Independent Supported Housing Versus Institutionalised Residential Rehabilitation for Individuals with Severe Mental Illness: A Survey of Attitudes and Working Conditions Among Mental Healthcare Professionals.

Despite widespread support for Independent Supported Housing (ISH) interventions, psychiatric housing rehabilitation still commonly takes place in residential care facilities (RCFs). This study compares preferences, attitudes and working conditions of mental healthcare professionals (MHCPs) in ISH and RCFs using an online survey. The survey included setting preferences, stress and strain at work, recovery attitudes, stigmatisation, and factors experienced as particularly important or obstructive in housing rehabilitation. Data were analysed using quantitative and qualitative approaches. Of the 112 participating MHCPs, 37% worked in ISH and 63% in RCFs. Professionals' education, work-related demands and influence at work were higher in ISH, stigmatising attitudes were higher in RCFs. MHCPs in both settings endorsed ISH. The support process was seen as particularly important whereas stigmatisation, regulatory and political requirements were seen as obstructive for successful housing rehabilitation. Results indicate that social inclusion of individuals with severe mental illness is seldom feasible without professional support.

Independent Supported Housing for non-homeless individuals with severe mental illness: Comparison of two effectiveness studies using a randomised controlled and an observational study design.

Background: No randomised controlled study (RCT) on the effectiveness of Independent Supported Housing (ISH) vs. housing as usual (HAU) settings for non-homeless individuals with severe mental illness (SMI) has been conducted to date because of limited feasibility. Alternative designs, such as observational studies, might be suitable for providing adequate evidence if well conducted. To test this hypothesis, this article reports on a prospective, direct comparison of the designs of two parallel studies in this field. Methods: A two-centre, parallel-group non-inferiority effectiveness study was conducted at two locations in Switzerland using identical instruments and clinical hypotheses. One centre applied an RCT design and the other an observational study (OS) design with propensity score methods (ClinicalTrials.gov: NCT03815604). The comparability of the two study centres was investigated in terms of participants, procedures, and outcomes. The primary outcome was social inclusion and the secondary outcomes were quality of life and psychiatric symptoms. Results: The study included 141 participants (RCT: n = 58; OS: n = 83). Within one year, 27% study dropouts occurred (RCT: 34%; OS: 22%). A similar balance of sample characteristics was achieved in the RCT and the OS using propensity score methods (inverse probability of treatment weighting). After one year, ISH was non-inferior to the control condition regarding social inclusion (mean differences [95% CI]) in the RCT (6.28 [-0.08 to 13.35]) and the OS (2.24 [-2.30 to 6.77]) and showed no significant differences in quality of life (RCT: 0.12 [-0.52 to 0.75]; OS: 0.16 [-0.26 to 0.58]) and symptoms (RCT: -0.18 [-0.75 to 0.40]; OS: 0.21 [-0.17 to 0.60]) in both study centres. However, strong and persistent preferences for ISH in the RCT control group reduced participants' willingness to participate. Because of several limitations in the RCT, the results of the RCT and the OS are not comparable. Conclusion: Participants were comparable in both study sites. However, there were significant problems in conducting the RCT because of strong preferences for ISH. The OS with propensity score methods provided results of more stable groups of participants and revealed balanced samples and valid outcome analysis. Our results do not support further investment in RCTs in this field.

A mirror-image analysis of psychiatric hospitalisations among people with severe mental illness using Independent Supported Housing.

BACKGROUND: Evidence on the effectiveness of Independent Supported Housing (ISH) for non-homeless people with severe mental illness primarily comes from observational cohort studies, which have high risk of bias due to confounding by time-invariant sample characteristics. The present study proposes an alternative study design known from pharmacology to overcome this bias and strengthen evidence. METHODS: We conducted a retrospective mirror-image analysis with medical records of 144 ISH service users to assess the effectiveness of ISH in reducing the number and duration of hospitalisations. Outcomes occurring in equal periods before and during ISH utilisation were compared for every ISH user. Differences between the periods were tested with incidence rate ratios (IRR). RESULTS: Included service users were on average 38.2 years old, female (54%) and predominately had an affective (28.5%) or a schizophrenic or psychotic (22.9%) disorder with ISH utilisation days ranging from 36-960. Fewer admissions (IRR = 0.41, 95%-CI 0.27-0.64) and fewer person-days hospitalised (IRR = 0.38, 95%-CI 0.35-0.41) were observed during ISH utilisation compared to prior to their ISH utilisation. While the reduction in psychiatric admissions may be somewhat confounded by time-variant characteristics, the substantial reduction in hospitalised bed-bays represents at least partially an intervention effect. CONCLUSIONS: The mirror-image study design allowed for a cost-effective investigation of ISH effectiveness in reducing hospitalisation without confounding by time-invariant sample characteristics. We provide recommendations for the design's application and suggest further research with larger samples.

Independent Supported Housing for Non-homeless People With Serious Mental Illness: A Pragmatic Randomized Controlled Trial.

BACKGROUND: Independent supported housing (ISH)-services to support independent housing are recommended by current guidelines. However, there is little evidence of ISH models for non-homeless people with severe mental illness (SMI). The aim of this study was to examine the effectiveness of ISH by comparing the clinical outcomes of a newly implemented ISH service with regular housing and support services. METHODS: A total of 58 adults with a broad spectrum of mental disorders experiencing housing problems were randomly assigned to either the intervention group (IG) with the possibility to use the ISH service in Zurich providing targeted, individual and flexible support for housing problems or to the control group (CG) with regular housing and support services currently available (trial registration at ClinicalTrials.gov: NCT03815604). RESULTS: After 12 months, almost all participants of the IG were able to live independently and need for inpatient treatment could be significantly reduced. Service utilization varied between 2 and 79 h. In the CG, 70% of the participants wanted to join a waiting list for the ISH service. The results indicated that IHS was comparable to regular housing and support services in terms of social inclusion and other social and clinical outcomes such as quality of life, capabilities, needs, mental state and functioning (p's > 0.05). The costs of service utilization were on average 115 Swiss Francs (about 124 USD) per participant per month. CONCLUSIONS: ISH is an effective service in housing rehabilitation in terms of social and clinical outcomes and costs. ISH is strongly preferred by service users. In line with the UN Convention on the Rights of Persons with Disabilities, access to ISH services for non-homeless people with SMI should be improved. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT03815604, December 04, 2019.