Suicide,ethnicity and psychiatric in-patient care: A case-control study

Abstract

This study compares patients with controls concerning sociodemographic variables and describes Swedish and foreign-born patients concerning psychiatric disorders. suicide risk. history of attempted suicide, suicide method, number of parasuicides and time from discharge to suicide. It is based on 59 psychiatric in-patients who had committed suicide, of whom 46 were native Swedes and 13 foreign-born, and on a random sample of 630 controls living in the same area of Stockholm, Sweden. There was an excess suicide risk for being foreign-born with a crude odds ratio of 1.94 (CI = 1.01?3.76) in an unconditional logistic regression. In the final model, single living, having a somatic disease and being unemployed were major risk factors for committing suicide. There were no differences between Swedes and those of foreign birth concerning distribution of certain background variables (i.e., suicide risk, diagnoses and quality of care assessed via clinical records). Only 39% of the patients were classified as high risk by the doctor-in-charge at admission. This is significantly lower p<0.001) than the retrospectively rated risk. Planned aftercare was considered as satisfactory for about half of the patients. About two-thirds of the patients did not participate in aftercare or almost immediately discontinued the contact. More attention is necessary in order to motivate the patients to take part in aftercare and there is a need for better co-operation between hospital and out-patient clinics.     

Total and differential white blood cell counts,high-sensitivity C-reactive protein,and the metabolic syndrome in non-affective psychoses

The metabolic syndrome is highly prevalent in patients with schizophrenia, and is associated with a state of chronic, low-grade inflammation. Schizophrenia is also associated with increased inflammation, including aberrant blood levels of pro-inflammatory cytokines and high-sensitivity C-reactive protein (hsCRP). The purpose of this study is to investigate the relationship between total and differential white blood cell (WBC) counts, hsCRP, and the metabolic syndrome in patients with schizophrenia and related non-affective psychoses. Fifty-nine inpatients and outpatients age 18–70 with non-affective psychotic disorders and 22 controls participated in this cross-sectional study. Subjects had a fasting blood draw between 8 and 9 am for glucose, lipids, total and differential WBC counts, and hsCRP. Vital signs and anthropometric measures were obtained. Patients with non-affective psychosis and the metabolic syndrome had significantly higher total WBC counts, monocytes, and hsCRP levels than patients without the metabolic syndrome (p ⩽ 0.04 for each). In binary logistic regression analyses, after controlling for potential confounding effects of age, race, sex, age at first hospitalization for psychosis, parental history of diabetes, smoking, and psychotropic medications, total WBC count, monocytes, and hsCRP were significant predictors of metabolic syndrome in patients (p ⩽ 0.04 for each). hsCRP was also a significant predictor of increased waist circumference and triglycerides in patients (p ⩽ 0.05 for each). Our findings suggest that measurement of total and differential WBC counts and hsCRP blood levels may be germane to the clinical care of patients with schizophrenia and related disorders, and support an association between inflammation and metabolic disturbance in these patients.     

Accessibility and pathways to psychiatric care in a community-based mental health system

Background The careful analysis of pathways to specialist mental health care, within the context of community-based services, is important because it allows a detailed understanding of the inter-relationship between the component parts of the whole system of care. Moreover, it permits a comparison of service functioning to made over time, and is one way to operationalise the measurement of accessibility to services. The aims of this study are to describe: (i) the pathways followed by patients with new episodes of care to community-based mental health services, (ii) the time intervals from onset of the problem to first contact with services, and then to onward referral to specialist care (accessibility), and (iii) to explore the short-term costs associated with different pathways. Methods Using data from the South-Verona Psychiatric Case Register, all new patients referred to any of the facilities which are part of the South-Verona Community Psychiatric Service (CPS) over a 6-month period (November 1999 – May 2000) were eligible to enter the study. Patients were interviewed by telephone using the Italian translation of the WHO Encounter Form. The costs of care provided in the 3 months following the index contact were assessed for all patients. Results The most common route to mental health services is via a GP (40 %), followed by a referral from a hospital doctor (26 %) and self-referral (23 %). The median interval from onset to direct contact with the South-Verona CPS (12 weeks) was shorter than the intervals from onset to direct contact with other service providers (the median interval for contact with GPs and hospital doctors was 24 weeks). The intervals varied considerably from 1 week (for attempted suicide), to 1.5 years (for disturbed behaviour). The results of backward regression modelling revealed a significant relationship between patients' characteristics and community costs or total psychiatric costs (44 % and 53 % of the variance explained respectively). Conclusion When the results are compared with a directly comparable earlier study in South-Verona, it is apparent that between 1991 and 1999 an increasing proportion of patients with insomnia and somatic disorders presented first to GPs, while a decreasing proportion of patients over the years sought care directly from specialist care. An increase in the role of local GPs as gatekeepers has, therefore, emerged. A prompt assessment by the South-Verona CPS of the patients' presenting problems was also confirmed, and this can be explained by the ‘drop-in’ approach at the Mental Health Centre, where patients can seek specialist care directly, without previously attending GPs. This method of measuring time intervals along pathways is proposed as a way to operationalise accessibility to services in future. Accepted: 16 July 2001     

Early manifestations, personality traits and pathways into care for Asian and white first-onset cases of schizophrenia

  Background: Previous studies have shown that manifestations of symptoms and premorbid personality of patients with schizophrenia differ across cultures. However, these have only been demonstrated in cultural settings apart from each other. Method: We set out to compare these across different ethnic groups from a catchment area in west London. The Asian and the white group had similar inception rates of schizophrenia and we therefore decided to compare these two groups to ascertain similarities in social, demographic and personality factors and pathways into care. First-onset cases of schizophrenia were studied on a number of parameters using previously validated instruments. Results: There were more similarities than differences between the two groups. When compared with the findings of a previous multicentre study in India, London Asians, like their counterparts in India, were more likely than the London white sample to present with loss of appetite, become more religious and behave as if hearing voices. However, compared to their Indian counterparts, the onset of symptoms was more likely to be insidious and alternative sources of healing were less likely to be approached. Conclusions: These findings are discussed in relation to the findings for white patients and recommendations made for future research. Accepted: 25 August 1999     

Ward atmosphere in acute psychiatric in-patient care: patients' perceptions, ideals and satisfaction

OBJECTIVE: To investigate the relationship between patients' perception of the real and ideal ward atmosphere and their satisfaction. METHOD: Patients filled in the Ward Atmosphere Scale (WAS, Real and Ideal Form) and a satisfaction questionnaire. Patient characteristics were derived from clinical assessments. RESULTS: WAS ratings were almost independent of patient characteristics. Patients in locked wards perceived more anger and aggression and patients subjected to coercive measures perceived less autonomy and practical orientation. Patient satisfaction was predicted by higher scores on the WAS Relationship- and System Maintenance dimensions, explaining 41% of the variance. In particular support, order and organization predicted satisfaction. Except from the areas of anger/aggression and staff control, patients gave the 'ideal' ward higher ratings on all subscales. The perceived gap between the 'ideal' and 'real' ward explained 45% of variance in satisfaction. CONCLUSION: Patients' perception of ward atmosphere is a clinically meaningful measure appearing to be a strong predictor of satisfaction.     

Attitude of health workers to the care of psychiatric patients

Background  

In a few months from the time of this report, wards for inpatient care of psychiatric patients at the Bayero University Medical School Aminu Kano Teaching Hospital will be ready for admissions. The attitude of staff to the care of such patients within the hospital was the focus of this study.     

Mental health service provision in juvenile justice facilities: pre- and postrelease psychiatric care

High prevalence rates of mental illness among adolescents in juvenile justice facilities require multifaceted interventions. Children entering justice systems are frequently underserved and having their first contact with psychiatric services. Programming must be multidisciplinary and multifaceted, combining treatment within the facility with postrelease planning. It examines the role of the psychiatrist and the structure of mental health services within juvenile justice facilities.     

Employing behavioral methods to improve the context of care in a public psychiatric hospital: some applications to health care management

While intervention procedures grounded in behavioral science have proven useful in the provision of direct care and in organizational management, they are seldom used effectively in many psychiatric care organizations. Behavioral practitioners often acknowledge this fact but few have applied their behavior change skills to change the behavior of the organization that is failing. This report outlines several examples of how behavioral technology was employed from an administrative perspective to encourage and strengthen needed changes in the interdisciplinary clinical care procedures of a public psychiatric hospital. The potential of these procedures for administering health care provision as well as the challenges encountered in realizing such applications are discussed.     

Patients with a first episode of schizophrenia spectrum psychosis and their pathways to psychiatric hospital care in South Germany

Abstract.Background: Several first-episode studies of schizophrenia suggest that many patients experience psychotic symptoms for a long time before receiving appropriate treatment. To reduce the time of untreated psychosis, it is necessary to know the patients pathways to psychiatric care. This study was designed to examine patients help-seeking contacts and the delays on their pathways to psychiatric care in Germany.Method: Sixty-six patients with first episode of schizophrenia spectrum psychosis were assessed by the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS) and were interviewed about their helpseeking contacts before psychiatric admission.Results: In contrast to other findings of long duration of untreated psychosis (DUP), 53% of our patients were admitted after 8 weeks (median) of untreated positive symptoms, although the mean value of 71 weeks corresponds well with the results of other studies. There were important differences in DUP depending on which kind of statistical parameter (median or mean) was used. In contrast to studies from other countries, only 18% of our patients had their first contact with a general practitioner. However, this was the fastest way to psychiatric admission. No differences were found between patients with short (< 1 year) and long (> 1 year) DUP in the duration of time from the first help-seeking contact up to admission.Conclusion: In Germany, a large number of mental health professionals in private practice or different services of psychosocial contact facilities exist in every region and general practitioners are not so important as a link to psychiatric care, although they seem to be functioning well if it is necessary. Therefore, programs designed to reduce the delay of treatment should focus less on general practitioners than on other health services.     

Enhancing pathways to care for black and minority ethnic populations: A systematic review

Background. Improving pathways to care is an important part of UK Government policy on delivering equitable treatment for black and minority ethnic (BME) patients. However, there is little guidance on how this can be achieved. This systematic review aimed to evaluate research studies reporting initiatives to enhance pathways to mental health care for BME groups.

Methods. A review of published English language literature of studies reporting an evaluated intervention that aimed to enhance care pathways for BME communities or that achieved this as a by-product. Data extracted included the type of pathway improved, samples characteristics, type of intervention and outcome.

Results. Six studies met inclusion criteria. In only one was the initiative UK based. There was evidence that interventions led to three types of pathways change; accelerated transit through care pathways, removal of adverse pathways, and the addition of a beneficial pathway. Ethnic matching promoted desired pathways in many groups but not African Americans, managed care improved equity a pre-treatment service improved access to detoxification and an education leaflet increased recovery.

Conclusion. Only a small number of papers satisfied the review criteria. Consequently, there is currently a dearth of information on which to build evidence-based guidance for service development. Evidence that is available is mainly not from the UK and hence needs to be treated with caution.     

Care pathways for south Asian and white people with depressive and anxiety disorders in the community

BACKGROUND: South Asian people with common mental disorders are less likely to have their problems recognised by their general practitioner and have lower rates of uptake of psychiatric services compared to native born white people. Less consideration has been given to their understanding of their mental health problems, their use of alternative supports and the treatment they receive in primary care. METHODS: A general population sample identified, using a semi-structured diagnostic interview, as having DSM-IIIR depressive or anxiety disorders was obtained. South Asian and white participants' appraisal of their mental health problems and their use of informal and formal assistance during the period they were unwell in the previous 6 months were compared. RESULTS: There was no difference between south Asian and white people, either in what they understood to be the matter with them or in what they perceived to be the cause of their problems. No south Asian participants reported seeking help from lay or traditional healers, while white people more often discussed their problems with a relative or friend. Most south Asian people consulted their GP and this was significantly higher than for whites. However, only around half the people in both groups reported disclosing their problem to a GP and only one in ten received psychiatric medication or was referred to specialist psychiatric services. CONCLUSIONS: Along with public education and GP training, the availability of appropriate and acceptable interventions for south Asian, and indeed white people, with common mental disorders consulting in primary care is key to ensuring that they gain access to necessary mental health care.