Torleif Ruud

The impact of mental illness on patient satisfaction with the therapeutic relationship

The relationship between patients and their clinicians is an essential factor in psychiatric treatment. The purpose of this study was to analyze the influence of psychopathology on patient satisfaction with the therapeutic relationship. Data from 969 patients from 40 different treatment teams collected from eight Norwegian community mental health centres were analyzed. Patient satisfaction with the therapeutic relationship was assessed with a six-item scale: sufficient time for contact/dialogue, clinicians’ ability to listen and understand, follow-up of planned interventions, respect for patients’ views/opinions, cooperation among clinicians, and patients’ influence on treatment. Mental illness was assessed using the Health of the Nation Outcome Scales (HoNOS) and Global Assessment of Functioning (GAF) scale. Diagnoses were established using the International Statistical Classification of Diseases and Related Health Problems—10th revision (ICD-10). Treatment outcomes were clinically assessed retrospectively by rating changes from start of treatment on seven items. Multilevel regression analysis was used for a simultaneous analysis of the contribution of patient and team variables. Satisfaction was associated with treatment outcome, better health as assessed using HoNOS, being female, of older age and having less psychiatric team severity indicated by the teams’ mean GAF score. Patients with a schizophrenia spectrum disorder were more satisfied when treated as in- and day patients, compared with outpatient treatment. Patients in other diagnostic categories were less satisfied with day treatment. Patients’ perceptions of the therapeutic relationship may be influenced by psychopathology. Teams comprising many patients with severe mental illness may constrain the therapeutic relationship. Hence, resources and organizational measures should be carefully considered in such care units.

Research priorities for public mental health in Europe: recommendations of the ROAMER project

BACKGROUND The ROAdmap for MEntal health Research in Europe project aimed to create an integrated European roadmap for mental health research. Leading mental health research experts across Europe have formulated consensus-based recommendations for future research within the public mental health field. METHODS Experts were invited to compile and discuss research priorities in a series of topic-based scientific workshops. In addition, a Delphi process was carried out to reach consensus on the list of research priorities and their rank order. Three web-based surveys were conducted. Nearly 60 experts were involved in the priority setting process. RESULTS Twenty priorities for public mental health research were identified through the consensus process. The research priorities were divided into summary principles-encompassing overall recommendations for future public mental health research in Europe-and thematic research priorities, including area-specific top priorities on research topics and methods. The priorities represent three overarching goals mirroring societal challenges, that is, to identify causes, risk and protective factors for mental health across the lifespan; to advance the implementation of effective public mental health interventions and to reduce disparities in mental health. CONCLUSIONS The importance of strengthening research on the implementation and dissemination of promotion, prevention and service delivery interventions in the mental health field needs to be emphasized. The complexity of mental health and its broader conceptualisation requires complementary research approaches and interdisciplinary collaboration to better serve the needs of the European population.

Inter-rater Reliability of Clinician-rated Outcome Measures in Child and Adolescent Mental Health Services

This study investigated the inter-rater reliability when 169 out of 171 clinicians working in 10 Norwegian child and adolescent mental health services rated 20 written vignettes using the following outcome measures: Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), Children’s Global Assessment Scale (CGAS) and Global Assessment of Psychosocial Disability (GAPD). Three clinicians rated both patients and vignettes. On vignettes the intraclass correlation coefficient (ICC) for the HoNOSCA total score was 0.81 (single scales 0.47–0.96), for the CGAS 0.61 and for the GAPD 0.60. The reliability was not lower on patients. The rater’s profession, experience or clinic did not have effect on the scores.

The Psychiatric Out-Patient Experiences Questionnaire (POPEQ): Data quality, reliability and validity in patients attending 90 Norwegian clinics

The aim of this study was to develop and evaluate the Psychiatric Out-Patient Experiences Questionnaire (POPEQ). The instrument was developed following a literature review, patient interviews and pre-testing of questionnaire items. The POPEQ was administered as part of a postal survey of 15,422 adult outpatients attending Norwegian clinics; 6677 (43.3%) patients responded to the questionnaire. Items had low levels of missing data. Factor analysis showed that 11 widely applicable items contribute to a measure of overall experiences. Sub-dimensions include clinician interaction (six items) information (two items) and outcomes (three items). Item-total correlations ranged from 0.5 to 0.8. Cronbachs alpha and test–retest reliability estimates exceeded the criterion of 0.7; the majority were over 0.8 and total scores over 0.9. Construct validity was supported by the results of 128 tests. The POPEQ includes important aspects of patient experience for psychiatric outpatients and has excellent evidence for reliability and construct validity. The instrument is recommended for the measurement of psychiatric outpatient experiences.

Comparison of short- and long-term dynamic group psychotherapy: randomised clinical trial

BACKGROUND There are no randomised clinical trials comparing the outcomes of short- with long-term psychodynamic group psychotherapy. AIMS To compare differences in outcome during and after short- and long-term group psychotherapy. METHOD In total, 167 out-patients with mood, anxiety and personality disorders were randomised to short- or long-term group therapy (20 or 80 weekly, 90 min sessions). Outcome measures were: symptoms (Symptom Checklist 90 - Revised), interpersonal problems (Inventory of Interpersonal Problems - Circumplex) and psychosocial functioning (Global Assessment of Functioning (GAF) split version: GAF-Symptom and GAF-Function). Change over the 3-year study period was assessed using linear mixed models. The study was registered in clinicalTrials.gov as NCT00521417. RESULTS Patients in both groups made significant gains. A significantly larger symptomatic change over time was found for long-term compared with short-term therapy, but no significant differences were detected for the three remaining outcome variables. There was a higher number of premature terminations in the long-term (33.3%) compared with the short-term group (8.6%). CONCLUSIONS Short- and long-term therapy seem equally effective for typical out-patients seeking group psychotherapy, except for symptomatic distress.

Block training in group analysis: The Norwegian program.

Block training in group psychotherapy makes it possible to train professionals living far apart and to import conductors to an area or country lacking sufficient expertise. This article reports experience with such a training program in Norway. Training is given in blocks of 5 weekends a year, each weekend containing small group therapy, supervision, theory courses, lectures, and large group experiences. The participants were questioned about their personal and professional gains from the training. These findings and the effect of the program in relation to stated goals are discussed.

Staff attitudes and thoughts about the use of coercion in acute psychiatric wards.

PurposePrevious research has shown considerable differences in how often coercive measures are used in mental health care between groups of patients, institutions and geographical areas. Staff attitudes towards the use of coercion have been put forward as a factor that may influence these differences.MethodThis study investigates the attitudes to coercion in 651 staff members within 33 Norwegian acute psychiatric wards. The newly developed Staff Attitude to Coercion Scale was used to measure staff attitudes.ResultsMultilevel analysis showed that there was significant variance among wards, estimated to be about 8–11% of the total variance on three scales.ConclusionsDespite substantial differences in attitudes among wards, most of the variance could be attributed to individual staff level factors. Hence, it is likely that staff attitudes are influenced, to a large extent, by each individual staff member’s personality and values.

The Staff Attitude to Coercion Scale (SACS): Reliability, validity and feasibility

OBJECTIVES Staff attitudes to the use of coercion are assumed to be a predictive factor for how much coercion is used in mental health care. The aim of this project has been to develop a questionnaire to measure staff attitudes to coercion. The development of the questionnaire is part of a broader project to investigate if staff attitudes to coercion influence how much coercion is actually used in mental health care. METHOD A 15-item questionnaire has been developed through a process that included item constructing and sampling, a pilot study and testing reliability and validity. The questionnaire has been tested on a sample of 215 staff members from 15 acute and sub-acute psychiatric wards in Norway. Descriptive statistics and Cronbach Alpha were used to examine the psychometric properties of the items, and principal component analysis was used to analyse the dimensional structure. RESULTS A model with three attitudes was found based on principal component analysis and clinical considerations. The three attitudes have been named: Coercion as offending (critical attitude) - the view of coercion as offensive towards patients; Coercion as care and security (pragmatic attitude) - the view of coercion as needed for care and security, and Coercion as treatment (positive attitude) - the view of coercion as a treatment intervention. CONCLUSION A 15-item questionnaire to measure staff attitudes to coercion has been developed and named the Staff Attitude to Coercion Scale (SACS). The questionnaire has shown good reliability, validity and feasibility.

Development of a measure of model fidelity for mental health Crisis Resolution Teams

BackgroundCrisis Resolution Teams (CRTs) provide short-term intensive home treatment to people experiencing mental health crisis. Trial evidence suggests CRTs can be effective at reducing hospital admissions and increasing satisfaction with acute care. When scaled up to national level however, CRT implementation and outcomes have been variable. We aimed to develop and test a fidelity scale to assess adherence to a model of best practice for CRTs, based on best available evidence.MethodsA concept mapping process was used to develop a CRT fidelity scale. Participants (n = 68) from a range of stakeholder groups prioritised and grouped statements (n = 72) about important components of the CRT model, generated from a literature review, national survey and qualitative interviews. These data were analysed using Ariadne software and the resultant cluster solution informed item selection for a CRT fidelity scale. Operational criteria and scoring anchor points were developed for each item. The CORE CRT fidelity scale was then piloted in 75 CRTs in the UK to assess the range of scores achieved and feasibility for use in a 1-day fidelity review process. Trained reviewers (n = 16) rated CRT service fidelity in a vignette exercise to test the scale’s inter-rater reliability.ResultsThere were high levels of agreement within and between stakeholder groups regarding the most important components of the CRT model. A 39-item measure of CRT model fidelity was developed. Piloting indicated that the scale was feasible for use to assess CRT model fidelity and had good face validity. The wide range of item scores and total scores across CRT services in the pilot demonstrate the measure can distinguish lower and higher fidelity services. Moderately good inter-rater reliability was found, with an estimated correlation between individual ratings of 0.65 (95% CI: 0.54 to 0.76).ConclusionsThe CORE CRT Fidelity Scale has been developed through a rigorous and systematic process. Promising initial testing indicates its value in assessing adherence to a model of CRT best practice and to support service improvement monitoring and planning. Further research is required to establish its psychometric properties and international applicability.

Walking the fine line: Self-reported reasons for substance use in persons with severe mental illness

Many theoretical models have been proposed to explain the relationship between severe mental illness (SMI) and substance use. Because many of these are contradictory quantitative American studies, a qualitative, exploratory study of a Scandinavian sample may offer a new perspective. The aim of the study is to explore reasons for substance use through analysis of the participants’ experiences. A qualitative study with semistructured interviews was used. Purposeful sampling (N=11) of patients with substance use disorder (SUD) and SMI, who were included in assertive community treatment teams, was completed. Inclusion criteria are increased quality of life or increased general functioning, and decreased substance use, after a minimum of 12 months in treatment. Reasons given for using substances were categorized as (a) controlling the symptoms of mental illness, (b) counteracting medication side effects, or (c) balancing the ambiguity. The conclusion is that the study findings mainly support secondary substance use models in explaining the comorbidity of SMI and substance use. However, there is some support for the traditional self-medication hypothesis (SMH), iatrogenic vulnerability, and the supersensitivity model. This may be because the majority of the study participants reported having a mental illness with subsequent substance use. The expressed ambivalence to substance use also lends some support to bidirectional models.