Does mental health service integration affect compulsory admissions?

Abstract. BACKGROUND: Over recent years, the number of compulsory admissions in many countries has increased, probably as a result of the shift from inpatient to outpatient mental health care. This might be mitigated by formal or collaborative relationships between services. METHODS: In a retrospective record linkage study, we compared two neighboring districts, varying in level of service integration. Two periods were combined: 1991-1993 and 2001-2003. We included patients aged 18-60, who had a first emergency compulsory admission (n=830). Their psychiatric history was assessed, and service-use after admission was monitored over a 12-month follow-up. RESULTS: Over a 10-year period, compulsory admission rates increased by 47%. Difference in relative increase between the integrated and non-integrated services was 14%. Patient characteristics showed different profiles in the two districts. Length of stay was >10 days shorter in the integrated district, where the proportion of involuntary readmissions decreased more, and where aftercare was swift and provided to about 10% more patients than in the non-integrated district. CONCLUSIONS: Services outcomes showed better results where mental healthcare was more integrated. However, limited effects were found and other factors than integration of services may be more important in preventing compulsory admissions

Symptomatic and functional remission and its associations with quality of life in patients with psychotic disorder in assertive community treatment teams.

Objectives: The aims of the present study were (1) to determine the proportion and characteristics of patients treated in Assertive Community Treatment teams who achieve symptomatic remission (SR) and/or functional remission (FR) and (2) to explore the association between both types of remission and (3) their bearing on quality of life (QoL). Methods: Data comprised assessments from 278 patients who were repeatedly assessed using the Positive and Negative Syndrome Scale to assess SR, the Health of the Nation Outcome Scales to assess FR, and a shortened version of the Manchester Short Assessment to assess QoL.

Evaluation of behavioral changes and subjective distress after exposure to coercive inpatient interventions

BACKGROUND: There is a lack of evidence to underpin decisions on what constitutes the most effective and least restrictive form of coercive intervention when responding to violent behavior. Therefore we compared ratings of effectiveness and subjective distress by 125 inpatients across four types of coercive interventions. METHODS: Effectiveness was assessed through ratings of patient behavior immediately after exposure to a coercive measure and 24 h later. Subjective distress was examined using the Coercion Experience Scale at debriefing. Regression analyses were performed to compare these outcome variables across the four types of coercive interventions. RESULTS: Using univariate statistics, no significant differences in effectiveness and subjective distress were found between the groups, except that patients who were involuntarily medicated experienced significant less isolation during the measure than patients who underwent combined measures. However, when controlling for the effect of demographic and clinical characteristics, significant differences on subjective distress between the groups emerged: involuntary medication was experienced as the least distressing overall and least humiliating, caused less physical adverse effects and less sense of isolation. Combined coercive interventions, regardless of the type, caused significantly more physical adverse effects and feelings of isolation than individual interventions. CONCLUSIONS: In the absence of information on individual patient preferences, involuntary medication may be more justified than seclusion and mechanical restraint as a coercive intervention. Use of multiple interventions requires significant justification given their association with significant distress

Changes in individual needs for care and quality of life in Assertive Community Treatment patients: An observational study

Background: It is largely unknown which unmet needs in the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS) need to be resolved in order to improve a patients' subjective quality of life (QoL). We therefore investigated the pattern of individual unmet needs over time and its relation to QoL over time. Methods: Using data gathered from 251 patients in a Routine Outcome Monitoring procedure in Assertive Community Treatment (ACT) teams, we used paired samples tests to analyze differences in QoL total scores and the number of unmet needs between baseline and follow-up data. Ordinal regression was used to analyze the relationship between outcome in individual unmet needs and QoL. Results: As well as small improvements in QoL over time in patients in contact with ACT, we found a small to moderate decrease in unmet needs over time. While a decreasing number of unmet needs was associated with an increase in QoL, outcomes in QoL and individual unmet needs were weakly related (r≤.165). Ordinal regression analysis showed that a better outcome in individual unmet needs related to accommodation and day-time activities was weakly related to a better outcome in QoL. Conclusions: Patients receiving ACT make small improvements in their QoL and ACT may help to solve some of their needs. QoL benefits from reducing needs for care, in particular the need for appropriate housing and meaningful daytime activities

Coping with medical threat: An evaluation of the Threatening Medical Situations Inventory (TMSI)

The Dutch Threatening Medical Situations Inventory (TMSI) has been developed to measure cognitive confrontation ('monitoring') and cognitive avoidance ('blunting') within the domain of medical threat. It consists of four scenarios of threatening medical situations, followed by monitoring and blunting alternatives. Its psychometric properties are investigated in students (N = 123), dental (N = 80), HIV - (N = 42) and surgery patients (N = 123). For both scales, internal consistencies proved to be satisfactory. Slight sex and age effects are found. Furthermore, there is a strong situation effect: the scenario highest in controllability shows relatively high monitoring and low blunting scores. Factor structure is stable across samples and shows a good fit with the predicted factor solution. Both scales are found to converge and diverge in a theoretically meaningful manner with a variety of coping style and anxiety measures. In two samples, a sample specific stress scenario was added, but the psychometric qualities of such an extension should not be taken for granted. In an additional sample of working people (N = 48) test-retest reliability proved to be good. It is concluded that the TMSI is a useful instrument for assessing cognitive confrontation and avoidance in medical patients. An English as well as a German translation are available. Copyrigh

Working Alliance in Patients with Severe Mental Illness Who Need a Crisis Intervention Plan

Working alliance has been characterized as an important predictor of positive treatment outcomes. We examined whether illness insight, psychosocial functioning, social support and locus of control were associated with working alliance as perceived by both patient and clinician. We assessed 195 outpatients with psychotic or bipolar disorders. Our findings indicated that patients rated the alliance more positively when they experienced a greater need for treatment, fewer behavioral and social problems, and more psychiatric symptoms. Clinicians rated the alliance more positively in patients who reported fewer social problems and better illness insight. Patients’ demographic characteristics, including being female and married, were also positively related to the clinician-rated alliance. Our results suggest that patients and clinicians have divergent perceptions of the alliance. Clinicians may need help developing awareness of the goals and tasks of patients with certain characteristics, i.e., singles, men, those with poor illness insight and those who report poor social functioning

The effects of motivation feedback in patients with severe mental illness: A cluster randomized controlled trial

Objective: To evaluate the effectiveness of providing clinicians with regular feedback on the patient’s motivation for treatment in increasing treatment engagement in patients with severe mental illness.Methods: Design: cluster randomized controlled trial (Dutch Trials Registry NTR2968). Participants: adult outpatients with a primary diagnosis of a psychotic disorder or a personality disorder and their clinicians, treated in 12 community mental health teams (the clusters) of two mental health institutions in the Netherlands. Interventions: monthly motivation feedback (MF) generated by clinicians additional to treatment as usual (TAU) and TAU by the community mental health teams. Primary outcome: treatment engagement at patient level, assessed at 12 months by clinicians. Randomization: teams were allocated to MF or TAU by a computerized randomization program that randomized each team to a single treatment by blocks of varying size. All participants within these teams received similar treatment. Clinicians and patients were not blind to treatment allocation at the 12-month assessment.Results: The 294 randomized patients (148 MF, 146 TAU) and 57 clinicians (29 MF, 28 TAU) of 12 teams (6 MF, 6 TAU) were analyzed according to the intention-to-treat principle. No statistically significant differences between treatment groups on treatment engagement were found (adjusted mean difference =0.1, 95% confidence interval =-2.2 to 2.3, P=0.96, d=0). Preplanned ancillary analyses showed statistically significant interaction effects between treatment group and primary diagnosis on treatment motivation and quality of life (secondary outcomes), which were beneficial for patients with a primary diagnosis of a personality disorder but not for those with a psychotic disorder. There were no reports of adverse events.Conclusion: The current findings imply that monitoring and discussing the patient’s motivation is insufficient to improve motivation and treatment engagement, and suggests that more elaborate interventions for severe mental illness patients are needed

Ethical acceptability of offering financial incentives for taking antipsychotic depot medication: Patients' and clinicians' perspectives after a 12-month randomized controlled trial

Background: A randomized controlled trial 'Money for Medication'(M4M) was conducted in which patients were offered financial incentives for taking antipsychotic depot medication. This study assessed the attitudes and ethical considerations of patients and clinicians who participated in this trial. Methods: Three mental healthcare institutions in secondary psychiatric care in the Netherlands participated in this study. Patients (n = 169), 18-65 years, diagnosed with schizophrenia, schizoaffective disorder or another psychotic disorder who had been prescribed antipsychotic depot medication, were randomly assigned to receive 12 months of either treatment as usual plus a financial reward for each depot of medication received (intervention group) or treatment as usual alone (control group). Structured questionnaires were administered after the 12-month intervention period. Data were available for 133 patients (69 control and 64 intervention) and for 97 clinicians. Results: Patients (88%) and clinicians (81%) indicated that financial incentives were a good approach to improve medication adherence. Ethical concerns were categorized according to the four-principles approach (autonomy, beneficence, non-maleficence, and justice). Patients and clinicians alike mentioned various advantages of M4M in clinical practice, such as increased medication adherence and improved illness insight; but also disadvantages such as reduced intrinsic motivation, loss of autonomy and feelings of dependence. Conclusions: Overall, patients evaluated financial incentives as an effective method of improving medication adherence and were willing to accept this reward during clinical treatment. Clinicians were also positive about the use of this intervention in daily practice. Ethical concerns are discussed in terms of patient autonomy, beneficence, non-maleficence and justice. We conclude that this intervention is ethically acceptable under certain conditions, and that further research is necessary to clarify issues of benefit, motivation and the preferred size and duration of the incentive. Trial registration: Nederlands Trial Register, number NTR2350

Depot-medication compliance for patients with psychotic disorders: The importance of illness insight and treatment motivation

Background: Noncompliance is a major problem for patients with a psychotic disorder. Two important risk factors for noncompliance that have a severe negative impact on treatment outcomes are impaired illness insight and lack of motivation. Our cross-sectional study explored how they are related to each other and their compliance with depot medication. Methods: Interviews were conducted in 169 outpatients with a psychotic disorder taking depot medication. Four patient groups were defined based on low or high illness insight and on low or high motivation. The associations between depot-medication compliance, motivation, and insight were illustrated using generalized linear models. Results: Generalized linear model showed a significant interaction effect between motivation and insight. Patients with poor insight and high motivation for treatment were more compliant (94%) (95% confidence interval [CI]: 1.821, 3.489) with their depot medication than patients with poor insight and low motivation (61%) (95% CI: 0.288, 0.615). Patients with both insight and high motivation for treatment were less compliant (73%) (95% CI: 0.719, 1.315) than those with poor insight and high motivation. Conclusion: Motivation for treatment was more strongly associated with depot-medication compliance than with illness insight. Being motivated to take medication, whether to get better or for other reasons, may be a more important factor than having illness insight in terms of improving depot-medication compliance. Possible implications for clinical practice are discusse