Ellie Newman

Longitudinal comparative evaluation of the equivalence of an integrated peer-support and clinical staffing model for residential mental health rehabilitation: a mixed methods protocol incorporating multiple stakeholder perspectives.

BackgroundA novel staffing model integrating peer support workers and clinical staff within a unified team is being trialled at community based residential rehabilitation units in Australia. A mixed-methods protocol for the longitudinal evaluation of the outcomes, expectations and experiences of care by consumers and staff under this staffing model in two units will be compared to one unit operating a traditional clinical staffing. The study is unique with regards to the context, the longitudinal approach and consideration of multiple stakeholder perspectives.Methods/designThe longitudinal mixed methods design integrates a quantitative evaluation of the outcomes of care for consumers at three residential rehabilitation units with an applied qualitative research methodology. The quantitative component utilizes a prospective cohort design to explore whether equivalent outcomes are achieved through engagement at residential rehabilitation units operating integrated and clinical staffing models. Comparative data will be available from the time of admission, discharge and 12-month period post-discharge from the units. Additionally, retrospective data for the 12-month period prior to admission will be utilized to consider changes in functioning pre and post engagement with residential rehabilitation care. The primary outcome will be change in psychosocial functioning, assessed using the total score on the Health of the Nation Outcome Scales (HoNOS). Planned secondary outcomes will include changes in symptomatology, disability, recovery orientation, carer quality of life, emergency department presentations, psychiatric inpatient bed days, and psychological distress and wellbeing. Planned analyses will include: cohort description; hierarchical linear regression modelling of the predictors of change in HoNOS following CCU care; and descriptive comparisons of the costs associated with the two staffing models. The qualitative component utilizes a pragmatic approach to grounded theory, with collection of data from consumers and staff at multiple time points exploring their expectations, experiences and reflections on the care provided by these services.DiscussionIt is expected that the new knowledge gained through this study will guide the adaptation of these and similar services. For example, if differential outcomes are achieved for consumers under the integrated and clinical staffing models this may inform staffing guidelines.

Implementing cognitive remediation therapy (CRT) in a mental health service: staff training

Objective: This paper describes the establishment of training in cognitive remediation for psychosis within a community mental health service. Methods: Clinical staff working in the community of a mental health service were surveyed to ascertain their interest in cognitive aspects of psychosis and skills training in cognitive remediation (CR). Based on the results of the survey a tiered training programme was established with attendance figures reported for each level of training. Fidelity assessment was conducted on the five CR programmes operating. Results: Of 106 clinical staff working in the community with people diagnosed with a psychotic illness 51 completed the survey (48% response rate). The training needs varied with all 106 staff receiving the fundamental (mandatory) training and 51 staff receiving CR facilitator training. Thirty three percent of staff trained as facilitators were delivering CR. Conclusions: Up skilling the mental health workforce to incorporate an understanding of the cognitive aspects of psychosis into care delivery can be facilitated by a tiered training structure. Fundamental training on the psychosocial aspects of psychosis can act as a platform for focussed CR skills based training. There is also a need for accessible therapy based supervision for staff wishing to develop competencies as CR therapists.

RANDOMISED CONTROLLED TRIAL OF SOCIAL COGNITION INTERACTION TRAINING

Abstract Background Enthusiasm for the importance of social cognition in schizophrenia has grown as research has revealed that it is more strongly related to functional outcomes than neurocognition. A promising therapy developed by Roberts and Penn is Social Cognitive Intervention Training (SCIT). This therapy is comprised of three phases (i.e., Introduction & Emotions, Figuring out Situations, Checking it out) administered in a group format. Objective To evaluate the efficacy of Social Cognition and Interaction Training (SCIT) in improving social cognitive and social functioning deficits of patients with schizophrenia spectrum disorder compared with standard of care, Befriending Therapy (BT). Methods A 10-week, single-blind, randomized controlled trial (RCT) of SCIT and BT was carried out in 120 patients with schizophrenia spectrum disorder. Primary outcome measure is the total score on the Bell Lysaker Emotion Recognition Task (BLERT) at 12 weeks. Mixed Model for Repeated Measures was used to analyse change in BLERT score from baseline to 3-month follow-up between SCIT and BT groups. Secondary measures of the study are improvements on the Social Functioning Scale, [1] [1] [1] Hinting Task, Social Skills Performance Assessment, Internal, Personal and Situational Attributions Questionnaire, and Meta Cognition Questionnaire. Results Among 120 patients, the mean age (SD) was 36.8 years (10.4) and 71.7% were males. Of these, 59 were randomized to the BT group and 61 to the SCIT group. The mean age of participants was 36.8 years. 85.8% were receiving government benefit and 50% lived in supported housing. 71.7% were males. Pre/Post data will be presented on the 91 participants who completed the study. Results examining the primary outcome measure found there was insufficient evidence to conclude that the SCIT group was significantly different compared to BT group in terms of emotion recognition (BLERT scores) (SCIT vs BT change: 0.437, 95% CI: -0.14 to 1.01; P = 0.136). There was an overall effect of time where both treatments showed a steady improvement over time from baseline to endpoint and the effect was maintained at the three-month follow-up. There was no significant time x treatment group interaction which indicated that there was no difference in patterns of change in the treatment group over time. Data on secondary outcomes is currently being analysed. Discussion In this medium sized RCT of social cognition interaction therapy that used an active control, (BT) and standardised measure of emotional recognition, (BLERT) we found no significant difference between the interventions in our primary outcome measure of emotional recognition. Improvement in emotional perception has been found in the majority of studies of social cognitive interventions for schizophrenia. More specifically our results differ to those of Hasson-Ohayon who found significant improvement in emotion recognition in a RCT of SCIT with social mentoring compared with social mentoring alone in people diagnosed with schizophrenia, schizoaffective disorder, depression or bipolar disorder (Hasson-Ohayon 2014). This study is the largest RCT of SCIT to find a negative result in regards to emotion perception.

Implementing cognitive remediation and social cognitive interaction training into standard psychosis care

BackgroundTo evaluate the planned implementation of group based Cognitive Remediation therapy (CR) and Social Cognitive Interaction Training (SCIT) into routine psychosis care in a mental health service in Australia.MethodThe study was conducted over 3 years in a mental health service in a metropolitan city in Australia. Participants were 22 program facilitators and 128 patients attending the programs. Implementation outcomes were assessed using administrative data, staff surveys and program audits.ResultsThere was fidelity to the particular therapies at a program level. Programs were assessed as being feasible within the study setting with each hospital district developing a capacity to run CR and SCIT. The establishment of new programs improved the reach, but waiting lists indicate a need to expand capacity. There was a relatively high dropout and several factors impacted on completion of the programs - notably, acute exacerbation of psychosis. Once initiated the therapies were acceptable with no-one ceasing SCIT due to loss of interest and only 10% of participants ceasing CR due to loss of interest. Annual audits of programs found programs established were maintained and facilitators were retained.ConclusionSCIT and CR programs were successfully implemented in three hospital districts. Several factors impeded participants receiving the recommended “dose” of the programs. The maintenance of the programs in the short term is encouraging in regards to organisational fit. Dissemination of cognitive rehabilitation programs to a service population takes planning. An implementation plan is essential for guiding development and maintenance of programs. These therapies are best suited to people in a stable phase of illness. Service user co-production is recommended to improve recruitment in future studies.