Psychometric Assessment of an Item Bank for Adaptive Testing on Patient-Reported Experience of Care Environment for Severe Mental Illness: Validation Study.

BACKGROUND: The care environment significantly influences the experiences of patients with severe mental illness and the quality of their care. While a welcoming and stimulating environment enhances patient satisfaction and health outcomes, psychiatric facilities often prioritize staff workflow over patient needs. Addressing these challenges is crucial to improving patient experiences and outcomes in mental health care. OBJECTIVE: This study is part of the Patient-Reported Experience Measure for Improving Quality of Care in Mental Health (PREMIUM) project and aims to establish an item bank (PREMIUM-CE) and to develop computerized adaptive tests (CATs) to measure the experience of the care environment of adult patients with schizophrenia, bipolar disorder, or major depressive disorder. METHODS: We performed psychometric analyses including assessments of item response theory (IRT) model assumptions, IRT model fit, differential item functioning (DIF), item bank validity, and CAT simulations. RESULTS: In this multicenter cross-sectional study, 498 patients were recruited from outpatient and inpatient settings. The final PREMIUM-CE 13-item bank was sufficiently unidimensional (root mean square error of approximation=0.082, 95% CI 0.067-0.097; comparative fit index=0.974; Tucker-Lewis index=0.968) and showed an adequate fit to the IRT model (infit mean square statistic ranging between 0.7 and 1.0). DIF analysis revealed no item biases according to gender, health care settings, diagnosis, or mode of study participation. PREMIUM-CE scores correlated strongly with satisfaction measures (r=0.69-0.78; P<.001) and weakly with quality-of-life measures (r=0.11-0.21; P<.001). CAT simulations showed a strong correlation (r=0.98) between CAT scores and those of the full item bank, and around 79.5% (396/498) of the participants obtained a reliable score with the administration of an average of 7 items. CONCLUSIONS: The PREMIUM-CE item bank and its CAT version have shown excellent psychometric properties, making them reliable measures for evaluating the patient experience of the care environment among adults with severe mental illness in both outpatient and inpatient settings. These measures are a valuable addition to the existing landscape of patient experience assessment, capturing what truly matters to patients and enhancing the understanding of their care experiences. TRIAL REGISTRATION: ClinicalTrials.gov NCT02491866; https://clinicaltrials.gov/study/NCT02491866.

Development of the PREMIUM computerized adaptive testing for measuring the access and care coordination for patients with severe mental illness.

Severe mental illness (SMI) patients often have complex health needs, which makes it difficult to access and coordinate their care. This study aimed to develop a computerized adaptive testing (CAT) tool, PREMIUM CAT-ACC, to measure SMI patients' experience with access and care coordination. This multicenter and cross-sectional study included 496 adult in- and out-patients with SMI (i.e., schizophrenia, bipolar disorder, or major depressive disorder). Psychometric analysis of the 13-item bank showed adequate properties, with preliminary evidence of external validity and no substantial differential item functioning for sex, age, care setting, and diagnosis, making it suitable for CAT administration. A post-hoc CAT simulation demonstrated that the tool was efficient and accurate, with an average of seven items, compared to the full item bank administration. Its use by clinicians can contribute to optimizing patient care pathways and transitioning towards more person-centered healthcare.

Potentially inappropriate psychotropic prescription at discharge is associated with lower functioning in the elderly psychiatric inpatients. A cross-sectional study.

OBJECTIVE: The objectives are to determine the rate of potentially inappropriate psychotropic (PIP) prescription at discharge in the elderly psychiatric inpatients and to determine whether PIP is associated with lowered functioning outcomes. METHODS: Sociodemographic, clinical, and treatment data for all inpatients aged ≥ 65 years consecutively hospitalized during 1 year in 13 psychiatry departments was analyzed. PIP+/PIP- groups were defined according to the French-updated Beers criteria. Daily functioning was evaluated by the daily living (ADL) scale. Logistic regression analysis was used to estimate odds ratios for the association between PIP administration at discharge and respectively functioning and potential confounding factors. RESULTS: Data was obtained for 327 patients. Overall, 124 (37.9 %) patients were males, and the mean age was 73.9 years (SD = 5.6); 163 (49.8 %) patients were diagnosed with affective disorders and 89 (27.2 %) with schizophrenia/schizotypal/delusional disorders. Overall, 249 (76.1 %) had one or more PIP medications, mainly anxiolytics (69.9 %) and hypnotics (17.2 %). In a multivariate analysis, PIP prescription at discharge has been associated with patient lowered personal care functioning, independently of age, gender, and psychiatric or somatic diagnoses (OR = 0.88 (0.79-0.97, p = 0.01). CONCLUSION: In the current increasingly fragmented health care systems, special attention must be given to PIP prescription in older population suffering from psychiatric disorders. Using the Beers criteria, the present study demonstrates the high prevalence of PIP prescription, which concerns a large panel of drugs but mostly anxiolytics and hypnotics independently of psychiatric or somatic diagnoses and sociodemographic characteristics. Our study has demonstrated for the first time an association between PIP prescription and lowered patient functioning. Further longitudinal studies should confirm a potential causal relation.

Schizophrenia-spectrum patients treated with long-acting injectable risperidone in real-life clinical settings: functional recovery in remitted versus stable, non-remitted patients (the EVeREST prospective observational cohort study).

BACKGROUND: Previous studies showed functional improvement in stable patients with schizophrenia treated with risperidone long-acting injection (LAI). We therefore re-investigated functional improvement with risperidone LAI in remitted patients, in comparison with stable patients. The study was conducted in real-life conditions because of the high heterogeneity of the patients' situations. METHOD: This was a multi-centre, prospective observational cohort study involving adult schizophrenia-spectrum chronic patients who were previously treated with risperidone LAI for 6 months. Remission was evaluated using the consensus criteria proposed by the Remission in Schizophrenia Working Group (RSWG). The primary endpoint was global functioning (assessed with the Global Assessment of Functioning scale, GAF) after one year of treatment. Social functioning was a secondary outcome. RESULTS: The analysis included 1490 patients. Attrition rate was 9.1 % at the end of the study. 27.7 % of patients were in remission after one year of risperidone LAI treatment. The mean GAF rating score (62.5 ± 1.5) was higher than the cut-off previously used to identify patients with satisfactory functioning (60) and significantly higher than the mean GAF score in stable, non-remitted patients (48.3, p < 0.001). Social functioning was also high in remitted patients (21.0 ± 3.6 vs. 17.2 ± 3.7 in non-remitted patients, p < 0.001). CONCLUSION: The results clearly show that after one year of treatment with risperidone LAI, RSWG-remitted patients have a high level of global functioning, which is significantly higher than in stable, non-remitted patients. Social functioning was also higher in remitted patients as compared with stable, non-remitted patients.

Association of metabolic syndrome and inflammation with neurocognition in patients with schizophrenia.

The aim of this study is to assess the relationships of metabolic syndrome (MetS) and inflammation with neurocognition in schizophrenia. In this cross-sectional study, we included patients with diagnosis of schizophrenia according to the DSM-IV-TR criteria. We collected socio-demographic information, clinical characteristics, anthropometric measurements, blood tests, and neurocognition measures. A multivariate analysis using multiple linear regressions was performed to determine variables that are potentially associated with neurocognition. The analyses were repeated using MetS as a dichotomised variable (< and ≥ 3 MetS criteria), a continuous variable (number of MetS criteria present), and for each component of MetS. One hundred and sixty-eight outpatients participated in our study. The prevalence of MetS was 27.4%. An association was found between the number of MetS criteria present and cognitive impairment. Among the different components of MetS, hypertriglycerides and abdominal obesity were the only factors associated with cognitive impairment. Other factors, such as smoking and alcohol dependence or abuse, also revealed a significant relationship, whereas inflammation was not associated with cognitive impairment. In conclusion, our findings suggest that MetS, alcohol use and non-smoking status are associated with cognitive impairment. These findings may support complementary therapeutic approaches in cognitive remediation that lessen the severity of cognitive impairment in schizophrenia.

Are cardiovascular risk factors associated with verbal learning and memory impairment in patients with schizophrenia? A cross-sectional study.

Objective. The aim of this study is to assess the relationships of cardiovascular risk factors with verbal learning and memory in patients with schizophrenia. Methods and Design. cross-sectional study. Inclusion Criteria. Diagnosis of schizophrenia according to the DSM-IV-TR criteria. Data Collection. Sociodemographic information, clinical characteristics, anthropometric measurements, blood tests, and episodic memory using the California Verbal Learning Test (CVLT). Analysis. A multivariate analysis using multiple linear regressions was performed to determine variables that are potentially associated with verbal learning and memory. Results. One hundred and sixty-eight outpatients participated in our study. An association was found between the metabolic syndrome (MetS) and memory impairment on measures of verbal learning, and short- and long-term memory. Among the different components of MeTS, hypertriglycerides, abdominal obesity, and low HDL cholesterol were the only factors associated with memory impairment. Alcohol dependence or abuse was associated with a higher rate of forgetting. Conclusion. Our findings suggest that MetS and alcohol use may be linked with memory impairment in schizophrenia. These findings provide important insights into the interdependencies of cardiovascular risk factors and cognitive disorders and support novel strategies for treating and preventing cognitive disorders in patients with schizophrenia.

Neurocognition, insight and medication nonadherence in schizophrenia: a structural equation modeling approach.

OBJECTIVE: The aim of this study was to examine the complex relationships among neurocognition, insight and nonadherence in patients with schizophrenia. DESIGN: Cross-sectional study. INCLUSION CRITERIA: Diagnosis of schizophrenia according to the DSM-IV-TR criteria. DATA COLLECTION: Neurocognition was assessed using a global approach that addressed memory, attention, and executive functions; insight was analyzed using the multidimensional 'Scale to assess Unawareness of Mental Disorder;' and nonadherence was measured using the multidimensional 'Medication Adherence Rating Scale.' ANALYSIS: Structural equation modeling (SEM) was applied to examine the non-straightforward relationships among the following latent variables: neurocognition, 'awareness of positive symptoms' and 'negative symptoms', 'awareness of mental disorder' and nonadherence. RESULTS: One hundred and sixty-nine patients were enrolled. The final testing model showed good fit, with normed χ(2) = 1.67, RMSEA = 0.063, CFI = 0.94, and SRMR = 0.092. The SEM revealed significant associations between (1) neurocognition and 'awareness of symptoms,' (2) 'awareness of symptoms' and 'awareness of mental disorder' and (3) 'awareness of mental disorder' and nonadherence, mainly in the 'attitude toward taking medication' dimension. In contrast, there were no significant links between neurocognition and nonadherence, neurocognition and 'awareness of mental disorder,' and 'awareness of symptoms' and nonadherence. CONCLUSIONS: Our findings support the hypothesis that neurocognition influences 'awareness of symptoms,' which must be integrated into a higher level of insight (i.e., the 'awareness of mental disorder') to have an impact on nonadherence. These findings have important implications for the development of effective strategies to enhance medication adherence.

Frequent visits to a French psychiatric emergency service: diagnostic variability in psychotic disorders.

OBJECTIVE: This study examined characteristics of frequent visitors to a psychiatric emergency service in a French public teaching hospital over six years. Diagnostic variability of psychotic disorders was documented. METHODS: A retrospective review of the service's administrative and medical databases identified 1,285 patients with more than one visit during the period who were given at least one diagnosis of a psychotic disorder. A total of 317 patients with six or more visits (frequent visitors) were compared with 968 patients with between two and five visits (occasional visitors). RESULTS: Frequent visitors were significantly more likely to be single and homeless and to have diagnostic variability, substance use disorders, and personality disorders. A total of 177 patients experienced diagnostic variability, which was found mainly in three diagnostic categories: schizophrenia, schizoaffective disorder, and bipolar disorder with psychotic features. CONCLUSIONS: Future studies should further examine the link between increased use of emergency services and diagnostic variability.

Factors associated with medication non-adherence in patients suffering from schizophrenia: a cross-sectional study in a universal coverage health-care system.

OBJECTIVE: To quantify the factors associated with non-adherence to medication among stable patients suffering from schizophrenia in the context of universal access to care. METHODS: This naturalistic, multicentric study was conducted in 15 French public hospitals in a region of south-eastern France during a 1 week period in 2008. All consecutive outpatients with stable schizophrenia were recruited. Adherence was assessed with the 10-item Drug Attitude Inventory (DAI). Measures included socio-demographic characteristics, clinical characteristics, insight using the Scale to assess Unawareness of Mental Disease (SUMD), and therapeutic alliance using the Patient Session Questionnaire (PSQ). Regression models were used to identify the risk factors associated with non-adherence. RESULTS: The study included 291 patients, 30% of whom were considered to be non-adherent. Non-adherence increased with duration of untreated psychosis (DUP) (OR = 1.12, 95%CI = 1.03-1.22), lack of insight only for the dimension 'effect of medication' (OR = 3.23, 95%CI = 1.05-9.89), and a low level of therapeutic alliance (OR = 0.45, 95%CI = 0.32-0.64). Individuals prescribed atypical antipsychotic drugs were more likely to be adherent than those prescribed typical antipsychotics (OR = 0.37, 95%CI = 0.13-1.0). CONCLUSIONS: DUP, prescription of typical antipsychotics, therapeutic alliance and insight were the most important features associated with non-adherence. This study also suggests that economic factors such as the service delivery system should not be neglected in public strategies aimed at addressing problems of non-adherence in non-universal coverage health systems.

Schizophrenia: the quest for a minimum sense of identity to ward off delusional disorder.

OBJECTIVE: This study was designed to analyze the language of patients with schizophrenia exhibiting negative symptoms during a 3-month period. METHOD: The computer-assisted ALCESTE method was used to simultaneously analyze the subjects' oral behaviour and speech patterns at various levels. RESULTS: The tested subjects had very specific speech patterns. Most significantly, analysis of the underlying syntactic processes showed that the patients exhibited a sense of identity, however minimum, based on their own pathologies and on the surrounding world. In our previous study, no such characteristics were observed in the discourse of schizophrenia patients with delusions (exhibiting positive symptoms). This suggests that the minimum sense of identity that develops in patients with schizophrenia allows them to avoid positive symptoms. CONCLUSION: In studies of language production by subjects suffering from schizophrenia, it is necessary to distinguish between patients with positive symptoms and those with negative symptoms. The speech patterns of these 2 groups have to be analyzed separately, which has not been done previously, since the groups differ in too many respects.