Sarah Conover

Randomized trial of critical time intervention to prevent homelessness after hospital discharge.

OBJECTIVE This study assessed the effectiveness of a previously tested model, critical time intervention (CTI), in producing an enduring reduction in the risk of homelessness for persons with severe mental illness who were discharged from inpatient psychiatric treatment facilities. METHODS A total of 150 previously homeless men and women with severe mental illness and who were discharged from inpatient psychiatric hospitalization to transitional residences on the hospital grounds were randomly assigned to receive usual care or usual care plus CTI at the point of discharge to the community. The nine-month intervention aims to gradually pass responsibility to community sources for providing ongoing support after the intervention ends, thereby leading to a durable reduction in risk of future homelessness. After participants were discharged from the transitional residence (length of stay six to 937 days), their housing status was assessed every six weeks for 18 months via participant self-report collected by interviewers blind to study condition. RESULTS In an intent-to-treat analysis, participants assigned to the CTI group had significantly less homelessness at the end of the follow-up period (the final three six-week intervals) than those assigned to the control group (odds ratio=.22, 95% confidence interval=.06-.88). CONCLUSIONS A relatively brief, focused intervention for persons with severe mental illness led to a reduction in the risk of homelessness that was evident nine months after the intervention ended. This work suggests that targeted, relatively short interventions applied at critical transition points may enhance the efficacy of long-term supports for persons with severe mental illness who are living in the community.

Critical Time Intervention: An Empirically Supported Model for Preventing Homelessness in High Risk Groups

Critical Time Intervention (CTI) is designed to prevent recurrent homelessness among persons with severe mental illness by enhancing continuity of care during the transition from institutional to community living. After providing the background and rationale of CTI, we describe the elements of the model and summarize the status of existing research on its effectiveness. We then briefly illustrate how the CTI model has begun to be adapted and implemented by providing a case example of a homeless woman’s transition from shelter to housing. Finally, we consider plans for the further adaptation, testing and dissemination of CTI in other populations and service delivery settings.

Trauma Exposure and Posttraumatic Stress Disorder Among Employees of New York City Companies Affected by the September 11, 2001 Attacks on the World Trade Center

OBJECTIVE Several studies have provided prevalence estimates of posttraumatic stress disorder (PTSD) related to the September 11, 2001 (9/11) attacks in broadly affected populations, although without sufficiently addressing qualifying exposures required for assessing PTSD and estimating its prevalence. A premise that people throughout the New York City area were exposed to the attacks on the World Trade Center (WTC) towers and are thus at risk for developing PTSD has important implications for both prevalence estimates and service provision. This premise has not, however, been tested with respect to DSM-IV-TR criteria for PTSD. This study examined associations between geographic distance from the 9/11 attacks on the WTC and reported 9/11 trauma exposures, and the role of specific trauma exposures in the development of PTSD. METHODS Approximately 3 years after the attacks, 379 surviving employees (102 with direct exposures, including 65 in the towers, and 277 with varied exposures) recruited from 8 affected organizations were interviewed using the Diagnostic Interview Schedule/Disaster Supplement and reassessed at 6 years. The estimated closest geographic distance from the WTC towers during the attacks and specific disaster exposures were compared with the development of 9/11-related PTSD as defined by the Diagnostic and Statistical Manual, Fourth Edition, Text Revision. RESULTS The direct exposure zone was largely concentrated within a radius of 0.1 mi and completely contained within 0.75 mi of the towers. PTSD symptom criteria at any time after the disaster were met by 35% of people directly exposed to danger, 20% of those exposed only through witnessed experiences, and 35% of those exposed only through a close associates direct exposure. Outside these exposure groups, few possible sources of exposure were evident among the few who were symptomatic, most of whom had preexisting psychiatric illness. CONCLUSIONS Exposures deserve careful consideration among widely affected populations after large terrorist attacks when conducting clinical assessments, estimating the magnitude of population PTSD burdens, and projecting needs for specific mental health interventions.

HIV prevention with severely mentally ill men: A randomised controlled trial

Abstract We conducted a randomised clinical trial to test the efficacy of an enhanced version of an intervention previously shown to reduce HIV sexual risk behaviours among men with severe mental illness. One-hundred-and-forty-nine subjects aged 18–59 years were randomly assigned to the experimental or control conditions. Sexual risk behaviours were assessed every three months for 12-months. The primary analysis compared experimental and control groups with respect to sexual risk behaviours with casual partners as measured by the Vaginal Episodes Equivalent (VEE) score. Additional analyses included comparison of VEE scores of those men sexually active in the three months prior to baseline and the proportion of condom-protected sexual acts with casual partners. There were no significant differences in sexual risk behaviours with casual partners between experimental and control subjects. Additional analyses demonstrated a trend toward sexual risk reduction at six months post-intervention (p=0.06) but not at 12 months. These results may reflect a lack of efficacy or a true reduction in risk that the trial was underpowered to detect at the 0.05-level. If there was a true reduction in risk, it was not maintained after the initial six months.

Course of Acute Affective Disorders in a Developing Country Setting

This report on the Chandigarh Acute Psychosis Study examines the early course of affective disorders of acute onset in a developing country setting. Forty-one cases of acute onset affective disorder (17 depressive and 24 manic subjects) were assessed at intake and evaluated at selected intervals up to 1 year. The rates of recovery and relapse and episode duration were determined for both the depressive and manic groups, and the relationship between possible predictors of outcome and the duration of the index episode was examined. All subjects experienced full recovery within the 1-year period. At 1-year follow-up, 71% of depressive patients and 75% of manic patients demonstrated no symptoms or social impairment. For depression and mania, respectively, the mean episode duration was 14.2 and 10.2 weeks, and the rate of relapse was 18% and 21%. Overall, these outcomes are considerably more favorable than in comparable studies of affective disorders in developed settings. Our findings suggest that acuteness of onset may be a major prognostic factor in predicting the course of affective disorders.

“I Hope I Can Make it Out There”: Perceptions of Women with Severe Mental Illness on the Transition from Hospital to Community

This study explores the experience of women with severe mental illness in transition from psychiatric hospital care to the community. Three focus groups were conducted among women with severe mental illness from transitional residences at two state psychiatric hospitals. Focus group transcripts and notes were coded according to women’s perceived challenges and facilitators of transition. Participants described several challenges including fear of insufficient treatment support, safety concerns, social isolation, stigma, and lack of resources to meet daily needs. The supports that women described as important were an orientation to the neighborhood and residence, access to treatment support with flexibility, and connection to social supports.

Using Local Resources in Patagonia A Model of Community-Based Rehabilitation

This paper proposes community-based rehabilitation (CBR) as a potentially useful model for care of the mentally ill in developing countries and illustrates an application of CBR in such a setting. CBR is an approach to rehabilitation that makes use of local resources in order to meet the needs of a chronically disabled group. Our companion paper in this journal issue discusses the primary health-care system of one province in the Patagonia region of Argentina. This health-care system can be viewed as a valuable local resource that has been applied to the care of people with mental illness. The present paper describes a specific rehabilitation program for chronic psychiatric patients in the same province. At the Instituto Austral de Salud Mental, CBR principles are being adapted for this population. We emphasize this programs use of a plentiful local resource, the primary-care doctor, who plays a pivotal role in the long-term care and rehabilitation of the mentally ill.

Developing an instrument for assessing fidelity to the intervention in the Critical Time Intervention - Task Shifting (CTI-TS) - preliminary report

Aim. The fidelity of an intervention can be defined as the degree to which a program is implemented following the program model, i.e. a set of well-defined procedures for such intervention. This article aims to describe the steps taken to develop an assessment tool of fidelity to the original protocol of intervention for Critical Time Intervention – Task Shifting (CTI-TS). Methods. The development of an instrument to assess fidelity includes some key stages, such as definition of the intervention model, definition of the key components of the intervention, preparation of a preliminary scale, development of fidelity assessment sheets, development of a manual on the application of fidelity scale, training fidelity assessor and testing the preliminary scale by carrying out a pilot study. results. Based on the experts’ opinion, 18 key components of the intervention were defined. From these components, a fidelity scale consisting of 20 items was built, divided into three sections, each evaluating one of the types of fidelity: compliance, context and competence. Conclusion. The CTI-TS had its fidelity assessment method developed in accordance with the recommendations in the current literature. The protocol compliance is essential for the results, whether positive or not, can be credited to the intervention itself.

SCHIZOPHRENIA, THE PREVENTION OF HOMELESSNESS, AND THE GLOBAL HEALTH MOVEMENT

Available evidence suggests that individuals with schizophrenia and other severe mental illnesses are at increased risk for homelessness in contemporary societies with diverse cultures and socioeconomic conditions. Yet the prevention of homelessness among individuals with mental illness has rarely been a focus of global health programs. We propose that it should be. In any given society, the overall risk of homelessness will reflect broad societal factors such as income inequality, housing, migration, economic conditions, and family ties. We strongly advocate for addressing these societal causes of homelessness. We also believe, however, that we need to develop special programs in parallel to prevent homelessness among individuals with severe mental illness. We use historical examples to draw attention to ways in which individuals with mental illness have been – and still are – explicitly excluded from societies. We suggest that this social exclusion requires us to take special measures to protect the rights of individuals with mental illness, and to develop programs to ensure they have access to basic necessities including a home. The form these measures take will of necessity vary widely according to local conditions. We describe mental health initiatives in two middle-income countries (Brazil and Argentina) which illustrate different approaches, and allude more briefly to efforts being made in other countries including low-income countries. Finally, we consider some of the efforts that are already being made by various international groups to further this agenda within the global health movement.