The WorkingWell Smartphone App for Individuals with Serious Mental Illnesses: A Proof-of-Concept, Mixed Methods Feasibility Study (Preprint)

Background: The disparities in employment for individuals with serious mental illnesses (SMI) have been well documented, as have the benefits of work. The benefits of mobile technology in providing accessible, in-the-moment support for these individuals has been demonstrated. The WorkingWell mobile app was developed to meet the need for accessible follow-along supports for individuals with SMI in the workplace. Objective: We explore the usability, usage, usefulness and overall feasibility of the WorkingWell mobile app with individuals with SMI receiving community-based services and actively employed. Methods: In this proof-of-concept, mixed methods, two-month feasibility study (N=40), employed individuals with SMI were recruited in mental health agencies. Participants completed surveys regarding background characteristics and cellphone use at enrollment; and responded to interview items regarding app usability, usage and usefulness in technical assistance calls at one, two, four and six weeks of study participation and in the exit interview at 8 weeks. Data on the frequency of app usage were downloaded and monitored on a daily basis. A version of the System Usability Scale (SUS) was administered in the exit interview. Feasibility was determined by the percent of users completing the study. General impressions were obtained from users regarding user support materials, technical assistance, and study procedures. Results: Over half of the participants were male (60%, 24/40). The majority were age 55 or under (70%, 28/40), Caucasian (80%, 32/40), had less than a 4-year college education (78%, 31/40), were employed part-time (98%, 39/40), had been working more than six months (60%, 24/40), and indicated a diagnosis of bipolar, schizoaffective or depressive disorder (84%, 16/25). The vast majority of participants owned cellphones (95%, 38/40), using them multiple times per day (83%, 33/40). Their average rating on SUS usability items was 3.93 (SD = 0.77; range = 1.57 to 5.00), reflecting positive responses. Participants, in general, indicated WorkingWell was “very easy”, “straightforward”, “simple”, and “user-friendly”. Usability challenges were related to personal issues (e.g., memory) or to difficulties with the phone or app. Data on app usage varied considerably. The most frequent navigations were to the home screen, followed by Rate My Day and My Progress, and then by Manage the Moment and Remind Me. The app was described as useful by most study participants; 86% (30/35) agreed the app would help them manage better on the job. Thirty-five of the 40 original participants (87%) completed the study. Conclusions: The WorkingWell app is a feasible approach to providing accessible, as-needed employment support for individuals with SMI. The app would benefit from additional modifications to address recommendations from feasibility testing. Controlled research with larger samples, more diverse in individual characteristics and workplace settings, is essential to demonstrating the effectiveness of the app

Fidelity to Assertive Community Treatment and Client Outcomes in the New Hampshire Dual Disorders Study

OBJECTIVE: The study examined the association between fidelity of programs to the assertive community treatment model and client outcomes in dual disorders programs. METHODS: Assertive community treatment programs in the New Hampshire dual disorders study were classified as low-fidelity programs (three programs) or high-fidelity programs (four programs) based on extensive longitudinal process data. The study included 87 clients with a dual diagnosis of severe mental illness and a comorbid substance use disorder. Sixty-one clients were in the high-fidelity programs, and 26 were in the low-fidelity programs. Client outcomes were examined in the domains of substance abuse, housing, psychiatric symptoms, functional status, and quality of life, based on interviews conducted every six months for three years. RESULTS: Clients in the high-fidelity assertive community treatment programs showed greater reductions in alcohol and drug use and attained higher rates of remission from substance use disorders than clients in the low-fidelity programs. Clients in high-fidelity programs had higher rates of retention in treatment and fewer hospital admissions than those in low-fidelity programs. No differences between groups were found in length of hospital stays and other residential measures, psychiatric symptoms, family and social relations, satisfaction with services, and overall life satisfaction. CONCLUSIONS: Faithful implementation of, and adherence to, the assertive community treatment model for persons with dual disorders was associated with superior outcomes in the substance use domain. The findings underscore the value of measures of model fidelity, and they suggest that local modifications of the assertive community treatment model or failure to comply with it may jeopardize program success

Legal system involvement and costs for persons in treatment for severe mental illness and substance use disorders

OBJECTIVE: Persons with co-occurring severe mental illness and substance use disorders were followed for three years to better understand how they are involved with the legal system and to identify factors associated with different kinds of involvement. METHODS: Data came from a three-year study of 203 persons enrolled in specialized treatment for dual disorders. Cost and utilization data were collected from multiple data sources, including police, sheriffs and deputies, officers of the court, public defenders, prosecutors, private attorneys, local and county jails, state prisons, and paid legal guardians. RESULTS: Over three years 169 participants (83 percent) had contact with the legal system, and 90 (44 percent) were arrested at least once. Participants were four times more likely to have encounters with the legal system that did not result in arrest than they were to be arrested. Costs associated with nonarrest encounters were significantly less than costs associated with arrests. Mean costs per person associated with an arrest were $2,295, and mean costs associated with a nonarrest encounter were$385. Combined three-year costs averaged $2,680 per person. Arrests and incarcerations declined over time. Continued substance use and unstable housing were associated with a greater likelihood of arrest. Poor treatment engagement was associated with multiple arrests. Men were more likely to be arrested, and women were more likely to be the victims of crime. CONCLUSIONS: Effective treatment of substance use among persons with mental illness appears to reduce arrests and incarcerations but not the frequency of nonarrest encounters. Stable housing may also reduce the likelihood and number of arrests

Incentives for community treatment. Mental illness management services

Serving people with mental and other chronic illnesses in community settings may improve compliance and satisfaction with treatment, but existing payment mechanisms often favor office-based treatment. This study examines the effect of a change in Medicaid payment on the location and amount of service provided by case managers. Amounts of service given by treatment providers to 185 of their clients in community settings and in mental health centers were compared before and after reimbursement changed from an all-inclusive prospective rate to a mixed prospective/retrospective payment. Clients were enrolled in two different treatment programs: continuous treatment teams with extensive training in in vivo treatment, and a case management program that emphasized office-based treatment. In-community service increased, and the amount of office-based treatment decreased. Continuous treatment teams increased in-community services more than case managers did; case managers decreased office-based treatment more. There was no change in total amount of services provided. It was concluded that mixed prospective and retrospective reimbursement can remove financial barriers to in-community treatment, but it works best in combination with a training program. Additional research is needed to determine the precise financial impact of such changes

Implementing Illness Management And Recovery Within Assertive Community Treatment: A Pilot Trial Of Feasibility And Effectiveness

Objective: In a pilot feasibility and effectiveness study, illness management and recovery (IMR), a curriculum-based program to help people with serious mental illness pursue personal recovery goals, was integrated into assertive community treatment (ACT) to improve participants\u27 recovery and functioning. Methods: A small-scale cluster randomized controlled design was used to test implementation of IMR within ACT teams in two states. Eight high-fidelity ACT teams were assigned to provide IMR (ACT+IMR; four teams) or standard ACT services (ACT only; four teams). Clinical outcomes from101 individuals with schizophrenia-spectrum or bipolar disorders were assessed at baseline, six months, and one year. Results: Exposure to IMR (session attendance and module completion) varied between the ACT+IMR teams, with participants on one team having significantly less exposure. Results fromintent-to-treat analyses showed that participants in ACT+IMR demonstrated significantly better outcomes with a mediumeffect size at follow-up on clinician-rated illness selfmanagement. A nonsignificant,mediumeffect sizewas found for one measure of functioning, and small effect sizes were observed for client-rated illness self-management and community integration. Session and module completion predicted better outcomes on four of the 12-month outcome measures. Conclusions: Findings support the feasibility of implementing IMR within ACT teams. Although there were few significant findings, effect sizes on some variables in this small-scale study and the dose-response relationships within ACT+IMR teams suggest this novel approach could be promising for improving recovery for people with serious mental illness. Further largescale studies utilizing a hybrid effectiveness-implementation design could provide a promising direction in this area

A method for analyzing longitudinal outcomes with many zeros

Health care utilization and cost data have challenged analysts because they are often correlated over time, highly skewed, and clumped at 0. Traditional approaches do not address all these problems, and evaluators of mental health and substance abuse interventions often grapple with the problem of how to analyze these data in a way that accurately represents program impact. Recently, the traditional 2-part model has been extended to mixed-effects mixed-distribution model with correlated random effects to deal simultaneously with excess zeros, skewness, and correlated observations. We introduce and demonstrate this new method to mental health services researchers and evaluators by analyzing the data from a study of assertive community treatment (ACT). The response variable is the number of days of hospitalization, collected every 6 months over 3 years. The explanatory variable is group: ACT vs. standard case management. Diagnosis (schizophrenia vs. bipolar disorder), time, and the baseline values of hospital days are covariates. Results indicate that clients in the ACT group have a higher probability of hospital admission, but tend to have shorter lengths of stay. The mixed-distribution model provides greater specification of a model to fit these data and leads to more refined interpretation of the results

Ten-Year Recovery Outcomes for Clients With Co-Occurring Schizophrenia and Substance Use Disorders

The long-term courses of people with schizophrenia and of those with substance use disorder have been studied separately and extensively. The long-term course of clients with co-occurring schizophrenic and substance use disorders has, however, not been examined. This article reports 10-year outcomes for 130 clients with co-occurring schizophrenic and substance use disorders in the New Hampshire Dual Diagnosis Study. In addition, we report on 6 “recovery outcomes,” identified by dual diagnosis clients, as examples of positive coping behaviors. Longitudinal data were modeled using generalized estimating equation (GEE) methods. Participants improved steadily over 10 years in the outcome domains of symptoms, substance abuse, institutionalization, functional status, and quality of life. Further, at the 10-year follow-up, substantial proportions were above cutoffs selected by dual diagnosis clients as indicators of recovery: 62.7% were controlling symptoms of schizophrenia; 62.5% were actively attaining remissions from substance abuse; 56.8% were in independent living situations; 41.4% were competitively employed; 48.9% had regular social contacts with non–substance abusers; and 58.3% expressed overall life satisfaction. These 6 outcomes were only weakly interrelated over time, suggesting that recovery, as defined by clients, is a multidimensional concept. Overall, the 10-year findings on recovery outcomes provide a hopeful long-term perspective for dual diagnosis clients

A prospective meta-analytic approach in a multisite study of homelessness prevention

This chapter describes a technique based on meta-analysis for analyzing data from multisite studies

Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: a clinical trial

Integrated mental health and substance abuse treatment within an assertive community treatment (ACT) approach was compared to that within a standard case management approach for 223 patients with dual disorders over three years. ACT patients showed greater improvements on some measures of substance abuse and quality of life, but the groups were equivalent on most measures, including stable community days, hospital days, psychiatric symptoms, and remission of substance use disorder