Severe Mental Illness Care Research Articles

Enhanced Primary Care for Severe Mental Illness Reduces Inpatient Admission and Emergency Room Utilization Rates.

Cardiovascular disease (CVD) is a leading cause of premature mortality among patients with severe mental illness (SMI). Effective care delivery models are needed to address this mortality gap. This study examines the impact of an enhanced primary care (PC) program that specializes in the treatment of patients with SMI, called Medicine in Psychiatry Service-Primary Care (MIPS-PC). Using multipayer claims data in Western New York from January 1, 2016 to December 31, 2021, patients with SMI and CVD were identified using International Classification of Diseases, Tenth Revision codes. National Provider Identification numbers of MIPS-PC providers were then used to identify those patients who were treated by MIPS-PC during the period. These MIPS-PC-treated patients were compared against a cohort of one-to-one propensity score matched contemporaneous comparison group (ie, patients receiving PC from providers unaffiliated with MIPS-PC). A difference-in-difference approach was used to identify the treatment effects of MIPS-PC on all-cause emergency department (ED) visits and hospitalization rates. The MIPS-PC group was associated with a downtrend in the acute care utilization rates over a 3-year period following the index date (ie, date of first MIPS-PC or other PC provider encounter), specifically a lower hospitalization rate in the first year since the index date (25%; P < 0.001). ED visit rate reduction was significant in the third-year period (18%; P = 0.021). In summary, MIPS-PC treatment is associated with a decreasing trend in acute care utilization. Prospective studies are needed to validate this effect of enhanced PC in patients with SMI and CVD.

Collaborative care approaches for people with severe mental illness.

Collaborative care for severe mental illness (SMI) is a community-based intervention that promotes interdisciplinary working across primary and secondary care. Collaborative care interventions aim to improve the physical and/or mental health care of individuals with SMI. This is an update of a 2013 Cochrane review, based on new searches of the literature, which includes an additional seven studies. To assess the effectiveness of collaborative care approaches in comparison with standard care (or other non-collaborative care interventions) for people with diagnoses of SMI who are living in the community. We searched the Cochrane Schizophrenia Study-Based Register of Trials (10 February 2021). We searched the Cochrane Common Mental Disorders (CCMD) controlled trials register (all available years to 6 June 2016). Subsequent searches on Ovid MEDLINE, Embase and PsycINFO together with the Cochrane Central Register of Controlled Trials (with an overlap) were run on 17 December 2021. Randomised controlled trials (RCTs) where interventions described as 'collaborative care' were compared with 'standard care' for adults (18+ years) living in the community with a diagnosis of SMI. SMI was defined as schizophrenia, other types of schizophrenia-like psychosis or bipolar affective disorder. The primary outcomes of interest were: quality of life, mental state and psychiatric admissions at 12 months follow-up. Pairs of authors independently extracted data. We assessed the quality and certainty of the evidence using RoB 2 (for the primary outcomes) and GRADE. We compared treatment effects between collaborative care and standard care. We divided outcomes into short-term (up to six months), medium-term (seven to 12 months) and long-term (over 12 months). For dichotomous data we calculated the risk ratio (RR) and for continuous data we calculated the standardised mean difference (SMD), with 95% confidence intervals (CIs). We used random-effects meta-analyses due to substantial levels of heterogeneity across trials. We created a summary of findings table using GRADEpro. Eight RCTs (1165 participants) are included in this review. Two met the criteria for type A collaborative care (intervention comprised of the four core components). The remaining six met the criteria for type B (described as collaborative care by the trialists, but not comprised of the four core components). The composition and purpose of the interventions varied across studies. For most outcomes there was low- or very low-certainty evidence. We found three studies that assessed the quality of life of participants at 12 months. Quality of life was measured using the SF-12 and the WHOQOL-BREF and the mean endpoint mental health component scores were reported at 12 months. Very low-certainty evidence did not show a difference in quality of life (mental health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.03, 95% CI -0.26 to 0.32; 3 RCTs, 227 participants). Very low-certainty evidence did not show a difference in quality of life (physical health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.08, 95% CI -0.18 to 0.33; 3 RCTs, 237 participants). Furthermore, in the medium term (at 12 months) low-certainty evidence did not show a difference between collaborative care and standard care in mental state (binary) (RR 0.99, 95% CI 0.77 to 1.28; 1 RCT, 253 participants) or in the risk of being admitted to a psychiatric hospital at 12 months (RR 5.15, 95% CI 0.67 to 39.57; 1 RCT, 253 participants). One study indicated an improvement in disability (proxy for social functioning) at 12 months in the collaborative care arm compared to usual care (RR 1.38, 95% CI 0.97 to 1.95; 1 RCT, 253 participants); we deemed this low-certainty evidence. Personal recovery and satisfaction/experience of care outcomes were not reported in any of the included studies. The data from one study indicated that the collaborative care treatment was more expensive than standard care (mean difference (MD) international dollars (Int$) 493.00, 95% CI 345.41 to 640.59) in the short term. Another study found the collaborative care intervention to be slightly less expensive at three years. This review does not provide evidence to indicate that collaborative care is more effective than standard care in the medium term (at 12 months) in relation to our primary outcomes (quality of life, mental state and psychiatric admissions). The evidence would be improved by better reporting, higher-quality RCTs and the assessment of underlying mechanisms of collaborative care. We advise caution in utilising the information in this review to assess the effectiveness of collaborative care.

Effectiveness of supported housing versus residential care in severe mental illness: a multicenter, quasi-experimental study

PurposeUp to now there are only few studies and no RCT comparing efficacy or effectiveness of supported housing (SH) versus residential care (RC) in severe mental illness (SMI) without homelessness. Here we present an observational follow-up study in SMI subjects, who entered SH or RC, to compare clinical and functional outcomes 2 years later.MethodsIn this prospective study in more than 30 locations throughout a German federal state, we included SMI subjects, who entered SH (n = 153) or RC (n = 104). About one quarter suffered from each substance use, psychotic, affective, or other disorders. To avoid sampling bias, we used the propensity score matching method to establish a quasi-experimental design. Outcome measures were social functioning (SFS), the number of psychiatric hospitalisations, psychopathology (SCL-9-K), and quality of life (MANSA). Apart from descriptive methods we analysed primarily using repeated-measures ANOVAS.ResultsOur analyses revealed significant effects of time for all outcomes in both study groups. However, there were not any group differences of outcome measures, i.e., not any significant effects of group or interactional effects of group x time. Moreover, these results hold true for intent-to-treat and per-protocol sample analyses.ConclusionThe results show, that SH and RC for non-homeless people with SMI achieve the same clinical and psychosocial outcomes across a 2-year period. Taking into account the users’ preferences, the present findings should give reason to ensure the availability of affordable housing and to support the expansion of supported housing approaches.

Experiences and views of carers regarding the physical health care of people with severe mental illness: An integrative thematic review of qualitative research.

WHAT IS KNOWN ON THE SUBJECT?: People with severe mental illness (SMI) have high rates of physical illnesses, and carers are core partners in managing their physical health. Qualitative research on carers' views/experiences of physical health care is limited, and there is no published systematic review that synthesizes the current evidence. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Carers' views from seven articles were synthesised into nine themes and six subthemes describing their perceived facilitators, barriers and roles regarding the physical health care of people with SMI. Carers' voiced similar concerns to those previously identified by professionals and service users, particularly in relation to poor service access/responsiveness and communication difficulties with healthcare professionals. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses should be aware of the risk of diagnostic overshadowing and ensure they are both responsive and sensitive to carers concerns about the physical health of people with SMI. It is essential for mental health nurses to actively involve carers in managing physical health, especially in formulating physical healthcare plans and providing clear practical advice/information. ABSTRACT: Introduction People with severe mental illness (SMI) have high rates of physical illnesses. Informal carers are core partners in addressing these issues, however research on their views/experiences is limited and there is no systematic review published on the topic. Aim This integrative thematic review explored the experiences and views of carers on physical health care in SMI by synthesizing the existing qualitative research findings. Methods Six databases were searched from 2000 to 2021. Data were extracted and synthesised using thematic integrative analysis. The quality of included studies was assessed with the JBI Critical Appraisal Checklist. Results Five studies were included. Nine themes were identified conceptualising carers' perceived facilitators, barriers and roles regarding physical health care for people with SMI. Discussion Carers felt that receiving practical help and a specialised role for mental health nurses would facilitate better physical health care. Lack of coordination/communication and poor service access/responsiveness were common barriers, often compounded by diagnostic overshadowing. Carers are involved in promoting healthy lifestyles, monitoring physical health and supporting access to services. Implications for Practice Mental health nurses should ensure they are responsive to carers' concerns and proactively support them to promote the physical health of people with SMI.

Mobile early detection and connected intervention to coproduce better care in severe mental illness.

Current approaches to the management of severe mental illness have four major limitations: 1) symptom reporting is intermittent and subject to problems with reliability; 2) service users report feelings of disengagement from their care planning; 3) late detection of symptoms delay interventions and increase the risk of relapse; and 4) care systems are held back by the costs of unscheduled hospital admissions that could have been avoided with earlier detection and intervention. The ClinTouch system was developed to close the loop between service users and health professionals. ClinTouch is an end-to-end secure platform, providing a validated mobile assessment technology, a web interface to view symptom data and a clinical algorithm to detect risk of relapse. ClinTouch integrates high-resolution, continuous longitudinal symptom data into mental health care services and presents it in a form that is easy to use for targeting care where it is needed. The architecture and methodology can be easily extended to other clinical domains, where the paradigm of targeted clinical interventions, triggered by the early detection of decline, can improve health outcomes.

Personalised care in severe mental illness – there's no need to wait

Personalised care in severe mental illness – there's no need to wait

Integrated care in German mental health services as benefit for relatives--a qualitative study.

BackgroundAs mental health services undergo the process of deinstitutionalization, this is resulting in a higher burden of care for relatives. Evidence suggests that interventions for carers have a beneficial impact on their psychological health. A reduction of responsibility for relatives is linked with a significantly improved outcome for the severely mentally ill. The aim of the study was to explore the relatives’ experiences with severely mentally ill patients in different integrated care service providers.MethodsSemi-structured focus groups and interviews were conducted with 24 relatives of patients receiving community based integrated care for severe mental illness. The collected data was transcribed and evaluated using qualitative content analysis. A deductive-inductive approach was used in generating thematic categories.ResultsFour main categories were found related to the structural aspects of the integrated care services and for the experiences of the relatives within these services. Relatives reported that the services offered significant relief and substantial support in daily life. In addition, relatives felt a reduced burden of carer responsibility and therefore that they were provided with more protection and stability. This resulted in a sense of encouragement and not feeling left alone to face challenges.ConclusionRelatives are a critical resource for patients suffering from mental health problems and benefit from formal structures and interventions to support them in carer role. An important need is to ensure continuity of care for patients and the bridging of gaps concerning information and support needs for relatives when providing integrated mental health services in the community.

Collaborative care approaches for people with severe mental illness.

Collaborative care for severe mental illness (SMI) is a community-based intervention, which typically consists of a number of components. The intervention aims to improve the physical and/or mental health care of individuals with SMI. To assess the effectiveness of collaborative care approaches in comparison with standard care for people with SMI who are living in the community. The primary outcome of interest was psychiatric admissions. We searched the Cochrane Schizophrenia Group Specialised register in April 2011. The register is compiled from systematic searches of major databases, handsearches of relevant journals and conference proceedings. We also contacted 51 experts in the field of SMI and collaborative care. Randomised controlled trials (RCTs) described as collaborative care by the trialists comparing any form of collaborative care with 'standard care' for adults (18+ years) living in the community with a diagnosis of SMI, defined as schizophrenia or other types of schizophrenia-like psychosis (e.g. schizophreniform and schizoaffective disorders), bipolar affective disorder or other types of psychosis. Two review authors worked independently to extract and quality assess data. For dichotomous data, we calculated the risk ratio (RR) with 95% confidence intervals (CIs) and we calculated mean differences (MD) with 95% CIs for continuous data. Risk of bias was assessed. We included one RCT (306 participants; US veterans with bipolar disorder I or II) in this review. We did not find any trials meeting our inclusion criteria that included people with schizophrenia. The trial provided data for one comparison: collaborative care versus standard care. All results are 'low or very low quality evidence'.Data indicated that collaborative care reduced psychiatric admissions at year two in comparison to standard care (n = 306, 1 RCT, RR 0.75, 95% CI 0.57 to 0.99).The sensitivity analysis showed that the proportion of participants psychiatrically hospitalised was lower in the intervention group than the standard care group in year three: 28% compared to 38% (n = 330, 1 RCT, RR 0.72, 95% CI 0.53 to 0.99).In comparison to the standard care group, collaborative care significantly improved the Mental Health Component (MHC) of quality of life at the three-year follow-up, (n = 306, 1 RCT, MD 3.50, 95% CI 1.80 to 5.20). The Physical Health Component (PHC) of the quality of life measure at the three-year follow-up did not differ significantly between groups (n = 306, 1 RCT, MD 0.50, 95% CI 0.91 to 1.91).Direct intervention (all-treatment) costs of collaborative care at the three-year follow-up did not differ significantly from standard care (n = 306, 1 RCT, MD -$2981.00, 95% CI $16934.93 to $10972.93). The proportion of participants leaving the study early did not differ significantly between groups (n = 306, 1 RCT, RR 1.71, 95% CI 0.77 to 3.79). There is no trial-based information regarding the effect of collaborative care for people with schizophrenia.No statistically significant differences were found between groups for number of deaths by suicide at three years (n = 330, 1 RCT, RR 0.34, 95% CI 0.01 to 8.32), or the number of participants that died from all other causes at three years (n = 330, 1 RCT, RR 1.54, 95% CI 0.65 to 3.66). The review did not identify any studies relevant to care of people with schizophrenia and hence there is no evidence available to determine if collaborative care is effective for people suffering from schizophrenia or schizophreniform disorders. There was however one trial at high risk of bias that suggests that collaborative care for US veterans with bipolar disorder may reduce psychiatric admissions at two years and improves quality of life (mental health component) at three years, however, on its own it is not sufficient for us to make any recommendations regarding its effectiveness. More large, well designed, conducted and reported trials are required before any clinical or policy making decisions can be made.

Call for information, call for quality in mental health care

The quality of routine mental health care is not optimal, it can vary greatly from region to region and among providers; in many occasions, it does not correspond to the standards of evidence-based mental health. To bridge this gap, the promotion of a systematic use of the information available for quality assurance would be most helpful, but measuring the quality of mental health care is particularly challenging. Quality measurement can play a key role in transforming health care systems, and the routine measurement of quality, using clinical indicators derived from evidence-based practice guidelines, is an important step to this end. In Italy, the use of clinical indicators is still sporadic: over the last 5 years only three projects have been aimed at analysing, in a structured way, the quality of care in severe mental illness, and two of these were led by the Italian Society of Psychiatric Epidemiology. Not only in Italy but also at global level there is an urgent need for the implementation of mental health information systems that could lead to a substantial improvement in information technology. Once this has been achieved, a common set of clinical indicators, agreed upon at the regional and national level and useful for benchmarking and for comparing mental health services, could be defined. Finally, using the implementation strategies, a system of quality improvement at both regional and local levels will be built.

Acute psychiatric inpatient care: A cross-cultural comparison between two hospitals in Germany and Japan

Intercultural differences influence acute inpatient psychiatric care systems. To evaluate characteristics of acute inpatient care in a German and a Japanese hospital. Based on a sample of 465 admissions to the Psychiatric State Hospital Regensburg (BKR) and 91 admissions to the Hirakawa Hospital (HH) over a six-month period in 2008, data from the psychiatric basic documentation system (BADO) were analysed with regard to socio-demographic characteristics, treatment processes and outcome indicators. Schizophrenia and related psychosis was the most common diagnosis in both hospitals. Cases at the BKR were admitted more quickly after onset of the present episode. Global Assessment of Psychosocial Functioning (GAF) ratings at admission were lower at the HH. Most admissions to both hospitals received psychopharmacological treatment, but more at the HH received psychotherapy. Length of stay was significantly longer at the HH (75 days) than at the BKR (28 days). Admissions to the HH were more improved with regard to GAF and clinical global impression (CGI). Acute admissions in Germany provide intensive care with short hospitalization as crisis intervention. For acute admissions in Japan, comprehensive care for severe mental illness precedes emergency admissions and achieves greater improvement with longer hospitalization.

Bridging experience and evidence in mental health care reform

Bridging experience and evidence in mental health care reform

The Feasibility of Computerized Patient Self-assessment at Mental Health Clinics

Improving the quality of care for severe mental illness (SMI) has been difficult because patients' clinical information is not readily available. Audio computer-assisted self-interviewing (ACASI) supports data collection by asking patients waiting for appointments clinical questions visually and aurally. It has improved outcomes for many disorders. While reliable and accurate for SMI in research settings, this study assesses questions about ACASI's feasibility in usual care. Patient and provider surveys and provider focus groups after 12 months of ACASI implementation. Two outpatient mental health clinics in Los Angeles, one run by the Department of Veterans Affairs and the other by Los Angeles County Department of Mental Health. 266 patients with SMI and 14 psychiatrists. Patients completed an ACASI survey on symptoms, drug use, medication adherence and side-effects by internet using a touch-screen monitor. A 1-page report summarizing each patient's results was printed and given to providers by patients during appointments. Feedback surveys (patients and psychiatrists) and focus groups and interviews (psychiatrists) assessed usability, usefulness, effects on treatment, and barriers to sustaining ACASI. Patients believed the PAS was enjoyable, easy to learn and use, and that it improved communication with their psychiatrists. Providers believed the PAS was easy to use, had a small impact on care, could be improved by being more detailed and comprehensive, and requires outside support to continue its use. ACASI was easy to use and enhanced communication. Systems like this can be a valuable part of quality improvement projects.

Deconstructing home‐based care for mental illness: can one identify the effective ingredients?

Home-based care for severe mental illness has been the focus of intense research over the last 30 years and has produced mixed results. Replications of Assertive Community Treatment (ACT) in Europe have consistently failed to find these differences and various explanations have been advanced for this. Studies were compared in context of health care, and then identifying and rating the components of the differing teams rather than simply their designation. Cluster analysis was used for the identification of common service characteristics and regression analysis to test for correlation with reduction in hospitalization. The nature of the control service may significantly explain the international variation in results. Six regularly occurring features of experimental services were identified from the examination of the components - smaller case loads, regularly visiting at home, a high percentage of contacts at home, responsibility for health and social care, multidisciplinary teams and a psychiatrist integrated in the team. Two of these, regularly visiting at home and responsibility for health and social care, are significantly associated with a reduction in hospitalization. It is premature to define an optimal configuration for home based care services. The need for introducing differing components of such care will depend on what is currently available locally. Where regular home visiting to psychotic patients plus a broad service model incorporating health and social care objectives are provided, major reductions in in-patient care are not currently to be anticipated by service re-configurations.

Barriers to care in severe mental illness: accounts from perpetrators of intra-familial homicide

To review perceptions of barriers to receiving effective mental health care described by patients who had committed intra-familial homicide in the context of untreated severe mental illness. Semi-structured interviews addressed issues such as support, help-seeking, experience of illness, and what participants felt might have helped prevent the death(s). Transcripts were analysed for themes related to barriers to help-seeking. Themes identified included: hiding or minimizing difficulties, lack of knowledge or understanding of mental illness, loss of control in the context of illness, seduction by the illness, reality-distorting effects of the illness, distortion of interpersonal relationships, diminished ability to trust and difficulty acknowledging need for medication. Barriers to care exist at individual, interpersonal and wider societal levels and need to be addressed at all of them.

The Faith Community and Mental Health Care

Back to table of contents Next article Taking IssueFull AccessThe Faith Community and Mental Health CareNorman A. Clemens, M.D., Norman A. ClemensSearch for more papers by this author, M.D., clinical professor of psychiatry at Case Western Reserve University in ClevelandPublished Online:1 Feb 2005https://doi.org/10.1176/appi.ps.56.2.133AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail From shamanism, ritual dances, and exorcism to modern pastoral counseling, efforts to deal with mental illness have been in the domain of religious practice throughout cultural history. Now that the demons of mental disorders have been substantially tamed by scientific approaches, people with mental illness in medically advanced cultures are likely to seek relief from a physician or mental health professional. However, many will turn first to clergy or a faith-based agency.Although the movement to fund faith-based agencies with federal monies raises concerns about eroding the constitutional separation of church and state, faith-based agencies serve a significant part of the population. Churches, synagogues, and mosques serve as surrogate families and community centers for millions of people. Religious writings and spiritual practices bring solace, support, sharing, practical wisdom, and guidance for dealing with myriad challenges, relationships, transitions, and losses. People with incipient mental illness may trust religious organizations far more than community health services.This issue of Psychiatric Services reports the results of two surveys of leaders in the faith community that sought to examine attitudes about mental illness and the types of care that congregants might expect to receive when they seek help within the faith community. Ali and colleagues surveyed the imams of 62 mosques across the country, and Dosset and coauthors surveyed 42 faith-based organizations—churches, schools, and nonprofit agencies—in Los Angeles. Both surveys found that although many congregants received individual or marital counseling within their religious organizations, relatively few of the counselors had formal training. Interestingly, in view of the concerns about the separation of church and state, half of the Los Angeles agencies were reluctant to collaborate with government agencies. Evidently the wariness is bilateral. However, because a large part of the care for severe mental illness occurs in governmental agencies, this attitude could impede access to treatment. A case could be made for faith-based agencies' having consultative arrangements with mental health facilities, rather than faith-based agencies' attempting to provide full-scale care for patients with serious mental illness.Fundamental incompatibilities exist between faith-based interventions, such as faith healing or exorcism, and a medical model of treating mental illness. Religious leaders and mental health professionals who conduct psychotherapy may differ markedly about basic concepts of psychological health and mental illness. These differences can yield to mutual respect, case-based consultation, education, and exchange of ideas between clergy and mental health professionals, to the benefit of those with mental disorders. FiguresReferencesCited byDetailsCited ByNone Volume 56Issue 2 February 2005Pages 133-133 Metrics PDF download History Published online 1 February 2005 Published in print 1 February 2005

Computer-Assisted Self-Assessment in Persons With Severe Mental Illness

It has been difficult to improve care for severe mental illness (SMI) in usual care settings because clinical information is not reliably and efficiently managed. Methods are needed for efficiently collecting this information to evaluate and improve health care quality. Audio computer-assisted self-interviewing (ACASI) can facilitate this data collection and has improved outcomes for a number of disorders, suggesting the need to test its accuracy and reliability in people with SMI. Ninety patients with DSM-IV schizophrenia or schizoaffective disorder (N = 45) or bipolar disorder (N = 45) recruited between Oct. 15, 2002, and July 1, 2003, were randomly assigned to 1 of 2 study groups and completed 2 standardized symptom surveys (Revised Behavior and Symptom Identification Scale and the symptom severity scale of the Schizophrenia Outcomes Module 2) 20 minutes apart in a crossover study design. Half of the patients first completed the scales via an in-person interview, and the other half first completed the scales via an ACASI survey self-administered through an Internet browser using a touchscreen developed to meet the cognitive needs of people with SMI. We evaluated attitudes toward ACASI, understanding of the ACASI survey, internal consistency, correlations between the ACASI and interview modes, concurrent validity, and a possible administration mode bias. All ACASI and in-person interview scales had similar internal reliability, high correlations (r = 0.78-1.00), and mean scores similar enough as not to be different at p < .05. A large majority rated the ACASI survey as easier, more enjoyable, more preferable if monthly completion of a survey were required, and more private, and 97% to 99% perfectly answered questions about how to use it. ACASI data collection is reliable among people with bipolar disorder and schizophrenia and could be a valuable tool to improve their care.

Models of community care for severe mental illness: a review of research on case management.

We describe different models of community care for persons with severe mental illness and review the research literature on case management, including the results of 75 studies. Most research has been conducted on the assertive community treatment (ACT) or intensive case management (ICM) models. Controlled research on ACT and ICM indicates that these models reduce time in the hospital and improve housing stability, especially among patients who are high service users. ACT and ICM appear to have moderate effects on improving symptomatology and quality of life. Most studies suggest little effect of ACT and ICM on social functioning, arrests and time spent in jail, or vocational functioning. Studies on reducing or withdrawing ACT or ICM services suggest some deterioration in gains. Research on other models of community care is inconclusive. We discuss the implications of the findings in terms of the need for specialization of ACT or ICM teams to address social and vocational functioning and substance abuse. We suggest directions for future research on models of community care, including evaluating implementation fidelity, exploring patient predictors of improvement, and evaluating the role of the helping alliance in mediating outcome.

Home based and hospital care for severe mental illness: Authors' reply

Home based and hospital care for severe mental illness: Authors' reply