Vol.5, No.2, 200-211 (2013) Health
Help received from relatives and services to satisfy
needs of adults with severe mental disorders
Marie-Josée Fleury1*, Guy Grenier2, Jean-Marie Bamvita2
1Department of Psychiatry, McGill University Douglas Hospital Research Centre, Montreal, Canada;
*Corresponding Author: flemar@douglas.mcgill.ca
2Douglas Hospital Research Centre, Montreal, Canada
Received 7 December 2012; revised 5 January 2013; accepted 12 January 2013
Background: Few studies have considered the
impact of demographic and clinical variables on
help received respectively from services and
relatives to satisfy needs of adults with severe
mental disorders (SMD). Purposes: To identify
major needs receiving help and, using the An-
dersen’s Behavioural Model of Health Service
Use, to identify and compare predisposing, en-
abling and need factors associated with help
given respec tiv ely by serv ices an d relatives. Me-
thods: 352 adults with SMD from Montreal (Ca-
nada) were interviewed using six standardized
instruments. Clinical records were consulted.
Multiple linear regression analyses were pro-
cessed to measure level of help received from
relatives and services. Results: Factors signifi-
cantly associated with help from relatives were:
higher number of perceived needs; fewer diag-
noses; better community functioning; being
younger, and in a conjugal relationship; living
autonomously; having social support and better
quality of life; and, marginally, being an immi-
grant. Factors significantly associated with help
from services w ere: higher number of perceived
needs, better quality of life, supervised housing,
adjustment disorder and schizophrenia. Con-
clusions: Help overall is insufficient to meet us-
ers’ needs. Services are more helpful than rela-
tives, in particular regarding health needs. Com-
paratively to help from services, help from rela-
tives is associated with predisposing factors
like age, marit al status and nationality.
Keywords: Help from Relatives; Help from Services;
Needs Assessment; Severe Mental Di sorders;
Service Utilisation
As a result of deinstitutionalization and greater focus
on treatment in the community, individuals with severe
mental disorders (SMD) have been increasingly living
with their family or regularly keeping in touch with them
[1]. The proportion of individuals with SMD in the
United States who have regular contacts with their family
is between 50% and 90% [2]. Between 40% and 50% of
individuals with schizophrenia in Canada live with their
family [3]. Consequently, relatives are called upon to
supply help—mostly related to daily activities—that was
formerly provided by psychiatric institutions [4].
While several studies discuss mental health service
utilisation, few compare use of professional services and
support from family and friends (informal supports) [5-9].
According to these studies, informal supports cannot
serve as a substitute for professional services and are
most effective in an adjunct role. However, such studies
do not usually draw a link between professional services
or informal supports and users’ perceived needs.
Needs assessment is a key issue as it relates to both
service planning and treatment [10]. From an epidemi-
ological perspective, needs assessments facilitate the
planning, provision and evaluation of mental health ser-
vices required to adequately serve a population within a
specific territory [11]. For case managers and caregivers,
needs assessments complete the clinical evaluation and
are useful to plan discharge from hospital and draft an
adequate intervention care plan [4,10,12]. Ideally, inter-
vention should be tailored to the user’s needs [13]. Those
needs can be met by health and social services (formal
help) or relatives (informal help).
While several studies have focussed on needs assess-
ments for adults with SMD, few of them have investi-
gated help provided respectively by services and rela-
tives [4,10,12,14-19]. Those studies have shown that
users usually received more help from services than from
relatives [14,16]. However, help from relatives is more
prominent in the weeks following a suicide attempt [10]
or a discharge from a psychiatric hospital [12]. Formal
and informal help are, in fact, complementary: users
generally received help from both services and relatives
for the majority of their needs [17].
Copyright © 2013 SciRes. OPEN ACCESS
M.-J. Fleury et al. / Health 5 (2013) 200-211 201
Furthermore, few studies have considered the impact
of demographic and clinical variables on help received
respectively from services and relatives to satisfy needs
[17,18]. The most frequently used tool for identifying
factors associated with service use is Andersen’s Beha-
vioural Model of Health Service Use [20]. This model
classifies predictors of service use into three categories:
1) predisposing, 2) enabling, and 3) needs factors. Pre-
disposing factors are individual characteristics that exist
prior to the illness such as age and gender. Enabling fac-
tors are features that influence care delivery and encom-
pass variables such as income and social support. Finally,
needs factors include assessments of physical and mental
health by patients and professionals, including diagnosis
and perceived needs. Using the behavioural model to
determine factors predictive of formal and informal help
for needs of older adults with SMD according the Cam-
berwell Assessment of Needs for the Elderly (CANE),
Cummings & Kropf [18] found three factors predicting
help from services (type of residence, daily activities and
dangerous behaviour needs areas) and four predicting
help from relatives (type of residence, and looking after
the home, money and self-care needs areas). To our
knowledge, however, the behavioural model has never
been used to identify factors associated with help re-
ceived to satisfy the needs of adults with SMD.
This article has a dual aim: 1) to identify which needs
of adults with SMD are mostly being met by services and
relatives; and 2) to identify and compare predisposing,
enabling and needs factors associated with help given by
services and relatives.
3.1. Study Design and Network
This study had a cross-sectional design. The study
population involved adults with SMD who were moni-
tored by a mental health institute (MHI) located in the
south-western part of the city of Montreal (Quebec,
Canada). This urban area, encompassing a population of
258,000, is served by two local health networks. The
MHI offers specialised mental healthcare care (i.e. se-
cond- and third-line services).Two health and social ser-
vice centres (HSSCs), created through the merger of a
general hospital, community local service centres, and-
nursing homes, provide mainly first-line mental health-
care services. Sixteen community-based agencies deli-
vering mental health services are also present (e.g. crisis
centre, day-care centres, self-help groups, back-to-work
programs). General practitioners and psychologists prac-
ticing in private clinics, and institutional mental health
housing (e.g. intermediate residence, foster home) com-
plete the mental health network in this area.
3.2. Sample Selection Criteria and
Recruitment of the Main Sample
To participate in the study, participants had to be aged
between 18 to 65 years old, and diagnosed with SMD
according to the DSM-IV (e.g. schizophrenia, bipolar
disorder). In addition, they had to live in the community
within the two HSSCs areas, have a stable mental health
condition, and be available for a follow-up assessment by
the mental health institute. Finally, the participants had to
give their consent to the research team consulting their
medical record, and they also had to refer the research
team to their principal case manager who would be asked
thereafter to fill a questionnaire on their functional con-
dition. Individuals with severe mental retardation, fol-
lowing involuntary psychiatric treatment as determined
by a judiciary board, or with a history of hospitalization
or emergency room visits in the three months prior to the
initial interview were considered unable to complete the
questionnaires and were thus excluded from the study.
Data collection ran from December 2008 to September
2010. Recruitment involved various strategies: posters at
the mental health institute (MHI) and HSSCs for par-
ticipant self-referral; recruitment at the MHI out-patient
clinics, and information sessions or letters sent to explain
the project to providers or the housing resource network.
The research team worked closely with an advisory com-
mittee of decision makers from the mental health net-
work to assist in data collection.
Interviews were conducted by a team of well-trained
clinical professionals, constantly in touch with a research
coordinator. Except for self-referral, participants selected
were contacted by their case manager, who gauged their
interest in participating in the study, and subsequently
referred participants to the research team. Two 90-minute
interviews, at one week interval, were conducted with
each patient. Each participant was required to sign a
consent form after the study was described to them. The
study protocol had been approved by the ethics boards of
the MHI and the two HSSC.
3.3. Measurement Instruments
Data was collected using six questionnaires, admini-
stered both in English and French, and from participants’
medical records at the MHI. 1) The Montreal Assess-
ments of Needs Questionnaire (MANQ) is derived from
the Camberwell Assessment of Need (CAN), which is
the most reliable and frequently used instruments for
needs assessment [21]. The CAN assesses participant
needs in 22 areas, divided into five categories: a) basic
needs (accommodations, food and day-time activities);
Copyright © 2013 SciRes. OPEN ACCESS
M.-J. Fleury et al. / Health 5 (2013) 200-211
b) health (physical health, psychotic symptoms, psycholo-
gical distress, safety to self, safety to others, alcohol use,
and drug use); c) functioning (self-care, looking after the
home, child care, basic education, and money); d) social
(company, intimate relationships, and sexual expression);
and e) services (information about illness and treatment,
transportation, telephone, and benefits). The CAN eva-
luates needs by taking into account their number and
intensity (no need, met need, unmet need), along with the
level of help received from relatives and services (no
help, low help, moderate help, high help), the level of
help that users need from local services (no help, low
help, moderate help, high help) and the adequacy of help
in regards to needs expressed, in term of quality and
quantity (yes, no). Within the MANQ, four areas were
added, for a total of 26: job integration, stress adaptation,
social exclusion, and involvement in treatment decisions.
For individuals with SMD, job integration is an impor-
tant issue since it is difficult for most of them to find
work due to individual characteristics or environmental
barriers [22]. The literature also mentions that social ex-
clusion and stigmatization is often more difficult to cope
with than the SMD itself [23,24]. Furthermore, vulner-
ability to stress is associated with a greater severity of
psychotic symptoms [25]. Finally, involvement in treat-
ment decisions constitutes an important dimension of re-
covery [26]. Contrary to the original CAN, in which
participants’ needs are measured based on ordinal scale
questions, the MANQ used analogical scales, ranging
from 0 to 10. The purpose of this change was to enhance
variability in the data without compromising precision.
Other standardized instruments used were as follows: 2)
Alcohol Use Disorders Identification Test (AUDIT),
measuring the degree of dependency and riskyalcohol-
consumption (Cronbach alpha—CA: 0.88; [27]); 3) Drug
Abuse Screening Test (DAST), evaluating drug abuse
and its consequences (CA: 0.74; [28]); 4) Social Pro-
visions Scale (SPS), exploring participants’ level of
integration and social support (CA: 0.92; [29]); 5) Satis-
faction with Life Domains Scale (SLDS), assessing
quality of life (CA: 0.92; [30]); and 6) Multnomah Com-
munity Ability Scale (MCAS), assessing patients’ func-
tional status in the community (CA: 0.87; [31]). All
questionnaires were completed by the participants, except
the MCAS, which was completed by the participant’s
principal case manager. Participants’ medical records were
used to compile complementary clinical data: DSM-IV
diagnoses, number of prior suicide attempts, and history
of prior violence.
3.4. Analyses
The MANQ has been validated using many analyses
(factor analyses, Chronbach Alpha, inter-rater, test-retest
reliability), concordance with other instruments (such as
MCAS and SLDS), and corresponding values on the
MANQ for each category of the CAN [32]. Participants
were asked to complete the MANQ and CAN during the
same interview. Overall, validation analyses showed
comparable results between the two instruments. Chron-
bach Alpha in the MANQ ranged from 0.70 to 0.73
(versus 0.68 to 0.71 for the CAN). The mean values for
CAN and MANQ for each needs domain were correlated
with global scores from MCAS and SLDS, forming a
consistent correlation pattern for both. The kappa co-
efficients ranged from 0.46 to 1.00 for the test-retest re-
liability and from 0.64 to 1.00 for the inter-rater re-
The analyses frame was built into the conceptual mo-
del displayed in Figure 1. Two continuous dependent
variables were built: “level of help received from re-
latives”, and “level of help received from services”. Each
dependent variable was given a score calculated by
adding, for each participant, the scores illustrating the
level of help received for each perceived need (from
relatives for the former, and from services for the latter).
The independent variables, as shown in Figure 1, are
organised in three categories: predisposing factors, en-
abling factors, and need factors, respecting Andersen’s
behavioural model.
Normality assumptions were verified before going
through analyses. No transformation was needed. Analy-
ses encompassed descriptive analyses, bivariate analyses
and hierarchical linear regression analyses. The purpose
of bivariate analyses was to select independent variables
associated with the dependent variables, for an alpha
value set at P < 0.10. Independent variables yielding a
significant association were used to build the hierarchical
linear regression models, setting the alpha value at P <
0.05. The total variance explanation and the goodness of
fit were generated.
Overall, 437 participants were approached. From the
housing mental health network, 116 (27%) lived in an
intermediate resource (i.e. a housing resource linked by
contract to a public institution), 61 (14%) in a foster
home, and 254 (58%) in other types of housing (e.g.
autonomous or supervised housing). Participants mean
age differed by housing types (respectively: 51 [SD: l9.5],
49 [SD: 11.5] and 45 [SD: 10.6] years old). A total of
352 potential subjects (81%) agreed to participate, while
86 declined (20%). Refusals were compared to parti-
cipants as to gender and housing type. No statistically
significant difference was found regarding 1) inter-
mediate residence participants (Khi-square: 5.999 [P =
0.199]); 2) foster home participants (Khi-square: 4.482
Copyright © 2013 SciRes. OPEN ACCESS
M.-J. Fleury et al. / Health 5 (2013) 200-211
Copyright © 2013 SciRes.
Predisposing factors:
Civil status
Level of education
Spoken Language
Quality of life (SLDS score
Enabling factors:
Source of income: Job
Type of housing
Social support (SPS score
Need factors:
Schizophrenia Mood disorders
Delusion and other psychotic disorders Schizophrenia spectrum disorders
Anxiety disorders Moderate or mild Mental retardation
Personality disorders Adjustment disorders
Number of diagnoses Alcohol Abuse (AUDIT score)
Drug Abuse (DAST score) Functional status in the community (MCAS score)
Number of perceived needs (MANQ) Intensity of needs (MANQ)
Number of prior suicide attempts History of prior violence
Level of help
from services
from relatives
Figure 1. Conceptual framework factors associated with help from relatives and services to satisfy needs among adults
with severe mental disorders.
[P = 0.482]); 3) or other housing type (Khi-square: 3.229
[P = 0.665]). Participants and refusals were also com-
pared as to gender distribution (total sample); again, no
statistically significant difference was found: Khi-square:
1210; P = 0.271.
Socio-demographic, socio-economic and clinical cha-
racteristics of the 352 participants are displayed in Table
1. The mean age for the 352 participants was 46.5 (SD:
10.9), with 186 males (53%) and 166 females (47%).
Most of the participants were natives of Canada (92%)
and French-speaking (64%). Only 13% were married or
in a conjugal relationship. Sixty-six per cent were on
social welfare. The majority did not have a post-secon-
dary diploma (65%). Sixty per cent lived in an auto-
nomous apartment. Considering cut-offs at 8 and 6 for
the AUDIT and the DAST scores respectively [33], 143
individuals (41%) versus 53 (15%) in the sample could
be considered as addicted to alcohol versus addicted to
drugs. The most prevalent severe mental health disorders
were mood disorders (41%) and schizophrenia (38%).
Presence of comorbidity was noted for 48% of partici-
pants, the most prevalent mental health disorder as se-
cond diagnosis was personality disorders (28%).
Detailed description of perceived needs and help re-
ceived for those needs are displayed in Table 2. The first
two results columns report the number of participants
having a specific need. The five most reported needs are:
psychological distress (70%), stress adaptation (63%),
physical health (56%), psychotic symptoms (48%), and
money (47%). The relative importance attributed to per-
ceived needs is shown in the second column. As regards
intensity of perceived needs, the highest means relate to
childcare (mean: 7.5), job integration (mean: 7.5), drugs
(mean: 7.4), sexual expression (mean: 7.4), intimate
relationships (7.3), and benefits (mean: 7.3). The third
and fourth columns display results related to the level of
M.-J. Fleury et al. / Health 5 (2013) 200-211
Table 1. Socio-demographic, socio-economic and clinical variables (N = 352).
Categories Sub-categories Variables n %
Age [Mea n (SD)] 46.5 10.9
Men 186 52.8
Gender Women 166 47.2
Canadian 323 91.8
Nationality Others 29 8.2
French 225 63.9
Socio-demographic variables English 73 20.7
French/English 8 2.3
Spoken language
Other 46 13.1
Single/Never married 251 71.3
In couple/Married/Remarried 46 13.1
Civil status
Separated/Divorced/Widow 55 15.6
Source of Social assistance 234 66.5
income Other sources 118 33.5
Primary school 39 11.1
Secondary school 190 54.0
College 72 20.5
University 51 14.5
Apartment (autonomous) 212 60.2
Intermediary resource 57 16.2
Type of housing Foster home 52 14.8
Temporary housing 15 4.3
Supervised housing 16 4.5
Socio-economic variables
Number of kids [Mean (SD)] 0.64 1.18
AUDIT score (Range: 0 - 35) 5.9 6.5
DAST score (Range: 0 - 15) 2.7 3.3
Scores from standardized
instruments SPS score (Range: 0 - 94) 70.6 8.1
[Mean (SD)] MCAS score (Range: 28 - 83) 65.2 9.7
SLDS score (Range: 45 - 140) 103.3 19.7
Severe mental disorders
Mood disorders 142 40.3
Bipolar disorders 62 17.7
Major Depression 55 15.7
Dysthymic disorders 20 5.7
Not specified 5 1.4
Schizophrenia 134 38.1
Clinical variables Schizophrenia spectrum disorders 45 12.8
Delusions and other psychotic disorders 33 9.4
Second diagnosis
Anxiety disorders 41 11.6
Personality disorders 97 27.6
Moderate or mild Mental retardation 45 12.8
Mental health
Adjustment disorders 13 3.7
Copyright © 2013 SciRes. OPEN ACCESS
M.-J. Fleury et al. / Health 5 (2013) 200-211 205
Table 2. Descriptive analyses of needs and help received (N = 352).
with specific
Intensity of
Level of help
received from
Level of help
received from
Comparison of the ratio of participants receiving
help from relatives versus from service providers
[(n (%)] [Mean (SD)][Mean (SD)][Mean (SD)]
receiving help
from relatives
for each specific
receiving help
from service
providers for
each specific
P value
Categories of needs
[(n (%)] [(n (%)] (Chi square)
Accommodation 123 (34.9) 5.9 (3.0) 1.6 (3.0) 3.2 (4.2) 31 (25.2) 52 (42.3) 0.642
Food 118 (33.5) 5.3 (2.4) 3.3 (3.9) 3.4 (4.0) 61 (51.7) 60 (50.8) 0.139
Looking after the home 116 (33.0) 5.8 (2.5) 2.4 (3.6) 1.7 (3.4) 46 (39.7) 27 (23.3) 0.003
Self-care 60 (17.0) 5.3 (2.8) 1.5 (3.0) 3.2 (4.2) 16 (26.7) 27 (45.0) 0.014
Day-time activities 121 (34.4) 5.5 (2.7) 1.9 (2.9) 3.3 (3.9) 46 (38.0) 61 (50.4) 0.762
Physical health 198 (56.3) 5.8 (2.8) 1.5 (3.1) 4.8 (3.7) 45 (22.7) 151 (76.3) 0.285
Psychotic symptoms 169 (48.0) 5.6 (2.8) 2.2 (3.6) 7.3 (3.3) 53 (31.4) 153 (90.5) 0.023
Information 80 (22.7) 6.0 (2.8) 0.9 (2.6) 2.3 (3.1) 14 (17.5) 37 (46.3) 0.037
Psychological distress 245 (69.6) 6.6 (2.7) 4.1 (4.2) 5.3 (3.9) 134 (54.7) 177 (72.2) 0.003
Safety to self 69 (19.6) 5.9 (2.8) 3.0 (4.1) 4.3 (4.1) 28 (40.6) 42 (60.9) 0.047
Safety to others 28 (8.0) 5.5 (3.0) 3.3 (4.6) 3.8 (3.9) 11 (39.3) 16 (57.1) 0.823
Alcohol 36 (10.2) 5.1 (2.4) 1.6 (3.2) 2.0 (3.2) 9 (25.0) 12 (33.3) 0.414
Drugs 131 (37.2) 7.4 (3.0) 1.4 (3.1) 6.4 (4.2) 25 (19.1) 98 (74.8) 0.166
Company 123 (34.9) 6.5 (2.7) 1.9 (3.1) 1.5 (2.8) 31 (25.2) 52 (42.3) 0.011
Intimate relationships 144 (40.9) 7.3 (2.8) 1.6 (2.9) 1.4 (2.9) 44 (30.6) 35 (24.3) 0.008
Sexual expression 110 (31.3) 7.4 (2.8) 1.7 (3.2) 1.4 (2.7) 32 (29.1) 33 (30.0) 0.003
Childcare 23 (6.5) 7.5 (2.9) 5.0 (4.4) 3.0 (3.9) 15 (65.2) 10 (43.5) 0.645
Basic education 51 (14.5) 5.9 (3.0) 1.9 (3.5) 1.9 (3.6) 16 (31.4) 14 (27.5) 0.346
Telephone 12 (3.4) 6.6 (2.8) 2.5 (4.5) 1.7 (1.9) 3 (25.0) 6 (50.0) 0.505
Transportation 83 (23.6) 6.9 (3.0) 2.7 (4.0) 2.7 (4.0) 30 (36.1) 33 (39.8) 0.368
Money 167 (47.4) 6.9 (2.9) 2.5 (3.8) 3.8 (4.3) 59 (35.3) 82 (49.1) <0.001
Benefits 40 (11.4) 7.3 (3.0) 1.0 (2.7) 2.0 (3.4) 10 (25.0) 14 (35.0) 0.251
Job integration 125 (35.5) 7.5 (2.5) 0.6 (2.0) 2.5 (3.7) 13 (10.4) 49 (39.2) 0.019
Stress adaptation 221 (62.8) 6.3 (2.6) 4.0 (4.0) 4.5 (3.9) 130 (58.4) 145 (65.6) 0.436
Social exclusion 110 (31.3) 6.5 (2.9) 2.4 (3.7) 2.6 (3.7) 41 (37.3) 44 (40.0) <0.001
Involvement in treatment decisions 71 (20.2) 6.5 (3.0) 1.8 (3.5) 2.7 (3.1) 17 (23.9) 38 (53.5) 0.106
TOTAL SAMPLE 107 (30.3) 6.6 (2.8) 2.3 (2.4) 3.9 (2.5) 37 (32.9) 56.5 (48.6) 0.021
help received from relatives and services respectively,
for each specific need reported. Perceived needs for
which participants received help mostly from relatives
are childcare, psychological distress, stress adaptation,
food and safety to others. At the same time, help from
services was mostly related to psychotic symptoms,
drugs, psychological distress, physical health and stress
adaptation. The level of help received from relatives is
higher than the level of help received from services in
five areas (childcare, telephone, looking after the home,
sexual expression, and intimate relationships) and equal
in two others (transportation, basic education). In health-
related areas (psychotic symptoms, physical health, drugs,
psychological distress, safety to self, safety to others, and
alcohol), the level of help received from services is
notably higher than the level of help received from
relatives. A majority of participants did not receive help
appropriate to their level of need, and a critical number
of these individuals received no help from services or
their informal network for one or more of their needs.
Copyright © 2013 SciRes. OPEN ACCESS
M.-J. Fleury et al. / Health 5 (2013) 200-211
The fifth and sixth columns (again in Table 2) indicate
the ratio of participants who received help from relatives
and services respectively. For each perceived need, a
comparison was also made between these ratios in the
seventh column. As illustrated by P values, the ratio of
participants receiving help from relatives is higher than
that of participants receiving help from services in only
two areas: looking after the home and intimate relation-
ships. In the following ten areas, significantly more par-
ticipants received help from services than from relatives:
self-care, psychotic symptoms, information, psychologi-
cal distress, safety to self, company, sexual expression,
money, job integration, and social exclusion.
The hierarchical linear regression model assessing help
from relatives is displayed in Table 3. From the block of
predisposing factors, four variables were retained: being
younger, being in a conjugal relationship, quality of life
according the SLDS score and, marginally, being of a
nationality other than Canadian. From the block of en-
abling factors, to live in autonomous housing and social
support according the SPS score were retained in the
model, both being positively associated with the depen-
dent variable. From the third block of need factors, three
variables were retained in the final model: number of
diagnoses (negatively associated), functional skills in the
community according the MCAS score and number of
perceived needs (both positively associated).
The goodness-of-fit for this model is acceptable, with
31% of total variance explained. From the block of pre-
disposing factors, one variable was retained: quality of
life according the SLDS score, which was positively as-
sociated. From the block of enabling factors, one vari-
able was retained: type of housing, which shows that
people living in autonomous housing received less help
from services. From the third block of need factors, three
variables were retained in the final model: schizophrenia,
adjustment disorders and number of perceived needs, the
three variables being positively associated with help
from services. The goodness-of-fit for this model is ac-
ceptable, with 39% of total variance explained. The hier-
archical linear regression model assessing help from ser-
vices is displayed in Table 4.
The purposes of this article were to identify needs
receiving help from relatives and services respectively
and to identify and compare predisposing, enabling and
need factors, associated respectively with help given by
services and relatives to meet the needs of adults with
SMD. Participants were interviewed using six instru-
ments, and clinical records were consulted.
Overall, participants’ cohort distribution with respect
to socio-demographic profiles and clinical characteristics
was comparable to that of most of previous studies con-
cerning needs assessments for adults with SMD [15,
34-36]. The main difference was the lower proportion of
schizophrenic cases in our sample, which could explain
Ta bl e 3 . Variables independently associated with level of help received from relatives among patients with severe mental disorders:
multiple linear regression analysis (N = 352).
Predisposing factors Enabling factors Need factors
95.0% CI
P Standardized
t P
Lower bound
Age 0.159 0.002 0.109 0.038 0.102 2.136 0.033 0.436
Civil status (single) 0.196 0.000 0.149 0.004 0.157 3.362 0.001 17.744
Nationality (Canadian) 0.070 0.048 0.099 0.041 0.081 1.767 0.078 14.975
Quality of life (SLDS score) 0.074 0.015 0.058 0.030 0.132 2.326 0.021 0.025
Type of housing (autonomous) 0.188 0.001 0.142 2.847 0.005 2.152
Social support (SPS score) 0.143 0.011 0.131 2.564 0.011 0.090
Number of diagnoses 0.134 2.901 0.004 5.888
Functional status in community
(MCAS score) 0.092 1.982 0.048 0.002
Number of perceived needs
(MANQ) 0.450 8.592 0.000 1.906
Total variance
explained: R2 14.3% 25.2% 30.5%
F 7.770 9.402 16.712
P <0.001 <0.001 <0.001
Copyright © 2013 SciRes. OPEN ACCESS
M.-J. Fleury et al. / Health 5 (2013) 200-211 207
Table 4. Variables independently associated with level of help received from services among patients with mental disorders: multiple
linear regression analysis (N = 352).
factors Enabling factors Need factors
95.0% CI
  P   P
 β t P
bound Upper
Quality of life (SLDS score) 0.074 0.016 0.005 0.019 0.289 5.772 0.000 0.220 0.447
Type of housing
(autonomous) 0.2180.000 0.230 4.891 0.000 14.935 6.368
Schizophrenia 0.110 2.421 0.016 0.966 9.334
Adjustment disorder 0.124 2.935 0.004 4.907 24.852
Number of perceived needs
(MANQ) 0.641 13.292 0.000 2.844 3.832
Total variance explained: R2 0.08% 0.21% 39.1%
F 1.930 8.855 44.415
Goodness-of-fit P <0.001 <0.001 0.001
lower prevalence of psychotic symptoms. Our sample
also presented a higher proportion of physical health
needs. According to Hansson et al. [14], women, older
persons, out-patients and individuals without a diagnosis
of psychosis have a higher risk of presenting a need in
this domain. Intensity of need is particularly high with
regards to intimate relationships and sexual expression,
which is similar to what most previous studies have
shown [15,16,37-39]. Lack of specialised services in
these areas could explain the high level of need [35,40].
Users generally perceived medication as being the main
cause of their sexual problems [39]. Moreover, care-
givers were often unaware of their clients’ needs re-
garding intimate relationships and sexual expression [12,
39,40]. Drugs, childcare, job integration and benefits are
other areas where the level of need was particularly high.
This is likely as a result of the difficulties in coordinating
mental health services with other health or social ser-
vices [18].
Like previous studies [4,10,12,15-17,19], our results
show that the level of help from services is particularly
high in health-related areas, such as psychotic symptoms,
physical health, psychological distress and drugs. There
are areas where clinical treatment and out-patient ser-
vices were clearly identified [4]. Formal help was lower
in social (company, intimate relationships, sexual ex-
pression), basic (accommodation, food, day-time activi-
ties) functioning (looking after the home, money, child-
care, self-care, basic education) and service needs (trans-
portation, benefits, information about illness and treat-
ment, telephone). In such areas, relatives can act as ad-
juncts to existing services and supply additional help
Areas where relatives provided the most help were the
same as those described in previous studies [16]. In areas
like childcare, looking after the home, basic education,
food, company, intimate relationships, transportation and
telephone, the level of help from relatives was higher or
equal to help received from services. These areas tradi-
tionally fall within the purview of the family [7].
Finally, a high proportion of users’ needs was not met
or was insufficiently met by services or relatives. Mental
health services are underused by individuals with mental
disorders [41,42] and, as a result, several needs are not
adequately met.
Two variables were significantly associated with both
formal and informal help: number of needs and quality of
life. It makes sense that individuals with a greater num-
ber of perceived needs would be more likely to receive
help from a greater variety of sources [9]. As concerns
quality of life, a greater number of needs are associated
with a favourable outcome according the literature [43].
It could indicate that consumers are more aware of their
needs, that services perform better assessments or that
there is closer consumer follow-up or greater service
utilisation [44].
There is a difference between formal and informal
help supplied according to the type of housing. Help
from services is significantly more important in sup-
ported housing, while families provide most of the help
to their relatives in autonomous housing. Individuals
with poorer functional status must be placed in supported
housing (foster homes, intermediary resources, tem-
porary housing, supervised housing, etc.). This is the
case of individuals affected by negative symptoms of
schizophrenia [45]. It is logical to expect that those
individuals would be more susceptible to having contacts
with professional caregivers and receiving more help
from services, for their health needs, but also in other
areas (accommodation, food, day-time activities, etc.)
Copyright © 2013 SciRes. OPEN ACCESS
M.-J. Fleury et al. / Health 5 (2013) 200-211
usually provided by the family.
According to Andersen’s Behavioural Model of Health
Service Use [20], need factors are the most influential
factors of health service utilisation. Help from services is
significantly associated with two particular diagnoses:
schizophrenia and adjustment disorder. As schizophrenia
affects most of life’s areas, it makes sense that indivi-
duals affected by this chronic mental disorder would re-
ceive more help from services [45]. Adjustment disorder
is a prime cause of psychiatric consultation. According
the literature, the incidence of this mental disorder in
psychiatric consultation services for adults would be
between 5% and 21% [46,47]. Adjustment disorder is en-
countered commonly in primary care and usually followed-
up in liaison psychiatry [47,48]. It is important to
consider that no users in our sample were affected
exclusively by an adjustment disorder. This is a second
diagnosis for some individuals affected by a severe men-
tal disorder (schizophrenia, mood disorders, etc.).
Predisposing factors (age, civil status and nationality)
are more often associated to help from relatives. The
association between age and help from relatives can be
explained by the fact that younger people are more likely
to live with their parents and to have a larger social
networks than older users [7]. In terms of marital status,
living with a spouse is conducive to sharing, which helps
in fulfilling basic needs and those of health and social
nature. Individuals with SMD living in a conjugal re-
lationship have a higher quality of life and are less likely
to have suicidal ideation than single, divorced, widowed
or estranged persons [49]. Finally, concerning nationality,
in some cultures (e.g. Spain, India) families and friends
represent the main source of help except in the areas
where specialized services are required [4,19].
There exists a logical association between quality of
the social support and level of help received from rela-
tives. We can also establish a link between help received
from relatives, lower number of diagnoses and the ability
to function better in the community, according to the
MCAS. This shows that family and friends are better
able to give help to individuals who are less problematic,
more clinically stable and less susceptible to represent a
burden for them [17].
Relatives are key caregivers who should be included
in the planning of care for users suffering from SMD.
Evidence-based practice such as psycho-educational in-
tervention for families [50] and respite services to reduce
the burden on families should be enhanced. These in-
terventions could indirectly improve relatives’ capacity
to provide adequate help for their loved ones suffering
from SMD.
Our study includes certain notable limitations. First,
information was lacking about family and social net-
works of our respondents. It is possible that some socio-
demographic, economic or geographic variables (age of
caregivers, familial income, employment, proximity, etc.)
influence relatives’ capacity to give help to individuals
with SMD [51]. Secondly, while we had information
about the number of relatives or professionals giving
help and the frequency of their contacts or visits, we did
not know the frequency and quality of relationships be-
tween families and mental health services. More effec-
tive collaboration with health services can influence in-
formal help [51]. Families are often unsatisfied of the
services offered to a relative suffering from a mental dis-
order [52]. In addition, they do not receive information
and emotional support from professionals [53] or are ex-
cluded from decisions concerning treatment of hospital
discharge planning [54]. There is also a severe lack of
respite care for family caregivers [55].
Our study demonstrates that help overall is insufficient,
both in quantity and intensity, to meet users’ needs. Ser-
vices are more helpful than relatives, but mostly for health
domains. However, relatives can give substantial help to
individuals who are clinically stable in domains such as
childcare, food and looking after the home—without
adding to much burden on family. These domains are
often overlooked or neglected by mental health profes-
sionals. Formal and informal help are in fact comple-
mentary therefore; a greater collaboration between rela-
tives and service providers could contribute to better meet
the needs of individuals with SMD. Being aware of fac-
tors associated with help improves services’ capacity to
complete adequately with help from relatives and vice-
versa. Overall, our results reinforce the importance of
consolidate strategies to reach patients and answer more
broadly their needs, and this in a concerted common effort
between services and family.
The study was funded by the Canadian Institute of Health Research
(CIHR-MOP-84512). We would like to thank this grant agency and all
the users who participated in the research.
[1] Pitschel-Walz, G., Leutch, S., Bäuml, J., Kissling, W. and
Engel, R.R. (2001) The effect of family interventions on
relapse and rehospitalization in schizophrenia—A meta-
analysis. Schizophrenia Bulletin, 27, 73-92.
[2] Anthony, W.A., Cohen, M. and Farkas, M. (1990) Psy-
chiatric rehabilitation. Boston University Centre for Psy-
chiatric Rehabilitation, Boston.
Copyright © 2013 SciRes. OPEN ACCESS
M.-J. Fleury et al. / Health 5 (2013) 200-211 209
[3] Ward-Griffin, C., Scholfield, R., Vos, S. and Coatsworth-
Puspoky, R. (2005) Canadian families caring for mem-
bers with mental illness: A vicious cycle. Journal of Fam-
ily Nursing, 11 , 140-161.
[4] Ochoa, S., Haro, J.M., Autonell, J., Pendàs, A., Teba, F.,
Màrquez, M. and the NEDES Group (2003) Met and un-
met needs of schizophrenia patients in a Spanish sample.
Schizophrenia Bulletin, 29, 201-210.
[5] Lam, J.A. and Rosenheck, R. (1999) Social support and
service use among homeless persons with serious mental
illness. International Journal of Social Psychiatry, 45, 13-
28. doi:10.1177/002076409904500103
[6] Snowden, L.R. (1998) Racial differences in informal help
seeking for mental health problems. Journal of Co mm un i t y
Psychology, 26, 429-438.
[7] Horwitz, A.V. and Uttaro, T. (1998) Age and mental health
services. Community Mental Health Journal, 34, 275-283.
[8] Pescosolido, B.A., Wright, E.R., Alegria, M. and Vera, M.
(1998) Social networks and patterns of use among the
poor with mental health problems in Puerto Rico. Medical
Care, 36, 1057-1072.
[9] Woodward, A.T., Taylor, R.J., Bullard, K.M., Neighbors,
H.W., Chatters, L.M. and Jackson, J.S. (2008) Use of pro-
fessional and informal support by African Americans and
Caribbean blacks with mental disorders. Psychiatric Ser-
vices, 59, 1292-1298. doi:10.1176/appi.ps.59.11.1292
[10] Cedereke, M. and Ojehagen, A. (2007) Formal and infor-
mal help during the year after a suicide attempt: A one
year follow-up. International Journal of Social Psychia-
try, 53, 419-429. doi:10.1177/0020764007078345
[11] Macpherson, R., Haynes, R., Summerfield, L., Foy, C.
and Slade, M. (2003) From research to practice. A local
mental health services needs assessment. Social Psychia-
try and Psychiatric Epidemiology, 38, 276-281.
[12] Simons, L. and Petch, A. (2002) Needs assessment and
discharge: A Scottish perspective. Journal of Psychiatric
and Mental Health Nursing, 9, 435-445.
[13] Schölzel-Dorenbos, C.J., Meeuwsen, E.J. and Olde-Rik-
kert, M.G. (2010) Integrating unmet needs into dementia
health-related quality of life research and care: Introduc-
tion of the hierarchy model of needs in dementia. Aging
& Mental Health, 14, 113-119.
[14] Hansson, L., Björkman, T. and Svensson, B. (1995) The
assessment of needs in psychiatric patients. Interrater re-
liability of the Swedish version of the Camberwell as-
sessment of needs instrument and results from a cross-
sectional study. Acta Psychiatrica Scandinavica, 92, 285-
293. doi:10.1111/j.1600-0447.1995.tb09584.x
[15] Bengtsson-Tops, A. and Hansson, L. (1999) Clinical and
social needs of schizophrenic outpatients living in the
community: The relationship between needs and subjec-
tive quality of life. Social Psychiatry and Psychiatric Epi-
demiology, 34, 513-518. doi:10.1007/s001270050169
[16] Middleboe, T., Mackeprang, T., Hansson, L., Werdelin, G.,
Karlsson, H., Bjarnason, O., Bengtsson-Tops, A., Dybbro,
J., Nilsson, L.L., Sandlund, M. and Sörgaard, K.W. (2001)
The Nordic study on schizophrenic patients living in the
community. Subjective needs and perceived help. Euro-
pean Psychiatry, 16, 207-214.
[17] Fleury, M.J., Grenier, G., Caron, J. and Lesage, A. (2008)
Patient’s report of help provided by relatives and services
to meet their needs. Community Mental Health Journal,
44, 271-281. doi:10.1007/s10597-008-9127-x
[18] Cummings, S.M. and Kropf, N.P. (2009) Formal and in-
formal support for older adults with severe mental illness.
Aging & Mental Health, 13, 619-627.
[19] Kulhara, P., Avashthi, A., Grover, S., Sharan, P., Sharma,
P., Malhotra, S. and Gill, S. (2010) Needs of Indian
schizophrenia patients: An exploratory study from India.
Social Psychiatry and Psychiatric Epidemiology, 45, 809-
818. doi:10.1007/s00127-009-0126-1
[20] Andersen, R.M. (1995) Revisiting the behavioral model
and access to medical care: Does it matter? Journal of
Health and Social Behavior, 36, 1-10.
[21] Phelan, M., Slade, M., Thornicroft, G., Dunn, G., Hollo-
way, F., Wykes, T., Strathdee, G., Loftus, L., McCrone, P.
and Hayward, P. (1995) The Camberwell assessment of
need: The validity and reliability of an instrument to as-
sess the needs of people with severe mental illness. Brit-
ish Journal of Psychiatry, 167, 589-595.
[22] Corbière, M., Zaniboni, S., Lecomte, T., Bond, G.R.,
Gilles, P.Y., Lesage, A. and Goldner, E. (2011) Job acqui-
sition for people with severe mental illness enrolled in
supported employment programs: A theoretically grounded
empirical study. Journal of Occupational Rehabilitation,
21, 342-354. doi:10.1007/s10926-011-9315-3
[23] Schulze, B. and Angermeyer, M.C. (2003) Subjective ex-
periences of stigma. A focus group study of schizo-
phrenic patients, their relatives and mental health profes-
sionals. Social Science & Medicine, 56, 299-312.
[24] Stuart, H. (2003) Stigma and the daily news: Evaluation
of a newspaper intervention. Canadian Journal of Psy-
chiatry, 48, 651-656.
[25] Pruessner, M., Iyer, S.N., Faridi, K., Joober, R. and Malla,
A.K. (2011) Stress and protective factors in individuals at
ultra-high risk for psychosis, first episode psychosis and
healthy controls. Schizophrenia Research, 129, 29-35.
[26] Piat, M., Sabetti, J. and Bloom, D. (2010) The transfor-
mation of mental health services to a recovery-oriented
system of care: Canadian decision maker perspectives.
International Journal of Social Psychiatry, 56, 168-177.
[27] Accietto, C. (2003) La validation d'une version française
Copyright © 2013 SciRes. OPEN ACCESS
M.-J. Fleury et al. / Health 5 (2013) 200-211
du questionnaire A.U.D.I.T. Alcohol use identification
test. Ph.D. Thesis, Geneva University, Geneva.
[28] Carey, K.B., Carey, M.P. and Chandra, P.S. (2003) Psy-
chometric evaluation of the Alcohol Use Disorders Identi-
fication Test and Short Drug Abuse Screening Test with
psychiatric patients in India. Journal of Clinical Psychia-
try, 64, 767-774. doi:10.4088/JCP.v64n0705
[29] Caron, J. (1996) L’échelle de provisions sociales: Une va-
lidation québécoise. Santé mentale au Québec, 21, 158-
180. doi:10.7202/032403ar
[30] Caron, J., Mercier, C. and Tempier, R. (1997) Une validation
québécoise du satisfaction with life Domains Scale. Santé
mentale au Québec, 17, 195-218. doi:10.7202/032422ar
[31] Hendryx, M.S., Dyck, D.G., McBride, D. and Whitbeck, J.
(2001) A test of the reliability and validity of the Mult-
nomah Community Ability Scale. Community Mental
Health Journal, 37, 157-168.
[32] Fleury, M.J., Grenier, G., Bamvita, J.M. and Tremblay, J.
(2013) Factors associated with needs of users with se-
vere mental disorders. Psychiatric Quarterly.
[33] Babor, T.F., Higgins-Biddle, J.C., Saunders, J.B. and Mon-
teiro, M. (2001) Audit. The Alcohol Use Disorders Iden-
tification Test guidelines for use in primary care. 2nd Edi-
tion, Department of Mental Health and Substance De-
pendence, World Health Organization, Geneva.
[34] Slade, M., Phelan, M. and Thornicroft, G. (1998) A com-
parison of needs assessed by staff and by an epidemi-
ologically representative sample of patients with psycho-
sis. Psy chological Medicine, 28, 543-550.
[35] Slade, M., Leese, M., Cahill, S., Thornicroft, G. and Kui-
pers, E. (2005) Patient-rated mental health needs and
quality of life improvement. British Journal of Psychiatry,
187, 256-261. doi:10.1192/bjp.187.3.256
[36] Wennström, E., Sörbom, D. and Wiesel, F.A. (2004) Fac-
tor structure in the Camberwell Assessment of Need. Brit-
ish Journal of Psychiatry, 185, 505-510.
[37] McCrone, P., Leese, M., Thornicroft, G., Schene, A.,
Knudsen, H.C., Vàzquez-Barquero, J.L., Tansella, M. and
Becker, T. (2001) A comparison of needs of patients with
schizophrenia in five European countries: The EPSILON
study. Acta Psychiatrica Scandinavica, 103, 370-379.
[38] Wiersma, D., van den Brink, R., Wolters, K., McCabe ,R.,
Bullenkamp, J., Hansson, L., Lauber, C., Martinez-Leal,
R., Rössler, W., Salize, H., Björkman, T., Torres-Gonzales,
F., Wright, D.J. and Priebe, S. (2009) Individual unmet
needs for care: Are they sensitive as outcome criterion for
the effectiveness of mental health services interventions?
Social Psychiatry and Psychiatric Epidemiology, 44, 317-
324. doi:10.1007/s00127-008-0432-z
[39] McCann, E. (2010) The sexual and relationship needs of
people who experience psychosis: Quantitative findings
of a UK study. Journal of Psychiatric and Mental Health
Nursing, 17, 295-303.
[40] Slade, M. (1996) Assessing the needs of the severely
mentally ill: Cultural and professional differences. Inter-
national Journal of Social Psychiatry, 42, 1-9.
[41] Andrews, G., Issakidis, C. and Carter, G. (2001) Shortfall
in mental health service utilisation. British Journal of
Psychiatry, 179, 417-425. doi:10.1192/bjp.179.5.417
[42] Tempier, R., Meadows, G.N., Vasiliadis, H.M., Mosier,
K.E., Lesage, A., Stiller, A., Graham, A. and Lepnurm, M.
(2009) Mental disorders and mental health care in Canada
and Australia: Comparative epidemiological findings. So-
cial Psychiatry and Psychiatric Epidemiology, 44, 63-72.
[43] Leese, M., Johnson, S., Slade, M., Parkman, S., Kelly, F.,
Phelan, M. and Thornicroft, G. (1998) User perspective
on needs and satisfaction with mental health services.
PRiSM psychosis study. 8. British Journal of Psychiatry,
173, 409-415. doi:10.1192/bjp.173.5.409
[44] Fleury, M.J., Piat, M., Grenier, G., Bamvita, J.M., Boyer,
R., Lesage, A. and Tremblay, J. (2010) Components asso-
ciated with adequacy of help for consumers with severe
mental disorders. Administration and Policy in Mental
Health and Mental Health Services Research, 37, 497-
508. doi:10.1007/s10488-010-0292-1
[45] Song, L. and Singer, M. (2001) The social functioning of
persons with chronic mental illness: An empirical typol-
ogy of consumers and correlates of social functioning.
International Journal of Social Psychiatry, 47, 36-51.
[46] Carta, M.G., Balestrieri, M., Murru, A. and Hardoy, M.C.
(2009) Adjustment disorder: Epidemiology, diagnosis and
treatment. Clinical Practice and Epidemiology in Mental
Health, 5, 15. doi:10.1186/1745-0179-5-15
[47] Jones, R., Yates, W.R., Williams, S., Zhou, M. and Hardman,
L. (1999) Outcome for adjustment disorder with depressed
mood: Comparison with other mood disorders. Journal of
Affective Disord ers, 55, 55-61.
[48] Casey, P. (2001) Adult adjustment disorder: A review of
its current diagnostic status. Journal of Psychiatric Prac-
tice, 7, 32-40. doi:10.1097/00131746-200101000-00004
[49] Nyer, M., Kascow, J., Fellows, I., Lawrence, E.C., Gol-
shan, S., Solorzano, E. and Zisook, S. (2010) The rela-
tionship of marital status and clinical characteristics in
middle-aged and older patients with schizophrenia and
depressive symptoms. Annals of Clinical Psychiatry, 22,
[50] Drake, R.E., Goldman, H.H., Leff, H.S., Lehman, F., Dixon,
L., Mueser, K.T. and Torrey, W.C. (2001) Implementing
evidence-based practices in routine mental health service
settings. Psychiatric Services, 52, 903-910.
[51] Holmes, A.M. and Deb, P. (1998) Factors influencing in-
formal care-giving. Journal of Mental Health Policy and
Economics, 1, 77-87.
[52] Ruggeri, M., Dall’Agnola, C., Agostini, C. and Bisoffi, G.
(1994) Acceptability, sensitivity and content validity of
Copyright © 2013 SciRes. OPEN ACCESS
M.-J. Fleury et al. / Health 5 (2013) 200-211
Copyright © 2013 SciRes. OPEN ACCESS
the VESC and VSSS in measuring expectations and sat-
isfaction in psychiatric patient and their relatives. Social
Psychiatry and Psychiatric Epidemiology, 29, 265-276.
[53] Doornbos, M.M. (2002) Family caregivers and the mental
health care system: Reality and dreams. Archives of Psy-
chatric Nursing, 16, 39-46. doi:10.1053/apnu.2002.30541
[54] Perreault, M., Tardif, H., Provencher, H., Paquin, G., Des-
marais, J. and Pawliuk, N. (2005) The role of relatives in
discharge planning from psychiatric hospitals: The per-
spective of patients and their relatives. Psychiatric Quar-
terly, 76, 297-315. doi:10.1007/s11126-005-4964-z
[55] Jeon, Y.H., Brodaty, H. and Chesterson, J. (2005) Respite
care for caregivers and people with severe mental illness:
Literature review. Journal of Advanced Nursing, 49, 297-
306. doi:10.1111/j.1365-2648.2004.03287.x