Clinical services research

Effectiveness of a Therapeutic Educational Oral Health Program for Persons with Schizophrenia: A Cluster Randomized Controlled Trial and Qualitative Approach

BACKGROUND

The oral health of people with schizophrenia (PWS) is very poor, suggesting a need for oral health promotion programmes with a high level of evidence. The aim of the EBENE study (Clinicaltrials.gov: NCT02512367) was to develop and evaluate the effectiveness of a multidisciplinary therapeutic educational programme in oral health (TEPOH) for PWS.

METHODS

A multicentre cluster randomised controlled trial, with outpatient psychiatry centres as the unit of randomisation, was designed to compare the effectiveness of TEPOH (intervention group) versus standard care (control group). The trial was conducted in 26 outpatient psychiatry centres in France (14 in the intervention group, 12 in the control group). Eligible patients with a diagnosis of schizophrenia were enroled between 2016 and 2020 and followed for 6 months. The TEPOH group received a multicomponent intervention (comprising an introductory session, three educational sessions, and a debriefing session). The primary endpoint was the evaluation of periodontal disease as a community periodontal index (CPI) score ≥ 3 at Month 6. The trial was completed using a qualitative approach based on semi-structured interviews with caregivers conducted between July 2018 and December 2019. The trial was stopped early due to difficulties in recruiting patients.

RESULTS

Overall, 81 patients (of 250 planned) were included, and 54 patients completed the trial: 40 in the TEPOH group and 14 in the control group. At baseline, the percentage of CPI ≥ 3 was 42.5% in the TEPOH group and 9.1% in the control group. At Month 6, the percentage of CPI ≥ 3 was 20% in the TEPOH group and 14.3% in the control group. The qualitative evaluation underlined that the professionals emphasised the "seriousness" and "assiduity" of the patients' participation in this programme and that the TEPOH reinforced carers' investment in oral hygiene. It also highlighted structural factors (lack of resources for professionals, lack of teeth in PWS, COVID-19 pandemic) that may have exacerbated the difficulties with enrolment and follow-up.

CONCLUSIONS

The effectiveness of this TEPOH, developed for PWS as part of the EBENE study, has not been demonstrated. Certain aspects of the programme's content and implementation need to be reconsidered. In particular, an adapted subjective measurement scale should be developed.

Quality of life in stabilized patients with schizophrenia is mainly associated with resilience and self-esteem

OBJECTIVE

Improving quality of life (QoL) is an important objective in the treatment of schizophrenia. The aim of the current study was to examine to what extent resilience, self-esteem, hopelessness, and psychopathology are correlated with QoL.

METHOD

We recruited 52 out-patients diagnosed with schizophrenia according to DSM-IV criteria and 77 healthy control subjects from the general community. In patients, psychopathology was quantified by the Positive and Negative Syndrome Scale. The following scales were used in both patients and control subjects: the Berliner Lebensqualitätsprofil, the Resilience Scale, the Rosenberg Self-Esteem Scale, and the Beck Hopelessness Scale to assess QoL, resilience, self-esteem, and hopelessness respectively.

RESULTS

Patients with schizophrenia presented with significantly less QoL, resilience, self-esteem, and hope compared to healthy control subjects. In patients, QoL correlated moderately with resilience, self-esteem, and hopelessness and weakly with symptoms. With respect to the latter, particularly depression and positive symptoms were negatively correlated with QoL.

CONCLUSION

Our results highlight the complex nature of QoL in patients suffering from schizophrenia. They underscore that significant efforts are necessary to enhance resilience and self-esteem and to diminish hopelessness as well as affective and positive symptoms in patients with schizophrenia.

Subjective and Objective Measures of Quality of Life Have Different Predictors for People with Schizophrenia

This study investigated the relationship between subjective and objective quality of life and assessed predictors in people with schizophrenia. The study population consisted of 99 stabilized outpatients with schizophrenia (DSM-IV) who had been regularly receiving outpatient treatment at the Department of Psychiatry, The Tokushima University Hospital. Subjective and objective quality of life were estimated using the Schizophrenia Quality of Life Scale and the Quality of Life Scale, respectively. Psychiatric symptoms were also measured with the Brief Psychiatric Rating Scale and the Calgary Depression Scale for Schizophrenia. Scores on the Schizophrenia Quality of Life Scale Motivation and Energy scales significantly correlated with the Quality of Life Scale total scores –.40 ( p <.001), and with the scores on Interpersonal Relations subscale –.42 ( p <.001), Instrumental Role subscale –.28 ( p = .005), Intrapsychic Foundations subscale –.39 ( p <.001), and Common Objects and Activities subscale –.25 ( p = .014). The Schizophrenia Quality of Life Scale Psychosocial scale significantly correlated with only the Quality of Life Scale total score –.20 ( p = .05), and there was no significant correlation between the scores on the Schizophrenia Quality of Life Scale Symptoms and Side-effects scales and the Quality of Life Scale. Stepwise regression analyses showed that the Calgary Depression Scale for Schizophrenia score was the most important predictor of each scale of the Schizophrenia Quality of Life Scale, and the Brief Psychiatric Rating Scale Negative Symptoms score was the most important predictor of the Quality of Life Scale total score and each subscale. These results suggest that subjective and objective quality of life have different predictors and should be considered as separate and complementary outcome variables.

Integrating Jungian and Self-Psychological Perspectives Within Cognitive-Behavior Therapy for a Young Man With a Fixed Religious Delusion

Although cognitive-behavior therapy (CBT) can be effective in reducing delusional thinking in schizophrenia, many patients are considered poor candidates, typically because of a lack of distress from the delusion and resistance or low motivation to challenge its validity. Recent developments in CBT for schizophrenia, however, stress the need to move from a sole focus on challenging beliefs toward a person-based model in which recognition of the vulnerability of the self guides treatment and the content of therapy is perceived as personally meaningful by the patient. This article demonstrates how the Jungian technique of archetypal amplification was modified and used within the structure of CBT treatment of a young man with schizophrenia with a religious delusion who refused to engage in standard CBT. His case demonstrates that schizophrenia patients who initially refuse to question the validity of their delusional beliefs can nevertheless be successfully engaged in CBT when the focus promotes alternative understandings of the self and preserves self-esteem.

Community matron caseload numbers: a literature review

In early 2005, the Department of Health published its strategy for addressing the health and social care needs of people with long-term conditions (2005a; b). Community matrons were recruited to deliver this strategy. Since this time, there has been some debate around the optimum caseload number for community matrons to function effectively (Abell et al, 2010). One study by Sargent et al (2008) concluded that community matrons were struggling to achieve and maintain 50 patients on their caseload, due to nine areas that impact on caseload manageability. This literature review concluded there is a wide variation regarding the optimum caseload number ranging from 14 patients in intensive case management to 80-100 families per full-time health visitor. A number of authors do not specify caseload numbers due to the complexity of the task. However, what clearly emerges is that the factors that impact on case management appear to correlate with the issues identified by Sargent et al (2008).

Evaluating costs of mental illness in Italy. The development of a methodology and possible applications

Scopo - Il presente lavoro, oltre a fare il punto sui più recenti sviluppi della valutazione economica degli interventi effettuati nel settore della salute mentale, propone una metodologia per la valutazione dei costi, applicable nella situazione assistenziale italiana, messa a punto tenendo conto degli sviluppi suddetti. Metodo e risultati - I presupposti per realizzare questo tipo di valutazione sono l'identificazione dei servizi sanitari e sociali offerti ai pazienti con disturbi psichici, la raccolta di dati sull'utilizzazione dei servizi sanitari (costi diretti) e sull'uso di altri servizi e risorse all'interno del sistema socio-economico (costi indiretti) e l'assegnazione di un valore monetario a tali costi. È stato quindi realizzato un elenco dettagliato degli interventi effettuati e delle attività svolte nei Servizi Psichiatrici Territoriali italiani, con particolare riferimento al Servizio di Verona-Sud. Di ciascuno/a di essi è stato stimato il costo (Lista dei Costi Unitari o LICU). Si è tenuto conto, inoltre, degli altri servizi socio-sanitari, pubblici e privati, disponibili sul territorio, degli interventi delle Forze dell'ordine, delle associazioni di volontariato e dei gruppi di self-help. In questo articolo vengono descritte, in dettaglio, le procedure che hanno portato alia quantificazione dei costi per tre di queste attività (le degenze in SPDC, le visite ambulatoriali ed i gruppi socio-riabilitativi). È stata inoltre sviluppata un'intervista (ICAP) per raccogliere i dati sull'utilizzazione dei servizi e sulle condizioni socio-economiche degli utenti. Per verificarne l'applicabilità, le eventuali difficoltà di comprensione e la durata di somministrazione, l'ICAP è stata testata in cinque pazienti. Conclusioni - Uno sviluppo particolarmente interessante ci sembra quello di utilizzare su vasta scala PICAP e la LICU, allo scopo di realizzare studi epidemiologically-based e poter predire ed analizzare i costi in relazione a variabili socio-demografiche, alia diagnosi, alia storia psichiatrica precedente ecc. È necessario sottolineare l'importanza, per le politiche e la pratica sanitaria, di un'analisi combinata di costi, bisogni ed esito (outcome). Una ricerca di questo tipo è attualmente in corso a Verona-Sud.

Quality of life and its predictors in people with schizophrenia

The author reviewed measurement of quality of life (QOL) of schizophrenia patients and the clinical factors related to their QOL. As schizophrenia patients were thought to be unable to assess their own QOL because of their cognitive impairment, objective QOL measures had been frequently used. However, nowadays, there is general agreement that symptomatically stabilized patients could assess their QOL by themselves. Therefore, researchers gradually have become interested in subjective QOL measure. Although most researchers often evaluate schizophrenia patients' QOL using only subjective or objective QOL measure, considering the fact that there is a discrepancy between the two types of measures, it is recommended to use both of them as complementary measures. As for clinical factors related to lowered QOL, several studies reported that depressive symptom was most associated with lowered subjective QOL, negative symptom was strongly related to lowered objective one and poor life skill was associated with both. Moreover, several studies found that cognitive dysfunctions in some cognitive domains were related to lowered objective QOL but the effects of them were much smaller than those of negative symptoms. It is suggested that improving depressive and negative symptoms and life skills may contribute to enhancement of QOL of schizophrenia patients.

Rethinking theoretical approaches to stigma: a Framework Integrating Normative Influences on Stigma (FINIS)

A resurgence of research and policy efforts on stigma both facilitates and forces a reconsideration of the levels and types of factors that shape reactions to persons with conditions that engender prejudice and discrimination. Focusing on the case of mental illness but drawing from theories and studies of stigma across the social sciences, we propose a framework that brings together theoretical insights from micro, meso and macro level research: Framework Integrating Normative Influences on Stigma (FINIS) starts with Goffman's notion that understanding stigma requires a language of social relationships, but acknowledges that individuals do not come to social interaction devoid of affect and motivation. Further, all social interactions take place in a context in which organizations, media and larger cultures structure normative expectations which create the possibility of marking "difference". Labelling theory, social network theory, the limited capacity model of media influence, the social psychology of prejudice and discrimination, and theories of the welfare state all contribute to an understanding of the complex web of expectations shaping stigma. FINIS offers the potential to build a broad-based scientific foundation based on understanding the effects of stigma on the lives of persons with mental illness, the resources devoted to the organizations and families who care for them, and policies and programs designed to combat stigma. We end by discussing the clear implications this framework holds for stigma reduction, even in the face of conflicting results.

Australian Schizophrenia Care and Assessment Programme: real-world schizophrenia: outcomes

OBJECTIVE

It has been increasingly recognized that there is need to assess patient outcomes in schizophrenia across a broad range of dimensions. But few studies have attempted to do this in clinical populations and no systematic study has broadly assessed outcomes in schizophrenia in Australia using a longitudinal design. Thus, a real-world study, the Schizophrenia Care and Assessment Programme (SCAP), was structured to collect comprehensive information over time to inform policy debate and extend current knowledge about the course of schizophrenia in an Australian context.

METHODS

A cohort of 347 patients with schizophrenia was followed up over 3 years. Clinical outcomes, occupational and psychosocial functioning and quality of life were assessed at 6 monthly intervals, and resource utilization and costing data were collected continuously from internal and external databases as well as from participants directly.

RESULTS

The participants as a group experienced an overall decline in positive and negative symptoms of schizophrenia, a reduction in general psychopathology and a reduction in severity of depression. There was an improvement in functioning, a reduction in mental health-related disability and an improvement in patient- and observer-rated quality of life. Change of severity within the variously assessed domains over time appeared to be relatively independent.

CONCLUSIONS

In the present sample of schizophrenia patients treatment was associated with positive health outcomes; but outcomes across assessment domains did not closely correlate across time. The scrutiny of a broad range of patient outcomes will assist with the assessment of new treatment modalities and with service planning.

Psychiatric symptoms and quality of life in schizophrenia: a meta-analysis

Quality of life (QoL) has been recognized as an important outcome of schizophrenia treatment, yet the determinants of QoL for individuals with schizophrenia are not well known. Research has consistently found psychiatric symptoms to be negatively related to QoL, however, findings concerning the strength of these relationships have been mixed, making it difficult to determine the degree to which such symptoms are related to poor QoL. This research presents a systematic meta-analysis of studies examining the relationship between psychiatric symptoms and QoL in schizophrenia, in an effort to elucidate the determinants of QoL for this population. A total of 56 studies were extracted from literature searches of relevant databases for empirical reports published between 1966 and 2005 examining the relationship between positive, negative, and/or general psychiatric symptoms and QoL. Weighted effect size analyses revealed small relationships between psychiatric symptoms and QoL, with general psychopathology showing the strongest negative associations across all QoL indicators. Moderator analyses indicated that variation in effect sizes could be accounted for by differing operationalizations of QoL, study design, sample, and participant treatment setting. In particular, positive and negative symptoms were more strongly related to poor QoL among studies of schizophrenia outpatients, whereas general psychopathology showed a consistent negative relationship with QoL across all study samples and treatment settings. Implications for future research and treatment development are discussed.

Using activity data to explore the influence of case-load size on care patterns

BACKGROUND

A limited case-load size is considered crucial for some forms of intensive case management and many countries have undertaken extensive reorganisation of mental health services to achieve this. However, there has been limited empirical work to explore this specifically.

AIMS

To test whether there is a discrete threshold for changes in intensive case management practice determined by case-load size.

METHOD

"Virtual" case-load sizes were calculated for patients from their actual contacts over a 2-year period and were compared with the proportions of contacts devoted to medical and non-medical care (as a proxy for a more comprehensive service model).

RESULTS

There were 39 025 recordings for 545 patients over 2 years, with a mean rate of contacts per full-time case manager per month of 48 (range 35-60). There was no variation in the proportion of non-medical contacts when case-load sizes were over 1:20 but there was a convincing linear relationship when sizes were between 1:10 and 1:20.

CONCLUSIONS

Case-load size between 1:10 and 1:20 does affect the practice of case management. However, there is no support for a paradigm shift in practice at a discrete level.

Outcome on quality of life in a Canadian national sample of patients with schizophrenia and related psychotic disorders

OBJECTIVE

To examine changes in subjective and objective dimensions of quality of life (QoL) in a large Canadian sample of patients with diagnosis of schizophrenia or schizoaffective disorder treated in academic and non-academic settings over a 2-year period.

METHOD

Patients recruited in the study across the country were assessed for QoL and functioning using the Client and Provider versions of the Wisconsin Quality of Life Questionnaire (WQoL) and the Short Form-36 (SF-36) at baseline (n = 448), 1 year (n = 308-353) and 2 years (188-297). Data were analyzed to examine change across time using multivariate analyses controlling for potential influence of variables such as age, regional variation, gender, duration of illness, type of treatment taken and baseline measures of symptoms and QoL.

RESULTS

The weighted quality of life index (W-QoL-I) showed a significant change on both the client and the provider versions of the WQoL while the physical and mental composites of the SF-36 showed change only at 2 years. These changes were influenced significantly by baseline scores on W-QoL-I and in the case of provider version of the WQoL by baseline Brief Psychiatric Rating Scale (BPRS) scores. Regional variation or type of medication had no impact on improvement in QoL.

CONCLUSION

Within a naturalistic sample of schizophrenia patients treated and followed in routine care the overall QoL showed an improvement over time but this improvement was not influenced by the type of medication prescribed.

Limitations of system integration in providing employment services for persons with mental illness

This study assessed the influence of service systems integration on employment outcomes for persons with mental illness. A survey was sent to all 125 key program staff that worked for community mental health treatment agencies or vocational rehabilitation agencies. The survey found that referral and employment rates were low; but that these rates were related to characteristics of the interagency systems integration. Community mental health staff referred 448 individuals for employment services. Staff from vocational rehabilitation agencies accepted only 26% of these referrals and found work for just 11%; 7% were employed six months later. Also, 39% of respondents reported that the linkage agreement between their agencies was never established. This study suggests the need for more effective strategies for integrating mental health treatment and vocational rehabilitation systems.

Psychometric Properties of the Spanish Version of Two Mental Health Outcome Measures: World Health Organization Disability Assessment Schedule II and Lehman’s Quality of Life Interview

This study presents data on the cultural adaptation to Latino populations of two outcome measures that respond to the need for developing comprehensive instruments for outcome assessments in minority populations. We examined the psychometric properties of outcome measures designed to assess impairment in functioning, and quality of life. Impairment in functioning was measured with the Disability Assessment Schedule II (WHO-DASII) developed by the World Health Organization (1997) and quality of life was measured with A. F. Lehman's (A. F. Lehman, 1983; A. F. Lehman, 1988) shortened Quality of Life Interview (QOLI). Spanish speaking consumers (N = 198) from Fresno (CA), San Antonio (TX) and San Juan (PR) participated in this study. They were recruited from both mental health outpatient clinics and primary care rural clinics. The WHO-DASII showed good to excellent internal consistency in all sites (alpha = .72 to .97) except for one subscale (Self-Care alpha = .47). Test-retest reliability estimates were mostly moderate to substantial (.57 to .83), again with one exception, the Self-Care subscale (.46). For the QOLI internal consistency ranged from .34 to .98 and test-retest reliability ranged from .40 to .86 across all sites. An initial validation strategy using both known-groups and concurrent validity produced promising evidence of the construct validity of both measures. The Spanish versions of the WHO-DASII and the QOLI lend support to the translation and adaptation process to which these instruments were subjected.

A longitudinal evaluation of two-year outcome in a community-based mental health service using graphical chain models. The South-Verona Outcome Project 9

The 2-year outcome of 178 patients attending a community-based mental health service was assessed from a multidimensional perspective. The study investigated: (1) the effect of disease-related characteristics (such as diagnosis and illness duration) and of a series of outcome variables measured at baseline (global functioning, psychopathology, social disability, quality of life and satisfaction with services) on total costs of care over 2 years; and (2) the effect of costs of care and outcome variables measured at baseline on the corresponding outcome variables at 2 years. To gain insight into the multivariate longitudinal dependencies among variables, we used graphical Gaussian chain models, a new multivariate method that analyses the relationship between continuous variables taking into account the effect of antecedent and intervening variables, to reveal not only direct but also indirect correlations. Outcome variables showed the tendency to segregate, both at baseline and follow-up, into two distinct groups: a clinician-rated dimension (given by global functioning, social disability and psychopathology) and a patient-rated dimension (given by service satisfaction and subjective quality of life). Higher costs at 2 years were predicted by higher psychopathology at baseline, diagnosis of psychosis and longer duration of illness. Baseline values for each variable were the main predictors of the corresponding values at two years. Improvement in satisfaction with life at follow-up was experienced in those subjects with a lower functioning at baseline. This study throws some light on the complex relationships between clinical, social and economic variables affecting the medium-term outcome of mental health care.

Evidence-based treatment for schizophrenia

Taken together, the research on what treatments help people with schizophrenia point to the value of treatment programs that combine medications with a range of psychosocial services. Provision of such packages of services likely reduces the need for crisis-oriented care hospitalizations and emergency room visits and enables greater recovery. For most people with schizophrenia, the combination of psychopharmacological and psychosocial interventions improves outcomes. Several psychosocial treatments have demonstrated efficacy. These include family intervention, supported employment, assertive community treatment, skills training, and CBT. In the same way that psychopharmacologic management must be tailored individually to the needs and preferences of the patient, so too should the selection of psychosocial treatments. At the very least, all people with schizophrenia should be provided with education about their illness. Beyond illness education, all of the recommended psychosocial interventions would be used rarely during any one phase of illness for an individual. Some psychosocial treatments share treatment components, and patients have different clinical and social needs at different points in their illness course. Knowledge regarding how best to combine treatments to optimize outcomes is scarce.

The Spanish translation and cultural adaptation of five mental health outcome measures

In this paper we report on the process of translating five mental health outcome measures into Spanish and adapting them to Latino culture. The instruments considered are the World Health Organization-Disability Assessment Scale, the Burden Assessment Scale, the Family Burden Scale, Lehman's Quality of Life Interview and the Continuity of Care in Mental Health Services Interview. A systematic process of translation and adaptation of the instruments was followed with the goal of achieving cultural equivalence between the English and Spanish versions of the instruments in five dimensions: semantic, content, technical, construct, and criterion equivalence. In this paper we present data about the semantic, content, and technical equivalence. Various steps were taken to achieve equivalence in these dimensions, including the use of a bilingual committee, a multi-national bilingual committee, back-translation, and focus groups with mental health patients and their relatives.

What outcomes to measure in routine mental health services, and how to assess them: a systematic review

OBJECTIVE

Routine outcome assessment in adult mental health services involves the on-going assessment of patient-level outcomes. Use of outcomes to inform treatment is widely recommended, but seldom implemented. The goals of this review were (i) to identify principles that have been proposed for implementing routine outcome assessment, (ii) to identify the full range of outcome domains that have been proposed for assessment, and (iii) to synthesize proposals for specific outcome domains into emergent categories.

METHOD

A systematic review of published and unpublished research was undertaken, using electronic databases, research registers, conference proceedings, expert informants and the World Wide Web. For goal (i) studies were included that proposed principles for implementing routine outcome assessment. For goal (ii) studies were included that identified at least two patient-level outcome domains for patients using adult mental health services and made some reference to a broader literature base.

RESULTS

Six thousand four hundred publications matched initial search criteria. Seven distinct sets of principles for choosing patient-level outcomes were located, which showed a fair degree of consensus. Sixteen outcome domain proposals were identified, which were synthesized into seven emergent categories: wellbeing, cognition/emotion, behaviour, physical health, interpersonal, society and services.

CONCLUSIONS

The findings from this review were used to develop a four-step method for adult mental health services wishing to implement routine outcome assessment.

Offenders with intellectual disability: the size of the problem and therapeutic outcomes

BACKGROUND

People with intellectual disability (ID) who offend may be subject to a variety of dispositions within the criminal justice system, or via diversion to health and social services in inpatient units or in community ID teams. Offenders with ID are a group with complex needs who may pose a recurrent risk to the public. Despite the significant number of offenders with ID, there is limited evidence on treatment effectiveness and outcomes.

METHODS

A literature search of all electronic databases was undertaken, and journals were hand-searched for clinical trials or case studies of interventions for offenders with ID. The main outcome was recidivism rates.

RESULTS

There were no published clinical trials of offenders with ID. A series of small-scale group cognitive-behavioural treatments for sex offenders offers the most persuasive evidence of success in reducing recidivism.

CONCLUSION

Offenders with ID often receive inadequate services as a result of poor identification through the criminal justice system and research into effective treatments is rudimentary. Further studies are necessary in order to improve treatment efficacy and service provision for a complex group of individuals.

Patients' subjective experiences of antipsychotics: clinical relevance

The subjective experience of patients with schizophrenia who are receiving antipsychotic medication has been a neglected research area, as has the satisfaction of patients with their drug treatments. This is unfortunate, as satisfaction with treatment appears to be related strongly to the readiness of patients to take their medication as prescribed, and thereby to outcome. Patients' perceptions of their treatment do not appear to be related strongly to severity of illness or symptom ratings, although there are associations between perceptions of treatment and adverse effects. Surveys of patient experience with typical antipsychotics have tended to indicate high levels of dissatisfaction and perceived adverse effects. There have been a number of surveys of patients' perceptions of treatment with the atypical antipsychotics. These tend to accord with the expectation that a relative freedom from adverse effects with the atypical antipsychotics will be reflected in enhanced levels of satisfaction and perceived well-being. In general, these studies share a number of weaknesses, including small sample sizes, bias in selection of respondents, open treatment and lack of suitable comparator groups. In addition, many have adopted a cross-sectional, rather than longitudinal, approach and have relied on nonvalidated and perhaps idiosyncratic rating measures. Recently, there have been studies of better methodological quality. These, too, have indicated that patients regard the newer treatments more positively than the older regimens. In addition, there is now evidence that the various new-generation antipsychotics may be evaluated differently by patients.

Feasibility, usefulness, limitations and perspectives of routine outcome assessment: the South Verona Outcome Project

Closing the gap between research and clinical practice is nowadays considered a priority in outcome studies. Survey studies in community settings having as their main aim the multidimensional measure of outcome of mental health care interventions, including the use of standardised instruments administered as part of the routine clinical activities in mental health services, have recently started to be planned in various countries, but have encountered several difficulties. A naturalistic, longitudinal study aimed to assess the outcome of care provided by a community-based mental health service, the South Verona Outcome Project, has been conducted in Italy starting from the beginning of the 90's and is running since then. This paper: a) describes a series of methodological aspects of the South Verona Outcome Project, such as instruments, study design, inclusion and exclusion criteria, training of the staff, and focuses on strategies used so to ensure feasibility of the assessment and good quality of the data; b) summarises some results of the study, characteristics of feed-back provided, and outputs; c) discusses the problems faced, the impact of this approach on service provision, its limitations and future perspectives.

Integrating Health Services Research Into Nursing Doctoral Programs: The Evolution of Nursing Research

Traditionally, nursing research has focused on the effect of an intervention on selected patients without considering the influence of the system of care and its myriad characteristics. Health services research (HSR) focuses on organization and financing of health services; access to health care; quality of care; clinical evaluation and outcomes research; informatics and clinical decision making; practitioner, patient, and consumer behavior; health professions workforce; health policy formulation and analyses; and health care model and service use. Doctoral students can benefit from HSR's broad perspective if it is included in existing nursing curricula. Ultimately, HSR could help the nursing profession achieve the capacity to develop health policy and new systems of health care for the 21st century.

The structure and invariance of a model of social functioning in schizophrenia

The authors proposed and tested a model of social functioning in schizophrenia. The model consisted of five indicators: social competence, quality of relations, satisfaction, symmetry of relationships, and the number of close friends. The model combines proximal and distal, quality and quantity, and self-report and observer ratings of social functioning. It was designed to have ecological validity in that it reflects real-world social functioning, and the data are all gathered in reference to naturally occurring social contexts. Two independent community samples of individuals diagnosed with schizophrenia or schizoaffective disorder (N = 172; N = 166) were used to test the structure of the measurement model and its invariance across samples. Additional measures of social functioning, prognosis, and intrapsychic deficits were used to further assess the validity of the proposed social functioning construct. A single-factor model had acceptable fit with the data from sample 1. The single-factor model was found to be invariant across the two independent samples. Correlations with other measures in both samples provided additional evidence for the construct validity of the proposed measurement model of social functioning. Implications for research and practice are discussed.

Determinants of subjective quality of life in patients attending community-based mental health services. The South-Verona Outcome Project 5

OBJECTIVE

Investigate the relationship of various domains of quality of life (QoL) with socio-demographics, clinical and social characteristics, service use and satisfaction in a representative sample of patients in contact with the South-Verona community mental health service.

METHOD

Measures included: Lancashire Quality of Life Profile (LQOLP), demographics, diagnosis and service utilization data from the Case Register, Brief Psychiatric Rating Scale (BPRS), Disability Assessment Schedule (DAS), Global Assessment of Functioning (GAF) and Verona Service Satisfaction Scale (VSSS). Analyses were conducted using a block-stratified multiple regression model.

RESULTS

Demographics, diagnosis, psychopathology, disability, functioning and service use together explained different amounts of variance in each LQOLP domain, but always less than 14%. VSSS explained more variance than any other indicator in health (13.1%), social relations (12.1%), leisure/participation (9.1%), and general wellbeing (9.0%).

CONCLUSION

Different domains of QoL are predicted by different indicators. In some important domains, self-perceived satisfactory and effective care might have an impact on the QoL of patients.

Adequacy of treatment for serious mental illness in the United States

OBJECTIVES

The purpose of this study was to assess the prevalence and correlates of treatment for serious mental illness.

METHODS

Data were derived from the National Comorbidity Survey, a cross-sectional, nationally representative household survey assessing the presence and correlates of mental disorders and treatments. Crude and adjusted likelihoods of receiving treatment for serious mental illness in the previous 12 months were calculated.

RESULTS

Forty percent of respondents with serious mental illness had received treatment in the previous year. Of those receiving treatment, 38.9% received care that could be considered at least minimally adequate, resulting in 15.3% of all respondents with serious mental illness receiving minimally adequate treatment. Predictors of not receiving minimally adequate treatment included being a young adult or an African American, residing in the South, being diagnosed as having a psychotic disorder, and being treated in the general medical sector.

CONCLUSIONS

Inadequate treatment of serious mental illness is an enormous public health problem. Public policies and cost-effective interventions are needed to improve both access to treatment and quality of treatment.

Quality of life and treatment costs in schizophrenic outpatients, treated with depot neuroleptics

Study aim was 1) to find out the influences on quality of life (QoL) of chronic outpatients with schizophrenia; 2) to calculate Quality Adjusted Life Years (QALY); and 3) to estimate direct 1-year treatment costs. In a 20% sample (100 males, 100 females) of schizophrenic outpatients from the Outpatients Clinic in Ljubljana, Slovenia receiving depot neuroleptics demographic, clinical, and treatment data were collected for the year 1996. The Krawiecka Scale, Global Assessment Scale (GAS), Abnormal Involuntary Movement Scale, Rating Scale for Drug-Induced Akathisia, Rating Scale for Extrapyramidal Side Effects, Quality of Life Scale (QLS), EQ-5D and QALY were used. Multivariate linear regression was used with the QLS score as dependent variable. The patients were on average 44 years old and had been treated for 14 years. The average GAS score was 70. GAS was positively related to the QLS score while the parkinsonism score was inversely correlated with QLS. The patients can expect to live for 10. 20 more QALY on average. The QoL on the EQ-5D scale was 0.73. The annual direct treatment costs amounted to $216,216 in 1996 prices. In well-adjusted chronic patients with schizophrenia the QoL seems to depend mostly on their psychosocial performance and side effects. Although rare, re-hospitalisations accounted for one-half of all treatment expenses.

Impact of phase-specific treatment of first episode of psychosis on Wisconsin Quality of Life Index (client version)

OBJECTIVE

The objective of this study was to assess the impact of a phase-specific community-focused treatment program on different dimensions of self-reported quality of life in a representative sample of first episode psychosis patients.

METHOD

Data were collected on patients presenting with a first episode of psychosis on the Wisconsin Quality of Life Index (client version), positive and negative symptoms, and demographic and clinical variables at baseline following clinical stabilization and at 1 year.

RESULTS

Complete data on a representative sample of 41 patients showed a significant improvement in most dimensions of the WQOL at 1 year; these changes were generally independent of changes in symptoms and there were no significant differences in the magnitude of improvement in QOL between those with DUP < or >6 months.

CONCLUSION

Patients with a first episode of predominantly schizophrenia spectrum psychosis show a highly significant improvement in subjectively assessed quality of life following a year of phase-specific comprehensive treatment.

Subject and observer-rated quality of life in schizophrenia

OBJECTIVE

We aimed to explore the relationship between objectively rated quality of life and subjective measures of social functioning and life satisfaction.

METHOD

Participants of the Schizophrenia Care and Assessment Program (SCAP) study at Dandenong in Australia were included in this analysis. Subjective ratings of several domains of social functioning and life satisfaction were taken from the SCAP instrument and comparisons made with data from the Quality of Life scale rated by research staff as well as several psychopathology measures.

RESULTS

Subjectively reported life satisfaction was not related to positive or negative symptoms of schizophrenia but did correlate with depressive symptoms. Quality of Life scale measures correlated with negative symptoms on most domains. There was very limited overlap in domain items between the life satisfaction and quality of life measures.

CONCLUSION

Life satisfaction and objectively rated quality of life are not closely related and appear to have different determinants in patients with schizophrenia.

Needs assessment for mentally disordered offenders: measurement of 'ability to benefit' and outcome

BACKGROUND

The Department of Health defines needs as "the ability to benefit from healthcare interventions". Outcome measurement is an integral component of needs assessment because it underpins 'ability to benefit'.

AIMS

To propose a framework for addressing the measurement of outcome in relation to mentally disordered offenders (MDOs).

METHOD

Based on a literature search, the paper reviews the definition and measurement of outcome in general mental health care and specifically in relation to MDOs. It analyses the problems of conducting outcome research in relation to MDOs.

RESULTS

A framework for outcome measurement in relation to MDOs is presented. Outcome is placed within a broader framework that relates to service evaluation.

CONCLUSIONS

Current measurement of outcome in relation to MDOs is inadequate. A comprehensive framework that acknowledges the multi-dimensional nature of outcome is essential. Researchers must be able to justify the dimensions they prioritise.

Patient compliance with drug therapy in schizophrenia. Economic and clinical issues

The effectiveness of drug treatment in clinical practice is considerably lower than the efficacy shown in controlled studies. The lower effectiveness in practice presumably leads to lower cost effectiveness of drug treatment in real-life situations compared with that demonstrated by studies based on results from controlled trials. Improved cost effectiveness in routine clinical practice would be a significant advantage in the treatment of schizophrenia, one of the most costly diseases in society. The aetiology of schizophrenia is unknown, and there is no cure. The main aims of therapy with antipsychotic medication include the effective relief of symptoms without the introduction of adverse effects or serious adverse events, improved quality of life, cost effectiveness and a positive long term outcome. The older classical antipsychotic drugs do not always meet these requirements because of their well-known limitations, such as a lack of response in a subgroup of individuals with schizophrenia and intolerable adverse effects. There has long been a need for new antipsychotics that can ameliorate more symptoms and have no or few adverse effects. Some of the recently introduced antipsychotics have been shown to be more effective in certain clinical situations and to have a more favourable adverse effect profile than the classical antipsychotics. A major factor contributing to the lower effectiveness of drug treatment is noncompliance, which may be very high in schizophrenia. There are several factors influencing compliance, including drug type and formulation, patient, disease status, physician, health care system, community care and family. There have been very few studies of compliance improvement strategies in schizophrenia or, indeed, in medicine in general. Current methods are relatively complex and there are differing opinions on their effectiveness. There are several ways to increase compliance in schizophrenia--the evidence is strongest for psychoeducative methods, changing to a new drug or using a depot formulation. However, considerably more research is needed in the field of compliance strategies.

Interactive risk factors for treatment adherence in a chronic psychotic disorders population

This study identified the unique and primary contributions of several concurrent risk factors for poor adherence to treatment recommendations in a clinic population of individuals with chronic psychotic disorders, i.e. 48% had DSM-IV diagnoses of schizoaffective disorder, 38% had schizophrenia, paranoid type, 12% had schizophrenia, undifferentiated type, and 2% had affective disorder with psychotic features. The target cohort consisted of 87 consecutive admissions to a continuing day treatment program. As part of a services-oriented quality assurance program, clinical staff completed rating scales for all patients. These included the BASIS-32 rating scale, which consisted of the following five subscales: psychosis; depression/anxiety; impulsive/addictive behavior; relation to self and others; and daily living and role functioning, and the Working Alliance Inventory-short form (therapist version), which consisted of the following three subscales: goal; task; and bond. These data were used to identify risk factors that weaken a patient's adherence to medication and non-medication treatment during the first 2 weeks of treatment in the clinic. Medication treatment consisted of both typical and atypical neuroleptic medications, with most patients being on multiple medications. Correlational analyses suggested that many of the risk factor variables were significantly associated with poor treatment adherence. Regression analyses suggested that the degree of psychoticism was most strongly associated with poor adherence to medication treatment and that difficulties relating to self and others were the strongest predictor of poor adherence to non-medication treatment. A large-sample services research design such as this can begin to determine patterns of associations between previous identified risk factors and poor treatment adherence in individuals with chronic psychotic disorders.

Health resource utilization and clinical outcomes with risperidone therapy in patients with serious mental illness

This report is an analysis of our experience with risperidone therapy in a veteran population with severe, suboptimally responsive psychosis from a perspective of clinical response and health resource utilization. We conducted a computer search for all patients who received risperidone therapy at our facility from February 1994 until July 1, 1996. Risperidone at our facility is prescribed when psychiatric symptoms appear to be refractory or suboptimally responsive to conventional antipsychotic therapy. A control group of patients on conventional antipsychotic therapy were also selected via the electronic data base. One hundred twenty-nine patients received risperidone therapy at a mean dosage of 5.05+/-2.4 mg/d, for a mean duration of 247.4+/-223.5 days. The largest proportion of patients (48.1%) had marked improvement on risperidone therapy. There were 35 patients who received at least 1 year of risperidone therapy. These patients had a significant decrease in hospital length of stay (LOS) from 80.7 to 28.7 days (P = .003) on risperidone with no compensatory increase in outpatient visits. The group of patients who received conventional antipsychotic therapy during the study time period had a more modest mean reduction in LOS over a 2-year time period from 78.9 days during the initial identified year of conventional antipsychotic therapy to 56.4 days during the second identified year of conventional antipsychotic therapy (P = .2). However, when change in LOS for the entire group was compared, the difference in change in LOS between risperidone and conventional antipsychotic treated patients did not reach statistical significance (P = .2). This preliminary study concurs with other reports that risperidone therapy may be effective in severely mentally ill patients and may be associated with significant reductions in health resource utilization. Comparison of resource utilization between patients receiving risperidone and conventional antipsychotic therapy is still unclear and should be explored in larger and prospective studies.

The efficacy of a consumer case management team: 2-year outcomes of a randomized trial

This article reports the results of a randomized trial of a team of case managers who are mental health consumers compared to a team of nonconsumer. Using a repeated measures MANOVA design, consumer case managers were found to be as effective as a team of nonconsumer case managers in maintaining the stability of severely mentally disabled clients served over a 2-year period. Implications for the employment of consumers in mental health services and the vocational capacity of persons with mental illness are discussed.

Public health policy, community services, and outcomes for patients with schizophrenia

Amidst the specter of managed care, individual mental health services are struggling to redefine their niche, consolidate with partners and provide a realistic continuum of care for persons with serious and persistent mental illness. Because of the chronicity of schizophrenia, its economic and social ramifications, the disparity in health insurance for these patients and limited resources, the development of community services has often proceeded in a fragmentary manner. Several states have well coordinated community programs with integration between private and public services. The Assertive Community Treatment (ACT) model has proved successful, although this is costly to maintain. Services that synergize optimum pharmacologic and psychosocial treatments can achieve favorable patient outcome, as evaluated across clinical, rehabilitative, humanitarian, and public welfare domains.

Benefits and costs of supported employment from three perspectives

Administrators, consumers, and policy makers are increasingly interested in supported employment as a way of helping persons with severe mental illness get and keep competitive jobs. However, in an atmosphere of increased expectations for performance and declining public financing, administrators want to know the costs and benefits of different approaches before they reallocate scarce treatment or rehabilitative dollars. This article discusses the net benefits of two approaches to supported employment that were compared in a randomized trial: Individual Placement and Support (IPS) and Group Skills Training (GST). The authors analyze costs and benefits from societal, government, and consumer perspectives. Although a previous analysis showed that IPS participants were significantly more likely to find work, worked more hours, and had higher earnings, net benefits of the two programs were not significantly different. The authors also discuss some of the strengths and weaknesses of cost-benefit analysis in mental health care and suggest future directions for policy and research.

Quality of life in schizophrenia: insight and subjective response to neuroleptics

The relationship between quality of life, insight, and subjective response to neuroleptics was assessed in a selected group of clinically stable outpatients with schizophrenia. A significant portion of the variance in these individuals' quality of life was explained by a combination of protracted illness duration and the presence of a dysphoric response to neuroleptics. However, there was no significant relationship between quality of life and the level of insight these individuals had into the nature of their illness. The development of treatment strategies to alleviate neuroleptic-induced dysphoria may enable outpatients with schizophrenia to benefit from rehabilitation programs devised to improve quality of life.

Work and nonvocational domains of functioning in persons with severe mental illness: a longitudinal analysis

In this study we sought to understand the relationship between obtaining competitive employment and changes in nonvocational domains of functioning (symptoms, substance abuse, hospitalizations, self-esteem, quality of life) in persons with severe mental illness. A group of 143 unemployed patients participating in a study of vocational rehabilitation programs were assessed in nonvocational areas of functioning at baseline and 6, 12, and 18 months later. Statistical analyses examined the relationship between work status at the follow-up assessments and nonvocational functioning, controlling for baseline levels of nonvocational variables. Patients who were working at follow-up tended to have lower symptoms (particularly thought disorder and affect on the Brief Psychiatric Rating Scale), higher Global Assessment Scores, better self-esteem, and more satisfaction with their finances and vocational services than unemployed patients. Employment is associated with better functioning in a range of different nonvocational domains, even after controlling for baseline levels of functioning.

New ethical challenges to mental health services research in the era of community-based care

Research on the use and effectiveness of mental health services conducted across a wide variety of settings, under new and diverse state-based legal statutes, and requiring the linking of a variety of existing and proposed data sources raises a number of ethical considerations. These new conditions are reviewed in the context of federal regulations for the protection of human subjects and, in particular, informed consent. Illustrations, suggestions, and resources are offered from recent experiences in a longitudinal, multisource study of the impact of a hospital closing on individual consumers, families, workers, and system costs.

Quality of life in schizophrenia: relationship to sociodemographic factors, symptomatology and tardive dyskinesia

The influence of sociodemographic, clinical and treatment factors on the quality of life of patients with schizophrenia has yet to be fully defined. We evaluated the quality of life of patients with schizophrenia who were attending a catchment area rehabilitation centre, in order to establish its clinical correlates. These patients had a poor to moderate quality of life which was inversely related to negative symptom severity, illness duration, the cumulative length of previous hospitalization and patient age. Patients residing in hostels or group homes had a poorer quality of life than those living independently or with their family. The presence of tardive dyskinesia was associated with a poorer quality of life. This association merits further investigation.

Outcomes of mental health care for children and adolescents: I. A comprehensive conceptual model

OBJECTIVE

Accountability for mental health care has become a standard of clinical practice. With the expansion of managed care as a corporate response to health reform, attention to outcomes will intensity. Assessment of clinical treatment has typically focused on symptom reduction at an individual level, whereas assessment of service effectiveness has more often targeted service-level change.

METHOD

A dynamic and interactional model of outcomes is presented that broadens the range of intended consequences of care. The model comprises five domains: symptoms, functioning, consumer perspectives, environmental contexts, and systems.

RESULTS

The model reflects the changeable interaction between children's evolving capacities and their primary environments (home, school, and community).

CONCLUSIONS

As health care practices shift, attention to improved care is likely to depend increasingly on scientifically credible evidence of its impact. Greater integration between research and standard practice will be needed. Such a partnership can be strengthened by a more comprehensive view of the impact of care.