Spirituality and religion in psychiatric rehabilitation and recovery from mental illness

While mental health professionals frequently express concerns about the function of spirituality and religion in the lives of people diagnosed with severe mental disorders, there are both clinical and research bases for the increased acceptance of spirituality's potentially positive role in psychiatric rehabilitation and recovery. This paper first addresses issues of religious experience in diagnosis, including the importance of religiocultural context and overall functioning in diagnostic assessments. It then examines the roles of spirituality in recovery, exploring both positive and negative relationships between religion and consumers' well-being. Finally, it describes several specific ways in which spiritual and religious concerns may be integrated into psychosocial rehabilitation services: conducting spiritual assessments; offering spiritually-informed discussion groups; incorporating spiritual dimensions of psychotherapy; and facilitating linkages to faith communities and spiritual resources.     

Toward a more culturally sensitive DSM-IV. Psychoreligious and psychospiritual problems.

In theory, research, and practice, mental health professionals have tended to ignore or pathologize the religious and spiritual dimensions of life. This represents a type of cultural insensitivity toward individuals who have religious and spiritual experiences in both Western and non-Western cultures. After documenting the "religiosity gap" between clinicians and patients, the authors review the role of theory, inadequate training, and biological primacy in fostering psychiatry's insensitivity. A new Z Code (formerly V Code) diagnostic category is proposed for DSM-IV: psychoreligious or psychospiritual problem. Examples of psychoreligious problems include loss or questioning of a firmly held faith, and conversion to a new faith. Examples of psychospiritual problems include near-death experiences and mystical experiences. Both types of problems are defined, and differential diagnostic issues are discussed. This new diagnostic category would: a) improve diagnostic assessments when religious and spiritual issues are involved; b) reduce iatrogenic harm from misdiagnosis of psychoreligious and psychospiritual problems; c) improve treatment of such problems by stimulating clinical research; and d) encourage clinical training centers to address the religious and spiritual dimensions of human existence.     

The influence of spirituality and religiousness on suicide risk and mental health of patients undergoing hemodialysis

BackgroundDespite the large amount of literature assessing how spiritual and religious beliefs have an impact on mental health and suicide risk in various groups of patients, few studies have investigated patients with chronic kidney disease (CKD). The purpose of this study is to investigate whether spirituality and religiousness (S/R) are associated with the presence of suicide risk as well as whether those beliefs are also associated with the presence of mental health problems in patients undergoing hemodialysis.MethodsCross-sectional study carried out in three Brazilian dialysis units involving hemodialysis patients. The study assessed religiousness (Duke Religion Index); spiritual well-being (FACIT-Sp 12); mental health - depression and anxiety (Mini International Neuropsychiatric Interview–MINI); and risk of suicide (MINI). For analysis, adjusted logistic regression models were applied.ResultsA total of 264 (80.7%) patients were included, 17.8% presented suicide risk, 14.0% presented current major depressive episode, and 14.7% presented generalized anxiety disorder. Concerning spiritual well-being (FACIT-Sp 12), the subscale of “Meaning” was associated with lower risk of suicide, depression, and anxiety. The subscale “Peace” was associated with lower depression and anxiety, whereas the subscale “Faith” was associated with lower suicide risk and depression. Religiousness measures were not associated with the study outcomes.ConclusionSpiritual beliefs were associated with lower suicide risk and better mental health among hemodialysis patients. Factors related to spiritual well-being, such as “meaning”, “peace” and “faith” were more associated with the outcomes studied than religious involvement. Further studies are needed to replicate our findings in different cultural and religious settings.     

The cure of souls: psychiatric dilemmas

Misunderstandings quite frequently occur between patients and their doctors because psychiatrists may be unable to comprehend and therefore accept their patient's experience. 'Soul' and 'spirit' are essential characteristics of human life: soul ultimately means 'quick moving', the principle of life; spirit etymologically refers to breath and is also the animating or vital principle.The spiritual aspects of a person include his or her aims and goals, the interrelatedness of human beings, wholeness of person in which spirit is not separate from body or mind, moral aspects of goodness, beauty and enjoyment and an awareness of God. Psychiatrists have historically had difficulties with the spiritual realm, some of the roots of psychiatry have been anti-ecclesiastical and currently psychiatrists are well aware of the harmful effects of some religious groups upon vulnerable patients.However, religious people, those who regard faith, religious practice and spiritual issues as important, have had distrust for some psychiatrists and their publications.There has also been a degree of professional rivalry between clergy and psychiatrists who share some of the same goals for their parishioners/patients. Patients feel themselves sometimes to have been caught in the cross-fire and this has resulted in reluctance to talk about spiritual issues to their psychiatrists or mental health problems to their priest.In practice there is considerable evidence for the benefit of religious belief in achieving good mental health and recovery from mental illness.It is important for the psychiatrist to be aware of patients'religious beliefs and spiritual aspirations, to understand these and know about patients' backgrounds. It is harmful for psychiatrists to try and impose their own views and understandings upon their patients.     

Dissociative Spectrum Disorders in the Primary Care Setting

Dissociative disorders have a lifetime prevalence of about 10%. Dissociative symptoms may occur in acute stress disorder, posttraumatic stress disorder, somatization disorder, substance abuse, trance and possession trance, Ganser's syndrome, and dissociative identity disorder, as well as in mood disorders, psychoses, and personality disorders. Dissociative symptoms and disorders are observed frequently among patients attending our rural South Carolina community mental health center. Given the prevalence of mental illness in primary care settings and the diagnostic difficulties encountered with dissociative disorders, such illness may be undiagnosed or misdiagnosed in primary care settings. We developed an intervention model that may be applicable to primary care settings or helpful to primary care physicians. Key points of the intervention are identification of dissociative symptoms, patient and family education, review of the origin of the symptoms as a method of coping with trauma, and supportive reinforcement of cognitive and relaxation skills during follow-up visits. Symptom recognition, Education of the family, Learning new skills, and Follow-up may be remembered by the mnemonic device SELF. We present several cases to illustrate dissociative symptoms and our intervention. Physicians and other professionals using the 4 steps and behavioral approaches will be able to better recognize and triage patients with dissociative symptoms. Behaviors previously thought to be secondary to psychosis or personality disorders may be seen in a new frame of reference, strengthening the therapeutic alliance while reducing distress and acting-out behaviors.     

Religiosity, psychosocial adjustment, and subjective burden of persons who care for those with mental illness

OBJECTIVE: The purpose of this study was to characterize the nature of religious and spiritual support received by family caregivers of persons with serious mental illness and to test hypotheses that religiosity would be associated with caregiver adjustment. METHODS: Eighty-three caregivers who participated in a study of the Family to Family Education Program of the National Alliance on Mental Illness were assessed at baseline in terms of their religiosity and receipt of spiritual support in coping. They also completed measures of depression, self-esteem, mastery, self-care, and subjective burden. Hierarchical regression was used to test hypotheses that religiosity would be associated with better adjustment, with confounding variables controlled for. RESULTS: Thirty-seven percent of participants reported that they had received spiritual support in coping with their relative's illness in the previous three months. When age, race, education, and gender were controlled for, religiosity was associated with less depression and better self-esteem and self-care. Personal religiosity was a stronger predictor of adjustment than religious service attendance. CONCLUSIONS: Family caregivers of persons with serious mental illness often turn to spirituality for support, and religiosity may be an important contributor to caregiver adjustment. Collaborative partnerships between mental health professionals and religious and spiritual communities represent a powerful and culturally sensitive resource for meeting the support needs of family members of persons with serious mental illness.     

Medical advance care planning for persons with serious mental illness

OBJECTIVE: This study examined preferences regarding medical advance care planning among persons with serious mental illness, specifically, experience, beliefs, values, and concerns about health care proxies and end-of-life issues. METHODS: A structured interview, the Health Care Preferences Questionnaire, was administered to a convenience sample of 150 adults with serious mental illness who were receiving community-based services from the Massachusetts Department of Mental Health. Clinical information and demographic data were also collected. RESULTS: A total of 142 participants completed the questionnaire. Although more than one-quarter had thought about their medical treatment preferences in the event that they became seriously medically ill, very few had discussed these preferences. A majority of respondents (72 percent) believed that someone should be designated to make medical health care decisions for a person who is too sick to make or communicate these decisions him- or herself. Common end-of-life concerns included financial and emotional burdens on family, pain and suffering, interpersonal issues such as saying "goodbye," spiritual issues, and funeral arrangements. Participants were most uneasy about the prolonging or stopping of life support by proxy decision makers. A total of 104 respondents (69 percent) expressed interest in formally selecting a health care proxy. CONCLUSIONS: Although persons with serious and persistent mental illness have little experience with medical advance care planning, they show substantial interest in it. Furthermore, they are able to consider and communicate their preferences. This study supports the feasibility, acceptability, and utility of a standardized approach to medical advance care planning with this population.     

Mapping Movement: Applying Motion Measurement Technologies to the Psychiatric Care of Older Adults

Purpose of Review

Recent advances in technology have changed the landscape of treatment for adults with mental illness. This review highlights technological innovations that may improve care for older adults with mental illness and neurocognitive disorders through the measurement and assessment of physical motion. These technologies include wearable sensors (such as smart watches and Fitbits), passive motion sensors, and smart home models that incorporate both active and passive motion technologies.

Recent Findings

Clinicians have evaluated motion measurement technologies in older adults with depression, dementia, anxiety, and schizophrenia. Results from studies in dementia populations suggest that motion measurement technologies can assist clinicians in diagnosing dementia earlier through the evaluation of gait, balance, and postural kinematics. Motion detection technologies can also be used to identify mood episodes at an earlier stage by detecting subtle behavioral changes.

Summary

Clinicians may use the objective data provided by technologies such as accelerometers to identify illnesses earlier, which may inform treatment decisions. The data may be used as a suitable surrogate marker for detecting depression in older adults, predicting the likelihood of falls, or quantifying physical activity in older adults with chronic mental illnesses or anxiety. Motion-based technologies also have the potential to detect physical activity for older adults residing in nursing homes. Wearable technologies are generally well tolerated in older adults, although the use of new technology and electronic health data could involve privacy and security concerns among this vulnerable population.

     

Religion,Spirituality, and Psychosis

This review discusses the relationships between religion, spirituality, and psychosis. Based on the DSM-IV, we comment on the concept of spiritual and religious problems, which, although they may seem to be psychotic episodes, are actually manifestations of nonpathological spiritual and religious experiences. Studies reporting that hallucinations also occur in the nonclinical population and thus are not exclusive to the diagnosed population are presented. Then, other studies pointing to the strong presence of religious content in psychotic patients are also presented. Finally, the criteria that could be used to make a differential diagnosis between healthy spiritual experiences and mental disorders of religious content are discussed. We conclude that the importance of this theme and the lack of quality investigations point to the necessity of further investigation.     

Shared Decision-Making and Evidence-Based Practice

Shared decision-making refers to a process of health care delivery in which practitioners and clients seeking help for problems or disorders collaborate to access relevant information and to enable client-centered selection of health care resources. Though nearly all clients express a desire for more information, preferences for participation in health care decisions vary by individual and by illness. Two common strategies to promote shared decision-making are communication training for clients and clinicians, and decision aids to provide targeted information and values clarification. Research in several areas of medicine shows that active client participation results in a variety of benefits, from increased satisfaction to decreased symptom burden. Many current mental health interventions promote client-centered care, client choice, and self-directed care, but research on shared decision-making in mental health for clients with severe and persistent mental illness is just beginning.Jared R. Adams is affiliated with the Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH 03755, USA.Robert E. Drake is affiliated with the New Hampshire-Dartmouth Psychiatric Research Center, Lebanon, NH 03766, USA.     

Help seeking behaviour of psychiatric patients before seeking care at a mental hospital.

BACKGROUND: A wide range of professionals including psychiatrists, psychologists, general physicians, faith-healers and religious healers cater to the needs of mentally ill patients. Psychiatric facilities are available at general hospitals, office based practice and mental hospitals. Psychiatrists are preferred the least due to stigma. The present work reports on treatment options used by a group of psychiatric patients before visiting a mental hospital. AIM: To study the help seeking behaviour of patients visiting a mental hospital. METHOD: Patients attending psychiatric outpatient service at a mental hospital were asked specifically about various treatment facilities utilized by them before coming to the hospital and the reasons thereof. RESULTS: A wide range of services was used by the subjects varying from professional care to faith healers. Trust, easy availability and accessibility, recommendations by the significant others and belief in supernatural causation of illness were the important reasons for choosing a particular facility. Thus sociocultural factors appeared to influence the help seeking behaviour. CONCLUSION: A substantial number of patients suffering from severe mental disorders seek non-professional care. There is a need of studies in community to assess the help seeking behaviour of psychiatric patients and factors associated with it.     

Missing Ingredients in Shared Decision-Making?

Shared decision-making (SDM) is a collaborative approach to making decisions in health care, and is a cornerstone of person-centered care. While providers are increasingly expected to utilize SDM in routine practice, widespread and sustainable implementation has proven difficult, especially in the care of individuals diagnosed with serious mental illnesses, and physicians and patients continue to identify barriers to effective collaboration. To date, SDM research has largely focused on the provision of high-quality clinical information from doctors to patients to the neglect of what may be the most important, and transformative, aspect of SDM—the relationship itself. In this forum, the lack of attention to the relationship in SDM research and practice will be explored, along with the relational qualities that need to be in place to implement SDM in the care of persons with serious mental illness based on the findings from a mixed-methods, participatory research project.

     

Annotation: New research into general psychiatric services for adults with intellectual disability and mental illness

Background   There are a variety of models for the mental health care of adults with comorbid intellectual disability (ID) and mental illness. There has been a long-running debate as to whether this should be provided by general psychiatric or specialised ID services. A previous review concluded that there was no clear evidence to support either model with research being often of a poor quality, lacking replication, and outcome measures were often inappropriate or varied between studies. This review aims assess differences in outcome for patients with ID and mental disorders treated in general or specialised ID mental health services.
Method   A literature review was conducted using electronic databases and websites of ID and mental health organisations to locate all references where people with ID receive mental health care in general psychiatric services from 2003. No meta-analysis was attempted because of the divergent nature of the studies.
Results   People with ID (especially severe ID) have reduced access to general psychiatric services. General psychiatric inpatient care is unpopular especially with carers but can be improved by providing specially trained staff and in-reach from community ID teams. Opportunities may exist to enhance the care of people with borderline intellectual functioning within general psychiatric services.
Conclusions   Although no new randomised controlled trials have been published, the weight of research is accumulating to suggest that provision of general psychiatric services without extra help is not sufficient to meet the needs of people with ID.     

The MATCH cohort study in the Netherlands: rationale,objectives, methods and baseline characteristics of patients with (long‐term) common mental disorders

Research in the last decades shows that common mental disorders may be long‐term and severely disabling, resulting in severe mental illness (SMI). The percentage of Dutch SMI‐patients with common mental disorders receiving mental health services is estimated at 65–70%. However, it is unclear which patients in fact become SMI‐patients. We need to know more about the possible course of common mental disorders, understand the origins of chronicity in more detail, and have more insight in related care processes and care use of patients with common mental disorders. The MATCH cohort study is a four‐year multicentre naturalistic cohort study, with yearly assessments in primary, secondary, and tertiary services in three large Dutch mental health services. Socio‐demographics, mental disorders, course and severity of psychopathology, physiological health indicators, neurocognitive functioning, past and present life events, health care use and contact with mental health services, social functioning and quality of life, and recovery and well‐being are assessed. Baseline findings of 283 participating individuals and their key clinicians are described. The sample appears to appropriately represent the distribution of individuals across diagnostic categories in services, and level of care (outpatient, day treatment, inpatient) in the Netherlands and other developed nations. Copyright © 2016 John Wiley & Sons, Ltd.     

Psychiatrists' Perceptions of Administrative Review: A Victorian Empirical Study

In 1987, the Mental Health Review Board commenced operations under the Mental Health Act 1986. Its principal purpose was to provide an independent review of persons involuntarily detained for treatment of mental illness. These legislative changes reflected a governmental desire for greater accountability and transparency in the provision of involuntary treatment and care, and a much greater focus on the protection of the rights of people with serious mental illness. At that time, independent review of psychiatric decisions was novel in Victoria, and was met with a degree of hostility and resentment by some public sector psychiatrists. In 1995, I conducted interviews with 22 senior public sector psychiatrists from across Victoria, in order to determine whether, and if so how, administrative review had impacted on them and their psychiatric practice between 1987 and 1995. I revisited the research in 2004 in interviews with 15 psychiatrists. In general terms, the 2004 findings reflected an increased level of support for the functions of the Board, and a significant increase in those who considered Board procedures and decisions had impacted on their clinical practice. Consistent with the 1995 findings, the 2004 research confirmed the legitimating effect of the Board for some psychiatrists, and also suggested an increase in those who may seek either to devolve responsibility for decision-making to the Board in difficult cases, or to share a degree of responsibility in such cases. The majority of those interviewed remained sceptical about the capacity of administrative review to raise standards of treatment and care or bring about positive therapeutic outcomes for patients. In view of this finding, it is argued that there is a role for increased education of, or promotion to, clinicians and Board members concerning the positive therapeutic potential of administrative review.     

Management of Mental Disorders in VA Primary Care Practices

The association between facility-level organizational features and management of mental health services was assessed based on a survey of directors from 219 VA primary care facilities. Overall, 26.4% of VA primary care facilities referred patients with depression, while 72.6% and 46.1% referred patients with serious mental illness and substance use disorders, respectively Staffing mix (i.e., physician extenders such as nurse practitioners) was associated with a lesser likelihood of mental health referral. Managed care (preauthorization requirement) was associated with a greater likelihood of referral for depression. VA primary care programs, while tending to refer for more serious mental illnesses, may also be using mental health specialists and physician extenders to provide mental health care within general medical settings.     

End-of-life treatment preferences of persons with serious mental illness

OBJECTIVE: The goal of this study was to ascertain preferences for end-of-life care among persons with serious mental illness. METHODS: The participants were 150 community-residing adults with serious mental illness. The Health Care Preferences Questionnaire was administered to obtain information about treatment preferences in response to hypothetical medical illness scenarios: use of pain medication in the case of incurable cancer and use of artificial life support in the case of irreversible coma. Participants were asked what their treatment preferences would be for an imaginary person in each scenario ("other") as well as their preferences for themselves ("self"). RESULTS: For the scenario involving pain medication for incurable cancer, most participants chose aggressive pain management even if cognition might be affected (64 percent of respondents under the "other" scenario and 66 percent under the "self" scenario). Few participants thought a doctor should provide patients with enough medication to end their life (34 percent for self and 24 percent for other). For the scenario involving irreversible coma, respondents were divided in their choice regarding life support. Approximately one-quarter said that they would prefer to immediately terminate life support (28 percent of respondents for other and 29 percent for self), and half said they would choose to turn it off after a defined period (48 percent for other and 45 percent for self). CONCLUSIONS: Persons with serious mental illness were able to designate treatment preferences in response to end-of-life health state scenarios. Future research is needed to test advance care planning methods, assess stability of choices over time, and ascertain the utility of scenario-based preferences to guide end-of-life care decisions in this population.     

Prevalence and Predictors of Limited Literacy in Public Mental Health Care

Literacy is an important predictor of health care utilization and outcomes. We examine literacy among people seeking care in a state funded mental health clinic (Site 1) and a safety-net hospital clinic (Site 2). Limited literacy was defined as literacy at or below the 8th grade level. At Site 1, 53% of participants had limited reading literacy and 78% had limited aural literacy. At Site 2, 72% had limited reading and 90% had limited aural literacy. Regression analyses examined associations among limited literacy and psychiatric, neurocognitive and sociodemographic characteristics. Few associations among psychiatric and neurocognitive factors, and literacy were found. At Site 2, black and “other” race participants had higher odds for limited literacy compared to white participants suggesting that limited literacy may be an under-examined mechanism in understanding racial disparities in mental health. Work is needed to understand the relationships among literacy, mental health and mental health care.

     

Neurocognitive impairment across the bipolar spectrum

Bipolar disorder is a severe mental illness that affects nearly 4.4% of the general population when bipolar spectrum disorders are taken into account. Neurocognitive impairment is thought to be a core deficit of this illness since it is present during euthymia. In fact, 40-60% of euthymic patients present with neurocognitive disturbances. Not only the clinical factors but also disturbances in neurocognition can influence the functional outcome of BD patients. Hence, further research is needed in order to clarify the relationship between these variables. Despite the growing body of evidence that has emerged during the last decade, no unique neurocognitive profile has been proposed yet for either BD subtype. The majority of the studies recluted heterogeneous samples (including both bipolar I and II) or focused on BD-I patients only. The aim of this review is to give an overall picture of the main neurocognitive disturbances found in the bipolar spectrum and particularly in BD-II, where the findings are more ambiguous. An extensive review of all the literature has been done regarding this subtype (from 1980 until July 2009). Data available until now suggest that deficits are present across the bipolar spectrum (BD-I and BD-II), but they seem slightly more severe in BD-I. The extent to which either subtype share-or not-some similarities is still unknown. More studies are required but it would also be interesting to reach a consensus in the neuropsychological assessment of BD to facilitate comparisons between the different studies.     

Correlates of insight in serious mental illness

This study extends research into insight by examining its relationship to a variety of demographic, clinical, neurocognitive, and psychosocial variables among a broad diagnostic sample of 211 adults with serious mental illness. Participants completed a full battery of instruments measuring these variables. Results support a relationship between ratings of poor insight and a psychotic (vs. mood) diagnosis, increased psychiatric symptoms, poorer social skills, and negative medication attitudes. Minorities and those with a substance abuse diagnosis were also more likely to be rated as having poor insight. No relationship was found between level of insight and age, gender, education level, neurocognitive deficits, hospitalization history, size of one's social network, or quality of life measures. Results are discussed in the context of improving the measurement and assessment of insight, conceptualizing interventions aimed at addressing level of insight, and improving outcomes for patients with severe and persistent mental illness. Findings also support a need for continued investigation of how mental illness is understood, experienced, and expressed across diverse groups of people living with mental illness.