Places in protecting housing 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.

Forensic 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.

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.

Mental Health and Medical Health Disparities in 5135 Transgender Veterans Receiving Healthcare in the Veterans Health Administration: A Case-Control Study

PURPOSE:

There are no large controlled studies of health disparities in transgender (TG) or gender dysphoric patients. The Veterans Health Administration (VHA) is the largest healthcare system in the United States and was an early adopter of electronic health records. We sought to determine whether medical and/or mental health disparities exist in VHA for clinically diagnosed TG veterans compared to matched veterans without a clinical diagnosis consistent with TG status.

METHODS:

Using four ICD-9-CM codes consistent with TG identification, a cohort of 5135 TG veterans treated in VHA between 1996 and 2013 was identified. Veterans without one of these diagnoses were matched 1:3 in a case-control design to determine if medical and/or mental health disparities exist in the TG veteran population.

RESULTS:

In 2013, the prevalence of TG veterans with a qualifying clinical diagnosis was 58/100,000 patients. Statistically significant disparities were present in the TG cohort for all 10 mental health conditions examined, including depression, suicidality, serious mental illnesses, and post-traumatic stress disorder. TG Veterans were more likely to have been homeless, to have reported sexual trauma while on active duty, and to have been incarcerated. Significant disparities in the prevalence of medical diagnoses for TG veterans were also detected for 16/17 diagnoses examined, with HIV disease representing the largest disparity between groups.

CONCLUSION:

This is the first study to examine a large cohort of clinically diagnosed TG patients for psychiatric and medical health outcome disparities using longitudinal, retrospective medical chart data with a matched control group. TG veterans were found to have global disparities in psychiatric and medical diagnoses compared to matched non-TG veterans. These findings have significant implications for policy, healthcare screening, and service delivery in VHA and potentially other healthcare systems.

Purchase full article at:   http://goo.gl/yZCiKY

By:  Brown GR1,2, Jones KT3.

• 1 Psychiatry Service, Mountain Home Veterans Affairs Medical Center , Johnson City, Tennessee.
• 2 Department of Psychiatry and Behavioral Sciences, Quillen College of Medicine, East Tennessee State University , Johnson City, Tennessee.
• 3 Office of Health Equity , Veterans Health Administration, Washington, District of Columbia.
• LGBT Health. 2016 Apr;3(2):122-31. doi: 10.1089/lgbt.2015.0058. Epub 2015 Dec 16. 

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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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Criminal Justice System Contact & Mortality among Offenders with Mental Illness in British Columbia

BACKGROUND:

Persons with mental illness are over-represented in prison populations around the world. They are more vulnerable to arrest and more likely to experience repeated encounters with the criminal justice system. Whether criminal justice involvement, in and of itself, is associated with higher mortality, particularly among offenders with mental illness, is unknown.

METHODS:

The authors conducted a mediation analysis of mortality rates in a cohort of 79,088 offenders from British Columbia using administrative records spanning 2001-2010, where the mediating variable was the individual-level rate of criminal sentencing.

RESULTS:

During 339,506 person-years of follow-up, there were 1841 deaths. The diagnosis of mental illness had no direct association with higher mortality after adjustment for confounders (HR=0.98, 95% CI 0.86 to 1.06). However, mental illness had an indirect association with mortality that was mediated through more frequent criminal justice involvement (HR=1.02, 95% CI 1.01 to 1.04).

CONCLUSIONS:

These findings support the hypothesis that offenders with mental illness experience higher mortality that is mediated by higher rates of criminal justice contact. The results of our study indicate that criminal justice diversion programmes are further warranted because they may contribute to the prevention of mortality among offenders with mental illness.

Purchase full article at:   http://goo.gl/QheVNV

By:  McCandless LC1, Stewart LC1, Rempel ES1, Venners SA1, Somers JM1.

• 1Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada. 

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Accuracy of Reported Service Use in a Cohort of People Who Are Chronically Homeless & Seriously Mentally Ill

Background

Self-reported service use is an integral feature of interventional research with people who are homeless and mentally ill. The objective of this study was to investigate the accuracy of self-reported involvement with major categories of publicly funded services (health, justice, social welfare) within this sub-population.

Methods

Measures were administered pre-randomization in two randomized controlled trials, using timeline follow back with calendar aids for Health, Social, and Justice Service Use, compared to linked administrative data. Variables examined were: psychiatric admissions (both extended stays of more than 6 months and two or more stays within 5 years); emergency department visits, general hospitalization and jail in the past 6 months; and income assistance in the past 1 month. Participants (n = 433) met criteria for homelessness and a least one mental illness.

Results

Prevalence adjusted and bias adjusted kappa (PABAK) values ranged between moderate and almost perfect for extended psychiatric hospital separations, multiple psychiatric hospitalizations, emergency department visits, jail, and income assistance. Significant differences in under versus over reporting were also found.

Conclusions

People who are homeless and mentally ill reliably reported their overall use of health, justice, and income assistance services. Evidence of under-reporting and over-reporting of certain variables has implications for specific research questions.

Full article at:   http://goo.gl/ROq2xv

By:  Julian M. Somers, Akm Moniruzzaman, Lauren Currie, Stefanie N. Rezansoff, Angela Russolillo, and Milad Parpouchi

Somers Research Group, Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada

Julian M. Somers, Email: ac.ufs@sremosj.

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Trajectories of Recovery among Formerly Homeless Adults with Serious Mental Illness

OBJECTIVE:

Recovery from mental illness is possible, but individuals with co-occurring disorders and homelessness face challenges. Although a nonlinear recovery course is assumed, few studies have analyzed recovery over time. This mixed-methods study examined recovery trajectories over 18 months after enrollment in supportive housing programs of 38 participants with DSM axis I diagnoses.

METHODS:

Qualitative interview data were quantified through consensual ratings to generate a recovery score for four waves of data collection based on eight recovery domains culled from the literature. Case study analyses were conducted of participants whose scores varied by one standard deviation or more between baseline and 18 months to identify which domains were important.

RESULTS:

Most of the 38 participants (N=23) had no significant change in recovery; seven had a negative trajectory, and eight had a positive trajectory. Case studies of these 15 participants indicated domains that contributed to change: significant-other relationships (N=9), engagement in meaningful activities (N=9), mental health (N=7), family relationships (N=6), general medical health (N=5), housing satisfaction (N=5), employment (N=2), and substance use (N=1). Except for mental health and substance use (which contributed only to negative trajectories), the influence of domains was both positive and negative. Domains were intertwined; for example, variation in relationships was linked to changes in meaningful activities.

CONCLUSIONS:

This study showed little change in recovery over time for most participants and a decline in mental health for a small minority. Findings underscore the importance of social relationships and meaningful activities among individuals with serious mental illness, who experience complex challenges.

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By:  Padgett DK1, Smith BT1, Choy-Brown M1, Tiderington E1, Mercado M1.

• 1Dr. Padgett, Ms. Choy-Brown, and Dr. Mercado are with the Silver School of Social Work, New York University, New York City (e-mail: dkp1@nyu.edu ). Ms. Smith is with the School of Social Service Administration, University of Chicago, Chicago, Illinois. Dr. Tiderington is with the School of Social Work, Rutgers University, New Brunswick, New Jersey. 
• Psychiatr Serv. 2016 Feb 14:appips201500126. 

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From Punishment to Treatment: The "Clinical Alternative to Punitive Segregation" (CAPS) Program in New York City Jails

The proliferation of jails and prisons as places of institutionalization for persons with serious mental illness (SMI) has resulted in many of these patients receiving jail-based punishments, including solitary confinement. 

Starting in 2013, the New York City (NYC) jail system developed a new treatment unit for persons with SMI who were judged to have violated jail rules (and previously would have been punished with solitary confinement) called the Clinical Alternative to Punitive Segregation (CAPS) unit. CAPS is designed to offer a full range of therapeutic activities and interventions for these patients, including individual and group therapy, art therapy, medication counseling and community meetings. 

Each CAPS unit requires approximately $1.5 million more investment per year, largely in additional staff as compared to existing mental health units, and can house approximately 30 patients. Patients with less serious mental illness who received infractions were housed on units that combined solitary confinement with some clinical programming, called Restrictive Housing Units (RHU). 

Between 1 December 2013 and 31 March 2015, a total of 195 and 1433 patients passed through the CAPS and RHU units, respectively. A small cohort of patients experienced both CAPS and RHU (n = 90). For these patients, their rates of self-harm and injury were significantly lower while on the CAPS unit than when on the RHU units. Improvements in clinical outcomes are possible for incarcerated patients with mental illness with investment in new alternatives to solitary confinement. We have started to adapt the CAPS approach to existing mental health units as a means to promote better clinical outcomes and also help prevent jail-based infractions. 

The cost of these programs and the dramatic differences in length of stay for patients who earn these jail-based infractions highlight the need for alternatives to incarceration, some of which have recently been announced in NYC.

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

By:  Glowa-Kollisch S1, Kaba F2, Waters A3, Leung YJ4, Ford E5, Venters H6.

• 1Correctional Health Services, New York City Health + Hospitals, New York, NY 11101, USA. sglowakollisch@nychhc.org.
• 2Correctional Health Services, New York City Health + Hospitals, New York, NY 11101, USA. fkaba@nychhc.org.
• 3Correctional Health Services, New York City Health + Hospitals, New York, NY 11101, USA. awaters1@nychhc.org.
• 4Correctional Health Services, New York City Health + Hospitals, New York, NY 11101, USA. yleung2@nychhc.org.
• 5Correctional Health Services, New York City Health + Hospitals, New York, NY 11101, USA. eford@nychhc.org.
• 6Correctional Health Services, New York City Health + Hospitals, New York, NY 11101, USA. hventer1@nychhc.org. 
• Int J Environ Res Public Health. 2016 Feb 2;13(2). pii: E182. doi: 10.3390/ijerph13020182

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Among Inpatients, Posttraumatic Stress Disorder Symptom Severity Is Negatively Associated with Time Spent Walking

This study aimed to determine whether posttraumatic stress disorder (PTSD) symptom severity and psychological and functional variables were associated with physical activity (PA) upon admission to an inpatient facility. 

PTSD symptoms, depression, anxiety and stress, sleep quality, and PA participation were assessed among 76 participants (age, 47.6 ± 11.9 years; 83% male). Backward stepwise regression analyses identified variables independently associated with time spent walking and engaging in moderate-vigorous PA (MVPA). No significant correlations were found between any of the variables and MVPA. Total PTSD symptoms (r = -0.39, p < 0.001), combined symptoms of depression, anxiety, and stress (r = -0.31, p < 0.01), and sleep behavior (r = -0.24, p < 0.05) were significantly and negatively associated with total walking time. Total PTSD symptoms were the only significant predictor of walking time (B = -0.03, SE = 0.008, β = -0.4; t = -3.4; p < 0.001). 

Results indicate that increased PTSD symptoms are associated with lower levels of walking. Results highlight the importance of considering symptoms when designing PA programs for people with PTSD.

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By:  Rosenbaum S1, Vancampfort D, Tiedemann A, Stubbs B, Steel Z, Ward PB, Berle D, Sherrington C.

• 1*School of Psychiatry, University of New South Wales; †South Eastern Sydney Local Health District, Bondi Early Psychosis Programme, Sydney, NSW; ‡Musculoskeletal Division, The George Institute for Global Health and Sydney Medical School, The University of Sydney, Sydney, Australia; §UPC KU Leuven, campus Kortenberg, Department of Neurosciences, KU Leuven-University of Leuven, Kortenberg; ∥Department of Rehabilitation Sciences, KU Leuven-University of Leuven, Leuven, Belgium; ¶School of Health and Social Care, University of Greenwich, London, UK; #St John of God Health Care Richmond Hospital, North Richmond; **Black Dog Institute, NSW; and ††Schizophrenia Research Unit, South Western Sydney Local Health District, Sydney, Australia. 
• J Nerv Ment Dis. 2016 Jan;204(1):15-9. doi: 10.1097/NMD.0000000000000415.

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Killing the Mother of One's Child: Psychiatric Risk Factors among Male Perpetrators & Offspring Health Consequences

OBJECTIVE:

To study possible psychiatric and criminological risk factors of intimate partner femicide (IPF) as well as the bereaved offspring's psychiatric morbidity and premature death.

METHOD:

We conducted a nested case-control study, based on Swedish national registries, including all perpetrators of IPF. We computed risk estimates relative to matched population controls, which were compared to those of non-IPF homicide offenders. Exposed children were matched to population controls and followed longitudinally up to 37 years. Offspring outcomes were psychiatric and substance use disorders (according to ICD) self-harm; violent crime; suicide; and premature, all-cause death.

RESULTS:

We identified 261 male IPF perpetrators and 494 bereaved children from 1973 through 2009. Multivariable logistic regression suggested that major mental disorder  and violent crime convictions were independent risk factors of IPF, but substance use disorders were not. Children exposed to IPF before age 18 years had elevated risks of major mental disorder, substance use disorders and self-harm. Offspring 18 years or older at the IPF had an increased risk of completed suicide.

CONCLUSIONS:

Previous major mental disorder and violent behavior were strong independent risk factors for IPF. Bereavement caused by IPF had significant associations with the offspring's future life, especially for those below 18 years of age at exposure. Our findings demonstrate the need of direct support to the exposed offspring by health care providers and social services.

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

By:  Lysell H1, Dahlin M, Långström N, Lichtenstein P, Runeson B.

• 1Karolinska Institutet, Department of Clinical Neuroscience/Stockholm County Council, Centre for Psychiatry Research, St Göran's Hospital, SE-112 81 Stockholm, Sweden henrik.lysell@ki.se. 
• J Clin Psychiatry. 2016 Jan 5. 

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From Positive Screen to Engagement in Treatment: A Preliminary Study of ihe Impact of a New Model of Care for Prisoners with Serious Mental Illness

BACKGROUND:

The high prevalence of serious mental illness (SMI) in prisons remains a challenge for mental health services. Many prisoners with SMI do not receive care. Screening tools have been developed but better detection has not translated to higher rates of treatment. In New Zealand a Prison Model of Care (PMOC) was developed by forensic mental health and correctional services to address this challenge. The PMOC broadened triggers for referrals to mental health teams. Referrals were triaged by mental health nurses leading to multidisciplinary team assessment within specified timeframes. This pathway for screening, referral and assessment was introduced within existing resources.

METHOD:

The PMOC was implemented across four prisons. An AB research design was used to explore the extent to which mentally ill prisoners were referred to and accepted by prison in-reach mental health teams and to determine the proportion of prison population receiving specialist mental health care.

RESULTS:

The number of prisoners in the study in the year before the PMOC (n = 19,349) was similar to the year after (n = 19,421). 24.6 % of prisoners were screened as per the PMOC in the post period. Referrals increased from 491 to 734 in the post period (Z = -7.23, p < 0.0001). A greater number of triage assessments occurred after the introduction of the PMOC (pre = 458; post = 613, Z = 4.74, p < 0.0001) leading to a significant increase in the numbers accepted onto in-reach caseloads (pre = 338; post = 426, Z = 3.16, p < 0.01). Numbers of triage assessments completed within specified time frames showed no statistically significant difference before or after implementation. The proportion of prison population on in-reach caseloads increased from 5.6 % in the pre period to 7.0 % in the year post implementation while diagnostic patterns did not change, indicating more prisoners with SMI were identified and engaged in treatment.

CONCLUSIONS:

The PMOC led to increased prisoner numbers across screening, referral, treatment and engagement. Gains were achieved without extra resources by consistent processes and improved clarity of professional roles and tasks. The PMOC described a more effective pathway to specialist care for people with SMI entering prison.

Below:  The Prison Model of Care Referral and Treatment Pathway

Below:  Diagnostic cumulative composition of in-reach case load under treatment over 12 month study period

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By:  Pillai K1, Rouse P2, McKenna B3, Skipworth J4, Cavney J5, Tapsell R6, Simpson A7, Madell D8.

• 1Auckland Regional Forensic Psychiatry Services, Waitemata District Health Board, Auckland, New Zealand. Krishna.Pillai@waitematadhb.govt.nz.
• 2The University of Auckland, Auckland, New Zealand. p.rouse@auckland.ac.nz.
• 3Australian Catholic University and NorthWestern Mental Health, Level 1 North, City Campus, The Royal Melbourne Hospital, Grattan Street, Parkville, VIC, Australia, 3050. Brian.McKenna@mh.org.au.
• 4Auckland Regional Forensic Psychiatry Services, Waitemata District Health Board, Auckland, New Zealand. Jeremy.Skipworthi@waitematadhb.govt.nz.
• 5Auckland Regional Forensic Psychiatry Services, Waitemata District Health Board, Auckland, New Zealand. James.Cavney@waitematadhb.govt.nz.
• 6Midlands Regional Forensic Psychiatric Service, Waikato District Health Board, Hamilton, New Zealand. Rees.Tapsell@waikatodhb.health.nz.
• 7Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada. Sandy.Simpson@camh.ca.
• 8The University of Auckland, Auckland, New Zealand. Dominic.Madell@middlemore.co.nz.
• BMC Psychiatry. 2016 Jan 15;16(1):9. doi: 10.1186/s12888-016-0711-2.

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