Ilana Nossel

Treatment engagement of individuals experiencing mental illness: review and update

Individuals living with serious mental illness are often difficult to engage in ongoing treatment, with high dropout rates. Poor engagement may lead to worse clinical outcomes, with symptom relapse and rehospitalization. Numerous variables may affect level of treatment engagement, including therapeutic alliance, accessibility of care, and a clients trust that the treatment will address his/her own unique goals. As such, we have found that the concept of recovery‐oriented care, which prioritizes autonomy, empowerment and respect for the person receiving services, is a helpful framework in which to view tools and techniques to enhance treatment engagement. Specifically, person‐centered care, including shared decision making, is a treatment approach that focuses on an individuals unique goals and life circumstances. Use of person‐centered care in mental health treatment models has promising outcomes for engagement. Particular populations of people have historically been difficult to engage, such as young adults experiencing a first episode of psychosis, individuals with coexisting psychotic and substance use disorders, and those who are homeless. We review these populations and outline how various evidence‐based, recovery‐oriented treatment techniques have been shown to enhance engagement. Our review then turns to emerging treatment strategies that may improve engagement. We focus on use of electronics and Internet, involvement of peer providers in mental health treatment, and incorporation of the Cultural Formulation Interview to provide culturally competent, person‐centered care. Treatment engagement is complex and multifaceted, but optimizing recovery‐oriented skills and attitudes is essential in delivery of services to those with serious mental illness.

Practical Monitoring of Treatment Fidelity: Examples From a Team-Based Intervention for People With Early Psychosis

Mental health programs can address many components of fidelity with routinely available data. Information from client interviews can be used to corroborate these administrative data. This column describes a practical approach to measuring fidelity that used both data sources. The approach was used in the Recovery After an Initial Schizophrenia Episode (RAISE) Connection Program, a team-based intervention designed to implement evidence-based practices for people experiencing early psychosis suggestive of schizophrenia. Data indicated that the intervention was implemented as intended, including program elements related to shared decision making and a range of evidence-based clinical interventions.

The RAISE Connection Program for Early Psychosis: Secondary Outcomes and Mediators and Moderators of Improvement.

Abstract The aims of this study were to explore secondary outcomes of a coordinated specialty care program for persons with early psychosis, including quality of life and recovery, as well as to explore mediators and moderators of improvement in occupational and social functioning and symptoms. Sixty-five individuals across two sites were enrolled and received services for up to 2 years. Trajectories for individuals’ outcomes over time were examined using linear and quadratic mixed-effects models with repeated measures. In addition, baseline prognostic factors of participant improvement in social and occupational functioning were explored based on previous literature and expert opinion of the analytic team. Results demonstrate that the program was effective in improving quality of life and recovery over time. Furthermore, processing speed was identified as a significant moderator of improvement in occupational Global Assessment of Function, and treatment fidelity, engagement, and family involvement were identified as mediators of improvement in social and occupational functioning.

Psychiatrists' Attitudes Toward Individuals With Substance Use Disorders and Serious Mental Illness

Objective: The attitudes of psychiatrists toward individuals with highly stigmatized conditions such as substance use disorders and serious mental illness may influence treatment effectiveness. These attitudes may be influenced by factors including previous specialty training and current practice patterns. This study examined the attitudes of addiction and community psychiatrists toward individuals with diagnosed schizophrenia, polysubstance dependence, comorbid schizophrenia and polysubstance dependence, and depression. Methods: A web-based survey link was sent to the electronic mailing lists of addiction and community psychiatry associations. Results: A total of 84 respondents identified themselves as either addiction (n = 54) or community (n = 30) psychiatrists. The majority were male (70% of addiction and 57% of community psychiatrists) with an average age of 56.0 (SD = 11.86) and 52.7 (SD = 11.8), respectively. Addiction psychiatrists had less stigmatizing attitudes than community psychiatrists for individuals with polysubstance dependence (p < .0001), while community psychiatrists had less stigmatizing attitudes than addiction psychiatrists for those with schizophrenia (p < .0001). Attitudes toward individuals with dual diagnosis did not vary significantly by psychiatrist group, but both addiction and community psychiatrists had more stigmatizing attitudes for individuals with dual diagnosis (p < .0001). Conclusions: These findings suggest that even psychiatrists working with highly stigmatized groups of individuals may continue to hold stigmatizing attitudes toward people with other diseases. Future work is needed to further assess stigmatizing attitudes among psychiatrists and the impact of these attitudes on quality of care, as well as interventions such as specialized education and training to reduce such stigma among psychiatrists.

Family member engagement with early psychosis specialty care

Family members of individuals with early psychosis (EP) play critical roles in their engagement with EP services, but family member experiences of those roles are insufficiently understood.

Use of Peer Staff in a Critical Time Intervention for Frequent Users of a Psychiatric Emergency Room

Project Connect, a clinical demonstration program developed in consultation with the New York State Office of Mental Health, adapted critical time intervention for frequent users of a large urban psychiatric emergency room (ER). Peer staff provided frequent users with time-limited care coordination. Participants increased their use of outpatient services over 12 months, compared with a similar group not enrolled in the program. For persons with significant general medical, psychiatric, and social needs, provision of this intervention alone is unlikely to reduce reliance on ERs, especially among homeless individuals.

Patterns of Emergency Department Use for Medical Conditions Among Persons With Serious Mental Illness

OBJECTIVE This study examined predictors of medical emergency department use among veterans with serious mental illness. METHODS Participants were 118 psychiatrically hospitalized veterans with a serious mental illness who were identified as at risk for treatment dropout. Participants completed an interview and had their charts reviewed as part of a larger study. RESULTS Nearly half of participants had at least one medical emergency visit, and 20% had two or more visits in the six months after hospital discharge. Outpatient service utilization of both general medical treatment and mental health-substance abuse treatment, as well as psychiatric symptoms, anxiety, and lower levels of satisfaction with current living situation, were associated with increased medical emergency department use. CONCLUSIONS Medical emergency department use was relatively common in this population of veterans with serious mental illness. Mental health and general medical health needs should be addressed in an integrated fashion to reduce the use of the emergency department.

OnTrackNY: The Development of a Coordinated Specialty Care Program for Individuals Experiencing Early Psychosis

OnTrackNY is a coordinated specialty care program that delivers early intervention services to youths experiencing a first episode of nonaffective psychosis. Treatment aims to help individuals improve their mental health and achieve personal goals related to work, school, and social relationships. This column describes OnTrackNYs progression from a research project to real-world implementation. The authors describe the treatment model, approach to training and dissemination, and procedures for collecting and sharing data with OnTrackNY teams and provide data on client characteristics and selected outcomes.

Our job and their jobs: mental health clinicians and patients' work functioning.

The capacity to love and work is a timeless definition of a mentally healthy individual. Conservatively 23 million working-age Americans have chronic health and mental health problems that diminish their ability to work (Hoffman and Rice, 1996). Millions more are projected to experience employment problems by 2030 (Lerner et al., 2005). There is a reciprocal relationship between illness and work, with symptoms impairing functioning and poor functioning worsening recovery. Mental health clinicians have long recognized the importance of work in their patients’ lives and know how to assess and manage symptom reduction and interpersonal functioning. However, they may feel less confident in their ability to assess work functioning beyond basic issues of employment status. Moreover, clinicians may ignore employment aspirations and job performance because of an assumption that function will improve as symptoms improve (Lerner and Henke, 2008). An evolving literature has documented the degree to which mental health conditions impair work functioning and has indicated that symptom reduction alone does not improve job performance and satisfaction (Adler et al., 2006; Bacharach et al., 2010; Blum et al., 1993; Greenberg et al., 2003; Kessler et al., 2001; Lerner et al., 2004b; Stewart et al., 2003). Using the example of depressive disorders, this article will provide a case presentation and offer a framework for understanding the impact of mental health conditions on work performance. We present a methodology for systematic assessment and treatment of work functioning as part of routine patient care. Improving work performance should be a principle goal of treatment. Depression affects almost 5% of the US working-age population (Berndt et al., 1998; Broadhead et al., 1990; Goetzel et al., 2003; Kessler et al., 1999a), and like several other mental disorders, it has been found to be associated with job loss, job turnover, absenteeism, and reduced job performance (now known as presenteeism; Adler et al., 2006; Budetti et al., 2000; Dooley et al., 1996; Greenberg et al., 2003; Kessler et al., 2001; Lerner et al., 2004a, 2004b, 2010; Stewart et al., 2003) at an estimated productivity cost of

Results of a Coordinated Specialty Care Program for Early Psychosis and Predictors of Outcomes

44 billion annually (Greenberg et al., 2003). Studies reveal that depressed workers miss an average of 0.5 to 4.0 workdays per month (Kessler et al., 1999a). Poor work performance may be an even larger problem. Stewart et al. (2003) suggest that it is more costly than medical care, absences, and disability combined. Conti and Burton (1995) found that depressed workers were impaired on the job approximately 35% of the time on average in a 2-week period. Despite the availability of effective pharmacological and therapeutic interventions, optimal care has been hindered by underdiagnosis, limited use of evidence-based approaches, and adherence problems (Calkins et al., 1991; Eisenberg, 1992; Kessler et al., 1996; Schulberg et al., 1995). In essence, depression causes a partial work disability. A second critical observation has been the low correlation between symptom response to treatment and functional improvement. Adler et al. (2006) found that compared with healthy controls, a recovered group of previously depressed employees had persistently lower ability to function on the job. Depression symptom severity explains part of the variation in work outcomes. Depression treatment studies indicate that guideline-concordant care may only partially prevent depression’s negative impact on work. A study of depression treatment and employment achieved a reduction in depressive symptoms and absenteeism but not improved job performance (Wang et al., 2007). COMMENTARY