The effect of lifestyle intervention on cardiometabolic risk factors in mental health rehabilitation hostel residents at-risk: a cluster-randomized controlled 15-month trial.

OBJECTIVE: Cardiometabolic disorders contribute to morbidity and mortality in people with severe mental illnesses (SMI), yet lifestyle-intervention efficacy in patients with SMI is unclear. Israel's unique mental-health rehabilitation hostels (MHRHs) provide housing to subjects with SMI. We tested how multi-component lifestyle intervention affects cardiometabolic risk-factors in at-risk SMI populations residing in MHRHs. METHODS: In a prospective, cluster-randomized, controlled study, six MHRHs, paired by residents' functioning level, were randomized to lifestyle intervention (nutrition education, physical education), or usual care. Subjects recruited included those with ≥1 of: BMI > 25 kg/m2; plasma triglycerides ≥150 mg/dL; HbA1c ≥ 5.7%; fasting plasma glucose ≥ 100 mg/dL and plasma HDL < 40(men)/ 50(women) mg/dL. Primary outcome was BMI change after 15 months; other outcomes were plasma lipids levels and glycemic control. Low cooperation in one MHRH pair led to their exclusion, the others were assigned to intervention or control. RESULTS: Eighty residents were enrolled to intervention groups and 74 to control. Compared to baseline, intervention-arm participants experienced improvements in BMI (-0.83 kg/m2 [-1.36, -0.29] 95%CI), triglycerides (-30.60 mg/dL [-49.39, -11.82]95%CI) and LDL (-15.51 mg/dL [-24.53, -6.50]95%CI) (all P ≤ 0.003). BMI improvement correlated with number of dietitian consultations (r = -0.30; P = 0.001). No significant differences were found between treatment arms in BMI (-0.46 kg/m2 [-1.11, 0.18]95%CI;P = 0.189), triglycerides (-24.70 mg/dL [-57.66, 8.25]95%CI), LDL (-9.24 mg/dL [-20.50, 2.03]95%CI), HDL and glycemic control. CONCLUSIONS: Lifestyle intervention significantly improved BMI, LDL and triglycerides compared to baseline in at-risk MHRHs residents with SMI, yet compared to usual care the differences did not reach statistical significance. The association between the number of dietitian's consultations and BMI improvement suggests that programs should highlight participants' adherence.

When Distance Becomes Closeness: Distance Learning as a Meaningful Learning Opportunity During the COVID-19 Pandemic.

The National School for Mental Health Rehabilitation, Integration, and Recovery in Israel developed responses to academic, pedagogical, and emotional needs that arose during the first wave of the COVID-19 pandemic. Despite reduced activity during the outbreak, the school continued all regular courses remotely and created new online workshops. In this article, we review the school's adjustment from being change agents on the frontal level to change agents on the virtual level, through descriptive and qualitative findings. We use the learning from success approach to examine development and implementation processes. The large number of participants who suddenly had access to distance learning and their highly positive responses indicated the creation of opportunities alongside the challenges we faced. To the best of our knowledge, this is the first description and analysis of the challenges, opportunities, and outcomes of a recovery-oriented online academic facility during a pandemic.

The Effect of Community-Based Mental Health Rehabilitation Services for Schizophrenia: a Retrospective Cohort Study.

Deliberative efforts are constantly made to provide community-based mental health rehabilitation services to people with mental health disabilities nationwide. In this study we aimed to assess the effectiveness of rehabilitation services in Israel by assessing the impact of utilization of rehabilitation services on hospitalization rates among a cohort of patients diagnosed with schizophrenia. Data derived from the Clalit Health Services were crossed with the Ministry of Health rehabilitation and psychiatric hospitalization case registries. Patients utilizing rehabilitation services were assessed for rates and durations of hospitalizations before and after the utilization of the rehabilitation services, and were compared to patients who did not use these services (n = 185). Mixed-model analyses of covariance (ANCOVA) were conducted to assess changes in rates and durations of hospitalizations at the beginning and end of the cohort period. Patients who used rehabilitation services showed higher rates and durations of hospitalizations prior to utilization of rehabilitation services, as well as higher decreases in number and duration of hospitalizations after utilizing their rights to rehabilitation services, as compared to patients who did not receive these services. Schizophrenia patients tend to show a decreasing trend in number and duration of hospitalizations over time. Nonetheless, the utilization of rehabilitation services offers larger gains in hospitalization prevention, primarily to schizophrenia patients who experience high rates and durations of hospitalizations at the beginning of illness. These findings provide additional support for the necessity of rehabilitation services, primarily for patients with severe onset.

Using Routine Outcome Measures to Provide Feedback at the Service Agency Level.

The use of routine outcome measurement (ROM) to assess service effectiveness has been on the rise in mental health settings. However, there is a scarcity of information on the use of ROM data to provide feedback to teams of service providers. In this paper we review the existing literature to identify the principles that can guide the use of ROM data as feedback with the aim to improve quality of service provision in mental health settings. We present a pilot trial of 12 agencies participating in group feedback sessions. The guiding principles and core processes, the procedure and implementation in a pilot trial, lessons learned and future directions are discussed. Based on this experience we conclude that using ROM to implement group feedback among mental health stakeholders is feasible and can generate discussions and directions for improvement.

Implementing routine outcome measurement in psychiatric rehabilitation services in Israel.

In this article we present the design, development and implementation of the Psychiatric Rehabilitation Routine Outcome Measurement (PR-ROM) project, the first systematic effort to implement mental health routine outcome measures in Israel. The goal of the PR-ROM is to provide updated information about the process and impact of psychiatric rehabilitation services in Israel and to establish a sustainable infrastructure and foundation for routine outcome monitoring of rehabilitation services to improve care, inform policy, generate incentives for service improvement, increase informed decision-making and provide data for research purposes. The rehabilitation services evaluated and the characteristics of the population being served are described and the methods and nature of the collected data as well as some preliminary findings are presented. We discuss the major barriers encountered, our efforts to deal with them and lessons learned during the process. We conclude with a description of the current state of the initiative and plans for the future.

Housing model for persons with serious mental illness moderates the relation between loneliness and quality of life.

This study compared levels of loneliness, quality of life (QOL) and social support among people with serious mental illness (SMI) living in two different types of housing: group homes and supportive community housing. Forty persons with SMI living in supportive community housing and 57 living in a group home completed measures of QOL, symptoms, perceived social support and loneliness. Analysis of variance tests were conducted to examine whether there were differences in degree of loneliness, QOL and social support between the groups living in the two residential types. No significant differences between the two housing models were found. Correlational analysis, however, indicated a strong relationship between loneliness and QOL. Subsequent regression analysis revealed that residence in group homes moderates the relationship between social loneliness and QOL, such that social loneliness impacted QOL only among group home residence. Implications of the findings for understanding the impact of housing on QOL are discussed.

Assessing psychiatric rehabilitation service (PRS) outcomes in Israel: conceptual, professional and social issues.

Since the implementation of the legislation in Israel concerning rehabilitation of people with psychiatric disabilities in the community in 2001, an increasing number of individuals, currently estimated at nearly 15,000, have been receiving the psychiatric rehabilitation "basket of services." A systematic investigation of the extent to which these services have had a positive impact on the intended outcome is required, to evaluate the effectiveness of the newly developed psychiatric rehabilitation basket of services. This evaluation has become a priority item on the mental health agenda in Israel. This opinion paper, based on a conceptual analysis and selective review of the relevant literature, discusses concepts and principles that seem important for the development of strategies to constructively assess the outcome of psychiatric rehabilitation services (PRS) in Israel. More specifically, several fundamental issues related to outcome monitoring are reviewed, such as what outcome domains should be assessed, who should conduct the assessments and from whom should data be collected and with whom and how should it be shared. The complexity of these issues are reviewed and possible strategies to deal with them are discussed.

Routine patient reported outcomes as predictors of psychiatric rehospitalization.

OBJECTIVE: Patient reported outcome measures (PROMs) are increasingly used to measure psychiatric service consumers' progress and to provide feedback to consumers and providers. We tested whether PROMs can predict and be used to identify groups at high risk for future hospitalization. METHODS: A total of 2842 Israeli users of psychiatric rehabilitation services reported on their quality of life (QoL) and the effect of symptoms on their daily functioning. Survey data were linked with information on psychiatric hospitalization 6 and 12months after survey completion. Variables associated with each of the outcomes were tested for significance and entered into a multivariate logistic regression model. Prediction scores were developed to identify the highest-risk groups according to each model. RESULTS: QoL was found to be a significant predictor of future hospitalization within 6months (odds ratio [OR]=0.71, 95% CI: 0.59-0.86), and self-report of the impact of symptoms on functioning significantly predicted 12-month hospitalization (OR=0.83, 95% CI: 0.74-0.93), controlling for known risk factors. Positive predictive values for the 6- and 12-month risk scores were 31.1 and 40.4, respectively, for the 10% highest risk categories. CONCLUSIONS: Reports of psychiatric service consumers on their QoL and on the effect of symptoms on their functioning significantly predict of future hospitalization risk, beyond other well-known risk factors. PROMs can identify consumers at high risk for future hospitalization and thus direct interventions for those at highest risk.

Relationship Between Psychiatric-Service Consumers' and Providers' Goal Concordance and Consumers' Personal Goal Attainment.

OBJECTIVE: This study tested concordance between consumers' and providers' reports of personal goal setting and its relationship to self-reported goal attainment. METHODS: Data are from the Israeli Psychiatric Rehabilitation Patient Reported Outcome Measurement project. Consumers (N=2,885) and the providers who were most knowledgeable about their care indicated two domains from a list of ten in which consumers had set goals during the previous year. Consumers reported on goal attainment in each domain. RESULTS: A total of 2,345 consumers (82%) reported a personal goal. Overall, consumer-provider concordance reached 54%. Concordance was greatest in the employment (76%), housing (71%), and intimate relationship (52%) domains and lowest in family relationships (23%) and finances (15%). For most domains, concordance was less than 50%. On average, 75% of consumers reported having achieved their goals. Consumer-provider concordance was associated with goal attainment (p<.001). CONCLUSIONS: These findings emphasize the importance of agreed-upon goals and call for conceptualizing goal setting as an interpersonal process central to recovery.

System flexibility in the rehabilitation process of mentally disabled persons in a hostel that bridges between the hospital and the community.

BACKGROUND: Deinstitutionalization and community mental health services have become the focus of mental health care in the United States, Italy and England, and now in Israel. METHODS: Tirat Carmel MHC developed an intervention model of organizational change implemented in a rehabilitation hostel. It is an interim service based on graduated transition from maintenance care to a transitional Half-way House, followed by a Transitional Living Skills Center oriented for independent community living. RESULTS: Of 205 rehabilitees who resided in the hostel since the beginning of the project, 138 were discharged to community residential settings: 67 patients were discharged to reinforced community hostels; 27 to sheltered housing and 23 to independent residential quarters; 7 patients were discharged to comprehensive hostels, 3 to old-age homes and 11 returned home to their families. In terms of employment, 79 were placed in sheltered employment facilities, 24 work in the open market and 3 returned to school; 22 work in therapeutic occupational settings and 10 patients discharged to comprehensive hostels and old-age homes are engaged in sheltered employment programs in those settings. CONCLUSION: The system flexibility model and the rehabilitation processes anchored in normalization supported the relocation of hospitalized psychiatric patients to community-based settings and enabled the rehabilitees to cope with readjustment to community life.

[Adherence to antipsychotic medication in schizophrenia patients].

Antipsychotic agents are the mainstay of treatment for schizophrenia. However, almost 50% of schizophrenia patients exhibit non-compliance with antipsychotic drug therapy. This in turn may account for high relapse rate, reduced quality of life and increased burden on society. Identification of factors that may mediate adherence to treatment is therefore a primary clinical challenge. This paper reviews the literature regarding medication adherence among schizophrenia patients, with an emphasis on four groups of mediating factors: illness-related, patient-related, treatment-related and environmental-related factors. In addition, we describe a modified health-belief model that may facilitate better understanding of empirical findings. Therapeutic interventions to encourage better treatment compliance are discussed.

Adherence to antipsychotic drug treatment in early-episode schizophrenia: a six-month naturalistic follow-up study.

BACKGROUND: The Health Belief Model states that medication adherence is primarily determined by beliefs (i.e., perceptions of: adherence costs and benefits, susceptibility, and outcome severity), yet little is known regarding the model's longitudinal utility. AIMS: To examine the longitudinal utility of the Health Belief Model in explaining non-adherence with antipsychotic medication in clinical settings in early-episode schizophrenia. METHOD: Participants (n=112) with a DSM-IV diagnosis of schizophrenia (n=84, 75%) or schizoaffective disorder (n=28, 25%) participated in a four wave six month study. Participants were assessed on adherence (Visual Analog Scale for Assessing Treatment Adherence), symptom severity indices, the Drug Attitudes Inventory, and extrapyramidal side-effects. RESULTS: Unlike non/partially adherent participants, adherent participants showed statistically significantly (p<.05) more: insight into illness, awareness of the need for medication, positive perceptions of trust in the doctor-patient therapeutic alliance, perceived family involvement in pharmacological treatment, positive attitudes towards medication in the family and fewer adverse events. Adherence rates at endpoint did not differ between typical, atypical and mixed antipsychotic medication groups. Structural equation modeling showed that over 6 months symptom severity, awareness for the need of medication and attitudes to medication predicted adherence. Awareness of the need of medication, awareness of social consequences, participant's perceived trust in physician and the severity of negative symptoms all predicted attitudes to medication that in turn predicted adherence. CONCLUSIONS: The current results partly support the adherence Health Belief Model, and emphasize the role of attitudes toward medication as a predictor of adherence.