Integrated IMR for psychiatric and general medical illness for adults aged 50 or older with serious mental illness

Physical health challenges faced by elders with severe mental illness: population-based retrospective cohort study

BACKGROUND

Severe mental illness (SMI), which includes schizophrenia, schizoaffective disorder and bipolar disorder, has profound health impacts, even in the elderly.

AIMS

To evaluate relative risk of hospital admission and length of hospital stay for physical illness in elders with SMI.

METHOD

To construct a population-based retrospective cohort observed from April 2007 to March 2016, data from a case registry with full but de-identified electronic health records were retrieved for patients of the South London and Maudsley NHS Foundation Trust, the single secondary mental healthcare service provider in south-east London. We compared participants with SMI aged >60 years old with the general population of the same age and residing in the same areas through data linkage by age-, sex- and fiscal-year-standardised admission ratios (SARs) for primary diagnoses at hospital discharge. Furthermore, we compared the duration of hospital stay with an age-, sex- and cause-of-admission-matched random group by linear regression for major causes of admission.

RESULTS

In total, records for 4175 older people with SMI were obtained, relating to 10 342 admission episodes, showing an overall SAR for all physical illnesses of 5.15 (95% CI: 5.05, 5.25). Among the top causes of admission, SARs ranged from 3.87 for circulatory system disorders (ICD-10 codes: I00-I99) to 6.99 for genitourinary system or urinary conditions (N00-N39). Specifically, the diagnostic group of 'symptoms, signs and findings, not elsewhere classified' (R00-R99) had an elevated SAR of 6.56 (95% CI: 6.22, 6.90). Elders with SMI also had significantly longer hospital stays than their counterparts in the general population, especially for digestive system illnesses (K00-K93), after adjusting for confounding.

CONCLUSIONS

Poorer overall physical health and specific patterns were identified in elders with SMI.

Therapeutic patient education for severe mental disorders: A systematic review

Objective

This systematic review aimed to review therapeutic patient education (TPE) programmes in managing psychiatric disorders, considering the diversity in delivering agents, intervention formats, targeted skills, and therapeutic outcomes.

Methods

Comprehensive database searches, including Web of Science, PubMed, and COCHRANE, were conducted from September 2019 to January 2023, yielding 514 unique records, with 33 making it through rigorous evaluation for full-text review. Eleven studies met the inclusion criteria, focusing on various psychiatric disorders such as depression, bipolar disorder, psychosis, and multiple serious mental illnesses. A total of 38 studies were included from our previous review to supplement the current database search.

Results

TPE programmes exhibited diversity in delivering agents and intervention formats, with a notable presence of multidisciplinary teams and various professionals. The interventions prioritized coping strategies and disease management techniques, though the extent varied based on the disorder. Effectiveness was heterogeneous across studies; some interventions showed significant benefits in areas such as symptom management, coping, and functional improvement, while others reported no significant outcomes.

Conclusion

The findings underscore the potential of TPE in psychiatric care, revealing its multifaceted nature and varied impact. TPE not only addresses deficits but also leverages patients' existing strengths and capabilities. Despite the reported benefits, a portion of the interventions lacked statistical significance, indicating the necessity for continuous refinement and evaluation.

Assessing the Psychometric Properties of the Illness Management and Recovery Scale: A Systematic Review Using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN)

The Illness Management and Recovery Scale (IMR-S) is based on the IMR program, developed to assess the recovery process for people with severe mental disorders by considering the perceptions of clients and clinicians involved in it. The aim of this study was to analyze the psychometric properties of the IMR-S so as to determine the reliability and suitability of its scores for evaluating recovery. Two coders searched five databases for studies, published between January 2004 and May 2023, that describe the psychometric assessment of the IMR-S. Studies were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) Risk of Bias checklist. Finally, 46 papers were included. Methodological quality was very good for most of the studies that provide information on internal validity, and limited for those that report on responsiveness. Measurement properties were positive for convergent validity and measurement error. The quality of evidence was high for structural validity studies. Although this study only includes research published in English and may have overlooked certain psychometric properties evaluated in studies published in other languages, our findings suggest that the IMR-S is a valid and reliable instrument, demonstrating its potential to offer guidance for clinical practice.

Interventions to Promote the Utilization of Physical Health Care for People with Severe Mental Illness: A Scoping Review

BACKGROUND

The main contributor to excess mortality in severe mental illness (SMI) is poor physical health. Causes include unfavorable health behaviors among people with SMI, stigmatization phenomena, as well as limited access to and utilization of physical health care. Patient centered interventions to promote the utilization of and access to existing physical health care facilities may be a pragmatic and cost-effective approach to improve health equity in this vulnerable and often neglected patient population.

OBJECTIVE/METHODS

In this study, we systematically reviewed the international literature on such studies (sources: literature databases, trial-registries, grey literature). Empirical studies (quantitative, qualitative, and mixed methods) of interventions to improve the utilization of and access to medical health care for people with a SMI, were included.

RESULTS

We identified 38 studies, described in 51 study publications, and summarized them in terms of type, theoretical rationale, outcome measures, and study author's interpretation of the intervention success.

CONCLUSIONS

Useful interventions to promote the utilization of physical health care for people with a SMI exist, but still appear to be rare, or at least not supplemented by evaluation studies. The present review provides a map of the evidence and may serve as a starting point for further quantitative effectiveness evaluations of this promising type of behavioral intervention.

Assessing a digital peer support self-management intervention for adults with serious mental illness: feasibility, acceptability, and preliminary effectiveness

OBJECTIVE

To assess the feasibility, acceptability, and preliminary effectiveness of digital peer support integrated medical and psychiatric self-management intervention ("PeerTECH") for adults with a serious mental illness.

METHODS

Twenty-one adults with a chart diagnosis of a serious mental illness (i.e., schizophrenia, schizoaffective disorder, bipolar disorder, or treatment-refractory major depressive disorder) and at least one medical comorbidity (i.e., cardiovascular disease, obesity, diabetes, chronic obstructive pulmonary disease, hypertension, and/or high cholesterol) aged 18 years and older received the PeerTECH intervention in the community. Nine peer support specialists were trained to deliver PeerTECH. Data were collected at baseline and 12-weeks.

RESULTS

This pilot study demonstrated that a 12-week, digital peer support integrated medical and psychiatric self-management intervention for adults with serious mental illness was feasible and acceptable among peer support specialists and patients and was associated with statistically significant improvements in self-efficacy to manage chronic disease and personal empowerment. In addition, pre/post non-statistically significant improvements were observed in psychiatric self-management, medical self-management skills, and feelings of loneliness.

CONCLUSIONS

This single-arm pre/post pilot study demonstrated preliminary evidence peer support specialists could offer a fidelity-adherent digital peer support self-management intervention to adults with serious mental illness. These findings build on the evidence that a digital peer support self-management intervention for adults with serious mental illness designed to improve medical and psychiatric self-management is feasible, acceptable, and shows promising evidence of improvements in clinical outcomes. The use of technology among peer support specialists may be a promising tool to facilitate the delivery of peer support and guided evidence-based self-management support.People with serious mental illness (SMI; defined as individuals diagnosed with schizophrenia spectrum disorder, bipolar disorder, or treatment-refractory major depressive disorder) are increasingly utilizing peer support services to support their health and recovery. Peer support is defined as shared knowledge, experience, emotional, social, and/or practical assistance to support others with similar lived experiences (Solomon, 2004). Most recently the definition also includes the provision of evidence-based peer-supported self-management services (Fortuna et al., 2020). Mental health peer support can augment the traditional mental health treatment system through providing support services to maintain recovery between clinical encounters (Solomon, 2004) and is classified by the World Health Organization as an essential element of recovery (World, Health, and Organization, About social determinants of health, 2017).

Nursing Interventions Designed to Improve Healthcare in General Healthcare Settings for Adults Living with Mental Illness: A Scoping Review

People living with mental illness have difficulty obtaining quality physical care services. Nurses find it hard to fully assume their role and adopt a person-centered approach when they care for people with both physical and mental health problems. A scoping review was carried out to document the breadth and depth of literature on nurse interventions designed to improve nursing care in general healthcare settings for adults living with mental illness. Two researchers independently screened titles, abstracts and full documents to obtain publications, and the relevant data was extracted from individual studies. Of the 384 studies identified, 16 documents were included in the study. Few interventions have been the subject of scientific publications and they are scattered in their objectives and very heterogeneous in their content. Interventions are often included in a large program that may be difficult to apply in various care settings. There are many different nursing roles and activities in care-management and in support of behavioral changes although their main measured outcomes differ. This study highlights a tendency for interventions to relegate people with mental health problems to specialized services, which reinforces the dichotomization of services and does not favor a holistic and person-centered approach. There is an urgent need to develop and evaluate nursing interventions in general healthcare settings for adults living with mental illness. The development of relevant continuing education and training must take into account both the point of view of the people living with mental illness and that of nurses.

Feasibility, Acceptability, and Potential Utility of Peer-supported Ecological Momentary Assessment Among People with Serious Mental Illness: a Pilot Study

To examine the feasibility, acceptability, and initial validity of using smartphone-based peer-supported ecological momentary assessment (EMA) as a tool to assess loneliness and functioning among adults with a serious mental illness diagnosis. Twenty-one adults with a diagnosis of a serious mental illness (i.e., schizophrenia, schizoaffective disorder, bipolar disorder, or treatment-refractory major depressive disorder) and at least one medical comorbidity (i.e., cardiovascular disease, obesity, diabetes, chronic obstructive pulmonary disease, hypertension, and/or high cholesterol) aged 18 years and older completed EMA surveys via smartphones once per day for 12-weeks. Nine peer support specialists prompted patients with SMI to complete the EMA surveys. Data were collected at baseline and 12-weeks. EMA acceptability (15.9%) was reported, and participants rated their experience with EMA methods positively. EMA responses were correlated with higher social support at 3 months. Higher levels of EMA-measured loneliness were significantly correlated with levels of social support, less hope, and less empowerment at 3 months. Lastly, those who contacted their peer specialist reported higher levels of loneliness and lower levels of functioning on that day suggesting that participants were able to use their peers for social support. Peer-supported EMA via smartphones is a feasible and acceptable data collection method among adults with SMI and appears to be a promising mobile tool to assess loneliness and functioning. These preliminary findings indicate EMA-measured loneliness and functioning are significantly predicted by baseline variables and such variables may impact engagement in EMA. EMA may contribute to future research examining the clinical utility of peer support specialists to alleviate feelings of loneliness and improve functioning.

Advancing the Science of Recovery: The Utility of the Recovery Assessment Scale in the Prediction of Self-Directed Health and Wellness Outcomes in Adults with a Diagnosis of a Serious Mental Illness

Adults with serious mental illness commonly experience comorbid chronic physical conditions and experience a reduced life expectancy of 10-25 years compared to the general population (Saha et al. in Arch Gen Psychiatry 64(10):1123-31.  2007; Hayes et al. in Acta Psychiatr Scand 131(6):417-25. 2015; Walker et al. in JAMA Psychiatry 72(4):334-41. 2015). Dimensions of personal recovery may have real-world implications that extend beyond functional and mental health outcomes to impact the self-directed health and wellness of adults with serious mental illness. This study examined the predictive utility of the Recovery Assessment Scale with respect to medical self-efficacy, self-management, psychiatric symptoms, and community functioning for adults with serious mental illness. Data were derived from a secondary analysis of baseline and 10-month data collected from a randomized control trial with adults aged 18 years and older with a diagnosis of bipolar disorder, schizoaffective disorder, schizophrenia, or major depressive disorder (N=56). A linear regression was conducted to examine the predictive value of total baseline RAS scores on self-efficacy at 10 months while controlling for study group. This model significantly predicted self-efficacy (F (2, 53) = 13.28, p < .001) and accounted for 36.1% of the variance. Total baseline RAS scores significantly predicted self-efficacy (β = 059, p < .001); specifically, higher baseline RAS scores were associated with greater self-efficacy. A greater degree of recovery may facilitate greater medical self-efficacy in managing chronic disease in people diagnosed with a serious mental illness. Future intervention approaches may consider recovery-focused therapeutic targets such as peer support to promote self-efficacy to manage chronic diseases in people with serious mental illness.

Shared Care Practices in Community Addiction and Mental Health Services: A Qualitative Study on the Experiences and Perspectives of Stakeholders

Shared care involves collaboration between primary care, secondary and tertiary care that enables the allocation of responsibilities of care according to the treatment needs of patients over the course of a mental illness. This study aims to determine stakeholders’ perspectives on the features of an ideal shared care model and barriers to practicing shared care within addiction and mental health programs in Edmonton, Canada. This is a qualitative cross-sectional study with data collected through focus group discussions. Participants included patients, general practitioners, psychiatrists, management, and therapists working in primary and secondary addiction and mental health. Responses were audio-recorded, transcribed, and analyzed thematically. Perceived barriers to the implementation of an ideal shared care model identified by participants include fragmented communication between primary and secondary healthcare providers, patient and family physician discomfort with discussing addiction and mental health, a lack of staff capacity, confidentiality issues, and practitioner buy-in. Participants also identified enablers to include implementing shared electronic medical record systems, improving communication and collaboration, physical co-location, and increasing practitioner awareness of appropriate referrals and services. This original research provides stakeholders’ perspectives on the features of an ideal shared care model and barriers to practicing shared care within addiction and mental health programs.

Attitudes and Beliefs on Aging Among Middle-Aged and Older Adults With Serious Mental Illness

Older adults with serious mental illness (SMI) experience increased medical comorbidities, disability, and early mortality, but little is known about how they perceive the process of aging. This study explored attitudes and beliefs about aging among n = 20 middle aged and older adults (M = 59.8 years; range 47-66) with SMI in a state psychiatric hospital. We conducted semistructured interviews using the Attitudes to Ageing Questionnaire (AAQ) and analyzed narrative accounts using a grounded theory approach. The mean scores of overall attitudes toward aging and of the subscale of perception of psychological growth were both positive compared to a neutral rating (p = 0.026 and p = 0.004, respectively). Study participants rated their experience on the subscales of psychosocial loss and physical health change as neutral. Despite substantial psychiatric, medical, and functional disabilities, older adults with SMI in this study of psychiatric inpatients perceived the process of aging as generally positive, suggesting resilience and potential positive emotional growth in older age.

Service Use by Medicaid Recipients With Serious Mental Illness During an RCT of the Bridge Peer Health Navigator Intervention

OBJECTIVE

Integration of general medical care and mental health care is a high priority for individuals with serious mental illnesses because of their high risk of morbidity and early mortality. The Bridge is a peer-led, health navigator intervention designed to improve access to and use of health care and self-management of medical services by individuals with serious mental illnesses. This study expands on a previous study in which the authors examined participants' self-reported outcomes from a 12-month randomized controlled trial of the Bridge. In the study reported here, Medicaid data were used to assess the impact of the intervention on service use during that trial.

METHODS

Medicaid data on use of general medical services (emergency room, outpatient, and inpatient) for 6 months were compared for 144 individuals with serious mental illnesses-Bridge participants (N=72) and a waitlist control group (N=72). An intent-to-treat approach was used, with regression models controlling for general medical services in the 6 months before baseline.

RESULTS

Zero-inflated negative binomial analyses, controlling for service use 6 months before baseline, found that the intervention group used the emergency room significantly less frequently, compared with the control group (adjusted mean±SD number of visits, 0.72±0.19 versus 1.59±0.42). No between-group differences were found in use of general medical inpatient or outpatient services.

CONCLUSIONS

The Bridge was effective in decreasing emergency room use among individuals with serious mental illnesses.

Usability Testing of a Mobile Health Application for Self-Management of Serious Mental Illness in a Norwegian Community Mental Health Setting

Background: For digital tools to have high usability and fit service users’ health needs and socio-environmental context, it is important to explore usability with end-users and identify facilitators and barriers to uptake. Objective: To conduct user testing of the smartphone health application, PeerTECH, in a Norwegian community mental health setting. Methods: Semistructured interviews and usability testing of the PeerTECH app using the Think-Aloud approach and task analysis among 11 people (three individuals with a serious mental illness, two peer support workers, and six mental health professionals). Results: Study participants perceived PeerTECH as a relevant tool to support self-management of their mental and physical health conditions, and they provided valuable feedback on existing features as well as suggestions for adaptions to the Norwegian context. The task analysis revealed that PeerTECH is easy to manage for service users and peer support workers. Conclusions: Adapting the PeerTECH smartphone app to the Norwegian context may be a viable and useful tool to support individuals with serious mental illness.

Preliminary Outcomes of an Older Peer and Clinician co-Facilitated Pain Rehabilitation Intervention among Adults Aged 50 Years and Older with Comorbid Chronic Pain and Mental Health Conditions

The present study aimed to examine the acceptability, feasibility, and preliminary effectiveness of an older peer and clinician co-facilitated Behavioral Activation for Pain Rehabilitation (BA-PR) intervention among adults aged 50 years and older with comorbid chronic pain and mental health conditions. This was a mixed-methods research design with eight participants aged 55 to 62 years old with mental health conditions including schizophrenia spectrum disorder, bipolar disorder, major depressive disorder, personality disorder, and adjustment disorder. The quantitative data were assessed from observational methods, a pain rating scale and related measures. We used semi-structured interviews for qualitative feedback on experiences with the BA-PR intervention after participation. Overall, the participants had positive experiences following receipt of the BA-PR intervention. The recruitment and adherence rates for participants were 72.7% and 100%, respectively. Approximately 75% of the participants remained enrolled in the study. Findings from a paired t-test showed the BA-PR intervention was linked to significantly reduced prescription opioid misuse risk, t (7) = 2.42, p < 0.05. There were also non-significant reductions in pain intensity and depression severity, in addition to improvements in active and passive pain coping strategies and behavioral activation.The BA-PR intervention is the first pain rehabilitation intervention specifically designed for middle-aged and older adults with comorbid chronic pain and mental health conditions. Our findings indicate promise for the BA-PR intervention to potentially reduce prescription opioid misuse risk, pain, and depressive symptoms. However, a quasi-experimental study is needed before rigorous effectiveness testing.

A Smartphone-Based Self-management Intervention for Bipolar Disorder (LiveWell): User-Centered Development Approach

BACKGROUND

Bipolar disorder is a serious mental illness that results in significant morbidity and mortality. Pharmacotherapy is the primary treatment for bipolar disorder; however, adjunctive psychotherapy can help individuals use self-management strategies to improve outcomes. Yet access to this therapy is limited. Smartphones and other technologies have the potential to increase access to therapeutic strategies that enhance self-management while simultaneously providing real-time user feedback and provider alerts to augment care.

OBJECTIVE

This paper describes the user-centered development of LiveWell, a smartphone-based self-management intervention for bipolar disorder, to contribute to and support the ongoing improvement and dissemination of technology-based mental health interventions.

METHODS

Individuals with bipolar disorder first participated in a field trial of a simple smartphone app for self-monitoring of behavioral targets. To develop a complete technology-based intervention for bipolar disorder, this field trial was followed by design sessions, usability testing, and a pilot study of a smartphone-based self-management intervention for bipolar disorder. Throughout all phases of development, intervention revisions were made based on user feedback.

RESULTS

The core of the LiveWell intervention consists of a daily self-monitoring tool, the Daily Check-in. This self-monitoring tool underwent multiple revisions during the user-centered development process. Daily Check-in mood and thought rating scales were collapsed into a single wellness rating scale to accommodate user development of personalized scale anchors. These anchors are meant to assist users in identifying early warning signs and symptoms of impending episodes to take action based on personalized plans. When users identified personal anchors for the wellness scale, the anchors most commonly reflected behavioral signs and symptoms (40%), followed by cognitive (25%), mood (15%), physical (10%), and motivational (7%) signs and symptoms. Changes to the Daily Check-in were also made to help users distinguish between getting adequate sleep and keeping a regular routine. At the end of the pilot study, users reported that the Daily Check-in made them more aware of early warning signs and symptoms and how much they were sleeping. Users also reported that they liked personalizing their anchors and plans and felt this process was useful. Users experienced some difficulties with developing, tracking, and achieving target goals. Users also did not consistently follow up with app recommendations to contact providers when Daily Check-in data suggested they needed additional assistance. As a result, the human support roles for the technology were expanded beyond app use support to include support for self-management and clinical care communication. The development of these human support roles was aided by feedback on the technology's usability from the users and the coaches who provided the human support.

CONCLUSIONS

User input guided the development of intervention content, technology, and coaching support for LiveWell. Users valued the provision of monitoring tools and the ability to personalize plans for staying well, supporting the role of monitoring and personalization as important features of digital mental health technologies. Users also valued human support of the technology in the form of a coach, and user difficulties with aspects of self-management and care-provider communication led to an expansion of the coach's support roles. Obtaining feedback from both users and coaches played an important role in the development of both the LiveWell technology and human support. Attention to all stakeholders involved in the use of mental health technologies is essential for optimizing intervention development.

Development of Coaching Support for LiveWell: A Smartphone-Based Self-Management Intervention for Bipolar Disorder

Despite effective pharmacological treatment, bipolar disorder is a leading cause of disability due to recurrence of episodes, long episode durations, and persistence of interepisode symptoms. While adding psychotherapy to pharmacotherapy improves outcomes, the availability of adjunctive psychotherapy is limited. To extend the accessibility and functionality of psychotherapy for bipolar disorder, we developed LiveWell, a smartphone-based self-management intervention. Unfortunately, many mental health technology interventions suffer from high attrition rates, with users rapidly failing to maintain engagement with the intervention technology. Human support reduces this commonly observed engagement problem but does not consistently improve clinical and recovery outcomes. To facilitate ongoing efforts to develop human support for digital mental health technologies, this paper describes the design decisions, theoretical framework, content, mode, timing of delivery, and the training and supervision for coaching support of the LiveWell technology. This support includes clearly defined and structured roles that aim to encourage the use of the technology, self-management strategies, and communication with care providers. A clear division of labor is established between the coaching support roles and the intervention technology to allow lay personnel to serve as coaches and thereby maximize accessibility to the LiveWell intervention.

A systematic scoping review of interventions to integrate physical and mental healthcare for people with serious mental illness and substance use disorders

Integrated care approaches have been recommended to remove barriers to healthcare and improve the physical health outcomes of people living with serious mental illness (SMI) and/or substance use disorders (SUDs). The aim of this systematic scoping review was to describe empirical investigations of interventions designed to integrate physical, mental, and addiction healthcare for this population. An iterative and systematic search of five electronic databases (Medline (Ovid), PsycINFO, CINAHL, Embase (Ovid) and Scopus) was conducted to identify peer-reviewed articles published between January 2000 and April 2019. Two reviewers independently screened publications in two successive stages of title and abstract screening, followed by full-text screening of eligible publications. Data from each included publication were extracted independently by two reviewers using a standardised spreadsheet. A total of 28 eligible publications were identified, representing 25 unique studies. Over half of the included studies investigated the use of case managers to provide self-management skills or to coordinate mental and physical healthcare (n = 14). Other interventions examined the co-location of services (n = 9) and the implementation of screening and referral pathways to specialist treatment (n = 2). Less than half of the included studies described a framework, theory or model that was underpinning the intervention tested. While some aspects of integrated care have been identified and addressed by interventions, other key dimensions have not been considered, such as shared decision-making. Identification of a comprehensive model of integrated care is recommended to inform the development and evaluation of future interventions for people with SMI/SUDs.

Coordination of services for people with serious mental illness and general medical conditions: Perspectives from rural northeastern United States

OBJECTIVE

The objective of the study was to investigate providers' perspectives on how medical, mental health, and social services are coordinated for people with serious mental illnesses and general medical conditions in 2 predominantly rural states.

METHOD

To achieve multiple perspectives on service coordination, this study includes perspectives from providers employed in community mental health centers, social service agencies, and primary care settings in 2 northern rural New England states with contrasting approaches to financing and organizing services. We conducted 29 individual semistructured interviews and 1 focus group, which included administrative leaders, team leaders, primary care providers, social workers, and case managers who provide services for people with serious mental illness. Data were analyzed using qualitative thematic content analysis.

RESULTS

We identified key themes at 3 levels: (a) provider-level coordination: bridging across services; managing interprofessional communications; and contrasting perspectives on the locus of responsibility for coordination; (b) individual-level coordination: support for self-management and care navigation; trusting and continuous relationships; and the right to individual choice and autonomy; (c) system-level coordination: linking appropriate residential and care provision services, funding, recruiting and retaining staff, policy enablers, and integration solutions.

CONCLUSIONS

Three levels of provider-reported coordination themes are described for the 2 states, reflecting efforts to coordinate and integrate service delivery across medical, mental health, and social services.

IMPLICATIONS

Improvements in patient outcomes will need additional actions that target key social determinants of health. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Shared decision-making preferences in mental health: does age matter? A systematic review

BACKGROUND

Research to date suggests older adults prefer a passive involvement in the clinical decision-making process; however, the empirical evidence underlying this claim in the mental health context is yet to be reviewed systematically.

AIMS

To understand whether older adults desire involvement in mental health-related clinical decisions.

METHOD

A systematic review was conducted to identify primary research that explored mental-health decision-making preferences of people with a mean age of over 55 from January 1990 through to December 2018.

RESULTS

Three independent studies of varying design and quality were included. Study settings were in the USA, Germany, and the UK. A preference for shared decision-making was seen in two studies, while a preference for active decision-making was identified in one.

CONCLUSIONS

In contrast to other reviews on clinical decision-making, this review focused on mental health-related decisions of older adults. The evidence suggests older adults desire involvement in mental health-related clinical decisions. Given the political drive to empower patients and the need to ensure evidence-based clinical practice, more high-quality research regarding the shared decision-making preferences and outcomes of older adults with mental ill-health is needed. Systematic Review Registration PROSPERO: CRD42018102009.

A systematic review of the effects of psychosocial interventions on social functioning for middle-aged and older-aged adults with severe mental illness

OBJECTIVES

The number of older adults with severe mental health problems such as schizophrenia is likely to double in the next 20 years. The needs of this patient group change across the life course, but difficulties with social functioning persist into older age. Poorer social functioning is associated with poorer outcomes and has been identified as a priority for intervention by patients themselves. This paper systematically reviews studies examining the effectiveness of psychosocial interventions on social functioning for people with severe mental health problems in later life.

METHODS

A systematic review of peer-reviewed journal articles was conducted and databases were searched from inception to December 2017. The review was limited to psychosocial interventions, for mid to older aged adults (≥40 years of age) with severe mental illness that included a validated measure of social functioning.

RESULTS

Fifteen studies (17 papers) met inclusion criteria. There was evidence to support skills training interventions that primarily focused on social skills training or integrated mental and physical health interventions. There was not sufficient evidence to recommend any other interventions.

CONCLUSIONS

The results highlight the limited nature of interventions designed specifically for older people with severe mental health problems that target social functioning and the need for more robust, large-scale studies in the area. Current evidence suggests that cognitive behaviour therapy can be effective in targeting social functioning in younger age groups, but, as yet, there is insufficient evidence to recommend this intervention for an older population.

Integrated Care for Older Adults with Serious Mental Illness and Medical Comorbidity: Evidence-Based Models and Future Research Directions

The excess risk of early mortality, medical comorbidity, early institutionalization, and high costs among older adults with serious mental illness necessitates development and dissemination of effective and sustainable integrated care models that simultaneously address mental and physical health needs. This overview highlights current, evidence-based integrated care models, which predominantly adopt the following approaches: (1) psychosocial skills training, (2) integrated illness self-management, and (3) collaborative care and behavioral health homes. Finally, innovative models that build on these approaches by incorporating novel uses of telehealth, mobile health technology and peer support, and strategies from developing economies are discussed.

Systematic Review of the Impact of Behavioral Health Homes on Cardiometabolic Risk Factors for Adults With Serious Mental Illness

OBJECTIVE

This systematic review examined the impact of health homes on cardiometabolic risk among adults with serious mental illness.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses procedures were used to conduct the systematic review. Databases were searched for peer-reviewed articles published between 1946 and August 2018 that compared health homes with a control condition (e.g., usual care and secondary data analyses using matched samples). Participants, interventions, comparisons, outcomes, and study design criteria were used to assess study eligibility. Studies were assessed for methodological quality by using the Quality Assessment of Before and After Studies With No Control Group and the Quality Assessment of Controlled Intervention Studies.

RESULTS

Eighteen studies (i.e., 11 observational studies, four quasi-experimental studies, and three randomized controlled trials) reported on 17 health homes. Most studies reported increases in receipt of screening for cardiometabolic risk factors and service use. There was a modest reduction in selected cardiometabolic risk factors among people with serious mental illness, but clinical outcomes varied widely among studies.

CONCLUSIONS

Improvement in cardiometabolic risk factors varied across the studies, and the clinical significance of these reductions was not clear. Peer support and self-management training may represent strategies to improve cardiometabolic risk factors. Colocation of services may not be enough to significantly affect cardiometabolic risk factors. Health homes that include standardized screening, peer support and self-management training, and intervention components that target interdependent risk factors may have a greater impact on clinical outcomes.

Clinical and brain structural effects of the Illness Management and Recovery program in middle-aged and older patients with schizophrenia

AIMS

In this study, we implemented the Illness Management and Recovery (IMR) program for middle-aged and older patients with schizophrenia hospitalized for long periods and assessed the effect of the IMR program on psychiatric symptoms and psychosocial function. The effects of the IMR program on brain structure were also evaluated.

METHODS

The IMR program was implemented for 19 patients with schizophrenia; 17 patients with schizophrenia receiving treatment as usual (TAU) were also recruited as controls. In all patients, mean age was 61.4 years (range, 50-77 years) and mean hospitalization duration was 13.1 years (range, 1-31 years) at enrollment. Structural magnetic resonance images and Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) scores as clinical variables were obtained at the beginning and end of the IMR program. Longitudinal analyses were performed to compare the effects of the IMR program on clinical symptoms and cortical thickness in the superior temporal gyrus (STG) between the IMR and TAU groups.

RESULTS

Significant improvements in GAF scores and the total, Insight and Judgment, and Positive components of the PANSS were found in the IMR group compared with the TAU group. Cortical thickness in the left STG was preserved in the IMR group compared with the TAU group.

CONCLUSIONS

This is the first report demonstrating the effectiveness of the IMR program for improving psychotic symptoms and psychosocial function and protecting brain structure in middle-aged and older inpatients with schizophrenia hospitalized for long periods.

Interventions to integrate care for people with serious mental illness and substance use disorders: a systematic scoping review protocol

INTRODUCTION

People with serious mental illness (SMI) and/or substance use disorders (SUDs) have an elevated risk of premature mortality compared with the general population. This has been attributed to higher rates of chronic illness among these individuals, but also to inequities in healthcare access and treatment. Integrated care has the potential to improve the health of people with SMI/SUDs. The aims of this scoping review are to: (1) identify empirical investigations of interventions designed to integrate care for people with SMI/SUDs; (2) describe the underlying theories, models and frameworks of integrated care that informed their development; and (3) determine the degree to which interventions address dimensions of a comprehensive and validated framework of integrated care.

METHODS AND ANALYSIS

Guidelines for best practice and reporting of scoping reviews will be followed using the framework of Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review checklist. An iterative and systematic search of peer-reviewed publications reporting empirical research findings will be conducted. This literature will be identified by searching five databases: Medline (Ovid), PsycINFO, CINAHL, Embase (Ovid) and Scopus. The search will be restricted to articles published between January 2000 and April 2019. Two reviewers will independently screen publications in two successive stages of title and abstract screening, followed by full-text screening of eligible publications. A tabular summary and narrative synthesis will be completed using data extracted from each included study. A framework synthesis will also be conducted, with descriptions of interventions mapped against a theoretical framework of integrated care.

ETHICS AND DISSEMINATION

This review will identify the extent and nature of empirical investigations evaluating interventions to integrate care for people with SMI/SUDs. Ethical approval was not required. A team of relevant stakeholders, including people with lived experience of mental health conditions, has been established. This team will be engaged throughout the review and will ensure that the findings are widely disseminated. Dissemination will include publication of the review in a peer-reviewed journal. The review protocol has been registered through Open Science Framework and can be accessed at https://osf.io/njkph/.

Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice

Background

Primary health professionals are well positioned to support the delivery of patient self-management in an evidence-based, structured capacity. A need exists to better understand the active components required for effective self-management support, how these might be delivered within primary care, and the training and system changes that would subsequently be needed.

Objectives

(1) To examine self-management support interventions in primary care on health outcomes for a wide range of diseases compared to usual standard of care; and (2) To identify the effective strategies that facilitate positive clinical and humanistic outcomes in this setting.

Method

A systematic review of randomized controlled trials evaluating self-management support interventions was conducted following the Cochrane handbook & PRISMA guidelines. Published literature was systematically searched from inception to June 2019 in PubMed, Scopus and Web of Science. Eligible studies assessed the effectiveness of individualized interventions with follow-up, delivered face-to-face to adult patients with any condition in primary care, compared with usual standard of care. Matrices were developed that mapped the evidence and components for each intervention. The methodological quality of included studies were appraised.

Results

6,510 records were retrieved. 58 studies were included in the final qualitative synthesis. Findings reveal a structured patient-provider exchange is required in primary care (including a one-on-one patient-provider consultation, ongoing follow up and provision of self-help materials). Interventions should be tailored to patient needs and may include combinations of strategies to improve a patient’s disease or treatment knowledge; independent monitoring of symptoms, encouraging self-treatment through a personalized action plan in response worsening symptoms or exacerbations, psychological coping and stress management strategies, and enhancing responsibility in medication adherence and lifestyle choices. Follow-up may include tailored feedback, monitoring of progress with respect to patient set healthcare goals, or honing problem-solving and decision-making skills. Theoretical models provided a strong base for effective SMS interventions. Positive outcomes for effective SMS included improvements in clinical indicators, health-related quality of life, self-efficacy (confidence to self-manage), disease knowledge or control. An SMS model has been developed which sets the foundation for the design and evaluation of practical strategies for the construct of self-management support interventions in primary healthcare practice.

Conclusions

These findings provide primary care professionals with evidence-based strategies and structure to deliver SMS in practice. For this collaborative partnership approach to be more widely applied, future research should build on these findings for optimal SMS service design and upskilling healthcare providers to effectively support patients in this collaborative process.

Application of Community-Engaged Research to Inform the Development and Implementation of a Peer-Delivered Mobile Health Intervention for Adults With Serious Mental Illness

Background

Involving certified peer specialists in all phases of intervention development and research is a high priority to advance peer-delivered services. Certified peer specialists are individuals with a lived experience of a mental illness, and they are trained and accredited to provide Medicaid reimbursable mental health services. Community-engaged research can facilitate the development and implementation of peer-delivered interventions; however, little is known about the processes. We present our application of community-engaged research to inform the development and implementation of a peer-delivered mobile health (mHealth) intervention for adults with serious mental illness.

Objective

The aim of this study was to present a framework that can be used as a guide for researchers and certified peer specialists to develop and implement peer-delivered mHealth interventions in community settings.

Methods

Informed by principles of community-engaged research, we developed the Academic Researchers-Certified Peer Specialists mHealth Research Continuum. Principles of community-engaged research included in the Continuum include the following: (1) develop a clear understanding of the purpose, goal, and population involved in community change; (2) become knowledgeable about all aspects of the community; (3) interact and establish relationships with the community; (4) encourage community self-determination; (5) partner with the community; (6) respect community diversity and culture; (7) activate community assets and develop capacity; (8) maintain flexibility; and (9) commit to long-term collaboration.

Results

Overall, 4 certified peer specialists participated in all phases of intervention development and research. Individuals who participated in the Academic Researchers-Certified Peer Specialists' mHealth Research Continuum collaborated on 5 studies advancing peers' roles in services delivery using mHealth and secured grant funding from a foundation to sustain their study. The Academic Researchers-Certified Peer Specialists' mHealth Research Continuum has created a rare environment of inclusion by combining scientific expertise and certified peer specialists' expertise to achieve a shared vision.

Conclusions

This study delineates a process by which academic researchers and certified peer specialists participated in community-engaged research to develop and implement peer-delivered mHealth interventions in community settings.

Text message exchanges between older adults with serious mental illness and older certified peer specialists in a smartphone-supported self-management intervention

OBJECTIVE

To identify the strategies peer specialists use to provide illness self-management support for older adults with serious mental illness (SMI) through text messaging.

METHOD

Transcripts of text message exchanges between 8 older adult participants with SMI who completed the PeerTECH intervention and 3 older adult certified peer specialists who delivered the 12-week program were analyzed. Text message analyses explored themes relevant to peer support and health behavior change. Quantitative data comprised frequency of text messages by either the peer or consumer.

RESULTS

Consumers (N = 8) had a mean age of 68.8 years (SD = 4.9) and were mainly women (88%), White (100%), and married (75%). Certified peer specialists (N = 3) were all 55 or older; 100% were female, 66% identified as White, and 33% identified as African American. Overall, peers sent 215 text messages whereas consumers sent 141 text messages. In the peer specialist-consumer text message exchanges, we identified 4 themes on different aspects of illness self-management, including health behavior change, self-management therapeutic techniques, engagement in health technology, and peer support.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This exploratory qualitative study offers preliminary support that peers are able to use text messages to support the delivery of a peer-delivered home-based medical and psychiatric self-management intervention. Certified peer specialists can potentially provide a range of illness self-management support to older adults with SMI via text messaging. These findings will inform the development of standardized peer text-messaging services to augment evidence-based illness self-management interventions for older adults with SMI. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Prevalence rates of arthritis among US older adults with varying degrees of depression: Findings from the 2011 to 2014 National Health and Nutrition Examination Survey

OBJECTIVE

Arthritis and depressive symptoms often interact and negatively influence one another to worsen mental and physical health outcomes. Better characterization of arthritis rates among older adults with different levels of depressive symptoms is an important step toward informing mental health professionals of the need to detect and respond to arthritis and related mental health complications. The primary objective is to determine arthritis rates among US older adults with varying degrees of depression.

METHODS

Using National Health and Nutrition Examination Survey 2011 to 2014 data (N = 4792), we first identified participants aged ≥50 years. Measures screened for depressive symptoms and self-reported doctor-diagnosed arthritis. Weighted logistic regression models were conducted.

RESULTS

Prevalence of arthritis was 55.0%, 62.9%, and 67.8% in participants with minor, moderate, and severe depression, respectively. In both unadjusted and adjusted regression models, a significant association between moderate depression and arthritis persisted. There were also significant associations between minor and severe depression with arthritis.

CONCLUSIONS

Arthritis is commonly reported in participants with varying degrees of depression. This study highlights the importance of screening for and treating arthritis-related pain in older adults with depressive symptoms and the need for future geriatric psychiatry research on developing integrated biopsychosocial interventions for these common conditions.

Certified Peer Specialists and Older Adults With Serious Mental Illness' Perspectives of the Impact of a Peer-Delivered and Technology-Supported Self-Management Intervention

We explored the perspectives of certified peer specialists and older adults with serious mental illness on the impact of a peer-delivered medical and psychiatric self-management intervention, "PeerTECH." Transcripts from interviews with consumers with serious mental illness and a focus group with certified peer specialists who were engaged in PeerTECH were analyzed. Consumer participants (n = 8) had a mean age of 68.8 years (SD = 4.9) and included individuals diagnosed with major depressive disorder (five people), schizophrenia spectrum disorders (two people), and bipolar disorder (one person). Certified peer specialists (n = 3) were aged 55 years or more. Themes included internal and external forces of accountability, confidence, internal and external locus of hope, human bonding, and peer support. This exploratory qualitative study found that human support from peers can potentially influence health behavioral change in a combined peer and technology-based medical and psychiatric illness self-management intervention.

Race analysis in an African American sample with serious mental illness and comorbid diabetes

OBJECTIVES

Targeted Training in Illness Management (TTIM) focuses on enhancing care engagement for people living with serious mental illness and diabetes. This secondary analysis from a 60-week, randomized controlled trial of TTIM versus treatment as usual evaluated racial subgroup outcomes.

METHOD

Demographics, clinical characteristics, and diabetes status were evaluated for those self-identifying as non-Hispanic White, African American, and Hispanic. Longitudinal response to TTIM was evaluated using a multiple domain risk index. Due to their small sample size; those identifying as Hispanic were excluded from this analysis.

RESULTS

Non-Hispanic White participants had greater baseline socioeconomic advantages. Baseline risk scores, glycosylated hemoglobin (HbA1c) values, and HbA1c differences over time were similar for African American and non-Hispanic White participants.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

African American participants living with serious mental illness and diabetes receiving TTIM did as well as non-Hispanic White participants. Inclusive approaches that feature peer support and are situated in safety-net health care settings need to be further investigated with respect to potentially impacting health disparities. (PsycINFO Database Record

Feasibility, Acceptability, and Preliminary Effectiveness of a Peer-Delivered and Technology Supported Self-Management Intervention for Older Adults with Serious Mental Illness

To assess the feasibility, acceptability, and preliminary effectiveness of a peer-delivered and technology supported integrated medical and psychiatric self-management intervention for older adults with serious mental illness. Ten older adults with serious mental illness (i.e., schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder) and medical comorbidity (i.e., cardiovascular disease, obesity, diabetes, chronic obstructive pulmonary disease, hypertension, and/or high cholesterol) aged 60 years and older received the PeerTECH intervention in their homes. Three certified peer specialists were trained to deliver PeerTECH. Data were collected at baseline, one-month, and three-month. The pilot study demonstrated that a three-month, peer-delivered and technology-supported integrated medical and psychiatric self-management intervention ("PeerTECH") was experienced by peer specialists and participants as feasible and acceptable. PeerTECH was associated with statistically significant improvements in psychiatric self-management. In addition, pre/post, non-statistically significant improvements were observed in self-efficacy for managing chronic health conditions, hope, quality of life, medical self-management skills, and empowerment. This pre/post pilot study demonstrated it is possible to train peers to use technology to deliver an integrated psychiatric and medical self-management intervention in a home-based setting to older adults with serious mental illness with fidelity. These findings provide preliminary evidence that a peer-delivered and technology-supported intervention designed to improve medical and psychiatric self-management is feasible, acceptable, and is potentially associated with improvements in psychiatric self-management, self-efficacy for managing chronic health conditions, hope, quality of life, medical self-management skills, and empowerment with older adults with serious mental illness and chronic health conditions.

Self-management assessment in multiple chronic conditions: A narrative review of literature

OBJECTIVES

Effective self-management in individuals with multiple chronic conditions is necessary to optimize health outcomes. Self-management in multiple chronic conditions involves an iterative process prioritizing multiple changing needs/conditions. However, self-management in multiple chronic conditions has been assessed with instruments designed to assess self-management of a single chronic illness. The instruments may not address the complexity of self-management in multiple chronic conditions. Thus, this review aimed to examine how self-management has been operationalized in the context of multiple chronic conditions.

DESIGN

A narrative review method was used.

DATA SOURCE

The online databases, Pubmed, CINAHL Plus, and PsycInfo, were searched. The search was conducted of the database from January 2006 through November 2017.

REVIEW METHODS

Peer-reviewed research articles which operationalized self-management in adults with at least two or more chronic illnesses were selected for review. Two reviewers read full text of selected articles and extracted data regarding operational definitions of self-management and instruments used to assess self-management. Operational definitions were categorized to conceptualize how self-management has been assessed.

RESULTS

A total of seven peer-reviewed research articles were selected for inclusion. This review found that self-management has been assessed through prerequisites of self-management and behaviors involved in self-management. Prerequisites of self-management included attitude, self-efficacy, perceived ability, and knowledge. Behaviors included an individual's engagement in self-management such as health-related behaviors, health service use, and medication adherence.

CONCLUSIONS

This review revealed that current literature does not operationalize self-management in multiple chronic conditions as a process, indicating incomplete assessments of self-management. To obtain a more comprehensive understanding of self-management in multiple chronic conditions, future studies should consider self-management as an iterative process in addition to prerequisites for self-management and behaviors. Such studies will inform the development of patient-centered self-management interventions for individuals with multiple chronic conditions.

Integrated Care for Older Adults with Serious Mental Illness and Medical Comorbidity: Evidence-Based Models and Future Research Directions

The excess risk of early mortality, medical comorbidity, early institutionalization, and high costs among older adults with serious mental illness necessitates development and dissemination of effective and sustainable integrated care models that simultaneously address mental and physical health needs. This overview highlights current, evidence-based integrated care models, which predominantly adopt the following approaches: (1) psychosocial skills training, (2) integrated illness self-management, and (3) collaborative care and behavioral health homes. Finally, innovative models that build on these approaches by incorporating novel uses of telehealth, mobile health technology and peer support, and strategies from developing economies are discussed.

Integrated Care to Address the Physical Health Needs of People with Severe Mental Illness: A Mapping Review of the Recent Evidence on Barriers, Facilitators and Evaluations

People with mental health conditions have a lower life expectancy and poorer physical health outcomes than the general population. Evidence suggests this is due to a combination of clinical risk factors, socioeconomic factors, and health system factors, notably a lack of integration when care is required across service settings. Several recent reports have looked at ways to better integrate physical and mental health care for people with severe mental illness (SMI). We built on these by conducting a mapping review that looked for the most recent evidence and service models in this area. This involved searching the published literature and speaking to people involved in providing or using current services. Few of the identified service models were described adequately and fewer still were evaluated, raising questions about the replicability and generalisability of much of the existing evidence. However, some common themes did emerge. Efforts to improve the physical health care of people with SMI should empower staff and service users and help remove everyday barriers to delivering and accessing integrated care. In particular, there is a need for improved communication among professionals and better information technology to support them, greater clarity about who is responsible and accountable for physical health care, and greater awareness of the effects of stigmatisation on the wider culture and environment in which services are delivered.

Impact of serious mental illness online training for certified nursing assistants in long term care

Certified nurse assistants (CNAs) spend the most staff time with nursing home residents, yet they receive little training in addressing the mental health needs of residents with serious mental illness (SMI). Forty CNAs from four long-term-care facilities took the online interactive CARES-^® Serious Mental Illness^™ training consisting of two modules guided by the Recovery Movement philosophy of care. Responses from pre-post testing, Likert-type items, and open-ended questions indicated that CNAs gained information, changed their perspectives, and had more confidence in dealing with SMI. Although there were minor concerns regarding length, clarity of content, and technical issues, CNAs found the online format acceptable and easy to use, and many said they would recommend the training. CARES Serious Mental Illness online training appears to be a viable way of helping CNAs address the mental health needs of long term care residents. Additional testing on CARES Serious Mental Illness is planned.

Adapting a Psychosocial Intervention for Smartphone Delivery to Middle-Aged and Older Adults with Serious Mental Illness

OBJECTIVE

To describe the process of adapting an integrated medical and psychiatric self-management intervention to a smartphone application for middle-aged and older adults with serious mental illness using an adaptive systems engineering framework and user-centered design.

METHODS

First, we determined the technical abilities and needs of middle-aged and older adults with serious mental illnesses using smartphones. Then, we developed smartphone content through principles of user-centered design and modified an existing smartphone platform. Finally, we conducted a usability test using "think aloud" and verbal probing.

RESULTS

We adapted a psychosocial self-management intervention to a smartphone application and tested its usability. Ten participants (mean age: 55.3 years, SD: 6.2 years) with serious mental illness and comorbid chronic health conditions reported a high level of usability and satisfaction with the smartphone application.

CONCLUSIONS

Middle-aged and older adults with serious mental illness and limited technical abilities were able to participate in a process involving user-centered design and adaptation of a self-management intervention to be delivered by a smartphone. High usability ratings suggest that middle-aged and older adults with serious mental illness have the potential to use tailored smartphone interventions. Future research is indicated to establish effectiveness and to determine the type and intensity of clinical support needed to successfully implement smartphone applications as a component of community-based services for older adults with psychiatric and medical conditions.

Systematic Review of Integrated General Medical and Psychiatric Self-Management Interventions for Adults With Serious Mental Illness

OBJECTIVE

Adults with serious mental illness are disproportionately affected by general medical comorbidity, earlier onset of disease, and premature mortality. Integrated self-management interventions have been developed to address both general medical and psychiatric illnesses. This systematic review examined evidence about the effect of self-management interventions that target both general medical and psychiatric illnesses and evaluated the potential for implementation.

METHODS

Databases, including CINAHL, Cochrane Central, Ovid MEDLINE, PsycINFO, and Web of Science, were searched for articles published between 1946 and July 2015. Studies evaluating integrated general medical and psychiatric self-management interventions for adults with schizophrenia spectrum or mood disorders and general medical comorbidity were included.

RESULTS

Fifteen studies (nine randomized controlled trials and six pre-post designs) reported on nine interventions: automated telehealth, Health and Recovery Peer program, Helping Older People Experience Success, Integrated Illness Management and Recovery, Life Goals Collaborative Care, Living Well, Norlunga Chronic Disease Self-Management program, Paxton House, and Targeted Training in Illness Management. Most studies demonstrated feasibility, acceptability, and preliminary effectiveness; however, clinical effectiveness could not be established in most studies because of methodological limitations. Factors identified that may deter implementation included operating costs, impractical length, and workforce requirements.

CONCLUSIONS

Integrated general medical and psychiatric illness self-management interventions appear feasible and acceptable, with high potential for clinical effectiveness. However, implementation factors were rarely considered in intervention development, which may contribute to limited uptake and reach in real-world settings.

Integrated care to address the physical health needs of people with severe mental illness: a rapid review

Background

People with mental health conditions have a lower life expectancy and poorer physical health outcomes than the general population. Evidence suggests that this discrepancy is driven by a combination of clinical risk factors, socioeconomic factors and health system factors.

Objective(s)

To explore current service provision and map the recent evidence on models of integrated care addressing the physical health needs of people with severe mental illness (SMI) primarily within the mental health service setting. The research was designed as a rapid review of published evidence from 2013–15, including an update of a comprehensive 2013 review, together with further grey literature and insights from an expert advisory group.

Synthesis

We conducted a narrative synthesis, using a guiding framework based on nine previously identified factors considered to be facilitators of good integrated care for people with mental health problems, supplemented by additional issues emerging from the evidence. Descriptive data were used to identify existing models, perceived facilitators and barriers to their implementation, and any areas for further research.

Findings and discussion

The synthesis incorporated 45 publications describing 36 separate approaches to integrated care, along with further information from the advisory group. Most service models were multicomponent programmes incorporating two or more of the nine factors: (1) information sharing systems; (2) shared protocols; (3) joint funding/commissioning; (4) colocated services; (5) multidisciplinary teams; (6) liaison services; (7) navigators; (8) research; and (9) reduction of stigma. Few of the identified examples were described in detail and fewer still were evaluated, raising questions about the replicability and generalisability of much of the existing evidence. However, some common themes did emerge from the evidence. Efforts to improve the physical health care of people with SMI should empower people (staff and service users) and help remove everyday barriers to delivering and accessing integrated care. In particular, there is a need for improved communication between professionals and better information technology to support them, greater clarity about who is responsible and accountable for physical health care, and awareness of the effects of stigmatisation on the wider culture and environment in which services are delivered.

Limitations and future work

The literature identified in the rapid review was limited in volume and often lacked the depth of description necessary to acquire new insights. All members of our advisory group were based in England, so this report has limited information on the NHS contexts specific to Scotland, Wales and Northern Ireland. A conventional systematic review of this topic would not appear to be appropriate in the immediate future, although a more interpretivist approach to exploring this literature might be feasible. Wherever possible, future evaluations should involve service users and be clear about which outcomes, facilitators and barriers are likely to be context-specific and which might be generalisable.

Funding

The research reported here was commissioned and funded by the Health Services and Delivery Research programme as part of a series of evidence syntheses under project number 13/05/11. For more information visitwww.nets.nihr.ac.uk/projects/hsdr/130511.

Crowdsourcing for conducting randomized trials of internet delivered interventions in people with serious mental illness: A systematic review

OBJECTIVE

Online crowdsourcing refers to the process of obtaining needed services, ideas, or content by soliciting contributions from a large group of people over the Internet. We examined the potential for using online crowdsourcing methods for conducting behavioral health intervention research among people with serious mental illness (SMI).

METHODS

Systematic review of randomized trials using online crowdsourcing methods for recruitment, intervention delivery, and data collection in people with SMI, including schizophrenia spectrum disorders and mood disorders. Included studies were completed entirely over the Internet without any face-to-face contact between participants and researchers.

DATABASES AND SOURCES

Medline, Cochrane Library, Web of Science, CINAHL, Scopus, PsychINFO, Google Scholar, and reference lists of relevant articles.

RESULTS

We identified 7 randomized trials that enrolled N=1214 participants (range: 39 to 419) with SMI. Participants were mostly female (72%) and had mood disorders (94%). Attrition ranged from 14% to 81%. Three studies had attrition rates below 25%. Most interventions were adapted from existing evidence-based programs, and consisted of self-directed education, psychoeducation, self-help, and illness self-management. Six studies collected self-reported mental health symptoms, quality of life, and illness severity. Three studies supported intervention effectiveness and two studies showed improvements in the intervention and comparison conditions over time. Peer support emerged as an important component of several interventions. Overall, studies were of medium to high methodological quality.

CONCLUSION

Online crowdsourcing methods appear feasible for conducting intervention research in people with SMI. Future efforts are needed to improve retention rates, collect objective outcome measures, and reach a broader demographic.

The Affordable Care Act, Accountable Care Organizations, and Mental Health Care for Older Adults: Implications and Opportunities

The Patient Protection and Affordable Care Act (ACA) represents the most significant legislative change in the United States health care system in nearly half a century. Key elements of the ACA include reforms aimed at addressing high-cost, complex, vulnerable patient populations. Older adults with mental health disorders are a rapidly growing segment of the population and are among the most challenging subgroups within health care, and they account for a disproportionate amount of costs. What does the ACA mean for geriatric mental health? We address this question by highlighting opportunities for reaching older adults with mental health disorders by leveraging the diverse elements of the ACA. We describe nine relevant initiatives: (1) accountable care organizations, (2) patient-centered medical homes, (3) Medicaid-financed specialty health homes, (4) hospital readmission and health care transitions initiatives, (5) Medicare annual wellness visit, (6) quality standards and associated incentives, (7) support for health information technology and telehealth, (8) Independence at Home and 1915(i) State Plan Home and Community-Based Services program, and (9) Medicare-Medicaid Coordination Office, Center for Medicare and Medicaid Innovation, and the Patient-Centered Outcomes Research Institute. We also consider potential challenges to full implementation of the ACA and discuss novel solutions for advancing geriatric mental health in the context of projected workforce shortages and the opportunities afforded by the ACA.

Factor structure of the autonomy preference index in people with severe mental illness

People vary in the amount of control they want to exercise over decisions about their healthcare. Given the importance of patient-centered care, accurate measurement of these autonomy preferences is critical. This study aimed to assess the factor structure of the Autonomy Preference Index (API), used widely in general healthcare, in individuals with severe mental illness. Data came from two studies of people with severe mental illness (N=293) who were receiving mental health and/or primary care/integrated care services. Autonomy preferences were assessed with the API regarding both psychiatric and primary care services. Confirmatory factor analysis was used to evaluate fit of the hypothesized two-factor structure of the API (decision-making autonomy and information-seeking autonomy). Results indicated the hypothesized structure for the API did not adequately fit the data for either psychiatric or primary care services. Three problematic items were dropped, resulting in adequate fit for both types of treatment. These results suggest that with relatively minor modifications the API has an acceptable factor structure when asking people with severe mental illness about their preferences to be involved in decision-making. The modified API has clinical and research utility for this population in the burgeoning field of autonomy in patient-centered healthcare.

Treating complexity: collaborative care for multiple chronic conditions

Individuals with co-morbid chronic medical illness and psychiatric illness are a costly and complex patient population, at high risk for poor outcomes. Health-risk behaviours (e.g. smoking, poor diet, and sedentary lifestyle), side effects from psychiatric medications, and poor quality medical care all contribute to poor outcomes. Individuals with major depression die, on average, 5 to 10 years before their age-matched counterparts. For individuals with severe mental illness such as bipolar disorder or schizophrenia, life expectancy may be up to 20 years shorter. As the majority of this premature mortality is due to cardiovascular disease, there is a critical need to engage these individuals around the care of chronic medical illness.

Automated telehealth for managing psychiatric instability in people with serious mental illness

BACKGROUND

Serious mental illness (SMI) with psychiatric instability accounts for disproportionately high use of emergency room visits and hospitalizations.

AIM

To evaluate the effectiveness of an automated telehealth intervention supported by nurse health care management for improving psychiatric illness management and reducing acute service use among individuals with SMI and psychiatric instability.

METHODS

Thirty-eight individuals with SMI received the automated telehealth intervention for 6 months. Psychiatric symptoms, illness self-management, and self-reported service use (emergency room visits and hospital admissions) were collected at baseline, 3- and 6-months. Measures of quality of life, health indicators, and subjective health status were also collected.

RESULTS

Participants demonstrated improvements in self-reported psychiatric symptoms and illness self-management skills, an 82% decrease in hospital admissions (from 76 to 14 hospitalizations, p < 0.001) and a 75% decrease in emergency room visits (from 63 to 16 visits, p < 0.001). Improvements were also observed in quality of life, severity of depressive symptoms, and mental health status.

CONCLUSION

These highly promising findings support the use of an automated telehealth device monitored by a nurse care manager for people with SMI, and highlight the potential for cost savings through reductions in acute health care utilization.

The Paradox of Scarcity in a Land of Plenty: Meeting the Needs of Older Adults with Mental Health and Substance Use Disorders

Between the ACA, innovative strategies to create a new type of workforce, and technology, we have a chance to redesign healthcare to adequately address physical and mental health.