Housing environments and community adjustment of severely mentally ill persons

Experiences of care perceived by users of supported accommodations for people with serious mental disorders: Can they impact quality of life?

BACKGROUND

To understand if supported accommodations (SA) are promoting the recovery of people with serious mental disorders, quality of life (QoL) is an important outcome. This study aimed to analyse the association between QoL and experiences of care in general and to identify specific experiences of care that are associated with QoL in users of SA.

METHODS

A random sample of users of 42 SA was interviewed to obtain standardized measures of QoL and personal experiences of care. The sample was also characterized according to sociodemographic and clinical aspects. Linear regressions models analysed the association between QoL and experiences of care, adjusting for potential confounders. Results include estimated regression coefficients, corresponding 95% confidence intervals and p-values.

RESULTS

The number of users interviewed was 272. The median QoL was 4.9 (2.3-6.8) out of 7. Although 84.9% of users were satisfied with the care received, only 16.2% felt involved in their treatment. Feeling safe (β = .73; 95% CI [0.22-1.24], p = .006) and having privacy (β = .42; 95% CI [0.09-0.75], p = .014) influenced QoL. Involvement in care (β = .44; 95% CI [0.13-0.74], p = .006), safety and privacy (β = .72; 95% CI [0.44-0.99], p = 8.38e-07) and user-professional relationship (β = .42; 95% CI [0.14-0.69], p = .003) were also associated with QoL.

CONCLUSIONS

Feeling safe, having privacy, feeling involved in care and having good user-professional relationships influence the QoL of users. These findings have implications from the political and economic level to the organizational and individual levels.

Associations of living arrangements with symptoms and functioning in schizophrenia

BACKGROUND

Living arrangements and accommodation are closely related, but no study had concurrently investigated their associations with outcomes in schizophrenia. This study seeks to describe and compare socio-demographic, clinical and functioning profiles of people with schizophrenia in different living arrangements and accommodation, and to examine the associations of living arrangements and accommodation with symptomatic remission and functioning.

METHODS

Community dwelling outpatients with schizophrenia (n = 276) were inquired on living arrangements, accommodation, socio-demographics and assessed on the Positive and Negative Syndrome Scale (PANSS) and the Social and Occupational Functioning Scale (SOFAS). Socio-demographics, symptoms and functioning of outpatients in different living arrangements and accommodation were compared. Symptomatic remission was investigated using logistic regression with living arrangements, socio-demographics and clinical variables as independent variables. Functioning was investigated using multiple regression with the same set of independent variables and the addition of PANSS factors. The same analyses were conducted with accommodation as independent variable.

RESULTS

185 (67.03%) participants lived with family and 195 (70.65%) participants lived in owned accommodation. People living with their spouses had significantly higher SOFAS, lower PANSS Total and PANSS Positive than people living with family, independently, or in rehabilitation centres. They also had lower PANSS Negative than people living with family and a higher likelihood to have achieved symptomatic remission. Types of accommodation was not associated with symptoms, symptomatic remission, and functioning.

CONCLUSION

Living arrangements, but not types of accommodation, were associated with symptoms and functioning in schizophrenia. Family education and support is important to help maintain a conducive environment for people with schizophrenia. People living independently may need more support.

Mental health supported accommodation services: a systematic review of mental health and psychosocial outcomes

BACKGROUND

Post-deinstitutionalisation, mental health supported accommodation services have been implemented widely. The available research evidence is heterogeneous in nature and resistant to synthesis attempts, leaving researchers and policy makers with no clear summary what works and for whom. In this context, we undertook a comprehensive systematic review of quantitative studies in order to synthesise the current evidence on mental health and psychosocial outcomes for individuals residing in mental health supported accommodation services.

METHODS

Using a combination of electronic database searches, hand searches, forward-backward snowballing and article recommendations from an expert panel, 115 papers were identified for review. Data extraction and quality assessments were conducted, and 33 articles were excluded due to low quality, leaving 82 papers in the final review. Variation in terminology and service characteristics made the comparison of service models unfeasible. As such, findings were presented according to the following sub-groups: 'Homeless', 'Deinstitutionalisation' and 'General Severe Mental Illness (SMI)'.

RESULTS

Results were mixed, reflecting the heterogeneity of the supported accommodation literature, in terms of research quality, experimental design, population, service types and outcomes assessed. There is some evidence that supported accommodation is effective across a range of psychosocial outcomes. The most robust evidence supports the effectiveness of the permanent supported accommodation model for homeless SMI in generating improvements in housing retention and stability, and appropriate use of clinical services over time, and for other forms of supported accommodation for deinstitutionalised populations in reducing hospitalisation rates and improving appropriate service use. The evidence base for general SMI populations is less developed, and requires further research.

CONCLUSIONS

A lack of high-quality experimental studies, definitional inconsistency and poor reporting continue to stymie our ability to identify effective supported accommodation models and practices. The authors recommend improved reporting standards and the prioritisation of experimental studies that compare outcomes across different service models.

Addressing Smoking in Supported Residential Facilities for People with Severe Mental Illness: Has Any Progress Been Achieved?

Background: Smoking rates for people with severe mental illness have remained high despite significant declines in smoking rates in the general population, particularly for residents of community supported residential facilities (SRFs) where smoking has been largely neglected and institutionalized. Methods: Two studies undertaken 10 years apart (2000 and 2010) with SRFs in Adelaide, Australia looked at historical trends to determine whether any progress has been made to address smoking for this population. The first study was ethnographic and involved narrative description and analysis of the social milieu of smoking following multiple observations of smoking behaviours in two SRFs. The second study involved an eight-week smoking cessation group program providing tailored support and free nicotine replacement therapy to residents across six SRFs. Changes in smoking behaviours were measured using pre and post surveys with residents, with outcomes verified by also seeking SRF staff and smoking cessation group facilitator qualitative feedback and reflection on their observations of residents and the setting. Results: The culture of smoking in mental health SRFs is a complex part of the social milieu of these settings. There appears to have been little change in smoking behaviours of residents and attitudes and support responses by staff of SRFs since 2000 despite smoking rates declining in the general community. Tailored smoking cessation group programs for this population were well received and did help SRF residents to quit or cut down their smoking. They did challenge staff negative attitudes to residents’ capacity to smoke less or quit. Conclusions: A more systematic approach that addresses SRF regulations, smoke-free policies, staff attitudes and training, and consistent smoking cessation support to residents is needed.

Residence Conditions on Community Treatment Orders

OBJECTIVE

To identify the clinical reasons and legal authority for including a residential placement condition in a community treatment order (CTO).

METHOD

We describe the clinical reasons for imposing a residence condition and discuss how this is authorized by the laws of the Canadian provinces (using Ontario as the main example).

RESULTS

A residence condition can facilitate numerous benefits, including: regular access to a person by a clinical team; continuing therapeutic relations; supervision of medication; provision of general medical care; and reduction in substance use, risks of victimization, and other unintended harm. A resident condition can be lawfully imposed when it clearly fits the purposes of the CTO legislation and stops short of authorizing detention in a community facility.

CONCLUSIONS

In certain circumstances, a residence condition is clinically justified and a lawful aspect of a CTO.

Single room occupancy (SRO) hotels as mental health risk environments among impoverished women: the intersection of policy, drug use, trauma, and urban space

BACKGROUND

Due to the significantly high levels of comorbid substance use and mental health diagnosis among urban poor populations, examining the intersection of drug policy and place requires a consideration of the role of housing in drug user mental health. In San Francisco, geographic boundedness and progressive health and housing polices have coalesced to make single room occupancy hotels (SROs) a key urban built environment used to house poor populations with co-occurring drug use and mental health issues. Unstably housed women who use illicit drugs have high rates of lifetime and current trauma, which manifests in disproportionately high rates of post-traumatic stress disorder (PTSD), anxiety, and depression when compared to stably housed women.

METHODS

We report data from a qualitative interview study (n=30) and four years of ethnography conducted with housing policy makers and unstably housed women who use drugs and live in SROs.

RESULTS

Women in the study lived in a range of SRO built environments, from publicly funded, newly built SROs to privately owned, dilapidated buildings, which presented a rich opportunity for ethnographic comparison. Applying Rhodes et al.'s framework of socio-structural vulnerability, we explore how SROs can operate as "mental health risk environments" in which macro-structural factors (housing policies shaping the built environment) interact with meso-level factors (social relations within SROs) and micro-level, behavioral coping strategies to impact women's mental health. The degree to which SRO built environments were "trauma-sensitive" at the macro level significantly influenced women's mental health at meso- and micro-levels. Women who were living in SROs which exacerbated fear and anxiety attempted, with limited success, to deploy strategies on the meso- and micro-level to manage their mental health symptoms.

CONCLUSION

Study findings underscore the importance of housing polices which consider substance use in the context of current and cumulative trauma experiences in order to improve quality of life and mental health for unstably housed women.

Quality of life and unmet need in people with psychosis in the London Borough of Haringey, UK

OBJECTIVES

Deinstitutionalization of long-term psychiatric patients produced various community-based residential care facilities. However, inner-city areas have many patients with severe mental illness (SMI) as well as deprivation, unemployment, and crime. This makes meeting their community needs complex. We undertook a needs assessment of service provision and consonance between service users' evaluation of need and by care workers.

DESIGN

Cross-sectional study with random sample of SMI service users in four housing settings: rehabilitation units; high-supported; medium-supported; low-supported housing.

SETTING

London Borough of Haringey.

OUTCOME MEASURES

110 SMI service users and 110 keyworkers were interviewed, using Camberwell Assessment of Need; SF-36; Lancashire Quality-of-Life profile; demographic and clinical information.

RESULTS

People in "low-support" and "high-support" housing had similar symptom scores, though low support had significantly lower quality of life. Quality of life was positively predicted by self-reported mental-health score and negatively predicted by unmet-need score in whole sample and in medium-support residents. Residents' and care-workers' assessments of need differed considerably.

CONCLUSIONS

Although patients' housing needs were broadly met, those in low-supported housing fared least well. Attendance to self-reported mental health and unmet social needs to quality of life underpins planning of residential services for those with SMI. Social and personal needs of people in supported housing may be underestimated and overlooked; service providers need to prioritise these if concept of "recovery" is to advance.

The physical environment of purpose-built and non-purpose-built supported housing for persons with psychiatric disabilities in Sweden

The primary aim of the present study was to investigate if methods derived from environmental psychology can be used to study the qualities of the physical environment of supported housing facilities for persons with psychiatric disabilities. Three units of analysis were selected: the private area, the common indoor area, and the outdoor area. Expert assessments of 110 features of the physical environment in these units and semantic environmental description of the visual experience of them consistently showed that purpose-built supported housing facilities had more physical features important for high quality residential environments than the non-purpose-built supported housing facilities. The employed methods were thus seen to be able to describe and discriminate between qualities in the physical environment of supported housing facilities. Suggestions for the development of tools for the assessment of the physical environment in supported housing are made.

Choosing "the best of the hells": mothers face housing dilemmas for their adult children with mental illness and a history of violence

Family members in the United States--especially mothers--are frequently caregivers, and provide housing for their adult relatives and children with mental illness. They often do so with little support from the mental health system. The purpose of this analysis was to explore mothers' experiences related to housing options available to their adult children with a mental illness and a history of violence (MIHV) toward the mothers. The results of this study reveal a complex mixing of desires, feelings, internal factors, and external forces experienced by mothers of adult children with MIHV when considering whether or not these children can live in their homes. The findings from this study illuminate needs for greater familial involvement in mental health treatment decisions, respite for caregiving families, and housing as a crucial element of a comprehensive mental health treatment plan.

Consumer participation in housing: reflecting on consumer preferences

OBJECTIVE

Historically, people living with mental illness have had limited chance to participate in mental health services other than as patients. Following on from a recent review focusing on consumer participation in mental health services, this paper looks at consumer participation in housing. Housing is a critical element in recovery from mental illness. Without suitable housing, people have little chance of maintaining other resources in their lives, such as supportive social relationships and meaningful activities.

CONCLUSIONS

Consumer participation is not a common topic in the recent literature, despite the significant public policy push to promote it. The importance of appropriate housing to the recovery of people living with mental illness cannot be underestimated. Even well-meaning and well-resourced housing initiatives can fall short of meeting consumers' recovery goals when they do not incorporate the expressed needs of consumers. These expressed needs include keeping units small in size and employing drop-in support models.

Support in housing: a comparison between people with psychiatric disabilities and people with intellectual disabilities

The primary objective of this study was to compare type of housing and support in housing in two groups (people with psychiatric disabilities and people with intellectual disabilities) typically dependent on support in everyday life. A second objective was to examine whether type of housing and support in housing were related to gender within the two groups. Information was obtained by available questionnaire reports provided by staff members. The results indicate unequal accessibility of support in housing in relation to the two groups. Moreover, the findings suggest that type of disability is a more determining factor than gender regarding support in housing.

A systematic review of the international published literature relating to quality of institutional care for people with longer term mental health problems

BACKGROUND

A proportion of people with mental health problems require longer term care in a psychiatric or social care institution. However, there are no internationally agreed quality standards for institutional care and no method to assess common care standards across countries. We aimed to identify the key components of institutional care for people with longer term mental health problems and the effectiveness of these components.

METHODS

We undertook a systematic review of the literature using comprehensive search terms in 11 electronic databases and identified 12,182 titles. We viewed 550 abstracts, reviewed 223 papers and included 110 of these. A "critical interpretative synthesis" of the evidence was used to identify domains of institutional care that are key to service users' recovery.

RESULTS

We identified eight domains of institutional care that were key to service users' recovery: living conditions; interventions for schizophrenia; physical health; restraint and seclusion; staff training and support; therapeutic relationship; autonomy and service user involvement; and clinical governance. Evidence was strongest for specific interventions for the treatment of schizophrenia (family psychoeducation, cognitive behavioural therapy (CBT) and vocational rehabilitation).

CONCLUSION

Institutions should, ideally, be community based, operate a flexible regime, maintain a low density of residents and maximise residents' privacy. For service users with a diagnosis of schizophrenia, specific interventions (CBT, family interventions involving psychoeducation, and supported employment) should be provided through integrated programmes. Restraint and seclusion should be avoided wherever possible and staff should have adequate training in de-escalation techniques. Regular staff supervision should be provided and this should support service user involvement in decision making and positive therapeutic relationships between staff and service users. There should be clear lines of clinical governance that ensure adherence to evidence-based guidelines and attention should be paid to service users' physical health through regular screening.

Conceptualizing community: a comparison of neighborhood characteristics of supportive housing for persons with psychiatric and developmental disabilities

Housing and services for persons with developmental disabilities (DD) have been shaped by the normalization approach, a commitment to full integration within the general community. In contrast, housing and services for persons with psychiatric disabilities (PD) have had various and sometimes conflicting goals, including provision of custodial care, promotion of therapeutic community, and community integration. This cross-field study compares the neighborhood characteristics of publicly-funded housing for the PD and DD populations in a metropolitan community. The aim of the study was to examine whether the contrasting housing approaches are reflected at an ecological level and to consider how these findings relate to the goal of community integration for people with PD and DD. Administrative databases provided residential addresses of 1932 residents with PD living in 297 locations and 1716 residents with DD living in 749 locations in the city of Philadelphia. The 2000 U.S. Census and city's police department database provided information on neighborhood characteristics. Geographic information system (GIS) methodology generated maps displaying the distribution of housing locations in relation to spatial dispersion, distress, stability, safety, and race/ethnic diversity. Statistical analyses compared neighborhood characteristics of the DD and PD populations. Findings indicated that the DD population in supportive housing was more spatially dispersed, and lived in less distressed, less unstable, more secure, but equally racially/ethnically diverse neighborhoods when compared to the PD population in supportive housing. Greater geographic dispersal among persons with DD may be the result of more emphasis on normalization within policies and programs determining the location of their housing. The higher funding levels for housing and residential support for persons with DD also provided programs with the option of placing people in higher income neighborhoods. Given that community integration has emerged as an organizing principle within mental health services over other models, policymakers in the field of psychiatric disabilities may have much to learn from the normalization movement for people with developmental disabilities.

Consumer perspectives on recovery: a focus on housing following discharge from hospital

Housing is a critical element in recovery from mental illness. Without suitable housing, people have little chance of maintaining other resources in their lives, such as supportive social relationships and meaningful activities. This study investigated consumers' perspectives on the recovery needs of people who are living with a mental illness, especially those who might need supported accommodation as part of their reintegration into the community. Good quality housing is a critical element in recovery for people living with a mental illness. Findings indicate that when people become unwell, they can destroy resources in their lives, such as housing and friendships. A lack of financial stability can be a problem and exacerbate other difficulties. Having a mental illness means living with loss, stigma, and loneliness, but having someone who understands contributes significantly to recovery. The literature suggests that 'recovery' can relate to the relief of symptoms or from the stigma of the illness, recovering from the effects of treatment, from the lack of opportunities, and from the destructive aspects of mental illness. Findings from this study support these aspects, but also that recovery seems to be more. After spending time with the participants, the authors concluded that recovery also means the recovery of a life that includes supportive friends, living in a community in which at least some people 'understand', and of recovering a life that includes activities that give that life meaning. Consumers can make a significant contribution to our understanding of mental illness and recovery.

Effects of housing circumstances on health, quality of life and healthcare use for people with severe mental illness: a review

Individuals with severe and persistent mental illness (SPMI) identify housing as an important factor in achieving and maintaining their health. However, many live in substandard accommodations that are physically inadequate, crowded, noisy and located in undesirable neighbourhoods. In much of the research on housing for persons with SPMI, the central outcome of interest is remaining housed; however, it is worth investigating whether housing has other benefits. This paper is a systematic review of studies that investigated the relationship between housing-related independent variables and health-related dependent variables. Ten online databases were searched for studies published since 1980 that had study populations of adults with SPMI, analysed primary or secondary empirical data, and measured housing-related independent variables and health-related dependent variables. Clearly defined epidemiological criteria were used to assess the strength of evidence of the selected studies. Twenty-nine studies met the suitability criteria, of which 14 reported healthcare utilisation outcomes; 12 examined mental status outcomes; and 9 reported quality-of-life outcomes. The findings of the review suggest that there is good evidence that housing interventions benefit the homeless population; however more research is needed about housing solutions for individuals with SPMI who are housed, but in precarious or inappropriate housing situations. Study methodologies could be improved by emphasising longitudinal designs that focus on participant retention and by implementing matched control groups or randomised interventions to strengthen internal validity. Ensuring that a person is adequately housed upon discharge from hospital should be a treatment priority. When housing eligibility is not dependent on psychiatric treatment compliance and sobriety, providing permanent housing minimises harm and may free people to voluntarily seek treatment. Housing that offers an unlimited length of stay is recommended because SPMI is a chronic and fluctuating condition that requires stable surroundings to maintain health.

The environment and staff of residential facilities: findings from the Italian 'progres' national survey

We administered structured interviews to managers and staff of a random sample of 265 Italian psychiatric Residential Facilities (RFs). Most are independent buildings, located in urban and suburban areas. The median number of residents is 10. The few RFs (5.7%) with more than 20 beds have a higher rate of drop-outs and escapes. The average indoor space per resident is 36 square meters, there is often a garden, and residents generally live in two-bed rooms. Most facilities are located within walking distance of shopping centers or recreational facilities. Three-quarters have 24-hour staff coverage. On average, each facility has about 10 full-time equivalent workers, with a staff:resident ratio of 0.92. Most of the professional input is provided by nurses and auxiliary staff. Critical issues to be considered in planning facilities include the physical environment, the size, and the staffing patterns.

Adjustment to community residential settings over time among older adults with serious mental illnesses

This exploratory cross-sectional study examined adjustment over time of three groups of seniors with serious mental illnesses (N=33), who were transferred from a psychiatric hospital to a community residential facility from 1995-1998. The study participants had lived in the community for 6-41 months. Outcomes included measures of global, social, cognitive and ADL functioning, quality of life and rehospitalizations. Analyses revealed no significant deterioration in symptomatology, cognitive and ADL functioning between groups and a significant change in social functioning. Five participants were readmitted for short hospitalizations. Participants in all groups expressed a positive quality of life in their current community residence.

Housing, social support and people with schizophrenia: a grounded theory study

The aim of this study was to develop a substantive grounded theory describing the relationship among housing, social support, and the mental health of people with schizophrenia. To achieve this aim, data were collected from people with schizophrenia living in boarding houses and living in their own home. Semi-structured in-depth interviews were conducted with 13 people with schizophrenia to explore their experiences and views regarding the impact of their housing on their mental health. Findings indicate a strong desire among all participants to live in their own home. When they do they feel they belong, they feel safe and most importantly they have greater opportunities to make and maintain supportive social relationships.

The cost-effectiveness of independent housing for the chronically mentally ill: do housing and neighborhood features matter?

OBJECTIVE

To determine the effects of housing and neighborhood features on residential instability and the costs of mental health services for individuals with chronic mental illness (CMI).

DATA SOURCES

Medicaid and service provider data on the mental health service utilization of 670 individuals with CMI between 1988 and 1993 were combined with primary data on housing attributes and costs, as well as census data on neighborhood characteristics. Study participants were living in independent housing units developed under the Robert Wood Johnson Foundation Program on Chronic Mental Illness in four of nine demonstration cities between 1988 and 1993.

STUDY DESIGN

Participants were assigned on a first-come, first-served basis to housing units as they became available for occupancy after renovation by the housing providers. Multivariate statistical models are used to examine the relationship between features of the residential environment and three outcomes that were measured during the participant's occupancy in a study property: residential instability, community-based service costs, and hospital-based service costs. To assess cost-effectiveness, the mental health care cost savings associated with some residential features are compared with the cost of providing housing with these features.

DATA COLLECTION/EXTRACTION METHODS

Health service utilization data were obtained from Medicaid and from state and local departments of mental health. Non-mental-health services, substance abuse services, and pharmaceuticals were screened out.

PRINCIPAL FINDINGS

Study participants living in newer and properly maintained buildings had lower mental health care costs and residential instability. Buildings with a richer set of amenity features, neighborhoods with no outward signs of physical deterioration, and neighborhoods with newer housing stock were also associated with reduced mental health care costs. Study participants were more residentially stable in buildings with fewer units and where a greater proportion of tenants were other individuals with CMI. Mental health care costs and residential instability tend to be reduced in neighborhoods with many nonresidential land uses and a higher proportion of renters. Mixed-race neighborhoods are associated with reduced probability of mental health hospitalization, but they also are associated with much higher hospitalization costs if hospitalized. The degree of income mixing in the neighborhood has no effect.

CONCLUSIONS

Several of the key findings are consistent with theoretical expectations that higher-quality housing and neighborhoods lead to better mental health outcomes among individuals with CMI. The mental health care cost savings associated with these favorable features far outweigh the costs of developing and operating properties with them. Support for the hypothesis that "diverse-disorganized" neighborhoods are more accepting of individuals with CMI and, hence, associated with better mental health outcomes, is mixed.

Measuring the impact of housing on people with schizophrenia

Review of the available literature, from various countries, on housing options indicates that, for people with a mental illness, boarding houses are the least desirable type of community accommodation and that living in their own home is the most desirable type of accommodation. The present research project provides a more in-depth examination of people with schizophrenia and the impact of living in their own home compared to living in a boarding house. In this Australian study there were 3231 subjects, 3033 who were living in their own homes and 201 living in boarding house accommodation. The study used two instruments from the Mental Health Classification and Service Cost Project, specifically the Health of the Nation Outcomes Scale, which is a measure of current symptoms, and a shortened version of the Life Skills Profile, which measures global level of functioning. Results indicated that while there were no differences in the level of psychiatric symptoms experienced, people living in boarding houses had less access to social support, meaningful activities and work; they also had a significantly lower level of global functioning. These findings contradict the conventional wisdom that people with schizophrenia resort to living in boarding houses because of their level of disability and highlights an area of potential intervention for community health services.

Supported housing for people with serious mental illness: resident perspectives on housing

Supported housing involves integrated housing that is adequate and affordable, paired with flexible, individualized mental health support services. In this qualitative study, interviews were conducted with supported housing residents in cities and towns in southwestern Ontario to examine their housing experience. Questions were organized around 4 dimensions of housing: (a) physical environment, (b) social environment, (c) affordability and choice, and (d) residential history. The inquiry, which occurred at neighbourhood and dwelling-unit levels, revealed 4 themes: (a) loneliness, (b) making do with socially and structurally inferior housing, (c) a desire for more understanding, and (d) a concern with an individual's sense of integration into a community.

Effects of involuntary outpatient commitment on subjective quality of life in persons with severe mental illness

Recent evidence suggests that involuntary outpatient commitment (OPC), when appropriately applied, can improve adherence with psychiatric treatment, decrease hospital recidivism and arrests, and lower the risk of violent behavior in persons with severe mental illness. Presumably these are benefits that improve quality of life (QOL); however, insofar as OPC involves legal coercion, the undesirable aspects of OPC could also exert a negative effect on quality of life, thus offsetting clinical benefits. Involuntarily hospitalized subjects, awaiting discharge under outpatient commitment, were randomly assigned to be released or continue under outpatient commitment in the community after hospital discharge, and were followed for one year. Quality of life was measured at baseline and 12 months follow-up. Treatment characteristics and clinical outcomes were also measured. Subjects who underwent longer periods of outpatient commitment had significantly greater quality of life as measured at the end of the 1 year study. Multivariable analysis showed that the effect of OPC on QOL was mediated by greater treatment adherence and lower symptom scores. However, perceived coercion moderated the effect of OPC on QOL. Involuntary outpatient commitment, when sustained over time, indirectly exerts a positive effect on subjective quality of life for persons with SMI, at least in part by improving treatment adherence and lowering symptomatology.

Perceived social support and community adaptation in schizophrenia

Prompted by the continuing transition to community care, mental health nurses are considering the role of social support in community adaptation. This article demonstrates the importance of distinguishing between kinds of social support and presents findings from the first round data of a longitudinal study of community adaptation in 156 people with schizophrenia conducted in Brisbane, Australia. All clients were interviewed using the relevant subscales of the Diagnostic Interview Schedule to confirm a primary diagnosis of schizophrenia. The study set out to investigate the relationship between community adaptation and social support. Community adaptation was measured with the Brief Psychiatric Rating Scale (BPRS), the Life Skills Profile (LSP) and measures of dissatisfaction with life and problems in daily living developed by the authors. Social support was measured with the Arizona Social Support Interview Schedule (ASSIS). The BPRS and ASSIS were incorporated into a client interview conducted by trained interviewers. The LSP was completed on each client by an informal carer (parent, relative or friend) or a professional carer (case manager or other health professional) nominated by the client. Hierarchical regression analysis was used to examine the relationship between community adaptation and four sets of social support variables. Given the order in which variables were entered in regression equations, a set of perceived social support variables was found to account for the largest unique variance of four measures of community adaptation in 96 people with schizophrenia for whom complete data are available from the first round of the three-wave longitudinal study. A set of the subjective experiences of the clients accounted for the largest unique variance in measures of symptomatology, life skills, dissatisfaction with life, and problems in daily living. Sets of community support, household support and functional variables accounted for less variance. Implications for mental health nursing practice are considered.

The relationship between housing characteristics, emotional well-being and the personal empowerment of psychiatric consumer/survivors

In this research, we examine the relationships between the housing characteristics and dimensions of community adaptation for 107 psychiatric consumer/survivors. Hypotheses about which housing characteristics best predict which dimensions of adaptation were made based on previous research and theory. Using a longitudinal research design, we found, after controlling for demographic variables and prior adaptation, that the number of living companions, housing concerns, and having a private room all significantly predicted different dimensions of community adaptation. The findings partially support our theoretical expectations and illuminate the relationship between physical, social and organizational aspects of community-based housing and the adaptation of psychiatric consumer/survivors. We discuss the implications of the results for policy and practice in providing housing for this population.

An investigation of work and unemployment among psychiatric clients

Employment and work can have a positive effect on mental health by providing opportunities for skill development, social contact, self-esteem, and income. Unemployment is a source of anxiety, stress, and depression. At the same time work can be a major source of stress by decreasing opportunities for control and autonomy. This article examines the role of work and unemployment and the relationship of work status to other indicators of community adjustment among a sample of 68 psychiatric clients in outpatient treatment. Comparisons are made between clients who are not working or seeking work, those who are unemployed and seeking work, and those who are currently working. Regression analysis is then used to examine the effect of work status on other indicators of community adjustment: psychiatric symptoms, functioning, social integration, stress, and mental hospitalizations. Working clients are more likely to be male and younger and to have had previous work experience. Working is related to higher levels of functioning in the community, while unemployment is positively related to stress. Work status was not related to social integration, indicating that work may be an alternative source of social support and should receive separate attention in assessments of community adjustment and integration.

Factors related to integrating persons with chronic mental illness into a peer social milieu

Client characteristics and their perceptions of the milieu in a psychosocial rehabilitation program were used to predict the clients' level of involvement in the peer-based social network. 81 clients in a psychosocial rehabilitation program participated in the study. The results indicated that client perceptions of higher support and clarity in the staff-client milieu, and being female, were strongly related to higher peer social involvement. Milieu factors were generally more important than client characteristics in predicting client social functioning. The implications of these findings for psychosocial intervention and for research on the social functioning of this population are discussed.

A behavior setting assessment for community programs and residences

Using the concept of person-environment fit to determine the effectiveness of residential and program placements for chronic psychiatric clients requires systematic and concrete information about these community environments in addition to information about the clients themselves. The conceptual and empirical development of the Behavior Setting Assessment (BSA), a measure based on Barker's behavior setting theory, is described. Use of the BSA with 28 residences (117 settings) and 11 programs (176 settings) from two community support systems demonstrated that all 293 settings assessed could be described and analyzed in terms of differences in their demands for self-care skills, food preparation and consumption, verbal/cognitive responses, and solitary or group activities. The BSA is an efficient measure for obtaining specific, concrete information about the behavioral demands of important community environments.