Correlates of family contact with the mental health system: allocation of a scarce resource

Clients' Preferences for Family Involvement and Subsequent Family Contact Patterns Within OnTrackNY Early Psychosis Services

OBJECTIVE

Little is known about clients' preferences for family involvement and subsequent family contact in naturalistic, community-based coordinated specialty care (CSC) settings. The study's primary goal was to characterize clients' preferences and longitudinal patterns of family contact with providers across the OnTrackNY network in New York.

METHODS

Clinical administrative data collected at 3-month intervals and spanning 21 OnTrackNY CSC sites were used to analyze the preferences of 761 clients at baseline (unconditional involvement, conditional involvement, or no involvement) and patterns of family contact with program staff (always, sometimes, never, or early discharge) and their correlates during the initial 12-month service period. Data from clients discharged before 12 months were included for comparison.

RESULTS

At baseline, most clients requested some form of family involvement (unconditional, 59%; conditional, 35%; and none, 6%). Within each 3-month assessment period, rates of family contact ranged from 73% to 84%. Variables associated with both client preferences and contact patterns included baseline insurance status, housing status, race, frequency of family contact, and employment. Clients' preferences for no or conditional family involvement were associated with higher rates of early discharge (i.e., before 1 year).

CONCLUSIONS

Structuring family involvement around clients' preferences did not appear to negatively affect family contact, and for some clients, it seemed to bolster such contact. Additional mixed-methods research is needed to deepen the understanding of the contexts and reasoning underlying both client preferences for family involvement and subsequent levels of family contact.

Implementing a family-inclusive practice model in youth mental health services in Australia

AIM

A brief family-inclusive practice model, single session family consultation (SSFC), was introduced at 4 youth mental health service sites to determine the extent to which the model could be implemented in this context and its acceptability as a means of engaging families of young people.

METHODS

Within an action research paradigm, both quantitative and qualitative measures were used for this implementation project with the former reported here. There were 2 components: (1) evaluation of the experiences of young people and their families and (2) evaluation of the extent of implementation of SSFC. Quantitative data were analysed descriptively (item scores, range and any changes over time).

RESULTS

Twenty practitioners who were trained and supported in the use of SSFC participated in the 6-month implementation evaluation. In 6 months, 131 SSFC sessions were conducted across the 4 sites and the young people and their families were very satisfied with sessions (overall mean = 5.2, range = 0-6). Six months post-training, there were statistically significant improvements in the practitioners' confidence in providing family interventions (mean improvement = -0.47 (95% confidence interval (CI) = -0.91, -0.04), P = .035) and familiarity with approaches to working with families (mean improvement = -0.61 (95% CI = -1.13, -0.10, P = .023). Practitioners perceived significant improvement in organizational support for working with families.

CONCLUSIONS

SSFC was acceptable to clients and their families, was adopted by practitioners and was successfully implemented in the participating sites. This suggests that SSFC, when appropriately implemented, is useful to engage families in the treatment of young people facing mental health issues.

The resource group method in severe mental illness: study protocol for a randomized controlled trial and a qualitative multiple case study

BACKGROUND

The resource group method provides a structure to facilitate patients' empowerment and recovery processes, and to systematically engage significant others in treatment and care. A patient chooses members of a resource group (RG) that will work together on fulfilling patients' recovery plan. By adopting shared decision-making processes and stimulating collaboration of different support systems, a broad and continuous support of patients' chosen goals and wishes is preserved and problem solving and communication skills of the RG members are addressed.

OBJECTIVE

The objectives of this study are (1) to establish the effectiveness of the RG method in increasing empowerment in patients with severe mental illnesses (SMI) in the Netherlands; (2) to investigate the cost-effectiveness and cost utility of the RG method; and (3) to qualitatively explore its dynamics and processes.

METHODS/DESIGN

This multisite randomized controlled trial will compare the effects of the RG-method integrated in Flexible Assertive Community Treatment (FACT) (90 patients) with those of standard FACT (90 patients). Baseline assessments and 9-month and 18-month follow-up assessments will be conducted in face-to-face home visits. The primary outcome measure, empowerment, will be assessed using the Netherlands Empowerment List (NEL). The secondary outcomes will be quality of life (MANSA); personal, community and clinical recovery (I.ROC); general, social and community functioning (WHODAS 2.0); general psychopathological signs and symptoms (BSI-18); and societal costs (TiC-P). An economic evaluation of the cost-effectiveness and cost utility of the RG method will also be conducted. A qualitative multiple case-study will be added to collect patients', RG members' and professionals' perspectives by in-depth interviews, observations and focus groups.

DISCUSSION

This trial will be the first to study the effects of the RG method on empowerment in patients with SMI. By combining clinical-effectiveness data with an economic evaluation and in-depth qualitative information from primary stakeholders, it will provide a detailed overview of the RG method as a mean of improving care for patients with SMI.Trial registration The study has been registered in the Dutch Trial Register, identifier: NTR6737, September 2017.

Professional views of supporting relatives of mental health clients with severe mental illness

BACKGROUND

Supporting families where one person suffers from long-term severe mental illness (SMI) is essential, but seems hard to reach. The aim of this study was to examine professionals' views of supporting relatives of persons with SMI.

MATERIAL

Individual interviews mirroring personal narratives and group interviews reflecting group-processed answers were conducted among 23 professionals and analyzed thematically.

RESULTS

Three themes emerged: (a) information and group interaction reduces stigma and increases well-being, (b) professionals need to feel secure and confident about how the support structure works and (c) collaboration is difficult but required on several levels.

CONCLUSION

Trusting relationships with families were considered important, although seldom achieved; professionals wished to feel secure in their role toward relatives of a person with SMI; and professionals wanted to feel confident when working together with other services to support families.

How Professionals View Multifamily Psychoeducation: A Qualitative Study

Severe mental illness causes suffering for the patient as well as the patient's immediate family. The Swedish National Board of Health and Welfare has recommended the implementation of multifamily psychoeducation in order to assist patient and family in the recovery process. The aim of this study was to determine how introducing multifamily psychoeducation in Sweden has been viewed by professionals. Semi-structured interviews were conducted with 11 service providers, who were involved in evaluating multifamily psychoeducation. Our main findings fell under the headings of defensive culture and unsuitable model. Resistance to introducing the new intervention was found on multiple levels. The model proposed was considered too rigid for both the target group and the organizations because it could not be adjusted to the needs of patients, families, or facilitators. Despite good evidence for the effectiveness of the intervention, there were difficulties introducing the multifamily psychoeducation model in clinical practice. The feasibility of an intervention needs to be evaluated before adopting it as a national guideline.

An Interpersonal CBT Framework for Involving Relatives in Interventions for Psychosis: Evidence Base and Clinical Implications

Working with families in psychosis improves outcomes and is cost effective. However, implementation is poor, partly due to lack of a clear theoretical framework. This paper presents an interpersonal framework for extending the more familiar cognitive behavioral therapy model of psychosis to include the role of relatives' behavior in the process of recovery. A summary of the framework is presented, and the evidence to support each link is reviewed in detail. Limitations of the framework are discussed and further research opportunities highlighted. Clinical implications and a case example are described to show how the framework can be used flexibly to facilitate clinical practice. Our aim is to shift the focus of psychosocial interventions from an individualistic approach to treatment, towards greater involvement of relatives and recognition of the importance of the social environment on mental health.

Supporting Recovery Orientated Services for People With Severe Mental Illness

There is now wide agreement that people with severe mental illness can be adequately treated and cared for in the community, provided back-up hospital care is available when needed. Another important development has been the recognition that clinical treatment and care is insufficient for recovery and restoration of role functioning following illness onset, and must be supplemented by evidence-based practices in psychiatric rehabilitation. This article describes how allied health professionals can lead recovery oriented approaches that incorporate evidence-based forms of psychiatric rehabilitation. Family psychoeducation and supported employment are provided as examples of such evidence-based practices that require wider implementation.

New challenges in family interventions for schizophrenia

This review first outlines the rationale and research base supporting the development of family interventions for schizophrenia. The over-riding principles guiding effective family interventions for schizophrenia are then presented, along with the key components (engagement, assessment, education, communication skills training and problem-solving) shared by most family programs in schizophrenia. Meta-analyses demonstrating the efficacy of family interventions in reducing relapse and rehospitalization in schizophrenia are then discussed, along with issues regarding minimal duration of effective treatment, differential benefits of single and multiple family modalities and mixed evidence for the maintenance of treatment effects after termination. The benefits of participation in family-organized, nonprofessional support and education programs are then described. Finally, three issues meriting further study are outlined.

Comparative review of family-professional communication: what mental health care can learn from oncology and nursing home care

Because family members take on caring tasks and also suffer as a consequence of the illness of the patient, communication between health-care professionals and family members of the patient is important. This review compares communication practices between these two parties in three different parts of health care: oncology, nursing home care, and mental health care. It shows that there are important differences between sectors. Mental health stands out because contacts between family members and professionals are considered problematic due to the autonomy and confidentiality of the patient. The article explores several explanations for this, and, by comparing the three health sectors, distils lessons to improve the relationship between family members and health-care professionals.

Routine outcomes monitoring to support improving care for schizophrenia: report from the VA Mental Health QUERI

In schizophrenia, treatments that improve outcomes have not been reliably disseminated. A major barrier to improving care has been a lack of routinely collected outcomes data that identify patients who are failing to improve or not receiving effective treatments. To support high quality care, the VA Mental Health QUERI used literature review, expert interviews, and a national panel process to increase consensus regarding outcomes monitoring instruments and strategies that support quality improvement. There was very good consensus in the domains of psychotic symptoms, side-effects, drugs and alcohol, depression, caregivers, vocational functioning, and community tenure. There are validated instruments and assessment strategies that are feasible for quality improvement in routine practice.

A proof of concept trial of an online psychoeducational program for relatives of both veterans and civilians living with schizophrenia

OBJECTIVES

Family psychoeducation has been found to reduce relapse in schizophrenia but penetration rates are low. In this study, we evaluate the feasibility of an online multifamily group program for relatives of persons with schizophrenia that can be accessed from participants' homes.

METHODS

We explored participation rates and evaluations of a 12-month multimodal website intervention. Using a quasi-experimental design, we compared illness outcomes (factors on the Brief Psychiatric Rating Scale, hospitalizations) of persons with diagnosed schizophrenia, and relative distress outcomes (somatic concerns and anxiety/depression subscales on the Brief Symptom Inventory) from relatives participating in the intervention (n = 26) to archival data we had from comparable dyads who received customary care (n = 16).

RESULTS

The majority of participants in the program attended more than half the core online support sessions, expressed high levels of satisfaction, and found the technology easy to access. There appeared to be little impact of online participation on clinical status of persons with schizophrenia or relatives' distress, although there was a trend for fewer hospitalizations in the online group. Small sample size is a factor in interpreting results.

CONCLUSIONS

Online interventions for relatives of persons with schizophrenia, while feasible, present unique challenges. These include 1) assuring access to the intervention in populations who do not own a computer; 2) addressing privacy concerns; 3) overcoming the special challenges of conducting groups in real time; 4) managing emergent situations adequately; and 5) questions about efficacy.

A comparison of early psychosis treatment services using consensus and evidence-based performance measures: moving towards setting standards

OBJECTIVE

This study used data from two Canadian early psychosis programs to assess the feasibility of using common performance measures and to assess the extent to which each program meets suggested standards for early intervention.

METHODS

Data were extracted from administrative databases and supplemented by health records for 332 individuals admitted to two services in order to calculate values for 19 performance indicators for January 2000 to January 2004. Inter-rater reliability was established for data abstraction.

RESULTS

The two samples had similar demographic and clinical profiles. There were no statistically significant differences in 1-, 2- and 3-year admission rates (year 1: 27% vs. 30%, P=0.625; year 2: 31% vs. 38%, P=0.248; year 3: 35% vs. 42%, P=0.260), duration of untreated psychosis (DUP) (24 vs. 28 weeks; P=0.844) and positive symptom remission at 1 year (72% vs. 78%; P=0.285). There were statistically significant differences between the two services in mean wait time (18 vs. 13 days; P=0.045), proportion of patients on second-generation anti-psychotics at 1 year (75% vs. 89%; P=0.002), and proportion of patients adherent to antipsychotic medication for a minimum of 12 months (76% vs. 83%; P=0.007).

CONCLUSION

The data provides useful information on the feasibility of implementing key performance measures across early psychosis programs to assess the extent to which they are meeting standards for such services.

Reengineering clinical research science: a focus on translational research

The burden of disease in the United States is high. Mental illness is currently the leading cause of disease burden among 15- to 44-year-olds. This phenomenon is occurring despite the many advances that have been made in clinical research. Several efficacious interventions are available to treat many of these disorders; however, they are greatly underutilized within community settings. Achievements in basic science such as the completion of the Human Genome project have provided access to the examination of the neurobiology of mental disorders. To address the overall burden of disease, a reengineering of clinical science must take place. Adopting a translational framework will capitalize on the synergy of integrating basic science and clinical knowledge to inform real-world practices. This article will define and discuss translational research and the current National Institutes of Health initiatives that have been developed to support its implementation.

The potential impact of the recovery movement on family interventions for schizophrenia: opportunities and obstacles

Many types of family interventions have been found to be effective in reducing exacerbations in schizophrenia; some also improve consumer social functioning and reduce family burden. Regardless of their origins, these interventions share a number of common features, such as showing empathy for all participants, providing knowledge about the illness, assuming a nonpathologizing stance, and teaching communication and problem-solving skills. Importantly, these family interventions have many characteristics that are consistent with the growing recovery movement in mental health in that they are community-based, emphasize achieving personally relevant goals, work on instilling hope, and focus on improving natural supports. Nevertheless, these interventions are generally reflective of older models of serious and persisting psychiatric illnesses that are grounded in a "patient being treated for a chronic illness" rather than a "consumer assuming as much responsibility as possible for his/her recovery" stance. These interventions could be made more consistent with recovery principles by (1) expanding the definition of family to include marital, parenting, and sibling relationships, (2) identifying better ways to match consumers with treatments, (3) broadening the research focus to include systems change that promotes making family members a part of the treatment team (with the consumer's consent), and (4) overcoming implementation obstacles that preclude access to effective family interventions for most consumers and their relatives.

Challenges to implementing and sustaining comprehensive mental health service programs

The President's New Freedom Commission recently concluded that the nation's mental health service delivery system is ill equipped to meet the complex needs of persons with mental illness. A major contributor to this service quality crisis has been the longstanding divergence of research efforts and clinical programs. In this article, the authors begin by describing the unique needs of persons with serious and persisting psychiatric disorders and the evolution of the mental health service system that has attempted to meet these needs. They then discuss recent efforts to upgrade services by emphasizing the use of evidence-based practices (EBPs) and the research underlying their development. Next, they describe the difficulties of using traditional research methods to develop and test interventions for persons receiving services at public mental health agencies. Finally, they outline the challenges confronted when trying to disseminate these EBPs to the wider clinical community.

Cure therapeutics and strategic prevention: raising the bar for mental health research

Mental disorders cause more disability than any other class of medical illness in Americans between ages 15 and 44 years. The suicide rate is higher than the annual mortality from homicide, AIDS, and most forms of cancer. In contrast to nearly all communicable and most non-communicable diseases, there is little evidence that the morbidity and mortality from mental disorders have changed in the past several decades. Mental health advocates, including psychiatric researchers, have pointed to stigma as one of the reasons for the lack of progress with mental illnesses relative to other medical illnesses. This review considers how the expectations and goals of the research community have contributed to this relative lack of progress. In contrast to researchers in cancer and heart disease who have sought cures and preventions, biological psychiatrists in both academia and industry have set their sights on incremental and marketable advances, such as drugs with fewer adverse effects. This essay argues for approaches that can lead to cures and strategies for prevention of schizophrenia and mood disorders.