Decrease in unmet needs contributes to improved motivation for treatment in elderly patients with severe mental illness.

PURPOSE: To investigate the pattern of associations between changes in unmet needs and treatment motivation in elderly patients with severe mental illness. METHODS: Observational longitudinal study in 70 patients treated by an assertive community treatment team for the elderly. Unmet needs and motivation for treatment were measured using the Camberwell assessment of needs for the elderly and the stages-of-change (SoC) scale, respectively, at baseline, after 9 and 18 months. SoC scores were dichotomized into two categories: motivated and unmotivated. Multinomial logistic regression analyses were conducted to determine whether changes in motivation were parallel to or preceded changes in unmet needs. RESULTS: The number of patients who were not motivated for treatment decreased over time (at baseline 71.4 % was not motivated, at the second measurement 51.4 %, and at 18 months 31.4 % of the patients were not motivated for treatment). A decrease in unmet needs, both from 0-9 to 0-18 months was associated with remaining motivated or a change from unmotivated to becoming motivated during the same observational period (parallel associations). A decrease in unmet needs from 0 to 9 months was also associated with remaining motivated or a change from unmotivated to motivated during the 9-18 months follow-up (sequential associations). CONCLUSIONS: Our findings suggest that a decrease in unmet needs is associated with improvements in motivation for treatment.

The effectiveness of assertive community treatment for elderly patients with severe mental illness: a randomized controlled trial.

BACKGROUND: Due to fragmented mental, somatic, and social healthcare services, it can be hard to engage into care older patients with severe mental illness (SMI). In adult mental health care, assertive community treatment (ACT) is an organizational model of care for treating patients with SMI who are difficult to engage. So far all outcome studies of assertive community treatment have been conducted in adults. METHODS: In a randomized controlled trial design we compared the effectiveness of ACT for elderly patients with that of treatment as usual (TAU). Sixty-two outpatients (60 years and older) with SMI who were difficult to engage in psychiatric treatment were randomly assigned to the intervention or control group (32 to ACT for elderly patients and 30 to TAU). Primary outcomes included number of patients who had a first treatment contact within 3 months, the number of dropouts (i.e. those discharged from care due to refusing care or those who unintentionally lost contact with the service over a period of at least 3 months); and patients' psychosocial functioning (HoNOS65+ scores) during 18 months follow-up. Secondary outcomes included the number of unmet needs and mental health care use. Analyses were based on intention-to-treat. RESULTS: Of the 62 patients who were randomized, 26 were lost to follow-up (10 patients in ACT for elderly patients and 16 in TAU). Relative to patients with TAU, more patients allocated to ACT had a first contact within three months (96.9 versus 66.7%; X2 (df = 1) = 9.68, p = 0.002). ACT for elderly patients also had fewer dropouts from treatment (18.8% of assertive community treatment for elderly patients versus 50% of TAU patients; X2 (df = 1) = 6.75, p = 0.009). There were no differences in the other primary and secondary outcome variables. CONCLUSIONS: These findings suggest that ACT for elderly patients with SMI engaged patients in treatment more successfully. TRIAL REGISTRATION: NTR1620.

Lack of motivation for treatment associated with greater care needs and psychosocial problems.

OBJECTIVE: To compare the care needs and severity of psychosocial problems in older patients with severe mental illness (SMI) between those who were and were not motivated for treatment. METHODS: Cross-sectional study in which we enrolled 141 outpatients with SMI aged 55 and older. Needs were measured using the Camberwell Assessment of Needs for the Elderly, and psychosocial problems with the Health of the Nation Outcome Scale 65+. Motivation for treatment was assessed using a motivation-for-change scale. Parametric and non-parametric tests were used to analyze differences between motivated and non-motivated patients. Explorative logistic regression analyses were used to establish, which unmet needs were associated with motivation. RESULTS: Less-motivated patients had greater unmet care needs and more psychosocial problems than those who were motivated. Logistic regression analyses showed that lack of motivation was associated with greater unmet needs regarding daytime activities, psychotic symptoms, behavioral problems, and addiction problems. CONCLUSIONS: Lack of treatment motivation was associated with more unmet needs and more severe psychosocial problems. Further research will be needed to identify other factors associated with motivation in older people with SMI and to investigate whether this group of patient benefits from interventions such as assertive outreach, integrated care or treatment-adherence therapy.

Assertive community treatment for elderly people with severe mental illness.

BACKGROUND: Adults aged 65 and older with severe mental illnesses are a growing segment of the Dutch population. Some of them have a range of serious problems and are also difficult to engage. While assertive community treatment is a common model for treating difficult to engage severe mental illnesses patients, no special form of it is available for the elderly. A special assertive community treatment team for the elderly is developed in Rotterdam, the Netherlands and tested for its effectiveness. METHODS: We will use a randomized controlled trial design to compare the effects of assertive community treatment for the elderly with those of care as usual. Primary outcome measures will be the number of dropouts, the number of patients engaged in care and patient's psychiatric symptoms, somatic symptoms, and social functioning. Secondary outcome measures are the number of unmet needs, the subjective quality of life and patients' satisfaction. Other secondary outcomes include the number of crisis contacts, rates of voluntary and involuntary admission, and length of stay. Inclusion criteria are aged 65 plus, the presence of a mental disorder, a lack of motivation for treatment and at least four suspected problems with functioning (addiction, somatic problems, daily living activities, housing etc.). If patients meet the inclusion criteria, they will be randomly allocated to either assertive community treatment for the elderly or care as usual. Trained assessors will use mainly observational instruments at the following time points: at baseline, after 9 and 18 months. DISCUSSION: This study will help establish whether assertive community treatment for the elderly produces better results than care as usual in elderly people with severe mental illnesses who are difficult to engage. When assertive community treatment for the elderly proves valuable in these respects, it can be tested and implemented more widely, and mechanisms for its effects investigated. TRIAL REGISTRATION: The Netherlands National Trial Register NTR1620.