Australian trial of behavioural activation for people with schizophrenia experiencing negative symptoms: a feasibility randomised controlled trial protocol.

INTRODUCTION: Negative symptoms are frequently experienced by people with schizophrenia. People with negative symptoms often have impaired social functioning and reduced quality of life. There is some evidence that cognitive-behavioural therapy results in a modest reduction in negative symptoms. Behavioural activation may be an effective alternative treatment for negative symptoms.The study aims to examine the feasibility and acceptability of implementing a behavioural activation trial delivered in three community mental health services in South Australia to support adult consumers experiencing negative symptoms of schizophrenia. METHOD AND ANALYSIS: This randomised controlled study will recruit a total of 60 consumers aged 18 years or above with mild-moderate negative symptoms of schizophrenia. The consumers will be randomly allocated to receive behavioural activation plus usual mental healthcare or usual mental healthcare alone. The intervention group will receive twelve 30 min sessions of behavioural activation, which will be delivered twice weekly over 6 weeks. In addition, we aim to recruit nine mental health workers from the three rural mental health services who will complete a 10-week online training programme in behavioural activation. Changes in negative symptoms of schizophrenia and depressive symptoms will be assessed at three time points: (a) at baseline, at 6 weeks and 3 month follow-ups. Changes in health-related quality of life (Short Form F36; secondary outcome) will be assessed at two time points: (a) at baseline and (b) immediately at postintervention after 6 weeks. At the end of the trial, interviews will be conducted with purposively selected mental health workers and consumers. Descriptive statistics and thematic analysis will be used to assess feasibility and acceptability. ETHICS AND DISSEMINATION: The findings from our feasibility study will inform the design of a fully powered randomised controlled trial to test the effectiveness of behavioural activation as a treatment for negative symptoms in schizophrenia. The study protocol was approved by the Central Adelaide Local Health Network Human Research Ethics Committee. The findings from this study will be disseminated through peer-reviewed scientific journals and conferences. TRIAL REGISTRATION NUMBER: ACTRN12623000348651p.

'Chugging along, plugging in and out of it': Understanding a place-based approach for community-based support of mental health recovery.

Community-based Mental Health (MH) organisations in the United Kingdom (UK) are facing challenges for sustaining in-person service delivery. Without empirical evidence that demonstrates the value of a place-based approach for MH recovery, and the types of resources needed to build nurturing spaces for peer support, community-based MH organisations will struggle to maintain their physical spaces. We present empirical insights from a case study involving interviews with 20 students accessing peer support services at the Recovery College Collective, a community-based MH organisation located in the North East of England. The interview study aims to evidence how a place-based approach can afford MH recovery. We draw from discourses on place-making and interpret our interview findings through an established framework that highlights four mechanisms through which place impacts recovery: place for doing, being, becoming and belonging. We use this framework to structure our findings and highlight key qualities of place for establishing and maintaining MH recovery. Our contribution is two-fold: we address a gap in the literature by providing empirical understandings of how place influences MH recovery, whilst extending previous research by considering the role that place plays in community-based organisations. This is timely because of the challenges faced in securing in-person service delivery post-pandemic, and a shift towards remote service provision models. We highlight key implications: (i) Accessing a physical place dedicated to MH support is vital for people who do not have anywhere else to go and are socially isolated due to their health conditions; (ii) Connecting through peer-to-peer interaction is an integral part of the recovery process, and learning from people with lived experience can inform a place-based approach that best suit their needs; and (iii) Recognising the value of place for MH support, and the resources needed for peer support delivery in the community, will help secure places that our research participants described as lifesaving.

Linking Primary Care to Community-Based Mental Health Resources via Family Navigation and Phone-Based Care Coordination.

Family navigation (FN) and phone-based care coordination may improve linkages from primary care to community-based mental health referrals, but research on their differential impact is limited. This mixed-methods study compared FN and phone-based care coordination in connecting families to mental health services from primary care. Families of children (56.3% male, mean age = 10.4 years, 85.4% Black) were sequentially assigned to either receive FN through a family-run organization or phone-based coordination via the child psychiatry access program (CPAP). Caregiver-reported children's mental health improved in both groups and both groups were satisfied with services. More families in the CPAP group had appointments made or completed (87%) than families in the FN group (71%) though the difference was not statistically significant. Future research with a larger sample that matches family needs and preferences (e.g., level and type of support) with navigation services would be beneficial.

Assessing a pilot scheme of intensive support and assertive linkage in levels of engagement, retention, and recovery capital for people in recovery housing using quasi-experimental methods.

INTRODUCTION: Strong and ever-growing evidence highlights the effectiveness of recovery housing in supporting and sustaining substance use disorder (SUD) recovery, especially when augmented by intensive support that includes assertive linkages to community services. This study aims to evaluate a pilot intensive recovery support (IRS) intervention for individuals (n = 175) entering certified Level II and III recovery residences. These individuals met at least three out of five conditions (no health insurance; no driving license; substance use in the last 14 days; current unemployment; possession of less than $75 capital). The study assesses the impact of the IRS on engagement, retention, and changes in recovery capital, compared to the business-as-usual Standard Recovery Support (SRS) approach (n = 1758). METHODS: The study employed quasi-experimental techniques to create weighted and balanced counterfactual groups. These groups, derived from the Recovery Capital assessment tool (REC-CAP), enabled comparison of outcomes between people receiving IRS and those undergoing SRS. RESULTS: After reweighting for resident demographics, service needs, and barriers to recovery, those receiving IRS exhibited improved retention rates, reduced likelihood of disengagement, and growth in recovery capital after living in the residence for 6-9 months. CONCLUSION: The results from this pilot intervention indicate that intensive recovery support, which integrates assertive community linkages and enhanced recovery coaching, outperforms a balanced counterfactual group in engagement, length of stay, and recovery capital growth. We suggest that this model may be particularly beneficial to those entering Level II and Level III recovery housing with lower levels of recovery capital at admission.

Effects of a culturally adapted counselling service for low-income ethnic minorities experiencing mental distress: a pragmatic randomised clinical trial.

BACKGROUND: Culturally competent early mental health interventions for ethnic minorities (EMs) with no formal diagnoses are needed. OBJECTIVES: To determine whether 8-12 weeks culturally adapted counselling (CAC) is better than waiting (waitlist (WL) group) to reduce depressive and anxiety symptoms and stress levels among EMs with elevated mental distress. METHODS: Hong Kong EMs with mild and above-mild mental distress were randomly assigned to CAC or WL in this pragmatic, randomised, WL-controlled trial. The CAC group received the intervention after randomisation and the WL group received the intervention after 8-12 weeks (T1). The prespecified primary outcomes were depressive and anxiety symptoms and stress levels measured by the Depression, Anxiety and Stress subscales of the Depression, Anxiety and Stress Scale (DASS-D, DASS-A and DASS-S, respectively) at postintervention (T1, 8-12 weeks). FINDINGS: A total of 120 participants were randomly assigned to either CAC (n=60) or WL (n=60), of whom 110 provided primary outcome data. At T1, CAC led to significantly lower depressive and anxiety symptom severity and stress levels compared with waiting, with unstandardised regression coefficients of -8.91 DASS-D points (95% CI -12.57 to -5.25; d=-0.90),-6.33 DASS-A points (95% CI -9.81 to -2.86; d=-0.68) and -8.60 DASS-S points (95% CI -12.14 to -5.06; d=-0.90). CONCLUSIONS: CAC clinically outperformed WL for mild and above-mild levels of mental distress in EMs. CLINICAL IMPLICATIONS: Making CAC routinely available for EMs in community settings can reduce healthcare burden. TRIAL REGISTRATION NUMBER: NCT04811170.

Measurement Characteristics of the Wraparound Fidelity Index Short Form: Results from a Statewide Implementation.

Implementation fidelity has been an important issue in the service provision and associated outcomes of Wraparound, an intensive, individualized care planning process that uses a team-based approach to integrate youth into the community to minimize the need for intensive, institutional services. In response to the growing need to monitor fidelity to the Wraparound process, a variety of instruments have been created and tested. In this study, the authors present the results of several analyses designed to better understand the measurement characteristics of the Wraparound Fidelity Index Short Form (WFI-EZ), a multi-informant fidelity instrument. The results from our analysis of 1027 WFI-EZ responses indicate that the internal consistency of the instrument is very good, although the negatively worded items did not appear to function as well as positively worded items. Results from two confirmatory factor analyses were unable to validate the original domains identified by the instrument developers, but for certain outcomes the WFI-EZ demonstrated deseriable predictive validity. Preliminary evidence is also provided that WFI-EZ responses likely differ by respondent type. We conclude by discussing the implications of using the WFI-EZ in programming, policy, and practice considering the findings of our study.

Examining the Prevalence and Forms of Leveraged Treatment Pressure and Its Relationship to Personal Recovery: A Canadian Cross-Sectional Study.

Across jurisdictions, the use of 'leverage' to promote adherence to mental health treatment is widespread. However, little research exists on the possible association between the application of leverage and personal recovery. We examined the prevalence of various forms of leverage in a Canadian context and compared these rates with those in other jurisdictions. Additionally, we examined the relationship between two prominent forms of leverage (financial and housing) and the experience of personal recovery. Structured interviews were conducted with people receiving community-based mental health care in Toronto, Canada. Rates of overall leverage in our sample were similar to rates reported in other jurisdictions. Personal recovery was negatively associated with financial leverage but was not associated with housing leverage. Our results highlight the importance of separately examining the relationship of specific forms of leverage and personal recovery and raise questions for future research about the possible effect of financial leverage on recovery.

The Role of Latina Peer Mentors in the Implementation of the Alma Program for Women With Perinatal Depression.

This study examines the role that compañeras (peer mentors) play in the implementation of a program, Alma, which was designed to support Latina mothers who are experiencing depression during pregnancy or early parenting and implemented in the rural mountain West of the United States. Drawing from the fields of dissemination and implementation and Latina mujerista (feminist) scholarship, this ethnographic analysis demonstrates how the Alma compañeras facilitate the delivery of Alma by creating and inhabiting intimate mujerista spaces with other mothers and create relationships of mutual and collective healing in the context of relationships de confianza (of trust and confidence). We argue that these Latina women, in their capacity as compañeras, draw upon their cultural funds of knowledge to bring Alma to life in ways that prioritizes flexibility and responsiveness to the community. Shedding light on contextualized processes by which Latina women facilitate the implementation of Alma illustrates how the task-sharing model is well suited to the delivery of mental health services for Latina immigrant mothers and how lay mental health providers can be agents of healing.

Opening Doors to Recovery: A Randomized Controlled Trial of a Recovery-Oriented Community Navigation Service for Individuals With Serious Mental Illnesses and Repeated Hospitalizations.

Objective: Opening Doors to Recovery (ODR) is a community navigation and recovery support model created in southeast Georgia by diverse, collaborative stakeholders. Following promising results from a quasi-experimental study, this randomized controlled trial hypothesized that, among patients with serious mental illnesses being discharged from inpatient psychiatric settings, compared to those randomized to traditional case management (CM) services, those randomized to ODR would have (1) lower likelihood of hospitalization, fewer hospitalizations, and fewer inpatient days; (2) lower likelihood of arrest, fewer arrests, and longer time to arrest; and, secondarily, (3) greater housing satisfaction and housing stability; and (4) higher scores on several scales measuring recovery-related constructs.Methods: 240 individuals with Structured Clinical Interview for DSM-5 Disorders-based psychotic or mood disorders, functional impairment, and repeated hospitalizations were randomized (December 2014 to June 2018) to ODR or CM. Hospitalization and arrest data were collected from State agencies after 12 months, and housing- and recovery-related measures were collected in person, longitudinally at 4, 8, and 12 months. Intention-to-treat analyses were conducted. Effects of dropout were accounted for, and sensitivity analyses were run.Results: ODR was associated with fewer days hospitalized (RR = 0.86, P = .001), a lower incidence of arrests (OR = 0.35, P < .0005), and longer time to arrest (HR = 0.42, P = .001). In addition, measures of housing satisfaction (Cohen d = 0.45) and recovery (Cohen d = 0.33) were significantly more improved in ODR patients compared to CM patients.Conclusions: The ODR model appears to have advantages over more traditional CM services and could fill a gap in the service array. Studying the mediators of success, cost benefit, dissemination, fidelity, and financing of the model is warranted.Trial Registration: ClinicalTrials.gov identifier: NCT04612777.

Patient Outcomes of Flexible Assertive Community Treatment Compared With Assertive Community Treatment.

OBJECTIVE: In many European countries, flexible assertive community treatment (FACT) has replaced assertive community treatment (ACT) despite limited evidence for FACT's effectiveness in improving functional and patient-reported outcomes. This study evaluated the effectiveness of FACT relative to ACT in improving functioning, client satisfaction, and the working alliance. METHODS: The authors used a nonblinded, quasi-experimental controlled study design to compare outcomes of patients treated by ACT teams that were reconfigured to FACT teams with those of patients treated by a remaining ACT team. Patients from nine ACT teams in the Capital Region of Denmark were included. Six of the nine ACT teams were reconfigured to FACT in 2018 and 2019 by integrating them with community mental health teams. The remaining three ACT teams were used as control groups. Assignment to treatment was based solely on administrative considerations. RESULTS: The study included 131 patients (FACT, N=74; ACT, N=57). Patients treated by FACT teams had poorer personal and social functioning than patients assigned to ACT teams (adjusted difference in means=-2.9, 95% CI=-5.8 to -0.1). No between-group differences were found in client satisfaction or working alliance. CONCLUSIONS: Patients treated by FACT teams had significantly lower functioning than patients treated by ACT teams, but the clinical relevance or causality of this finding remains unclear. Given the reconfiguration of the FACT teams during follow-up, along with substantial drop-out rates and baseline differences between the two groups, these results must be interpreted with caution. The findings require further examination in a randomized controlled trial that includes fidelity measures of the treatment models.

(Cost)-effectiveness and implementation of integrated community-based care for patients with severe mental illness: a study protocol.

BACKGROUND: As severe mental illness (SMI) is associated with a high disease burden and persistent nature, patients with SMI are often subjected to long-term mental healthcare and are in need of additional social support services. Community-based care and support services are organized via different providers and institutions, which are often lacking structural communication, resulting in a fragmented approach. To improve the efficiency of care provision and optimize patient wellbeing, an integrated multi-agency approach to community-based mental health and social services has been developed and implemented. AIM: To present a research protocol describing the evaluation of flexible assertive community teams integrated with social services in terms of effectiveness, cost-effectiveness, and implementation. METHODS/DESIGN: A quasi-experimental study will be conducted using prospective and retrospective observational data in patients with severe mental illness. Patients receiving care from three teams, consisting of flexible assertive community treatment and separately provided social support services (care as usual), will be compared to patients receiving care from two teams integrating these mental and social services into a single team. The study will consist of three parts: 1) an effectiveness evaluation, 2) a health-economic evaluation, and 3) a process implementation evaluation. To assess (cost-)effectiveness, both real-world aggregated and individual patient data will be collected using informed consent, and analysed using a longitudinal mixed model. The economic evaluation will consist of a cost-utility analysis and a cost-effectiveness analysis. For the process and implementation evaluation a mixed method design will be used to describe if the integrated teams have been implemented as planned, if its predefined goals are achieved, and what the experiences are of its team members. DISCUSSION: The integration of health and social services is expected to allow for a more holistic and recovery oriented treatment approach, whilst improving the allocation of scarce resources. This study aims to identify and describe these effects using a mixed-method approach, and support decision-making in the structural implementation of integrating mental and social services.

Health-related quality of life in severe psychotic disorders during integrated care: 5-year course, prediction and treatment implications (ACCESS II).

PURPOSE: Studies on outcomes mapping Quality of Life (QoL) as patient-reported outcome over a longer period in severe psychotic disorders are scarce. However, such data would be particularly important for structuring, implementing and operating effective and efficient care models and for promoting satisfaction with care, service engagement and adherence. METHODS: The ACCESS II study is a prospective long-term study of an integrated care model for people with severe psychotic disorders. The model includes Therapeutic Assertive Community Treatment within a cross-sectoral and interdisciplinary network. This publication analyses the course of QoL assessed with the Q-LES-Q-18 using a mixed model for repeated measures. RESULTS: Mapping the course of QoL in N = 329 participants, there is a significant increase in the first 6 weeks of treatment (early course). Comparison to a published norm show significant lower QoL for severe psychotic disorders. The variable having a traumatic event before the age of 18 was significantly negatively associated with QoL. A decrease in the severity of depressive as well as in positive symptomatology in the first six weeks after admission was associated with increase of QoL. CONCLUSION: Results indicate that the overall symptom burden at time of inclusion is not decisive for the perceived QoL in the long-term course while the reduction in the severity of depressive and positive symptoms is important. This means focusing even more on the treatment of depressive symptoms and include traumatherapeutic aspects in the long-term treatment of severe psychotic disorders if needed. TRAIL REGISTRATION: ClinicalTrials.gov (identifier: NCT01888627).

Standardized Versus Tailored Implementation of Measurement-Based Care for Depression in Community Mental Health Clinics.

Objective: Measurement-based care (MBC) is an evidence-based practice that is rarely integrated into psychotherapy. The authors sought to determine whether tailored MBC implementation can improve clinician fidelity and depression outcomes compared with standardized implementation. Methods: This cluster-randomized trial enrolled 12 community behavioral health clinics to receive 5 months of implementation support. Clinics randomized to the standardized implementation received electronic health record data captured with the nine-item Patient Health Questionnaire (PHQ-9), a needs assessment, clinical training, guidelines, and group consultation in MBC fidelity. Tailored implementation support included these strategies, but the training content was tailored to clinics' barriers to MBC, and group consultation centered on overcoming these barriers. Clinicians (N=83, tailored; N=71, standardized) delivering individual psychotherapy to 4,025 adults participated. Adult patients (N=87, tailored; N=141, standardized) contributed data for depression outcome analyses. Results: The odds of PHQ-9 completion were lower in the tailored group at baseline (odds ratio [OR]=0.28, 95% CI=0.08­0.96) but greater at 5 months (OR=3.39, 95% CI=1.00­11.48). The two implementation groups did not differ in full MBC fidelity. PHQ-9 scores decreased significantly from baseline (mean±SD=17.6±4.4) to 12 weeks (mean=12.6±5.9) (p<0.001), but neither implementation group nor MBC fidelity significantly predicted PHQ-9 scores at week 12. Conclusions: Tailored MBC implementation outperformed standardized implementation with respect to PHQ-9 completion, but discussion of PHQ-9 scores in clinician-patient sessions remained suboptimal. MBC fidelity did not predict week-12 depression severity. MBC can critically inform collaborative adjustments to session or treatment plans, but more strategic system-level implementation support or longer implementation periods may be needed.

Lockdown logistics in consultation-liaison psychiatry.

We describe the adaptation of services to allow flexible and practical responses to the coronavirus-19 (COVID-19) public health crisis by four Consultation-Liaison Psychiatry (CLP) services; Galway University Hospital (GUH), Beaumont Hospital, University Hospital Waterford and St Vincent's University Hospital (SVUH) CLP services. This article also illustrates close collaboration with community adult mental health services and Emergency Department (ED) colleagues to implement effective community diversion pathways and develop safe, effective patient assessment pathways within the EDs. It highlights the high levels of activity within each of the CLP services, while also signposting that many of the rapidly implemented changes to our practice may herald improvements to mental health patient care delivery in the post-COVID-19 world, if our psychiatry services receive appropriate resources.

Effectiveness of Resource Groups for Improving Empowerment, Quality of Life, and Functioning of People With Severe Mental Illness: A Randomized Clinical Trial.

Importance: Although the importance of recovery-oriented care for people with severe mental illness (SMI) is widely acknowledged, essential elements such as personalization and involvement of significant others are not adequately implemented in practice. Objective: To determine whether using resource groups (RGs) within flexible assertive community treatment (FACT) has favorable effects on empowerment and recovery-related outcomes in people with SMI. Design, Setting, and Participants: This assessor-blind, multisite randomized clinical trial was conducted from September 1, 2017, to September 30, 2020, with follow-up at 9 and 18 months. A total of 158 participants aged 18 to 65 years meeting the criteria for SMI were randomly allocated to FACT plus RG vs FACT as usual (1:1) in 20 FACT teams throughout the Netherlands. Data were analyzed from September 1, 2020, to January 31, 2021. The study was prespecified in the trial protocol and data from the intent-to-treat population were analyzed. Interventions: In the FACT plus RG condition, patients chose members from their informal and formal networks to form an RG that meets quarterly to discuss self-formulated recovery goals. The RG was integrated into the multidisciplinary support provided by the FACT team. In the FACT as-usual condition, empowerment (defined as overcoming powerlessness and gaining control of one's life) and involvement of significant others was also part of the provided care, but without the structure of the RG. Main Outcomes and Measures: The primary outcome was self-reported empowerment, measured with the Netherlands Empowerment List. Results: A total of 158 participants with SMI (median age, 38 [median absolute deviation, 13] years; 93 men [58.9%]) were randomized to FACT plus RG (n = 80) or FACT as usual (n = 78) care. Intention-to-treat analyses showed that randomization to the RG condition was associated with a clinically significant increase in empowerment (Cohen d, 0.54; 95% CI, 0.21-0.86) and improved outcomes with small to medium effect sizes in terms of quality of life (Cohen d, 0.25; 95% CI, -0.07 to 0.56), personal recovery (Cohen d, 0.38; 95% CI, 0.06-0.69), quality of social contact (Cohen d, 0.24; 95% CI, -0.07 to 0.56), disability (Cohen d, 0.29; 95% CI, -0.03 to 0.60), general functioning (Cohen d, 0.30; 95% CI, -0.01 to 0.62), and social functioning (Cohen d, 0.28; 95% CI, -0.04 to 0.59). No differences between conditions were found regarding psychopathological symptoms, attachment, frequency of social contact, and employment. Compared with FACT as usual, participants who stayed with the assigned treatment in the RG condition were more satisfied with treatment at 9 (Cohen d = 0.45; t135 = -2.62; P = .009) and 18 (Cohen d = 0.41; t116 = -2.22; P = .02) months. Conclusions and Relevance: These findings show that working with RGs improves empowerment and other mental health outcomes in people with SMI who receive community-based mental health services. This method of network-oriented care empowers people with SMI within their own environment. Trial Registration: Netherlands Trial Register Identifier: NL6548.

Children and Adolescent Mental Health in a Time of COVID-19: A Forgotten Priority.

Globally, 10-20% of children and adolescents experience mental health conditions, but most of them do not receive the appropriate care when it is needed. The COVID-19 deaths and prevention measures, such as the lockdowns, economic downturns, and school closures, have affected many communities physically, mentally, and economically and significantly impacted the already-neglected children and adolescents' mental health. As a result, evidence has shown that many children and adolescents are experiencing psychological effects such as depression and anxiety without adequate support. The consequences of not addressing the mental health conditions in children and adolescents extend through adulthood and restrict them from reaching their full potential. The effects of COVID-19 on children and adolescents' mental health highlight the urgent need for multisectoral home-grown solutions to provide early diagnosis and treatment and educate caregivers on home-based interventions and community outreach initiatives to address children and adolescents' mental health challenges during this pandemic and beyond.

Insights from homeless men about PRISM, an innovative shelter-based mental health service.

PRISM (Projet Réaffiliation Itinérance Santé Mentale-mental health and homelessness reaffiliation project), is a new shelter-based mental health service in Montreal, Canada. It offers short-term residential services in a shelter with the aim of housing and connecting the person to the appropriate services in the community. This qualitative research project was designed to gain a rich understanding of service-user experience within this program, and to apply these impressions to a broader reflection concerning how to best serve the needs of homeless people living with severe mental illness. We conducted in-depth interviews with 20 clients from the all-male PRISM-Welcome Hall Mission at program intake and departure between May 2018 and March 2019. We used methods stemming from grounded theory to analyze themes emerging from the interviews. Analysis revealed three core aspects endorsed by PRISM clients as helpful to their recovery: first, the community-based and flexible PRISM structure allows for continuity in daily routine through the preservation and expansion of the client's existing informal resource network; second, the secure environment is conducive to improving one's physical and mental health; and third, the multimodal mental health and social service approach used at PRISM is appreciated and stands in contrast to what most have experienced during other inpatient experiences. This led us to reflect more broadly on the benefits of a shelter-based intervention, as a catalyst to the achievement of longer-term goals such as housing, as well as flexible care adapted to the specific needs of these individuals. Even though this study took place in a specific program in Quebec, it sheds light more broadly on how to best meet the needs of individuals with mental illness living in homeless situations and contributes to the growing literature on men's mental health.

Impact of the coronavirus outbreak on mental health in the different Spanish regions.

COVID-19 is an infectious disease that has affected millions of people worldwide, Spain being one of the countries most affected by the pandemic. It is key to study its impact on the mental health of the Spanish population during the lockdown situation.