Measuring Fidelity to Evidence-Based Practices: Psychometrics.

This special section presents the psychometric properties of fidelity scales used in a national mental health services project in Norway to improve the quality of care of people with psychoses. Across Norway, 39 clinical units in six health trusts participated. The project provided education, implementation support and fidelity assessments. The papers in the section address the psychometrics of fidelity measurement for the specific evidence-based practices: illness management and recovery, family psychoeducation, physical healthcare and antipsychotic medication management. Another paper analyzes the psychometrics of a scale measuring individualization and quality improvement that may be used in conjunction with fidelity scales for specific evidence-based practices. The first paper in the section presents the development and field of fidelity scales, and the two final papers with comments add some additional perspectives and discuss fidelity scales in a wider context. The psychometrics of the five scales were good to excellent. Fidelity assessment is a necessary and effective strategy for quality improvement.

The Family Psychoeducation Fidelity Scale: Psychometric Properties.

This study examined psychometric properties and feasibility of the Family Psychoeducation (FPE) Fidelity Scale. Fidelity assessors conducted reviews using the FPE fidelity scale four times over 18 months at five sites in Norway. After completing fidelity reviews, assessors rated feasibility of the fidelity review process. The FPE fidelity scale showed excellent interrater reliability (.99), interrater item agreement (88%), and internal consistency (mean = .84 across four time points). By the 18-month follow-up, all five sites increased fidelity and three reached adequate fidelity. Fidelity assessors rated feasibility as excellent. The FPE fidelity scale has good psychometric properties and is feasible for evaluating the implementation of FPE programs. Trial registration ClinicalTrials.gov Identifier: NCT03271242.

Calibration of the beginning of the age of mammals in patagonia.

Beds of the Rio Chico Formation containing the earliest known land mammals in Patagonia, southern Argentina, were calibrated by potassium-argon age determinations and paleomagnetic polarity data. The Riochican land mammal age encompasses the middle and late Paleocene and corresponds in time with Torrejonian and Tiffanian land mammal faunas in North America.

First radioisotope (potassium-argon) age of marine neogene rionegro beds in northeastern patagonia, Argentina.

An average age of 9.41 million years was obtained from radioisotope (potassium-argon) age determinations of three glass concentrates of a tuff from the upper part of the marine Rionegrense at Punta Cracker in Golfo Nuevo, Argentina. This age correlates with the Tortonian marine stage of Europe and the Chasicoan Land Mammal Age of South America.

South american geochronology: radiometric time scale for middle to late tertiary mammal-bearing horizons in patagonia.

Radiometric (potassium-argon) age determinations for basalts and tuffs associated with middle to late Tertiary mammal-bearing horizons in Patagonia, southern Argentina, permit refinement of boundaries and hiatuses between beds of Deseadan (early Oligocene) through Friasian (middle to late Miocene) age. At two localities beds of Deseadan age are overlain by basalts, which gave dates of 33.6 and 35.4 million years ago; 34.0 million years ago is tentatively accepted as a terminal date for known Deseadan. At several localities beds of Colhuehuapian age are underlain by basalts, which gave dates ranging from 28.8 to 24.3 million years ago; 25.0 million years is tentatively taken as a basal age for known Colhuehuapian. The paleontological hiatus between known Deseadan and known Colhuehuapian is thus in the order of 9.0 million years. Two tuffs from the Santa Cruz Formation (Santacrucian) gave ages of 21.7 and 18.5 million years. Plagioclase and biotite concentrates of an ignimbrite from the Collón Curá Formation (Friasian) gave ages ranging from 15.4 to 14.0 million years.

Geochronology of type uquian (late cenozoic) land mammal age, Argentina.

Mammal faunas collected from the Uquía Formation at Chucalezna and Esquina Blanca in Jujuy Province, northwest Argentina, are calibrated by potassium-argon age determinations and paleomagnetic polarity data. The sediments range in age from 2.5 million years old to perhaps as young as 1.5 million years, from late Pliocene through early Pleistocene, and correspond in time to late Blancan and early Irvingtonian land mammal age faunas in North America.

Calibration of the great american interchange.

From radioisotopic (potassium-argon) age determinations of tuffs and magnetostratigraphy of Late Tertiary mammal-bearing beds in Catamarca Province, northwest Argentina, refined estimates have been obtained for the durations and boundaries of beds of Chasicoan (Middle Miocene) through Chapadmalalan (Pliocene) age. An age of 9.0 million years is tentatively accepted for the Chasicoan-Huayquerian boundary, 5.0 million years for the Huayquerian-Montehermosan boundary, and 3.0 million years for the Montehermosan-Chapadmalalan boundary. Procyonids (raccoons and their allies), a group of North American origin, are first recorded in South America in a level immediately below a unit dated at 6.0 million years. Cricetine rodents of the tribe Sigmodontini are first recorded in South America in beds of Montehermosan age in Argentina. Ground sloths, a group of South American origin, first appear in North America in Early Hemphillian time in beds dated between 9.5 and 9.0 million years. The Panamanian land bridge was established by 3.0 million years ago, and an interchange of the terrestrial faunas was well under way by Late Blancan time (around 2.5 million years before present) in North America and by Chapadmalalan time in South America.

Psychiatric rehabilitation in Europe.

To describe the core elements of modern psychiatric rehabilitation. Based on selected examples we describe the discussion about values in mental health care with focus on Europe. We present outcome data from studies, which have tried to implement care structures based on this value discussion. In the second half of the 20th century, mental health care in all European and other high-income countries changed conceptually and structurally. Deinstitutionalisation reduced the number of psychiatric beds and transferred priority to outpatient care and community-based services, but community mental health programs developed differently across and within these countries. High-income countries in Europe continued to invest in costly traditional services that were neither evidence-based nor person-centered by emphasising inpatient services, sheltered group homes and sheltered workshops. We argue that evidence-based, person-centred, recovery-oriented psychiatric rehabilitation offers a parsimonious solution to developing a consensus plan for community-based care in Europe. The challenges to scaling up effective psychiatric rehabilitation services in high-income countries are not primarily a lack of resources, but rather a lack of political will and inefficient use and dysfunctional allocation of resources.

New directions for psychiatric rehabilitation in the USA.

American researchers have led the world in developing, evaluating, and disseminating evidence-based psychiatric rehabilitation practices for people with serious mental illness. Paradoxically, however, the USA lags behind most industrialized nations in providing access to high-quality mental health and psychiatric services. This essay examines several evidence-based practices developed in the USA, the spread of these practices, the barriers to ensuring availability to people who could benefit from these services, and some promising directions for overcoming the barriers. Factors influencing the growth and sustainment of effective client-centred practices include the availability of adequate and stable funding, committed leadership, and the influence of vested interests. Two strategies for promoting the spread and sustainment of well-implemented evidence-based practices are the adoption of fidelity scales and learning communities.

Maturity of ego defenses in relation to DSM-III axis II personality disorder.

Independent raters assessed a cohort of 307 inner-city men on three dimensions of psychosocial dysfunction: the Health-Sickness Rating Scale (HSRS), axis II of DSM-III, and dominant choice of ego mechanisms of defense. Two thirds of the 74 men with personality disorders and three fourths of the 55 men with the low scores (0 to 65) on the HSRS primarily used immature defense mechanisms (ie, projection, schizoid fantasy, passive aggression, dissociation, hypochondriasis, and acting out). Only 10% of men without personality disorders and only 10% of men with HSRS scores of over 70 were noted to favor such defenses.

A randomized clinical trial of supported employment for inner-city patients with severe mental disorders.

BACKGROUND: This experiment evaluated the effectiveness of 2 approaches to vocational services for persons with severe mental disorders: (1) individual placement and support (IPS), in which employment specialists within the mental health center help patients to obtain competitive jobs and provide ongoing support, and (2) enhanced vocational rehabilitation (EVR), in which stepwise vocational services are delivered by rehabilitation agencies. METHODS: One hundred fifty-two unemployed, inner-city patients with severe mental disorders who expressed interest in competitive employment were randomly assigned to IPS or EVR and followed up for 18 months. Following diagnostic assessment, participants were assessed with standardized measures of work, income, self-esteem, quality of life, symptoms, and hospitalization at baseline and at 6-, 12-, and 18-month follow-up evaluations. Employment was tracked monthly and job satisfaction every 2 months. RESULTS: During the 18-month study, participants in the IPS program were more likely to become competitively employed (60.8% vs 9.2%) and to work at least 20 hours per week in a competitive job (45.9% vs 5.3%), whereas EVR participants had a higher rate of participation in sheltered employment (71.1% vs 10.8%). Total earnings, job satisfaction, and nonvocational outcomes were similarly improved for both groups. CONCLUSION: The IPS model of supported employment is more effective than standard, stepwise EVR approaches for achieving competitive employment, even for inner-city patients with poor work histories and multiple problems.

Employment and educational outcomes in early intervention programmes for early psychosis: a systematic review.

AIMS: Young adults with early psychosis want to pursue normal roles - education and employment. This paper summarises the empirical literature on the effectiveness of early intervention programmes for employment and education outcomes. METHODS: We conducted a systematic review of employment/education outcomes for early intervention programmes, distinguishing three programme types: (1) those providing supported employment, (2) those providing unspecified vocational services and (3) those without vocational services. We summarised findings for 28 studies. RESULTS: Eleven studies evaluated early intervention programmes providing supported employment. In eight studies that reported employment outcomes separately from education outcomes, the employment rate during follow-up for supported employment patients was 49%, compared with 29% for patients receiving usual services. The two groups did not differ on enrolment in education. In four controlled studies, meta-analysis showed that the employment rate for supported employment participants was significantly higher than for control participants, odds ratio = 3.66 [1.93-6.93], p < 0.0001. Five studies (four descriptive and one quasi-experimental) of early intervention programmes evaluating unspecified vocational services were inconclusive. Twelve studies of early intervention programmes without vocational services were methodologically heterogeneous, using diverse methods for evaluating vocational/educational outcomes and precluding a satisfactory meta-analytic synthesis. Among studies with comparison groups, 7 of 11 (64%) reported significant vocational/education outcomes favouring early intervention over usual services. CONCLUSIONS: In early intervention programmes, supported employment moderately increases employment rates but not rates of enrolment in education. These improvements are in addition to the modest effects early programmes alone have on vocational/educational outcomes compared with usual services.

Suicide attempts associated with akathisia.

The authors report two cases of impulsive suicide attempts associated with akathisia. In both cases, suicidal ideation appeared suddenly, concurrent with neuroleptic-induced akathisia, and disappeared when the akathisia was treated.

A validity study of axis II of DSM-III.

The authors examine DSM-III personality disorders in a longitudinally followed community sample of middle-aged inner city men. Eighty-six (23%) of the subjects received an axis II diagnosis of personality disorder. Although these men received relatively little psychiatric attention, they were severely impaired in terms of how they felt about themselves, how others saw their global mental health, and their ability to work and to love. When the strong overlap with alcoholism was controlled for, personality disorder was clearly related to adaptive problems that manifested by early adolescence. The evidence suggests that early deficiencies of biology, environmental support, and ego strength contribute to the development of personality disorder.

Mental patients' attitudes toward hospitalization: a neglected aspect of hospital tenure.

Recent research on hospital tenure has neglected mental patients' attitudes toward hospitalization. The authors consider problems with past research on these attitudes and examine "living preference"--the patient's preference for living in the hospital or the community. Assessments of patients' living preferences were obtained from clinicians working with 187 chronically mentally ill patients in a state hospital aftercare program. These assessments strongly predicted both components of hospital tenure--rehospitalization and in-hospital days--during a 1-year follow-up. The authors point out the conceptual, heuristic, and practical clinical advantages of examining living preference rather than traditional correlates of hospital tenure.

Treatment of alcoholism among schizophrenic outpatients: 4-year outcomes.

In this pilot study, the authors assessed 4-year outcomes for 18 schizophrenic outpatients with alcoholism who were treated in an innovative dual-diagnosis program. Over half (61.1%) achieved stable remissions from alcoholism. The mean duration of remission was 26.5 months.

Alcohol abuse, depression, and suicidal behavior in schizophrenia.

Alcohol use was correlated with depression and suicidal behavior in two independent studies of schizophrenic outpatients. Depression alone accounted for over 80% of the explained variance in suicidal behavior in both studies; alcohol use alone and the correlation between depression and alcohol use accounted for only small amounts of variance.

Housing instability and homelessness among rural schizophrenic patients.

OBJECTIVE: The authors examined housing instability among treated schizophrenic patients in a rural area and compared the findings with those from their previous study of urban patients. METHOD: Seventy-five patients with schizophrenia or schizoaffective disorder who were treated in a rural mental health center were assessed with research interviews and ratings by their clinical case managers. The patients were followed for 1 year to identify episodes of psychiatric hospitalization, incarceration, and literal homelessness. RESULTS: Of the 75 patients, 19 (25%) had housing situations characterized as unstable by their case managers. For the majority, housing instability signified tenuousness of living arrangements rather than literal homelessness. Noncompliance with medications, alcohol use, and negative symptoms accounted for 30% of the variance in unstable housing. During follow-up, the unstably housed patients, compared to those in stable living situations, were no more likely to be rehospitalized but were somewhat more likely to be jailed and significantly more likely to be literally homeless. CONCLUSIONS: In the authors' previous study of urban psychiatric patients, unstably housed patients were more likely to be literally homeless, highly symptomatic, and rehospitalized during follow-up than the rural patients with unstable housing. Better outcomes in the rural area appeared to be related to the greater availability of housing alternatives and to intensive case management. For patients with unstable housing in both settings, noncompliance with medications and substance abuse, as well as housing arrangements, should be assertively addressed.

Dartmouth Assessment of Lifestyle Instrument (DALI): a substance use disorder screen for people with severe mental illness.

OBJECTIVE: Despite high rates of co-occurring substance use disorder in people with severe mental illness, substance use disorder is often undetected in acute-care psychiatric settings. Because underdetection is related to the failure of traditional screening instruments with this population, the authors developed a new screen for detection of substance use disorder in people with severe mental illness. METHOD: On the basis of criterion ("gold standard") diagnoses of substance use disorder for 247 patients admitted to a state hospital, the authors used logistic regression to select the best items from 10 current screening instruments and constructed a new instrument. They then tested the validity of the new instrument, compared with other screens, on an independent group of 73 admitted patients. RESULTS: The new screening instrument, the Dartmouth Assessment of Lifestyle Instrument (DALI), is brief, is easy to use, and exhibits high classification accuracy for both alcohol and drug (cannabis and cocaine) use disorders. Receiver operating characteristic curves showed that the DALI functioned significantly better than traditional instruments for both alcohol and drug use disorders. CONCLUSIONS: Initial findings suggest the DALI may be useful for detecting substance use disorder in acutely ill psychiatric patients. Further research is needed to validate the DALI in other settings and with other groups of psychiatric patients.

Correlates and outcomes of alcohol use disorder among rural outpatients with schizophrenia.

BACKGROUND: The use of alcohol by persons with schizophrenia is common and has been associated with increased severity of psychiatric symptoms, multiple psychosocial problems, abuse of other drugs, and poor treatment outcomes. Most of the previous research in this area has been with urban patients. METHOD: The authors examined the correlates and outcomes of alcohol use in a rural sample of 75 DSM-III-R outpatients with schizophrenia. Based on multiple measures, 25% (N = 19) of 75 rural patients with schizophrenia were diagnosed with current co-occurring alcohol use disorders. Clinicians' ratings and self-reported symptoms were used to examine correlates of alcohol use, and the study group was followed prospectively for 1 year to identify all episodes of rehospitalization, incarceration, or literal homelessness. RESULTS: Alcohol use disorder was statistically significantly associated with unstable housing, conceptual disorganization, denial of mental illness, and rehospitalization during 1-year follow-up. Several trends suggested that alcohol use was also related to positive symptoms of psychosis. CONCLUSION: Among rural patients with schizophrenia, alcohol use appears to play a significant role in destabilizing psychosocial adjustment. These results replicate similar findings in urban settings.