Research

3 Paper Study of rehabilitation services

In-patient psychiatric rehabilitation services: survey of service users in three metropolitan boroughs | The Psychiatrist | Cambridge Core

The DEMoBinc Study (Development of a European Measure of Best Practice for People with Long Term Mental Illness in Institutional Care)

The DEMoBinc Study was funded by the European Commission to develop a toolkit to assess the quality of longer-term mental health care facilities. The study was led by Professor Helen Killaspy (University College London) and involved ten European countries. It produced the Quality Indicator for Rehabilitative Care (QuIRC) which is available as an on-line quality assessment tool completed by the manager of any longer-term mental health care unit (community or hospital-based). The content of the QuIRC was derived from:

1. A review of the published literature on the most effective components of care provided in these facilities.
2. A Delphi expert consensus exercise with service users, carers, advocates and mental health professionals.
3. An international review of care standards in these settings.
4. Review by an international panel of experts on mental health care quality. 

The QuIRC was validated against service user experiences of care and its psychometric properties were found to be excellent. It is free to use and takes around 60 minutes to complete. It is available here and provides a printable report of the unit’s performance showing its percentage scores, and those of similar units across the same country, on seven domains of care:

• living environment
• therapeutic environment
• treatments and interventions
• self-management and autonomy
• human rights
• social inclusion; recovery-based practice.

The QuIRC has been incorporated into the Royal College of Psychiatrists’ Centre for Quality Improvement peer accreditation programme (AIMS-Rehab) and a national programme of research in England investigating mental health rehabilitation services (the REAL study).

• Killaspy, H., White, S., Wright, C. et al (2012). Association between service user experiences and staff rated quality of care in European facilities for people with longer term mental health problems. PLoS One 7(6): e38070.doi:10.1371/journal.pone.0038070
• Killaspy, H., White, S., Wright, C. et al (2011). The Development of the Quality Indicator for Rehabilitative Care (QuIRC): a Measure of Best Practice for Facilities for People with Longer Term Mental Health Problems. BMC Psychiatry 11:35
• Turton, P., Wright, C., White, S. et al (2011). Promoting recovery in long term mental health institutional care: an international Delphi study. Psychiatric Services, 61(3), 293-299
• Taylor, T., Killaspy, H., Wright, C. et al (2009). A  systematic review of the international published literature relating to quality of institutional care for people with longer term mental health problems. BMC Psychiatry, 9: 55

The REFOCUS Study

This five-year programme funded by the National Institute for Health Research aimed to improve the implementation of recovery orientated practice in community mental health services. The programme included a systematic literature review to build a theory based  conceptualisation of recovery, a large survey of staff and service users to assess current practice, the development of a staff training programme to improve recovery orientated practice, and a trial to assess the efficacy of the training. The project developed the concept of personal recovery into the CHIME framework (connectedness, hope, identity, meaning, empowerment) but the staff training was not found to be effective. 

• Leamy M, Bird V, Le Boutillier C, Williams J, Slade M (2011) A conceptual framework for personal recovery in mental health: systematic review and narrative synthesis, British Journal of Psychiatry, 199, 445-452
• Slade M, Bird V, Clarke E, Le Boutillier C, McCrone P, Macpherson R, Pesola F, Wallace G, Williams J, Leamy M (2015) Supporting recovery in patients with psychosis using adult mental health teams (REFOCUS): a multi-site cluster randomised controlled trial, Lancet Psychiatry, 2, 503-514
• Research into recovery

Study of Irish mental health rehabilitation services 

This study was funded by the Irish Mental Health Commission and led by Dr Ena Lavelle (past Chair, Rehabilitation Faculty, Irish College of Psychiatry) to survey rehabilitation services and their clients in Ireland. Outcomes for service users who did and did not have access to rehabilitation services in five geographical areas were assessed and compared over 18 months.

The main findings were that those receiving rehabilitation were eight times more likely to succeed in community living than those awaiting rehabilitation and had greater improvement in social functioning. No specific interventions predicted better outcomes, but those with greater unmet needs, substance misuse and more challenging behaviours fared worse. (Lavelle, E., Ijaz, A., Killaspy, H.et al (2011).

Mental Health Rehabilitation and Recovery Services in Ireland: a multicentre study of current service provision, characteristics of service users and outcomes for those with and without access to these services. Final Report for the Mental Health Commission of Ireland, 2011)

The REAL (Rehabilitation Effectiveness for Activities for Life) Study

The REAL Study was a five-year research programme funded by the National Institute of Health Research and led by Professor Helen Killaspy (University College London). It comprised: 

1. A national survey of all NHS inpatient mental health rehabilitation services across England 
2. Development of a training intervention for front-line staff of inpatient mental health rehabilitation units to facilitate service users’ engagement in activities 
3. A cluster randomised controlled trial involving 40 inpatient rehabilitation units to assess the clinical and cost-effectiveness of the staff training intervention; 

4. A naturalistic cohort study involving 50 rehabilitation units investigating outcomes over one year for service users of inpatient rehabilitation units.

The study found that NHS inpatient mental health rehabilitation services successfully support the recovery of the majority of service users with complex needs, but the staff training intervention did not increase service users’ engagement in activities. Download The Rehabilitation Effectiveness for Activities for Life (REAL) study: a national programme of research into NHS inpatient mental health rehabilitation services across England.

Longitudinal outcomes of mental health rehabilitation in North London

This cohort study followed 141 service users within a mental health rehabilitation service in North London over five years. Findings were that two-thirds achieved and/or sustained successful community living, with 10% achieving completely independent living.  Service users who had any recorded episode of medication non-adherence were eight times less likely to achieve/maintain community tenure. (Killaspy H, Zis P. Predictors of outcomes of mental health rehabilitation services: a 5-year retrospective cohort study in inner London, UK. SPPE. June 2013, Volume 48, Issue 6, pp 1005-1012. doi 10.1007/s00127-012-0576-8)

Longitudinal outcomes of long-stay psychiatric inpatients

This cohort study of long-stay psychiatric inpatients, regarded as unsuitable for community placement, reported that whilst level of functioning and social behaviour showed minimal change after 1 year, it improved over the following 4 years. Problematic behaviours reduced significantly over 5 years with physical aggression practically disappearing. This enabled 40% to be resettled in various care homes, gaining better access to community amenities and living more independently. (Trieman N. & Leff J. (2002). Long term outcome of long-stay psychiatric inpatients considered unsuitable to live in the community TAPS project 44.  British Journal of Psychiatry, 181, 428-432)

Longitudinal outcomes of persons with psychotic illness 

This historic prospective study of outcome over 15- and 25-year illness trajectory found about 50% of surviving cases having favourable outcomes.  Early (2-year) course patterns were the strongest predictor of 15-year outcomes. Sociocultural conditions appeared to modify long-term course. (Harrison G, Hopper K, Craig T, et al (2001) Recovery from psychotic illness: a 15-and 25-year international follow-up study.  British Journal of Psychiatry, 178, 506-517.)

Longitudinal outcomes of long stay in patients in the community 

This cohort study followed several hundred long-stay patients after 1- and 5-years in the community. Whilst there was no change in clinical state or problems of social behaviour, they gained domestic and community living skills and acquired friends and confidants. The great majority wanted to remain in the freer conditions of their current homes. It was concluded that community care had enhanced the quality of life of this cohort involved in this well-planned and adequately resourced programme. (Leff J and Treiman N (2000).  Long-stay patients discharged from hospitals. British Journal of Psychiatry, 176, 319-323)

Longitudinal outcomes persons with psychosis in the Netherlands 

This cohort study followed 82 clients with a functional psychotic illness over 15-years, the study revealed a pattern of chronicity and relapse with a high suicide risk; two-thirds had at least one relapse and after each relapse one of six did not achieve remission. 10% committed suicide. Insidious onset and delays in mental health treatment predicted a longer duration of first and subsequent episodes. The importance of early treatment and relapse prevention programmes was highlighted. (Wiersma D, Nienhuis F. Sloof C, et al (1998).  Natural course of schizophrenic disorders:  a 15-year follow-up of a Dutch incidence cohort.  Schizophrenia Bulletin 24, 75-85)

NICE guidelines on mental health rehabilitation

This article summarizes the first guideline from the National Institute for Health and Care Excellence (NICE) of mental health rehabilitation for adults with complex psychosis. It described how to identify people who should be offered rehabilitation, what rehabilitation services should be provided within the local mental health service, and the treatment programmes that these services should offer (Killaspy H, Baird G, Bromham N, Bennett A. Rehabilitation for adults with complex psychosis: summary of NICE guidance. BMJ 2021; 372 )

The Effectiveness of Mental Health Rehabilitation Services 

This systematic review of quantities studies considered the effectiveness of inpatient and community rehabilitation services. The strongest evidence was for services for homeless people. Access to inpatient rehabilitation services was associated with a reduction in acute inpatient service use post discharge. However fewer than one-half of people moved on from higher to lower levels of supported accommodation within expected timeframes. The review called for more high-quality research of contemporary rehabilitation services. (Dalton-Locke C, Marston L, McPherson P, Killaspy H. The Effectiveness of Mental Health Rehabilitation Services: A Systematic Review and Narrative Synthesis; Frontiers in Psychiatry, 2021 (11): 607933.

• Killaspy H, Bebbington P, Blizard R. et al (2006) REACT: A Randomised Evaluation of Assertive Community Treatment in North London.  BMJ, 332, 815-819.
• McCrone P, Killaspy H, Bebbington P, Johnson S, Nolan F, Pilling S, King M. (2009). The REACT Study: Cost-Effectiveness of Assertive Community Treatment in North London. Psychiatric Services. 60, 908-913

Meta-analysis and reviews  of supported employment outcomes

• Modini M, Tan L, Brinchmann B, Wang MJ, Killackey E, Glozier N, Mykletun A, Harvey SB. Supported employment for people with severe mental illness: systematic review and meta-analysis of the international evidence. The British Journal of Psychiatry. 2016 Jul;209(1):14-22.
• Twamley E.W, Jeste D.V, and Lehman A.F. (2003).  Vocational rehabilitation in schizophrenia and other psychotic disorders: A literature review and meta-analysis of randomized controlled trials. The Journal of Nervous and Mental Disease, 191, 515-523.
• Crowther R.E, Marshall M, Bond G.R & Huxley P (2001).  Helping people with Severe Mental Illness to obtain work: systematic review. British Medical Journal 322 204-208.

Employment outcomes of Individual Placement, and Support (IPS) within Supported Housing settings  

This study compared feasibility and employment outcomes of IPS being delivered within supported housing services, with its implementation through mental health treatment settings in the Netherlands. Supported housing services had better connections with employers which facilitated more rapid job searching and greater diversity in employment opportunities, however the average total client employment rate did not significantly differ (Roeg D, de Winter L, Bergmans C, Couwenbergh C, McPherson P, Killaspy H, van Weeghel J. IPS in Supported Housing: Fidelity and Employment Outcomes Over a 4 Year Period. Frontiers in Psychiatry, 2021 (11): 622061 

The QUEST Study (Quality and Effectiveness of Supported Tenancies for people with mental health problems)

The QEST Study was a five year programme of research funded by the National Institute of Health Research led by Professor Helen Killaspy (University College London). It comprised:

1. Adaptation of the Quality Indicator for Rehabilitative Care for use in supported accommodation (QuIRC-SA)
2. A national survey of supported accommodation services in 12 geographically representative regions of England.
3. A cohort study investigating outcomes for clients of supported accommodation services over 30 months.
4. In-depth qualitative investigation of staff and service users’ experiences of supported accommodation.

5. A feasibility trial comparing two existing models of supported accommodation – supported housing (staff on-site, time-limited tenancies) and floating outreach (visiting staff, time unlimited tenancies).

This research programme found mixed evidence on different models of mental health supported accommodation but conducting a randomised trial to assess effectiveness of different models was not feasible. Download the report: Supported accommodation for people with mental health problems: the QuEST research programme with feasibility RCT

Review of outcomes of supported accommodation services

This systematic review of individuals living within supported accommodation found mixed psychosocial outcomes reflecting the heterogeneity of the studies, service types and outcomes assessed. Most robust evidence supported the permanent supported accommodation model for homeless SMI in generating improvements in housing stability and appropriate use of clinical services, and for other forms of supported accommodation for deinstitutionalised populations in reducing hospitalisation rates and improving appropriate service use. (McPherson P, Krotofil J, Killaspy H. Mental health supported accommodation services: a systematic review of mental health and psychosocial outcomes. BMC psychiatry. 2018 Dec;18(1):128)

Review of effectiveness of institutional care

This systematic review identified 8eight components of institutional care for people with longer term mental health problems that were key to recovery: living conditions; interventions for schizophrenia; physical health; restraint and seclusion; staff training and support; therapeutic relationship; autonomy and service user involvement; and clinical governance. Evidence was strongest for specific interventions for schizophrenia (family psychoeducation, CBT and vocational rehabilitation). (Taylor T, Killaspy H, Wright C et al. A systematic review of the international published literature relating to quality of institutional care for people with longer term mental health problems. BMC Psychiatry, 9: 55)

More than shelter

This review of evidence on what kind of supported accommodation is most effective for people with mental health problems noted that available evidence is limited. However most people prefer support to be given in their own home, compared to being in sheltered or transitional accommodation. Small-scale studies indicate that housing support can reduce the costs of hospital stays for people who would otherwise require inpatient care. The highest quality evidence points to the 'Housing First' approach for people who are homeless and have multiple needs including mental ill-health. The approach helps people to secure independent tenancies first, rather than using temporary accommodation. Recommendations were made for mental health and housing policy, include recognising housing as a health intervention by mental health services; providing a wide range of support to meet the different needs of people with mental health problems; and locating people who require support in safe and local neighbourhoods.

The Trieste model of de-institutionalisation and community living

This is a review of mental health care within the city of Trieste, described as a laboratory for innovation on social psychiatry. It describes a network of 24-hour community mental health centres with a focus on recovery and social inclusion, which was put in place since de-institutionalisation. This “whole system, whole community” model of care is described in detail and its role as a World Health Organisation collaborating centre in disseminating best practice. (Mezzina R. Community mental health care in Trieste and beyond: An “Open Door–No Restraint” system of care for recovery and citizenship. The Journal of nervous and mental disease. 2014 Jun 1;202(6):440-5)

Re-institutionalisation in Europe

This study across six European Countries that have all experienced deinstitutionalisation since the 1970s found that The number of psychiatric hospital beds had reduced in five countries, but only in two countries does this reduction outweigh the number of additional places in forensic institutions and supported housing. It is also noted that the general prison population has substantially increased in all countries in this time frame. It concluded that re-institutionalisation is taking place although with significant variation between countries studied. It was considered that societal attitudes to risk containment may be important phenomena in these changes. (Priebe S, Badesconyi A, Fioritti A, Hansson L, Kilian R, Torres-Gonzales F, Turner T, Wiersma D. Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries. Bmj. 2005 Jan 13;330(7483):123-6)

Characteristics of AOT placements 

• Hatfield B, Ryan T, Simpson V, Sharma I. Independent sector mental health care: a 1‐day census of private and voluntary sector placements in seven Strategic Health Authority areas in England. Health & social care in the community. 2007 Sep;15(5):407-16.
• Ryan T, Hatfield B, Sharma I, Simpson V, McIntyre A. A census study of independent mental health sector usage across seven Strategic Health Authorities. Journal of mental health. 2007 Jan 1;16(2):243-53.

Out of sight, out of mind

The ‘virtual asylum’

NICE guidelines on psychosis and schizophrenia in adults: prevention and management (PDF).

Adherence therapy for people with a diagnosis of schizophrenia 

Results have been mixed. An RCT of motivational-interviewing-based adherence therapy over 6 sessions found significantly improved adherence and insight and reduced symptom severity and duration of re-hospitalisations over 18-month follow-up compared with usual care alone (Chien WT, Mui J, Gray R, Cheung E. Adherence therapy versus routine psychiatric care for people with schizophrenia spectrum disorders: a randomised controlled trial. BMC psychiatry. 2016 Dec;16(1):42).

However a RCT of “compliance therapy” over 5 sessions found no advantage over non-specific therapy in improving compliance at one year or improve secondary outcomes such as symptomatology, insight and functioning. Attitudes to treatment at baseline predicted adherence one year later and may be a clinically useful tool (O'Donnell, C., Donohoe, G., Sharkey, L., et al (2003).  Compliance therapy:  a randomised controlled trial in schizophrenia.  BMJ, 327, 834-836)

Augmentation strategies for Clozapine refractory schizophrenia 

This meta-analysis found the most effective augmentation agents for total psychosis symptoms were Aripiprazole (standardised mean difference: 0.48; 95% confidence interval: −0.89 to −0.07) Fluoxetine (standardised mean difference: 0.73; 95% confidence interval: −0.97 to −0.50) and Sodium valproate (standardised mean difference: 2.36 95% confidence interval: −3.96 to −0.75). Memantine was effective for negative symptoms (standardised mean difference: −0.56 95% confidence interval: −0.93 to −0.20). However, the conclusions were tempered by short follow-up periods and poor study quality. (Siskind DJ, Lee M, Ravindran A, Zhang Q, Ma E, Motamarri B, Kisely S. Augmentation strategies for clozapine refractory schizophrenia: a systematic review and meta-analysis. Australian & New Zealand Journal of Psychiatry. 2018 Aug;52(8):751-67).

Lithium in managing Clozapine-induced neutropenia 

This review concluded that Lithium is useful in raising the WBC in individuals whose baseline count is too low to allow treatment with Clozapine, and in protecting against Clozapine-induced neutropenia, thus allowing more individuals to benefit from treatment with Clozapine. However it does not protect against agranulocytosis and is not licensed for this indication, thus psychiatrists should be aware of the medicolegal implications of prescribing. (Paton C, Esop R. Managing clozapine-induced neutropenia with lithium. Psychiatric Bulletin. 2005 May;29(5):186-8).

Combining non-Clozapine atypical antipsychotics 

In situations where Clozapine is deemed inappropriate, this review concludes that combination therapy with non-Clozapine atypical antipsychotics is a strategy worth considering. Combinations using Olanzapine with either Amisulpride or Risperidone — or Quetiapine with Risperidone — which in theory act on different receptor profiles, in the limited data available showed improvement in symptoms, have been used most frequently, and on balance have more data on safety. It noted however that caution was required due to limited safety data and the need for further research in this area. (Chan, J. & Sweeting, M (2007).  Combination therapy with non-clozapine atypical antipsychotic medication: a review of current evidence.  Journal of Psychopharmacology, 6, 657-64).

Amisulpride augmentation of Clozapine

This non‐randomized study of patients with sub‐optimal response to Clozapine assessed outcomes with Amisulpride augmentation. There was a significant improvement in positive and negative symptoms without worsening the side effect burden. (Munro, J., Matthiasson, P., Osborne, S, et al (2004).  Amisulpride augmentation of Clozapine: an open non-randomized study in patients with schizophrenia partially responsive to Clozapine.  Acta Pyschiatrica Scandinavica, 110, 292-298).

Review of Sulpiride augmentation of Clozapine

This double-blind placebo-controlled study of patients with sub‐optimal response to Clozapine found that augmentation with Sulpiride (600m) resulted in significant improvements in positive and negative psychotic symptoms. (Shiloh R. Zemishlanym Z, Aizenberg D, et al (1997).  Sulpiride augmentation in people with schizophrenia partially response to Clozapine. A double-blind placebo-controlled study. British Journal of Psychiatry, 171, 569-573).

Review of psychological treatments in schizophrenia

This meta-analysis of family intervention, CBT, social skills and cognitive remediation found that family therapy had clear preventative effects on psychotic relapse and readmission, in addition to benefits in medication compliance and as such may be useful to offer those with carers. CBT produced higher rates of improvement in mental state and may be useful for those with treatment-resistant symptoms. Social skills training and cognitive remediation did not appear to confer reliable benefits for individuals with schizophrenia.

• Pilling, S., Bebbington, P., Kuipers, E., et al (2002).  Psychological treatments in schizophrenia I: Meta-analyses of family intervention and cognitive behaviour therapy. Psychological Medicine, 32, 763-782.
• Pilling, S., Bebbington, P., Kuipers, E., et al (2002).  Psychological treatments in schizophrenia: II. Meta-analyses of randomized controlled trials of social skills training and cognitive remediation. Psychological Medicine, 32, 783-791.

Review of psychosocial interventions in low and middle-income countries

This umbrella review of meta-analyses of psychosocial interventions in low and middle-income countries (LMICs) found a relatively large amount of evidence suggesting the benefits of psychosocial interventions on various mental health outcomes in LMICs. However, strength of associations and credibility of evidence were variable, depending on the target mental health condition, type of population and setting, and outcome of interest. (Barbui C, Purgato M, Abdulmalik J, Acarturk C, Eaton J, Gastaldon C, Gureje O, Hanlon C, Jordans M, Lund C, Nosè M. Efficacy of psychosocial interventions for mental health outcomes in low-income and middle-income countries: an umbrella review. The Lancet Psychiatry. 2020 Jan 13).

Evidence-based guidelines for the pharmacological treatment of schizophrenia

This is a link to the latest guidance from the British Association for Psychopharmacology on pharmacological treatment of schizophrenia.  It includes a specific section on treatment refractory symptoms.

Evidence-based guidelines for the pharmacological treatment of schizophrenia.

Supporting people with SMI to manage self-care

This systematic review of interventions to assist people with SMI to manage their personal self-care used a narrative synthesis to summarise its findings. The paucity of research was noted, with the strongest evidence being for cognitive adaptation training, comprising environmental supports provided in the home that address the functional problems arising from specific cognitive impairments  (Birken M, Wong HT, McPherson P, Killaspy H. A systematic review of the published literature on interventions to improve personal self-care for people with severe mental health problems. British Journal of Occupational Therapy. 2021 (In Press);  Doi 10.1177/0308022620979467).

Study of rehabilitation services for ethnic minority groups