Measuring Fidelity to Evidence-Based Practices: Psychometrics.

This special section presents the psychometric properties of fidelity scales used in a national mental health services project in Norway to improve the quality of care of people with psychoses. Across Norway, 39 clinical units in six health trusts participated. The project provided education, implementation support and fidelity assessments. The papers in the section address the psychometrics of fidelity measurement for the specific evidence-based practices: illness management and recovery, family psychoeducation, physical healthcare and antipsychotic medication management. Another paper analyzes the psychometrics of a scale measuring individualization and quality improvement that may be used in conjunction with fidelity scales for specific evidence-based practices. The first paper in the section presents the development and field of fidelity scales, and the two final papers with comments add some additional perspectives and discuss fidelity scales in a wider context. The psychometrics of the five scales were good to excellent. Fidelity assessment is a necessary and effective strategy for quality improvement.

The Family Psychoeducation Fidelity Scale: Psychometric Properties.

This study examined psychometric properties and feasibility of the Family Psychoeducation (FPE) Fidelity Scale. Fidelity assessors conducted reviews using the FPE fidelity scale four times over 18 months at five sites in Norway. After completing fidelity reviews, assessors rated feasibility of the fidelity review process. The FPE fidelity scale showed excellent interrater reliability (.99), interrater item agreement (88%), and internal consistency (mean = .84 across four time points). By the 18-month follow-up, all five sites increased fidelity and three reached adequate fidelity. Fidelity assessors rated feasibility as excellent. The FPE fidelity scale has good psychometric properties and is feasible for evaluating the implementation of FPE programs. Trial registration ClinicalTrials.gov Identifier: NCT03271242.

Psychiatric rehabilitation in Europe.

To describe the core elements of modern psychiatric rehabilitation. Based on selected examples we describe the discussion about values in mental health care with focus on Europe. We present outcome data from studies, which have tried to implement care structures based on this value discussion. In the second half of the 20th century, mental health care in all European and other high-income countries changed conceptually and structurally. Deinstitutionalisation reduced the number of psychiatric beds and transferred priority to outpatient care and community-based services, but community mental health programs developed differently across and within these countries. High-income countries in Europe continued to invest in costly traditional services that were neither evidence-based nor person-centered by emphasising inpatient services, sheltered group homes and sheltered workshops. We argue that evidence-based, person-centred, recovery-oriented psychiatric rehabilitation offers a parsimonious solution to developing a consensus plan for community-based care in Europe. The challenges to scaling up effective psychiatric rehabilitation services in high-income countries are not primarily a lack of resources, but rather a lack of political will and inefficient use and dysfunctional allocation of resources.

New directions for psychiatric rehabilitation in the USA.

American researchers have led the world in developing, evaluating, and disseminating evidence-based psychiatric rehabilitation practices for people with serious mental illness. Paradoxically, however, the USA lags behind most industrialized nations in providing access to high-quality mental health and psychiatric services. This essay examines several evidence-based practices developed in the USA, the spread of these practices, the barriers to ensuring availability to people who could benefit from these services, and some promising directions for overcoming the barriers. Factors influencing the growth and sustainment of effective client-centred practices include the availability of adequate and stable funding, committed leadership, and the influence of vested interests. Two strategies for promoting the spread and sustainment of well-implemented evidence-based practices are the adoption of fidelity scales and learning communities.

Employment and educational outcomes in early intervention programmes for early psychosis: a systematic review.

AIMS: Young adults with early psychosis want to pursue normal roles - education and employment. This paper summarises the empirical literature on the effectiveness of early intervention programmes for employment and education outcomes. METHODS: We conducted a systematic review of employment/education outcomes for early intervention programmes, distinguishing three programme types: (1) those providing supported employment, (2) those providing unspecified vocational services and (3) those without vocational services. We summarised findings for 28 studies. RESULTS: Eleven studies evaluated early intervention programmes providing supported employment. In eight studies that reported employment outcomes separately from education outcomes, the employment rate during follow-up for supported employment patients was 49%, compared with 29% for patients receiving usual services. The two groups did not differ on enrolment in education. In four controlled studies, meta-analysis showed that the employment rate for supported employment participants was significantly higher than for control participants, odds ratio = 3.66 [1.93-6.93], p < 0.0001. Five studies (four descriptive and one quasi-experimental) of early intervention programmes evaluating unspecified vocational services were inconclusive. Twelve studies of early intervention programmes without vocational services were methodologically heterogeneous, using diverse methods for evaluating vocational/educational outcomes and precluding a satisfactory meta-analytic synthesis. Among studies with comparison groups, 7 of 11 (64%) reported significant vocational/education outcomes favouring early intervention over usual services. CONCLUSIONS: In early intervention programmes, supported employment moderately increases employment rates but not rates of enrolment in education. These improvements are in addition to the modest effects early programmes alone have on vocational/educational outcomes compared with usual services.

Treating co-morbid chronic medical conditions and anxiety/depression.

AIMS: This systematic review examines interventions for care of people with co-morbid chronic medical illness and anxiety/depression disorders--a group with high risks for morbidity and mortality. METHODS: Systematic search of Medline 1995 to January 2011 for randomized controlled trials of treatment interventions designed for adult outpatients with diagnosed chronic medical illness (diabetes mellitus, cardiovascular disorders, and chronic respiratory disorders) and anxiety/depression disorders. RESULTS: Six trials studied complex interventions based on the chronic care model, and eight trials studied psychosocial interventions. Most interventions addressed the mental health aspect of the co-morbidity and showed improvements in anxiety/depression but not in the co-morbid medical disorder. CONCLUSIONS: Further research might focus on interventions integrating mental health treatment with enhanced medical care components, incorporating shared-decision making and information technology advances.

A pilot study testing a medication algorithm to reduce polypharmacy.

BACKGROUND: Polypharmacy is common in the treatment of persons with severe mental illness, yet it is not an evidence-based practice. To address this, an attempt was made to reduce medications for patients already receiving polypharmacy during an episode of acute psychiatric hospitalization. METHODS: A medication-reduction algorithm was developed , based on the best available evidence regarding indications for and efficacy of medications and principles of collaborative care. A feasibility pilot study was conducted using a matched case-control design for 12 patients treated with the algorithm and 12 patients treated as usual. RESULTS: The intervention patients were discharged on significantly fewer medications than controls; symptom reduction and length of stay did not differ significantly. CONCLUSION: A collaborative approach to reducing polypharmacy may reverse the trend to add medications during hospitalization.

Edemagenic gain and interstitial fluid volume regulation.

Under physiological conditions, interstitial fluid volume is tightly regulated by balancing microvascular filtration and lymphatic return to the central venous circulation. Even though microvascular filtration and lymphatic return are governed by conservation of mass, their interaction can result in exceedingly complex behavior. Without making simplifying assumptions, investigators must solve the fluid balance equations numerically, which limits the generality of the results. We thus made critical simplifying assumptions to develop a simple solution to the standard fluid balance equations that is expressed as an algebraic formula. Using a classical approach to describe systems with negative feedback, we formulated our solution as a "gain" relating the change in interstitial fluid volume to a change in effective microvascular driving pressure. The resulting "edemagenic gain" is a function of microvascular filtration coefficient (K(f)), effective lymphatic resistance (R(L)), and interstitial compliance (C). This formulation suggests two types of gain: "multivariate" dependent on C, R(L), and K(f), and "compliance-dominated" approximately equal to C. The latter forms a basis of a novel method to estimate C without measuring interstitial fluid pressure. Data from ovine experiments illustrate how edemagenic gain is altered with pulmonary edema induced by venous hypertension, histamine, and endotoxin. Reformulation of the classical equations governing fluid balance in terms of edemagenic gain thus yields new insight into the factors affecting an organ's susceptibility to edema.

Evolving U.S. service model for patients with severe mental illness and co-occurring substance use disorder.

Co-occurring severe mental illness and substance use disorder has been recognized as a common problem in the U.S. since the early 1980s (1-3). For these individuals with co-occurring disorders, research demonstrates the effectiveness of various forms of combining, blending, or integrating mental health and substance abuse treatments (4). The evolving U.S. service model for integrated dual disorders treatment emphasizes several key elements: implementation, leadership, training, engagement, assessment, counseling for all patients, ancillary treatments for those with multiple needs, secondary treatments for patients who are nonresponders, and quality assurance regarding process and outcomes.

Pulmonary edema and elevated left atrial pressure: four hours and beyond.

Cardiogenic pulmonary edema is caused by the increase in left atrial pressure when the left heart fails. The increased pressure causes rapid fluid accumulation within the lung interstitial spaces. However, over the following days to weeks, additional fluid may accumulate due to the deposition of excess lung connective tissue.

Policy implications for implementing evidence-based practices.

The authors describe the policy and administrative-practice implications of implementing evidence-based services, particularly in public-sector settings. They review the observations of the contributors to the evidence-based practices series published throughout 2001 in Psychiatric Services. Quality and accountability have become the watchwords of health and mental health services; evidence-based practices are a means to both ends. If the objective of accountable, high-quality services is to be achieved by implementing evidence-based practices, the right incentives must be put in place, and systemic barriers must be overcome. The authors use the framework from the U.S. Surgeon General's 1999 report on mental health to describe eight courses of action for addressing the gap between science and practice: continue to build the science base; overcome stigma; improve public awareness of effective treatments; ensure the supply of mental health services and providers; ensure delivery of state-of-the-art treatments; tailor treatment to age, sex, race, and culture; facilitate entry into treatment; and reduce financial barriers to treatment.

Reliability of instruments in a cooperative, multisite study: employment intervention demonstration program.

Reliability of well-known instruments was examined in 202 people with severe mental illness participating in a multisite vocational study. We examined interrater reliability of the Positive and Negative Syndrome Scale (PANSS) and the internal consistency and test-retest reliability of the PANSS, the Rosenberg Self-Esteem Scale, the Medical Outcomes Study Short Form-36 (SF-36), and the Quality of Life Interview. Most scales had good levels of reliability, with intraclass correlation coefficients (ICCs) and coefficient alphas above .70. However, the SF-36 scales were generally less stable over time, particularly Social Functioning (ICC = .55). Test-retest reliability was lower among less educated respondents and among ethnic minorities. We recommend close monitoring of psychometric issues in future multisite studies.

Developing effective treatments for posttraumatic disorders among people with severe mental illness.

OBJECTIVE: The purpose of the study was to examine strategies for developing effective interventions for clients who have both serious mental illness and posttraumatic symptoms. METHODS: The authors conducted searches for articles published between 1970 and 2000, using MEDLINE, PsycLIT, and PILOTS. They assessed current practices, interviewed consumers and providers, and examined published and unpublished documents from consumer groups and state mental health authorities. RESULTS AND CONCLUSIONS: Exposure to trauma, particularly violent victimization, is endemic among clients with severe mental illness. Multiple psychiatric and behavioral problems are associated with trauma, but posttraumatic stress disorder (PTSD) is the most common and best-defined consequence of trauma. Mental health consumers and providers have expressed concerns about several trauma-related issues, including possible underdiagnosis of PTSD, misdiagnosis of other psychiatric disorders among trauma survivors, incidents of retraumatization in the mental health treatment system, and inadequate treatment for trauma-related disorders. Despite consensus that trauma and PTSD symptoms should be routinely evaluated, valid assessment techniques are not generally used by mental health care providers. PTSD is often untreated among clients with serious mental illness, or it is treated with untested interventions. It is important that policy makers, service system administrators, and providers recognize the prevalence and impact of trauma in the lives of people with severe mental illness. The development of effective treatments for this population requires a rational, orderly process, beginning with the testing of theoretically grounded interventions in controlled clinical trials.

Requirements for multidisciplinary teamwork in psychiatric rehabilitation.

Psychiatric rehabilitation by its very nature is multidisciplinary because of the many competencies required for its implementation. In promoting optimal levels of recovery from schizophrenia and other disabling mental disorders, teams must combine the expert contributions of professionals and paraprofessionals who can individualize a comprehensive array of evidence-based services with competency, consistency, continuity, coordination, collaboration, and fidelity. The authors describe the properties and functions of the multidisciplinary team and key attributes of effective teams. The importance of teams' involving clients, their relatives, and other supporters in setting personally relevant life goals is emphasized. The authors provide examples of the challenges posed by the need to individualize services and of the ways in which barriers to communication and coordination can be overcome. The roles of the various team members are described, including leadership roles and the unique role of the psychiatrist, in the context of newly emerging, evidence-based treatments for psychiatric rehabilitation.

Managing comorbid schizophrenia and substance abuse.

Effective treatments for co-occurring schizophrenia and substance abuse have emerged over the past 15 years. They involve integration and melding of mental health and substance abuse treatments, helping people to acquire the skills and supports they need to manage both illnesses and to pursue functional goals, and a comprehensive, long-term approach to recovery. Further research is needed to refine specific interventions and to improve knowledge regarding implementing integrated treatment settings in routine mental health programs.

Social patterns of substance use among people with dual diagnoses.

An ethnography, part of the larger New Hampshire Dual Diagnosis Study, discovered in a small subsample (n = 16) that clients participated in 1 (or sometimes 2) of 4 distinct and different social patterns of substance-use. These 4 patterns, (1) "the lone user," (2) "the small, closed social clique," (3) "the large, open user syndicate," and (4) the "entrepreneurial drug provider," manifest important social functions of such substance-use. These social functions need to be taken into account as case managers attempt to persuade clients to abstain from using substances, because changing one's substance-use immediately affects one's participation in these user networks. Case managers can understand the social pressures toward certain patterns of substance-use by attending to the social patterning of that use. Many social functions provided by these social patterns must be continued by other means if clients, once persuaded to attempt abstinence, are to be effectively supported in their sobriety.

Does competitive employment improve nonvocational outcomes for people with severe mental illness?

The authors examined the cumulative effects of work on symptoms, quality of life, and self-esteem for 149 unemployed clients with severe mental illness receiving vocational rehabilitation. Nonvocational measures were assessed at 6-month intervals throughout the 18-month study period, and vocational activity was tracked continuously. On the basis of their predominant work activity over the study period, participants were classified into 4 groups: competitive work, sheltered work, minimal work, and no work. The groups did not differ at baseline on any of the nonvocational measures. Using mixed effects regression analysis to examine rates of change over time, the authors found that the competitive work group showed higher rates of improvement in symptoms; in satisfaction with vocational services, leisure, and finances; and in self-esteem than did participants in a combined minimal work-no work group. The sheltered work group showed no such advantage.