EPA guidance on physical activity as a treatment for severe mental illness: a meta-review of the evidence and Position Statement from the European Psychiatric Association (EPA), supported by the International Organization of Physical Therapists in Mental Health (IOPTMH)

Physical activity (PA) may be therapeutic for people with severe mental illness (SMI) who generally have low PA and experience numerous life style-related medical complications. We conducted a meta-review of PA interventions and their impact on health outcomes for people with SMI, including schizophrenia-spectrum disorders, major depressive disorder (MDD) and bipolar disorder. We searched major electronic databases until January 2018 for systematic reviews with/without meta-analysis that investigated PA for any SMI. We rated the quality of studies with the AMSTAR tool, grading the quality of evidence, and identifying gaps, future research needs and clinical practice recommendations. For MDD, consistent evidence indicated that PA can improve depressive symptoms versus control conditions, with effects comparable to those of antidepressants and psychotherapy. PA can also improve cardiorespiratory fitness and quality of life in people with MDD, although the impact on physical health outcomes was limited. There were no differences in adverse events versus control conditions. For MDD, larger effect sizes were seen when PA was delivered at moderate-vigorous intensity and supervised by an exercise specialist. For schizophrenia-spectrum disorders, evidence indicates that aerobic PA can reduce psychiatric symptoms, improves cognition and various subdomains, cardiorespiratory fitness, whilst evidence for the impact on anthropometric measures was inconsistent. There was a paucity of studies investigating PA in bipolar disorder, precluding any definitive recommendations. No cost effectiveness analyses in any SMI condition were identified. We make multiple recommendations to fill existing research gaps and increase the use of PA in routine clinical care aimed at improving psychiatric and medical outcomes.

Generalizability of the Individual Placement and Support (IPS) model of supported employment outside the US

While reviews of controlled studies of the Individual Placement and Support (IPS) model of supported employment for clients with severe mental illness have documented its effectiveness in the US, its generalizability to other countries has not been systematically evaluated. This is the first review to compare US to non-US studies. We identified 15 randomized controlled trials of IPS programs, 9 in the US and 6 outside the US. We examined competitive employment outcomes, including employment rate, days to first job, weeks worked during follow-up, and hours worked. We also considered noncompetitive employment, program retention, and nonvocational outcomes. IPS programs had significantly better outcomes across a range of competitive employment indicators and higher retention in services than control groups. The overall competitive employment rate for IPS clients in US studies was significantly higher than in non-US studies (62% vs. 47%). The consistently positive competitive employment outcomes strongly favoring IPS over a range of comparison programs in a group of international studies suggest that IPS is an evidence-based practice that may transport well into new settings as long as programs achieve high fidelity to the IPS model, but further research is needed on international adaptations.

Mental Health Disparities, Treatment Engagement, and Attrition Among Racial/Ethnic Minorities with Severe Mental Illness: A Review

Mounting evidence indicates that there are mental health disparities in the United States that disadvantage racial/ethnic minorities in medical and mental health settings. Less is known, however, about how these findings apply to a particularly vulnerable population, individuals with severe mental illness (SMI). The aim of this paper is to (1) provide a critical review of the literature on racial/ethnic disparities in mental health care among individuals with SMI; (2) identify factors which may contribute to the observed disparities; and (3) generate recommendations on how best to address these disparities. Specifically, this article provides an in-depth review of sociocultural factors that may contribute to differences in treatment engagement and rates of attrition from treatment among racial/ethnic minorities with SMI who present at medical and mental health facilities. This review is followed by a discussion of specific strategies that may promote engagement in mental health services and therefore reduce racial/ethnic disparities in SMI.

Premature mortality among people with severe mental illness - New evidence from linked primary care data

Studies assessing premature mortality in people with severe mental illness (SMI) are usually based in one setting, hospital (secondary care inpatients and/or outpatients) or community (primary care). This may lead to ascertainment bias. This study aimed to estimate standardised mortality ratios (SMRs) for all-cause and cause-specific mortality in people with SMI drawn from linked primary and secondary care populations compared to the general population. SMRs were calculated using the indirect method for a United Kingdom population of almost four million between 2004 and 2013. The all-cause SMR was higher in the cohort identified from secondary care hospital admissions (SMR: 2.9; 95% CI: 2.8-3.0) than from primary care (SMR: 2.2; 95% CI: 2.1-2.3) when compared to the general population. The SMR for the combined cohort was 2.6 (95% CI: 2.5-2.6). Cause specific SMRs in the combined cohort were particularly elevated in those with SMI relative to the general population for ill-defined and unknown causes, suicide, substance abuse, Parkinson's disease, accidents, dementia, infections and respiratory disorders (particularly pneumonia), and Alzheimer's disease. Solely hospital admission based studies, which have dominated the literature hitherto, somewhat over-estimate premature mortality in those with SMI. People with SMI are more likely to die by ill-defined and unknown causes, suicide and other less common and often under-reported causes. Comprehensive characterisation of mortality is important to inform policy and practice and to discriminate settings to allow for proportionate interventions to address this health injustice.

Individual placement and support in Sweden - a randomized controlled trial

BACKGROUND

Currently there is no evidence on the effectiveness of Individual Placement and Support (IPS) in Sweden.

AIMS

To determine the effectiveness of IPS on vocational outcomes among people with severe mental illness (SMI) in a Swedish context. A secondary aim was to evaluate a community integration effect.

METHODS

A randomized controlled trial with a parallel design was used. Mental health outpatients with SMI were randomized to IPS or traditional vocational rehabilitation (TVR) services. The allocation status was assessor-blinded. The primary outcome was competitive employment. All vocational outcomes were collected continuously, and socio-demographic and clinical variables at baseline, 6 and 18 months. The trial is registered with ClinicalTrials.gov: NCT00960024.

RESULTS

One hundred and twenty participants were randomized. Eighty seven per cent were assessed after 6 months, and 73% after 18 months. IPS was more effective than TVR in terms of gaining employment at 18-month follow-up (46% vs. 11%; difference 36%, 95% CI 18-54), along with the amount of working hours and weeks, longer job tenure periods and income. Cox regression analysis showed that IPS participants gained employment five times quicker than those in TVR. Ninety per cent of the IPS participants became involved in work, internships or education, i.e. activities integrated in mainstream community settings, while 24% in the TVR group achieved this.

CONCLUSIONS

IPS is effective in a Swedish context in terms of gaining employment and becoming integrated within the local community. The welfare system presented obstacles for gaining competitive employment directly and it was indicated that internships delayed time to first competitive employment.

Does employment alter the course and outcome of schizophrenia and other severe mental illnesses? A systematic review of longitudinal research

INTRODUCTION

This review synthesized prospective evidence to assess whether achieving employment alters the course of schizophrenia-spectrum disorder.

METHOD

Researchers identified relevant analyses for review via PubMed, expert referral, and reference review and systematically applied two levels of screening to 1484 citations using seven a priori criteria.

RESULTS

A total of 12 analyses representing eight cohorts, or 6844 participants, compared illness course over time by employment status in majority schizophrenia-spectrum samples. Employment was consistently associated with reductions in outpatient psychiatric treatment (2 of 2 studies) as well as improved self-esteem (2 of 2 studies). Employment was inconsistently associated with positive outcomes in several other areas, including symptom severity, psychiatric hospitalization, life satisfaction, and global wellbeing. Employment was consistently unrelated to worsening outcomes.

DISCUSSION

Achieving employment does not cause harm among people with schizophrenia-spectrum disorder and other severe mental illnesses. Further detailed mechanistic analyses of adequately powered long-term follow-up studies using granular descriptions of employment are needed to clarify the nature of associations between employment and hypothesized benefit.

Therapeutic intervention for internalized stigma of severe mental illness: A systematic review and meta-analysis

OBJECTIVE

Internalized stigma can lead to pervasive negative effects among people with severe mental illness (SMI). Although prevalence of internalized stigma is high, there is a dearth of interventions and meanwhile a lack of evidence as to their effectiveness. This study aims at unraveling the existence of different therapeutic interventions and the effectiveness internalized stigma reduction in people with SMI via a systematic review and meta-analysis.

METHODS

Five electronic databases were searched. Studies were included if they (1) involved community or hospital based interventions on internalized stigma, (2) included participants who were given a diagnosis of SMI>50%, and (3) were empirical and quantitative in nature.

RESULTS

Fourteen articles were selected for extensive review and five for meta-analysis. Nine studies showed significant decrease in internalized stigma and two showed sustainable effects. Meta-analysis showed that there was a small to moderate significant effect in therapeutic interventions (SMD=-0.43; p=0.003). Among the intervention elements, four studies suggested a favorable effect of psychoeducation. Meta-analysis showed that there was small to moderate significant effect (SMD=-0.40; p=0.001).

CONCLUSION

Most internalized stigma reduction programs appear to be effective. This systematic review cannot make any recommendation on which intervention is more effective although psychoeducation seems most promising. More Randomized Controlled Trials (RCT) on particular intervention components using standard outcome measures are recommended in future studies.

Do people with mental illness receive adequate smoking cessation advice? A systematic review and meta-analysis

BACKGROUND

Prevalence rates of smoking in people with mental illness are high, and premature mortality attributed to tobacco related physical comorbidity is a major concern. We conducted a meta-analysis comparing rates of receipt of smoking cessation advice among people with and without mental illness.

METHOD

Major electronic databases were searched from inception till August 2014 for studies comparing rates of receipt of smoking cessation advice of people with and without a mental illness. Two independent authors completed methodological appraisal and extracted data. A random-effects meta-analysis was utilized.

RESULTS

Seven studies of satisfactory methodological quality (n mental illness=68,811, n control=652,847) were included. Overall there was no significant difference in smoking cessation advice rates between those with and without a mental illness [relative risk (RR)=1.02, 95% confidence interval (CI)=0.94-1.11, n=721,658, Q=1421, P<.001]. Subgroup analyses demonstrated people with severe mental illness (SMI) received comparable rates of smoking cessation advice to those without SMI (RR=1.09, 95% CI=0.98-1.2, n=559,122). This remained true for people with schizophrenia (RR=1.09, 95% CI=0.68-1.70) and bipolar disorder (RR=1.14, 95% CI=0.85-1.5). People with non-SMIs were slightly more likely to receive smoking cessation advice (RR=1.16, 95% CI=1.04-1.30, Q=1364, P<.001, n=580,206).

CONCLUSIONS

People with SMI receive similar smoking cessation advice rates to people without mental illness, while those with non-SMI are slightly more likely to receive smoking cessation advice. While progress has been made, offering smoking cessation advice should receive a higher priority in everyday clinical practice for patients with a mental health diagnosis.

Supported employment for persons with serious mental illness: current status and future directions

The individual placement and supported (IPS) model of supported employment is the most empirically validated model of vocational rehabilitation for persons with schizophrenia or another serious mental illness. Over 18 randomized controlled trials have been conducted throughout the world demonstrating the effectiveness of supported employment at improving competitive work compared to other vocational programs: IPS supported employment is defined by the following principles: 1) inclusion of all clients who want to work; 2) integration of vocational and clinical services; 3) focus on competitive employment; 4) rapid job search and no required prevocational skills training; 5) job development by the employment specialist; 6) attention to client preferences about desired work and disclosure of mental illness to prospective employers; 7) benefits counseling; and 8) follow-along supports after a job is obtained. Supported employment has been successfully implemented in a wide range of cultural and clinical populations, although challenges to implementation are also encountered. Common challenges are related to problems such as the failure to access technical assistance, system issues, negative beliefs and attitudes of providers, funding restrictions, and poor leadership. These challenges can be overcome by tapping expertise in IPS supported employment, including standardized and tested models of training and consultation. Efforts are underway to increase the efficiency of training methods for supported employment and the overall program, and to improve its effectiveness for those clients who do not benefit. Progress in IPS supported employment offers people with a serious mental illness realistic hope for achieving their work goals, and taking greater control over their lives.

Contributions of specific causes of death to lost life expectancy in severe mental illness

The life expectancy gap between people with severe mental illness (SMI) and the general population persists and may even be widening. This study aimed to estimate contributions of specific causes of death to the gap. Age of death and primary cause of death were used to estimate life expectancy at birth for people with SMI from a large mental healthcare case register during 2007-2012. Using data for England and Wales in 2010, death rates in the SMI cohort for each primary cause of death category were replaced with gender- and age-specific norms for that cause. Life expectancy in SMI was then re-calculated and, thus, the contribution of that specific cause of death estimated. Natural causes accounted for 79.2% of lost life-years in women with SMI and 78.6% in men. Deaths from circulatory disorders accounted for more life-years lost in women than men (22.0% versus 17.4%, respectively), as did deaths from cancer (8.1% versus 0%), but the contribution from respiratory disorders was lower in women than men (13.7% versus 16.5%). For women, cancer contributed more in those with non-affective than affective disorders, while suicide, respiratory and digestive disorders contributed more in those with affective disorders. In men, respiratory disorders contributed more in non-affective disorders. Other contributions were similar between gender and affective/non-affective groups. Loss of life expectancy in people with SMI is accounted for by a broad range of causes of death, varying by gender and diagnosis. Interventions focused on multiple rather than individual causes of death should be prioritised accordingly.

Ethnic inequalities and pathways to care in psychosis in England: a systematic review and meta-analysis

BACKGROUND

As part of a national programme to tackle ethnic inequalities, we conducted a systematic review and meta-analysis of research on ethnic inequalities in pathways to care for adults with psychosis living in England and/or Wales.

METHODS

Nine databases were searched from inception to 03.07.17 for previous systematic reviews, including forward and backward citation tracking and a PROSPERO search to identify ongoing reviews. We then carried forward relevant primary studies from included reviews (with the latest meta-analyses reporting on research up to 2012), supplemented by a search on 18.10.17 in MEDLINE, Embase, PsycINFO and CINAHL for primary studies between 2012 and 2017 that had not been covered by previous meta-analyses.

RESULTS

Forty studies, all conducted in England, were included for our updated meta-analyses on pathways to care. Relative to the White reference group, elevated rates of civil detentions were found for Black Caribbean (OR = 3.43, 95% CI = 2.68 to 4.40, n = 18), Black African (OR = 3.11, 95% CI = 2.40 to 4.02, n = 6), and South Asian patients (OR = 1.50, 95% CI 1.07 to 2.12, n = 10). Analyses of each Mental Health Act section revealed significantly higher rates for Black people under (civil) Section 2 (OR = 1.53, 95% CI = 1.11 to 2.11, n = 3). Rates in repeat admissions were significantly higher than in first admission for South Asian patients (between-group difference p < 0.01). Some ethnic groups had more police contact (Black African OR = 3.60, 95% CI = 2.15 to 6.05, n = 2; Black Caribbean OR = 2.64, 95% CI = 1.88 to 3.72, n = 8) and criminal justice system involvement (Black Caribbean OR = 2.76, 95% CI = 2.02 to 3.78, n = 5; Black African OR = 1.92, 95% CI = 1.32 to 2.78, n = 3). The White Other patients also showed greater police and criminal justice system involvement than White British patients (OR = 1.49, 95% CI = 1.03 to 2.15, n = 4). General practitioner involvement was less likely for Black than the White reference group. No significant variations over time were found across all the main outcomes.

CONCLUSIONS

Our updated meta-analyses reveal persisting but not significantly worsening patterns of ethnic inequalities in pathways to psychiatric care, particularly affecting Black groups. This provides a comprehensive evidence base from which to inform policy and practice amidst a prospective Mental Health Act reform.

TRIAL REGISTRATION

CRD42017071663.

Is it possible for people with severe mental illness to sit less and move more? A systematic review of interventions to increase physical activity or reduce sedentary behaviour

Individuals with severe mental illness (SMI) (schizophrenia-spectrum, bipolar disorder and major depressive disorder) die 10-20 years prematurely due to physical disorders such as cardiovascular disease. Physical activity (PA) is effective in preventing and managing these conditions in the general population, however individuals with SMI engage in substantially less PA and more sedentary behaviour (SB) compared to healthy counterparts. Furthermore, the effectiveness of intervening to increase PA or reduce SB in SMI populations is unknown. Therefore, we systematically reviewed studies measuring changes in PA or SB following behavioural interventions in people with SMI. A systematic search of major databases was conducted from inception until 1/3/2018 for behavioural interventions reporting changes in PA or SB in people with SMI. From 3018 initial hits, 32 articles were eligible, including 16 controlled trials (CT's; Treatment n = 1025, Control n = 1162) and 16 uncontrolled trials (n = 655). Of 16 CTs, seven (47%) reported significant improvements in PA, although only one found changes with an objective measure. Of 16 uncontrolled trials, 3 (20%) found improvements in PA (one with objective measurement). No intervention study had a primary aim of changing SB, nor did any note changes in SB using an objective measure. In conclusion, there is inconsistent and low quality evidence to show that interventions can be effective in changing PA or SB in this population. Future robust randomized controlled trials, using objectively-measured PA/SB as the primary outcome, are required to determine which behavioural interventions are effective in improving the sedentary lifestyles associated with SMI. Systematic review registration- PROSPERO registration number CRD42017069399.

Access to primary and specialized somatic health care for persons with severe mental illness: a qualitative study of perceived barriers and facilitators in Swedish health care

BACKGROUND

Persons with severe mental illness (e.g. schizophrenia, bipolar disorder) have a high prevalence of somatic conditions compared to the general population. Mortality data in the Nordic countries reveal that these persons die 15-20 years earlier than the general population. Some factors explaining this high prevalence may be related to the individuals in question; others arise from the health care system's difficulty in offering somatic health care to these patient groups. The aim of the present study was therefore to explore the experiences and views of patients, relatives and clinicians regarding individual and organizational factors which facilitate or hinder access to somatic health care for persons with severe mental illness.

METHODS

Flexible qualitative design. Data was collected by means of semi-structured individual interviews with patients with severe mental illness, relatives and clinicians representing primary and specialized health care. In all, 50 participants participated.

RESULTS

The main barrier to accessing somatic care is the gap between the organization of the health care system and the patients' individual health care needs. This is observed at both individual and organizational level. The health care system seems unable to support patients with severe mental illness and their psychiatric-somatic comorbidity. The main facilitators are the links between severe mental illness patients and medical departments. These links take the form of functions (i.e. systems which ensure that patients receive regular reminders), or persons (i.e. professional contacts who facilitate patients' access the health care).

CONCLUSIONS

Health care services for patients with severe mental illness need reorganization. Organizational structures and systems that facilitate cooperation between different departments must be put in place, along with training for health care professionals about somatic disease among psychiatric patients. The links between individual and organizational levels could be strengthened by introducing professional contacts, such as liaison physicians and case managers. This is also important to reduce stress and responsibility among relatives.

Health Literacy Among People with Serious Mental Illness

People diagnosed with a mental illness are at higher risk of developing preventable chronic diseases; thus, health literacy improvements may have great potential to impact health outcomes for this typically underserved population. However, there is a dearth of research on health literacy of persons with severe mental illness. The purpose of this research was to investigate aspects of health literacy and identify factors associated with low literacy among adults with severe mental illness using three literacy assessment tools. Seventy-one adults with serious mental illness were assessed and a high proportion had limited literacy levels: 42% with the Single Item Literacy Screener, 50% with the Rapid Estimate of Adult Literacy in Medicine-Short Form, and 67% with the Newest Vital Sign. Findings suggest that individuals with certain mental illnesses and lower functioning may have more difficulty understanding health information and have limited numerical literacy.

Creative art therapy for mental illness

Creative art therapy (CAT) for severe mental illness (SMI) represents an extremely heterogenous body of literature that encompasses the use of a large variety of creative mediums (i.e. visual art, music, dance, drama, writing) in the treatment of mental disorders. The present review provides a narrative summary of the findings on the use of CAT for the selected SMI, being: schizophrenia, trauma-related disorders, major depression, and bipolar disorder. A database search of PubMed and the Cochrane Library was conducted related to the use of CAT in the treatment of mental disorders published between January 2008 and March 2019. A total of 9697 citations were identified to match the search criteria and 86 full-texts were reviewed. Although literature suggests CAT to be a potentially low-risk and high benefit intervention to minimize symptoms and maximize functioning in individuals living with SMI, the lack of methodological rigor, and inconsistency in study methods and outcome measures have prevented the advancement of CAT for use in SMI. Although creation of a single CAT regimen for all psychiatric disorders stands neither practical nor advisable, greater standardization of methods would improve evaluation of CAT interventions. Future research should elucidate biological mechanisms underlying CAT methods.

The Art of Helpful Relationships with Professionals: A Meta-ethnography of the Perspective of Persons with Severe Mental Illness

Relationships with professionals have been shown to be helpful to persons with severe mental illness (SMI) in relation to a variety of services. In this article, we aimed to synthesize the available qualitative research to acquire a deepened understanding of what helpful relationships with professionals consists of, from the perspective of persons with SMI. To do this, we created a meta-ethnography of 21 studies, through which ten themes and an overarching interpretation were created. The findings show that helpful relationships with professionals are relationships where the persons with SMI get to spend time with professionals that they know and trust, who gives them access to resources, support, collaboration and valued interpersonal processes, which are allowed to transgress the boundaries of the professional relationship. The overarching interpretation shows that the relationship that persons with SMI form with professionals is a professional relationship as well as an interpersonal relationship. Both these dimensions entail actions and processes that can be helpful to persons with SMI. Therefore, it is important to recognize and acknowledge both the functional roles of service user and service provider, as well as the roles of two persons interacting with each other, in a manner that may go beyond the purview of the traditional professionalism. Furthermore, the helpful components of this relationship are determined by the individual preferences, needs and wishes of persons with SMI.

Worlds apart? A scoping review addressing different stakeholder perspectives on barriers to family involvement in the care for persons with severe mental illness

BACKGROUND

Empirical evidence shows that family involvement (FI) can play a pivotal role in the coping and recovery of persons with severe mental illness (SMI). Nevertheless, various studies demonstrate that FI in mental healthcare services is often not (sufficiently) realized. In order to develop more insights, this scoping review gives an overview of how various stakeholders conceptualize, perceive and experience barriers to FI. Central questions are: 1) What are the main barriers to FI reported by the different key stakeholders (i.e. the persons with SMI, their families and the professionals, and 2) What are the differences and similarities between the various stakeholders' perspectives on these barriers.

METHODS

A systematic search into primary studies regarding FI was conducted in four databases: Medline/Pubmed, Cinahl, PsychInfo and Web of Knowledge with the use of a PICO scheme. Thematic analysis focused on stakeholder perspectives (i.e. which stakeholder group reports the barrier) and types of barriers (i.e. which types of barriers are addressed).

RESULTS

Thirty three studies were included. The main barriers reported by the stakeholder groups reveal important similarities and differences between the stakeholder groups and were related to: 1) the person with SMI, 2) the family, 3) the professionals, 4) the organization of care and 5) the culture-paradigm.

DISCUSSION

Our stakeholder approach elicits the different stakeholders' concepts, presuppositions and experiences of barriers to FI, and gives fundamental insights on how to deal with barriers to FI. The stakeholders differing interpretations and perceptions of the barriers related to FI is closely related to the inherent complexity involved in FI in itself. In order to deal better with these barriers, openly discussing and reflecting upon each other's normative understandings of barriers is needed.

CONCLUSIONS

Differences in perceptions of barriers to FI can itself be a barrier. To deal with barriers to FI, a dialogical approach on how the different stakeholders perceive and value FI and its barriers is required. Methods such as moral case deliberation or systematic ethics reflections can be useful.

Can computer-assisted cognitive remediation improve employment and productivity outcomes of patients with severe mental illness? A meta-analysis of prospective controlled trials

BACKGROUND

Computer-assisted cognitive remediation (CACR) has been demonstrated to enhance cognition of patients with severe mental illness (SMI). Patients with improved cognitive skills may find it easier to be employed, and the ability to maintain employment is an important sign of recovery.

AIM

To assess whether CACR is an effective method to enhance work-related outcomes in patients with SMI.

METHOD

Prospective controlled trials evaluating CACR on productivity outcomes were systematically identified from the OVID databases. Employment rates, total days of work in a year, and total annual earnings were defined as the productivity outcomes.

RESULTS

Nine trials were published between 2005 and 2014 and were conducted in the United States, Germany, Italy, Singapore and Japan. A total of 740 patients with mean age of 36.4 years were included. The duration of CACR ranged from 2 months to 2 years, and the patients were followed-up from 1 year to 3 years. Patients receiving CACR showed 20% higher employment rate (95% CI = 5%-35%), worked 19.5 days longer in a year (95% CI = 2.5-36.6 days), and earned US$959 more in total annual earnings (95% CI = US$285 to US$1634) than those not receiving CACR.

CONCLUSION

CACR can enhance productivity outcomes for patients with SMI, including higher employment rate, longer duration of work and higher income. The economic benefit of CACR can enhance the quality of life for patients with SMI, and may reduce financial burden on the health and welfare system. Therefore, CACR can be recommended and incorporated into regular vocational rehabilitation programs.

The effectiveness of narrative enhancement and cognitive therapy: a randomized controlled study of a self-stigma intervention

PURPOSE

Stigma has been proposed to be one of the most serious obstacles to successful treatment, rehabilitation and inclusion in society of people with severe mental illness. An aspect of stigma which has been increasingly discussed is self-stigma, which refers to the internalization of negative stereotypes among people with severe mental illness. The aim of the present study was to investigate the effectiveness of a group-based anti self-stigma intervention, narrative enhancement and cognitive therapy (NECT) as an add-on to treatment as usual, with regard to changes in self-stigma, self-esteem, and subjective quality of life.

METHOD

After screening for eligibility 106 participants were included in a randomized controlled trial using a wait-list control group, of which 87 completed the study. Assessments were made at baseline, at termination of the intervention, and at a 6-month follow-up (intervention group only).

RESULTS

The results showed that NECT was effective in reducing self-stigma and improving self-esteem compared to treatment as usual only. No differences were shown regarding subjective quality of life. Changes shown in the intervention group at termination of intervention were stable at the 6-month follow-up. A regression analysis showed that there was a positive relationship between exposure to the intervention and reduction of self-stigma.

CONCLUSIONS

The conclusion of the present study is that, using a sample size with adequate power, NECT seems to be an effective intervention with regard to diminishing self-stigma and improving self-esteem, and that these improvements were stable at a 6-month follow-up. There was a distinct relationship between number of sessions attended and improvements in self-stigma and self-esteem controlling for confounding factors. This puts attention to the importance of creating a group climate which facilitate and encourage participation through the various phases of the intervention.

Multidimensional impact of severe mental illness on family members: systematic review

OBJECTIVE

The impact of severe mental illnesses (SMIs) is not limited to the person with the illness but extends to their family members and the community where the patient comes from. In this review, we systematically analyse the available evidence of impacts of SMI on family members, including parents, grandparents, siblings, spouses and children.

DATA SOURCES

PubMed, PsycINFO, Embase and Global Index Medicus were searched from the inception of each database up to 9 November 2019. We also did manual searches of grey literature.

ELIGIBILITY CRITERIA

We included studies that assessed the impacts of SMI on any family member. We excluded studies in admitted clinics and acute wards to rule out the acute effect of hospitalisation.

DATA EXTRACTION

Two reviewers extracted data independently using the Cochrane handbook guideline for systematic reviews and agreed on the final inclusion of identified studies.

RISK OF BIAS

The quality of the included studies was assessed using effective public health practice project quality assessment tool for quantitative studies.The review protocol was registered in the PROSPERO database.

RESULTS

We screened a total of 12 107 duplicate free articles and included 39 articles in the review. The multidimensional impact of SMI included physical health problems (sleeplessness, headache and extreme tiredness.), psychological difficulties (depression and other psychological problems) and socioeconomic drift (less likely to marry and higher divorce rate and greater food insecurity). Impacts on children included higher mortality, poor school performance and nutritional problems. However, the quality of one in five studies was considered weak.

CONCLUSIONS

Our review indicated a high level of multidimensional impact across multiple generations. The serious nature of the impact calls for interventions to address the multidimensional and multigenerational impact of SMI, particularly in low/middle-income countries. Given the relatively high number of studies rated methodologically weak, more robust studies are indicated.

PROSPERO REGISTRATION NUMBER

CRD42018064123.

Utilization of the Behavior Change Wheel framework to develop a model to improve cardiometabolic screening for people with severe mental illness

BACKGROUND

Individuals with severe mental illness (e.g., schizophrenia, bipolar disorder) die 10-25 years earlier than the general population, primarily from premature cardiovascular disease (CVD). Contributing factors are complex, but include systemic-related factors of poorly integrated primary care and mental health services. Although evidence-based models exist for integrating mental health care into primary care settings, the evidence base for integrating medical care into specialty mental health settings is limited. Such models are referred to as "reverse" integration. In this paper, we describe the application of an implementation science framework in designing a model to improve CVD outcomes for individuals with severe mental illness (SMI) who receive services in a community mental health setting.

METHODS

Using principles from the theory of planned behavior, focus groups were conducted to understand stakeholder perspectives of barriers to CVD risk factor screening and treatment identify potential target behaviors. We then applied results to the overarching Behavior Change Wheel framework, a systematic and theory-driven approach that incorporates the COM-B model (capability, opportunity, motivation, and behavior), to build an intervention to improve CVD risk factor screening and treatment for people with SMI.

RESULTS

Following a stepped approach from the Behavior Change Wheel framework, a model to deliver primary preventive care for people that use community mental health settings as their de facto health home was developed. The CRANIUM (cardiometabolic risk assessment and treatment through a novel integration model for underserved populations with mental illness) model focuses on engaging community psychiatrists to expand their scope of practice to become responsible for CVD risk, with significant clinical decision support.

CONCLUSION

The CRANIUM model was designed by integrating behavioral change theory and implementation theory. CRANIUM is feasible to implement, is highly acceptable to, and targets provider behavior change, and is replicable and efficient for helping to integrate primary preventive care services in community mental health settings. CRANIUM can be scaled up to increase CVD preventive care delivery and ultimately improve health outcomes among people with SMI served within a public mental health care system.

Crisis resolution and home treatment: stakeholders' views on critical ingredients and implementation in England

BACKGROUND

Crisis resolution teams (CRTs) can provide effective home-based treatment for acute mental health crises, although critical ingredients of the model have not been clearly identified, and implementation has been inconsistent. In order to inform development of a more highly specified CRT model that meets service users' needs, this study used qualitative methods to investigate stakeholders' experiences and views of CRTs, and what is important in good quality home-based crisis care.

METHOD

Semi-structured interviews and focus groups were conducted with service users (n = 41), carers (n = 20) and practitioners (CRT staff, managers and referrers; n = 147, 26 focus groups, 9 interviews) in 10 mental health catchment areas in England, and with international CRT developers (n = 11). Data were analysed using thematic analysis.

RESULTS

Three domains salient to views about optimal care were identified. 1. The organisation of CRT care: Providing a rapid initial responses, and frequent home visits from the same staff were seen as central to good care, particularly by service users and carers. Being accessible, reliable, and having some flexibility were also valued. Negative experiences of some referral pathways, and particularly lack of staff continuity were identified as problematic. 2. The content of CRT work: Emotional support was at the centre of service users' experiences. All stakeholder groups thought CRTs should involve the whole family, and offer a range of interventions. However, carers often feel excluded, and medication is often prioritised over other forms of support. 3. The role of CRTs within the care system: Gate-keeping admissions is seen as a key role for CRTs within the acute care system. Service users and carers report that recovery is quicker compared to in-patient care. Lack of knowledge and misunderstandings about CRTs among referrers are common. Overall, levels of stakeholder agreement about the critical ingredients of good crisis care were high, although aspects of this were not always seen as achievable.

CONCLUSIONS

Stakeholders' views about optimal CRT care suggest that staff continuity, carer involvement, and emotional and practical support should be prioritised in service improvements and more clearly specified CRT models.

A systematic review of the impact of media reports of severe mental illness on stigma and discrimination, and interventions that aim to mitigate any adverse impact

PURPOSE

This review aims to summarise the evidence on the impact of news media and social media reports of severe mental illness (SMI) on stigma, and interventions that aim to mitigate any adverse impact.

METHODS

A systematic search of electronic databases was conducted in December 2017 to identify studies that report on the impact of media coverage or media interventions on stigma related to schizophrenia, psychosis, bipolar disorder, or mental illness in general. Data were synthesised narratively.

RESULTS

12 studies met inclusion criteria; seven explored the impact of news media on stigma towards SMI or general mental illness, two explored the impact of social media, while three evaluated interventions that aimed to mitigate this impact. These studies showed that positive news reports and social media posts are likely to lead to reductions in stigmatizing attitudes and negative reports and social media posts are likely to increase stigmatizing attitudes. There were a limited number of interventions aiming to mitigate the negative impact of news reports of mental illness on stigma; however, these were ineffective. Interventions with media professionals appear to be successful at reducing their stigmatizing attitudes, but can also act to increase both positive and negative reports in the media.

CONCLUSIONS

Given the limited research evidence on the impact of news and social media on stigma towards SMI, and on the effectiveness of interventions aiming to mitigate this impact, further studies of higher quality are needed in this area. Due to mixed findings, interventions with media professionals are also an area of research priority.

Mindfulness improves psychological quality of life in community-based patients with severe mental health problems: A pilot randomized clinical trial

OBJECTIVE

To examine the effectiveness of group mindfulness-based intervention (MBI) in patients diagnosed with severe mental illness. The primary outcome was health-related psychological quality of life. Secondary measures were environmental, social and physical health related quality of life, frequency and intensity of psychotic symptoms and daily-life mindfulness.

METHOD

Forty-four patients from a public community rehabilitation center for people with severe mental illness were recruited, and randomly allocated to Integrated Rehabilitation Treatment (IRT) or IRT plus MBI. Measures included PANSS interview, WHOQOL-BREF, and Mindfulness Attention Awareness Scale. MBI comprised 26 one-hour weekly sessions. Intention-to-treat analysis was used.

RESULTS

One patient did not complete IRT+MBI and two did not complete IRT. At baseline there were no statistical group differences in demographic characteristics or primary and secondary outcomes. At post-treatment interaction between treatment and time in health-related psychological quality of life was statistically significant, and simple effect analysis showed significant differences for between and within subject factor in favor of MBI. Interaction was also significant in PANSS negative symptoms, simple effects showed a statistical trend in within subject factor. Time factor was significant in environmental and physical quality of life.

CONCLUSIONS

Data suggest mindfulness added to IRT may enhance psychological quality of life in people with severe mental illness from a public community center. Results also suggest that mindfulness may impact frequency and intensity of negative symptoms.

European Psychiatric Association (EPA) guidance on the quality of eMental health interventions in the treatment of psychotic disorders

The main aim was to develop recommendations on eMental health interventions for the treatment of psychotic disorders. A systematic literature search on eMental health interventions was performed, and 24 articles about interventions in psychotic disorders were retrieved and systematically assessed for their quality. Studies were characterized by a large heterogeneity with regard to study type, sample sizes, interventions and outcome measures. Five graded recommendations were developed dealing with the feasibility of eMental health interventions, beneficial effects of psychoeducation, preliminary results of clinical efficacy, the need of moderation in peer support eMental health groups and the need to develop quality standards.