Community Psychiatric Treatment Research Articles

Evaluation of a flexible assertive community treatment (FACT) program for patients with severe mental illness: an observational study in Salzburg, Austria

Abstract Background Inpatient treatment of severe mentally ill patients binds substantial resources and creates the dilemma of “revolving-door hospitalizations”. Evidence suggests that these patients benefit more from an assertive outreach community psychiatric treatment. This descriptive study evaluates the implementation of a new treatment program for severe mentally ill patients provided by a flexible assertive community treatment (FACT) team. Methods An uncontrolled design with routine data was used to measure the total length of stays, readmission rates and number of contacts one year prior to the implementation of the FACT program and the following first three years of treatment. Results A continuous decrease of hospitalization among patients with severe mental illness was observed with the implementation of the FACT program with declines in total length of stays and readmission rates and accompanied with a decreasing number of contacts per year. Conclusion Our findings indicate that this program may create effects in stabilizing patients with severe mental illness and may be highly relevant also for other patient groups.

Suicidal Behavior and Difficulty of Patients, as Perceived by Community Mental Health Nurses

Mental health professionals who work in community mental health services play an important role in treating patients after attempted suicide or deliberate self-injury. When such behaviors are interpreted negatively, patients may be seen as difficult, which may lead to ineffective treatment and mutual misunderstanding. The goal of this study was to assess the association between the grading of suicidality and perceived difficulty. We hypothesized that a higher grading of suicidality is associated with increased perceived difficulty. We analyzed cross-sectional data from 176 patients who participated in 2 cohort studies: 92 patients in the MATCH-cohort study and 84 patients in the Interpersonal Community Psychiatric Treatment (ICPT) study. The dependent variable was perceived difficulty, as measured by the Difficult Doctor-Patient Relationship Questionnaire (DDPRQ) and the Difficulty Single-item (DSI), a single item measuring the difficulty of the patient as perceived by the professional. Grading of suicidality was considered as the independent variable. Multiple linear and logistic regression was performed. We found a significant association between perceived difficulty (DDPRQ) and high gradings of suicidality (B: 3.96; SE: 1.44; β: 0.21; P=0.006), increasing age (B: 0.09; SE: 0.03; β: 0.22; P<0.003), sex (female) (B: 2.33; SE: 0.83; β: 0.20; P=0.006), and marital status (being unmarried) (B: 1.92; SE: 0.85; β: 0.17; P=0.025). A significant association was also found between the DSI and moderate (odds ratio: 3.04; 95% CI: 1.355-6.854; P=0.007) and high (odds ratio: 7.11; 95% CI: 1.8.43-24.435; P=0.005) gradings of suicidality. In this study, we found that perceived difficulty was significantly associated with moderate and high gradings of suicidality, increasing age, female sex, and being unmarried.

Barriers to the Use of the Mental Health Treatment Requirement as Part of a Community-Based Criminal Sentence for Mentally Disordered Offenders

AimsDue to the high rates of mental disorder in prison there have been a number of initiatives to divert mentally disordered offenders out of custody. One of these is the Mental Health Treatment Requirement (MHTR): a criminal sentence available as part of a Community Order, offered as an alternative to short-term custodial sentences in an attempt to address recidivism and encourage concordance with community psychiatric treatment. In spite of the prevalence of mental disorder amongst offenders, MHTRs represent less than 1% of all community sentences. Here we aim to identify obstacles to the use of the MHTR at sentencing and to suggest ways of overcoming them.MethodsA literature review and brief case series will be used to identify and illustrate what may be obstructing or limiting the use of the MHTR. The terms ‘MHTR’ and ‘Mental Health Treatment Requirement’ were searched on Google, Google Scholar, Athens, and PubMed, and results analysed for recurrent themes. The issues encountered clinically by one of the authors who referred three defendants for MHTRs in psychiatric sentencing reports in 2021 were reviewed with the same purpose.ResultsThe main barriers to the use of the MHTR which were identified were issues related to a lack of clinician awareness and experience, homelessness and housing, and service structure and provision. There may be a reluctance for Community Mental Health Teams (CMHTs) to accept offenders onto their caseloads, and there are challenges in obtaining assessments and recommendations for MHTRs. There are difficulties in securing an MHTR for homeless defendants on remand for whom identifying housing prior to sentencing, and thus a CMHT to supervise the MHTR, can be challenging. The MHTR assessment and referral process is more lengthy and cumbersome than that for most other disposals, leaving the defendant awaiting sentencing (potentially in custody) while the referral is processed.ConclusionSuggested solutions to improve access to the MHTR include increasing clinician awareness and confidence by providing teaching and training, and multi-agency meetings to enhance communication and create an understanding amongst professionals of duties, roles, and responsibilities. Initiatives to identify housing for homeless remand prisoners before their release, as well as ensuring the availability of community services to supervise treatment, would overcome some of the obstacles identified and increase availability of the MHTR. Funding for additional staff to conduct the assessment and referrals process would also be likely to improve uptake.

The Impact of the Community Psychiatric Treatment Program on the User's Quality of Life - experience of the Study Participants.

Community psychiatric treatment (CPT) is a novelty in the primary health care system for the people with mental health problems. The service operates according to the Flexible Assertive Community Treatment (FACT) model. FACT is a rehabilitation-oriented clinical case management model based on the ACT model (Assertive Community Treatment). This study aimed to assess how involvement in a community psychiatry program affects the quality of life of program participants. Between December 2020 and March 2021 we conducted a qualitative study. To obtain information, semi-structured interviews with twelve patients treated in the Community Psychiatric Treatment program were conducted. All restriction regarding COVID pandemic were considered at the research. Content analysis of the text was used for data analysis, which means that we interpreted the analysed text and determine the meaning of individual parts of the text. Twelve persons participated in the interviews, six of which were women (50%) and six men (50%). All the participants were of Slovenian nationality. They were from 28 to 80 years old, with a mean age of 47 years. We identified twelve categories and four themes: treatment problems, principles of operating of CPT program, satisfaction with inclusion in the CPT and improvement of quality of life through inclusion in the program. Quality of life is essential for every individual, as well as for people with mental health problems. In our study we have proved that the Community psychiatric programs could significantly impact the quality of life of people with mental health problems.

Assessing evidence for seasonality of hospital admissions for schizophrenia in Queensland, Australia: a time series observational study.

Most evidence on seasonal admission patterns for schizophrenia derives from the Northern Hemisphere with results from the Southern Hemisphere less documented. This study examines seasonal patterns in hospital admissions due to schizophrenia in Queensland, Australia, a large area that has a range of different climatic features. Daily hospital admissions data for people with the primary diagnosis of schizophrenia were collected from Queensland Health Department for the period from January 1996 to December 2015. A generalised linear regression model with Quasi-Poisson distribution was used to assess seasonal admission patterns across different climatic regions. The evidence for seasonality was also explored in subgroups that had different socio-demographic characteristics or history of prior hospitalisation for psychiatric disorders. Overall, a significant winter pattern (RR 1.05, 95%CI 1.01-1.13) was found with a peak in August (RR 1.08, 95%CI 1.03-1.17) in temperate Southeast Queensland. However, the hot humid North and Far North Queensland showed a peak in October (RR 1.10, 95%CI 1.02-1.22). Males (RR 1.11, 95%CI 1.07-1.14), people aged 40-59 years old (RR 1.10, 95%CI 1.05-1.15) and those who had never married (RR 1.09, 95%CI 1.06-1.12), were Australian by birth (RR 1.07, 95%CI 1.04-1.10) or were unemployed (RR 1.13, 95%CI 1.09-1.18) had significantly higher risk for hospital admissions, particularly during the winter months. The seasonal admission pattern for schizophrenia did not change significantly according to admission status and history of outpatient or community psychiatric treatment. The study found some evidence for seasonality of hospital admissions for schizophrenia that differed from northern tropical to southern temperate regions of Queensland.

Effectiveness and cost effectiveness of interpersonal community psychiatric treatment (ICPT) for people with long-term severe non-psychotic mental disorders: a multi-Centre randomized controlled trial

BackgroundLong-term community mental health treatment for non-psychotic disorder patients with severe mental illness (SMI) who are perceived as difficult by clinicians, is poorly developed and lacks a structured, goal-centred approach. This study compares (cost-)effectiveness of Interpersonal Community Psychiatric Treatment (ICPT) with Care As Usual (CAU) on quality of life and clinician perceived difficulty in the care for non-psychotic disorder SMI-patients. A multi-centre cluster-randomized clinical tria was conducted in which Community Mental Health Nurses (Clinicians) in three large community mental health services in the Netherlands were randomly allocated to providing either ICPT or CAU to included patients. A total of 56 clinicians were randomized, who treated a total of 93 patients (59 in ICPT-group and 34 in CAU-group).MethodsPrimary outcome measure is patient-perceived quality of life as measured by the Manchester Short Assessment of Quality of Life (MANSA). Secondary outcome measures include clinician-perceived difficulty, general mental health, treatment outcomes, illness management and recovery, therapeutic relationship, care needs and social network. Patients were assessed at baseline, during treatment (6 months), after treatment (12 months) and at 6 months follow-up (18 months). Linear mixed-effects models for repeated measurements were used to compare mean changes in primary and secondary outcomes between intervention and control group of patients over time on an intention to treat basis. Potential efficiency was investigated from a societal perspective. Economic evaluation was based on general principles of a cost-effectiveness analysis. Outcome measures for health economic evaluation, were costs, and Quality Adjusted Life Years (QALYs).ResultsHalf of the intended number of patients were recruited. There was no statistically significant treatment effect found in the MANSA (0.17, 95%-CI [− 0.058,0.431], p = 0.191). Treatment effects showed significant improvement in the Different Doctor-Patient Relationship Questionnaire-scores and a significant increase in the Illness Management and Recovery–scale Client-version scores). No effects of ICPT on societal and medical costs nor QALYs were found.ConclusionsThis is the first RCT to investigate the (cost)-effectiveness of ICPT. Compared with CAU, ICPT did not improve quality of life, but significantly reduced clinician-perceived difficulty, and increased subjective illness management and recovery. No effects on costs or QALY’s were found.Trial registrationNTR 3988, registered 13 May 2013.

Satisfaction, independent living skills and perceived change of patients undergoing community psychiatric treatment

To estimate quality parameters in the treatments offered, these criteria be evaluated in a continuous and integrated manner, considering patients' and family members' perspectives as well as that of professionals. Literature has highlighted the need to evaluate the results of treatment in psychosocial care facilities from the user point of view. From a quantitative perspective, some studies seek to identify a “degree” of social reinsertion, presenting some variables. Thus, the present study evaluated parameters considered as possible indicators of good results in the psychosocial rehabilitation process, constituting a tool for the planning of managers and mental health professionals. This is a observational study performed between January 2015 and August 2016 in Brazil. The study included 84 patients invited to a verbal interview. The sample consisted of 84 patients treated by Psychosocial Care Facility. The results obtained reveal the achievement of a satisfactory mean regarding the service, about which 85% of the users declare themselves satisfied. However, we found that patients need significant support to perform simple tasks. Independent living skills and perceived change have a lower score when related to satisfaction with the services provided, suggesting, then, that rehabilitation needs to focus on the acquisition of independent living skills, so that the patient can seek a life as close to normal as possible.

A Qualitative Study of the Working Alliance between Patient and Community Mental Health Nurse during Interpersonal Community Psychiatric Treatment

In the Netherlands, long-term community psychiatric treatment for patients with a severe mental illness (SMI) is poorly developed and lacks a structured, goal-centered approach. Often this form of treatment is provided by community mental health nurses (CMHN’s).Especially in the group of nonpsychotic patients with SMI, it often leads to care-as-usual with limited proven interventions and an unstructured treatment. Interpersonal Community Psychiatric Treatment (ICPT) was developed to provide this group of patients a focus, a theoretical view, and a methodological structure. A pilot study has been conducted on ICPT. As a result, a randomized controlled trial (RCT) was recently conducted in which this study is part. The pilot study showed improvement on a number of treatment outcomes. However, the working alliance (WA) experienced by the patients, although not significant, was considered to be decreased. The aim of study was to gain insight into how the ICPT-elements shape the WA and the possible self-determination of patients in general.The main part of this mixed-methods study was a qualitative study with a Grounded Theory approach. For the selection of the participants, quantitative data from the current RCT has been used. Semistructured interviews have been conducted with 13 participants, divided over three mental health institutions throughout the Netherlands. Interviews and analysis were alternated, so that the interview topics were developed by constant comparison.Eleven participants were female and 11 participants received social benefit. Six of the participants were above 50 years of age. Four participants suffered either from a depressive or anxiety disorder. Seven participants had a borderline personality disorder. The results are linked to Bordin’s theory of the therapeutic alliance, which is agreement on therapeutic tasks, agreement on therapeutic goals, and the quality of the personal bond. The WA could be analyzed from three different perspectives: mutually agreed on goals, tasks, and experienced interpersonal relationship. ICPT had limited influence on the mutually agreed on goals and interpersonal relationship but mainly on the mutually agreed on tasks. In daily practice, ICPT may have a positive influence on the perceived WA.The main factors that affected the perceived WA during ICPT were the tasks that had been mutually agreed on, the use of an agenda, the structure of the sessions, the alliance between the CMHN and the patient, and the patient’s own self-determination. There was a limited influence on the mutually agreed on goals and the quality of the personal relationship between the CMHN and the patient. The present research revealed valuable information about the significance of the WA in ICPT and the opinions of the respondents about ICPT and information about what might be helpful or unhelpful in their relationship with their CMHN.

Functioning of the various forms of mental health care in Poland in the years 2010-2013. Organizational, economic and financial aspects.

The main objective of the study was to verify the hypothesis about the high growth rate of expenditure on the provision of mental health in the past few years. High dynamics of the expenditure increase will result in the development of a model of community psychiatry and a gradual move away from the hospital psychiatric treatment towards mental health care in the open system, including the community one. This research is based on data on the implementation of services for mental health care in the framework of agreements with the National Health Fund, which has been collected in the NFZ IT system. Some information is from 2010, which was adopted as the base date for the implementation of the principles of the National Mental Health Program in 2011. The data from the implementation of individual benefits in 2013 were used for the comparison. In addition, other selected organizational, economic and financial elements of the psychiatric care system were analyzed. In 2013, compared to 2010, increased the number of mental health care organizations: outpatient mental health clinics (an increase of 37 clinics), outpatient mental health day hospital wards (an increase of 25 wards) and community psychiatric treatment teams (an increase of 74 teams). The largest increase in the value of contracts (approx. 150%) was related to community treatment teams. Between 2010 and 2013 there was an increase in the value of cleared contracts in psychiatric care, in general and in each of the three forms of psychiatric care (i.e., in day wards, outpatient mental health clinics and in community teams). The highest increase in investments included community treatment teams, to a lesser extent day wards and outpatient clinics. The adopted organizational, economic and financial solutions in the mental health care system are in line with the objectives of the National Mental Health Program, including the assumed structure of Mental Health Centers.

Obesity among Patients with Schizophrenia: When we Fix One Problem and Create Another

One day I had a conversation with one of my patient with schizophrenia at his home. He was discharged from the hospital and admitted to a Community psychiatric treatment, where I worked at that time. He was stable, without symptoms. However at that moment his major problem and the main reason for his admission to a Community psychiatric treatment was social isolation. He told me: “I was admitted to a hospital because I had voices, and I was really scared, so I didn’t left the house. Psychiatrist at the ward gave me an antipsychotic medication, and symptoms slowly vanished. Now I am at home, I don’t hear voices, I am not afraid anymore, but I don’t socialize with other people and I don’t go out of the house. I am ashamed because of my obesity, I have gained 30 kilograms”.

Cost effectiveness of interpersonal community psychiatric treatment for people with long-term severe non-psychotic mental disorders: protocol of a multi-centre randomized controlled trial.

BackgroundThis study aims for health gain and cost reduction in the care for people with long-term non-psychotic psychiatric disorders. Present care for this population has a limited evidence base, is often open ended, little effective, and expensive. Recent epidemiological data shows that 43.5% of the Dutch are affected by mental illness during their life. About 80% of all patients receiving mental health services (MHS) have one or more non-psychotic disorders. Particularly for this group, long-term treatment and care is poorly developed. Care As Usual (CAU) currently is a form of low-structured treatment/care. Interpersonal Community Psychiatric Treatment (ICPT) is a structured treatment for people with long-term, non-psychotic disorders, developed together with patients, professionals, and experts. ICPT uses a number of evidence-based techniques and was positively evaluated in a controlled pilot study.Methods/DesignMulti-centre cluster-randomized clinical trial: 36 professionals will be randomly allocated to either ICPT or CAU for an intervention period of 12 months, and a follow-up of 6 months. 180 Patients between 18–65 years of age will be included, who have been diagnosed with a non-psychotic psychiatric disorder (depressive, anxiety, personality or substance abuse disorder), have long-term (>2 years) or high care use (>1 outpatient contact per week or >2 crisis contacts per year or >1 inpatient admission per year), and who receive treatment in a specialized mental health care setting. The primary outcome variable is quality of life; secondary outcomes are costs, recovery, general mental health, therapeutic alliance, professional-perceived difficulty of patient, care needs and social contacts.DiscussionNo RCT, nor cost-effectiveness study, has been conducted on ICPT so far. The empirical base for current CAU is weak, if not absent. This study will fill this void, and generate data needed to improve daily mental health care.Trial registrationNetherlands Trial Register (NTR): 3988. Registered 13th of May 2013.

Interpersonal Community Psychiatric Treatment for non-psychotic chronic patients and nurses in outpatient mental health care: A controlled pilot study on feasibility and effects

BackgroundIn psychiatric care professionals perceive some patients as ‘difficult’, especially patients with long-term non-psychotic disorders. For these patients few evidence-based treatments exist. An intervention program, Interpersonal Community Psychiatric Treatment (ICPT), was developed by the authors. It was evaluated with the aim to increase effective behaviours by both patients and community psychiatric nurses (CPNs). ObjectiveTo assess the feasibility and effectiveness of an intervention program for use by CPNs in the care of ‘difficult’ patients with non-psychotic chronic disorders, in a controlled pilot study. DesignA mixed-methods quasi-experimental study using process and outcome measures across several dimensions. Measurements took place at 0, 3, and 6 months. SettingsThree community mental health centres in the centre of The Netherlands. Participants14 CPNs and 36 long-term non-psychotic patients who were perceived as ‘difficult’ were selected. Patients were offered either ICPT (20) or care as usual (16). All patients and CPNs could be followed up at all measurements. MethodsQuantitative data included type and severity of psychiatric disorder, psychosocial functioning, needs for care, quality of life and social participation. Also, service use, satisfaction with care, and quality of the therapeutic alliance were measured. Qualitative interviews were conducted with all CPNs and patients in the experimental group. ResultsICPT was found feasible by both CPNs and patients. Both the experimental and control condition showed improvement on a number of outcomes. ICPT, however, resulted in significantly better results in some areas. Patients’ social network size increased and their care utilization decreased. Also, the quality of the working alliance increased and perceived patient difficulty decreased, both as scored by professionals. ConclusionsICPT is one of very few intervention programs aimed at ‘difficult’ non-psychotic chronic patients. In this pilot study was found that it can be successfully carried out by CPNs, is generally experienced as acceptable and useful by patients and CPNs alike, and results in some significantly better effects on both process and outcome measures. In the main study, some alterations will be made to the instruction manual and training program. Also, the diagnostic interview may be briefer, and the characteristics and treatment integrity of CPNs will be included in measurements. Further controlled and randomized research is needed to test the effectiveness of the program in a larger group of patients.

Excessive Antipsychotic Dosing in a Canadian Outpatient Population

Excessive Antipsychotic Dosing in a Canadian Outpatient Population

Use of ICD-10 diagnoses in Danish psychiatric hospital-based services in 2001-2007

The Danish version of the ICD-10 chapter on mental and behavioural disorders has 380 different diagnoses when three digits are used. This study examines how many of the available diagnoses were used and to what extent in Danish psychiatric hospital-based services in the period from 2001 to 2007, through an analysis of the total number of diagnoses reported to the Danish Psychiatric Central Research Register (n=1,260,097). The 50th percentile (50.1%) was reached by using 16 diagnoses (4.2% of 380 available). The three most frequently registered diagnoses were paranoid schizophrenia, alcohol dependence and adjustment disorder, used 10.2%, 8.3% and 5.9% of the times, respectively. Seven diagnoses (1.8%) were used between 1 and 4 times during the 7-year period. One hundred nine (28.7% of available diagnoses) were used less than 100 times each. These data suggest that it may be sensible to reconsider the number of diagnoses needed in the revision of the ICD-10 chapter on mental and behavioural disorders.

Treatment for depression and change in mood instability

Background Mood varies along at least 2 dimensions, severity and instability (MI). Compared with severity, there is little research on the treatment of MI. We assessed changes in MI with community psychiatric treatment, in patients with depression and mood swings. Method Diagnoses were obtained with the MINI. Thirty-four patients completed the Mood Disorders Questionnaire, the Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI-T). MI was calculated from visual analogue scales (VAS) ratings for depression and anxiety. The VAS was rated twice a day for a week. The BDI, STAI-T and VAS were repeated after 3–6 months of treatment. Results Patients improved with treatment on depression (BDI) and anxiety (STAI-T) severity but not on MI. However, change in MI predicted change in depression severity (BDI). Limitations The sample size was relatively small and information on treatment waslimited. There was no control group. Studies of longer duration and with more comprehensive treatment might be necessary to show changes in MI. Conclusions MI does not respond consistently within 3–6 months to common effective psychiatric treatments for depression and anxiety. Improved treatment of MI could result in improved treatment for major depression.

Persistent Antipsychotic Polypharmacy and Excessive Dosing in the Community Psychiatric Treatment Setting

The present study aimed (1) to determine the proportion of patients treated with persistent antipsychotic polypharmacy in an outpatient population and (2) to determine if persistent antipsychotic polypharmacy is associated with excessive dosing. Using a province-wide network that links all pharmacies in British Columbia, Canada, to a central set of data systems, we identified community mental health outpatients who had been treated with the same pharmacologic regimen for at least 90 days. Apart from antipsychotics, data collection included anticholinergics, antidepressants, mood stabilizers, benzodiazepines, lipid-lowering agents, and antidiabetic agents. Demographic data including sex, age, and diagnosis were obtained from the patient's chart. In order to compare dosages of the various antipsychotics we used a fixed unit of measurement based on dividing the prescribed daily dose (PDD) by the defined daily dose (DDD). A PDD/DDD ratio greater than 1.5 was defined as excessive dosing. Four hundred thirty-five patients met the inclusion criteria and were included in the analysis. Overall, the prevalence of persistent antipsychotic polypharmacy was 25.7% for the entire cohort. The prevalence of persistent antipsychotic polypharmacy was highest for patients with schizoaffective disorder (33.7%), followed by schizophrenia (31.7%), psychosis not otherwise specified (20.0%), bipolar disorder (16.9%), and major depression (14.3%). The mean +/- SD PDD/DDD ratio for all patients prescribed persistent antipsychotic polypharmacy was not only excessive, it was significantly greater compared to that of patients receiving antipsychotic monotherapy (1.94 +/- 0.12 vs 0.94 +/- 0.04, P < .005). Using a diagnostically heterogeneous outpatient population, this study is, we believe, the first to report that persistent antipsychotic polypharmacy is associated with excessive dosing, in and of itself as well as compared to antipsychotic monotherapy.

Family and Community Responses to Mental Illness

Cultural groups respond differently to mental illness depending on the explanations of the cause, attitudes in the community toward mental illness and its treatment, and the social and community resources available to patients and their families. Our column last month explored these explanations and attitudes. This column focuses on family and community treatment of mental illness and the care of the mentally ill, especially those with severe mental illness. In Western and developed countries, mental illness treatment may be highly organized and provided by mental health institutions and professionals. Ideally, supportive community resources, together with family and friend networks, facilitate effective coping with mental illness (US Department of Health and Human Services [USDHHS], 2001). Often, however, this ideal is not achieved in practice. For example, in Italy there is a general belief and acceptance of biomedical explanations, the use of psychotropic medications, and a community psychiatric treatment model accompanied, nevertheless, by a belief that those with severe mental illness should not have children (Magliano et al., 2004). In developed and resource-rich societies such as the US, social stigma, shame, and embarrassment associated with mental illness, distrust of the health care system, and fear of psychotropic drugs still exist and may lead to denial and a failure to seek treatment (Matthews et al., 2006). Some modern societies embrace both biomedical and traditional treatments — psychiatrists and psychopharmacologic medications coexisting with holy men, religious rituals, and pilgrimages to shrines in

Long‐term homelessness in men with a psychosis: Limitation of services

A proportion of persistently homeless men with psychosis are unable to function in the community, despite intensive outreach. The present study aimed to (i) develop a method to measure the number of homeless clients with a psychosis who are unable to maintain basic levels of function, despite the application of intensive community treatment; and (ii) determine if the proportion of these men had increased in an Australian inner urban setting over a 5-year period. Criteria were developed and validated to define this group. A review of records of clients engaged in homeless settings was conducted in order to compare the proportion of men with these features in 2000 and 2005. In 2005, 23% met the criterion of long-term homelessness with poor function, despite intensive outreach, as compared with 17% in 2000 (P = 0.62). The 2005 cohort was more likely to have attempted intensive community psychiatric treatment (P = 0.04). We conclude that a proportion of homeless men with a psychosis in Australia do not achieve basic function, despite access to intensive outreach. The proportion of these men did not change between 2000 and 2005. These men require additional specialized services, including access to long-term supported housing.

Family and Community Responses to Mental Illness

Cultural groups respond differently to mental illness depending on the explanations of the cause, attitudes in the community toward mental illness and its treatment, and the social and community resources available to patients and their families. Our column last month explored these explanations and attitudes. This column focuses on family and community treatment of mental illness and the care of the mentally ill, especially those with severe mental illness. In Western and developed countries, mental illness treatment may be highly organized and provided by mental health institutions and professionals. Ideally, supportive community resources, together with family and friend networks, facilitate effective coping with mental illness (US Department of Health and Human Services [USDHHS], 2001). Often, however, this ideal is not achieved in practice. For example, in Italy there is a general belief and acceptance of biomedical explanations, the use of psychotropic medications, and a community psychiatric treatment model accompanied, nevertheless, by a belief that those with severe mental illness should not have children (Magliano et al., 2004). In developed and resource-rich societies such as the US, social stigma, shame, and embarrassment associated with mental illness, distrust of the health care system, and fear of psychotropic drugs still exist and may lead to denial and a failure to seek treatment (Matthews et al., 2006). Some modern societies embrace both biomedical and traditional treatments — psychiatrists and psychopharmacologic medications coexisting with holy men, religious rituals, and pilgrimages to shrines in

Predictors of changes in needs for care in patients receiving community psychiatric treatment: a 4‐year follow‐up study

This study aimed to investigate changes and predictors of change in needs for care, as assessed by both patients and mental health professionals, in a sample of subjects receiving community-based psychiatric care. The study was conducted using a 4-year prospective longitudinal design. A cohort of patients from the South-Verona Community Mental Health Service (CMHS) was assessed at baseline and follow-up using the Camberwell Assessment of Need, both staff and patient versions. Predictors of changes in needs were explored using block-stratified multiple regression analyses. An overall stability for both patient-rated and staff-rated needs was found over time; however, significant changes in some specific need domains were found, such as self-rated health needs (improvement), self-rated social needs (deterioration) and staff-rated health needs (deterioration). Changes over time in self-rated and staff-rated needs are influenced by different and specific set of predictors, thus indicating that the two measures are not overlapping and convey different types of information. Our data support the adoption of a negotiated approach in which both staff and users' views should be given equal weight when planning and providing needs-led mental health care.