Effectiveness of the Boston University Approach to Psychiatric Rehabilitation in Improving Social Participation in People With Severe Mental Illnesses: A Randomized Controlled Trial

Factors encouraging participation in social activities after hospital discharge in people with severe mental illness who received occupational therapy

Introduction

Occupational therapy (OT), a vital part of psychiatric rehabilitation, encourages participation in social activities, which is critical for the recovery of people with severe mental illnesses (SMI). However, the effects of OT on the subsequent social activities of patients with SMI have not been fully clarified. We aimed to identify the factors that encourage post-discharge social activity participation among patients with SMI who received OT.

Method

Patients who underwent OT at the Kyorin University Hospital between April 2016 and March 2020 were retrospectively examined for baseline data during hospitalization and social activity status 1 year after discharge. Occupational support, group adaptation, artistic activities, and exercise programs were considered. Activities requiring social interaction were defined as social activities, including employment, schooling, sheltered work, and volunteer work. Multiple logistic regression analyses using demographic and medical data, prehospitalization social activity status, and OT participation rates as independent variables were used to examine the factors encouraging social activity participation after discharge. Decision tree analysis was conducted to identify patients who specifically needed to increase OT participation.

Results

Of 524 eligible patients, 247 were included in the study. The number of patients who were socially active at admission and after discharge was 116 and 188, respectively. Multiple logistic regression analyses revealed that the following factors were likely to encourage social activity participation after discharge: higher rates of OT participation to facilitate group adaptation (OR = 1.015, 95% CI 1.003-1.027), being socially active at admission (OR = 4.557, 95% CI 2.155-9.637), and no marital history (OR = 0.293, 95% CI 0.130-0.661). Decision tree analysis showed that for patients who were socially inactive at admission and had a history of marriage, increasing OT participation to 52.6% or higher may ensure social activity participation after discharge.

Conclusions

This study identified patients whose social participation after discharge could be boosted by OT that facilitates group adaptation. Our findings would facilitate the development of individualized add-on rehabilitation based on the effects of real-world OT practices.

Community-based models of care facilitating the recovery of people living with persistent and complex mental health needs: a systematic review and narrative synthesis

Objective

This study aims to assess the effectiveness of community-based models of care (MoCs) supporting the recovery of individuals who experience persistent and complex mental health needs.

Method

We conducted a systematic review and narrative synthesis of MoC studies reporting clinical, functional, or personal recovery from October 2016 to October 2021. Sources were Medline, EMBASE, PsycInfo, CINAHL, and Cochrane databases. Studies were grouped according to MoC features. The narrative synthesis was led by our researchers with lived experience.

Results

Beneficial MoCs ranged from well-established to novel and updated models and those explicitly addressing recovery goals and incorporating peer support: goal-focused; integrated community treatment; intensive case management; partners in recovery care coordination; rehabilitation and recovery-focused; social and community connection-focused; supported accommodation; and vocational support. None of our diverse group of MoCs supporting recovery warranted a rating of best practice. Established MoCs, such as intensive case management, are promising practices regarding clinical and functional recovery, with potential for enhancements to support personal recovery. Emerging practice models that support personal and functional recovery are those where consumer goals and priorities are central.

Conclusion

Evidence for established models of care shows that there is a need for inevitable evolution and adaptation. Considering the high importance of effective MoCs for people experiencing persistent and complex mental health needs, further attention to service innovation and research is required. Greater emphasis on the inclusion of lived and living experience in the design, delivery, implementation, and research of MoCs is needed, to enhance MOCs' relevance for achieving individual consumer recovery outcomes.

Addressing victimization to enable societal participation in flexible assertive community treatment: A process evaluation of the implementation of a new intervention

BACKGROUND

Individuals with severe mental illness experience more victimization and discrimination than other persons in the community. Effective rehabilitation and recovery-oriented care interventions aimed at addressing this issue are lacking. We therefore developed a victimization-informed intervention (accompanied by a training module for professionals) called the Victoria intervention. The purpose of the present study was to understand the trial effects by examining the implementation process and the factors that influenced it.

MATERIALS AND METHODS

A process evaluation was conducted using a mixed-methods design. During the professionals' intervision sessions, we used observations to understand the learning processes (n = 25). Subsequently, we studied the use of the intervention in practice through structured questionnaires (n = 215) and semi-structured interviews (n = 34) with clients and professionals. We used descriptive and inferential statistics for the quantitative data and the framework method for the analyses of the qualitative data.

RESULTS

The observations showed that the trainings were well received. The professionals shared the urgency of paying attention to victimization and discrimination and its harmful effects on participation. They also found the intervention steps to be logical and the intervention protocol easy to use. Nevertheless, they mentioned in the interviews that they had experienced difficulties initiating a conversation about victimization, and if they started one, they did not always follow the steps of the intervention as intended. Few clients said that victimization was placed on the agenda, though those who had discussed victimization with their caregivers expressed their appreciation in the interviews; they felt acknowledged and supported.

DISCUSSION

The findings indicate that the intervention was considered helpful in raising awareness and the acknowledgment of victimization. However, professionals remain reluctant to talk about the subject, and the results show they need more practical training in this regard. This process evaluation has an important added value in that it helps us to understand the results of the effect evaluation of the intervention. The findings will facilitate the development and implementation of interventions that address clients' victimization experiences in community mental healthcare settings and subsequently enable their participation in society.

Cost Effectiveness and Budget Impact of the Boston University Approach to Psychiatric Rehabilitation for Increasing the Social Participation of Individuals With Severe Mental Illnesses

BACKGROUND

The purpose of this study was to investigate the cost-effectiveness and budget impact of the Boston University Approach to Psychiatric Rehabilitation (BPR) compared to an active control condition (ACC) to increase the social participation (in competitive employment, unpaid work, education, and meaningful daily activities) of individuals with severe mental illnesses (SMIs). ACC can be described as treatment as usual but with an active component, namely the explicit assignment of providing support with rehabilitation goals in the area of social participation.

METHOD

In a randomized clinical trial with 188 individuals with SMIs, BPR (n = 98) was compared to ACC (n = 90). Costs were assessed with the Treatment Inventory of Costs in Patients with psychiatric disorders (TIC-P). Outcome measures for the cost-effectiveness analysis were incremental cost per Quality Adjusted Life Year (QALY) and incremental cost per proportional change in social participation. Budget Impact was investigated using four implementation scenarios and two costing variants.

RESULTS

Total costs per participant at 12-month follow-up were € 12,886 in BPR and € 12,012 in ACC, a non-significant difference. There were no differences with regard to social participation or QALYs. Therefore, BPR was not cost-effective compared to ACC. Types of expenditure with the highest costs were in order of magnitude: supported and sheltered housing, inpatient care, outpatient care, and organized activities. Estimated budget impact of wide BPR implementation ranged from cost savings to €190 million, depending on assumptions regarding uptake. There were no differences between the two costing variants meaning that from a health insurer perspective, there would be no additional costs if BPR was implemented on a wider scale in mental health care institutions.

CONCLUSIONS

This was the first study to investigate BPR cost-effectiveness and budget impact. The results showed that BPR was not cost-effective compared to ACC. When interpreting the results, one must keep in mind that the cost-effectiveness of BPR was investigated in the area of social participation, while BPR was designed to offer support in all rehabilitation areas. Therefore, more studies are needed before definite conclusions can be drawn on the cost-effectiveness of the method as a whole.

Targeting Personal Recovery of People With Complex Mental Health Needs: The Development of a Psychosocial Intervention Through User-Centered Design

Long-term admissions in psychiatric facilities often result in a gradual erosion of the identity of people diagnosed with severe mental illnesses (SMIs) into merely "patient." Moreover, experiences of loss often reduced people's sense of purpose. Although regaining a multidimensional identity and a sense of purpose are essential for personal recovery, few interventions specifically address this, while at the same time take people's often considerable cognitive and communicative disabilities into consideration. This study describes the development process of a new intervention through user-centered design (UCD). UCD is an iterative process in which a product (in this case, an intervention) is developed in close cooperation with future users, such that the final product matches their needs. The design process included three phases: an analysis, design, and evaluation phase. In the analysis phase, the "problem" was defined, users' needs were identified, and design criteria were established. In the design phase, the collected information served as input to create a testable prototype using a process of design and redesign, in close collaboration with service users and other stakeholders. This resulted in an intervention entitled "This is Me" (TiM) in which service users, together with a self-chosen teammate, actively engage in new experiences on which they are prompted to reflect. Finally, in the evaluation phase, TiM was implemented and evaluated in a real-life setting. In a small feasibility pilot, we found indications that some people indeed demonstrated increased reflection on their identity during the intervention. Furthermore, TiM seemed to benefit the relationship between the service users and the mental health professionals with whom they underwent the experiences. The pilot also revealed some aspects of the (implementation of) TiM that can be improved. Overall, we conclude that UCD is a useful method for the development of a new psychosocial intervention. The method additionally increased our knowledge about necessary factors in targeting personal recovery for people with complex mental health needs. Moreover, we conclude that TiM is a promising tool for supporting people with SMI in redeveloping a multidimensional identity and a renewed sense of purpose.