The mental health system in Brazil: Policies and future challenges

Background

The aim of this paper is to assess the mental health system in Brazil in relation to the human resources and the services available to the population.

Methods

The World Health Organization Assessment Instrument for Mental Health Systems (WHO AIMS) was recently applied in Brazil. This paper will analyse data on the following sections of the WHO-AIMS: a) mental health services; and b) human resources. In addition, two more national datasets will be used to complete the information provided by the WHO questionnaire: a) the Executive Bureau of the Department of Health (Datasus); and b) the National Register of Health Institutions (CNS).

Results

There are 6003 psychiatrists, 18,763 psychologists, 1985 social workers, 3119 nurses and 3589 occupational therapists working for the Unified Health System (SUS). At primary care level, there are 104,789 doctors, 184, 437 nurses and nurse technicians and 210,887 health agents. The number of psychiatrists is roughly 5 per 100,000 inhabitants in the Southeast region, and the Northeast region has less than 1 psychiatrist per 100,000 inhabitants. The number of psychiatric nurses is insufficient in all geographical areas, and psychologists outnumber other mental health professionals in all regions of the country. The rate of beds in psychiatric hospitals in the country is 27.17 beds per 100,000 inhabitants. The rate of patients in psychiatric hospitals is 119 per 100,000 inhabitants. The average length of stay in mental hospitals is 65.29 days. In June 2006, there were 848 Community Psychosocial Centers (CAPS) registered in Brazil, a ratio of 0.9 CAPS per 200,000 inhabitants, unequally distributed in the different geographical areas: the Northeast and the North regions having lower figures than the South and Southeast regions.

Conclusion

The country has opted for innovative services and programs, such as the expansion of Psychosocial Community Centers and the Return Home program to deinstitutionalize long-stay patients. However, services are unequally distributed across the regions of the country, and the growth of the elderly population, combined with an existing treatment gap is increasing the burden on mental health care. This gap may get even wider if funding does not increase and mental health services are not expanded in the country. There is not yet a good degree of integration between primary care and the mental health teams working at CAPS level, and it is necessary to train professionals to act as mental health planners and as managers. Research on service organization, policy and mental health systems evaluation are strongly recommended in the country. There are no firm data to show the impact of such policies in terms of community service cost-effectiveness and no tangible indicators to assess the results of these policies.     

National trends in hospitalization of youth with intentional self-inflicted injuries

OBJECTIVE: The authors examined national trends from 1990 to 2000 in the utilization of community hospital inpatient services by young people (5-20 years of age) with intentional self-inflicted injuries. METHOD: Discharge abstracts from a nationally representative sample of community hospitals were analyzed, with a focus on youth discharges (N=10,831) with a diagnosis of intentional self-inflicted injury (ICD-9-CM: E950-E959). Census data were used to derive national population-based rates of self-inflicted injuries requiring inpatient treatment. Overall population-based trends in hospitalizations for self-inflicted injury were calculated and stratified by gender and age. Among youths hospitalized with a self-inflicted injury, trends were also calculated for length of stay, inpatient costs, method of injury, and associated mental disorder diagnoses. RESULTS: The annual hospitalization rate of youths with self-inflicted injuries declined from 49.1 per 100,000 in 1990 to 44.9 per 100,000 in 2000, and the mean length of inpatient stay significantly declined from 3.6 days to 2.7 days. Among the hospitalized patients, there were increases in the rate of cutting (4.3% to 13.2%) and ingestion of acetaminophen (22.1% to 26.9%), antidepressants (10.0% to 14.0%), and opiates (2.3% to 3.3%) as a cause of injury, whereas there were decreases in the ingestion of salicylates (14.9% to 10.2%) and barbiturates (1.5% to 0.7%). There were significant increases in the proportion of subjects with primary mental disorder discharge diagnoses of depressive disorder (29.2% to 46.0%), bipolar disorder (1.3% to 8.2%), and substance use disorder (5.4% to 10.7%) and significant decreases in the rate of adjustment disorders (22.2% to 11.4%) and nonmental disorders (31.9% to 13.6%). After excluding cutting, which may be more closely related to self-mutilation than suicidal self-injury, the annual hospitalization rate of youths with self-inflicted injuries declined from 47.2 per 100,000 in 1990 to 39.4 per 100,000 in 2000. CONCLUSIONS: Over the decade of study, young people admitted to community hospitals with self-inflicted injuries tended to have more severe psychiatric diagnoses and to be treated during shorter inpatient stays. These trends suggest that the role of youth inpatient care has narrowed, becoming focused on those with severe psychiatric disorders.     

Relationship between criminal arrest and community treatment history among patients with bipolar disorder

OBJECTIVE: This study examined the relationship between criminal arrest and gender, substance use disorder, and use of community mental health services among patients with bipolar I disorder. METHODS: Los Angeles County's computerized management information system was used to retrospectively identify all inmates with a DSM-IV diagnosis of bipolar I disorder who were evaluated over a seven-month period in the psychiatric division of Los Angeles County Jail and had a history of psychiatric hospitalization in the community. Patients without a history of arrest who were involuntarily hospitalized in the community and treated for bipolar I disorder over the same seven-month period served as a comparison group. The use of community mental health services that inmates received before their arrest was quantified and compared with the services that patients in the comparison group received before their involuntary hospitalization. RESULTS: Patients who had been arrested (N = 66) were more likely than patients in the comparison group (N = 52) to be male (55 percent compared with 31 percent) and to have a history of substance use disorder (76 percent compared with 19 percent) but were less likely to have a history of treatment while under a mental health conservatorship (8 percent compared with 29 percent). In contrast to patients in the comparison group, patients who had been arrested were hospitalized more frequently (a mean of 3.4 hospitalizations per year compared with a mean of 1.1 hospitalizations per year) and had a briefer average length of stay (a mean of 9.2 days compared with a mean of 16.4 days). CONCLUSIONS: In contrast to patients in the comparison group, patients who had been arrested were more likely to be male, to have comorbid substance use disorder, and to have a treatment history characterized by more frequent, briefer hospitalizations.     

Impact of the New Mental Health Services on Rates of Suicide and Hospitalisations by Attempted Suicide,Psychiatric Problems,and Alcohol Problems in Brazil

A sizeable proportion of all suicides have mental health issues in the background. The association between access to mental health care in the community and decreased suicide rates is inconsistent in the literature. Brazil undertook a major psychiatric reform strengthening psychiatric community-based care. To evaluate the impact of the new Brazilian community mental health care units (CAPS-Psychosocial-Community-Centres) on municipal rates of suicide, and hospitalisations by attempted suicide, psychiatric and alcohol problems. We performed robust multivariable negative binomial regression models with fixed effect for panel data from all 5507 Brazilian municipalities. Suicide and hospitalization rates were calculated by sex and standardised by age for each municipality and year from 2008 to 2012. The main variable of interest was municipal CAPS coverage. CAPS municipal coverage was associated with lower suicide rates but this was not statistically significant (RR: 0.981; 95% CI 0.952–1.011). However, increased CAPS coverage was associated with lower hospitalizations for attempted suicide (RR: 0.887; 95% CI 0.841–0.935), psychiatric (RR: 0.841; 95% CI 0.821–0.862), and alcohol problems (RR: 0.882; 95% CI 0.860–0.904). Our results suggest that access to community mental health services seems to reduce hospitalisations due to attempted suicide, psychiatric and alcohol problems but not suicidal rates. Therefore, increased investments in community mental health services in low-middle-income countries might decrease costs associated with potentially avoidable hospitalizations.     

Soins psychiatriques sans consentement pour les personnes détenues : une étude descriptive de 73 mainlevées consécutives en unité hospitalière spécialement aménagée

IntroductionThe procedure of involuntary psychiatric hospitalization has been recently modified in France. Indeed, since 2011, a liberty and custody judge is appointed for each measure, to guarantee the rights of psychiatric inpatients and to prevent abusive hospitalizations. As a result, if procedural errors are noted, the liberty and custody judge may order the immediate ending of the psychiatric hospitalization. To date, only two studies described the reasons for judiciary discharge from involuntary psychiatric hospitalizations, but no study has been conducted in forensic psychiatric units for incarcerated people. The objective of the current study was to describe the main reasons judges use to decide on the irregularity of the hospitalization (against the opinion of psychiatrists) for detained patients, and to compare these reasons with those for patients in the community psychiatric unit.MethodsWe included all the discharges ordered between 2011 and 2018 in two units of the same hospital: a forensic psychiatric unit for incarcerated people and a community involuntary psychiatric unit. We extracted sociodemographic characteristics and judiciary information such as date of discharge, resason fordischarge, presence of the patient at the hearing. We analyzed the judge-ordered discharge rate (corresponding to the number of discharges divided by the number of involuntary psychiatric hospitalizations) for each year. Then, we examined the reason of discharge for each measure.ResultsOne hundred and forty-seven discharges were analyzed: 73 in the psychiatric forensic unit and 73 in the community psychiatric unit. Rates of discharges were 6.7% and 8.8% for the forensic unit and the general psychiatric unit, respectively. Several reasons for the discharges were common for the two units (failure to inform the patient, lack of physical examination), but others were specific to the forensic unit, such as the impossibility for the patients to communicate with their lawyer, or the lack of immediate dangerousness for the person or for the others.ConclusionThis study highlights the specific aspects of involuntary psychiatric hospitalizations for people in prison in France. Future studies are needed to assess the impact of these judge-ordered discharge on patient's mental health, particularly for incarcerated patients.     

High utilizers of psychiatric emergency services

OBJECTIVE: The purpose of this study was to examine the sociodemographic and clinical characteristics of high utilizers of psychiatric emergency services. METHODS: Data were collected over four years for 761 patients who were identified as high utilizers according to three definitions (two standard deviations above the mean number of visits to an urban psychiatric emergency service, six visits in a year, and four visits in a quarter) and for 1,585 nonfrequent utilizers (control group). Univariate analysis of variance and logistic regression models were used to determine group differences. RESULTS: Two distinct groups of high utilizers emerged: high utilizers by quarter and high utilizers by standard deviation. Compared with the control group, the high utilizers were more likely to be homeless, to have developmental delays, to be enrolled in a mental health plan, to have a history of voluntary and involuntary hospitalizations, to be uncooperative, to have personality disorders, to have unreliable social support, and to have a lifetime history of incarceration and detoxification. Compared with the high utilizers by quarter, the high utilizers by standard deviation had more visits and were more likely to have a history of incarceration and psychiatric hospitalization, more likely to be enrolled in mental health plan, and less likely to be homeless. CONCLUSIONS: High utilizers make up a small percentage of individuals who seek care in psychiatric emergency services and disproportionately use resources. It may be helpful to use two definitions of high utilizer to identify patients at different phases of their illness and to guide clinical interventions and mental health policies.     

Suicide attempts and associated factors in Newfoundland and Labrador, 1998-2000.

OBJECTIVE: This study examined the epidemiology and associated factors for suicide attempts requiring hospitalization in the province of Newfoundland and Labrador. METHOD: We extracted data from the provincial hospital separation database. Outcome measures included incidence rates (IRs) of suicide attempts by age, sex, and geographical region of residence. We also analyzed sociodemographic data to determine associated factors. RESULTS: A total of 978 patients who were hospitalized owing to suicide attempts were identified for 1998-2000, giving an overall IR of 68.7 per 100,000 person-years (P-Y). The age-specific rate for people aged 15 to 19 years was much greater, at 143.0 per 100,000 P-Y. The overall female-to-male ratio was 1.3, with an attempted suicide rate of 76.1 per 100,000 P-Y for female patients and 60.3 per 100,000 P-Y for male patients (P = 0.001). Labrador (210.2 per 100,000 P-Y), a region with a high Aboriginal population, had a higher rate of suicide attempts, compared with the island portion of the province (59.0 per 100,000 P-Y) (P < 0.001). More than 70% of hospitalizations were associated with psychiatric diagnosis. Poisoning was the most frequent method of attempting suicide. Higher IRs of suicide attempts were found among people who were divorced or separated and among those who were less educated (P < 0.001). CONCLUSIONS: Suicide attempt represents a significant public health concern in the province, particularly in Labrador. An increased risk of suicide attempts was associated with single status, female sex, younger age (teen or young adult), and low educational level during the index attempt. Further research is needed to explicate these findings and increase our understanding of attempted suicide.     

Intensive outpatient treatment of persons with mental retardation and psychiatric disorder: a preliminary study

The impact of intensive outpatient mental health interventions (in a dual diagnosis clinic) on the hospitalization rate and length of stay was examined for 28 adults with mental retardation and severe psychiatric disorder. They were selected on the basis of frequent use of mental, medical, and social services. Charts were reviewed for the 12-month periods before and after referral to the program to compare service utilization. A single group pretest-posttest design with no control group was employed. Correlated t tests comparing the pre- and post-program number of hospitalizations and lengths of stay indicated significant decreases in both hospitalizations and lengths of stay after program entry, which may result in significant reductions in hospital costs.     

中国精神卫生机构中的专业人员数量和特征

背景：精神障碍在我国疾病总负担中占有相当大的比例,但可提供于精神障碍患者心理卫生服务的专业人员数量,分布和特点还是未知数。目的：全面了解我国精神卫生机构人力资源分布现状和特点。方法：从卫生部统计信息中心获得2010年在中国精神卫生机构中工作的卫生技术人员的数量和特征,比较七个地理区域精神卫生专业人员的人口比例和特征。结果：在757家精神卫生机构内,649家（86％）是精神病院。在这些机构内卫生技术人员共计68,796人（5．16人／lo万人口）,包括精神科医师20,480人（1．54人／lo万人口）和注册护士35,337人（2．65人／lo万人口）。超过80％的卫生技术人员都工作在精神病院。29％的精神科医生人仅具有技校学历,而14％的精神科医生没有学位。在护士中有46％的护士没有学历。我国经济比较落后的北部地区精神科医生或护士的工龄较其长。在我国相对较富裕的东部和东北部地区,精神卫生机构中执业医师和注册护士的人口比例要高于平均水平。结论：我国几乎所有的精神卫生技术人员都工作在精神科专科医院。训练有素的卫生技术人员在数量和地区的分布上远远无法满足人们对卫生健康的需求。与其他中上等收入国家相比,我国每10万人口拥有的精神卫生资源较少,所能提供精神卫生服务的专业人员范围也较窄。     

Association between interruptions in medicaid coverage and use of inpatient psychiatric services

OBJECTIVES: Persons with schizophrenia are heavy and persistent users of Medicaid services. Interruptions in their Medicaid coverage may have serious consequences for the mental health of these individuals and their subsequent use of mental health services. This study sought to determine the impact of interruptions in Medicaid coverage on the use of Medicaid-reimbursed inpatient psychiatric services over a four-year period. METHODS: Inpatient Medicaid claims and eligibility files for 1,830 Medicaid beneficiaries with schizophrenia in Utah from December 1990 to December 1994 were used to identify differences in hospital admissions and total number of days in a hospital associated with interrupted Medicaid coverage. Of the 1,830 Medicaid beneficiaries identified, 1,463 experienced continuous Medicaid eligibility, and 367 had interruptions in their eligibility. RESULTS: Interruptions in Medicaid coverage were associated with an average of.63 more psychiatric hospitalizations per beneficiary over the four-year period, representing an 86 percent higher hospital admission rate. This increase appeared to be largely due to a subset of persons who have much higher hospitalization rates after an interruption in Medicaid coverage. Interruptions in Medicaid coverage were associated with a mean of 8.3 more days of psychiatric hospitalization over the four-year period, representing 61 percent more hospital days. CONCLUSIONS: Medicaid beneficiaries who experience interruptions in coverage have, on average, a significantly greater use of inpatient psychiatric services while participating in Medicaid than beneficiaries with continuous Medicaid coverage. These findings suggest potential benefits of maintaining continuous Medicaid eligibility for beneficiaries with a severe mental illness.     

Crisis Visits and Psychiatric Hospitalizations Among Patients Attending a Community Clinic in Rural Southern California

Ethnic minorities from disadvantaged socioeconomic backgrounds report increased utilization of mental health emergency services; however findings have been inconsistent across ethnic/racial groups. In this study we describe patients who present to a rural crisis unit in Southern California, examine rates of psychiatric hospitalizations across ethnic/racial groups, and investigate factors that are associated with increased psychiatric hospitalizations in this sample. This is a retrospective study of 451 racially and ethnically diverse patients attending a crisis unit in Imperial County, California. Chart review and data abstraction methods were used to characterize the sample and identify factors associated with psychiatric crises and subsequent hospitalizations. The sample was predominantly Latino/Hispanic (58.5%). Based on chart review, common psychosocial stressors which prompted a crisis center visit were: (a) financial problems; (b) homelessness; (c) partner or family conflict; (d) physical and health problems; (e) problems at school/work; (f) medication compliance; (g) aggressive behavior; (h) delusional behavior; (i) addiction and (j) anxiety/depression. Bivariate analyses revealed that Hispanics had a disproportionately lower rate of psychiatric hospitalizations while African Americans had a higher rate. Multivariate analyses which included demographic, clinical and psychosocial stressor variables revealed that being African American, having a psychotic disorder, and presenting as gravely disabled were associated with a higher likelihood of hospitalization while partner/family conflict was associated with a lesser likelihood in this rural community. These data elucidate the need for longitudinal studies to understand the interactions between psychosocial stressors, ethnicity and social support as determinants of psychiatric hospitalizations.     

Perceived Need and Use of Child Mental Health Services in Korea

This study examined the degree of perceived need and use of child mental health services in Korea, as well as the factors associated therewith. The sample consisted of 3,477 children aged 8–13 years. Overall, 10.4% of the parents demonstrated a perceived need for mental health services regarding their children’s emotional or behavioral problems, while 1.9% used mental health services. Although the perceived need for mental health services is high, only a small proportion of children receive them. Whether a child receives mental health care is influenced by the child’s psychopathology, especially when social and/or thought problems exist.     

WHO's Assessment Instrument for Mental Health Systems: collecting essential information for policy and service delivery

Information about mental health systems is essential for mental health planning to reduce the burden of neuropsychiatric disorders. Unfortunately, many low- and middle-income countries lack systematic information on their mental health systems. The objectives, scope, structure, and contents of mental health assessment and monitoring instruments commonly used in high-income countries may not be appropriate for use in middle- and low-income countries. The World Health Organization (WHO) has recently developed the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS), a comprehensive assessment tool for mental health systems designed for middle- and low-income countries. WHO-AIMS was developed through an iterative process that included input from in-country and international experts on the clarity, content, validity, and feasibility of the instrument, as well as a pilot trial. The resulting instrument, WHO-AIMS 2.2, consists of six domains: policy and legislative framework, mental health services, mental health in primary care, human resources, public information and links with other sectors, and monitoring and research. These domains address the ten recommendations of the World Health Report 2001 through 28 facets and 155 items. All six domains need to be assessed to form a basic, yet broad, picture of a mental health system, with a focus on health sector activities. WHO-AIMS provides essential information for mental health policy and service delivery. Countries will be able to develop information-based mental health policy and plans with clear baseline information and targets. Moreover, they will be able to monitor progress in implementing reform policies, providing community services, and involving consumers, families, and other stakeholders in mental health promotion, prevention, care and rehabilitation. This article provides an overview of the rationale, development process, and potential uses and benefits of WHO-AIMS.     

Family members' opinions about civil commitment

As part of a survey of 260 Oregon family members with mentally ill relatives, respondents were asked about their experiences with civil commitment and their opinions about proposed modifications in the commitment statutes. Family members typically described their mentally ill relative as a schizophrenic man in his thirties who had had six psychiatric hospitalizations and was currently being treated with medications at a community mental health center. Three-fourths of the relatives had been committed. A majority (57 percent) of the respondents were in favor of mandatory outpatient treatment and medication after involuntary hospitalization but were not enthusiastic about outpatient commitment without hospitalization. Family members also wanted more education about mental illness, more information about the commitment process, and assignment of a professional to help in the commitment process.     

Critères de prise de décision aux urgences de l’hospitalisation sans le consentement

In the current context of the new French bill on the rights and protection of persons under psychiatric care, clinical practice in the emergency setting requires that mental healthcare professionals better clarify the criteria they use for the decision of involuntary hospitalization. After defining the concept of consent for treatment and a brief literature review, this study examined the impact of clinical and contextual characteristics on the decision to admit patients whether involuntarily or voluntarily to inpatient psychiatric units. Data was collected from 442 successive patients admitted in hospital for care from five psychiatric emergency facilities in Paris and covered sociodemographic information, previous hospitalizations, recent treatment, clinical diagnosis, Global Assessment of Functioning scale (GAF) and insight measured by the Q8 Bourgeois questionnaire. Patients were also assessed based on criteria established by the French healthcare agency (HAS) for the severity of mental disorders and the necessity of emergency care. Using multivariable logistic regression, diagnosis does not affect the decision of hospitalization. Agitation, aggressiveness toward others, being under the influence of drugs or alcohol, being married or divorced as well as being referred by a doctor are all factors that increase the risk of involuntary hospitalization. Last, low Q8 and GAF scores are strong predictors for involuntary admission. This supports using insight and GAF evaluation in clinical practice for clarifying assessment and decision-making in emergency setting about involuntary hospitalization.     

Effects of the Personalized Recovery Oriented Services (PROS) Program on Hospitalizations

Though the recovery model has been implemented widely in outpatient mental health settings, there are no large sample evaluations of recovery oriented psychiatric rehabilitation programs that address both serious mental illness (SMI) and co-occurring disorders (COD) using a more comprehensive Medicaid reimbursable approach. This study examined preliminary hospitalization outcomes, for adults with SMI and COD enrolled in the NYS Personalized Recovery Oriented Services (PROS) program. McNemar’s chi-square test was used to examine changes in hospitalization rates from pre-PROS admission to post-PROS discharge in a sample of 12,006 adults discharged from PROS. Negative binomial regression models were used to calculate adjusted rates of hospitalizations and hospital days. Demographic, psychosocial, and diagnosis predictor variables were extracted from the OMH web-based Child and Adult Integrated Reporting System. Hospitalization data were extracted from the Mental Health Automated Recordkeeping System, and Medicaid. From pre-admission to post-discharge, psychiatric hospitalization rate decreased significantly, from 24% to 14%. Substance related hospitalizations also decreased significantly, from 5% to 3%. Average number of hospitalizations and number of days hospitalized decreased even after adjusting for sociodemographic factors. PROS serves a high number of COD patients, and the number of psychiatric and substance related hospitalizations decreased after an episode of PROS, as did the number of days hospitalized. Findings support the maintenance of psychiatric rehabilitation models that include recovery oriented components. Further analyses with control samples are proposed.     

Association between cannabis and psychiatric hospitalization

Schubart CD, Boks MPM, Breetvelt EJ, van Gastel WA, Groenwold RHH, Ophoff RA, Sommer IEC, Kahn RS. Association between cannabis and psychiatric hospitalization. Objective: To investigate the relationship between cannabis use and mental health. Method: A cross‐sectional analysis in a sample of 17 698 individuals with a mean age of 22 years (SD: 4.2). Participants provided information on the amount and initial age of cannabis use and history of psychiatric hospitalizations through a web‐based questionnaire. To quantify Δ⁹‐tetrahydrocannabinol exposure, we operationalized cannabis use as the amount of money spent on cannabis per week over the last month. The odds ratio of having a history of psychiatric hospitalizations was the primary outcome measure. Results: We found a dose–response relationship between the amount of cannabis use and the odds for psychiatric hospitalization. Adjusted odds ratios for hospitalization increased with the amount of cannabis consumed from 1.6 (95% CI: 1.1–2.3) in incidental users to 6.2 (95% CI: 4.3–8.9) in heavy users (>€25/week). Our data suggested that concomitant drug use was an intermediate factor. Exposure to cannabis before the age of 12 years was found to carry a 4.8 (95% CI: 2.9–7.8) times increased odds for past psychiatric hospitalizations. Conclusion: We conclude that early and heavy uses of cannabis are each and independently associated with poor mental health in its users.     

Patterns of Care Consumption after Compulsory Admission: A Five-Year Follow-Up to the Amsterdam Study of Acute Psychiatry VIII

Significant numbers of involuntary admissions and the fact that compulsory hospitalization is a drastic intervention in a patient’s life justify the introduction of preventive measures. This study looks at the five-year outcome of involuntary admissions after psychiatric emergency consultations in Amsterdam. A cohort of 460 involuntarily admitted patients was investigated prospectively. The annual numbers of involuntary readmissions and the utilization of mental health services were studied, with sociodemographic and clinical characteristics and psychiatric history as predictors. The odds ratios for involuntary readmission during the fourth and fifth follow-up years were 0.71 (95%CI = 0.50–1.01; P = 0.059) and 0.64 (95%CI = 0.45–0.92; P = 0.015), respectively. Readmission was associated with low discontinuity of treatment (Chi2 P ≤ 0.001) and high total consumption of services (Chi2 P ≤ 0.001) during follow-up. It emerged that involuntary readmission could be predicted on the basis of high care consumption five years before inclusion (OR 2.61 CI 1.44–4.73; P 0.002), a history of involuntary admission (OR 1.56 CI = 1.03–2.35; P = 0.034), being older than 44 years at baseline (OR 0.57 CI = 0.39–0.84; P = 0.007), and living alone (OR 1.68 CI = 1.22–02.33; P = 0.002). The risk of involuntary readmission declines after three years. In Amsterdam, low levels of treatment discontinuity and high levels of service use do not seem to reduce this risk for patients with severe and persistent psychiatric disorders. Our findings should be an incentive to explore and reappraise the methods employed in our current system of community mental health care.     

Mortality in Western Australian psychiatric patients

  Background: The aim was to examine mortality in psychiatric patients in Western Australia (WA), over a time period of considerable change in the delivery of mental health services. Methods: A population-based record linkage analysis was undertaken to quantify mortality among people with mental illness in WA. Mortality rates were calculated in users of mental health services and compared with rates in the whole population of WA. Trends in mortality were also examined using relative survival analysis, and proportional hazards regression. Results: The overall mortality rate ratio was 2.57 in males (95% CI: 2.51–2.64), and 2.18 in females (2.12–2.24). The highest cause-specific mortality rate ratio was for deaths due to suicide [RR: 7.37 in males (95% CI: 6.74–8.05) and 8.38 in females (95% CI: 7.11–9.89)], with mortality rate ratios being significantly greater than 1 for all other major causes of death. A relative survival analysis found that the excess mortality risk was concentrated in the first few years after first contact with mental health services. Proportional hazards regression analysis found a slight elevation of mortality rates over time. Conclusions: Mortality among psychiatric patients remains high and appears to be increasing. Highest excess mortality rate is associated with suicide, but mortality rates are significantly elevated for all major causes of death. Accepted: 10 April 2000     

Length of Involuntary Hospitalization Related to the Referring Physician’s Psychiatric Emergency Experience

Although involuntary commitment (IC) is a serious intervention in psychiatry and must always be regarded as an emergency measure, the knowledge about influencing factors is limited. Aims were to test the hypothesis that duration of involuntary hospitalization and associated parameters differ for IC’s mandated by physicians with or with less routine experience in psychiatric emergency situations. Duration of involuntary hospitalization and duration until day-passes of 508 patients with IC at the University Hospital of Psychiatry Zurich were analyzed using a generalized linear model. Durations of involuntary hospitalization and time until day-passes were significantly shorter in patients referred by physicians with less routine experience in psychiatric emergency situations than compared to experienced physicians. Shorter hospitalizations following IC by less-experienced physicians suggest that some IC’s might be unnecessary. A specific training or restriction to physicians being capable of conducting IC could decrease the rate of IC.