Multi-method investigation of normative integration in a novel inter-sectoral collaboration between mental health care services and public sick leave insurance organizations in Denmark

Introduction: Inter-sectoral integration is increasingly warranted between the health care sector and other welfare-sectors. However, lack of normative integration (shared mission, values. and culture) among stakeholders is considered an important barrier. An integrated vocational rehabilitation intervention was established in a novel collaboration between public mental health care and sick leave insurance organizations in Denmark. The purpose of this study is to describe how normative integration was developed between the professionals in the inter-sectoral teams delivering the intervention.Theory and Methods: Gittells’ theory of relational coordination (RC) was used to design the interventions’ integration-activities. The theoretical sub-concepts from RC shared knowledge, shared goals and respect were considered aspects of normative integration and constituted the main analytical framework for this study. A mixed methods approach was used to examine the professionals’ perceptions of and experiences with mutual respect, shared goals, and shared knowledge across sectoral borders. This was investigated abductively through 30 semi-structured interviews with professionals and supervisors, 12 participant observations of inter-sectoral meetings, document analysis of 12 inter-sectoral plans, and the validated RC questionnaire. Contextual factors influencing normative integration was investigated inductively through the same data. Data collection began one year after intervention initiation.Results: Synthesizing data showed that mutual respect was established through trust and shared experiences between individual workers from the two sectors. Development of shared goals mainly took place through a growing focus on the predefined purpose of the intervention ‘fast return to work’, though this was initially difficult to internalize for health care professionals. Inter-sectoral meetings with both professionals and the service user on sick leave were assessed to have great potential as a forum for the creation of shared knowledge about the service users. Few inter-sectoral working relationships with co-located full-time professionals supported the development of normative integration.Discussions: This study found that the shared experiences between individual professionals from two sectors were key to the creation of normative integration in the inter-sectoral team. Organization of integrated teams with very few inter-sectoral relationships might be difficult to implement and could compromise intra-professional specialization. However, we argue that team-size and full-time commitment of employees should be considered important factors in novel team-based inter-sectoral collaboration.Conclusions: Normative integration in the intervention was developed through professional’s adaption of intervention goals, increasingly better use of intersectoral meetings and respect build on shared experiences and trust. Few inter-sectoral relationships, full-time employees and co-location were valued important for integration by the professionals.Lessons learned: Few inter-sectoral relationships and shared experiences were facilitators of normative integration across sectors.Limitations: Following initial data collection, the organization of professionals was changed, and analysis showed that there was considerable potential for further development of normative integration thereafter. The long-term perspective was subsequently only investigated through follow-up interviews with supervisors 2.5 years after intervention initiation.Suggestions for future research: We suggest the development of respect, shared goals, and shared knowledge in newly established inter-sectoral integration should be investigated with a long-term longitudinal design

Doing Identity Work with Transgendered Women

Gender, sexuality and identity in relation to individual freedom and equality go to the core of who we are, as well as shape our actions. By offering a glimpse into the identity work processes of two transgendered women, I hope to make visible some of the forces and mechanisms that influence all of us, regardless of our gender or status. The transgendered are a group of people who have long been excluded, diagnosed, defined and oppressed by our current gender system. By making my interviewees’ stories heard, I hope to contribute to change in the prevailing hetero normative and dichotomic gender system. This thesis is a narrative analysis on identity work and gender. In this thesis I aim at answering how the two transgendered women engage in identity work during our consecutive discussions. I also try to identify what the role of gender is during these discussions and in identity work. I have conducted this thesis by interviewing both women in two consecutive in-depth interviews that took place a little over a year apart. After each interview I constructed a narrative that focused on the interviewee’s working life experiences regarding her gender reassignment process and career. Later on, these narratives have worked as background against which I have reflected the identity work and the practice of narrating identity that took place during our meetings. The concept of identity is based on multiple, always changing and socially constructed identities brought forward in popular queer theory literature. I have also used queer theory as a guide in identifying gender related identity work regarding my interviewees. I use the popular identity work literature and my data to name the dominant elements that are present during identity work. I also present a framework for identity work that shows how the previous identity work episode and the micro-level context have an effect on both: narrative identity practice and identity work. In addition I show how gender was present as a subject that was referred to and discussed about and a force that was always looming in the background when we were having our identity discussions. This thesis adds to current identity work literature and queer theory. By making the gender related identity work visible, it helps us to grasp on and change current gendered practices and to undo gender. It also helps us to see and identify some of the forces that contribute to shaping our identities and action

Tapered discontinuation vs. maintenance therapy of antipsychotic medication in patients with first-episode schizophrenia:Obstacles, findings, and lessons learned in the terminated randomized clinical trial TAILOR

AIM: Evidence is insufficient regarding the consequences of discontinuing vs. maintaining antipsychotic medication in patients with first-episode schizophrenia. Our aim was to examine tapered discontinuation vs. maintenance treatment regarding remission of psychotic symptoms and impact on other areas. METHODS: Patients included had a diagnosis of schizophrenia, were treated with antipsychotic medication, and were in remission of psychotic symptoms. Participants were randomized to tapered discontinuation or maintenance treatment with antipsychotic medication. Assessments were undertaken at baseline and after 1-year. The primary outcome was remission of psychotic symptoms without antipsychotic medication. RESULTS: The trial was terminated due to insufficient recruitment. In total, 29 participants were included: 14 in the tapering/discontinuation group and 15 in the maintenance group. Adherence to maintenance treatment was poor. At 1-year follow-up, remission of psychotic symptoms without antipsychotic medication for 3 months was observed in five participants in the tapering/discontinuation group and two in the maintenance group. CONCLUSION: Due to insufficient recruitment this study does not provide a conclusion on whether unfavorable outcomes or advantages follow tapering of antipsychotic medication. Recruitment and adherence to maintenance treatment encountered obstacles. Based on experiences from this trial, we discussed alternative study designs as consistent evidence is still needed on whether to continue or discontinue antipsychotic medication in remitted patients with first-episode schizophrenia. CLINICAL TRIAL REGISTRATION: https://www.clinicaltrialsregister.eu/ctr-search/trial/2016-000565-23/DK, EU Clinical Trials Register—EudraCT no. 2016–000565–23

Illness management and recovery (IMR) in Danish community mental health centres

<p>Abstract</p> <p>Background</p> <p>Schizophrenia and bipolar disorder are severe mental illnesses that can have a significant disabling impact on the lives of people. Psychosocial interventions that stress hope and recovery as a part of a multi-dimensional approach are possibly indicated to support people with severe mental illness in facilitating recovery. Illness Management and Recovery (IMR) is a curriculum-based psychosocial intervention designed as structured program with a recovery-oriented approach. The aim of IMR is to rehabilitate people with severe mental illnesses by helping them acquire knowledge and skills in managing their illness and achieve personal recovery goals. Previous randomised clinical trials indicate that IMR can be implemented with a good effect and a high fidelity though further trials are crucial to demonstrate the potential effectiveness of IMR.</p> <p>Methods/Design</p> <p>The trial design is a randomised, assessor-blinded, multi-centre, clinical trial of the IMR program compared with treatment as usual for 200 participants diagnosed with schizophrenia or bipolar disorder under the care of two community mental health centres in the Capital Region of Denmark. The primary outcome is level of functioning at the end of treatment. The secondary outcomes are disease symptoms; use of alcohol/drugs; individual meaning of recovery; hope; hospital admissions and out-patient psychiatric treatment at the end of treatment and the abovementioned and level of functioning at follow-up 21 months after baseline.</p> <p>Discussion</p> <p>If the results of this trial show IMR to be effective these positive results will strengthen the evidence of IMR as an effective comprehensive psychosocial intervention with a recovery-oriented approach for people with severe mental illness. This will have significant implications for the treatment and recovery of people with severe mental illness.</p> <p>Trial registration</p> <p>Registration number <a href="http://www.clinicaltrials.gov/ct2/show/NCT01361698">NCT01361698</a>.</p

Organisational and student characteristics, fidelity, funding models, and unit costs of recovery colleges in 28 countries:a cross-sectional survey

Background: Recovery colleges were developed in England to support the recovery of individuals who have mental health symptoms or mental illness. They have been founded in many countries but there has been little international research on recovery colleges and no studies investigating their staffing, fidelity, or costs. We aimed to characterise recovery colleges internationally, to understand organisational and student characteristics, fidelity, and budget. Methods: In this cross-sectional study, we identified all countries in which recovery colleges exist. We repeated a cross-sectional survey done in England for recovery colleges in 28 countries. In both surveys, recovery colleges were defined as services that supported personal recovery, that were coproduced with students and staff, and where students learned collaboratively with trainers. Recovery college managers completed the survey. The survey included questions about organisational and student characteristics, fidelity to the RECOLLECT Fidelity Measure, funding models, and unit costs. Recovery colleges were grouped by country and continent and presented descriptively. We used regression models to explore continental differences in fidelity, using England as the reference group. Findings: We identified 221 recovery colleges operating across 28 countries, in five continents. Overall, 174 (79%) of 221 recovery colleges participated. Most recovery colleges scored highly on fidelity. Overall scores for fidelity (β=–2·88, 95% CI 4·44 to –1·32; p=0·0001), coproduction (odds ratio [OR] 0·10, 95% CI 0·03 to 0·33; p&lt;0·0001), and being tailored to the student (OR 0·10, 0·02 to 0·39; p=0·0010), were lower for recovery colleges in Asia than in England. No other significant differences were identified between recovery colleges in England, and those in other continents where recovery colleges were present. 133 recovery colleges provided data on annual budgets, which ranged from €0 to €2 550 000, varying extensively within and between continents. From included data, all annual budgets reported by the college added up to €30 million, providing 19 864 courses for 55 161 students. Interpretation: Recovery colleges exist in many countries. There is an international consensus on key operating principles, especially equality and a commitment to recovery, and most recovery colleges achieve moderate to high fidelity to the original model, irrespective of the income band of their country. Cultural differences need to be considered in assessing coproduction and approaches to individualising support. Funding: National Institute for Health and Care Research.</p