The impact of adverse child and adult experiences on recovery from serious mental illness.

OBJECTIVE: The purpose of this study was to compare effects of adverse childhood experiences and adverse adult experiences on recovery from serious mental illnesses. METHODS: As part of a mixed-methods study of recovery from serious mental illnesses, we interviewed and administered questionnaires to 177 members of a not-for-profit health plan over a 2-year period. Participants had a diagnosis of bipolar disorder, affective psychosis, schizophrenia, or schizoaffective disorder. Data for analyses came from standardized self-reported measures; outcomes included recovery, functioning, quality of life, and psychiatric symptoms. Adverse events in childhood and adulthood were evaluated as predictors. RESULTS: Child and adult exposures to adverse experiences were high, at 91% and 82%, respectively. Cumulative lifetime exposure to adverse experiences (childhood plus adult experiences) was 94%. In linear regression analyses, adverse adult experiences were more important predictors of outcomes than adverse childhood experiences. Adult experiences were associated with lower recovery scores, quality of life, mental and physical functioning and social functioning and greater psychiatric symptoms. Emotional neglect in adulthood was associated with lower recovery scores. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Early and repeated exposure to adverse events was common in this sample of people with serious mental illnesses. Adverse adult experiences were stronger predictors of worse functioning and lower recovery levels than were childhood experiences. Focusing clinical attention on adult experiences of adverse or traumatic events may result in greater benefit than focusing on childhood experiences alone.

Recovery from serious mental illness: trajectories, characteristics, and the role of mental health care.

OBJECTIVE The objective was to identify trajectories of recovery from serious mental illnesses. METHODS A total of 177 members (92 women; 85 men) of a not-for-profit integrated health plan participated in a two-year mixed-methods study of recovery (STARS, the Study of Transitions and Recovery Strategies). Diagnoses included schizophrenia, schizoaffective disorder, bipolar disorder, and affective psychosis. Data sources included self-reported standardized measures, interviewer ratings, qualitative interviews, and health plan data. Recovery was conceptualized as a latent construct, and factor analyses and factor scores were used to calculate recovery trajectories. Individuals with similar trajectories were identified through cluster analyses. RESULTS Four trajectories were identified-two stable (high and low levels of recovery) and two fluctuating (higher and lower). Few demographic or diagnostic factors differentiated clusters at baseline. Discriminant analyses for trajectories found differences in psychiatric symptoms, physical health, satisfaction with mental health clinicians, resources and strains, satisfaction with medications, and mental health service use. Those with higher scores on recovery factors had fewer psychiatric symptoms, better physical health, greater satisfaction with mental health clinicians, fewer strains and greater resources, less service use, better quality of care, and greater satisfaction with medication. Consistent predictors of trajectories included psychiatric symptoms, physical health, resources and strains, and use of psychiatric medications. CONCLUSIONS Having access to good-quality mental health care-defined as including satisfying relationships with clinicians, responsiveness to needs, satisfaction with psychiatric medications, receipt of services at needed levels, support in managing deficits in resources and strains, and care for general medical conditions-may facilitate recovery. Providing such care may improve recovery trajectories.

The recovery group project: development of an intervention led jointly by peer and professional counselors.

OBJECTIVE The objective of this study was to develop and evaluate a low-cost, strengths-based group intervention led jointly by peer counselors and professional counselors to foster recovery among adults with serious mental illnesses. METHODS Cohort 1 included development of materials and a feasibility pilot, with participants recruited from community mental health centers (CMHCs). Cohorts 2 and 3 included a small randomized controlled trial with participants recruited from members of a not-for-profit, integrated health plan. Cohorts 4 and 5 involved evaluation of the most appropriate length for the intervention with a pre-post design that allowed intervention length to vary between 12 and 18 sessions; participants and peer leaders were recruited from two CMHCs (N=82). RESULTS Participants were very satisfied with the recovery-focused group intervention, preferred a greater number of weekly sessions (17 or 18 sessions), and reported improved outcomes across multiple domains. CONCLUSIONS Using peer-developed materials and a combination of peer and professional counselors as group leaders is feasible to offer and valuable to participants. Outcomes measures suggest that the intervention has potential to facilitate recovery in multiple domains.

Understanding how clinician-patient relationships and relational continuity of care affect recovery from serious mental illness: STARS study results.

OBJECTIVE: Recommendations for improving care include increased patient-clinician collaboration, patient empowerment, and greater relational continuity of care. All rely upon good clinician-patient relationships, yet little is known about how relational continuity and clinician-patient relationships interact, or their effects on recovery from mental illness. METHODS: Individuals (92 women, 85 men) with schizophrenia, schizoaffective disorder, affective psychosis, or bipolar disorder participated in this observational study. Participants completed in-depth interviews detailing personal and mental health histories. Questionnaires included quality of life and recovery assessments and were linked to records of services used. Qualitative analyses yielded a hypothesized model of the effects of relational continuity and clinician-patient relationships on recovery and quality of life, tested using covariance structure modeling. RESULTS: Qualitative data showed that positive, trusting relationships with clinicians, developed over time, aid recovery. When "fit" with clinicians was good, long-term relational continuity of care allowed development of close, collaborative relationships, fostered good illness and medication management, and supported patient-directed decisions. Most valued were competent, caring, trustworthy, and trusting clinicians who treated clinical encounters "like friendships," increasing willingness to seek help and continue care when treatments were not effective and supporting "normal" rather than "mentally ill" identities. Statistical models showed positive relationships between recovery-oriented patient-driven care and satisfaction with clinicians, medication satisfaction, and recovery. Relational continuity indirectly affected quality of life via satisfaction with clinicians; medication satisfaction was associated with fewer symptoms; fewer symptoms were associated with recovery and better quality of life. CONCLUSIONS: Strong clinician-patient relationships, relational continuity, and a caring, collaborative approach facilitate recovery from mental illness and improved quality of life.

A multi-site study of Medicaid-funded managed care versus fee-for-service plans' effects on mental health service utilization of children with severe emotional disturbance.

Although Medicaid-funded managed care arrangements are commonly used in the delivery of mental health and substance abuse services to low-income children and youth, little is known about the effectiveness of such efforts. This article examines differences in mental health services utilization between children and youth with severe emotional disturbance covered by Medicaid-funded managed care behavioral health plans and those covered by fee-for-service plans. Data are from a federally funded multi-site study. In multivariate analyses controlling for child and caregiver demographic and clinical factors, enrollment in a managed care behavioral health plan was associated with lower inpatient/residential, psychiatric medication, and nontraditional services utilization. No difference was found in outpatient services utilization. Medicaid-funded managed care behavioral health plans appear to reduce use of some types of mental health services, but it is important to address the question of whether low-income children's enrollment in such programs deprives them of needed services.

Child welfare privatization: quantitative indicators and policy issues.

The purpose of this study was to demonstrate the development of safety, permanency, and child well-being indicators by using administrative data sets as well as by using these indicators as tools for evaluating Florida's Community-Based Care (CBC) initiative. Longitudinal data from 37 counties including 4 counties that implemented community-based care were examined in this study. The results of the study indicated that the overall performance of CBC counties is at least as good as the performance of their comparison run by the state counties. The findings that emerged from this study may provide important lessons for developing a performance measurement system in the child welfare field.

Effects of alcohol and drug use on inpatient and residential treatment among youth with severe emotional disturbance in Medicaid-funded behavioral health care plans.

This study examined the use of alcohol and recreational drugs among 875 youth with severe emotional disturbance (SED) enrolled in Medicaid-funded behavioral health care plans, and whether co-occurring SED and substance use affected the subsequent likelihood of receiving inpatient and/or residential treatment. Youth at five sites nationwide were interviewed about their use of drugs and alcohol, while interviews with their caregivers elicited information about youths' service utilization, degree of functional impairment, and a series of demographic and environmental variables. Results indicated that half of the youth (52%) reported lifetime use of alcohol, street drugs, or over-the-counter medications for recreational purposes, while 18% reported use in the past 30 days. Among those reporting recent use, 32% reported using drugs only, 34% alcohol only, and 33% reported use of both drugs and alcohol. In multivariate logistic regression analyses, the effect of recent use was stronger than that of lifetime use; however, the largest effect occurred for those reporting recent use of both drugs and alcohol, versus either alone, or none. Differences remained significant when controlling for managed care versus fee for service enrollment as well as child, family, and environmental characteristics including study site. These results mirror those of prior studies that found an association between substance use and greater likelihood of inpatient services, even in managed care settings.

Beyond components: using fidelity scales to measure and assure choice in program implementation and quality assurance.

Fidelity scales have become an accepted part of intervention research. Initially, fidelity scales focused on critical components of an intervention. In this paper we argue that the next generation of fidelity scales should include key process variables such as choice. Since choice is an essential element in all empowerment and recovery driven intervention models, a fidelity scale for an enhanced version of the Individual Placement and Support (IPS) supported employment model that incorporates choice as a fundamental component was developed as part of a SAMHSA community action grant. The process for developing the choice component and the dimensions measured are also described.