Psychiatric emergency service use and homelessness, mental disorder, and violence

OBJECTIVE: This study examined relationships between homelessness, mental disorder, violence, and the use of psychiatric emergency services. To the authors' knowledge, this study is the first to examine these issues for all episodes of care in a psychiatric emergency service that serves an entire mental health system in a major city. METHODS: Archival databases were examined to gather data on all individuals (N=2,294) who were served between January 1, 1997, and June 30, 1997, in the county hospital's psychiatric emergency service in San Francisco, California. RESULTS: Homeless individuals accounted for approximately 30 percent of the episodes of service in the psychiatric emergency service and were more likely than other emergency service patients to have multiple episodes of service and to be hospitalized after the emergency department visit. Homelessness was associated with increased rates of co-occurring substance-related disorders and severe mental disorders. Eight percent of persons who were homeless had exhibited violent behavior in the two weeks before visiting the emergency service. CONCLUSIONS: Homeless individuals with mental disorders accounted for a large proportion of persons who received psychiatric emergency services in the community mental health system in the urban setting of this study. The co-occurrence of homelessness, mental disorder, substance abuse, and violence represents a complicated issue that will likely require coordination of multiple service delivery systems for successful intervention. These findings warrant consideration in public policy initiatives. Simply diverting individuals with these problems from the criminal justice system to the community mental health system may have limited impact unless a broader array of services can be brought to bear.     

Use of mental health care services by Canadians with co-occurring substance dependence and mental disorders

OBJECTIVES: This study contributes to knowledge of the processes underlying help seeking by those with mental and substance use disorders by examining relationships among need, service use, and satisfaction with mental health care in a population-based sample. METHODS: Secondary data analyses were performed on responses to the 2002 Canadian Community Health Survey (N=36,984). Diagnostic algorithms classified respondents by past-year diagnostic status, including substance dependence and selected mood and anxiety disorders. Logistic regressions examined associations between diagnostic status and service use, satisfaction, and unmet need for care. RESULTS: Ten percent of Canadians and 39% of Canadians with a mental disorder or substance dependence sought services in the year preceding data collection. Although those with co-occurring substance dependence and mental disorders reported the poorest mental health and were most likely to seek care, the presence of a mental disorder, regardless of co-occurring substance dependence, contributed primarily to help seeking. Among those who sought services, the use of informal sources of care, including self-help groups, was more common among those with substance dependence. Those with co-occurring disorders reported the lowest satisfaction with care and the greatest prevalence of unmet need. CONCLUSIONS: The differential use of services, satisfaction, and unmet need across diagnostic status allowed for speculation on differing levels of disability and stigma in the help-seeking process for different types of disorders. The strong association between co-occurring disorders and unmet need for care, including a large proportion of respondents who stated they preferred to self-manage their symptoms, is particularly troubling and deserves future research attention.     

A national survey of care for persons with co-occurring mental and substance use disorders

OBJECTIVE: The delivery of appropriate treatment to persons who have mental and substance use disorders is of increasing concern to clinicians, administrators, and policy makers. This study sought to describe use of appropriate mental health and comprehensive substance abuse care among adults in the United States with probable co-occurring disorders. METHODS: Data from the Healthcare for Communities survey, which is based on a national household sample studied in 1997 and 1998, were used to identify individuals who had probable co-occurring mental and substance use disorders. The sociodemographic and clinical characteristics of these individuals and their use of services were recorded. Logistic regression analysis was used to identify variables associated with receipt of mental health and substance abuse treatment and with receipt of appropriate treatment. RESULTS: Estimates for the U.S. adult population based on the weighted survey data indicated that 3 percent of the population had co-occurring disorders. Seventy-two percent did not receive any specialty mental health or substance abuse treatment in the previous 12 months; only 8 percent received both specialty mental health care and specialty substance abuse treatment. Only 23 percent received appropriate mental health care, and 9 percent received supplemental substance abuse treatment. Perceived need for treatment was strongly associated with receipt of any mental health care and with receipt of appropriate care. CONCLUSIONS: Despite the availability of effective treatments, most individuals who had co-occurring mental health and substance use problems were not receiving effective treatment. Efforts to improve the care provided to persons who have co-occurring disorders should focus on strategies that increase the delivery of effective treatment.     

Characteristics of recent violence among entrants to acute mental health and substance abuse services

OBJECTIVE: The aim of this study was to describe the characteristics of recent interpersonal violence perpetrated and experienced by individuals recruited from acute crisis mental health and substance abuse treatment settings and to examine differences among incidents involving individuals with mental disorders only (MDO), substance use disorders only (SDO), and co-occurring mental and substance use disorders (COD). METHOD: Participants (N = 419) were interviewed about their involvement in specific acts of violence in the past 30 days. Participants were also asked about where each incident took place, who was involved, whether individuals were injured, and whether alcohol or drugs were used before the incident. We examined distributions of violence characteristics for the full sample and used logistic regression analyses to test differences among incidents involving participants with MDO, SDO, and COD. RESULTS: Approximately 41% (n = 171) of the sample was involved in at least one incident of violence as a perpetrator or a victim, generating a total of 379 incidents. Far more incidents of violence involved victimization (62%) than perpetration (38%). Most incidents were isolated and involved only perpetration or only victimization. However, a total of 98 (26%) incidents occurred with another incident and constituted 49 episodes of violence that included incidents of perpetration and victimization. Characteristics of perpetration and victimization incidents were similar, except that victimization incidents involved more serious types of violence. The majority of incidents took place outdoors and did not result in injuries. Participants used drugs or alcohol prior to over 40% of incidents. Most incidents of perpetration (70%) targeted someone known to the participant. Diagnostic group was the strongest predictor of type of injury, location of incident, and use of alcohol and drugs before the incident. Individuals with substance use disorders, either alone or co-occurring with mental disorders, were more likely to report that violent incidents took place outdoors. Individuals with mental disorders, either alone or co-occurring with substance use disorders, were less likely to report alcohol and drug use prior to involvement in violence. CONCLUSIONS: Violence is common among individuals entering acute crisis mental health and substance abuse treatment. We found that such persons are more likely to report being victims of violence than perpetrators of violence. In contrast to prior studies, we found that most incidents took place outdoors. Although individuals in different diagnostic groups were no more or less likely to perpetrate or experience violence, they perpetrated and experienced violence under different circumstances. Implications and directions for future research and practice are discussed.     

Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders

OBJECTIVE: Women with co-occurring mental health and substance use disorders frequently have a history of interpersonal violence, and past research has suggested that they are not served effectively by the current service system. The goal of the Women, Co-occurring Disorders, and Violence Study was to develop and test the effectiveness of new service approaches specifically designed for these women. METHODS: A quasi-experimental treatment outcome study was conducted from 2001 to 2003 at nine sites. Although intervention specifics such as treatment length and modality varied across sites, each site used a comprehensive, integrated, trauma-informed, and consumer-involved approach to treatment. Substance use problem severity, mental health symptoms, and trauma symptoms were measured at baseline, and follow-up data were analyzed with prospective meta-analysis and hierarchical linear modeling. RESULTS: A total of 2,026 women had data at the 12-month follow-up: 1,018 in the intervention group and 1,008 in the usual-care group. For substance use outcomes, no effect was found. The meta-analysis demonstrated small but statistically significant overall improvement in women's trauma and mental health symptoms in the intervention relative to the usual-care comparison condition. Analysis of key program elements demonstrated that integrating substance abuse, mental health, and trauma-related issues into counseling yielded greater improvement, whereas the delivery of numerous core services yielded less improvement relative to the comparison group. A few person-level characteristics were associated with increases or decreases in the intervention effect. These neither moderated nor supplanted the effects of integrated counseling. CONCLUSIONS: Outcomes for women with co-occurring disorders and a history of violence and trauma may improve with integrated treatment.     

Use of mental health care and substance abuse treatment among adults with co-occurring disorders

OBJECTIVES: This study investigated patterns of use of mental health care and substance abuse treatment for a nationally representative sample of adults with co-occurring mental health problems and a substance use disorder and compared these patterns with those of persons with either a mental health problem or a substance use disorder. METHODS: Data were from the 2001 and 2002 National Surveys on Drug Use and Health. The study examined rates of substance use disorders and mental health problems among adults aged 18 years and older, rates of substance use disorders among adults with mental health problems, and rates of mental health problems among adults with substance use disorders. Next, rates of substance abuse treatment and mental health care use were calculated among five groups that were formed on the basis of the presence of a substance use disorder, mental health problems, or both in the past year. RESULTS: A total of 2,851 respondents had a substance use disorder only, 1,633 had a substance use disorder with one or more mental health symptoms and without serious mental illness, 1,872 had a substance use disorder with serious mental illness, 13,759 had one or more mental health symptoms only, and 7,530 had a serious mental illness only. A substantial proportion of adults with comorbid mental health problems and a substance use disorder did not receive any treatment (46 percent of those with serious mental illness and 65 percent of those with one or more mental health symptoms). Co-occurring substance use disorder was not associated with increased use of mental health care. The likelihood of receiving any substance abuse treatment increased with the presence and severity of mental health problems. Across all five groups, use of mental health care was more common than use of substance abuse treatment. Less than one-third of patients with comorbid mental health problems and a substance use disorder who used mental health care also received substance abuse treatment. CONCLUSIONS: The large proportion of untreated individuals with mental and substance use disorders reinforces existing concerns about barriers to beneficial treatment. Low rates of use of substance abuse treatment among patients who have comorbid mental health problems and a substance use disorder and use mental health care suggest that recommendations that substance use disorders be treated before, or concurrently with, mental disorders have not been widely adopted.     

Impact of co-occurring substance use on 6 month outcomes for young people seeking mental health treatment

OBJECTIVE: Co-occurring substance use and mental health disorders are highly prevalent among young people attending services, yet few studies have examined the effect of such comorbidity among those referred for treatment. The aim of the current study was to examine the impact of co-occurring substance use disorders (SUDs) on 6 month outcomes for young people seeking mental health treatment. METHOD: One hundred and six young people (aged 15-24 years) with a non-psychotic DSM-IV Axis I disorder were assessed following referral to a specialist youth public mental health service. Participants were given a structured interview, as well as questionnaires assessing drug use, psychopathology, psychosocial functioning and self-esteem at baseline and 6 month follow up. RESULTS: At baseline, 23 participants met criteria for a co-occurring SUD and 83 had a non-psychotic Axis I disorder. Both the non-SUD and the co-occurring SUD groups had high levels of psychopathology, serious impairments in functioning and moderate levels of suicidal ideation, although those with co-occurring SUD had significantly poorer levels of functioning. At 6 month follow up the co-occurring SUD group continued to experience substantial problems with symptoms and functioning whereas the non-SUD group had significant improvement in both of these domains. CONCLUSIONS: The present findings are consistent with studies examining the impact of co-occurring substance use and mental health issues across different treatment settings, and reinforce recommendations that young people with co-occurring disorders require more intensive and integrated interventions. The present findings also highlight the need for routine assessment and management of substance use issues within youth mental health settings.     

Treatment for co-occurring mental and substance use disorders in five state Medicaid programs

OBJECTIVES: This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with co-occurring mental and substance use disorders in five states. METHODS: Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated. RESULTS: A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone. CONCLUSIONS: Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders.     

Perceived unmet need for mental health care for Canadians with co-occurring mental and substance use disorders

OBJECTIVE: Previous analyses demonstrated an elevated occurrence of perceived unmet need for mental health care among persons with co-occurring mental and substance use disorders in comparison with those with either disorder. This study built on previous work to examine these associations and underlying reasons in more detail. METHODS: Secondary data analyses were performed on a subset of respondents to the 2002 Canadian Community Health Survey (unweighted N=4,052). Diagnostic algorithms classified respondents by past-year substance dependence and selected mood and anxiety disorders. Logistic regressions examined the associations between diagnoses and unmet need in the previous year, accounting for recent service use and potential predisposing, enabling, and need factors often associated with help seeking. Self-reported reasons underlying unmet need were also tabulated across diagnostic groups. RESULTS: Of persons with a disorder, 22% reported a 12-month unmet need for care. With controls for service use and other potential confounders, the odds of unmet need were significantly elevated among persons with co-occurring disorders (adjusted odds ratio=3.25; 95% confidence interval=1.96-5.37). Most commonly, the underlying reason involved a preference to self-manage symptoms or not getting around to seeking care, with some variation by diagnosis. CONCLUSIONS: The findings highlight potential problems for individuals with mental and substance use disorders in accessing services. The elevated occurrence of perceived unmet need appeared to be relatively less affected by contact with the health care system than by generalized distress and problem severity. Issues such as stigma, motivation, and satisfaction with past services may influence help-seeking patterns and perceptions of unmet need and should be examined in future work.     

Three-year outcomes of long-term patients with co-occurring bipolar and substance use disorders.

Little is known about the long-term outcomes of patients in the public mental health system who are disabled by co-occurring bipolar and substance use disorders. This article reports on the 3-year course of 51 patients with co-occurring bipolar and substance use disorders in the New Hampshire Dual Diagnosis Study. Participants received integrated dual disorders treatments in the state mental health system and were independently assessed with standardized measures at baseline and every 6 months for 3 years. Though psychiatric symptoms improved only modestly, participants improved steadily in terms of remission from substance abuse (61% in full remission at 3 years); they also achieved greater independent living (average 239 days in third year), competitive employment (49% in third year), regular social contacts with nonsubstance abusers (46% at 3 years), and quality of life (56% satisfied with life at 3 years). Different domains of outcome were only weakly related to each other. Long-term, disabled patients with co-occurring bipolar and substance use disorders have potential for remission from substance abuse and substantial improvements in functioning and quality of life.     

A public health perspective on violent offenses among persons with mental illness

OBJECTIVE: This study reanalyzed existing data to assess the extent to which persons with mental illness might contribute to criminal violence in the community. METHODS: Data were examined from a representative sample of 1,151 remanded offenders who underwent a full structured diagnostic interview that was used to provide one-month prevalence rates of mental illnesses as defined by the Structured Clincal Interview for DSM-III-R. Diagnoses of interest were mood, psychotic, anxiety, psychoactive substance use, adjustment, and miscellaneous axis I disorders and axis II personality disorders. Criminological data describing the number of offenses against persons and property and the number of victimless crimes were abstracted from police arrest reports and warrants. A violent crime was defined as any crime against a person. RESULTS: The one-month prevalence of major mental and substance use disorders of newly admitted inmates was 61 percent. About 3 percent of violent offenses could be attributed to individuals who had a principal diagnosis of any non-substance use-related disorder. An additional 7 percent of violent offenses could be attributed to individuals who had a primary diagnosis of a substance use disorder. CONCLUSIONS: The results of the study support the hypothesis that people with mental and substance use disorders are not major contributors to police-identified criminal violence. Public perceptions of mentally ill persons as criminally dangerous appear to be greatly exaggerated.     

Risk reconsidered: targets of violence in the social networks of people with serious psychiatric disorders

Risk Reconsidered: Targets of violence in the Social Networks of People with Serious Mental illness. This exploratory analysis addresses the questions: 1) Who among the members of the social network of a person diagnosed with a major psychiatric disorder is likely to become a target of violence?; 2) What kind of relationships do targets have with respondents in terms of the quality and quantity of interactions?, and 3) What are the risk factors that contribute to being a target of violence for people who are in the social networks of persons with serious mental disorders? The samples of 169 people with serious mental disorders were followed for 30 months. A logistic regression model of the risk for being a target of violence among the members of the cohort's social network reveals that both target and respondent characteristics are salient, and that mothers who live with adult children who have schizophrenia and co-occurring substance abuse bear a substantially elevated risk of becoming a target of violence, compared to other social network members. Other factors that elevate the risk for being a target of violence are being an immediate family members of the respondent, more time in residence with the respondent, and whether the respondent is financially dependent on the family. Respondents with the most mental health center visits had lower odds of committing an act or threat of violence against a social network member.

     

Substance Use and Five-Year Survival in Washington State Mental Hospitals

This report combines five-year survival and cause of death in individuals discharged from Washington State mental hospitals with (1) mental illness only, (2) co-occurring mental illness and substance use disorder, or (3) substance use disorder only. Five-year survival was similar in the three groups, although after adjusting for age, individuals with co-occurring disorders or substance use disorder were almost 50% more likely to die than those with mental illness only. Persons with these conditions need treatment to prevent premature death and medical conditions directly related to substance use disorder.     

Limited English proficiency as a barrier to mental health service use: A study of Latino and Asian immigrants with psychiatric disorders

Language barriers pose problems in mental health care for foreign-born individuals in the United States. Immigrants with psychiatric disorders may be at particular risk but are currently understudied. The purpose of this study was to examine the effect of limited English proficiency (LEP) on mental health service use among immigrant adults with psychiatric disorders. Drawn from the National Latino and Asian American Study (NLAAS), Latino and Asian immigrant adults aged 18-86 with any instrument-determined mood, anxiety, and substance use disorder (n = 372) were included in the present analysis. Results from hierarchical logistic regression analyses showed that having health insurance, poor self-rated mental health, and more psychiatric disorders were independently associated with higher probability of mental health service use in the Latino group. After controlling for all background characteristics and mental health need factors, LEP significantly decreased odds of mental health service use among Latino immigrants. None of the factors including LEP predicted mental health service use among Asian immigrants, who were also the least likely to access such services. LEP was a barrier to mental health service use among Latino immigrants with psychiatric disorders. This study suggests that future approaches to interventions might be well advised to include not only enhancing the availability of bilingual service providers and interpretation services but also increasing awareness of such options for at least Latino immigrants. In addition, further investigation is needed to identify factors that can enhance access to mental health care services among Asians.     

Incarceration associated with homelessness, mental disorder, and co-occurring substance abuse

OBJECTIVE: This study assessed relationships between homelessness, mental disorder, and incarceration. METHODS: Using archival databases that included all 12,934 individuals who entered the San Francisco County Jail system during the first six months of 2000, the authors assessed clinical and behavioral characteristics associated with homelessness and incarceration. RESULTS: In 16 percent of the episodes of incarceration, the inmates were homeless, and in 18 percent of the episodes, the inmates had a diagnosis of a mental disorder; 30 percent of the inmates who were homeless had a diagnosis of a mental disorder during one or more episodes. Seventy-eight percent of the homeless inmates with a severe mental disorder had co-occurring substance-related disorders. Inmates with dual diagnoses were more likely to be homeless and to be charged with violent crimes than other inmates. Multiple regression analyses showed that inmates who were homeless and had co-occurring severe mental disorders and substance-related disorders were held in jail longer than other inmates who had been charged with similar crimes. CONCLUSIONS: People who were homeless and who were identified as having mental disorders, although representing only a small proportion of the total population, accounted for a substantial proportion of persons who were incarcerated in the criminal justice system in this study's urban setting. The increased duration of incarceration associated with homelessness and co-occurring severe mental disorders and substance-related disorders suggests that jails are de facto assuming responsibility for a population whose needs span multiple service delivery systems.     

Risk of Reincarceration Among Prisoners with Co-occurring Severe Mental Illness and Substance Use Disorders

This study examined whether the presence of a comorbid substance use disorder increased the risk of criminal recidivism and reincarceration in prison inmates with a severe mental illness. Our analyses of more than 61,000 Texas prison inmates showed that those with a co-occurring psychiatric and substance use disorder exhibited a substantially higher risk of multiple incarcerations over a 6-year period compared to inmates with psychiatric disorders alone or substance use disorders alone. Further research is needed to identify the factors associated with criminal recidivism among released prisoners with co-occurring disorders.     

Long-term use of VA mental health services by older patients with substance use disorders

OBJECTIVE: The authors studied long-term patterns and predictors of use of mental health services by older surviving patients with substance use disorders in the Veterans Affairs (VA) health care system. METHODS: In this prospective longitudinal study, patient treatment records were used to determine long-term (ten-year) patterns and predictors of use of VA mental health services in a nationwide cohort of 10,678 surviving patients with a substance use disorder who were 55 years of age or older. The patients were categorized into three groups based on diagnosis during the index episode: patients with alcohol or drug abuse or dependence, patients with alcohol or drug psychosis, and patients with both a substance use and a psychiatric disorder. Most of the patients had alcohol use disorders. RESULTS: Over the ten-year period, successively fewer patients obtained outpatient and inpatient mental health care. Among patients who did obtain such care, the intensity of service use increased. Medical care did not substitute for mental health treatment. Younger age, being unmarried, and having a more severe disorder were associated with a greater likelihood of mental health service use over the ten-year period. Patients with a dual diagnosis were significantly more likely to obtain outpatient mental health care. Treatment on a residential care unit and longer initial hospital stay were associated with a lower rate of mental health readmissions. CONCLUSIONS: Of the substantial number of patients with substance use disorders who survive into old age, those with more long-standing substance use problems and with dual diagnoses have the greatest need for long-term mental health treatment.     

Residential mobility of individuals with diagnosed schizophrenia

Background Several studies have compared the residential mobility of individuals with schizophrenia to mobility of individuals with other mental disorders or with no mental disorders. Little research has been undertaken to describe differences between single (i.e., infrequent) and multiple (i.e., frequent) movers with schizophrenia, and the association between frequency of mobility and health and health service use. Methods The data source is population-based administrative records from the province of Manitoba, Canada. Hospital separations and physicians claims are linked to health registration files to identify a cohort with diagnosed schizophrenia and track changes in residential postal code over time. Single movers (N = 736), who had only one postal code change in a 2.5-year observation period, are compared to multiple movers (N = 252), who had two or more postal code changes. Differences in demographic, socioeconomic, and geographic characteristics, measures of health service use, and the prevalence of several chronic diseases were examined using χ² tests, logistic regression, and generalized linear regression. Results Multiple movers were significantly more likely to be young, live in socioeconomically disadvantaged neighborhoods, and reside in the urban core. The prevalence of a co-occurring substance use disorder and arthritis was higher for multiple than single movers. Use of acute and ambulatory care for schizophrenia, other mental disorders, as well as physical disorders was generally higher for multiple than single movers. Conclusions Frequency of mobility should be considered in the development of needs-based funding plans and service delivery interventions. Other opportunities to use record-linkage techniques to examine residential mobility are considered.     

The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in obstetrics

OBJECTIVE: This investigation assessed the detection and treatment of psychiatric disorders and at-risk substance use among pregnant women in the obstetric sector. METHOD: The Primary Care Evaluation of Mental Disorders Patient Health Questionnaire and modified CAGE questionnaires were used to assess current psychiatric disorders and at-risk substance use among 186 women receiving prenatal care. Medical records were reviewed for evidence of obstetrical providers' recognition of psychiatric and substance use symptoms and diagnoses and initiation of evaluations and treatments. The associations between patient characteristics and chart-documented evaluations and treatments were ascertained. RESULTS: Seventy (38%) of the women met screening criteria for psychiatric disorders or substance use. Among women who screened positive, symptoms were recorded in 43% of the charts, diagnoses in 18%, evaluations in 35%, and treatments in only 23% Patients who screened positive for psychiatric disorders and/or substance use were significantly more likely to have a documented mental health evaluation if they were less well educated, had inadequate prenatal care, or had longer hospital stays at delivery. CONCLUSIONS: A substantial number of women treated in obstetrics have unrecognized and untreated psychiatric disorders and substance use. Given the potential impact of antenatal mental disturbances on maternal and infant outcomes, further investigations into the psychiatric evaluation and treatment of pregnant women in the obstetrical sector are required.