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In recent years, patient needs and satisfaction with psychiatric care have been increasingly studied. This research has generated information that is useful for improving the quality of care and for implementing therapeutic programs based on evidence-based criteria and on patients’ subjective experiences (1–7). A relatively new research area is represented by studies exploring patient opinions on the benefits of treatment provided in both inpatient (8–10,12) and outpatient services (11). McIntyre and others described the opinions of 99 psychiatric inpatients regarding the care they received in a London psychiatric teaching hospital (mean length of stay, 21 weeks) (8). Patients were asked to answer 10 questions about drug treatment, the ward round, being in hospital, having free passes, having visitors, talking to doctors, talking to nurses, talking to other patients, ward groups, and occupational therapy. Patients rated these components on a 5-point scale ranging from 0 (“not at all helpful”) to 4 (“extremely helpful”). According to the patients, the following aspects of care were the most helpful: having free passes, having visitors, talking to the doctor, talking to nurses, drug treatment, being in hospital, occupational therapy, ward rounds, talking to other patients, and ward groups. Frager and others studied 500 patients at the Menninger Memorial Hospital, using the Client Satisfaction Questionnaire and the Components of Treatment Questionnaire (9). Their results indicated that the most helpful treatment components were individual time with the hospital doctor, the psychotherapist, the chaplain, the social worker, and the primary nurse; educational and vocational testing; and counselling on individual problems and goals. Patterns of dissatisfaction focused on community meetings and group therapy. The authors suggested that having at least 1 key ongoing treatment relationship as a central organizing component of therapy is a key treatment factor. Vartiainen and others used a questionnaire to ascertain the attitude toward treatment of 203 psychiatric patients in a maximum security hospital (10). These patients were asked to respond to the following: “What kind of treatment seems to help you at the moment?” and “Assess the meaning of the following types of treatment and rehabilitation and check the item that best fits your opinion.” A total of 38 common forms of treatments were assessed, and the possible answers were as follows: “I have not participated or have no experience,” “seems harmful,” “no help,” “a little help,” “quite a lot help,” “very much help.” The last open question was “What else do you want to say about the treatment?” Most patients experienced help from medication (41%), from conversations with psychiatric nurses (26%), and from occupational therapy (for example, confidential tasks, hygiene education, and duty to work in the ward) (21%). Among the 38 treatment forms evaluated with the second question, the most successful were free walking, holidays, trips, individual sessions with a psychiatrist, having a personal psychiatric nurse, communication, and support from the staff. The third open question revealed that most patients were satisfied with their treatment. The authors concluded that liberties (such as free walking and holidays), interactive treatment forms (such as a personal psychiatric nurse, support from personnel, and communication), medication, and some form of rehabilitation or occupational therapy were experienced as more helpful, while restrictions and isolation were considered less helpful. McGrew and others enrolled a sample of Assertive Community Treatment (ACT) patients (11). Between 6 and 12 months after discharge, they asked patients “What do you like best about ACT?” Patients identified the following features: staff availability (17.6%); help with daily problems such as transportation and money management, as well as assistance with medical care, obtaining housing, and living resources (15.8%); recreational support (10.9%); home visits (5.5%); intensity of service (4.2%); and shared caseloads (3.0%).The helping relationship was perceived as precious by clients presenting a high level of functioning on the Global Assessment of Functioning scale. The authors indicated that attention to daily living was rated as the key element in preventing hospital admissions. These briefly summarized studies highlight specific treatment components, in particular, components with a relational value (for example, talking to one’s doctor, staff availability, conversation, and time with hospital doctors) and components that indicate a less restrictive setting and the preservation of contacts with the outside world (for example, free passes, free walking, visitors, and holidays) (8–11) . These findings agree with findings from studies focusing on patient requests concerning psychiatric care, which emphasized the relevance of interventions based on psychological expertise and psycho- dynamic insight (12). In Italy, the dismantlement of psychiatric hospitals has been followed by the implementation of a network of outpatient psychiatric services acting in close conjunction with inpatient wards set up in general hospitals. In addition, residential facilities have been developed to provide care for patients with chronic disorders and, more recently, as possible alternatives to hospital admission for acutely ill patients accepting voluntary treatment (13). However, data assessing patient opinions on the benefit of residential treatment are lacking, both in the literature and in our country. This study therefore aimed to assess patients’ subjective perception regarding the helpfulness of treatment delivered in a residential facility for intensive, short-term care. Material and MethodsThe study was carried out in a community residential facility located in the middle of the north Italian city of Ferrara. This facility is part of the Department of Mental Health (DMH) Local Health Agency, which serves the population of the town and its province (catchment area, 350 000 inhabitants). The residential facility wherein this study was carried out is part of the University Unit of Psychiatry, which is linked with the DMH. It provides short- to medium-term care (that is, a length of stay between 1 and 3 months) for patients with acute and subacute psychiatric conditions who accept voluntary treatment. The facility is staffed by 2 psychiatrists and 1 psychologist, who are present during the day, and 15 nurses, who rotate during the 24-hour period (specifically, 3 nurses in the morning, 2 in the afternoon–evening, and 2 at night). There are 8 bedrooms (2 with 3 beds, 4 with 2 beds, and 2 with 1 bed). The unit is also equipped with a private courtyard for the patients. Patients may be transferred from the general hospital acute inpatient unit, or, at the request of the outpatient mental centres, they may be admitted for worsening of psychiatric conditions. Treatments include individual psychological support, group psychotherapy, rehabilitation activities, individual meetings with a doctor or nurse, leisure time activities, and medication. Patients Measurements The expanded version of the Brief Psychiatric Rating Scale (BPRS-E) (14) was used to assess psychopathological symptoms at admission and immediately before discharge. Before they left the facility, a researcher not belonging to the staff asked patients to complete the Opinions on Curative Factors Questionnaire (OCFQ), developed from research findings by McIntyre and others (8) and Gunderson (15) and adapted to the characteristics of the residential facility. The OCFQ is an 18-item questionnaire asking patients to rate the benefit and helpfulness of the single components of their psychiatric care on a 5-point Likert scale (from 0 = “not helpful at all” to 4 = “very helpful”). Of the 18 questions, 3 refer to the benefit of talking privately to doctors, talking to nurses, and talking to family members; 1 asks about support received from the team; 3 concern different aspects of group psychotherapy (that is, feelings expression–catharsis, clarifications, and universality); 1 concerns group activities (such as journal reading and movie watching); 1 inquires about making friends with other patients; 1 investigates opinions about medication; 1 concerns opinions about rehabilitation activities; 1 deals with the structure of daily life; 1 is about facility regulations (for example, the prohibition of sexual or aggressive acts); 1 is about leisure activities; 1 is about free pass; 1 is about visitors; 1 is about separation from the daily-life milieu; and the last refers to the helpfulness of being in a nonhospital setting. The OCFQ also has 3 open questions: “Which component of treatment seems to be most helpful to you?” “What do you think about the length of stay in the facility?” and “What else could have been helpful to you?” To evaluate the first open-ended question, we grouped the several answers into 7 categories: talking with staff members (doctors or nurses), medication, group therapy, rehabilitation activities, free pass, making friends with other patients, and other. Statistical Analysis ResultsPatients’ Sociodemographic and Clinical Characteristics
There were 66 men (42%) and 91 women (58%) with a mean age of 46.7 years (SD 13.5, range 21 to 77 years). More than one-third had never married (n = 60, 38.2%), and lived with their own family (n = 64, 40.8%). Most patients were unemployed (n = 133, 84.7%). Diagnosed according to ICD-10 criteria, nearly one-half of the patients suffered from affective disorders (n = 76, 48.4%), and one-third had psychotic disorders (n = 50, 31.9%). Personality disorders were diagnosed in 28 subjects (17.8%), whereas neurotic disorders accounted for a minority of the diagnoses (n = 3, 1.9%). The mean age at illness onset was 28.8 years, SD 12.5. The mean number of previous psychiatric admissions was 8.9, SD 12.6. The mean length of stay in the facility was 49.9 days, SD 47.4, range 3 to 258 days, with 76 patients (48.4%) staying for less than 1 month and 81 (51.6%) for more than 1 month. BPRS-E scores significantly improved from admission to discharge (mean 61.6, SD 12. 9 vs mean 37.9, SD 11. 1; t = 17.45, P = 0.001). Factor Structure We used Cronbach’s alpha coefficient to assess factor reliability and the internal consistency of the questionnaire. A high coefficient was obtained for factor 2 (alpha 0.81), whereas moderate coefficients were obtained for factor 1 (0.69), factor 3 (0.65), factor 4 (0.62), and factor 5 (0.74). A lower coefficient was obtained for factor 6 (0.54). As expected, however, significant correlations between the factors were shown. Patient Opinions Regarding Therapeutic Factors
All therapeutic factors tested by the OCFQ were considered helpful or very helpful by most of the sample. The item with the highest score was “talking to doctor,” followed by “free pass,” “medication,” “visitors,” “nonhospital setting,” “making friends with patients,” “structure of daily life,” “support from team,” and “talking to nurses.” The least-valued item was “group activities.” (mean score 2.51, SD 1.21). The open-ended questions highlighted relational factors such as talking to staff members and making friends (Table 3). Most rated their length of stay as “ideal,” and answers to the last open-ended question revealed that about one-half did not request additional treatment.
Differences According to Sociodemographic and Clinical Variables No differences were found between men and women with regard to the scale factors, except for a higher score on factor 4 among men (mean score 9.17, SD 10.14), compared with women (mean score 8.4, SD 9.4) (F = 3.93, P = 0.049). No differences were found with regard to the scale factors between the different educational levels and lengths of stay (that is, < 1 month vs > 1 month). After we excluded patients with a diagnosis of anxiety disorder (n = 3), we found no difference on the factors scale when we compared the remaining ICD-10 psychiatric diagnoses (Table 4).
When we analyzed patients’ responses to the single items, we found significant differences between diagnostic groups. Compared with patients having other diagnoses, those with a diagnosis of affective disorders perceived as more helpful the items “feelings expression in group therapy” (c2 = 22.69, df 8; P = 0.004) and “visitors” (c2 = 17.8, df 8; P = 0.023). Patients with a diagnosis of psychotic disorders perceived the rehabilitation activities to be more helpful (c2 = 17.34, df 8; P = 0.027). DiscussionAlthough not widely used as alternatives to hospitalization for severe mental illness, residential facilities have been proven as effective as hospital care (17,18) and have significantly lower costs (19). These facilities usually provide a wide range of treatment modalities, including psychiatric evaluations, medication, individual or group psychotherapy, rehabilitation, and other group-based activities, offered in a supportive, homelike, nonrestrictive setting (20). To our knowledge, this is the first study investigating patients’ opinions on treatment provided during their admission to a residential facility. The vast majority of patients rated specific modalities of treatment, such as talking with a doctor and medication, as very helpful—a finding that can be considered for individual-based approaches. Further, they also rated aspects of care such as free pass, visitors, and the nonhospital setting as very helpful. These aspects offer patients a home-like environment, that is, the possibility of maintaining a familiar life style (for example, preserving relationships with friends, family members, and their community). These results are comparable to results that emerged in other studies. In fact, McIntyre and others found that free pass, visitors, and talking to a doctor were perceived as the most helpful factors, without significant differences between diagnoses (8). Similarly, Frager and others showed that individualized components of treatment (that is, individual psychotherapy, meeting with a hospital doctor, or medication) achieved the highest scores (9). Vartiainen and others carried out a study in a forensic hospital wherein almost all patients received compulsory treatment (10). These researchers found that patients rated as most helpful liberties (for example, free walking, holidays, and trips) and interactive, individualized treatment forms (for example, sessions with a psychiatrist and having a personal psychiatric nurse), whereas they considered restrictions and isolation less helpful. As already suggested, the high score given to such important individualized treatment components as talking to doctors and medication underlines the relevance of linking mind and brain (21) in a process that integrates psychologically and biologically based treatments. From this perspective, the importance of acquiring psychotherapeutic skills seems essential, as suggested by McIntyre and others (8). This observation is also supported by studies on satisfaction with psychiatric care that find high levels of satisfaction to be related to individual therapy (22). The value accorded to such environmental factors as “free pass,” “visitors,” and a “nonhospital setting” confirmed the helpfulness of a therapeutic milieu characterized by few restrictions, no stigma, and many social interactions with the outside world. These elements constitute the cornerstone of community care (23). Findings in line with these results come from recent studies documenting a lower level of general satisfaction, as well as less satisfaction with medication, ward equipment, visiting opportunities, and regulations for going out, on a closed ward, compared with an open ward (24), and a higher degree of autonomy in a residential setting, compared with an inpatient setting (25). Answers to open-ended questions in our study seem to further support this: patients rated as highly relevant talking to staff members, individual sessions, and medication; they felt that rules and separation from their daily milieu had low treatment relevance. Verbal group activities (that is group therapy, journal reading, or watching movies followed by group discussion) were considered less helpful. This finding agrees with the few studies carried out in this area, the results of which indicated that, in patients’ opinions, the lowest-ranked intervention components were daily meetings on the ward (8) or group-based modalities such as community meetings, treatment-team meetings, and group therapy (9). In our facility, group sessions are open, short, and heterogeneous (that is, they include almost all the patients admitted, who have different ages and diagnoses). It is possible that these aspects, along with high patient turnover, do not allow cohesive groups to develop and do not allow individual problems to be addressed. The correlations between the 6 principal factors and demographic and clinical variables documented that patients who improved more considered factor 3 (care) and factor 4 (separation) to be more helpful, whereas older patients attributed less value to factor 1 (residential activities) and factor 4 (separation). In our analysis, diagnosis was not associated with any factor, indicating that all patients perceived the same components of treatment to be helpful. However, the analysis of the relation between diagnosis and single items revealed that patients suffering from psychosis highlighted the helpfulness of rehabilitation activities specifically organized to improve their disability, whereas patients with affective disorders benefited from catharsis and relationships. Some limitations should be borne in mind. First, the results reported here apply to voluntarily admitted psychiatric patients only. This sample selection may explain the favourable attitudes toward the treatments received and the preference for a nonhospital setting. To minimize this source of bias, the OCFQ was administered by a researcher not belonging to the staff. The interview took place before patients left the facility but after the discharge decision was taken. Second, we cannot interpret the ratings of helpfulness as ratings of treatment efficacy. These studies can be an interesting way to recognize and describe patients’ experiences, needs, and opinion. As well, they help to increase patient involvement in planning therapeutic strategies; however, they cannot provide information on efficacy (12). In conclusion, our findings appear to document that psychiatric patients consider several therapeutic factors helpful. They rate as very helpful factors based on individual approaches (for example talking with a doctor and medication) or on aspects of the therapeutic milieu that assure few restrictions, no stigma, and interactions with the outside world. The results presented here may be a valuable contribution to clinicians seeking to improve the planning of therapeutic strategies that take into account patient opinions. References1. Kalman TP. An overview of patient satisfaction with psychiatric treatment. Hosp Community Psychiatry 1983;34:48–54. 2. Ruggeri M. Patients’ and relatives’ satisfaction with psychiatric services: the state of the art of its measurement. Soc Psychiatry Psychiatr Epidemiol 1994;29:212–27. 3. Henderson C, Phelan M, Loftus L, Dall’Agnola R, Ruggeri M. Comparison of patient satisfaction with community-based vs. hospital psychiatric services. Acta Psychiatr Scand 1999;99:188–95. 4. Greenwood N, Key A, Burns T, Bristow M, Sedgwick P. Satisfaction with in-patient psychiatric services. Br J Psychiatry 1999; 74:159–63. 5. Kelstrup A, Lund K, Lauritsen B, Bech P. Satisfaction with care reported by psychiatric inpatients. Relationship to diagnosis and medical treatment. Acta Psychiatr Scand 1993;87:374–9. 6. Slade M. Needs assessment: involvement of staff and users will help to meet needs. Br J Psychiatry 1994;165:293–6. 7. Lasalvia A, Ruggeri M, Mazzi MA, Dall’Agnola RB. The perception of needs for care in staff and patients in community-based mental health services. The South-Verona Outcome Project 3. Acta Psychiatr Scand 2000;102:366–75. 8. McIntyre K, Farrell M, David A. In-patient psychiatric care: the patient’s view. Br J Med Psychol 1989;62:249–55. 9. Frager DC, Coyne L, Lyle J, Coulter PL, Graham P, Sargent J, and others. Which treatments help? The patient’s perspective. Bull Menninger Clin 1999;63:388–99. 10. Vartiainen H, Vuorio O, Halonen P, Hakola P. The patients’ opinions about curative factors in involuntary treatment. Acta Psychiatr Scand 1995;91:163–6. 11. McGrew JH, Wilson RG, Bond GR. Client perspectives on helpful ingredients of assertive community treatment. Psychiatr Rehabil J 1996;19:13–21. 12. Noble LM, Douglas BC, Newman SP. What do patients want and do we want to know? A review of patients’ requests of psychiatric services. Acta Psychiatr Scand 1999;100:321–7. 13. De Girolamo G, Picardi A, Micciolo R, Falloon I, Fioritti A, Morosini P. Residential care in Italy. Br J Psychiatry 2002;181:220–5. 14. Ventura J, Green M, Shaner A, Liberman R. Training and quality assurance with the Brief Psychiatric Rating Scale: ‘The drift busters.’ Int J Meth Psychiatr Res 1993;3:221–44. 15. Gunderson JG. Defining the therapeutic processes in psychiatric milieus. Psychiatry 1978;41:327–35. 16. Norusis MJ: Statistical package for the social sciences. Version 10.1. Chicago (IL): SPSS Inc; 2001. 17. Fenton WS, Mosher LR, Herrell JM, Blyler CR. Randomized trial of general hospital and residential alternative care for patients with severe and persistent mental illness. Am J Psychiatry 1998;155:516–22. 18. Hawthorne WB, Green EE, Lohr JB, Hough R, Smith PG. Comparison of outcomes of acute care in short-term residential treatment and psychiatric hospital settings. Psychiatr Serv 1999;50:401–6. 19. Fenton WS, Hoch JS, Herrel JM, Mosher L, Dixon L. Cost and cost-effectiveness of hospital vs residential crisis care for patients who have serious mental illness. Arch Gen Psychiatry 2002;59:357–64. 20. Stroul BA. Residential crisis services: a review. Hosp Community Psychiatry 1988;39:1095–9. 21. Gabbard GO. A neurobiologically informed perspective on psychotherapy. Br J Psychiatry 2000;177:117–22. 22. Hansson L, Bjorkman T, Berglund I. What is important in psychiatric inpatient care? Quality of care from the patients’ perspective. Qual Assur Health Care 1993;5:41–7. 23. Mosher LR. Soteria and other alternatives to acute psychiatric hospitalisation. J Nerv Ment Dis 1999;187:142–9. 24. Muller MJ, Schlosser R, Kapp-Steen G, Schanz B, Benkert O. Patients’ satisfaction with psychiatric treatment: comparison between an open and a closed ward. Psychiatr Q 2002;73:93–107. 25. Brunt D, Hansson L. A comparison of the psychosocial environment of two types of residences for persons with severe mental illness: small congregate community residences and psychiatric inpatient settings. Int J Soc Psychiatry 2002;48:243–52. Author(s)Manuscript received June 2003, revised, and accepted September 2003. 1. Attending Pychiatrist, Department of Mental Health, Local Health Agency, Ferrara, Italy; Assistant Professor, Section of Psychiatry, Department of Medical Sciences of Communication and Behaviour, University of Ferrara, Ferrara, Italy. 2. Assistant Professor of Psychiatry, Section of Psychiatry, Department of Medicine and Public Health, University of Verona, Verona, Italy. 3. Resident, Section of Psychiatry, Department of Medical Sciences of Communication and Behaviour, University of Ferrara, Ferrara, Italy. 4. Psychology Fellow, Section of Psychiatry, Department of Medical Sciences of Communication and Behaviour, University of Ferrara, Ferrara, Italy. 5. Professor of Psychiatry, Chief Section of Psychiatry, Department of Medical Sciences of Communication and Behaviour, University of Ferrara, Ferrara, Italy. Address for correspondence: Dr L Grassi, Clinica Psichiatrica Università di Ferrara, Corso Giovecca 203, 44100 Ferrara, Italy e-mail: luigi.grassi@unife.it
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