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

Results from a randomized controlled trial investigating effectiveness of a community-based intervention on empowerment of people with severe mental illness

PURPOSE

The effectiveness of community mental health services with respect to enhancing empowerment among patients with severe mental illness (SMI) has rarely been investigated. In this multicenter trial the effectiveness of a community mental health intervention (acronym: GBV) added to treatment as usual (TAU) compared to TAU alone was investigated.

METHODS

In a randomized controlled multicenter trial with twelve sites spread across Germany, people living with SMI aged 18-82 years were investigated over 24 months. The trial was conducted from 2020 to 2023, a time period affected by the Covid-19 pandemic. The intervention was delivered by multiprofessional GBV teams based on the Functional Assertive Community Treatment (FACT) program and was supplemented by strategies that increase the degree of self-determination. The primary outcome was measured by the Assessment of Empowerment in Patients with Affective and Schizophrenic Disorders (EPAS). Difference in difference (DiD) effect sizes were estimated on an intention-to-treat basis.

RESULTS

A total of 929 persons with SMI were randomly assigned to the GBV plus TAU intervention (n = 470) or to TAU alone (n = 459). The dropout rate over 24 months amounted to 28%. DiD effect sizes over 24 months indicate significant treatment effects for empowerment (d = 0.27; 95% CI = 0.14 0.40). Serious adverse events (SAE) were reported for 15 (3.2%) participants in the GBV + TAU vs. 17 (3.7%) in the TAU group.

CONCLUSION

The addition of GBV to TAU, for patients with SMI, can be recommended as an effective measure to improve key psychosocial outcomes in mental health care settings across Germany.

TRIAL REGISTRATION

German Clinical Trial Register, DRKS00019086. Registered on 3 January 2020, https://drks.de/search/de/trial/DRKS00019086 .

Does personality moderate the association between social involvement and personal recovery in psychosis?

OBJECTIVE

Social factors are central in personal recovery (PR) and treatment of psychosis. However, weak associations between social involvement and PR were found. We aimed to replicate this weak association, and test whether it was explained by a moderating effect of neuroticism and extraversion.

METHOD

This cross-sectional study included 284 psychotic disorder patients. PR was assessed using the Recovery Quality of Life (ReQoL) questionnaire. Social involvement with a formative measure of the frequency of social interaction, and neuroticism and extraversion with the NEO Five Factor Inventory (NEO-FFI).

RESULTS

A small direct effect of social involvement on PR (β=-0.24, p < 0.001) was found, explaining 6% of the variance in PR. The addition of neuroticism (β=-0.60, p < 0.001) predicted 41% of variance in PR; extraversion (β = 0.34, p < 0.001) predicted 16%. We did not observe a moderating effect of neither neuroticism (β=-0.06, p = 0.232), nor extraversion (β = 0.01, p = 0.956).

CONCLUSION

The weak association between social involvement and PR could not be explained by the moderating effect of neuroticism or extraversion. The increase in explained variance in PR implies that neuroticism is associated with PR in a direct and clinically relevant way. This emphasizes the importance of attending to negative emotions and underlying stressors in treatment of psychosis.

SEED-AN and a non-specialised, severe mental illness (SMI) community treatment model: perspectives of professionals and patients of a QoL-focussed treatment

BACKGROUND

Improving care for SEED-AN patients is urgently needed. Current specialist eating disorder (SEDU) programs have minimal impact, resulting in poor quality of life. Flexible assertive community treatment (FACT) focuses on improving the quality of life of people with severe mental illness.

AIM

This study systematically examined professionals' and patients' experiences with existing care for SEED AN in two settings in two health districts in the Netherlands. Specifically, the specialised Eating Disorder Unit and FACT.

METHODS

A qualitative approach was used: Twelve professionals participated in focus groups, and four professionals and six patients were interviewed individually. Reflective thematic analysis was used to analyse the data.

RESULTS

Four themes were constructed: "We feel ignorant in the treatment of SEED-AN patients"; "There is a disability to act"; "We are more than executive practitioners alone"; and "The professionals at FACT have given me back my confidence in treatment". The findings reflect how support for SEED-AN patients is provided by both FACT and SEDU professionals and how SEED-AN patients experience the FACT approach.

DISCUSSION

A resource group model promotes collaboration among professionals, patients and the patient's support system. The model is expected to increase knowledge about SEED-AN among stakeholders who support the quality of life of SEED-AN patients.

Perspective matters in recovery: the views of persons with severe mental illness, family and mental health professionals on collaboration during recovery, a qualitative study

BACKGROUND

Recovery from severe mental illness, including psychosis has been described as a personal and unique process, but it rarely is a journey undertaken without profound influences of significant others (family, mental health professionals). Diverging perspectives between persons with severe mental illness, family and professionals are frequent during the recovery process, notably in psychotic disorders. We aimed to explore processes of collaboration during recovery, to inform recovery supporting practices.

METHODS

Current qualitative study had a participatory design and was set within long-term mental healthcare for severe mental illness. We conducted semi-structured interviews and focus groups with persons with severe mental illness (most had a history of psychosis), family and professionals on their mutual contact during recovery. Using reflexive thematic analysis, we developed themes representing processes of collaboration during recovery.

RESULTS

We described roles persons with severe mental illness, family and professionals attribute to each other in mutually influential terms of unconditional and meaningful contact (which takes time to establish) and problem-oriented aspects. Secondly, experienced differences over problem definition, "needing help" and consequently over the role parties attribute to one another, may result in negative interactions, in the area of having expectations; (not) informing; (not) having agency to change; experiencing (dis)agreement or struggle.

CONCLUSIONS

unconditional, meaningful contact and knowing each other's perspective are important to fruitful interaction in a triad when perspectives on mental health problems diverge. Relationally centered and process oriented care with continuity of family and professionals involved are needed to advance recovery in severe mental illness, especially psychosis.

Fair space for life: A dynamic care monitor working up to growth and flourishing for all

BACKGROUND

Mental health disparities persistently cause inequity and social exclusion. Extensive research underpins the need to embrace the social determinants of health and facilitate network learning at various ecosystem levels. Despite valuable quality frameworks and ratified conventions, local practices which counter health inequity are scarce.

METHODS

The Dutch HOP-TR study collected health and needs of Homeless Service Users (HSU) in a rights-based, transdiagnostic, recovery framework. We assessed the survival modes and conducted a socio-ecological analysis, exploring what happened in care pathways at three ecosystem levels: individual HSU, caregiver networks, society. While documenting vital conditions for growth and citizenship, we explore major opportunities to develop 'fair space for life'.

RESULTS

Under low distress levels, prosocial behavior is prominent (32.9%). High distress levels are found with an avoidant (42.0%) or aggressive mode (24.9%). Rising distress levels give more frictions in relations, psychiatric admissions, and police-justice contacts. The distress-induced descent in the social hierarchy causes social withdrawal, alienation, and marginalization. At society level, fair conditions for growth and citizenship are challenged by the cumulative impact of distress over the HSU' lives.

DISCUSSION

This care monitor uncovers the impact of distress on caregiver interactions. The care pathways reveal that the survival strategies reflect a systematic, pervasive neglect. Unfair representations hold HSU personally responsible of their situation, disregarding the cumulative impact of environmental conditions over their lives. The diverse sources of unfairness are intrinsic to the health care system and culture. Therefore, the survival modes ask for profound culture transformations in a whole-system-whole-society approach.

CONCLUSION

Given the need for action on health equity and the social determinants of health, this paper provides an example of a dynamic care monitor. The actionable data elicit dialogs and stimulate to enrich opportunities for inclusion and growth in communities and societies.

The African American Transplant Access Program: Mitigating Disparities in Solid Organ Transplantation

Black Americans experience end-stage kidney disease (ESKD) at a disproportionately higher rate than other racial and ethnic groups in the United States. Kidney transplantation provides the best outcomes for patients with ESKD. However, Black patients frequently have decreased access to kidney transplantation. This article summarizes the robust literature on disparities in transplantation for Black patients and presents a practical solution to this complex issue by redesigning the transplant access process for Black patients challenged by structural and institutional barriers. The authors provide a detailed overview of a novel African American Transplant Access Program (AATAP) with its pillars of cultural congruency, trust, health literacy, and psychosocial support. This overview includes a thorough description of the program's conceptualization, the process of creating the program, the preliminary results, and guidance to establish similarly culturally congruent transplant access programs.

Place-Based FACT: Treatment Outcomes and Patients' Experience with Integrated Neighborhood-Based Care

Locating specialized mental healthcare services in the neighborhood of people with severe mental illnesses (SMI) has been suggested as a way of improving treatment outcomes by increasing patient engagement and integration with the local care landscape. The current mixed methods study aimed to examine patient experience and treatment outcomes in three Flexible Assertive Community Treatment (FACT) teams that relocated to the neighborhood they served, compared to seven teams that continued to provide FACT as usual from a central office. Routine Outcome Measurement (ROM) and care use data were analyzed to compare change in treatment outcomes for patients in place-based FACT (n = 255) and FACT as usual (n = 833). Additionally, retrospective in-depth interviews were conducted with twenty patients about their experience with place-based FACT. Quantitative analysis showed mental health admission days decreased more in place-based than FACT as usual, although this difference was small. Both groups showed improved quality of life, psychosocial functioning, and symptomatic remission rates, and decreased unmet and overall needs for care. There was no change over time in met needs for care, employment, and daily activities. Qualitative analysis showed that patients experienced place-based FACT as more accessible, a better safety net, a more personal approach, better integrated with other forms of care, involving their social network, and embedded in their neighborhood and daily environment. This study showed that location and integration matter to patients, and the long term impact of place-based FACT on treatment outcomes should be explored.

Personal recovery in first-episode psychosis: Beyond clinical and functional recovery

BACKGROUND

The concept of personal recovery after psychotic illness focuses more on patients' social and existential needs compared to traditional outcome measures including clinical and functional recovery. This research aims to contribute to a broad framework on (personal) recovery and associated factors.

METHODS

Data from 203 persons with symptomatic remission of their first-episode psychosis from the ongoing HAMLETT study were analyzed. To determine the relative importance of several biological, clinical, psychological, and social factors in explaining personal recovery as measured by the Recovery Assessment Scale (RAS), partial Spearman correlations (controlling for clinical recovery (PANSS) and functional recovery (WHODAS 2.0)) and a bootstrapped multiple regression were performed. Indirect effects on personal recovery within these factors, clinical recovery, and functional recovery were explored using a regularized partial correlation network.

RESULTS

Of the factors that explained personal recovery beyond the effects of clinical and functional recovery, social support was the strongest predictor, followed by self-esteem, internalized stigma, and insecure attachment, collectively explaining 48.2 % of the variance. Anhedonia/apathy showed a trend towards a negative correlation. Age at onset, sex, early trauma/neglect, cognition, and being married/cohabiting did not significantly correlate with personal recovery. The network (n = 143) was consistent with these findings and indicated possible mediation pathways for early trauma/neglect, insecure attachment, cognition, and being married/cohabiting.

CONCLUSIONS

Personal recovery is an important addition to traditional measures of outcome after psychosis. Various quality of life indicators, such as self-esteem and social support, explain variance in personal recovery over clinical and functional recovery.

Understanding Lifelong Factors and Prediction Models of Social Functioning After Psychosis Onset Using the Large-Scale GROUP Cohort Study

BACKGROUND AND HYPOTHESIS

Current rates of poor social functioning (SF) in people with psychosis history reach 80% worldwide. We aimed to identify a core set of lifelong predictors and build prediction models of SF after psychosis onset.

STUDY DESIGN

We utilized data of 1119 patients from the Genetic Risk and Outcome in Psychosis (GROUP) longitudinal Dutch cohort. First, we applied group-based trajectory modeling to identify premorbid adjustment trajectories. We further investigated the association between the premorbid adjustment trajectories, six-year-long cognitive deficits, positive, and negative symptoms trajectories, and SF at 3-year and 6-year follow-ups. Next, we checked associations between demographics, clinical, and environmental factors measured at the baseline and SF at follow-up. Finally, we built and internally validated 2 predictive models of SF.

STUDY RESULTS

We found all trajectories were significantly associated with SF (P < .01), explaining up to 16% of SF variation (R2 0.15 for 3- and 0.16 for 6-year follow-up). Demographics (sex, ethnicity, age, education), clinical parameters (genetic predisposition, illness duration, psychotic episodes, cannabis use), and environment (childhood trauma, number of moves, marriage, employment, urbanicity, unmet needs of social support) were also significantly associated with SF. After validation, final prediction models explained a variance up to 27% (95% CI: 0.23, 0.30) at 3-year and 26% (95% CI: 0.22, 0.31) at 6-year follow-up.

CONCLUSIONS

We found a core set of lifelong predictors of SF. Yet, the performance of our prediction models was moderate.

What do we not know (yet) about recovery colleges? A study protocol on their (cost-)effectiveness, mechanisms of action, fidelity and positioning

BACKGROUND

Recovery Colleges (RCs) have spread across the globe as a new way of supporting people with mental vulnerabilities in their recovery journey. RCs focus on 'learning' rather than 'curing' and in that line facilitate a transition from being a passive, dependent patient/client to an active, empowered student learning to live life, despite vulnerabilities. Peer support and co-creation are central in RCs, as peers learn from each other by sharing personal experiences with mental vulnerabilities in an accessible, inspiring and stimulating atmosphere. The implementation of RCs is highly encouraged internationally, and as a result RCs and related self-help initiatives increasingly emerge. However, high-quality research on RCs is scarce and there is a call for thorough investigation of (cost-)effectiveness, mechanisms of action, cross-border fidelity and positioning of RCs. In response, this research project aims to fill these gaps.

METHODS

This research project entails (1) a prospective quasi-experimental effectiveness study and economic evaluation, (2) a multifaceted qualitative study to elaborate on the mechanisms of action of RCs for those involved (3) a study to develop a (Dutch) Fidelity Measure of Recovery Colleges, and (4) an organisational case study to describe the positioning of RCs in relation to other mental health care services and community-based initiatives. Following the ideals of co-creation and empowerment in RCs we conduct this research project in co-creation with RC students from Enik Recovery College in Utrecht, the Netherlands.

DISCUSSION

This research project will lead to one of the first longitudinal controlled quantitative evaluations of both cost-effectiveness and effectiveness of RC attendance in a broad sense (beyond attending courses alone). Moreover, we will gather data on a micro level (i.e., impact on RC students), meso level (i.e., organisational fidelity) and macro level (i.e., positioning in the care and support domain), capturing all important perspectives when scrutinizing the impact of complex systems. Finally, we will demonstrate the validity and value of embracing experiential knowledge in science as a complementary source of information, leading to a more profound understanding of what is researched.

TRIAL REGISTRATION

The prospective quasi-experimental study has been pre-registered at clinicaltrails.gov (#NCT05620212).

Current insights of community mental healthcare for people with severe mental illness: A scoping review

Background

For the last four decades, there has been a shift in mental healthcare toward more rehabilitation and following a more humanistic and comprehensive vision on recovery for persons with severe mental illness (SMI). Consequently, many community-based mental healthcare programs and services have been developed internationally. Currently, community mental healthcare is still under development, with a focus on further inclusion of persons with enduring mental health problems. In this review, we aim to provide a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision on the ingredients of community mental healthcare.

Methods

We conducted a scoping review by systematically searching four databases, supplemented with the results of Research Rabbit, a hand-search in reference lists and 10 volumes of two leading journals. We included studies on adults with SMI focusing on stimulating independent living, integrated care, recovery, and social inclusion published in English between January 2011 and December 2022 in peer-reviewed journals.

Results

The search resulted in 56 papers that met the inclusion criteria. Thematic analysis revealed ingredients in 12 areas: multidisciplinary teams; collaboration within and outside the organization; attention to several aspects of health; supporting full citizenship; attention to the recovery of daily life; collaboration with the social network; tailored support; well-trained staff; using digital technologies; housing and living environment; sustainable policies and funding; and reciprocity in relationships.

Conclusion

We found 12 areas of ingredients, including some innovative topics about reciprocity and sustainable policies and funding. There is much attention to individual ingredients for good community-based mental healthcare, but very little is known about their integration and implementation in contemporary, fragmented mental healthcare services. For future studies, we recommend more empirical research on community mental healthcare, as well as further investigation(s) from the social service perspective, and solid research on general terminology about SMI and outpatient support.

Physical Healthcare, Health-Related Quality of Life and Global Functioning of Persons with a Severe Mental Illness in Belgian Long-Term Mental Health Assertive Outreach Teams: A Cross-Sectional Self-Reported Survey

Research shows that care delivery regarding somatic health problems for patients with a severe mental illness (SMI) in community and mental health is difficult to establish. During the last decade, long term mental health outreach teams in Belgium were implemented to provide treatment and follow-up at home. This study aimed to map physical health status, care professionals, health related quality of life and global functioning in persons with SMI in Belgian long term outreach teams for mental health. Using a self-administered questionnaire, 173 persons, 58.1% female with a mean age of 48.3, were questioned. Our findings suggest an undertreatment of somatic comorbid conditions, with only half of physical health complaints being addressed. Although treatment rates for hypertension, when detected were high, treatment of respiratory complaints, pain and fatigue was lacking. Although the majority of respondents responded to have a GP or psychiatrist, contact rates were rather limited. Other disciplines, such as primary care nurses, when present, tend to have more contact with people with SMI. Notably, having regular contacts with GPs seems to improve physical health complaints and/or treatment. Being treated by an outreach team did not show significant correlations with physical health complaints and/or treatment suggesting a more proactive approach by outreach teams or primary care providers is desirable.

Storytelling and training to advance individual recovery skills (STAIRS). A feasibility study of a blended program to support personal recovery among patients with a major depressive disorder in remission

Because major depressive disorder (MDD) has a strong negative impact on patients' lives, well-designed treatment programs are needed that address the lasting effects of MDD. Previous work has shown that such programs should not only focus on symptomatic recovery, but also on the subsequent personal recovery process. Currently, few programs with this specific focus exist. Therefore, this study aimed to assess the feasibility of a newly developed blended program to support the personal recovery process of MDD patients: Storytelling and Training to Advance Individual Recovery Skills (STAIRS). STAIRS is a program using peer support and guidance by experts by experience and clinicians, which can be added to regular depression treatment when symptomatic recovery is almost reached. Topics addressed in this program are: (1) effects of depression and treatment; (2) structure; (3) (self) stigma; (4) self-image; (5) meaning of life; (6) connection to others; (7) physical health; (8) relaxation; and (9) preventing relapse. Experiences with the STAIRS program were collected from five participating patients with questionnaires and a focus-group interview, as well as from four trainers using semi-structured interviews. Participants valued the topics addressed in STAIRS, the used working methods, the presence of an expert by experience and the ability to share experiences with peers. The use of an online platform and the involvement of others is seen as potentially supportive but turned out to be more challenging. Perceived effects of STAIRS include positive changes in participants' daily lives and their contacts with others. Overall, the results indicate that when implemented accessibly, STAIRS is a promising and feasible program to foster personal recovery among patients recovering from MDD.

Case Study in Youth Flexible Assertive Community Treatment: An Illustration of the Need for Integrated Care

Youth Flexible Assertive Community Treatment (Youth Flexible ACT) is a client- and family-centered service delivery model for young people up to 24 years of age who have interrelated psychiatric- and social problems across multiple life domains and do not readily engage with office-based mental health services. Youth Flexible ACT teams were set up to meet the multifaceted needs of this subgroup in an integrated manner. In this paper, we present a case study to (1) describe the core principles of Youth Flexible ACT and (2) illustrate the application of the mental healthcare model. Subsequently, we describe the contribution of model elements to a positive care process and discuss the challenges of the team in working with the model. The case study displays the importance of integrated flexible and personalized care services to enable adolescents to remain engaged in care.