Routine Mental Health Services Research Articles

The effect of dialectical behaviour therapy in autism spectrum patients with suicidality and/ or self-destructive behaviour (DIASS): study protocol for a multicentre randomised controlled trial

BackgroundMany persons with autism spectrum disorder (ASD) are treated in long-term specialised care. In this population, suicidal behaviour troubles patients, families, and specialists in the field because it is difficult to treat. At present, there is no documented effective therapy for suicidal behaviour in ASD (Autism Research 7:507-521, 2014; Crisis 35:301-309, 2014). Dialectical Behaviour Therapy (DBT) is an efficacious treatment programme for chronically suicidal and/or self-harm behaviour in patients with Borderline Personality Disorder (J Psychiatry 166:1365-1374, 2014; Linehan MM. Cognitive behavioural therapy of borderline personality disorder. 1993). This study will evaluate the efficacy of DBT in persons with ASD and suicidal/ self- destructive behaviour in a multicentre randomised controlled clinical trial.MethodOne hundred twenty-eight persons with autism and suicidal and/or self-harming behaviour will be recruited from specialised mental healthcare services and randomised into two conditions: 1) the DBT condition in which the participants have weekly individual cognitive behavioural therapy sessions and a 2.5 h skills training group session twice per week during 6 months, and 2) the treatment as usual condition which consists of weekly individual therapy sessions of 30–45 min with a psychotherapist or social worker. Assessments will take place at baseline, at post-treatment (6 months), and after a follow-up period of 12 months. The mediators will also be assessed at 3 months. The primary outcome is the level of suicidal ideation and behaviour. The secondary outcomes are anxiety and social performance, depression, core symptoms of ASD, quality of life, and cost-utility. Emotion regulation and therapeutic alliance are hypothesised to mediate the effects on the primary outcome.DiscussionThe results from this study will provide an evaluation of the efficacy of DBT treatment in persons with ASD on suicidal and self-harming behaviour. The study is conducted in routine mental health services which enhances the generalisability of the study results to clinical practice.Trial registrationISRCTN96632579. Registered 1 May 2019. Retrospectively registered.

From research to practice: Implementing an experimental home treatment model into routine mental health care.

In line with previous findings, in a recent randomized controlled trial (RCT), we found that home treatment (HT) for acute mental health care can reduce (substitute) hospital use among severely ill patients in crises. This study examined whether the findings of the RCT generalize to HT services provided under routine care conditions. We compared patients who received HT during the RCT study phase with patients who received the same HT service after it had become part of routine mental health services in the same catchment area. Sociodemographic and clinical characteristics as well as service use (HT and hospital bed days) were compared between the RCT and the subsequent routine care study period. Compared to patients who received HT during the RCT, routine care HT patients were more often living with others, less often admitted compulsorily, more often diagnosed with anxiety and stress-related disorders (ICD-10F4) and less often diagnosed with schizophrenia spectrum disorders (F2). When compared to patients who were exclusively treated on hospital wards, involvement of the HT team in patients' care was associated with a clear-cut reduction of hospital bed days both during the RCT and under routine care conditions. However, unlike during the RCT study period, involvement of HT was associated with longer overall treatment episodes (inpatient + HT days) under routine care conditions. HT seems to reduce the use of hospital bed days even under routine care conditions but is at risk of producing longer overall acute treatment episodes.

The Importance of Social Exchange for Internet-based Eating Disorder Prevention

The Importance of Social Exchange for Internet-based Eating Disorder Prevention Internet-based interventions have the potential to complement routine care mental health services. Yet, dissemination and implementation into routine care is challenging and often fails. From a public health point of view, facilitating access to care and dissemination of prevention have great potential to reduce eating disorder related suffering in the general population. In order to exploit that potential effective strategies to involve users in internet-based prevention are of utmost importance. User-behaviors of N = 980 predominantly female (80 %) participants with an average age of 19.4 years (SD = 7.0) of an internet-based intervention for the prevention of eating disorders (ProYouth) were analyzed. Specifically, differences in users' pathways between early and late phases of participation were compared in order to identify patterns of program utilization that are associated with elevated adherence. During their first login, users explore all modules of the platform. Enduring participation is characterized by increased usage of the modules that offer social exchange with other participants, i. e. the forums and the chat. Static modules, e. g., psychoeducation, are rarely accessed after the first login. Additionally, enduring users were more often female, older, and displayed higher levels of psychological impairment (ps < .001). The results support the relevance of social exchange for the adherence in internet-based interventions for the prevention of eating disorders.

Training to enhance user and carer involvement in mental health-care planning: the EQUIP research programme including a cluster RCT

Background Service users and carers using mental health services want more involvement in their care and the aim of this research programme was to enhance service user and carer involvement in care planning in mental health services. Objectives Co-develop and co-deliver a training intervention for health professionals in community mental health teams, which aimed to enhance service user and carer involvement in care planning. Develop a patient-reported outcome measure of service user involvement in care planning, design an audit tool and assess individual preferences for key aspects of care planning involvement. Evaluate the clinical effectiveness and the cost-effectiveness of the training. Understand the barriers to and facilitators of implementing service user- and carer-involved care planning. Disseminate resources to stakeholders. Methods A systematic review, focus groups and interviews with service users/carers/health professionals informed the training and determined the priorities underpinning involvement in care planning. Data from focus groups and interviews were combined and analysed using framework analysis. The results of the systematic review, focus groups/interviews and a review of the training interventions were synthesised to develop the final training intervention. To develop and validate the patient-reported outcome measure, items were generated from focus groups and interviews, and a psychometric analysis was conducted. Patient-reported outcome measure items and a three-round consensus exercise were used to develop an audit tool, and a stated preference survey was undertaken to assess individual preferences for key aspects of care planning. The clinical effectiveness and cost-effectiveness of the training were evaluated using a pragmatic cluster trial with cohort and cross-sectional samples. A nested longitudinal qualitative process evaluation using multiple methods, including semistructured interviews with key informants involved locally and nationally in mental health policy, practice and research, was undertaken. A mapping exercise was used to determine current practice, and semistructured interviews were undertaken with service users and mental health professionals from both the usual-care and the intervention arms of the trial at three time points (i.e. baseline and 6 months and 12 months post intervention). Results The results from focus groups (n = 56) and interviews (n = 74) highlighted a need to deliver training to increase the quality of care planning and a training intervention was developed. We recruited 402 participants to develop the final 14-item patient-reported outcome measure and a six-item audit tool. We recruited 232 participants for the stated preference survey and found that preferences were strongest for the attribute ‘my preferences for care are included in the care plan’. The training was delivered to 304 care co-ordinators working in community mental health teams across 10 NHS trusts. The cluster trial and cross-sectional survey recruited 1286 service users and 90 carers, and the primary outcome was the Health Care Climate Questionnaire. Training was positively evaluated. The results showed no statistically significant difference on the primary outcome (the Health Care Climate Questionnaire) (adjusted mean difference –0.064, 95% confidence interval –0.343 to 0.215; p = 0.654) or secondary outcomes at the 6-month follow-up. Overall, the training intervention was associated with a net saving of –£54.00 (95% confidence interval –£193.00 to £84.00), with a net quality-adjusted life-year loss of –0.014 (95% confidence interval –0.034 to 0.005). The longitudinal process evaluation recruited 54 service users, professionals and carers, finding a failure of training to become embedded in routine care. Limitations Our pragmatic study was designed to improve service user and care involvement in care planning among routine community mental health services. We intervened in 18 sites with &gt; 300 care co-ordinators. However, our volunteer sites may not be fully representative of the wider population, and we lacked data with which to compare our participants with the eligible population. Conclusions We co-developed and co-delivered a training intervention and developed a unidimensional measure of service user and carer involvement in care planning and an audit tool. Despite a high level of satisfaction with the training, no significant effect was found; therefore, the intervention was ineffective. There was a failure of training to become embedded and normalised because of a lack of organisational readiness to accept change. Working with NHS trusts in our ‘Willing Adopters’ programme with enhanced organisational buy-in yielded some promising results. Future work Research should focus on developing and evaluating new organisational initiatives in addition to training health-care professionals to address contextual barriers to service and carer involvement in care planning, and explore co-designing and delivering new ways of enhancing service users’ and carers’ capabilities to engage in care planning. Trial registration Current Controlled Trials ISRCTN16488358. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 9. See the NIHR Journals Library website for further project information.

Pathways to care, DUP, and types of interventions over 5years following psychosis onset: findings from a naturalistic study conducted in routine generalist mental health services.

To describe pathways to care, duration of untreated psychosis (DUP), and types of interventions provided to first-episode psychosis (FEP) patients by routine Italian mental health services over 5years since the first service contact. Naturalistic study conducted in Veneto, within the context of the Psychosis Incident Cohort Outcome Study (PICOS). A comprehensive set of measures was used, including schedules designed to collect information on referrals to psychiatric services and on psychological and pharmacological treatments at 1, 2, and 5years since first service contact. Overall, 397 patients were assessed. Most engaged with services with the help of family members (47.4%) and through emergency routes (60.3%). Those referred by clinicians were more likely to access care in a non-emergency way. Mean DUP was 5.62months (SD 11.8) and longer DUP was associated with poorer functioning at 2 and 5years. Interventions provided over 5years were mainly constituted by antipsychotic medications (95.4% at 1year; 85.8% at 2years; 80.6% at 5years), whereas a lower percentage (69.1% at 1year; 61.5% at 2years; 44.9% at 5years) also received some forms of psychological interventions, mainly consisting of unspecific support sessions. Other structured interventions, such as CBT or family interventions, were seldom provided at each time-point. Mental health services in Veneto seem effective in engaging FEP patients within a short time since illness onset. However, type of care provided does not meet quality standards recommended by treatment guidelines, especially regarding psychological interventions.

Reasons for Tobacco Use and Perceived Tobacco-Related Health Risks in an Inpatient Psychiatric Population

People with mental illness (MI) have a disproportionate tobacco-related disease burden and mortality. Tobacco-use rates in people with MI are nearly twice that of the general population. Reasons for tobacco-use in this population may be a result of diminished tobacco-related disease risk perceptions. The purpose of this study was to examine the reasons for tobacco-use and perceived tobacco-related health risks among psychiatric inpatients. A correlational design was employed to survey a convenient sample of 137 patients from a psychiatric facility in central Kentucky. Information obtained from participants included demographics, psychiatric diagnoses, tobacco-use and exposure history, medical illness history, reasons for tobacco-use, and tobacco-related illness risk perceptions. The primary reasons participants endorsed for tobacco-use were for stress reduction, followed by addiction, then boredom, psychiatric symptom control, social, and negative mood. In addition, about 72% of participants used tobacco to cope with MI symptoms and 52% to manage the side effects of their medications. Participants were most likely to endorse that tobacco-use caused lung disease (83.2%), heart disease (79.6%), cancer (77.4%), and premature mortality (79.6%) but were less likely to admit that it may cause addiction to other drugs (39.4%) or MI (23.4%). Given the high endorsement of tobacco-use for stress reduction and psychiatric symptom control, it is important for mental health nurses to properly educate consumers on tobacco addiction and evidence of its effects on mental health. Strategies to incorporate our study findings into routine mental health services may address the tobacco-use disparities experienced by people with MI.

Measuring broader wellbeing in mental health services: validity of the German language OxCAP-MH capability instrument

PurposeThe OxCAP-MH capabilities questionnaire was developed and validated in the UK for outcome measurement in mental health clinical studies. Its broader wellbeing construct or validity in routine mental health services so far has not been assessed. The objectives were to investigate the extent the OxCAP-MH measures broader wellbeing compared to the EQ-5D-5L and to test psychometric properties of the German language OxCAP-MH in routine mental health services in Austria.MethodsStudy sample consisted of patients in socio-psychiatric services (n = 159) assessed at baseline and 6-month follow-up. Underlying factors associated with quality-of-life/wellbeing concepts measured by the OxCAP-MH and EQ-5D-5L were identified in exploratory factor analysis (EFA). Responsiveness was assessed using anchor questionnaires and standardised response mean (SRM). For discriminant validity, subgroups of respondents were compared using t test and one-way ANOVA. Test–retest analysis was assessed for a period of maximum 30 days from the baseline assessment with intra-class correlation coefficient (ICC).ResultsEFA identified a two-factor structure. All EQ-5D-5L items and seven OxCAP-MH items loaded on one factor and nine remaining OxCAP-MH items loaded on a separate factor. Responsiveness was found for patients who improved in anchor questionnaire scores with large or moderate SRM statistics. OxCAP-MH discriminated between various groups in univariable and multivariable analyses. Reliability of the German language OxCAP-MH was confirmed by ICC of 0.80.ConclusionsBesides providing evidence that the OxCAP-MH measures broader wellbeing constructs beyond traditional health-related quality of life, the study also confirms the validity of the instrument for implementation in routine evaluation of mental health services.

Embedding shared decision-making in the care of patients with severe and enduring mental health problems: The EQUIP pragmatic cluster randomised trial.

BackgroundSevere mental illness is a major driver of worldwide disease burden. Shared decision-making is critical for high quality care, and can enhance patient satisfaction and outcomes. However, it has not been translated into routine practice. This reflects a lack of evidence on the best way to implement shared decision-making, and the challenges of implementation in routine settings with limited resources. Our aim was to test whether we could deliver a practical and feasible intervention in routine community mental health services to embed shared decision-making for patients with severe mental illness, by improving patient and carer involvement in care planning.MethodsWe cluster randomised community mental health teams to the training intervention or usual care, to avoid contamination. Training was co-delivered to a total of 350 staff in 18 teams by clinical academics, working alongside patients and carers. The primary outcome was the Health Care Climate Questionnaire, a self-report measure of ‘autonomy support’. Primary and secondary outcomes were collected by self-report, six months after allocation.FindingsIn total, 604 patients and 90 carers were recruited to main trial cohort. Retention at six months was 82% (n = 497). In the main analysis, results showed no statistically significant difference in the primary outcome between the intervention and usual care at 6 months (adjusted mean difference -0.064, 95% CI -0.343 to 0.215, p = 0.654). We found significant effects on only 1 secondary outcome.ConclusionsAn intervention to embed shared decision-making in routine practice by improving involvement in care planning was well attended and acceptable to staff, but had no significant effects on patient outcomes. Enhancing shared decision-making may require considerably greater investment of resources and effects may only be apparent over the longer term.

Transparency about the outcomes of mental health services (IAPT approach): an analysis of public data

SummaryBackgroundInternationally, the clinical outcomes of routine mental health services are rarely recorded or reported; however, an exception is the English Improving Access to Psychological Therapies (IAPT) service, which delivers psychological therapies recommended by the National Institute for Health and Care Excellence for depression and anxiety disorders to more than 537 000 patients in the UK each year. A session-by-session outcome monitoring system ensures that IAPT obtains symptom scores before and after treatment for 98% of patients. Service outcomes can then be reported, along with contextual information, on public websites.MethodsWe used publicly available data to identify predictors of variability in clinical performance. Using β regression models, we analysed the outcome data released by National Health Service Digital and Public Health England for the 2014–15 financial year (April 1, 2014, to March 31, 2015) and developed a predictive model of reliable improvement and reliable recovery. We then tested whether these predictors were also associated with changes in service outcome between 2014–15 and 2015–16.FindingsFive service organisation features predicted clinical outcomes in 2014–15. Percentage of cases with a problem descriptor, number of treatment sessions, and percentage of referrals treated were positively associated with outcome. The time waited to start treatment and percentage of appointments missed were negatively associated with outcome. Additive odd ratios suggest that moving from the lowest to highest level on an organisational factor could improve service outcomes by 11–42%, dependent on the factor. Consistent with a causal model, most organisational factors also predicted between-year changes in outcome, together accounting for 33% of variance in reliable improvement and 22% for reliable recovery. Social deprivation was negatively associated with some outcomes, but the effect was partly mitigated by the organisational factors.InterpretationTraditionally, efforts to improve mental health outcomes have largely focused on the development of new and more effective treatments. Our analyses show that the way psychological therapy services are implemented could be similarly important. Mental health services elsewhere in the UK and in other countries might benefit from adopting IAPT's approach to recording and publicly reporting clinical outcomes.FundingWellcome Trust.

How Do Certified and Uncertified Therapists Differ in Their Perceptions of a Mental Health Intervention for ASD?

ABSTRACTGiven the increasing efforts to implement evidence-based practices (EBPs) in routine mental health (MH) services, it is necessary to examine MH therapists’ perspectives of the training and delivery process to better understand the outcomes of EBP implementation efforts and influences on these outcomes. However, there is limited research examining how therapists who successfully completed training and receive certification in an EBP intervention differ in their perceptions of these implementation outcomes and influences from those therapists who do not successfully complete training and receive certification in an intervention. As such, the present study examined variability in therapists’ perspectives in the training and implementation of the An Individualized Mental Health Intervention for ASD (AIM HI) intervention, a package of well-established, evidence-based strategies developed to address challenging behaviors in children with autism spectrum disorder within community MH clinics, based on training certification status (i.e. certified vs. noncertified). Overall, both certified and noncertified therapists perceived the AIM HI intervention as useful and effective with their clients, described the increased use of structure and improved clinical skills, and reported intended sustained use of parts of the AIM HI protocol. Conversely, certified and noncertified therapists differed in their approaches to addressing the perceived challenges of EBP training and implementation, specifically time commitment and program structure, providing valuable insight into why some therapists did not achieve certification status. These data support the development of organizational leadership and provider engagement interventions designed to address attitudinal and organizational barriers to facilitate the successful training and implementation of evidence-based interventions.

Implementing shared decision making in routine mental health care.

Shared decision making (SDM) in mental health care involves clinicians and patients working together to make decisions. The key elements of SDM have been identified, decision support tools have been developed, and SDM has been recommended in mental health at policy level. Yet implementation remains limited. Two justifications are typically advanced in support of SDM. The clinical justification is that SDM leads to improved outcome, yet the available empirical evidence base is inconclusive. The ethical justification is that SDM is a right, but clinicians need to balance the biomedical ethical principles of autonomy and justice with beneficence and non-maleficence. It is argued that SDM is "polyvalent", a sociological concept which describes an idea commanding superficial but not deep agreement between disparate stakeholders. Implementing SDM in routine mental health services is as much a cultural as a technical problem. Three challenges are identified: creating widespread access to high-quality decision support tools; integrating SDM with other recovery-supporting interventions; and responding to cultural changes as patients develop the normal expectations of citizenship. Two approaches which may inform responses in the mental health system to these cultural changes - social marketing and the hospitality industry - are identified.

Clinical characteristics of adolescents referred for treatment of depressive disorders.

Adolescence is a period of increased risk for the development of depression. Epidemiological and clinical studies suggest that the phenomenology of depression may differ during childhood and adolescence. However, participants in these studies may not reflect depressed young people referred to routine clinical services. The aim of this paper was to describe referrals for depression to a UK routine public healthcare service for children and adolescents with mental health difficulties. This paper describes a consecutive series of adolescents (N=100, aged 12-17years), referred for depression to a routine public healthcare child and adolescent mental health service, in the south of England. Young people and their caregivers completed a structured diagnostic interview and self-report measures of anxiety and depression. Fewer than half of young people referred for depression met diagnostic criteria for a depressive disorder. The key symptoms reported by those with depression were low mood or irritability, cognitive disturbances, sleep disturbances and negative self-perceptions. Suicidal ideation was common and was considerably higher than reported in other studies. Caregiver and young person's accounts of adolescent symptoms of depression and anxiety were uncorrelated. Caregivers also reported fewer symptoms of depression in their child than adolescents themselves. These data have direct relevance to the design and delivery of public mental health services for children and adolescents. However, we do not know how representative this sample is of other clinical populations in the UK or in other countries. There is a need to collect routine data from other services to assess the needs of this group of high-risk adolescents.

Ecological momentary interventions in psychiatry.

In this review, we discuss feasibility, content, and where possible efficacy of ecological momentary interventions (EMIs) in psychiatry. EMIs adopt mobile devices, such as personal digital assistants or smartphones, for the delivery of treatments in the daily life of patients. We will discuss EMIs in the field of schizophrenia, bipolar disorder and major depression disorder, as well as one generic, transdiagnostic EMI. The few studies that are available all underscore feasibility and acceptability of mobile health approaches in patients with severe mental illness. In terms of content, there is a huge variety in approaches ranging from a mixture of face-to-face contacts augmented with EMI components to a fully automated EMI. With regard to efficacy, only two randomized clinical trials have been conducted, supporting the efficacy of EMIs in mental health. Evidence seems to point toward greater efficacy when EMI is integrated with real-life assessment using experience sampling methodology, preferentially tailoring the intervention toward the specific needs of the individual as well as toward those moments when intervention is needed. The review demonstrates that mobile health may be an important asset to the mental health field but underscores that it still is in its very early ages. In the discussion, we point toward ways of improving EMIs for severe mental illness, changing our perspective from testing feasibility to testing efficacy and ultimately implementing EMIs in routine mental health services.

Bridging the gap: What have we done and what more can we do to reduce the burden of avoidable death in people with psychotic illness?

Despite overwhelming evidence demonstrating a persisting gap in life expectancy between those with psychotic illness and the general population, there has been no widespread implementation of interventions to improve the physical wellbeing of people with psychotic illness. This article explores opportunities to 'Bridge the Gap' in life expectancy. We describe an Australian evidence-based intervention that has substantially improved the physical health of young people recently commenced on antipsychotic medication. Further epidemiological research, accompanied by cultural change within mental health services, is an essential precursor to the implementation of effective and sustainable lifestyle interventions. There are other relatively neglected areas of physical wellbeing for people with psychotic illness, such as screening and diagnosis of malignancies, which need more research and clinical attention. While there has been progress with intervention development and evaluation, translation of evidence-based short-term intervention studies into feasible and sustainable system-wide changes within routine mental health service settings remains a challenge. Developing an implementation framework to support such change is an urgent priority so as to bridge the persisting premature mortality in people living with psychotic illness.

Feasibility and Effectiveness of a Multi-Element Psychosocial Intervention for First-Episode Psychosis: Results From the Cluster-Randomized Controlled GET UP PIANO Trial in a Catchment Area of 10 Million Inhabitants.

Integrated multi-element psychosocial interventions have been suggested to improve the outcomes of first-episode psychosis (FEP) patients, but they have been studied primarily in experimental settings and in nonepidemiologically representative samples. Thus, we performed a cluster-randomized controlled trial, comparing an integrated multi-element psychosocial intervention, comprising cognitive behavioral therapy, family intervention, and case management, with treatment as usual (TAU) for FEP patients in 117 community mental health centers (CMHCs) in a large area of northern Italy (10 million inhabitants). The randomized units (clusters) were the CMHCs, and the units of observation the patients (and, when available, their family members). The primary hypotheses were that add-on multicomponent intervention: (1) results in greater improvements in symptoms, as assessed with positive and negative syndrome scale and (2) reduces in-hospital stay, based on days of hospitalization over the 9-month follow-up. Four hundred and forty-four FEP patients received the intervention or TAU and were assessed at baseline and 9 months. Based on the retention rates of patients (and families) in the experimental arm, multi-element psychosocial interventions can be implemented in routine mental health services. Regarding primary outcomes, patients in the experimental arm showed greater reductions in overall symptom severity, while no difference could be found for days of hospitalization. Among the secondary outcomes, greater improvements were detected in the experimental arm for global functioning, emotional well-being, and subjective burden of delusions. No difference could be found for service disengagement and subjective burden of auditory hallucinations. These findings support feasibility and effectiveness of early interventions for psychosis in generalist mental health services.

Development and psychometric properties of the parent version of the Profile of Neuropsychiatric Symptoms (PONS) in children and adolescents.

BackgroundThe use of neuropsychiatric Patient Centred Outcome Measures (PCOMs) in routine child mental health and paediatric services is very time consuming and often requires multiple scales being completed as no single scale covers all areas of psychopathology. The use of a web-based programme can overcome these problems and contribute to improved use of PCOMs in clinical practice. We aim to develop a web-based scale (using HealthTracker™) to screen and identify young people with significant neuropsychiatric symptoms to enable early intervention.MethodsQualitative development of the Profile of Neuropsychiatric Symptoms (PONS) and quantitative evaluation of the psychometric properties of the PONS scale (parent version). Parents of 929 from the general population and 147 with neuropsychiatric disorders (5–18 years old) completed the PONS online. In addition, those children with neuropsychiatric disorders were assessed for the presence of current and lifetime psychiatric disorders using the Development and Well-Being Assessment (DAWBA).ResultsThe PONS scale (parent version) consists of 30 symptom domains rated on a 7-point scale for both frequency and impairment. We found an intra-class correlation coefficient for single measures was 0.44 (0.42-0.46 95 % CI, F = 22.84, p ≤ 0.0001) and for average measures was 0.96 (0.95-0.96 95 % CI, F = 22.84, p ≤ 0.0001). The factor analysis showed a 4-factor model: Neurodevelopmental Disability; Behavioural and Emotional Dysregulation; Psychoses and Personality Dysfunction; and Anxiety and Depression. The receiver operating characteristic area for the 4-factors was 0.96 (SE = 0.006; 0.95-0.97 95 % CI).ConclusionsThe PONS scale (parent version) is a web-based PCOM on the HealthTracker™ system that is a rapid, engaging measure that has excellent reliability and validity. The system allows for automated scoring and immediate feedback of statistical cut-off points and assists clinicians with diagnostic decision-making and optimises use of clinician time.Electronic supplementary materialThe online version of this article (doi:10.1186/s12887-015-0376-x) contains supplementary material, which is available to authorized users.

Evaluating Innovative Mental Health Care in Germany

Evaluating innovative mental health care in Germany Thomas Becker, Annabel Stierlin, Reinhold Kilian, Ulm/Gunzburg, Germany There is an interest in innovative mental health service models in Germany. This comprises, among others, crisis intervention and home treatment service models and assertive community treatment teams. Innovative funding models are being put to test. There are several catchment areas in the country where care is provided according to a capitation funding model that gives a high degree of freedom to health care providers in what services they use to provide care for patients (Regionale Psychiatriebudgets). Models of this type are also used in so-called model projects on the basis of federal law (Modellvorhaben §64b SGBV). In Hamburg, a comprehensive community- and hospital-based service for people with severe mental illness has been implemented (IV Vertrag) and put to test in the ACCESS trial. The focus of this talk is on an observational controlled trial (IVPower) studying the effectiveness and cost-effectiveness of an integrated community-base care programme (NWpG) implemented in several regions of Germany (in five federal states, Schleswig-Holstein, Northrhine-Westfalia, Berlin, Saxony and Bavaria. The 18-month multi-centre observational trial enrolls 250 patients in the NWpG programme and 250 patients who receive treatment as usual from routine mental health services in five catchment areas. Data are collected at baseline and three follow-ups after 6, 12 and 18 months Preliminary study results will be presented and discussed.

Embedding advance directives in routine care for persons with serious mental illness: implementation challenges.

For people with serious mental illness, research demonstrates the potential positive effects of having an advance directive with specific instructions for mental health care. The Commonwealth of Virginia has undertaken efforts to incorporate the completion of psychiatric advance directives into routine mental health services for individuals with serious mental illness. The inherent complexities of advance directives-a single legal tool for use by a heterogeneous array of consumers, providers, and organizations-have led to more barriers than had been anticipated. This article describes challenges encountered in the first three years of implementation efforts. Data are from feedback on early training attempts and experiences of staff at pilot sites and work groups convened for the implementation project. The authors describe a range of challenges, such as how to present a complete and clear message about the nature, purposes, and potential advantages of psychiatric advance directives to various audiences, in particular their use in recovery-oriented care; how to promote cross-system collaboration among potential users of these directives; and how to overcome resource constraints and sustain interest in the process. Virginia's experience reinforces the importance of developing multifaceted implementation strategies, such as the creation of informational and training tools to spread implementation more effectively, the identification of "champions" or staff members who are invested in implementation, and the development of multiple approaches to facilitating completion of advance directives by consumers.

Embedding Advance Directives in Routine Care for Persons with Serious Mental Illness: The Virginia Advance Directive Project

For people with serious mental illness, research demonstrates the potential positive effects of having an advance directive with specific instructions for mental health care. The Commonwealth of Virginia has undertaken efforts to incorporate completion of psychiatric advance directives into routine mental health services for individuals with serious mental illness. The following sequence of three articles aims to acquaint specialists in mental health law, health services research, and policy implementation research with the Virginia Advance Directive Project. The first describes the origins and structure of the Project, including the legislative history and content of the law, and the multi-stakeholder structure created to implement it. The second article identifies the innovations that were needed to translate the opportunity created by the law into routine practice on a statewide basis. The third article describes the barriers to statewide implementation that have been encountered during the first three years of the project.

Psychometric Properties of Two Brief Versions of the Voices Acceptance and Action Scale (VAAS): Implications for the Second-wave and Third-wave Behavioural and Cognitive Approaches to Auditory Hallucinations.

Despite a steep rise in the evidence base for third-wave cognitive and behavioural therapy approaches over the past decade, a scarcity of change measures relevant to these therapies as applied to psychosis is arguably slowing empirical progress in the area. The Voices Acceptance and Action Scale (VAAS), a measure of acceptance of voice experiences, is a notable exception. However, there are no published data on its psychometric properties outside of that provided by the scale developers. The current study explored the psychometric properties of two brief versions of the VAAS in a sample of psychotic voice hearers in a routine outpatient mental health service. Evidence from the current study suggests that both brief versions are robust measures of acceptance of voice experiences. Some limited support for the shortened VAAS-9 as being a marginally improved scale over the original brief VAAS-12 was also found. The current study found acceptance of voices to be highly related to depression, anxiety, stress and general negative affect and to predict unique variance in depression and general negative affect beyond that attributable to negative beliefs about voices and thought suppression. It was also found that acceptance was positively related to the use of reappraisal, indicating that the distinctiveness of acceptance from appraisal processes may be less pronounced in this context than what was has been reported previously. Implications for future research, as well as the practice of second-wave and third-wave cognitive and behavioural approaches to psychosis, are discussed. Two brief versions of the VAAS instrument were found to be robust measures of acceptance of psychotic voice experiences. The construct of acceptance of voices is highly related to indices of well-being and negative appraisal processes in psychosis and appears to offer an alternative route to therapeutically addressing the toxic effects of negative beliefs about voices. The recent focus on acceptance-based techniques within cognitive and behavioural approaches to psychosis was supported.