Fidelity and Clinical Competence in Providing Illness Management and Recovery: An Explorative Study.

Illness Management and Recovery (IMR) is a psychosocial intervention supporting people with serious mental illnesses. In this study, 15 IMR groups were assessed for fidelity and clinician competency to establish the implementation level of all IMR elements and explore complementarity of the IMR Treatment Integrity Scale (IT-IS) to the standard IMR Fidelity Scale. Use of the IT-IS was adapted, similar to the IMR Fidelity Scale. Descriptive statistics were applied. Implementation success of IMR elements varied widely on the IMR Fidelity Scale and IT-IS (M = 3.94, SD = 1.13, and M = 3.29, SD = 1.05, respectively). Twelve IMR elements (60%) were well-implemented, whereas eight (40%) were implemented insufficiently, including some critical cognitive-behavioral techniques (e.g., role-playing). The scales appeared largely complementary, though strongly correlated (r (13) = 0.74, p = 0.002). Providing all IMR elements adequately requires a variety of clinical skills. Specific additional training and supervision may be necessary.

Adding EMDR for PTSD at the onset of treatment of borderline personality disorder: A pilot study.

BACKGROUND AND OBJECTIVES: Eye movement desensitization and reprocessing (EMDR) is an effective treatment for individuals suffering from posttraumatic stress disorder (PTSD). However, EMDR is not typically offered to people with PTSD who also meet the criteria for borderline personality disorder (BPD). This study examines the feasibility and clinical benefits of EMDR for PTSD delivered in addition to the onset of treatment as usual (TAU) for BPD. METHODS: In a non-concurrent, multiple baseline design, 12 patients with BPD and PTSD received fifteen weekly 45-min sessions of TAU. During this period, eight weekly 90-min EMDR sessions were added. Outcome measures were obtained weekly for self-reported PTSD symptoms (PTSD checklist for DSM-5), levels of psychopathology (Brief Symptom Checklist), and the effect of psychopathology on different areas of life (Sheehan Disability Scale). RESULTS: 9 participants completed the treatment protocol. In the EMDR phase, PTSD severity scores decreased significantly between sessions, while no between-session drop in scores occurred during the TAU only phase. Similar results were obtained for general symptoms and disability. No adverse events were reported. LIMITATIONS: Results on the efficacy and safety of EMDR in patients with BPD and PTSD need to be replicated in larger samples and in RCTs before they can be generalized to the entire population. CONCLUSIONS: The results of our study suggest that EMDR may be feasible and effective in reducing PTSD symptoms in patients concurrently receiving BPD treatment. EMDR appears to be a promising intervention for patients with BPD and comorbid PTSD.

Impact of Comorbid Personality Disorders on Depression Treatment in Routine Outpatient Care.

OBJECTIVE: The impact of personality disorder on treatment effectiveness for depression has been debated, and study results have been inconsistent. However, studies that report a negative impact of personality disorders on depression treatment outcomes are often characterized by uncontrolled treatment designs. Within such contexts, individuals with depression and personality disorders are at risk to receive suboptimal treatment. The aim of this retrospective observational study was to investigate whether and to what extent comorbid personality disorders were associated with the type and amount of depression treatment received in routine outpatient care. METHODS: Retrospectively extracted data from electronic records of 1,455 outpatients treated for depression at several sites of a nationwide mental health provider in the Netherlands were included. The type and number of treatment sessions and visits were analyzed by using regression models. RESULTS: Individuals with depression and comorbid personality disorders received more psychotherapy sessions than individuals without personality disorders, irrespective of depression severity. The number of pharmacotherapy sessions and supportive and crisis visits did not differ between individuals with and without comorbid personality disorders. CONCLUSIONS: Individuals with depression and personality disorders received more intensive treatment than individuals without comorbid personality disorders. These results conflict with treatment guidelines and recommendations from high-quality studies and may be indicative of overtreatment among this large group of patients.

Effects of Illness Management and Recovery: A Multicenter Randomized Controlled Trial.

There have been inconsistent findings in the literature with respect to the efficacy of Illness Management and Recovery (IMR) in the psychosocial treatment of people with schizophrenia or other severe mental illnesses. This study aimed to comprehensively investigate the effectiveness of IMR, including the impact of completion and fidelity. In this randomized controlled trial (RCT), 187 outpatients received either IMR plus care as usual (CAU) or only CAU. Multilevel modeling was implemented to investigate group differences over an 18-month period, comprising 12 months of treatment and six months of follow-up. The primary outcome was overall illness management, which was assessed using the client version of the IMR scale. Secondary outcomes included measures regarding illness management, clinical, personal, and functional recovery, and hospitalizations. The interviewers were blinded to group allocation. This clinical trial was registered with the Netherlands Trial Register (NL4931, NTR5033). Patients who received IMR showed statistically significant improvement in self-reported overall illness management (the primary outcome). Moreover, they showed an improvement in self-esteem, which is a component of personal recovery. There were no effects within the other questionnaires. There were also no statistically significant between-group differences in terms of hospitalizations. Patients in both groups showed statistically significant improvement in clinician-rated overall illness management, social support, clinical and functional recovery, and self-stigma over time. IMR completion was associated with stronger effects. High IMR fidelity was associated with self-esteem. This study confirms the efficacy of IMR in overall illness self-management. To our knowledge, this is the first RCT on IMR to explore the impact of fidelity on treatment efficacy. Future studies should further establish efficacy in personal recovery. To improve efficacy, it appears important to promote IMR completion and fidelity.

Impact of Comorbid Personality Disorders on Depression Treatment in Routine Outpatient Care.

OBJECTIVE: The impact of personality disorder on treatment effectiveness for depression has been debated, and study results have been inconsistent. However, studies that report a negative impact of personality disorders on depression treatment outcomes are often characterized by uncontrolled treatment designs. Within such contexts, individuals with depression and personality disorders are at risk to receive suboptimal treatment. The aim of this retrospective observational study was to investigate whether and to what extent comorbid personality disorders were associated with the type and amount of depression treatment received in routine outpatient care. METHODS: Retrospectively extracted data from electronic records of 1,455 outpatients treated for depression at several sites of a nationwide mental health provider in the Netherlands were included. The type and number of treatment sessions and visits were analyzed by using regression models. RESULTS: Individuals with depression and comorbid personality disorders received more psychotherapy sessions than individuals without personality disorders, irrespective of depression severity. The number of pharmacotherapy sessions and supportive and crisis visits did not differ between individuals with and without comorbid personality disorders. CONCLUSIONS: Individuals with depression and personality disorders received more intensive treatment than individuals without comorbid personality disorders. These results conflict with treatment guidelines and recommendations from high-quality studies and may be indicative of overtreatment among this large group of patients.

Intervention to prevent and manage the effects of victimization related to social participation for people with severe mental illness: Results from a cluster randomized controlled trial.

OBJECTIVE: Individuals with severe mental illness often face (anticipated) discrimination and (criminal) victimization, which have severe consequences for their social participation. The aim of the present study is to assess the effectiveness of a new intervention to manage and prevent revictimization, and to support safe participation by recognizing and acknowledging the impact of their victimization experiences. METHOD: A multicenter cluster randomized controlled trial was performed by following clients from four intervention teams and four teams providing care as usual. The primary outcomes were social participation, victimization, and discrimination. The secondary outcomes were acknowledgment of difficulties, self-efficacy and empowerment, quality of life, and psychosocial functioning. Data were collected at baseline, and after 10- and 20-month follow-ups. The data were analyzed according to the intention-to-treat principle using linear mixed models and generalized estimating equations. In total, 400 clients were included in the analyses: 216 in the intervention group and 184 in the control group. RESULTS: For experienced discrimination and acknowledgment of difficulties and recovery support, we found small but significant time by condition interactions after 20 months. Both experienced and anticipated discrimination, and self-efficacy increased slightly in both groups. No significant differences were found for other outcome measures. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The intervention had no effect on victimization and participation, but there were indications that it was successful in moderating experienced discrimination. The clients also felt significantly more acknowledged and supported in their recovery process. Further development of the intervention is needed, and future research should focus on improving implementation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Determinants of clinical, functional and personal recovery for people with schizophrenia and other severe mental illnesses: A cross-sectional analysis.

OBJECTIVE: To analyze the relationships between insight, medication adherence, addiction, coping and social support-components of Illness Management and Recovery (IMR)-as determinants of clinical, functional and personal recovery in patients with schizophrenia and other severe mental illnesses. Our rationale lay in the interrelations between these concepts suggested in a conceptual framework of IMR. METHODS: The cross-sectional design used baseline data of outpatient participants in a randomized clinical trial on IMR (N = 187). We used structural equation modeling (SEM) to describe pathways between degrees of insight, medication adherence, addiction, coping and social support, and degree of clinical, functional and personal recovery. We also explored whether clinical recovery mediated functional and personal recovery. RESULTS: Our final model showed that coping was associated with clinical, functional and personal recovery. Direct associations between coping and functional and personal recovery were stronger than indirect associations via clinical recovery. Although SEM also showed a significant but weak direct pathway between social support and functional recovery, there were no significant pathways either between social support and clinical or personal recovery, or between insight, medication adherence, addiction and any type of recovery. CONCLUSIONS: Coping may be a determinant of all three types of recovery, and social support a determinant of functional recovery. Clinical recovery appears not to be a prerequisite for functional or personal recovery. While our results also suggest the relevance of improving coping skills and of enhancing social support, they only partially support the conceptual framework of IMR.

Illness Management & Recovery (IMR) in the Netherlands; a naturalistic pilot study to explore the feasibility of a randomized controlled trial.

BACKGROUND: Illness Management & Recovery (IMR) is a curriculum-based program for people with severe and persistent mental illness. To date, four randomized controlled trials (RCTs) have been published on it. As these produced mixed results, we conducted a pilot study to test the feasibility of conducting a new RCT in a Dutch psychiatric institute. Because our primary objective was to evaluate support for implementing IMR on a broader scale, we examined participant recruitment, client outcomes, and clients' and clinicians' satisfaction. Secondary objectives were to evaluate fidelity, trainers' training and supervision, and to explore program duration, dropout, and client characteristics related to dropout. For reporting, we used the checklist for pilot studies adopted from the CONSORT Statement. METHODS: This program evaluation included a process-evaluation and an outcome evaluation with a One Group Pre-Posttest Design (N = 81). Interviews and internal reports were used to monitor participant numbers, program duration, dropout, and completers' characteristics. Clients' and clinicians' satisfaction and provision of trainers' training and supervision were assessed through interviews. Fidelity was assessed on the IMR Fidelity Scale; client outcomes were assessed on the IMR scale (client and clinician versions) and the Recovery Markers Questionnaire (RMQ). RESULTS: Eighty-one participants were recruited of 167 people who were assessed for eligibility. Completers and clinicians were satisfied, and scores for completers improved significantly on the IMR scale (clinician version) (d = 0.84) and RMQ (d = 0.52), and not significantly on the IMR scale client version (d = 0.41). Mean fidelity was good, but three groups had only moderate fidelity. Our feasibility criterion for trainers' education and supervision was partly attained. Dropout from treatment was 51 %; female participants and people who scored higher on both IMR-scales at baseline had a significantly lower chance of dropping out. The duration of IMR varied (M = 12.7 months, SD = 2.87). CONCLUSIONS: Results suggested that feasibility of conducting an RCT on IMR was good. Special attention is required to fidelity, IMR duration, trainers' education and supervision, and dropout, especially of men. One study limitation was our inability to conduct follow-up measurements of non-completers.

Prevalence and classification of hallucinations in multiple sensory modalities in schizophrenia spectrum disorders.

BACKGROUND: Auditory hallucinations are experienced by 60-80% of all patients diagnosed with a schizophrenia spectrum disorder. However, in this patient group, the prevalence of hallucinations in multiple sensory modalities, i.e. multimodal hallucinations (MMHs), is unknown. AIMS: To assess the prevalence of MMHs in patients diagnosed with a schizophrenia spectrum disorder, data were analyzed from 750 patients who participated in the Dutch Genetic Risk and Outcome of Psychosis (GROUP) study. METHOD: We drew on the section of the CASH (Comprehensive Assessment of Symptoms and History) that probes into the lifetime presence of auditory, visual, somatic/tactile, and olfactory hallucinations. RESULTS: A lifetime prevalence of 80% was found in this group for hallucinations in any of these modalities. Within the whole group, 27% of the participants reported unimodal hallucinations and 53% MMHs. There were no significant differences in prevalence rate for Dutch versus migrant participants from Morocco, Turkey, Surinam or the (former) Dutch Antilles. CONCLUSION: We conclude that MMHs, rather than auditory hallucinations, are the most frequent perceptual symptom of patients diagnosed with a schizophrenia spectrum disorder. Our data also suggest that hallucinations experienced in a single sensory modality (notably auditory ones) stochastically increase the risk for more sensory modalities to join in. We recommend that future studies take into account all 14 sensory modalities in which hallucinations can be experienced. For this we provide a classification of MMHs that allows characterization of their serial versus simultaneous occurrence and their congruent versus incongruent nature.

A masked negative self-esteem? Implicit and explicit self-esteem in patients with Narcissistic Personality Disorder.

The mask model of narcissism states that the narcissistic traits of patients with NPD are the result of a compensatory reaction to underlying ego fragility. This model assumes that high explicit self-esteem masks low implicit self-esteem. However, research on narcissism has predominantly focused on non-clinical participants and data derived from patients diagnosed with Narcissistic Personality Disorder (NPD) remain scarce. Therefore, the goal of the present study was to test the mask model hypothesis of narcissism among patients with NPD. Male patients with NPD were compared to patients with other PD's and healthy participants on implicit and explicit self-esteem. NPD patients did not differ in levels of explicit and implicit self-esteem compared to both the psychiatric and the healthy control group. Overall, the current study found no evidence in support of the mask model of narcissism among a clinical group. This implicates that it might not be relevant for clinicians to focus treatment of NPD on an underlying negative self-esteem.

Effectiveness of illness management and recovery (IMR) in the Netherlands: a randomised clinical trial.

BACKGROUND: Illness Management and Recovery (IMR) is intended to provide a structured psychosocial programme that helps to manage the disabling effects of severe mental illnesses such as schizophrenia and bipolar disorders. It is curriculum based and aims to improve different aspects of illness management and recovery through interventions such as goal-setting, psycho-education, coping and social skills training. Its overall aim is to improve illness outcomes and support subjective and objective recovery. To date there have been four RCTs on IMR; as these yielded mixed results, further research is needed. Our hypotheses aim to test the interrelatedness assumed in Mueser's Conceptual Framework for IMR for the many aspects of illness management, illness management outcomes and recovery. METHODS/DESIGN: This randomised multi-centre, single-blinded clinical trial is intended to compare IMR with treatment as usual for 200 outpatient clients with a severe and persistent mental illness (SMI). We will investigate whether IMR leads to better illness management, fewer symptoms and fewer relapses, and also to better subjective and objective recovery. The primary outcome measure is the score on the client version of the Illness Management and Recovery Scale. Secondary outcome measures are the clinician version of the Illness Management and Recovery scale, measures of illness management, coping, symptoms, the number of relapses, and measures of recovery. Measurement will take place before randomisation, and 12 and 18 months after randomisation. DISCUSSION: Overall, our study has the following strengths: 1.) our use of an RCT design in a country where the earlier RCTs on IMR were not conducted; 2.) the fact that participants will consist not only of people with a diagnosis of schizophrenia, but also of those with various types of SMI; 3.) our inclusion of 200 participants; and 4.) the fact that we will explore the working mechanisms described in Mueser's Conceptual Framework for IMR. Finally, 5.) because the RCT will be conducted in everyday clinical practice, we believe that the generalisability of our results will be good. TRIAL REGISTRATION: The Netherlands National Trial Register (identifier: NTR 5033 ). Date registered: 13 January 2015.

Five-Year Mental Health Care Use by Patients Referred to Collaborative Care or to Specialized Care.

OBJECTIVE: This study compared long-term use of mental health care by two groups of patients who had common mental disorders in the Netherlands-those treated in a collaborative care setting and those referred to off-site specialized mental health services if indicated. METHODS: The study was a retrospective analysis of use of mental health care over five years by 139 patients who participated in a cluster-randomized parent study. The parent study involved 27 general practitioners (GPs) who provided either collaborative care or usual care. In the collaborative care condition, a mental health professional worked on site at the GP's practice and was available to provide short-term treatment. In the usual-care condition, the GP referred the patient to off-site specialized mental health services if indicated; if not indicated, the GP provided usual care. The two treatment groups were compared on the number of mental health care contacts and total treatment duration, the proportion that initiated a new treatment episode after termination of the initial treatment, and time to new treatment. RESULTS: Patients in the collaborative care condition received about half the number of mental health care contacts as those in the usual-care condition, and no differences were found in the rate of initiation of new treatment episodes after initial treatment, time to new treatment, and total treatment duration. CONCLUSIONS: Referral of patients with common mental disorders to collaborative mental health care as a first intervention led to fewer contacts with a mental health care professional over the long term, compared with referral to specialized mental health care.

Disturbed emotion recognition in patients with narcissistic personality disorder.

Although theoretically the lack of empathy is a supposed key symptom of narcissistic personality disorder (NPD), empirical studies examining empathy in NPD are scarce. In the present study it was examined whether patients with NPD differ from healthy controls and a psychiatric control group in their empathic abilities. In order to examine this question, 20 patients with NPD, 20 patients with a personality disorder in the Cluster C spectrum and 20 healthy control participants were presented with a questionnaire and a facial recognition task designed to measure empathic abilities. It was found that patients with NPD did not differ from the two control groups on a self-report questionnaire indicating that patients regard themselves as sensitive to the feelings of others. On the contrary, it was found NPD patients generally performed worse on a facial emotion recognition task compared to both control groups. In addition to this general deficit in emotion recognition, patients with NPD showed a specific deficit for emotions representing fear and disgust. These results provide the first empirical evidence for impaired emotion recognition in patients with NPD.