusions

Continuous elective mental and somatic care for 73% of the patients with schizophrenia showed better quality of care at lower costs. Providing continuous elective care to the remaining patients may improve health while reducing acute illness episodes.

[Integrated care for patients with first and multiple episodes of severe psychotic illnesses: 3-year results of the Hamburg model]

BACKGROUND

The so-called "Hamburg model" is a designated integrated care model according to § 140 of the Social Code Book (SGB) V for psychosis patients fulfilling the definition of severe mental illness (SMI).

OBJECTIVES

Description of the model and evaluation of efficacy of all patients being treated for ≥ 3 years.

MATERIALS AND METHODS

Service entry illness status, course of illness, and interventions were assessed within a continuous quality assurance study. One hundred and fifty-eight patients who fulfilled the criterion of being treated for ≥ 3 years were analyzed.

RESULTS

At service entry, SMI were among others mirrored by a high level of psychopathology (Brief Psychiatric Rating Scale [BPRS]: 80.3) and severity of illness (Clinical Global Impression Severity [CGI-S]/Clinical Global Impression Bipolar scales [CGI-BP]: 5.8), low functioning level (Global Assessment of Functioning scale [GAF]: 35.9), and high rates of comorbid psychiatric (94.3 %) and somatic (81.6 %) disorders. Only 8 patients (5.1 %) disengaged from the service within the 3-year treatment period. The course of the illness over 3 years showed significant and stable improvements in psychopathology (BPRS: p < 0.001), the severity of illness (CGI-S/CGI-BP: p < 0.001), functioning (GAF: p < 0.001), quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire [Q-LES-Q-18]: p < 0.001), and satisfaction with care (Client Satisfaction Questionnaire [CSQ-8]: 2.0 to 3.3; p = 0.164; nonsignificant because of early improvements). Further, compulsory admissions were reduced and medication adherence in addition to working ability improved (all p < 0.001). Data on interventions showed a continuously high frequency of outpatient interventions over time (on average 112.0 per year), a high percentage of patients in psychotherapy (67 %), and a nearly 90 % reduction in inpatient treatment days from year 1 to year 3.

CONCLUSION

Integrated care in severely ill patients with psychotic disorders leads to multidimensional illness improvement and stabilization by offering intensive outpatient care.

The Hourglass Model: Are There Structural Problems with the Scarcity of Positive Results for Flexible ACT?

The aim of the present article was to discuss the commentary by van Veldhuizen, Delespaul and Mulder (2015) regarding the review by Nordén and Norlander (2014) based on five empirical articles about Flexible Assertive Community Treatment (FACT). Veldhuizen et al. agree on that there is insufficient evidence for the effectiveness of FACT. However, van Veldhuizen et al. avoid a discussion of the lack of positive results despite extensive research during several years and therefore an analysis of why FACT did not fare better is missing. According to FACT it is an advantage that one single team spans the entire chain of care and rehabilitation, but no evidence is given for such an opinion. Instead there may be difficulties for the staff to shift between psychiatric care and psychiatric rehabilitation and the clients perhaps don’t want to encounter the same professional team during all phases of care and rehabilitation.

Challenges Highlighted During Peer Supervision by Mental Health Nurses and Social Workers Recently Trained as Case Managers in Sweden

This study looked at 13 mental health nurses and social workers who were recently trained as case managers (CMs) and the work-related challenges they faced in community mental health services. Data were collected during ten peer supervisions sessions. Participants expressed pride and enthusiasm about their new function as CMs, but they also acknowledged that their new position meant they had to confront existing systems and posed several challenges, including organizational hindrances, economic prerequisites, nominated administrators, role function, and model fidelity. We conclude that the existing organizations seemed to be unprepared to hold and facilitate more person-centered approaches, such as designating CMs. The model fidelity is important, but has to be flexible according to clients' daily state.

How many Assertive Community Treatment Teams are Needed in Japan? Estimate from Need Survey in Sendai City

Despite the increasing ACT teams in Japan, no research exists on the need of ACT within the Japanese mental health system. The aim of this study was to describe the needs and feasibility of ACT teams. Furthermore, we estimated the number of po-tential ACT users and ACT teams needed in Japan. This study consists of two cross-sectional surveys in Sendai city. The primary survey was a self-completed questionnaire on the need and feasibility of ACT. In the secondary survey, the number of patients eligible for ACT was estimated based on primary physicians’ evaluations. In the primary survey, 17 of the 57 in-stitutions responded (response rate 29.8%). All respondents answered that ACT teams are needed in the city of Sendai and “Crisis response” was as the most needed role of ACT. Based on the results of the secondary survey, approximately 900 to 3,600 patients in Sendai are estimated to be eligible for ACT. This finding indicates that the estimated number of ACT teams needed for 100,000 populations is from 0.9 to 3.5 in Japan, a result that is in general agreement with data from other coun-tries.

Absence of Positive Results for Flexible Assertive Community Treatment. What is the next Approach?

Aims were to review results of the five psychiatric studies on Flexible Assertive Community Treatment (FACT) published during 2007-2013, and to compare FACT with Resource-group Assertive Community Treatment (RACT) which specifically focuses on empowerment and rehabilitation of clients in the stable phase. During 2007 articles appeared in scientific journals arguing in favor of the need for the development of the treatment method Assertive Community Treatment (ACT). A particularly notable article was one that featured a Dutch version of ACT, namely FACT. The initiative received great sympathy given that clinical practice and research showed that both American and British versions of ACT were in need of new impulses to be able to maintain an optimal level of care. Seven years have passed since the Dutch model was international presented and five empirical studies about FACT have been published and therefore a first critical examination of FACT was conducted. The review indicated that the five empirical studies failed to show that FACT involves improvement of the clients in terms of symptoms, functioning, or well-being. The conclusions were that at present there is no evidence for FACT and that RACT with its small, flexible ACT teams, where the client him/herself is included and decides on the treatment goals, might be able to provide new impulses and a new vitality to the treatment mode of an assertive community treatment.

Effects of interferential care: a community-based care program for persons with severe problems on several life areas

BACKGROUND AND AIMS

Interferential care differs from the current community-based care programs in that it targets a larger, heterogeneous group and combines brokerage and full service elements in a multi-organizational care team. The team provides all the services itself, but with the aim to prepare clients within a few months for referral to regular (ambulant) healthcare services. The aim of this study was to assess the effectiveness of interferential care.

METHODS

In a multisite, pretest-posttest design, 523 patients of three interferential care teams were followed. Quality of life, problem severity, problems with referral and engagement were assessed at baseline, at referral and again after 6 months. Analyses were performed using linear mixed modeling.

RESULTS

Interferential care showed moderate to strong effects on quality of life and problem severity. These effects persisted (quality of life) or further improved (problem severity) until follow-up 6 months after referral to regular services. There were also small effects on both engagement and problems with referral.

CONCLUSION

Interferential care offers significant improvements in quality of life and problem severity in persons who have severe problems on several life areas and who are currently not reached by healthcare services. It is a promising community-based care program for healthcare systems in which regular care already contains many elements of home-based practice.

Sailing for rehabilitation of patients with severe mental disorders: results of a cross over randomized controlled trial

This study set out to evaluate the effectiveness of a sailing and learning-to-sail rehabilitation protocol in a sample of patients diagnosed with severe mental disorders. The study was a randomized, crossover, waiting-list controlled trial, following recruitment in the Departments of Mental Health of South Sardinia. Participants were outpatients diagnosed with severe mental disorders, recruited through announcements to the directors of the Departments of Mental Health of South Sardinia. Out of the 40 patients enrolled in the study, those exposed to rehabilitation with sailing during a series of guided and supervised sea expeditions near the beach of Cagliari (Sardinia), where the aim to explore the marine environment while sailing was emphasized, showed a statistically significant improvement of their clinical status (measured by BPRS) and, as well, of their general functioning (measured by HoNOS Scale) against the control group. The improvement was maintained at follow-up for some months only: after 12 months, the patients returned to their baseline values on the measures of psychopathology and showed a worsening trend of their quality of life. Sailing can represent a substitute of important experiences that the patients with severe mental disorders miss because of their illness.

Sailing can improve quality of life of people with severe mental disorders: results of a cross over randomized controlled trial

The aim of this study was to evaluate the impact of a sailing rehabilitation program on the quality of life (QoL) in a sample of patients with severe mental disorders. The study adopted a randomized, crossover, waiting-list controlled design. The participants enrolled in the study were outpatients diagnosed with severe chronic mental disorders. The participants (N=40) exposed to rehabilitation with sailing took part in a series of supervised cruises near the gulf of Cagliari, South Sardinia, and showed a statistically significant improvement of their quality of life compared to the control group. This improvement was comparable to the improvement in psychopathologic status and social functioning as shown in a previous report of the same research project. The improvement was maintained at follow-up only during the trial and for a few months later: after 12 months, patients returned to their baseline values and their quality of life showed a worsening trend. This is the first study to show that rehabilitation with sailing may improve the quality of life of people with severe chronic mental disorders. In all likelihood, a program grounded on learning how to manage a sailing vessel - during which patients perform cruises that emphasize the exploration of the marine environment by sailing - might be interesting enough and capture the attention of the patients so as to favour greater effectiveness of standard rehabilitation protocols, but this should be specifically tested.

Coping with the crisis: people with severe mental disorders acting for social change through sustainable energy

BACKGROUND

The aim of the study was to examine the efficacy of a vocational training program on renewable energy sources in reducing disabilities of people with chronic psychosis (CP). The innovative element was that the project could produce major advantages regarding the economic needs of the whole area involved.

METHODS

Experimental Cohort, 26 subjects with CP (EC); Control Cohort1, 130 subjects with CP following pharmacotherapy plus other rehabilitation activities (CIC); Control Cohort2, 101 subjects with CP following the usual treatment (pharmacotherapy) (CUC). Study tool: Health of the Nation Outcome Scales (HoNOS). Assessment made at the start of the study (T0) and after three months (T1). Statistical analysis made by MANOVA.

RESULTS

Improvement in HoNOS total score in both groups (F=7.574, p=0.000) with non-significant differences between groups over time (F=1.336, p=0.252) was found comparing EC vs. CIC. Greater improvement in EC vs. CIC was shown in the HoNOS "impairment" scale (F=4.910, p=0.028). EC vs. CUC: both groups improved in HoNOS total score (F=9.440, p=0.000) but the improvement was greater in EC (F = 2.273, P=0.048).

CONCLUSIONS

Work inclusion, as well as other rehabilitation treatments, reduces the social needs of people with chronic psychosis. Work inclusion in a project with real relevance for the area where these people live, produces more improvement of cognitive, physical and somatic disabilities, probably related to a better outcome in self-efficacy.

Flexible Assertive Community Treatment, Severity of Symptoms and Psychiatric Health Service Use, a Real life Observational Study

Background:

Introduction of Flexible Assertive Community Treatment (FACT) may be associated with increased remission rates and changes in patterns of care. The present paper reports on differences in psychosocial functioning and health care use between patients in FACT and two groups of patients not currently provided with a specific model of community service.

Methods:

The ongoing "Pharmacotherapy Monitoring and Outcome Survey" provided routine outcome measures of patients using antipsychotics in the north of the Netherlands. Level of psychosocial functioning was assessed using the Health of the Nations Outcome Scales (HoNOS) and matched with psychiatric health care consumption obtained from the Psychiatric Case Register. Patients who never received FACT, patients ever in FACT but not at assessment date, and patients in FACT were identified. Data were subjected to multilevel linear regression analysis.

Results:

Data showed that most patients in FACT also had non-FACT episodes after the start of FACT. Furthermore, patients in FACT displayed higher levels of psychosocial functioning and used more outpatient care than the other two groups.

Conclusions:

Patients in FACT receive more outpatient care and have better psychosocial functioning. However, causal inferences cannot be derived from these data. In addition, membership of a FACT-team in this setting did not last indefinitely.