Improving care for people with serious mental illness

What if there were an intervention that would reduce relapse rates for people with serious mental illnesses, such as bipolar disorder and schizophrenia, by as much as half over standard treatments? It turns out there is, Shirley M. Glynn, PhD, said at an APA 2009 Annual Convention session on serious mental illness.

Family-based interventions differ from standard care because they include the patient's family in therapy sessions, keeping them informed of the patient's progress, which helps them care for their loved one. In one study of people with schizophrenia published in Schizophrenia Bulletin, (Vol. 27, No. 1), interventions without family involvement resulted in a 48 percent relapse rate, while those with family involvement had a 28 percent relapse rate.

"But the bottom line is, nobody's doing it," Glynn said.

To prove her point, she asked the room of 30-plus session attendees if they were conducting a family-based, evidence-based treatment. No one raised a hand.

The reason that family-based therapy is relatively rare, said Glynn, is that it's time-consuming for families and therapists. Previous family-care models, developed 30 to 40 years ago, required family members to be constantly available and attend frequent sessions for as long as two years.

"The big problem here is that we've created a Hummer and most people only want a Saturn," said Glynn. "Not everyone needs intensive family interventions. Some people just need recovery-oriented family services. One of the big issues is to figure out how to make that happen."

For Glynn, the answer lies in offering a continuum of family services at increasing levels of intensity to meet unique family and consumer needs. Much of the developmental work on this continuum was supported by the Department of Veterans Affairs' Office of Mental Health Services. To begin, mental health agencies can retool to ensure they are family-friendly by providing evening and phone sessions and a comfortable meeting place so that families feel included in treatment without necessarily committing to intensive therapy themselves.

Glynn also suggested involving family in patients' job-skills and social skills training. When families get involved at that level, the patient receives more support from those who have vested interest in their recovery, she said.

Another symposium speaker, Kim Mueser, PhD, suggested that a good way to increase recovery for people with serious mental illness is by reintroducing the patient to the community. One of the best ways to do that is providing patients with work matched to their skills.

"Recovery means being able to live and work in the community," said Mueser, of the Dartmouth Psychiatric Research Center. "The job tenure [for patients] was about twice as long for people who got jobs that matched their interests."

However, family involvement in work programs is key, added Glynn.

"Nothing will make the program hit the wall faster than a family member saying, 'You're not going to go out and get a job because you'll lose your benefits and we won't be able to pay the rent,'" said Glynn. "We need to educate families from the get-go."

Psychologists should also provide families with regular updates on a patient's condition. When families feel that they're in the loop, they become more active in the recovery process, she added.

Some families may need more intensive family consultation, in which family members come in for one to five therapy sessions to discuss specific treatment and recovery issues with a therapist. Glynn's continuum of family support has recently been offered at several VA medical centers, and so far results are good, she said. "Part of recovery is having people in the community that care about you," she said.

More interventions

In addition to offering family-centered therapy, psychologists can help people with serious mental illness by employing the same cognitive enhancement techniques, such as brain-fitness games and emotion-recognition exercises, used to combat dementia, said Steven Silverstein, PhD. With regular practice, people with serious mental illness can improve their social and vocational success, he said.

Shared decision-making is another crucial ingredient to successfully treating serious mental illness, said Sandra Wilkniss, PhD. That is, both the provider and client must work together to find the best treatment balance, including medication management, vocational assistance and family therapy. "The goal is to have well-informed experts—the health-care provider and the patient—making collaborative decisions about the best treatment options because the provider knows the science and the patient knows himself," Wilkniss said.

At least in California, psychologists are increasingly well-positioned to encourage these collaborations, said Bill Safarjan, PhD. That's thanks to new rules in the California Hospital System that give psychologists new authority, including the ability to place patients under suicide watch and dictate changes in diagnosis, he said. The extra freedoms did come at a cost, though, as psychologists in California hospitals now find themselves busier than ever and with less autonomy thanks to more physician oversight.

Despite these advances, children and teens with serious mental illness have largely been left behind, Susan McCammon, PhD, added. Almost all past research focuses on adults, and there are still no evidence-based treatments for children with serious mental illness. "Our concern is that very few youth have access to [evidence-based] interventions," she said.

The reason that family therapy is relatively rare is that it's time consuming for families and therapists.