The impact of routine outcome measurement on treatment processes in community mental health care: approach and methods of the MECCA study

Three issues characterise the background to the MECCA study: A) Throughout Europe, most patients with severe forms of psychotic disorders are cared for in the community. The challenge now is to make processes in community mental health care more effective. B) There are widespread calls to implement regular outcome measurement in routine settings. This, however, is more likely to happen, if it provides a direct benefit to clinicians and patients. C) Whilst user involvement is relatively ?" easy to achieve on a political level, new mechanisms may have to be established to make the views of patients feed into individual treatment decisions. The MECCA study is a cluster randomised controlled trial following the same protocol in community mental health teams in six European countries. In the experimental group, patients' subjective quality of life, treatment satisfaction and wishes for different or additional help are assessed in key worker-patient meetings every two months and intended to inform the therapeutic dialogue and treatment decisions. The trial tests the hypothesis that the intervention - as compared to current best standard practice - will lead to a better outcome in terms of quality of life and other criteria in patients with psychotic disorders over a one year period. This more favourable outcome is assumed to be mediated through different treatment input based on more appropriate joint decisions or a more positive therapeutic relationship in line with a partnership model of care or both. Moreover, the study will hopefully reveal new insights into how therapeutic processes in community mental health care work and how they can be optimise

Structured patient-clinician communication and 1-year outcome in community mental healthcare - Cluster randomised controlled trial

Background Patient-clinician communication is central to mental healthcare but neglected in research. Aims To testa new computer-mediated intervention structuring patient-clinician dialogue (DIALOG) focusing on patients' quality of life and needs for care. Method In a cluster randomised controlled trial, 134 key workers in six countries were allocated to DIALOG or treatment as usual; 507 people with schizophrenia or related disorders were included. Every 2 months for I year, clinicians asked patients to rate satisfaction with quality of life and treatment, and request additional or different support. Responses were fed back immediately in screen displays, compared with previous ratings and discussed. Primary outcome was subjective quality of life, and secondary outcomes were unmet needs and treatment satisfaction. Results Of 507 patients, 56 were lost to follow-up and 451 were included in intention-to-treat analyses. Patients receiving the DIALOG intervention had better subjective quality of life, fewer unmet needs and higher treatment satisfaction after 12 months. Conclusions Structuring patient clinician dialogue to focus on patients' views positively influenced quality of life, needs for care and treatment satisfaction

Associations between Therapeutic Relationship and Adherence to Antipsychotic Medication in depot subgroup in a logistic regression model based on 90 patients.

<p>Associations between Therapeutic Relationship and Adherence to Antipsychotic Medication in depot subgroup in a logistic regression model based on 90 patients.</p

Associations between Therapeutic Relationship and Adherence to Antipsychotic Medication in a logistic regression model based on 466 patients.

<p>Associations between Therapeutic Relationship and Adherence to Antipsychotic Medication in a logistic regression model based on 466 patients.</p

Sociodemographic & Clinical Characteristics of Clinicians and Patients.

<p>Sociodemographic & Clinical Characteristics of Clinicians and Patients.</p

Distribution of Adherence Ratings.

<p>Distribution of Adherence Ratings.</p

Cost of treatment in schizophrenia in six European countries

Background and aims: As part of an RCT in six European sites, the direct mental health care cost for 422 patients with schizophrenia was analysed according to how total and medication costs differed across sites and which variables were likely to predict total or service-specific costs. Method: Service use was recorded continuously during a 12-month follow-up. Prescribed psychotropic medication was recorded at baseline and 12 months later. Service use data were transformed into EURO, log-transformed and analysed using linear regression models. Results: Although samples were homogeneous, large inter-site cost differences were found (annual means ranging from 2958 E in Spain up to 36978 E in Switzerland). Psychopharmacologic costs were much more constant across sites than costs for other services. Total costs were associated more with region or socio-demographic characteristics than with disorder related parameters. Conclusions: The findings confirm remarkable differences in direct costs of patients with schizophrenia across Europe. However, the relative stability of medication costs suggests a need to analyse mechanisms that influence service-specific costs for schizophrenia. (C) 2009 Elsevier B.V. All rights reserved

Non-uniform effectiveness of structured patient–clinician communication in community mental healthcare: an international comparison

BACKGROUND: The effectiveness of psychosocial interventions in community mental healthcare has been shown to depend on the setting in which they are implemented. Recently structured patient-clinician communication was found to be effective in a multi-centre trial in six European countries, the DIALOG trial. In the overall study, differences between centres were controlled for, not studied. Here, we test whether the effectiveness of structured patient-clinician communication varies between services in different countries, and explore setting characteristics associated with outcome. METHODS: The study is part of the DIALOG trial, which included 507 patients with schizophrenia or related disorder, treated by 134 keyworkers. The keyworkers were allocated to intervention or treatment as usual. RESULTS: Positive effects were found on quality of life (effect size 0.20: 95% CI 0.01-0.39) and treatment satisfaction (0.27: 0.06-0.47) in all centres, but reductions in unmet needs for care were only seen in two centres (-0.83 and -0.60), and in positive, negative and general symptoms in one (-0.87, -0.78, -0.87). The intervention was most effective in settings with patient populations with many unmet needs for care and high symptom levels. CONCLUSIONS: Psychosocial interventions in community mental healthcare may not be assumed to have uniform effectiveness across settings. Differences in patient population served and mental healthcare provided, should be studied for their influence on the effectiveness of the intervention. Structured patient-clinician communication has a uniform effect on quality of life and treatment satisfaction, but on unmet needs for care and symptom levels its effect differs between mental healthcare settings

Individual unmet needs for care: are they sensitive as outcome criterion for the effectiveness of mental health services interventions?

BACKGROUND: Mental health interventions should demonstrate an effect on patients' functioning as well as his/her needs, in particular on unmet needs whose assessment depends on the perspective of either the patient or the clinician. However, individual met and unmet needs appear to change over time, qualitatively and quantitatively, raising questions about their sensitivity to change and about the association between level of needs and treatment. METHODS: Data on baseline and follow-up need assessment in community mental health services in four European countries in the context of a cluster randomised trial on a novel mental health service intervention were used, which involved 102 clinicians with key worker roles and 320 patients with schizophrenia or related psychotic disorders. Need assessment was performed with the Camberwell assessment of needs short appraisal schedule (CANSAS) among patients as well as clinicians. Focus is the sensitivity to change in unmet needs over time as well as the concordance between patient and clinician ratings and their relationship with treatment condition. RESULTS: At follow-up 294 patients (92%) had a full need assessment, while clinician rated needs were available for 302 patients (94%). Generally, the total number of met needs remained quite stable, but unmet needs decreased significantly over time, according to patients as well as to clinicians. Sensitivity to change of unmet needs is quite high: about two third of all unmet needs made a transition to no or met need, and more than half of all unmet needs at follow-up were new. Agreement between patient and clinician on unmet needs at baseline as well as follow-up was rather low, without any indication of a specific treatment effect. CONCLUSIONS: Individual unmet needs appear to be quite sensitive to change over time but as yet less suitable as outcome criterion of treatment or specific interventions