Proactive case finding for severe mental illness in a rural area in the Indian Punjab: findings and lessons

People with severe mental illnesses may experience barriers in accessing community mental health services. We used the key informant method to detect people with untreated severe mental illness in seven villages in the Indian state of Punjab. The key informant was a local community leader. We were able to contact 11 patients who were identified as suffering from severe mental illness by the key informants. On assessment, eight of them had intellectual disability and three had psychotic and affective illness. We discuss the barriers and opportunities for providing mental health services in the community.

     

Law & psychiatry: Responsibility for torts: should the courts continue to ignore mental illness?

Although courts routinely consider whether a criminal defendant's mental illness makes punishment unfair, the rules are very different for civil liability. When people with mental illness harm others, courts refuse to consider their mental states in determining civil liability. The justifications offered for this rule range from the difficulty of assessing the impact of mental illness on behavior to the desire to place the burden of loss on the person who caused the injury. Undeniably, though, mental disabilities are treated differently from physical impairments, and the law's resistance to change seems largely based on misunderstanding and prejudice against mental illness.     

Psychotic denial of pregnancy: legal and treatment considerations for clinicians

The authors examine the legal questions raised by the involuntary medical and psychiatric treatment of a patient with psychotic denial of pregnancy. A case is presented, and psychotic denial of pregnancy is defined. Legal cases are reviewed that set precedent for state intervention on behalf of either the pregnant mother or the fetus when the mother refuses care. Included are specific cases that have a bearing on the rights of pregnant women with co-morbid mental illness. A distinction is made between cases in which the mother is competent versus incompetent to make treatment decisions, and particular attention is paid to California law. The authors conducted systematic Westlaw and LexisNexis searches of relevant case law and legal precedent. Laws that address the rights of pregnant women are complex, and courts have allowed medical interventions against objection in cases of both competent and incompetent mothers. No clear legal precedent was found to guide decision-making in the specific case of a woman with psychotic denial of pregnancy. The principles of substituted judgment and best interest may help guide clinicians in making decisions about the treatment of pregnant patients in the absence of clear legal precedent.     

Mentally abnormal homicide in New Zealand as defined by legal and clinical criteria: a national study

BACKGROUND: Homicides by people with mental illness have been studied using either clinical or legal categorization of the homicide as abnormal. No previous study has employed both definitions in the same population. METHOD: A retrospective study of all homicides in New Zealand between 1988 and 2000 considered mentally abnormal homicide using a legal definition (when the courts deemed a contribution of mental illness was present) and a clinical definition (defined as the presence of a discharge diagnosis from inpatient mental health treatment) of 'mentally abnormal'. Rates, characteristics and time trends were investigated. RESULTS: Of the 844 cases, 7.1% met legal criteria for being mentally abnormal, while 7.7% had ever received a diagnosis for a psychotic illness, and a further 14.5% had been admitted to a psychiatric hospital for any other reason. The majority (60%) of perpetrators with a psychotic diagnosis received a mental health disposition from the court. Of these, 60% were first diagnosed with their psychotic illness prior to the homicide, while 28% were first diagnosed at the time of the offence and a further 12% after imprisonment. Of all those who received a psychotic diagnosis, 89% had post-conviction admissions or a mental health disposition. CONCLUSION: Legal and clinical definitions of mentally abnormal homicide detect similar rates of mentally abnormal homicide, but illustrate somewhat different dimensions of the relationship between mental illness and homicide.     

Postpartum psychosis and the courts

Although mental state defenses frequently are raised in cases of infanticide, legal criteria for these defenses vary across jurisdictions. We reviewed outcomes of such cases in states using M'Naughten or model penal code (MPC) standards for insanity, and the factors considered by the courts in reaching these decisions. LexisNexis and Westlaw searches were conducted of case law, legal precedent, and law review articles related to infanticide. Google and other Internet search engines were used to identify unpublished cases. Despite the differing legal standards for insanity among states, the outcomes of infanticide cases do not appear to be dependent solely on which standard is used. The presence of psychosis was important in the successful mental state defenses. This case series suggests that states that use the stricter M'Naughten standard have not been less likely than states with an MPC standard to adjudicate women who have committed infanticide as not guilty by reason of insanity.     

Demographic and clinical characteristics of people with intellectual disabilities with and without substance abuse disorders in a Medicaid population

Little is known about the demographic and clinical characteristics of people with intellectual disabilities and substance abuse problems. Drawing on health care billing claims for people with Medicaid coverage aged 12-99 years, the characteristics of people with intellectual disability and a history of substance abuse (N=9,484) were explored and compared with people with intellectual disability but without substance abuse. Age- and/or gender-adjusted odds ratios were derived from logistic regression analyses to consider differences in demographic and clinical diagnoses. People with intellectual disability and substance abuse constituted 2.6% of all people with intellectual disability, most of whom had a diagnosis of mild or moderate intellectual disability. People with intellectual disability and substance abuse problems were, on average, 2 years older than the comparison group and less likely to be White. The sample was more likely than the comparison group to have serious mental illness or depression and substance abuse-related disorders were not prevalent. These data provide a comparison point for existing studies of mental health diagnoses as well as new information about substance abuse disorders. Implications relate to the identification of substance abuse among people with intellectual disabilities as well as the establishment of demographic and clinical correlates.     

The associations between mental illness and homelessness among older people: An exploratory study

Rough sleeping has increased in Britain since the late 1980s, and there is a known high prevalence of mental illness in this population. There have been few studies of older homeless people however, and little is known about the association between mental illness and homelessness among this group. This paper explores the role of mental illness in contributing to the entry to homelessness, and its prevalence among a sample of older homeless people. Through an intensive field study which lasted for 15 months, multiple semi-structured interviews were conducted with 225 subjects over the age of 55 years in four British cities. There was a high prevalence of mental illness among the subjects and this was a factor in the entry to homelessness in many cases. There were indications that some subjects with mental health problems became homeless because their needs had been neglected or undetected. Mental health problems also had an impact on the circumstances of older homeless people and affected their ability to seek and accept help. More effective measures need to be taken to prevent homelessness amongst vulnerable older people.     

Mental illness, gender and homicide: A population-based descriptive study

In England and Wales, a lifetime history of mental disorder is recorded in almost a third of homicides but mental illness as a defence in homicide cases has recently come under review. In this study, we aimed to compare the social, criminological and clinical characteristics of women and men convicted of homicide and secondly, to understand how pathways through the judicial system differ by gender of the perpetrator, characteristics of the offence and mental illness. A cross sectional study of 4572 convicted homicide perpetrators in England and Wales 1997-2004 was performed. Significantly more women who had committed homicide had a lifetime history of mental illness and were more likely to be mentally ill at the time of offence compared to men. Women more often received non-custodial sentences, whether or not they had mental illness. If the victim were a child or other relative, the courts were more lenient with women. Gender and the presence of mental illness both influence the characteristics of homicide and outcome of the legal process in the UK. Our findings suggest that all perpetrators of homicide should have a psychiatric assessment pre-trial. Psychiatrists need to rate risk objectively in a gender blind way when providing psychiatric reports to be used as evidence in court.     

Psychosis and epilepsy in young people

The aim of this study was to describe the clinical characteristics of children and young people under 19 with both epilepsy and a psychotic state (schizophrenia-like psychotic episode, organic delusional disorder, or other brief psychotic episode). In total, the clinical case notes for 17 young people with these characteristics were identified retrospectively from three different sources. Compared with a group of young people with psychosis without epilepsy, children with epilepsy and psychosis more frequently had other neuropsychological problems like learning disability and autism. Both groups had a high rate of family histories of mental illness and social disability. Contrary to the findings in adults with psychosis and epilepsy, in this group of young people, psychosis was associated neither with temporal lobe epilepsy nor with mesial temporal sclerosis. The children with psychosis and epilepsy had a variety of seizure types and structural abnormalities.     

End-of-life decisions, powers of attorney, and advance directives

In modern medicine, decisions about the kind of treatment at life's end are often inevitable. According to German law, powers of attorney and advance directives can be of help in these decisions. When a patient in a state of competence has issued a lasting power of attorney, there is no need for courts to appoint a proxy, and physicians immediately have a legally empowered decision-maker they can address. According to current German law, advance directives are legally valid and binding expressions of a patient's will. They are, however, more powerful when issued after consultation with a physician. If treatment at life's end no longer complies with the patient's will or loses its medical indication, the goal of treatment should be redirected towards palliation. This implies that life-sustaining treatment may be withdrawn or withheld, which is best accomplished with sensitivity to the needs of patients, relatives, and health care professionals.     

The relationship between mental illness severity and stigma

OBJECTIVE: To investigate influencing factors for lay perception of mental illness severity and their effects on the stigma of mental illness. METHOD: Selective review including attitude surveys assessing social distance towards different diagnostic labels, and attitudes towards treatment professions, treatment strategies, and psychopharmacotherapy. RESULTS: Lays differentiate in their attitudes towards people with mental illness according to the given diagnostic label, the involved treatment professions or institutions, the applied treatment methods, and the perceived psychosocial disability. CONCLUSION: Beside perceived treatment intensity and diagnostic label, the perception of social disability of mentally ill people accounts for a differentiated stigma. The question arises how anti-stigma-programmes can include the topic of social disability into their messages without risking to strengthen the stigma of mental illness.     

Working, receiving disability benefits, and access to mental health care in individuals with bipolar disorder

OBJECTIVE: The objective of this study was to determine the extent to which people in a bipolar disorder (BPD) registry were working, factors associated with working and obtaining disability benefits, and the impact disability benefits have on work. METHODS: We compared the socio-demographic, disease, treatment, and health insurance characteristics among three work disability groups - working, not working, and not working and receiving disability benefits - using a chi-square statistical test on categorical data, one-way analysis of variance (ANOVA) to compare means, and a Kruskal-Wallis non-parametric test of significance with skewed data. RESULTS: Among 1,855 individuals, 49.4% reported they were working. Those working were younger, more frequently self-identified as Caucasian, were more highly educated, had a higher income, were more often married, had a shorter duration of illness, and reported the shortest illness duration, the lowest percentage of suicide attempts, and manic and mixed or rapid symptoms in the past 6 months compared to the two non-working groups. Working individuals least often reported receiving electroconvulsive therapy and being hospitalized and had the longest median duration since last hospitalization and the lowest percentage with treatment in the past 6 months. They were currently likelier to be treated by a primary care physician or other health professional than a psychiatrist compared to non-working groups. Finally, compared to the non-working groups, the working group had the highest percentage with no health insurance and private health insurance, the highest percentage using managed care, and the lowest percent under a fee-for-service plan. All work disability groups had similar perceptions of their mental health care plan in terms of the number of doctors or clinics from which to choose, the location of their health care providers, and the quality of mental health care. Those in the working group were least satisfied with the range of mental health services provided in their health plan. CONCLUSIONS: Disability benefits are rarely awarded when a person is working. Moreover, receipt of disability benefits increases the likelihood that a person with BPD will be receiving health care benefits and, in many cases, those benefits provide greater access to treatment compared to health care insurance received through an employer. We conclude that the incentives to work run counter to access to treatment among people with BPD.     

Use of the Sequential Intercept Model as an approach to decriminalization of people with serious mental illness

The Sequential Intercept Model provides a conceptual framework for communities to use when considering the interface between the criminal justice and mental health systems as they address concerns about criminalization of people with mental illness. The model envisions a series of points of interception at which an intervention can be made to prevent individuals from entering or penetrating deeper into the criminal justice system. Ideally, most people will be intercepted at early points, with decreasing numbers at each subsequent point. The interception points are law enforcement and emergency services; initial detention and initial hearings; jail, courts, forensic evaluations, and forensic commitments; reentry from jails, state prisons, and forensic hospitalization; and community corrections and community support. The model provides an organizing tool for a discussion of diversion and linkage alternatives and for systematically addressing criminalization. Using the model, a community can develop targeted strategies that evolve over time to increase diversion of people with mental illness from the criminal justice system and to link them with community treatment.     

Employment specialists’ perspectives on implementing supported employment with young adults

Objective: Youth and young adults with serious mental health conditions have particularly poor records of stable employment, but stable employment is a key to recovery. Employment specialists have a key role in supported employment services in assisting them with employment. This article describes the thoughts and concerns of employment specialists about finding and supporting employment for youth and young adults with serious mental health conditions. Method: The authors undertook 12 intensive interviews with supported employment specialists in two states. These interviews were transcribed and coded by the authors. A number of themes were identified and prototypical examples identified and included in the findings. Results: Although the employment specialists varied in their enthusiasm and optimism about the job, they agreed on key problems that they face in supporting employment for young adults that include employer resistance to hiring people with mental illness, increasing use of online applications, larger organizations not making hiring decisions locally and thus the decisions are not responsive to the employment specialist, resistance from family and mental health professionals and the young adults themselves to full-time employment and putting benefits at risk, and resistance from young adults to disclosing their disability to coworkers and thus being unwilling to take supported employment positions. Conclusions and Implications for Practice: These interviews suggest that some of the features of supported employment practice might need to be modified if young adults with serious mental health issues are to gain employment that over time could lead to significant careers and recovery.     

Prevalence and severity of mental health-related disability and relationship to diagnosis.

OBJECTIVE: Psychiatric disability has been defined largely from measures that focus on serious mental illness. This practice may have led to substantial underestimation of the total impact of mental disorders on community health. In this study a generic measure of mental health-related disability was used to examine disabilities attributable to various common mental disorders. METHODS: Data were drawn from the Australian National Survey of Mental Health and Wellbeing, a household survey of 10,641 adults that assessed participants for 14 DSM-IV disorders with use of the Composite International Diagnostic Interview. Screening instruments were used to identify likely cases of ICD-10 personality disorder, neurasthenia (an undifferentiated somatoform disorder), and psychosis. Mental health disability was assessed with the Medical Outcomes Study 12-item Short Form (SF-12) mental health summary scale, which was administered to all participants. RESULTS: Disability was significantly greater among participants with a current psychiatric diagnosis, and disability varied by type of disorder. Diagnosis remained a strong predictor of disability after sociodemographic factors and physical illness were controlled for. Disorders found to be independently associated with disability were depression, panic disorder, agoraphobia, social phobia, generalized anxiety disorder, alcohol dependence, and drug dependence. CONCLUSIONS: Substantial proportions of persons with mental disorders that are not usually classified as major mental disorders reported moderate and severe disability. A generic measure of mental health-related disability was able to detect variations in disability among persons with different diagnoses. Although such a measure is not as sensitive as a disorder-specific measure developed for use in psychiatric populations, it can facilitate comparison of disability across common mental disorders.     

The treatment and care of mentally ill offenders in Victoria,Australia

This article explains, examines and evaluates the effectiveness of the legislative scheme for the provision of psychiatric services to forensic patients in Victoria.¹ The term “forensic patients” is used to describe people who have mental illness and who have come into contact with the criminal justice system.² This includes people who receive treatment for mental illness in jail, in psychiatric in‐patient services, or in the community. New initiatives were introduced by Victoria's Mental Health Act in 1986 and 1990, and in the Sentencing Act 1991.³ The aims of the reforms are to provide the best possible care and treatment for people with mental illness, and to give sentencing judges and magistrates a range of dispositional options when dealing with mentally ill people who appear before the criminal courts. This encompasses the often conflicting aims of providing treatment and care, and protecting the public. It also involves a number of agencies whose roles are explained and examined.     

Structural stigma in state legislation

OBJECTIVE: This article discusses examples of structural stigma that results from state governments' enactment of laws that diminish the opportunities of people with mental illness. METHODS: To examine current trends in structural stigma, the authors identified and coded all relevant bills introduced in 2002 in the 50 states. Bills were categorized in terms of their effect on liberties, protection from discrimination, and privacy. The terms used to describe the targets of bills were examined: persons with "mental illness" or persons who are "incompetent" or "disabled" because of mental illness. RESULTS: About one-quarter of the state bills reviewed for this survey related to protection from discrimination. Within that category, half the bills reduced protections for the targeted individuals, such as restriction of firearms for people with current or past mental illness and reduced parental rights among persons with a history of mental illness. Half the bills seemed to expand protections, such as those that required mental health funding at the same levels provided for other medical conditions and those that disallowed use of mental health status in child custody cases. Legislation frequently confuses "incompetence" with "mental illness." CONCLUSIONS: Examples of structural stigma uncovered by surveys such as this one can inform advocates for persons with mental illness as to where an individual state stands in relation to the number of bills that affect persons with mental illness and whether these bills expand or contract the liberties of this stigmatized group.     

The case against outpatient commitment

Among individuals with severe mental illness, a small proportion commit violent acts. Since these individuals are often not engaged in ambulatory treatment, there has been a move in the states to legislate and implement outpatient commitment programs. The American Psychiatric Association Council on Psychiatry and Law has issued a Resource Document that supports the use of mandatory outpatient treatment. The purpose of this article is to challenge the logic and legitimacy of using the courts to force treatment compliance of individuals who are neither incompetent by legal standards nor at imminent risk of harming themselves or others.     

Religion and Spirituality in the Lives of People with Serious Mental Illness

Although there is a fair sized literature documenting the relationship of religiousness and spirituality with health and well-being, far fewer studies have examined this phenomenon for people with serious mental illness. In this research, religiousness is defined as participation in an institutionalized doctrine while spirituality is framed as an individual pursuit of meaning outside the world of immediate experience. In this study, 1,824 people with serious mental illness completed self-report measures of religiousness and spirituality. They also completed measures of three health outcome domains: self-perceived well-being, psychiatric symptoms, and life goal achievement. Results showed that both religiousness and spirituality were significantly associated with proxies of well being and symptoms, but not of goal achievement. Implications of these findings for enhancing the lives of people with psychiatric disability are discussed.     

Prevalence of intellectual disability and comorbid mental illness in an Australian community sample

OBJECTIVE: The aim of this study was to bring to light the high prevalence of Australians affected by intellectual disability and comorbid serious mental illnesses. Results from a broad scale study are used to explore the reasons for this regularly overlooked phenomenon. METHODS: This study was based on secondary analysis of data collected in the national 'Disability, Ageing and Carers Survey, 1998'. The analysed data consisted of an Australian wide sample of 42 664 individuals living at home or in cared accommodation. Classification of intellectual disability and comorbid psychosis, anxiety and depressive disorder was based on the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). RESULTS: The prevalence of intellectual disability in the sampled population was 1.25%. Of these people 1.3% had a psychotic disorder, 8% had a depressive disorder and 14% had an anxiety disorder that had been present for at least 6 months and was of such severity that it too was disabling. CONCLUSIONS: Findings indicate that people with intellectual disability are at high risk of developing comorbid serious mental illness. Dual diagnosis is however, often overlooked due to difficulties associated with establishing a diagnosis of a mental disorder in people with an intellectual disability, a problem which is heightened when the individual's capacity to participate in a clinical assessment is limited.