Diffusion and dissemination of a family peer-education program on mental disorders: a case study of the Omotenashi--Family Experiences Learning Program.

OBJECTIVES: The families of people with mental illnesses need sufficient opportunities to learn about such illnesses. Therefore, a family peer-education program about mental disorders, the Omotenashi - Family Experiences Learning Program, has been developed in Japan following the design of similar programs in the U.S. and Hong Kong. We aimed to clarify the factors related to the diffusion and dissemination of the program and to identify areas for improvement in its dissemination strategies. METHODS: This report was a case study based on the conceptual framework of the diffusion and dissemination of innovation in a health-care organization. The conceptual framework incorporates the adoption and routinization of the innovations by individuals and organizations in the external context. Interview data from fifteen family members in three family groups that had adopted the program were analyzed. They were interviewed about their backgrounds, the adoption of the program, and their experiences with the program implementation. We extracted descriptions based on the conceptual framework from the transcribed interview data and classified them into the framework components. We also compared the processes of adoption and routinization employed by the three family groups. RESULTS: Adoption processes were affected by the sense of crisis caused by decreased membership, member aging, and the necessity of policy change in family groups as well as the anticipation that the program may solve problems and the strength of the leader's intention to change and sustain the family group. Cooperative families and sufficient funding were necessary for the adoption of the program. Support from relevant organizational staff encouraged the family groups to adopt the program. Adopters encountered difficulties in gaining program participants but continued to take part in the program after realizing their anticipated positive results and receiving positive feedback from program participants. CONCLUSION: Our results suggest that the following may be effective for further dissemination of the program: an explanation about the ripple effects of the program on family groups and obtaining assistance from the relevant organizational staff in consulting for funding of the program and referring program participants.

[Factors related to adoption of a family peer-education program on mental disorders. Dissemination research of the Omotenashi-Family Experiences Learning Program].

OBJECTIVES: To identify effective dissemination strategies regarding a family peer-education program, the Omotenashi-Family Experiences Learning Program, on mental disorders, we evaluated factors related to the program adoption by family groups. METHODS: A cross-sectional mail survey was conducted from June to September 2013, involving 12 family group associations for mental disorders and their affiliated local family groups. For the analysis, we used the conceptual framework of diffusion and dissemination of innovations in a health-care organization. We divided the adaptation process into two steps: (1) understanding the program information, involved the level of program information sharing (with or without family group members); and (2) adaptation decision, involved the adaptation plan (planned or under consideration, or no plan). Data were analyzed regarding the differences between the two categories of the dependent variable in each step, and a logistic regression was conducted in the first step. RESULTS: Ten associations agreed to participate in the survey. Of the 177 family groups that had not adopted the program, 110 family groups responded to the survey (response rate 62.1%). In the first step, a municipal population where the family groups were located of over 10,000 (OR = 5.53, 95%CI; 1.93-15.89), influential individuals who strongly recommended the program (OR=5.22, 95%CI; 1.46-18.69), and information acquisition through the association (OR=3.41, 95% CI; 1.27-9.17) were related to the shared program information in the family group. In the second step, data from 39 family groups that shared the program information with family members were analyzed. The family groups with adaptation plans that were planned or under consideration had significantly more board members, labor, and motivated members compared to the family groups without adaptation plans. The former groups had significantly fewer concerns with the program's difficulties, risks, and tasks than the latter groups. The former groups expected significantly more memberships and more effective mutual member support, experienced greater correspondence between concerns of the family group or family group members and the program's content, and were not opposed to the program. CONCLUSION: Greater family-group awareness of the program could occur through the involvement of influential figures and provision of program information through family group associations. Program implementation involving other family groups and for non-group member families could lead to increased program adoption.

Preliminary outcome study on assertive community treatment in Japan.

AIMS: The beneficial effects of assertive community treatment (ACT), which has been widely acclaimed as being successful in several foreign countries, must also be objectively evaluated with respect to the transition from inpatient to community-based mental health treatment in Japan. This was the first study that examined effects of the ACT program in Japan using pre/post design data of the pilot trial of the ACT program in Japan project. METHODS: The study included 41 subjects hospitalized at Kohnodai Hospital, National Center of Neurology and Psychiatry between May 2003 and April 2004 for severe mental illness and who met inclusion criteria for entry regarding age, diagnosis, residence, utilization of mental health services, social adjustment, and ability to function in daily activities. All subjects provided informed consent for study participation and were followed for 1 year after hospital discharge. RESULTS: Comparison of the number of days and frequency of inpatient psychiatric hospitalization and frequency of emergency psychiatric visits between the 1-year period before hospitalization and 1-year period after hospital discharge showed a significant decrease in number of days and frequency of hospitalization. Comparison at 1 year after discharge with baseline showed no change in satisfaction with overall quality of life or Brief Psychiatric Rating Scale scores, but the Global Assessment of Functioning score significantly increased, and the antipsychotic dose (chlorpromazine equivalent) significantly decreased. CONCLUSION: Despite some limitations in methodology and conclusions, this study suggests that ACT enables persons with severe mental illness to live for longer periods in the community, without worsening of symptoms, decreased social function, or deterioration in quality of life.

Family support in assertive community treatment: an analysis of client outcomes.

Assertive Community Treatment (ACT) is an outreach-based case management model that assists people with severe mental illness through an intensive and integrated approach. In this program, a multidisciplinary team provides medical and psychosocial services. The purpose of this study was to examine the effectiveness of the following two ACT intervention strategies: "replacement" (supporting the clients) versus "backup" (supporting family members who provide care to clients). Admission days, psychiatric symptoms, quality of life, self-efficacy, and service satisfaction ware evaluated as outcome variables. To identify effective methods of supporting family members, clients living with family were divided into two groups based on the amount and types of services received-the backup group and the replacement group. ANCOVA was used to compare the outcomes between the two groups. The replacement group displayed significantly better psychiatric symptoms, social functioning, self-efficacy, and service satisfaction scores. No differences in admission days or quality of life were found. Clients provided more support directly to clients themselves than to family members was found to have better client outcomes in improving psychiatric symptoms, social functioning, and self-efficacy, resulting in higher levels of service satisfaction. This indicates that society should reduce the responsibility of the family and share responsibility for the care of people with mental illness to effectively improve outcomes for people with mental illnesses.

Association between feasibility of discharge, clinical state, and patient attitude among inpatients with schizophrenia in Japan.

AIM: There have been some studies on the feasibility of discharging mentally ill inpatients from mental hospitals. The purpose of the present study was to investigate how a psychiatrist judges whether an inpatient can be discharged. METHODS: A survey regarding such judgments on discharge was conducted involving 549 inpatients with schizophrenia with a hospital stay of > or =1 year. Relationships between psychiatrist judgments on discharge and the Brief Psychiatric Rating Scale (BPRS), Scales for the Assessment of Negative Symptoms (SANS), Global Assessment Scale (GAS), patient attitude to discharge, and other variables were investigated. A similar analysis was conducted regarding patient attitudes toward discharge. RESULTS: After controlling for potential confounding factors using multiple logistic regression, the judgments showed significant relationships with BPRS-P, SANS, GAS, and age. Patient attitudes showed significant relationships with the length of the current hospital stay, SANS, and psychiatrists' judgments. CONCLUSION: A psychiatrist's judgment regarding discharge is a comprehensive decision that takes into account psychiatric symptoms, social functioning, and age. Such a judgment could also affect a patient's own attitude toward discharge.

Family needs and related factors in caring for a family member with mental illness: adopting assertive community treatment in Japan where family caregivers play a large role in community care.

AIM: In Japan the family plays a large role in community care for persons with mental illness; therefore the aim of the present study was to describe the needs of family caregivers related to assertive community treatment (ACT) and to analyze the relationship of these needs to underlying factors. METHODS: Participants were recruited from the membership of three family associations of persons with mental illness. Of the 224 family members, 152 (67.9%) completed a self-report questionnaire consisting of the following measures: demographic variables, family life difficulty scale, global burden, general life satisfaction, subjective health status, family rejection scale, quantity of supportive behaviors, and needs for ACT. RESULTS: More than 70% of participants reported that service components of ACT would be beneficial, especially in the future. Functions that helped maintain the ordinary routine of family life were significantly correlated with current needs for ACT. CONCLUSIONS: When a person has chronic mental illness the family has many needs related to ACT. When functions that maintained the ordinary routine of family life were disturbed, the need for ACT support increased. Elderly parents or siblings were also concerned about the future, when caring for the member with mental illness would become more difficult.

Development of the Nurse Attitude Scale short form: factor analysis in a large sample of Japanese psychiatric clinical staff.

The Nurse Attitude Scale (NAS) measures nurses' Expressed Emotion. A short form of the NAS was developed and its reliability and validity examined. After performing factor analysis using 1252 samples, three factors were extracted. Cronbach's alpha for individual subscales was 0.852 for Hostility, 0.846 for Criticism and 0.645 for Positive Remarks. There was a significant correlation between individual subscales in the NAS short form and corresponding subscale in the Maslach Burnout Inventory (P < 0.001). The NAS short form seems to have acceptable reliability and validity.

Intervention study for promoting partnerships between professionals and self-help groups of families of individuals with severe mental illness in Japan.

OBJECTIVE: This study was performed to examine effects of an intervention aimed at promoting partnerships between professionals and self-help groups for family members (family groups) of persons with severe mental illness in Japan. METHODS: A group randomization design where the unit of randomization was the family group as a whole was used, with family groups (N = 24) randomly assigned to either intervention or control groups. Twelve family groups and 15 professionals made up the intervention group, and 12 family groups and 14 professionals made up the control group. A total of 149 family members were eligible participants in the study; 76 from family groups in the intervention group and 73 from the control group. A semi-structured program was conducted for six months. The effects of the intervention were analyzed at three levels: the family group level, the individual family member level and the individual professional level. RESULTS: Significant increases were found in the number of family members registered in family groups and program satisfaction for members of the intervention family groups. Professionals involved with family groups in the intervention group felt greater empowerment than those in the control group. CONCLUSION: The tested intervention proved effective for both family groups and professionals associated with the groups.

Living arrangements of individuals with schizophrenia in Japan: impact of community-based mental health services.

AIMS: In Japan psychiatric hospitals and family play the predominant roles in caring for people with serious mental illness. This study explored how the introduction of community-based care has changed this situation by examining living arrangements of individuals with schizophrenia who were treated in one of the most progressive systems in Japan (Kawasaki) compared with national norms. METHODS: The proportion of clients with schizophrenia in the community versus hospital and living arrangements for those in the community were compared between the Kawasaki and national treated population, using data from the Kawasaki psychiatric service users survey in 1993 and two national surveys in 1993 and 1983. The variation in living arrangements was examined across five different age cohorts. RESULTS: The estimated national population was 36.7, which was similar to 32.7 clients per 10,000 population in Kawasaki. Some 71% of the Kawasaki clients were treated in the community compared with 55% nationally. The difference between the Kawasaki and national populations was the largest among clients aged 40 to 59. The Kawasaki community clients had a higher proportion of clients living alone. CONCLUSIONS: The community mental health services available in Kawasaki appeared to reduce hospitalisation and help clients to live alone in the community.

The quality of life among persons with severe mental illness enrolled in an assertive community treatment program in Japan: 1-year follow-up and analyses.

BACKGROUND: Toward effective community care for persons with severe mental illness and deinstitutionalization in Japan, we assessed the impact of the first trial of an assertive community treatment program on the lives and subjective perceptions of persons with mental illness without closing hospitals. METHODS: Forty-three subjects were enrolled from the newly admitted patients of a hospital, who met our criteria of problematic hospital use, severity of psychiatric disorders, and behavioral problems. The intervention team aimed to intensively support them in various life domains in their communities to decrease clients' admissions. The Quality of Life Interview was administered at baseline and after 12 months. Data were analyzed to assess the pre-post changes in their QOL, and were explained in association with other descriptive variables. RESULTS: The objective changes included increase in persons whose longest residence in a year were in communities, increase in income, and decrease in family contacts. Most subjective items were not changed except the decrease in satisfaction with family relationships. Satisfaction with family relationships was negatively correlated with hospital days at 1 year follow-up after controlling for symptoms, but was not so at baseline. Also, correlation between satisfaction with family relationships and global well-being was attenuated. A change in the positioning of family by clients and the autonomy of clients were suggested. However, previous studies showed that dissatisfaction with family relationships predicted rehospitalizations independently from symptoms, and our findings suggest our subjects' characteristics and a possible improvement in community-based care. CONCLUSION: Our program predominantly fulfilled the primary goal, but it must be further refined to reflect the detailed characteristics of the target population and resource distribution. Assessing subjective perceptions, or the QOL of clients is useful for evaluating the program localization.

Effects of environmental deprivation on negative symptoms of schizophrenia: a nationwide survey in Japan's psychiatric hospitals.

Research into the effects of environmental deprivation on negative symptoms of schizophrenia is limited, and few attempts have been made to differentiate secondary symptoms caused by the social environment. Japan's mental health system allows us to examine the extent to which understimulating social environments in hospitals contribute to negative symptoms of institutionalized patients while controlling for other factors. A random sample of inpatients of diagnosed with schizophrenia and hospitalized for 1 year or longer was drawn from the universe of inpatients attending a convenience sample of 20 hospitals across Japan. Data were collected for 549 study participants (a response rate of 91.5%). Measures included the Scale for the Assessment of Negative Symptoms (SANS), other clinical condition scales such as the Manchester Scale, and social condition scales including the Nurses' Opinion Scale and the Ward Restrictiveness Scale. Hierarchical regression analyses were conducted to determine the contribution of social environment to negative symptoms. Results showed significant correlations between negative symptom scales and most of the social environment scales, where social environment scales accounted for 18% of the variance in SANS scores. The study confirms the influence of understimulating social environments in psychiatric hospitals on negative symptoms.

A randomized controlled trial of individual placement and support in Japan.

OBJECTIVE: The individual placement and support (IPS) model of supported employment has been implemented throughout North America and Europe, with multiple randomized controlled trials documenting its effectiveness, but it has not been widely implemented in Asia. To date, no rigorous evaluations of IPS have been conducted in Japan. We sought to evaluate whether IPS could be implemented in Japan and produce superior competitive employment outcomes compared with conventional vocational services. METHOD: We employed a randomized controlled trial with a 6-month follow-up; 18 participants were randomly assigned to IPS and 19 to conventional vocational services. We assessed competitive employment rates, hours and weeks worked, and wages earned. RESULTS: Over the 6-month follow-up period, IPS participants were more likely than those in usual care to work competitively (44.4% for IPS vs. 10.5% for controls, p = .022), work more hours (mean of 168 hr for IPS vs. 41 hr for controls, p = .002), and work more weeks (mean of 6.4 weeks for IPS vs. 1.8 weeks for controls, p = .003). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: IPS can be implemented in Japan and yield better competitive employment outcomes than conventional vocational services. Adoption of the IPS model might have a dramatic impact on the mental health service system in Japan where psychiatric hospitals play a central role in mental health care.

How many long-stay schizophrenia patients can be discharged in Japan?

The mental health-care system in Japan remains hospital-based, and has the largest number of psychiatric beds per capita in the world. However, serious discussion about deinstitutionalization has recently begun. This study attempts to determine the proportion of inpatients that would benefit from community-based programs, as judged by hospital psychiatrists, and to evaluate the need for community resources for their community placement. Inpatients with schizophrenia from 139 hospitals were randomly selected. Data on the psychiatrists' judgment of discharge and required resources for community placement were obtained for 2758 subjects. Among the subjects, 1097 (39.8%) were judged to have the possibility of being discharged using community resources (possible discharge group; PDG). Provided that the proportion of PDG was 40%, controlling for the hospital background variables, the number of schizophrenia inpatients with a hospital stay of > or = 1 year who could be discharged from psychiatric hospitals in Japan was estimated to be 66,000. For the PDG, the required community resources, including accommodation, daytime activity, and daily living support services, were calculated. The numbers of governmental targets for community resources, including community accommodation, daytime activities, and daily living support services may have been underestimated.

Seasonality of birth in patients with schizophrenia in Japan.

Although most Western studies have found a birth excess during winter or early spring among patients with schizophrenia, this has not been found in Japanese samples. The purpose of the present paper was to investigate this finding using a large Japanese sample. Distributions of monthly birth numbers of patients with schizophrenia were compared to those of the general population. Patients were from the governmental data, numbering 88 788. A significant birth excess during winter to early spring was found in male and female subjects with schizophrenia compared to the general population. There is a significant birth excess during winter to early spring for schizophrenia in Japan. The authors consider that the discrepancy between the current study and the previous Japanese studies was caused by small sample size and selection bias in the previous Japanese studies.

Effective components of a nationwide case management program in Japan for individuals with severe mental illness.

This study identified effective components in a case management program based on the Japan Case Management Guidelines (JCM-GL). Subjects (n = 295) with severe mental illness were enrolled throughout Japan. Four outcome scales were utilized. The independent variable, "Fidelity to the JCM-GL" was the subject of interest. Case management components comprised three factors, extracted from factor analysis to fidelity scales, with the "needs-oriented approach" factor displaying the highest score. Subjects demonstrating high fidelity on this factor showed significantly higher quality of life and service satisfaction than low scorers. This component should be established first in countries where community care is underdeveloped.

Institutionalisation and schizophrenia in Japan: social environments and negative symptoms: Nationwide survey of in-patients.

BACKGROUND: The number of psychiatric beds per capita in Japan is the highest in the world, and a replication of earlier British research is needed to identify possible means of improving the mental health system. Aims To describe the current situation of psychiatric hospitals in Japan and to examine the relationship between negative symptoms of schizophrenia and social environments. METHOD: In-patients with schizophrenia were randomly selected from 139 hospitals. Data were obtained for 2758 participants using several scales, including the Manchester Scale and social environment scales. RESULTS: Negative symptom scales showed a significant correlation with understimulating social environments in hospitals. CONCLUSIONS: This study confirms the results from the UK and provides evidence for the importance of community-based care and for providing more-stimulating rehabilitation environments.