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      Psychiatric advance directives for people living with schizophrenia, bipolar I disorders, or schizoaffective disorders: Study protocol for a randomized controlled trial – DAiP study

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          Abstract

          Background

          Compulsory admission to psychiatric hospital is rising despite serious ethical concerns. Among measures to reduce compulsory admissions, Psychiatric Advance Directives (PAD) are the most promising, with intensive PAD (i.e. facilitated and shared) being the most effective. The aim of the study is to experiment Psychiatric Advance Directives in France.

          Methods

          A multicentre randomized controlled trial and qualitative approach conducted from January 2019 to January 2021 with intent-to-treat analysis.

          Setting

          Seven hospitals in three French cities: Lyon, Marseille, and Paris. Research assistants meet each participant at baseline, 6 months and 12 months after inclusion for face-to-face interviews.

          Participants

          400 persons with a DSM-5 diagnosis of bipolar I disorder (BP1), schizophrenia (SCZ), or schizoaffective disorders (SCZaff), compulsorily admitted to hospital within the last 12 months, with capacity to consent (MacCAT-CR), over 18 years old, and able to understand French.

          Interventions

          The experimental group (PAD) (expected n = 200) is invited to fill in a document describing their crisis plan and their wishes in case of loss of mental capacity. Participants meet a facilitator, who is a peer support worker specially trained to help them. They are invited to nominate a healthcare agent, and to share the document with them, as well as with their psychiatrist. The Usual Care (UC) group (expected n = 200) receives routine care.

          Main outcomes and measures

          The primary outcome is the rate of compulsory admissions to hospital during the 12-month follow-up. Secondary outcomes include quality of life (S-QoL18), satisfaction (CSQ8), therapeutic alliance (4-PAS), mental health symptoms (MCSI), awareness of disorders (SUMD), severity of disease (ICG), empowerment (ES), recovery (RAS), and overall costs.

          Discussion

          Implication of peer support workers in PAD, potential barriers of supported-decision making, methodological issues of evaluating complex interventions, evidence-based policy making, and the importance of qualitative evaluation in the context of constraint are discussed.

          Trial registration

          ClinicalTrials.gov identifier: NCT03630822. Registered 14th August 2018.

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          Most cited references67

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          The client satisfaction questionnaire. Psychometric properties and correlations with service utilization and psychotherapy outcome.

          An 18-item version of the Client Satisfaction Questionnaire (CSQ-18) was included in an experimental study of the effects of pretherapy orientation on psychotherapy outcome. The psychometric properties of the CSQ-18 in this study were compared with earlier findings. In addition, the correlations of the CSQ-18 with service utilization and psychotherapy outcome measures were examined. Results indicated that the CSQ-18 had high internal consistency (coefficient alpha = .91) and was substantially correlated with remainer-terminator status (rs = .61) and with number of therapy sessions attended in one month (r = .54). The CSQ-18 was also correlated with change in client-reported symptoms (r = -.35), indicating that greater satisfaction was associated with greater symptom reduction. Results also demonstrated that a subset of items from the scale (the CSQ-8) performed as well as the CSQ-18 and often better. The excellent performance of the CSQ-8, coupled with its brevity, suggests that it may be especially useful as a brief global measure of client satisfaction.
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            Peer support among persons with severe mental illnesses: a review of evidence and experience.

            Peer support is largely considered to represent a recent advance in community mental health, introduced in the 1990s as part of the mental health service user movement. Actually, peer support has its roots in the moral treatment era inaugurated by Pussin and Pinel in France at the end of the 18th century, and has re-emerged at different times throughout the history of psychiatry. In its more recent form, peer support is rapidly expanding in a number of countries and, as a result, has become the focus of considerable research. Thus far, there is evidence that peer staff providing conventional mental health services can be effective in engaging people into care, reducing the use of emergency rooms and hospitals, and reducing substance use among persons with co-occurring substance use disorders. When providing peer support that involves positive self-disclosure, role modeling, and conditional regard, peer staff have also been found to increase participants' sense of hope, control, and ability to effect changes in their lives; increase their self-care, sense of community belonging, and satisfaction with various life domains; and decrease participants' level of depression and psychosis.
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              Awareness of illness in schizophrenia and schizoaffective and mood disorders.

              The literature on insight, or self-awareness, in schizophrenia suggests that this cognitive dimension may be of nosological value. Poor insight has descriptive validity at the phenomenological and neuropsychological levels of schizophrenia and has prognostic validity in terms of the prediction of the course of illness. The lack of empirical data on the diagnostic specificity of poor insight to schizophrenia and the previous use of insight measures with questionable reliability and validity have limited this interpretation. In the present study, we assessed insight into multiple aspects of mental disorder using a measure with demonstrated reliability and validity. A sample of 412 patients with psychotic and mood disorders coming from geographically diverse regions of the United States and one international site was studied. The main aims were to determine the prevalence of self-awareness deficits in patients in whom schizophrenia was diagnosed, to examine the relative severity of self-awareness deficits associated with schizophrenia compared with that of schizoaffective and mood disorders with and without psychosis, and to evaluate the clinical correlates of self-awareness in patients with schizophrenia. The results indicated that poor insight is a prevalent feature of schizophrenia. A variety of self-awareness deficits are more severe and pervasive in patients with schizophrenia than in patients with schizoaffective or major depressive disorders with or without psychosis and are associated with poorer psychosocial functioning. The results suggest that severe self-awareness deficits are a prevalent feature of schizophrenia, perhaps stemming from the neuropsychological dysfunction associated with the disorder, and are more common in schizophrenia than in other psychotic disorders.
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                Author and article information

                Contributors
                aurelie.tinland@gmail.com
                Journal
                BMC Psychiatry
                BMC Psychiatry
                BMC Psychiatry
                BioMed Central (London )
                1471-244X
                27 December 2019
                27 December 2019
                2019
                : 19
                : 422
                Affiliations
                [1 ]ISNI 0000 0001 2176 4817, GRID grid.5399.6, School of medicine – La Timone Medical Campus, EA 3279: CEReSS – Health Service Research and Quality of Life Center, , Aix-Marseille University, ; 27 Boulevard Jean Moulin, F-13005 Marseille Cedex 5, France
                [2 ]ISNI 0000 0001 0407 1584, GRID grid.414336.7, Department of Psychiatry, , Sainte-Marguerite University Hospital, ; F-13009 Marseille, France
                [3 ]ISNI 0000 0001 0407 1584, GRID grid.414336.7, Department of Clinical Research and Innovation, Support Unit for clinical research and economic evaluation, Assistance Publique – Hôpitaux de Marseille, ; F-13385 Marseille, France
                [4 ]ISNI 0000 0001 1941 5482, GRID grid.482726.d, Centre Max Weber, UMR 5283 – Centre hospitalier Le Vinatier, ; Lyon, France
                [5 ]Mental Health and Social Sciences Research Unit, Paris Psychiatry and Neurosciences University Hospital Group, Paris, France
                [6 ]ISNI 0000 0001 2172 4233, GRID grid.25697.3f, Resource center of psychosocial rehabilitation, Centre hospitalier Le Vinatier, UMR 5229, , CNRS & Université Claude Bernard Lyon 1, Université de Lyon, ; Lyon, France
                Author information
                http://orcid.org/0000-0002-8168-930X
                Article
                2416
                10.1186/s12888-019-2416-9
                6935101
                31881954
                419cc1f9-14e6-4827-8795-1b99bd1c852b
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 20 November 2019
                : 17 December 2019
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100009243, Direction Générale de l’offre de Soins;
                Award ID: PREPS-17-0575
                Categories
                Study Protocol
                Custom metadata
                © The Author(s) 2019

                Clinical Psychology & Psychiatry
                facilitated psychiatric advances directives,advance decision making,supported decision making,peer support workers,compulsory admission

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