International Journal of Psychiatry in Clinical Practice
ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20
Effect of executive functioning on perceived needs in chronic schizophrenia Jane Buhler, Lindsay G Oades, Susan J Leicester, Carmen J Bensley, Allison M Fox To cite this article: Jane Buhler, Lindsay G Oades, Susan J Leicester, Carmen J Bensley, Allison M Fox (2001) Effect of executive functioning on perceived needs in chronic schizophrenia, International Journal of Psychiatry in Clinical Practice, 5:2, 119-122 To link to this article: http://dx.doi.org/10.1080/136515001300375307
Published online: 12 Jul 2009.
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Article views: 43
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijpc20 Download by: [University of California Santa Barbara]
Date: 06 November 2015, At: 03:57
Ó
2001 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2001 Volume 5 Pages 119 ± 122
119
Effect of executive functioning on perceived needs in chronic schizophrenia
Downloaded by [University of California Santa Barbara] at 03:57 06 November 2015
JANE BUHLER,1 LINDSAY G OADES,1 ,2 SUSAN J LEICESTER,1 ,2 CARMEN J BENSLEY1 ,2 AND ALLISON M FOX2 ,3 1
Department of Psychology, University of Wollongong, Australia; 2 Illawarra Institute for Mental Health, Australia; and 3 Department of Psychology, University of Western Australia
Recent approaches to needs assessment involve patients in this process; however, little is known of the effects of mental illness on patients’ ability to assess their own needs. INTRODUCTION:
The needs of 26 subjects with schizophrenia were assessed over 22 domains by patients and staff, using the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS). Patients’ executive functioning was assessed using the Wisconsin Card Sorting Test (WCST). METHOD:
Mean discrepancies between ratings by staff and by patients were compared across executive functioning; results showed no effect of executive functioning on the discrepancy between staff and patient ratings. Higher executive functioning was associated with more met needs. Multivariate analysis showed higher executive functioning associated with more needs in some but not all areas. RESULTS:
Results suggest that patients with schizophrenia and impaired executive functioning can validly estimate their needs. Better executive functioning may be associated with the ability to get one’s needs met, increased awareness of needs, better ability to communicate needs, or more needs in certain areas. Need is shown to be a complex variable, and not simply an index of functioning. Hospitals and clinics must ensure that patients’ views find full expression in ratings. Needs ratings and rehabilitatio n status should be viewed in the light of neuropsycholo gical functioning. (Int J Psych Clin Pract 2001; 5: 119 ± 122) CONCLUSIONS:
Correspondence Address Jane Buhler, 60 Cliff Drive, Katoomba NSW 2780, Australia Tel: 02 4782 1317 Fax: 02 9628 0651 E-mail: [email protected]
Received 11 April 2000; accepted for publication 20 November 2000.
Keywords schizophrenia needs executive functioning rehabilitation neuropsychol ogical functioning
INTRODUCTION
T
here is increasing recognition that people with severe mental illness have a complex mixture of clinical and social needs, and that regular, comprehensive and systematic assessment of those needs is integral to the development, monitoring and evaluation of accountable psychiatric services.1 It has been suggested that decisions about treatment should be based on assessmen t of patients’ needs, rather than on diagnosis ,1 ,2 and that basing treatment on such assessment s may lead to improved outcomes, including adherence to treatment, engagement with services, and resource use.1
Whereas need was previously conceptualize d as ``a normative concept which is to be defined by experts’’,3 a more recent view is that needs are ``socially negotiated’’:4 while patients and staff may assess patients’ needs differently , informed by their differing values, a combination of both perspective s should produce a comprehensi ve and balanced consideratio n of patients’ needs. However, while it is argued that patients with psychotic illnesses may make a valid contribution to the process of negotiating needs, 4 there is little evidence as to the impact of psychosis on patients’ self-assessm ent of their needs. Patients with psychotic illnesses have been found to underrate their need for help with psychotic symptoms;4 patients with poorer
Downloaded by [University of California Santa Barbara] at 03:57 06 November 2015
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J Buhler et al
insight into their illness have been found to underestimat e their needs for help with alcohol misuse and social contact; 5 and patients with more negative symptoms have been found to underestimat e psychosocia l needs in general. 6 The present study examines the impact of neuropsycho logical impairment, which is a reliable finding in schizophreni a,7 on patients’ self-assess ment of needs. Since it has been proposed that deficits in executive functioning ± planning, organizing , volition, and goaldirected behaviour8 ± underlie the neuropsycho logical deficits reliably observed in schizophreni a,9 the effect of executive functioning on patients’ self-assessm ent of needs and staff’s assessmen t of patients’ needs was specificall y examined. Three hypotheses were derived from the literature. First, lower executive functioning will be associated with more needs, both met and unmet.1 0 Second, since patients with impaired executive functioning may tend to underestimate their psychosocia l needs,1 1 lower executive functioning will be associated with greater discrepanc y between staff and client ratings of needs. Thirdly, the level of executive functioning may be differentiall y associated with different types of needs, with some groups of needs associated with higher, and others with lower, functioning. 1 2
METHOD Data were collected as part of regular clinical practice at a regional Australian psychiatri c rehabilitation unit for patients diagnosed with chronic schizophreni a. The following data were collected for 26 patients: 1. The Camberwell Assessmen t of Need Short Appraisal Schedule (CANSAS).1 1 This instrument assesses client needs by means of structured interviews with both the patient and a staff member responsibl e for the patient’s care. Needs over the past month are rated across 22 areas of functioning. Needs are rated as ``no need’’, ``met need’’ or ``unmet need’’; a fourth category (``not known’’) was treated for the purposes of analysis as ``no need’’, following Slade et al (1996).5 2. The Wisconsin Card Sorting Test (WCST). The WCST was developed to assess abstract reasoning and cognitive flexibility,1 3 and has been extensively used in research on executive functioning in schizophreni a.7 ,9 A variety of scores can be derived from the WCST; Total Errors and Categories Completed were used in analysis, as the most normally distributed scores in this sample.
RESULTS The 26 patients consisted of 21 men and five women. Their age ranged from 19 to 49 years, with a mean age of 34. Thirteen were inpatients and 13 outpatients. All had a clinical
DSM-IV diagnosis of schizophrenia. Time since diagnosis ranged from 2 ± 29 years, with a mean time of 12 years. Patients reported a mean of 5.46 met needs, 4.30 unmet needs, and a total needs rating of 9.76. Staff reported a mean of 3.26 met needs, 4.80 unmet needs, and total needs rating of 8.76. There was a significan t correlation (r=0.66, P < 0.01) between total needs ratings by patients and by staff. Staff and patient ratings for each item were crosstabulat ed: this showed a highly significan t association (phi and Cramer’s V, P < 0.001) between the pattern of staff and patient ratings for each item, apart from item 12 (need for help with alcohol misuse), which still showed a significan t associatio n (P < 0.045). There was a significan t positive association between higher executive functioning and the number of met needs (r=0.408, P < 0.05) and total needs (r=0.417, P < 0.05). WCST Categories Completed scores ranged from 0 to 6, with a mean of 2.53 and a standard deviation of 2.23. Total Errors ranged from 6 to 91, with a mean of 53.69, and a standard deviation of 24.92. Patients were divided into high and low executive functioning groups via a median split. Mean discrepancie s between staff and patients’ ratings were compared across the high and low executive functioning groups. Results showed no effect of executive functioning on the discrepanc y between patients’ and staff ratings. The effect of executive functioning within groups of needs was tested by multivariat e analysis. Needs were grouped into five subdomains , following Slade et al (1998): Health, Basic, Social, Services, and Functioning .1 Patients with higher executive functioning rated their needs significant ly higher in the areas of health, functioning , services, and social needs; their needs were more highly rated by staff in the areas of health and services (Wilks’ lambda=0.256, F(10,13)=3.7 85, P < 0.014).
DISCUSSION In summary, higher executive functioning was associated with a higher total need rating (both met and unmet needs), more met needs, and with more needs in some but not all areas. Lower executive functioning was not associated with more discrepanc y between self-rated and staff-rated needs. Higher executive functioning was associated with more self-reporte d met needs, and a higher level of self-reporte d total (met and unmet) need. Better executive functioning may assist patients to get their needs met in a variety of ways, as a consequence of increased volition, planning, organization , and goal-directe d behaviour, and may also be associated with more awareness of one’s needs. More needs may be experienced as a consequence of better functioning . Higher executive functioning was associated with higher self-rated needs in the areas of health, functioning , services and social needs, and higher staff-rated needs in health and services. Better executive functioning may be associated with a better ability to communicat e one’s needs,
Downloaded by [University of California Santa Barbara] at 03:57 06 November 2015
Executive functioning and needs in schizophrenia
as well as with increased needs in certain areas, or with increased awareness of one’s needs. Staff have noted increased needs associated with higher executive functioning in areas (health and services) with well-define d service responses, whereas patients’ ratings also reflect an association between higher executive functioning and social needs (needs for company, intimate relationship s and sexual expression) , which lack a specific service response . This reflects the observation that staff may tend to focus more on needs for which there is a definabl e response.5 Groupings of needs were based on a priori subdomains,1 not on empirically- derived clusters of needs; examining the relationship between executive functioning and empirically-derive d clusters of needs may further illuminate the effect of executive functioning on needs. These results also support the view of need as a complex variable, and not simply an index of functioning .1 2 These results underline the importance of viewing needs ratings in the light of neuropsycho logical functioning , thus supporting the practice of incorporati ng neuropsycho logical assessmen t into rehabilitation planning.1 4 No relationship was found between the level of executive functioning and the level of discrepanc y between staff and patients’ ratings of needs. This suggests that patients with psychotic illnesses and lower executive functioning can validly estimate their needs, and thus supports the practice of consulting patients on their needs. However, it should be noted that CANSAS patients’ needs assessment s are rated by staff ± in this case the same staff members who produced the staff needs ratings ± raising the possibilit y of patients’ ratings being affected by staff views, so these results must be viewed with caution. The strong association between staff and patients’ ratings for all items supports the possibilit y that patients’ views may not have been fully represente d in ratings. Ways of addressing this difficult y would be to have different staff members rating staff and patients’ needs, or training patients where possible to rate their own needs via a computerized or pencil-and-p aper questionnaire . This latter option would be particularl y appropriat e with a chronic population, in settings where regular needs assessment s may be undertaken as part of the process of monitoring progress and planning rehabilitation . These results underline the importance of adequate staff training in CANSAS administration , regular communication with staff and monitoring of results, to ensure that data are valid and comprehensi ve. In this context, it should be pointed out that examination of the raw data showed a majority of ``not known’’ ratings (15/27: 6/6 client and 9/21 staff ratings) clustered around only two CANSAS items (15 and 16: intimate relationship s and sexual expression) . A similar pattern has been noted in a previous study.5 It is also of interest that a similar study omitted several items, including item 16, though the reason for this decision was not stated.6 While the reason for the high number of ``not known’’ ratings for these items is unclear, it is a matter
121
of concern that staff may not be raising these issues for discussio n with patients in all cases, thus possibly missing significan t information about an important aspect of their patients’ lives and potential needs. It is notable that the weakest (though still significant ) associatio n between staffs’ and patients’ views was in the area of alcohol misuse; an association has previousl y been observed between poor insight and underestimatio n of this need relative to staff estimates.6 Accountable mental health services are obliged to consult the consumers of those services on their views about their illnesses , their treatment, and their lives, and to incorporate those views into the treatment approach in a meaningful way. Needs assessmen t is a central aspect of this process. The present study supports the ability of patients with psychotic illnesses and impaired executive functioning to validly assess their own needs. Care must be taken, however, when using an instrument such as the CANSAS, to ensure that patients’ views are fully represented, and not subsumed by those of the staff who are rating the patients’ views. The present study also supports the practice of needs assessment , by making it clear that need is a complex variable, and not simply an index of functioning , and stresses the importance of viewing needs ratings and rehabilitation status in the light of neuropsychologica l functioning. A major limitation of this study was the fact that patients’ and staff needs ratings were made by the same staff member, entailing possible loss of information. Results must therefore be viewed with caution. The small sample size is a further limitation. The study examined only one aspect of neuropsycho logical functioning , viz. executive functioning ; future studies should examine the effect of other aspects of this complex process, and also factors such as general ability, on needs assessment . Examination of the differentia l impact of these factors on empirically- supported clusters of needs may further illuminat e the areas of functioning and needs assessment .
KEY POINTS
· · · · ·
Executive functioning did not affect patients’ ability to validly estimate their needs Better executive functioning was associated with more met needs and more expressed total needs Executive functioning was differentiall y associated with needs ratings; higher executive functioning was associated with more expressed needs in some but not all areas Need should be understood as a complex variable, and not simply an index of functioning Care should be taken to ensure that patients’ views are fully expressed, and not subsumed by those of staff raters.
122
J Buhler et al
ACKNOWLEDGEMENTS We would like to record warm thanks to patients and staff of Lakeview House, Illawarra Area Health Service, for providing access to the data used in this study. Peter Caputi’s advice and assistanc e with statistical analysis is
gratefully acknowledge d. This research was supported by a Summer Scholarship from the Illawarra Institute for Mental Health, and was carried out as part of a Master of Psychology (Clinical) degree at the Universit y of Wollongong, NSW, Australia.
Downloaded by [University of California Santa Barbara] at 03:57 06 November 2015
REFERENCES 1. Slade M, Phelan M, Thornicroft G (1998) A comparison of needs assessed by staff and by an epidemiologically representative sample of patients with psychosis. Psychol Med 28: 543 ± 50. 2. Spitzer R (1998) Diagnosis and need for treatment are not the same. Arch Gen Psychiatry 55: 120. 3. Bebbington P (1992) cited in Slade M (1994) Needs assessment: involvement of staff and users will help to meet needs. Br J Psychiatry 165: 293 ± 6. 4. Slade M (1994) Needs assessment: involvement of staff and users will help to meet needs. Br J Psychiatry 165: 293 ± 6. 5. Slade M, Phelan M, Thornicroft G, Parkman S (1996) The Camberwell Assessment of Need (CAN): comparison of assessments by staff and patients of the needs of the severely mentally ill. Soc Psychiatry Psychiatr Epidemiol 31: 109 ± 13. 6. Carroll A, Mortimer A (1998) Perceived needs in chronic schizophrenia.Int J Psychiatry Clin Pract 2: 139 ± 41. 7. Heinrichs RW, Zakzanis KK (1998) Neurocognitive deficit in schizophrenia: a quantitative review of the evidence. Neuropsychology 12: 426 ± 45. 8. Lezak MD (1995) Neuropsychological Assessment (3rd edn). Oxford: Oxford University Press.
9. Stratta P, Daneluzzo E, Prosperini P et al (1997) Is Wisconsin Card Sorting Test performance related to ``working memory’’ capacity? Schizophrenia Res 25: 21 ± 31. 10. Velligan DI, Mahurin RK, Diamond PL et al (1997) The functional significance of symptomatology and cognitive function in schizophrenia. Schizophrenia Res 27: 11 ± 19. 11. Comtois G, Morin C, Lesage A et al (1998) Patients versus rehabilitation practitioners: a comparison of assessments of needs for care. Can J Psychiatry 43: 159 ± 65. 12. Phelan M, Slade M, Thornicroft G et al (1995) The Camberwell Assessment of Need: the validity and reliability of an instrument to assess the needs of people with severe mental illness. Br J Psychiatry 167: 598 ± 95. 13. Heaton RK, Chelune GJ, Talley JL et al (1993) Wisconsin Card Sorting Test Manual: Revised and expanded. Odessa, FL: Psychological Assessment Resources. 14. Silverstein SM, Hitzel H, Schenkel L (1998) Identifying and addressing cognitive barriers to rehabilitation readiness. Psychiatr Services 49: 34 ± 6.
ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20
Effect of executive functioning on perceived needs in chronic schizophrenia Jane Buhler, Lindsay G Oades, Susan J Leicester, Carmen J Bensley, Allison M Fox To cite this article: Jane Buhler, Lindsay G Oades, Susan J Leicester, Carmen J Bensley, Allison M Fox (2001) Effect of executive functioning on perceived needs in chronic schizophrenia, International Journal of Psychiatry in Clinical Practice, 5:2, 119-122 To link to this article: http://dx.doi.org/10.1080/136515001300375307
Published online: 12 Jul 2009.
Submit your article to this journal
Article views: 43
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijpc20 Download by: [University of California Santa Barbara]
Date: 06 November 2015, At: 03:57
Ó
2001 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2001 Volume 5 Pages 119 ± 122
119
Effect of executive functioning on perceived needs in chronic schizophrenia
Downloaded by [University of California Santa Barbara] at 03:57 06 November 2015
JANE BUHLER,1 LINDSAY G OADES,1 ,2 SUSAN J LEICESTER,1 ,2 CARMEN J BENSLEY1 ,2 AND ALLISON M FOX2 ,3 1
Department of Psychology, University of Wollongong, Australia; 2 Illawarra Institute for Mental Health, Australia; and 3 Department of Psychology, University of Western Australia
Recent approaches to needs assessment involve patients in this process; however, little is known of the effects of mental illness on patients’ ability to assess their own needs. INTRODUCTION:
The needs of 26 subjects with schizophrenia were assessed over 22 domains by patients and staff, using the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS). Patients’ executive functioning was assessed using the Wisconsin Card Sorting Test (WCST). METHOD:
Mean discrepancies between ratings by staff and by patients were compared across executive functioning; results showed no effect of executive functioning on the discrepancy between staff and patient ratings. Higher executive functioning was associated with more met needs. Multivariate analysis showed higher executive functioning associated with more needs in some but not all areas. RESULTS:
Results suggest that patients with schizophrenia and impaired executive functioning can validly estimate their needs. Better executive functioning may be associated with the ability to get one’s needs met, increased awareness of needs, better ability to communicate needs, or more needs in certain areas. Need is shown to be a complex variable, and not simply an index of functioning. Hospitals and clinics must ensure that patients’ views find full expression in ratings. Needs ratings and rehabilitatio n status should be viewed in the light of neuropsycholo gical functioning. (Int J Psych Clin Pract 2001; 5: 119 ± 122) CONCLUSIONS:
Correspondence Address Jane Buhler, 60 Cliff Drive, Katoomba NSW 2780, Australia Tel: 02 4782 1317 Fax: 02 9628 0651 E-mail: [email protected]
Received 11 April 2000; accepted for publication 20 November 2000.
Keywords schizophrenia needs executive functioning rehabilitation neuropsychol ogical functioning
INTRODUCTION
T
here is increasing recognition that people with severe mental illness have a complex mixture of clinical and social needs, and that regular, comprehensive and systematic assessment of those needs is integral to the development, monitoring and evaluation of accountable psychiatric services.1 It has been suggested that decisions about treatment should be based on assessmen t of patients’ needs, rather than on diagnosis ,1 ,2 and that basing treatment on such assessment s may lead to improved outcomes, including adherence to treatment, engagement with services, and resource use.1
Whereas need was previously conceptualize d as ``a normative concept which is to be defined by experts’’,3 a more recent view is that needs are ``socially negotiated’’:4 while patients and staff may assess patients’ needs differently , informed by their differing values, a combination of both perspective s should produce a comprehensi ve and balanced consideratio n of patients’ needs. However, while it is argued that patients with psychotic illnesses may make a valid contribution to the process of negotiating needs, 4 there is little evidence as to the impact of psychosis on patients’ self-assessm ent of their needs. Patients with psychotic illnesses have been found to underrate their need for help with psychotic symptoms;4 patients with poorer
Downloaded by [University of California Santa Barbara] at 03:57 06 November 2015
120
J Buhler et al
insight into their illness have been found to underestimat e their needs for help with alcohol misuse and social contact; 5 and patients with more negative symptoms have been found to underestimat e psychosocia l needs in general. 6 The present study examines the impact of neuropsycho logical impairment, which is a reliable finding in schizophreni a,7 on patients’ self-assess ment of needs. Since it has been proposed that deficits in executive functioning ± planning, organizing , volition, and goaldirected behaviour8 ± underlie the neuropsycho logical deficits reliably observed in schizophreni a,9 the effect of executive functioning on patients’ self-assessm ent of needs and staff’s assessmen t of patients’ needs was specificall y examined. Three hypotheses were derived from the literature. First, lower executive functioning will be associated with more needs, both met and unmet.1 0 Second, since patients with impaired executive functioning may tend to underestimate their psychosocia l needs,1 1 lower executive functioning will be associated with greater discrepanc y between staff and client ratings of needs. Thirdly, the level of executive functioning may be differentiall y associated with different types of needs, with some groups of needs associated with higher, and others with lower, functioning. 1 2
METHOD Data were collected as part of regular clinical practice at a regional Australian psychiatri c rehabilitation unit for patients diagnosed with chronic schizophreni a. The following data were collected for 26 patients: 1. The Camberwell Assessmen t of Need Short Appraisal Schedule (CANSAS).1 1 This instrument assesses client needs by means of structured interviews with both the patient and a staff member responsibl e for the patient’s care. Needs over the past month are rated across 22 areas of functioning. Needs are rated as ``no need’’, ``met need’’ or ``unmet need’’; a fourth category (``not known’’) was treated for the purposes of analysis as ``no need’’, following Slade et al (1996).5 2. The Wisconsin Card Sorting Test (WCST). The WCST was developed to assess abstract reasoning and cognitive flexibility,1 3 and has been extensively used in research on executive functioning in schizophreni a.7 ,9 A variety of scores can be derived from the WCST; Total Errors and Categories Completed were used in analysis, as the most normally distributed scores in this sample.
RESULTS The 26 patients consisted of 21 men and five women. Their age ranged from 19 to 49 years, with a mean age of 34. Thirteen were inpatients and 13 outpatients. All had a clinical
DSM-IV diagnosis of schizophrenia. Time since diagnosis ranged from 2 ± 29 years, with a mean time of 12 years. Patients reported a mean of 5.46 met needs, 4.30 unmet needs, and a total needs rating of 9.76. Staff reported a mean of 3.26 met needs, 4.80 unmet needs, and total needs rating of 8.76. There was a significan t correlation (r=0.66, P < 0.01) between total needs ratings by patients and by staff. Staff and patient ratings for each item were crosstabulat ed: this showed a highly significan t association (phi and Cramer’s V, P < 0.001) between the pattern of staff and patient ratings for each item, apart from item 12 (need for help with alcohol misuse), which still showed a significan t associatio n (P < 0.045). There was a significan t positive association between higher executive functioning and the number of met needs (r=0.408, P < 0.05) and total needs (r=0.417, P < 0.05). WCST Categories Completed scores ranged from 0 to 6, with a mean of 2.53 and a standard deviation of 2.23. Total Errors ranged from 6 to 91, with a mean of 53.69, and a standard deviation of 24.92. Patients were divided into high and low executive functioning groups via a median split. Mean discrepancie s between staff and patients’ ratings were compared across the high and low executive functioning groups. Results showed no effect of executive functioning on the discrepanc y between patients’ and staff ratings. The effect of executive functioning within groups of needs was tested by multivariat e analysis. Needs were grouped into five subdomains , following Slade et al (1998): Health, Basic, Social, Services, and Functioning .1 Patients with higher executive functioning rated their needs significant ly higher in the areas of health, functioning , services, and social needs; their needs were more highly rated by staff in the areas of health and services (Wilks’ lambda=0.256, F(10,13)=3.7 85, P < 0.014).
DISCUSSION In summary, higher executive functioning was associated with a higher total need rating (both met and unmet needs), more met needs, and with more needs in some but not all areas. Lower executive functioning was not associated with more discrepanc y between self-rated and staff-rated needs. Higher executive functioning was associated with more self-reporte d met needs, and a higher level of self-reporte d total (met and unmet) need. Better executive functioning may assist patients to get their needs met in a variety of ways, as a consequence of increased volition, planning, organization , and goal-directe d behaviour, and may also be associated with more awareness of one’s needs. More needs may be experienced as a consequence of better functioning . Higher executive functioning was associated with higher self-rated needs in the areas of health, functioning , services and social needs, and higher staff-rated needs in health and services. Better executive functioning may be associated with a better ability to communicat e one’s needs,
Downloaded by [University of California Santa Barbara] at 03:57 06 November 2015
Executive functioning and needs in schizophrenia
as well as with increased needs in certain areas, or with increased awareness of one’s needs. Staff have noted increased needs associated with higher executive functioning in areas (health and services) with well-define d service responses, whereas patients’ ratings also reflect an association between higher executive functioning and social needs (needs for company, intimate relationship s and sexual expression) , which lack a specific service response . This reflects the observation that staff may tend to focus more on needs for which there is a definabl e response.5 Groupings of needs were based on a priori subdomains,1 not on empirically- derived clusters of needs; examining the relationship between executive functioning and empirically-derive d clusters of needs may further illuminate the effect of executive functioning on needs. These results also support the view of need as a complex variable, and not simply an index of functioning .1 2 These results underline the importance of viewing needs ratings in the light of neuropsycho logical functioning , thus supporting the practice of incorporati ng neuropsycho logical assessmen t into rehabilitation planning.1 4 No relationship was found between the level of executive functioning and the level of discrepanc y between staff and patients’ ratings of needs. This suggests that patients with psychotic illnesses and lower executive functioning can validly estimate their needs, and thus supports the practice of consulting patients on their needs. However, it should be noted that CANSAS patients’ needs assessment s are rated by staff ± in this case the same staff members who produced the staff needs ratings ± raising the possibilit y of patients’ ratings being affected by staff views, so these results must be viewed with caution. The strong association between staff and patients’ ratings for all items supports the possibilit y that patients’ views may not have been fully represente d in ratings. Ways of addressing this difficult y would be to have different staff members rating staff and patients’ needs, or training patients where possible to rate their own needs via a computerized or pencil-and-p aper questionnaire . This latter option would be particularl y appropriat e with a chronic population, in settings where regular needs assessment s may be undertaken as part of the process of monitoring progress and planning rehabilitation . These results underline the importance of adequate staff training in CANSAS administration , regular communication with staff and monitoring of results, to ensure that data are valid and comprehensi ve. In this context, it should be pointed out that examination of the raw data showed a majority of ``not known’’ ratings (15/27: 6/6 client and 9/21 staff ratings) clustered around only two CANSAS items (15 and 16: intimate relationship s and sexual expression) . A similar pattern has been noted in a previous study.5 It is also of interest that a similar study omitted several items, including item 16, though the reason for this decision was not stated.6 While the reason for the high number of ``not known’’ ratings for these items is unclear, it is a matter
121
of concern that staff may not be raising these issues for discussio n with patients in all cases, thus possibly missing significan t information about an important aspect of their patients’ lives and potential needs. It is notable that the weakest (though still significant ) associatio n between staffs’ and patients’ views was in the area of alcohol misuse; an association has previousl y been observed between poor insight and underestimatio n of this need relative to staff estimates.6 Accountable mental health services are obliged to consult the consumers of those services on their views about their illnesses , their treatment, and their lives, and to incorporate those views into the treatment approach in a meaningful way. Needs assessmen t is a central aspect of this process. The present study supports the ability of patients with psychotic illnesses and impaired executive functioning to validly assess their own needs. Care must be taken, however, when using an instrument such as the CANSAS, to ensure that patients’ views are fully represented, and not subsumed by those of the staff who are rating the patients’ views. The present study also supports the practice of needs assessment , by making it clear that need is a complex variable, and not simply an index of functioning , and stresses the importance of viewing needs ratings and rehabilitation status in the light of neuropsychologica l functioning. A major limitation of this study was the fact that patients’ and staff needs ratings were made by the same staff member, entailing possible loss of information. Results must therefore be viewed with caution. The small sample size is a further limitation. The study examined only one aspect of neuropsycho logical functioning , viz. executive functioning ; future studies should examine the effect of other aspects of this complex process, and also factors such as general ability, on needs assessment . Examination of the differentia l impact of these factors on empirically- supported clusters of needs may further illuminat e the areas of functioning and needs assessment .
KEY POINTS
· · · · ·
Executive functioning did not affect patients’ ability to validly estimate their needs Better executive functioning was associated with more met needs and more expressed total needs Executive functioning was differentiall y associated with needs ratings; higher executive functioning was associated with more expressed needs in some but not all areas Need should be understood as a complex variable, and not simply an index of functioning Care should be taken to ensure that patients’ views are fully expressed, and not subsumed by those of staff raters.
122
J Buhler et al
ACKNOWLEDGEMENTS We would like to record warm thanks to patients and staff of Lakeview House, Illawarra Area Health Service, for providing access to the data used in this study. Peter Caputi’s advice and assistanc e with statistical analysis is
gratefully acknowledge d. This research was supported by a Summer Scholarship from the Illawarra Institute for Mental Health, and was carried out as part of a Master of Psychology (Clinical) degree at the Universit y of Wollongong, NSW, Australia.
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REFERENCES 1. Slade M, Phelan M, Thornicroft G (1998) A comparison of needs assessed by staff and by an epidemiologically representative sample of patients with psychosis. Psychol Med 28: 543 ± 50. 2. Spitzer R (1998) Diagnosis and need for treatment are not the same. Arch Gen Psychiatry 55: 120. 3. Bebbington P (1992) cited in Slade M (1994) Needs assessment: involvement of staff and users will help to meet needs. Br J Psychiatry 165: 293 ± 6. 4. Slade M (1994) Needs assessment: involvement of staff and users will help to meet needs. Br J Psychiatry 165: 293 ± 6. 5. Slade M, Phelan M, Thornicroft G, Parkman S (1996) The Camberwell Assessment of Need (CAN): comparison of assessments by staff and patients of the needs of the severely mentally ill. Soc Psychiatry Psychiatr Epidemiol 31: 109 ± 13. 6. Carroll A, Mortimer A (1998) Perceived needs in chronic schizophrenia.Int J Psychiatry Clin Pract 2: 139 ± 41. 7. Heinrichs RW, Zakzanis KK (1998) Neurocognitive deficit in schizophrenia: a quantitative review of the evidence. Neuropsychology 12: 426 ± 45. 8. Lezak MD (1995) Neuropsychological Assessment (3rd edn). Oxford: Oxford University Press.
9. Stratta P, Daneluzzo E, Prosperini P et al (1997) Is Wisconsin Card Sorting Test performance related to ``working memory’’ capacity? Schizophrenia Res 25: 21 ± 31. 10. Velligan DI, Mahurin RK, Diamond PL et al (1997) The functional significance of symptomatology and cognitive function in schizophrenia. Schizophrenia Res 27: 11 ± 19. 11. Comtois G, Morin C, Lesage A et al (1998) Patients versus rehabilitation practitioners: a comparison of assessments of needs for care. Can J Psychiatry 43: 159 ± 65. 12. Phelan M, Slade M, Thornicroft G et al (1995) The Camberwell Assessment of Need: the validity and reliability of an instrument to assess the needs of people with severe mental illness. Br J Psychiatry 167: 598 ± 95. 13. Heaton RK, Chelune GJ, Talley JL et al (1993) Wisconsin Card Sorting Test Manual: Revised and expanded. Odessa, FL: Psychological Assessment Resources. 14. Silverstein SM, Hitzel H, Schenkel L (1998) Identifying and addressing cognitive barriers to rehabilitation readiness. Psychiatr Services 49: 34 ± 6.
