A Qualitative Exploration of Patient and Clinician Views on Patient Reported Outcome Measures in Child Mental Health and Diabetes Services

Patient Reported Outcome Measures (PROMs) are increasingly being recommended for use in both mental and physical health services. The present study is a qualitative exploration of the views of young people, mothers, and clinicians on PROMs. Semi-structured interviews were conducted with a sample of n = 10 participants (6 young people, 4 clinicians) from mental health services and n = 14 participants (4 young people, 7 mothers, 3 clinicians) from a diabetes service. For different reasons, young people, mothers, and clinicians saw feedback from PROMs as having the potential to alter the scope of clinical discussions.     

Estimated rates of mental disorders in, and situational characteristics of, incidents of nonfatal use of force by police

Purpose

To examine the estimated rates of mental disorders and associated situational characteristics in people involved in nonfatal use of force incidents with police in VIC, Australia.

Methods

A random sample of 4,267 cases between 1995 and 2008 from a dedicated police Use of Force Register were linked with the state-wide public mental health database and a police contacts database. Rates of ICD 9 and ICD 10 mental disorders recorded on the public mental health database were examined, as well as rates of criminal offending and the characteristics of force used by both parties.

Results

More than a third of people on whom the police resorted to using force (n = 1,621, 38 %) had a history of mental disorder. Significant overrepresentations of the estimated prevalence of psychosis [12.5 %, OR = 9.03, 95 % CI (7.41, 11.01), p < 0.001] and schizophrenia [9.1 %, OR = 9.73, 95 % CI (7.59, 12.47) p < 0.001] were found. Those diagnosed with mental disorders were 1.52 times more likely to use or threaten to use weapons on police, even after taking into account age, sex, substances intoxication and violent behaviour [95 % CI (1.23, 1.91), p < 0.001]; however, they were no more likely to injure or be injured by police than those without a recorded history of mental disorder. There was a noted trend for police to use, or threaten to use, weapons on people with a history of psychosis (other than schizophrenia) [OR = 1.40, 95 % CI (1.11, 1.78), p = 0.005].

Conclusions

Psychoses and schizophrenia are dramatically overrepresented in cases where police resort to using force. Situational characteristics evident in the encounters are suggestive of a sub-group of people with mental disorders presenting with aggressive and otherwise problematic behaviours coupled with histories of criminal offending; this presents significant ongoing challenges for the police.     

Mental disorders: employment and work productivity in Singapore

Aim

To examine the association between mental disorders and work disability in the adult resident population in Singapore.

Method

Data are from the Singapore Mental Health Study, which was a household survey of a nationally representative sample. The main instrument used was the Composite International Diagnostic Interview (CIDI). Employment-related information was collected using the modified employment module of the CIDI.

Results

A total of 6,429 respondents were included in the analysis, 71 % (n = 4,594) were employed, 24.5 % (n = 1,522) were economically inactive and 4.5 % (n = 313) were unemployed. Among the employed, 2.3 % had a 12-month prevalence of at least one mental disorder, while 5.3 % of the unemployed had at least one mental disorder. The average number of work loss days (absenteeism) per capita among those with a mental disorder was 0.5 per month that is equivalent to an annualized national projection of approximately 0.3 million productivity days. The average work-cutback days (presenteeism) were 0.4 days among this group. Of the mentally ill in the workforce, a high proportion (86.5 %) did not ever seek help for problems related to mental health.

Conclusion

Our findings provide information on the significant consequences of mental disorders on the workforce in terms of lost work productivity, which could pave the way for a more rational allocation of scarce resources.     

The impact of co-morbid personality disorder on use of psychiatric services and involuntary hospitalization in people with severe mental illness

Purpose

To examine the impact of co-morbid personality disorder (PD), on inpatient and community-based service use and risk of involuntary hospitalization, amongst patients with severe mental illness (SMI).

Methods

We identified SMI cases (schizophrenia, schizoaffective and bipolar disorder) with and without co-morbid PD, and PD cases, aged ≥18 years, in a large secondary mental healthcare case register. Using multivariable logistic regression, we examined the association between co-morbid PD and high level of inpatient and community-based service use (defined as the top decile of service use), and involuntary hospitalization, respectively, adjusting for socio-demographics, clinical symptoms and social functioning.

Results

Severe mental illness patients with co-morbid PD (SMI-PD) (n = 961) had more severe symptoms and social functioning problems compared to SMI patients without PD (n = 10,963) and patients who had PD but no concurrent SMI (n = 2,309). A greater proportion of SMI-PD patients were high inpatient service users (22.4 vs. 10.1 %). This association was attenuated but remained significant, after adjustment (fully adjusted odds ratio, OR 2.31, 95 % CI 1.88–2.84). The association between SMI-PD and high community-based service use was confounded by symptoms and social functioning. Compared to patients with SMI, SMI-PD patients were significantly more likely to experience involuntary hospitalization (fully adjusted OR 1.56, 95 % CI 1.31–1.85).

Conclusions

In SMI patients, co-morbidity with PD is robustly associated with both high use of inpatient psychiatric services and an increased likelihood of involuntary hospitalization. Patients with SMI and co-morbid PD are likely to require tailored interventions that target both the underlying personality pathology as well as the Axis I disorder.     

Prior Service Utilization in Detained Youth with Mental Health Needs

This study examined the prevalence of mental health needs and rates of service utilization among youth detained in a metropolitan juvenile justice system in California. Of the 345 youth in the sample, 265 (76.8 %) qualified for high or acute mental health need and 210 (60.9 %) had at least one prior contact with mental health services. No differences in mental health need were found across ethnicities; however rates of prior service utilization significantly differed (χ² = 19.18, p < 0.001). Asian and Pacific Islander participants were less likely to have had prior contact with county services than any other ethnic group.     

Prevalence and Correlates of Criminal Victimization Among New Admissions to Outpatient Mental Health Services in Hawaii

Adults with serious mental illness (SMI) experience criminal victimization at rates higher than the general population whether they reside in the community or correctional settings. This study examines the past-six month prevalence and correlates of criminal victimization among a large community sample (N = 2,209) of consumers with SMI newly admitted to outpatient mental health services during 2005 through 2008. A cross-sectional design was used with self-report and clinical data collected from administrative records. Victimization was determined by responses to direct questions about experiences in the previous 6 months with respect to victimization of a non-violent and/or violent crime. Socio-demographic, clinical and criminal correlates of victimization were abstracted from a quality of life survey and clinical assessment interview conducted at admission. Overall, 25.4 % of consumers reported being a victim of any crime (violent or non-violent) in the past 6 months, with 20.3 % reporting non-violent and 12.3 % violent victimization. The risk of victimization was elevated for those who were female, White, not taking atypical psychotropic medication, not feeling safe in their living arrangement, and were arrested or homeless in the six-months prior to engaging in mental health outpatient treatment. Policy and practice implications of these findings are discussed.     

Severe Mental Illness and Acute Stress: A Study of Service Utilization in a Conflict Zone

Patients suffering from severe mental illness (SMI) are considered especially vulnerable to stress. In this study, their use of acute stress services in a military context affecting civilian populations was assessed, using naturally occurring data. The proportion of patients with a previously known SMI, defined as any chronic psychotic disorder or bipolar disorder, among all civilians examined at a center for treatment of stress during a military conflict versus at the ER in usual times, was compared, using the Chi square statistical test. Among 354 subjects examined at the center for treatment of stress, 12 had a SMI diagnosis. Among 404 subjects examined at the ER in usual times, 16 had a SMI diagnosis. Patients with SMI were under-represented, but not in a statistically significant manner, at the center for treatment of stress (χ² = 0.31, p = ns). Although these results may imply that patients with SMI are not more vulnerable to external stress than the general population, we believe that they may have difficulties in seeking immediate help in such traumatogenic contexts. In order to reduce the occurrence of PTSD and gain efficacy in the treatment of the primary disorder, psychiatric services should perhaps make a reaching out effort to identify and examine these patients in the community. .     

Posttraumatic Stress Disorder and Use of Psychiatric and Alcohol Related Services: The Effect of the 2004–2005 Florida Hurricane Seasons on Veterans

The purpose of this study was to document preliminary findings of the association between posttraumatic stress disorder (PTSD), mental health service use, and alcohol related health visits among veterans following 2004–2005 Florida hurricane seasons. A retrospective review of the Veterans Health Administration Medical SAS Outpatient Dataset was conducted to identify veterans residing in Florida during the 2004–2005 hurricane seasons with a history of PTSD and/or PTSD and a substance use disorder. It was found that veterans with PTSD residing in counties affected by hurricanes demonstrated an immediate 28 % increase in use of mental health services following hurricane landfall versus veterans residing in non-hurricane affected counties (+28.0 vs. ?6.5 %, p = 0.001). Additionally, veterans residing in affected counties were found to use more group psychotherapy treatment sessions overall (30.3 vs. 27.2 %, p = 0.001). Of note, veterans with PTSD experienced a ?0.16 per month (p = 0.114) decrease in alcohol related visits following the 2004 hurricane season. These findings provide insight into the mental health needs of veterans with PTSD following a disaster and can inform delivery of services to veterans with PTSD and alcohol related issues in disaster prone areas.     

Evaluation of a campaign to improve awareness and attitudes of young people towards mental health issues

Purpose

This study evaluated the effectiveness of the In One Voice campaign for raising mental health awareness and improving attitudes of youth and young adults towards mental health issues. The campaign featured a prominent male sports figure talking about mental health issues and used online social media.

Methods

A successive independent samples design assessed market penetration and attitudinal changes among the young people. Two samples completed an online questionnaire either immediately before (T1: n = 403) or 2 months after (T2: n = 403) the campaign launch. Website analytics determined changes in activity levels of a youth-focused mental health website (mindcheck.ca).

Results

One-quarter (24.8 %, n = 100) of the respondents remembered the campaign. The proportion of respondents who were aware of the website increased significantly from 6.0 % at T1 to 15.6 % at T2. Average overall scores on standardized measures of personal stigma and social distance were not significantly different between T1 and T2 respondents. Attitudes towards mental health issues were statistically similar between respondents who were or were not exposed to the campaign. Those who were exposed to the campaign were significantly more likely to talk about and seek information relating to mental health issues.

Conclusions

The proximal outcomes of the campaign to increase awareness and use of the website were achieved. The distal outcome of the campaign to improve attitudes towards mental health issues was not successfully achieved. The brief social media campaign improved mental health literacy outcomes, but had limited effect on personal stigma and social distance.     

Trauma Risk Management (TRiM): Promoting Help Seeking for Mental Health Problems Among Combat-Exposed U.K. Military Personnel

Objectives: Trauma Risk Management (TRiM) is a peer-led, occupational mental health support process that aims to identify and assist U.K. military personnel with persistent mental ill health related to potentially traumatic events (PTEs). This study compared help seeking, mental disorder symptoms, and alcohol use between TRiM recipients and personnel experiencing similar combat events who did not receive TRiM; an unexposed group provided context. Methods: Records of TRiM activity during a U.K. military deployment in Afghanistan were linked to contemporaneous survey data assessing mental health and combat experiences. The resulting deployment data set was amalgamated with mental health, alcohol use, and help-seeking data collected within 12 weeks of homecoming and again one to two years later. Mental health and help-seeking outcomes were compared between a nonexposed, non-TRiM sample (n = 161), an exposed, non-TRiM sample (n = 149), and an exposed, TRiM-recipient sample (n = 328) using logistic regression analyses. Results: At follow-up, TRiM recipients were significantly more likely to seek help from mental health services than exposed, non-TRiM personnel. At baseline, TRiM recipients had significantly greater adjusted odds of reporting possible posttraumatic stress disorder (PTSD) symptoms than exposed non-TRiM personnel; the difference was not significant at follow-up. TRiM recipients were significantly more likely to report persistent mental disorder and alcohol misuse caseness over the follow-up period. Conclusions: TRiM recipients were significantly more likely to seek help from mental health services than a similar PTE-exposed group that did not receive TRiM; however, TRiM recipients experienced more persistent mental ill-health symptoms and hazardous alcohol use over the period of follow-up despite seeking help.     

Examining the Impact of Mental Illness and Substance Use on Time till Re-incarceration in a County Jail

This paper examines the role that substance use and serious mental illness play in criminal justice recidivism by examining the time to return to jail for a cohort of people admitted to jail in 2003 (N = 16,434). These analyses found that people with serious mental illness alone experienced the longest time in the community before returning to jail and were found to have a risk of re-incarceration that did not differ significantly from individuals with no psychiatric or substance use diagnoses. People with co-occurring disorders had a risk of re-incarceration that was over 40 % higher than that of individuals with no diagnosis.     

Another time point,a different story: one year effects of a social media intervention on the attitudes of young people towards mental health issues

Purpose

This study extends an evaluation of a brief, social media intervention, called In One Voice, for raising mental health awareness and improving attitudes of youth and young adults towards mental health issues.

Methods

A successive independent samples design assessed market penetration and attitudinal changes among the young people who completed an online questionnaire 1 year after (T3: n = 438) the intervention. This is compared with two samples that completed a survey either immediately before (T1: n = 403) or 2 months after (T2: n = 403) the campaign launch.

Results

The proportion of respondents who remembered the campaign grew from 24.8 % at T2 to 48.6 % at T3. Elevated website activity on mindcheck.ca was sustained 1 year after In One Voice had ended. Small but significant reductions in personal stigma and social distance were detected from T1 and T3, which were not observed at T2. Respondents’ self-rated ability to help others with mental health issues and to engage in positive behaviors relating to mental health issues (e.g., seeking information) did not improve significantly from T1 to T3.

Conclusions

Improved attitudes towards mental health issues were observed among young people 1 year following a brief social media campaign. The campaign was less effective at providing the tools young people need to feel capable of helping someone who may be experiencing mental health issues, and motivating them to engage in constructive behaviors related to mental health.     

Smartphone Ownership,Use, and Willingness to Use Smartphones to Provide Peer-Delivered Services: Results from a National Online Survey

Assess certified peer specialists’ smartphone ownership, use, and willingness to use smartphones to provide peer-delivered services. Certified peer specialist from 38 states completed an online survey. The final sample of 267 certified peer specialists included respondents from 38 states. The majority of certified peer specialists were female (73%; n =?195) and Caucasian (79.8%; n =?213), with an average age of 50.9 (SD =?12) years, range from 21 to 77 years. More than half of the certified peer specialists (82.1%; n =?184) were currently working in peer support positions. Of those who reported their mental health diagnoses, 11% reported their diagnosis as schizophrenia spectrum disorder, 22% of respondents reported bipolar disorder, and 23% reported persistent major depressive disorder. Nearly all respondents owned a smartphone (94.8%; n =?253), and everyone indicated that smartphones and tablets could enhance the services they deliver. Certified peer specialists reported substantial ownership and use of smartphones, comparable to existing national data. They are willing to deliver smartphone interventions for mental health and physical health self-management, suggesting that smartphones may be an increasingly useful tool for offering evidence-based care. Without Medicaid mandate, certified peer specialists are naturally trying to enhance peer delivered services with technology. Peer support could act as a mechanism to promote consumer engagement in a smartphone-based intervention. Certified peer specialist own and utilize smartphones, and the majority are willing to deliver technology-based and technology-enhanced interventions using these devices to address medical and psychiatric self-management.     

'Forensic' labelling: an empirical assessment of its effects on self-stigma for people with severe mental illness

Increasingly, specialized ‘forensic’ mental health services are being developed to address the criminogenic and clinical needs of people with mental illness who are involved in the criminal justice system. Theoretically, the construction of such specialized services can produce simultaneous positive benefits and negative consequences. This mixed methods study examined and compared the level of self-stigma that was experienced by people who receive compulsory community-based treatment services in the forensic (n = 52) and civil (n = 39) mental health systems of British Columbia, Canada. The quantitative findings indicate that ‘forensic’ labelling was not associated with elevated levels of self-stigma. Quantitative level of self-stigma was significantly associated with psychiatric symptom severity, history of incarceration, and history of homelessness. The qualitative findings suggest that access to high-quality, well-resourced forensic mental health services may, for some service users, come at the risk of increased exposure to social and structural stigma. Together, these findings reveal some of the strengths and weaknesses that are associated with organizing forensic mental health services using a specialized service delivery model.     

Mental Health Referrals Reduce Recidivism in First-Time Juvenile Offenders,But How Do We Determine Who is Referred?

While psychiatric disorders are common among juvenile delinquents, many mental health problems go undetected, increasing the likelihood for persistent difficulties. This is the first known study to examine mental health referral rates and recidivism in the juvenile justice system. In addition to the study, we review juvenile justice mental health screening to improve detection and treatment. Juvenile criminal records in conjunction with behavioral health screenings were analyzed to determine differences in referrals and recidivism among first time offenders. Recidivism rates were significantly lower (p = 0.04) and time to recidivism was significantly longer (p = 0.03) for those referred specifically for mental health services than for those without any referrals, even after adjusting for offense severity. While black youths had a significantly higher recidivism rate (p = 0.02) and a shorter time to recidivism (p = 0.009) than white youths, there was no significant difference between races when referred specifically for mental health services. Among the groups studied, black youths had the most profound positive effect from mental health referrals (p < 0.0001). This study indicates the importance of detecting mental health problems among juvenile delinquents, especially for black offenders. The apparent protective effect of mental health interventions necessitates screening that better identifies underlying psychosocial factors rather than strict reliance upon diagnostic criteria and self-report. Broader or even universal mental health referrals for juvenile offenders could reduce future legal system involvement and costs to society. We review potential reasons that mental health problems go undetected and provide recommendations.     

Serious Mental Illness in Heavy Drinkers Is Associated with Poor Treatment Outcomes in Outpatients with Co-occurring Disorders

The objective of this study was to determine whether the interaction between type of serious mental illness (SMI) and pre-treatment drinking severity, assessed by ethyl glucuronide (EtG), predicts EtG-positive urine samples submitted during treatment in outpatients with co-occurring alcohol dependence and SMI. Seventy-nine participants were randomized to treatment-as-usual or treatment-as-usual and contingency management (CM) targeting alcohol abstinence. Generalized estimating equations were used to assess the interaction of pre-treatment drinking (heavy drinking or light drinking) and SMI diagnosis (major depression, bipolar, or schizophrenia-spectrum disorders) across a 12-week treatment period. In the overall sample, the interaction of drinking severity and SMI diagnosis (p = 0.006) was associated with alcohol abstinence. Exploratory analyses of the interaction term among participants randomized to CM (n = 40; p = 0.008) were associated with alcohol abstinence during CM. Type of SMI diagnosis was associated with treatment outcomes in individuals who engaged in heavy drinking, but not light drinking, prior to treatment.     

Racial–Ethnic Variation in Mental Health Service Utilization Among People with a Major Affective Disorder and a Criminal History

Using a nationally representative sample, this study examined the extent to which the utilization of various mental health services was associated with racial–ethnic identity among people with major affective disorders who have a criminal history. Approximately 33.7 % of the sample received any type of mental health services in a given year. Multivariate models indicated that married Blacks and Latinos were less likely to use specialty mental health care than their white counterparts. To provide equitable mental health treatment for vulnerable subgroups of this population, mental health professionals should account for the heterogeneity of mental health care in diverse cultural contexts.     

Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis

Purpose

To evaluate the effectiveness of peer-delivered interventions in improving clinical and psychosocial outcomes among individuals with severe mental illness (SMI) or depression.

Methods

Systematic review and meta-analysis of randomised controlled trials comparing a peer-delivered intervention to treatment as usual or treatment delivered by a health professional. Random effect meta-analyses were performed separately for SMI and depression interventions.

Results

Fourteen studies (10 SMI studies, 4 depression studies), all from high-income countries, met the inclusion criteria. For SMI, evidence from three high-quality superiority trials showed small positive effects favouring peer-delivered interventions for quality of life (SMD 0.24, 95 % CI 0.08–0.40, p = 0.003, I ² = 0 %, n = 639) and hope (SMD 0.24, 95 % CI 0.02–0.46, p = 0.03, I ² = 65 %, n = 967). Results of two SMI equivalence trials indicated that peers may be equivalent to health professionals in improving clinical symptoms (SMD ?0.14, 95 % CI ?0.57 to 0.29, p = 0.51, I ² = 0 %, n = 84) and quality of life (SMD ?0.11, 95 % CI ?0.42 to 0.20, p = 0.56, I ² = 0 %, n = 164). No effect of peer-delivered interventions for depression was observed on any outcome.

Conclusions

The limited evidence base suggests that peers may have a small additional impact on patient’s outcomes, in comparison to standard psychiatric care in high-income settings. Future research should explore the use and applicability of peer-delivered interventions in resource poor settings where standard care is likely to be of lower quality and coverage. The positive findings of equivalence trials demand further research in this area to consolidate the relative value of peer-delivered vs. professional-delivered interventions.     

Twelve-month treatment of psychiatric disorders in the South African Stress and Health Study (World Mental Health Survey Initiative)

Background

The proportion of people with mental disorders in treatment is relatively small in low and middle income countries. However, little is known about patterns of recent service use in a country like South Africa.

Methods

A nationally representative household survey of 4,351 adult South Africans was carried out. Twelve-month DSM-IV disorders were determined using the WHO composite international diagnostic interview (CIDI). Prevalence and correlates of treatment were assessed among respondents with anxiety, mood and substance use disorders.

Results

One-fourth (25.5%) of respondents with a 12-month disorder had received treatment in the past 12 months either from a psychiatrist (3.8%), nonpsychiatrist mental health specialist (2.9%), general medical provider (16.6%), human services provider (6.6%), or complementary-alternative medical (CAM) provider (5.9%). Only 27.6% of severe cases had received any treatment. In addition, 13.4% of respondents with no disorder had accessed services in the past year. Blacks were significantly more likely than other racial groups to access the CAM sector while Whites were more likely to have seen a psychiatrist.

Conclusions

The majority of South Africans with a 12-month mental disorder have unmet treatment needs. In addition to a greater allocation of resources to mental health services, more community outreach and awareness initiatives are needed.     

A Qualitative Study of Addiction Help-Seeking in People with Different Co-occurring Mental Disorders and Substance Use Problems

People with mental disorders (MD) have high rates of substance use problems (SUP) that are undertreated and understudied despite their adverse outcomes. The objective of this study is to examine barriers and facilitators that influence help-seeking to addiction treatment from the perspective of people with co-occurring MD and SUP. Forty-three individuals with MD and SUP were selected from the sample (n = 127) of a larger research project. This sub-group participated in semi-structured interviews and completed questionnaires. Interview contents were thematically analyzed using a trajectory approach. Based on participants’ addiction trajectories, two mental health experiences were identified: the “multiple disorders experience” and the “anxiety disorder experience.” The analysis highlighted how participants relate to barriers and facilitators to addiction help-seeking at the individual level (denial/minimization of problematic drug use, fear of being labeled an addict, influence of social networks, and knowledge of addiction services) and health system level (waiting time, costs, relationships with health providers, therapeutic approaches, and availability of psychological support). Interventions should be sensitive to the different experiences of people with MD and SUP. Integrated addiction services and a “no wrong door” approach are suggested.