Increasing person-centeredness in psychosis inpatient care: care consumption before and after a person-centered care intervention.

BACKGROUND: Patients with psychotic disorders often need hospitalization with long stays. Person-centered care (PCC) has been shown to improve care quality and decrease the length of hospital stay in non-psychiatric settings. We carried out an educational intervention for inpatient staff, aiming to increase person-centeredness at a major Swedish psychosis clinic. The aim of this study was to test if the intervention could be associated with decreased length of hospital stay (LoS), involuntary stay (LoIS), and reduction in rapid readmissions. METHODS: Data from the clinic's administrative registry were compared for patients with a discharge diagnosis within the schizophrenia-spectrum treated during the one-year periods before and after the PCC intervention. RESULTS: Contrary to our hypotheses, a quantile regression estimated longer LoS post-intervention, median difference 10.4 d (CI 4.73-16.10). Neither age, sex nor diagnostic category were associated with LoS. Of all inpatient days, ∼80% were involuntary. While LoIS was numerically longer post-intervention, the difference did not reach significance in the final regression model (median difference 7.95 d, CI -1.40 to 17.31). Proportions with readmission within 2 weeks of discharge did not differ (7.7% vs 5.2%, n.s.). CONCLUSIONS: Increased length of inpatient care was observed after the PCPC intervention. This could reflect an increased focus on the unmet needs of persons with serious psychotic conditions, but it needs to be explored in future research using a more rigorous study design. TRIAL REGISTRATION: This study is part of a larger evaluation of Person-Centered Psychosis Care (PCPC), registered during data collection (after the study start, before analysis) at clinicaltrials.gov, identifier NCT03182283.

Striving for a more person-centered psychosis care: results of a hospital-based multi-professional educational intervention.

BACKGROUND: Reluctance on the part of mental health professionals constitutes an important barrier to patient participation in care. In order to stimulate person-centeredness in the inpatient care of persons with psychotic illness, we developed and tested an educational intervention for hospital staff (including psychiatrists) at all four wards at the Psychosis Clinic, Sahlgrenska University Hospital in Gothenburg, Sweden. The intervention was co-created by professionals, patients, and researchers using a participatory approach. In addition to lectures and workshops, staff created and implemented small projects to increase person-centeredness on their own wards. A primary focus was to establish a partnership between patient and staff by capturing and utilizing the patient's narrative to support active engagement in the care process. This included the development of a person-centered care plan. We hypothesized that the intervention would be associated with increased patient empowerment (primary outcome) and satisfaction with care (secondary outcome). METHODS: A before and after design was used to test group differences in patient empowerment (Empowerment Scale) and consumer satisfaction (UKU-ConSat Rating Scale). All patients receiving inpatient psychosis care during measuring periods were eligible if meeting inclusion criteria of schizophrenia spectrum disorder, age > 18, and ability to comprehend study information. Severe cognitive deficit and inadequate Swedish language skills were exclusion criteria. Data on possible confounding variables including overall health (EQ-5D), symptom burden (PANSS), and functional ability (GAF) were collected alongside outcome measures. RESULTS: ANCOVAs with overall health as a confounding variable showed no group differences regarding empowerment before (n = 50) versus after (n = 49) intervention, sample mean = 2.87/2.99, p = .142, eta2 = .02, CI = -.27-.04. Consumer satisfaction (n = 50/50) was higher in the post-implementation group (4.46 versus 11.71, p = .041 eta2 = .04, CI = -14.17- -.31). CONCLUSION: The hypothesis regarding the primary outcome, empowerment, was not supported. An increase in the secondary outcome, satisfaction, was observed, although the effect size was small, and results should be interpreted with caution. Findings from this staff educational intervention can inform the development of future studies aimed at improvement of inpatient care for persons with severe mental illness. TRIAL REGISTRATION: The trial was retrospectively registered at ClinicalTrials.gov June 9, 2017, identifier: NCT03182283.

Study protocol design and evaluation of a hospital-based multi-professional educational intervention: Person-Centred Psychosis Care (PCPC).

BACKGROUND: While patient involvement in mental health care is repeatedly stressed in policy documents, there are actually few studies that evaluate person-centred care interventions within psychiatric services. We present here the design and planned evaluation of an educational intervention for inpatient staff involved in the care of persons with schizophrenia and similar psychoses. METHODS/DESIGN: The care intervention will be assessed using a non-randomised trial with a before and after approach. The intervention involves an educational and experimental learning phase for hospital staff, followed by an implementation phase. The intervention is multi-professional; psychiatrists, psychiatric nurses, psychiatric carers, social workers, occupational therapists, and a medical secretary will be engaged in a participatory approach where they practice how to create a partnership and explore recovery-related goals together with patients. Patient-related outcomes include empowerment and satisfaction with care. Ward-level outcomes include daily ward burden, length of inpatient stay, and number of days with involuntary care. In addition, qualitative methods will be applied to capture patient, next-of-kin, and staff perspectives. DISCUSSION: The care intervention is expected to contribute to the improvement of inpatient care for persons with severe and complex mental health issues. TRIAL REGISTRATION: The trial was retrospectively registered at ClinicalTrials.gov June 9, 2017, identifier: NCT03182283 .

Stigma and Burden Among Relatives of Persons With Schizophrenia: Results From the Swedish COAST Study.

OBJECTIVE: The aim was to apply a structured questionnaire, the Inventory of Stigmatizing Experiences (ISE), to study experiences of stigma (associated stigma) among relatives of persons with schizophrenia who attended outpatient clinics, using an approach based on assertive community treatment in a Swedish major city. A second aim was to explore the relationship between associated stigma and overall burden among these relatives. METHODS: Relatives (N=65) of persons taking oral antipsychotics who attended outpatient clinics completed a mailed questionnaire that included the ISE and the Burden Inventory for Relatives of Persons with Psychotic Disturbances. Associations were analyzed with ordinal logistic regression. RESULTS: More than half of the relatives (53%) stated that their ill relative had been stigmatized, but only 18% (N=11) reported that they themselves had been stigmatized (responses of sometimes, often, or always). One-fifth of the relatives (23%) acknowledged that they avoided situations that might elicit stigma. Neither experienced stigma nor anticipated stigma was associated with overall burden level in ordinal logistic regression models. The impact of stigma on both the relative's personal quality of life and the family's quality of life were both significantly associated with overall burden after adjustment for patient age and level of functioning. CONCLUSIONS: Stigma had an impact on quality of life at the personal and family levels, and this was associated with overall burden. Increased awareness among service providers may decrease the impact of stigma on relatives, but associations need to be examined in larger studies in diverse cultures and treatment settings.

Stigma, discrimination and medication adherence in schizophrenia: results from the Swedish COAST study.

The aims of this naturalistic non-interventional study were to quantify the level of stigma and discrimination in persons with schizophrenia and to test for potential associations between different types of stigma and adherence to antipsychotics. Antipsychotic medication use was electronically monitored with a Medication Event Monitoring System (MEMS®) for 12 months in 111 outpatients with schizophrenia and schizophrenia-like psychosis (DSM-IV). Stigma was assessed at endpoint using the Discrimination and Stigma Scale (DISC). Single DISC items that were most frequently reported included social relationships in making/keeping friends (71%) and in the neighborhood (69%). About half of the patients experienced discrimination by their families, in intimate relationships, regarding employment and by mental health staff. Most patients (88%) wanted to conceal their mental health problems from others; 70% stated that anticipated discrimination resulted in avoidance of close personal relationships. Non-adherence (MEMS® adherence≤0.80) was observed in 30 (27.3%). When DISC subscale scores (SD) were entered in separate regression models, neither experienced nor anticipated stigma was associated with adherence. Our data do not support an association between stigma and non-adherence. Further studies in other settings are needed as experiences of stigma and levels of adherence and their potential associations might vary by a healthcare system or cultural and sociodemographic contexts.

Twelve months of electronic monitoring (MEMS®) in the Swedish COAST-study: a comparison of methods for the measurement of adherence in schizophrenia.

The primary aim was to compare objective and subjective measures of adherence in a naturalistic cohort of schizophrenia outpatients over 12 months between October 2008 and June 2011. Antipsychotic medication adherence was monitored in 117 outpatients diagnosed with schizophrenia or schizophrenia-like psychosis according to DSM-IV criteria in a naturalistic prospective study. Adherence was determined by the Medication Event Monitoring System (MEMS®), pill count, plasma levels and patient, staff, psychiatrist and close informant ratings. The plasma level adherence measure reflects adherence to medication and to lab visits. Relationships between MEMS® adherence and other measures were expressed as a concordance index and kappa (K). Non-adherence (MEMS® ≤0.80) was observed in 27% of the patients. MEMS® adherence was highly correlated with pill count (concordance= 89% and K=0.72, p<0.001). Concordance and K were lower for all other adherence measures and very low for the relationship between MEMS® adherence and plasma levels (concordance=56% and K=0.05, p=0.217). Adherence measures were also entered into a principal component analysis that yielded three components. MEMS® recordings, pill count and informant ratings had their highest loadings in the first component, plasma levels alone in the second and patient, psychiatrist and staff ratings in the third. The strong agreement between MEMS® and pill count suggests that structured pill count might be a useful tool to follow adherence in clinical practice. The large discrepancy between MEMS® and the adherence measure based on plasma levels needs further study in clinical settings.

Drug attitude and other predictors of medication adherence in schizophrenia: 12 months of electronic monitoring (MEMS(®)) in the Swedish COAST-study.

The aim was to investigate clinical predictors of adherence to antipsychotics. Medication use was electronically monitored with a Medication Event Monitoring System (MEMS(®)) for 12 months in 112 outpatients with schizophrenia and schizophrenia-like psychosis according to DSM-IV. Symptom burden, insight, psychosocial function (PSP) and side effects were rated at baseline. A comprehensive neuropsychological test battery was administered and a global composite score was calculated. The Drug Attitude Inventory (DAI-10) was filled in. A slightly modified DAI-10 version for informants was distributed as a postal questionnaire. Non-adherence (MEMS(®) adherence ≤0.80) was observed in 27%. In univariate regression models low scores on DAI-10 and DAI-10 informant, higher positive symptom burden, poor function, psychiatric side effects and lack of insight predicted non-adherence. No association was observed with global cognitive function. In multivariate regression models, low patient-rated DAI-10 and PSP scores emerged as predictors of non-adherence. A ROC analysis showed that DAI-10 had a moderate ability to correctly identify non-adherent patients (AUC=0.73, p<0.001). At the most "optimal" cut-off of 4, one-third of the adherent would falsely be identified as non-adherent. A somewhat larger AUC (0.78, p<0.001) was observed when the ROC procedure was applied to the final regression model including DAI-10 and PSP. For the subgroup with informant data, the AUC for the DAI-10 informant version was 0.68 (p=0.021). Non-adherence cannot be properly predicted in the clinical setting on the basis of these instruments alone. The DAI-10 informant questionnaire needs further testing.