Development and validation of the mental health professional culture inventory.

AIMS: No instrument has been developed to explicitly assess the professional culture of mental health workers interacting with severely mentally ill people in publicly or privately run mental health care services. Because of theoretical and methodological concerns, we designed a self-administered questionnaire to assess the professional culture of mental health services workers. The study aims to validate this tool, named the Mental Health Professional Culture Inventory (MHPCI). The MHPCI adopts the notion of 'professional culture' as a hybrid construct between the individual and the organisational level that could be directly associated with the professional practices of mental health workers. METHODS: The MHPCI takes into consideration a multidimensional definition of professional culture and a discrete number of psychometrically derived dimensions related to meaningful professional behaviour. The questionnaire was created and developed by a conjoint Italian-Canadian research team with the purpose of obtaining a fully cross-cultural questionnaire and was pretested in a pilot study. Subsequently, a validation survey was conducted in northern Italy and in Canada (Montreal area, Quebec). Data analysis was conducted in different steps designed to maximise the cross-cultural adaptation of the questionnaire through a recursive procedure consisting of performing a principal component analysis (PCA) on the Italian sample (N = 221) and then testing the resulting factorial model on the Canadian sample (N = 237). Reliability was also assessed with a test-retest design. RESULTS: Four dimensions emerged in the PCA and were verified in the confirmatory factor analysis: family involvement, users' sexuality, therapeutic framework and management of aggression risk. All the scales displayed good internal consistency and reliability. CONCLUSIONS: This study suggests the MHPCI could be a valid and reliable instrument to measure the professional behaviour of mental health services workers. The content of the four scales is consistent with the literature on psychosocial rehabilitation, suggesting that the instrument could be used to evaluate staff behaviour regarding four crucial dimensions of mental health care.

["What's up, doc?" The context, limitations, and issues for clinicians in evidence-based medicine]. / "What's up, doc?" Le contexte, les limites et les enjeux de la médecine fondée sur des données probantes pour les cliniciens (Evidence-Based Medicine).

BACKGROUND: The evidence-based medicine approach could be considered a new name given to the contemporary medicine dialectics between the practice of an art and the insight provided by the best scientific data. METHODS: In this 3-part article, the background is introduced, then the design limits of the approach are shown through an example of metaanalysis applied to 4 psychiatric situations, and the conclusion is left to a clinician. RESULTS: In the background, evidence-based medicine is first associated with the period of budget cuts, then with the widespread popularity of the Internet. A few snags in this seemingly flawless system are seen when the subjective items involved in metaanalysis are taken into account. There are also problems linked to unpublished data, homogenization of populations studied, and the assumption that only random studies lead to valid scientific knowledge. The clinician will probably not be surprised and will link this to the old debate between empiricists and rationalists. CONCLUSION: In its purest form, evidence-based medicine supports the necessary continuous inquiry about our practices.

Downsizing psychiatric hospitals: needs for care and services of current and discharged long-stay inpatients.

BACKGROUND: With the psychiatric deinstitutionalization movement in its fourth decade, questions are being raised concerning its relevance for long-stay inpatients with severe disabilities and the risk that those discharged into the community may be abandoned. METHODS: A random sample taken in 1989 of long-stay inpatients at Louis-H Lafontaine Hospital made it possible to examine 96 pairs of patients. Each pair included 1 patient discharged between 1989 and 1998 and 1 patient hospitalized. Pairs were matched for sex, age, length of stay, and level of psychiatric care in 1989. Patients and staff were interviewed using standardized questionnaires, and case notes were reviewed to assess symptoms, daily living skills, residential status, quality of residential setting, and clinical and social problems and needs. RESULTS: The investigation revealed that discharged patients moved to highly supervised settings, which included professionally supervised group homes, supervised hostels, and foster families. About 20% went to nursing homes owing to loss of autonomy from physical disorders. Only 4 discharged patients were lost to follow-up, of whom 2 were probable vagrants. Both those discharged and those remaining as inpatients presented with major clinical problems and daily living skill deficits. The care needs of discharged patients were generally met, and placement in the community was considered appropriate. Of those who had remained hospitalized, over one-half could be moved to supervised settings immediately, or after 1 to 2 years' preparation in a discharge unit, while 13% could be moved to nursing homes. Over 25% required intensive, individualized rehabilitation treatment targeting engagement, psychotic symptoms, withdrawal, and dangerous and socially embarrassing behaviours. CONCLUSION: Deinstitutionalization in the largest Canadian psychiatric hospital did not lead to patient abandonment in the community.

Cost-effectiveness analysis of psychiatric deinstitutionalization.

BACKGROUND: The cost-effectiveness of the eventual deinstitutionalization of patients with severe and persistent mental disorders who are currently hospitalized in long-term care remains a controversial matter. METHODS: A retrospective cohort of 96 pairs of psychiatric hospital patients with 1 member deinstitutionalized between 1989 and 1998 was followed up for nearly 10 years. All use of medical and social services was documented. Patients were evaluated at the start and end of the study on various clinical and social dimensions, as well as on quality of life. RESULTS: On several dimensions, deinstitutionalized patients scored more positively than did those patients still hospitalized. The lower daily cost of living accommodations for deinstitutionalized patients easily offsets the cost of services required for treatment in the community. CONCLUSION: Deinstitutionalization, as implemented in the hospital studied, remains for many patients a less costly option than continued hospitalization and is likely to improve their mental state and well-being.

Organizational analysis of deinstitutionalization in a psychiatric hospital.

BACKGROUND: Few studies have been conducted of the organizational aspects that impact on the course of psychiatric deinstitutionalization. METHOD: A case study was undertaken of 10 years of deinstitutionalization in a Montreal psychiatric hospital. RESULTS: Deinstitutionalization has forged ahead in the hospital over the past few years, although the course it has taken is not the one initially plotted by its promoters. Care management of deinstitutionalized patients remains under the control of the psychiatric hospital and its physicians. However, the patients' well-being has remained a focus of concern and does not seem to have been detrimentally affected by this development. CONCLUSION: Deinstitutionalization is both a solution to the criticisms levelled at the hospital-psychiatric approach of managing persons with severe and persistent mental disorders and an extremely useful tool in the power struggle among the various stakeholders in mental health services reform. Deinstitutionalization has become unavoidable.

Assessment of a new rehabilitative coping skills module for persons with schizophrenia.

A rehabilitative coping skills module employing problem solving and cognitive behavioral therapy and an experimental repeated-measure design was tested on 55 randomly selected persons severely handicapped by schizophrenia, most of whom had lived almost half of their lives in psychiatric wards. Unlike the control group of 44 comparable schizophrenics, the experimental group exhibited a significant decrease in delusions and increase in self-esteem, and maintained hygiene levels.

[Implementation of intensive follow-up in the community: lessons to be considered]. / L'implantation du suivi intensif dans la communauté: des leçons à tirer du passé.

OBJECTIVE: To examine various issues concerning the implementation of a program for assertive community treatment (ACT). METHOD: In-depth interviews were conducted with participants of an ACT project implemented in the 1970s. A quality analysis was undertaken, assessing the issues that prevented the expansion of such an approach as well as issues to be considered in future implementation of ACT. RESULTS: Social, cultural, organizational, professional, and economic factors were identified that will continue to play decisive roles in the integration of such a program. The ACT implementation in question occurred at the same time as the shift to community psychiatry, without having been linked to that approach. Currently, social factors such as self-help groups and parents foster the implementation of such programs. The organizational factors include the importance of linking ACT to existing health care services, as well as adapting ACT to these services. The association of this type of project with a research team did not ensure a successful implementation. A third factor is the psychiatrist's training and motivation with respect to the practice of this approach. Finally, economic issues are playing a larger role in the implementation of this approach. CONCLUSION: This study relates different issues regarding the implementation of an ACT. The results represent assumptions that need to be confirmed by assessing ACT implementation in Quebec as well as in the rest of Canada.

Estimating local-area needs for psychiatric care: a case study.

BACKGROUND: Different approaches to estimating local catchment-area needs for psychiatric services are illustrated and compared. METHOD: Data from an epidemiological morbidity survey of a random sample of 496 adults were available, as were actual service utilisation rates. Four types of utilisation were modelled (i.e. overall, out-patient, in-patient, emergency clinic) using social indicators available from Statistics Canada census-tract data. Finally, a case-control study compared out-patients from a deprived and an affluent catchment area, matched case by case for primary diagnosis, age, sex and residential status (n = 52). RESULTS: Modelling proved highly predictive of utilisation, the overall-use model accounting for 73% of the variance. The case-control study indicated a higher rate of Axis II traits, substance abuse and needs for social care in the deprived catchment area. CONCLUSIONS: Resource allocation based on the social indicators modelling method was more consistent with sensible distribution of human resources. None of the methods, however, appear to reflect adequately the severity of caseloads evidenced in the case-control study.

The reliability of the community version of the MRC Needs for Care Assessment.

One hundred and nine adults were screened in the community using the abridged version of the CIDI (CIDIS). The subjects comprised DSM-III-R current cases (N = 48), lifetime cases (N = 31) and non-cases (N = 30). The interviews with the 109 subjects were conducted by one of two pairs of clinicians and videotaped. Each interviewer-pair included a psychiatrist and a clinical psychologist. They rated the community version of the Needs for Care (NFCAS-C) by consensus. The other pair of judges then viewed the video and rated the NFCAS-C independently. The agreement on overall needs was excellent (kappa = 0.75), and very good for four of the seven specific sections (from kappa = 0.61 to 0.81). One section could not be rated because of low prevalence, and agreement was less good for the remaining two sections. Agreement was good on specific interventions (medication, kappa = 0.60; specific psychotherapy, kappa = 0.55), but poor on non-specific interventions. The majority of disagreements were due to differences in clinical judgement rather than to technical errors. A new instruction manual has been produced and should help training as well as stabilizing reliability. In devising reliable and valid instruments based on clinical judgement, a balance must be achieved between enhancing reliability with more precise rules and constraining clinical judgement so tightly that validity is lost.

Problems and needs for care of patients suffering from severe mental illness.

Recently, evaluative research has yielded a procedure, the Needs for Care Assessment Schedule (NFCAS), which articulates the problems and the corresponding interventions required by psychiatric patients in a systematic and reproducible manner that is of interest to both administrators and clinicians. Although the NFCAS decisions are ultimately subjective and there is no absolute standard, the procedure limits variation and offers a framework for comparison and further elaboration. A group of 98 patients who were receiving treatment at the Louis-Hippolyte Lafontaine Psychiatric Hospital in Montréal, Québec and who were suffering from severe mental disorders were assessed with the NFCAS procedure. Subjects were selected from four treatment settings representing different levels of problems and needs: long-term in- and outpatients and short-term in- and outpatients. Results of the NFCAS were examined, along with those of standardized questionnaires. The NFCAS allowed a comprehensive understanding of the clinical realities for problem and need assessment. There was an average of 3.9 clinical problems and 4.5 social problems per patient. Long-term patients and patients residing in the hospital had more problems. A total of 76% of the problems assessed were rated as receiving appropriate interventions, whereas 17% of the problems assessed were considered in need of an assessment or in need of treatment. A greater need for intervention was found for social problems than for clinical problems.

Assessment of independent living skills for psychotic patients. Further validity and reliability.

It is well known that psychotic patients have severe social and life-skill deficits. Psychiatric rehabilitation programs are designed to teach these skills to patients. Before implementing such a program, patient deficits should be evaluated with reliable measures. The present study assessed the psychometric properties of the French version of the "Independent Living Skills Survey" (ILSS) developed by Wallace, Kochanowicz and Wallace (Wallace C J, Kochanowicz N, Wallace J [1985] Independent living skills survey. Unpublished manuscript, Mental Health Clinical Research Center for the Study of Schizophrenia, West Los Angeles Veterans Administration Medical Center, Rehabilitation Medicine Service [Brentwood Division], Los Angeles, CA). Although widely used, the patient version of this scale has unknown psychometric properties. The ILSS was composed of 75 items, rated as present or absent and distributed in 10 scales. The French version was administered to 145 patients with a psychotic diagnosis who were living in the community. All scales had very good psychometric qualities with the exception of the job-maintenance scale. The test-retest reliability varied from .48 to .85, and alpha coefficients were good for seven of the nine scales. Various aspects of construct validity were explored. The scales discriminated between patients as a function of their subgroups, sex, and diagnosis. Concurrent validity confirmed the specificity of the ILSS dimensions. Factor analysis revealed two factors, one for basic skills and one representing higher order skills. Recommendations for future development of the ILSS are proposed.

Comprehensive community care without long stay beds in mental hospitals: trends from an Italian good practice area.

Despite the scientific evidence that long stays in mental hospitals are clinically deleterious, inhumane and probably not cost-effective, this practice still occurs in most Western countries. The continued use of long stay beds in mental hospitals is a policy decided by many authorities, including psychiatrists. Alternatives to the mental hospital exist and may limit the use of hospital beds through comprehensive community care that also includes proper residential provisions. Alternatives may also decrease, but not impede the tendency to chronicity in some patients, who become long term users of these community services. Italy passed a law in 1978 prohibiting admissions to mental hospitals and encouraging the development of community care. In South Verona, Italy, the policy has been properly implemented and evaluated. Data from the case register and intensive studies of a cohort of patients will be used to show that long stay hospitalization can be discontinued while meeting the needs of the most severely handicapped patients. Implications of South Verona's experience for future training of psychiatrists will also be discussed.

Assessing the needs for care of non-psychotic patients. A trial with a new standardized procedure.

Recent psychiatric epidemiological studies using standardized interviews in the community have yielded high rates of non-psychotic disorders. The implications for service provision in terms of treatment and planning remain unclear. No methodology exists to link the individual needs for care and services to problems associated with disorders. The Needs for Care Assessment Schedule (NFCAS) is a relatively new procedure for assessing the needs of long-term mentally ill patients, mostly psychotic and attending psychiatric services. We report here a trial application of a modified version of the NFCAS on a sample of 39 non-psychotic patients, most of whom were attending psychiatric outpatient services. The results show that the modified procedure requires further refinement to achieve acceptability and reliability. Some improvements are suggested for refining items and for the collation of others. The difficulties encountered underline the key issues in developing such technology: specifying the threshold for recognizing the problems, detailing the interventions considered appropriate, defining the model of care and specifying the composition of the research team.

Social factors affecting clinical caseload in Italian good practice areas.

Italian statistics indicate that fewer people are living alone than in Great Britain. Psychiatric Case Register figures show that the treated prevalences are nearly half those found in British Case Register areas. The level of staffing in good practice areas like South-Verona or Trieste is at least similar and at times higher than British or American counterparts. The clinical caseload of Italian clinical teams is therefore lower. The Italian patients may have a greater social network's availability by the mere fact of living in the same household of relatives. It is hypothesized that these elements affect a clinical team's availability to offer alternatives to hospitalisation. A ratio caseload/staff should be taken into account in assessing the Italian psychiatric reform and alternatives to hospitalisation.