Community Mental Health Care Settings Research Articles

Exploring the Outcomes of a Pilot Education Program Tailored for Adults With Type 2 Diabetes and Mental Illness in a Community Mental Health Care Setting

ObjectivesPeople with mental illness and type 2 diabetes are more likely to experience diabetes complications than the general population. Diabetes management can be improved with tailored lifestyle intervention content. The purpose of this pilot study was to investigate diabetes insights of mental health-care patients after participation in a tailored education intervention. MethodsA 12-session diabetes education program was created to address the learning needs and challenges that people with mental illness may experience. The program was assessed through conducting interviews with 6 participants combined with quantitative data to describe the population. Interviews were transcribed verbatim, assessed for quality and coded to identify relationships and meanings between identified themes. ResultsThroughout the year of participation, blood sugar control and physical activity level improved for some and worsened for others. Weight remained stable and dietary intake patterns appeared to improve overall. Participants described the appropriateness of the teaching strategies and program structure developed, and all improved their understanding about diabetes and gained practical self-management knowledge. Opportunities for program improvement included extending care beyond the counselling room to address financial limitations, incorporating a practical activity component and creating opportunities for social support. Additionally, leaving some sessions as patient directed would further individualize education care. ConclusionsOur study offers a concrete education program strategy that aligns with Diabetes Canada’s self-management education guidelines to support the provision of diabetes care for people with mental illness. Modifying program delivery may help to curtail the increasing rates of morbidity and mortality currently observed in this population.

Combining online and offline peer support groups in community mental health care settings: a qualitative study of service users\u2019 experiences

BackgroundPeer support for people with long-term mental health problems is central to recovery-oriented approaches in mental health care. Peer support has traditionally been conducted offline in face-to-face groups, while online groups on the Internet have increased rapidly. Offline and online peer support groups are shown to have differing strengths and weaknesses. However, little is known about how combining the two formats might be experienced by service users, which this paper aims to illuminate.MethodsIn this exploratory and descriptive study, a recovery-oriented Internet-based portal called ReConnect was used by service users in two mental health communities in Norway for 6–12 months. The portal included an online peer support group which also facilitated participation in local offline peer support groups. Both group formats were moderated by an employed service user consultant. Qualitative data about service users’ experiences were collected through focus groups and individual interviews and inductively analyzed thematically.ResultsA total of 14 female service users 22–67 years of age with various diagnoses participated in three focus groups and 10 individual interviews. Two main themes were identified: (1) balancing anonymity and openness, and (2) enabling connectedness. These themes are further illustrated with the subthemes: (i) dilemmas of anonymity and confidentiality, (ii) towards self-disclosure and openness, (iii) new friendships, and (iv) networks in the local community. Three of the subthemes mainly describe benefits, while challenges were more implicit and cut across the subthemes. Identified challenges were related to transitions from anonymity online to revealing one’s identity offline, confidentiality, and barriers related to participation in offline peer support groups.ConclusionsThis study suggests that online and offline peer support groups complement each other, and that combining them is mainly described as beneficial by service users. Identified benefits appeared to arise from service users’ options of one format or the other, or that they could combine formats in ways that suited their individual values and comfort zones. Moderation by a trained service user consultant appeared essential for both formats and can be used systematically to address identified challenges. Combining online and offline peer support groups is a promising concept for facilitating recovery-oriented care and warrants continued research.

Availability of Integrated Primary Care Services in Community Mental Health Care Settings.

This study examined the availability of primary care and wellness services in community mental health centers (CMHCs) and outpatient mental health facilities (OMHFs). This study used data from the 2016 National Mental Health Services Survey to examine the proportion of facilities that reported offering integrated primary care and wellness services (smoking and tobacco cessation counseling, diet and exercise counseling, and chronic disease and illness management). The study used logistic regression to model the odds that a facility offered integrated primary care as a function of facility characteristics. Across states, 23% of CMHCs and 19% of OMHFs offered integrated primary care. The odds of offering integrated primary care were significantly higher among facilities that reported more quality improvement practices, prohibited smoking, or offered wellness services. Less than one third offered smoking and tobacco cessation counseling or other wellness services. Integrated primary care remains uncommon in CMHCs and OMHFs and is more likely among facilities with certain characteristics.

Case-Mix Classification for Mental Health Care in Community Settings: A Scoping Review.

As mental health care transitions from facility-based care to community-based services, methods to classify patients in terms of their expected health care resource use are an essential tool to balance the health care needs and equitable allocation of health care resources. This study performed a scoping review to summarize the nature, extent, and range of research on case-mix classifications used to predict mental health care resource use in community settings. This study identified 17 eligible studies with 32 case-mix classification systems published since the 1980s. Most of these studies came from the USA Veterans Affairs and Medicare systems, and the most recent studies came from Australia. There were a wide variety of choices of input variables and measures of resource use. However, much of the variance in observed resource use was not accounted for by these case-mix systems. The research activity specific to case-mix classification for community mental health care was modest. More consideration should be given to the appropriateness of the input variables, resource use measure, and evaluation of predictive performance. Future research should take advantage of testing case-mix systems developed in other settings for community mental health care settings, if possible.

Implementation and fidelity assessment of the NAVIGATE treatment program for first episode psychosis in a multi-site study

The NAVIGATE program was developed for the Recovery After Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study, which compared NAVIGATE to usual Community Care in a cluster randomized design involving 34 sites and 404 patients. This article describes the approach to training and implementing the NAVIGATE program at the 17 sites (including 134 practitioners) randomized to provide it, and to evaluating the fidelity of service delivery to the NAVIGATE model. Fidelity was evaluated to five different components of the program, all of which were standardized in manuals in advance of implementation. The components included four interventions (Individualized Resiliency Training, Family Education Program, Supported Employment and Education, Personalized Medication Management) and the overall organization (staffing and structure) of the NAVIGATE team. Most of the sites demonstrated acceptable or higher levels of fidelity in their implementation of the four interventions and the organization of the program, with all 17 sites demonstrating at least acceptable overall fidelity to the NAVIGATE program. The results indicate that the NAVIGATE program can be implemented with good fidelity to the treatment model in a diverse array of community mental health care settings serving persons with a first episode psychosis.

The effect of a brief educational programme added to mental health treatment to improve patient activation: A randomized controlled trial in community mental health centres

ObjectiveWhile there is growing interest in improving patient activation in general medical health services, there are too few randomized controlled trials in mental health settings which show how improvement can be achieved. Using the Patient Activation Measure-13 (PAM-13), we aimed to assess the effect of pre-treatment, peer co-led educational intervention on patient activation. Secondary outcomes included measures of patient satisfaction, well-being, mental health symptoms, motivation, and treatment participation. MethodsPatients from two community mental health centres were randomized to a control group (CG, n=26) receiving treatment as usual, or an intervention group (IG, n=26) consisting of a four-hour group educational seminar (aiming to encourage patients to adopt an active role in their treatment) followed by treatment as usual. ResultsOnly the IG improved on PAM-13, at one- and four-month follow-ups. The intervention had significant effects on patient satisfaction and treatment participation, compared to CG. ConclusionProviding pre-treatment, peer co-led education improves patient activation in community mental health care settings. Practice implicationsThe use of peers as co-educators may contribute to a different mental health care delivery, ensuring patient activation and participation in treatment. Further studies should examine peers’ needs for supervision, challenges for the services, long-term and cost-benefit effects. Clinicaltrials.gov identifierNCT01601587.

Study protocol: cross-national comparative case study of recovery-focused mental health care planning and coordination (COCAPP).

BackgroundThe collaborative care planning study (COCAPP) is a cross-national comparative study of care planning and coordination in community mental healthcare settings. The context and delivery of mental health care is diverging between the countries of England and Wales whilst retaining points of common interest, hence providing a rich geographical comparison for research. Across England the key vehicle for the provision of recovery-focused, personalised, collaborative mental health care is the care programme approach (CPA). The CPA is a form of case management introduced in England in 1991, then revised in 2008. In Wales the CPA was introduced in 2003 but has now been superseded by The Mental Health (Care Co-ordination and Care and Treatment Planning) (CTP) Regulations (Mental Health Measure), a new statutory framework. In both countries, the CPA/CTP requires providers to: comprehensively assess health/social care needs and risks; develop a written care plan (which may incorporate risk assessments, crisis and contingency plans, advanced directives, relapse prevention plans, etc.) in collaboration with the service user and carer(s); allocate a care coordinator; and regularly review care. The overarching aim of this study is to identify and describe the factors that ensure CPA/CTP care planning and coordination is personalised, recovery-focused and conducted collaboratively.Methods/designCOCAPP will employ a concurrent transformative mixed methods approach with embedded case studies. Phase 1 (Macro-level) will consider the national context through a meta-narrative mapping (MNM) review of national policies and the relevant research literature. Phase 2 (Meso-level and Micro-level) will include in-depth micro-level case studies of everyday ‘frontline’ practice and experience with detailed qualitative data from interviews and reviews of individual care plans. This will be nested within larger meso-level survey datasets, senior-level interviews and policy reviews in order to provide potential explanations and understanding.DiscussionCOCAPP will help identify the key components that support and hinder the provision of personalised, recovery-focused care planning and provide an informed rationale for a future planned intervention and evaluation.

Preferences for participation in shared decision making of psychiatric outpatients with affective disorders

Objective: To assess preferences for participation in shared decision making in a representative sample of psychiatric outpatients with affective disorders and to understand how clinical and socio-demographic variables influence patients’ preferences for participation. Method: A cross-sectional survey of 172 consecutive psychiatric outpatients with affective disorders attending at Community Mental Health Care setting was carried out. Patients expressed preferences on each of 3 aspects of decision making (seeking information, discussing options, making the final decision). The “CGI Severity and Improvement Scales” and the “Beck Depression Inventory” scale were used for severity assessment. Additionally the “Drug Attitude Inventory”, the “Beliefs about Medicine Questionnaire” and the “Leeds Attitude toward Concordance Scale” were applied to all participants. Effects of variables considered on preferences were assessed using proportional odds regression models. Results: We registered a high response rate of 85%. Nearly all patients (91%) preferred to leave final decisions to their treating psychiatrists and 87% preferred to rely on psychiatrists for medical knowledge rather than seeking their own information. In contrast, 81% of patients preferred to be offered options and to be asked their opinion by their doctors. Gender, age, educational level, number of psychotropics used and belief about psychiatric medication overuse were significant predictors in decision making dimensions considered. Conclusion: Shared decision making approach of patients with affective disorder must take into consideration a more doctor-directed approach preferred by the patients in which the desire to be offered options is not automatically linked with the willingness of taking decisions or getting more knowledge.

Evaluating Genetic Counseling for Family Members of Individuals With Schizophrenia in the Molecular Age

Myths and concerns about the extent and meaning of genetic risk in schizophrenia may contribute to significant stigma and burden for families. Genetic counseling has long been proposed to be a potentially informative and therapeutic intervention for schizophrenia. Surprisingly, however, available data are limited. We evaluated a contemporary genetic counseling protocol for use in a community mental health-care setting by non-genetics professionals. We used a pre-post study design with longitudinal follow-up to assess the impact of genetic counseling on family members of individuals with schizophrenia, where molecular testing had revealed no known clinically relevant genetic risk variant. We assessed the outcome using multiple measures, including standard items and scales used to evaluate genetic counseling for other complex diseases. Of the 122 family members approached, 78 (63.9%) actively expressed an interest in the study. Participants (n = 52) on average overestimated the risk of familial recurrence at baseline, and demonstrated a significant improvement in this estimate postintervention (P < .0001). This change was associated with an enduring decrease in concern about recurrence (P = .0003). Significant and lasting benefits were observed in other key areas, including increased knowledge (P < .0001) and a decreased sense of stigma (P = .0047). Endorsement of the need for genetic counseling was high (96.1%). These results provide initial evidence of the efficacy of schizophrenia genetic counseling for families, even in the absence of individually relevant genetic test results or professional genetics services. The findings support the integration of contemporary genetic counseling for families into the general management of schizophrenia in the community.

Competencies of More and Less Successful Employment Specialists

The competencies of individual employment specialists influence rates of competitive employment among consumers and programs. Identifying competencies can lead to the development of more effective specialists and improve employment outcomes for consumers enrolled in employment services in community mental health care settings. The purpose of this study was to examine how more successful employment specialists performed supported employment duties in comparison to less successful employment specialists. Ethnographic researchers observed more and less successful employment specialists performing job duties related to the five phases of supported employment. Using grounded theory, they identified factors that differentiated the two groups. More successful employment specialists worked efficiently, developed egalitarian relationships with consumers, and collaborated well with other partners. Less successful employment specialists understood the model but lacked these behavioral skills. Service providers should screen and train employment specialists for efficiency, flexibility, and interpersonal skills.

Integrating Tobacco Treatment Into Mental Health Settings

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Which factors influence the psychological distress among relatives of patients with chronic functional psychoses? An exploratory study in a community mental health care setting

AimThis research aimed to assess the contribution of the five core areas of the transactional stress model to the relatives’ psychological distress (PD) when informally taking care of patients with functional psychoses treated in community mental health care.Subjects and methodsCross-sectional data from 163 relatives were collected in interviews, while data on 158 patients were collected by analyzing clinical charts. The following areas were assessed: socio-demographic and illness-related features of the patients, socio-demographic features of the relatives (environmental variables); sense of coherence, mastery, causal attributions and opinions of relatives about mental disorders (person variables); interpersonal problems with the patients as well as the assessment of their symptoms by the relatives themselves (primary appraisal); support received, critical life events and burden of relatives caused by their own illnesses (secondary appraisal); control behavior and efforts of relatives to engage the patients in activities (coping). PD was assessed with the 12-item version of the General Health Questionnaire. Bi-variate correlation analysis and a multiple linear regression model were the main test statistical approaches.ResultsCorrelation analysis showed that differences between diagnostic groups referred to primary and secondary appraisal processes, in particular. Results of the statistical model provided evidence for the importance of primary appraisal and person variables for influencing PD, and for the lack of importance of coping and environmental variables.ConclusionThe study enhanced the validity of the transactional stress model to demonstrate the influence of salutogenetic concepts such as sense of coherence.

Public-Academic Partnerships: The Thresholds-Dartmouth Partnership and Research on Shared Decision Making

Thresholds Rehabilitation Centers is one of the largest providers of psychiatric rehabilitation services in the United States, and the Dartmouth Psychiatric Research Center is a highly regarded team of rehabilitation researchers. This column describes efforts to build upon the long-standing collaborative relationship between Thresholds (community partner) and Dartmouth (academic partner) to implement and study shared decision making in a community mental health care setting that serves an ethnoracially diverse population. Shared decision making encompasses a client-centered approach in which client and practitioner are equal partners. This joint project incorporates modern information technology, decision science, cultural competence, stakeholder collaboration, outcomes research, and training. The partnership itself provides an exemplar of shared decision making.

Implementing the Illness Management and Recovery Program in Community Mental Health Settings: Facilitators and Barriers

Implementing the Illness Management and Recovery Program in Community Mental Health Settings: Facilitators and Barriers

Risperidone long-acting injection in the treatment of schizophrenia spectrum illnesses: A retrospective chart review of 19 patients in the Vancouver Community Mental Health Organization (Vancouver, Canada)

Background: Schizophrenia is a chronic debilitating disease that affects ~110,000 Canadians (0.55% lifetime prevalence). Risperidone long-acting injection (RLAI) is the first injectable, long-acting, atypical antipsychotic drug marketed in Canada. Objective: The aim of this study was to assess the clinical effectiveness and hospitalization rates of patients with schizophrenia, schizoaffective disorder, or schizophreniform disorder treated with RLAI in a community mental health care setting. Methods: Data were collected between August 1, 2006 and September 30, 2006 via a retrospective chart review of outpatients diagnosed with schizophrenia, schizoaffective disorder, or schizophreniform disorder who received treatment from 1 of the 8 mental health teams within the Vancouver Community Mental Health Organization (VCMHO) in Vancouver, British Columbia, Canada. Collected data included: frequency and duration of institutional care, discharge and relapse rates, demographic variables, diagnosis history, RLAI medication history, and history of other medications. The overall severity of symptoms before and after RLAI treatment and the improvement in symptoms during treatment were evaluated using the Clinical Global Impression Scales for severity (CGI-S)(1 = not ill to 7 = extremely ill) and improvement (CGI-I)(1 = very much improved to 7 = very much worse). Results: Forty-four patients were identified as having received RLAI. The charts of 19 patients (10 men, 9 women; mean [SD] age at time of chart audit, 36.7 [11.7] years; mean [SD] age at primary diagnosis, 23.6 [7.4] years; race: white, 10 [52.6%]; Asian, 6 [31.6%]; American Indian, 1 [5.3%]; black, 1 [5.3%]; other, 1 [5.3%]) were included in the analysis. The majority of patients (78%) had been treated with another antipsychotic drug prior to treatment with RLAI: risperidone (77%), quetiapine (47%), zuclopenthixol (43%), olanzapine (43%), and loxapine (17%). Mean (SD) CGI-S Scale score declined significantly from 5.29 (1.3) before treatment initiation to 3.05 (1.0) posttreatment ( P < 0.001). Mean (SD) CGI-I Scale score was 2.58 (0.71) ( P < 0.001); 94% of patients had a CGI-I score ≤3. Mean (SD) duration of hospitalization decreased significantly from 15.7 (19.7) days before treatment to 2.4 (6.0) days after treatment ( P < 0.05). Mean (SD) number of hospializations also decreased significantly from 2.0 (1.8) before treatment to 0.5 (1.3) after treatment ( P < 0.01). Conclusions: The results of this pilot study suggest that use of the atypical-antipsychotic medication RLAI significantly decreased duration and rates of hospitalization, compared with baseline, in these VCMHO patients with schizophrenia spectrum illnesses.

Monitoring the Physical Health of Patients on Long‐term Antipsychotics ‐ How Easy Will It Be?

The physical health of patients with severe mental illness is often neglected or managed poorly, and regular review of physical health is now being strongly advised. The study described here explored the feasibility of such reviews in a community mental health care setting. A small group of patients was invited to attend for blood tests and a brief physical examination. The findings from the study suggest that the monitoring of patients with severe enduring mental illness is an important but difficult task. It will require careful planning and the engagement of patients, general practitioners and community mental health teams.

Clinical and economic impact of newer versus older antipsychotic medications in a community mental health center

This pilot study was conducted to compare both the clinical effectiveness and the treatment costs of newer (atypical) antipsychotic medications (clozapine and risperidone) with those of older (classic) neuroleptic medications (chlorpromazine and haloperidol) for psychosis in a community mental health care setting. The study used a retrospective, uncontrolled, open, nonrandomized, within-subjects design and relied on medical records as a data source for 37 clients. All clients received older antipsychotics for at least 1 year, newer antipsychotics for a transition period of 3 months, and the newer agents for at least an additional year. The newer antipsychotic medications were more effective and less costly (total cost of care, $3000 less per client per year [1997 dollars]) than the older medications. Effectsize estimates for the measured variables provide a guide for future research into the cost-effectiveness of these newer medications within the community mental health care setting. These findings can provide policy makers with guidance on treating people with major mental disorders in the most effective and efficient manner. Because of limited budgets, community mental health centers making the investment in newer, more expensive medications to improve client outcomes have to maintain the same or lower total cost of care. Results of the current study suggest that short-term investment in the newer medications by community mental health centers offers superior clinical effectiveness and lower long-term overall cost of care.

Experience with clozapine in a community mental health care setting.

Clozapine has been heralded as the first major breakthrough in antipsychotic drug therapy for treatment-resistant schizophrenia in 40 years. This study reports on the experience with clozapine in an outpatient, community mental health care setting. All clinic patients receiving clozapine during the 4-year period 1992 to 1996 were retrospectively studied. Measures of improvement were changes in the Clinical Global Improvement (CGI) Scale and reduction in the number of hospital days after clozapine therapy. Testing with the CGI scale showed moderate or marked improvement in 63% of patients. Hospital days dropped from 7,919 to 1,833 for comparable time periods. Clozapine therapy had to be discontinued in only 21% of patients, and no serious side-effects occurred. Clozapine is an effective medication for treatment-resistant schizophrenia and can be safely used in chronic mental illness. Although the drug is expensive, the cost is offset by a remarkable reduction in hospital days.