Are We Really Addressing the Patient’s Needs?

When treating patients, we often focus primarily on improving their clinical outcomes, and as such inadvertently overlook their broader care needs. These include their perceived problems across health, social, service, and daily functioning areas.

Individuals with psychosis, a mental condition characterized by a distortion of reality, often experience poor overall functioning, meaning a difficulty in managing everyday activities, including self-care, social relationships, and work or study, which tends to be even worse when childhood adversities occur. This low functioning appears to be linked to a higher level of unmet needs for care. Importantly, care needs are strong predictors of quality of life, and patients tend to prioritize improvements in daily functioning over purely health-related outcomes.

I am a PhD Student in Neuroscience at the Section of Psychiatry of the University of Verona, and I work on the interplay between psychiatry, biology, and genetics. In this piece, I am going to talk about the needs for care in individuals affected by psychosis. In my research, I work closely with Sarah Tosato, Associate Professor at the Section of Psychiatry, who has co-written this piece with me.

The impact of childhood adversity, such as sexual and physical abuse, on needs for care remains poorly studied in people experiencing their first episode of psychosis (FEP), who are individuals in whom psychotic symptoms have only recently emerged. Addressing the effects of childhood abuse is crucial for developing more precise and effective treatments tailored to the individual’s specific care needs.

Image Source: Author used OpenAI's Sora to generate the illustration

In our study, we examined the longitudinal association between physical and sexual abuse and needs for care in a sample of FEP patients. More specifically, we assessed the extent to which physical or sexual abuse and specific care needs occur across various domains, as well as the extent to which these needs remain unmet. We hypothesized that abused patients would have a worse outcome than non-abused patients in terms of a greater number of unmet needs.

This study is in the framework of the wider GET-UP project. In our study, we involved 276 individuals experiencing their first episode of psychosis. Of these, almost 30% reported childhood physical abuse and 16.5% reported childhood sexual abuse.

Needs for care were evaluated using the Camberwell Assessment of Need (CAN), an instrument that gathers information about basic, social, health, functioning, and service-related needs, assessing both the total number of needs and whether these needs are met or unmet. For example, it asks questions such as “Do you have problems keeping clean and tidy?” and “How do you find budgeting your money?”. Each item is scored 0 (no problem), 1 (there is a problem that is met given an ongoing intervention), or 2 (actual serious problem and no interventions received, unmet need).

The GET UP project:

Patients were recruited from the Genetics Endophenotypes and Treatment: Understanding

Early Psychosis (GET-UP): Early Intervention and Assessment of Needs and Outcome (PIANO)Trial, a multicenter longitudinal study conducted in 117 Community Mental Health Centers located in the Veneto region, Italy. The GET-UP PIANO aimed to study the feasibility and effectiveness of an integrated psychosocial intervention (cognitive behavioral therapy for psychosis (CBTp), psychosis-focused Family Intervention (FIp), and multiprofessional case management (CM) of early-stage patients and their families) compared to usual care. In Italy, usual care for FEP patients typically consists of personalized outpatient psychopharmacological treatment, combined with psychosocial management by a multi-professional mental health team. Instead, CBTp focused on the formulation and modification of psychotic experiences, emotional distress, and maladaptive beliefs, using standard CBT techniques adapted for psychosis. An optimal number of 20-30 CBT sessions per patient was expected to be delivered over a time frame of 9 months. FIp aimed to improve family communication, problem-solving skills, and coping strategies, as well as to reduce expressed emotion. It included an optimal number of 10-15 sessions over 9 months, with each individual family. Every patient/family had a dedicated CM, who coordinated all planned interventions.

Key findings

Image Source: Author used OpenAI's Sora to generate the illustration

The main result of our study shows that individuals experiencing their first episode of

psychosis, who were physically or sexually abused as children, tend to have more needs for

care than those who were not abused, especially those who experienced physical abuse.

Physical abuse was more strongly linked to unmet needs, particularly in social (sexualexpression, social networks, and intimate relationships) and services areas (like having a

phone and access to the internet, or having information about personal condition and

treatment, and being independent with transportation). It can be hypothesized that prior

exposure to physical abuse increases relational vulnerability, making it more difficult for

individuals to recognize, express, and address their own needs within care settings.

Interestingly, sexual abuse did not appear to be associated with unmet needs in our sample.

This was surprising as other studies have shown that individuals with a history of sexual abuse

often report unmet needs, particularly in areas related to intimacy and relationships. One

possible explanation is that participants in previous studies were older and had been living with

psychosis for longer, meaning their needs may have become more complex over time. Another

possibility is that in our sample, patients with a history of sexual abuse may have had better

access to healthcare, which effectively addressed their needs for care.

The study also found that greater severity of psychotic symptoms and lower functioning were

both associated with a higher number of needs, especially unmet needs, suggesting that

difficulties in daily life may make it harder to engage with appropriate services. This is crucial

because it highlights the importance of targeted intervention following discharge to prevent a

cycle of rehospitalization.

Implications for treatments

Image Source: Author used OpenAI's Sora to generate the illustration

Overall, these findings suggest that early traumatic experiences, particularly physical abuse,

may have long-lasting effects that extend beyond symptom severity and influence how well

individuals are able to access and benefit from care. Identifying each person’s specific needs

for care is essential to providing effective, individualized treatment. Even in well-functioning

mental health systems, some needs often remain unmet, especially among those with a history

of childhood trauma. These individuals may feel more isolated and less able to seek help, which

can make recovery more challenging.

This underlines the importance of considering trauma history in both clinical practice and

research, as overlooking it may mean missing critical opportunities to provide appropriate

support.