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PubMed1993

Detection of substance use disorders in severely mentally ill patients.

Severe mental illness is frequently complicated by substance use disorder. Approximately half of the severely mentally ill patients treated in acute care psychiatric settings have abused one or more of these substances. Despite the high rate of comorbidity, substance use disorders are generally not detected in acute care psychiatric settings, leading to incorrect diagnoses and ineffective treatments. The reasons for nondetection are complex, and research is needed to refine instruments and procedures for the detection of substance abuse in the severely mentally ill population. Nevertheless, clinicians can make better use of existing techniques of multimodal assessment to increase significantly the rate of accurate detection.

Age Factors↗
PubMedDate not supplied

Methods for studying course of illness with severely mentally ill adults.

This study examined methods for obtaining course of illness data on adults who are severely mentally ill. A convenience sample (N = 60) was recruited within 4 programs serving different subgroups of adults with severe mental illness. Forty-three participants were able to complete follow-up interviews, using a life chart format to report on personal history in the domains of housing, employment, finances, psychiatric service utilization, health problems, use of psychotropic medication, drug and alcohol use, social relationships, and other major life events. Corresponding information was abstracted from treatment records and examined for concordance with self-reports. Results showed distinct areas of concordance, including recent (1 year) life events, psychiatric care, psychotropic medications, and use of alcohol. Areas of disagreement included legal problems, illicit drug use, and general health. With multiple data sources, it is possible to involve a range of adults with severe mental illness in research and to incorporate their knowledge into course of illness studies.

Adaptation, Psychological↗
PubMed1996

Analysis of three interventions for substance abuse treatment of severely mentally ill people.

Severely mentally ill people with co-occurring substance abuse disorders are difficult to treat and the course of their psychiatric treatment is worsened by substance abuse. Despite increased attention to the problem, few studies of specialized treatment are reported in the literature and most lack detail about the specialized interventions employed. Qualitative data, gathered as part of a larger study of the cost-effectiveness of three substance abuse interventions for severely mentally ill people, are presented which describe the interventions, their implementation in four community mental health centers over 18 months of the study, and their relationship to the quantitative outcomes. Illustrated is the difficulty of implementing innovative programs and the need for vigilance concerning program fidelity.

Activities of Daily Living↗
PubMed1997

Overview of severe mental illness.

The severe mental illnesses are psychiatric disorders characterized by their persistence and extensive disability. Classification of these disorders has seen improved reliability, but problems remain with validity. Etiological formulations emphasize the biological origins of the disorders, but psychological factors, chiefly in the area of stress, are recognized as important in the management of relapse. Psychological features, especially those apparent during psychotic episodes, make the disorders particularly difficult to treat. Patients tend to be noncompliant. In addition, these features dispose people with severe mental illnesses to behaviors that place them at risk for HIV and other catastrophic illnesses. New psychopharmacological treatments may improve compliance and reduce relapse, but none has made psychosocial treatments unnecessary. Progress in developing effective treatments has been slow, but prospects are encouraging.

Acquired Immunodeficiency Syndrome↗
PubMed2000

Treatment programmes for people with both severe mental illness and substance misuse.

BACKGROUND: Substance misuse in the context of severe mental illness can have detrimental effects. A variety of treatments exist, but the drive has been to provide programmes integrating treatment of both substance misuse and severe mental illness. Such programmes require additional resources and may require radical redesign of service delivery systems. OBJECTIVES: To evaluate the effectiveness of treatment programmes within psychiatric care for people with problems of both substance misuse and serious mental illness. SEARCH STRATEGY: Biological Abstracts (1985-1998), CINAHL (1982-1998), The Cochrane Library (Issue 3, 1998), The Cochrane Schizophrenia Group's Register of trials (August 1998), EMBASE (1980-1998), MEDLINE (1966-1998), PsycLIT (1974-1998) and Sociofile (1974-1998) were comprehensively searched. Citations of all trials were searched and further studies sought from published trials and their authors. SELECTION CRITERIA: All randomised trials of any programme of substance misuse treatment for people with serious mental illness and current problems of substance misuse. DATA COLLECTION AND ANALYSIS: Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were also independently extracted. For homogeneous dichotomous data the Peto odds ratio (OR), and 95% confidence intervals (CI) were calculated on an intention-to-treat basis. MAIN RESULTS: Six relevant studies, four of which were small, were identified. In general, the quality of design and reporting was not high. Clinically important outcomes such as relapse of severe mental illness, violence to others, patient or carer satisfaction, social functioning and employment were not reported. There is no clear evidence supporting an advantage of any type of substance misuse programme for those with serious mental illness over the value of standard care. No one programme is clearly superior to another. REVIEWER'S CONCLUSIONS: The problems posed by substance misuse in the context of severe mental illness will not go away. The current momentum for integrated programmes is not based on good evidence. Implementation of new specialist substance misuse services for those with serious mental illnesses should be within the context of simple, well designed controlled clinical trials.

Comorbidity↗
PubMed2000

Ziprasidone for schizophrenia and severe mental illness.

BACKGROUND: Typical antipsychotic drugs are widely used as the first line treatment for people with schizophrenia. However, the atypical class of antipsychotic drugs are making important inroads into this approach. Atypical is a widely used term used to describe some antipsychotics which have a low propensity to produce movement disorders, sedation and raised serum prolactin. There is some suggestion that the different adverse effect profiles of the atypical antipsychotic group make them more acceptable to people with schizophrenia. Ziprasidone is one of the newer atypicals with a high serotonin/dopamine receptor affinity. OBJECTIVES: To determine the effects of ziprasidone compared with placebo, typical and other atypical antipsychotic drugs for schizophrenia and related psychoses. SEARCH STRATEGY: Electronic searches of Biological Abstracts (1980-1999), The Cochrane Library (Issue 1, 1999), The Cochrane Schizophrenia Group's Register (January 1999), EMBASE (1980-1999), MEDLINE (1966-1999), LILACS (1982-1996), PSYNDEX (1977-1995) and PsycLIT (1974-1999) were undertaken. In addition, pharmaceutical databases on the Dialog Corporation Datastar and Dialog services were searched. References of all identified studies were searched for further trials. Pharmaceutical companies and authors of trials were contacted. SELECTION CRITERIA: All randomised controlled trials that compared ziprasidone to other treatments for schizophrenia and schizophrenia-like psychoses were included by independent assessment. DATA COLLECTION AND ANALYSIS: Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were independently extracted. Data were excluded if loss to follow up was greater than 50%. For homogeneous dichotomous data the risk ratio (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, weighted mean differences were calculated (WMD). All data were inspected for heterogeneity. MAIN RESULTS: Data for this compound range from very short (1 week) studies of the intramuscular preparation, to trials lasting over six months. For measures of mental state ziprasidone seems more effective than placebo (RR 0.8 CI 0.7-0.9) and as effective as haloperidol (RR 0.8 CI 0.7-1). It is less likely than haloperidol to cause movement disorders (RR 0.4 CI 0.2-0.6), but may cause more nausea and vomiting (RR 2.1 CI 1.2-3.8). The injected form of the drug may cause more pain at the injection site than haloperidol (RR 5.3 CI 1.3-22). REVIEWER'S CONCLUSIONS: Currently data are limited. Ziprasidone may be an effective antipsychotic with less extrapyramidal effects than haloperidol. It also may, however, cause more nausea and vomiting than the typical drugs, and, at present, there is no data suggesting that it is different to other atypical compounds. Well planned, conducted and reported long term randomised trials are needed if ziprasidone is to be accepted into everyday use.

Antipsychotic Agents↗
PubMed2000

Individual psychodynamic psychotherapy and psychoanalysis for schizophrenia and severe mental illness.

BACKGROUND: People with schizophrenia and severe mental illness may need much support from health care professionals, in most cases over a long period of time. Research on the effects of psychotherapy for schizophrenia shows mixed results. Although pharmacological interventions remain the treatment of choice for schizophrenia patients, it is also of interest to look at the effects of treatment methods focusing on psychosocial factors affecting schizophrenia. OBJECTIVES: To review the effects of individual psychodynamic psychotherapy and/or psychoanalysis for people with schizophrenia or severe mental illness. SEARCH STRATEGY: Electronic searches of Biological Abstracts (1985-1999), CINAHL (1982-1999), The Cochrane Library CENTRAL (Issue 1, 1999), The Cochrane Schizophrenia Group's Register (1999), Dissertation Abstracts On disc (1866-1999), EMBASE (1980-1999), MEDLINE (1966-1999), PsycLIT (1974-1999), and Sociofile (1974-1998) were made. Authors of included trials were contacted for information on further trials. SELECTION CRITERIA: All randomised trials of individual psychodynamic psychotherapy or psychoanalysis for people with schizophrenia or severe mental illness (however defined) were selected. DATA COLLECTION AND ANALYSIS: Data were independently extracted by at least two reviewers. For dichotomous data relative risks (RR) were calculated and for continuous data weighted mean differences (WMD) between groups were calculated. MAIN RESULTS: No trials of a psychoanalytic approach were identified. Data are sparse for all comparisons involving a psychodynamic approach. There is no evidence of any positive effect of psychodynamic therapy and the possibility of adverse effects seems never to have been considered. The psychodynamic approach may be more acceptable to people than a more cognitive reality-adaptive therapy. REVIEWER'S CONCLUSIONS: Current data do not support the use of psychodynamic psychotherapy techniques for hospitalised people with schizophrenia. If psychoanalytic therapy is being used for people with schizophrenia there is an urgent need for trials.

Humans↗
PubMed2002

Managing physical illness in people with severe mental illness.

People with severe mental illness have poor physical health, and increased morbidity and mortality compared to the general population. Community-based mental health care has led to hospital doctors being more involved in the physical care of psychiatric patients. This paper focuses on key issues in the medical management of psychiatric patients in a general hospital setting.

Acute Disease↗
PubMed2002

Electroconvulsive therapy and newer modalities for the treatment of medication-refractory mental illness.

Severe mental illnesses often remain chronic and refractory to medication, leading to substantial morbidity and mortality. For more than 60 years, electroconvulsive therapy has been the only nonpharmacological psychiatric procedure available to treat severe or medication-refractory major depressive disorder and other psychiatric conditions. Memory dysfunction remains the most serious adverse effect, and current research focuses on attempts to ameliorate this complication. Transcranial magnetic stimulation and vagus nerve stimulation, 2 new neuropsychiatric technologies, are emerging as possible additions to our therapeutic armamentarium. Besides providing therapeutic benefits, these 3 methods may help elucidate the pathophysiology of psychiatric illness.

Drug Resistance↗
PubMed2003

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.

Employment, Supported↗
PubMed1997

A survey on issues in the lives of women with severe mental illness.

OBJECTIVE: Women with severe mental illness were surveyed to explore issues in living with mental illness, personal relationships, and professional relationships and health care. The topics were drawn from the literature on the psychology of women and from separate focus groups of therapists and mental health care consumers. The women's survey responses were compared with men's responses to an equivalent survey to determine if the issues affected women and men similarly. METHODS: A 76-item questionnaire was completed by 107 women and 59 men from ten rehabilitation centers in Maryland. RESULTS: A larger proportion of women than men cited personal relationships as their most important formative experiences, with only 32 percent of women citing severe mental illness or related issues as formative experiences. Despite acknowledging the negative impact of several mental illness on their lives, most respondents reported normal concerns rather than illness-related ones, and most were relatively satisfied with their lives. Respondents made sense of their problems in diverse ways, although most knew their diagnosis. Women reported both more and better quality personal relationships than men. However, women were more likely than men to report a history of sexual abuse. Women reported generally good relationships with providers. About one-quarter to one-third of women reported not receiving proper care for birth control and menopause and not receiving pelvic or breast examinations. CONCLUSIONS: The survey results suggested that personal relationships are central in women's lives, that women with severe mental illness do not see their mental illness as the main feature of their identities, and that women's experience of living with severe mental illness is considerably different from that of men.

Adaptation, Psychological↗
PubMed2000

Identifying clinical competencies that support rehabilitation and empowerment in individuals with severe mental illness.

Individuals with severe mental illness often do not receive appropriate treatment or rehabilitation. One approach to improving their care begins by identifying competencies that clinicians should possess. This project developed a set of core clinical competencies that pertain to community-based care and support the goals of empowerment and rehabilitation. Development of the competency set began with review of existing literature and competency statements, and focus groups and interviews with clients, family members, clinicians, managers, experts, and advocates. Representatives from each of these groups participated in a national panel and used a structured process to identify 37 final competencies. Panel members agreed that these competencies are very important in determining outcomes and often are not present in current clinicians. This project demonstrates that it is possible to develop a core competency set that can be strongly supported by diverse groups of stakeholders. These competencies may be useful in clinician training, recruitment, and credentialing efforts.

Clinical Competence↗
PubMed2006

Psychiatric and psychosocial correlates of sexual risk behavior among adults with severe mental illness.

Persons with severe mental illness (SMI) are disproportionately affected by HIV/AIDS. This study examined multivariate correlates of sexual risk among 152 adults with SMI receiving outpatient psychiatric treatment. Structured interviews assessed psychiatric, psychosocial, and behavioral risk factors. The majority was sexually active (65%), and many reported unprotected intercourse (73%), multiple partners (45%), and sex trading (21%) in the past year. Logistic regression models found that sexual behaviors were differentially associated with non-psychotic disorder, psychiatric symptoms, substance abuse, childhood sexual abuse, romantic partnership, and social support (all ps < .05). Findings underscore the need for targeted HIV prevention interventions that address psychiatric and psychosocial risk factors.

Acquired Immunodeficiency Syndrome↗
PubMed2004

Forensic assertive community treatment: preventing incarceration of adults with severe mental illness.

OBJECTIVE: Persons with severe mental illness are overrepresented in jails and prisons in the United States. A national survey was conducted to identify assertive community treatment programs that have been modified to prevent arrest and incarceration of adults with severe mental illness who have been involved with the criminal justice system. METHODS: Members of the National Association of County Behavioral Health Directors (NACBHD) were surveyed to identify assertive community treatment programs serving persons with criminal justice histories and working closely with criminal justice agencies. Programs were identified that met three study criteria: all enrollees had a history of involvement with the criminal justice system, a criminal justice agency was the primary referral source, and a close partnership existed with a criminal justice agency to perform jail diversion. Senior representatives of each program were subsequently contacted, and a telephone survey was administered to gather information about the design and operation of the programs. RESULTS: A total of 291 of 314 NACBHD members (93 percent) responded to the survey. Sixteen programs that met the study criteria were identified in nine states. The primary referral sources for 13 of these programs (81 percent) were local jails. Eleven programs (69 percent) incorporated probation officers as members of their assertive community treatment teams. Eight programs (50 percent) had a supervised residential component, with five providing residentially based addiction treatment. Eleven of the 16 programs have begun operating since 1999. Only three programs have published outcome data on program effectiveness. CONCLUSIONS: Forensic assertive community treatment is an emerging model for preventing arrest and incarceration of adults with severe mental illness who have substantial histories of involvement with the criminal justice system. Further research is needed to establish the structure, function, and effectiveness of this developing model of service delivery.

Adult↗
PubMed1995

The Camberwell Assessment of Need: the validity and reliability of an instrument to assess the needs of people with severe mental illness.

BACKGROUND: People with severe mental illness often have a complex mixture of clinical and social needs. The Camberwell Assessment of Need (CAN) is a new instrument which has been designed to provide a comprehensive assessment of these needs. There are two versions of the instrument: the clinical version has been designed to be used by staff to plan patients' care; whereas the research version is primarily a mental health service evaluation tool. The CAN has been designed to assist local authorities to fulfil their statutory obligations under the National Health Service and Community Care Act 1990 to assess needs for community services. METHOD: A draft version of the instrument was designed by the authors. Modifications were made following comments from mental health experts and a patient survey. Patients (n = 49) and staff (n = 60) were then interviewed, using the amended version, to assess the inter-rater and test-retest reliability of the instrument. RESULTS: The mean number of needs identified per patient ranged from 7.55 to 8.64. Correlations of the inter-rater and test-retest reliability of the total number of needs identified by staff were 0.99 and 0.78 respectively. The percentage of complete agreement on individual items ranged from 100-81.6% (inter-rater) and 100-58.1% (test-retest). CONCLUSIONS: The study suggests that the CAN is a valid and reliable instrument for assessing the needs of people with severe mental illness. It is easily learnt by staff from a range of professional backgrounds, and a complete assessment took, on average, around 25 minutes.

Adult↗
PubMed2003

Families living with severe mental illness: a literature review.

Schizophrenia is a severe mental illness, which is stressful not only for patients, but also for family members. Numerous studies have demonstrated that family caregivers of persons with a severe mental illness suffer from significant stresses, experience moderately high levels of burden, and often receive inadequate assistance from mental health professionals. Effective family functioning in families with schizophrenia may be influenced by a variety of psychosocial factors. The purpose of this article was to present a review of the social science literature related to families living with schizophrenia that has been published during the last three decades. There is general agreement in the literature that a multitude of variables affect families with a severe mental illness, such as schizophrenia. Therefore, this literature review examined the most frequently investigated variables (coping, psychological distress and caregiver burden, social support, caregiver resiliency and depression, and client behavioral problems) as they are related to families and schizophrenia.

Adaptation, Psychological↗
PubMed2001

Economic impacts of supported employment for persons with severe mental illness.

BACKGROUND: Most persons with severe mental illness prefer competitive to sheltered vocational settings. Supported employment (SE) has become a clearly defined model for helping people with severe mental illness to find and maintain competitive jobs. It involves individualized and rapid placement, ongoing support and assessment, and integration of vocational and mental health staff within a single clinical team. Previous studies show that SE secures competitive employment much more effectively than do other approaches. This review focuses on its economic impacts. METHODS: Studies reporting some service use or monetary outcomes of adding SE programs were identified. These outcomes were tabulated and are discussed in narrative form. RESULTS: Five nonrandomized and 3 randomized studies compare SE programs with day treatment or transitional employment programs. The introduction of SE services can result in anything from an increase to a decrease in vocational service costs, depending on the extent to which they substitute for previous vocational or day treatment services. Overall service costs tend to be lower, but differences are not significant. Earnings increase only slightly on average. CONCLUSIONS: Converting day treatment or other less effective vocational programs into SE programs can be cost-saving or cost-neutral from the hospital, community centre, and government points of view. Investments of new money into SE programs are unlikely to be materially offset by reductions in other health care costs, by reductions in government benefit payments, or by increased tax revenues. Such investments must be motivated by the value of increasing the community integration of persons with severe mental illness.

Canada↗
PubMed2006

Performance of subjects with and without severe mental illness on a clinical test of problem solving.

Severe mental illness is associated with impairments in executive functions, such as conceptual reasoning, planning, and strategic thinking all of which impact problem solving. The present study examined the utility of a novel assessment tool for problem solving, the Rapid Assessment of Problem Solving Test (RAPS) in persons with severe mental illness. Subjects were 47 outpatients with severe mental illness and an equal number healthy controls matched for age and gender. Results confirmed all hypotheses with respect to how subjects with severe mental illness would perform on the RAPS. Specifically, the severely mentally ill subjects (1) solved fewer problems on the RAPS, (2) when they did solve problems on the test, they did so far less efficiently than their healthy counterparts, and (3) the two groups differed markedly in the types of questions asked on the RAPS. The healthy control subjects tended to take a systematic, organized, but not always optimal approach to solving problems on the RAPS. The subjects with severe mental illness used some of the problem solving strategies of the healthy controls, but their performance was less consistent and tended to deteriorate when the complexity of the problem solving task increased. This was reflected by a high degree of guessing in lieu of asking constraint questions, particularly if a category-limited question was insufficient to continue the problem solving effort.

Adult↗