Gursharan Virdee

Mental health reform at a systems level: widening the lens on recovery-oriented care.

This paper is an initial attempt to collate the literature on psychiatric inpatient recovery-based care and, more broadly, to situate the inpatient care sector within a mental health reform dialogue that, to date, has focused almost exclusively on outpatient and community practices. We make the argument that until an evidence base is developed for recovery-oriented practices on hospital wards, the effort to advance recovery-oriented systems will stagnate. Our scoping review was conducted in line with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (commonly referred to as PRISMA) guidelines. Among the 27 papers selected for review, most were descriptive or uncontrolled outcome studies. Studies addressing strategies for improving care quality provide some modest evidence for reflective dialogue with former inpatient clients, role play and mentorship, and pairing general training in recovery oriented care with training in specific interventions, such as Illness Management and Recovery. Relative to some other fields of medicine, evidence surrounding the question of recovery-oriented care on psychiatric wards and how it may be implemented is underdeveloped. Attention to mental health reform in hospitals is critical to the emergence of recovery-oriented systems of care and the realization of the mandate set forward in the Mental Health Strategy for Canada.

Cognitive remediation for individuals with psychosis in a supported education setting: A randomized controlled trial

Cognitive remediation (CR) has demonstrated good outcomes when paired with supported employment, however little is known about its effectiveness when integrated into a supported education program. This randomized controlled trial examined the effectiveness of integrating CR within a supported education program compared with supported education without CR. Thirty-seven students with psychosis were recruited into the study in the 2012 academic year. Academic functioning, cognition, self-esteem, and symptomatology were assessed at baseline, at 4months following the first academic term in which CR was provided, and at 8months assessing maintenance of gains. The treatment group demonstrated better retention in the academic program and a trend of improvement across a range of academic functional domains. While both treatment and control groups showed improvement in cognitive measures, the outcomes were not augmented by CR training. CR was also associated with significant and sustained improvements in self esteem. Further research, investigating specific intervention components is required to clarify the mixed findings regarding the effectiveness of CR in an education setting.

Locating community among people with schizophrenia living in a diverse urban environment

ABSTRACT Increasing the community participation of people with severe mental illness is a primary goal of recovery-oriented services. Despite this emphasis, the construct of community remains understudied and poorly articulated. This study provides an in-depth examination of the experiences, beliefs, behaviors, and spaces that constitute community participation for a highly diverse group of people with schizophrenia who are urban dwellers. An in-depth, longitudinal qualitative design was employed with 30 individuals with schizophrenia residing in inner-city neighborhoods in Canada’s largest city. For these individuals, community participation is a dynamic process, shaped by illness and non-illness-associated social relationships and spaces, self-concept, and the resources accessible to the person. The complexity of factors that are associated with “community” for people with schizophrenia, with overlays of culture, poverty, victimization, and discrimination, calls for a critical examination of the community rhetoric employed in practice and policy contexts.

Racialized Women with Severe Mental Illness: An Arts-Based Approach to Locating Recovery in Intersections of Power, Self-Worth, and Identity

This qualitative study employed an arts-based methodology to explore the intersection of gender and ethnicity with the recovery experiences of six racialized women with severe mental illness in a large and highly diverse Canadian urban centre. The study was designed to address a gap in the recovery literature, which has minimally accounted for gender and ethnicity, and much less the intersection of the two. The arts-based approach revealed experiences centered on the three main themes of power, self-worth, and determining a coherent identity, all of which were described as being negotiated in contexts of supportive relationships and community participation. Although these themes are evident in the recovery experiences of most people with severe mental illness, the intersections of gender, ethnicity and racialized identities comprise additional layers of complexity and negotiation.

The role of gender in housing for individuals with severe mental illness: a qualitative study of the Canadian service context

Objective This study was undertaken to examine the role of gender as it relates to access to housing among individuals with severe mental illness (SMI) in Canada. Design An exploratory, qualitative approach was used to assess the perspectives of Canadian housing experts. The focus of inquiry was on the role of gender and associated intersections (eg, ethnicity) in pathways to housing access and housing needs for individuals with SMI. Setting A purposeful sampling strategy was undertaken to access respondents across all Canadian geographic regions, with diversity across settings (urban and rural) and service sectors (hospital based and community based). Participants –29 individuals (6 men and 23 women) considered to be experts in a housing service context as it pertains to SMI were recruited. On average, participants had worked for 15 years in services that specialised in the support and delivery of housing services to people with SMI. Measures Semistructured interviews with participants focused on the role gender plays in access to housing in their specific context. Barriers and facilitators were examined as were intersections with other relevant factors, such as ethnicity, poverty and parenthood. Quantitative ratings of housing accessibility as a function of gender were also collected. Results Participants across geographic contexts described a lack of shelter facilities for women, leading to a reliance on exploitative circumstances. Other findings included a compounding of discrimination for ethnic minority women, the unique resource problems faced in rural contexts, and the difficulties that attend access to shelter and housing for parents with SMI. Conclusions These findings suggest that, along with a generally poor availability of housing stock for individuals with SMI, access problems are compounded by a lack of attention to the unique needs and illness trajectories that attend gender.

Community participation within the context of recovery: multiple perspectives on South Asians with schizophrenia

ABSTRACT Community participation is a key component of recovery for people with schizophrenia however, little is known about this process for persons of South Asian origin. This study explores the community participation and recovery amongst South Asians with schizophrenia living in Toronto, Canada. Seven people of South Asian origin with a diagnosis of psychosis or schizophrenia participated in a longitudinal qualitative study, with interviews taking place at three time points over 10 months. Nineteen service providers and community members were also interviewed in an effort to capture multi-level perspectives of persons of South Asian origin. Using a grounded theory approach we identified five major themes: (i) forces of collectivist community; (ii) religious and supernatural conceptualizations of schizophrenia; (iii) cultivating identity and belonging; (iv) points of exclusion; and (v) points of inclusion. The multi-level analysis provided insight into the many systems and structures that influence the recovery process, impacting identity, self-concept, and use of social space. Provider efforts to encourage community participation and recovery for persons of South Asian origin with schizophrenia should take into account individual identity and community of origin factors. Social and identity capital theories provide a mechanism to promote the social inclusion of individuals with schizophrenia.

A pilot study of a family cognitive adaptation training guide for individuals with schizophrenia.

Objective: There is a paucity of accessible, evidence-based tools for caregivers of individuals with schizophrenia. This study examines changes in the self-assessed and caregiver-assessed outcomes of people with schizophrenia after exposure to a cognitive adaptation training (CAT) guide that addressed pragmatic, in-home approaches to offset the cognitive impacts of the illness. Method: This study examined the 4-month, pre–post outcomes of a CAT guide, as compared with a popular, general manual, for families of individuals with schizophrenia. A total of 17 caregiver-supported individual dyads completed all measures, having been randomized to either a CAT-guide group or a support-manual group. Measures included medication adherence, adaptive functioning, quality of life, and caregiver burden. Semistructured interviews assessed use and utility questions. Results: Caregiver-assessed improvements in community functioning with medium–high effect sizes were observed in both study conditions. Self-report ratings by supported individuals did not change from baseline to 4 months and no change was observed in medication adherence or quality of life for either condition. Caregiver-burden ratings significantly declined with a large effect size, again with no difference as a function of manual type. Conclusion and Implications for Practice: These findings suggest that there is some promise in providing families with evidence-based information in manual form. Further research informed by this study’s findings should include assessments of whether and how environmental cognitive supports can be of specific benefit to families affected by schizophrenia.

19.1 FROM CLINICAL TRIAL TO THE CLINIC: OPTIMIZING COGNITIVE ADAPTATION TRAINING FOR CASE MANAGEMENT TEAMS

Abstract Background Cognitive Adaptation Training (CAT) has consistently demonstrated effectiveness in enhancing community functioning in clinical trials of its 9-month application by a specialist. This is a compelling development in the field as clinicians struggle to support gains in independent functioning among patients with schizophrenia. However, outreach interventions delivered by specialists are difficult to support in many contexts where investment in mental health care is insufficient for population needs. This presentation will describe research and implementation efforts that support the delivery of CAT in routine clinical practice. Methods This program of work began with a feasibility study of a modified version of CAT. CAT was modified to decrease the duration of specialist-delivered CAT to 4 months, with the intervention subsequently supported by the individual’s case manager who received rudimentary training and could consult specialists. Twenty-three people with schizophrenia participated in this study of symptom and functional outcomes, evaluating improvements after 4 months of CAT specialist intervention and after an additional 5 months of case manager support. Also described briefly will be (i) preliminary findings from a superiority randomized controlled trial of modified CAT in an early intervention population comparing CAT (n=25) with Action Based Cognitive Remediation (n=23) and (ii) efforts to build out CAT implementation in a tertiary facility enabled through the above clinical trial resources. Results Analysis of feasibility study findings revealed significant improvements in adaptive functioning, psychiatric symptomatology, and goal attainment that were maintained throughout case management follow-up. Effect sizes for the specialist delivered period ranged from .33 (negative symptoms) to 2.01 (goal attainment scaling) with a modest decline in the follow-up period with community functioning remaining at ES=.66. Improvement in the large effect size range was also observed in community functioning in the trial of modified CAT in early intervention. In this period over 70 allied health clinicians were intensively training in CAT locally and regionally and a community of practice was established. These impacts were further extended through the development of an open-access CAT guide for families that can be used independently or with clinician support. Discussion This study supports a model for extending the accessibility of CAT in settings that might not otherwise sustain the intervention as it was originally designed. Functional impacts similar to the original clinical trials were observed in a briefer period of specialist delivered CAT and show the promise of being largely sustained over an indefinite period by rudimentary-trained case managers in a consultation model. This observation would appear to apply to both early intervention and general schizophrenia populations. Additionally, this program of work has demonstrated how research-practice synergies can foster implementation that can be sustained after initial research investments.

A Qualitative Description of Community Service, Business and Organization Perspectives on Mental Illness and Inclusion

ABSTRACT Although stigma associated with mental illness is pervasive, less is known about community stakeholder perspectives on inclusion and exclusion. This study provides a qualitative analysis of the mental illness–related experiences and perspectives of individuals who form much of the fabric of “community” for individuals with severe mental illness. In-depth interviews were conducted with a diverse group of 94 key community stakeholders in five neighborhoods in a large Canadian urban center. Qualitative analysis revealed a range of strategies that were used to foster inclusive spaces, the dilemmas that attended more severe forms of mental illness, and the importance of the meanings ascribed to mental illness in determining responses. Differences in response as a function of stakeholder group were also explored. There exist very promising resources and diverse perspectives on inclusion in urban communities that warrant further investigation given the intensive emphasis upon ‘community’ in policy and practice dialogues.