Recent advances in psychiatric rehabilitation for patients with severe mental illness

Ethnic inequalities in community rehabilitation use and psychiatric hospitalizations among people with chronic psychotic disorder

PURPOSE

Community rehabilitation is crucial for the long-term treatment of people with chronic psychotic disorder. Ethnic minorities are less likely to seek care and have accessible treatment. This study examines whether the use of rehabilitation services and the relationship between rehabilitation and number of hospitalization days differ between Arabs and Jews.

METHODS

Data from the Israel National Psychiatric Case Register on 18,684 adults with schizophrenia/schizoaffective disorders hospitalized in 1963-2016 were merged with data from the national Mental Rehabilitation Register. Associations between the use of rehabilitation services and demographic and clinical characteristics were assessed through logistic regression modeling. Associations between ethnicity and duration of rehabilitation (housing or vocational) and annual hospitalization days during Period1: 2001-2009 and Period2: 2010-2016 were analyzed using ANOVA.

RESULTS

Among Jewish patients (N = 2556), 37% and 57% used rehabilitation services during Period1 and Period2, respectively, compared with 18% and 40% among Arab patients (N = 15,145) (p < 0.0001). The use of rehabilitation services was significantly higher among Jews (adjusted OR = 2.26, 95% CI 2.07-2.47). Average duration of housing and vocational rehabilitation services did not differ between Arab and Jewish patients. In both groups, duration of rehabilitation was inversely associated with annual hospitalization days.

CONCLUSIONS

The ethnic disparity in the use of rehabilitation services has narrowed over time, yet remains. Although fewer Arab patients use rehabilitation, Jewish and Arab benefit similarly from the services with regard to reduced hospitalization days. To further close the ethnic gap, greater efforts must be made to expand the availability of culturally appropriate rehabilitation services for the Arab minority.

Effect of a Tobacco Cessation Intervention Incorporating Weight Management for Adults With Serious Mental Illness: A Randomized Clinical Trial

Importance

Tobacco smoking drives markedly elevated cardiovascular disease risk and preventable death in persons with serious mental illness, and these risks are compounded by the high prevalence of overweight/obesity that smoking cessation can exacerbate. Guideline-concordant combined pharmacotherapy and behavioral smoking cessation treatment improves abstinence but is not routinely offered in community settings, particularly to those not seeking to quit smoking immediately.

Objective

To determine the effectiveness of an 18-month pharmacotherapy and behavioral smoking cessation intervention incorporating weight management and support for physical activity in adults with serious mental illness interested in quitting smoking within 1 or 6 months.

Design, Setting, and Participants

This was a randomized clinical trial conducted from July 25, 2016, to March 20, 2020, at 4 community health programs. Adults with serious mental illness who smoked tobacco daily were included in the study. Participants were randomly assigned to intervention or control, stratified by willingness to try to quit immediately (within 1 month) or within 6 months. Assessors were masked to group assignment.

Interventions

Pharmacotherapy, primarily varenicline, dual-form nicotine replacement, or their combination; tailored individual and group counseling for motivational enhancement; smoking cessation and relapse prevention; weight management counseling; and support for physical activity. Controls received quitline referrals.

Main Outcome and Measures

The primary outcome was biochemically validated, 7-day point-prevalence tobacco abstinence at 18 months.

Results

Of the 298 individuals screened for study inclusion, 192 enrolled (mean [SD] age, 49.6 [11.7] years; 97 women [50.5%]) and were randomly assigned to intervention (97 [50.5%]) or control (95 [49.5%]) groups. Participants self-identified with the following race and ethnicity categories: 93 Black or African American (48.4%), 6 Hispanic or Latino (3.1%), 90 White (46.9%), and 9 other (4.7%). A total of 82 participants (42.7%) had a schizophrenia spectrum disorder, 62 (32.3%) had bipolar disorder, and 48 (25.0%) had major depressive disorder; 119 participants (62%) reported interest in quitting immediately (within 1 month). Primary outcome data were collected in 183 participants (95.3%). At 18 months, 26.4% of participants (observed count, 27 of 97 [27.8%]) in the intervention group and 5.7% of participants (observed count, 6 of 95 [6.3%]) in the control group achieved abstinence (adjusted odds ratio [OR], 5.9; 95% CI, 2.3-15.4; P < .001). Readiness to quit within 1 month did not statistically significantly modify the intervention's effect on abstinence. The intervention group did not have significantly greater weight gain than the control group (mean weight change difference, 1.6 kg; 95% CI, -1.5 to 4.7 kg).

Conclusions and Relevance

Findings of this randomized clinical trial showed that in persons with serious mental illness who are interested in quitting smoking within 6 months, an 18-month intervention with first-line pharmacotherapy and tailored behavioral support for smoking cessation and weight management increased tobacco abstinence without significant weight gain.

Trial Registration

ClinicalTrials.gov Identifier: NCT02424188.

Community Rehabilitation and Hospitalizations Among People With Chronic Psychotic Disorder: Is There a Differential Association by Co-occurring Substance Use Disorder?

Objective: Co-occurrence of chronic psychotic disorders and substance use disorder (SUD) is clinically challenging and increasingly prevalent. In 2000, legislation was passed in Israel to foster rehabilitation and integration in the community of persons with mental health disorders. In 2010, the need to allocate resources for patients with these co-occurring disorders (COD) was officially recognized. Yet, most rehabilitation services were not specifically designed for COD. This study examines the relationship between duration of community rehabilitation and number of psychiatric hospitalization days among persons with/without COD in Israel. Methods: Data from the National Psychiatric Case Register on 18,684 adults with schizophrenia/schizoaffective disorders hospitalized in 1963-2016, was merged with data from the Israel Mental Rehabilitation Register. Associations and interactions between COD-status (COD/non-COD), time-period (Period₁: 2001-2009, Period₂: 2010-2016), duration of housing or vocational rehabilitation on hospitalization days per year were analyzed using repeated-measures ANOVA. Results: The proportion of non-COD chronic psychotic patients who received rehabilitation services increased from 56% in Period₁ to 63% in Period₂, as it did among COD patients-from 30 to 35%. The proportion of non-COD patients who received longer-duration vocational rehabilitation (≥1 year) was significantly higher (43%) than among COD patients (28%) in both time periods. For housing rehabilitation, these proportions were 79 and 68%, respectively. Persons with COD experienced more hospitalization days annually than non-COD patients. Duration of rehabilitation (less/more than a year) was inversely associated with annual number of hospitalization days (p < 0.0001). This pattern was noted in both COD and non-COD groups and remained significant after controlling for age, sex, COD group, percent of hospitalizations with SUD, and age at first hospitalization. Conclusions: COD patients with prolonged rehabilitation seemingly achieve long-term clinical improvement similar to non-COD patients, despite most rehabilitation settings in Israel not being designed for COD patients. Yet, COD patients receive overall less rehabilitation services and for shorter periods than non-COD patients. Long-term rehabilitation services should be provided to COD patients, who may need more time to commit to treatment. To achieve better long-term mental health improvements, a continued expansion of community-based integrative treatment and rehabilitation services for COD patients is needed in Israel.

Exploring the experiences of people vlogging about severe mental illness on YouTube: An interpretative phenomenological analysis

BACKGROUND

Evidence suggests that, compared to the general population, individuals with severe mental illness (SMI) are more likely to engage in online social networking and share personal experiences through blogging. However, little is known about the impact of creating and publicly sharing mental health videos (vlogging) on individuals with self-identified SMIs.

AIMS

The present study aims to investigate the experiences of individuals with self-identified SMIs who vlog about their SMI on YouTube.

METHODS

YouTube was systematically searched using four key search items ("schizophrenia", "bipolar disorder", "major depressive disorder" and "schizoaffective disorder"). After manually screening approximately 50 channels, a set of 30 videos by individuals with self-identified SMIs discussing their experience of vlogging was selected and transcribed verbatim. An interpretative phenomenological analysis (IPA) was employed for the analysis of the data.

RESULTS

The analysis produced three global themes: Minimising Isolation; Vlogging as Therapy; and Fighting stigma.

LIMITATIONS

The data collected was limited as regards depth of content by the inability to ask follow-up questions.

CONCLUSIONS

The findings suggest that engaging in the act of vlogging about mental illness may benefit and encourage recovery in individuals with SMIs by providing them with peer support, enhancing self-efficacy, and reducing self-stigma. Future research should employ interviews to produce more robust data for analysis.

The Relationship of Perceived Social Support with Well-Being in Adults with Visual Impairments

The relationship between perceived social support and multiple indicators of well-being in adults with visual impairments was investigated. The results included significant correlation of social support and depressive symptoms, satisfaction with life, as well as with physical, psychological, economic, family, and social well-being. Implications for future research and practice are discussed.

Need for Cardiovascular Risk Reduction in Persons With Serious Mental Illness: Design of a Comprehensive Intervention

Persons with serious mental illness (SMI) comprise a high-risk group for cardiovascular disease (CVD)-related mortality with rates at least twice those of the overall US. Potentially modifiable CVD risk behaviors (tobacco smoking, obesity, physical inactivity, unhealthy diet) and risk factors (hypertension, diabetes, dyslipidemia) are all markedly elevated in persons with SMI. Evaluations of programs implementing integrated medical care into specialty mental health settings have not shown meaningful effects on CVD risk factor reduction. Rigorously tested, innovative interventions are needed to address the large burden of CVD risk in populations with SMI. In this article, we describe the design of a comprehensive 18-month intervention to decrease CVD risk that we are studying in a randomized clinical trial in a community mental health organization with psychiatric rehabilitation programs. The individual-level intervention incorporated health behavior coaching and care coordination/care management to address all seven CVD risk behaviors and risk factors, and is delivered by a health coach and nurse. If successful, the intervention could be adopted within current integrated care models and significantly improve the physical health of persons with SMI.

An Audit of an Integrated Care Pathway for a Crisis Resolution/Home Treatment Team

The development of crisis resolution/home treatment (CRHT) teams was outlined as a requirement in the National Health Service Plan (Department of Health 2000) and reiterated in the recent guidelines to have an impact on the provision of mental health care (Care Services Improvement Partnership [CSIP] 2006). The Home Option Service in Central Manchester, one of the first CRHT teams in the United Kingdom, provides support and a range of interventions, 24 hours a day, 7 days a week, for those service users experiencing a crisis in their mental health, as an alternative to hospital admission. The need for team working is explicit in the guidance statement to ensure fidelity and best practice for crisis services and it urges teams to provide clarity regarding their roles and responsibilities within the team approach (CSIP 2006).

This paper illustrates a model for occupational therapists working within a crisis team in order to ensure that service users have access to occupational therapy when admitted to crisis care. Specific standards, in accordance with those outlined in the research and development strategic vision for occupational therapists in mental health (Association of Occupational Therapists in Mental Health 2006), have been identified to instigate a clear pathway for the stakeholders of crisis teams. A description of the development, implementation and evaluation of an integrated care pathway is provided, alongside a subsequent audit to measure the effectiveness of this model.

Facilitating Intrinsic Motivation in Individuals with Psychiatric Illness: A Study on the Effectiveness of an Occupational Therapy Intervention

This study examined the effectiveness of an occupational therapy intervention to facilitate intrinsic motivation in individuals with psychiatric illness who had motivational deficits. The clinical problem, motivational deficits, was referred to the passive or coercive behaviors resulting from cumulative psychosocial frustrations. The intervention was based on a motivational frame of reference developed by the researcher, involving strategies of autonomy support and moderate structure. The research design was a mixed-effects nested design, involving one experimental group and one control group, and two different groups of therapists to carry out the two types of treatment. The treatment was carried out in one-hour, twice-a-week individual therapy sessions for 12 weeks. The results showed that the motivational intervention effectively facilitated intrinsic motivation, and that there was a corresponding change in social behavior observed by independent therapists. It was concluded that the motivational frame of reference has potential to be used in occupational therapy practice, and further research is needed to investigate its long-term effects.

Effectiveness of Psychiatric Rehabilitation Approaches for Employment of People with Severe Mental Illness

The authors review studies of (a) traditional psychiatric rehabilitation (including clubhouse programs and approaches offering an array of employment options) and (b) supported employment approaches for helping people with severe mental illness gain and maintain competitive employment. Based on the results of this review, the authors conclude that the effectiveness of traditional psychiatric rehabilitation in helping people gain competitive employment cannot be conclusively determined at this point. On the other hand, research on the effectiveness of supported employment was consistently positive. The authors recommend that further research be conducted on model definition, intermediate vocational options, interaction between client characteristics and program models, and long-term outcomes.

A frame of mind from psychiatry

A distinctive characteristic of psychiatry is that it is a discipline that deals with both the physical and the mental lives of individuals. Largely because of this characteristic, different models are used for different disorders, however, there is still a remnant tendency towards reductionist views in the field. In this paper I argue that the available empirical evidence from psychiatry gives us reasons to question biological reductionism and that, in its place, we should adopt a pluralistic explanatory model that is more suited to the needs of the discipline and to the needs of the patients it is meant to help. This will allow us to retain psychiatry as an autonomous science that can productively co-exist with neuroscience while also giving patients the kind of attention they need. I further argue that this same evidence supports a view of the mind that is anti-reductive and that allows that causation can be both bottom-up and top-down and that such a view is available in emergentism coupled with an interventionist model of causation.

Psychosocial treatments for schizophrenia

The current state of the literature regarding psychosocial treatments for schizophrenia is reviewed within the frameworks of the recovery model of mental health and the expanded stress-vulnerability model. Interventions targeting specific domains of functioning, age groups, stages of illness, and human service system gaps are classified as evidence-based practices or promising practices according to the extent to which their efficacy is currently supported by meta-analyses and individual randomized controlled trials (RCTs). Evidence-based practices include assertive community treatment (ACT), cognitive behavior therapy (CBT) for psychosis, cognitive remediation, family psychoeducation, illness self-management training, social skills training, and supported employment. Promising practices include cognitive adaptive therapy, CBT for posttraumatic stress disorder, first-episode psychosis intervention, healthy lifestyle interventions, integrated treatment for co-occurring disorders, interventions targeting older individuals, peer support services, physical disease management, prodromal stage intervention, social cognition training, supported education, and supported housing. Implications and future directions are discussed.

Enhancing work-focused supports for people with severe mental illnesses in australia

Persons with severe mental illness (SMI) have reduced workforce participation, which leads to significant economic and social disadvantage. This theoretical review introduces the strategies that have been implemented to address this issue. These include Individual Placement and Support (IPS) services, the most widely researched form of supported employment, to which cognitive remediation has more recently been recognised in the USA, as an intervention to improve employment outcomes by addressing the cognitive impairments often experienced by people with SMI. The authors review the international literature and discuss specifically the Australian context. They suggest that Australia is in a prime position to engage clients in such a dual intervention, having had recent success with increasing access to supported employment programs and workforce reentry, through implementation of the Health Optimisation Program for Employment (HOPE). Such programs assist with gaining and maintaining employment. However, they do not address the cognitive issues that often prevent persons with SMI from effectively participating in work. Thus, optimising current interventions, with work-focused cognitive skills development is critical to enhancing employment rates that remain low for persons with SMI.

Trends in the use of rehabilitation services in the community by people with mental disabilities in Israel; the factors involved

Background

In 2001, the Rehabilitation of the Mentally Disabled Law was implemented, defining a basket of rehabilitation services to which people with mental disabilities are entitled.

Objectives

To describe change over time in the characteristics of applicants to rehabilitation committees, types of referral agencies, and the proportion of those referred who were admitted. To identify factors affecting implementation of decisions to admit people with mental disabilities into different rehabilitation services and predictors of the length of time they remain in the services.

Methods

The study population consisted of all applicants to rehabilitation committees during 2001-2008. Rehabilitation services included hostels, supported housing, and vocational services. Data were extracted from Ministry of Health rehabilitation and psychiatric hospitalization case registers. Findings were analyzed using descriptive statistics, Kaplan-Meier survival analyses, and Cox regressions.

Results

There was a trend over time for more patients with shorter or no psychiatric hospitalization histories to be referred to rehabilitation services. Moreover, there was an increase in the proportion of referrals from the community, although the majority of referrals still came from psychiatric hospitals. Less than half of those recommended for a rehabilitation program were admitted and remained in a rehabilitation facility for one year or more. One factor predicting participants' longer stays in rehabilitation services after hospitalization was the proximity of the committees' decisions to the hospitalization. Another factor was the patient receiving vocational services while in residential care.

Conclusion

Although over time the new law has resulted in a broader spectrum of people with mental disabilities receiving rehabilitation services, additional efforts are needed to enable them to remain in the system for a sufficient amount of time. Programs addressing specific needs should be developed accordingly.

A randomised controlled trial of acceptance-based cognitive behavioural therapy for command hallucinations in psychotic disorders

Command hallucinations represent a special problem for the clinical management of psychosis. While compliance with both non-harmful and harmful commands can be problematic, sometimes in the extreme, active efforts to resist commands may also contribute to their malignancy. Previous research suggests Cognitive Behaviour Therapy (CBT) to be a useful treatment for reducing compliance with harmful command hallucinations. The purpose of this trial was to evaluate whether CBT augmented with acceptance-based strategies from Acceptance and Commitment Therapy could more broadly reduce the negative impact of command hallucinations. Forty-three participants with problematic command hallucinations were randomized to receive 15 sessions of the intervention "TORCH" (Treatment of Resistant Command Hallucinations) or the control, Befriending, then followed up for 6 months. A sub-sample of 17 participants was randomized to a waitlist control before being allocated to TORCH or Befriending. Participants engaged equally well with both treatments. Despite TORCH participants subjectively reporting greater improvement in command hallucinations compared to Befriending participants, the study found no significant group differences in primary and secondary outcome measures based on blinded assessment data. Within-group analyses and comparisons between the combined treatments and waitlist suggested, however, that both treatments were beneficial with a differential pattern of outcomes observed across the two conditions.

Dealing with Real-Life Challenges: Outcome of a Home-Based Occupational Therapy Intervention for People with Severe Psychiatric Disability

The authors offered home-based occupational therapy integrated into supported or sheltered housing to help individuals with severe psychiatric disability identify their specific needs of engagement in meaningful daily occupations. This study aimed to evaluate the client outcomes in activities of daily living (ADL) ability and health factors following their participation in occupation-centered interventions in home and community settings. Seventeen participants (7 women) between the ages of 27 and 66 years participated in the intervention project based on the Everyday Life Rehabilitation (ELR). The following instruments were administered before and after the intervention and at a 6-month follow-up: Goal Attainment Scaling, Assessment of Motor and Process Skills, Assessment of Social Interaction, Satisfaction with Daily Occupations, ADL-taxonomy with an effort-scale, and the Symptom Check List-90. Pretest, posttest, and follow-up differences in test scores on goal attainment, occupation, and health-related factors indicate that important progress was made. These findings support the use of the ELR intervention and suggest that larger randomized clinical trials are needed.

Psychosocial treatments for people with co-occurring severe mental illnesses and substance use disorders (dual diagnosis): a review of empirical evidence

Considerable research documents the health consequences of psychosis and co-occurring substance use disorders. Results of randomized controlled trials assessing the effectiveness of psychosocial interventions for persons with dual diagnoses are equivocal but encouraging. Many studies are hampered by small, heterogeneous samples, high attrition rates, short follow-up periods, and unclear description of treatment components. The treatments available for this group of patients (which can be tailored to individual needs) include motivational interviewing, cognitive-behavioral therapy, contingency management, relapse prevention, case management, and skills training. Regardless of whether services follow integrated or parallel models, they should be well coordinated, take a team approach, be multidisciplinary, have specialist-trained personnel (including 24-hour access), include a range of program types, and provide for long-term follow-up. Interventions for substance reduction may need to be further developed and adapted for people with serious mental illnesses. Further quality trials in this area will contribute to the growing body of data of effective interventions.

Work, recovery, and comorbidity in schizophrenia: a randomized controlled trial of cognitive remediation

Employment is central to the concept of recovery in severe mental illness. However, common comorbid conditions present significant obstacles to consumers seeking employment and benefiting from vocational rehabilitation. We review research on the effects of three common comorbid conditions on work and response to vocational rehabilitation, including cognitive impairment, substance abuse, and medical conditions, followed by research on vocational rehabilitation. We then present the results of a randomized controlled trial evaluating the effects of adding cognitive remediation to a vocational rehabilitation program compared with vocational rehabilitation alone in 34 consumers with severe mental illness. Consumers who received both cognitive remediation and vocational rehabilitation demonstrated significantly greater improvements on a cognitive battery over 3 months than those who received vocational rehabilitation alone and had better work outcomes over the 2-year follow-up period. Substance abuse was associated with worse employment outcomes, but did not interact with treatment group, whereas medical comorbidity was not related to work outcomes. More research is warranted to evaluate the interactions between substance abuse and medical comorbidity with vocational rehabilitation and cognitive remediation.

Setting the stage: from prodrome to treatment resistance in bipolar disorder

Bipolar disorder is common, and both difficult to detect and diagnose. Treatment is contingent on clinical needs, which differ according to phase and stage of the illness. A staging model could allow examination of the longitudinal course of the illness and the temporal impact of interventions and events. It could allow for a structured examination of the illness, which could set the stage for algorithms that are tailored to the individuals needs. A staging model could further provide as structure for assessment, gauging treatment and outcomes. The model incorporates prodromal stages and emphasizes early detection and algorithm appropriate intervention where possible. At the other end of the spectrum, the model attempts to operationalize treatment resistance. The utility of the model will need to be validated by empirical research.

Beyond the Prescription Pad: Psychosocial Treatments for Individuals with Schizophrenia

Individuals with schizophrenia face multiple barriers to the achievement of optimal health, including apathy and poor concentration, sedative effects of medication, and poverty and lack of access to health education and treatment programs. In addition, the symptoms of the disease negatively affect their social functioning, which may result in isolation and lack of social support. In addition to providing psychiatric care and monitoring, both generalist nurses and advanced practice psychiatric nurses may assess physical and psychological risk factors, monitor medication responses, and provide health promotion to these individuals. Health promotion for individuals with schizophrenia includes psychosocial treatments to prevent relapse (e.g., education on the importance of treatment adherence) and to promote recovery (e.g., involving family members in treatment when possible). This article describes the key elements of recommended psychosocial treatments, briefly reviews the evidence for these treatments, and discusses clinical implications for all psychiatric nurses.

Efficacy of the Community Re-Entry Module for patients with schizophrenia in Beijing, China: outcome at 2-year follow-up

BACKGROUND

Few psychosocial interventions have been developed in China that are suitable for use in the community.

AIMS

To evaluate the effectiveness of the Chinese version of the Community Re-Entry Module (CRM; a module of a standardised, structured social skills training programme devised at the University of California, Los Angeles) for patients with schizophrenia compared with standard group psychoeducation.

METHOD

Patients with schizophrenia (n=103) were randomly allocated to CRM or psychoeducation groups and followed up for 24 months. Outcome measures included social functioning, psychiatric symptoms, insight, re-employment, relapse and re-hospitalisation rates.

RESULTS

The CRM group significantly improved in terms of social functioning, insight and psychiatric symptoms compared with the psychoeducation group; the re-employment rate was significantly higher and relapse and rehospitalisation rates were significantly lower in the CRM group.

CONCLUSIONS

The findings support the feasibility and effectiveness of CRM as a psychosocial intervention for Chinese patients with schizophrenia in the community.

Integrated psychological therapy (IPT) for schizophrenia: is it effective?

Against the background of evidence-based treatments for schizophrenia, nowadays the implementation of specific cognitive and behavioral interventions becomes more important in the standard care of these patients. Over the past 25 years, research groups in 9 countries have carried out 30 independent evaluations of Integrated Psychological Therapy (IPT), a group program that combines neurocognitive and social cognitive interventions with social skills approaches for schizophrenic patients. The aim of the present study was to evaluate the effectiveness of IPT under varying treatment and research conditions in academic and nonacademic sites. In a first step, all 30 published IPT studies with the participation of 1393 schizophrenic patients were included in the meta-analysis. In a second step, only high-quality studies (HQS) (7 studies including 362 patients) were selected and analyzed to check whether they confirmed the results of the first step. Positive mean effect sizes favoring IPT over control groups (placebo-attention conditions, standard care) were found for all dependent variables, including symptoms, psychosocial functioning, and neurocognition. Moreover, the superiority of IPT continued to increase during an average follow-up period of 8.1 months. IPT obtained similarly favorable effects across the different outcome domains, assessment formats (expert ratings, self-reports, and psychological tests), settings (inpatient vs outpatient and academic vs nonacademic), and phases of treatment (acute vs chronic). The HQS confirmed the results of the complete sample. The analysis indicates that IPT is an effective rehabilitation approach for schizophrenia that is robust across a wide range of patients and treatment conditions.

Cognitive-behavioural therapy for refractory psychotic symptoms of schizophrenia resistant to atypical antipsychotic medication. Randomised controlled trial

BACKGROUND

There is increasing evidence that cognitive-behavioural therapy can be an effective intervention for patients experiencing drug-refractory positive symptoms of schizophrenia.

AIMS

To investigate the effects of cognitive-behavioural therapy on in-patients with treatment-refractory psychotic symptoms.

METHOD

Manualised therapy was compared with supportive counselling in a randomised controlled study. Both interventions were delivered by experienced psychologists over 16 sessions of treatment. Therapy fidelity was assessed by two independent raters. Participants underwent masked assessment at baseline, after treatment and at 6 months' follow-up. Main outcome measures were the Positive and Negative Syndrome Scale and the Psychotic Symptoms Rating Scale. The analysis was by intention to treat.

RESULTS

Participants receiving cognitive cognitive-behavioural therapy had improved with regard to auditory hallucinations and illness insight at the post-treatment assessment, but these findings were not maintained at follow-up.

CONCLUSIONS

Cognitive-behavioural therapy showed modest short-term benefits over supportive counselling for treatment-refractory positive symptoms of schizophrenia.

The effect of a cognitive and a physical stress-reducing programme on psychological complaints

OBJECTIVES

To investigate the short-term and long-term effectiveness of two, brief, preventive, work stress management programmes. One programme was a cognition-focused programme, the other was a newly developed intervention in which physical exercise and relaxation were combined. It was hypothesised that the newly developed intervention would be more effective in reducing psychological complaints than the cognitive intervention. Both programmes consisted of four sessions in a period of 10 weeks.

METHODS

From a working population engaged in a periodic health check-up, employees above a minimum stress level (n=396) were invited to participate in a randomised comparative outcome study with pre-trial, post-trial and 6-month follow-up measures. After giving informed consent 130 participants entered the study (response rate 33%). Outcome measures consisted of three self-reported questionnaires on psychological complaints.

RESULTS

It was found that both interventions revealed a positive impact on psychological complaints, burnout and fatigue, both at short-term and at 6-month follow-up. No statistical interaction effects between the two interventions were found. Calculation of the clinical significance of the effects indicated that 50% of the employees with psychological complaints who participated in the physical intervention and 60% of the employees who participated in the cognitive intervention improved and returned to functioning within normal range both in the short term and in the long term at 6 months.

CONCLUSION

The data indicate that interventions were equally effective on psychological complaints, burnout and fatigue.

Evaluation of an Individual Placement and Support model (IPS) program

While randomized clinical trials (RCTs) have helped to establish Individual Placement and Support (IPS) programs as an evidence-based practice, it is important to evaluate whether "real world" IPS programs can be implemented with fidelity and achieve outcomes comparable to programs evaluated in RCTs. The current evaluation examined retrospectively employment outcomes for go participants from an IPS-model Services for Employment and Education (SEE) program in Massachusetts over a 4.5-year period. Evaluators accessed demographic, functioning, and employment data from three sources--SEE program records/database, clinical records, and the Massachusetts Department of Mental Health Client Tracking system. Results indicate that the SEE program maintained high IPS fidelity and achieved employment outcomes comparable or superior to other SE and IPS model programs described in the literature.

The history of community mental health treatment and rehabilitation for persons with severe mental illness

The authors review the evolution of the treatments for persons with severe mental illnesses over the past 40 years in three areas: pharmacological and other somatic treatments, psychosomatic treatments, and rehabilitation. Current treatments are based on a much stronger evidence base, are more patient-centered, and are more likely to target autonomy and recovery.

Implementing evidence-based practices for people with severe mental illness

Persons with severe mental illnesses (SMI) often lack access to effective treatments. The authors describe the Implementing Evidence-Based Practices (EBPs) Project, designed to increase access for people with SMI to empirically supported interventions. The EBP Project aims to improve access through development of standardized implementation packages, created in collaboration with different stakeholders, including clinicians, consumers, family members, clinical supervisors, program leaders, and mental health authorities. The background and philosophy of the EBP Project are described, including the six EBPs identified for initial package development: collaborative psychopharmacology, assertive community treatment, family psychoeducation, supported employment, illness management and recovery skills, and integrated dual disorders treatment. The components of the implementation packages are described as well as the planned phases of the project. Improving access to EBPs for consumers with SMI may enhance outcomes in a cost-effective manner, helping them pursue their personal recovery goals with the support of professionals, family, and friends.

Costs of schizophrenia and other psychoses in urban Australia: findings from the Low Prevalence (Psychotic) Disorders Study

OBJECTIVE

To estimate the costs associated with the treatment and care of persons with psychosis in Australia based on data from the Low Prevalence Disorders Study (LPDS), and to identify areas where there is potential for more efficient use of existing health care resources.

METHOD

The LPDS was a one-month census-based survey of people with psychotic disorders in contact with mental health services, which was conducted in four metropolitan regions in 1997-1998. Mental health and service utilization data from 980 interviews were used to estimate the economic costs associated with psychotic disorders. A prevalence-based, 'bottom-up' approach was adopted to calculate the government and societal costs associated with psychosis, including treatment and non-treatment related costs.

RESULTS

Annual societal costs for the average patient with psychosis are of the order of 46,200 Australian dollars , comprising 27,500 Australian dollars in lost productivity, 13,800 Australian dollars in inpatient mental health care costs and 4900 Australian dollars in other mental health and community services costs. Psychosis costs the Australian government at least 1.45 billion Australian dollars per annum, while societal costs are at least 2.25 billion Australian dollars per annum (including 1.44 billion Australian dollars for schizophrenia). We also report relationships between societal costs and demographic factors, diagnosis, disability and participation in employment.

CONCLUSIONS

Current expenditure on psychosis in Australia is probably inefficient. There may be substantial opportunity costs in not delivering effective treatments in sufficient volume to people with psychotic disorders, not intervening early, and not improving access to rehabilitation and supported accommodation.

Allocation of resources and psychosis

OBJECTIVE

This commentary reviews current expenditure on psychosis in Australia, identifies discretionary expenditure that could be used more efficiently, discusses the factors influencing resource allocation and intervention selection decisions, and suggests priorities for change.

METHOD

Cost-of-illness findings from the Low Prevalence Disorders Study (LPDS), and related service use and psychosocial data, are used to highlight patterns of expenditure on psychosis and potential resource allocation issues. Arguments are also presented suggesting that mental health resource allocation in Australia should be informed primarily by treatment efficiency, equity and humanitarian considerations, not differences in the global burden of disease. However, our evidence-base about the effectiveness and costs associated with individual treatments, programmes, and organizational structures is also shown to be limited.

CONCLUSIONS

The patterns of service use and expenditure on psychosis suggest certain imbalances, including an over-reliance on hospitalization, low levels of supported community accommodation, and inadequate provision of evidence-based psychosocial treatments, rehabilitation and supported employment programmes. We need to identify and develop efficient interventions and programmes, re-orientate our services to better utilize those interventions, increase community awareness, improve monitoring of outcomes and costs, and undertake timely evaluations at multiple levels, from the individual to the societal perspective.

interACTION: case managers and social skills teaching

There is good evidence that social skills are important to the community adjustment of persons with serious and persistent mental health problems. There is also conjecture that inattention to the development of social skills may explain the lack of impact that case management services are having on social functioning. This paper describes a series of social skills education groups provided by case managers over several years. Ways that assisted people in maintaining regular attendance at the groups are also described.

How does work work for people with bipolar affective disorder?

Despite modern treatments, bipolar disorder remains a chronic, relapsing disorder that leads to long-term psychosocial disability. A review of the literature suggests that while employment rates amongst individuals with bipolar disorder may improve over time, and are relatively better compared to some other chronic mental disorders, employment prospects do not match the high scholastic achievements seen amongst this group of people before the onset of their illness. For those with bipolar disorder, clinical recovery does not necessarily mean functional recovery, and the usual early age of onset may further reduce an individual's preparedness for employment. Two brief vignettes are used to discuss how occupational therapists can help their clients maintain their sense of hope in vocational recovery, gain better self-awareness and work with clients at various stages of recovery rather than waiting for full functional recovery. Further research is required to help identify specific factors that contribute to the success of employment integration amongst people with bipolar disorder.

The role of work in the recovery of persons with psychiatric disabilities

This study explored the role of work in the recovery of employed and unemployed persons with psychiatric disabilities. Fourteen persons with psychiatric disabilities participated in semi-structured interviews. Content analysis revealed that the experience of recovery was based on six major dimensions: self-definition, empowerment, connections to others, meaning of work, vocational future, and meaning of recovery. Differences in these six dimensions led to the identification of three profiles of recovery: recovery as uncertain, recovery as a self-empowering experience, and recovery as a challenging experience. Each profile described a specific context in which participation in work or avoidance of work can be understood and vocational interventions can be designed.

Co-occurring psychosocial distress and substance abuse in community clients: initial validity and reliability of self-report measures

The current study examines the self-reports of 227 community support clients using a paper and pencil questionnaire that included the South Shore Problem Inventory-revised (a brief multidimensional psychosocial distress scale), a one-item index of self-rated substance abuse (SRSA), a quantity-frequency index for alcohol consumption (QFI), and a one-item index measuring the frequency of marijuana use. Results support the factor structure and internal consistency of the SSPI-r, and show significant correlations among the substance use indices. Implications for including brief mental health and substance abuse measures are discussed within the context of routine assessment and practice evaluation.

The relationship between involvement in activities and quality of life for people with severe and enduring mental illness

A number of authors have indicated that people who have greater and more satisfactory social activity tend to report that they have higher life satisfaction. This study was concerned with examining the relationship between involvement in activities and self-reported quality of life for people with severe and enduring mental illness. It is part of a larger study of quality of life for this client group. A random sample of 92 respondents was drawn from the population of people who met the criteria for severe and enduring mental illness in a Health Board in Northern Ireland. Data were gathered using a reliable and valid interview schedule based on a quality of life profile developed for the larger study. The findings indicated that over half of the respondents (56.5%, n=52) had no structured activity in their everyday life and there was a low level of participation in 14 listed activities of living. The respondents also reported a low level of self-reported quality of life. There was also a weak, but statistically significant, correlation between involvement in activities and self-reported quality of life. However, a moderate positive statistically significant correlation was found to exist between satisfaction with involvement in activities and self-reported quality of life. The implications for the care of people who are experiencing severe and enduring mental illness within and outside the United Kingdom are discussed.

Cognitive behavioral psychotherapy for schizophrenia: a review of recent empirical studies

A set of cognitive behavioral psychotherapies (CBT) has been developed for schizophrenia. These interventions have been used for the treatment of both recent onset patients and those with treatment-refractory symptoms. This article reviews clinical trials of CBT for schizophrenia since 1990. The CBT interventions appear to be beneficial in reducing overall symptom levels, especially the severity of delusions. The relative efficacy of CBT is more evident when CBT is compared with routine care than when it is compared with other therapies matched for therapist attention. Further studies are needed to objectively determine the active ingredients of CBT and to better identify the interactions of CBT with concurrent psychosocial and medication treatments.

Development and validation of the workshop behavior checklist: a scale for assessing work performance of people with severe mental illness

The Workshop Behavior Checklist is a standardized assessment instrument to assess the work performance of people with severe mental illness using the situational assessment approach. It is modified from the Behavior Identification Form developed by the Material Development Center. The modification process was conducted by enlisting input from mental health professionals (n = 150) and potential employers of discharged patients with mental illness (n = 31) by questionnaires specially designed for this purpose. The results of these questionnaires were then analyzed by an expert panel consisting of 10 therapists and one psychiatrist working in relevant fields. Altogether 14 items in general behaviors, vocational behaviors, and social behaviors were selected. In addition, a new version of the checklist together with its rating guidelines were designed. Exploratory factor analysis (n = 112) shows that all 14 items fit well into a four-factor model explaining 67.2% of total variance, which is in line with the original design of the revised checklist. Cronbach alpha analysis shows that the revised checklist has acceptable to very good internal consistency (.51 to .84) and intraclass correlation coefficients indicate that it has good to excellent inter-rater (.57 to .81) and test-retest (.86 to .94) reliability. Clinical implications and further research are discussed.

State-of-the-art challenges for mental health services research

BACKGROUND: Research-based, state-of-the-art services for people with serious mental disorders would consist of demonstrably effective treatments, organized synergistically, and financed in ways that create incentives to provide such treatment. While research exists in these domains of treatment, organization and financing, this research base contains significant gaps, and what is known frequently neither informs policy making nor enters practice. REVIEW: The NIMH services-research portfolio has identified successful patient-level and system-level interventions for people with serious mental disorders, but much of this research has yet to make its way into practice. Similarly, while we have made progress in asking "what is good care?", we have much less information about the answers to "what constitutes an adequate try?". Writing a prescription for an efficacious medication does not constitute an adequate trial of that medication. Similarly, offering people boring psychosocial rehabilitation programs does not constitute an adequate try of promoting recovery via rehabilitation services, but what does? Defining what constitutes an adequate try can be a way of allocating scarce resources or it can be a polite way of defining when a system gets to give up on someone. As state governments move to contract with managed care entities for services for Medicaid beneficiaries, one of the great contracting challenges is defining and monitoring the provision of what constitutes an adequate try. DISCUSSION: To obtain better value for our health care expenditures, we need to find ways to get what we know works into practice, whether we are contracting for services or deciding which clinical therapies to pursue. For example, problem-oriented family therapy has been shown to improve clinical outcomes for people with schizophrenia, yet such interventions are rare in practice. We also need to pay more attention to the quality of the clinical care actually being delivered - not what was prescribed, nor what the clinician was trained in, nor what the job description was, but what actually is occurring. Figuring out how to contract for and disseminate efficacious treatments so that they occur and are effective in real-world settings is critically important yet is a largely unexplored area of services research. We need to answer both "what is good care?" and "how do we get it to happen?".

Research on the individual placement and support model of supported employment

This paper reviews research on the Individual Placement and Support (IPS) model of supported employment for people with severe mental illness. Current evidence indicates that IPS supported employment is a more effective approach for helping people with psychiatric disabilities to find and maintain competitive employment than rehabilitative day programs or than traditional, stepwise approaches to vocational rehabilitation. There is no evidence that the rapid-job-search, high-expectations approach of IPS produces untoward side effects. IPS positively affects satisfaction with finances and vocational services, but probably has minimal impact on clinical adjustment. The cost of IPS is similar to the costs of other vocational services, and cost reductions may occur when IPS displaces traditional day treatment programs. Future research should be directed at efforts to enhance job tenure and long-term vocational careers.