Moderators and Mediators of Client Satisfaction in Case Management Programs for Clients with Severe Mental Illness

This randomized experiment first determined that clients with severe mental illness who received Assertive Community Treatment (ACT) were more satisfied with their treatment program than were clients in a brokered case management program (BCM). Eight demographic and diagnostic variables were examined as potential moderators of the treatment effect. Only one of the eight varables, diagnosis of depression, interacted with treatment condition to effect client satisfaction. However, there were several important mediators of client satisfaction: intensity of program contacts, continuity of program contacts, supportive services (i.e, assistance with activities of daily living), and the strength of the helping alliance as perceived by the client.     

Clinical practice and research activities for early psychiatric intervention at Japanese leading centres

Aim: To describe clinical practice and research activities for early psychiatric intervention in Japan, a country with a huge number of psychiatric beds and a history of long‐stay, hospital‐based psychiatry. Methods: The characteristics, methods and activities of early intervention studies and implementation at four leading institutions in Japan are described. Results: The Tokyo Youth Club (Tokyo), the Department of Neuropsychiatry of Toyama University Hospital (Toyama), the S endai A t‐risk Mental State and F irst E pisode (SAFE) service (Sendai), and the Il Bosco of Toho University Omori Medical Center (Tokyo) have unique and active psychiatric programmes. Eachcentre has its own clinical research programme and treatment strategies. The Japanese Society for the Prevention of Psychiatric Disorders, founded in 1996, has made a steady contribution to psychiatric care by providing a forum for members to promote best practices for early intervention and by hosting annual meetings to discuss research and treatment. Conclusions: The Japanese psychiatry service is continuing its transition from hospital‐based psychiatry to community‐based psychiatry. Despite these difficult circumstances, the publication of data on the duration of untreated psychosis in Japan along with evidence that early detection determines outcome has encouraged new attempts to promote early psychiatric intervention.     

The outcome of early intervention in first episode psychosis

Abstract

The last 20?years have seen an increased focus on early intervention in psychotic disorders in research and clinical practice. Interventions have typically aimed at either reducing the duration of untreated psychosis (DUP), or developing specialized treatment facilities for patients with first episode psychosis (FEP). This review presents an overview of the most important trials and meta-analytic evidence within this field. The possibilities for reducing DUP and elements included in specialized early intervention treatment are discussed. Further, it examines long-term outcomes of early interventions and results from prolonged early intervention trials. Lastly, it analyses possible interactions between DUP and specialized early intervention treatment. In conclusion, both elements appear necessary in order to develop an integrated service that can provide the optimal treatment for patients with FEP. The aim of this article is to provide an overview over the most important trials and evidence regarding the outcome of early intervention in first episode psychosis.     

Assessing change in early intervention programs for children with autism

Assessing the efficacy of any intervention can be a difficult task. In the case of children with autism who require comprehensive and long-lasting interventions, the task becomes even more difficult. In this paper, intervention studies based on comprehensive interventions for young children with autism are reviewed and examined in reference to elements that are essential to a well-designed treatment study, e.g., randomization/matching procedures, and outcome measures. Given the complexity of these comprehensive intervention programs, and the few data available on interventions with clear empirical validation, a plea is made for studies to consider the active ingredients or component parts of an intervention, e.g., number of hours, type of setting, and teaching approach. Suggestions are further made for improving future studies, including more rigorous designs, and measuring change.     

Group programmes in early intervention services

Aim: Group interventions can be a developmentally appropriate treatment option for young people with mental illness; however, there is a paucity of research into these programmes. This study had three aims: (i) to document and compare both clinicians' and clients' reasons for referral to the Orygen Youth Health Recovery Group Program (RGP); (ii) to describe demographic characteristics of patients referred to the RGP; and (iii) to delineate and differentiate characteristics of clients who do and do not engage with the RGP's activities. Methods: Referral and assessment data from 212 clients referred to the RGP between July 2001 and November 2003 were collated and analysed. Results: Main reasons for referral to the programme were relationships followed by vocational/educational issues. Similarly, the most common goals identified by clients were around relationships, followed by time use and vocational issues. Clients referred to the RGP but who did not attend were more likely to have a psychotic disorder, to be older, unemployed and have difficulties with time management and substance use. Conclusions: Social functioning and vocation are important considerations in facilitating young people's recovery from mental illness. Such issues can be addressed within the context of psychosocial recovery group programmes. Further research is needed not only to address problems regarding client engagement but also to evaluate outcomes from participation in such programmes.     

The promise of early intervention

The focus of this review is the research and clinical work in early psychosis and early intervention which over the past 10-15 years has had a tremendous impact on the field of schizophrenia. Unparalleled progress has been made in programme and service development with a wide range of reported research results, outcome studies, treatment approaches and new initiatives. Traditional areas are being explored in the first episode that can add to our knowledge of schizophrenia. New areas that have a specific relevance for early intervention such as the duration of untreated psychosis and pathways to care are being widely studied. Despite the criticism of the lack of randomized controlled trials, there is a wealth of positive outcome from both effectiveness studies and limited controlled trials. However, there are still many unanswered issues which are in developing stages or which require further investigation.     

Family peer support work in an early intervention youth mental health service

This paper describes the evolution of a family peer support programme in an early intervention service in Melbourne, Australia. In response to policy directions from Federal and State governments calling for carer participation in public mental health services, and feedback from the families of young people at Orygen Youth Health, the ‘Families Helping Families’ project was developed. The positive acceptance by families of this innovative programme also warrants further exploration. The programme has overcome many organizational hurdles associated with specifically trained and employed family carers working alongside professional mental health clinicians. This article describes the change processes involved in implementing this programme and documents preliminary expressions of the benefits of family peer support. The contribution of lived experience in treatment and consumer care plans needs rigorous research and evaluation.     

Integrating primary care and early intervention in psychosis services: a general practitioner perspective

Aims: Earlier detection and treatment of psychosis is associated with improved health outcomes. While the role of specialist services to facilitate early diagnosis and treatment has been extensively described internationally, little data on their impact on general practice has been reported. A new specialist service for psychosis – the ‘Dublin East Treatment and Early Care Team (DETECT)’– has recently been established. This study aimed to describe general practitioners' (GPs) attitudes towards working within the catchment area of an early intervention service. Methods: A purposive sample of GPs practising in DETECT's catchment area was identified from the Irish Medical Directory and invited to participate in a semi‐structured interview. The sampling parameters were solo/practice and area of practice. Participants were provided with information regarding the new service and a range of educational material. Each interview was reviewed by two researchers who identified dominant themes. The study was approved by the Research Ethics Committee of the Irish College of GPs. Results: 16 GPs were interviewed. The DETECT early intervention model was identified as reducing the challenges of managing psychosis in primary care including the practical difficulties of accessing psychiatric assessment and the pervasive effect of stigma. Participants viewed communication between primary and specialist care as essential to the success of early intervention services. Conclusions: General Practice has an important role in early detection of psychosis and accessing timely psychiatric evaluations of suspected psychosis. Increasing awareness among GPs and ensuring the early intervention model is responsive to primary care can support this role.     

Paediatric major depressive disorder: neurobiology and implications for early intervention

Aim: Paediatric major depressive disorder (MDD) is associated with chronicity and poor outcomes. The goals of this review are (i) to integrate how developing biological systems contribute to the pathophysiology of paediatric MDD, and (ii) to consider the role of early intervention for depressed youth. Methods: A developmental perspective is applied herein to review and integrate key neurobiological systems that are implicated in paediatric MDD. We also review recent treatment research for adolescents with MDD. Results: Available evidence in paediatric and adult populations support an integrative model for the pathophysiology of MDD that involves fronto‐limbic neural circuitry and the neuroendocrine stress response system. Evidence from treatment research supports the efficacy of available treatments modalities, including antidepressant medications, cognitive behavioral therapy, and their combination, for the majority of adolescents with moderate to severe MDD. Conclusions: Since the biological systems implicated in MDD mature through adolescence, adolescents may be more susceptible to developing depression but also may be more amenable to treatment interventions. Early identification and treatment of paediatric MDD may be able to divert negative trajectories and lead to improved outcomes.     

Social and symptomatic outcomes of first-episode bipolar psychoses in an early intervention service

Aim: We aimed to establish the relative proportions of all diagnoses in people aged 14–35 years presenting to an early intervention in psychosis service, and to compare demographic variables, symptoms and outcomes between the bipolar psychoses and other psychoses at 3–6 months and 1 year post referral. Methods: Prospective 3‐ to 6‐month diagnostic and symptomatic assessments were carried out. Diagnoses were established using the Diagnostic Interview for Psychoses – Diagnostic Module. Symptoms and outcomes were assessed using standardized instruments at 3–6 months and 1 year. Bipolar diagnoses were grouped together in a bipolar group (n=16) and compared with all other diagnoses, in a non‐bipolar group (n=62). Parallel analysis was carried out using groups of lifetime elevated, expansive or irritable mood (n=32) and no lifetime elevated, expansive or irritable mood (n=46). Results: Bipolar disorders account for 20.5% of all new presentations to our service. Differences in outcomes over the range of psychotic diagnoses relate to early presence of negative symptoms. Psychoses with bipolar diagnoses or lifetime elevated, expansive or irritable mood showed lower rates of negative symptoms than other psychoses and had a higher quality of life and higher function at 3–6 months and 1 year. Conclusions: Planning for future early intervention services should take the high rate of affective psychoses and their need for diagnosis‐specific, evidence‐based treatments into account. Lifetime elevated, expansive or irritable mood may predict improved outcomes in early psychoses, possibly mediated by lower levels of negative symptoms.     

Contextualized behavioral support in early intervention for children with autism and their families

Parent education programs have become an effective mode of treatment delivery for teaching families effective behavioral strategies to manage challenging behavior in young children with autism. Functional assessment and functional communication training (FCT) are empirically validated procedures that have recently been introduced into parent education programming to help resolve challenging behaviors. The success of these procedures, however, is contingent on family members' ability to integrate them into the specific contexts in which challenging behaviors occur. Consequently, the application of these procedures in home settings necessitates consideration of the family context in the assessment and treatment planning process. A study is presented that investigated the use of information on family context (i.e., caregiving demands, family support, patterns of social interaction) to direct the assessment and intervention planning process. More specifically, information on family context was used to individualize behavioral support plans designed to support family use of functional communication training within important family routines. Through parent-investigator collaboration we individualized the manner in which functional communication training procedures were taught and implemented so they were contextually relevant. Utilizing a multiple baseline design, the challenging behaviors and functional communication of three children with autism were monitored across baseline, intervention (i.e., FCT, and contextulized FCT), and follow-up phases. Multiple routines for each participant were selected and monitored across all phases to evaluate changes in the dependent measures within training and generalization routines. A self-report questionnaire was administered intermittently to parents to determine if consideration of family context improved the goodness of fit of the functional communication training treatment packages across FCT and contextualized FCT intervention phases. Results from the study indicate that consideration of family context in the assessment and intervention planning process does not jeopardize and may contribute to the stability and durability of reductions in challenging behavior achieved with functional assessment and functional communication training procedures.     

Psychological needs of adolescents in the early phase of bipolar disorder: implications for early intervention

Aim: This paper will describe the rationale for, and importance of, psychological interventions for young people early in the course of bipolar disorder. Methods: Emerging literature in this field will be discussed in addition to describing specific clinical challenges and opportunities with this population. Results: In order to be more developmentally appropriate for young people with bipolar disorder, eight aspects of clinical work which may require modification were identified. Conclusions: The evidence base for the effectiveness of psychological interventions for people diagnosed with bipolar disorder is growing. However, some aspects relating to working with adults with bipolar disorder require modification to be effective in working with young people early in the course of the disorder.