Sustained outcomes of a peer-taught family education program on mental illness.

OBJECTIVE: This study examines 6-month follow-up data from participants in a randomized trial of a peer-driven 12-session family support and education program, called family-to-family (FTF) and offered by the US National Alliance on Mental Illness, to determine whether improvements in distress, family functioning, coping and empowerment were sustained. METHOD: Individuals randomized to the FTF condition were assessed after program completion and then 3 months later on measures of distress, family functioning, coping, and empowerment. We used a multilevel regression model (sas proc mixed) to test for significant changes over time (baseline, 3 and 9 months). RESULTS: All significant benefits that FTF participants gained between baseline and immediately post-FTF were sustained at 9 months including reduced anxiety, improved family problem-solving, increased positive coping, and increased knowledge. Greater class attendance was associated with larger increases in empowerment and reductions in depression and displeasure with ill relative. CONCLUSION: Evidence suggests that benefits of the FTF program were sustained for at least 6 months without any additional boosters or supports. Peer-based programs may produce sustained benefits for individuals seeking help in addressing challenges and stresses related to having a family member with a mental illness.

Outcomes of the peer-taught 12-week family-to-family education program for severe mental illness.

OBJECTIVE: Family-to-Family Education Program (FFEP) is a 12-week course for family members of adults with serious mental illness (SMI). This study evaluates the effectiveness of FFEP for several family member outcomes. METHOD: The FFEP enrollees on a > or =3-month waiting list were eligible; 95 consenting family members agreed to four interviews (waitlist, pre-FFEP, post-FFEP, and 6 months post-FFEP) regarding subjective and objective burden, empowerment, and depression. Mixed effects ANOVA models tested hypotheses of decreased burden and increased empowerment after FFEP. RESULTS: The FFEP was associated with reduced subjective burden (P < 0.01) and increased empowerment (P < 0.01) without changes in objective burden. Knowledge about SMI, understanding the mental health system, and self-care also improved. There was no significant decay at 6-month followup. CONCLUSION: This study provides evidence that FFEP is helpful to relatives of persons with SMI by reducing subjective burden and worry, and increasing empowerment, knowledge about SMI, understanding the mental health system, and self-care.

Variables associated with disparities in treatment of patients with schizophrenia and comorbid mood and anxiety disorders.

OBJECTIVE: The study compared self-reported comorbid affective and anxiety disorder diagnoses and treatments of African-American and Caucasian subjects in a large sample of patients who had a diagnosis of schizophrenia. METHODS: A total of 685 patients receiving treatment for schizophrenia were interviewed as part of the Schizophrenia Patient Outcomes Research Team study. The associations of race with past and current diagnoses and with current treatment for depression, mania, and anxiety disorders were assessed with multivariate analyses. RESULTS: African Americans were significantly less likely than Caucasians to report having a past or current diagnosis of depression, manic-depression, or anxiety disorder and to be receiving current treatment for these disorders. Gender, education, and marital status were also associated with presence of a comorbid diagnosis and receipt of treatment. CONCLUSIONS: The study suggests the possibility of racial and other disparities in the diagnosis and treatment of patients with schizophrenia and comorbid affective and anxiety disorders. Although various causal explanations are plausible, all point toward the need for enhanced cross-cultural competence at all levels of mental health care, especially in the diagnosis and treatment of comorbid psychiatric illnesses.

Evidence-based practices for services to families of people with psychiatric disabilities.

Family psychoeducation is an evidence-based practice that has been shown to reduce relapse rates and facilitate recovery of persons who have mental illness. A core set of characteristics of effective family psychoeducation programs has been developed, including the provision of emotional support, education, resources during periods of crisis, and problem-solving skills. Unfortunately, the use of family psychoeducation in routine practice has been limited. Barriers at the level of the consumer and his or her family members, the clinician and the administrator, and the mental health authority reflect the existence of attitudinal, knowledge-based, practical, and systemic obstacles to implementation. Family psychoeducation dissemination efforts that have been successful to date have built consensus at all levels, including among consumers and their family members; have provided ample training, technical assistance, and supervision to clinical staff; and have maintained a long-term perspective.

Pilot study of the effectiveness of the family-to-family education program.

This study assessed the efficacy of the Family-to-Family Education Program, a structured 12-week program developed by the National Alliance for the Mentally Ill. A total of 37 family members who participated in the program were evaluated by an independent research team of trained family member assessors at baseline, after completing the program, and six months after program completion. After completing the program, the participants demonstrated significantly greater family, community, and service system empowerment and reduced displeasure and worry about the family member who had a mental illness. These benefits were sustained at six months.

Use and costs of ambulatory care services among Medicare enrollees with schizophrenia.

OBJECTIVE: The objective of this study was to identify predictors of the use and cost of ambulatory care services among Medicare recipients with schizophrenia. METHODS: The design was a cross-sectional analysis of Medicare claims in 1991. The study subjects were a 5 percent random sample of all persons in the United States who had at least one Medicare service claim in 1991 and who were diagnosed as having schizophrenia in any care setting. Outcome measures included use and cost of any ambulatory care service, individual therapy, psychiatric somatotherapy, group therapy, or family therapy. RESULTS: For nearly 25 percent of the total sample of 12,440, no claims were filed for ambulatory care services in 1991. The mean+/-SD number of ambulatory care visits during the year was 7.9+/-21. The most frequently used type of therapy was individual therapy (5+/-14 visits). The mean+/-SD yearly cost of care for persons who received ambulatory care services was $470+/-$1,028. Among persons under 65 years of age, Caucasians were about 1.5 times as likely as African Americans to have received an ambulatory care service and 1.3 times as likely to have received individual therapy. Persons who were 65 or older were less likely to have received any service. Among service recipients, costs of care were lower for African Americans and for older people. CONCLUSIONS: The use of Medicare-funded ambulatory care services by persons with schizophrenia varied by race and age. Further investigation is required to determine whether subgroups of individuals who do not have additional insurance coverage or access to services are receiving substandard care.

Correlates of long-term unemployment among inner-city adults with serious and persistent mental illness.

This study identified demographic, clinical, and vocational rehabilitation-related correlates of long-term unemployment among 219 adults with severe mental illness. Fifty-one percent of the sample had been unemployed five or more years before enrollment. Older age, a diagnosis of psychosis, severity of negative symptoms, and more previous hospitalizations were all significantly related to long-term unemployment. Gender, race, education, substance disorder diagnosis, severity of negative symptoms, and vocational training experience were not. The findings underscore the relevance of clinical and neurocognitive impairments to long-term unemployment and point to the need to critically reevaluate the effectiveness of traditional vocational rehabilitation services.

Therapists' contacts with family members of persons with severe mental illness in a community treatment program.

Thirty-six therapists at an urban community mental health center responded to a survey about contacts with family members of 214 clients with serious mental illness. For 61 percent of the clients, the therapists reported at least one past-year contact with a family member or someone acting as a family member. Contacts were typically by telephone and often took place during crises. The focus was on problem solving rather than on providing family therapy. Therapists perceived significant benefit from the contacts, which were achieved with little effort on their part. The results suggest that informal-and perhaps nonbillable-brief services to families are common. Such informal services fall short of recommended best-practice standards.

Prevalence and correlates of diabetes in national schizophrenia samples.

People with schizophrenia may be at increased risk for Type II diabetes because of the side effects of antipsychotic medication, poorer overall physical health, less healthy lifestyles, and poorer health care. The present study uses data bases collected by the Schizophrenia Patient Outcomes Research Team (PORT) to assess the prevalence and demographic and clinical correlates of diabetes within large populations of persons receiving treatment for schizophrenia. In the Schizophrenia PORT, Medicaid and Medicare data from 1991 and more recent interview data were collected regarding the comorbidity of schizophrenia and diabetes: prevalence, quality of life, physical health, and services utilization and costs. The study found that rates of diagnosed diabetes exceeded general population statistics well before the widespread use of the new antipsychotic drugs. Risk factors for diabetes were similar to those observed in the general population. The linkage of diabetes to poor physical health, medical morbidity, and increased service use and cost requires attention. This study of diabetes in the early 1990s suggests that even before the widespread use of the atypical antipsychotic drugs, diabetes was a major problem for persons with schizophrenia.

A focus group pilot study of tobacco smoking among psychosocial rehabilitation clients.

OBJECTIVE: The study explored the perceived advantages and disadvantages of tobacco smoking and quitting among clients in psychosocial rehabilitation programs. Deeper understanding of such perceptions may be useful in creating maximally effective cessation and prevention interventions for this population. METHODS: Five focus groups of six to ten persons were formed with a total of 40 clients from two programs. Participants included smokers and nonsmokers-including former smokers and smokers who explicitly were not interested in quitting smoking. The semistructured, researcher-facilitated discussions covered pros and cons of smoking and not smoking, barriers to and facilitators of abstinence, and other issues. Audiotapes of the group discussions were transcribed and analyzed qualitatively. RESULTS: Participants emphasized their reasons for smoking, reasons for quitting or wanting to quit, views on smoking-related health concerns, perceived social costs and benefits of smoking, and strategies for quitting and maintaining abstinence. Many similarities between the focus groups' views and those of the general population were noted, along with some issues that are specific to having a mental illness or attending a psychosocial rehabilitation program, such as coping with psychiatric symptoms and limited access to information, support, and other coping methods. All of these views influenced participants' motivations and perceived readiness to smoke or to abstain, or to struggle between the two alternatives. CONCLUSIONS: Issues and needs that are specific to smokers who use mental health services must be addressed in the development of smoking prevention and cessation interventions in psychosocial rehabilitation and other mental health programs. The importance of messages about smoking that clients receive from program rules, program staff, and other sources is highlighted, as is the possibility that the regulation of affect and stress provided by tobacco use is especially important for people experiencing psychiatric symptoms.

Update on family psychoeducation for schizophrenia.

The Schizophrenia Patient Outcomes Research Team and others have previously included family psychoeducation and family support in best practices guidelines and treatment recommendations for persons with schizophrenia. In this article we review in detail 15 new studies on family interventions to consider issues around the implementation of family interventions in current practice. The data supporting the efficacy of family psychoeducation remain compelling. Such programs should remain as part of best practices guidelines and treatment recommendations. However, assessment of the appropriateness of family psychoeducation for a particular patient and family should consider (1) the interest of the family and patient; (2) the extent and quality of family and patient involvement; (3) the presence of patient outcomes that clinicians, family members, and patients can identify as goals; and (4) whether the patient and family would choose family psychoeducation instead of alternatives available in the agency to achieve outcomes identified.

Quality of care in services to family members of people with serious mental illnesses.

This paper discusses the current status, importance, and future directions of quality of care work regarding support and information services for family members of people with serious mental illnesses. In reviewing existing literature, it highlights the need for research that documents the services currently received by family members in more depth and detail, the importance of including family-member services in quality-of-care standards and evaluations, and the necessity of grappling with fundamental questions such as who defines "quality" and "optimal" care, whose outcomes are foregrounded in such inquiry, and the development of methodologies to advance this area of inquiry.

Consumer perceptions of pressure and force in psychiatric treatments.

OBJECTIVE: Mental health consumers with serious mental illness were surveyed to obtain information about their experiences with and attitudes toward forced psychiatric treatment. METHODS: A 61-item survey questionnaire developed by the authors was administered by consumer volunteers to 105 persons with serious mental illness who were attending seven rehabilitation centers in Maryland. The questionnaire covered consumers' experiences and attitudes in three areas of forced treatment: medication, outpatient therapy or rehabilitation, and hospitalization. RESULTS: At some time during the course of their illness, 57 percent of the respondents reported having been pressured or forced into hospitalization. In the year before the survey, 30 percent reported being pressured or forced into taking medication and 26 percent into attending a therapy or rehabilitation program. The most common type of pressure or force was verbal persuasion. Generally, respondents reported negative effects from forced treatment, although the intensity of the negative effects varied by treatment area, and about half retrospectively felt that the forced treatment was in their best interest. Many respondents believed that pressure or force has an appropriate role in psychiatric treatment, although most wished to maintain the right to refuse treatment that they considered not in their best interest. CONCLUSIONS: Differences in patterns of response to pressure and force in the three treatment areas highlight the variety of consumer experiences and the need to know more about the role of forced or pressured treatment in their lives.