Universal Coverage without Universal Access: Institutional Barriers to Health Care among Women Sex Workers in Vancouver, Canada

Background

Access to health care is a crucial determinant of health. Yet, even within settings that purport to provide universal health coverage (UHC), sex workers’ experiences reveal systematic, institutionally ingrained barriers to appropriate quality health care. The aim of this study was to assess prevalence and correlates of institutional barriers to care among sex workers in a setting with UHC.

Methods

Data was drawn from an ongoing community-based, prospective cohort of women sex workers in Vancouver, Canada (An Evaluation of Sex Workers’ Health Access). Multivariable logistic regression analyses, using generalized estimating equations (GEE), were employed to longitudinally investigate correlates of institutional barriers to care over a 44-month follow-up period (January 2010-August 2013).

Results

In total, 723 sex workers were included, contributing to 2506 observations. Over the study period, 509 (70.4%) women reported one or more institutional barriers to care. The most commonly reported institutional barriers to care were long wait times (54.6%), limited hours of operation (36.5%), and perceived disrespect by health care providers (26.1%). In multivariable GEE analyses, recent partner- (adjusted odds ratio [AOR] = 1.46, % 95% Confidence Interval [CI] 1.10–1.94), workplace- (AOR = 1.31, 95% CI 1.05–1.63), and community-level violence (AOR = 1.41, 95% CI 1.04–1.92), as well as other markers of vulnerability, such as self-identification as a gender/sexual minority (AOR = 1.32, 95% CI 1.03–1.69), a mental illness diagnosis (AOR = 1.66, 95% CI 1.34–2.06), and lack of provincial health insurance card (AOR = 3.47, 95% CI 1.59–7.57) emerged as independent correlates of institutional barriers to health services.

Discussion

Despite Canada’s UHC, women sex workers in Vancouver face high prevalence of institutional barriers to care, with highest burden among most marginalized women. These findings underscore the need to explore new models of care, alongside broader policy changes to fulfill sex workers’ health and human rights.

Below: Frequency of institutional-level barriers to health care among sex workers in Vancouver, Canada, 2010–2013

Full article at:   http://goo.gl/2p7VoO

By: 

M. Eugenia Socías, Paul Nguyen, Julio Montaner, Kate Shannon 
British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC, Canada

M. Eugenia Socías, Julio Montaner, Kate Shannon 

Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, BC, Canada

Jean Shoveller 

School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada

Chili Bean

Sex Workers United Against Violence Society, Vancouver, BC, Canada

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Psychiatric hospital beds per 100 000 inhabitants from 1990 to 2012, Western Europe

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How has the extent of institutional mental healthcare changed in Western Europe? Analysis of data since 1990.

Chow WS¹, Priebe S¹.

¹Unit for Social and Community Psychiatry (WHO Collaborating Centre for Mental Health Services Development), Queen Mary University of London, London, UK.

BMJ Open. 2016 Apr 29;6(4):e010188. doi: 10.1136/bmjopen-2015-010188.

Homicide-suicide and the role of mental disorder: A national consecutive case series

PURPOSE:

There is a lack of robust empirical research examining mental disorder and homicide-suicide. Primary care medical records are seldom used in homicide-suicide research. The aims of this study were to describe the characteristics of offenders and victims; determine the prevalence of mental disorder and contact with mental health services and examine adverse events prior to the offence.

METHODS:

This was a mixed-methods study based on a consecutive case series of offences in England and Wales occurring between 2006 and 2008. 60 homicide-suicides were recorded. Data sources included coroner's records, police files, General Practice (GP) and specialist mental health records, and newspaper articles.

RESULTS:

The results show that most victims were spouse/partners and/or children. Most perpetrators were male (88 %) and most victims were female (77 %). The incidents were commonly preceded by relationship breakdown and separation. 62 % had mental health problems. A quarter visited a GP for emotional distress within a month of the incident. Few had been in recent contact with mental health services before the incident (12 %). Self-harm (26 %) and domestic violence (39 %) were common.

CONCLUSION:

In conclusion, GPs cannot be expected to prevent homicide-suicide directly, but they can reduce risk generally, via the treatment of depression and recognising the risks associated with domestic violence.

Full article at:   http://goo.gl/DwrChG

By:   Flynn S1, Gask L2, Appleby L3, Shaw J3.

• 1The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Mental Health and Safety, Institute of Brain Behaviour and Mental Health, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK. sandra.m.flynn@manchester.ac.uk.
• 2Institute of Population Health, University of Manchester, Williamson Building, Oxford Road, Manchester, M13 9PL, UK.
• 3The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Mental Health and Safety, Institute of Brain Behaviour and Mental Health, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK. 
• Soc Psychiatry Psychiatr Epidemiol. 2016 Apr 16.

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Impact of Mental Health and Substance Use Disorders on Emergency Department Visit Outcomes for HIV Patients

INTRODUCTION:

A disproportionate number of individuals with human immunodeficiency virus (HIV) have mental health and substance-use disorders (MHSUDs), and MHSUDs are significantly associated with their emergency department (ED) visits. With an increasing share of older adults among HIV patients, this study investigated the associations of MHSUDs with ED outcomes of HIV patients in four age groups: 21-34, 35-49, 50-64, and 65+ years.

METHODS:

We used the 2012 Nationwide Emergency Department Sample (NEDS) dataset (unweighted n=23,244,819 ED events by patients aged 21+, including 115,656 visits by patients with HIV). Multinomial and binary logistic regression analyses, with "treat-and-release" as the base outcome, were used to examine associations between ED outcomes and MHSUDs among visits that included a HIV diagnosis in each age group.

RESULTS:

• Mood and "other" mental disorders had small effects on ED-to-hospital admissions, as opposed to treat-and-release, in age groups younger than 65+ years, while suicide attempts had medium effects . 
• Cognitive disorders had medium-to-large effects on hospital admissions in all age groups and large effects on death in the 35-49 age groups. 
• Alcohol use disorders (AUDs) had small effects on hospital admission in all age groups. 
• Drug use disorders (DUDs) had small-to-medium effects on hospital admission. AUDs and DUDs were also significantly related to the risk of death, and DUDs had a small effect on the risk of discharge against medical advice in the 35-49 and 50-64 age groups.

CONCLUSION:

The high prevalence of MHSUDs and their significant roles in ED visit outcomes in patients with HIV provide support for integrated care for these patients outside the ED to reduce their ED visits and costly hospital admissions and institutional care that follows, especially for the increasing numbers of older adults with HIV.

Full article at:   http://goo.gl/3tf6pP

By:  Choi BY1, DiNitto DM2, Marti CN2, Choi NG2.

• 1Warren Alpert Medical School at Brown Univeristy and Rhode Island Hospital, Department of Emergency Medicine, Providence, Rhode Island.
• 2The University of Texas at Austin, School of Social Work, Austin, Texas. 
• West J Emerg Med. 2016 Mar;17(2):153-64. doi: 10.5811/westjem.2016.1.28310. Epub 2016 Mar 2.

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A Longitudinal Study of Mental Health Symptoms in Young Prisoners: Exploring the Influence Of Personal Factors & the Correctional Climate

BACKGROUND:

Despite the high prevalence rate of mental health problems among young prisoners, little is known about the longitudinal course and covariates of their mental health symptoms during incarceration, especially the influence of the correctional climate. The current study aimed: (1) to examine changes in young prisoners' mental health symptoms during incarceration, (2) to identify personal factors associated with their mental health symptoms and perceptions of the correctional climate, and (3) to test the incremental effect of perceptions of the correctional climate on mental health symptoms.

METHODS:

Data were obtained from a sample of 75 youths (aged 17 to 22 years) detained in a Portuguese young offender prison. Data were gathered 1, 3, and 6 months after their admission in this facility. Socio-demographic, clinical and criminological variables were collected. Mental health symptoms and perceptions of the correctional climate were assessed through self-report assessment tools. Linear and logistic (multi-level) regressions and tests for differences between means were performed to analyze the data.

RESULTS:

Overall, mental health symptoms marginally declined by the sixth month in prison. Prisoners with a history of mental health treatment were more likely to have increased symptoms. Higher levels of mental health symptoms were associated with a history of mental health treatment, remand status, and a lower educational level. Better perceptions of the correctional climate were associated with Black race and participation in prison activities. A negative perception of the correctional climate was the strongest covariate of young prisoners' mental health symptoms and had incremental validity over that of personal variables.

CONCLUSIONS:

The results highlight that both characteristics of the prisoners and of the prison environment influence young prisoners' mental health. Prison management can try to reduce young prisoners' mental health problems by developing scientific procedures for their mental health assessment and creating a more beneficial correctional climate.

Level and Changes in Mental Health Symptoms over Time in Prison

	Month 1 (n = 70)	Month 3 (n = 58)	Month 6 (n = 49)
BSI Subscale	Mean (SD)	Mean (SD)	Mean (SD)	Mean difference/Contrast
Somatizationa	0.76 (0.82)	0.75 (0.74)	0.62 (0.70)	χ 2 = 6.70*
				M6 vs. M3*
Obsessive-compulsive	1.21 (0.70)	1.26 (0.81)	1.06 (0.78)	χ 2 = 6.97*
				M6 vs. M3*
Interpersonal sensitivitya	1.04 (0.83)	1.09 (0.77)	0.97 (0.86)	ns
Depression	1.28 (0.78)	1.26 (0.86)	1.12 (0.83)	ns
Anxietya	0.93 (0.79)	0.86 (0.72)	0.77 (0.71)	ns
Hostilitya	0.96 (0.69)	0.99 (0.89)	0.93 (0.74)	ns
Phobic anxietya	0.68 (0.67)	0.63 (0.67)	0.52 (0.65)	χ 2 = 5.88†
				M6 vs. M1†
Paranoid ideationa	1.25 (0.69)	1.34 (0.88)	1.31 (0.85)	ns
Psychoticisma	1.09 (0.78)	1.10 (0.77)	1.07 (0.89)	ns
GSIa	1.04 (0.63)	1.03 (0.65)	0.93 (0.65)	χ 2 = 5.87†
				M6 vs. M3†

Note. SD Standard deviation, M1 Month 1, M3 Month 3, M6 Month 6, ns not significant, BSI Brief Symptom Inventory, GSI Global Severity Index

a Distribution normalized through square root transformation. Descriptive statistics are based on the original data. Mean differences analyses are based on the transformed variables

† p < .10, * p < .05, two-tailed

Full article at:   http://goo.gl/FbBGHB

By:  Gonçalves LC1, Endrass J2,3, Rossegger A1,4, Dirkzwager AJ5.

• 1Department of Mental Health Services, Office of Corrections, Canton of Zurich, Hohlstrasse 552, P.O. Box 8090, Zurich, Switzerland.
• 2Department of Mental Health Services, Office of Corrections, Canton of Zurich, Hohlstrasse 552, P.O. Box 8090, Zurich, Switzerland. Jerome.Endrass@uni-konstanz.de.
• 3Department of Psychology, University of Konstanz, Universitätsstrasse 10, 78464, Konstanz, Germany. Jerome.Endrass@uni-konstanz.de.
• 4Department of Psychology, University of Konstanz, Universitätsstrasse 10, 78464, Konstanz, Germany.
• 5Netherlands Institute for the Study of Crime and Law Enforcement, 71304, 1008 BH, Amsterdam, Netherlands. 
• BMC Psychiatry. 2016 Apr 6;16(1):91. doi: 10.1186/s12888-016-0803-z.

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The Use of a Brief Mental Health Screener to Enhance the Ability of Police Officers to Identify Persons with Serious Mental Disorders

Police agencies in Canada and elsewhere have received much criticism over how they respond to persons with serious mental disorders. The adequacy of training provided to police officers on mental health issues and in particular on recognizing indicators of serious mental disorders has been a major concern. 

This paper describes the process that led to the development of a new brief mental health screener (interRAI Brief Mental Health Screener, BMHS) designed to assist police officers to better identify persons with serious mental disorders. The interRAI BMHS was developed in collaboration with interRAI, an international, not-for-profit consortium of researchers. The government of Ontario had previously partnered with interRAI to develop and implement the Resident Assessment Instrument for Mental Health (RAI-MH), the assessment system mandated for use on all persons admitted into inpatient psychiatric care in the province. Core items on the interRAI BMHS were obtained through analysis (N=41,019) of RAI-MH data together with input from representatives from health care, police services, and patient groups. 

Two police services in southwestern Ontario completed forms (N=235) on persons thought to have a mental disorder. Patient records were later accessed to determine patient disposition. The use of summary and inferential statistics revealed that the variables significantly associated with being taken to hospital by police included performing a self-injurious act in the past 30days, and others being concerned over the person's risk for self-injury. Variables significantly associated with being admitted included abnormal thought process, delusions, and hallucinations. 

The results of the study indicate that the 14-variable algorithm used to construct the interRAI BMHS is a good predictor of who was most likely to be taken to hospital by police officers and who was most likely to be admitted. The instrument is an effective means of capturing and standardizing police officer observations enabling them to provide more and better quality information to emergency department (ED) staff. 

Teaching police officers to use the form constitutes enhanced training on major indicators of serious mental disorders. Further, given that items on the interRAI BMHS are written in the language of the health system, language acts as common currency between police officers and ED staff laying the foundation for a more collaborative approach between the systems.

Full article at:   http://goo.gl/4FA5EB

By:  Hoffman R1, Hirdes J2, Brown GP3, Dubin JA4, Barbaree H5.

• 1Ministry of Community Safety and Correctional Services, Ontario Police College, 10716 Hacienda Road, Aylmer, Ontario N5H 2T2, Canada; Faculty of Applied and Professional Studies, School of Criminology and Criminal Justice, Nipissing University, 100 College Drive, Box 5002, North Bay, Ontario P1B 8L, Canada. Electronic address: Ron.Hoffman@sympatico.ca.
• 2School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada.
• 3Faculty of Applied and Professional Studies, School of Criminology and Criminal Justice, Nipissing University, 100 College Drive, Box 5002, North Bay, Ontario P1B 8L7, Canada.
• 4Department of Statistics and Actuarial Science, School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada.
• 5Division of Forensic Psychiatry, Department of Psychiatry, University of Toronto, Toronto, Ontario M5T 1R, Canada; Waypoint Centre for Mental Health Care, 500 Church Street, Penetanguishene, Ontario L9M 1G3, Canada. 
• Int J Law Psychiatry. 2016 Apr 1. pii: S0160-2527(16)30044-9. doi: 10.1016/j.ijlp.2016.02.031.

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Recidivism Following Mental Health Court Exit: Between & Within-Group Comparisons

Over the past decade, Mental Health Courts (MHCs) have spread rapidly across the U.S. These courts aim to reduce recidivism among adults with mental illnesses through diversion into community-based treatment. 

Extant research suggests that MHCs can be effective in reducing recidivism, but also demonstrates that effectiveness varies as a function of characteristics of the participants (e.g., criminal history) and the program (e.g., coercion). Less is known regarding the extent to which process-related factors (e.g., length of participation, time between referral and receipt of services) impact effectiveness. 

Prior research also is limited by a focus on recidivism during MHC as opposed to postexit. To address these knowledge gaps, we examined recidivism 1 year postexit for a group of MHC participants (n = 57) and offenders receiving treatment as usual (TAU; n = 40), total N = 97. We also investigated the influence of individual characteristics and process factors on changes in jail days 1 year preentry to 1 year postexit for MHC participants. 

Overall, results provide some evidence supporting the effectiveness of MHCs. MHC participants had significantly fewer jail days, but not charges or convictions, relative to TAU participants. Among MHC participants, graduation from the MHC, presence of co-occurring substance use, and longer length of MHC participation were associated with greater reductions in jail days. Other process factors were unrelated to reductions in recidivism. 

Findings suggest that MHCs may be particularly effective for high-risk participants and that time spent in a MHC has positive effects on recidivism, regardless of graduation status.

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By:  Lowder EM1, Desmarais SL1, Baucom DJ1.

• 1Department of Psychology, North Carolina State University. 
• Law Hum Behav. 2016 Apr;40(2):118-27. doi: 10.1037/lhb0000168. Epub 2015 Nov 23.

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Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: A retrospective, descriptive study

Objectives

To identify patterns in euthanasia requests and practices relating to psychiatric patients; to generate recommendations for future research.

Design

Retrospective analysis of data obtained through medical file review.

Setting

Outpatient psychiatric clinical setting in the Dutch-speaking region of Belgium, between October 2007 and December 2011; follow-up at the end of December 2012.

Participants

100 consecutive psychiatric patients requesting euthanasia based on psychological suffering associated with psychiatric disorders (77 women, 23 men; mean age 47 years; age range 21–80 years).

Main outcome measures

Patient sociodemographic characteristics; diagnoses; decisions on euthanasia requests; circumstances of euthanasia procedures; patient outcomes at follow-up.

Results

Most patients had been referred for psychiatric counselling by their physician (n=55) or by LEIF (Life End Information Forum) (n=36). 90 patients had >1 disorder; the most frequent diagnoses were depression (n=58) and personality disorder (n=50). 38 patients required further testing and/or treatment, including 13 specifically tested for autism spectrum disorder (ASD); 12 received an ASD diagnosis (all Asperger syndrome). In total, 48 of the euthanasia requests were accepted and 35 were carried out. Of the 13 remaining patients whose requests were accepted, 8 postponed or cancelled the procedure, because simply having this option gave them enough peace of mind to continue living. In December 2012, 43 patients had died, including 35 by euthanasia; others died by suicide (6), palliative sedation (1) and anorexia nervosa (1).

Conclusions

Depression and personality disorders are the most common diagnoses in psychiatric patients requesting euthanasia, with Asperger syndrome representing a neglected disease burden. Further research is needed, especially prospective quantitative and qualitative studies, to obtain a better understanding of patients with psychiatric disorders who request euthanasia due to unbearable psychological suffering.

Below:  Frequency of age in 100 psychiatric patients who requested euthanasia, by gender

Full article at:   http://goo.gl/6fSQex

By:  Lieve Thienpont,1 Monica Verhofstadt,2 Tony Van Loon,3 Wim Distelmans,3 Kurt Audenaert,4 and Peter P De Deyn5,6,7

¹University Hospital Brussels, Brussels, Belgium

2MSc student at the Open University of the Netherlands, Heerlen, The Netherlands

3Free University of Brussels, Brussels, Belgium

4Department of Psychiatry, Ghent University Hospital, Ghent, Belgium

5University of Antwerp, Institute Born-Bunge, Wilrijk, Belgium

6University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

7

²MSc student at the Open University of the Netherlands, Heerlen, The Netherlands

³Free University of Brussels, Brussels, Belgium

⁴Department of Psychiatry, Ghent University Hospital, Ghent, Belgium

⁵University of Antwerp, Institute Born-Bunge, Wilrijk, Belgium

⁶University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

⁷Middelheim General Hospital, ZNA, Antwerp, Belgium

1University Hospital Brussels, Brussels, Belgium

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Depression & HIV Risk among Men Who Have Sex with Men in Tanzania

Studies have shown high rates of depression among men who have sex with men (MSM) in developed countries. Studies have also shown association between depression and HIV risk among MSM. However, very little research has been done on depression among African MSM. 

We assessed depression and HIV risk among a sample of MSM in Tanzania. We reviewed data on 205 MSM who were recruited from two Tanzanian cities using the respondent driven sampling method. Demographic and behavioral data were collected using a structured questionnaire. HIV and sexually transmitted infections data were determined from biological tests. Depression scores were assessed using the Patient Health Questionnaire (PHQ-9). For the analysis, depression scores were dichotomized as depressed (PHQ > 4) and not depressed (PHQ ≤ 4). Bivariate and multivariable Poisson regression analyses were conducted to assess factors associated with depression. 

The prevalence of depression in the sample was 46.3%. The mean (±SD) age of the sample was 25 (±5) years. In bivariate analysis, depression was associated with self-identifying as gay (p = .001), being HIV positive (p < .001: <8% of MSM knew they were HIV infected) and having a high number of sexual partners in the last 6 months (p = .001). 

Depression was also associated with sexual (p = .007), physical (p = .003) and verbal (p < .001) abuse. In the Poisson regression analysis, depression was associated with verbal abuse (APR = 1.91, CI = 1.30-2.81). Depression rates were high among MSM in Tanzania. It is also associated with abuse, HIV and HIV risk behaviors. Thus, reducing the risk of depression may be helpful in reducing the risk of HIV among MSM in Africa. 

We recommend the colocation of mental health and HIV preventive services as a cost-effective means of addressing both depression and HIV risk among MSM in Africa.

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By:  Ahaneku H1, Ross MW2, Nyoni JE3, Selwyn B1, Troisi C4, Mbwambo J5, Adeboye A6, McCurdy S6.

• 1 Department of Epidemiology, Human Genetics and Environmental Sciences , The University of Texas School of Public Health , Houston , TX , USA.
• 2 Department of Family Medicine and Community Health , University of Minnesota , Minneapolis , MN , USA.
• 3 Department of Sociology and Anthropology , University of Dar es Salaam , Dar es Salaam , Tanzania.
• 4 Department of Management, Policy and Community Health , The University of Texas School of Public Health , Houston , TX , USA.
• 5 Department of Psychiatry , Muhimbili University of Health Sciences , Dar es Salaam , Tanzania.
• 6 Department of Health Promotion and Behavioral Sciences , The University of Texas School of Public Health , Houston , TX , USA
• AIDS Care. 2016 Mar;28 Suppl 1:140-7. doi: 10.1080/09540121.2016.1146207. 

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Sexual Orientation & Symptoms of Common Mental Disorder or Low Wellbeing: Combined Meta-Analysis of 12 UK Population Health Surveys

BACKGROUND:

Previous studies have indicated increased risk of mental disorder symptoms, suicide and substance misuse in lesbian, gay and bisexual (LGB) adults, compared to heterosexual adults. Our aims were to determine an estimate of the association between sexual orientation identity and poor mental health and wellbeing among adults from 12 population surveys in the UK, and to consider whether effects differed for specific subgroups of the population.

METHODS:

Individual data were pooled from the British Cohort Study 2012, Health Survey for England 2011, 2012 and 2013, Scottish Health Survey 2008 to 2013, Longitudinal Study of Young People in England 2009/10 and Understanding Society 2011/12. Individual participant meta-analysis was used to pool estimates from each study, allowing for between-study variation.

RESULTS:

Of 94,818 participants, 1.1 % identified as lesbian/gay, 0.9 % as bisexual, 0.8 % as 'other' and 97.2 % as heterosexual. Adjusting for a range of covariates, adults who identified as lesbian/gay had higher prevalence of common mental disorder when compared to heterosexuals, but the association was different in different age groups: apparent for those under 35 (OR = 1.78, 95 % CI 1.40, 2.26), weaker at age 35-54.9 (OR = 1.42, 95 % CI 1.10, 1.84), but strongest at age 55+ (OR = 2.06, 95 % CI 1.29, 3.31). These effects were stronger for bisexual adults, similar for those identifying as 'other', and similar for 'low wellbeing'.

CONCLUSIONS:

In the UK, LGB adults have higher prevalence of poor mental health and low wellbeing when compared to heterosexuals, particularly younger and older LGB adults. Sexual orientation identity should be measured routinely in all health studies and in administrative data in the UK in order to influence national and local policy development and service delivery. These results reiterate the need for local government, NHS providers and public health policy makers to consider how to address inequalities in mental health among these minority groups.

• Adults identifying as lesbian, gay, bisexual or ‘other’ are at increased risk of poor mental health and low wellbeing compared to those identifying as heterosexual.
• The association varies across the life course, with the lowest relative risks seen in midlife and the highest among older adults
• Our study used cross-sectional data suitable for estimating prevalence, but future studies should consider longitudinal patterns (such as onset and persistence of new mental health problems) and clarify mechanisms

Full article at:  http://goo.gl/c6MrVB

By:  Semlyen J1, King M2, Varney J3, Hagger-Johnson G4.

• 1Department of Psychology, London Metropolitan University, London, UK.
• 2Division of Psychiatry, UCL, London, UK.
• 3Public Health England, London, UK.
• 4Administrative Data Research Centre for England (ADRC-E), Farr Institute, UCL, London, NW1 2DA, UK. G.Hagger-Johnson@ucl.ac.uk.
• BMC Psychiatry. 2016 Mar 24;16(1):67. doi: 10.1186/s12888-016-0767-z. 

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