Further reliability and validity studies of a procedure to assess the needs for care of the chronically mentally ill

Service use and unmet needs in youth suicide: a study of trajectories

OBJECTIVE

While 90% of suicide victims have suffered from mental health disorders, less than one-half are in contact with a mental health professional in the year preceding their death. Service use in the last year of life of young suicide victims and control subjects was studied in Quebec. We wanted to determine what kinds of health care services were needed and if they were actually received by suicide victims.

METHOD

We recruited 67 consecutive suicide victims and 56 matched living control subjects (aged 25 years and younger). We evaluated subjects' psychopathological profile and determined which services would have been indicated by conducting a needs assessment. We then compared this with what services were actually received.

RESULTS

Suicide victims were more likely than living control subjects to have a psychiatric diagnosis. They were most in need of services to address substance use disorder, depression, interpersonal distress, and suicide-related problems. There were significant deficits in the domains of coordination and continuity of care, mental health promotion and training, and governance.

CONCLUSIONS

Our results show that we need to urgently take action to address these identified deficits to prevent further loss of life in our young people.

Treatment with antipsychotics: The impact on the patient in the community

The assessment of new treatment strategies such as the atypical antipsychotic agents goes far beyond the assessment of psychopathology, and includes evaluation of their effects on a variety of needs associated with living in the community. This article provides some empirical data for such a multidimensional perspective in analysing drug treatment with conventional antipsychotics. We focus on two groups of schizophrenic patients discharged from a psychiatric hospital, who were followed up for one year. One group was treated with oral and the other with depot medication. The two groups were assessed on their needs for care, quality of life, and rehospitalisation rates. We found few significant differences between depot- and orally-medicated patients. However, patients treated with depot antipsychotics were receiving higher mean daily doses. Patients taking oral medication had a lower rate of adverse effects but were more non-compliant, which resulted in a higher rehospitalisation rate, confirming our assumpt on that patients take different risk-to-benefit decisions. Orally-medicated patients did not have a better functional status than depot-medicated patients.

Systematic services audit of consecutive suicides in New Brunswick: the case for coordinating specialist mental health and addiction services

OBJECTIVE

To weight the potential of promotion, prevention, and treatment programs to help establish priorities in multipronged suicide prevention strategies.

METHODS

Psychological autopsy methods served to collect information on consecutive suicides over 14 months in New Brunswick (n = 102). A panel of researchers, clinicians, provincial planners, and consumers reviewed the cases and applied a systematic needs assessment procedure to establish interventions and services received, unmet needs at the individual level, and programmatic and systemic shortcomings.

RESULTS

More than two-thirds of the individuals suffered from a depressive disorder and a similar proportion from substance (essentially alcohol) abuse or dependence; one-half also presented a personality disorder. In the last year, more than one-half had been in contact with a mental health services specialist, but less than 5% had contact with addiction services, though one-third had previous contact in their lifetime. In one-third of the cases, service gaps called for greater coordination and integration of mental health specialists and addiction services within the health care system. In one-half of the cases, system needs were found to be unmet for public awareness efforts aimed at encouraging individuals to consult health and social services professionals, and in terms of training efforts geared to improving detection, treatment, and referral for mental illness, substance-related problems, and suicidal behaviour by primary medical, social, and specialist services.

CONCLUSION

This study supports multipronged suicide prevention strategies that should include integrated public promotion, professional development campaigns, and better program coordination. Authorities in New Brunswick have opted to favour the latter strategy component, whose development and application must be evaluated to determine its impact on suicide rates.

Schizophrenia and quality of life: a one-year follow-up in four EU countries

BACKGROUND

This article systematically monitors the quality of life (QOL) of patients with schizophrenia from seven different sites across four European countries: France, Ireland, Portugal and Spain.

METHODS

A one-year prospective cohort study was carried out. Inclusion criteria for patients were: a clinical lifetime diagnosis of schizophrenia according to ICD-10 (F20) diagnostic criteria for research, age between 18 and 65 years and at least one contact with mental health services in 1993. Data concerning QOL were recorded in seven sites from four countries: France, Portugal, Ireland and Spain, and were obtained using the Baker and Intagliata scale. At baseline, 339 patients answered the QOL questionnaire. At one-year follow-up, Spain could not participate, so only 263 patients were contacted and 219 agreed to take part. QOL was compared across centres by areas and according to a global index. QOL was correlated with presence of clinical and social problems, needs for care and interventions provided during the one-year follow-up.

RESULTS

We did not find any link between gender and QOL. There were some significant differences between centres concerning many items. What is more, these differences were relative: in Lisbon where the lowest level of satisfaction was recorded, people were satisfied with food but highly dissatisfied with finances, whereas in St Etienne, where the highest level of satisfaction was recorded, people were less satisfied with food when they were more satisfied with finances. The evolution in one year among those respondents who took part in the follow-up (excluding the subjects from Granada) showed different patterns depending on the items.

CONCLUSION

The four countries have different resources and patients live in rather different conditions. However, the main differences as far as their QOL is concerned very much depend on extra-psychiatric variables, principally marital status and income.

Professional team's choices of intervention towards problems and needs of patients suffering from schizophrenia across six European countries

OBJECTIVES

This article compares in a systematic way the team's intervention choices of professionals across seven European countries: France, Ireland, Italy, the Netherlands, Portugal and Spain towards problems and needs of patients with schizophrenia and relates this to the diversity of psychiatric systems.

METHODS

The clinical and social status of 433 patients was assessed by means of the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and the Needs for Care Assessment instrument (NFCAS) which was used to determine teams' intervention choices toward the NFCAS problems.

RESULTS

There is no, or little, consensus across Europe on teams' intervention choices towards either the clinical or the social problems and needs of patients suffering from schizophrenic disorders. These comparisons outlined the cultural differences concerning the interventions that were proposed and should be taken into account when interpreting the number of needs and the need status since the need status relies heavily on the interventions proposed. The differences were not connected with the availability of resources; most of the comparisons show differences between centers as well as differences between groups of relatively similar resource countries.

The "carers' needs assessment for Schizophrenia": an instrument to assess the needs of relatives caring for schizophrenia patients

OBJECTIVE

For the purpose of service planning, an instrument was developed for the systematic assessment of interventions needed by the caregivers of schizophrenia patients.

METHOD

The development of this instrument was based on in-depth interviews and focus groups. It consists of 18 areas describing common problems of schizophrenia caregivers. For each of these problem areas several possible interventions are offered. Concurrent validity, inter-rater and retest reliability were tested among 50 caregivers.

RESULTS

The kappa values for the inter-rater reliability are predominantly excellent (kappa > 0.75). The values for the retest reliability show a wide range between excellent (kappa > 0.75) and fair agreement (kappa 0.40-0.60). The significant correlations found between summary scores of this new instrument and several sub-scales of the Family Problem Questionnaire support the assumption that the concurrent validity is satisfactory.

CONCLUSION

These results suggest that this instrument is both valid and reliable.

[The fate of patients with very severe and chronic mental disorders when there is no psychiatric hospital: a case study]

The Eastern Townships (Estrie) is an area of Québec which has never had a psychiatric hospital and is thus an extreme example of deinstitutionalization. How can people with the most severe mental illnesses be cared for? Does this system have harmful consequences? The authors present a case study with both qualitative and quantitative data to elucidate their questions. They found 36 patients with very severe mental illness (prevalence 12,4/100 000). This region does not send its most severely ill patients outside and generally succeeds in providing them with care and services in a network of small and medium size residential facilities. On the other hand, the authors have also been able to identify a certain drift of patients towards the correctional system ; cases with double or triple diagnosis do not easily have access to care ; through lack of an alternative, patients with potentially chronic violence often are stuck in a hospital in short stay beds (prevalence 1,6/100 000). It thus appears possible to eliminate the use of a psychiatric hospital for patients with very severe mental disorders as long as they are provided with supervised and long term care facilities (need : 10-20 places/100 000).

Suicidality of chronic schizophrenic patients in long-term community care

In the provision of mental health care for chronic schizophrenic patients, the specific problems and requirements of long-term community care of suicidal behavior is an area of research not yet fully explored. This study focuses on a 4 1/2-year prospective assessment of normative and subjective needs for care related to this specific area for a cohort living in the Dresden region (Germany). One significant result of this study shows the constant high level of needs for care in the area of suicidal behavior imposed on community services by 30-40% of this diagnostic group. Furthermore, the study identified a special high-risk subgroup for suicides as well as specific needs for care. This subgroup is characterized by clinical reasons for the index hospitalization (suicidal risk or attempt) as well as by psychopathological features (suicidal thoughts and higher levels of anxiety/depression) 1 month after release from index hospitalization. Four items of care were rated as potentially effective for addressing suicidality in the community setting: clinical assessment, increased supervision or systematic recording of (suicidal) behavior, medication, and a sheltered environment. Because these care measures are provided, the percentage of unmet normative needs for the area of suicidal behavior was rather low. Due to limitations of the instrument used for assessment of normative needs, the Needs for Care Assessment (NFCAS), the care measures most frequently provided do not define a quality standard of community care for this problem. A subjective needs assessment differing from the normative approach has to be integrated in establishing guidelines for effective community care.

Toward benchmarks for tertiary care for adults with severe and persistent mental disorders

BACKGROUND

Scarce attention has been paid to establishing benchmarks for tertiary care for adults with severe mental disorders. Yet, the availability and efficient utilization of residential resources partly determines the capacity of a comprehensive system of care to avoid clogging ever-shrinking acute care bed facilities.

OBJECTIVES

To describe the actual utilization of and projected needs for residential resources, one part of tertiary care, in the catchment area of a psychiatric hospital in east-end Montreal. To compare results obtained against actual utilization and projected needs evaluated in other Canadian provinces and in other countries, with a view to establishing national benchmarks.

METHODS

Two surveys were undertaken to establish the number of places in these facilities that were utilized and needed for adults aged 18 to 65 years with severe mental disorders, without a primary diagnosis of mental retardation or organic brain syndrome, and originally from the catchment area. A first survey ascertained the number of places utilized and of those needed for residential care among all long-stay inpatients and all adults in supervised residential facilities. A second survey identified the need for such long-stay hospitalization, nursing homes, and supervised facilities as an alternative or as a complement to hospitalization among acute care inpatients.

RESULTS

The actual ratio of places in long-stay hospital units, nursing homes, and supervised residential facilities was 150:100,000 inhabitants. The ideal ratio, according to estimated needs, is 171:100,000. The figure breakdown is as follows: 20:100,000 for long-stay hospital units, 20:100,000 for nursing homes, 40:100,000 for group homes, 40:100,000 for private hostels or foster families, and 51:100,000 for supervised apartments. The needs of this urban, blue-collar population for supervised residential places hovered in the upper range of utilization and standards for European countries and within the proposed standards for Canadian provinces.

DISCUSSION

Needs for long-stay hospitalization or for supervised residential facilities cannot be treated as absolute. For example, evaluation conducted in this hospital-led system of psychiatric care may produce higher estimates of institutional care. Comparing actual utilization and projected needs in this urban catchment area with current utilization in other jurisdictions in Canada and Europe should contribute to establishing sound national benchmarks within ranges.

CONCLUSIONS

It is possible to establish benchmarks that guide the development of supervised residential settings to best meet the needs of the population of adults with severe and persistent mental disorders. The methods used here to assess needs should serve as guidelines for future research, because they were designed to contain the bias of over- or underprovision of care in the current utilization.

Normative needs for community-based psychiatric care of patients with schizophrenia in different residential settings

This study aims to assess the extent of needs for mental health care of patients with schizophrenia living in different residential settings and to evaluate the quality of care in these types of complementary services recently established in the East German region of Dresden. Survey data from the first wave of a longitudinal study of five patient subgroups (N=244) living in (1) a psychiatric nursing home, (2) social therapeutic hostels, (3) sheltered community residential care, (4) at home in the family and (5) alone in one's own home are reported. Normative individual needs for care were assessed using the needs for care assessment (NCA). The patient groups show clear differences in the extent of needs for care, especially in the social NCA section. Patients in the psychiatric nursing home and in the social therapeutic hostels exhibit the highest numbers of areas of need. Positive psychotic symptoms, negative symptoms and neuroleptic side effects are the most prominent clinical areas of need in all subgroups. Patients are most frequently socially disabled in terms of managing household affairs, recreational activities and household chores. Deficits in the need status could be found in the NCA areas of 'negative symptoms,' 'recreational activities,' and 'communication.' The basic needs for mental health care of patients with schizophrenia are met in the established sheltered residential settings. Current deficiencies in providing psychological and educational interventions focusing on coping strategies and social skills training should be minimised in order to decrease the identified deficits in the need status.

Downsizing psychiatric hospitals: needs for care and services of current and discharged long-stay inpatients

BACKGROUND

With the psychiatric deinstitutionalization movement in its fourth decade, questions are being raised concerning its relevance for long-stay inpatients with severe disabilities and the risk that those discharged into the community may be abandoned.

METHODS

A random sample taken in 1989 of long-stay inpatients at Louis-H Lafontaine Hospital made it possible to examine 96 pairs of patients. Each pair included 1 patient discharged between 1989 and 1998 and 1 patient hospitalized. Pairs were matched for sex, age, length of stay, and level of psychiatric care in 1989. Patients and staff were interviewed using standardized questionnaires, and case notes were reviewed to assess symptoms, daily living skills, residential status, quality of residential setting, and clinical and social problems and needs.

RESULTS

The investigation revealed that discharged patients moved to highly supervised settings, which included professionally supervised group homes, supervised hostels, and foster families. About 20% went to nursing homes owing to loss of autonomy from physical disorders. Only 4 discharged patients were lost to follow-up, of whom 2 were probable vagrants. Both those discharged and those remaining as inpatients presented with major clinical problems and daily living skill deficits. The care needs of discharged patients were generally met, and placement in the community was considered appropriate. Of those who had remained hospitalized, over one-half could be moved to supervised settings immediately, or after 1 to 2 years' preparation in a discharge unit, while 13% could be moved to nursing homes. Over 25% required intensive, individualized rehabilitation treatment targeting engagement, psychotic symptoms, withdrawal, and dangerous and socially embarrassing behaviours.

CONCLUSION

Deinstitutionalization in the largest Canadian psychiatric hospital did not lead to patient abandonment in the community.

[Therapeutic needs in psychiatric patients: a systematic review of the literature. I. General concepts and assessment measures. Needs for services]

OBJECTIVE

In Italy, mental health care is in phase of reorganisation. In this frame the measurement of users' needs may be a useful tool in planning individualised mental health service interventions and in their evaluation. Aims of the present study are (I) to highlight the basic concepts of 'needs for care' and give a brief description of the main needs assessment tools specifically developed for psychiatric patients; (II) to review studies assessing needs for mental health services in the general population; (III) to discuss the role played by the assessment of needs in planning mental health care.

METHODS

Studies published in the international literature from January 1980 to June 1999 were reviewed. The studies were located through a computerised search of the databases MEDLINE and PsycLit; in addition, the reference lists of the studies located through the computerised search and the content of main international psychiatric journals were manually scanned in order to avoid possible omissions. Studies assessing needs for services and studies assessing needs on individual level were separately reviewed. Both groups of studies, in turn, were divided in studies assessing needs for mental health care in the general population and in psychiatric patients.

RESULTS

Although most studies on needs for services used indirect methodologies and employed quite heterogeneous experimental design, they provide at large overlapping results. In the general population, about 60%-70% of patients with anxiety, depression and other neurotic disorders and 30%-40% of psychotic patients do not receive any specialist mental health care, suggesting that the majority of subjects suffering from a psychiatric disorder do not receive the mental health care they need.

CONCLUSIONS

Unmet needs for services show a higher frequency in patients with neurotic and depressive disorders, indicating a shortage in services delivery that should be taken into account both by psychiatrists and mental health planners. Moreover, the finding that a large number of patients suffering from psychotic disorders do not receive any kind of mental health care is of particular relevance for planning mental health services, since these subjects are usually the most problematic and difficult to treat.

Patients versus rehabilitation practitioners: a comparison of assessments of needs for care

OBJECTIVE

A group of 47 young adults suffering from schizophrenia was interviewed to garner their views on their needs for care.

METHOD

Three members of a specialized multidisciplinary rehabilitation team, who had been caring for these patients, on average, for the past 4 years, completed a questionnaire to assess the needs for care of these individuals. Patient and staff assessments were then compared.

RESULTS

Patients and staff do not share similar views on the presence of clinical and social problems. Further analyses of the perceived importance of living-skills deficits, the perceived difficulties in dealing with these, and the recent developments in rehabilitation practices challenge whether patient-staff consensus is indeed essential for rehabilitation.

CONCLUSION

We propose that staff should listen to patients' points of view more carefully, especially in the areas of work, studies, and independent living.

Population needs assessment for mental health services. Prospects for the future

The concept of need and the development of methods for measuring population needs represent, in a way, a new paradigm in evaluative research and planning of mental health services.

As with all new paradigms, this one has arisen as a way of overcoming a conceptual crisis: the crisis that has resulted from the application of the curative and medical model to the organisation and evaluation of mental health care, and from the traditional way of planning mental health services according to factors more centred on services and staff problems than on the actual problems of the populations.

As is the case with all new paradigms, the concept of needs also represents a radical change at the epistemological level. In fact, this concept integrates a new perspective on: 1. The nature and range of the problems experienced by the mentally ill (seen not only in terms of symptoms and behavioural problems but also in terms of social disability problems); 2. The interventions required to reduce or contain those problems(integrating the dimension of treatment in a more comprehensive dimension of care); 3. The principles of mental health services organisation (seen from a more community-centred perspective).

Assessment of needs for care among patients with schizophrenic disorders 15 and 17 years after first onset of psychosis

Severe and long term mental disorders, like schizophrenia, show in general a wide range of psychiatric signs and symptoms, psychological and physiological impairments and social disablement (Shepherd, 1994; Wing, 1982) reflecting a variety of mental health needs. Many studies provide only a cross-sectional view of the clinical and social problems of the patient population, for example at intake or admission to a mental hospital. Longitudinal studies following patients after discharge for some period of months or years show in general the expected improvement of functioning (e.g. Nienhuis et al., 1994), but as far as only chronic patients are concerned such a positive change is much less noted. The concept of chronicity of mental disorders would presume that after some time needs are fairly predictable and stable and do not change much over time. Our investigation on the long-term course of schizophrenia (Wiersma et al., 1996; 1997) enables us to study over a period of two years, from 15 to 17 years since first onset of psychosis, the stability or variability of needs in schizophrenic disorder. We are not aware of empirical studies on changes in needs among patients with long-term disorders.

Assessment of the need for care 15 years after onset of a Dutch cohort of patients with schizophrenia, and an international comparison

Assessment of needs for care is crucial in the evaluation of ongoing changes from institutional care to various forms of day- and outpatient treatment. Do patients really do better in the community and are they adequately cared for? The 15-year follow-up of a Dutch incidence cohort of patients with schizophrenia and other functional non-affective psychoses showed that 47 (out of 63) patients had positive ratings of symptoms and disabilities. They were assessed by means of the Needs for Care Assessment Schedule, which articulates the problems and corresponding interventions resulting in a judgement of met or unmet need for treatment or assessment. There was a mean of 2.1 clinical problems and 2.1 social problems per patient. Few problems were considered to generate unmet needs: 14% of the clinical problems and only 7% of the social problems. Nevertheless, 32% of the patients had one or more unmet needs. These results were compared with data from six research centres in the United Kingdom (Camberwell, Oxford and South Glamorgan), Canada (Montreal), Italy (Verona) and Finland (Tampere). Despite differences in health care settings in the four countries, the ratio of met to unmet needs (about 4-5 to 1) among chronic, mostly schizophrenic patients is more or less the same with the exception of an apparently underserved hostel population in Oxford and the Finnish patient population probably due to high expectations with respect to independent community living.

The reliability of the community version of the MRC Needs for Care Assessment

One hundred and nine adults were screened in the community using the abridged version of the CIDI (CIDIS). The subjects comprised DSM-III-R current cases (N = 48), lifetime cases (N = 31) and non-cases (N = 30). The interviews with the 109 subjects were conducted by one of two pairs of clinicians and videotaped. Each interviewer-pair included a psychiatrist and a clinical psychologist. They rated the community version of the Needs for Care (NFCAS-C) by consensus. The other pair of judges then viewed the video and rated the NFCAS-C independently. The agreement on overall needs was excellent (kappa = 0.75), and very good for four of the seven specific sections (from kappa = 0.61 to 0.81). One section could not be rated because of low prevalence, and agreement was less good for the remaining two sections. Agreement was good on specific interventions (medication, kappa = 0.60; specific psychotherapy, kappa = 0.55), but poor on non-specific interventions. The majority of disagreements were due to differences in clinical judgement rather than to technical errors. A new instruction manual has been produced and should help training as well as stabilizing reliability. In devising reliable and valid instruments based on clinical judgement, a balance must be achieved between enhancing reliability with more precise rules and constraining clinical judgement so tightly that validity is lost.

The Cardinal Needs Schedule--a modified version of the MRC Needs for Care Assessment Schedule

This paper describes a modified version of the MRC Needs for Care Schedule (the Cardinal Needs Schedule), for measuring needs for psychiatric and social care amongst patients with severe psychiatric disorders. The modified schedule has three new features: (i) it is quick and easy to use; (ii) it takes systematic account of the views of patients and their carers; (iii) it defines and identifies need in a way that is concise and easy to interpret. The paper describes why the three new features were considered necessary, and then gives an overview of the structure of the Cardinal Needs Schedule, together with a description of how the three new features were developed. During a study of social services care management the practicality of the modified schedule was investigated and further data were obtained on the reliability and validity of the standardized approach to measuring need, in domains not previously investigated. Because of its speed and simplicity, the Cardinal Needs Schedule offers a new choice to researchers who wish to use a standardized and practical assessment of need in evaluative studies of community care. Examples of the usage of the modified schedule are given in an Appendix.

Problems and needs for care of patients suffering from severe mental illness

Recently, evaluative research has yielded a procedure, the Needs for Care Assessment Schedule (NFCAS), which articulates the problems and the corresponding interventions required by psychiatric patients in a systematic and reproducible manner that is of interest to both administrators and clinicians. Although the NFCAS decisions are ultimately subjective and there is no absolute standard, the procedure limits variation and offers a framework for comparison and further elaboration. A group of 98 patients who were receiving treatment at the Louis-Hippolyte Lafontaine Psychiatric Hospital in Montréal, Québec and who were suffering from severe mental disorders were assessed with the NFCAS procedure. Subjects were selected from four treatment settings representing different levels of problems and needs: long-term in- and outpatients and short-term in- and outpatients. Results of the NFCAS were examined, along with those of standardized questionnaires. The NFCAS allowed a comprehensive understanding of the clinical realities for problem and need assessment. There was an average of 3.9 clinical problems and 4.5 social problems per patient. Long-term patients and patients residing in the hospital had more problems. A total of 76% of the problems assessed were rated as receiving appropriate interventions, whereas 17% of the problems assessed were considered in need of an assessment or in need of treatment. A greater need for intervention was found for social problems than for clinical problems.