Relational continuity may give better clinical outcomes in patients with serious mental illness - a systematic review

BACKGROUND

Continuity of care is considered important for results of treatment of serious mental illness (SMI). Yet, evidence of associations between relational continuity and different medical and social outcomes is sparse. Research approaches differ considerably regarding how to best assess continuity as well as which outcome to study. It has hitherto been difficult to evaluate the importance of relational continuity of care. The aim of this systematic review was to investigate treatment outcomes, including effects on resource use and costs associated with receiving higher relational continuity of care for patients with SMI.

METHODS

Eleven databases were searched between January 2000 and February 2021 for studies investigating associations between some measure of relational continuity and health outcomes and costs. All eligible studies were assessed for study relevance and risk of bias by at least two independent reviewers. Only studies with acceptable risk of bias were included. Due to study heterogeneity the synthesis was made narratively, without meta-analysis. The certainty of the summarized result was assessed using GRADE. Study registration number in PROSPERO: CRD42020196518.

RESULTS

We identified 8 916 unique references and included 17 studies comprising around 300 000 patients in the review. The results were described with regard to seven outcomes. The results indicated that higher relational continuity of care for patients with serious mental illness may prevent premature deaths and suicide, may lower the number of emergency department (ED) visits and may contribute to a better quality of life compared to patients receiving lower levels of relational continuity of care. The certainty of the evidence was assessed as low or very low for all outcomes. The certainty of results for the outcomes hospitalization, costs, symptoms and functioning, and adherence to drug treatment was very low with the result that no reliable conclusions could be drawn in these areas.

CONCLUSIONS

The results of this systematic review indicate that having higher relational continuity of care may have beneficial effects for patients with severe mental illness, and no results have indicated the opposite relationship. There is a need for better studies using clear and distinctive measures of exposure for relational continuity of care.

Outcomes associated with higher relational continuity in the treatment of persons with asthma or chronic obstructive pulmonary disease: A systematic review

Background

Asthma and chronic obstructive pulmonary disease (COPD) are chronic conditions where relational continuity of care, as in regularly meeting the same health care provider, creates opportunities for monitoring and adjustment of treatment based on an individual's changing needs, potentially affecting quality of delivered care. The aim of this systematic review was to investigate the effects of relational continuity in the treatment of persons with asthma or COPD.

Methods

Eleven databases (CINAHL, Medline, PsycINFO, Scopus, Embase, Cochrane Library, Database of Systematic Review of Effects, DARE, Epistemonikos, NICE Evidence Search, KSR Evidence and AHRQ) were searched between January 1, 2000, and February 1 - 4, 2021, for controlled and observational studies about relational continuity and health outcomes for persons with asthma and/or COPD. Inclusion criteria were studies investigating an index or aspect relevant to relational continuity between a health professional/team of health professionals and patients. After screening, and assessment of study relevance and quality by at least two independent reviewers, studies with acceptable risk of bias were included and summary data was extracted from the publications. Main outcomes were mortality, morbidity (including health care utilization) and cost measures. Syntheses without metanalyses were performed due to considerable study heterogeneity. The certainty of the summarized result was assessed using GRADE (the Grading of Recommendations Assessment, Development and Evaluation). PROSPERO study registration number: CRD42020196518.

Findings

We identified 2824 unique references and included 15 studies (14 observational and 1 randomized controlled trial) in the review, from which results were derived for six outcomes. For persons with asthma or COPD we found that higher compared to lower relational continuity of care prevents premature mortality (low certainty; 2 studies, 111 545 participants), lowers risk of emergency department visits (low certainty, 5 studies, 362 305 participates) and risk of hospitalization (moderate certainty, 9 studies, 525 716 participants), and lowers health care costs (low certainty; 4 studies, 390 682 participants). Results regarding treatment adherence (1 study, 971 participants) and patient perceptions (3 studies, 2026 participants) were assessed as having very low certainty.

Interpretation

Low to moderate certainty evidence suggests that higher versus lower relational continuity of care for persons with asthma or COPD prevents premature mortality, lowers risks of unplanned health care utilization and reduces health care costs. The results may be of value when planning care for individuals and for policymakers in organizing health care and developing guidelines for treatment and follow-up routines.

Funding

None.

Changes in rehabilitation actors' mental health literacy and support to employers: An evaluation of the SEAM intervention

BACKGROUND

Lack of mental health literacy among rehabilitation professionals and employers in the return-to-work of persons with mental health problems resulted in the development of a three-day group training program, the Support to Employers from rehabilitation Actors about Mental health (SEAM) intervention.

OBJECTIVE

To evaluate the impact of SEAM on rehabilitation professionals' knowledge and beliefs, attitudes, and supporting behaviors towards people with mental health problems and employers as part of the return-to-work process.

METHODS

In this longitudinal study, 94 rehabilitation professionals were included. Data were collected prior to (T1), immediately after (T2) and 6 months after SEAM training (T3) using knowledge and attitude scales and a questionnaire on supporting behaviors. SEAM includes training in Mental Health First Aid, presentations and discussions on current research on work and mental health, and strategies and communication guidelines to use when meeting service users and employers as part of the return-to-work of persons with mental health problems. SEAM also includes a homepage with targeted employer information. Data were analyzed using non-parametric statistics.

RESULTS

SEAM significantly increased rehabilitation professionals' knowledge of mental health (T1-T2: z = -2.037, p = 0.042; T2-T3: z = -5.093, p = 0.001), and improved their attitudes towards persons with mental health problems (T1-T2: z = 4.984, p = 0.001). Professionals (50-60%) also estimated that they had increased their use of supporting strategies towards service users and employers.

CONCLUSIONS

The study suggests that SEAM can increase mental health literacy among rehabilitation professionals and lead to a greater focus on service users' resources and work ability, as well as on employers' support needs.

Dynamic navigation guided surgery and prosthetics for immediate loading of complete-arch restoration

OBJECTIVE

To assess clinical and radiological performance of novel digital workflow integrating dynamic guided surgery, to streamline execution of implant placement, soft and bone tissue sculpturing, and immediate delivery of navigation guided complete-arch prosthesis.

MATERIALS AND METHODS

This proof of concept prospective single cohort study investigated 10 consecutive patients (three males, seven females; mean age 62.5 ± 8.9 years; range, 48-75) requiring at least one complete-arch fixed dental prostheses (FDP) in both jaws, treated between January and August 2019. Primary outcomes were implant and prosthetic success rates, surgical and prosthetic complications. Secondary outcomes were marginal bone loss (MBL), implant stability quotient (ISQ), periodontal parameters (plaque and bleeding indexes).

RESULTS

Sixty implants (32 NobelParallel TiUltra and 28 NobelActive TiUltra, Nobel Biocare) were placed and 14 complete-arch FDPs immediately loaded (mean follow-up 16.2 ± 1.7 months, 14-18). One implant failed and was immediately replaced. No other surgical or biological complications occurred, accounting for a cumulative success rate of 98.3%. No prosthetic complication occurred, leading to 100% prosthetic success rate. Mean ISQ at implant placement was 71 ± 2.8 (65-78). The mean MBL was -0.53 ± 0.28 mm (-0.22 to -1.12 mm). Plaque and bleeding scores were 14.4 ± 8.18 and 7.15 ± 4.4, respectively.

CONCLUSION

Within the limitations of this proof-of-concept dynamic navigation was effective to deliver in the planned coordinates both implants and prosthesis and guide bone and soft tissue sculpturing. Immediate loading of digitally prefabricated esthetically driven complete-arch FDP was facilitated, resulting in high implant and prosthetic success rates.

CLINICAL SIGNIFICANCE

The investigated digital workflow integrating dynamic navigation may overcome the difficulties related to immediate positioning and loading of digitally prefabricated complete-arch FDP. The navigation guided soft and bone tissues sculpturing, associated to xenogeneic collagen matrix grafting, represented a predictable technique to achieve the digitally planned interface, reestablishing the mucosal dimension required for the protection of underlying bone while maintaining tissue health.

Decreased IL-1β-induced CCL20 response in human iPSC-astrocytes in schizophrenia: Potential attenuating effects on recruitment of regulatory T cells

Schizophrenia (SCZ) is a severe mental disorder with a high heritability. Although its pathophysiology is mainly unknown, dysregulated immune activation and inflammation have recently emerged as possible candidates in the underlying mechanisms of SCZ. Previous studies suggest that aberrant inflammasome activation, glia dysregulation, and brain inflammation may be involved in the pathophysiology of the disorder. Here, we studied the effects of inflammatory modulation on human induced pluripotent stem cell (iPSC)-derived astrocytes generated from SCZ patients and healthy controls (CTRL). Inflammasome activation was mimicked by short-term IL-1β exposure, and gene expression were measured with high-coverage RNA-Seq to ensure a global characterization of the transcriptional effects of the treatment. IL-1β exposure modulated several pathways involved in innate immune responses, cell cycle regulation, and metabolism in both SCZ and CTRL astrocytes. Significant differences were found in the expression of HILPDA and CCL20 genes, both of which had reduced up-regulation upon IL-1β treatment in SCZ astrocytes compared to CTRL astrocytes. CCL20 data were further validated and confirmed using qPCR, ELISA, and regulatory T lymphocyte (T_reg) migration assays. Additionally, we found significantly decreased mRNA expression of the T_reg-specific marker FOXP3 in the blood of a large cohort of SCZ patients (n = 484) compared to CTRL (n = 472). Since CCL20 is a specific chemoattractant for CD4⁺CD25⁺CCR6⁺ T_regs, which are crucially involved in anti-inflammatory responses during brain (auto)inflammation, our results imply a plausible role for an altered astroglia-CCL20-CCR6-T_reg axis in SCZ pathophysiology.

Exploring the service and knowledge gap between rehabilitation professionals and employers in the return-to-work process of people with mental health problems in Sweden

BACKGROUND

Research is needed on how to optimize the return-to-work process for persons with mental health problems.

OBJECTIVE

To develop a model that explains how employer and rehabilitation professional mental health literacy may influence strategies used in the return-to-work of persons with mental health problems.

METHODS

A grounded theory study design was used to collect and analyse interview data from 23 employers and 22 rehabilitation professionals.

RESULTS

The analysis resulted in four categories, illustrated in a conceptual process model: 1) seeing mental health problems through past experiences; 2) separating understandable and incomprehensible mental health problems; 3) balancing safeguarding one's personal interest with providing adequate support; and 4) facing conflicts and uncertainty in employee/service user return-to-work. A positional map of employer/rehabilitation types was created based on level of negative attitudes and uncertainty in supporting employees/service users and the employer in relation to the level of comprehensive understanding of mental health problems.

CONCLUSIONS

Professional mental health literacy needs to be increased. Interventions need to be developed that provide employers with targeted support and knowledge in mental health literacy. Education on how to prevent and detect common mental health problems in the workplace is needed.

The influence of temperament and character on functioning and aspects of psychological health among people with schizophrenia

Research findings that link personality factors to functioning and symptoms in schizophrenia are inconsistent, and further studies are needed within the area. The purpose of this study was to investigate how personality, as measured by the Temperament and Character Inventory (TCI), was related to demographic factors, subtypes of diagnoses, level of functioning, and aspects of psychological health, including sense of coherence, perceived control, and self-esteem, among people with schizophrenia. Subjects were 104 individuals, aged 20–55 years, in psychiatric outpatient care. The results indicated that personality was not related to subtypes of diagnoses or demographic characteristics of the respondents, but to level of functioning and all aspects of psychological health. Especially self-directedness distinguished three groups of functioning and was highly correlated with the different aspects of psychological health. The article discusses how knowledge of schizophrenic patients’ personality structure might be used for tailoring psychiatric treatments.

Appraisal of caregiving, burden and psychological distress in relatives of psychiatric inpatients

Appraisal of caregiving and its relationship to family burden and experienced mental health problems in the relatives were investigated as part of a multi-centre study of the quality of mental health services in Sweden performed in 1997. The sample was drawn from relatives of involuntarily and voluntarily admitted patients to acute psychiatric wards. The instrument used was a semi-structured questionnaire, interviewing relatives about the burden, experience of mental health problems and appraisal of the caregiving situation. The results showed a high proportion of relatives engaged in caregiving activities on a daily basis the month before the patient's admission to hospital and a high proportion of relatives appraising the caregiving activities negatively. The burden was more extensive if the relative and the patient were living together, had a longer duration of their relationship, if the relative was rendering caregiving on a daily basis and if the relative appraised caregiving negatively. The relatives' psychological distress was not related to their negative appraisal of caregiving, nor was patient characteristics, such as diagnosis and level of psychosocial functioning. The only factor found to influence the relatives' psychological distress was the duration of relationship to the patient. Interventions reducing psychological distress for relatives who have known the patients for more than 20 years, who live with the patient, who give care on a daily basis and who appraise their caregiving negatively are suggested.

The Nordic comparative study on sectorized psychiatry: characteristics of repeat users of emergency outpatient services in two Nordic psychiatric services. A 1-year follow-up study

To characterise frequent use of psychiatric emergency outpatients services, this paper reports results from a prospective investigation of use of psychiatric services by new patients in two Nordic psychiatric services, Frederiksberg in Denmark and Oulu in Finland. One year treated incidence cohorts were used. Total number of patients included was 1,055. The repeat user was defined as a patient having at least three emergency outpatient contacts during a 1-year follow-up. The repeat users constituted 15.8% of the sample and 70.8% of all the emergency contacts in Frederiksberg. In Oulu the respective figures were 9.3% and 33.8%. The number of planned outpatient contacts or the number of hospital admissions of the repeat users did not differ from the non-repeaters. Repeaters in Frederiksberg were more likely to be self-referrals, male, divorced or unmarried, living with their parents, without their own housing, unemployed, aged between 25 and 44 years, and to have a diagnosis of dependency or personality disorder. In Oulu they did not differ from the other patients with regard to sociodemographic or diagnostic characteristics.

Perceived curative factors and their relationship to outcome: a study of schizophrenic patients in a comprehensive treatment program based on cognitive therapy

Twenty-eight schizophrenic and other long-term mentally ill patients who were given cognitive therapy sessions twice a week in the context of a comprehensive inpatient treatment program were assessed every 5 weeks regarding perceived curative factors. The assessments were made by a self-rating questionnaire (Curative Factors Questionnaire [CFQ]) and a qualitative assessment from the patients of what they perceived as helpful in treatment. The results showed that milieu therapeutic elements and therapy sessions were perceived as the most helpful throughout the treatment period. No correlations were found between patient characteristics and perceived curative factors. The factors “instillation of hope”, “problem solution” and “learning I’m not alone” as rated in the initial phase of treatment showed a positive relationship with a favourable outcome of treatment at discharge.

A Qualitative Study of Caregivers' Experiences, Motivation and Challenges Using a Web-Based Mindfulness Intervention

Caregivers report experiences of stress and burden that can affect their health negatively. Web-based mindfulness interventions have shown beneficial health effects in clinical and non-clinical populations, including caregivers. The study's aim was to explore the experiences of a web-based mindfulness program, including motivation and challenges to use, in caregivers of a person with somatic illness. Ten participants were interviewed. Data was analyzed with content analysis, resulting in four categories illustrating the participants' experiences of the program, including motivations and barriers to training: A timely or untimely intervention; Mainly positive effects even at low levels of training; Relationship to the patient; and Creating a routine and maintaining motivation. Qualitative studies can contribute to enrich our understanding of the value of such interventions, which may be a flexible supportive tool for caregivers. The findings illuminate the importance of supporting motivation and adherence to such interventions, with the potential for enhanced beneficial outcomes.

Elevated expression of a minor isoform of ANK3 is a risk factor for bipolar disorder

Ankyrin-3 (ANK3) is one of the few genes that have been consistently identified as associated with bipolar disorder by multiple genome-wide association studies. However, the exact molecular basis of the association remains unknown. A rare loss-of-function splice-site SNP (rs41283526*G) in a minor isoform of ANK3 (incorporating exon ENSE00001786716) was recently identified as protective of bipolar disorder and schizophrenia. This suggests that an elevated expression of this isoform may be involved in the etiology of the disorders. In this study, we used novel approaches and data sets to test this hypothesis. First, we strengthen the statistical evidence supporting the allelic association by replicating the protective effect of the minor allele of rs41283526 in three additional large independent samples (meta-analysis p-values: 6.8E-05 for bipolar disorder and 8.2E-04 for schizophrenia). Second, we confirm the hypothesis that both bipolar and schizophrenia patients have a significantly higher expression of this isoform than controls (p-values: 3.3E-05 for schizophrenia and 9.8E-04 for bipolar type I). Third, we determine the transcription start site for this minor isoform by Pacific Biosciences sequencing of full-length cDNA and show that it is primarily expressed in the corpus callosum. Finally, we combine genotype and expression data from a large Norwegian sample of psychiatric patients and controls, and show that the risk alleles in ANK3 identified by bipolar disorder GWAS are located near the transcription start site of this isoform and are significantly associated with its elevated expression. Together, these results point to the likely molecular mechanism underlying ANK3´s association with bipolar disorder.

Psychometric evaluation of the Swedish version of Rosenberg's self-esteem scale

BACKGROUND

The widely used Rosenberg's self-esteem scale (RSES) has not been evaluated for psychometric properties in Sweden.

AIMS

This study aimed at analyzing its factor structure, internal consistency, criterion, convergent and discriminant validity, sensitivity to change, and whether a four-graded Likert-type response scale increased its reliability and validity compared to a yes/no response scale.

METHODS

People with mental illness participating in intervention studies to (1) promote everyday life balance (N = 223) or (2) remedy self-stigma (N = 103) were included. Both samples completed the RSES and questionnaires addressing quality of life and sociodemographic data. Sample 1 also completed instruments chosen to assess convergent and discriminant validity: self-mastery (convergent validity), level of functioning and occupational engagement (discriminant validity). Confirmatory factor analysis (CFA), structural equation modeling, and conventional inferential statistics were used.

RESULTS

Based on both samples, the Swedish RSES formed one factor and exhibited high internal consistency (>0.90). The two response scales were equivalent. Criterion validity in relation to quality of life was demonstrated. RSES could distinguish between women and men (women scoring lower) and between diagnostic groups (people with depression scoring lower). Correlations >0.5 with variables chosen to reflect convergent validity and around 0.2 with variables used to address discriminant validity further highlighted the construct validity of RSES. The instrument also showed sensitivity to change.

CONCLUSIONS

The Swedish RSES exhibited a one-component factor structure and showed good psychometric properties in terms of good internal consistency, criterion, convergent and discriminant validity, and sensitivity to change. The yes/no and the four-graded Likert-type response scales worked equivalently.

Outcomes of clients in need of intensive team care in Flexible Assertive Community Treatment in Sweden

BACKGROUND

Flexible Assertive Community Treatment (Flexible ACT) has been implemented in Sweden during recent years due to increasing interest in integrated services for people with severe mental illness. To date, few studies have been done on Flexible ACT effectiveness.

AIMS

The overall aim of this study was to explore the extent to which clients assigned to the Flexible ACT board for ACT intensive care were stabilized with improved everyday functioning, social outcomes, and changes in healthcare use.

METHODS

Ninety-three participants with psychosis, in need of ACT from six newly started Flexible ACT teams, were included. Data were collected using the Social Outcome Index scale (SIX), Practical and Social Functioning Scale, and a healthcare usage questionnaire.

RESULTS

There was a significant positive change in everyday functioning and in the SIX-item 'friendship' at 18-months follow-up. A positive correlation was also found between everyday functioning and the SIX-item 'friendship' and a negative correlation between duration of ACT and everyday functioning. A significant increase in number of inpatient hospital days and psychiatric outpatient visits also occurred.

CONCLUSION

Clients with psychosis who need ACT may benefit from Flexible ACT through improved social functioning. Being involved in meaningful activities and supported by others are key aspects of recovering from mental illness and are enhanced by Flexible ACT.

Psychopathological Symptoms and Satisfaction with Mental Health in Patients with Schizophrenia

BACKGROUND

The patient's view of their mental health is a central aspect in research and practice. Yet, little is known about which psychopathological symptoms are linked with patients' satisfaction with their mental health. We aimed to identify these symptoms in patients with schizophrenia.

METHODS

An individual patient data meta-analysis was conducted with data from 2,488 patients from 8 independent studies. Satisfaction with mental health was rated on a 7-point scale, and symptoms were observer-rated using identical items from the Brief Psychiatric Rating Scale and the Positive and Negative Symptom Scale. Mixed multilevel univariate followed by multivariate regression models were used to identify symptoms associated with satisfaction with mental health.

RESULTS

In univariate regressions, all subscales - not age and gender - were associated with mental health satisfaction. In the multivariate regression, only affective and negative symptoms were significantly associated with a lower satisfaction with mental health, explaining 22.5% of the variance.

CONCLUSIONS

Observer-rated psychopathological symptoms are linked to patients' mental health satisfaction. In addition to affective symptoms - which are commonly negatively linked with satisfaction ratings - a higher level of negative symptoms makes patients less satisfied with their mental health, whilst positive and other symptoms do not influence mental health satisfaction.

What influences a sustainable implementation of evidence-based interventions in community mental health services? Development and pilot testing of a tool for mapping core components

BACKGROUND

An important aspect of research regarding the implementation of evidence-based practice is the sustainability and long-term stability of a programme. There is a need to measure these critical components for establishing successful programmes.

AIM

The aim was to develop and pilot test the sustainable implementation scale (SIS) for measuring the critical components in the sustainable implementation of community mental health services.

METHOD

The scale was based on implementation research and consisted of three subscales regarding (1) the organisational level, (2) the team level and (3) continuous support. Data from interviews and documents were collected from 14 programmes implementing the Individual Placement and Support model of supported employment.

RESULTS

Internal consistency was acceptable for all subscales and for the scale as a whole. Regarding the scale, an analysis of the differences between fully established programmes and the programmes that were not established or were or only partially established after three years showed statistically significant differences, indicating that a greater number of implementation components were present in the fully established programmes.

CONCLUSIONS

SIS showed both good reliability and acceptable internal consistency as well as the ability to predict programme survival.

Mental health first aid for the elderly: A pilot study of a training program adapted for helping elderly people

OBJECTIVES

Epidemiological studies have shown a high prevalence of mental illness among the elderly. Clinical data however indicate both insufficient detection and treatment of illnesses. Suggested barriers to treatment include conceptions that mental health symptoms belong to normal aging and lack of competence among staff in elderly care in detecting mental illness. A Mental Health First Aid (MHFA) training program for the elderly was developed and provided to staff in elderly care. The aim of this study was to investigate changes in knowledge in mental illness, confidence in helping a person, readiness to give help and attitudes towards persons with mental illness.

METHOD

Single group pre-test-post-test design.

RESULTS

The study group included staff in elderly care from different places in Sweden (n = 139). Significant improvements in knowledge, confidence in helping an elderly person with mental illness and attitudes towards persons with mental illness are shown. Skills acquired during the course have been practiced during the follow-up.

CONCLUSIONS

The adaption of MHFA training for staff working in elderly care gives promising results. Improvements in self-reported confidence in giving help, attitudes towards persons with mental illness and actual help given to persons with mental illness are shown. However, the study design allows no firm conclusions and a randomized controlled trail is needed to investigate the effectiveness of the program. Outcomes should include if the detection and treatment of mental illness among the elderly actually improved.

User value and usability of a web-based mindfulness intervention for families living with mental health problems

Mental health problems affect the patients and their families, who may also need therapeutic interventions. Mindfulness interventions have shown beneficial health effects for clinical and healthy populations. A web-based mindfulness intervention was tailored to address families' needs of support and tested in a pilot intervention study. The aim of this study was to explore the participants' experiences of using an 8-week web-based mindfulness programme in terms of user value and usability. Qualitative semi-structured interviews were carried out over the phone (Spring 2015, Sweden) with 15 randomly selected participants after the 3-month follow-up as part of the pilot study. Data were also collected through usability surveys online post intervention and at the 3-month follow-up. Qualitative data were analysed with content analysis and quantitative data with descriptive statistics. The analysis of the interviews resulted in four categories describing the participants' experiences of the programme's usability and value: A valuable and flexible tool that requires time and discipline, New perspective and coping strategies for an enhanced well-being, I'm important too - my limits, my responsibility, and Taming the inner critic. The programme's usability was satisfactory and largely corroborated by the surveys. The programme was experienced as a valuable tool to cope with stress in both private and professional contexts, making it a viable option to support families living with mental health problems. Time for self-care, a widened perspective, a less judgmental and more accepting attitude, deterring automatic reactions and setting limits helped the participants to deal with their situation and health. The programme's ease and flexibility of use were major advantages, although the training requires discipline. Motivators and barriers to use were illuminated, which should be considered in the development of further online services and study designs.

Effectiveness and Usability of a Web-Based Mindfulness Intervention for Families Living with Mental Illness

Families living with mental illness express needs of support and experiences of burden that may affect their own health detrimentally and hence also their ability to support the patient. Mindfulness-based interventions have shown beneficial health effects in both clinical and healthy populations. The aim of the current study was to explore the effectiveness and usability of a web-based mindfulness program for families living with mental illness, which was first tested in a feasibility study. The study was designed as a randomized controlled trial with an experiment group and a wait-list control group with assessments on primary and secondary outcomes at baseline, post-intervention, and at a 3-month follow-up. Significant positive improvements in mindfulness and self-compassion, and significant decreases in perceived stress and in certain dimensions of caregiver burden were found, with good program usability. Easily accessible mindfulness-based interventions may be useful in addressing caregivers' needs of support and in preventing further ill health in caregivers. Further studies are needed, among others, to further customize interventions and to investigate the cost-effectiveness of such programs.

Profiles of Occupational Engagement in People with Schizophrenia (POES): The Development of a New Instrument Based on Time-Use Diaries

Previous time-use research suggests that it is highly relevant for an occupational therapist to estimate time use and occupational engagement in order to understand some of the determinants of wellbeing for people with schizophrenia. This article describes the development and the testing of the psychometric properties of an instrument, Profiles of Occupational Engagement in people with Schizophrenia (POES), with the aim of helping to interpret and evaluate time-use diaries and thus providing a systematic description of status regarding occupational engagement. The first part of POES involves completion of time-use diaries and the second part, the assessment, is based on nine items that are rated on a four-point ordinal scale.

The time-use diaries of 41 people with schizophrenia and the judgements from 12 occupational therapists were used in the study. A test of content validation involved experts from Sweden and the United Kingdom and resulted in two stages of revisions. The strength of agreement between two raters resulted in a mean weighted kappa of 0.70. Internal consistency was calculated for both raters separately and the alpha coefficients were 0.97 and 0.95.

This study provides initial support for the content validity, interrater agreement and internal consistency of POES. Based on the judgements of the occupational therapists in this study, POES seems to have good clinical utility. However, further research on the clinical utility as well as the criterion validity of the construct is warranted.

A Loss-of-Function Variant in a Minor Isoform of ANK3 Protects Against Bipolar Disorder and Schizophrenia

BACKGROUND

Ankyrin-3 (ANK3) was one of the first genes to reach significance in a bipolar disorder genome-wide association study. Many subsequent association studies confirmed this finding and implicated this gene in schizophrenia. However, the exact nature of the role of ANK3 in the pathophysiology remains elusive. In particular, the specific isoforms involved and the nature of the imbalance are unknown.

METHODS

We genotyped a Norwegian sample of 402 patients with bipolar disorder, 293 patients with schizophrenia, and 330 healthy control subjects genome-wide with the Illumina Human Exome BeadChip. We performed allelic association tests at the genome-wide and gene levels and found a significantly associated single nucleotide polymorphism in a splice site of ANK3. We replicated this finding in two other samples and studied the functional effect of this single nucleotide polymorphism by performing quantitative polymerase chain reaction on the affected exon junction in complementary DNA from blood total RNA.

RESULTS

The splice site single nucleotide polymorphism (rs41283526) is located in an alternatively spliced exon of ANK3 and has a strong and significant protective effect against bipolar disorder (odds ratio = .31) and schizophrenia (odds ratio = .21). The minor allele of rs41283526 is a loss-of-function variant that disables the correct splicing of the transcript. Data from the BrainSpan human developmental transcriptome show that the exon bearing this variant is expressed only in a minor isoform of ANK3, the transcription of which is initiated in early adolescence.

CONCLUSIONS

Our results suggest that an elevated expression of this transcript starting in adolescence may be an important factor in the pathophysiology of schizophrenia and bipolar disorder.

Changes in attitudes, intended behaviour, and mental health literacy in the Swedish population 2009-2014: an evaluation of a national antistigma programme

OBJECTIVE

Public stigma of mental illness is still a major problem where numerous population studies during the last decade have mainly shown no improvements. A Swedish national antistigma campaign has been running 2010-2014. The aim of this study was to investigate changes in public stigma during this period as compared to baseline in 2009.

METHODS

Yearly population surveys were made between 2009 and 2014 including assessments of mental health literacy, attitudes, and intended future behaviour. Two surveys were made, one including a nationally representative sample and one including a representative sample from three original campaign regions. Multiple regression analyses, also including age, gender, education, and familiarity with mental illness were made to investigate yearly changes in public stigma compared to baseline.

RESULTS

Mental health literacy improved significantly in the campaign regions between 2009 and 2014, as did intended future behaviour. Attitudes toward mental illness also improved significantly. Improvements were also shown in the national population surveys, but the time pattern of these compared to that of the original campaign regions indicated that these changes took place mainly after the campaign had been extended to a further five Swedish regions.

CONCLUSION

The results of our surveys suggest that a campaign primarily based on social contact theory and involving people with lived experience of mental illness may, even in a rather short-term perspective, have a significant positive impact on mental health literacy, attitudes, and intentions of social contact with people with mental illness.

Outcome of a web-based mindfulness intervention for families living with mental illness - A feasibility study

BACKGROUND

Families living with a person with mental illness can experience distress requiring therapeutic interventions. Web-based mindfulness interventions have shown beneficial health outcomes for both clinical and healthy populations, and may help families cope and overcome barriers that can otherwise hinder a help-seeking process.

AIMS

To develop and assess outcomes of a web-based mindfulness intervention for families living with a person with mental illness.

METHODS

A pilot study investigating an 8-week web-based mindfulness intervention with a pre-post design and follow-up after 3 months, with mindfulness as the primary outcome and perceived stress, caregiver burden and self-compassion as secondary outcomes. The study included a sample of 97 persons approached by advertisement in newspapers, newsletters, and online.

RESULTS

The study showed significant improvements in levels of mindfulness post-intervention and at follow-up as well as significant improvements in levels of perceived stress, caregiver burden, and self-compassion both post-intervention and at follow-up.

DISCUSSION

Acceptability and feasibility of the intervention were high, outcomes were relevant, and the intervention showed positive and significant results supporting the hypothesis that the intervention may help families cope with a stressful situation.

CONCLUSION

Further randomized controlled studies of the intervention are needed to investigate the intervention's effectiveness, including dose-effect studies.

How mental health literacy and experience of mental illness relate to stigmatizing attitudes and social distance towards people with depression or psychosis: A cross-sectional study

Background Evidence suggests that mental health literacy among the public is low, and stigmatizing attitudes are widespread. So far the effects of anti-stigma campaigns are small, and studies demonstrate that negative attitudes have been quite stable through recent decades. Aims To investigate the relationships between mental health literacy, experience of mental illness and stigmatizing attitudes/social distance towards people with depression or psychosis. Methods A cross-sectional study in which staff members from public services in Sweden (n = 1027) completed questionnaires covering demographic data, self-reported experience of mental illness, identification of a vignette for depression or psychosis, beliefs about helpful interventions for the illness presented in the vignette, and attitudes and social distance towards people with the illness. Results About 50% of participants could identify depression and less than 40% psychosis. A higher degree of mental health literacy was related to less stigma and social distance but mainly towards people with depression. A similar relationship was shown for having personal or family experience of mental illness and attitudes/social distance. Negative attitudes and social distance were significantly higher in all aspects measured towards a person with psychosis than a person with depression. Conclusions A higher degree of mental health literacy relates to more positive attitudes and less desire for social distance towards people with depression. The differences between depression and psychosis should be taken into account in anti-stigma interventions.

A psychometric study of the multidimensional fatigue inventory to assess fatigue in patients with schizophrenia spectrum disorders

Fatigue is frequently reported by patients with mental illness. The multidimensional fatigue inventory (MFI-20) is a self-assessment instrument with 20 items including five dimensions of fatigue. The purpose of this study was to examine the test-retest reliability, internal consistency, convergent construct validity and feasibility of using MFI-20 in patients with schizophrenia spectrum disorders. Patients completed two self-assessment instruments, MFI-20 (n = 93) and Visual Analogue Scale (n = 79), twice within 1 week ± 2 days. Fifty-three patients also rated the feasibility of responding to the MFI-20 with a Likert scale. The test-retest reliability and validity were analysed by using Spearman's correlations and internal consistency by calculating Cronbach's α. The test-retest showed a correlation between .66 and .91 for all subscales of MFI. The internal consistency was .92. The analysis of convergent construct validity showed a correlation of .68 (time 1) and .77 (time 2). No item was systematically identified as being difficult to answer.

Predictors of vocational outcomes using individual placement and support for people with mental illness

OBJECTIVE

People with disabilities find it harder to enter the labour market than people without disabilities and those with a mental illness are, in relation to people with other disabilities, employed at an essentially lower extent. Many are effectively helped by the vocational rehabilitation model Individual Placement and Support (IPS), but there are still many individuals left in undesired unemployment. This study investigates potential predictors of the vocational outcomes of a one-year follow up of IPS in the north of Sweden.

PARTICIPANTS

The participants were 65 men and women, mostly younger than 30 years of age diagnosed with a mental illness (predominantly with a diagnosis of anxiety and/or depression).

METHODS

Baseline data related to sociodemographic and clinical characteristics of the client, the client's own perceptions of every day living and participation, self-esteem and quality of life, as well as the quantity of employment support, were investigated using analyses of logistic regression.

RESULTS

Of three identified potential predictors, only psychiatric symptoms remained significant in the multivariate logistic regression analyses. A lower level of symptoms increased the odds with 5.5 for gaining employment during one year.

CONCLUSIONS

Careful investigation of how psychiatric symptoms influence clients' occupational performance is of importance. By understanding essential aspects of the relationships between the clients' individual characteristics, the rehabilitation context and the vocational outcomes, more appropriate and effective interventions may be offered to the individual client.

A 2-year follow-up study of people with severe mental illness involved in psychosocial rehabilitation

BACKGROUNDS. A focus on psychiatric rehabilitation in order to support recovery among persons with severe mental illness (SMI) has been given great attention in research and mental health policy, but less impact on clinical practice. Despite the potential impact of psychiatric rehabilitation on health and wellbeing, there is a lack of research regarding the model called the Psychiatric Rehabilitation Approach from Boston University (BPR).

AIM

The aim was to investigate the outcome of the BPR intervention regarding changes in life situation, use of healthcare services, quality of life, health, psychosocial functioning and empowerment.

METHODS

The study has a prospective longitudinal design and the setting was seven mental health services who worked with the BPR in the county of Halland in Sweden. In total, 71 clients completed the assessment at baseline and of these 49 completed the 2-year follow-up assessments.

RESULTS

The most significant finding was an improved psychosocial functioning at the follow-up assessment. Furthermore, 65% of the clients reported that they had mainly or almost completely achieved their self-formulated rehabilitation goals at the 2-year follow-up. There were significant differences with regard to health, empowerment, quality of life and psychosocial functioning for those who reported that they had mainly/completely had achieved their self-formulated rehabilitation goals compared to those who reported that they only had to a small extent or not at all reached their goals.

CONCLUSIONS

Our results indicate that the BPR approach has impact on clients' health, empowerment, quality of life and in particular concerning psychosocial functioning.

Effectiveness of mental health first aid training in Sweden. A randomized controlled trial with a six-month and two-year follow-up

Background

According to a recent report from the European Brain Council and the European Colleague of Neuropsychopharmacology the one year prevalence of some kind of mental disorder is around 27% among the adult population in Europe. Research has shown a lack of mental health literacy in the population in general and it is thus important to find ways to improve the public's knowledge and skills to provide first hand support to people with mental disorders. Mental Health First Aid (MHFA) is a training program that has shown positive changes in knowledge and helping behavior. This study investigates if MHFA training in a Swedish context provides a sustained improvement in knowledge about mental disorders, a better ability to be helpful in contacts with people who are ill and if it changes attitudes in a positive direction.

Methods and Findings

The introduction of the training program was made in accordance with the constructor's instructions. Participants were mainly public sector employees from a county in the west of Sweden. The study was a randomized controlled trial with an experiment group (n = 199) and a control group (n = 207) placed on a waiting list during a 6-month follow-up. A two-year follow-up was conducted for participants (n = 155) from both the intervention and waiting list group who had completed the training and during the follow-up been in contact with persons with mental disorders. The intervention group improved in knowledge as well as in confidence in providing help for someone in need. The two-year follow-up showed that the improvements were to a great extent maintained.

Conclusions

Mental Health First Aid might raise the level of awareness of mental disorders and have an influence on the number of people who can receive professional treatment for their problems.

Relatives' experiences of the Boston Psychiatric Rehabilitation approach: a qualitative study

The Boston Psychiatric Rehabilitation (BPR) approach is individualized and characterized by being based entirely on the individual's unique needs and preferences in the areas of working, learning, social contacts, and living environment. Relatives of clients in mental health services influence the client's possibilities for recovery by their everyday relationship. Relatives have, however, traditionally had a subordinated role in the care of their mentally ill family member. The perspective of relatives is an important aspect in the development of new approaches to psychiatric rehabilitation. The purpose of this study was thus to describe and explore relatives’ experiences of the BPR approach. Ten relatives of clients in mental health services taking part in the BPR were interviewed. The interviews were transcribed and analyzed with a qualitative content analysis method to explore relatives’ experiences of the BPR intervention in a county in Sweden. The findings from the interviews could be summarized in the theme “To meet the clients’ needs” consisting of three categories: “Dependence on staffs’ competence,” “Responsibility for user involvement,” and “The necessity for coordination between authorities and caregivers.” The findings suggest that relatives may contribute with important information about clients’ needs related to outcome of care. Relatives’ perspectives may be of importance in future development of BPR. Further research about the relatives’ role in psychiatric rehabilitation is needed as well as studies that compare different kinds of psychiatric rehabilitation from the perspective of relatives.

Clients' experiences of the Boston Psychiatric Rehabilitation Approach: a qualitative study

The Boston Psychiatric Rehabilitation Approach (BPR) is person-centered and characterized by being based entirely on the individual's unique needs and preferences in the areas of working, learning, social contacts, and living environment. Nevertheless, the person-centered approach is lacking firm evidence regarding outcomes, and empirical studies regarding clients' experiences of this particular model are needed. A qualitative content analysis of 10 transcribed semistructured individual interviews was used to describe and explore clients' experiences of the BPR during an implementation project in Sweden. The findings from the interviews could be summarized in "A sense of being in communion with self and others" theme, consisting of three categories: increased self-understanding, getting new perspectives, and being in a trusting relationship. The results showed that clients do not always recognize nor are able to verbalize their goals before they have been given the possibility to reflect their thoughts in collaboration with a trusted person. The guidelines of the approach are intended to support the clients' ability to participate in decision making regarding their own care. More research about efficacy of different rehabilitation approaches and exploration of fidelity to guidelines of rehabilitation programs are required.

A web-based supportive intervention for families living with depression: content analysis and formative evaluation

Background

Relatives of people with a mental illness who live together can experience additional burdens that may require support. A Web-based tool including a psychoeducation module, a diary, and a password-protected forum was developed to support relatives of a person with depression.

Objective

The objective of our study was to explore participants’ use of the Web-based tool, with focus on the forum, and to assess its potential health and psychosocial benefits.

Methods

Twenty-five people participated in this explorative open trial. Self-rating instruments assessing caregiver burden, stigma, and the tool’s usability were analyzed with Carer QoL7-D, DISC-12, and a system usability scale. A summary measure of subjective burden was assessed with CarerQoL-VAS. The forum posts were studied using content analysis.

Results

The majority reported fulfillment from their caregiving tasks (84%, 21/25), and had relational problems (76%, 19/25), their own mental health problems (72%, 18/25), support (72%, 18/25), and difficulties coordinating daily activities with caregiving (56%, 14/25). Most (72%, 18/25) reported having been able to use their inner strength to cope with stigma and discrimination, 64% (16/25) had concealed or hidden the person’s condition, and 40% (10/25) reported having been avoided or shunned by people who knew about the illness. Forty-eight percent (12/25) reported unfair treatment from family; 40% (10/25) in marriage or divorce and 36% (9/25) from mental health staff. Almost one-third (28%, 7/25) reported having stopped themselves from having a close personal relationship. Participants’ subjective assessment of the tool’s usability resulted in a mean of 61.5 (range, 22.5-90; possible total value 0-100; >70=good). Ten people participated in the forum; content analysis resulted in five categories describing relatives’ situations: balancing the caregiver’s role and relationship to the patient; their own lives and need for support; resources and patient advocacy; a looming shadow on leisure, social, and professional life; and interaction and social support.

Conclusions

Further studies are needed to explore optimal ways of using Web-based tools to address support for relatives of a person with mental illness. Professional feedback may enhance the use and value of online communities.

Overcoming recruitment barriers revealed high readiness to participate and low dropout rate among people with schizophrenia in a randomized controlled trial testing the effect of a Guided Self-Determination intervention

BACKGROUND

Recruitment is one of the most serious challenges in performing randomized controlled trials. Often clinical trials with participants diagnosed with schizophrenia are terminated prematurely because of recruitment challenges resulting in a considerable waste of resources in the form of time, funding, and the participants' efforts. Dropout rates in schizophrenia trials are also high.Recruitment challenges are often due to patients not wanting to participate in research but can also be due to clinicians' concerns regarding individuals diagnosed with schizophrenia as participants in research. This paper reports how overcoming recruitment challenges not related to patients revealed high readiness to take part and low dropout rates in a one year long randomized controlled trial testing Guided Self-Determination (GSD) among outpatients with schizophrenia receiving treatment in Assertive Outreach Teams in the northern part of Denmark.

METHODS

GSD is a shared decision-making and mutual problem-solving method using reflection sheets, which was developed in diabetes care and adjusted for this study and utilized by patients with schizophrenia. Descriptive data on strategies to overcome recruitment challenges were derived from notes and observations made during the randomized controlled trial testing of GSD in six outpatient teams.

RESULTS

Three types of recruitment challenges not related to patients were identified and met during the trial: 1) organizational challenges, 2) challenges with finding eligible participants and 3) challenges with having professionals invite patients to participate. These challenges were overcome through: 1) extension of time, 2) expansion of the clinical recruitment area and 3) encouragement of professionals to invite patients to the study. Through overcoming these challenges, we identified a remarkably high patient-readiness to take part (101 of 120 asked accepted) and a low dropout rate (8%).

CONCLUSION

Distinction between recruitment challenges was important in discovering the readiness among patients with schizophrenia to take part in and complete a trial with the GSD-intervention.