Evidens for integrerede indsatser mikael sandlund m d ph d ume university sweden
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Evidens for integrerede indsatser Mikael Sandlund, M.D., Ph.D . Umeå University, Sweden. Or: How to implement evidence based interventions (in psychiatric and social services) for persons with SMI/psychiatric disablity – a Swedish perspective. What is psychiatric disability ?.

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Evidens for integrerede indsatser Mikael Sandlund, M.D., Ph.D . Umeå University, Sweden

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Evidens for integreredeindsatserMikael Sandlund, M.D., Ph.D.Umeå University, Sweden

Or: How to implementevidencebased interventions (in psychiatric and social services) for persons with SMI/psychiatricdisablity – a Swedish perspective.

What is psychiatric disability?

Impairments in:

  • Body functions (memory, processing skills)

  • Activities (tasks and actions by an individual)

  • Participation (involvement in a life situation)

    As consequences of a mental disorder. Functioning and disability - a result of complex interactions between the health condition/history of the individual and contextual factors of the environment. (ICF)

psychiatric disability / diagnosis

  • A majority of persons has a psychosis diagnosis (but not all), of which:

    - A majority has a diagnosis of schizophrenia (but not all).

  • Most RCT’s on psychosocial interventions include persons with a mixture of diagnosis.

  • Diagnosis is the main concept according to “psychiatric research tradition”.

  • Psychosocial interventions (probably) NOT diagnosis specific in most cases.

Life situation







Lack of continuity

Not adapted to needs



Emphasis on medications

Psychosocial interventions underdeveloped

Transition from hospital-based to community-basedpsychiatricservices: Not alwaysa success story for peoplewith psychiatricdisablity


Contextual factors of the environment;

  • Fear, Prejudices

  • Lack of Knowledge

  • Lack of Reasonable Accommodations

  • Lack of work/employment opportunities

    - for People with Psychiatric Disability

  • Self-stigmatization!

What are the needs of persons with psychiatric disabilities?

  • Housing, support

  • Employment

  • Daily activities

  • Social network, Family support

  • Medical care: psychiatric needs, somatic needs, needs due to substance misuse

What are the needs of persons with psychiatric disabilities?

Medical care: psychiatric needs, somatic needs

  • Medications, as well as psychotherapy develops rapidly

  • Life expectancy 10 ys shorter!

  • Causes of death: cardiac, pulmonary diseases, diabetes/obesity – preventable conditions!

  • Co-morbidity (addiction, somatic disease)

    -Recent findings point at discrimination in somatic services of persons with psychiatric disability

What are the needs of persons with psychiatric disabilities?


  • Less than 10 % of persons in the target group are employed at the open labor market.

  • At least half of the persons in that group wish to have a job.

Good services for persons with psychiatric disabilities?

  • Continuity of care

  • Comprehensive services

  • Flexibility and around-the-clock accessibility

  • Facilitative and positive interpersonal relationships with the helper have in-built benefits (Hewitt, Coffey, J Adv Nurs. 2005 Dec;52(5):561-70)

  • Hope! Recovery orientation.(Slade et al)

  • User involvement. Involvement of relatives.

Common feature: Integration

Interventions supported by strong evidence:

  • Often need multidisciplinary teams

  • Are comprehensive – include responsibilities for social services as well as psychiatric services (Swedish context) – social psychiatry as well as psychiatric services (Danish context) – and also a lot of other agencies…

  • Should preferably be delivered in cooperation/integration

Winston Churchill:

“Never in the field of human conflict

was so much owed

- by so many

- to so few.”

Lack of integration…inefficiency…lack of resources

“Never in the field of human services

was so little owed

  • by so relatively few

  • to so many”

Is there evidence for all this integration “propaganda”?


  • Some important areas not guided by scientific results (yet)

  • Several important service components have strong evidence as to efficiency

    NOT (at all) ALL

  • Evidence based interventions are offered today

Patterns of treatment for patients with schizophrenia in routine psychiatric care

  • Psychoeducation43 %

  • CBT28 %

  • Case management38 %

  • Work rehabilitation 0 %

  • Social skillstraining14 %

West et al, Psychiatric Services, 2005


  • National guidelines for Psychosocial interventions for persons with schizophrenia or schizophrenia like conditionslaunched by the National Board /Socialstyrelsen/ in 2011.

  • Based on:

    The effectiveness of psychosocial interventions for persons with severe mental illness, including those with concomitant substance use disorders, 2009.Öjehagen, Sandlund m fl

    Ethical and administrative considerations; workshops with user organizations and representatives of services (communes and health care)

Evidence of effectiveness of psychosocial interventions (schizophrenia)

Strong evidence

  • Work rehabilitation: Supportedemployment (IPS)

  • Family interventions

  • Psychoeducation

  • Case Management: AssertiveCommunity Treatment (ACT)

    Good evidence

  • Social skillstraining

  • Psychologicaltreatment: CognitiveBehaviouralTherapy(CBT)

    Almost no evidence

  • Housing interventions

  • Daily occupation programs

The National GUIDE-LINES

  • Designed to guide decisions in health services (county councils), as well as in social services (communes) – despite:

  • Separate founding (county tax, commune tax)

  • Separate legislation (Health care law, Social service law)

  • Separate political governance (regional/county parliament, communes parliament).

  • Separate “labeling concepts” (diagnosis – needs)

Guide-Lines for Psychosocial Interventions for Persons with Schizophrenia or Schiz-likeConditions

Recommendations (1 – 10) based on:

  • evidence based knowledge on effects of interventions

    • severity of the condition (remaining symptoms, impairments, needs)

  • best aviable knowledge on cost effectiveness or costs of interventions.

    In all: 28 recommendationsin 10 fields

The National GUIDE-LINES

  • Early interventions

  • Participation

  • Psycho education

  • Family interventions

  • Psychological treatments

  • Cognitive training

  • Social skills training

  • Vocational training

  • Housing

  • Integrated service

The National GUIDE-LINES

  • Early interventions

    Health services should:

  • Train GP’s in early detection of signs of psychosis

  • Persons with early signs of psychosis should be offered direct referral to specialist team (priority 3).

The National GUIDE-LINES

  • Early interventions for persons newly diagnosed with psychosis

    Health services should:

  • offer integrated services according to the ACT-model, including family interventions and social skills training, in addition to TAU (priority 3).

The National GUIDE-LINES

  • Interventions to strengthen individual’s participation in care and support

    Health services AND Social services should:

  • Offer users shared decision making (SDM) in the planning of treatments and support (priority 3).

Shared Decision Making (SDM)

  • To establish why and when a decision will be made

  • To convey (full) information about the alternatives

  • To discuss the alternatives – and the consequences of the alt’s - at an equal level

  • To make a decision “together”

  • To make plans about follow-up

The National GUIDE-LINES

  • Psycho educational programs

    Health services AND Social services should:

  • Offer the user and his/her family joint education (priority 1).

  • Offer IMR– Illness Management and Recovery (priority 4).

  • (if impossible) Offer the family education (prio 3)

  • (if impossible) Offer the usereducation (prio7).

Psycho-educational programs

  • Programs for patient education include

    • Knowledge about the illness

    • How to manage illness and relapses

    • Knowledge about treatment alternatives

    • A safe environment to discuss illness and life situation

  • And…

    • Reduce relapse rates

    • Improve psychosocial functioning and

    • Improve knowledge about illness and treatment alternatives

The National GUIDE-LINES

Family interventions to reduce stress in the family and as relapse prevention

Health services AND Social services should:

  • Offer users who stay in contact with his/her family or other relatives family interventions (priority 1).

Family intervention

  • Several family intervention models are effective in reducing relapse and inpatient treatment, and in improving compliance with treatment

  • Common features of these programs

    • Intervention > 9 months

    • Creating a positive alliance with relatives

    • Crisis intervention

    • Problem solving

    • Knowledge about illness and treatment

    • Reducing negative aspects of emotional climate in the family (hostility, criticism and overinvolvement)

The National GUIDE-LINES

  • Cognitive training to increase functions

    Health services should:

  • Offer persons with remaining symptoms, cognitive and social skills impairments Integrated Psychological Therapy – Cognitive training – IPT-k (priority 1).

The National GUIDE-LINES

  • Independent living skills training

    Health services AND Social services should:

    Offer persons who need better social skills training in accordance with the ”ESL-model” – Ett självständigt liv(priority 2).

Independent living skills program

Group treatment with role play with several modules:

  • Medication management

  • Symptom management – early detection of relapse

  • Substance abuse management

  • Recreation for leisure

  • Basic conversation skills

  • Interpersonal problem solving

  • Friendship and intimacy

The National GUIDE-LINES

  • Vocational rehabilitation (to increase participation on labor market)

    Health services AND Social services should:

    ”under their areas of responsibility AND in contact with the National Social Insurance Agency and the National Employment Agency”

  • Offer users who are unemployed and motivated for competitive employment, individually tailored support according to the IPS-model (Individual Placement and Support) – place then train - (priority 1).

    Health services AND Social services can:

  • In exceptional cases offer pre-vocational models (train then place) (priority 10).

Supported employment

  • “Place then train” in competitive work situation

  • Avoidance of pre-vocational training

  • Minimal screening for employability “wish to work”

  • Individualized placement and support

  • Team-based time-unlimited support

  • Consideration of client preferences

  • Integration with support from the mental health care system

The National GUIDE-LINES

  • Daily occupation

    Social services should:

    • offer individually tailored daily occupation, day centers, with regular follow-up, suitable for the person (priority 3).

The National GUIDE-LINES

  • Accommodation:

    Social services should:

    • Offer homeless persons a sustainable accommodation (priority 1).

    • Offer housing according to the ”Housing first-model” (without conditions as compliance to treatment etc) (priority 3).

    Social services can in exceptional cases:

  • offer homeless persons accommodations according to a step-wise model, but independent living must be the goal (priority 10).

The National GUIDE-LINES

  • Co-ordination/Integration of services to assure the person continuity of care

    Health services AND Social services should:

  • Offer persons with schizophrenia who are high users of care, at high risk of inpatient care, drop out of treatment - intensive case management according to the ACT-model - Assertive Community Treatment (priority 1).

    Health services AND Social services can:

    • in exceptional cases offer less intensive case management (priority 10).

And now: Implementation!

Policy instruments

  • Hard governance: the use of direct and compulsory steering forms to ensure compliance among local actors – ”sticks”

  • Soft governance: non-binding self-regulation forms based on flexible instruments, information and guidance – ”carrots”

    (MaycraftKall 2011; Lindqvist, Markström, Rosenberg 2010)

Instrument types

  • Regulatory steering: legislation, rules, directives, binding guidelines

  • Financial steering: positive incentives, ”free money”, taxes, charges

  • Information steering: general information, recommendations, newsletters


The case of Sweden

  • Tradition of soft governance– explained by the principle of localindependence

  • Tradition of financialsteering(”carrots”) and cautiousinformation steering

  • Traditional:shortsightedprojects with federal funding (in advance).

  • Recent:agencies that can show goodpractice get extra money (after delivery).



  • The local authorities (communes, county councils) in Sweden are independent. They rise their own money (taxes), they have their own parliaments.

  • The roles of federal agencies are mainly support and surveillance.

Some implementation mistakes

  • We substitute our perceptions for those of potential users

  • We use intervention creators as intervention communicators

  • We assume that information will influence decision-making

  • We advocate single interventions as the solution to a problem

Dearing 2007

Good hope…

  • A number of Supported Employment projects are operating or in the process of getting started

  • (A few) Good examples of ACT-like teams are present

  • The involvement of users and relatives becomes more frequent


  • Only a few politicians have the wish to be connected to the needs and policies important to people with psychiatric disabilities.

    (as long as there are no current scandals in today's newspaper I rather keep away from this area…)

    On the other hand: if effective and user friendly services are developed the area will be more attractive (also to politicians….)


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