'Placement budgets' for supported employment: impact on employment rates in a multicentre randomised controlled trial.

BACKGROUND: The most effective rehabilitation model for job (re-)entry of people with mental illness is supported employment. A barrier to introducing supported employment into standard care is its temporally unlimited provision, which conflicts with health and social legislation in many European countries. AIMS: To test the impact of different 'placement budgets', i.e. a predefined maximum time budget for job seeking until take-up of competitive employment. METHOD: Participants (116) were randomly assigned to 25 h, 40 h or 55 h placement budgets in an intent-to-treat analysis. We applied the individual placement and support model over 24 months, following participants for 36 months. Primary outcome was employment in the labour market for at least 3 months. RESULTS: The proportion of participants obtaining competitive employment was 55.1% in the 25 h group, 37.8% in the 40 h group and 35.8% in the 55 h group. In a Cox regression analysis, time to employment was slightly lower in the 25 h group relative to the 40 h (hazard ratio 1.78, 95% CI 0.88-3.57, P = 0.107) and 55 h groups (hazard ratio 1.74, 95% CI 0.86-3.49, P = 0.122), but this was not statistically significant. The vast majority of all participants who found a job did so within the first 12 months (80.4%). CONCLUSION: A restricted time budget for job finding and placement does not affect the rate of successful employment. In accordance with legislation, a restriction of care provision seems justified and enhances the chances of supported employment being introduced in statutory services.

"Placement Budgets" for Supported Employment-Impact on Quality of Life in a Multicenter Randomized Controlled Trial.

Background: Employment is an important aspect of psychiatric rehabilitation. The objective of this analysis was to explore how quality of life (QoL) may affect the outcome of supported employment and vice versa. Methods: A total of 116 participants with severe mental disorders were randomly assigned to either 25, 40, or 55 h placement budgets, which comprises job coaches' time resources to support a client in finding a job. The intervention followed the individual placement and support model and lasted up to 36 months. Primary outcome was employment in the first labor market for at least 3 months. QoL was assessed 7 times over the entire 36-months observation period using the WHO QoL Bref, which comprises the dimensions physical health, psychological, social relationships, and environment. Results: The three placement budgets did not differentially relate to QoL, but QoL environment showed a significant increase over time across all three groups. Baseline QoL environment weakly predicted subsequent obtainment of employment (F = 4.08, df = 1, p = 0.046, Cohen's d = 0.39). Controlling for baseline QoL, those participants who obtained a job, as compared to those who did not, showed persistent increases in QoL physical health (b = 0.39, p = 0.002, Cohen's d = 0.50) and QoL psychological (b = 0.40, p < 0.001, Cohen's d = 0.47). Conclusion: Obtaining employment in the first labor market improves patients' QoL. Supported employment is a valuable intervention that may benefit patients with severe mental disorder.

Honest, Open, Proud for adolescents with mental illness: pilot randomized controlled trial.

BACKGROUND: Due to public stigma or self-stigma and shame, many adolescents with mental illness (MI) struggle with the decision whether to disclose their MI to others. Both disclosure and nondisclosure are associated with risks and benefits. Honest, Open, Proud (HOP) is a peer-led group program that supports participants with disclosure decisions in order to reduce stigma's impact. Previously, HOP had only been evaluated among adults with MI. METHODS: This two-arm pilot randomized controlled trial included 98 adolescents with MI. Participants were randomly assigned to HOP and treatment as usual (TAU) or to TAU alone. Outcomes were assessed pre (T0/baseline), post (T1/after the HOP program), and at 3-week follow-up (T2/6 weeks after T0). Primary endpoints were stigma stress at T1 and quality of life at T2. Secondary outcomes included self-stigma, disclosure-related distress, empowerment, help-seeking intentions, recovery, and depressive symptoms. The trial is registered on ClinicalTrials (NCT02751229; http://www.clinicaltrials.gov). RESULTS: Compared to TAU, adolescents in the HOP program showed significantly reduced stigma stress at T1 (d = .92, p < .001) and increased quality of life at T2 (d = .60, p = .004). In a longitudinal mediation model, the latter effect was fully mediated by stigma stress reduction at T1. HOP further showed significant positive effects on self-stigma, disclosure-related distress, secrecy, help-seeking intentions, attitudes to disclosure, recovery, and depressive symptoms. Effects at T1 remained stable or improved further at follow-up. In a limited economic evaluation HOP was cost-efficient in relation to gains in quality of life. CONCLUSIONS: As HOP is a compact three-session program and showed positive effects on stigma and disclosure variables as well as on symptoms and quality of life, it could help to reduce stigma's negative impact among adolescents with MI.

Mental Health Literacy, Attitudes to Help Seeking, and Perceived Need as Predictors of Mental Health Service Use: A Longitudinal Study.

Many people with mental health problems do not use mental health care, resulting in poorer clinical and social outcomes. Reasons for low service use rates are still incompletely understood. In this longitudinal, population-based study, we investigated the influence of mental health literacy, attitudes toward mental health services, and perceived need for treatment at baseline on actual service use during a 6-month follow-up period, controlling for sociodemographic variables, symptom level, and a history of lifetime mental health service use. Positive attitudes to mental health care, higher mental health literacy, and more perceived need at baseline significantly predicted use of psychotherapy during the follow-up period. Greater perceived need for treatment and better literacy at baseline were predictive of taking psychiatric medication during the following 6 months. Our findings suggest that mental health literacy, attitudes to treatment, and perceived need may be targets for interventions to increase mental health service use.

Influence of Time to Change's social marketing interventions on stigma in England 2009-2011.

BACKGROUND: England's Time To Change (TTC) social marketing campaign emphasised social contact between people with and without mental health problems to reduce stigma and discrimination. AIMS: We aimed to assess the effectiveness of the mass media component and also that of the mass social contact events. METHOD: Online interviews were performed before and after each burst of mass media social marketing to evaluate changes in knowledge, attitudes and behaviour and associations between campaign awareness and outcomes. Participants at social contact events were asked about the occurrence and quality of contact, attitudes, readiness to discuss mental health and intended behaviour towards people with mental health problems. RESULTS: Prompted campaign awareness was 38-64%. A longitudinal improvement was noted for one intended behaviour item but not for knowledge or attitudes. Campaign awareness was positively associated with greater knowledge (ß = 0.80, 95% CI 0.52-1.08) and more favourable attitudes (commonality OR 1.37, 95% CI 1.10-1.70; dangerousness OR 1.41, 95% CI 1.22-1.63) and intended behaviour (ß = 0.75, 95% CI 0.53-0.96). Social contact at events demonstrated a positive impact (M = 2.68) v. no contact (M = 2.42) on perceived attitude change; t(211) = 3.30, P = 0.001. Contact quality predicted more positive attitude change (r = 0.33, P<0.01) and greater confidence to challenge stigma (r = 0.38, P<0.01). CONCLUSIONS: The favourable short-term consequences of the social marketing campaign suggest that social contact can be used by anti-stigma programmes to reduce stigma.

'Placement budgets' for supported employment--improving competitive employment for people with mental illness: study protocol of a multicentre randomized controlled trial.

BACKGROUND: Vocational integration of people with mental illness is poor despite their willingness to work. The 'Individual Placement and Support' (IPS) model which emphasises rapid and direct job placement and continuing support to patient and employer has proven to be the most effective vocational intervention programme. Various studies have shown that every second patient with severe mental illness was able to find competitive employment within 18 months. However, the goal of taking up employment within two months was rarely achieved. Thus, we aim to test whether the new concept of limited placement budgets increases the effectiveness of IPS. METHODS/DESIGN: Six job coaches in six out-patients psychiatric clinics in the Canton of Zurich support unemployed patients of their clinic who seek competitive employment. Between June 2010 and May 2011 patients (N=100) are randomly assigned to three different placement budgets of 25h, 40h, or 55h working hours of job coaches. Support lasts two years for those who find a job. The intervention ends for those who fail to find competitive employment when the respective placement budgets run out. The primary outcome measure is the time between study inclusion and first competitive employment that lasted three months or longer. Over a period of three years interviews are carried out every six months to measure changes in motivation, stigmatization, social network and social support, quality of life, job satisfaction, financial situation, and health conditions. Cognitive and social-cognitive tests are conducted at baseline to control for confounding variables. DISCUSSION: This study will show whether the effectiveness of IPS can be increased by the new concept of limited placement budgets. It will also be examined whether competitive employment leads in the long term to an improvement of mental illness, to a transfer of the psychiatric support system to private and vocational networks, to an increase in financial independence, to a reduction of perceived and internalized stigma, and to an increase in quality of life and job satisfaction of the patient. In addition, factors connected with fast competitive employment and holding that job down in the long term are being examined (motivation, stigmatization, social and financial situation). TRIAL REGISTER: ISRCTN89670872.

Preventing compulsory admission to psychiatric inpatient care through psycho-education and crisis focused monitoring.

BACKGROUND: The high number of involuntary placements of people with mental disorders in Switzerland and other European countries constitutes a major public health issue. In view of the ethical and personal relevance of compulsory admission for the patients concerned and given the far-reaching effects in terms of health care costs, innovative interventions to improve the current situation are much needed. A number of promising approaches to prevent involuntary placements have been proposed that target continuity of care by increasing self-management skills of patients. However, the effectiveness of such interventions in terms of more robust criteria (e.g., admission rates) has not been sufficiently analysed in larger study samples. The current study aims to evaluate an intervention programme for patients at high risk of compulsory admission to psychiatric hospitals. Effectiveness will be assessed in terms of a reduced number of psychiatric hospitalisations and days of inpatient care in connection with involuntary psychiatric admissions as well as in terms of cost-containment in inpatient mental health care. The intervention furthermore intends to reduce the degree of patients' perceived coercion and to increase patient satisfaction, their quality of life and empowerment. METHODS/DESIGN: This paper describes the design of a randomised controlled intervention study conducted currently at four psychiatric hospitals in the Canton of Zurich. The intervention programme consists of individualised psycho-education focusing on behaviours prior to and during illness-related crisis, the distribution of a crisis card and, after inpatient admission, a 24-month preventive monitoring of individual risk factors for compulsory re-admission to hospital. All measures are provided by a mental health care worker who maintains permanent contact to the patient over the course of the study. In order to prove its effectiveness the intervention programme will be compared with standard care procedures (control group). 200 patients each will be assigned to the intervention group or to the control group. Detailed follow-up assessments of service use, psychopathology and patient perceptions are scheduled 12 and 24 months after discharge. DISCUSSION: Innovative interventions have to be established to prevent patients with mental disorders from undergoing the experience of compulsory admission and, with regard to society as a whole, to reduce the costs of health care (and detention). The current study will allow for a prospective analysis of the effectiveness of an intervention programme, providing insight into processes and factors that determine involuntary placement.

Mass social contact interventions and their effect on mental health related stigma and intended discrimination.

BACKGROUND: Stigma and discrimination associated with mental health problems is an important public health issue, and interventions aimed at reducing exposure to stigma and discrimination can improve the lives of people with mental health problems. Social contact has long been considered to be one of the most effective strategies for improving inter-group relations. For this study, we assess the impact of a population level social contact intervention among people with and without mental health problems. METHODS: This study investigated the impact of social contact and whether presence of specific facilitating factors (equal status, common goals, cooperation and friendship potential): (1) improves intended stigmatising behaviour; (2) increases future willingness to disclose a mental health problem; and (3) promotes behaviours associated with anti-stigma campaign engagement. Two mass participation social contact programmes within England's Time to Change campaign were evaluated via a 2-part questionnaire. 403 participants completed initial questionnaires (70% paper, 30% online) and 83 completed follow-up questionnaires online 4-6 weeks later. RESULTS: This study investigated the impact of social contact and whether presence of specific facilitating factors (equal status, common goals, cooperation and friendship potential): (1) improves intended stigmatising behaviour; (2) increases future willingness to disclose a mental health problem; and (3) promotes behaviours associated with anti-stigma campaign engagement. Two mass participation social contact programmes within England's Time to Change campaign were evaluated via a 2-part questionnaire. 403 participants completed initial questionnaires (70% paper, 30% online) and 83 completed follow-up questionnaires online 4-6 weeks later. Campaign events facilitated meaningful intergroup social contact between individuals with and without mental health problems. Presence of facilitating conditions predicted improved stigma-related behavioural intentions and subsequent campaign engagement 4-6 weeks following social contact. Contact, however, was not predictive of future willingness to disclose mental health problems. CONCLUSIONS: Findings emphasise the importance of facilitating conditions to promote positive social contact between individuals and also suggest that social contact interventions can work on a mass level. Future research should investigate this type of large scale intervention among broader and more representative populations.

Implicit self-stigma in people with mental illness.

People with mental illness often internalize negative stereotypes, resulting in self-stigma and low self-esteem ("People with mental illness are bad and therefore I am bad, too"). Despite strong evidence for self-stigma's negative impact as assessed by self-report measures, it is unclear whether self-stigma operates in an automatic, implicit manner, potentially outside conscious awareness and control. We therefore assessed (i) negative implicit attitudes toward mental illness and (ii) low implicit self-esteem using 2 Brief Implicit Association Tests in 85 people with mental illness. Implicit self-stigma was operationalized as the product of both implicit measures. Explicit self-stigma and quality of life were assessed by self-report. Greater implicit and explicit self-stigma independently predicted lower quality of life after controlling for depressive symptoms, diagnosis, and demographic variables. Our results suggest that implicit self-stigma is a measurable construct and is associated with negative outcomes. Attempts to reduce self-stigma should take implicit processes into account.