Mental health care Monitor Older adults (MEMO): monitoring patient characteristics and outcome in Dutch mental health services for older adults

Information on which older adults attend mental health care and whether they profit from the care they receive is important for policy‐makers. To assess this information in daily practice, the “Mental health care Monitor Older adults” (MEMO) was developed in the Netherlands. The aim of this paper is to describe MEMO and the older adults who attend outpatient mental health care regarding their predisposing and enabling characteristics and need for care. In MEMO all patients referred to the division of old age psychiatry of the participating mental health care organisations are assessed at baseline and monitored at 4, 8 and 12‐month follow‐up. Primary outcomes are mental and social functioning, consumer satisfaction, and type of treatment provided (MEMO Basic). Over the years, MEMO Basic is repeated. In each cycle, additional information on specific patient groups is added (e.g. mood disorders). Data collection is supported by a web‐based system for clinicians, including direct feedback to monitor patients throughout treatment. First results at baseline showed that the majority of patients that entered the division of old age psychiatry was female (69%), had low education (83%), lived alone (53%), was depressed (42%) and had a comorbid condition (82%). It seemed that older immigrants were not sufficiently reached. The current study is the first in the Netherlands to evaluate patient characteristics and outcome in mental health care provided for older adults in day‐to‐day practice. If MEMO works out successfully, the method should be extended to other target groups. Copyright © 2013 John Wiley & Sons, Ltd.     

Operating conditions of psychiatric hospitals and early readmission--effects of high patient turnover

OBJECTIVE: To study the association between hospitals' operating conditions and the risk of early readmission. The hypothesis was that high patient turnover might lead to a rise in the risk of readmission soon after discharge (within 30 days). METHOD: A multivariate model including hospital and patient variables was tested using Cox's regression analysis, adjusting for clustering effects. The material included data from 20 hospitals, with 5,520 patients in the final model. RESULTS: High patient turnover (annual discharges per bed) was significantly associated with an increased risk of readmission (hazard ratio (HR)= 3.37 (95% CI = 2.39-4.75)). In addition, being discharged from a ward with relatively low access to therapists increased the hazard further. CONCLUSION: High patient turnover at the discharging ward was found to increase the patients' hazard of early readmission. This observation supports the hypothesis of a link between the operation conditions of the hospitals and patient outcome on a short time-scale.     

Psychometric evaluation of the Spanish version of CONNECT: a measure of continuity of care in mental health services

This article provides the results of the psychometric testing of the Spanish version of CONNECT(-S), a measure of continuity of care in mental health services. CONNECT-S is a multidimensional measure designed for use with seriously mentally ill respondents. Consisting of 12 scales and one single-item indicator, it addresses qualities of interaction in current relationships between mental health service providers and consumers in five conceptual domains: (1) practitioner knowledge of their clients, (2) creating flexibility, (3) practitioner availability, (4) practitioner co-ordination, and (5) smoothing transitions. One-hundred-and-fifty participants took part in the study. Participants were recruited from mental health outpatient clinics in both the Puerto Rican (n = 109) and the San Antonio (n = 41) samples. Internal consistency for scales in a combined site estimate ranged from 0.68 to 0.96. Test-retest reliability ranged from fair to substantial in all but one scale. Concurrent validity hypotheses based on a priori predictions were mostly supported. The Spanish translation and adaptation of CONNECT-S provided sound psychometric results across both sites. CONNECT-S addresses the gap in measurement of continuity of care for the two largest US Latino subgroups, Mexican Americans and Puerto Ricans; and provides an encouraging starting point for a measure that is both relevant and culturally sensitive.     

Individual unmet needs for care: are they sensitive as outcome criterion for the effectiveness of mental health services interventions?

Background  Mental health interventions should demonstrate an effect on patients’ functioning as well as his/her needs, in particular on unmet needs whose assessment depends on the perspective of either the patient or the clinician. However, individual met and unmet needs appear to change over time, qualitatively and quantitatively, raising questions about their sensitivity to change and about the association between level of needs and treatment. Methods  Data on baseline and follow-up need assessment in community mental health services in four European countries in the context of a cluster randomised trial on a novel mental health service intervention were used, which involved 102 clinicians with key worker roles and 320 patients with schizophrenia or related psychotic disorders. Need assessment was performed with the Camberwell assessment of needs short appraisal schedule (CANSAS) among patients as well as clinicians. Focus is the sensitivity to change in unmet needs over time as well as the concordance between patient and clinician ratings and their relationship with treatment condition. Results  At follow-up 294 patients (92%) had a full need assessment, while clinician rated needs were available for 302 patients (94%). Generally, the total number of met needs remained quite stable, but unmet needs decreased significantly over time, according to patients as well as to clinicians. Sensitivity to change of unmet needs is quite high: about two third of all unmet needs made a transition to no or met need, and more than half of all unmet needs at follow-up were new. Agreement between patient and clinician on unmet needs at baseline as well as follow-up was rather low, without any indication of a specific treatment effect. Conclusions  Individual unmet needs appear to be quite sensitive to change over time but as yet less suitable as outcome criterion of treatment or specific interventions.     

Proposing the stroke levity scale: a valid, reliable, simple, and time-saving measure of stroke severity

Background and purpose:  National Institutes of Health Stroke Scale (NIHSS) is long and complex. Our objective was to design a valid, reliable, simple, and time-saving stroke severity scale.
Methods:  About 103 and 100 consecutive stroke patients in Berlin (Germany) and Ibadan (Nigeria), respectively were evaluated using the measures listed below. The Stroke Levity Scale (SLS) was calculated as maximum power (0–5) in the dexterous hand + maximum power in the weaker lower limb + mobility score−1(if aphasia present).
Results:  It took less than 2 min to administer the SLS in contrast to 8 min for the NIHSS. The SLS showed significant correlation to the NIHSS ( ρ  = −0.79, P  < 0.0001), the modified Rankin Scale ( ρ  = −0.79, P  < 0.0001), and the health-related quality of life (QOL) in stroke patient's questionnaire ( ρ  = 0.78, P  < 0.0001). It had Cronbach's α of 0.75 (Ibadan) and 0.71 (Berlin). The κ -value for test-retest reliability was 0.77 with P  < 0.0001.
Conclusions:  The SLS is a concise, valid, and reliable stroke impairment scale that can be used routinely to monitor outcome in stroke patients. Because it is brief and simple to apply, non-neurologists can be taught to administer it in addition to QOL and disability scales for stroke survivors without significantly increasing the respondent burden.     

Patient,Provider, and Treatment Factors Associated with Poor-Quality Care for Schizophrenia

Interventions are needed to improve the quality of care for schizophrenia. However, in designing these interventions it would be helpful to understand better which patients are at highest risk for poor-quality care and why care for this disorder is often of poor quality. We study the extent to which patient and treatment factors are associated with poor-quality care in 224 patients randomly sampled from two mental health clinics. Quality of medication management is evaluated using an established method based on national treatment recommendations. Multivariate regression is used to study the effect of patient and treatment factors on treatment quality, controlling for provider. Risk for poor-quality care was greater for patients who were more severely ill, older, and less compliant with treatment recommendations. There were trends toward poor management of symptoms in men and substance abusers, and poor management of side effects in Black patients. Provision of poor-quality care was associated with failure to document symptoms and side effects in the medical record. Interventions to improve care for schizophrenia should attend to the need for accurate clinical assessment and strategies for managing challenging clinical situations.     

Outcome measures in forensic mental health services: A systematic review of instruments and qualitative evidence synthesis

BackgroundOutcome measurement in forensic mental health services can support service improvement, research, and patient progress evaluation. This systematic review aims to identify instruments available for use as outcome measures in this field and assess the evidence for the most common instruments, specific to the forensic context, which cover multiple outcome domains.MethodsStudies were identified by searching seven online databases. Additional searches were then performed for 10 selected instruments to identify additional information on their psychometric properties. Instrument manuals and gray literature was reviewed for information about instrument development and content validity. The quality of evidence for psychometric properties was summarized for each instrument based on the COnsensus-based Standards for health Measurement INstruments (COSMIN) approach.ResultsA total of 435 different instruments or variants were identified. Psychometric information on the 10 selected instruments was extracted from 103 studies. All 10 instruments had a clinician reported component with only two having patient reported scales. Half of the instruments were primarily focused on risk. No instrument demonstrated adequate psychometric properties in all eight COSMIN categories assessed. Only one instrument, the Camberwell Assessment of Need: Forensic Version, had adequate evidence for its development and content validity. The most evidence was for construct validity, while none was identified for construct stability between groups.ConclusionsDespite the large number of instruments potentially available, evidence for their use as outcome measures in forensic mental health services is limited. Future research and instrument development should involve patients and carers to ensure adequate content validity.     

Does Additional Care Provided by a Consumer Self-Help Group Improve Psychiatric Outcome? A Study in an Italian Community-based Psychiatric Service

This study compares the two-year clinical and social outcome, the use of services and the direct costs of patients of the South-Verona Community Psychiatric Service who were members of a self-help group, with those who were not. Use of services and costs in the two years before the baseline were compared with those occurring two years after the baseline. Self-help subjects decreased their use of hospital stay as to number of admissions and days in hospital, with a reduction of costs; they were more satisfied as to work/education while non self-help matches presented an increase of unmet needs. Clinical and social outcome showed no significant difference. The findings suggest that consumer participation may possibly enhance the effects of psychiatric treatment on outcome.     

Outcome revealed by preference in schizophrenia (OPS): development of a new class of outcome measurements

The objective of this paper is to describe the development of a new type of outcome measurement, based on revealed preference, which can be used in serious chronic illnesses. Fifteen texts of about 200 words each were written by one of the authors on the day-to-day life of 15 schizophrenic patients. These 15 'slices of life' thus described were then ranked in terms of acceptability by a second group of 10 schizophrenic patients and by a group of 12 relatives of schizophrenic patients. From these rankings, six situations were selected so as to obtain evenly distributed positioning on an axis of acceptability. These six situations comprised the final instrument. In administration, the patients were first asked if the 'slices of life' that were described were acceptable or not, then if the 'slices of life' described were more or less acceptable than their own lives. Two scores were derived, one for an absolute level and the other for a relative level of the patient's satisfaction with his or her existence. Validation results were presented to a new sample of 229 schizophrenic patients. Internal consistency appeared good and the initial ranking of the six situations in terms of acceptability was confirmed. This study encourages the development of global outcome measures based on revealed preference in chronic serious illnesses.     

Relationship Between Diagnosis and Disposition of Patients Admitted to a State Psychiatric Hospital

The lifetime outcome for individuals diagnosed with affective disorders is generally more favorable than for those diagnosed with a schizophrenic disorder. We determined if a similar differential outcome could be detected among 139 patients hospitalized on the admissions unit of a state psychiatric facility between 1998 and 2001, and diagnosed with a Schizophrenic, Schizoaffective or Affective Disorder. The placement of each patient on discharge was categorized as an outpatient environment, a minimum-security treatment unit, a locked ward, or a highly secure forensic facility. Patients with an affective disorder were significantly less likely than the other two groups to have a co-occurring diagnosis of substance abuse, and they performed better on the neuropsychological assessments. However, the groups did not differ in their discharge placements, or in their length of stay. These findings suggest that resolution of more acute symptomatology may be unrelated to factors associated with long-term outcome for individuals suffering from severe and persistent mental illness.     

Profile of health-related quality of life in Nigerian stroke survivors

Background and purpose:  No study using a stroke-specific measure has been previously conducted to determine the profile of health-related quality of life (HRQOL) in Nigerian stroke patients. Such a study is pre-requisite to planning of patient-centered rehabilitative care aimed at maximizing HRQOL improvement. Our objectives were to develop and validate a stroke-specific HRQOL measure, and determine the profile of HRQOL using it.
Methods:  The HRQOL in stroke patients (HRQOLISP) questionnaire was developed and administered to 100 stroke patients and a control group of 100 age- and gender-matched healthy adults. The Stroke Levity Score (SLS) and modified Rankin Scale (mRS) were applied to measure stroke severity and disability respectively.
Results:  The HRQOLISP surpassed the Nunnaly's criterion for reliability and was able to discriminate between stroke (HRQOLsum = 73.5 ± 9.1) and normal subjects (HRQOLsum = 84.4 ± 6.9, P  = 0.002). It differentiated strokes of various severities in the physical dimension (physical, psychological, cognitive and social domains). SLS and mRS correlated only to the domains in the physical dimension.
Conclusion:  The HRQOLISP demonstrated good content, construct and discriminant validity and internal consistency reliability. Stroke had a multifaceted effect on HRQOL, which was more pronounced in the physical dimension.     

Subjective quality of life and standard of living: a 10-year follow-up of out-patients with schizophrenia

In 1984, a study in Göteborg, Sweden, reported the quality of life of 61 outpatients with schizophrenia (DSM-III) to be low, despite their high standard of living. The respondents used an instrument (QLS-100) developed by the author to indicate which of 100 items they considered to be unsatisfactory. Interviews captured objective conditions of the patients' lives and their quality-of-life goals for each unsatisfactory item. The results of the study led during the late 1980s to deliberately individualized services, aimed at helping patients to attain their own quality-of-life goals. In total, 40 of the subjects took part in a 10-year follow-up. The 1994 study showed that the incidence of living alone in one's own home increased. Overall quality of life remained unchanged. Although still low, quality of life increased significantly in three of 14 domains, namely contacts, inner experiences, and knowledge and education. The reasons for these improvements and the maintained overall quality of life could be that patients increased their ability to interact with the environment, that they increased and/or modified their aspirations in the light of available resources and/or deficits, and that housekeeping assistance and service were provided conditional on the patients' own quality-of-life goals and needs.     

A 16-year follow-up study of schizophrenia and related disorders in Sofia,Bulgaria

A total of 60 patients with functional non-affective psychoses were assessed 16 years after their inclusion in the WHO co-ordinated study on reduction and assessment of psychiatric disability. All patients at inclusion had a recent onset of a psychotic disorder. About one-third of the patients had a good outcome. The rest showed moderate to severe psychiatric symptoms and social disability. Comparison with other similar studies suggested that our results show a low mortality rate, high levels of clinical symptoms, high levels of social disability and a low percentage of institutionalized patients. These findings are discussed in the context of the high level of family involvement in patients' care, which could reflect a cultural factor.     

Outcomes of involuntary hospital admission--a review

INTRODUCTION: This paper reviews studies on outcomes of involuntary hospital admissions in general adult psychiatry, and predictors of outcomes. METHOD: Studies assessing observer-rated clinical change and self-rated outcomes were identified. Relevant databases were searched and authors were contacted. Studies were classified according to quality criteria. RESULTS: Eighteen studies fulfilled the inclusion criteria. Most involuntarily admitted patients show substantial clinical improvement over time. Retrospectively, between 33% and 81% of patients regard the admission as justified and/or the treatment as beneficial. Data on predictors of outcomes is limited and inconsistent. Patients with more marked clinical improvement tend to have more positive retrospective judgements. CONCLUSION: A substantial number of involuntary patients do retrospectively not feel that their admission was justified and beneficial. At least for this group, new approaches might have to be considered. Larger studies are required to identify predictors on which patients are likely to fall into this group.     

Developing core sets for persons with bipolar disorder based on the International Classification of Functioning, Disability and Health

INTRODUCTION: Functioning is increasingly being taken into account when assessing the impact of bipolar disorder (BD) on the individual, as well as the effectiveness of treatments. With the International Classification of Functioning, Disability and Health (ICF), we can now rely on a globally agreed-upon framework and system for classifying the typical spectrum of problems in functioning, given the environmental context in which subjects live. ICF Core Sets are subgroups of ICF items selected to capture those aspects of functioning that are most likely to be affected by specific disorders. Within a given disorder, both Brief and Comprehensive Core Sets can be established to serve specific purposes. OBJECTIVE: The aim of this paper is to outline the development process of the ICF Core Sets for BD. METHODS: The final definition of ICF Core Sets for BD will be determined at an ICF Core-Sets Consensus Conference, which will integrate evidence from preliminary studies, namely (a) semi-structured interviews with people with BD in different countries, (b) a Delphi exercise with international experts participating and (c) a cross-sectional study. CONCLUSION: ICF Core Sets are being designed with the goal of providing useful standards for research, clinical practice and teaching. We believe that these ICF Core Sets for BD will stimulate research leading to improved understanding of functioning, disability and health in BD. Such research, we hope, will lead to interventions and accommodations to improve restoration and maintenance of functioning and minimise disability among people with BD throughout the world.     

Therapist effectiveness: Implications for accountability and patient care

Abstract

Significant therapist variability has been demonstrated in both psychotherapy outcomes and process (e.g., the working alliance). In an attempt to provide prevalence estimates of “effective” and “harmful” therapists, the outcomes of 6960 patients seen by 696 therapists in the context of naturalistic treatment were analyzed across multiple symptom and functioning domains. Therapists were defined based on whether their average client reliably improved, worsened, or neither improved nor worsened. Results varied by domain with the widespread pervasiveness of unclassifiable/ineffective and harmful therapists ranging from 33 to 65%. Harmful therapists demonstrated large, negative treatment effect sizes (d=?0.91 to ?1.49) while effective therapists demonstrated large, positive treatment effect sizes (d=1.00 to 1.52). Therapist domain-specific effectiveness correlated poorly across domains, suggesting that therapist competencies may be domain or disorder specific, rather than reflecting a core attribute or underlying therapeutic skill construct. Public policy and clinical implications of these findings are discussed, including the importance of integrating benchmarked outcome measurement into both routine care and training.