Subjective measures of quality of life (QOL) in patients with mental illness may be inaccurate because of:
B. QOL is measurable using questionnaires; these measures can be subjective or objective and many standardized instruments for both are available. Most but not all QOL instruments contain ‘emotional’ items, mostly relating to depression and anxiety. Such scales when applied to psychiatric conditions become tautological as the content of both measures largely overlap, e.g. the Quality of Life in Depression Scale (QLDS), which is made up mainly of depressive symptoms. Subjective measures of QOL in psychiatry are particularly problematic because of ‘affective, cognitive or reality distortion fallacies’. A depressed patient may underestimate his true QOL; similarly, psychopathological states may lead to distorted appraisal of one’s QOL. Hence external (e.g. relatives/carers) appraisal may be necessary to complement subjective QOLs in psychiatry. Another specific type of bias noted in QOL studies in psychiatry is what is termed as ‘standard drift fallacy’. Quality of life can be thought of as the gap between a person’s expectations and achievements. This gap can be kept minimal (i.e. good QOL) either by living up to one’s expectations or lowering these expectations. Many patients with long-term mental disorders report being ‘satisfied with life’ in conditions that would be regarded as inadequate or unbearable by other factions of the society. This is due to the tendency of chronic mentally ill people to lower their standards over time and thus keep the gap between expectations and achievements narrow (falsely inflated subjective QOL).
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Which of the following projects refers to promoting spontaneous recovery in schizophrenia without compulsory use of psychotropics?
B. Different models of therapeutic communities have been tried as alternatives to hospitalization for people diagnosed with schizophrenia. Some of these models emphasized the need for individuals to experience psychosis with minimal interference and high levels of support instead of early intervention with antipsychotic medication. In the UK, initiatives such as Kingsley Hall, associated with Laing, and Villa 21, associated with David Cooper, are examples. In the USA, the ‘Soteria paradigm,’ was developed by Mosher and colleagues; the critical elements of Soteria are provision of a small, community-based therapeutic milieu; significant lay person staffing; preservation of personal power and social networks; sustained communal responsibilities; a ‘phenomenological’ relational style (giving meaning to the subjective experience of psychosis by ‘being with’ and ‘doing with’ the client); and no or low-dose antipsychotic medication administered from a position of choice and without coercion. Henderson hospital is a therapeutic community for personality disorders, not schizophrenia. The PACE (Personal Assessment and Crisis Evaluation) Clinic is a centre for people with suspected incipient psychosis in Australia where trialled interventions aimed at preventing or delaying the onset of psychotic disorders are used; these interventions include psychological and social interventions, either alone or in combination with pharmacotherapy. Partial hospitalisation refers to mentalization-based therapy for borderline personality disorder.
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According to the health belief model of treatment compliance, patients consider all of the following factors when deciding upon treatment adherence except:
E. According to the health belief model four main belief categories have an impact on patients’ compliance with prescribed treatment. These are:
This model emphasizes the patient’s decision-making process, which is composed of a subjective cost–benefit analysis in the context of the patient’s personal goals and priorities. Thus any changes in levels of adherence are possible only via alteration of the patient’s perceptions. The more severe the illness, the higher the likelihood of perceived benefits. Social criticism does not constitute a major factor in adherence according to the health benefits model, unless avoiding it is perceived directly as a benefit by the patient.
The vocational rehabilitation programme with best evidence in schizophrenia is:
B. Competitive employment rates are low in schizophrenia. People with mental health disorders represent the largest group (40%) who claim incapacity benefit. Various vocational programmes have been tried and tested in schizophrenia rehabilitation. Work acts as both a process and the outcome for rehabilitation in chronic schizophrenia. Sheltered employment refers to the traditional ‘train and place model’ where gradual stepwise skills training is initially carried out; when an individual makes sufficient progress, later placement is offered, often in sheltered workshops but not in competitive job markets. This approach remains the most widespread in Europe. Models that emphasize relatively quick placement in competitive jobs with continued support from employment specialists (supported employment models) are shown to have considerable impact compared with schemes that concentrate on social skills training or voluntary non-competitive work. This is the individual placement and support model in contrast to traditional stepwise support-till-placement (train and place approach) models. A Multicentre RCT of Individual placement and training model (IPS) was carried out across six centres in Europe, including London. The results indicated that IPS was more effective than usual rehabilitation and vocational services for every work-related outcome, with 55% of patients assigned to IPS working for at least 1 day compared with 28% patients assigned to vocational services; the drop-out and readmission rates were comparatively lower in the IPS group. Local unemployment rates across the six centres accounted for a substantial amount of the heterogeneity in IPS effectiveness. Clubhouses offer an opportunity for a person with schizophrenia to resume an independent lifestyle with decent housing, facilities for education, job training, and placement via membership at a common day centre. Token economy cannot be considered as a vocational model; it is a behavioural technique using secondary reinforcers (tokens) in rehabilitation units to enable desirable behaviour.
The proportion of patients of working age with serious mental health problems who are employed actively in the UK is:
A. Annual (now quarterly) labour force surveys in the UK yield the rates of employment for the mentally ill population. Patients with a significant mental illness are among the most excluded in society. It is estimated that, at best, 15% of working age people with long-term mental health problems are working, far lower than any other group of disabled people. Even when working they work fewer hours and earn only two-thirds of the national average hourly rate. The employment rates for those with less serious mental health problems are relatively better at 20–25% but still people with mental disorders constitute 39% of all claimants of Disability Allowance and 34%of Incapacity Benefit, according to Department of Works and Pensions, UK. Joblessness and lack of social networks are often exacerbated by discrimination and profound loss of social status suffered by the mentally ill. Recovery from mental illness is significantly impeded by the above.
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