The longitudinal dispositions of people diagnosed with adjustment or severe stress disorders.

BACKGROUND: Adjustment and stress-related disorders are prevalent among psychiatric service users. Despite their prevalence, little is known about their prognosis. To reduce that gap, the present article documents the service use and diagnostic outcomes of people with adjustment or stress-related disorders presenting at Singapore's largest psychiatric emergency department. METHODS: Administrative data from 2014 to 2021 was retrieved to follow a group of 683 service users whose first-ever psychiatric presentation in 2014 warranted a diagnosis of adjustment or stress-related disorder. People were grouped a priori depending on whether different diagnoses were recorded within 7 days, 9 months, after 9 months or not at all. Survival curves characterized conversion to other diagnoses and engagement with healthcare services. Service use outcomes include the number of hospitalizations, outpatient appointments, emergency department visits, and prescriptions. RESULTS: Sixty-one percent (n = 417) never received another diagnosis over the 8-year period. This group used emergency services most and received the most pharmacotherapy shortly after their first visit. Of those who received another diagnosis, depression, personality disorders, and psychotic disorders were the most common. Those who received another diagnosis within 7 days (n = 70, 10%) received it on their first day of hospitalization (IQR 1-1), making the most use of inpatient services. The group who received another diagnosis within 9 months (n = 105, 15%) did so after 42 days (IQR 26-84) and had the highest relative number of deaths. Those who received another diagnosis after 9 months (n = 91, 13%) did so after 1,134 days (IQR 613-1,823) and had the longest period of engagement but made the least use of any psychiatric service, potentially suggesting a group whose early index diagnosis heralded vulnerability to future disorders. CONCLUSIONS: A large group of service users with acute stress or adjustment disorders will likely never be given another psychiatric diagnosis and appear to disengage following an initial period of high-intensity service use. The group that received a different diagnosis after the 9-month mark had prolonged contact with services but low intensity of service use and may represent a target for preventative intervention to help them improve their stress-managing skills and avoid developing other disorders.

Prevalence and economic burden of depression and anxiety symptoms among Singaporean adults: results from a 2022 web panel.

BACKGROUND: Major depressive disorder (MDD) and generalized anxiety disorder (GAD) are leading causes of disability and premature mortality. At a global level, over 300 million people are estimated to suffer from major depressive disorders, equivalent to 4·4% of the world's population. Pandemic era stressors have increased rates for depression and anxiety by upwards of 25%. The goal of this study is to estimate the prevalence and economic burden of depression and anxiety symptoms in Singapore after the peak of the COVID-19 pandemic. METHODS: An existing web panel was queried between April 2022 and June 2022. Adult participants aged > 21 years old who screened positive for depression and anxiety symptoms based on the Patient Health Questionnaire-4 (PHQ-4) Screener were eligible for participation. Prevalence estimates were quantified by dividing the number of respondents who screened positive for these symptoms by the total number of respondents. Participants who screened positive were asked about healthcare utilization, days missed from work, and reduced productivity due to these symptoms. These values were then monetized and scaled based on prevalence and population counts to generate per capita and total annual costs. RESULTS: Two thousand three hundred forty-eight respondents filled out the PHQ-4 depression/anxiety screener on behalf of the 5,725 adults living in their households (including respondents themselves). Prevalence estimates were calculated based on the responses recorded for these 5,725 adults. 14.1% adults had symptoms consistent with depression and 15.2% had symptoms consistent with anxiety. In total, 20.0% may experience symptoms consistent with at least one of these two conditions, yet approximately half reported never being formally diagnosed. 350 respondents screened positive for depression or anxiety symptoms and thus were eligible to fill out the healthcare utilization, presenteeism, and absenteeism survey. Direct annual healthcare costs due to depression and anxiety symptoms averaged Singapore dollar (SGD) $1,050 for these respondents. The employed subset (n = 304) missed an extra 17.7 days of work on average per year, which translates to SGD $4,980 per worker. These workers also reported being ~ 40% less productive at work, which equates to SGD $28,720 in economic losses annually. In total, these symptoms caused SGD $15.7 billion in increased costs. Presenteeism accounts for 81.6% of this total (SGD $12.8 billion), absenteeism for 14.2% (SGD $2.3 billion) and healthcare accounts for 4.2% (SGD $0.7 billion). CONCLUSIONS: The health and economic burden associated with depression and anxiety symptoms is large in Singapore, representing 2.9% of Singapore's gross domestic product (GDP). Employers and governments should look to identify effective remediation strategies, including strategies to address the high rates of undiagnosed cases. Increasing psychiatric resources, general practitioner mental health competency, access to peer support, and increased efforts to reduce mental health stigma should be considered to address this growing public health crisis.

A Longitudinal Qualitative Analysis of the Way Peer Support Specialist Roles Change Over Time in a Psychiatric Hospital Setting in Asia.

The current study seeks to determine how peer support roles change as peer support specialists' positions within organizations and departments mature. We followed ten peer support specialists over the course of a year, interviewing them at three points, starting approximately three months after they began working as peer support specialists. We used an inductive process to analyze our data and followed guidelines on the structuring of longitudinal qualitative trajectories to divide the data into watershed moments. Our participants worked in a variety of departments in the hospital, and their service use experiences generally echo those of their service users. Participants appear to pass through four phases over the course of their employment as peers: early beginnings, establishing the role, role narrowing, and role sustainability. Services wishing to integrate new peers must be aware of the time required for integration. Having general job descriptions limited to specifying that peers are expected to use their lived experience to support current service users may lead to uncertainty amongst new and existing staff. Without role clarity, peers may struggle to find their place. Pairing new staff with mentors may limit this burden. As roles consolidate, boundaries may emerge. If these boundaries narrow the role of the PSS, they may no longer find the role appealing. They may then choose other caregiver roles with wider or different spheres of influence. Organizations may benefit by clearly indicating if they expect peer support positions to be static or transitionary.

Selection of New Psychiatry Residents Within a National Program: a Qualitative Study of Faculty Perspectives on Competencies and Attributes.

OBJECTIVE: Admission committees use multiple sources of information to select residents. However, the way in which faculty members use each data source remains unclear and highly context-specific. The present study seeks to understand how faculty members use various sources of information about candidates to make admission decisions to a National Psychiatry Residency Program. METHODS: The theory of core competencies was used as a foundation for this qualitative study. Framework analysis was used to structure the project and data presentation. Twenty key informants from the faculty were purposefully sampled in accordance with the initial theory. Open-ended semi-structured interviews were conducted to obtain their views about the essential competencies of psychiatrists and the ways in which these competencies could be reliably gauged. RESULTS: Participants described numerous competencies that they believed were essential to becoming competent psychiatrists. These competencies fell within the six core competencies of the Accreditation Council for Graduate Medical Education framework. However, several non-competency attributes (such as perseverance, empathy, and compassion) were also relevant in the selection process. To reduce the impact of self-presentation bias, to which these attributes were vulnerable, the faculty relied heavily on sources of information obtained from third parties, such as feedback from co-workers with first-hand experience of the candidate during their clinical placements. CONCLUSION: Faculty members place importance on informal informant-derived information about a candidate's non-competency attributes in addition to core competencies when deciding whether or not to select a candidate for admission into a residency training program.

Food security among individuals experiencing homelessness and mental illness in the At Home/Chez Soi Trial.

OBJECTIVE: Individuals experiencing homelessness are particularly vulnerable to food insecurity. The At Home/Chez Soi study provides a unique opportunity to first examine baseline levels of food security among homeless individuals with mental illness and second to evaluate the effect of a Housing First (HF) intervention on food security in this population. DESIGN: At Home/Chez Soi was a 2-year randomized controlled trial comparing the effectiveness of HF compared with usual care among homeless adults with mental illness, stratified by level of need for mental health services (high or moderate). Logistic regressions tested baseline associations between food security (US Food Security Survey Module), study site, sociodemographic variables, duration of homelessness, alcohol/substance use, physical health and service utilization. Negative binomial regression determined the impact of the HF intervention on achieving levels of high or marginal food security over an 18-month follow-up period (6 to 24 months). SETTING: Community settings at five Canadian sites (Moncton, Montreal, Toronto, Winnipeg and Vancouver). SUBJECTS: Homeless adults with mental illness (n 2148). RESULTS: Approximately 41 % of our sample reported high or marginal food security at baseline, but this figure varied with gender, age, mental health issues and substance use problems. High need participants who received HF were more likely to achieve marginal or high food security than those receiving usual care, but only at the Toronto and Moncton sites. CONCLUSIONS: Our large multi-site study demonstrated low levels of food security among homeless experiencing mental illness. HF showed promise for improving food security among participants with high levels of need for mental health services, with notable site differences.

A Randomised Controlled Trial of Evidence Based Supported Employment for People Who have Recently been Homeless and have a Mental Illness.

Individual placement and support (IPS) has not been tested experimentally among people recently housed with a scattered-site Housing First program. Ninety recently housed people were randomized to IPS or usual services. Regression models estimated via GEE were used to compare employment outcomes. Over 8 months of follow-up with good fidelity, fifteen (34 %) people in the IPS group versus nine (22 %) in the control group found competitive employment (p = 0.16). Adjusted odds of obtaining competitive employment were greater in the IPS group (OR 2.42, 95 %CI 1.13-5.16). Other employment outcomes were not significantly different between groups. Satisfaction with services was greater in the group receiving IPS. In this study, IPS was a modestly useful adjunct to scattered-site Housing First for people with mental illness who have been homeless.

Changes in the nature and intensity of stress following employment among people with severe mental illness receiving individual placement and support services: an exploratory qualitative study.

BACKGROUND: Most people with severe mental illness (SMI) want to work. Individual placement and support (IPS) programs have proven effective in helping them obtain and keep competitive jobs. Yet, practitioners often fear that competitive jobs might be too stressful. AIMS: To explore how the nature and intensity of stress experienced by IPS clients changed after the transition from looking for work to being employed. METHODS: Semi-structured interviews explored the experiences of 16 clients of an IPS program who had recently been competitively employed. Grounded theory was used to structure the analysis. RESULTS: Most participants reported that their stress level decreased once they found work. Stress following work was associated with fear of failure, pressure to perform and uncertainty. The support that people perceived in their return-to-work project, and where they were on their recovery journey, modulated their perception of stress. Many cited IPS as a source of support. CONCLUSIONS: Competitive work changed the nature of stress and was mostly associated with a decrease in stress level. Adjunctive interventions aiming to buffer self-stigma or help participants use more adaptive coping mechanisms may merit investigation.

Persisting Barriers to Employment for Recently Housed Adults with Mental Illness Who Were Homeless.

Adults with mental illness who are homeless experience multiple barriers to employment, contributing to difficulties securing and maintaining housing. Housing First programs provide quick, low-barrier access to housing and support services for this population, but their success in improving employment outcomes has been limited. Supported employment interventions may augment Housing First programs and address barriers to employment for homeless adults with mental illness. The present paper presents data from qualitative interviews to shed light on the persisting barriers to employment among people formerly homeless. Once housed, barriers to employment persisted, including the following: (1) worries about disclosing sensitive information, (2) fluctuating motivation, (3) continued substance use, and (4) fears about re-experiencing homelessness-related trauma. Nevertheless, participants reported that their experiences of homelessness helped them develop interpersonal strength and resilience. Discussing barriers with an employment specialist helps participants develop strategies to overcome them, but employment specialists must be sensitive to specific homelessness-related experiences that may not be immediately evident. Supported housing was insufficient to help people return to employment. Supported employment may help people return to work by addressing persisting barriers.

Employment and Income of People Who Experience Mental Illness and Homelessness in a Large Canadian Sample.

OBJECTIVES: Research suggests that homeless people with mental illness may have difficulty obtaining employment and disability benefits. Our study provides a comprehensive description of sources of income and employment rates in a large Canadian sample. METHODS: Participants (n = 2085) from the 5 sites of the At Home/Chez Soi study were asked about their income, employment, and desire for work during the pre-baseline period. The proportion of participants employed, receiving government support, and relying on income from other activities were compared across sites, as were total income and income from different sources. Generalized linear models were used to identify participant characteristics associated with total income. RESULTS: Unemployment ranged from 93% to 98% across 5 sites. The per cent of participants who wanted to work ranged from 61% to 83%. Participants relied predominantly on government assistance, with 29.5% relying exclusively on welfare, and 46.2% receiving disability benefits. Twenty-eight per cent of participants received neither social assistance nor disability income. Among the 2085 participants, 6.8% reported income from panhandling, 2.1% from sex trade, and 1.2% from selling drugs. Regression models showed that income differed significantly among sites and age groups, and was significantly lower for people with psychotic illnesses. CONCLUSION: These results suggest that homeless people with mental illness are predominantly unemployed, despite expressing a desire to work. In Canada, this group relies predominantly on welfare, but has access to disability benefits and employment insurance. These findings highlight the importance of developing effective interventions to support employment goals and facilitate access to benefits.

Barriers to obtaining employment for people with severe mental illness experiencing homelessness.

BACKGROUND: The rate of unemployment among homeless people is estimated to exceed 80%. A high prevalence of mental illness partially explains this figure, but few studies about the relationship between employment and homelessness have focused on homeless people with mental illness. AIM: The present study explores the self-reported barriers to employment in a sample of individuals with mental illness when they were homeless. METHODS: A sample of 27 individuals with mental illness and recent experiences of homelessness, who had expressed an interest in working, participated in semi-structured qualitative interviews. Inductive analysis was used to identify barriers to employment. FINDINGS: The prominent barriers include: (1) current substance abuse, (2) having a criminal record, (3) work-impeding shelter practices, and (4) difficulties obtaining adequate psychiatric care. CONCLUSION: Individuals who have been homeless and have a mental illness report facing specific barriers associated with mental illness, homelessness, or the interaction between the two. Additional research should explore how supported housing and employment interventions can be tailored to effectively serve this group.

Healthcare utilization and costs of singaporean youth with symptoms of depression and anxiety: results from a 2022 web panel.

BACKGROUND: There is evidence that the prevalence of depression and anxiety among youth is increasing and that these factors contribute to high healthcare costs and poor school performance. The goal of this study is to provide up-to-date estimates of the prevalence and economic burden of depression and anxiety among youth in Singapore. METHODS: Using an existing web panel, 991 parents filled out the PHQ-4 screener on behalf of 1,515 youth. 104 of these parents whose children (ages 4 to 21) had symptoms consistent with depression or anxiety filled out a full survey with questions on mental health symptoms, school absences, school performance, and healthcare utilization. The survey was fielded between April and June 2022. Publicly available prices were used to estimate the cost associated with the observed rates of health service use. FINDINGS: Based on parental responses, 11.7% (95% CI:10.2 - 13.5%) of youth had symptoms consistent with depression and 12.8% (95% CI:11.2 - 14.6%) had symptoms consistent with anxiety. In total, 16.2% (95% CI:14.5 - 18.3%) were reported to have symptoms consistent with at least one of these conditions. These youths missed an average of 190 (95% CI: 126-254) hours of school per year due to their mental health conditions and parents reported that school and daily activities performance was significantly degraded. Per capita annual healthcare costs averaged S$10,250 (95% CI: 7,150-13,350), with 64% of youth receiving emergency or inpatient services. In aggregate, annual costs associated with these conditions were estimated to be S$1.2 billion (95% CI:S$1.1bn - S$1.4bn). INTERPRETATION: Even with significant potential for underreporting, these results reveal concerning rates of Singaporean youth with symptoms consistent with depression or anxiety, many of whom remain untreated. Results also reveal the short-term economic burden caused by these symptoms and hint at longer-term consequences resulting from poor school performance. This study should represent a call to action for Singapore to address poor mental health among youth.

The development of clinical reasoning throughout the training and career of psychiatrists in Singapore.

Objectives: The current study sought to explain how different professional experiences led Singaporean psychiatrists to alter their clinical reasoning processes as their careers evolved from psychiatry residents to senior consultant psychiatrists. Methods: The current qualitative study interviewed 26 clinicians at various stages of their psychiatric career, spanning residents to senior psychiatrists.  The authors used a constructivist grounded theory approach to structure the collection and analysis of data. Analyses produced a dense theoretical explanation rooted in the experiences of participants. Results: Several differences emerged between the way psychiatry residents and senior psychiatrists explained their reasoning process and the experiences on which they based their preference. Residents preferred using deductive logic-driven frameworks that were diagnosis-centric, because of the pressures they experienced during their training and assessments. Senior psychiatrists emphasized a more holistic and problem-centric approach. Participants attributed the changes that occurred over time to practical experiences, such as their greater clinical responsibility and independence, and individual experiences, such as growing sensitivity to the clinical reasoning process or their growing propensity for professional reflectiveness. These changes manifest as an increase in repertoire and flexibility in deployment of different clinical reasoning strategies. Conclusions: It is important for trainees to be aware of the deductive and inductive modes of clinical reasoning during supervision and to be comfortable with shifting clinical focus from diagnoses to specific individual problems. Training programs should provide and plan adequate longitudinal clinical exposure to develop clinical reasoning abilities in a way that allows consequences of decisions to be explored. Continued faculty development to ease the diversification of clinical reasoning skills should be encouraged, as should reflectivity in the learners during clinical supervision.

Quality Improvement Approach to Increasing Psychiatric Rehabilitation in the Inpatient Setting.

This clinical practice improvement project (CPIP) sought to increase the rate of referrals to psychiatric rehabilitation units among inpatients on a 44-bed men's ward at the Institute of Mental Health, Singapore. Three root causes of low referral rates were targeted for intervention, and three plan-do-study-act cycles were conducted to address these causes. Interrupted time-series analysis was used to assess the impact of the interventions. Addressing these causes significantly and sustainably improved the rate of referral. The rate of rehabilitation program attrition did not worsen because of the increased number of referrals. These findings indicate that CPIPs can significantly improve processes.

The impact of peer support work on the mental health of peer support specialists.

BACKGROUND: Peers support specialists have positive impacts on the mental health of their service users. However, less is known about how their mental health changes as a result of their activities. METHODS: We followed 10 peer support specialists over their first year of employment and interviewed them thrice. We used grounded theory to analyse the way in which the health of participants changed. RESULTS: Self-reported mental health of our participants did not change over the course of the study. However, the role did help participants grow and learn about their condition and their strengths. While sharing their past experiences could be taxing, they learned how to harness their recovery journey without risking relapse. CONCLUSION: Entering the role of a peer support specialist does not appear to negatively impact mental health, but might enhance insight and resilience. However, this appears to occur in individuals who already possess an inclination toward introspection.

Barriers and facilitators of peer support work in a large psychiatric hospital: a thematic analysis.

BACKGROUND: Peer support workers are an important addition to the mental healthcare profession. However, much of the literature and knowledge of the peer support role is derived from western countries. This concept is relatively new in Asian countries. AIMS: The study sought to improve the understanding of the barriers and facilitators of peer support work in a large psychiatric hospital in Singapore. METHODS: This study used qualitative data from a larger mixed-methods study. Thematic analysis was conducted based on the five steps recommended by Braun and Clarke (2006): (1) familiarisation of data whereby transcripts were read and reread, (2) generating initial codes, (3) searching for themes by gathering relevant codes, (4) reviewing themes and (5) defining and naming themes. RESULTS: Four subthemes under the broader notion of facilitators (supportive figures, defined role, opportunities for personal growth and identifying personalised coping strategies) and three subthemes under the concept of barriers (unclear role, hostility from non-peer-support-specialist staff and unsupportive working environments) were identified. CONCLUSION: Our findings echoed those of previous studies conducted in western countries providing some evidences for the cross-cultural nature of these barriers and facilitators. However, the way their impact can be mitigated or enhanced is likely to be different owing to cultural barriers, such as the general consensus and acceptance of larger personal recovery ideologies. Further research is required in community settings to better understand the boundaries and limitations of our findings. This information will allow us to continue improving peer support worker integration in diverse mental healthcare settings.

The personal recovery movement in Singapore - past, present and future.

The personal recovery movement is beginning to gain traction within Singapore's mental healthcare systems. We believe it is timely to give a broad overview of how it developed and provide suggestions on how it can evolve further. From the early custodial care in the 1800s to the community-centric programmes of the 1900s and early 2000s, we now find ourselves at the forefront of yet another paradigm shift towards a more consumer-centric model of care. The following decades will allow personal recovery practitioners and researchers to innovate and identify unique but culturally appropriate care frameworks. We also discuss how the movement can continue to complement existing mental healthcare systems and efforts.

Coping Patterns Among Primary Informal Dementia Caregivers in Singapore and Its Impact on Caregivers-Implications of a Latent Class Analysis.

BACKGROUND AND OBJECTIVES: Existing studies typically explore the factor structure of coping strategies among dementia caregivers. However, this approach overlooks the fact that caregivers often use different coping strategies simultaneously. This study aims to explore the coping patterns of primary informal dementia caregivers in Singapore, examine their significant correlates, and investigate whether different patterns would affect the depressive symptoms of caregivers. RESEARCH DESIGN AND METHODS: Two hundred eighty-one primary informal caregivers of persons with dementia (PWD) were assessed. Coping strategies were measured by the Brief Coping Orientation to Problem Experienced inventory. A latent class analysis was performed to explore caregivers' coping patterns, followed by logistic regressions to identify the significant correlates and the relationships between coping patterns and caregiver depression. RESULTS: The latent class analysis suggested a three-class solution that was featured by the frequency and variety of coping strategies used by caregivers-high coping (36.3%), medium coping (37.7%), and low coping (26.0%). Factors influencing the coping patterns of our sample were mainly related to caregivers' individual resources such as personal characteristics and caregiving stressors like PWD's problematic behaviors and caregiving burden. Compared to caregivers in the low coping group, those in the medium coping group had significantly higher risks of potential depression. DISCUSSION AND IMPLICATIONS: The current study confirmed that there are distinct coping patterns among primary informal dementia caregivers, and caregivers with the low coping pattern had fewer depressive symptoms. Future research is needed to explore if coping patterns from our sample are generalizable to dementia caregivers elsewhere.

Stakeholder perspective on barrier to the implementation of Advance Care Planning in a traditionally paternalistic healthcare system.

BACKGROUND: Advance psychiatric agreements could guide medical teams in providing care consistent with the incapacitated service user's wishes. However, these types of agreements are rarely completed in Asian settings. What challenges can a traditionally paternalistic healthcare system expect to encounter when attempting to implement psychiatric advance directives? METHODS: We answered this research question by exploring the cultural, administrative and logistical challenges that might impede the implementation of the system supporting the service. We interviewed key stakeholders, 28 service users and 22 service providers, to seek their views and interests in the implementation of directives. We structured our analyses along a literature-review-based framework designed to guide further implementation studies, proposed by Nicaise and colleagues (2013). Accordingly, we divided our inductively generated themes into four longitudinal categories: pre-development stage, development stage, implementation stage, post-implementation stage. RESULTS: Overall, the findings indicated that many service users and service providers are interested in advance care planning. They believed that foreseeable challenges could be overcome with appropriate measures. However, the multiple challenges of implementation led some service providers to be ambivalent about their implementation and led service users to dismiss them. Specifically, factors related to the local culture in Singapore necessitated adjustments to the content and structure of the directives. These include language barriers in a multicultural society, conflicting wishes in a collectivist society, taboos for speaking about undesirable outcomes in a traditionalist society, and time limitations in a fast-paced society. CONCLUSION: While culture-specific changes may be required to enable service users in a small Asian country to employ existing advance psychiatric agreement approaches, service providers and service users see their benefits. However, service providers must be mindful not to assume that service users are willing to defer every decision to their physician.

Promoting Medication Adherence Among Psychiatric Patients With a History of Nonadherence: A Clinical Practice Improvement Program.

BACKGROUND: People with serious mental illness may require long-term psychotropic medications. However, nonadherence is prevalent after discharge, often leading to re-admission. Several strategies exist to reduce nonadherence. The current project uses clinical practice improvement methodologies to test and adjust strategies to improve medication adherence at the Institute of Mental Health in Singapore. METHODS: Two focus groups (one of which involved nonadherent individuals and the other adherent individuals) were conducted to explore the root cause of our service users' nonadherence. On the basis of the causes identified, the team developed and implemented a person-centered medication adherence counseling intervention, incorporating motivational interviewing and psychoeducation. Data from all service users (n=156) who were nonadherent to psychotropic medications upon admission to our men's ward between October 2017 and December 2018 were examined, with 63 of the men serving as the baseline sample and 93 receiving the adherence intervention. The team also reduced medication frequency and actively explored patients' willingness to switch to long-acting injectable antipsychotics. A validated visual analogue self-reporting scale was used to measure adherence at screening and 30 days after discharge. Interrupted time series analysis was used to assess the effects. RESULTS: After an intervention involving 3 specific strategies that addressed the concerns identified during the focus groups, the percentage of people who adhered to their treatment regimen 30 days after discharge increased by 33% (95% confidence interval: 15%-51%, P=0.001). Our balance measure (a secondary outcome that may be negatively or positively affected by efforts to influence the primary outcome), which was the percentage of people readmitted within 30 days of their discharge, showed a significant improvement (ie, a decrease in percentage readmitted). CONCLUSIONS: Quality improvement methodologies can be used to solve common problems with context-specific solutions. The implementation of person-centered medication adherence counseling led by an advanced practice nurse in concert with optimization of medication regimens appears to be a promising strategy for improving adherence in nonadherent patients admitted to the psychiatric ward.