Psychiatric Rehabilitation Journal最新文献

Objective: To examine the evidence and practice of antipsychotic dose reduction from the lens of biomedical ethics (specifically principlism) to support evidence-based practice and patient choice and self-determination.

Methods: An overview of the evidence from randomized controlled trials of antipsychotic dose reduction versus maintenance is presented. This is followed by a theoretical examination of the four key biomedical ethical principles of autonomy, nonmaleficence, beneficence, and justice and how they apply in the case of antipsychotic dose reduction.

Results: Existing clinical trial research is dominated by relapse as the primary outcome, with dose reduction associated with a higher risk of relapse than maintenance. Few studies have measured other patient-centered outcomes but have shown preliminary evidence for superior cognitive functioning, lower negative symptoms, and better functioning following dose reduction. Respect for autonomy is a cornerstone of psychiatric rehabilitation, and this includes the right of people to choose to reduce or discontinue antipsychotic medication. Reduced capacity for treatment decision making can be supported. Autonomy and appraisal of nonmaleficence and beneficence associated with dose reduction can be facilitated through shared or supported decision making. Clinicians should continue to strive for justice through the fair allocation of resources to support all people who request antipsychotic dose reduction.

Conclusions and implications for practice: Clinicians have a responsibility to balance the four core ethical principles to the best of their ability when supporting a person in their recovery journey. Exploring, trialing, and supporting antipsychotic dose reduction may be part of this process if that is the patient's choice. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: Personalized dose optimization is desirable to improve subjective well-being and support rehabilitation. Therefore, N = 1 trials investigating tools to self-manage functional outcomes during dose optimization are necessary. The aim of this pilot study was to determine in two N = 1 trials whether an experience sampling method (ESM) smartphone app could be used to monitor and detect changes in subjective well-being and psychotic experiences during and after dose reduction.

Method: Two participants with a psychotic disorder in remission underwent gradual dose reduction under a longitudinal self-monitoring paradigm, accompanied by regular clinical monitoring by the attending physician. Subjective well-being was monitored with an (ESM) app through momentary affective experience (positive and negative affect) and physical well-being (tiredness, feeling unwell, and pain). Momentary psychotic experiences were assessed with four items. Time-series linear regression models were used to detect changes in reduction phases compared to baseline.

Results: Whereas significant improvements in subjective well-being and psychotic experiences during dose reduction were detected in one participant, the opposite was demonstrated for the other participant, showing worsened subjective well-being and increased psychotic experiences in the reduction phase compared to baseline.

Conclusions and implications for practice: Self-monitoring with an ESM smartphone app offers a tool for detecting changes in subjective well-being and psychotic experiences during antipsychotic dose reduction. In this way, ESM may increase an individual's sense of control and empowerment. It may further facilitate dose optimization and shared decision-making at an individual level, which is required considering the high heterogeneity in psychotic disorders. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Most individuals in recovery are likely to attempt discontinuing their prescribed medication at least once. The collection of articles in this special issue uses research with quantitative and qualitative methods, reviews of the literature, conceptualization of theory, and first-person accounts from various perspectives to begin to shift the field of psychiatric rehabilitation from a narrow focus on symptom reduction and a fear-driven emphasis on medication adherence to a new perspective in which dilemmas and strong feelings about medication use are commonplace. We issue a call to action for training psychiatric rehabilitation practitioners, who often have the most direct and frequent interactions with people in recovery, to explore their clients' experiences with using medication and its impact on a range of life domains. Rehabilitation, recovery, and medication have ongoing mutual influences and require an inclusive, multidimensional framework that integrates complex ongoing interactions between personal, societal, and biological processes and assures that treatment decisions are in alignment with recovery goals. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A brief autoethnographic commentary that describes the harms of a pervasive emphasis on medications and medication adherence in the treatment of schizophrenia, including within "best practice" early psychosis programs. The narrative emphasizes the extent to which, in spite of endless rhetoric of person-centered, recovery-oriented care, the reality remains that medication-centric treatment tends to dominate clinical services and programs, fueling the objectification and alienation of service users, and ultimately, in all too many cases, disengagement. The author's personal experiences are provided as an illustration of the potentially devastating impacts that a narrow and rigid focus on medications (and medicalized clinical relationships) can have. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: The current guidelines recommend continuation of antipsychotic medication for a minimum of at least 1 year following a first episode of psychosis (FEP). There have been several trials investigating whether early dose reduction or cessation leads to improved functional outcomes. The aim of this study was to explore the experience of consenting to and participating in a randomized controlled trial (RCT) of antipsychotic medication cessation.

Method: Five participants in the Reduce trial-an RCT evaluating early antipsychotic medication dose reduction/cessation following FEP-aged 22-24 years completed a semistructured qualitative interview following the RCT. Interpretive phenomenological analysis was undertaken to understand the key themes.

Results: A superordinate theme was derived from interviews: the Liminal Space of FEP and treatment. Themes within the Liminal Space included: rejection versus identification with psychosis, medication as symbolic of illness versus wellness, embodiment of wellness and illness with medication, medication as symbolic of independence versus dependence, discovery of independence when autonomously choosing medication, the Reduce trial offered safety to navigate the liminal space, and self-exploration versus altruism.

Conclusions and implications for practice: The experience and treatment of FEP involves young people feeling torn between multiple, competing perspectives, demands, and priorities. Participation in an RCT exploring dose reduction provided additional supports contributing to the perception of greater safety to navigate their own experiences of treatment that was appropriate for them. When treatment is experienced as collaborative, involves shared decision making and support, other than medication, young people feel more equipped to navigate the liminal space. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: The COVID-19 pandemic had a profound impact on the mental health of individuals with serious mental illness, with restricting social gatherings and limiting access to essential community and psychosocial support services. For programs like clubhouses, adapting typically in-person programming to online settings led to the creation of virtual clubhouse programming that persists at many sites even after reopening. Although it has been documented how clubhouses adapted their programming online, it has not been investigated at the individual level how those programs were utilized over time, by different member cohorts, and how they persist in comparison to one another.

Method: The present article presents descriptive and inferential statistics, analysis of variance, and secondary trend analysis of the Fountain House clubhouse in-person and virtual engagements of three member cohorts who enrolled in either three time periods before pandemic restrictions (the prior cohort), during pandemic restrictions (the pandemic cohort), and after lockdown restrictions (the reopening cohort).

Result: Initial findings show that the prior cohort sustained their overall rate of engagement across time periods. The pandemic cohort had a significantly higher rate of engagement than the prior cohort within the during period but demonstrated a significant decrease in engagement rate between the during and after period. Prior and pandemic cohorts had statistically similar virtual and in-person engagement ratios in the after period, but the reopen cohort differed significantly with a predominant ratio of in-person engagements.

Conclusions and implications for practice: Member engagement trends within in-person and virtual offerings across the three different pandemic related time periods indicate important considerations for the sustainability and innovation of clubhouse virtual programming. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: The theory of social practice describes a therapeutic community process for people living with serious mental illness, while the methods involve engaging people to become collaborators and contributors to a social environment. Confusion in the mental health field surrounding the applied methods of social practice-as occurring within the clubhouse model-has not been sufficiently addressed. This article aims to outline the methodology of social practice, as well as provide guidance on its practical application.

Methods: Specific constructs of social practice are defined, and empirical support is provided to emphasize how practices to support recovery are applied in the clubhouse.

Results: Five key elements of social practice-that is, transformational social design, engagement, relationship development, natural feedback and intervention, and transitional environments-are described. Practical examples of therapeutic techniques associated with each element are also provided.

Conclusions and implications for practice: Social practice addresses the social determinants of health by focusing on five key elements that support individual and community recovery. Here, we detail social practice techniques utilized in the clubhouse as a way of unifying theory, providing practical guidance to mental health professionals and improving the measurement of community as therapy for serious mental illness. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: This study examines adaptations, successes, and persistent challenges engaging members in virtual or hybrid community-based psychosocial rehabilitation centers called Clubhouses.

Methods: Fifteen members and staff from five Clubhouses across two Hawaiian Islands participated in a virtual Photovoice process.

Results: Results illustrated several unexpected positive outcomes from the transition to hybrid or virtual formats including opportunities for growth, learning new technology, cross-Clubhouse collaborations, deepened relationships, and better access to some hard-to-reach members. Persistent challenges included members reporting "something missing" in the socioemotional quality of virtual engagement and losing members who had low digital literacy or who preferred in-person engagement.

Conclusions and implications for practice: Overall, participants described that virtual Clubhouse supported their wellness by fostering a sense of purpose, companionship, and potential, despite sustained uncertainty from the COVID-19 pandemic. However, they also made clear that virtual and hybrid formats should be a complement to, not a replacement for, in-person Clubhouse services. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: The Clubhouse model of psychosocial rehabilitation supports the personal recovery of individuals with severe mental health challenges. To date, there has never been a multisite, longitudinal study examining the outcomes of Clubhouse members in Canada. Therefore, the purpose of the present study was to longitudinally assess the psychosocial outcomes and hospitalization rates of Clubhouse members from six Clubhouses across Canada. An exploratory aim of this study was to assess the psychosocial impact of the COVID-19 pandemic on Clubhouse members.

Method: The present study used a participatory approach with six accredited Clubhouses across Canada. A total of 462 Clubhouse members consented to participate in the study. Members completed a questionnaire battery every 6 months over a 2-year period (five data points total). The last three data points were collected during the COVID-19 pandemic. Primary outcomes included community functioning, measured by the Multnomah Community Ability Scale, and self-reported hospitalization rates. Data were analyzed using multilevel growth models.

Results: The results of the analysis indicated stability over the study period in community functioning and rates of hospitalization. Subscales of community functioning, including interference in functioning and behavioral problems improved over the course of the study, while adjustment to the community and social competence remained stable.

Conclusions and implications for practice: The consistency in outcomes across the study is notable, due to the worldwide impact of COVID-19 on mental health. Clubhouses may have had a buffering effect for members, in that membership diminished the impact of the pandemic on mental health. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: Though the efficacy of the Clubhouse model's interventions and practices in supporting recovery from serious mental illness (SMI) have been demonstrated by prior research, the causal mechanisms and theory driving these outcomes have yet to be comprehensively defined. This theory article aims to synthesize existing knowledge of these methods to define a unified theory of social practice, outline its role in SMI recovery, and discuss future implications.

Method: Historical, theoretical, and practical foundations of social practice were synthesized to define a current theory of social practice and expand the term to apply to the methods and interventions that define the Clubhouse model.

Results: Based on prior theory and findings, we define social practice as "the informed application of a specialized form of environmental therapy that utilizes an intentional community to assist people in their recovery." Key facets of social practice in the Clubhouse model of SMI recovery are discussed, including the efficacy of the practice in addressing SMI outcomes such as isolation and low self-efficacy, as well as its impact on both internal and external motivational forces.

Conclusions and implications for practice: The theory of social practice describes a process of engaging people to become collaborators and contributors to a social environment. This article describes the philosophy and practices of Clubhouses and introduces the theory of social practice as an empirical means of unifying and communicating the methods, practices, and outcomes of both the Clubhouse model and the broader implications of intentional community as therapy. (PsycInfo Database Record (c) 2024 APA, all rights reserved).