Do we do what we know works, and if not why not?

Receipt and targeting of evidence-based psychosocial interventions for people living with psychoses: findings from the second Australian national survey of psychosis

AIMS.

Clinical Practice Guidelines (CPGs) recommend evidence-based psychosocial interventions (EBPIs) to improve consumer recovery; however, availability appears limited. We describe receipt of six EBPIs, reported by people with psychoses, and associations with service and consumer characteristics, including indicators of need (eligibility) and benefit (suitability).

METHODS.

Participants in the 2010 Australian national survey of psychosis (n = 1825) were interviewed to assess demographic, functional, mental and physical health characteristics and service use in the previous year. Six EBPIs (Cognitive Behaviour Therapy for psychosis; Family Psycho-Education (FPE); Relapse Prevention Planning (RPP); Skills Training; Supported Employment; and Assertive Community Treatment) were chosen, based on the strength and consistency of CPG recommendations. Associations between receipt of interventions and eligibility and suitability indicators were examined via correlations and χ2. Logistic regression was used to predict receipt of one or more EBPIs and to identify predictors of each individual EBPI.

RESULTS.

Less than one-quarter of the sample reported receipt of an evidence-based level of any intervention: rates ranged from 3.4% (FPE) to 21.1% (RPP). The model predicting receipt of one or more EBPIs was statistically significant (χ2 (20, n = 1746) = 216.12, p < 0.01) and marginally useful. Nine variables contributed uniquely, of which six were service characteristics. The strongest predictors of receipt were being assigned a psychologist as a case manager (p < 0.01, OR(CI) = 2.36(1.50-3.72)) and accessing a non-clinical mental health support service in the past year (p < 0.01, OR(CI) = 2.01(1.60-2.51)).

CONCLUSIONS.

Prior reports of limited receipt of EBPIs are reinforced. There is patchy evidence for targeting of EBPIs to those who might benefit most. Service characteristics contribute more to the prediction of receipt than clinical characteristics. Greater implementation effort and better targeting are required to bridge evidence-practice gaps, including improved evidence-based practice literacy among professionals and needs-based service re-design to improve provision and optimise consumer outcomes.

A randomized controlled trial of vocational intervention for young people with first-episode psychosis: method

AIM

Young people who are experiencing first-episode psychosis (FEP) are at increased risk of being unemployed compared to either their same age peers in the general population, or those with other mental illnesses. Significant research has been conducted examining employment interventions for those with chronic psychotic illness. This has yielded strong results in favour of an intervention called individual placement and support (IPS). However, significantly less work has examined the benefit of this approach to those in FEP when the potential for vocational rehabilitation is perhaps greater. This study adds to the knowledge of vocational intervention in first-episode psychotic illness. Additionally, it expands this work into the areas of cognition, social cognition, social inclusion and economics.

METHODS

The study is a single-blind, randomized controlled trial comparing receiving high-quality FEP treatment as usual plus IPS (IPS + TAU) to a FEP treatment as usual (TAU) intervention alone within a specialized FEP service.

RESULTS

The study recruited 146 people attending a first-episode psychosis service over 2 years. They were assessed at baseline, 6 months (end of intervention) 12 and 18 months with a battery covering psychopathology, economic, demographic, social cognitive, cognitive and diagnostic variables.

CONCLUSIONS

This paper describes the methodology for the largest attempted study of IPS in FEP. This study has the capacity to answer questions about the benefits on illness and economic impacts of vocational recovery in FEP. Further, it has the capacity to extend knowledge about the contribution of cognitive and social cognitive factors to recovery in this domain.

Self-rated assessment of needs for mental health care: a qualitative analysis

This study explored perceived mental health-related needs and barriers to meeting them in primary and mental health care settings. Fifty-one participants completed the Perceived Need for Care Questionnaire and an interview to qualitatively explore the meanings behind self-identified needs for medication, information, counselling, practical help, and skills development. Qualitative content analysis indicated perceived needs for care are multifaceted. Dissatisfaction with taking medication may coexist with perceiving medication needs as met; information needs predominantly concerned wanting to better understand one's illness; and communication was the main perceived barrier to meeting these needs. Counselling-related needs included being listened to, supported or assisted with problem-solving, with service attitudes, staff expertise or cost seen as limiting access. Needs for practical help and skills development were described as unmet or addressed by family, and help-seeking for these needs constrained by efforts to self-manage, insufficient information, and affordability. Collaborative care and information-sharing appear important to better meet mental health-related perceived needs.

Targeted intervention to improve monitoring of antipsychotic-induced weight gain and metabolic disturbance in first episode psychosis

OBJECTIVE

International guidelines recommend monitoring for weight gain and metabolic disturbance in patients prescribed second generation antipsychotics. We aimed to investigate whether a targeted intervention could improve levels of monitoring in a first episode psychosis clinic.

METHOD

A pre-intervention audit of both metabolic screening rates and specific monitoring of weight and metabolic indices following the initiation of antipsychotic medication was performed in our first episode psychosis clinic. This was repeated 18 months later, following an intervention that included a number of targeted improvement strategies based on an analysis of barriers and enablers to performing monitoring within the clinic. The intervention included provision of monitoring equipment, interactive educational events, reminders and prompts and embedding processes for monitoring within team structure.

RESULTS

There were significant improvements in both the screening of metabolic indices and the monitoring of indices following initiation of antipsychotic medications. There were also improvements in the number of active interventions offered to clients by clinicians. However, the level of guideline concordant monitoring remains low within our service.

CONCLUSIONS

A comprehensive programme of implementation strategies can improve both screening and monitoring of the metabolic side-effects of antipsychotic medications. Further focused strategies are necessary to continue to improve monitoring to guideline concordant levels.

What can we do to reduce the burden of avoidable deaths in those with serious mental illness?

Individuals with schizophrenia have higher mortality rates compared to the general community. Apart from an increased risk of suicide, people with schizophrenia have an increased risk of death related to a wide range of comorbid physical conditions. There is evidence to suggest that much of this mortality is avoidable. The provision of assertive management of comorbid physical disorders has the potential to help close the differential mortality gap. While the primary data are robust, there is less empirical evidence to guide policy makers and service providers when dealing with these problems. Focused clinical programs aimed at reducing risk factors (e.g. smoking, obesity) and shared care between mental health teams and primary care providers can help reduce the burden of avoidable deaths. In light of recent evidence suggesting that the mortality gap has widened in recent decades, there is an urgent need to address the burden of avoidable deaths in those with serious mental illnesses.

Promoting physical health in youth mental health services: ensuring routine monitoring of weight and metabolic indices in a first episode psychosis clinic

OBJECTIVE

Clinicians are increasingly being asked to implement guideline recommendations into their practice, but are given little practical guidance on this complex task. In this paper we outline a promising theory-driven approach we took to implementing guideline recommendations about routine monitoring of weight gain and metabolic disturbance in our first-episode psychosis clinic. While there is significant psychological and physical morbidity associated with weight gain and metabolic disturbance, routine monitoring was not being undertaken according to guideline recommendations. We examined the factors that make it difficult to undertake routine monitoring by interviewing psychiatrists. This barrier analysis allowed us to develop and introduce feasible and acceptable strategies to address these barriers, increasing the likelihood that routine monitoring would take place.

CONCLUSION

This paper advocates for undertaking an analysis of the barriers clinicians face to undertaking evidence-based practice in order to develop more sophisticated approaches to address areas where clinical practice and evidence are divergent. Such an approach is more likely to ensure that measures to improve practice are successful, are meaningful for the clinicians involved, and become imbedded in the clinical practice of the service.

The trend in mental health-related mortality rates in Australia 1916-2004: implications for policy

BACKGROUND

This study determines the trend in mental health-related mortality (defined here as the aggregation of suicide and deaths coded as "mental/behavioural disorders"), and its relative numerical importance, and to argue that this has importance to policy-makers. Its results will have policy relevance because policy-makers have been predominantly concerned with cost-containment, but a re-appraisal of this issue is occurring, and the trade-off between health expenditures and valuable gains in longevity is being emphasised now. This study examines longevity gains from mental health-related interventions, or their absence, at the population level. The study sums mortality data for suicide and mental/behavioural disorders across the relevant ICD codes through time in Australia for the period 1916-2004. There are two measures applied to the mortality rates: the conventional age-standardised headcount; and the age-standardised Potential Years of Life Lost (PYLL), a measure of premature mortality. Mortality rates formed from these data are analysed via comparisons with mortality rates for All Causes, and with circulatory diseases, cancer and motor vehicle accidents, measured by both methods.

RESULTS

This study finds the temporal trend in mental health-related mortality rates (which reflects the longevity of people with mental illness) has worsened through time. There are no gains. This trend contrasts with the (known) gains in longevity from All Causes, and the gains from decreases achieved in previously rising mortality rates from circulatory diseases and motor vehicle accidents. Also, PYLL calculation shows mental health-related mortality is a proportionately greater cause of death compared with applying headcount metrics.

CONCLUSIONS

There are several factors that could reverse this trend. First, improved access to interventions or therapies for mental disorders could decrease the mortality analysed here. Second, it is important also that new efficacious therapies for various mental disorders be developed. Furthermore, it is also important that suicide prevention strategies be implemented, particularly for at-risk groups. To bring the mental health sector into parity with many other parts of the health system will require knowledge of the causative factors that underlie mental disorders, which can, in turn, lead to efficacious therapies. As in any case of a knowledge deficit, what is needed are resources to address that knowledge gap. Conceiving the problem in this way, ie as a knowledge gap, indicates the crucial role of research and development activity. This term implies a concern, not simply with basic research, but also with applied research. It is commonplace in other sectors of the economy to emphasise the trichotomy of invention, innovation and diffusion of new products and processes. This three-fold conception is also relevant to addressing the knowledge gap in the mental health sector.

Psychosocial and psychological interventions in early psychosis: essential elements for recovery

AIM

To briefly review evidence for some of the psychological and psychosocial interventions in early psychosis that are commonly recommended in treatment guidelines.

METHOD

Four psychological interventions (cognitive behavioural therapy, cognitive remediation, family interventions and compliance therapy) and two psychosocial interventions (vocational interventions and behavioural weight management) were chosen. The evidence for the use of each intervention in the first-episode population was briefly considered.

RESULTS

There was considerable evidence for some of these interventions (particularly cognitive behavioural therapy, behavioural weight management, vocational intervention and family interventions). However, most of this evidence has been gathered in populations of people with established schizophrenia and results have been extrapolated to first-episode populations.

CONCLUSION

Although early evidence indicated that psychological and psychosocial interventions in early psychosis may be more effective than in populations with more established illness (thus, warranting their inclusion in treatment packages), more research is needed. In addition to gathering data on symptom and functional outcomes, this research should provide a base for further arguments for reform of treatment approaches to routinely include psychological and psychosocial interventions.