Life is better but not without challenges: experiences following discharge from community-based residential mental health rehabilitation-a qualitative content analysis.

PURPOSE: Community-based residential mental health rehabilitation units for people experiencing severe and persistent mental illness are increasingly available in Australia. Research completed 20 years ago suggested that people leaving these services often experienced impoverished social lives and other challenges in the community. It is unclear whether contemporary consumers experience similar difficulties. This qualitative study explored contemporary consumers' experiences after leaving community-based residential services. METHODS: An inductive qualitative content analysis of individual interviews was completed with consumers 12-18 months following discharge from three community care units (CCUs) in Queensland, Australia. The interview schedule explored three questions: (1) What does life look like after leaving the CCU, (2) Has the CCU impacted their life, and (3) How could the CCU experience be improved? A convenience sample was used, with sampling continuing until thematic saturation was achieved. A member of the research team who had relevant lived experience actively supported the analysis and interpretation. RESULTS: Seventeen interviews were completed. Three themes were identified: 'life is better but not without challenges', 'the CCU helps you get ready to go out into the world', and 'strict rules are important but rigid expectations can be hard; things could be better'. CONCLUSION: Consumers reflected positively on their lives post-discharge from a community-based residential rehabilitation unit and viewed the service as having supported improvements in their lives. The findings suggest the appropriateness of optimism about the possibility of sustained improvements in quality of life after leaving community-based transitional residential rehabilitation support.

International Experience of Implementing Cognitive Remediation for People With Psychotic Disorders.

BACKGROUND: Cognitive remediation (CR) is an effective therapy for the cognitive impact of mental illness, especially schizophrenia. Global efforts are being made to implement CR into routine mental health services with the aim of improving functional outcomes for the population of people recovering from mental illness. Implementation and dissemination of CR in heterogeneous settings require knowledge gleaned from formal implementation research and pragmatic experiential learning. This article describes cross-cultural approaches to CR implementation, focusing on initiatives in France, the United States, Australia, and Japan. METHOD: Key leaders in the implementation of CR in France, the United States, Australia, and Japan were asked to describe the implementation and dissemination process in their settings with respect to the categories of context, implementation, outcomes, facilitators, and barriers. RESULTS: All 4 sites noted the role of collaboration to leverage the implementation of CR into mental health rehabilitation services. In France, high-level, government organizational backing enhanced the dissemination of CR. Academic and clinical service partnerships in the United States facilitated the dissemination of programs. The advocacy from service users, families, and carers can aid implementation. The support from international experts in the field can assist in initiating programs but maintenance and dissemination require ongoing training and supervision of staff. CONCLUSIONS: CR is an effective intervention for the cognitive impact of schizophrenia. Programs can be implemented in diverse settings globally. Adaptations of CR centering upon the core components of effective CR therapy enhance outcomes and enable programs to integrate into diverse settings.

Reward Learning as a Potential Mechanism for Improvement in Schizophrenia Spectrum Disorders Following Cognitive Remediation: Protocol for a Clinical, Nonrandomized, Pre-Post Pilot Study.

BACKGROUND: Cognitive impairment is common with schizophrenia spectrum disorders. Cognitive remediation (CR) is effective in improving global cognition, but not all individuals benefit from this type of intervention. A better understanding of the potential mechanism of action of CR is needed. One proposed mechanism is reward learning (RL), the cognitive processes responsible for adapting behavior following positive or negative feedback. It is proposed that the structure of CR enhances RL and motivation to engage in increasingly challenging tasks, and this is a potential mechanism by which CR improves cognitive functioning in schizophrenia. OBJECTIVE: Our primary objective is to examine reward processing in individuals with schizophrenia before and after completing CR and to compare this with a group of matched clinical controls. We will assess whether RL mediates the relationship between CR and improved cognitive function and reduced negative symptoms. Potential differences in social RL and nonsocial RL in individuals with schizophrenia will also be investigated and compared with a healthy matched control group. METHODS: We propose a clinical, nonrandomized, pre-post pilot study comparing the impact of CR on RL and neurocognitive outcomes. The study will use a combination of objective and subjective measures to assess neurocognitive, psychiatric symptoms, and neurophysiological domains. A total of 40 individuals with schizophrenia spectrum disorders (aged 18-35 years) will receive 12 weeks of CR therapy (n=20) or treatment as usual (n=20). Reward processing will be evaluated using a reinforcement learning task with 2 conditions (social reward vs nonsocial reward) at baseline and the 12-week follow-up. Functional magnetic resonance imaging responses will be measured during this task. To validate the reinforcement learning task, RL will also be assessed in 20 healthy controls, matched for age, sex, and premorbid functioning. Mixed-factorial ANOVAs will be conducted to evaluate treatment group differences. For the functional magnetic resonance imaging analysis, computational modeling will allow the estimation of learning parameters at each point in time, during each task condition, for each participant. We will use a variational Bayesian framework to measure how learning occurred during the experimental task and the subprocesses that underlie this learning. Second-level group analyses will examine how learning in patients differs from that observed in control participants and how CR alters learning efficiency and the underlying neural activity. RESULTS: As of September 2023, this study has enrolled 15 participants in the CR group, 1 participant in the treatment-as-usual group, and 11 participants in the healthy control group. Recruitment is expected to be completed by September 2024. Data analysis is expected to be completed and published in early 2025. CONCLUSIONS: The results of this study will contribute to the knowledge of CR and RL processes in severe mental illness and the understanding of the systems that impact negative symptoms and cognitive impairments within this population. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52505.

Developments in rehabilitation psychiatry within the RANZCP and the creation of a mental health rehabilitation curriculum.

OBJECTIVE: This paper describes the initial development of a mental health rehabilitation curriculum for Australian mental health settings and for psychiatrists and trainees wishing to develop specialist skills in mental health rehabilitation. METHOD: Members of the Section of Social Cultural and Rehabilitation Psychiatry (SSCRP) established an expert working group under the auspices of the RANZCP. Existing college training resources were reviewed, and a gap analysis was conducted to guide development of new training modules. RESULTS: A tiered curriculum structure was created that allows a staged development of rehabilitation knowledge, skills and attitudes required to be a specialist in mental health rehabilitation. An introductory module was developed to establish the principles of modern mental health rehabilitation. Most of the curriculum was based on existing resources that are relevant to rehabilitation practice. Finalisation of a draft for review was undertaken with the assistance of the RANZCP education project advisors and curriculum experts. CONCLUSIONS: As a national body responsible for training psychiatric registrars and maintenance of training for psychiatrists, the RANZCP is well situated to train the specialist medical mental health workforce required to lead rehabilitation services in Australia. The RANZCP mental health rehabilitation curriculum will provide a platform to train the skilled workforce that will enable these services to be fully realised.

Cognitive remediation therapy - implementation and translation into clinical practice in rural and metropolitan New South Wales mental health services.

OBJECTIVE: Cognitive Remediation Therapy (CRT) is an effective intervention in managing the significant cognitive deficits experienced by those living with psychosis. Given its strong evidence base CRT is recommended in Australian and international guidelines for rehabilitation of people with psychosis, however, access to CRT remains limited. In this commentary, we describe recent efforts to implement CRT programs within NSW mental health services. Development of CRT delivery has been successfully achieved in both rural and metropolitan settings, utilising both face-to-face and telehealth methods. CONCLUSIONS: The delivery of CRT in public mental health services is feasible and adaptable to diverse settings. We strongly advocate for sustainable implementation of CRT into routine clinical practice. This will require policy and practice change to enable resources for CRT training and delivery to become embedded in the roles of the clinical workforce.

Examining the outcomes of the first one hundred residents in a community based residential rehabilitation unit for people affected by severe and persistent mental illness.

OBJECTIVE: Community-based residential rehabilitation for people experiencing severe and persistent mental illness (SPMI) is increasingly available as an alternative to psychiatric inpatient care. Understanding who accesses these services and their outcomes will inform the optimal allocation of limited public mental health resources. METHOD: This retrospective cohort study explored the outcomes of the first 100 consumers supported by a new Australian Community Care Unit (CCU). The primary outcome focus was acute mental health service use (emergency department presentations, acute mental health inpatient admission days), and secondary outcome foci were accommodation independence and substance use. RESULTS: When the 365 days before and after CCU support were compared, significant reductions in acute mental health bed days were observed (22 days, W = 3.373, p = .001); greater reductions were noted for those staying >182 days (31 days, W = 3.373, p = .001). Additionally, significant improvements in accommodation independence were found, (W = 3.373, p = .001). CONCLUSION: CCU consumers experienced reductions in acute mental health inpatient service use and improved accommodation independence. These observations are consistent with the intended functioning of the residential rehabilitation service.

Measuring recovery-oriented rehabilitation language in clinical documentation to enhance recovery-oriented practice.

BACKGROUND: Mental health services are encouraged to use language consistent with principles of recovery-oriented practice. This study presents a novel approach for identifying whether clinical documentation contains recovery-oriented rehabilitation language, and evaluates an intervention to improve the language used within a community-based rehabilitation team. AIMS: This is a pilot study of training to enhance recovery-oriented rehabilitation language written in care review summaries, as measured through a text-based analysis of language used in mental health clinical documentation. METHOD: Eleven case managers participated in a programme that included instruction in recovery-oriented rehabilitation principles. Outcomes were measured with automated textual analysis of clinical documentation, using a custom-built dictionary of rehabilitation-consistent, person-centred and pejorative terms. Automated analyses were run on Konstanz Information Miner (KNIME), an open-source data analytics platform. Differences in the frequency of term categories in 50 pre-training and 77 post-training documents were analysed with inferential statistics. RESULTS: The average percentage of sentences with recovery-oriented rehabilitation terms increased from 37% before the intervention to 48% afterward, a relative increase of 28% (P < 0.001). There was no significant change in use of person-centred or pejorative terms, possibly because of a relatively high frequency of person-centred language (22% of sentences) and low use of pejorative language (2.3% of sentences) at baseline. CONCLUSIONS: This computer-driven textual analysis method identified improvements in recovery-oriented rehabilitation language following training. Our study suggests that brief interventions can affect the language of clinical documentation, and that automated text-analysis may represent a promising approach for rapidly assessing recovery-oriented rehabilitation language in mental health services.

CBTp for people with treatment refractory schizophrenia on clozapine: a systematic review and meta-analysis.

BACKGROUND: Cognitive behavioural therapy for psychosis (CBTp), an effective treatment for people with schizophrenia, may have a role in clozapine refractory schizophrenia. AIMS: A systematic-review and meta-analysis on the impact of CBTp on psychotic symptoms in people on clozapine. METHODS: We searched PubMed, Embase, PsycInfo, CINAHL and Cochrane for randomised control trials of CBTp as augmentation in people with treatment-refractory schizophrenia on clozapine and conducted pair-wise meta-analyses. RESULTS: Four studies met inclusion criteria. On pairwise meta-analyses, the primary outcome of total psychotic symptoms was not significantly altered by CBTp at either therapy endpoint or six to twelve months follow-up. Secondary outcomes showed that CBT improved positive symptoms at both therapy endpoint (SMD -0.33, 95%CI -0.50 to -0.16, p = 0.002, I2 = 0%) and six to twelve months follow-up (SMD -0.20, 95%CI -0.38 to -0.02, p = 0.03, I2 = 0%) though did not alter negative psychotic symptoms at either timepoint. CONCLUSIONS: CBTp may lead to small benefits for positive symptoms refractory to clozapine. Given the low risks associated with CBTp, and the limited alternative options for clozapine refractory schizophrenia, this approach should be considered in this population.

Staff Experiences of Integrating Peer Support Workers and Clinical Staff in Community-Based Residential Mental Health Rehabilitation: A Pragmatic Grounded Theory Analysis.

Mental health services are increasingly incorporating the views and expertise of people with a lived experience of mental illness in service delivery. A novel approach to this is the 'integrated staffing model' being trialled at two Australian public residential mental health rehabilitation services (Community Care Units, CCUs) where peer support workers (PSWs) occupy the majority of staff roles and work alongside clinicians. Semi-structured interviews were completed with fifteen staff 12-to-18-months after service commencement. Transcripts were analysed following principles of grounded theory analysis. Key emergent themes were: (1) recovery is a deeply personal and non-linear process; (2) The CCU as a transitional learning environment; (3) the integrated staffing model facilitates an effective rehabilitation team; and (4) coming together under the integrated staffing model required a steep learning curve. The findings suggest that the integrated staffing approach may provide a pathway to facilitate the meaningful inclusion of PSWs in rehabilitation settings.

Cognitive remediation therapy: is it a feasible and acceptable psychological treatment for borderline personality disorder?

OBJECTIVE: Cognitive remediation (CR) is increasingly being used to address the cognitive impairment that can occur in people diagnosed with borderline personality disorder (BPD). This study aimed to understand attitudes towards CR in this service user group from the perspective of the person with the diagnosis and clinicians involved in their care. METHOD: Anonymous online surveys were made available to people with a diagnosis of BPD in a public mental health service and clinicians of the same service. RESULTS: Thirty-three percent of service users with a diagnosis of BPD responded to the survey. Most respondents (93%) expressed a desire to improve their cognition and were interested in cognitive remediation therapy (83%). Most staff (88%) recognised cognitive impairment can occur in people with a diagnosis of BPD and the same proportion believed cognitive skills impact on patient's emotional and mental health. Seventy percent of respondents believed CR would be useful for this service user group. CONCLUSIONS: It is important that interventions to address the cognitive impairment associated with BPD are made available and that they are well integrated into the person's overall care plan.

Formulation in psychiatry - a guide to developing competence.

OBJECTIVE: This paper highlights the importance of psychiatric formulation and provides guidance to those learning the art of formulation. To achieve this, we explore the guidance on formulation that has been previously published in Australasian Psychiatry, identify the key components of psychiatric formulation, and outline an approach to comprehensive formulation in routine clinical practice. CONCLUSION: Formulation is the foundation of good psychiatric practice but presents a considerable challenge to the novice practitioner. Understanding the ingredients of formulation and a method for meaningfully putting these together will guide deliberate practice to learn the art of psychiatric formulation.

Understanding the Impact of COVID-19 on People with Severe and Persistent Mental Illness within Rehabilitation Services: A Thematic Analysis.

The COVID 19 pandemic has required major changes in healthcare delivery. This study sought to understand the impact of the mental healthcare changes associated with COVID-19 on people living with severe and persisting mental illness (SPMI) and staff working in rehabilitation teams in Queensland in Australia. Telephone interviews were completed with participants diagnosed with SPMI who were supported by the rehabilitation teams of a public mental health service (n = 18). Additionally, an anonymous survey was completed with staff from these teams (n = 20, 17.5% of staff). Both datasets were analysed separately using thematic analysis. Four themes were identified through the analysis of the patient interviews: wishing the whole thing would go away; [COVID-19 has] delayed my recovery; being more socially aware; and (you've) got to be clean (which is a) good thing. Four themes emerged through the analysis of the staff survey data: needing to change the model of care; impact on patients, the impact on staff, positive impact. The perceived impact on participant's mental health was like that which was reported in the general population. Participants' emphasised anxiety, loneliness, boredom, and depression rather than a relapse of their primary psychotic illness. Participants noted the pandemic slowed the pace of personal recovery and limited the delivery of specialised rehabilitation programs. Supplementary Information: The online version contains supplementary material available at 10.1007/s40737-022-00320-5.

Biopsychology of Physical Activity in People with Schizophrenia: An Integrative Perspective on Barriers and Intervention Strategies.

People with severe mental illness such as schizophrenia experience high physical comorbidity, leading to a 15-20-year mortality gap compared with the general population. Lifestyle behaviours such as physical activity (PA) play important roles in the quest to bridge this gap. Interventions to increase PA engagement in this population have potential to be efficacious; however, their effectiveness can be hindered by low participant engagement, including low adherence and high drop-out, and by implementation of interventions that are not designed to compensate for the cognitive and motivational impairments characteristic for this group. Moreover, and importantly, the negative symptoms of schizophrenia are associated with neurobiological changes in the brain, which-based on principles of biopsychology-can contribute to poor motivation and impaired decision-making processes and behavioural maintenance. To increase PA levels in people with schizophrenia, better understanding of these neurological changes that impact PA engagement is needed. This has the potential to inform the design of interventions that, through enhancement of motivation, could effectively increase PA levels in this specific population. Incorporating strategies that address the dopamine dysregulation associated with schizophrenia, such as boosting the role of reward and self-determined motivation, may improve long-term PA maintenance, leading to habitual PA. Consideration of motivation and behavioural maintenance is also needed to impart health benefits such as prevention of chronic disease, which is associated with currently low PA levels in this high metabolic risk population. Taking a biopsychological perspective, we outline the neural pathways involved in motivation that are impacted by schizophrenia and propose strategies for promoting motivation for and PA engagement from adoption to habit formation.

N-Acetylcysteine (NAC) in Schizophrenia Resistant to Clozapine: A Double-Blind, Randomized, Placebo-Controlled Trial Targeting Negative Symptoms.

BACKGROUND AND HYPOTHESIS: Clozapine is the most effective antipsychotic for treatment-resistant schizophrenia, yet a significant proportion of individuals on clozapine continue to experience disabling symptoms, despite being treated with an adequate dose. There is a need for adjunct treatments to augment clozapine, notably for negative and cognitive symptoms. One such potential agent is the glutathione precursor N-acetylcysteine (NAC). STUDY DESIGN: A randomized double-blind, multi-center, placebo-controlled trial for clozapine patients with enduring psychotic symptoms (n = 84) was undertaken to investigate the efficacy of adjunctive NAC (2 g daily) for negative symptoms, cognition and quality of life (QoL). Efficacy was assessed at 8, 24, and 52 weeks. STUDY RESULTS: NAC did not significantly improve negative symptoms (P = .62), overall cognition (P = .71) or quality of life (Manchester quality of life: P = .11; Assessment of quality of life: P = .57) at any time point over a 1-year period of treatment. There were no differences in reported side effects between the groups (P = .26). CONCLUSIONS: NAC did not significantly improve schizophrenia symptoms, cognition, or quality of life in treatment-resistant patients taking clozapine. This trial was registered with "Australian and New Zealand Clinical Trials" on the 30 May, 2016 (Registration Number: ACTRN12615001273572).

A Randomized Control Trial of Cognitive Compensatory Training (CCT) and Computerized Interactive Remediation of Cognition-Training for Schizophrenia (CIRCuiTS).

Background: Various modes of delivering cognitive remediation (CR) are effective, but there have been few head-to-head trials of different approaches. This trial aimed to evaluate the relative effectiveness of two different programmes, Cognitive Compensatory Training (CCT) and Computerized Interactive Remediation of Cognition-Training for Schizophrenia (CIRCuiTs). Methods: The study used a single-blind randomized, controlled trial to examine the efficacy and effectiveness of the two therapies. The study aimed to enroll 100 clinically stable patients between the ages of 18 and 65 years who had been diagnosed with a schizophrenia spectrum disorder. Participants were randomized to either the CCT or CIRCuiTs therapy groups. The primary outcome measures were neurocognition using the Brief Assessment of Cognition Scale (BACS) and the Subjective Scale to Investigate Cognition in Schizophrenia (SSTICS). The secondary measure was functional outcomes using the Social Functioning Scale (SFS). Results: There was no group difference in any of the outcome measures post-intervention or at follow-up. Both groups had a small improvement on their SSTICS scores between baseline (M = 30.52 and SD = 14.61) and post-intervention (M = 23.96 and SD = 10.92). Verbal memory scores as measured by list learning improved for both groups between baseline (z = -1.62) and 3-month follow-up (z = -1.03). Both groups improved on the token motor task between baseline (z = -1.38) and post-intervention (z = -0.69). Both groups had a decline in Symbol Coding scores between baseline (z = 0.05) and 3-month follow-up (z = -0.82). Discussion: This underpowered study found no difference in effect between the two approaches studied. If future studies confirm this finding, then it has implications for services where cost and lack of computer technology could pose a barrier in addressing the cognitive domain of schizophrenia spectrum disorders. The final sample size compromised the power of the study to conclusively determine a significant effect.

Adapting evidence-based group therapies following COVID-19 restrictions.

AIM: The COVID-19 pandemic has created barriers to the running of group therapies due to the need to maintain social distance. This paper aims to describe modifications of existing therapeutic groups delivered to people diagnosed with serious and enduring mental illnesses (SMIs) to enable the therapies to continue in an online format due to the COVID-19 restrictions. CONCLUSIONS: Therapists and consumers were motivated to find a way to continue the therapies described despite the context of the restrictions imposed due to COVID-19. This paper describes what was involved in 'pivoting' to a new mode of practice and modifications that were required over time and as new regulations were put in place. Formal research is required to establish an evidence base if these therapies were required to be regularly delivered in an online mode.

Consumer experiences of community-based residential mental health rehabilitation for severe and persistent mental illness: A pragmatic grounded theory analysis.

Semi-structured interviews were used to explore the consumer experience of community-based residential mental health rehabilitation support at Community Care Units in Australia. These clinical services provide recovery-oriented residential rehabilitation to people affected by severe and persistent mental illness. Typically, nurses occupy the majority of staff roles. However, two of the three sites in the study were trialling a novel integrated staffing model where the majority of staff were people with a lived experience of mental illness employed as peer support workers (PSWs). The interviews explored consumers' experiences of care 12-18 months after admission. Fifteen interviews were completed with an independent interviewer. Most participants were diagnosed with schizophrenia or a related psychotic disorder. The analysis followed a pragmatic approach to grounded theory. Consumers viewed the CCU favourably, emphasizing the value of the relationships formed with staff and co-residents. No major differences in consumers' experience under the traditional versus integrated staffing models were identified; however, those from the integrated staffing model sites valued the contributions of the peer support workers. The understanding of the consumer experience emerging through this study aligned with their expectations of the service at the time of commencement.

Placing rehabilitation at the core of assertive community treatment.

OBJECTIVES: Assertive community treatment (ACT) teams are increasingly being adapted to suit the needs of consumers who have never experienced long-term institutional care yet struggle to retain community tenure and quality of life due to residual functional disabilities associated with severe mental illness. Support needs can be provided by the growing disability support sector but recovery-orientated rehabilitation services delivered by specialist rehabilitation clinicians are also required. The Mobile Intensive Rehabilitation Team (MIRT) within the Metro South Addiction and Mental Health Service has adapted the ACT model to deliver assertive outreach that aims to work collaboratively with the person and their chosen supports to improve their function and their sense of self-efficacy in illness self-management. We described the characteristics of the consumers referred to MIRT over a 20-month time period, and reported on on their discharge location. CONCLUSION: After two years with MIRT, half the participants were discharged out of case-management. Being on clozapine was a barrier to discharge from case-management despite functional improvement. Psychiatric hospitalisations predicted longer duration working with MIRT.