Experiences and needs of welfare benefit recipients regarding their welfare-to-work services and case workers.

BACKGROUND: This study aimed to explore the experiences and needs of (ex-)welfare benefit recipients from a large urban municipality in the Netherlands regarding their welfare-to-work services and their case workers. METHODS: Quantitative data from a client satisfaction survey that was filled out by 213 people (response rate 11%) who received welfare-to-work services was combined with results from four group interviews with a total of 15 people receiving welfare-to-work services. Verbatim transcripts from the interviews were analysed using inductive thematic analysis. RESULTS: The survey results showed that most clients were reasonably satisfied with the welfare-to-work services they received. Four main themes emerged from the interviews: (1) experiences and needs related to the interactions between case workers and benefit recipients; (2) the need for tailored services; (3) the complicating role of the system the case workers operate within; and (4) the existence of differences between case workers regarding how strict they followed the rules and to what extent they connected with their clients on a personal level. CONCLUSIONS: Our findings show that clients were reasonably satisfied with the welfare-to-work services provided by their municipality but that there is still room for improvement. Case workers should have good social skills to build a trusting relationship with the client, welfare-to-work services should be tailored to the individual, and clear concise information should be given to welfare benefit recipients, especially with regard to what benefit recipients can expect of the municipality and the case workers, given their dual role in supporting (re-)integration to work and monitoring benefit eligibility.

Mental health issues and illness and substance use disorder (non-)disclosure to a supervisor: a cross-sectional study on beliefs, attitudes and needs of military personnel.

OBJECTIVES: Research suggests that military personnel frequently delay disclosing mental health issues and illness (MHI), including substance use disorder, to supervisors. This delay causes missed opportunities for support and workplace accommodations which may help to avoid adverse occupational outcomes. The current study aims to examine disclosure-related beliefs, attitudes and needs, to create a better understanding of personnel's disclosure decision making. DESIGN: A cross-sectional questionnaire study among military personnel with and without MHI. Beliefs, attitudes and needs regarding the (non-)disclosure decision to a supervisor were examined, including factors associated with (non-)disclosure intentions and decisions. Descriptive and regression (logistic and ordinal) analyses were performed. SETTING: The study took place within the Dutch military. PARTICIPANTS: Military personnel with MHI (n=324) and without MHI (n=554) were participated in this study. OUTCOME MEASURE: (Non-)disclosure intentions and decisions. RESULTS: Common beliefs and attitudes pro non-disclosure were the preference to solve one's own problems (68.3%), the preference for privacy (58.9%) and a variety of stigma-related concerns. Common beliefs and attitudes pro disclosure were that personnel wanted to be their true authentic selves (93.3%) and the desire to act responsibly towards work colleagues (84.5%). The most reported need for future disclosure (96.8%) was having a supervisor who shows an understanding for MHI. The following factors were associated both with non-disclosure intentions and decisions: higher preference for privacy (OR (95% CI))=(1.99 (1.50 to 2.65)intention, 2.05 (1.12 to 3.76)decision) and self-management (OR (95% CI))=(1.64 (1.20 to 2.23)intention, 1.79 (1.00 to 3.20)decision), higher stigma-related concerns (OR (95% CI))=(1.76 (1.12 to 2.77)intention, 2.21 (1.02 to 4.79)decision) and lower quality of supervisor-employee relationship (OR (95% CI))=(0.25 (0.15 to 0.42)intention, 0.47 (0.25 to 0.87)decision). CONCLUSION: To facilitate (early-)disclosure to a supervisor, creating opportunities for workplace support, interventions should focus on decreasing stigma and discrimination and align with personnels' preference for self-management. Furthermore, training is needed for supervisors on how to recognise, and effectively communicate with, personnel with MHI. Focus should also be on improving supervisor-employee relationships.

Cost Effectiveness and Budget Impact of the Boston University Approach to Psychiatric Rehabilitation for Increasing the Social Participation of Individuals With Severe Mental Illnesses.

Background: The purpose of this study was to investigate the cost-effectiveness and budget impact of the Boston University Approach to Psychiatric Rehabilitation (BPR) compared to an active control condition (ACC) to increase the social participation (in competitive employment, unpaid work, education, and meaningful daily activities) of individuals with severe mental illnesses (SMIs). ACC can be described as treatment as usual but with an active component, namely the explicit assignment of providing support with rehabilitation goals in the area of social participation. Method: In a randomized clinical trial with 188 individuals with SMIs, BPR (n = 98) was compared to ACC (n = 90). Costs were assessed with the Treatment Inventory of Costs in Patients with psychiatric disorders (TIC-P). Outcome measures for the cost-effectiveness analysis were incremental cost per Quality Adjusted Life Year (QALY) and incremental cost per proportional change in social participation. Budget Impact was investigated using four implementation scenarios and two costing variants. Results: Total costs per participant at 12-month follow-up were € 12,886 in BPR and € 12,012 in ACC, a non-significant difference. There were no differences with regard to social participation or QALYs. Therefore, BPR was not cost-effective compared to ACC. Types of expenditure with the highest costs were in order of magnitude: supported and sheltered housing, inpatient care, outpatient care, and organized activities. Estimated budget impact of wide BPR implementation ranged from cost savings to €190 million, depending on assumptions regarding uptake. There were no differences between the two costing variants meaning that from a health insurer perspective, there would be no additional costs if BPR was implemented on a wider scale in mental health care institutions. Conclusions: This was the first study to investigate BPR cost-effectiveness and budget impact. The results showed that BPR was not cost-effective compared to ACC. When interpreting the results, one must keep in mind that the cost-effectiveness of BPR was investigated in the area of social participation, while BPR was designed to offer support in all rehabilitation areas. Therefore, more studies are needed before definite conclusions can be drawn on the cost-effectiveness of the method as a whole.

Targeting Personal Recovery of People With Complex Mental Health Needs: The Development of a Psychosocial Intervention Through User-Centered Design.

Long-term admissions in psychiatric facilities often result in a gradual erosion of the identity of people diagnosed with severe mental illnesses (SMIs) into merely "patient." Moreover, experiences of loss often reduced people's sense of purpose. Although regaining a multidimensional identity and a sense of purpose are essential for personal recovery, few interventions specifically address this, while at the same time take people's often considerable cognitive and communicative disabilities into consideration. This study describes the development process of a new intervention through user-centered design (UCD). UCD is an iterative process in which a product (in this case, an intervention) is developed in close cooperation with future users, such that the final product matches their needs. The design process included three phases: an analysis, design, and evaluation phase. In the analysis phase, the "problem" was defined, users' needs were identified, and design criteria were established. In the design phase, the collected information served as input to create a testable prototype using a process of design and redesign, in close collaboration with service users and other stakeholders. This resulted in an intervention entitled "This is Me" (TiM) in which service users, together with a self-chosen teammate, actively engage in new experiences on which they are prompted to reflect. Finally, in the evaluation phase, TiM was implemented and evaluated in a real-life setting. In a small feasibility pilot, we found indications that some people indeed demonstrated increased reflection on their identity during the intervention. Furthermore, TiM seemed to benefit the relationship between the service users and the mental health professionals with whom they underwent the experiences. The pilot also revealed some aspects of the (implementation of) TiM that can be improved. Overall, we conclude that UCD is a useful method for the development of a new psychosocial intervention. The method additionally increased our knowledge about necessary factors in targeting personal recovery for people with complex mental health needs. Moreover, we conclude that TiM is a promising tool for supporting people with SMI in redeveloping a multidimensional identity and a renewed sense of purpose.

The resource group method in severe mental illness: study protocol for a randomized controlled trial and a qualitative multiple case study.

BACKGROUND: The resource group method provides a structure to facilitate patients' empowerment and recovery processes, and to systematically engage significant others in treatment and care. A patient chooses members of a resource group (RG) that will work together on fulfilling patients' recovery plan. By adopting shared decision-making processes and stimulating collaboration of different support systems, a broad and continuous support of patients' chosen goals and wishes is preserved and problem solving and communication skills of the RG members are addressed. OBJECTIVE: The objectives of this study are (1) to establish the effectiveness of the RG method in increasing empowerment in patients with severe mental illnesses (SMI) in the Netherlands; (2) to investigate the cost-effectiveness and cost utility of the RG method; and (3) to qualitatively explore its dynamics and processes. METHODS/DESIGN: This multisite randomized controlled trial will compare the effects of the RG-method integrated in Flexible Assertive Community Treatment (FACT) (90 patients) with those of standard FACT (90 patients). Baseline assessments and 9-month and 18-month follow-up assessments will be conducted in face-to-face home visits. The primary outcome measure, empowerment, will be assessed using the Netherlands Empowerment List (NEL). The secondary outcomes will be quality of life (MANSA); personal, community and clinical recovery (I.ROC); general, social and community functioning (WHODAS 2.0); general psychopathological signs and symptoms (BSI-18); and societal costs (TiC-P). An economic evaluation of the cost-effectiveness and cost utility of the RG method will also be conducted. A qualitative multiple case-study will be added to collect patients', RG members' and professionals' perspectives by in-depth interviews, observations and focus groups. DISCUSSION: This trial will be the first to study the effects of the RG method on empowerment in patients with SMI. By combining clinical-effectiveness data with an economic evaluation and in-depth qualitative information from primary stakeholders, it will provide a detailed overview of the RG method as a mean of improving care for patients with SMI.Trial registration The study has been registered in the Dutch Trial Register, identifier: NTR6737, September 2017.

Trajectories of patients with severe mental illness in two-year contact with Flexible Assertive Community Treatment teams using Routine Outcome Monitoring data: An observational study.

OBJECTIVE: Using outcome data collected routinely over a continuous two-year treatment period, we wished to distinguish homogeneous subgroups of patients with a severe mental illness whose psychosocial problems followed a similar pattern over time. By identifying the effectiveness of health services for different patient groups, this approach allowed us to identify patients at risk of deterioration and those recovering from their symptoms. METHODS: In total we included 2,660 patients who were in two-year continuous contact with a Flexible Assertive Community Treatment team (FACT). We collected outcome data on psychosocial functioning, needs for care and quality of life. We performed a latent class growth analysis (LCGA). RESULTS: The LCGA identified six homogenous patient subgroups using trajectories of HoNOS scores. On the basis of the patterns of patients' psychosocial problems over time, we labelled these as follows: 1) stable at a low problem-severity level (N = 709; 27%); 2) stable at a low medium problem-severity level (N = 1,208; 45%); 3) stable at a high medium problem-severity level (N = 528; 20%); 4) stable at a high problem-severity level (N = 116; 4%); 5) amelioration of problems (N = 42; 2%); and 6) deterioration of problems (N = 57; 2%). Patients with stable and a high severity of psychosocial problems had more practical and somatic unmet needs than those in other subgroups, and also had the fewest decrease in the number of unmet needs. DISCUSSION: After linking patient subgroups with clinical features such as the need for care, we found that, over two years, most patients remained relatively stable in terms of psychosocial functioning, but that their unmet needs decreased over time. However, in terms of needs for treatment during two years of contact with a FACT team, patients in the subgroup with a stable and high problem-severity level tended to derive little or no benefit.

Effectiveness of an intervention for managing victimization risks related to societal participation for persons with severe mental illness: a cluster RCT study protocol.

BACKGROUND: People with severe mental illness (SMI) are more likely to experience criminal victimization than other community members. In addition, (self-) stigma and perceived discrimination are highly prevalent in this group. These adversities in the social context often have major adverse effects on the rehabilitation and recovery of these persons. Current practice, however, lacks instruments to address these issues. As a reaction, the Victoria intervention was developed and pilot-tested with client representatives, professionals, trainers and researchers. The Victoria intervention is a method for community mental health care workers to expand their awareness of this topic and support them in assessing victimization and incorporate appropriate services, including trauma screening and rehabilitation services, in their health care planning. For clients, the Victoria intervention aims to increase their awareness, active management of possible victimization risks and promote safe social participation. As a new intervention, little is known about its use in real practice and its effects on client outcomes. METHODS/DESIGN: To determine the feasibility and effectiveness of this intervention, a process evaluation and a first cluster randomized controlled trial (RCT) will be carried out. Outpatients from eight Flexible Assertive Community Treatment (F-ACT) teams from two mental health care (MHC) organizations in the Netherlands are included in the study. Teams in the intervention group will receive three half-day training sessions, and bi-monthly supervision meetings for 18 months. Teams in the control group provide care as usual. For the process evaluation, a multi-method design is used. To assess effects on client outcomes, clients will be interviewed about their experiences on victimization and societal participation using validated questionnaires at baseline, and after 9 and 18 months. DISCUSSION: This study is the first to evaluate an intervention aiming at recognition of victimization, (self-) stigma and perceived discrimination, and targeting outpatients' insights into possible risks and coping skills to tackle these risks to enhance safe societal participation. Results of this study may validate the Victoria intervention as a practice to better manage risk for adversities related to societal participation. TRIAL REGISTRATION: Dutch Trial Register (NTR): 5585 , date of registration: 11-01-2016.

Cost effectiveness and budgetary impact of the Boston University approach to Psychiatric Rehabilitation for societal participation in people with severe mental illness: a randomised controlled trial protocol.

BACKGROUND: People with Severe Mental Illness (SMI) frequently experience problems with regard to societal participation (i.e. work, education and daily activities outside the home), and require professional support in this area. The Boston University approach to Psychiatric Rehabilitation (BPR) is a comprehensive methodology that can offer this type of support. To date, several Randomised Controlled Trials (RCT's) investigating the effectiveness of BPR have yielded positive outcomes with regard to societal participation. However, information about the cost-effectiveness and budgetary impact of the methodology, which may be important for broader dissemination of the approach, is lacking. BPR may be more cost effective than Care As Usual (CAU) because an increase in participation and independence may reduce the costs to society. Therefore, the aim of this study is to investigate, from a societal perspective, the cost-effectiveness of BPR for people with SMI who wish to increase their societal participation. In addition, the budget impact of implementing BPR in the Dutch healthcare setting will be assessed by means of a budget impact analysis (BIA) after completion of the trial. METHODS: In a multisite RCT, 225 adults (18-64 years of age) with SMI will be randomly allocated to the experimental (BPR) or the control condition (CAU). Additionally, a pilot study will be conducted with a group of 25 patients with severe and enduring eating disorders. All participants will be offered support aimed at personal rehabilitation goals, and will be monitored over a period of a year. Outcomes will be measured at baseline, and at 6 and 12 months after enrolment. Based on trial results, further analyses will be performed to assess cost-effectiveness and the budgetary impact of implementation scenarios. DISCUSSION: The trial results will provide insight into the cost-effectiveness of BPR in supporting people with SMI who would like to increase their level of societal participation. These results can be used to make decisions about further implementation of the method. Also, assessing budgetary impact will facilitate policymaking. The large sample size, geographic coverage and heterogeneity of the study group will ensure reliable generalisation of the study results. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN88987322. Registered 13 May 2014.

Effectiveness and cost-effectiveness of cognitive adaptation training as a nursing intervention in long-term residential patients with severe mental illness: study protocol for a randomized controlled trial.

BACKGROUND: Despite the well-known importance of cognitive deficits for everyday functioning in patients with severe mental illness (SMI), evidence-based interventions directed at these problems are especially scarce for SMI patients in long-term clinical facilities. Cognitive adaptation Training (CAT) is a compensatory approach that aims at creating new routines in patients' living environments through the use of environmental supports. Previous studies on CAT showed that CAT is effective in improving everyday functioning in outpatients with schizophrenia. The aim of this study is to evaluate the effect of CAT as a nursing intervention in SMI patients who reside in long-term clinical facilities. METHODS/DESIGN: This is a multicenter cluster randomized controlled trial comparing CAT (intervention group) as a nursing intervention to treatment as usual (control group). The primary goal is to evaluate the effectiveness of CAT on everyday functioning. Secondary outcomes are quality of life, empowerment and apathy. Further, an economic evaluation will be performed. The study has a duration of one year, with four follow-up assessments at 15, 18, 21 and 24 months for the intervention group. DISCUSSION: There is a need for evidence-based interventions that contribute to the improvement of the functional recovery of long-term residential patients. If our hypotheses are confirmed, it may be recommended to include CAT in the guidelines for SMI care and to implement the method in standardized care. TRIAL REGISTRATION: Nederlands Trial Register (identifier: NTR3308 ). Date registered: 12 February 2012.

Illness self-management assessment in psychiatric vocational rehabilitation.

OBJECTIVE: People with severe mental illnesses experience difficulty finding and maintaining employment, even if they are offered psychiatric vocational rehabilitation services. When service recipients are able to apply more effective illness self-management strategies, vocational rehabilitation outcomes improve. To assess the use of these strategies, the Illness Self-Management assessment instrument for Psychiatric Vocational Rehabilitation (ISM-PVR) was developed. METHODS: Experts were consulted to design the ISM-PVR instrument which was then tested by 8 vocational rehabilitation workers and 26 of their service recipients. RESULTS: This study indicated sufficient internal consistency of the ISM-PVR self-report questionnaire, especially for the subscales assessing goal related self-efficacy, perceived illness-related barriers, and four of the eight coping scales. The number of self-reported illness barriers was associated with a higher number of reported work-related coping strategies. The ISM-PVR aided the identification of specific mental illness-related barriers perceived by the service recipients. The instrument also facilitated obtaining information on individual self-management strategies that clients employed to overcome such barriers or make them manageable. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The application of the ISM-PVR in vocational rehabilitation practice warrants further research. The study suggests that this instrument is a useful add-on to existing vocational assessment and provides insight in self-management strategies that people use, and that may help those people and their job coaches make more effective vocational plans.

A regional assessment of the quality of care for people with schizophrenia in The Netherlands.

UNLABELLED: This study examined the quality of mental health care for people with schizophrenia in eight regions in The Netherlands as assessed by the QUARTS: Quality Assessment of Regional Treatment Systems for Schizophrenia. The focus was on determining whether the introduction of multidisciplinary guidelines improved quality in service provision. METHODS: The QUARTS, a standardized interview instrument, addresses the availability of and satisfaction with services from the perspectives of clinicians, patients, families, and community organizations. The first QUARTS assessment was done about the time the guidelines were introduced in The Netherlands (2005), and the second was two to four years later. RESULTS: In all regions progress was made in the availability of care elements, although progress was limited for evidence-based rehabilitation interventions. CONCLUSIONS: Key clinicians in all regions perceived the guidelines as an important factor in improving the quality of schizophrenia care. QUARTS can be a helpful instrument for service monitoring and development.

The Generic Work Behavior Questionnaire (GWBQ): assessment of core dimensions of generic work behavior of people with severe mental illnesses in vocational rehabilitation.

The purpose of this study was the development of a short self-reporting and supervisor-reporting questionnaire to assess generic work behavior of people with severe mental illnesses participating in psychiatric vocational rehabilitation. An 18-item generic work behavior questionnaire (GWBQ) was developed, which contains core dimensions derived from both supervisor scores and self-report scores. The factor structure of the GWBQ was replicated for both versions (supervisor and self reports). The GWBQ was very reliable for supervisor reports and moderately so for self-reports. Although self-report scores and supervisor scores correlated significantly, participants rated their own work behavior consistently higher than supervisors did.