Implementing the illness management and recovery program in community mental health settings: facilitators and barriers.

OBJECTIVE: There is little research on how to effectively implement the illness management and recovery program for people with severe mental illness in community mental health settings. This study aimed to examine which factors promote or hinder successful implementation of illness management and recovery in these settings. METHODS: Twelve community mental health centers implemented illness management and recovery over a two-year period. They were supported in this endeavor by an implementation resource kit and regular meetings with a consultant trainer. Implementation efforts at each center were monitored by a supervised researcher (an implementation monitor) over the two years. This researcher conducted qualitative interviews with key informants every six months and conducted more frequent observations of routine activity in order to discern the implementation progress. These qualitative data were gathered into a database that was examined by the authors to discern key cross-site barriers to and facilitators of the implementation of illness management and recovery. RESULTS: Through content analysis of the qualitative data, four broad cross-site themes emerged that appear to meaningfully determine success or failure of implementation. These were leadership, organizational culture, training, and staff and supervision. These overlapping themes worked synergistically to effect implementation. CONCLUSIONS: Implementation of illness management and recovery in community mental health settings is facilitated through strong leadership, an organizational culture that embraces innovation, effective training, and committed staff. Where these factors are lacking, strategies may need to be developed to effectively implement and sustain illness management and recovery.

Implementation of integrated dual disorders treatment: a qualitative analysis of facilitators and barriers.

OBJECTIVE: Approximately half of the people who have serious mental illnesses experience a co-occurring substance use disorder at some point in their lifetime. Integrated dual disorders treatment, a program to treat persons with co-occurring disorders, improves outcomes but is not widely available in public mental health settings. This report describes the extent to which this intervention was implemented by 11 community mental health centers participating in a large study of practice implementation. Facilitators and barriers to implementation are described. METHODS: Trained implementation monitors conducted regular site visits over two years. During visits, monitors interviewed key informants, conducted ethnographic observations of implementation efforts, and assessed fidelity to the practice model. These data were coded and used as a basis for detailed site reports summarizing implementation processes. The authors reviewed the reports and distilled the three top facilitators and barriers for each site. The most prominent cross-site facilitators and barriers were identified. RESULTS: Two sites reached high fidelity, six sites reached moderate fidelity, and three sites remained at low fidelity over the two years. Prominent facilitators and barriers to implementation with moderate to high fidelity were administrative leadership, consultation and training, supervisor mastery and supervision, chronic staff turnover, and finances. CONCLUSIONS: Common facilitators and barriers to implementation of integrated dual disorders treatment emerged across sites. The results confirmed the importance of the use of the consultant-trainer in the model of implementation, as well as the need for intensive activities at multiple levels to facilitate implementation. Further research on service implementation is needed, including but not limited to clarifying strategies to overcome barriers.

Fidelity outcomes in the National Implementing Evidence-Based Practices Project.

OBJECTIVE: This article presents fidelity outcomes for five evidence-based practices that were implemented in routine public mental health settings in the National Implementing Evidence-Based Practices Project. METHODS: Over a two-year period 53 community mental health centers across eight states implemented one of five evidence-based practices: supported employment, assertive community treatment, integrated dual disorders treatment, family psychoeducation, and illness management and recovery. An intervention model of practice dissemination guided the implementation. Each site used both human resources (consultant-trainers) and material resource (toolkits) to aid practice implementation and to facilitate organizational changes. External assessors rated fidelity to the evidence-based practice model every six months from baseline to two years. RESULTS: More than half of the sites (29 of 53, or 55%) showed high-fidelity implementation at the end of two years. Significant differences in fidelity emerged by evidence-based practice. Supported employment and assertive community treatment had higher fidelity scores at baseline and across time. Illness management and recovery and integrated dual disorders treatment had lower scores on average throughout. In general, evidence-based practices showed an increase in fidelity from baseline to 12 months, with scores leveling off between 12 and 24 months. CONCLUSIONS: Most mental health centers implemented these evidence-based practices with moderate to high fidelity. The critical time period for implementation was approximately 12 months, after which few gains were made, although sites sustained their attained levels of evidence-based practice fidelity for another year.

The state of nursing science - cultural and lifespan issues in depression: part I: focus on adults.

Depression is a devastating disorder, affecting approximately 17 million persons within the United States. The manifestation of depressive phenomena is a complex, dynamic, biopsychosocial process involving lifespan and cultural aspects. Unless appropriately treated, depression persists over time having a significant negative effect on life and increasing the risk of suicide. Psychiatric mental health (PMH) nurses are uniquely positioned to address this epidemic health concern. This manuscript is Part I of the review of current nursing literature on adult depression. This review can be used to enhance PMH nurses' knowledge of current nursing research and their efforts in addressing prevention, early intervention, education and treatment of adults who experience depression.

The state of nursing science--cultural and lifespan issues in depression: part II: focus on children and adolescents.

The manifestation of depressive phenomena is a complex, dynamic biopsychosocial process across cultures and the lifespan. Without appropriate treatment, depression persists and can have significant negative effects on the lives of youth, including an increased risk of suicide. Psychiatric mental-health (PMH) nurses are uniquely positioned to address this health concern. This manuscript is Part II of a review of current nursing literature on culture and lifespan aspects of depression. The review presented in Part II focuses on children and adolescents. This information can be used to enhance PMH nurses' knowledge of current nursing research and their efforts in addressing prevention, early intervention, education, and treatment of youth who experience depression.

Children's communication about distressing events: the role of emotional openness and psychological attributes of family members.

This study documents the importance of emotional openness to the recovery process in families following traumatic events. In this longitudinal study, relationships are examined between emotional openness and parents' psychological attributes, and mothers' and children's open disclosure of feelings. After September 11, 2001, 48 mothers and their 11-year-old children were interviewed about their reactions to the terrorist attacks. Measures included interview-based scores of children's and mothers' degree of openness, mothers' openness assessed during pregnancy and infancy, and parental depression and anxiety in close relationships. Emotional openness is a stable and reliably measured construct. Mothers' emotional openness was significantly related to earlier assessments of openness, indicators of their own and their spouse's emotional health, and their children's open expression of emotion about the terrorist attacks.

Consumer and case manager perspectives of service empowerment: relationship to mental health recovery.

This study examines the relationship between service empowerment and recovery. Service empowerment is defined as the extent to which consumers participate in service decisions and the level of reciprocity and respect within the relationship with their case managers. Assessments were made from two perspectives: consumers and their case managers. Structural equation models were developed to examine the direct and indirect effects of service empowerment on four recovery outcomes: Quality of Life, Level of Functioning, Consumer-Reported Symptomatology, and Case Manager-Reported Symptomatology. Consumers' perceptions of service empowerment were the most powerful predictor of recovery outcomes across the four models. Consumers' and case managers' perceptions were related but the magnitude of the relationship was small, indicating that considerable differences exist between their perceptions of service empowerment.

Predicting children's reactions to terrorist attacks: the importance of self-reports and preexisting characteristics.

Forty-eight mothers and their 11-year-old children, who were participants in a longitudinal study, were interviewed in their home after the terrorist attacks of September 11, 2001. Children's verbatim statements were analyzed for fear, separation anxiety, denial, rationalization, anger, and empathy. In the final model, preexisting child anxiety and maternal worry significantly explained 33% of the variance in children's self-reported fearful feelings.

Parental emotions following the birth of the first child: gender differences in depressive symptoms.

This study addresses psychological issues that put first-time parents at risk for depressive disorders. In a community sample of 107 men and their wives, employment variables, marital quality, and personality attributes (fear of abandonment and loneliness) significantly explained 43% of the variance in men's, and almost 25% in women's, depressive symptoms. Men reported more symptoms than women. Men with heightened fear of loneliness were particularly at risk for depressive symptoms after birth of the first child.