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The aim of the study was to develop and preliminarily validate a self-completed questionnaire that could help in the assessment of families before and during psycho-educational interventions. The questionnaire was developed according to the cognitive-behavioural psycho-educational model. From an initial 38-item version of the questionnaire, a final shorter 24-item version was derived. The validation study of the final version was conducted on relatives of schizophrenic and schizoaffective patients: 31 for the test-retest reliability study and 92 for the confirmation of the subscales and convergent validity study vs. SF-36 and the questionnaire on Family Problems, PF. The final questionnaire showed good psychometric properties. The three-core dimensions of Problem-Solving, Communication Skills, and Personal Goals were clearly outlined in the items correlation analysis. The association with family burden and health-related quality of life was as expected. The FF provides a promising assessment of the family functioning pattern that is the object of psychoeducational family interventions. Further studies are needed to confirm the validity of the instrument, that could be helpful both in planning and in monitoring psycho-educational interventions and in mental health promotion projects.

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OBJECTIVE: This study investigated whether a specific structured planning and evaluation approach called VADO (in English, Skills Assessment and Definition of Goals) resulted in improved personal and social functioning among patients with chronic schizophrenia. METHODS: A total of 85 patients with chronic schizophrenia who were under a stable medication regimen were randomly allocated to the VADO-based intervention or to routine care; 78 completed the program. Interventions were carried out in nine Italian day treatment or residential rehabilitation facilities. Assessment at the beginning of the study and at the one-year follow-up included the Personal and Social Performance scale (PSP) and Brief Psychiatric Rating Scale Version 4.0 (BPRS). Clinically significant improvement was defined as an increase of at least 10 points on the PSP or a decrease of at least 20 percent on the BPRS total score. RESULTS: At baseline, average PSP scores in the experimental group and in the control group were 33.9+/-8.1 and 34.0+/-11.2, respectively (possible scores range from 1 to 100, with higher scores indicating better functioning). At six months, the score improved markedly in the experimental group (40.8+/-10.9) and minimal change was observed in the control group (35.3+/-11.6); the difference between groups was significant (difference of 6.9 points compared with 1.3 points; t=2.21, df=81, p<.05). At 12 months, the same trend was observed (difference of 12.0 points compared with 3.5 points), and the difference between groups was both statistically and clinically significant (t=2.99, df=75, p<.01). CONCLUSIONS: A statistically and clinically significant improvement in functioning was observed among patients treated with the VADO approach.

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OBJECTIVES: The Sasagawa Project aimed to investigate the effects of deinstitutionalization and evidence-based strategies for the treatment of mental disorders among long-stay patients after their discharge from a mental hospital using a quasi-experimental longitudinal study design and to assess the patients' social and clinical outcomes over a 2-year post-discharge period. METHOD: Seventy-eight patients with schizophrenia were transferred to a community facility (Sasagawa Village) following the closure of Sasagawa Hospital in Koriyama in March 2002. The patients had undergone psychosocial training following the protocol outlined by the Optimal Treatment Project. All evaluations were performed prior to the patients' discharge and were repeated 12 and 24 months after discharge using the Positive and Negative Syndrome Scales, the Global Assessment for Functioning, the Schedule for Assessment of Insight, the Rehabilitation Evaluation Hall and Baker Scale, the Social Functioning Scale, the Drug Attitude Inventory, and the Mini-Mental State Examination. RESULTS: During the 24-month study period, 18 residents had incidents that made their continued stay at Sasagawa Village impossible. Only four (5.1%) of these residents were readmitted to psychiatric wards because of exacerbations of their conditions. Twelve residents were admitted to hospital because of serious physical illnesses. The 60 residents who remained in the community facility for 2 years demonstrated significant improvements in not only their psychiatric symptoms, but also their social functioning, as evidenced by their scores for Social Activity, Speech Skills, Disturbed Speech, Self-Care and General Behaviour on the Rehabilitation Evaluation Hall and Baker Scale and Withdrawal, Independence (Performance), Independence (Competence), and Employment on the Social Functioning Scale. CONCLUSIONS: Careful planning that minimized social and clinical dislocation may have contributed to the successful transition from mental hospital to community facility assessed in this study. Patients with a long history of illness showed favourable outcomes with little clinical deterioration and various improvements in their psychiatric symptoms and social functioning.

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BACKGROUND: Recent studies on representative samples of psychiatric services have shown that low proportions of cases received effective rehabilitation interventions. The following are likely to be the most important causes: the scarcity of mental health workers trained in social and work skills strategies and the absence of a structured framework to formulate rehabilitation practices. The aim of this study was to assess if a specific structured planning and evaluation manual, called VADO (Valutazione delle Abilità e Definizione degli Obiettivi--in english: Skills Assessment and Definition of Goals), is more effective than routine interventions in reducing disability in patients with schizophrenia. METHOD: Each of 10 mental health services were invited to recruit 10 patients with a schizophrenic disorder. Altogether 98 patients were recruited. Of these, 62 patients were randomly allocated to the intervention/experimental or a control group. The remaining group of 36 patients was not randomised and it was considered as a parallel effectiveness study. Assessment measures at the beginning of the study and at the one-year follow-up included the FPS scale of social functioning and the BPRS 4.0. Between group (VADO vs. Routine) and time effects were examined with ANOVA, Chi-square or Fisher exact. Clinical "improvement" was defined as an increase of at least ten points on the FPS or a decrease of at least 20% on BPRS scores. RESULTS: 31 of the 62 randomized patients received the experimental interventions, while 31 followed the routine ones. At follow-up, the experimental group showed statistically and clinically greater improvements in psychopathology and social functioning. Better outcomes of both social functioning and symptom severity were observed in non randomised patients (parallel effectiveness study). CONCLUSION: The results suggest that setting personalised and measurable objectives, as recommended by the manual, can improve the outcome of rehabilitation of severe mental disorders. Better outcomes in the parallel effectiveness study could be attributed to the greater confidence and enthusiasm of staff in centres where the VADO approach originated.

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OBJECTIVE: The authors describe the development of the Clinical Strategies Implementation Scale (CSI), an instrument designed to help providers measure the extent to which evidence-based strategies have been implemented in the treatment of persons with schizophrenia spectrum disorders. METHODS: Nine ordinal scales were devised to measure key aspects of treatment strategies that have been associated with clinical and social recovery from schizophrenia: goal- and problem-oriented assessment, medication strategies, assertive case management, mental health education, caregiver-based problem solving, living skills training, psychological strategies for residual problems, crisis prevention and intervention, and booster sessions. A study of interrater reliability was conducted with 15 trained raters from participating centers in Athens, Auckland, Bonn, Budapest, Gothenburg, and Tokyo who assessed 54 cases. Each treatment strategy was weighted according to its effect size in clinical trials. Correlation analyses were conducted to explore associations between the total CSI score and ratings of clinical, social, and caregiver outcomes each year over four years of continued treatment of 51 patients. RESULTS: Interrater reliability ranged from .93 to .99. Four annual total CSI ratings were significantly correlated with impairment, disability, functioning, work activity, and an index of recovery. Most correlations were stronger in years 3 and 4 than in years 1 and 2. CONCLUSIONS: Reliable and valid assessment of the implementation of evidence-based strategies in clinical practice is feasible. The quality of integrated program implementation may be associated with improved clinical and social recovery from schizophrenic disorders.

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BACKGROUND: To investigate the outcome of patients transferred from hospital to community care in Como, Italy after 6 months intensive psychosocial rehabilitation prior to discharge. METHOD: All 149 residents with a primary psychiatric diagnosis were assigned to receive either a 6-month pre-discharge course of goal-oriented rehabilitation, (IT), or routine management, (RT). BPRS and GAF ratings were made by blind, independent assessors before and at 12, 24, 36, 48, and 60 months after discharge and the results examined with repeated measures analysis of variance. RESULTS: Overall change in residence was achieved without any major detriment to the health and welfare of most patients. The cohort of patients who received intensive rehabilitation, (IT), prior to discharge showed significantly lower impairment and disability throughout the five years compared to the cohort receiving routine management, (RT), prior to discharge. Total BPRS scores remained significant when initial differences in the cohorts were covaried, whereas GAF failed to remain significant (p = 0.051). CONCLUSION: The treatment provided prior to transfer from long-stay hospital to community residence may have long-term clinical benefits for chronically disabled patients.

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Japanese psychiatric services are still typically hospital-based. The Sasagawa Project is the first systematized deinstitutionalization project in Japan that aims to make the transition from hospital to residential living while ensuring both the quality and continuity of care for the patients. Seventy-eight (51 males) patients (mean age 54.6) with chronic schizophrenia, who were considered appropriate for discharge received continuous cognitive behavioural therapies based on the Optimal Treatment Project manualised protocol, both before and after the hospital closure. During the first 12 months after the deinstitutionalisation was initiated on April 1st, 2002, ten people had incidents that interrupted their stay in the residential Sasagawa Village. A common criticism of many treatment outcome trials is that evaluation is focused on changes in clinical severity. In the Sasagawa project the transition appeared to have been smooth and relatively few incidents occurred could be related to the transition to a less intensive residential care. This project might be a useful model for effecting and monitoring transition from hospital to community care in Japan and other countries where such changes have been proposed.

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BACKGROUND: To estimate the prevalence and correlates of clinician-diagnosed DSM-IV nonaffective psychosis (NAP) in a national household survey. METHODS: Data came from the United States National Comorbidity Survey Replication (NCS-R). A screen for NAP was followed by blinded sub-sample clinical reappraisal interviews. Logistic regression was used to impute clinical diagnoses to respondents who were not re-interviewed. The method of Multiple Imputation (MI) was used to estimate prevalence and correlates. RESULTS: Clinician-diagnosed NAP was well predicted by the screen (area under the curve [AUC] = .80). The MI prevalence estimate of NAP (standard error in parentheses) is 5.0 (2.6) per 1000 population lifetime and 3.0 (2.2) per 1000 past 12 months. The vast majority (79.4%) of lifetime and 12-month (63.7%) cases met criteria for other DSM-IV hierarchy-free disorders. Fifty-eight percent of 12-month cases were in treatment, most in the mental health specialty sector. CONCLUSIONS: The screen for NAP in the NCS-R greatly improved on previous epidemiological surveys in reducing false positives, but coding of open-ended screening scale responses was still needed to achieve accurate prediction. The lower prevalence estimate than in total-population incidence studies raises concerns that systematic nonresponse bias causes downward bias in survey prevalence estimates of NAP.

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According to clinical trials literature, every person with a schizophrenic disorder should be provided with the combination of optimal dose antipsychotics, strategies to educate himself and his carers to cope more efficiently with environmental stresses, cognitive-behavioural strategies to enhance work and social goals and reducing residual symptoms, and assertive home-based management to help prevent and resolve major social needs and crises, including recurrent episodes of symptoms. Despite strong scientific support for the routine implementation of these 'evidence-based' strategies, few services provide more than the pharmacotherapy component, and even this is seldom applied in the manner associated with the best results in the clinical trials. An international collaborative group, the Optimal Treatment Project (OTP), has been developed to promote the routine use of evidence-based strategies for schizophrenic disorders. A field trial was started to evaluate the benefits and costs of applying evidence-based strategies over a 5-year period. Centres have been set up in 18 countries. This paper summarises the outcome after 24 months of 'optimal' treatment in 603 cases who had reached this stage in their treatment by the end of 2002. On all measures the evidence-based OTP approach achieved more than double the benefits associated with current best practices. One half of recent cases had achieved full recovery from clinical and social morbidity. These advantages were even more striking in centres where a random-control design was used.

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This paper examines the correlations between 'Theory of Mind' (ToM) and neurocognitive performance, together with clinical and social functioning, in out-patients with schizophrenic disorders. It was hypothesised that, since the ability to make inferences about the environment and about other peoples' mental states is a key ingredient of social competence, the assessment of ToM would correlate more strongly with current social functioning than with more traditional neurocognitive measures. 'Independent raters' assessed Theory of Mind, neurocognitive and clinical variables as well as community functioning in 44 subjects with schizophrenia. The neuropsychological measures were more closely associated with community functioning than with psychiatric symptoms. These associations remained evident when the effects of intelligence were controlled. Patients with a higher level of competence in making social inferences had better overall community functioning than those who showed less ability in this aspect of social cognition. In a regression model, the capacity to comprehend other people's mental states (ToM-2) was among the best predictors of global social functioning, together with recent onset of illness, good verbal fluency and low levels of negative and positive symptoms. These results are consistent with other recent findings. ToM measures of social cognition may be a useful addition to neuropsychological assessment when developing programmes for reducing clinical impairments and improving the community functioning of subjects with schizophrenic disorders. Further studies are needed to verify the value of these measures as predictors of the successful application of specific psychosocial rehabilitation strategies.

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Ratings of stress and burden and mental symptoms which were screened by the General Health Questionnaire (GHQ) caseness were collected from two types of primary caregivers either living with (n = 37) or separately from (n = 48) a patient with a chronic schizophrenic disorder. The stress levels and burden of caregivers living apart were similar to those who were living together with patients and around 25 percent of both groups met GHQ criterion for having a mental disorder. Multiple regression analyses of all subjects identified stress with the patient's disorder and strain in their own marital relationships as most predictive of their subjective global stress ratings. These results suggest that mental health services should aim to assist key caregivers of people with chronic schizophrenic disorders to manage stress whether or not the patient lives in the same household as the caregiver.

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