Schizophrenia in the Elderly Population

A Comparison of Assertive Community Treatment and Intensive Case Management for Patients in Rural Areas

Initiation of Assertive Community Treatment Among Veterans With Serious Mental Illness: Client and Program Factors

Effect of PACT on Inpatient Psychiatric Treatment for Adolescents With Severe Mental Illness: A Preliminary Analysis

Introduction Chronic and transient loneliness are two clinically distinct conditions that have different impacts on mental health. However, there is limited information regarding the prevalence of chronic and transient loneliness, and their associated risk factors. Objectives This study aims to (1) assess the prevalence of chronic and transient loneliness among Spanish adults, (2) identify and compare the risk factors associated with both forms of loneliness, (3) examine how perceptions of loneliness contribute to its persistence, and (4) evaluate the effects of chronic versus transient loneliness on depression, anxiety, and substance use disorders. Methods A total of 1,503 Spanish adults were interviewed by phone from May to June 2024. Loneliness was measured with a direct question, and the three-item loneliness scale from the University of California, Los Angeles, was used for the sensitivity analyses. Chronic loneliness was defined as reported loneliness both two years ago and currently, while transient loneliness was defined as reported loneliness only two years ago. The CAGE Adapted to Include Drugs (CAGE-AID) questionnaire was used to assess substance use disorder within the previous month, anxiety symptoms were measured using the GAD-2, and depressive symptoms were assessed using the PHQ-2. Logistic regression models were constructed to examine sociodemographic and behavioral risk factors for chronic and transient loneliness, as well as the impact of loneliness perceptions on the likelihood of chronicity and the association of both types of loneliness with mental disorders. Results 11.4% of the sample reported chronic loneliness, while 9.5% reported transient loneliness. Risk factors associated with chronic loneliness included being a younger adult, female, living alone or with roommates, having low education level, and poor health status. In contrast, the risk factors for transient loneliness included being single or separated and frequent use of social media. Poor social support was a risk factor for both types of loneliness, though it had a significantly stronger impact on chronic loneliness (OR = 10.1, 95% CI: 5.5–18.4) compared to transient loneliness (OR = 2.2, 95% CI: 1.2–3.8). Feelings of emptiness (OR = 2.7, 95% CI: 1.4–5.4) and perceiving loneliness as insurmountable (OR = 2.6, 95% CI: 1.4–4.6) were risk factors for chronicity among individuals feeling loneliness. Sensitivity analyses showed similar results to the main findings. Only chronic loneliness was longitudinally associated with higher odds of depression (OR = 5.0, 95% CI: 3.4–7.4), anxiety (OR = 3.1, 95% CI: 1.3–4.1), and substance use disorder (OR = 3.6, 95% CI: 1.9–6.6). Conclusions Chronic loneliness can be identified through its risk factors and the perceptions of those experiencing it, highlighting the importance of addressing these issues to improve mental health outcomes. Disclosure of Interest None Declared

Review objective The objective of this review is to synthesize the best available evidence on the effectiveness of psychological and psychosocial interventions on quality of life (QoL) of patients with schizophrenia and related disorders. Review questions In patients with schizophrenia and related disorders: what is the effect of a psychological intervention as compared to usual care on QoL? what is the effect of a psychological intervention as compared to another psychological or psychosocial intervention on QoL? what is the effect of a psychosocial intervention as compared to usual care on QoL? what is the effect of a psychosocial intervention as compared to another psychosocial intervention or psychological intervention on QoL? Inclusion criteria Types of participants This review will consider studies that include patients with schizophrenia or related disorders (schizotypal and delusional disorders) in all stages of their illness and in all treatment settings. We will include studies where the majority of participants are adults (18 years or over) and were the majority of participants have a diagnosis of schizophrenia or a related disorder (schizotypal disorder, persistent delusional disorder, F20-F22; schizoaffective disorder, F-25) based on International Statistical Classification of Diseased and related health Problems 10 th Revision (ICD-10). Types of interventions This review will consider studies that evaluate psychological or psychosocial interventions. Included interventions will be family interventions, psychoeducation / patient education, cognitive-behavioral therapy, cognitive remediation, social skills training, and supported employment / vocational rehabilitation. These interventions are most often recommended in practice guidelines for the treatment of patients with schizophrenia 16,17,18,19 . The format of the intervention may be individual or group-based. The providers of interventions may include nurses, physicians, psychologists, social workers or other allied health providers. The control comparison will be any other psychological or psychosocial intervention or standard care (also called “treatment as usual”) defined as the care a person would normally receive if they would not been included in the research. Standard care includes any appropriate mental health care as deemed necessary by the clinician without program of the types described above. Types of outcomes This review will consider studies that include QoL as an outcome measure. Studies will be reviewed for evidence of standardized valid and reliable tools measuring subjective QoL, such as the Quality of Life Scale, the World Health Organization Quality of Life, the Lehmans Quality of Life Interview or the Manchester Short Assessment of Quality of Life.

Back to table of contents Previous article Next article Professional NewsFull AccessSuccessful ACT Programs Share Key ElementsAaron LevinAaron LevinSearch for more papers by this authorPublished Online:1 Jun 2012https://doi.org/10.1176/pn.47.11.psychnews_47_11_9-aAbstractPractical steps to measure and ensure the quality of assertive community treatment (ACT) programs are supported by scarce evidence, but a multi-pronged approach may help maintain ACT team quality and program fidelity until firmer ground is reached.“[N]o single strategy is sufficient for ensuring adequate ACT implementation and services of consistently good quality,” said Maria Monroe-DeVita, Ph.D., director of the Washington Institute for Mental Health Research and Training and an acting assistant professor of psychiatry at the University of Washington School of Medicine, and colleagues in Psychiatric Services in Advance, published online April 15.ACT programs have reported largely positive outcomes since their development 35 years ago, Monroe-DeVita and colleagues noted. These include fewer psychiatric hospitalizations, better retention in treatment, better housing stability, and more. However, programs show a mixed record in meeting basic standards over time, and that might be worrisome, said the authors. “[I]nadequate model implementation suggests less-effective services.”In practice, numerous problems cause difficulties in maintaining fidelity to program ideals, said Robert Kiesling, M.D., medical director of Pathways to Housing in Washington, D.C., which operates four ACT teams. He was not involved with Monroe-DeVita’s research.“It takes time to get up and running,” said Kiesling in an interview with Psychiatric News. “We have challenging patients with long histories of mental illness and chronic general medical ailments, and staff burnout is a fact of life.”Monroe-DeVita and colleagues reviewed 57 articles published from 2000 to 2011, dividing them into four strategies that the programs use to maintain quality:Policy and administration: “ACT programs need clearly defined practice standards,” they said, noting that several states have already mandated such standards. Licensing or certifying ACT programs is another way to hold programs to their original ideals. Adequate funding is critical, especially in a program’s early years, when start-up and recruitment costs are greater than reimbursements. “Funding strategies that support outreach efforts to consumers who may be difficult to locate or engage in services … are particularly crucial for ACT teams,” they said.Training and consultation: Practice-based training and supervision are also important, said Monroe-DeVita and colleagues. “Even mature ACT teams … will often require ongoing, periodic consultation and training, especially given the high rate of turnover among staff at community mental health programs.”ACT programs do need an outside look, said Kiesling. “Funders have a vested interest in how the organization is functioning.”Team operations: Finding the right mixture of clinical skills, street smarts, pragmatism, and persistence is necessary but never easy, said the authors. “Experience in traditional office-based mental health programs is not necessarily a good predictor of success as an ACT team member, because ACT involves extensive outreach.”When Pathways to Housing hires new staff, for example, it conducts an extensive interview process, but the candidate also spends time with the team as members work in the community, said Kiesling. Once on board, new hires spend two to three weeks taking didactic courses (like the D.C. Department of Mental Health’s day-long training) and shadowing staff on their rounds.Program evaluation: “ACT teams rarely collect outcome data,” they noted. But they emphasized that staff should gather and evaluate regular measurements of frequency, duration, and type of services provided, along with consumer outcomes like employment, housing, symptom reduction, and psychiatric hospitalization.Doing research at his program would require a full-time staff person, something Pathways to Housing can’t afford now, said Kiesling. Keeping up with the documentation required by insurers or Medicaid is time-consuming enough, he noted.These approaches should be seen as “working hypotheses” for the moment, said the authors. “Additional rigorous research on implementing and sustaining the quality of ACT and other evidence-based practices is needed.” “Program Fidelity and Beyond: Multiple Strategies and Criteria for Ensuring Quality of Assertive Community Treatment” is posted at http://ps.psychiatryonline.org/Article.aspx?ArticleID=1103903. ISSUES NewArchived

Recovery From Schizophrenia: A Concept in Search of Research

Early onset psychosis (EOP), referring to psychosis with onset before the age of 18 years, is a more severe form of psychosis associated with worse prognosis. While medication is the treatment of choice, psychological interventions are also considered to have an important role in the management of symptoms and disability associated with this condition. The present review aimed to explore the effectiveness of such interventions. An electronic search was conducted on the Embase, Medline, and PsychInfo databases for papers of randomized controlled trials (RCTs) referring to psychological interventions in EOP. References of identified papers were hand searched for additional studies. Identified studies were quality assessed. Eight studies were included in the present review evaluating cognitive remediation therapy (CRT), cognitive behavioural therapy (CBT), a family intervention and psychoeducation. CRT was associated with improvement in cognitive function and CBT and CRT seem to also have a positive effect in psychosocial functioning. Symptom reduction appears to not be significantly affected by the proposed treatments. There is some evidence supporting the effectiveness of psychological interventions in EOP. However, most research on adolescents is focused on CRT and its effects on cognitive deficits. More studies on the effects of psychological interventions in EOP are needed.

Three types of case management were compared to determine their relative effectiveness in helping people with severe mental illness who were homeless or at risk of homelessness. Subjects recruited from a psychiatric emergency room and inpatient units were randomly assigned to one of the three treatment conditions: broker case management, in which the client's needs were assessed, services were purchased from multiple providers, and the client was monitored; assertive community treatment only, in which comprehensive services were provided for an unlimited period; and assertive community treatment augmented by support from community workers, who assisted with activities of daily living and were available for leisure activities. Of 165 subjects recruited, 135 were followed for 18 months. Compared with clients assigned to broker case management, clients assigned to assertive community treatment only and assertive community treatment with community workers had superior outcomes on several variables. They were number of contacts with the assigned treatment program, resource utilization (for example, use of entitlements), severity of thought disorder, activity level, and client satisfaction. Clients in the assertive community treatment only condition achieved more days in stable housing than those in the other two treatment conditions. No significant treatment group effects were found on income, self-esteem, or substance abuse. Assertive community treatment is superior to broker case management in assisting individuals with serious mental illness who are at risk of homelessness.

ABSTRACTEngagement of individuals with serious mental illnesses in community mental health services is a significant challenge. The Program of Assertive Community Treatment (PACT) is an individual-centered and self-contained mental health program that provides psychiatric treatment, rehabilitation, and support services to persons with serious mental illness who have a history of or likelihood of disengagement with services. Understanding what helps and hinders consumers’ involvement in PACT services may provide information on how to tailor engagement strategies to individuals based on their treatment needs and preferences. The current study builds on existing studies by exploring factors that help and hinder engagement in PACT services from the perspectives of individuals receiving treatment. We conducted open-ended, semi-structured interviews with 17 individuals receiving PACT services. Nine themes were identified through thematic analysis: Desirable qualities of PACT, Focusing on positive outcomes, PACT as a safety net, Recovery orientation, Practical barriers, Conflictual relationships, and Medication side-effects. We conclude that the development of a trusting, therapeutic relationship that is collaborative and person-centered and that is facilitated by both practical and emotional support is critical to engaging individuals in treatment and maximizing positive outcomes.

This article presents fidelity outcomes for five evidence-based practices that were implemented in routine public mental health settings in the National Implementing Evidence-Based Practices Project. Over a two-year period 53 community mental health centers across eight states implemented one of five evidence-based practices: supported employment, assertive community treatment, integrated dual disorders treatment, family psychoeducation, and illness management and recovery. An intervention model of practice dissemination guided the implementation. Each site used both human resources (consultant-trainers) and material resource (toolkits) to aid practice implementation and to facilitate organizational changes. External assessors rated fidelity to the evidence-based practice model every six months from baseline to two years. More than half of the sites (29 of 53, or 55%) showed high-fidelity implementation at the end of two years. Significant differences in fidelity emerged by evidence-based practice. Supported employment and assertive community treatment had higher fidelity scores at baseline and across time. Illness management and recovery and integrated dual disorders treatment had lower scores on average throughout. In general, evidence-based practices showed an increase in fidelity from baseline to 12 months, with scores leveling off between 12 and 24 months. Most mental health centers implemented these evidence-based practices with moderate to high fidelity. The critical time period for implementation was approximately 12 months, after which few gains were made, although sites sustained their attained levels of evidence-based practice fidelity for another year.

IntroductionAs part of the intervention, patients with severe schizophrenia who are cared for in psychiatric rehabilitation units need psychological treatments. However, there is great variability within the psychotherapy alternatives that are proposed for rehabilitation in schizophrenia, and it is necessary to know which are the most efficient interventions in order to prioritize their inclusion in intervention programs.ObjectivesTo know the level of evidence of the existing psychotherapy alternatives for the rehabilitation treatment in schizophrenia through the systematic review of recently published studies.MethodsConsecutive systematic searches in the scientific literature were used in a sensitive and specific way, aimed at identifying the existence of documents in databases and clinical practice guidelines based on evidence of psychological treatment in schizophrenia. Psychosocial and social approaches and family members interventions were excluded, and the search was limited to the last 5 years. The PICO format has been used, and a subsequent critical reading using the AGREE II tool, considering the inclusion criteria of presenting a score >60% in 4 domains.ResultsThe following interventions have been found to be therapeutically effective: Level 1B (Early intervention in Psychosis; Patient and Family psychoeducational intervention; Basic ando social skills training; Social cognition and Metakognition training; Cognitive Remediation; Cognitive Behavioral Individual Therapy; Assertive Community treatment; Supported employment). Level 2B (Family Problem Solving Therapy, Dynamic Psychotherapy; Cognitive Behavioral Group Therapy); Level 2C (Horticultural, Art, Music, Animals Therapies).ConclusionsSeveral psychotherapy alternatives are proposed for rehabilitation in schizophrenia, with known level of evidenca in order to prioritize their inclusion in intervention programs.Disclosure of InterestNone Declared

Treatment of internalizing disorders in youth often entails a multimodal approach, including pharmacotherapy, psychotherapy, and systems-based intervention in familial, school, and social settings. Prior to selecting appropriate treatments, a comprehensive, lifetime assessment employing multiple informants (youth, parents, teachers) and methods (questionnaires, semi-structured evaluation, clinical interview) should be conducted. Given the high rate of co-occurrence of multiple internalizing disorders, comorbidity of mood and anxiety with other psychiatric problems, and symptom overlap across diagnostic categories, thorough assessment taking into account differential diagnoses is essential. Following evaluation, treatment selection should be based on the primary presenting problem, degree of impairment, and current evidence. For moderate-to-severe adolescent depression, a combination of cognitive-behavioral therapy (CBT) with pharmacotherapy (e.g., selective serotonin reuptake inhibitors [SSRIs]) has the strongest empirical base. Mounting evidence also supports the use of CBT and interpersonal therapy (IPT) as monotherapies for depressed youth. CBT for depression involves identifying and challenging cognitive distortions, behavioral activation, problem solving, and emotion regulation, while IPT aims to reduce interpersonal conflict via interpersonal problem-solving and communication skills. For pediatric bipolar disorders, family psychoeducation about the etiology, course, and treatment of mood disorders, plus skill building (problem solving, CBT, communication, emotion regulation), should be employed adjunctive to pharmacotherapy. Finally, for anxiety disorders, various forms of CBT have demonstrated efficacy. Typically, use of SSRIs concurrently with CBT offers additional benefit for anxious youth. Though the format and focus of CBT varies depending on the specific anxiety disorder, most interventions involve psychoeducation, emotion identification and management strategies, cognitive restructuring, exposure, and familial involvement. Recent preliminary research also supports the use of other psychotherapies (e.g., attachment-based family therapy, parent-child interaction therapy, attention bias modification training) and healthy lifestyle changes (e.g., sleep, diet, exercise). In conclusion, CBT-based treatments currently have the most empirical support, and should be considered first-line psychosocial interventions for pediatric internalizing disorders.

The aim of this study was to develop indicators of conformance in clinical practice with guidelines for care in schizophrenia. Recommended guidelines rarely apply to all patients and need to allow for social ability, family context, and phase of the disorder. These indicators were therefore devised for tailoring to patient characteristics and allowing for factors that may justify the lack of adherence to clinical guidelines. A team of senior clinicians and methodologists reviewed three clinical guidelines (from the Schizophrenia Patient Outcomes Research Team, McEvoy and colleagues, and the National Institute for Health and Clinical Excellence) and defined criteria for their operationalization into clinical indicators. For each indicator, the team defined criteria for eligibility (requirements to be met to qualify for evaluation), conformance (criteria to be satisfied to comply with each recommendation), and moderators (factors that could justify the lack of application of a given recommendation). These indicators were tested with a random sample of 807 patients with schizophrenia or schizoaffective disorders in outpatient facilities, long-term residential facilities, and hospital units for acute care in the Piedmont region of Italy. A set of 15 indicators was derived, nine concerning pharmacological treatment and six for general care and psychosocial rehabilitation. Moderators such as patient or family refusal of antipsychotic treatment and the patient's level of disability helped to justify a considerable proportion of nonconformant care. The indicators developed are a simple and useful tool to monitor the conformance of care with recommended practices and to identify areas needing improvement.

Adapting the assertive community treatment (ACT) for the needs of different communities: A comparative case study of KUINA ACT Japan and Mt. Sinai ACT Canada