Publicação
Supported accommodations for people with mental disorders in Portugal: the influence of user characteristics, care provision and contextual factors on the quality of care
| Resumo: | ABSTRACT: Background: Serious mental disorders (SMDs) are mental disorders that cause severe functional impairment. SMDs affect up to 6.8% of the global population, and frequently impact social relationships, education, employment, and independent living. In particular, people with SMD have a higher risk of homelessness and housing instability, which is usually associated with a worse prognosis. Psychiatric rehabilitation aims at helping people to restore their ability to live independently and better integrate into the community. Supported accommodations (SAs) provide psychiatric rehabilitation and housing, mainly targeting users with SMDs. These services have been implemented worldwide and are associated with significant costs. Despite this, little research has been conducted on them. This thesis aimed to characterise the provision of care in SAs for people with SMD in Portugal and investigate how residents’ and service characteristics, and contextual factors such as the COVID-19 pandemic are associated with the current care provision. Methods: We conducted an observational study of residents and professionals of 43 SAs in Portugal. For quantitative assessments, all residents in SAs with up to 10 residents were invited to participate, while in each SA with over 10 residents a randomised sample of 10 residents was obtained. Residents completed questionnaires regarding their care pathways and quality of life; additional sociodemographic and clinical data was provided by the SAs. Professionals of all SAs were also invited to participate and complete an online questionnaire on the impact of the COVID-19 pandemic. In addition, the manager of each SA completed an online questionnaire about the quality of care provided by SAs. Fifteen months later, the same managers provided information on which residents had been discharged and where to. Data was complemented by qualitative information obtained by conducting semi-structured interviews with a purposeful sample of 11 residents and 11 professionals with management roles. This work was complemented by secondary analysis of data from a study conducted in 2016 by the Lisbon Institute of Global Mental Health on the SAs residents’ views on provided care . Results: vi Residents of SAs tend to have long-term mental health disorders, housing instability, economic fragility, and lack of social support. They tend to have a history of high use of mental health services and treatment non-adherence. Almost half have previously attended psychosocial rehabilitation services, which mostly consists of another SA. The median entry age at the current SA was 50 years and the length of stay was 4.5-5 years. The main reasons for referral to SAs included a lack of housing and support. In general, residents expected SAs to help them gain autonomy and improve mental health, but most were ambivalent about discharge. Professionals recognised many would always need a very structured support, and that, for those being discharged, outreach support would be necessary. Residents generally reported a high quality of life, which tended to be superior in less supported SAs, and were satisfied with the care provided by SAs. However, only a minority felt involved in treatment. Quality of care tended to be lower in maximum support SA and hospital-based SAs. Feeling safe, having privacy, feeling involved in care, and having good resident-professional relationships were positively associated with residents’ quality of life. At follow-up, less than 10% were discharged to more independent living. Having a diagnosis of bipolar disorder or having been in a minimum to moderate support SA was positively associated with discharge to more independent living, while age was negatively associated. Common barriers to discharge include economic and housing constraints, lack of social support, inadequate/inexistent outreach support, and residents wanting to remain in the SAs. SAs were generally unprepared for the COVID-19 pandemic and some had to close or move to hospital grounds. Most residents did not report any significant impact of the pandemic on their mental health, but professionals noted weight gain, inactivity, autonomy loss, and cognition impairment in some residents. The organisational changes, staff shortages, and the fear of the pandemic, led many professionals to feel burned out and exhausted. New technologies, clear communication, shared decision making, official recommendations, team cohesion, open-air spaces, and staff hiring were issues that helped during the pandemic. Conclusions: This research contributed to a better understanding of the current situation of SAs. Residents spend long periods at these services and discharges to more independent living are quite low. Several factors seem to underlie this situation. These are multifactorial and include the characteristics of service users; family/other social support; care provided in SAs; investment in and organisation of mental health care; public policies; contextual factors; and stigma. Even though these factors operate at vii different levels of influence, they are interdependent. Therefore, actions at all these different levels are necessary in order to improve the current situation of SAs. |
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| Autores principais: | Pedrosa, Bárbara |
| Assunto: | Mental disorders Serious mental disorders Psychiatric |
| Ano: | 2025 |
| País: | Portugal |
| Tipo de documento: | tese de doutoramento |
| Tipo de acesso: | acesso embargado |
| Instituição associada: | Universidade Nova de Lisboa |
| Idioma: | inglês |
| Origem: | Repositório Institucional da UNL |
| Resumo: | ABSTRACT: Background: Serious mental disorders (SMDs) are mental disorders that cause severe functional impairment. SMDs affect up to 6.8% of the global population, and frequently impact social relationships, education, employment, and independent living. In particular, people with SMD have a higher risk of homelessness and housing instability, which is usually associated with a worse prognosis. Psychiatric rehabilitation aims at helping people to restore their ability to live independently and better integrate into the community. Supported accommodations (SAs) provide psychiatric rehabilitation and housing, mainly targeting users with SMDs. These services have been implemented worldwide and are associated with significant costs. Despite this, little research has been conducted on them. This thesis aimed to characterise the provision of care in SAs for people with SMD in Portugal and investigate how residents’ and service characteristics, and contextual factors such as the COVID-19 pandemic are associated with the current care provision. Methods: We conducted an observational study of residents and professionals of 43 SAs in Portugal. For quantitative assessments, all residents in SAs with up to 10 residents were invited to participate, while in each SA with over 10 residents a randomised sample of 10 residents was obtained. Residents completed questionnaires regarding their care pathways and quality of life; additional sociodemographic and clinical data was provided by the SAs. Professionals of all SAs were also invited to participate and complete an online questionnaire on the impact of the COVID-19 pandemic. In addition, the manager of each SA completed an online questionnaire about the quality of care provided by SAs. Fifteen months later, the same managers provided information on which residents had been discharged and where to. Data was complemented by qualitative information obtained by conducting semi-structured interviews with a purposeful sample of 11 residents and 11 professionals with management roles. This work was complemented by secondary analysis of data from a study conducted in 2016 by the Lisbon Institute of Global Mental Health on the SAs residents’ views on provided care . Results: vi Residents of SAs tend to have long-term mental health disorders, housing instability, economic fragility, and lack of social support. They tend to have a history of high use of mental health services and treatment non-adherence. Almost half have previously attended psychosocial rehabilitation services, which mostly consists of another SA. The median entry age at the current SA was 50 years and the length of stay was 4.5-5 years. The main reasons for referral to SAs included a lack of housing and support. In general, residents expected SAs to help them gain autonomy and improve mental health, but most were ambivalent about discharge. Professionals recognised many would always need a very structured support, and that, for those being discharged, outreach support would be necessary. Residents generally reported a high quality of life, which tended to be superior in less supported SAs, and were satisfied with the care provided by SAs. However, only a minority felt involved in treatment. Quality of care tended to be lower in maximum support SA and hospital-based SAs. Feeling safe, having privacy, feeling involved in care, and having good resident-professional relationships were positively associated with residents’ quality of life. At follow-up, less than 10% were discharged to more independent living. Having a diagnosis of bipolar disorder or having been in a minimum to moderate support SA was positively associated with discharge to more independent living, while age was negatively associated. Common barriers to discharge include economic and housing constraints, lack of social support, inadequate/inexistent outreach support, and residents wanting to remain in the SAs. SAs were generally unprepared for the COVID-19 pandemic and some had to close or move to hospital grounds. Most residents did not report any significant impact of the pandemic on their mental health, but professionals noted weight gain, inactivity, autonomy loss, and cognition impairment in some residents. The organisational changes, staff shortages, and the fear of the pandemic, led many professionals to feel burned out and exhausted. New technologies, clear communication, shared decision making, official recommendations, team cohesion, open-air spaces, and staff hiring were issues that helped during the pandemic. Conclusions: This research contributed to a better understanding of the current situation of SAs. Residents spend long periods at these services and discharges to more independent living are quite low. Several factors seem to underlie this situation. These are multifactorial and include the characteristics of service users; family/other social support; care provided in SAs; investment in and organisation of mental health care; public policies; contextual factors; and stigma. Even though these factors operate at vii different levels of influence, they are interdependent. Therefore, actions at all these different levels are necessary in order to improve the current situation of SAs. |
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