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Effectiveness of Psychosocial Interventions for Persons with Severe Mental Illness

Effectiveness of Psychosocial Interventions for Persons with Severe Mental Illness

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Effectiveness of Psychosocial Interventions for Persons with Severe Mental Illness

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  1. Effectiveness of Psychosocial Interventions for Persons with Severe Mental Illness Lars Hansson Center for Evidence Based Psychosocial interventions Department of Health Sciences, Lund university, Sweden

  2. Life situation Homelessness Unemployment Criminality Drug abuse Services Lack of continuity Not adapted to needs Fragmentized Low accessibility Transition from hospital-based to community- based psychiatric services not always succesful for people with severe mental illness

  3. Need to develop psychosocial interventions to support people living in the community • Housing • Work • Meaningful daily occupation (if not working) • Social skills/social relations • Family situation • Management of illness (knowledge, coping) • Psychological treatment • Co-ordination/Integration of services (Case Management)

  4. Reviews of effectiveness of psychosocial interventions • A number of systematic reviews summarizing evidence of effectiveness from randomized controlled studies has been performed • Cochrane Collaboration • US research groups: the PORT-study • UK research groups: Burns et al • A recent Swedish systematic review of systematic reviews

  5. Evidence of effectiveness of psychosocial interventions (schizophrenia) Strong evidence • Work rehabilitation: Supported employment • Family interventions • Psychoeducation • Case Management: Assertive community treatment Good evidence • Social skills training • Psychological treatment: Cognitive Behavioural Therapy Almost no evidence • Housing interventions • Daily occupation programs

  6. Three models of work rehabilitation • Pre-vocational training ”train then place” • Supported employment ”place then train” • Fountain house movement ”social clubs”

  7. Strong evidence I Work rehabilitation • Supported employment is more effective than pre-vocational training models in • Finding and keeping competitive work • No differences in other clinical or social outcome • Pre-vocational training is not more effective than treatment as usual in finding and keeping competitive work • No clear indications of the effectiveness of the club house model

  8. Supported employment • “Place then train” in competitive work situation • Avoidance of pre-vocational training • Minimal screening for employability “wish to work” • Individualized placement and support • Team-based time-unlimited support • Consideration of client preferences • Integration with support from the mental health care system

  9. Strong evidence II Family intervention • Several family intervention models are effective in reducing relapse and inpatient treatment, and in improving compliance with treatment • Common features of these programs • Intervention > 9 months • Creating a positive alliance with relatives • Crisis intervention • Problem solving • Knowledge about illness and treatment • Reducing negative aspects of emotional climate in the family (hostility, criticism and overinvolvement)

  10. Strong evidence III Psychoeducational programs • Programs for patient education include • Knowledge about the illness • How to manage illness and relapses • Knowledge about treatment alternatives • A safe environment to discuss illness and life situation • And… • Reduce relapse rates • Improve psychosocial functioning and • Improve knowledge about illness and treatment alternatives

  11. Case management – a number of models • Broker model (co-ordination of services) • Strengths model (user oriented) • Rehabilitation model • Clinical case management (includes treatment) • Assertive community treatment (intensive team-based model

  12. Strong evidence IV Case management • Intensive case management: Assertive Community Treatment • reduces inpatient treatment • stabilizes housing situation, reduces homelessness • more people in work • keeps clients in contact with services • Less intensive case management • improves compliance with treatment but • increases admissions to inpatient care and days in hospital

  13. Assertive Community Treatment“high consumers of care” • Multidisciplinary assertive outreach teams • Each team member responsible for 10 clients • Time-unlimited support • In vivo training and support • Most treatment and rehabilitation work performed by the team • 24 hour crisis support

  14. Good evidence I Psychotherapy • Cognitive behavioral therapy in addition to other rehabilitation efforts is effective in • Reducing positive and negative symptoms • Improving compliance with medication • Improving psychosocial functioning • But does not reduce relapse or rehospitalization • Psychodynamic therapy is not effective

  15. Good evidence II: Social skills training Independent living skills program (Liberman) Effective regarding: • Acquisition and utilization of social skills • Improvements in social functioning • Reductions in relapse rates and hospitalization Contradictory evidence whether social skills training is effective in: • Improving social skills in real life situations and not just in training situations. More high quality (RCT) studies are needed

  16. Independent living skills program Group treatment with role play with several modules: • Medication management • Symptom management – early detection of relapse • Substance abuse management • Recreation for leisure • Basic conversation skills • Interpersonal problem solving • Friendship and intimacy

  17. Lack of evidence • There is no evidence concerning the effectiveness of supported housing models • Lack of randomized controlled studies • And no evidence concerning the effectiveness of social daily occupation interventions • Lack of randomized controlled studies • An urgent need for effectiveness studies

  18. Conclusions • This review identified six types of psychosocial interventions with strong or good evidence of effectiveness • In several important areas further research is of high priority • E.g. supported housing and day-care activities

  19. Are effective interventions implemented in routine care? • Psychological treatment 45% • Family interventions 10% • Work rehabilitation 23% • Case management (ACT) 10% Lehman et al, PORT- study US 2003

  20. Patterns of treatment for patients with schizophrenia in routine psychiatric care • Psychoeducation 43 % • CBT 28 % • Case management 38 % • Work rehabilitation 0 % • Social skills training 14 % West et al, Psychiatric Services, 2005

  21. Top ten implementation mistakes • We assume that evidence matters in the decision-making of potential users • We substitute our perceptions for those of potential users • We use intervention creators as intervention communicators • We introduce interventions before they are ready • We assume that information will influence decision-making • We confuse authority with influence • We allow the first to adopt (innovators) to self-select into our dissemination efforts • We fail to distinguish among change agents, authority figures, opinion leaders, and innovation champions • We select demonstration sites on criteria of motivation and capacity • We advocate single interventions as the solution to a problem Dearing 2007

  22. Elements of implementation • Identify current and best care gaps and the need for change • Identify barriers to providing optimal care • Review evidence on implementation interventions • Tailor or develop intervention to improve performance • Implement intervention • Evaluate the process of implementation • Evaluate outcomes of the intervention Bhattacharyya 2007