Randomized trial of a brief peer support intervention for individuals with schizophrenia transitioning from hospital to community.

This phase 2 randomized trial examined the outcomes of a brief, transitional, peer support intervention designed to address the poor outcomes that are common for individuals with schizophrenia spectrum illnesses in the period immediately following hospitalization. In the context of treatment-as-usual, participants were provided with a peer support intervention, 'the Welcome Basket,' in which participants received 1-2 sessions of peer support in the two weeks before discharge and met weekly for a month post-discharge. The study also piloted a brief version of this intervention with only one community session post-discharge with the same pre-discharge process. It was hypothesized that the full intervention would improve community transition outcomes, with community functioning (Multnomah Community Ability Scale) being the primary measure and secondary measures including symptomatology, community integration, personal recovery, quality of life, and social support. The examination of the brief intervention was exploratory. Measures were completed at baseline, 1-month post-discharge, and follow-up at 6 months. A total of 110 participants were randomized to one of three interventions, with outcome data obtained from 82 and follow-up from 74. While feasible, we did not find that the Welcome Basket intervention was superior to treatment as usual for any of our primary or secondary outcome measures. Future work is needed to determine whether a more extended intervention is required and whether specific subgroups of patients may benefit (e.g. those without access to immediate psychiatric care or those better able to engage with a peer).

A comparison of compensatory and restorative cognitive interventions in early psychosis.

This randomized trial examined the relative effectiveness of primarily compensatory and primarily restorative cognitive interventions in an early psychosis population. A total of 56 patients were randomized to one of two treatments which were applied for four months with a five month follow up assessment. Comparisons were between (1) Cognitive Adaptation Training (CAT) - a treatment that uses environmental supports and weekly home visits to compensate for cognitive challenges and improve community functioning and (2) Action Based Cognitive Remediation (ABCR) - a treatment involving computerized cognitive drill and practice exercises, simulations, goal setting, and behavioral activation. Linear mixed effects models demonstrated significant effects on community functioning for both CAT and ABCR without a difference between conditions (n = 39), with an indication of greater gains at follow up in the ABCR group (n = 31). Improvements in symptomatology were less robust with mixed findings across neurocognition metrics. This study concluded that both CAT and ABCR hold promise as interventions for early intervention psychosis populations but more work is needed to identify illness severity, subtype and contextual considerations that might indicate an emphasis on more compensatory versus more restorative cognitive interventions.

Sertraline-induced hypersensitivity pneumonitis.

Hypersensitivity pneumonitis (HP), also known as extrinsic allergic alveolitis, is a granulomatous, non-IgE-mediated hypersensitivity reaction of the alveoli and distal bronchioles presenting as an acute, subacute or chronic condition. It is most commonly associated with exposure to extrinsic allergens (eg, avian dust, mould and tobacco) and medications including antiarrhythmics (eg, amiodarone), cytotoxics (eg, methotrexate) and antiepileptics (eg, carbamazepine). Individuals diagnosed with this condition can present with severe hypoxia and respiratory failure. The fundamental principle of management is to remove the causative allergen. Evidence implicating selective serotonin reuptake inhibitors as a causative agent is limited, and this case report describes a rare clinical presentation of HP associated with sertraline, how it was diagnosed and subsequently treated. It is anticipated that raising awareness of this interaction will assist multidisciplinary teams, managing patients diagnosed with HP, to be more cognisant of sertraline as being an aetiological factor for this condition.

Validation of the MUSIC Model of Motivation Inventory for use with cognitive training for schizophrenia spectrum disorders: A multinational study.

AIM: Low motivation is a core symptom of schizophrenia which significantly impacts successful engagement in and benefit from psychosocial treatments. Therefore, it is important for clinicians to design psychosocial treatments to effectively motivate and engage patients during the treatment. The MUSIC® Model of Academic Motivation Inventory (MMI) is an 18-item instrument with five scales that assess students' motivation during academic tasks. The objective of the current study was to validate the MMI for use with schizophrenia-spectrum patients undergoing cognitive training. METHODS: Participants included 181 people with schizophrenia spectrum disorders enrolled in cognitive training in four countries. A confirmatory factor analysis (CFA) assessed construct validity. Quality of fit was determined using the Comparative Fit Index (CFI), the Standardized Root Mean Square Residual (SRMR), and the Root Mean Square Error of Approximation (RMSEA). Pearson's correlation coefficients assessed construct validity and Cronbach's alphas assessed reliability. Furthermore, we examined factor loadings for each inventory item and assessed predictive validity by analyzing MMI scales with attendance outcomes. RESULTS: Consistent with the original MMI validation studies used in academic settings, we found CFI values indicated a good fit, as did the SRMR and RMSEA values. The scales were correlated yet distinct. Cronbach's alpha values ranged from good to excellent and factor loadings showed that all items loaded very well onto their intended factors. The MMI had a positive relationship to treatment intensity. CONCLUSION: The MMI is a valid and reliable tool to use with individuals with schizophrenia spectrum disorders undergoing a cognitive training intervention.

A pilot study of a family cognitive adaptation training guide for individuals with schizophrenia.

OBJECTIVE: There is a paucity of accessible, evidence-based tools for caregivers of individuals with schizophrenia. This study examines changes in the self-assessed and caregiver-assessed outcomes of people with schizophrenia after exposure to a cognitive adaptation training (CAT) guide that addressed pragmatic, in-home approaches to offset the cognitive impacts of the illness. METHOD: This study examined the 4-month, pre-post outcomes of a CAT guide, as compared with a popular, general manual, for families of individuals with schizophrenia. A total of 17 caregiver-supported individual dyads completed all measures, having been randomized to either a CAT-guide group or a support-manual group. Measures included medication adherence, adaptive functioning, quality of life, and caregiver burden. Semistructured interviews assessed use and utility questions. RESULTS: Caregiver-assessed improvements in community functioning with medium-high effect sizes were observed in both study conditions. Self-report ratings by supported individuals did not change from baseline to 4 months and no change was observed in medication adherence or quality of life for either condition. Caregiver-burden ratings significantly declined with a large effect size, again with no difference as a function of manual type. CONCLUSION AND IMPLICATIONS FOR PRACTICE: These findings suggest that there is some promise in providing families with evidence-based information in manual form. Further research informed by this study's findings should include assessments of whether and how environmental cognitive supports can be of specific benefit to families affected by schizophrenia. (PsycINFO Database Record

Understanding perceptions of community participation in persons with severe mental illness: A mixed-methods approach.

OBJECTIVES: This study aims to measure community participation in persons with severe mental illness (SMI) in Toronto, Ontario and outlines a methodological approach for understanding the dimensions of community participation. METHODS: A mixed methods approach was used to define activity spaces through participatory mapping and a qualitative survey interview for participants (N = 31), selected through a stratified purposeful sampling strategy. Five neighbourhoods in Toronto were sampled in an attempt to obtain an ethnically diverse sample. Participants were interviewed over the study period and asked to draw maps indicating places that constituted their community. A qualitative interview was also administered to understand participants' perceptions of their communities. Point locations from the mapping exercise were used to measure and construct activity spaces using a mean circle approach; outlying locations were simultaneously recorded. Observed spatial patterns were then analyzed alongside the findings of the qualitative interviews. RESULTS: There were no observed relationships between the number of locations reported by participants and the resultant activity space or outlier count. There were no quantitative relationships between activity space size and perceptions of community by participants. However, qualitative data revealed that a number of underlying factors (mental health status and associated stigma; relationships with friends and family; cultural background; income; and neighbourhood safety) influenced participants' activity spaces. CONCLUSIONS: These results highlight the ways that community participation is influenced by an interplay of determinants, all of which have implications for service delivery and population-level interventions. They also point to the importance of mixed methods approaches in spatial analysis.

The welcome basket revisited: Testing the feasibility of a brief peer support intervention to facilitate transition from hospital to community.

OBJECTIVE: This paper describes outcome and feasibility findings for a novel, brief intervention to facilitate discharge from lengthy psychiatric hospitalization. The examination of such transitional interventions is important given the suboptimal outcomes for many individuals with severe mental illness at discharge, particularly in the first month. METHOD: In this study a mixed methods design was used to examine a 6-week peer support worker-provided transitional intervention called the 'Welcome Basket.' The intervention involves contact on hospital wards immediately prior to discharge and 1-1 community contacts along with the provision of a 'welcome basket' of needed/desired items and environmental supports to facilitate greater independence and illness self-management. The study took place in a large Canadian city. RESULTS: Thirty-one individuals with severe mental illness were referred and 23 completed the intervention. Pre-post analysis indicated no change in psychiatric symptoms but improvement in community functioning, community integration, and quality of life. Compared with mean rehospitalization rates for referring inpatient units, significant differences in rates for the study participants were not observed. Qualitative feasibility and process findings were very positive and suggested domains for improvement. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These findings suggest that this brief transitional intervention is feasible and promising, although further investigation is warranted. Study findings also support the need for transitional interventions to address the service disconnects at the time of discharge for people with severe mental illness. (PsycINFO Database Record

Mental health reform at a systems level: widening the lens on recovery-oriented care.

This paper is an initial attempt to collate the literature on psychiatric inpatient recovery-based care and, more broadly, to situate the inpatient care sector within a mental health reform dialogue that, to date, has focused almost exclusively on outpatient and community practices. We make the argument that until an evidence base is developed for recovery-oriented practices on hospital wards, the effort to advance recovery-oriented systems will stagnate. Our scoping review was conducted in line with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (commonly referred to as PRISMA) guidelines. Among the 27 papers selected for review, most were descriptive or uncontrolled outcome studies. Studies addressing strategies for improving care quality provide some modest evidence for reflective dialogue with former inpatient clients, role play and mentorship, and pairing general training in recovery oriented care with training in specific interventions, such as Illness Management and Recovery. Relative to some other fields of medicine, evidence surrounding the question of recovery-oriented care on psychiatric wards and how it may be implemented is underdeveloped. Attention to mental health reform in hospitals is critical to the emergence of recovery-oriented systems of care and the realization of the mandate set forward in the Mental Health Strategy for Canada.

Cognitive remediation for individuals with psychosis in a supported education setting: a randomized controlled trial.

Cognitive remediation (CR) has demonstrated good outcomes when paired with supported employment, however little is known about its effectiveness when integrated into a supported education program. This randomized controlled trial examined the effectiveness of integrating CR within a supported education program compared with supported education without CR. Thirty-seven students with psychosis were recruited into the study in the 2012 academic year. Academic functioning, cognition, self-esteem, and symptomatology were assessed at baseline, at 4months following the first academic term in which CR was provided, and at 8months assessing maintenance of gains. The treatment group demonstrated better retention in the academic program and a trend of improvement across a range of academic functional domains. While both treatment and control groups showed improvement in cognitive measures, the outcomes were not augmented by CR training. CR was also associated with significant and sustained improvements in self esteem. Further research, investigating specific intervention components is required to clarify the mixed findings regarding the effectiveness of CR in an education setting.

The role of gender in housing for individuals with severe mental illness: a qualitative study of the Canadian service context.

OBJECTIVE: This study was undertaken to examine the role of gender as it relates to access to housing among individuals with severe mental illness (SMI) in Canada. DESIGN: An exploratory, qualitative approach was used to assess the perspectives of Canadian housing experts. The focus of inquiry was on the role of gender and associated intersections (eg, ethnicity) in pathways to housing access and housing needs for individuals with SMI. SETTING: A purposeful sampling strategy was undertaken to access respondents across all Canadian geographic regions, with diversity across settings (urban and rural) and service sectors (hospital based and community based). PARTICIPANTS: -29 individuals (6 men and 23 women) considered to be experts in a housing service context as it pertains to SMI were recruited. On average, participants had worked for 15 years in services that specialised in the support and delivery of housing services to people with SMI. MEASURES: Semistructured interviews with participants focused on the role gender plays in access to housing in their specific context. Barriers and facilitators were examined as were intersections with other relevant factors, such as ethnicity, poverty and parenthood. Quantitative ratings of housing accessibility as a function of gender were also collected. RESULTS: Participants across geographic contexts described a lack of shelter facilities for women, leading to a reliance on exploitative circumstances. Other findings included a compounding of discrimination for ethnic minority women, the unique resource problems faced in rural contexts, and the difficulties that attend access to shelter and housing for parents with SMI. CONCLUSIONS: These findings suggest that, along with a generally poor availability of housing stock for individuals with SMI, access problems are compounded by a lack of attention to the unique needs and illness trajectories that attend gender.