Optimizing Scripted Dialogues for an e-Health Intervention for Suicidal Veterans with Major Depression.

Suicide is a health concern among Veterans with depression. We had previously reported on scripted dialogues adapted for an e-health system that engages at-risk veterans with schizophrenia. Here we report a further adaptation of the dialogues for Veterans with depression. Usability was assessed with nine outpatients with a history of major depression and suicidality. We noted that participants preferred greater specificity in the wording of questions. Topics that elicited an emotional response dealt with questions on suicide, social isolation and family relationships. Based on feedback, dialogues were revised for patients with depression. We also compared responses between those with depression and those with schizophrenia who were previously tested. The two groups shared similar themes. Also, individuals with a history of major depression had less trouble with vocabulary comprehension but were less willing to answer more questions daily.

Development of telehealth dialogues for monitoring suicidal patients with schizophrenia: consumer feedback.

Suicide is a health concern among individuals with schizophrenia. A telehealth system for monitoring suicidal patients with schizophrenia was developed using the Health Buddy©. The existing dialogues were improved using an expert panel; the new dialogues were tested in 10 consumers with schizophrenia and a history of suicidal behavior. Using qualitative editing, several themes emerged: (1) Certain topics elicited strong emotional responses; (2) There were concerns with confidentiality; (3) Some content was too vague and (4) There were problems with vocabulary and wording. The process yielded information for improving the intervention and demonstrated that the approach is feasible in this population.

Chronicity reconsidered: improving person-environment fit through a consumer-run service.

In the past, the term "chronic" referred to people who had serious mental illness and who typically received long-term care in a state mental hospital. Although this term recently has fallen out of favor, we resurrect the term here, not to revive a demeaning euphemism, but rather to redefine it as the result of a poor person-environment fit between the complex and challenging needs of those with serious psychiatric disorders and a community-based service system that often is ill-equipped to treat them. Previous research indicates that recurrent acute hospitalizations and an inability to establish or maintain tenure in the community may be due to a disconnection from community-based services and supports, social isolation, and demoralization. One promising approach to addressing these issues is that of peer support. To illustrate the potential utility of peer support in improving person-environment fit and decreasing the chronicity of the subsample of people who continue to have difficulty in establishing viable footholds in the community, we describe a peer support-based program, the Welcome Basket, developed, staffed, and managed entirely by mental health consumers. Preliminary analyses that evaluate Welcome Basket's effectiveness are included, and we discuss the implications of these data for future research and program development in this area.

Impact of panic attacks on rehabilitation and quality of life among persons with severe psychotic disorders.

OBJECTIVE: The study evaluated data from a sample of persons with severe psychotic disorders to determine whether those with and without comorbid panic attacks differed in rates of comorbidity of other psychiatric disorders, in quality of life, and in rehabilitation outcomes. METHODS: A total of 120 individuals with psychotic disorders were assessed with the Center for Epidemiologic Studies-Depression scale, the Structured Clinical Interview for DSM-III-R, the General Health Questionnaire, the Global Assessment of Functioning scale, and several quality-of-life measures at baseline and four and a half months after they had participated in a social rehabilitation program. Multivariate analyses of variance and Pearson's chi square tests were used to compare baseline and follow-up scores between individuals who did and did not have panic attacks. RESULTS: Eighteen (15 percent) of the participants who had severe psychotic disorders also had panic attacks. Participants with this type of comorbidity had significantly higher rates of major depressive disorder, specific phobia, sedative abuse, polysubstance abuse, other substance abuse, and anorexia nervosa than participants who did not have panic attacks. Participants who had panic attacks also had poorer rehabilitative outcomes and poorer quality of life at baseline and at follow-up than participants who did not have panic attacks. CONCLUSIONS: These data are the first to show that comorbid panic attacks are associated with poorer rehabilitative outcomes and poorer quality of life among individuals with severe psychotic disorders than among those who have psychotic disorders without panic attacks. Panic attacks may be a valuable prognostic indicator among persons with psychotic disorders and may have implications for treatment and rehabilitation.

"Simply to be let in": inclusion as a basis for recovery.

This article takes its inspiration from a poem by Borges, in which the author makes a plea to simply be "let in" without being wondered at or required to succeed. Based on the view that these issues have applied historically to people with mental illnesses--first during the period of the asylum, and now more recently as a result of deinstitutionalization--this article argues for the adoption of a broad conceptual framework of inclusion that, based on a disability paradigm, neither alienates or requires people to succeed. First, the ways in which such a framework augments existing approaches to treatment, rehabilitation, and recovery are outlined. Next, the authors describe the three elements of friendship, reciprocity, and hopefulness as aspects of inclusion that may provide a foundation for efforts toward recovery, and illustrate each of these elements through the stories of participants in a supported socialization program. Implications for future research and policy are suggested based on these data.

"It was just realizing ... that life isn't one big horror": a qualitative study of supported socialization.

This report describes the qualitative component of a large-scale study of supported socialization. Paralleling the recent advances made through supported housing, supported employment, and supported education, this approach seeks to increase the involvement of individuals with psychiatric disabilities in naturally occurring social and recreational activities in community settings of their choice. After a review of social relationships and psychiatric disability, we describe the Partnership Project and present findings from a series of qualitative interviews conducted with a subsample of participants. We then discuss the implications of these findings for the community integration of individuals with psychiatric disabilities.

Client-case manager racial matching in a program for homeless persons with serious mental illness.

OBJECTIVE: This study evaluated the relationship between client-case manager racial matching and both service use and clinical outcomes in a case management program for homeless persons with serious mental illness. METHODS: The study focused on 1,785 clients from the first cohorts that entered the Center for Mental Health Services' Access to Community Care and Effective Services and Supports (ACCESS) program, a five-year demonstration program for homeless persons with mental illness established at 18 sites between 1994 and 1996. A series of two-way analyses of variance was used to assess the effect of client and case manager race and their interaction on changes in outcomes and service use over a 12-month period. RESULTS: Although African Americans had more severe problems on several measures and higher levels of service use at baseline, no differences in service use at 12 months or in the changes in client outcomes as measured by nine variables were associated with the different pairings of African-American and white clients and case managers. White clients had a greater reduction in psychotic symptoms than did African-American clients, regardless of client- case manager racial pairing. No differences were found between white and African-American clients on the amount of services received over time. CONCLUSIONS: This study found virtually no evidence of a relationship between client race, case manager race, or client-case manager racial matching on either outcomes or service use.

The case management relationship and outcomes of homeless persons with serious mental illness.

OBJECTIVE: The effect of the case management relationship on clinical outcomes was examined among homeless persons with serious mental illness. METHODS: The sample consisted of the first two cohorts that entered the Access to Community Care and Effective Services and Supports (ACCESS) program, a five-year demonstration program for mentally ill homeless persons funded by the Center for Mental Health Services in 1994. At baseline, three months, and 12 months, clients were characterized as not having a relationship with their case manager or as having a low or high therapeutic alliance with their case manager. Analyses were conducted to test the association between the case manager relationship at baseline, three months, and 12 months and clinical outcomes at 12 months. RESULTS: Multivariate analyses of covariance were conducted for 2,798 clients who had outcome data at 12 months. No significant associations were found between the relationship with the case manager at baseline and outcomes at 12 months. At three months, clients who had formed an alliance with their case manager had significantly fewer days of homelessness at 12 months. Clients who reported a high alliance with their case manager at 12 months had significantly fewer days of homelessness at 12 months than those with a low alliance, and those with a low alliance at 12 months had fewer days of homelessness than clients who reported no relationship with their case manager. Clients with a higher alliance at both three and 12 months reported greater general life satisfaction at 12 months. CONCLUSIONS: The study found that clients' relationship with their case manager was significantly associated with homelessness and modestly associated with general life satisfaction.

How are we doing? A statewide survey of community adjustment among people with serious mental illness receiving intensive outpatient services.

Although mental health consumers often prefer community living, the factors influencing community outcomes are not well understood. In order to address this issue in Connecticut, the Department of Mental Health and Addiction Services (DMHAS) commissioned a statewide study of 6,800 clients receiving the most intensive community-based mental health services funded by the state. DMHAS clinicians provided the ratings for their clients on a variety of variables including demographics, diagnosis, clinical stability, current psychotic symptomology, adherence to prescribed medications, substance abuse, history of violent crime, community trouble-making or victimization, likelihood of threatening behavior, frequency of social contacts, and difficulty in adjusting to life in the community. Also, the total length of stay and total number of admissions during a two year period were taken from the statewide management information system for each client in the study. Descriptive data analysis included frequencies and means to describe the demographic, the diagnostic, and the clinical profile of the DMHAS clients. A stepwise hierarchical multiple regression analysis (MRA) was performed to determine what factors predict a composite score of overall functioning, community adjustment, and psychiatric impairment. Clients with better composite scores were those who had a prescription for medications, adhered more to their medication regimen, perceived to be less threatening, and had more frequent social interactions. Implications of these findings for outpatient treatment are discussed.

Comparing consumer and nonconsumer provided case management services for homeless persons with serious mental illness.

This study compared the outcomes of services provided by case managers who are mental health system consumers and case managers who were not consumers. The study focused on the first two cohorts that entered the ACCESS program, a 5-year demonstration program funded by the Center for Mental Health Services between 1994 and 1996. We tested the associations between the type of case manager and clinical outcomes at three time points (baseline, 3 months, and 12 months). A series of one-way repeated measures of analyses of variance were conducted on clients from ACCESS sites that hired consumer providers. Although there were significant effects of Time for almost every outcome measure (clients improved over time), there were no significant Time x Case Manager Type interactions. Staff age, race, or gender did not significantly alter the pattern of these results. Given that services provided by consumers and nonconsumers were associated with equivalent client outcomes, the present study shows, using a large sample, the ability of consumers to provide mental health services as members of a case management team.

Therapeutic agents of assertive community treatment.

The goal of this study was to learn how assertive community treatment (ACT) contributes to the improvement of those with serious mental illness in order to contribute to the growing clinical literature regarding the therapeutic agents of ACT teams. Methods included reviewing the case records of three ACT clients who have improved significantly, as well as interviewing the clients themselves and their clinicians. The results indicated that there was significant agreement among the case records, the clients, and their clinicians in identifying the most useful aspects of assertive community treatment. Primary among these factors were the persistence demonstrated by ACT clinicians in engaging their clients, the trust that clients developed in their clinicians, and as a result, the process by which their clinicians became "guides" to the world of psychiatric and social services that further facilitated their clients' community adjustment. In closing, we consider implications from these findings both for staff development for ACT team members, and for suggestions toward the development of a model of recovery from serious mental illness.

On the road to collaborative treatment planning: consumer and provider perspectives.

Although consumers have made significant gains in having their voices heard in several areas within mental health, they have made less progress in being able to collaborate with their own treaters in setting treatment goals. On the basis of several years of groundwork by staff at the Connecticut Mental Health Center (CMHC), the Patient Care Committee conducted a needs assessment of providers and consumers to assess both groups' current involvement, interest in, and attitudes toward collaborative treatment planning. The results indicate that providers tend to place much of the responsibility for the difficulties in implementing collaborative treatment planning on consumers. Also, providers tend to underestimate consumers' interest in participating in this process. Implications of these findings for the development of an agency-wide training to enhance the collaborative nature of treatment planning are discussed.

An ecological assessment of community-based interventions for prevention and health promotion: approaches to measuring community coalitions.

Presented an ecological assessment of a community coalition to prevent alcohol, tobacco, and other drug abuse, and related risks. Ecological assessment is defined as occurring at multiple social levels and along a continuum of stages of coalition readiness. The assessment is aided by the triangulation, or combining of assessment methods and strategies. Measures used to assess the coalition's formation, implementation of community initiatives, and production of community impacts are described, along with the triangulation strategies used to enhance the assessment findings.