Health of the Nation Outcome Scales (HoNOS). Research and development.
TL;DR: The resulting 12-item HoNOS instrument is simple to use, covers clinical problems and social functioning with reasonable adequacy, has been generally acceptable to clinicians who have used it, is sensitive to change or the lack of it, and showed good reliability in independent trials.
Abstract: BACKGROUND An instrument was required to quantify and thus potentially measure progress towards a Health of the Nation target, set by the Department of Health, "to improve significantly the health and social functioning of mentally ill people".
METHOD A first draft was created in consultation with experts and on the basis of literature review. This version was improved during four stages of testing: two preliminary stages, a large field trial involving 2706 patients (rated by 492 clinicians) and tests of the final Health of the Nation Outcome Scales (HoNOS), which included an independent study (n = 197) of reliability and relationship to other instruments.
RESULTS The resulting 12-item instrument is simple to use, covers clinical problems and social functioning with reasonable adequacy, has been generally acceptable to clinicians who have used it, is sensitive to change or the lack of it, showed good reliability in independent trials and compared reasonably well with equivalent items in the Brief Psychiatric Rating Scales and Role Functioning Scales.
CONCLUSIONS The key test for HoNOS is that clinicians should want to use it for their own purposes. In general, it has passed that test. A further possibility, that HoNOS data collected routinely as part of a minimum data set, for example for the Care Programme Approach, could also be useful in anonymized and aggregated form for public health purposes, is therefore testable but has not yet been tested.
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TL;DR: At one year's follow-up, psychotic symptoms changed favourably to a mean of 1.09 (standard deviation 1.27) with an estimated mean difference between groups of −0.31 (95% confidence interval −0-0.07, P = 0.02) in favour of integrated treatment.
Abstract: Objectives To evaluate the effects of integrated treatment for patients with a first episode of psychotic illness.
Design Randomised clinical trial.
Setting Copenhagen Hospital Corporation and Psychiatric Hospital Aarhus, Denmark.
Participants 547 patients with first episode of schizophrenia spectrum disorder.
Interventions Integrated treatment and standard treatment. The integrated treatment lasted for two years and consisted of assertive community treatment with programmes for family involvement and social skills training. Standard treatment offered contact with a community mental health centre.
Main outcome measures Psychotic and negative symptoms (each scored from 0 to a maximum of 5) at one and two years' follow-up.
Results At one year's follow-up, psychotic symptoms changed favourably to a mean of 1.09 (standard deviation 1.27) with an estimated mean difference between groups of –0.31 (95% confidence interval –0.55 to –0.07, P = 0.02) in favour of integrated treatment. Negative symptoms changed favourably with an estimated difference between groups of –0.36 (–0.54 to –0.17, P < 0.001) in favour of integrated treatment. At two years' follow-up the estimated mean difference between groups in psychotic symptoms was –0.32 (–0.58 to –0.06, P = 0.02) and in negative symptoms was –0.45 (–0.67 to –0.22, P < 0.001), both in favour of integrated treatment. Patients who received integrated treatment had significantly less comorbid substance misuse, better adherence to treatment, and more satisfaction with treatment.
Conclusion Integrated treatment improved clinical outcome and adherence to treatment. The improvement in clinical outcome was consistent at one year and two year follow-ups.
502 citations
01 Jun 2008-Epidemiologia E Psichiatria Sociale-an International Journal for Epidemiology and Psychiatric Sciences
TL;DR: Development of recovery-focussed mental health services internationally is reviewed, and two innovative, generalisable and empirically investigated examples of implementing a focus on personal recovery are given.
Abstract: SUMMARY. Aims – To review developments in recovery-focussed mental health services internationally. Methods – Two forms of ‘recovery’ which have been used in the literature are considered, and international examples of recovery-focussed initiatives reviews. A ‘litmus test’ for a recovery-focussed service is proposed. Results – ‘Clinical recovery’ has emerged from professional literature, focuses on sustained remission and restoration of functioning, is invariant across individuals, and has been used to establish rates of recovery. ‘Personal recovery’ has emerged from consumer narratives, focuses on living a satisfying, hopeful and contributing life even with limitations caused by the illness, varies across individuals, and the empirical evidence base relates to stages of change more than overall prevalence rates. Clinical and personal recovery are different. Two innovative, generalisable and empirically investigated examples are given of implementing a focus on personal recovery: the Collaborative Recovery Model in Australia, and Trialogues in German-speaking Europe. The role of medication is an indicator: services in which all service users are prescribed medication, in which the term ‘compliance’ is used, in which the reasoning bias is present of attributing improvement to medication and deterioration to the person, and in which contact with and discussion about the service user revolves around medication issues, are not personal recovery-focussed services. Conclusions – The term ‘Recovery’ has been used in different ways, so conceptual clarity is important. Developing a focus on personal recovery is more than a cosmetic change – it will entail fundamental shifts in the values of mental health services. Declaration of Interest: None.
327 citations
Cites background from "Health of the Nation Outcome Scales..."
...Moreover, the national initiative around routine outcome measurement includes measures of symptoms and functioning such as the Health of the Nation Outcome Scale (Wing et al., 1998) and the Life Skills Profile (Rosen et al., 1989), but totally excludes reference to any recovery-related constructs....
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TL;DR: There was moderate-quality evidence that ICM probably makes little or no difference in reducing death by suicide, and overall quality for clinically important outcomes using the GRADE approach, and possible risk of bias within included trials.
Abstract: Background
Intensive Case Management (ICM) is a community-based package of care aiming to provide long-term care for severely mentally ill people who do not require immediate admission. Intensive Case Management evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (fewer than 20) and high-intensity input.
Objectives
To assess the effects of ICM as a means of caring for severely mentally ill people in the community in comparison with non-ICM (caseload greater than 20) and with standard community care. We did not distinguish between models of ICM. In addition, to assess whether the effect of ICM on hospitalisation (mean number of days per month in hospital) is influenced by the intervention's fidelity to the ACT model and by the rate of hospital use in the setting where the trial was conducted (baseline level of hospital use).
Search methods
We searched the Cochrane Schizophrenia Group's Trials Register (last update search 10 April 2015).
Selection criteria
All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community care setting, where ICM is compared to non-ICM or standard care.
Data collection and analysis
At least two review authors independently selected trials, assessed quality, and extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses.
We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect. We assessed overall quality for clinically important outcomes using the GRADE approach and investigated possible risk of bias within included trials.
Main results
The 2016 update included two more studies (n = 196) and more publications with additional data for four already included studies. The updated review therefore includes 7524 participants from 40 randomised controlled trials (RCTs). We found data relevant to two comparisons: ICM versus standard care, and ICM versus non-ICM. The majority of studies had a high risk of selective reporting. No studies provided data for relapse or important improvement in mental state.
1. ICM versus standard care
When ICM was compared with standard care for the outcome service use, ICM slightly reduced the number of days in hospital per month (n = 3595, 24 RCTs, MD -0.86, 95% CI -1.37 to -0.34,low-quality evidence). Similarly, for the outcome global state, ICM reduced the number of people leaving the trial early (n = 1798, 13 RCTs, RR 0.68, 95% CI 0.58 to 0.79, low-quality evidence). For the outcome adverse events, the evidence showed that ICM may make little or no difference in reducing death by suicide (n = 1456, 9 RCTs, RR 0.68, 95% CI 0.31 to 1.51, low-quality evidence). In addition, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment due to very low-quality evidence (n = 1129, 4 RCTs, RR 0.70, 95% CI 0.49 to 1.0, very low-quality evidence).
2. ICM versus non-ICM
When ICM was compared with non-ICM for the outcome service use, there was moderate-quality evidence that ICM probably makes little or no difference in the average number of days in hospital per month (n = 2220, 21 RCTs, MD -0.08, 95% CI -0.37 to 0.21, moderate-quality evidence) or in the average number of admissions (n = 678, 1 RCT, MD -0.18, 95% CI -0.41 to 0.05, moderate-quality evidence) compared to non-ICM. Similarly, the results showed that ICM may reduce the number of participants leaving the intervention early (n = 1970, 7 RCTs, RR 0.70, 95% CI 0.52 to 0.95,low-quality evidence) and that ICM may make little or no difference in reducing death by suicide (n = 1152, 3 RCTs, RR 0.88, 95% CI 0.27 to 2.84, low-quality evidence). Finally, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment as compared to non-ICM (n = 73, 1 RCT, RR 1.46, 95% CI 0.45 to 4.74, very low-quality evidence).
3. Fidelity to ACT
Within the meta-regression we found that i.) the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36, 95% CI -0.66 to -0.07); and ii.) the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20, 95% CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but the 'baseline hospital use' result still significantly influences time in hospital (regression coefficient -0.18, 95% CI -0.29 to -0.07, P = 0.0027).
Authors' conclusions
Based on very low- to moderate-quality evidence, ICM is effective in ameliorating many outcomes relevant to people with severe mental illness. Compared to standard care, ICM may reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. Intensive Case Management is at least valuable to people with severe mental illnesses in the subgroup of those with a high level of hospitalisation (about four days per month in past two years). Intensive Case Management models with high fidelity to the original team organisation of ACT model were more effective at reducing time in hospital.
However, it is unclear what overall gain ICM provides on top of a less formal non-ICM approach.
We do not think that more trials comparing current ICM with standard care or non-ICM are justified, however we currently know of no review comparing non-ICM with standard care, and this should be undertaken.
311 citations
TL;DR: The results provide preliminary empirical validation of the Stages of Recovery Instrument as a measure of the consumer definition of recovery, however, refinement of the measure is needed to improve its capacity to discriminate between the stages of the model.
Abstract: Objective: In order to realize the vision of recovery-orientated mental health services, there is a need for a model and a method of measuring recovery as the concept is described by mental health consumers. A preliminary five-stage model based on consumer accounts was developed in an earlier study by the authors. This next stage of the research program describes the development and initial testing of a stage measure which, when validated, can be used in testing that model.Method: Existing measures of recovery were reviewed to assess their concordance with the model, and a new measure, the Stages of Recovery Instrument (STORI) was subsequently developed. A postal survey was conducted of 94 volunteers from the NISAD Schizophrenia Research Register. Participants completed the STORI and measures of mental health, psychological wellbeing, hope, resilience and recovery.Results: The STORI correlated with all of the psychological health variables, and the five stage subscales were found to be internally consiste...
293 citations
Additional excerpts
...HoNOS[ 33 ] is a 12-item measure of severity of psychiatric symptoms....
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TL;DR: Collectively, the Health of the Nation Outcome Scales family of measures can assess outcomes for different groups on a range of mental health-related constructs, and can be regarded as appropriate for routinely monitoring outcomes.
Abstract: The Health of the Nation Outcome Scales was developed to routinely measure outcomes for adults with mental illness. Comparable instruments were also developed for children and adolescents (the Health of the Nation Outcome Scales for Children and Adolescents) and older people (the Health of the Nation Outcome Scales 65+). All three are being widely used as outcome measures in the United Kingdom, Australia and New Zealand. There is, however, no comprehensive review of these instruments. This paper fills this gap by reviewing the psychometric properties of each. Articles and reports relating to the instruments were retrieved, and their findings synthesised to assess the instruments' validity (content, construct, concurrent, predictive), reliability (test-retest, inter-rater), sensitivity to change, and feasibility/utility. Mostly, the instruments perform adequately or better on most dimensions, although some of their psychometric properties warrant closer examination. Collectively, the Health of the Nation Outcome Scales family of measures can assess outcomes for different groups on a range of mental health-related constructs, and can be regarded as appropriate for routinely monitoring outcomes.
249 citations
Cites background or methods from "Health of the Nation Outcome Scales..."
...There are some exceptions, with low correlations being found between the HoNOS and the Brief Psychiatric Rating Scale in one study [29] and the Beck Depression Inventory in another [19]....
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...The Health of the Nation Outcome Scales (HoNOS) arose out of the UK's Health of the Nation Strategy, and was created by Wing and colleagues as an instrument that could be routinely used to measure outcomes for adults with mental illness [1,2]....
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...In the main, the HoNOS has been shown to perform well against clinician-rated instrument such as the Role Functioning Scale [1], Brief Psychiatric Rating Scale [1,14-16], Global Assessment Scale [14- 16,23-25], Life Skills Profile [20,23], Manchester Audit Tool [26], Clifton Assessment Procedures for the Elderly – Behaviour Rating Scale [14], Clinical Dementia Rating [14], Mini-Mental State Examination [14], Schedules for Clinical Assessment in Neuropsychiatry [25,27], Broad Rating Schedule [25], Disability Assessment Schedule [25], Social Adjustment Scale [25], Location of Community Support Scale [15], Social Behaviour Schedule [15,27], Hamilton Rating Scale for Depression [28] and Positive and Negative Symptoms Scale [28]....
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...Items identified as problematic include Item 4 (Cognitive problems) [27], Item 7 (Problems with depressed mood) [27], Item 8 (Other mental and behavioural problems) [1,27], Item 9 (Problems with relationships) [15], Item 11 (Problems with living conditions) [15,46] and Item 12 (Problems with occupation and activities) [1,27,46]....
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...Using these crite- Page 5 of 12 (page number not for citation purposes) ria, McClelland et al [16] found the HoNOS to perform commensurately with the Global Assessment Scale and the Brief Psychiatric Rating Scale....
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References
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TL;DR: A general statistical methodology for the analysis of multivariate categorical data arising from observer reliability studies is presented and tests for interobserver bias are presented in terms of first-order marginal homogeneity and measures of interob server agreement are developed as generalized kappa-type statistics.
Abstract: This paper presents a general statistical methodology for the analysis of multivariate categorical data arising from observer reliability studies. The procedure essentially involves the construction of functions of the observed proportions which are directed at the extent to which the observers agree among themselves and the construction of test statistics for hypotheses involving these functions. Tests for interobserver bias are presented in terms of first-order marginal homogeneity and measures of interobserver agreement are developed as generalized kappa-type statistics. These procedures are illustrated with a clinical diagnosis example from the epidemiological literature.
64,109 citations
TL;DR: The Brief Psychiatric Rating Scale (BRS) as mentioned in this paper was developed to provide a rapid assessment technique particularly suited to the evaluation of patient change, and it is recommended for use where efficiency, speed, and economy are important considerations.
Abstract: The Brief Psychiatric Rating Scale was developed to provide a rapid assessment technique particularly suited to the evaluation of patient change. Sixteen symptom constructs which have resulted from factor analyses of several larger sets of items, principally Lorr's Multidimensional Scale for Rating Psychiatric Patients (MSRPP) (1953) and Inpatient Multidimensional Psychiatric Scale (IMPS) (1960), have been included for rating on 7-point ordered category rating scales. The attempt has been to include a single scale to record degree of symptomacology in each of the relatively independent symptom areas which have been identified. Some of the preliminary work which has led to the identification of primary symptom constructs has been published (Gorham & Overall, 1960, 1961, Overall, Gorharn, & Shawver, 1961). While other reports are in preparation, applications of the Brief Scale in both pure and applied research suggest the importance of presenting the basic instrument to the wider scientific audience at this time, together with recommendations for its standard use. The primary purpose in developing the Brief Scale has been the development of a highly efficient, rapid evaluation procedure for use in assessing treatment change in psychiatric patients while at the same time yielding a rather comprehensive description of major symptom characteristics. It is recommended for use where efficiency, speed, and economy are important considerations, while more detailed evaluation procedures, such as those developed by Lorr (1953, 1961) should perhaps be wed in other cases. In order to achieve the maximum effectiveness in use of the Brief Scale, a standard interview procedure and more detailed description of rating concepts are included in this report. In addition, each symptom concept is defined briefly in the rating scale statements themselves. Raters using the scale should become thoroughly familiar with the scale definitions presented herein, after which the rating scale statements should be sufficient to provide recall of the nature and delineation of each symptom area. , To increase the reliability of ratings, it is recommended that patients be interviewed jointly by a team of two clinicians, with the two raters making independent ratings at the completion of the interview. An alternative procedure which has been recommended by some is to have raters discuss and arrive at a
10,457 citations
TL;DR: Data is reported on reliability and validity of the Role Functioning Scale a measure of level of functioning of adults in four domains and the Global RFS Index was significantly correlated with self-esteem and degree of disturbance.
Abstract: This paper reports data on reliability and validity of the Role Functioning Scale (RFS) a measure of level of functioning of adults in four domains. Psychometric properties were tested on an inner city sample of 112 psychiatrically disturbed and well, predominantly African-American, low-income mothers of young children. The RFS has good interitem, test-retest, and interrater reliability. The four scales and global RFS Index discriminated accurately between well and disturbed subjects. The Global RFS Index was significantly correlated with self-esteem and degree of disturbance. Individual scales demonstrated predicted relationships with quality of child-rearing and other independent behavioral indices. Results are discussed in terms of the unique information provided by the RFS and its potential contribution to treatment planning.
263 citations
TL;DR: The Department of Health is reviewing the mental health minimum dataset (the information that NHS provider units must pass to purchasers and to the department) and this offers an important chance to ensure that the right data are collected in the right way.
Abstract: Information systems in psychiatry must be released from the asylums and updated
Clinical care in British psychiatry has been changing radically in the past two decades. Lifelong care for chronically disabled patients in institutions is giving way to networks of day hospitals, mental health centres, and small residential units. Care in hospital is now reserved largely for episodes of acute mental illness. But the information systems that record what patients, staff, and services are doing are still rooted in the asylum, and lack of appropriate data is impeding clinical work and the development of services. The Department of Health is reviewing the mental health minimum dataset (the information that NHS provider units must pass to purchasers and to the department). This offers an important chance to ensure that the right data are collected in the right way.
What information should be collected, and who needs to use it? At the point of care, staff need user friendly, accurate, and confidential information about patients' past and current problems and care, particularly when emergencies arise outside normal working hours. Electronically held current clinical summaries can also ensure that staff know their responsibilities in each patient's care.1 The Clinical Standards Advisory Group has recently emphasised the value of maintaining a register of patients' care plans.2 Providers managing clinical teams need to …
14 citations
TL;DR: The introduction of new technology into medicine has been limited by cost and ethical considerations rather than doctors' resistance, which has led to systems that have “an administrative rather than a clinical bias”.
Abstract: Don't forget the doctor is the customer
The introduction of new technology into medicine has been limited by cost and ethical considerations rather than doctors' resistance. Far from being Luddites, doctors have taken a lead in developments. Why then do recent initiatives in health service information systems leave them so cold? The short answer is that doctors regard the current systems, unlike technology that they have embraced, as offering no obvious benefits either for patient care or for their own working conditions.
The information management group of the NHS Management Executive has spent eight years, and about (pounds sterlling)250m, developing and implementing an information strategy for the NHS. Despite this a recent review commissioned by the information management group from CASPE Consulting found that no computing initiative in Britain had successfully married a hospital-wide range of clinical activity with electronic means of recording.
The group's hospital information support system project (HISS)1 has led to systems that, according to the project's director, have “an administrative rather than a clinical bias.”2 These systems often do little to support patient …
10 citations