Economic contribution of families caring for persons with severe and persistent mental illness

The author suggests that family expenditures are a significant factor in the overall system of care and should be included in economic analyses of mental health services. Data indicate that family contribution should be viewed as a resource and may be serving as a substitute for resources from the formal mental health system. Suggestions for policy are presented that support the concept of shared responsibility between the family and the formal system.     

Underinsurance for severe mental illness

Mental health care for the severely mentally ill in the United States is financed by a combination of public and private funds. Both public and private health insurance programs handle mental illness differently than they do other illnesses. This article documents uninsurance and underinsurance for severe mental illness in the United States based on studies conducted during the last decade. The relationship between private insurance and public assistance is analyzed, and major arguments around equality in insurance coverage for severe mental illness are examined. Alternatives for reducing uninsurance and underinsurance for severe mental illness in order to avoid undertreatment are discussed.     

Skills training for people with severe mental illness

There is a growing empirical literature on psychosocial rehabilitation strategies for schizophrenia and other severe mental illnesses. Three of the best-supported and most promising approaches were reviewed: social skills training (SST), cognitive behavior therapy (CBT), and cognitive remediation (CR). Of the three, SST has the strongest empirical support and can be considered an evidence-based treatment. However, it is appropriate as a targeted treatment for social impairment, not as a broad based treatment for schizophrenia. CBT has only recently been applied to patients with psychotic disorders and the preliminary results are promising for reducing distress associated with residual psychotic symptoms. All but a handful of trials have been carried out in the context of the public health system in the UK with specially selected patients. Consequently, it is not yet clear if it would be effective in public health systems in the US, with highly impaired patients, or for patients with comorbid substance abuse. There is an extensive literature documenting that a variety of training techniques can improve performance on neuropsychological tests, and there is a growing literature of more clinically relevant CR trials that have produced small to medium effect sizes. No studies have yet demonstrated a clinically significant effect on community functioning. This is a promising area for further research, but CR, like CBT, does not have a sufficient evidentiary base for widespread dissemination to the public mental health system at this time.     

Recovery centers for people with severe mental illness: a survey of programs

Recovery centers are physical entities offering various services and resources for people living with severe mental illness. In this study we identified and surveyed 24 recovery centers recruited through snowball sampling. The goal was to understand the range, common features and nature of current incarnations of recovery centers, assessing commonalities and differences with regards to: (1) overarching philosophies; (2) organizational and operational factors; (3) clientele; (4) service offerings; (5) staffing and financing; and (6) governance and oversight. We discuss some of the advantages and disadvantages of recovery centers, especially important given wider policy commitment to recovery, detailing the importance of future research and evaluation.     

Hormone modulation: a novel therapeutic approach for women with severe mental illness

OBJECTIVES: Accumulating evidence describes the effects of oestrogen and other gonadal hormones on the central nervous system and, in particular, on the mental state of women. Evidence supporting the psychotherapeutic effects of exogenous oestrogen has started to emerge only over the past two decades. The purpose of the present paper was to provide an overview of different applications of adjunctive hormones, as treatments for symptoms of severe mental illness in women. METHODS: Three case reports are presented: in each case the woman selected had participated in large, double-blind, randomized controlled trials exploring hormone modulation. Case study 1 presents a premenopausal woman with schizophrenia, who received an 8 week trial of daily adjunctive 200 microg transdermal oestradiol. Case study 2 presents a postmenopausal woman with schizophrenia on a 12 week trial of adjunctive raloxifene hydrochloride 120 mg per day. Case study 3 presents a woman with schizoaffective disorder, in the manic phase, who received tamoxifen 40 mg per day for 28 days. RESULTS: Adjunctive oestradiol was associated with an improvement in symptoms of psychosis in a premenopausal woman with schizophrenia; adjunctive raloxifene was associated with an improvement in cognitive functioning in a postmenopausal woman with schizophrenia; and adjunctive tamoxifen was associated with an improvement in symptoms of mania in a woman with schizoaffective disorder. CONCLUSIONS: These findings are consistent with preliminary research trials suggesting that adjunctive hormone modulation is a promising area of gender-specific treatment for serious mental illness.     

Implementing evidence-based practices for people with severe mental illness

Persons with severe mental illnesses (SMI) often lack access to effective treatments. The authors describe the Implementing Evidence-Based Practices (EBPs) Project, designed to increase access for people with SMI to empirically supported interventions. The EBP Project aims to improve access through development of standardized implementation packages, created in collaboration with different stakeholders, including clinicians, consumers, family members, clinical supervisors, program leaders, and mental health authorities. The background and philosophy of the EBP Project are described, including the six EBPs identified for initial package development: collaborative psychopharmacology, assertive community treatment, family psychoeducation, supported employment, illness management and recovery skills, and integrated dual disorders treatment. The components of the implementation packages are described as well as the planned phases of the project. Improving access to EBPs for consumers with SMI may enhance outcomes in a cost-effective manner, helping them pursue their personal recovery goals with the support of professionals, family, and friends.     

Case management for individuals with a severe mental illness: a 6-year follow-up study

BACKGROUND: As a part of a set of reforms launched in 1995, 10 pilot case management services were established in Sweden, which have been subject to an evaluation with regard to outcome and changes in use of services. The present study was designed to provide information about client outcomes over a 6-year follow-up period. AIMS: The aim of the study was to investigate changes during the follow-up period with regard to symptoms, needs for care, psychosocial functioning, quality of life and social network. METHODS: The study used a time series design with 6-year follow-up of client outcomes. RESULTS: Of the original 176 clients, 92 clients participated in the 6-year follow-up. Improvements were found in a number of clinical aspects, quality of life and social network, and a decrease in use of psychiatric services during the follow-up period. CONCLUSIONS: The findings support results from earlier studies showing a decrease in use of psychiatric services and sustained improvements in social functioning. The study also supports the findings that client outcomes change over time and that certain outcomes do not appear in a short-term perspective.     

Desire for information of people with severe mental illness

Purpose

To assess (1) the desire of people with severe mental illness for information on their treatment and (2) whether the desire for information is associated with socio-demographic variables, diagnosis, illness duration, therapeutic relationship, needs and symptom severity.

Methods

588 outpatients with severe mental illness were recruited in six European countries (Germany, Denmark, Hungary, Italy, Switzerland, United Kingdom) during the “Clinical decision making and outcome in routine care of people with severe mental illness (CEDAR)” study (ISRCTN75841675). Desire for information was assessed by the Information subscale of the Clinical Decision Making Style Scale. Study participants with high desire for information were compared with those with moderate or low desire for information.

Results

80 % of study participants (n = 462) wanted to receive information on all aspects of their treatment (management, prognosis, alternative options for care). Participants with a high desire for information had less severe symptoms (OR = 0.988, CI = 0.977–1.000) and a better self-rated therapeutic alliance (OR = 1.304, CI = 1.130–1.508) with their clinician.

Conclusions

Most, but not all, people with severe mental illness have a high desire for information. Desire for information is associated with variables, such as therapeutic relationship and symptom severity, which are amenable to change during treatment.     

Experience with post-secondary education for individuals with severe mental illness

There is a need for increased understanding and support of students with severe and persistent psychiatric disabilities in post-secondary education. Advancements in the pharmacological treatment of psychiatric disabilities are permitting a broader range of mental health consumers to reach a level of recovery allowing these consumers to begin or restart college careers (Eudaly, 2002). A post-secondary education is now considered a mandatory investment in the future ("Higher Education," 2003). There are a growing number of people pursuing higher education including those with serious mental illness. I am working on a Master's degree in a Rehabilitation Counselor Education program and face many obstacles due to my psychiatric disability, Bipolar Disorder.     

Needs of people with severe mental illness

OBJECTIVE: This study reviews conceptual and methodological issues of needs for care among people with severe mental illness (SMI) and presents data on their prevalence, correlates and consequences for mental health care. METHOD: Focus is on the definition of the concept of need as what people can benefit from and its measurement by means of two instruments, the Needs for Care Assessment (NCA) and the Camberwell Assessment of Needs (CAN). RESULTS: The prevalence of needs among patients with SMI varies between 4 and 10, which appears to be rather unrelated to gender, age or education, but not to severity of symptoms, diagnosis or treatment setting. Important is the perspective of the beholder: patient and professional differ significantly from each other in the assessment of number of needs and their adequate fulfillment. One of two to four needs are unmet, in particular in the area of psychological distress, daily activities, social contacts and psychotic symptoms. Prevalence of unmet needs seems to be related to the system of mental health care and to socioeconomic circumstances as well: the less integrated and continuous care and the poorer the life situation, the more unmet needs. CONCLUSION: Unmet needs are a strong predictor of less favourable health perceptions and a lower quality of life. Needs are to a certain extent changeable, and thus amenable by treatment or mental health interventions. The prevalence of (un)met needs should be an outcome criterion for the evaluation of mental health service systems and for cross-cultural comparison.     

Persons with severe mental illness in jails and prisons: a review

One of the greatest problems of deinstitutionalization has been the very large number of persons with severe mental illness who have entered the criminal justice system instead of the mental health system.     

Living with chronic mental illness: Understanding the role of work

This paper is based upon an exploratory study designed to examine the role of work within the lives of those with severe, persistent mental illness (SPMI). Indepth, open ended interviews were conducted with a small number of consumers (n=10) who attend a clubhouse for those with SPMI where emphasis is placed upon preparation for work. Given that little is known about how work impinges upon or enriches the lives of consumers we asked consumers about their experience of mental illness and work throughout their life trajectories. This paper describes these work experiences, the effect of mental illness and treatment compliance upon their ability to work, and the relationship of work to stress. We found that in general some kind of meaningful activity was important to these consumers, but many had found work experiences to be stressful and were cautious about their subsequent abilities to sustain meaningful employment. We suggest that subsequent research needs to examine the nature of the work environment, and that work environments may be usefully distinguished in terms of level of expressed emotion.Paper presented at the Society for the Study of Scientific Problems Annual Meetings, Miami, Florida (August 10–12) 1993. The authors wish to thank Bruce Link for his helpful commentary on this earlier draft, Ellen Jane Hollingsworth for her review and support and the comments of two anonymous reviewers although we accept responsibility for the conclusions offered. We would also like to acknowledge the research assistance provided by Candice Cherrybone.Dr. Scheid is an Assistant Professor of Sociology at the University of North Carolina at Charlotte and is currently on academic leave in order to complete a NIMH postdoctoral fellowship at the University of Wisconsin, Madison (until August 1994). Cliff Anderson is Director of the Psychosocia1 Rehabilitation Program, Continuing Care Division of the Mecklenberg County Area Mental Health Program.     

Cognitive-behavioral treatment for PTSD among people with severe mental illness: a proposed treatment model

The lifetime prevalence of posttraumatic stress disorder (PTSD) is about 8%-14% in the general population, and trauma victimization (51%-98%) and PTSD (up to 42%) are even more prevalent among persons treated within public-sector mental health clinics. Despite this, individuals with PTSD and severe mental illness (SMI) who are treated within the public sector tend to receive inadequate mental health services. In addition, treatments for PTSD for this population remain undeveloped, with virtually no available empirical treatment outcome data to guide clinicians. We propose a model for a comprehensive, multicomponent cognitive-behavioral treatment program for this target population that includes elements of consumer education, anxiety management training, social skills training, exposure therapy, "homework" assignments, and long-term follow-up care. Special considerations for public-sector consumers with PTSD and SMI are addressed, as are directions for future research.     

Implementing dual diagnosis services for clients with severe mental illness

After 20 years of development and research, dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice. Effective dual diagnosis programs combine mental health and substance abuse interventions that are tailored for the complex needs of clients with comorbid disorders. The authors describe the critical components of effective programs, which include a comprehensive, long-term, staged approach to recovery; assertive outreach; motivational interventions; provision of help to clients in acquiring skills and supports to manage both illnesses and to pursue functional goals; and cultural sensitivity and competence. Many state mental health systems are implementing dual diagnosis services, but high-quality services are rare. The authors provide an overview of the numerous barriers to implementation and describe implementation strategies to overcome the barriers. Current approaches to implementing dual diagnosis programs involve organizational and financing changes at the policy level, clarity of program mission with structural changes to support dual diagnosis services, training and supervision for clinicians, and dissemination of accurate information to consumers and families to support understanding, demand, and advocacy.     

Providing continuity of care for people with severe mental illness

Abstract.Background: Service users and providers have stated that delivering continuity of care to people with severe mental illness should be a service priority. We reviewed literature on continuity of care for people with severe mental illness (SMI) in order to identify factors that promote and impede this process.Method: A systematic search of electronic databases, sources of grey literature and contact with experts in the field. Two reviewers independently rated all papers for possible inclusion. Data extracted from papers formed the basis of a narrative review.Results: We identified 435 papers on continuity of care, of which 60 addressed the study aims. Most did not define continuity of care. Available evidence suggests that assertive community treatment, case management, community mental health teams and crisis intervention reduce the likelihood of patients dropping out of contact with services.Conclusions: Evidence on which to base services that enhance continuity of care for people with SMI is limited because previous research has often failed to define continuity of care or consider the patients perspective.     

A level-of-functioning self-report measure for consumers with severe mental illness

OBJECTIVE: Most scales that measure the ability of consumers with severe mental illness to function in community settings are designed to be completed by case managers or other clinicians. The objective of this study was to develop an instrument that could be completed by consumers. METHODS: The 17-item clinician version of the Multnomah Community Ability Scale (MCAS) was adapted for use as a self-report instrument (MCAS-SR). An initial version of the MCAS-SR was reviewed for appropriateness and clarity by 20 consumers and four peer counselors and then revised. Test-retest reliability was studied with 37 consumers, and construct validity was examined in a correlational study of 288 consumers. Further validation involved correlations among consumer self-reports, case manager ratings, and ratings by research interviewers. RESULTS: The instrument was acceptable to consumers; most consumers (80 percent) could complete it without assistance. The total score test-retest intraclass correlation was.91. Internal consistency was high (Cronbach's alphas greater than.80). The total score on the MCAS-SR was correlated with that on the Brief Symptom Inventory (Spearman's rho=-.59) and with that on the Mental Component Scale of the Short Form 12 (Spearman's rho=.61). The Spearman's rho correlation between consumer and case manager total scores was.41 for urban consumers and.21 for rural consumers. The correlation between consumer total scores and research interviewer total scores was.57 in the urban sample and.31 in the rural sample. CONCLUSIONS: The MCAS-SR is a reliable self-report instrument and can be valuable as an outcome measure and in treatment planning.     

Insight in severe mental illness: implications for treatment decisions

This article reviews recent research related to impaired insight in schizophrenia and its consequences for cognitive, behavioral, legal, and treatment compliance issues affecting this population. It discusses efforts to find the neurobiological basis for lack of insight and the various structures or circuits of the brain that have been implicated. In the search for a more reliable and valid measure of insight for treatment decisions, the development of various assessment instruments is summarized. Impaired insight is shown to be related to a poorer course of the illness and noncompliance with necessary treatment. The implications of these findings for treatment decisions, legal interventions, and ongoing treatment monitoring are discussed.     

Computer-assisted self-assessment in persons with severe mental illness

BACKGROUND: It has been difficult to improve care for severe mental illness (SMI) in usual care settings because clinical information is not reliably and efficiently managed. Methods are needed for efficiently collecting this information to evaluate and improve health care quality. Audio computer-assisted self-interviewing (ACASI) can facilitate this data collection and has improved outcomes for a number of disorders, suggesting the need to test its accuracy and reliability in people with SMI. METHOD: Ninety patients with DSM-IV schizophrenia or schizoaffective disorder (N = 45) or bipolar disorder (N = 45) recruited between Oct. 15, 2002, and July 1, 2003, were randomly assigned to 1 of 2 study groups and completed 2 standardized symptom surveys (Revised Behavior and Symptom Identification Scale and the symptom severity scale of the Schizophrenia Outcomes Module 2) 20 minutes apart in a crossover study design. Half of the patients first completed the scales via an in-person interview, and the other half first completed the scales via an ACASI survey self-administered through an Internet browser using a touchscreen developed to meet the cognitive needs of people with SMI. We evaluated attitudes toward ACASI, understanding of the ACASI survey, internal consistency, correlations between the ACASI and interview modes, concurrent validity, and a possible administration mode bias. RESULTS: All ACASI and in-person interview scales had similar internal reliability, high correlations (r = 0.78-1.00), and mean scores similar enough as not to be different at p < .05. A large majority rated the ACASI survey as easier, more enjoyable, more preferable if monthly completion of a survey were required, and more private, and 97% to 99% perfectly answered questions about how to use it. CONCLUSION: ACASI data collection is reliable among people with bipolar disorder and schizophrenia and could be a valuable tool to improve their care.