Desire to Quit Smoking in an Outpatient Population of Persons with Serious Mental Illness.

National survey data indicates that about 32% of adults with any mental illness smoke, compared with 23% of adults without a psychiatric disorder. Smoking rates are higher in clinical populations, where up to 53% of persons with serious mental illnesses (schizophrenia and bipolar disorder) are estimated to smoke. Despite higher rates of smoking among persons with mental illnesses, motivation to quit in this population is similar to that of the general population of smokers. Nevertheless, smoking cessation rates in the USA have been significantly lower among persons with mental illnesses than among persons without a mental illness. Advising patients to quit is among the most basic approaches to smoking cessation used by health care professionals, and there is evidence that the likelihood of cessation increases with even minimal advising. Indeed, advising is the second of five smoking cessation activities recommended in the US Department of Health and Human Services clinical guideline, Treating Tobacco Use and Dependence, which promotes physician intervention activities in steps known as the five A's (ask, advise, assess, assist, and arrange). A randomized, state-wide survey was used to estimate the smoking prevalence among psychiatric outpatients served in Ohio's publicly funded behavioral health care system. A follow-up survey explored a self-selected sample's exposure to cessation advising by health care practitioners and the relationship between that advising and subjects' desire to quit.

Description and impact of a structured psychoeducational and salutogenetic approach (InteGRO) to support the recovery of people with severe mental disorders / Descrizione e impatto di un approccio psicoeducativo strutturato (InteGRO) di salutogenesi per sostenere il percorso di recovery delle persone con disturbo mentale grave

Aim: In mental health services there is an increasing attention to the recovery of people with severe mental illness. Consequently there is a growing literature on this topic focused above-all on the description of excellence paths that often include variables related to the organizational aspects of the service. Less attention is given to specific interventions to foster all the goals that are essential to improve the living conditions, including defining and planning goal, emotional perception, effective communication for negotiation, practical interpersonal and intrapersonal problem-solving. The aim of this paper is to describe an innovative and salutogenetic approach and to illustrate the results of the impact after a year of "active intervention". Methods: We used a "quasi-experiment" design-study with a pre-post assessment without a control group on 21 subjects with schizophrenia or bipolar disorder according to DSM-IV-TR criteria. We used to evaluate Functioning, the primary outcome, the Personal and Social Performance Scale. For the secondary outcome measures we used the Stress-Scale, the Modified Five-Point Test for cognitive flexibility, the APEN/G e APEP/G Scale for perceived self-efficacy, the Integrative Hope Scale, the items "subjective and objective load" of the "Aid received, Needs and Burden" self-filled questionnaire. The clinical assessment was made by the Brief Psychyatric Rating Scale, while we used the Repeatable Battery for the Assessment of Neuropsychological Status. Results: Of the 21 subjects included, 18 completed the assessment. Significant improvements were noted for all variables considered, with particular relevance for Personal and Social Functioning (p<0.001). Predictive variables for this dimension were the level of stress and perceived self-efficacy (p<0.05). Conclusions: The observed data confirm the effectiveness of this innovative approach, above all on Personal and Social Functioning where there has been improvement from two or more marked dysfunction areas to one area.

'Recovery' in the Real World: Service User Experiences of Mental Health Service Use and Recommendations for Change 20 Years on from a First Episode Psychosis.

Little is known about how recovery oriented policy and legislative changes influence service users' perceptions of mental health care over time. Although the recovery approach is endorsed in many countries, qualitative research examining its impact on service use experiences has been lacking. This study aimed to explore this impact as well as experiences of service utilisation and suggestions for change with people diagnosed with a First Episode Psychosis between 1995 and 1999. Participants had used services during the 10 year period prior to, and 10 years post, policy and legislative shifts to the recovery approach. Semi-structured interviews were conducted with 10 participants who met criteria for 'full functional recovery' and 10 who did not. Data were analysed using Thematic Networks Analysis to develop Basic, Organising, and Global Themes. Over time, recovered participants perceived an improvement in service quality through the 'humanising' of treatment and non-recovered participants experienced their responsibility in recovery being recognised, but felt abandoned to the recovery approach. Findings suggest the importance of viewing service users as demonstrating personhood and having societal value; examining the personal meaning of psychotic experiences; and matching expectations with what services can feasibly provide. The implementation and the principal tenets of the recovery approach warrant further investigation.

Optimizing delivery of recovery-oriented online self-management strategies for bipolar disorder: a review.

OBJECTIVES: Self-management is emerging as a viable alternative to difficult-to-access psychosocial treatments for bipolar disorder (BD), and has particular relevance to recovery-related goals around empowerment and personal meaning. This review examines data and theory on BD self-management from a recovery-oriented perspective, with a particular focus on optimizing low-intensity delivery of self-management tools via the web. METHODS: A critical evaluation of various literatures was undertaken. Literatures on recovery, online platforms, and self-management in mental health and BD are reviewed. RESULTS: The literature suggests that the self-management approach aligns with the recovery framework. However, studies have identified a number of potential barriers to the utilization of self-management programs for BD and it has been suggested that utilizing an online environment may be an effective way to surmount many of these barriers. CONCLUSIONS: Online self-management programs for BD are rapidly developing, and in parallel the recovery perspective is becoming the dominant paradigm for mental health services worldwide, so research is urgently required to assess the efficacy and safety of optimization methods such as professional and/or peer support, tailoring and the development of 'online communities'.

Assisting Social Security Disability Insurance beneficiaries with schizophrenia, bipolar disorder, or major depression in returning to work.

OBJECTIVE: People with psychiatric impairments (primarily schizophrenia or a mood disorder) are the largest and fastest-growing group of Social Security Disability Insurance (SSDI) beneficiaries. The authors investigated whether evidence-based supported employment and mental health treatments can improve vocational and mental health recovery for this population. METHOD: Using a randomized controlled trial design, the authors tested a multifaceted intervention: team-based supported employment, systematic medication management, and other behavioral health services, along with elimination of barriers by providing complete health insurance coverage (with no out-of-pocket expenses) and suspending disability reviews. The control group received usual services. Paid employment was the primary outcome measure, and overall mental health and quality of life were secondary outcome measures. RESULTS: Overall, 2,059 SSDI beneficiaries with schizophrenia, bipolar disorder, or depression in 23 cities participated in the 2-year intervention. The teams implemented the intervention package with acceptable fidelity. The intervention group experienced more paid employment (60.3% compared with 40.2%) and reported better mental health and quality of life than the control group. CONCLUSIONS: Implementation of the complex intervention in routine mental health treatment settings was feasible, and the intervention was effective in assisting individuals disabled by schizophrenia or depression to return to work and improve their mental health and quality of life.

Risk assessment and psychosocial interventions for suicidal patients.

OBJECTIVES: Suicide is a leading cause of death in the USA. Although factors elevating long-term risk for suicide are known and include bipolar disorder, signs of imminent suicide risk are difficult to study and not well specified. Acute risk determinations must be made to determine the appropriate level of care to safeguard patients. To increase safety among at-risk patients in the short term and to decrease risk over time, psychosocial interventions to prevent suicide have been developed and tested in acute care and outpatient settings. METHODS: A narrative review of studies of imminent risk factors for suicide, suicide risk decision-making, and psychosocial suicide prevention interventions was conducted. RESULTS: Although some long-term risk factors of suicide have been established, accurate identification of individuals at imminent risk for suicide is difficult. Therefore, prevention efforts targeting individuals at high suicide behavior risk discharging from acute care settings tend to be generic and focus on psychoeducation and supportive follow-up contact. Data regarding the effectiveness of brief interventions (i.e., those not requiring more than one individualized treatment session) are mixed, showing better outcomes in the shorter term and when the incidence of suicidal behavior or ideation is the outcome. With respect to longer-term suicide prevention interventions (i.e., those with a minimum of ten sessions), Dialectical Behavior Therapy has the largest evidence base. CONCLUSIONS: To improve suicide prevention efforts, more rigorous study of imminent risk factors and psychosocial interventions is needed. Adaptations specific to individuals with bipolar disorder are possible and needed.

Randomized trial of social rehabilitation and integrated health care for older people with severe mental illness.

OBJECTIVE: The Helping Older People Experience Success (HOPES) program was developed to improve psychosocial functioning and reduce long-term medical burden in older people with severe mental illness (SMI) living in the community. HOPES includes 1 year of intensive skills training and health management, followed by a 1-year maintenance phase. METHOD: To evaluate effects of HOPES on social skills and psychosocial functioning, we conducted a randomized controlled trial with 183 older adults with SMI (58% schizophrenia spectrum) age 50 and older at 3 sites who were assigned to HOPES or treatment as usual with blinded follow-up assessments at baseline and 1- and 2-year follow-up. RESULTS: Retention in the HOPES program was high (80%). Intent-to-treat analyses showed significant improvements for older adults assigned to HOPES compared to treatment as usual in performance measures of social skill, psychosocial and community functioning, negative symptoms, and self-efficacy, with effect sizes in the moderate (.37-.63) range. Exploratory analyses indicated that men improved more than women in the HOPES program, whereas benefit from the program was not related to psychiatric diagnosis, age, or baseline levels of cognitive functioning, psychosocial functioning, or social skill. CONCLUSIONS: The results support the feasibility of engaging older adults with SMI in the HOPES program, an intensive psychiatric rehabilitation intervention that incorporates skills training and medical case management, and improves psychosocial functioning in this population. Further research is needed to better understand gender differences in benefit from the HOPES program.

Access to supported employment for consumers with criminal justice involvement.

OBJECTIVE: This paper aims to provide further understanding of the influence of severe mental illness (SMI) and criminal justice involvement (CJI) on access to Supported Employment (SE) services. The authors investigate differences between consumers with and without CJI regarding access to SE and explore reasons for group differences. METHOD: This study employs a mixed-methods design. The quantitative portion compares employment service utilization of consumers with CJI to consumers without CJI to examine hypothesized differences in frequency of access and time to receipt of SE services. The qualitative portion includes in-depth, individual interviews with consumers with CJI and service providers to gain various perspectives on consumers' with CJI entry to SE. RESULTS: Consumers with CJI take longer to access SE services. Consumers with CJI and service providers identify the following as barriers or facilitators to access to SE: competing challenges for consumers with CJI such as mental health probation, the adverse impact of CJI on consumers' psychosocial functioning, social networks, consumers' relationships with practitioners, and practitioners' relationship with SE. CONCLUSIONS: Consumers with CJI do receive SE services at the same rate as those without CJI, but it takes them substantially longer to engage in SE services. Both programmatic and policy level interventions and modifications may ameliorate this problem.

Positive screens for psychiatric disorders in primary care: a long-term follow-up of patients who were not in treatment.

OBJECTIVE: Screening for psychiatric disorders has gained acceptance in some general medical settings, but critics argue about its value. The purpose of this study was to determine the clinical utility of screening by conducting a long-term follow-up of patients who screened positive for psychiatric disorders but who were initially not in treatment. METHODS: A cohort of 519 low-income, adult primary care patients were screened for major depression and bipolar, anxiety, and substance use disorders and reassessed with the Structured Clinical Interview for DSM-IV after a mean of 3.7 years by a clinician blind to the initial screen. Data on treatment utilization was obtained through hospital records. The sample consisted of 348 patients who had not received psychiatric care in the year before screening. RESULTS: Among 39 patients who screened positive for major depression, 62% (95% confidence interval=45.5%-77.6%) met criteria for current major depressive disorder at follow-up. Those who screened positive reported significantly poorer mental and social functioning and worse general health at follow-up than the screen-negative patients and were more likely to have visited the emergency department for psychiatric reasons (12.1% and 3.0%, odds ratio [OR]=6.4) and to have major depression (OR=7.6). Generally similar results were observed for patients who screened positive for other disorders. CONCLUSIONS: Commonly used screening methods identified patients with psychiatric disorders; about four years later, those not initially in treatment were likely to have enduring symptoms and to use emergency psychiatric services. Screening should be followed up by clinical diagnostic assessment in the context of available mental health treatment.

Perceptions of user involvement: a user-led study.

BACKGROUND: User involvement in health services has been a priority for government since 1990. In mental health, concern has been expressed that involved service users (activists) are not representative of 'ordinary' patients. AIMS: (i) To investigate service users' perceptions of the outcomes of user involvement in two London boroughs. (ii) To determine whether the perceptions of outcomes differ between activists and non-activists. METHOD: The study was user-led. The user-researchers compiled a semi-structured interview schedule which they then administered to a sample of 40 people; 20 were defined as activists and 20 as non-activists. There were also 20 participants in each borough. RESULTS: Activists were aware of more user groups and forms of user involvement than non-activists. However, in terms of perceptions of the outcomes of user involvement, there was little difference between the activists and non-activists. DISCUSSION: There is very little extant work on the outcomes of user involvement in mental health services. This study examined this and, contrary to reservations often expressed, there was little difference between activists and non-activists. CONCLUSION: This is a pilot study. Further work should examine perceptions of the outcomes of user involvement by other stakeholders, for example, front-line workers, managers, carers and commissioners.

The REACT study: cost-effectiveness analysis of assertive community treatment in north London.

OBJECTIVE: Assertive community treatment (ACT) is a key component of mental health care, but recent information on its cost-effectiveness is limited. This article provides a cost-effectiveness analysis of assertive community treatment and usual care from community mental health teams (CMHTs) in the United Kingdom. METHODS: Participants who had difficulties engaging with community services were randomly assigned to ACT (N=127) or continued usual care from CMHTs (N= 124). Costs were measured at baseline and 18 months later and compared between the two groups. In the analysis, cost data were linked to information on satisfaction, which had been shown to be significantly higher with ACT. RESULTS: Total follow-up costs over 18 months were higher for the ACT group by pounds sterling 4,031 ($6,369), but this was not statistically significant (95% confidence interval of - pounds sterling 2,592 to pounds sterling 10,690 [-$4,095 to $16,890]). A one-unit improvement in satisfaction was associated with extra costs in the ACT group of pounds sterling 473 ($747). CONCLUSIONS: The costs of ACT were not significantly different from usual care. ACT did, however, result in greater levels of client satisfaction and engagement with services and as such may be the preferred community treatment option for patients with long-term serious mental health problems.

Implementation of integrated dual disorders treatment: a qualitative analysis of facilitators and barriers.

OBJECTIVE: Approximately half of the people who have serious mental illnesses experience a co-occurring substance use disorder at some point in their lifetime. Integrated dual disorders treatment, a program to treat persons with co-occurring disorders, improves outcomes but is not widely available in public mental health settings. This report describes the extent to which this intervention was implemented by 11 community mental health centers participating in a large study of practice implementation. Facilitators and barriers to implementation are described. METHODS: Trained implementation monitors conducted regular site visits over two years. During visits, monitors interviewed key informants, conducted ethnographic observations of implementation efforts, and assessed fidelity to the practice model. These data were coded and used as a basis for detailed site reports summarizing implementation processes. The authors reviewed the reports and distilled the three top facilitators and barriers for each site. The most prominent cross-site facilitators and barriers were identified. RESULTS: Two sites reached high fidelity, six sites reached moderate fidelity, and three sites remained at low fidelity over the two years. Prominent facilitators and barriers to implementation with moderate to high fidelity were administrative leadership, consultation and training, supervisor mastery and supervision, chronic staff turnover, and finances. CONCLUSIONS: Common facilitators and barriers to implementation of integrated dual disorders treatment emerged across sites. The results confirmed the importance of the use of the consultant-trainer in the model of implementation, as well as the need for intensive activities at multiple levels to facilitate implementation. Further research on service implementation is needed, including but not limited to clarifying strategies to overcome barriers.

Development and evaluation of a patient-rated version of the Camberwell Assessment of Need short appraisal schedule (CANSAS-P).

The comprehensive assessment of patients with severe mental health problems includes the evaluation of needs, as this informs service planning, and levels of unmet need have been found to be associated with lower subjective quality of life. The Camberwell Assessment of Need is the most widely used instrument for this purpose. We report the development and evaluation of a new, patient-rated, short form (CANSAS-P). The CANSAS-P exhibited comparable detection of needs with its predecessor, better identification of domains that are problematic for patients to respond to, good test-retest reliability, especially for unmet needs, and generally positive evaluations by patients. We recommend the CANSAS-P as the needs assessment measure of choice for completion by patients.

What is the heartland of psychiatry?

Psychiatry has long identified schizophrenia as its defining disorder, its heartland as it has been called. In the past 20 years, this has had a number of negative consequences for psychiatry as a medical specialty, which result from the uncertainty of diagnosis and an increasing emphasis on demedicalising services in an attempt to provide social care outside hospital. These changes have probably increased the stigma attached to psychiatric practice and threaten to deskill doctors. They have also meant that services for other disorders do not meet the needs of patients. To continue to allow schizophrenia to be the paradigm condition is against the interests of psychiatrists and their patients.

Suicide attempts among depressed adolescents in primary care.

Although depression is strongly associated with suicide attempts and suicide deaths, most depressed youth do not make an attempt, indicating the need to identify additional risk factors. We examined suicide attempts among 451 depressed primary care patients, 13 to 21 years of age. In bivariate analyses, youth classified as suicide attempters showed elevated levels of psychopathology, specifically depressive symptoms, externalizing behaviors, anxiety, substance use, mania, and posttraumatic stress disorder symptoms. Externalizing behaviors and depression severity uniquely contributed to the prediction of suicide attempts in multivariate analyses. High levels of environmental stress as well as a few key stressful events were associated with suicide attempts; a recent romantic breakup or being assaulted added to suicide attempt risk, beyond the effects of psychopathology. Implications of results for primary care preventive services and suicide attempt prevention are discussed.

Analysis of U.S. trends in discharges from general hospitals for episodes of serious mental illness, 1995-2002.

OBJECTIVE: The aim of this study was to ascertain trends from 1995 to 2002 in general hospital discharges among adults in the United States with serious mental illness. METHODS: As of 2002 the National Hospital Discharge Survey collected data on approximately 327,000 discharges from 445 hospitals. ICD-9-CM codes were used to identify the discharges between 1995 and 2002 associated with serious mental illness. RESULTS: Annual discharge rates involving serious mental illness increased by 34.7%, from 29.1 discharges per 10,000 in the U.S. adult population (18 years and older) in 1995 to 39.2 discharges per 10,000 in the U.S. adult population in 2002. Hospital discharges involving serious mental illness increased significantly in the black population and among young adults. For adults of ages 18 to 24, discharges per 10,000 increased from 19.9 in 1995 to 42.3 in 2002. A substantial increasing trend was seen for the Northeast and South census regions. There was an increase in the proportion of discharges associated with hospitalizations for serious mental illness that were covered by private payers, whereas there was a significant decline in such discharges when patients were covered by government programs. CONCLUSIONS: The increasing trend in general hospital discharges involving serious mental illness has continued into recent years. Further investigations are needed to understand how patient- and system-level factors have contributed to the increasing trend in general hospital discharges involving an episode of serious mental illness.