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1.  Development and psychometric properties of the client’s assessment of treatment scale for supported accommodation (CAT-SA) 
BMC Psychiatry  2016;16:43.
Background
Patient-Reported Outcome Measures (PROMs) are important for evaluating mental health services. Yet, no specific PROM exists for the large and diverse mental health supported accommodation sector. We aimed to produce and validate a PROM specifically for supported accommodation services, by adapting the Client’s Assessment of Treatment Scale (CAT) and assessing its psychometric properties in a large sample.
Methods
Focus groups with service users in the three main types of mental health supported accommodation services in the United Kingdom (residential care, supported housing and floating outreach) were conducted to adapt the contents of the original CAT items and assess the acceptability of the modified scale (CAT-SA). The CAT-SA was then administered in a survey to service users across England. Internal consistency was assessed using Cronbach’s alpha. Convergent validity was tested through correlations with subjective quality of life and satisfaction with accommodation, as measured by the Manchester Short Assessment of Quality of Life (MANSA).
Results
All seven original items of the CAT were regarded as relevant to appraisals of mental health supported accommodation services, with only slight modifications to the wording required. In the survey, data were obtained from 618 clients. The internal consistency of the CAT-SA items was 0.89. Mean CAT-SA scores were correlated with the specific accommodation item on the MANSA (rs = 0.37, p˂.001).
Conclusions
The content of the CAT-SA has relevance to service users living in mental health supported accommodation. The findings from our large survey show that the CAT-SA is acceptable across different types of supported accommodation and suggest good psychometric properties. The CAT-SA appears a valid and easy to use PROM for service users in mental health supported accommodation services.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-016-0755-3) contains supplementary material, which is available to authorized users.
doi:10.1186/s12888-016-0755-3
PMCID: PMC4766675  PMID: 26911904
Patient Reported Outcome; Supported Accommodation; Treatment Satisfaction; Mental Health
2.  Exploring the Mechanisms of a Patient-Centred Assessment with a Solution Focused Approach (DIALOG+) in the Community Treatment of Patients with Psychosis: A Process Evaluation within a Cluster-Randomised Controlled Trial 
PLoS ONE  2016;11(2):e0148415.
Background
DIALOG+ is a new intervention to make routine community mental health meetings therapeutically effective. It involves a structured assessment of patient concerns and a solution-focused approach to address them. In a randomised controlled trial, DIALOG+ was associated with better subjective quality of life and other outcomes in patients with psychosis, but it was not clear how this was achieved. This study explored the possible mechanisms.
Methods
This was a mixed-methods process evaluation within a cluster-randomised controlled trial. Focus groups and interviews were conducted with patients and clinicians who experienced DIALOG+ and were analysed using thematic analysis. The content of DIALOG+ sessions was recorded and analysed according to (i) the type of actions agreed during sessions and (ii) the domains discussed. The subjective quality of life measure was analysed with mixed-effects models to explore whether the effect of DIALOG+ was limited to life domains that had been addressed in sessions or consistent across all domains.
Results
Four qualitative themes emerged regarding the mechanisms of DIALOG+: (1) a comprehensive structure; (2) self-reflection; (3) therapeutic self-expression; and (4) empowerment. Patients took responsibility for the majority of actions agreed during sessions (65%). The treatment effect on subjective quality of life was largest for living situation (accommodation and people that the patient lives with) and mental health. Two of these domains were among the three most commonly discussed in DIALOG+ sessions (accommodation, mental health, and physical health).
Conclusion
DIALOG+ initiates positive, domain-specific change in the areas that are addressed in sessions. It provides a comprehensive and solution-focused structure to routine meetings, encourages self-reflection and expression, and empowers patients. Future research should strengthen and monitor these factors.
Trial Registration
ISRCTN Registry ISRCTN34757603.
doi:10.1371/journal.pone.0148415
PMCID: PMC4747516  PMID: 26859388
3.  Assessing Social Networks in Patients with Psychotic Disorders: A Systematic Review of Instruments 
PLoS ONE  2015;10(12):e0145250.
Background
Evidence suggests that social networks of patients with psychotic disorders influence symptoms, quality of life and treatment outcomes. It is therefore important to assess social networks for which appropriate and preferably established instruments should be used.
Aims
To identify instruments assessing social networks in studies of patients with psychotic disorders and explore their properties.
Method
A systematic search of electronic databases was conducted to identify studies that used a measure of social networks in patients with psychotic disorders.
Results
Eight instruments were identified, all of which had been developed before 1991. They have been used in 65 studies (total N of patients = 8,522). They assess one or more aspects of social networks such as their size, structure, dimensionality and quality. Most instruments have various shortcomings, including questionable inter-rater and test-retest reliability.
Conclusions
The assessment of social networks in patients with psychotic disorders is characterized by a variety of approaches which may reflect the complexity of the construct. Further research on social networks in patients with psychotic disorders would benefit from advanced and more precise instruments using comparable definitions of and timescales for social networks across studies.
doi:10.1371/journal.pone.0145250
PMCID: PMC4692496  PMID: 26709513
4.  Specialised teams or personal continuity across inpatient and outpatient mental healthcare? Study protocol for a natural experiment 
BMJ Open  2015;5(11):e008996.
Introduction
Mental healthcare organisation can either pursue specialisation, that is, distinct clinicians and teams for inpatient and outpatient care or personal continuity of care, that is, the same primary clinician for a patient across the two settings. Little systematic research has compared these approaches. Existing studies subject have serious methodological shortcomings. Yet, costly reorganisations of services have been carried out in different European countries, inconsistently aiming to achieve specialisation or personal continuity of care. More reliable evidence is required on whether specialisation or continuity of care is more effective and cost-effective, and whether this varies for different patient groups and contexts.
Design and methods
In a natural experiment, we aim to recruit at least 6000 patients consecutively admitted to inpatient psychiatric care in Belgium, Germany, Italy, Poland, and the UK. In each country, care approaches supporting specialisation and personal continuity coexist. Patients will be followed up at 1 year to compare outcomes, costs and experiences. Inclusion criteria are: 18 years of age or older; clinical diagnosis of psychosis, affective disorder or anxiety/somatisation disorder; sufficient command of the language of the host country; absence of cognitive deterioration and/or organic brain disorders; and capacity to provide informed consent.
Ethics and dissemination
Ethical approval was obtained in all countries: (1) England: NRES Committee North East—Newcastle & North Tyneside (ref: 14/NE/1017); (2) Belgium: Comité d'Ethique hospitalo-facultaire des Cliniques St-Luc; (3) Germany: Ethical Board, Technische Universität Dresden; (4) Italy: Comitati Etici per la sperimentazione clinica (CESC) delle provincie di Verona, Rovigo, Vicenza, Treviso, Padova; (5) Poland: Komisja Bioetyczna przy Instytucie Psychiatrii i Neurologii w Warszawie. We will disseminate the findings through scientific publications and a study-specific website. At the end of the study, we will develop recommendations for policy decision-making, and organise national and international workshops with stakeholders.
Trial registration number
ISRCTN registry: ISRCTN40256812.
doi:10.1136/bmjopen-2015-008996
PMCID: PMC4663441  PMID: 26608634
MENTAL HEALTH; PUBLIC HEALTH
5.  Can mental health interventions change social networks? A systematic review 
BMC Psychiatry  2015;15:297.
Background
Social networks of patients with psychosis can provide social support, and improve health and social outcomes, including quality of life. However, patients with psychosis often live rather isolated with very limited social networks. Evidence for interventions targeting symptoms or social skills, are largely unsuccessful at improving social networks indirectly. As an alternative, interventions may directly focus on expanding networks. In this systematic review, we assessed what interventions have previously been tested for this and to what extent they have been effective.
Methods
A systematic review was conducted of randomised controlled trials, testing psychosocial interventions designed to directly increase the social networks of patients with psychosis. Searches of five online databases (PsycINFO, CINAHL, Cochrane Database, MEDLINE, Embase), hand searching of grey literature, and both forward and backward snowballing of key papers were conducted and completed on 12 December 2014. Trial reports were included if they were written in English, the social network size was the primary outcome, participants were ≥ 18 years old and diagnosed with a psychotic disorder.
Results
Five studies (n = 631 patients) met the complete inclusion criteria. Studies were from different countries and published since 2008. Four trials had significant positive results, i.e. an observable increase in patients’ social network size at the end of the intervention. The interventions included: guided peer support, a volunteer partner scheme, supported engagement in social activity, dog-assisted integrative psychological therapy and psychosocial skills training. Other important elements featured were the presence of a professional, and a focus on friendships and peers outside of services and the immediate family.
Conclusions
Despite the small number and heterogeneity of included studies, the results suggest that interventions directly targeting social isolation can be effective and achieve a meaningful increase in patients’ networks. Thus, although limited, the existing evidence is encouraging, and the range of interventions used in the reported trials leave various options for future research and further improvements. Future research is needed to test the findings in different settings, identify which components are particularly effective, and determine to what extent the increased networks, over time, impact on patients’ symptoms and quality of life.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-015-0684-6) contains supplementary material, which is available to authorized users.
doi:10.1186/s12888-015-0684-6
PMCID: PMC4654911  PMID: 26590161
Social networks; Psychosis; Social isolation; Psychosocial intervention; Review
8.  Long-term mental health of war-refugees: a systematic literature review 
Background
There are several million war-refugees worldwide, majority of whom stay in the recipient countries for years. However, little is known about their long-term mental health. This review aimed to assess prevalence of mental disorders and to identify their correlates among long-settled war-refugees.
Methods
We conducted a systematic review of studies that assessed current prevalence and/or factors associated with depression and anxiety disorders in adult war-refugees 5 years or longer after displacement. We searched Medline, Embase, CINAHL, PsycINFO, and PILOTS from their inception to October 2014, searched reference lists, and contacted experts. Because of a high heterogeneity between studies, overall estimates of mental disorders were not discussed. Instead, prevalence rates were reviewed narratively and possible sources of heterogeneity between studies were investigated both by subgroup analysis and narratively. A descriptive analysis examined pre-migration and post-migration factors associated with mental disorders in this population.
Results
The review identified 29 studies on long-term mental health with a total of 16,010 war-affected refugees. There was significant between-study heterogeneity in prevalence rates of depression (range 2.3–80 %), PTSD (4.4–86 %), and unspecified anxiety disorder (20.3–88 %), although prevalence estimates were typically in the range of 20 % and above. Both clinical and methodological factors contributed substantially to the observed heterogeneity. Studies of higher methodological quality generally reported lower prevalence rates. Prevalence rates were also related to both which country the refugees came from and in which country they resettled. Refugees from former Yugoslavia and Cambodia tended to report the highest rates of mental disorders, as well as refugees residing in the USA. Descriptive synthesis suggested that greater exposure to pre-migration traumatic experiences and post-migration stress were the most consistent factors associated with all three disorders, whilst a poor post-migration socio-economic status was particularly associated with depression.
Conclusions
There is a need for more methodologically consistent and rigorous research on the mental health of long-settled war refugees. Existing evidence suggests that mental disorders tend to be highly prevalent in war refugees many years after resettlement. This increased risk may not only be a consequence of exposure to wartime trauma but may also be influenced by post-migration socio-economic factors.
doi:10.1186/s12914-015-0064-9
PMCID: PMC4624599  PMID: 26510473
Refugees; War trauma; PTSD; Depression; Anxiety; Risk factors
9.  Overcoming Barriers to Skills Training in Borderline Personality Disorder: A Qualitative Interview Study 
PLoS ONE  2015;10(10):e0140635.
Despite evidence suggesting that skills training is an important mechanism of change in dialectical behaviour therapy, little research exploring facilitators and barriers to this process has been conducted. The study aimed to explore clients’ experiences of barriers to dialectical behaviour therapy skills training and how they felt they overcame these barriers, and to compare experiences between treatment completers and dropouts. In-depth qualitative interviews were conducted with 40 clients with borderline personality disorder who had attended a dialectical behaviour therapy programme. A thematic analysis of participants’ reported experiences found that key barriers to learning the skills were anxiety during the skills groups and difficulty understanding the material. Key barriers to using the skills were overwhelming emotions which left participants feeling unable or unwilling to use them. Key ways in which participants reported overcoming barriers to skills training were by sustaining their commitment to attending therapy and practising the skills, personalising the way they used them, and practising them so often that they became an integral part of their behavioural repertoire. Participants also highlighted a number of key ways in which they were supported with their skills training by other skills group members, the group therapists, their individual therapist, friends and family. Treatment dropouts were more likely than completers to describe anxiety during the skills groups as a barrier to learning, and were less likely to report overcoming barriers to skills training via the key processes outlined above. The findings of this qualitative study require replication, but could be used to generate hypotheses for testing in further research on barriers to skills training, how these relate to dropout, and how they can be overcome. The paper outlines several such suggestions for further research.
doi:10.1371/journal.pone.0140635
PMCID: PMC4605586  PMID: 26465757
10.  Social networks of patients with psychosis: a systematic review 
BMC Research Notes  2015;8:560.
Background
Social networks are important for mental health outcomes as they can mobilise resources and help individuals to cope with social stressors. Individuals with psychosis may have specific difficulties in establishing and maintaining social relationships which impacts on their well-being and quality of life. There has been a growing interest in developing social network interventions for patients with psychotic disorders. A systematic literature review was conducted to investigate the size of social networks of patients with psychotic disorders, as well as their friendship networks.
Methods
A systematic electronic search was carried out in MEDLINE, EMBASE and PsychINFO databases using a combination of search terms relating to ‘social network’, ‘friendship’ and ‘psychotic disorder’.
Results
The search identified 23 relevant papers. Out of them, 20 reported patient social network size. Four papers reported the mean number of friends in addition to whole network size, while three further papers focused exclusively on the number of friends. Findings varied substantially across the studies, with a weighted mean size of 11.7 individuals for whole social networks and 3.4 individuals for friendship networks. On average, 43.1 % of the whole social network was composed of family members, while friends accounted for 26.5 %.
Conclusions
Studies assessing whole social network size and friendship networks of people with psychosis are difficult to compare as different concepts and methods of assessment were applied. The extent of the overlap between different social roles assessed in the networks was not always clear. Greater conceptual and methodological clarity is needed in order to help the development of effective strategies to increase social resources of patients with psychosis.
Electronic supplementary material
The online version of this article (doi:10.1186/s13104-015-1528-7) contains supplementary material, which is available to authorized users.
doi:10.1186/s13104-015-1528-7
PMCID: PMC4603917  PMID: 26459046
Schizophrenia; Psychosis; Social network; Friendship; Social relationships
11.  Cost-Effectiveness of Financial Incentives to Promote Adherence to Depot Antipsychotic Medication: Economic Evaluation of a Cluster-Randomised Controlled Trial 
PLoS ONE  2015;10(10):e0138816.
Background
Offering a modest financial incentive to people with psychosis can promote adherence to depot antipsychotic medication, but the cost-effectiveness of this approach has not been examined.
Methods
Economic evaluation within a pragmatic cluster-randomised controlled trial. 141 patients under the care of 73 teams (clusters) were randomised to intervention or control; 138 patients with diagnoses of schizophrenia, schizo-affective disorder or bipolar disorder participated. Intervention participants received £15 per depot injection over 12 months, additional to usual acute, mental and community primary health services. The control group received usual health services. Main outcome measures: incremental cost per 20% increase in adherence to depot antipsychotic medication; incremental cost of ‘good’ adherence (defined as taking at least 95% of the prescribed number of depot medications over the intervention period).
Findings
Economic and outcome data for baseline and 12-month follow-up were available for 117 participants. The adjusted difference in adherence between groups was 12.2% (73.4% control vs. 85.6% intervention); the adjusted costs difference was £598 (95% CI -£4 533, £5 730). The extra cost per patient to increase adherence to depot medications by 20% was £982 (95% CI -£8 020, £14 000). The extra cost per patient of achieving 'good' adherence was £2 950 (CI -£19 400, £27 800). Probability of cost-effectiveness exceeded 97.5% at willingness-to-pay values of £14 000 for a 20% increase in adherence and £27 800 for good adherence.
Interpretation
Offering a modest financial incentive to people with psychosis is cost-effective in promoting adherence to depot antipsychotic medication. Direct healthcare costs (including costs of the financial incentive) are unlikely to be increased by this intervention.
Trial Registration
ISRCTN.com 77769281
doi:10.1371/journal.pone.0138816
PMCID: PMC4598185  PMID: 26448540
12.  Offering Financial Incentives to Increase Adherence to Antipsychotic Medication 
Abstract
Financial incentives for medication adherence in patients with psychotic disorders are controversial. It is not yet known whether fears expressed by clinicians are borne out in reality. We aimed to explore community mental health clinicians’ experiences of the consequences of giving patients with psychotic disorders a financial incentive to take their depot medication. We implemented descriptive and thematic analyses of semistructured interviews with the clinicians of patients assigned to receive incentives within a randomized controlled trial. Fifty-nine clinicians were interviewed with regard to the effect of the incentives on 73 of the 78 patients allocated to receive incentives in the trial. Most commonly, the clinicians reported benefits for clinical management including improved adherence, contact, patient monitoring, communication, and trust (n = 52). Positive effects on symptoms, insight, or social functioning were reported for some (n = 33). Less commonly, problems for patient management were reported (n = 19) such as monetarization of the therapeutic relationship or negative consequences for the patient (n = 15) such as increased drug and alcohol use. Where requests for increased money occurred, they were rapidly resolved. It seems that, in most cases, the clinicians found that using incentives led to benefits for patient management and for patient health. However, in 33% of cases, some adverse effects were reported. It remains unclear whether certain clinical characteristics are associated with increased risk for adverse effects of financial incentives. The likelihood of benefit versus the smaller risk for adverse effects should be weighed up when deciding whether to offer incentives to individual patients.
doi:10.1097/JCP.0000000000000276
PMCID: PMC4352071  PMID: 25692797
schizophrenia; antipsychotics; medication adherence; incentives
13.  Did female prisoners with mental disorders receive psychiatric treatment before imprisonment? 
BMC Psychiatry  2015;15:5.
Background
Throughout the world, high prevalence rates of mental disorders have been found in prison populations, especially in females. It has been suggested that these populations do not access psychiatric treatment. The aim of this study was to establish rates of psychiatric in- and outpatient treatments prior to imprisonment in female prisoners and to explore reasons for discontinuation of such treatments.
Methods
150 consecutively admitted female prisoners were interviewed in Berlin, Germany. Socio-demographic characteristics, mental disorders, and previous psychiatric in- and outpatient treatments were assessed by trained researchers. Open questions were used to explore reasons for ending previous psychiatric treatment.
Results
A vast majority of 99 prisoners (66%; 95% CI: 58–73) of the total sample reported that they had previously been in psychiatric treatment, 80 (53%; 95 CI: 45–61) in inpatient treatment, 62 (41%; 95 CI: 34–49) in outpatient treatment and 42 (29%; 21–39) in both in- and outpatient treatments. All prisoners with psychosis and 72% of the ones with any lifetime mental health disorder had been in previous treatment. The number of inpatient treatments and imprisonments were positively correlated (rho = 0.27; p < 0.01). Inpatient treatment was described as successfully completed by 56% (N = 41) of those having given reasons for ending such treatment, whilst various reasons were reported for prematurely ending outpatient treatments.
Conclusion
The data do not support the notion of a general ‘mental health treatment gap’ in female prisoners. Although inpatient care is often successfully completed, repeated inpatient treatments are not linked with fewer imprisonments. Improved transition from inpatient to outpatient treatment and services that engage female prisoners to sustained outpatient treatments are needed.
doi:10.1186/s12888-015-0387-z
PMCID: PMC4307137  PMID: 25608668
Prisoners; Mental health; Psychiatric hospitalized care; Outpatient mental health treatment
14.  Implementing family involvement in the treatment of patients with psychosis: a systematic review of facilitating and hindering factors 
BMJ Open  2014;4(10):e006108.
Objective
To synthesise the evidence on implementing family involvement in the treatment of patients with psychosis with a focus on barriers, problems and facilitating factors.
Design
Systematic review of studies evaluating the involvement of families in tripartite communication between health professionals, ‘families’ (or other unpaid carers) and adult patients, in a single-family context. A theoretical thematic analysis approach and thematic synthesis were used.
Data sources
A systematic electronic search was carried out in seven databases, using database-specific search strategies and controlled vocabulary. A secondary manual search of grey literature was performed as well as using forwards and backwards snowballing techniques.
Results
A total of 43 studies were included. The majority featured qualitative data (n=42), focused solely on staff perspectives (n=32) and were carried out in the UK (n=23). Facilitating the training and ongoing supervision needs of staff are necessary but not sufficient conditions for a consistent involvement of families. Organisational cultures and paradigms can work to limit family involvement, and effective implementation appears to operate via a whole team coordinated effort at every level of the organisation, supported by strong leadership. Reservations about family involvement regarding power relations, fear of negative outcomes and the need for an exclusive patient–professional relationship may be explored and addressed through mutually trusting relationships.
Conclusions
Implementing family involvement carries additional challenges beyond those generally associated with translating research to practice. Implementation may require a cultural and organisational shift towards working with families. Family work can only be implemented if this is considered a shared goal of all members of a clinical team and/or mental health service, including the leaders of the organisation. This may imply a change in the ethos and practices of clinical teams, as well as the establishment of working routines that facilitate family involvement approaches.
doi:10.1136/bmjopen-2014-006108
PMCID: PMC4187461  PMID: 25280809
15.  Testing the Psychopathology of Psychosis: Evidence for a General Psychosis Dimension 
Schizophrenia Bulletin  2012;39(4):884-895.
Background: Psychiatric taxonomists have sometimes argued for a unitary psychosis syndrome and sometimes for a pentagonal model, including 5 diagnostic constructs of positive symptoms, negative symptoms, cognitive disorganization, mania, and depression. This continues to be debated in preparation for impending revisions of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases. We aimed to identify general and specific dimensions underlying psychopathological features of psychosis. Methods: The samples comprised 309 patients admitted to psychiatric services in the acute phase of their first or second episode of psychosis and 507 patients with enduring psychosis recruited from community mental health teams. Patients’ symptoms were assessed on the Positive and Negative Symptom Scale. Analyses compared unitary, pentagonal, and bifactor models of psychosis. Results: In both samples, a bifactor model including 1 general psychosis factor and, independently, 5 specific factors of positive symptoms, negative symptoms, disorganization, mania, and depression gave the best fit. Scores of general and specific symptom dimensions were differentially associated with phase of illness, diagnosis, social functioning, insight, and neurocognitive functioning. Conclusions: The findings provide strong evidence for a general psychosis dimension in both early and enduring psychosis. Findings further allowed for independent formation of specific symptom dimensions. This may inform the current debate about revised classification systems of psychosis.
doi:10.1093/schbul/sbr182
PMCID: PMC3686436  PMID: 22258881
classification; DSM-V; dimensions; item response modeling; psychosis; schizophrenia
16.  How do psychiatrists address delusions in first meetings in acute care? A qualitative study 
BMC Psychiatry  2014;14:178.
Background
Communicating about delusions can be challenging, particularly when a therapeutic relationship needs to be established in acute care. So far, no systematic research has explored how psychiatrists address patients’ delusional beliefs in first meetings in acute care. The aim of this study was to describe how psychiatrists address patients’ delusional experiences in acute in-patient care.
Methods
First meetings between five psychiatrists and 14 patients in acute care were audio-recorded and analysed using thematic content analysis.
Results
296 psychiatrist statements about delusions were identified and coded. Three commonly used approaches (with a total of 6 subthemes) were identified. The most common approaches were eliciting the content (1 subtheme: eliciting content and evidence) and understanding the impact (3 subthemes: identifying emotions, exploring links with dysfunctional behaviour and discussing reasons for hospital admission) while questioning the validity of the beliefs (2 subthemes: challenging content and exploring alternative explanations) was less common. The last approach sometimes put patients in a defensive position.
Conclusions
Psychiatrists commonly use three approaches to address patients’ delusions in the first meeting in acute in-patient care. Questioning the patients’ beliefs can lead to disagreement which might hinder establishing a positive therapeutic relationship. Future research should explore the impact of such an approach on outcomes and specify to what extent questioning the validity of delusional beliefs is appropriate in the first meeting.
doi:10.1186/1471-244X-14-178
PMCID: PMC4067065  PMID: 24935678
Delusions; Acute care; Communication; Therapeutic relationships
17.  Mechanisms of Psychological Distress following War in the Former Yugoslavia: The Role of Interpersonal Sensitivity 
PLoS ONE  2014;9(3):e90503.
While high prevalence rates of psychological symptoms have been documented in civilian survivors of war, little is known about the mechanisms by which trauma exposure might lead to poor psychological outcomes in these populations. One potential mechanism that may underpin the association between war-related traumatic experiences and psychopathology is interpersonal sensitivity. In the current study, we applied structural equation modeling to investigate the impact of interpersonal sensitivity on posttraumatic stress disorder (PTSD) symptoms, depression symptoms, and anger responses following exposure to war trauma. 3313 survivors of the war in the former Yugoslavia were identified and selected using a multistage, probabilistic sampling frame and random walk technique. Participants were interviewed regarding trauma exposure, interpersonal sensitivity, and PTSD symptoms, depression symptoms, and anger responses. Structural equation modeling analyses revealed that the relationship between trauma and PTSD symptoms and depression symptoms was partly statistically mediated by interpersonal sensitivity. Further, findings indicated that the relationship between trauma and anger responses was fully statistically mediated by interpersonal sensitivity. These results suggest that interpersonal sensitivity may function as a key mechanism that contributes to psychopathology following trauma.
doi:10.1371/journal.pone.0090503
PMCID: PMC3962331  PMID: 24658334
18.  Factors associated with quality of services for marginalized groups with mental health problems in 14 European countries 
Background
Different service characteristics are known to influence mental health care delivery. Much less is known about the impact of contextual factors, such as the socioeconomic circumstances, on the provision of care to socially marginalized groups.
The objectives of this work were to assess the organisational characteristics of services providing mental health care for marginalized groups in 14 European capital cities and to explore the associations between organisational quality, service features and country-level characteristics.
Methods
617 services were assessed in two highly deprived areas in 14 European capital cities. A Quality Index of Service Organisation (QISO) was developed and applied across all sites. Service characteristics and country level socioeconomic indicators were tested and related with the Index using linear regressions and random intercept linear models.
Results
The mean (standard deviation) of the QISO score (minimum = 0; maximum = 15) varied from 8.63 (2.23) in Ireland to 12.40 (2.07) in Hungary. The number of different programmes provided was the only service characteristic significantly correlated with the QISO (p < 0.05). The national Gross Domestic Product (GDP) was inversely associated with the QISO. Nearly 15% of the variance of the QISO was attributed to country-level variables, with GDP explaining 12% of this variance.
Conclusions
Socioeconomic contextual factors, in particular the national GDP are likely to influence the organisational quality of services providing mental health care for marginalized groups. Such factors should be considered in international comparative studies. Their significance for different types of services should be explored in further research.
doi:10.1186/1472-6963-14-49
PMCID: PMC3915221  PMID: 24490720
Mental health services; Quality index of service organization; Socially marginalized groups; Multi-level analysis
19.  Diagnostic Utility of the Impact of Event Scale–Revised in Two Samples of Survivors of War 
PLoS ONE  2013;8(12):e83916.
The study aimed at examining the diagnostic utility of the Impact of Event Scale-Revised (IES-R) as a screening tool for post-traumatic stress disorder (PTSD) in survivors of war. The IES-R was completed by two independent samples that had survived the war in the Balkans: a sample of randomly selected people who had stayed in the area of former conflict (n = 3,313) and a sample of refugees to Western European countries (n = 854). PTSD was diagnosed using the MINI International Neuropsychiatric Interview. Prevalence of PTSD was 20.1% in the Balkan sample and 33.1% in the refugee sample. Results revealed that when considering a minimum value of specificity of 0.80, the optimally sensitive cut-off score for screening for PTSD in the Balkan sample was 34. In both the Balkan sample and the refugee sample, this cut-off score provided good values on sensitivity (0.86 and 0.89, respectively) and overall efficiency (0.81 and 0.79, respectively). Further, the kappa coefficients for sensitivity for the cut-off of 34 were 0.80 in both samples. Findings of this study support the clinical utility of the IES-R as a screening tool for PTSD in large-scale research studies and intervention studies if structured diagnostic interviews are regarded as too labor-intensive and too costly.
doi:10.1371/journal.pone.0083916
PMCID: PMC3877127  PMID: 24391844
20.  Effectiveness of financial incentives to improve adherence to maintenance treatment with antipsychotics: cluster randomised controlled trial 
Objective To test whether offering financial incentives to patients with psychotic disorders is effective in improving adherence to maintenance treatment with antipsychotics.
Design Cluster randomised controlled trial.
Setting Community mental health teams in secondary psychiatric care in the United Kingdom.
Participants Patients with a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder, who were prescribed long acting antipsychotic (depot) injections but had received 75% or less of the prescribed injections. We randomly allocated 73 teams with a total of 141 patients. Primary outcome data were available for 35 intervention teams with 75 patients (96% of randomised) and for 31 control teams with 56 patients (89% of randomised).
Interventions Participants in the intervention group were offered £15 (€17; $22) for each depot injection over a 12 month period. Participants in the control condition received treatment as usual.
Main outcome measure The primary outcome was the percentage of prescribed depot injections given during the 12 month intervention period.
Results 73 teams with 141 consenting patients were randomised, and outcomes were assessed for 131 patients (93%). Average baseline adherence was 69% in the intervention group and 67% in the control group. During the 12 month trial period adherence was 85% in the intervention group and 71% in the control group. The adjusted effect estimate was 11.5% (95% confidence interval 3.9% to 19.0%, P=0.003). A secondary outcome was an adherence of ≥95%, which was achieved in 28% of the intervention group and 5% of the control group (adjusted odds ratio 8.21, 95% confidence interval 2.00 to 33.67, P=0.003). Although differences in clinician rated clinical improvement between the groups failed to reach statistical significance, patients in the intervention group had more favourable subjective quality of life ratings (β=0.71, 95% confidence interval 0.26 to 1.15, P=0.002). The number of admissions to hospital and adverse events were low in both groups and did not show substantial differences.
Conclusion Offering modest financial incentives to patients with psychotic disorders is an effective method for improving adherence to maintenance treatment with antipsychotics.
Trial registration Current Controlled Trials ISRCTN77769281.
doi:10.1136/bmj.f5847
PMCID: PMC3805491  PMID: 24100934
21.  Gender differences in coerced patients with schizophrenia 
BMC Psychiatry  2013;13:257.
Background
Despite the recent increase of research interest in involuntary treatment and the use of coercive measures, gender differences among coerced schizophrenia patients still remain understudied. It is well recognized that there are gender differences both in biological correlates and clinical presentations in schizophrenia, which is one of the most common diagnoses among patients who are treated against their will. The extent to which these differences may result in a difference in the use of coercive measures for men and women during the acute phase of the disease has not been studied.
Methods
291 male and 231 female coerced patients with schizophrenia were included in this study, which utilized data gathered by the EUNOMIA project (European Evaluation of Coercion in Psychiatry and Harmonization of Best Clinical Practice) and was carried out as a multi-centre prospective cohort study at 13 centers in 12 European countries. Sociodemographic and clinical characteristics, social functioning and aggressive behavior in patients who received any form of coercive measure (seclusion and/or forced medication and/or physical restraint) during their hospital stay were assessed.
Results
When compared to the non-coerced inpatient population, there was no difference in sociodemographic or clinical characteristics across either gender. However coerced female patients did show a worse social functioning than their coerced male counterparts, a finding which contrasts with the non-coerced inpatient population. Moreover, patterns of aggressive behavior were different between men and women, such that women exhibited aggressive behavior more frequently, but men committed severe aggressive acts more frequently. Staff used forced medication in women more frequently and physical restraint and seclusion more frequently with men.
Conclusions
Results of this study point towards a higher threshold of aggressive behavior the treatment of women with coercive measures. This may be because less serious aggressive actions trigger the application of coercive measures in men. Moreover coerced women showed diminished social functioning, and more importantly more severe symptoms from the “excitement/hostile” cluster in contrast to coerced men. National and international recommendation on coercive treatment practices should include appropriate consideration of the evidence of gender differences in clinical presentation and aggressive behaviors found in inpatient populations.
doi:10.1186/1471-244X-13-257
PMCID: PMC3852852  PMID: 24118928
Gender; Schizophrenia; Involuntary treatment; Seclusion; Restraint; Forced medication; Aggressive behavior; EUNOMIA project
22.  Exploration of experiences in therapeutic groups for patients with severe mental illness: development of the Ferrara group experiences scale (FE- GES) 
BMC Psychiatry  2013;13:242.
Background
Group therapies are routinely provided for patients with severe mental illness. The factors important to the group experience of patients are still poorly understood and are rarely measured. To support further research and practice, we aimed to develop a questionnaire that captures how patients experience groups within a community mental health context.
Methods
An initial pool of 39 items was conceptually generated to assess different aspects of group experiences. Items were completed by 166 patients with severe mental illness attending group therapies in community mental health services in Italy. Patients with different psychiatric diagnoses who attended at least 5 group sessions were included. An exploratory factor analysis was used to identify different dimensions of group experiences and to reduce the number of items for each dimension.
Results
The resulting questionnaire has five subscales: 1) sharing of emotions and experiences, 2) cognitive improvement, 3) group learning, 4) difficulties in open expression and 5) relationships. Each subscale has 4 items. The scale and sub-scales have good internal consistency.
Conclusions
The Ferrara Group Experiences Scale is conceptually derived and assesses dimensions of group experience that are theoretically and practically relevant. It is brief, easy to use and has good psychometric properties. After further validation, the scale may be used for research into patient experiences across different group therapy modalities and for evaluation in routine care.
doi:10.1186/1471-244X-13-242
PMCID: PMC3851601  PMID: 24083824
Group therapy; Patient experiences; Severe mental illness; Community mental health care
23.  Study to assess the effect of a structured communication approach on quality of life in secure mental health settings (Comquol): study protocol for a pilot cluster randomized trial 
Trials  2013;14:257.
Background
Forensic mental health services have largely ignored examining patients’ views on the nature of the services offered to them. A structured communication approach (DIALOG) has been developed with the aim of placing the patient’s perspective on their care at the heart of the discussions between patients and clinicians. The effectiveness of the structured communication approach in community mental health services has been demonstrated, but no trial has taken place in a secure psychiatric setting. This pilot study is evaluating a 6-month intervention combining DIALOG with principles of solution-focused therapy on quality of life in medium-secure settings.
Methods and design
A cluster randomized controlled trial design is being employed to conduct a 36-month pilot study. Participants are recruited from six medium-secure inpatient services, with 48 patients in the intervention group and 48 in the control group. The intervention uses a structured communication approach. It comprises six meetings between patient and nurse held monthly over a 6-month period. During each meeting, patients rate their satisfaction with a range of life and treatment domains with responses displayed on a tablet. The rating is followed by a discussion of how to improve the current situation in those domains identified by the patient. Assessments take place prior to the intervention (baseline), at 6 months (postintervention) and at 12 months (follow-up). The primary outcome is the patient’s self-reported quality of life.
Discussion
This study aims to (1) establish the feasibility of the trial design as the basis for determining the viability of a large full-scale trial, (2) determine the variability of the outcomes of interest (quality of life, levels of satisfaction, disturbance, ward climate and engagement with services), (3) estimate the costs of the intervention and (4) refine the intervention following the outcome of the study based upon the experiences of the nurses and patients. The intervention allows patients to have a greater say in how they are treated and targets care in areas that patients identify as important to them. It is intended to establish systems that support meaningful patient and caregiver involvement and participation.
Trial registration
Current Controlled Trials, ISRCTN34145189
doi:10.1186/1745-6215-14-257
PMCID: PMC3765869  PMID: 23947774
Comquol; DIALOG; Forensic; Mental health; Quality of life; Solution-focused brief therapy
24.  Recovery from Posttraumatic Stress Symptoms: A Qualitative Study of Attributions in Survivors of War 
PLoS ONE  2013;8(8):e70579.
Objective
The study explored factors to which people traumatized by war attribute their recovery from posttraumatic symptoms and from war experiences.
Methods
: In-depth interviews were conducted with two groups of participants with mental sequelae of the war in the former Yugoslavia: 26 people who had recovered from posttraumatic stress disorder (PTSD) and 17 people with ongoing symptoms of PTSD. Participants could attribute their recovery to any event, person or process in their life. The material was subjected to thematic analysis.
Results
Eight themes covered all factors to which participants attributed their recovery. Six themes described healing factors relevant for both groups of participants: social attachment and support, various strategies of coping with symptoms, personality hardiness, mental health treatment, received material support, and normalization of everyday life. In addition to the common factors, recovered participants reported community involvement as healing, and recovered refugees identified also feeling safe after resolving their civil status as helpful. Unique to the recovered group was that they maintained reciprocal relations in social attachment and support, employed future-oriented coping and emphasised their resilient personality style.
Conclusions
The reported factors of recovery are largely consistent with models of mental health protection, models of resilience and recommended interventions in the aftermath of massive trauma. Yet, they add the importance of a strong orientation towards the future, a reciprocity in receiving and giving social support and involvement in meaningful activities that ensure social recognition as a productive and valued individual. The findings can inform psychosocial interventions to facilitate recovery from posttraumatic symptoms of people affected by war and upheaval.
doi:10.1371/journal.pone.0070579
PMCID: PMC3737411  PMID: 23950965
25.  A Systematic Review of Music Therapy Practice and Outcomes with Acute Adult Psychiatric In-Patients 
PLoS ONE  2013;8(8):e70252.
Background and Objectives
There is an emerging evidence base for the use of music therapy in the treatment of severe mental illness. Whilst different models of music therapy have been developed in mental health care, none have specifically accounted for the features and context of acute in-patient settings. This review aimed to identify how music therapy is provided for acute adult psychiatric in-patients and what outcomes have been reported.
Review Methods
A systematic review using medical, psychological and music therapy databases. Papers describing music therapy with acute adult psychiatric in-patients were included. Analysis utilised narrative synthesis.
Results
98 papers were identified, of which 35 reported research findings. Open group work and active music making for nonverbal expression alongside verbal reflection was emphasised. Aims were engagement, communication and interpersonal relationships focusing upon immediate areas of need rather than longer term insight. The short stay, patient diversity and institutional structure influenced delivery and resulted in a focus on single sessions, high session frequency, more therapist direction, flexible use of musical activities, predictable musical structures, and clear realistic goals. Outcome studies suggested effectiveness in addressing a range of symptoms, but were limited by methodological shortcomings and small sample sizes. Studies with significant positive effects all used active musical participation with a degree of structure and were delivered in four or more sessions.
Conclusions
No single clearly defined model exists for music therapy with adults in acute psychiatric in-patient settings, and described models are not conclusive. Greater frequency of therapy, active structured music making with verbal discussion, consistency of contact and boundaries, an emphasis on building a therapeutic relationship and building patient resources may be of particular importance. Further research is required to develop specific music therapy models for this patient group that can be tested in experimental studies.
doi:10.1371/journal.pone.0070252
PMCID: PMC3732280  PMID: 23936399

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