Time use of people with schizophrenia living in North London: Predictors of participation in occupations and their implications for improving social inclusion

'I'm institutionalised … there's not much I can do': Lived experience of housing related delayed discharge

INTRODUCTION

Delayed discharge from inpatient mental health units is the continued hospitalisation of consumers after being assessed as ready to be discharged. This is common in adult inpatient mental health services and is usually due to a lack of appropriate housing for discharge. Research indicates a range of possible negative impacts, but no studies have explored consumers' perspectives on this issue. This study explores consumers' perspectives of the experience of housing related delayed discharge (HRDD).

METHOD

Using a grounded theory approach, in-depth interviews were conducted with 10 consumers. All consumers were experiencing HRDD from inpatient mental health units in one Sydney local health district. The data were analysed using constant comparative analysis.

FINDINGS

A lack of choice and control was the central theme that characterised participants' experiences. The combined experience of being delayed in hospital and being homeless led to a lack of choice and control over the basics in life, how consumers spent their time and with whom, and their futures. This lack of autonomy was shaped by the features of the hospital and participants' personal circumstance. The hospital features included rules and routines, physical and social environments, resources, and support from staff. Personal circumstances included individual situations, social networks, and support from community organisations. Participants described a variety of impacts, including reduced mental and physical well-being, and anticipated difficulty transitioning back into the community.

CONCLUSION

This study is the first of its kind and provides consumer perspectives on the impacts of HRDD on their well-being and recovery. The inability to participate in meaningful and necessary occupations is an occupational injustice and implies the need for occupational therapists to advocate for both the prevention of HRDD through government investment in affordable and readily available housing and the mitigation of its effects through modified hospital environments and practices.

Self-reported needs of people living with psychotic disorders: Results from the Australian national psychosis survey

Person-centered care is a collaborative approach to health care. To provide effective, person-centered care to people living with severe mental illness, it is necessary to understand how people view their own needs. The Perceived Need for Care Questionnaire (PNCQ) was used in the Australian National Survey of High Impact Psychosis (SHIP) to deepen understanding and evaluate, at a population level, the needs of Australian adults living with psychotic illness. SHIP participants were 1,825 adults, aged 18-65 years, living with psychotic illness and in contact with public specialized mental health services across Australia in 2010. The survey package included demographic and clinical items, and various scales including the PNCQ appraising a comprehensive range of life domains. Logistic regressions measured the impact that various demographic, clinical and psychosocial independent variables (e.g., loneliness, health-related quality of life, disability, accommodation type) had on the likelihood of inadequately met PNCQ domain-related need. Over two-thirds of people living with psychosis reported at least two areas of unmet need for care despite most being in contact with mental health services. Work or using one's time and socializing, counseling, and self-care domains had the largest proportion of inadequately met needs (range between 49 and 57%). Feelings of loneliness and/or social isolation were significantly associated with unmet needs across all PNCQ domains, except for financial needs. Health-related quality of life was significantly associated with unmet needs across all domains, except for housing needs. Disability was significantly associated with unmet social, occupation (work or time use), housing and medication-related needs. Consumers view their needs for care as unmet across many life areas despite being in contact with mental health services. Loneliness, unmet psychosocial needs, and health-related quality of life appear strongly interconnected and warrant greater attention in the delivery of person-centered care for people living with psychosis. Support to address social, work or time use and housing related needs among people living with psychosis appears less well targeted toward those with disability. Results underscore the link between quality of life, recovery and needs. These inter-relationships should be considered in mental health services research and evaluation.

Implementing an Action Over Inertia Group Program in Community Residential Rehabilitation Services: Group Participant and Facilitator Perspectives

Introduction: A time-use focused intervention, Action Over Inertia (AOI) designed to address restricted activity patterns and support recovery, was adapted for use in Australian community residential mental health services. Method: Qualitative case study research explored the use of AOI groups across three Community Care Units from the perspectives of group participants with enduring mental illness and group facilitators. Fifteen interviews were conducted: five group participants were interviewed twice 4 weeks apart, and five group facilitators on completion of the group intervention. Interview data were analyzed thematically using constant comparative methods. Findings: Two overarching themes, "Making Change" and "Facilitating Change" were identified. Efforts to make change in their lives were supported by participants recognising the value of personally meaningful activities for well-being and of activity experiences that fostered hope and recovery, whereas a sense of "stuckness," time for activities and life events could disrupt "getting me going." For the facilitators, facilitating change involved recognizing inertia as a challenge; getting people going; and looking at how AOI intervention works to impact inertia. Conclusion: AOI in a group format supports participants to identify barriers to more active living; to appreciate how time-use and well-being interrelate; and to reframe and take steps to overcome inertia. Further research should evaluate AOI groups as a means of providing individualized support for activity re-engagement as part of recovery oriented mental health rehabilitation.

Prevalence and correlates of job loss among schizophrenia outpatients at St. AmanuelMental Specialized Hospital, Addis Ababa, Ethiopia; cross sectional study

BACKGROUND

Job loss in patient with chronic illness like schizophrenia is the most serious public concern in the clinical and socio-economic terms worldwide. Patients with schizophrenia usually have unsatisfactory job termination like quitting or getting fired which results well-established negative outcomes. The complex interplay between one another has made job and mental illness the focus areas. In the developing nations, there is limited study on these areas in spite of higher rates of job loss.

OBJECTIVES

This study aimed to assess the prevalence and correlates of job loss among schizophrenia outpatient units in Addis Ababa, Ethiopia.

METHODS

Institutional based cross-sectional study was conducted at Saint Amanuel Mental Specialized Hospital among schizophrenia outpatient units in Addis Ababa from May to June 2018. A total of 421 study subjects were interviewed using Positive and Negative Syndrome Scale and Perceived devaluation and discrimination scale. Out of the total study participants, female populations were slightly higher (50.4%) and the majorities (38.6%) were orthodox religion followers. Study characteristics was summarized using descriptive statistics and bi-variable and multivariable analysis was performed using Statistical Package for Social Science version 24. Furthermore, those factors at p value ≤ 0.05 were considered as statistically significant.

RESULTS

The prevalence of job loss among patients with schizophrenia was 37.3%. Factors including unmarried [AOR = 2.42:95% CI (1.28, 4.54)], divorced [AOR = 2.34: 95% CI (1.16, 4.71)], severe positive symptoms [AOR = 2.03: 95% CI (1.15, 3.60)], severe general psychopathology [AOR = 1.76: 95% CI (1.01, 3.08)], and poor level of social and occupational functioning [AOR = 5.05: 95% CI (2.81, 9.09)] were significantly associated with job loss among schizophrenia people.

CONCLUSION

This study suggested that job loss among schizophrenia outpatients was high. There was significant association among people with unmarried, divorced, severe positive symptoms, poor functionality and higher general psychopathology. Therefore, clinical and psychosocial factors were responsible for job loss which warrant further attention and investigation.

Concepts of social inclusion, exclusion and mental health: a review of the international literature

Social inclusion and exclusion are concepts which have been widely associated with politics and policy in the first decade of the 2000s. People with mental health problems have become the focus of a range of social inclusion initiatives. A literature review was conducted to explore the peer-reviewed evidence relating social inclusion/exclusion and mental health. In total 36 papers were included in the review from the UK, Canada, Australia and Scandinavia. The papers had used a range of different approaches to research and evaluation. The included papers associated being socially included to: social roles and responsibilities such as employment, participation in social activities, environmental work and voting. Although some papers engaged in a critical discussion of the concept, many offered only simplistic accounts or definitions. Social inclusion is such a widely used term within political and policy discourses that it is surprising so little research is available within the mental health realm. There was a lack of clarity related to the concept of social exclusion and the qualitative studies focused entirely on the experiences of being excluded within an institutional or semi-institutional setting. The relationship between exclusion, inequality and injustice is identified and the relevance of the concept to current and future mental health policy is questioned.

Understanding the social costs of psychosis: the experience of adults affected by psychosis identified within the second Australian National Survey of Psychosis

BACKGROUND

Social inclusion is a key priority of the Fourth National Mental Health Plan for Australia (2009-2014), with strong evidence for its protective impact on mental health. Social integration has been associated with enhanced well-being for people with mental illnesses such as psychosis.

OBJECTIVE

To explore the impact of psychosis on an individual's social and community participation.

METHOD

The second Australian national survey of psychosis was conducted across seven Australian sites. Semi-structured interviews with adults living with psychosis assessed mental health status, social and role functioning, life satisfaction and future goals. The cohort comprised 1825 adults with a psychotic illness (59.6% were male; 42.4% were aged 18-34 years; 31.5% had 12 years or more of education) of whom 32.7% had been employed in the past year.

RESULTS

Most adults indicated experiencing loneliness (80.1%) and a need for more friends (48.1%). Men were more likely to have never had a long-term relationship (59.4% M, 33.2% F). Even though women were more likely to experience anxiety in social situations [(χ(2)(1) = 8.95, p < 0.01)], they were more likely to have attended a social activity in the past year [χ(2)(2) = 11.84, p < 0.01]. Just over half of the survey participants (56.7%) reported having daily or nearly daily contact with family members. In the past year, 69% had not attended any social activity and 43% described stigma as a barrier. Although 63.2% showed significant impairment in social functioning, only 29.5% had received help for this in the last year. Social isolation and loneliness were rated as major challenges by 37.2% of the cohort.

CONCLUSIONS

Social isolation and dysfunction experienced by people with psychosis have not decreased since the last Australian national survey of people with psychosis. Alongside education and employment, social functioning and participation must be addressed to improve social inclusion for people with psychosis. Programs targeting social opportunities (befriending, peer support), social anxiety and social functioning for all stages of psychosis are warranted.

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.

Promoting wellbeing in young unemployed adults: the importance of identifying meaningful patterns of time use

AIM

This study set out to explore the differences in time use between 'unemployed', 'unemployed but in education' and part-time and full-time employed 18- to 25-year-old Australians. Unemployed individuals generally experience poor health and this may be related to the way they use their time. Activity-based interventions may be one health-promoting strategy. This knowledge is important for all occupational therapists, as many service users are likely to be unemployed.

METHOD

Time use of unemployed 18- to 25-year-olds (measured using the Modified Occupational Questionnaire) was compared with the time use of part- and full-time employed 18- to 25-year-olds (from the 2006 Australian Time Use Survey).

RESULTS

Individuals in the 'unemployed' groups spent significantly less time engaged in work-related activities than their employed peers. This time was reallocated mainly to recreation and leisure and household work (for both men and women) and child care and sleeping (women only). Recreation and leisure activities were generally passive, home-based activities such as watching television or 'doing nothing'. Individuals in the 'unemployed but in education' groups also spent less time in employment-related activities, but the majority of this time was reallocated to education activities.

CONCLUSIONS

Individuals in the 'unemployed' groups spent large amounts of time engaged in potentially non-directed use of time (e.g. watching television or 'doing nothing'). Such patterns of time use have previously been associated with poor health. To support the health of unemployed individuals more effectively, occupational therapy interventions must focus on enhancing the quality of time use for this population.

Measuring Social Inclusion: A Staff Survey of Mental Health Service Users' Participation in Community Occupations

Mental health service users frequently experience social exclusion and limited occupational engagement. A survey was conducted to gather staff reports of 199 service users' levels of engagement and social inclusion across eight domains of community occupation.

The staff reported that the majority of service users (54%) engaged in two or fewer of the community occupation domains over a 7-day period, the most common being the use of local facilities (92%) and contact with family and friends (61%). The staff reports suggested that far fewer service users were engaged in the other domains: day centres (25%), education (14%), sport (13%), arts (12%), employment (11%) and faith (8%). With regard to social inclusion, activities occurred most frequently in mainstream settings for the domains of faith (100%), use of local facilities (98%), sport (80%), and family and friends (79%). Lower levels of social inclusion were reported for the other domains. Statistical analysis revealed that service users' occupational engagement related to their accommodation type, age and gender, but not to ethnicity.

These findings indicate that further research is needed to explore service users' views on social inclusion and what they feel would support them to engage in community occupations at a level that suits their individual needs.

Experiences of Engagement in Occupations and Assertive Outreach Services

Aim:

The purpose of this study was to describe the experience and meaning of engagement for staff and clients of assertive outreach teams.

Method:

Interpretative phenomenological analysis was selected for its flexibility and transparency. Data were collected by semi-structured interviews from a sample of five client and five staff participants (n = 10). The interviews were analysed idiographically, inductively and interrogatively.

Findings:

Four themes identified by both staff and client participants emerged: engagement as an interpersonal relationship, engagement in and through time, enabling and disabling factors and engagement in occupation. In addition, clients developed a theme around engagement as a means to self-actualisation. Staff also raised a specific theme around the role of engagement in mental health services.

Conclusion:

Staff and clients experienced engagement in broadly similar ways, but with differing emphases. Although all participants described it as both an invisible ‘means’ and a visible ‘end’, the staff related engagement only to mental health services whereas the clients experienced it in the context of both mental health services and occupations.

Relevance:

This study is relevant to all occupational therapists who work with people experiencing mental health problems.

Occupational Performance, Self-Esteem, and Quality of Life in Substance Addictions Recovery

A non-randomized pretest—posttest design was used to evaluate changes in occupational performance, self-esteem, and quality of life among clients completing a substance abuse recovery program that included occupational therapy services addressing life skills. Seventy-five clients participated in intake and discharge assessment (4- to 6-month interval) that used the Occupational Performance History Interview (Version 2.0), the Rosenberg Self-Esteem Scale, and the Quality of Life Rating scale. A limited number of follow-up interviews at 3 and 6 months were also conducted. Marked improvement with significant differences and large effect sizes were found between intake and discharge scores for all measures. Most clients scored in the range of moderate occupational dysfunction at discharge, when their highest performance level was seen. Follow-up data revealed that occupational performance declined at 3 months and improved again at 6 months. Change in occupational performance is clearly reflected in the recovery process, but recovery is challenged when clients leave the supportive halfway house environment.

The Camden Schizophrenia Surveys. III: Five-year outcome of a sample of individuals from a prevalence survey and the importance of social relationships

BACKGROUND

Most studies of outcome in schizophrenia have focused on incidence cohorts or samples identified through specialist mental health services; population-based samples provide a more complete picture of the effectiveness of community services.

AIMS

To examine whether outcome predictors, derived from studies of selected patients with prolonged schizophrenia, would emerge in a largely community-dwelling population sample.

METHODS

A follow-up sample of 114 adults with schizophrenia was identified via two censuses of key informants conducted for two prevalence surveys in North London, five years apart. Symptomatic, clinical and functional outcomes were assessed after five years. A composite score was derived for each individual. Multiple Linear Regression analyses were conducted in two phases to derive a best subset of predictors for global outcome.

RESULTS

After five years, 33% were worse and 62% were better overall. The four best predictors (social isolation, living apart from relatives, longer illness and being an inpatient at first census) accounted for 32% of the variance in outcome of those with schizophrenia and related diagnoses.

CONCLUSIONS

Social relationships during the course of illness are an important predictor of overall outcome and relationships with friends and family each seem to make a positive contribution. Policy and service developments should focus on improving participation in community life for people with schizophrenia, particularly their social connectedness.