Is ‘gender disappointment’ a unique mental illness?

Medicine, Health Care and Philosophy - ‘Gender disappointment’ is the feeling of sadness when a parent’s strong desire for a child of a certain sex is not realised. It is...     

Civil commitment of sex offenders to mental institutions: should the standard be based on serious mental illness or mental disorder?

Civil commitment to mental institutions requires that an individual be both seriously mentally ill and dangerous. This principle is erroneously being applied to incarcerated sex offenders nearing release from prison under the theory that they have antisocial personalities or paraphilia disorders, which are called mental illnesses. However, the mental health and legal communities are at odds regarding the use of a diagnosis of personality disorder or paraphilia to justify civil commitment. The author reviews the differences between serious mental illness and mental disorder, the flaws with assessing sex offenders as mentally ill, and the ethical dilemma for social workers employed in mental hospitals.     

Fear,black people and mental illness: A vicious circle?

The relationships between black communities and the mental health (MH) services are fraught. Paradoxically, black communities receive the MH services they don't want, but not the ones they do or might want. Black people mistrust and often fear services, and staff are often wary of the black community, fearing criticism, and not knowing how to respond, are fearful of black people, in particular, young black men. The situation is fueled by prejudice, misunderstanding, misconceptions and sometimes racism. The present paper describes the findings of a study to explore the issues in greater depth. The study was premised on a belief that there are 'circles of fear' which lead to poorer treatment of black communities. A purposive sampling approach was used to seek out groups and individuals in whom the 'circles of fear' were likely to be evident. The findings suggest that there are fears which impact negatively on the interaction between black communities and MH services. Two major themes emerged in this study, i.e. the sources of fear and the consequences of fear. Sources of fear included perceptions of MH services, attitudes to mental illness and diagnosis, and experiences of hospital care. The impact of fear included limited trust, limited engagement and delayed help-seeking behaviour. The study concludes that these fears mar the interactions between these communities and MH services, affect help-seeking behaviour adversely, and lead to restrictive and punitive interventions. Progress will only be made in breaking the 'circles of fear' if there is a systematic change in the experience of black services users at each point in the care pathway.     

Putting policy into practice? Poverty and people with serious mental illness

This paper addresses the effects of chronic poverty on people with serious mental illness. More specifically, we are concerned with the extent to which welfare restructuring, by deepening the poverty facing people with serious mental illness, undermines the expressed intent of mental health policy to improve the quality of life (QOL) of this population. The province of Ontario in Canada forms the setting for the study. The paper first examines recent trends in mental health care and social assistance policy in Ontario. While income support is consistently recognized as a core element of mental health care, welfare restructuring has led to a significant decline in the real value of income supports received by people with serious mental illness. The paper then examines the implications of this trend for the QOL of residential care facility tenants in Hamilton, Ontario. Here, the case study is explicitly connected to QOL scholarship. In addition, the study is grounded in an analysis of the broader transformation of the welfare state in Ontario. Interview data suggest that tenants experience chronic poverty that has a deleterious impact on multiple life domains including basic needs, family, social relations, leisure and self-esteem. Implications for research and policy are discussed.     

Treating acute mental illness in rural general hospitals: Necessity or choice?

OBJECTIVE: To identify reasons why rural general practitioners (GPs) treat a large proportion of patients with a primary psychiatric diagnosis in general beds of their local hospitals, and the barriers encountered when providing this treatment. DESIGN: A postal questionnaire was developed and distributed to a sample of rural GPs, asking about the treatment of patients with an acute mental illness in their local hospital. RESULTS: The majority of GPs agreed that they treat the acutely mentally ill in general beds of their local hospital due to lack of availability of, and inability to gain access to, mental health beds in the larger centres; and also to enable ongoing family involvement and continuity of care. Distance factors were identified as least significant. Barriers to providing care to this group of patients included a perceived lack of support by consultant psychiatrists, confidentiality issues, lack of community mental health workers to provide assistance, aggression levels of patients, inappropriate local hospital setting, and lack of confidence of GPs and general hospital nursing staff. CONCLUSION: Addressing these barriers is necessary if rural Australians are to receive a quality of care that is equal to that received by those located in metropolitan Australia. Continuing research in this area is crucial.     

Can the suicide rate be used as a performance indicator in mental illness?

This paper follows from an examination of death rates from suicide as a possible performance indicator in mental illness. The wide variations observed in the proportion of undetermined deaths to suicides in Yorkshire district health authorities, suggest that coroners differ in their legal definition of suicide. To counteract the problem of coroner bias it is suggested that deaths from suicide and self-inflicted injury, and deaths from injury undetermined, whether accidentally or purposely inflicted in the 15 and over age group be combined. The paper outlines the advantages of such a performance indicator and stresses that a 'poor' indicator value merely poses questions which lead to a search for reasons for the value and is not an explanation in itself.     

Service penetration by persons with severe mental illness: how should it be measured?

As performance indicators and outcomes measures become essential parts of doing business, providers of mental health services are developing and using a number of access measures. One that is being used with increasing frequency is service penetration. However, the lack of standard methods for calculating and reporting service penetration has made the comparison of penetration rates across studies difficult. This article discusses the conceptualization and operationalization of service penetration. In addition, it presents an exploratory study of service penetration using data from the same persons using very different data sources; these data were collected during an evaluation of a Medicaid managed care system in Florida. The article offers recommendations for the use and reporting of service penetration rates.     

'Old' and 'new' institutions for persons with mental illness: treatment, punishment or preventive confinement?

Despite countless promises for a better life by national commissions, governments and the international community, there has evolved a vicious cycle of neglect, abandonment, indignity, cruel and inhuman treatment, and punishment of persons with mental illness. This shameful history of benign, and sometimes malignant, neglect of persons with mental illness is well understood, with the deep stigma and unredressed discrimination, the deplorable living conditions, and the physical and social barriers preventing their integration and full participation in society. The maltreatment of this vulnerable population has been reinforced by the hurtful stereotypes of incompetency and dangerousness. The belief that persons with mental illness are uniformly dangerous is an equally harmful myth. It provides policy makers with an ostensible justification to exercise control over persons with mental illness, even if they have not committed a violent offence. However, research demonstrates that the class of persons with most mental illnesses is no more dangerous than other populations, and that the vast majority of violence is committed by persons without mental illness. This article will show how this vulnerable population has been unconscionably treated. First, the gross violations of human rights that have occurred, and continue to occur, in 'old' psychiatric institutions will be examined. The deinstitutionalization movement, however, resulted in new places of confinement for this population, such as jails, prisons and homeless shelters. The second part of this paper will explore the new realities of criminal confinement of persons with mental illness. As we will see, incarceration of this vulnerable population in the criminal justice system has caused enormous suffering. If Dostoyevsky was correct that the 'degree of civilization... can be judged by entering its prisons', then by that measure, we are a deeply uncivilized society.     

Are resilience and perceived stress related to social support and housing stability among homeless adults with mental illness?

Perceived stress has been associated with adverse health outcomes. Although people experiencing homelessness often report multiple acute and chronic stressors, research on resilience and perceived stress on the general homeless population is limited. This longitudinal study examined homeless adults with mental illness who were part of a 24‐month trial of Housing First to explore: (a) changes in levels of resilience and perceived stress during the trial, and (b) the association between levels of resilience and perceived stress with measures of social support, social functioning and percentage of days stably housed over the study period. This longitudinal study (2009–2013) that used trial data included 575 participants in Toronto, Ontario. Of these individuals, 507 were included in this study. Connor‐Davidson Resilience Scale and Perceived Stress Scales (PSS) measured the two outcomes, resilience and perceived stress. Time (baseline, 12 and 24 months), housing stability and three measures of social support and social functioning were the main predictors. A longitudinal analysis was done with repeated measures analysis of resilience and perceived stress using linear mixed models with random intercepts. Mean resilience scores increased (baseline: 5.1 [95% CI: 4.9, 5.2], 12 months: 5.5 [95% CI: 5.3, 5.7], 24 months: 5.6 [95% CI: 5.4, 5.8]), and PSS scores decreased (baseline: 22.3 [95% CI: 21.5, 23.0], 24 months: 18.6 [95% CI: 17.9, 19.4]). In the multivariable analyses, increased resilience was associated with higher scores on the three social support and social functioning measures, (estimates = 0.12, 0.04, 0.02) but not percentage days stably housed. Lower PSS scores were associated with higher scores on all three social support and social functioning measures (?0.20, ?0.33, ?0.21) and higher percentages of days stably housed (?0.015). Strong social support and social functioning may minimise the harmful effects of stressful life events on homeless individuals by increasing resilience and reducing stress. Interventions to help homeless people build appropriate support networks should be delivered in parallel to efforts that increase housing stability.     

New spaces of inpatient care for people with mental illness: A complex ‘rebirth’ of the clinic?

This paper examines the implications for design of inpatient settings of community-based models of care and treatment of mental illness. The study draws on ideas from relational geographies and expands interpretations based on Foucault's writing. We analyse material from a case study which explored the views of patients, consultants, and other staff from a new Psychiatric Inpatient Unit in a deprived area of East London, UK. We discuss in particular: the tension between providing a caring and supportive institutional environment and ensuring that patients are returned to the community when they are ready; the links between an acute inpatient facility and its local community; the potential significance of the psychiatric hospital as a relatively stable feature in the otherwise insecure and unpredictable geographical experience of people with long-term mental illnesses. We discuss the relevance of these issues for design of new psychiatric inpatient facilities.     

Can urban regeneration programmes assist coping and recovery for people with mental illness? Suggestions from a qualitative case study

Researchers and policy-makers are increasingly recognizing that urban socio-environmental conditions can affect the development and course of numerous health problems. The aim of this paper is to investigate the impact an urban regeneration programme can have on everyday functioning, coping and recovery for people with a mental illness. We were also interested in discerning which component parts of the regeneration are the most important in positively affecting people with mental illness. These questions were explored through an in-depth qualitative case study of the Gospel Oak neighbourhood in London, which recently underwent an intensive urban regeneration programme. Interviews and focus groups were conducted with residents living with a mental illness (n = 16). Relevant participant observation was also conducted. Participants reported that interventions that improved community safety were by far the most important in affecting everyday coping and functioning. Interventions that improved the quantity and quality of shared community facilities had a positive, but milder effect on mental health. Component parts that appeared to have little effect included environmental landscaping and greater community involvement in decision-making processes. Most participants reported that their mental illness was a consequence of severe insults over the life-span, for example childhood neglect or family breakdown. Thus, the regeneration was seen as something that could assist coping, but not something that could significantly contribute to complete recovery. Our results thus suggest that urban regeneration can have a mild impact on people with mental illness, but this appears to be outweighed by life-span experience of severe individual-level risk factors. That said, some of our findings converge with other studies indicating that community safety and community facilities can play a role in positively affecting mental health. Further ethnographic and epidemiological research is necessary to explore these two factors.     

Assessing the causal effect of Section?8 housing vouchers as the active ingredient for decreasing homelessness in veterans with mental illness

Estimating the causal effect of an active ingredient in a randomized treatment may be complicated when participants receive heterogeneous doses of the active ingredient. For example, homeless veterans with mental illness were randomized to receive either case management only, or case management plus special access to a Section?8 housing voucher. However, a quarter of those randomized to the housing voucher group did not actually use the voucher, while a few of those randomized to case management actually used a housing voucher. Our goal is to estimate the causal effect of the proposed active ingredient (i.e., using a housing voucher), as opposed to the effect of being randomized to the active ingredient. The proposed instrumental variable methodology assumes that the outcome is proportional to the dose of the active ingredient and tests the significance of the instrumental variable estimate using a permutation test such as the Hodges?CLehman aligned rank statistic proposed by Rosenbaum for pair-matched data (Rosenbaum, Observational studies, 2002; The design of observational studies, 2010). This method removes unmeasured confounding when the assumptions of monotonicity and the exclusion restrictions hold; however, in practice these assumptions may not hold perfectly. Consequently, we extend and strengthen this approach by incorporating optimal full matching on the propensity to use the active ingredient, to further reduce bias and variability in the IV estimation.     

Perceptions of illness causation among new referrals to a community mental health team: "explanatory model" or "exploratory map"?

The health beliefs of people suffering from mental health problems are important. Such beliefs have been identified as key factors in models of health and illness behaviour, and may therefore indirectly influence clinical outcome. In addition, the increasing move towards patient-centred health care suggests that such beliefs need to be identified if a patient's perspective of his or her illness is to be addressed in the care process. Past research on health beliefs surrounding depression have concentrated on identifying "explanatory models" among the general community or among people who already have an established diagnosis of depression. This paper describes the content and status of health beliefs among people who are in the process of receiving a diagnosis. In-depth interviews were carried out with new referrals to a community mental health team (CMHT). Individuals expressed a variety of perceived causes throughout the interview. Beliefs were therefore characterised as changeable. It is argued that the concept of an "explanatory model" is too fixed to fully convey the fluid status of beliefs among this patient group. The concept of an "exploratory map" is suggested as a replacement. Such maps outline the avenues of thought which individuals explored when attempting to understand why they were currently experiencing particular psychological problems. The strength and persistence of beliefs is discussed in relation to both theoretical and clinical implications.     

Do attachment patterns of parents with a mental illness have an impact upon how they view the quality of life of their children?

This study examines the relationship between the attachment patterns of 61 parents with a mental illness and their perception of their children's health-related (QoL). Parental attachment patterns were assessed using the Bielefeld Partnership Expectations Questionnaire (BFPE); health-related QoL of children was measured with the parent version of KINDL-R. Compared to the general population, parents showed different attachment patterns and rated their children's QoL significantly lower overall as well as in the dimensions “emotional well-being”, “friends” and “family”. QoL ratings were associated with specific parental attachment styles. Parents with secure patterns also differed from those with other patterns in their ratings of their children's QoL. These results suggest a role of parental attachment for the perception of child well‐being and functioning. They also underline the need for more research into the association between parent attachment and child well-being in families with mental health problems.