Experiences of healthcare staff providing community-based mental healthcare as a multidisciplinary community mental health team in Central and Eastern Europe findings from the RECOVER-E project: an observational intervention study.

BACKGROUND: Community Mental Health Teams (CMHTs) deliver healthcare that supports the recovery of people with mental illness. The aim of this paper was to explore to what extent team members of five CMHTs newly implemented in five countries perceived that they had introduced aspects of the recovery-oriented, strength-based approach into care after a training week on recovery-oriented practice. In addition, it evaluated what the team members' perceptions on their care roles and their level of confidence with this role were. METHOD: An observational intervention study using a quantitative survey that was administered among 52 health professionals (21 Nurses, 13 Psychiatrists, 9 Psychologists, 8 Social Workers) and 14 peer workers including the Recovery Self-Assessment Tool Provider Version (RSA-P), the Team Member Self-Assessment Tool (TMSA), and demographic questions was conducted. The measures were self-reported. Descriptive statistics were used to calculate the means and standard deviations for continuous variables and frequencies and percentages for categorical variables (TMSA tool and demographic data). The standard technique to calculate scale scores for each subscale of the RSA-P was used. Bivariate linear regression analyses were applied to explore the impact of predictors on the subscales of the RSA-P. Predictors with significant effects were included in multiple regression models. RESULT: The RSA-P showed that all teams had the perception that they provide recovery-oriented practice to a moderately high degree after a training week on recovery-oriented care (mean scores between 3.85-4.46). Health professionals with fewer years of professional experience perceived more frequently that they operated in a recovery-oriented way (p = 0.036, B = - 0.268). Nurses and peer workers did not feel confident or responsible to fulfil specific roles. CONCLUSION: The findings suggest that a one-week training session on community-based practices and collaborative teamwork may enhance recovery-oriented practice, but the role of nurses and peer workers needs further attention. TRIAL REGISTRATION: Each trial was registered before participant enrolment in the clinicaltrials.gov database: Croatia, Zagreb (Trial Reg. No. NCT03862209 ); Montenegro, Kotor (Trial Reg. No. NCT03837340 ); Romania, Suceava (Trial Reg. No. NCT03884933 ); Macedonia, Skopje (Trial Reg. No. NCT03892473 ); Bulgaria, Sofia (Trial Reg. No. NCT03922425 ).

Perceived Support for Recovery and Level of Functioning Among People With Severe Mental Illness in Central and Eastern Europe: An Observational Study.

Background: Many people with severe mental illness experience limitations in personal and social functioning. Care delivered in a person's community that addresses needs and preferences and focuses on clinical and personal recovery can contribute to addressing the adverse impacts of severe mental illness. In Central and Eastern Europe, mental health care systems are transitioning from institutional-based care toward community-based care. The aim of this study is to document the level of functioning and perceived support for recovery in a large population of service users with severe mental illness in Central and Eastern Europe, and to explore associations between perceived support for recovery and the degree of functional limitations. Methods: The implementation of community mental health teams was conducted in five mental health centers in five countries in Central and Eastern Europe. The present study is based on trial data at baseline among service users across the five centers. Baseline data included sociodemographic, the World Health Organization Disability Assessment Schedule (WHODAS 2.0) for functional limitations, and the Recovery Support (INSPIRE) tool for perceived staff support toward recovery. We hypothesized that service users reporting higher levels of perceived support for their recovery would indicate lower levels of functional limitation. Results: Across all centers, the greatest functional limitations were related to participation in society (43.8%), followed by daily life activities (33.3%), and in education or work (35.6%). Service users (N = 931) indicated that they were satisfied overall with the support received from their mental health care provider for their social recovery (72.5%) and that they valued their relationship with their providers (80.3%). Service users who perceived the support they received from their provider as valuable (b = -0.10, p = 0.001) and who reported to have a meaningful relationship with them (b = -0.13, p = 0.003) had a lower degree of functional limitation. Conclusion: As hypothesized, the higher the degree of perceived mental health support from providers, the lower the score in functional limitations. The introduction of the community-based care services that increase contact with service users and consider needs and which incorporate recovery-oriented principles, may improve clinical recovery and functional outcomes of service users with severe mental illness.

Changes in national rates of psychiatric beds and incarceration in Central Eastern Europe and Central Asia from 1990-2019: A retrospective database analysis.

BACKGROUND: Numbers of psychiatric beds (general, forensic, and residential) and prison populations have been considered to be indicators of institutionalisation of people with mental illnesses. The present study aimed to assess changes of those indicators across Central Eastern Europe and Central Asia (CEECA) over the last three decades to capture how care has developed during that historical period. METHODS: We retrospectively obtained data on numbers of psychiatric beds and prison populations from 30 countries in CEECA between 1990 and 2019. We calculated the median of the percent changes between the first and last available data points for all CEECA and for groups of countries based on former political alliances and income levels. FINDINGS: Primary national data were retrieved from 25 out of 30 countries. Data from international registries were used for the remaining five countries. For all of CEECA, the median decrease of the general psychiatric bed rates was 33•8% between 1990 and 2019. Median increases were observed for forensic psychiatric beds (24•7%), residential facility beds (12•0%), and for prison populations (36•0%). Greater reductions of rates of psychiatric beds were observed in countries with lower per capita income as well as in countries that were formerly part of the Soviet Union. Seventeen out of 30 countries showed inverse trends for general psychiatric beds and prison populations over time, indicating a possible shift of institutionalisation towards correctional settings. INTERPRETATION: Most countries had decreased rates of general psychiatric beds, while there was an increase of forensic capacities. There was an increase in incarceration rates in a majority of countries. The large variation of changes underlines the need for policies that are informed by data and by comparisons across countries. FUNDING: Agencia Nacional de Investigación y Desarrollo in Chile, grant scheme FONDECYT Regular, grant number 1190613.

Towards community-based and recovery-oriented care for severe mental disorders in Southern and Eastern Europe: aims and design of a multi-country implementation and evaluation study (RECOVER-E).

BACKGROUND: Substantial strides have been made around the world in reforming mental health systems by shifting away from institutional care towards community-based services. Despite an extensive evidence base on what constitutes effective care for people with severe mental ill-health, many people in Europe do not have access to optimal mental health care. In an effort to consolidate previous efforts to improve community mental health care and support the complex transition from hospital-based to community-based care delivery, the RECOVER-E (LaRge-scalE implementation of COmmunity based mental health care for people with seVere and Enduring mental ill health in EuRopE) project aims to implement and evaluate multidisciplinary community mental health teams in five countries in Central and Eastern Europe. This paper provides a brief overview of the RECOVER-E project and its methods. METHODS: Five implementation sites were selected (Sofia, Bulgaria; Zagreb, Croatia; Skopje, North Macedonia; Kotor, Montenegro; Siret-Suceava, Romania) where hospital-based mental health services are available (care as usual, CAU) for patients with severe mental disorders (severe depression, bipolar disorder, schizophrenia). The intervention consists of the introduction of a new service delivery model in each site, consisting of community-based recovery-oriented care delivered by trained multidisciplinary community mental health teams (including a peer worker with lived experience of a severe mental disorder). The implementation outcomes of the teams and the effect of the team's approach on patient and service utilisation outcomes will be evaluated using a mix of research methods. The study includes five planned hybrid implementation-effectiveness trials (1 per site) with patient-level randomization (n = 180, with patients randomised to either care as usual or intervention condition). Effectiveness is evaluated using a pragmatic non-blinded design with patients randomised into two parallel groups: receiving new community-based care or receiving usual care in the form of institutional, hospital-based mental health care. Trial-based health economic evaluation will be conducted; implementation outcomes will be evaluated, with data aligned with dimensions from the RE-AIM framework. Pathways to sustaining project results will be developed through policy dialogue sessions, which will be carried out in each country and through ongoing policy engagement activities at the European level. DISCUSSION: The RECOVER-E project has been developed and conducted to demonstrate the impact of implementing an evidence-based service delivery model for people with severe mental illness in different contexts in middle-income countries in Central and Eastern Europe. It is expected that the results will contribute to the growing evidence-base on the health and economic benefits of recovery-oriented and community-based service models for health systems in transition.Trial registration Each trial was registered before participant enrolment in the clinicaltrials.gov database: Site-Croatia, Zagreb (Trial Reg. No. NCT03862209); Montenegro, Kotor (Trial Reg. No. NCT03837340); Romania, Suceava (Trial Reg. No. NCT03884933); Macedonia, Skopje (Trial Reg. No. NCT03892473); Bulgaria, Sofia (Trial Reg. No. NCT03922425).

Sustainability of Community-Based Specialized Mental Health Services in Five European Countries: Protocol for Five Randomized Controlled Trial-Based Health-Economic Evaluations Embedded in the RECOVER-E Program.

BACKGROUND: Community-based recovery-oriented mental health services for people with severe mental disorders have not been fully implemented in Bulgaria, Croatia, Macedonia, Montenegro, and Romania. The RECOVER-E project facilitates the implementation of specialized mental health care delivered by setting up services, implementing the services, and evaluating multidisciplinary community mental health teams. The outcomes of the RECOVER-E project are assessed in a trial-based outcome evaluation in each of the participating countries with a health-economic evaluation linked to these trials. OBJECTIVE: The aim of this protocol paper is to describe the methodology that will be used for the health-economic evaluation alongside the trials. METHODS: Implementation sites have been selected in each of the five countries where hospital-based mental health services are available (care as usual [CAU]) for patients with severe mental disorders (severe depression, bipolar disorder, schizophrenia, and other psychotic disorders). The newly implemented health care system will involve community-based recovery-oriented mental health care (CMHC). At each site, 180 consenting patients will be randomized to either CAU or CMHC. Patient-level outcomes are personal and social functioning and quality-adjusted life years (QALYs). Data on participants' health care use will be collected and corresponding health care costs will be computed. This enables evaluation of health care costs of CMHC as compared with CAU, and these costs can be related to patient-level outcomes (functioning and QALY gains) in health-economic evaluation. RESULTS: Data collection was started in December 2018 (Croatia), February 2019 (Montenegro), April 2019 (Romania), June 2019 (North Macedonia), and October 2019 (Bulgaria). The findings of the outcome evaluations will be reported for each of the five countries separately, and the five trials will be pooled for multilevel analysis on a combined dataset. CONCLUSIONS: The results of the health-economic evaluation of the RECOVER-E project will contribute to the growing evidence base on the health and economic benefits of recovery-oriented and community-based service models for health systems in transition. TRIAL REGISTRATION: (1) ClinicalTrials.gov NCT03922425 (Bulgaria); https://clinicaltrials.gov/ct2/show/NCT03922425 (2) ClinicalTrials.gov NCT03862209 (Croatia); https://clinicaltrials.gov/ct2/show/NCT03862209 (3) ClinicalTrials.gov NCT03892473 (Macedonia); https://clinicaltrials.gov/ct2/show/NCT03892473 (4) ClinicalTrials.gov NCT03837340 (Montenegro); https://clinicaltrials.gov/ct2/show/NCT03837340 (5) ClinicalTrials.gov NCT03884933 (Romania); https://clinicaltrials.gov/ct2/show/NCT03884933. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17454.