Staff Experiences of Integrating Peer Support Workers and Clinical Staff in Community-Based Residential Mental Health Rehabilitation: A Pragmatic Grounded Theory Analysis.

Mental health services are increasingly incorporating the views and expertise of people with a lived experience of mental illness in service delivery. A novel approach to this is the 'integrated staffing model' being trialled at two Australian public residential mental health rehabilitation services (Community Care Units, CCUs) where peer support workers (PSWs) occupy the majority of staff roles and work alongside clinicians. Semi-structured interviews were completed with fifteen staff 12-to-18-months after service commencement. Transcripts were analysed following principles of grounded theory analysis. Key emergent themes were: (1) recovery is a deeply personal and non-linear process; (2) The CCU as a transitional learning environment; (3) the integrated staffing model facilitates an effective rehabilitation team; and (4) coming together under the integrated staffing model required a steep learning curve. The findings suggest that the integrated staffing approach may provide a pathway to facilitate the meaningful inclusion of PSWs in rehabilitation settings.

Cognitive remediation therapy: is it a feasible and acceptable psychological treatment for borderline personality disorder?

OBJECTIVE: Cognitive remediation (CR) is increasingly being used to address the cognitive impairment that can occur in people diagnosed with borderline personality disorder (BPD). This study aimed to understand attitudes towards CR in this service user group from the perspective of the person with the diagnosis and clinicians involved in their care. METHOD: Anonymous online surveys were made available to people with a diagnosis of BPD in a public mental health service and clinicians of the same service. RESULTS: Thirty-three percent of service users with a diagnosis of BPD responded to the survey. Most respondents (93%) expressed a desire to improve their cognition and were interested in cognitive remediation therapy (83%). Most staff (88%) recognised cognitive impairment can occur in people with a diagnosis of BPD and the same proportion believed cognitive skills impact on patient's emotional and mental health. Seventy percent of respondents believed CR would be useful for this service user group. CONCLUSIONS: It is important that interventions to address the cognitive impairment associated with BPD are made available and that they are well integrated into the person's overall care plan.

Examining the outcomes of the first one hundred residents in a community based residential rehabilitation unit for people affected by severe and persistent mental illness.

OBJECTIVE: Community-based residential rehabilitation for people experiencing severe and persistent mental illness (SPMI) is increasingly available as an alternative to psychiatric inpatient care. Understanding who accesses these services and their outcomes will inform the optimal allocation of limited public mental health resources. METHOD: This retrospective cohort study explored the outcomes of the first 100 consumers supported by a new Australian Community Care Unit (CCU). The primary outcome focus was acute mental health service use (emergency department presentations, acute mental health inpatient admission days), and secondary outcome foci were accommodation independence and substance use. RESULTS: When the 365 days before and after CCU support were compared, significant reductions in acute mental health bed days were observed (22 days, W = 3.373, p = .001); greater reductions were noted for those staying >182 days (31 days, W = 3.373, p = .001). Additionally, significant improvements in accommodation independence were found, (W = 3.373, p = .001). CONCLUSION: CCU consumers experienced reductions in acute mental health inpatient service use and improved accommodation independence. These observations are consistent with the intended functioning of the residential rehabilitation service.

Formulation in psychiatry - a guide to developing competence.

OBJECTIVE: This paper highlights the importance of psychiatric formulation and provides guidance to those learning the art of formulation. To achieve this, we explore the guidance on formulation that has been previously published in Australasian Psychiatry, identify the key components of psychiatric formulation, and outline an approach to comprehensive formulation in routine clinical practice. CONCLUSION: Formulation is the foundation of good psychiatric practice but presents a considerable challenge to the novice practitioner. Understanding the ingredients of formulation and a method for meaningfully putting these together will guide deliberate practice to learn the art of psychiatric formulation.

Developments in rehabilitation psychiatry within the RANZCP and the creation of a mental health rehabilitation curriculum.

OBJECTIVE: This paper describes the initial development of a mental health rehabilitation curriculum for Australian mental health settings and for psychiatrists and trainees wishing to develop specialist skills in mental health rehabilitation. METHOD: Members of the Section of Social Cultural and Rehabilitation Psychiatry (SSCRP) established an expert working group under the auspices of the RANZCP. Existing college training resources were reviewed, and a gap analysis was conducted to guide development of new training modules. RESULTS: A tiered curriculum structure was created that allows a staged development of rehabilitation knowledge, skills and attitudes required to be a specialist in mental health rehabilitation. An introductory module was developed to establish the principles of modern mental health rehabilitation. Most of the curriculum was based on existing resources that are relevant to rehabilitation practice. Finalisation of a draft for review was undertaken with the assistance of the RANZCP education project advisors and curriculum experts. CONCLUSIONS: As a national body responsible for training psychiatric registrars and maintenance of training for psychiatrists, the RANZCP is well situated to train the specialist medical mental health workforce required to lead rehabilitation services in Australia. The RANZCP mental health rehabilitation curriculum will provide a platform to train the skilled workforce that will enable these services to be fully realised.

Cognitive remediation therapy - implementation and translation into clinical practice in rural and metropolitan New South Wales mental health services.

OBJECTIVE: Cognitive Remediation Therapy (CRT) is an effective intervention in managing the significant cognitive deficits experienced by those living with psychosis. Given its strong evidence base CRT is recommended in Australian and international guidelines for rehabilitation of people with psychosis, however, access to CRT remains limited. In this commentary, we describe recent efforts to implement CRT programs within NSW mental health services. Development of CRT delivery has been successfully achieved in both rural and metropolitan settings, utilising both face-to-face and telehealth methods. CONCLUSIONS: The delivery of CRT in public mental health services is feasible and adaptable to diverse settings. We strongly advocate for sustainable implementation of CRT into routine clinical practice. This will require policy and practice change to enable resources for CRT training and delivery to become embedded in the roles of the clinical workforce.

CBTp for people with treatment refractory schizophrenia on clozapine: a systematic review and meta-analysis.

BACKGROUND: Cognitive behavioural therapy for psychosis (CBTp), an effective treatment for people with schizophrenia, may have a role in clozapine refractory schizophrenia. AIMS: A systematic-review and meta-analysis on the impact of CBTp on psychotic symptoms in people on clozapine. METHODS: We searched PubMed, Embase, PsycInfo, CINAHL and Cochrane for randomised control trials of CBTp as augmentation in people with treatment-refractory schizophrenia on clozapine and conducted pair-wise meta-analyses. RESULTS: Four studies met inclusion criteria. On pairwise meta-analyses, the primary outcome of total psychotic symptoms was not significantly altered by CBTp at either therapy endpoint or six to twelve months follow-up. Secondary outcomes showed that CBT improved positive symptoms at both therapy endpoint (SMD -0.33, 95%CI -0.50 to -0.16, p = 0.002, I2 = 0%) and six to twelve months follow-up (SMD -0.20, 95%CI -0.38 to -0.02, p = 0.03, I2 = 0%) though did not alter negative psychotic symptoms at either timepoint. CONCLUSIONS: CBTp may lead to small benefits for positive symptoms refractory to clozapine. Given the low risks associated with CBTp, and the limited alternative options for clozapine refractory schizophrenia, this approach should be considered in this population.

Adapting evidence-based group therapies following COVID-19 restrictions.

AIM: The COVID-19 pandemic has created barriers to the running of group therapies due to the need to maintain social distance. This paper aims to describe modifications of existing therapeutic groups delivered to people diagnosed with serious and enduring mental illnesses (SMIs) to enable the therapies to continue in an online format due to the COVID-19 restrictions. CONCLUSIONS: Therapists and consumers were motivated to find a way to continue the therapies described despite the context of the restrictions imposed due to COVID-19. This paper describes what was involved in 'pivoting' to a new mode of practice and modifications that were required over time and as new regulations were put in place. Formal research is required to establish an evidence base if these therapies were required to be regularly delivered in an online mode.

Placing rehabilitation at the core of assertive community treatment.

OBJECTIVES: Assertive community treatment (ACT) teams are increasingly being adapted to suit the needs of consumers who have never experienced long-term institutional care yet struggle to retain community tenure and quality of life due to residual functional disabilities associated with severe mental illness. Support needs can be provided by the growing disability support sector but recovery-orientated rehabilitation services delivered by specialist rehabilitation clinicians are also required. The Mobile Intensive Rehabilitation Team (MIRT) within the Metro South Addiction and Mental Health Service has adapted the ACT model to deliver assertive outreach that aims to work collaboratively with the person and their chosen supports to improve their function and their sense of self-efficacy in illness self-management. We described the characteristics of the consumers referred to MIRT over a 20-month time period, and reported on on their discharge location. CONCLUSION: After two years with MIRT, half the participants were discharged out of case-management. Being on clozapine was a barrier to discharge from case-management despite functional improvement. Psychiatric hospitalisations predicted longer duration working with MIRT.

Life in 90 words: opportunities for person-centred care amidst COVID-19.

OBJECTIVE: Coronavirus disease 2019 and the consequent public health and social distancing measures significantly impacted on service continuity for mental health patients. This article reports on contingency planning initiative in the Australian public sector. METHODS: Ninety-word care synopses were developed for each patient. These formed the basis for guided conversations between case managers and consultant psychiatrists to ensure safe service provision and retain a person-centred focus amidst the threat of major staffing shortfalls. RESULTS: This process identified vulnerable patient groups with specific communication needs and those most at risk through service contraction. The challenges and opportunities for promoting safety and self-management through proactive telehealth came up repeatedly. The guided conversations also raised awareness of the shared experience between patients and professionals of coronavirus disease 2019. CONCLUSION: There is a parallel pandemic of anxiety which creates a unique opportunity to connect at a human level.

Predictors of unplanned discharge from community-based residential mental health rehabilitation for people affected by severe and persistent mental illness.

BACKGROUND: Little is known about what predicts disengagement from rehabilitation treatment for people affected by severe and persistent mental illness (SPMI). AIMS: To identify predictors of unplanned discharge among consumers admitted to community-based residential rehabilitation units in Australia. METHOD: Secondary analysis of data from a prospective cohort study of consumers admitted to three Community Care Units (CCUs) between 2014 and 2017 (n = 139). CCUs provide transitional residential rehabilitation support to people affected by SPMI. Demographic, treatment-related and clinical predictors of unplanned discharge were identified using binomial regression models controlling for site-level variability. Factors associated with self- vs staff-initiated unplanned discharge were also examined. RESULTS: 38.8% of consumers experienced unplanned discharge. Significant predictors of unplanned discharge were younger age, higher alcohol consumption and disability associated with mental illness, as well as recovery stage indicating a sense of growth and higher competence in daily task performance. 63.0% of unplanned discharges were initiated by staff, mostly for substance-related reasons (55.9%). History of trauma was more likely among consumers with self-initiated discharge than those with staff-initiated unplanned and planned discharge. CONCLUSIONS: Assertive intervention to address alcohol-use, and ensuring care is trauma-informed, may assist in reducing rates of unplanned discharge from rehabilitation care.

Randomized controlled trial of social cognition and interaction training compared to befriending group.

BACKGROUND: Deficits in social cognition are common in people with schizophrenia and are associated with impaired functioning. Finding effective interventions to address these deficits is a priority. Social Cognition Interaction Training (SCIT) is a psychosocial intervention that has demonstrated acceptability and feasibility in various health care settings. Larger, well-designed randomized controlled trials are needed to examine the effectiveness of this intervention. DESIGN: A randomized controlled trial. METHODS: One hundred and twenty adults diagnosed with schizophrenia spectrum disorder were randomized to receive SCIT (n = 61) or Befriending Therapy (BT) (n = 59). Both intervention groups were delivered weekly for 2 hr over 12 weeks. Neurocognitive assessment was completed at baseline. Participants completed assessments of social cognition, social functioning, and meta-cognition at baseline, post-intervention, and 3-month follow-up. RESULTS: There were no clinically significant differences between group outcomes on any measure of social cognition or social functioning. There was a trend for both groups to improve over time but not at a level of statistical significance. CONCLUSIONS: SCIT did not show any additional benefits on measures of social cognition compared to Befriending Therapy for people with schizophrenia spectrum disorder. The findings are discussed in terms of potential improvements to the programme. PRACTITIONER POINTS: Effective interventions for the social cognitive deficits of schizophrenia spectrum disorders are still being refined. Social Cognition Interaction Training is a promising therapy but requires further modifications to improve its effectiveness.

A comparison study of three physical activity measurement tools examining acceptability in people with psychosis.

OBJECTIVE: To compare the acceptability of three distinct physical activity measurement tools in people with psychosis: an objective measurement tool, a self-report measure, and an exercise capacity test. METHODS: We measured the completion rate for each measurement tool. Participants rated the ease/difficulty of each measure using a 7-point Likert scale. Participants were also asked to rank the three tools in order of the ease of use. RESULTS: Sixty-six per cent (46/69) of participants completed all three assessment tools, and 60.9% (42/69) completed the acceptability questionnaire. The majority of the participants found it easy to complete all three measurement tools. The majority (52.8%) of the participants ranked the objective measurement tool as the easiest to use. CONCLUSION: All three measures were acceptable to people with psychosis, but objective measurement tools may be easier to use.

A systematic review of service models and evidence relating to the clinically operated community-based residential mental health rehabilitation for adults with severe and persisting mental illness in Australia.

BACKGROUND: Clinically operated community-based residential rehabilitation units (Community Rehabilitation Units) are resource intensive services supporting a small proportion of the people with severe and persisting mental illness who experience difficulties living in the community. Most consumers who engage with these services will be diagnosed with schizophrenia or a related disorder. This review seeks to: generate a typology of service models, describe the characteristics of the consumers accessing these services, and synthesise available evidence about consumers' service experiences and outcomes. METHOD: A systematic review was undertaken to identify studies describing Community Rehabilitation Units in Australia, consumer characteristics, and evidence about consumer experiences and outcomes. Search strings were applied to multiple databases; additional records were identified through snowballing. Records presenting unique empirical research were subject to quality appraisal. RESULTS: The typology defined two service types, Community-Based Residential Care (C-BRC), which emerged in the context of de-institutionalisation, and the more recent Transitional Residential Rehabilitation (TRR) approach. Key differentiating features were the focus on transitional care and 'recovery' under TRR. Schizophrenia spectrum disorders were the most common primary diagnosis under both service types. TRR consumers were more likely to be male, referred from community settings, and less likely to be subject to involuntary treatment. Regarding outcomes, the limited quantitative evidence (4 records, 2 poor quality) indicated C-BRC was successful in supporting the majority of consumers transferred from long-term inpatient care to remain out of hospital. All qualitative research conducted in C-BRC settings was assessed to be of poor quality (3 records). No methodologically sound quantitative evidence on the outcomes of TRR was identified. Qualitative research undertaken in these settings was of mixed quality (9 records), and the four records exploring consumer perspectives identified them as valuing the service provided. CONCLUSIONS: While there is qualitative evidence to suggest consumers value the support provided by Community Rehabilitation Units, there is an absence of methodologically sound quantitative research about the consumer outcomes achieved by these services. Given the ongoing and increasing investment in these facilities within the Australian context, there is an urgent need for high-quality research examining their efficiency and effectiveness. TRIAL REGISTRATION: PROSPERO ( CRD42018097326 ).

Implementing cognitive remediation and social cognitive interaction training into standard psychosis care.

BACKGROUND: To evaluate the planned implementation of group based Cognitive Remediation therapy (CR) and Social Cognitive Interaction Training (SCIT) into routine psychosis care in a mental health service in Australia. METHOD: The study was conducted over 3 years in a mental health service in a metropolitan city in Australia. Participants were 22 program facilitators and 128 patients attending the programs. Implementation outcomes were assessed using administrative data, staff surveys and program audits. RESULTS: There was fidelity to the particular therapies at a program level. Programs were assessed as being feasible within the study setting with each hospital district developing a capacity to run CR and SCIT. The establishment of new programs improved the reach, but waiting lists indicate a need to expand capacity. There was a relatively high dropout and several factors impacted on completion of the programs - notably, acute exacerbation of psychosis. Once initiated the therapies were acceptable with no-one ceasing SCIT due to loss of interest and only 10% of participants ceasing CR due to loss of interest. Annual audits of programs found programs established were maintained and facilitators were retained. CONCLUSION: SCIT and CR programs were successfully implemented in three hospital districts. Several factors impeded participants receiving the recommended "dose" of the programs. The maintenance of the programs in the short term is encouraging in regards to organisational fit. Dissemination of cognitive rehabilitation programs to a service population takes planning. An implementation plan is essential for guiding development and maintenance of programs. These therapies are best suited to people in a stable phase of illness. Service user co-production is recommended to improve recruitment in future studies.

The 2016 Royal Australian and New Zealand College of Psychiatrists guidelines for the management of schizophrenia and related disorders.

INTRODUCTION: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical practice guidelines for the management of schizophrenia and related disorders provide evidence-based recommendations for optimising treatment and prognosis. This update to the 2005 RANZCP guidelines has a greater emphasis on psychosocial treatments, physical health comorbidities and vocational rehabilitation. Main recommendations: The guidelines advise a clinical staging approach and deliver specific recommendations for:•comprehensive treatment using second generation antipsychotic agents continuously for 2-5 years;•early treatment of comorbid substance use;•community treatment after initial contact, during crises and after discharge from hospital;•physical health monitoring and management of comorbidities, particularly metabolic health;•interventions to optimise recovery of social function and return to study or work; and•management of schizophrenia in specific populations and circumstances. Changes in management as a result of the guidelines: The guidelines provide benchmarks against which the performance of services and clinical teams can be assessed. Measuring treatment response and clinical outcome is essential. General practitioners have an important role, particularly in monitoring and reducing the high cardiovascular risk in this population. Clinical services focusing on early detection, treatment and recovery need continuous funding to be proactive in implementing the guidelines and closing the gap between what is possible and what actually occurs.

A substantial peer workforce in a psychiatric service will improve patient outcomes: the case for.

OBJECTIVES: This statement of opinion relates to an invited debate on the role of peer workers in psychiatric services during the Royal Australian and New Zealand College of Psychiatrists conference 2016. The views presented in this statement of opinion are those of the team for the affirmative. CONCLUSIONS: Peer workers are increasingly being employed within mental health services. Early adopters of this new workforce note advantages in terms of engagement of peers but also a bidirectional sharing of knowledge between clinicians and peer workers that has been mutually beneficial. Greater research and evaluation needs to occur to understand how best to incorporate peer workers into mental health care.

The 2016 RANZCP Guidelines for the Management of Schizophrenia and Related Disorders - what's next?

OBJECTIVES: The recently published RANZCP guidelines for schizophrenia and related disorders reviewed recent scientific evidence, and, where lacking, referred to clinical expertise to supply a template for raising the standard of care. This paper builds on the guidelines and recommends how they might be used to improve outcomes. METHODS: The guidelines call for evidence-based mental health policies, inclusive of mobilising affected families, communities and the public in support of policies that ensure better care and protect the wellbeing of people with severe mental disorders. The process of preparing the guidelines highlighted the limits of our scientific understanding of schizophrenia and shortcomings in the care currently provided. RESULTS: Writing the guidelines evinced the need for a culture of measuring outcomes and response to treatment, and harnessing such data to monitoring and optimising patient care. CONCLUSIONS: We recommend creation of a national case cohort for mental health research involving a collaborative network of clinical research centres, using the guidelines and generating scientific evidence for translation into clinical practice protocols that enable personalised treatment plans for patients and criteria for the performance of clinical services.

Longitudinal comparative evaluation of the equivalence of an integrated peer-support and clinical staffing model for residential mental health rehabilitation: a mixed methods protocol incorporating multiple stakeholder perspectives.

BACKGROUND: A novel staffing model integrating peer support workers and clinical staff within a unified team is being trialled at community based residential rehabilitation units in Australia. A mixed-methods protocol for the longitudinal evaluation of the outcomes, expectations and experiences of care by consumers and staff under this staffing model in two units will be compared to one unit operating a traditional clinical staffing. The study is unique with regards to the context, the longitudinal approach and consideration of multiple stakeholder perspectives. METHODS/DESIGN: The longitudinal mixed methods design integrates a quantitative evaluation of the outcomes of care for consumers at three residential rehabilitation units with an applied qualitative research methodology. The quantitative component utilizes a prospective cohort design to explore whether equivalent outcomes are achieved through engagement at residential rehabilitation units operating integrated and clinical staffing models. Comparative data will be available from the time of admission, discharge and 12-month period post-discharge from the units. Additionally, retrospective data for the 12-month period prior to admission will be utilized to consider changes in functioning pre and post engagement with residential rehabilitation care. The primary outcome will be change in psychosocial functioning, assessed using the total score on the Health of the Nation Outcome Scales (HoNOS). Planned secondary outcomes will include changes in symptomatology, disability, recovery orientation, carer quality of life, emergency department presentations, psychiatric inpatient bed days, and psychological distress and wellbeing. Planned analyses will include: cohort description; hierarchical linear regression modelling of the predictors of change in HoNOS following CCU care; and descriptive comparisons of the costs associated with the two staffing models. The qualitative component utilizes a pragmatic approach to grounded theory, with collection of data from consumers and staff at multiple time points exploring their expectations, experiences and reflections on the care provided by these services. DISCUSSION: It is expected that the new knowledge gained through this study will guide the adaptation of these and similar services. For example, if differential outcomes are achieved for consumers under the integrated and clinical staffing models this may inform staffing guidelines.

N-acetylcysteine (NAC) in schizophrenia resistant to clozapine: a double blind randomised placebo controlled trial targeting negative symptoms.

BACKGROUND: Clozapine is an effective treatment for a proportion of people with schizophrenia (SZ) who are resistant to the beneficial effects of other antipsychotic drugs. However, anything from 40-60 % of people on clozapine experience residual symptoms even on adequate doses of the medication, and thus could be considered 'clozapine resistant'. Agents that could work alongside clozapine to improve efficacy whilst not increasing the adverse effect burden are both desired and necessary to improve the lives of individuals with clozapine-resistant SZ. N-Acetylcysteine (NAC) is one such possible agent. Previous research from our research group provided promising pilot data suggesting the efficacy of NAC in this patient population. The aim of the study reported here is to expand this work by conducting a large scale clinical trial of NAC in the treatment of clozapine-resistant SZ. METHODS: This study is an investigator initiated, multi-site, randomised, placebo-controlled trial. It aims to include 168 patients with clozapine-resistant SZ, divided into an intervention group (NAC) and a control group (placebo). Participants in the intervention group will receive 2 g daily of NAC. The primary outcome measures will be the negative symptom scores of the Positive and Negative Syndrome Scale (PANSS). Secondary outcome measures will include: changes in quality of life (QoL) as measured by the Lancashire Quality of Life Profile (LQoLP) and cognitive functioning as measured by the total score on the MATRICS. Additionally we will examine peripheral and cortical glutathione (GSH) concentrations as process outcomes. DISCUSSION: This large scale clinical trial will investigate the efficacy of NAC as an adjunctive medication to clozapine. This trial, if successful, will establish a cheap, safe and easy-to-use agent (NAC) as a 'go to' adjunct in patients that are only partly responsive to clozapine. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registration Number: Current Randomised Controlled Trial ACTRN12615001273572 . The date of registration 23 November 2015.