Evaluating the Health of the Nation Outcome Scales. Reliability and validity in a three-year follow-up of first-onset psychosis

Predictors of disengagement from cognitive behavioural therapy for psychosis in a National Health Service setting: A retrospective evaluation

OBJECTIVES

To evaluate whether demographic and clinical variables are related to disengagement rates in cognitive behavioural therapy (CBT) for psychosis in a clinical setting.

METHODS

The medical records and symptom severity data (from Health of the Nation Outcome Scales) were analysed retrospectively for 103 referrals for CBT for psychosis in a National Health Service secondary care and Early Intervention in Psychosis team.

RESULTS

Overall, 42.7% (n = 44) disengaged from CBT. There was no impact of gender or ethnicity, and no impact of clinical variables such as risk history and comorbid diagnosis. However, risk of disengagement was significantly higher for those who were younger, F = 6.89, partial η²  = .064, p = <.05; those with greater total HoNOS scores, F = 4.22, partial η²  = .04, p < .05; more severe symptoms on the HoNOS items of overactive, aggressive, disruptive, or agitated behaviour, χ²  = 6.13, p < .01; problem drinking or drug taking, χ²  = 7.65, p < .05; depressed mood, χ²  = 7.0, p < .01; and problems with occupation and activities: χ²  = 3.68, p < .05. There was a non-significant trend for shorter waiting times to be associated with greater levels of disengagement.

CONCLUSIONS

These results indicate that it may not be psychosis per se that disrupts engagement in CBT, but linked behavioural and emotional factors. A more assertive approach to these factors - overactive, aggressive, disruptive, or agitated behaviour, problem drinking or drug taking, depressed mood, and problems with occupation and activities, particularly in younger people - may be valuable prior to or early on in therapy as a means of increasing engagement in CBT for psychosis.

PRACTITIONER POINTS

Risk of disengagement from CBT for psychosis increases with overactive, aggressive, disruptive, or agitated behaviour (54.9% vs. 30.8%), problem drinking and drug taking (61.1% vs. 32.8%), depressed mood (56% vs. 30.2%), and problems with occupation and activities (53.3% vs. 34.5%), with a trend for younger age. An assertive and motivational approach to engagement and a focus on addressing low mood and problematic behaviours, prior to or early in therapy, may be warranted, particularly for younger people. This evaluation is limited by small sample size and being retrospective. These results speak to the question of whether psychosis itself renders people inappropriate for CBT for psychosis, or whether problems arise due to behavioural and emotional factors that might be addressed to increase access to CBT for psychosis.

Implementation of outcome measurement (HoNOS) in an outpatient psychiatric clinic in Sligo/Leitrim mental health service

BACKGROUND

Routine clinical outcome monitoring (RCOM) is the standardised gathering of measures of clinical outcomes in everyday practice. HoNOS (Health of the Nation Outcome Scales) is a tool used in RCOM.

AIMS

To examine (a) agreement between HoNOS and Global Assessment of Functioning (GAF), (b) HoNOS changes over time/attendance and (c) clinical parameters affecting HoNOS scores.

METHODS

Data from outpatient clinics were collected at each contact over 2 years until June 2016 including: gender, age, diagnosis (ICD-10) and HoNOS scores. In a subsample, the GAF also were completed by community psychiatric nurses blind to HoNOS scores.

RESULTS

A number of 470 outpatients have undergone 1125 HoNOS assessments during the study period. Mean age of the attendants was 43.12; SD 14.6. Male = 220 (46.8%). Longitudinal analysis demonstrated that lower HoNOS scores are independently significantly associated to number of assessments and diagnosis in ICD-10 categories of F20-F29 (Schizophrenia, schizotypal and delusional disorders) F30-F39 (mood disorders) F40-F48 (neurotic, stress-related and somatoform disorders) and F50-F59 (behavioural disorders associated with physiological disturbances). Gender and age were not significantly associated with decline of HoNOS scores. Neither were other diagnostic categories. Agreement between HoNOS and GAF was excellent (N = 261, rho = - 0.919, p < 0.001).

CONCLUSIONS

This study shows that HoNOS is a feasible instrument which can be potentially used in ROCM in mental health services in Ireland and supports further the need for implementation of routine measurements in Mental Health Services. It adds longitudinal data which is lacking in similar previous studies.

The impact of waiting time on patient outcomes: Evidence from early intervention in psychosis services in England

Recently, new emphasis was put on reducing waiting times in mental health services as there is an ongoing concern that longer waiting time for treatment leads to poorer health outcomes. However, little is known about delays within the mental health service system and its impact on patients. We explore the impact of waiting times on patient outcomes in the context of early intervention in psychosis (EIP) services in England from April 2012 to March 2015. We use the Mental Health Services Data Set and the routine outcome measure the Health of the Nation Outcome Scale. In a generalised linear regression model, we control for baseline outcomes, previous service use, and treatment intensity to account for possible endogeneity in waiting time. We find that longer waiting time is significantly associated with a deterioration in patient outcomes 12 months after acceptance for treatment for patients that are still in EIP care. Effects are strongest for waiting times longer than 3 months, and effect sizes are small to moderate. Patients with shorter treatment periods are not affected. The results suggest that policies should aim to reduce excessively long waits in order to improve outcomes for patients waiting for treatment for psychosis.

Providers' competencies positively affect personal recovery of involuntarily admitted patients with severe mental illness: A prospective observational study

OBJECTIVE

There is limited research on the patient-provider relationship in inpatient settings. The purpose of this study was to measure the effect of mental healthcare providers' recovery-promoting competencies on personal recovery in involuntarily admitted psychiatric patients with severe mental illness.

METHODS

In all, 127 Dutch patients suffering from a severe mental illness residing in a high-secure psychiatric hospital reported the degree of their personal recovery (translated Questionnaire about Processes of Recovery questionnaire (QPR)) and the degree of mental healthcare providers' recovery-promoting competence (Recovery Promoting Relationship Scale (RPRS)) at two measurement points, 6 months apart.

ANALYSES

(Mixed-effects) linear regression analysis was used to test the effect of providers' recovery-promoting competence on personal recovery, while controlling for the following confounding variables: age, gender drug/alcohol problems, social relationships, activities of daily living, treatment motivation and medication adherence.

RESULTS

Analyses revealed a significant positive effect of providers' recovery-promoting competencies on the degree of personal recovery ( t = 8.4, p < .001) and on the degree of change in personal recovery over time ( ts > 4, p < .001).

CONCLUSION

This study shows that recovery-promoting competencies of mental healthcare providers are positively associated with (a change in) personal recovery of involuntarily admitted patients. Further research is necessary on how to organize recovery-oriented care in inpatient settings and how to enhance providers' competencies in a sustainable way.

Routine measurement of mental health service outcomes: Health of the Nation Outcome Scales in Nova Scotia

Aims and Method

Although the Health of the Nation Outcome Scales (HoNOS) were designed for routine clinical use, completion rates in clinical settings rarely exceed 60%. We evaluated two initiatives to increase completion rates: timely feedback to clinicians, useful at individual, team and service levels, and improved supporting materials (tabulated glossaries for all versions covering the life-span).

Results

Clinicians in South Shore Health district provided ratings on all outpatient referrals over 12 months as part of routine care. Data were captured using the Nova Scotia routine administrative data system. Completion rates rose from 61% to 86% (n=1190). Clinicians' ratings of the instrument's ease of use were significantly improved.

Clinical Implications

Use of a tabulated glossary and enhanced feedback of clinically useful information improved clinician support for the routine measurement of health outcomes with HoNOS.

Use of Health of the Nation Outcome Scales in psychiatry

Routine outcome measures are essential to chart individual patient progress and evaluate models of service provision. The Health of the Nation Outcome Scales (HoNOS) were commissioned by the Royal College of Psychiatrists as a simple, brief measure for this purpose. It is one of the most widely used outcome measures in mental health services globally and has been translated into at least seven languages. Its use has broadened beyond its original purpose and in several countries collection of HoNOS data is mandatory. We review 585 potential articles to chart the development and evolution of HoNOS, as well as its psychometric properties, qualitative attributes and uses in clinical practice and research. The potential barriers to implementation of HoNOS on a wide scale are considered and its future role in evaluating effectiveness and benchmarking of services are discussed.

The Representativeness of Participants With Severe Mental Illness in a Psychosocial Clinical Trial

Introduction: Cardiovascular morbidity and mortality are increased in severe mental illnesses (SMI). Trials of psychosocial health interventions to improve physical health in SMI, including in treatment-resistant schizophrenia, have shown some benefit. However, the representativeness of participants in such trials has not been determined. Method: We utilized an anonymised case register to determine if participants in a randomized controlled trial (RCT) of a novel psychosocial health intervention aiming to improve physical health in SMI had similar severity of illness to eligible non-participants. A retrospective database analysis was performed, using Health of the Nation Outcome Scale (HoNOS) data from the sample of patients participating in the IMPaCT (Improving Physical health and reducing substance use in Psychosis) RCT (n = 293) compared to all eligible participants with a psychotic illness (n = 774). Results: The mean total HoNOS score in the eligible comparator population (Mean = 9.09, SD = 5.8, range = 0-30) was significantly greater than that of the IMPaCT RCT participants (Mean = 7.16, SD = 4.7, range = 0-26), (t = 3.810, p = 0.006), as was the degree of overall illness severity and functional impairment, as measured by HoNOS. Conclusion: This study shows for the first time that the patient population participating in an RCT of a lifestyle intervention for those with SMI had a better mental health status at entry to the trial, than the total eligible population, although there was no difference in physical health needs. This has relevance to the applicability of RCTs of lifestyle interventions in service planning and suggests that when people are more unwell, greater effort may be needed to include them in psychosocial interventions. A more careful and focused recruitment approach should be followed to improve the participation of the more severely ill patients in psychosocial interventions in order to enhance the external validity of such studies.

A systematic review of clinician-rated instruments to assess adults' levels of functioning in specialised public sector mental health services

BACKGROUND

Functioning is one of the key domains emphasised in the routine assessment of outcomes that has been occurring in specialised public sector mental health services across Australia since 2002, via the National Outcomes and Casemix Collection. For adult consumers (aged 18-64), the 16-item Life Skills Profile (LSP-16) has been the instrument of choice to measure functioning. However, review of the National Outcomes and Casemix Collection protocol has highlighted some limitations to the current approach to measuring functioning. A systematic review was conducted to identify, against a set of pre-determined criteria, the most suitable existing clinician-rated instruments for the routine measurement of functioning for adult consumers.

METHOD

We used two existing reviews of functioning measures as our starting point and conducted a search of MEDLINE and PsycINFO to identify articles relating to additional clinician-rated instruments. We evaluated identified instruments using a hierarchical, criterion-based approach. The criteria were as follows: (1) is brief (<50 items) and simple to score, (2) is not made redundant by more recent instruments, (3) relevant version has been scientifically scrutinised, (4) considers functioning in a contemporary way and (5) demonstrates sound psychometric properties.

RESULTS

We identified 20 relevant instruments, 5 of which met our criteria: the LSP-16, the Health of the Nation Outcome Scales, the Illness Management and Recovery Scale-Clinician Version, the Multnomah Community Ability Scale and the Personal and Social Performance Scale.

CONCLUSION

Further work is required to determine which, if any, of these instruments satisfy further criteria relating to their appropriateness for assessing functioning within relevant service contexts, acceptability to clinicians and consumers, and feasibility in routine practice. This should involve seeking stakeholders' opinions (e.g. about the specific domains of functioning covered by each instrument and the language used in individual items) and testing completion rates in busy service settings.

Prevalence and characteristics of suicide attempters and ideators among acutely admitted psychiatric hospital patients in northwest Russia and northern Norway

BACKGROUND

More knowledge about suicidality and suicide risk profiles in acute psychiatric hospital patients (both first-time and chronic patients) is needed. While numerous factors are associated with suicidality in such populations, these may differ across cultures. Better understanding of factors underlying suicide risk can be informed by cross-cultural studies, and can aid development of therapeutic and preventive measures.

METHODS

An explorative, cross-sectional cohort study was carried out. Acutely admitted patients at one psychiatric hospital in northwest Russia and two in northern Norway were included. At admission, demographic, clinical, and service use data were collected, in addition to an assessment of suicidal ideation and attempts, comprising five dichotomic questions. Data from 358 Norwegian and 465 Russian patients were analyzed with univariate and multivariate statistics. Within each cohort, attempters and ideators were compared with patients not reporting any suicidality.

RESULTS

The observed prevalence of suicidal ideation and attempts was significantly higher in the Norwegian cohort than in the Russian cohort (χ(2) = 168.1, p < 0,001). Norwegian suicidal ideators and attempters had more depressed moods, more personality disorders, and greater problems with alcohol/drugs, but fewer psychotic disorders, cognitive problems or overactivity than non-suicidal patients. Russian suicidal ideators and attempters were younger, more often unemployed, had more depressed mood and adjustment disorders, but had fewer psychotic disorders and less alcohol/drug use than the non-suicidal patients.

CONCLUSIONS

Rates of suicidal ideation and non-fatal attempts in Norwegian patients were intermediate between those previously reported for patients admitted for the first time and those typical of chronic patients. However, the significantly lower rates of suicidal ideation and non-fatal attempts in our Russian cohort as compared with the Norwegian, contrasted with what might be expected in a region with much higher suicide rates than in northern Norway. We suggest that suicide-related stigma in Russia may reduce both patient reporting and clinicians' recognition of suicidality. In both cohorts, overlapping risk profiles of ideators and attempters may indicate that ideators should be carefully evaluated and monitored, particularly those with depressed moods, alcohol/substance abuse disorders, and inadequate treatment continuity.

Health of the Nation Outcome Scales (HoNOS): use in an Irish psychiatric outpatient population

Objectives: To evaluate the clinical utility and validity of the Health of the Nation Outcome Scales (HoNOS) in an Irish catchment area psychiatric service.

Method: One hundred consecutive outpatients were assessed using the HoNO S and Global Assessment of Functioning (GAF) scales.

Results: It was feasible to administer HoNOS in day-to-day clinical practice. There was a statistically significant correlation between the HoNO S and GAF scores. Attenders at the outpatient department had significantly lower HoNOS scores compared to individuals assessed on domiciliary visits or at the day hospital. Individuals with schizophrenia had significantly higher HoNO S scores compared to affective disordered patients. However, this difference was confined to the Social subscale of HoNOS.

Conclusions: Although these findings indicate that HoNOS has significant convergent and criterion validity as a measure of psychiatric morbidity, its widespread use in day-to-day clinical practice may be premature.

Does an educational intervention improve the usefulness of the Health of the Nation Outcome Scales in an acute mental health setting?

The purpose of the current study was to measure the effect of an educational intervention on the Health of the Nation Outcome Scales (HoNOS) completion rates. Additionally, interrater reliability and accuracy amongst nurses completing the instrument was assessed. We used a pre- and post-intervention design with videoed vignettes providing the basis for the educational intervention. Mental health nurses were assessed four times: at baseline, immediately after the intervention, 1 week later and again, 2 months after the intervention. There was a non-statistical increase in the number of patients assessed on admission using the HoNOS from 12.5% to 22.6%. Interrater reliability was low and did not improve through the course of the study. Intraclass correlation coefficients ranged 0.41-0.48. Accuracy was poor when discrete scoring between 0-4 was analyzed but improved when scores were dichotomised to reflect a clinically significant cut-off of 2 or more. The intervention improved completion rates marginally but interrater reliability and accuracy were low and did not improve over the study period. Opportunities for improvement were identified.

Psychometric properties of the Dutch version of the Health of the Nation Outcome Scales for older adults (HoNOS 65+) in daily care

BACKGROUND

The Health of the Nation Outcome Scales (HoNOS) is widely used to evaluate mental health care outcomes. For appropriate use and interpretation in routine clinical practice, further validation of the adapted version for older clients (HoNOS 65+) is needed.

OBJECTIVE

The aim of this study is to compare scoring profiles produced by different categories of professionals, assess the internal consistency of the sum score and proposed subscales, and concurrent validity of the total sum score of the Dutch version of HoNOS 65+.

METHODS

We used baseline data from fourteen mental health care organizations participating in the MEntal health care Monitor Older adults (MEMO), a nationwide routine outcome monitoring system. A total of 767 older clients, referred for gerontopsychiatric disorders, were administered HoNOS 65+ by non-academic (primarily nurses, n=430) or academic professionals (psychologists/physicians, n=337). Demographics and full DSM-IV classification, including the Global Assessment of Functioning (GAF), were derived from the electronic medical dossier.

RESULTS

HoNOS 65+ seemed to discriminate between clients with and without a depressive disorder, adjustment disorder, anxiety disorder and psychotic disorder on the items expected. In clients suffering from a depressive or psychotic disorder, nurses/social workers and physicians/psychologists did not differ in scoring on all items of HoNOS 65+. In clients with an adjustment disorder or anxiety disorder, professions differed in rating on two items. Confirmatory Factor Analyses supported neither the factor structure of the original HoNOS nor the initially reported structure of HoNOS 65+ version. Cronbach's alpha of the total sum score was 0.60. Internal consistency of previously identified subscales was low. A new set of subscales could not be identified satisfactorily. A medium-sized correlation of the HoNOS 65+ sum score and the GAF was found (r=-.30, p<.001).

CONCLUSIONS

It is preferable to use individual HoNOS 65+ items, to evaluate care outcomes. The HoNOS 65+ items discriminate between clients with and without a particular diagnosis. Nonetheless, in some of the most prevalent gerontopsychiatric disorders rating differs between professionals with different educational backgrounds.

Treatment needs, diagnoses and use of services for acutely admitted psychiatric patients in northwest Russia and northern Norway

Background

We compared demography, diagnoses and clinical needs in acutely admitted psychiatric hospital patients in northwest Russia and northern Norway.

Method

All acutely admitted psychiatric patients in 1 psychiatric hospital in north-west Russia and 2 in northern Norway were in a three months period assessed with HoNOS and a Norwegian form developed to study acute psychiatric services (MAP). Data from a total of 841 patients were analysed (377 Norwegian, 464 Russian) with univariate and multivariate statistics.

Results

Russian patients were more often males who had paid work. 2/3 were diagnosed with alcohol and organic disorders, and 70% reported problems related to sleep. Depression was widespread, as were problems associated with occupation. Many more Norwegian patients were on various forms of social security and lived in community supported homes. They had a clinical profile of affective disorders, use of drugs, suicidality and problems with activities involved of daily life. Slightly more Norwegian patients were involuntary admitted.

Conclusion

Acutely admitted psychiatric patients in North West Russia and Northern Norwegian showed different clinical profiles: alcohol, depression and organic disorders characterised Russian patients, affective disorders, suicidality and use of drugs characterised the Norwegians. Whereas Norwegian patients are mainly referred from GPs the Russians come via 1.line psychiatric services (“dispensaries”). Average length of stay for Russian patients was 2.5 times longer than that of the Norwegian.

Validation of the Health of the Nation Outcome Scales as a routine measure of outcome in early intervention programmes

AIM

So far, no study has assessed the validity of the Health of the Nation Outcome Scales (HoNOS) in patients enrolled in early intervention programmes, nor has any study evaluated the validity of the HoNOS in people at ultra high-risk (UHR) of psychosis. This study set out to assess the validity and reliability of the HoNOS as a measure of outcome in the patients enrolled in an early intervention programme.

METHODS

The concurrent, discriminant and predictive validity, and the reliability of the HoNOS as a measure of outcome in an early intervention programe were assessed in 87 first-episode psychosis (FEP) patients, and in 81 patients at UHR of psychosis.

RESULTS

Reliability indexes were good in the FEP sample, and less good in the UHR sample. HoNOS total scores differentiated between FEP and UHR patients, and the HoNOS subscales proved able to assess a specific profile of symptoms in the two samples, demonstrating a helpful adjunctive measure of health status without complete overlap with other scales. Sensitivity to change was also very good, again with differences between FEP and UHR patients. HoNOS scores at intake did not predict failure to attain remission in FEP patients. There were too few cases of transition to psychosis (n = 2) to assess predictive validity of HoNOS in the UHR sample.

CONCLUSION

HoNOS possesses satisfactory sensitivity and validity to be used in the routine assessment in early intervention programmes.

The validity of the severity-psychosis hypothesis in depression

BACKGROUND

Psychotic depression (PD) is classified as a subtype of severe depression in the current diagnostic manuals. Accordingly, it is a common conception among psychiatrists that psychotic features in depression arise as a consequence of depressive severity. The aim of this study was to determine whether the severity of depressive and psychotic symptoms correlate in accordance with this "severity-psychosis" hypothesis and to detect potential differences in the clinical features of PD and non-psychotic depression (non-PD).

METHODS

Quantitative analysis of Health of the Nation Outcome Scales (HoNOS) scores from all patients admitted to a Danish general psychiatric hospital due to a severe depressive episode in the period between 2000 and 2010 was performed.

RESULTS

A total of 357 patients with severe depression, of which 125 (35%) were of the psychotic subtype, formed the study sample. Mean HoNOS scores at admission differed significantly between patients with non-PD and PD on the items hallucinations and delusions (non-PD=0.33 vs. PD=1.37, p<0.001), aggression (non-PD=0.20 vs. PD=0.36, p=0.044) and on the total score (non-PD=10.55 vs. PD=11.87, p=0.024). The HoNOS scores on the two items "depression" and "hallucinations and delusions" were very weakly correlated.

LIMITATIONS

Diagnoses were based on normal clinical practice and not formalized research criteria.

CONCLUSIONS

The symptomatology of PD and non-PD differs beyond the mere psychosis. Furthermore, severity ratings of depressive and psychotic symptoms are very weakly correlated. These findings offer further support to the hypothesis stating that the psychotic- and non-psychotic subtypes of depression may in fact be distinct clinical syndromes.

An Acute Recovery Unit: the first 18 months

OBJECTIVES

To describe a new type of acute inpatient unit, the Acute Recovery Unit, at the Concord Centre for Mental Health, Sydney and to report patient characteristics and outcome data for the first 18 months of operation.

METHODS

The mission, values, principles of care and operation of the Acute Recovery Unit are presented, including the lessons from a review of the first 18 months of operation. The specialist assessment procedure, academic detailing and range of specialist interventions are described.

RESULTS

Clinical outcome measures including the Health of the Nation Outcome Scale, Multidimensional Incomplete Recovery - Clinical Global Index and community tenure time post-discharge are presented.

CONCLUSIONS

The Acute Recovery Unit is an important component of the range of services required at a regional level to respond to those who will develop treatment refractory mental illness.

Validation aspects of the health of the nation outcome scales

Background

The purpose of the current study was the psychometric evaluation of the Health of the Nation Outcome Scales (HoNOS), an instrument developed to meet the necessity of a clinically acceptable outcome scale for routine use in mental illness services.

Methods

The study participants included 2,162 outpatients and residential inpatients (rated on the HoNOS on three occasions during the year 2000) with a range of mental illnesses in different diagnostic groups from ten Mental Health Departments, located in the area of Milan (Italy). Principal Component Analysis, Confirmatory Factor Analysis, Discriminant Analysis and Partial Credit Rasch Model were used to assess two sources of validity: the internal structure and the relationships with other variables.

Results

The results of the 12-item HoNOS demonstrate a significant departure from uni-dimensionality, confirmed by the Rasch analysis (which identified three misfitting items). However, HoNOS scores demonstrate stability and precision of item difficulties over time. Discriminant analysis showed that HoNOS scores have an acceptable level of discriminatory power in predicting the severity of patients' conditions (as represented by setting).

Conclusions

It was concluded that the Italian version of the HoNOS does not measure a single, underlying construct of mental health status. The internal structure validity analysis recommends a note of caution to use a summary index of the HoNOS scores, given the presence of multidimensionality and misfit. Nonetheless, the finding that the instrument is more multidimensional than unidimensional does not preclude the use of the HoNOS as a clinically valid tool for routine outcome assessment. In fact, item scores have demonstrated sufficient reliability (over diagnostic groups and care settings) and high precision in time, indicating that HoNOS items can be utilized as valid measurement instruments in longitudinal analyses.

Family intervention for schizophrenia

BACKGROUND

People with schizophrenia from families that express high levels of criticism, hostility, or over involvement, have more frequent relapses than people with similar problems from families that tend to be less expressive of emotions. Forms of psychosocial intervention, designed to reduce these levels of expressed emotions within families, are now widely used.

OBJECTIVES

To estimate the effects of family psychosocial interventions in community settings for people with schizophrenia or schizophrenia-like conditions compared with standard care.

SEARCH STRATEGY

We updated previous searches by searching the Cochrane Schizophrenia Group Trials Register (September 2008).

SELECTION CRITERIA

We selected randomised or quasi-randomised studies focusing primarily on families of people with schizophrenia or schizoaffective disorder that compared community-orientated family-based psychosocial intervention with standard care.

DATA COLLECTION AND ANALYSIS

We independently extracted data and calculated fixed-effect relative risk (RR), the 95% confidence intervals (CI) for binary data, and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated mean differences (MD).

MAIN RESULTS

This 2009-10 update adds 21 additional studies, with a total of 53 randomised controlled trials included. Family intervention may decrease the frequency of relapse (n = 2981, 32 RCTs, RR 0.55 CI 0.5 to 0.6, NNT 7 CI 6 to 8), although some small but negative studies might not have been identified by the search. Family intervention may also reduce hospital admission (n = 481, 8 RCTs, RR 0.78 CI 0.6 to 1.0, NNT 8 CI 6 to 13) and encourage compliance with medication (n = 695, 10 RCTs, RR 0.60 CI 0.5 to 0.7, NNT 6 CI 5 to 9) but it does not obviously affect the tendency of individuals/families to leave care (n = 733, 10 RCTs, RR 0.74 CI 0.5 to 1.0). Family intervention also seems to improve general social impairment and the levels of expressed emotion within the family. We did not find data to suggest that family intervention either prevents or promotes suicide.

AUTHORS' CONCLUSIONS

Family intervention may reduce the number of relapse events and hospitalisations and would therefore be of interest to people with schizophrenia, clinicians and policy makers. However, the treatment effects of these trials may be overestimated due to the poor methodological quality. Further data from trials that describe the methods of randomisation, test the blindness of the study evaluators, and implement the CONSORT guidelines would enable greater confidence in these findings.

Family intervention for schizophrenia

BACKGROUND

People with schizophrenia from families that express high levels of criticism, hostility, or over involvement, have more frequent relapses than people with similar problems from families that tend to be less expressive of emotions. Forms of psychosocial intervention, designed to reduce these levels of expressed emotions within families, are now widely used.

OBJECTIVES

To estimate the effects of family psychosocial interventions in community settings for people with schizophrenia or schizophrenia-like conditions compared with standard care.

SEARCH STRATEGY

We updated previous searches by searching the Cochrane Schizophrenia Group Trials Register (September 2008).

SELECTION CRITERIA

We selected randomised or quasi-randomised studies focusing primarily on families of people with schizophrenia or schizoaffective disorder that compared community-orientated family-based psychosocial intervention with standard care.

DATA COLLECTION AND ANALYSIS

We independently extracted data and calculated fixed-effect relative risk (RR), the 95% confidence intervals (CI) for binary data, and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated mean differences (MD).

MAIN RESULTS

This 2009-10 update adds 21 additional studies, with a total of 53 randomised controlled trials included. Family intervention may decrease the frequency of relapse (n = 2981, 32 RCTs, RR 0.55 CI 0.5 to 0.6, NNT 7 CI 6 to 8), although some small but negative studies might not have been identified by the search. Family intervention may also reduce hospital admission (n = 481, 8 RCTs, RR 0.78 CI 0.6 to 1.0, NNT 8 CI 6 to 13) and encourage compliance with medication (n = 695, 10 RCTs, RR 0.60 CI 0.5 to 0.7, NNT 6 CI 5 to 9) but it does not obviously affect the tendency of individuals/families to leave care (n = 733, 10 RCTs, RR 0.74 CI 0.5 to 1.0). Family intervention also seems to improve general social impairment and the levels of expressed emotion within the family. We did not find data to suggest that family intervention either prevents or promotes suicide.

AUTHORS' CONCLUSIONS

Family intervention may reduce the number of relapse events and hospitalisations and would therefore be of interest to people with schizophrenia, clinicians and policy makers. However, the treatment effects of these trials may be overestimated due to the poor methodological quality. Further data from trials that describe the methods of randomisation, test the blindness of the study evaluators, and implement the CONSORT guidelines would enable greater confidence in these findings.

Determinants of subjective quality of life in first-episode schizophrenia: perspective from Malaysia

AIM

This study sought to examine the determinants of subjective quality of life among patients with first-episode schizophrenia in a developing country.

METHOD

One-hundred and twenty patients registered with National Mental Health Registry for Schizophrenia from 1 January 2003 to 31 August 2005 were included. They were diagnosed with first-episode schizophrenia, schizoaffective and schizophreniform disorders and had been compliant to treatment. Sociodemographic data were obtained and the Brief Psychiatric Rating Scale-Anchored Version, Health of The Nation Outcome Scales, Simpson-Angus Extrapyramidal Side Effects Scale, Barnes Akathisia Scale and the World Health Organization Quality of Life were used to assess psychopathology, side effects from antipsychotics and subjective quality of life.

RESULTS

Gender, positive and disorganized symptoms of schizophrenia, and cognitive and physical impairments appeared to be the most important predictors of subjective quality of life among the patients from this centre in Malaysia.

CONCLUSION

Different domains of self-rated quality of life correlated with different sociodemographic and clinical characteristics. Some of the characteristics were malleable and a better understanding of these could lead to improvements in the management of patients with schizophrenia.

Outcome study of first-episode schizophrenia in a developing country: quality of life and antipsychotics

AIM

Quality of life has recently been emphasized in the management of schizophrenia, yet data from developing country is lacking. We explored the differences in subjective quality of life between conventional antipsychotics (CAs) and atypical antipsychotics (AAs).

METHODS

This is a naturalistic study conducted in Kuala Lumpur, Malaysia. Patients with first-episode schizophrenia and related psychosis were recruited from Kuala Lumpur Hospital. WHOQOL-BREF, side effects of medications and other variables were assessed after 1 year of treatment in routine clinical situation.

RESULTS

The study comprised 120 adults. There were no significant statistical differences between groups concerning subjective quality of life, extrapyramidal side effects and employment. Significant less benzhexol usage was reported among AAs (P<0.001) compared to CAs and sulpiride.

CONCLUSION

Patients treated with CAs, sulpiride or AAs experienced similar quality of life, clinical and health outcomes after 1 year commencing treatment. Overall, the results are in line with other major pragmatic clinical trials. This study also found sulpiride cost-effective.

Admission decisions following contact with an emergency mental health assessment and intervention service

AIMS

To define the demographic and clinical profile of individuals referred to an emergency mental health assessment team. To identify factors associated with being admitted to inpatient psychiatric services or not admitted following an emergency assessment.

BACKGROUND

Crisis resolution and home treatment services are being developed across the UK, targeted towards people with severe mental health problems, who would otherwise require hospitalization. Further information about people presenting to an emergency mental health assessment service may clarify the skills that are required to deliver effective crisis resolution and home treatment services.

METHOD

Over a six-month period referrals to, and admission decisions by, an emergency mental health assessment team were recorded. Measures used were the Health of the Nation Outcome Scale and the Crisis Triage Rating Scale. Age, sex and postcode data were recorded. Postcode data were used to identify the Townsend Deprivation Index for each individual. Reasons given for the referral were categorized. A preliminary descriptive analysis was performed for all people referred. The Demographic and clinical characteristics of referrals admitted and not admitted were then compared. A multivariate logistic regression was performed in order to investigate the possible impact of demographic and clinical characteristics on admission status.

RESULTS

A total of 375 individuals were referred. Forty-eight (12.8%) were admitted. Higher referral rates were significantly associated with more deprived areas of the city. Referrers most frequently identified suicide risk as the reason for referral, followed by deterioration of an existing serious mental health problem. The mean Health of the Nation Outcome Scale score of all people referred was 10.5. Those admitted had a significantly greater mean Health of the Nation Outcome Scale score than those not admitted. The mean Crisis Triage Rating Scale score of all people referred was 11.0. Those admitted had a significantly lower (worse) mean Crisis Triage Rating Scale score than those not admitted. Individuals with lower Crisis Triage Rating Scale scores tended to have a higher (more deprived) Townsend index scores. Crisis Triage Rating Scale and Health of the Nation Outcome Scale scores were significantly negatively correlated. Conclusions. Crisis resolution and home treatments need to target areas of greatest deprivation. Social interventions will be important. Presentations related to suicide risk are likely to be common. The Crisis Triage Rating Scale may be a useful brief alternative to Health of the Nation Outcome Scale.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the valuable role of mental health nurses in frontline emergency mental health care in particular mental health nurses skills in conducting a risk assessment in an emergency.

Are the Health of the Nation Outcome Scales a valid and practical instrument to measure outcomes in North America? A three-site evaluation across Nova Scotia

We tested the usability, sensitivity and validity of the Health of the Nation Outcome Scales (HoNOS) in routine clinical practice in North America. Three pilot sites provided ratings on all inpatient and outpatient referrals over 4 months using versions covering children and adolescents (HoNOSCA), working-age adults and the over-65s. Data were entered using the routine administrative data system. Sixty-one percent of eligible patients had at least one HoNOS rating (n = 485). Following the initial rating, subsequent completion rates reached 80%. Ratings were sensitive to time and setting, with significantly higher scores in inpatients than outpatients. Individual diagnoses had different patterns of scores, further supporting validity.

Structured assessment of mental health status in psychogeriatrics: validity of the French HoNOS65+

OBJECTIVE

To assess the reliability, validity, and feasibility of a French version of the Health of the Nation Outcome Scales for Elderly People (HoNOS65+).

METHOD

Twenty mental health professionals completed the scale for 126 elderly patients. We assessed interrater reliability in inpatient and outpatient settings, together with construct and discriminant validity, as well as concurrent validity compared with several widely used clinical instruments.

RESULTS

Excellent agreement among raters was observed in the outpatient subgroup (kappa range 0.77 to 1.00), whereas interrater reliability was modest in the inpatient subgroup (kappa values < 0.55). In cases where the patient-caregiver relationship lasted more than 1 month, the reliability of the scale improved. Construct validity analysis revealed no subscale structure. All items except "self-injury" displayed high concurrent validity (significant Spearman correlations with 8 other questionnaires). In terms of discriminant validity, the "cognitive impairment" (area under the curve [AUC] 0.91) and "depressive symptoms" (AUC 0.79) items showed high sensitivity and specificity values.

CONCLUSION

Our results indicate that the French version of HoNOS65+ is a promising clinical assessment tool to evaluate mental disorders in the elderly in outpatient settings. We support its use in routine clinical practice, with the condition that a relatively long and individualized patient-caregiver relationship has been established.

Discriminant ability and criterion validity of the HoNOS in Italian psychiatric residential facilities

BACKGROUND

The Health of the Nation Outcomes Scales (HoNOS) was developed as an inclusive and comprehensive instrument to assess patient outcomes in 4 main domains: behaviour, cognitive and physical impairment, symptoms and social functioning/context. Concerns about the reliability and validity of the HoNOS have been raised. The aim of this study was to further investigate the discriminatory ability of the HoNOS; criterion validity was also examined.

SAMPLING AND METHODS

A broad sample of patients with psychotic disorders, admitted to 265 Italian residential facilities, were rated by trained research assistants and local staff on the HoNOS, Global Assessment of Functioning, Life Skills Profile, and Physical Health Index. Discriminant function analysis was used to examine the ability of the HoNOS items to correctly classify patients with positive symptoms, substantial psychosocial impairment or physical disability. The HoNOS criterion validity was also examined.

RESULTS

On the whole, the pattern of correlations between the HoNOS and the other corresponding measures was consistent. However, the majority of the correlations were only moderate. In discriminant function analysis, the classification procedure correctly classified 55.7% of the patients.

CONCLUSIONS

Although the HoNOS has many advantages in its brevity, it may lack sufficient discriminatory ability for certain patient groups. Further, it correlates only moderately with measures of disability and physical health status. These findings suggest that the HoNOS alone might be insufficient for routine evaluation and should probably be supplemented by additional measures.

Socio-economic deprivation and duration of hospital stay in severe mental disorder

Adults from South Auckland, New Zealand who required acute admission to hospital were followed from admission to discharge. After adjusting for demographic factors, diagnosis, chronicity, severity, consultant psychiatrist and involuntary admission, the length of stay for those from more deprived areas was significantly longer by 7 days than for those from less deprived areas. Information on socio-economic deprivation should be used in discharge planning and in optimising access to community care. Research is needed on group-level factors that may affect recovery from mental disorders.

A review of the psychometric properties of the Health of the Nation Outcome Scales (HoNOS) family of measures

Background

The Health of the Nation Outcome Scales was developed to routinely measure outcomes for adults with mental illness. Comparable instruments were also developed for children and adolescents (the Health of the Nation Outcome Scales for Children and Adolescents) and older people (the Health of the Nation Outcome Scales 65+). All three are being widely used as outcome measures in the United Kingdom, Australia and New Zealand. There is, however, no comprehensive review of these instruments. This paper fills this gap by reviewing the psychometric properties of each.

Method

Articles and reports relating to the instruments were retrieved, and their findings synthesised to assess the instruments' validity (content, construct, concurrent, predictive), reliability (test-retest, inter-rater), sensitivity to change, and feasibility/utility.

Results

Mostly, the instruments perform adequately or better on most dimensions, although some of their psychometric properties warrant closer examination.

Conclusion

Collectively, the Health of the Nation Outcome Scales family of measures can assess outcomes for different groups on a range of mental health-related constructs, and can be regarded as appropriate for routinely monitoring outcomes.

A review of the psychometric properties of the Health of the Nation Outcome Scales (HoNOS) family of measures

BACKGROUND

The Health of the Nation Outcome Scales was developed to routinely measure outcomes for adults with mental illness. Comparable instruments were also developed for children and adolescents (the Health of the Nation Outcome Scales for Children and Adolescents) and older people (the Health of the Nation Outcome Scales 65+). All three are being widely used as outcome measures in the United Kingdom, Australia and New Zealand. There is, however, no comprehensive review of these instruments. This paper fills this gap by reviewing the psychometric properties of each.

METHOD

Articles and reports relating to the instruments were retrieved, and their findings synthesised to assess the instruments' validity (content, construct, concurrent, predictive), reliability (test-retest, inter-rater), sensitivity to change, and feasibility/utility.

RESULTS

Mostly, the instruments perform adequately or better on most dimensions, although some of their psychometric properties warrant closer examination.

CONCLUSION

Collectively, the Health of the Nation Outcome Scales family of measures can assess outcomes for different groups on a range of mental health-related constructs, and can be regarded as appropriate for routinely monitoring outcomes.

Multilevel investigation of variation in HoNOS ratings by mental health professionals: a naturalistic study of consecutive referrals

Episodes of mental healthcare in specialist psychiatric services often begin with the assessment of clinical and psychosocial needs of patients by healthcare professionals. Particularly for patients with complex needs or severe problems, ratings of clinical and social functioning at the start of each episode of care may serve as a baseline against which subsequent measures can be compared. Currently, little is known about service variations in such assessments on referrals from primary care. We set out to quantify variability in initial assessments performed by healthcare professionals in three CMHTs in Bristol (UK) using the Health of the Nation Outcome Scales (HoNOS). We tested the hypothesis that variations in HoNOS total and sub-scale scores are related to referral source (general practices), healthcare assessor (in CMHTs) and the assessor's professional group. Statistical analysis was performed using multilevel variance components models with cross-classified random effects. We found that variation due to assessor substantially exceeded that due to referral source (general practices). Furthermore, patient variance differed by assessor profession for the HoNOS--Impairment scores. Assessor variance differed by assessor profession for the HoNOS--Social scores. As HoNOS total and subscale scores show much larger variation by assessor than by referral source, investigations of HoNOS scores must take assessors into account. Services should implement and evaluate interdisciplinary training to improve consistency in use of rating thresholds; such initiatives could be evaluated using these extensions of multilevel models. Future research should aim to integrate routine diagnostic data with continuous outcomes to address selection effects (of patients to assessors) better.

[HoNOS-Rome: an extended, customized, and longitudinal oriented version of the HoNOS]

AIMS

To clarify the acceptability, reliability and factorial validity of a new Italian version of the HoNOS called HoNOS-Rome. Its main innovations are both in design and in contents.

METHODS

Face validity was assessed by surveying 3 focus groups. Reliability was assessed in 8 different pairs of raters on a sample of 24 patients; construct validity was analysed by factor analysis using a sample of 187 patients at 6 day centres. Acceptability was investigated by means an anonymous questionnaire filled by professionals that were using the instrument.

RESULTS

Time of completion was low (range 4-12 minutes), the tool proved very acceptable and the reliability was good (weighted kappa > or = 0.71 for all items). Factor analysis was consistent with the division of HoNOS-Rome into four sensible factors accounting for 52% of the total variance.

CONCLUSIONS

The findings indicate that HoNOS-Rome has a satisfactory degree of acceptability, construct validity and reliability, and may promote the routine evaluation of outcomes in mental health services.

A conceptual review of functioning: implications for the development of consumer outcome measures

OBJECTIVE

Australia's National Mental Health Strategy aims to achieve improved consumer outcomes. The development and refinement of consumer outcome measures is targeted within the Second National Mental Health Plan. The National Standards for Mental Health Services identify measures of functioning, quality of life and satisfaction with services as relevant to assessing and monitoring consumer outcome. Consumers have described gauging their own recovery through the achievement of functional goals in everyday life. This paper reviews how functioning is viewed within the mental health field, and implications for developing better functional outcome measures.

METHOD

Literature describing the development of measures of functioning, principles of outcome measurement, and functional outcomes for people with severe mental illness was identified, using PsycLIT. A review yielded themes reflecting a number of assumptions about the concept of functioning.

RESULTS

Functioning is inadequately defined, raising issues about what is focused on, and from whose viewpoint, each of which has implications for using measures of functioning to monitor consumer outcome. Conflation of dissimilar functional domains, and flawed assumptions about the importance of symptomatology in influencing functional outcome limit the sensitivity to meaningful change of functional measures. Consumer perspectives are relatively neglected in functional tool development.

CONCLUSIONS

A conceptual framework that recognizes lived experience and the interaction between persons and their environment is much needed to guide the development of functional outcome measures. Qualitative and quantitative research methodologies should be used to advance understanding of functioning and to address limitations of current approaches to functional outcome measurement.

Pathways and outcomes of psychiatric care: does it depend on who you are, or what you've got?

OBJECTIVES

To investigate predictors of outcome and cost for patients treated by Mental Health Services in the south metropolitan area of Perth using logistic regression to control for potential confounding factors.

METHOD

Data were collected over a 3-month period on 2691 subjects (47% male, 53% female) as part of the Mental Health Classification and Services Cost Project.

RESULTS

The average age of subjects was 44.3 years. Nearly 80% of care occurred in community settings and virtually all inpatient care was for acute emergencies. The most common diagnosis was schizophrenia (33%) followed by mood disorders (30%). Within the study period, 88% of patients had only one episode of care (n = 2361) and a further 8% two (n = 223). Patients with schizophrenia were one-third as likely to be discharged from care (95% CI = 0.2-0.4) and 30% as likely to have longer episodes of care (95% CI = 1.1-1.6). Patients with personality, substance or adjustment disorders spent less time in treatment, and those with personality or substance disorders were more likely to be discharged from psychiatric care. A past history of inpatient care was associated with a worse outcome in terms of length of care, or not being successfully discharged. Severity of illness as determined by involuntary treatment or elevated Health of the Nation Outcome Scales and Life Skills Profile (LSP) scores was associated with increased costs. Greater disability on the LSP was also associated with increased length of care. Sociodemographic factors were as least as important as diagnosis in predicting the cost and outcome of treatment.

CONCLUSIONS

Demographic factors may better predict increased health service use than diagnostic casemix. Since sociodemographic variables contribute as much to outcome as diagnosis, comparing results between units is likely to be misleading unless adjusted for these factors.

Use of quantitative rating scales to assess outcome in schizophrenia prevention studies

OBJECTIVE

To present a summary of quantitative scales relevant to schizophrenia prevention studies.

METHOD

Fifteen scales were reviewed and summarised in terms of structure, domains assessed, previous use and psychometric properties. Instruments of symptom measurement, role functioning and global functioning were considered, along with multidimensional instruments and other scales of potential interest to research in schizophrenia prevention.

RESULTS AND CONCLUSIONS

No scales of potential value in measuring premorbid risk for schizophrenia have been sufficiently tested for reliability and validity in the context of primary prevention of schizophrenia. The absence of a sufficiently sensitive and specific means for identifying those at high risk of schizophrenia before the onset of psychosis is a major barrier to valid measurement of the outcome of attempts at primary prevention. However, there have been advances in the development of instruments relevant to the goals of secondary and tertiary prevention. Most studies use instruments developed for patients with established psychoses and have applied them to early psychosis groups with some success, although possible 'floor' effects may confound measurement in the 'prodromal' period.