Continuity of care for people with non-psychotic disorders

Factors Associated with Perceived Continuity of Care Among Patients Suffering from Mental Disorders

This cross-sectional study identified variables associated with continuity of care among 327 patients with mental disorders receiving services from a variety of professionals in different Quebec settings. Based on the Andersen's Behavioral Model, a linear regression analysis was performed. Attention deficit and mood disorders were negatively associated with continuity of care, while substance use disorders and quality of life revealed positive associations. Consulting a psychologist was linked to weaker continuity of care whereas visiting a drug rehabilitation center, social support, and satisfaction with services were positively related. Fostering social support, comprehensive and integrated care, and facilitating access to psychologists could lead to improved continuity of care.

Typology of patients with mental health disorders and perceived continuity of care

Background: While multiple socio-demographic, clinical and service use variables have been associated with continuity of care (CoC) in patients diagnosed with mental health disorders (MHDs), little is known about how these variables may inform clinical practice and service planning.Aim: This article identified profiles of patients with MHDs to better understand their perceptions of CoC.Method: The sample for this cross-sectional study comprised 327 patients recruited by staff or self-referred from four local health networks in Quebec (Canada). Data were collected using standardized instruments, and patient medical records. A three-factor conceptual framework based on Andersen's Behavioral Model was used, integrating predisposing, needs and enabling factors.Results: Cluster analyses identified five patient profiles. Profiles that included relatively more patients with common MHDs reported less continuity than those with patients primarily affected by severe MHDs.Conclusions: Service planning and delivery should be better adapted to patient profiles in order to improve CoC, and increased access to services prioritized.

Quality of life and service satisfaction in outpatients with severe or non-severe mental illness diagnoses

Purpose

Our study investigated quality of life (QoL) in patients with severe or non-severe mental illness diagnoses (SMI and non-SMI) and the association between QoL and service satisfaction measured as patients’ perception of continuity of care (CoC), therapeutic relationship, and unmet service needs.

Methods

We conducted a national cross-sectional survey among 3836 mental health outpatients, of whom 1327 (34.6%) responded. We assessed QoL with the Manchester Short Assessment of Quality of Life (MANSA), CoC with the CONTINUUM, the therapeutic relationship with the Therapeutic Relationship in Community Mental Health Care (STAR-P) and developed a simple scale to measure unmet service needs.

Results

Outpatients with SMI (n = 155) reported significantly better QoL than those with non-SMI (n = 835) (p = 0.003). In both groups, QoL was positively associated with cohabitation (p = 0.007 for non-SMI and p = 0.022 for SMI), good contact with family and friends (p < 0.001 for both) and positive ratings of CoC (p < 0.001 for non-SMI and p = 0.008 for SMI). A positive association between QoL and therapeutic relationship (p = 0.001) and a negative association between QoL and unmet needs for treatment (p = 0.009) and activity (p = 0.005) was only found in the non-SMI group.

Conclusion

Our study highlights the important differences between those with SMI and those with non-SMI in their reported QoL and in the relationship between QoL and service satisfaction, with only non-SMI patients’ QoL influenced by the therapeutic relationship and unmet needs for treatment and activity. It also shows the importance of continuity of care and social factors for good QoL for both groups.

Coercion in mental health: a trial of the effectiveness of community treatment orders and an investigation of informal coercion in community mental health care

Background

Coercion comprisesformal coercionorcompulsion[treatment under a section of the Mental Health Act (MHA)] andinformal coercion(a range of treatment pressures, includingleverage). Community compulsion was introduced in England and Wales as community treatment orders (CTOs) in 2008, despite equivocal evidence of effectiveness. Little is known about the nature and operation of informal coercion.

Design

The programme comprised three studies, with associated substudies: Oxford Community Treatment Order Evaluation Trial (OCTET) – a study of CTOs comprising a randomised controlled trial comparing treatment on CTO to voluntary treatment via Section 17 Leave (leave of absence during treatment under section of the MHA), with 12-month follow-up, an economic evaluation, a qualitative study, an ethical analysis, the development of a new measure of capabilities and a detailed legal analysis of the trial design; OCTET Follow-up Study – a follow-up at 36 months; and Use of Leverage Tools to Improve Adherence in community Mental Health care (ULTIMA) – a study of informal coercion comprising a quantitative cross-sectional study of leverage, a qualitative study of patient and professional perceptions, and an ethical analysis.

Participants

Participants in the OCTET Study were 336 patients with psychosis diagnoses, currently admitted involuntarily and considered for ongoing community treatment under supervision. Participants in the ULTIMA Study were 417 patients from Assertive Outreach Teams, Community Mental Health Teams and substance misuse services.

Outcomes

The OCTET Trial primary outcome was psychiatric readmission. Other outcomes included measures of hospitalisation, a range of clinical and social measures, and a newly developed measure of capabilities – the Oxford Capabilities Questionnaire – Mental Health. For the follow-up study, the primary outcome was the level of disengagement during the 36 months.

Results

Community treatment order use did not reduce the rate of readmission [(59 (36%) of 166 patients in the CTO group vs. 60 (36%) of 167 patients in the non-CTO group; adjusted relative risk 1.0 (95% CI 0.75 to 1.33)] or any other outcome. There were no differences for any subgroups. There was no evidence that it might be cost-effective. Qualitative work suggested that CTOs’ (perceived) focus on medication adherence may influence how they are experienced. No general ethical justification was found for the use of a CTO regime. At 36-month follow-up, only 19 patients (6% of 329 patients) were no longer in regular contact with services. Longer duration of compulsion was associated with longer time to disengagement (p = 0.023) and fewer periods of discontinuity (p < 0.001). There was no difference in readmission outcomes over 36 months. Patients with longer CTO duration spent fewer nights in hospital. One-third (35%) of the ULTIMA sample reported lifetime experiences of leverage, lower than in the USA (51%), but patterns of leverage experience were similar. Reporting leverage made little difference to patients’ perceived coercion. Patients’ experiences of pressure were wide-ranging and pervasive, and perceived to come from family, friends and themselves, as well as professionals. Professionals were committed to patient-centred approaches, but felt obliged to assert authority when patients relapsed. We propose a five-step framework for determining the ethical status of offers by mental health professionals and give detailed guidance for professionals about how to exercise leverage.

Conclusions

Community Treatment Orders do not deliver clinical or social functioning benefits for patients. In the absence of further trials, moves should be made to restrict or stop their use. Informal coercion is widespread and takes different forms.

Trial registration

Current Controlled Trials ISRCTN73110773.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Defining continuity of care from the perspectives of mental health service users and professionals: an exploratory, comparative study

Background

Continuity of care (COC) is central to the organization and delivery of mental health services. Traditional definitions have excluded service users, and this lack of involvement has been linked to poor conceptual clarity surrounding the term. Consequently, very little is known about the differences and similarities in the conceptualization of COC by mental health service users and professionals.

Objective

To explore and compare mental health service users’ and professionals’ definitions of COC.

Methods

Using an exploratory, qualitative design, five focus groups with 32 service users each met twice. Data were analysed thematically to generate a service user‐defined model of COC. In a cross‐sectional survey, health and social care professionals (n = 184) defined COC; responses were analysed thematically. Service user and professional definitions were conceptually mapped and compared to identify similarities and differences.

Results

There was crossover between the service user and professional derived models of COC. Both contained temporal, quality, systemic, staff, hospital and needs‐related elements of COC. Service users prioritized access, information, peer support and avoiding services; health professionals most frequently referred to staff, cross‐sectional and temporal COC. Service users alone identified service avoidance, peer support and day centres as COC elements; professionals alone identified cross‐sectional working.

Conclusions

Important similarities and differences exist in service user and professional conceptualizations of COC. Further research is necessary to explore these differences, prior to integrating service user and professional perspectives in a validated COC framework which could enable the development and evaluation of interventions to improve COC, informing policy and practice.

The effects of motivation feedback in patients with severe mental illness: a cluster randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of providing clinicians with regular feedback on the patient's motivation for treatment in increasing treatment engagement in patients with severe mental illness.

DESIGN

cluster randomized controlled trial (Dutch Trials Registry NTR2968).

PARTICIPANTS

adult outpatients with a primary diagnosis of a psychotic disorder or a personality disorder and their clinicians, treated in 12 community mental health teams (the clusters) of two mental health institutions in the Netherlands.

INTERVENTIONS

monthly motivation feedback (MF) generated by clinicians additional to treatment as usual (TAU) and TAU by the community mental health teams.

PRIMARY OUTCOME

treatment engagement at patient level, assessed at 12 months by clinicians.

RANDOMIZATION

teams were allocated to MF or TAU by a computerized randomization program that randomized each team to a single treatment by blocks of varying size. All participants within these teams received similar treatment. Clinicians and patients were not blind to treatment allocation at the 12-month assessment.

RESULTS

The 294 randomized patients (148 MF, 146 TAU) and 57 clinicians (29 MF, 28 TAU) of 12 teams (6 MF, 6 TAU) were analyzed according to the intention-to-treat principle. No statistically significant differences between treatment groups on treatment engagement were found (adjusted mean difference =0.1, 95% confidence interval =-2.2 to 2.3, P=0.96, d=0). Preplanned ancillary analyses showed statistically significant interaction effects between treatment group and primary diagnosis on treatment motivation and quality of life (secondary outcomes), which were beneficial for patients with a primary diagnosis of a personality disorder but not for those with a psychotic disorder. There were no reports of adverse events.

CONCLUSION

The current findings imply that monitoring and discussing the patient's motivation is insufficient to improve motivation and treatment engagement, and suggests that more elaborate interventions for severe mental illness patients are needed.

Continuity of care for carers of people with severe mental illness: results of a longitudinal study

INTRODUCTION

Continuity of care has been demonstrated to be important for service users and carer groups have voiced major concerns over disruptions of care. We aimed to assess the experienced continuity of care in carers of patients with both psychotic and non-psychotic disorders and explore its association with carer characteristics and psychological well-being.

METHODS

Friends and relatives caring for two groups of service users in the care of community mental health teams (CMHTs), 69 with psychotic and 38 with non-psychotic disorders, were assessed annually at three and two time points, respectively. CONTINUES, a measure specifically designed to assess continuity of care for carers themselves, was utilized along with assessments of psychological well-being and caregiving.

RESULTS

One hundred and seven carers participated. They reported moderately low continuity of care. Only 22 had had a carer's assessment and just under a third recorded psychological distress on the GHQ. For those caring for people with psychotic disorders, reported continuity was higher if the carer was male, employed, lived with the user and had had a carer's assessment; for those caring for people with non-psychotic disorders, it was higher if the carer was from the service user's immediate family, lived with them and had had a carer's assessment.

CONCLUSION

The vast majority of the carers had not had a carer's assessment provided by the CMHT despite this being a clear national priority and being an intervention with obvious potential to increase carers' reported low levels of continuity of care. Improving continuity of contact with carers may have an important part to play in the overall improvement of care in this patient group and deserves greater attention.