Perceptions of discrimination among persons with serious mental illness

OBJECTIVES: The authors sought to gain further perspective on discrimination experienced by persons with mental illness by comparing self-reports of discrimination due to mental illness to self-reports of discrimination due to other group characteristics, such as race, gender, and sexual orientation. METHODS: A total of 1,824 persons with serious mental illness who participated in a baseline interview for a multistate study on consumer-operated services completed a two-part discrimination questionnaire. The first part of the questionnaire assessed participants' perceptions about discrimination due to mental illness as well as more than half a dozen other group characteristics. The second part of the questionnaire asked participants who reported some experience with discrimination to identify areas in which this discrimination occurred, such as employment, education, and housing. RESULTS: More than half of the study participants (949 participants, or 53 percent) reported some experience with discrimination. The most frequent sources of this discrimination were mental disability, race, sexual orientation, and physical disability. Areas in which discrimination frequently occurred included employment, housing, and interactions with law enforcement. Areas in which discrimination was experienced did not significantly differ among groups of study participants characterized by mental disability, race, gender, sexual orientation, or physical disability. CONCLUSIONS: Discrimination based on group characteristics other than mental illness does not diminish the impact of stigma associated with mental illness. Antistigma programs need to target not only discrimination related to mental illness but also that associated with other group characteristics, such as race, gender, sexual orientation, and physical disability.     

HIV risk factors for persons with serious mental illness

HIV risk factors were assessed among 120 persons in treatment for serious mental illness. Although subjects had good general knowledge regarding HIV, many engaged in high risk behaviors. Condom use was infrequent among those who had multiple sexual partners, and sharing needles was common for those who used IV drugs. Clearly, factual knowledge about HIV was not sufficient to prevent risky behavior. Nearly half of the sample was categorized as at medium to high risk, and almost half of the participants, especially those at medium risk, underestimated their own level of risk. The results suggest that education and intervention strategies should focus on increasing the accuracy of the individual's risk assessment as well as changing attitudes towards condoms and improving skills in using condoms. Assessing personal risk and adopting risk-reduction strategies are the keys to successful AIDS prevention for persons with serious mental illness.Michael D. Knox is Professor and Chair of the Department of Community Mental Health at the University of South Florida's Florida Mental Health Institute. He also serves as Director of the USF Center for HIV Education and Research. Timothy L. Boaz is Associate Professor in the Department of Community Mental Health. Martha A. Friedrich is Assistant Professor in the Department of Community Mental Health and Associate Director of the USF Center for HIV Education and Research. Michael G. Dow is Associate Professor and Director of Research in the Department of Community Mental Health.This research was funded in part through contract #91MF57230401D with the National Institute of Mental Health. The support and guidance of Armand Checker and Juan Ramos, National Institute of Mental Health, is appreciated.     

Medical advance care planning for persons with serious mental illness

OBJECTIVE: This study examined preferences regarding medical advance care planning among persons with serious mental illness, specifically, experience, beliefs, values, and concerns about health care proxies and end-of-life issues. METHODS: A structured interview, the Health Care Preferences Questionnaire, was administered to a convenience sample of 150 adults with serious mental illness who were receiving community-based services from the Massachusetts Department of Mental Health. Clinical information and demographic data were also collected. RESULTS: A total of 142 participants completed the questionnaire. Although more than one-quarter had thought about their medical treatment preferences in the event that they became seriously medically ill, very few had discussed these preferences. A majority of respondents (72 percent) believed that someone should be designated to make medical health care decisions for a person who is too sick to make or communicate these decisions him- or herself. Common end-of-life concerns included financial and emotional burdens on family, pain and suffering, interpersonal issues such as saying "goodbye," spiritual issues, and funeral arrangements. Participants were most uneasy about the prolonging or stopping of life support by proxy decision makers. A total of 104 respondents (69 percent) expressed interest in formally selecting a health care proxy. CONCLUSIONS: Although persons with serious and persistent mental illness have little experience with medical advance care planning, they show substantial interest in it. Furthermore, they are able to consider and communicate their preferences. This study supports the feasibility, acceptability, and utility of a standardized approach to medical advance care planning with this population.     

Identifying and using reinforcers to enhance the treatment of persons with serious mental illness

Successful engagement of clients with serious and persistent mental illnesses in the planning and implementation of treatment requires the identification of individualized reinforcers through motivational analyses. Reinforcer surveys are interviews or questionnaires that list numerous objects, persons, activities, and settings, and then assess the client's perception of the value of each item. Such surveys help identify the type of reward that might be useful for motivating the client. If properly assessed and delivered, reinforcers can increase clients' skill acquisition, attainment of goals, and feelings of self-efficacy.     

Outcomes of shelter use among homeless persons with serious mental illness

OBJECTIVE: The purpose of this study was to examine the extent to which the use of case management services predicted public shelter use among homeless persons with serious mental illness after the termination of Access to Community Care and Effective Services and Supports (ACCESS), a five-year outreach and case management program. METHOD: The sample consisted of 475 Philadelphia ACCESS program participants. Client-level interview data and case manager service delivery records that were collected during the ACCESS intervention period were linked with administrative data on public shelter use for the 12-month period after the ACCESS program was terminated. By using Cox's proportional hazards model, multivariate analyses were conducted to test how the characteristics of the participants and the intensity of case management service use affected the rate of the first entry into a public shelter. RESULTS: Homeless individuals with serious mental illness who were younger, were African American, had fewer years of schooling, and had longer shelter stays during the ACCESS intervention period were more likely to enter shelters in the 12 months after the ACCESS program ended. Although use of vocational and supportive services was associated with a lower probability of shelter entry, use of housing assistance was associated with a higher probability of shelter entry. CONCLUSIONS: The study found that the total number of case management service contacts was not significantly associated with residential outcomes. Rather, the use of specific types of services was important in reducing the use of homeless shelters. These findings suggest that case management efforts should focus on developing vocational and psychosocial rehabilitation services to reduce the risk of recurrent homelessness among persons with serious mental illness.     

Designing psychoeducational services for spouses of persons with serious mental illness

Psychoeducational and support groups for families of mentally ill adults may not be adequately addressing the needs of spouses with mentally ill partners. This paper describes a group psychoeducational approach which has been developed and implemented through collaboration between professionals and well spouses. The high attrition of spouses in a general family psychoeducational group was dramatically reduced in this spouse psychoeducational group. Significant improvements were found in well spouse knowledge about the illness and coping strategies, personal distress, and negative attitudes towards the ill spouse over the 3-month intervention and at 1-year followup. Implications for practitioners and researchers are discussed.This pilot study was partially supported by grants from the Pew Charitable Trusts and the City of Philadelphia Office of Mental Health/Mental Retardation. The authors gratefully acknowledge Rita Packard, Marilyn Meisel, Margaret Douglas Sayers and all of the Spouse Task Force members and Spouse Workshop participants for their countless contributions to this work.     

Integrating physical activity into mental health services for persons with serious mental illness

This article reviews evidence supporting the need for interventions to promote physical activity among persons with serious mental illness. Principles of designing effective physical activity interventions are discussed along with ways to adapt such interventions for this population. Individuals with serious mental illness are at high risk of chronic diseases associated with sedentary behavior, including diabetes and cardiovascular disease. The effects of lifestyle modification on chronic disease outcomes are large and consistent across multiple studies. Evidence for the psychological benefits for clinical populations comes from two meta-analyses of outcomes of depressed patients that showed that effects of exercise were similar to those of psychotherapeutic interventions. Exercise can also alleviate secondary symptoms such as low self-esteem and social withdrawal. Although structured group programs can be effective for persons with serious mental illness, especially walking programs, lifestyle changes that focus on accumulation of moderate-intensity activity throughout the day may be most appropriate. Research suggests that exercise is well accepted by people with serious mental illness and is often considered one of the most valued components of treatment. Adherence to physical activity interventions appears comparable to that in the general population. Mental health service providers can provide effective, evidence-based physical activity interventions for individuals with serious mental illness.     

The residential needs and preferences of persons with serious mental illness: a comparison of consumers and family members

This study reports on a systematic statewide effort to determine the residential needs and preferences of two important groups: primary consumers of mental health services and family members of consumers. Two comparable surveys regarding the residential needs of consumers were conducted. In all, 314 consumers and 459 family members participated in the survey. A comparison of the preferences of family members and consumers suggests that family members more often prefer congregate living situations and more staff support than do consumers. Consumers more often express a desire to reside by themselves without staff and without other persons who are mentally ill. While the direct comparison of preferences from these two constituencies has limitations, these data do suggest significant variability in needs and preferences voiced by consumers and their family members; discrepancies that need to be addressed by mental health policymakers and planners.     

Homelessness among persons with serious mental illness in an enhanced community-based mental health system

OBJECTIVE: Homelessness and patterns of service use were examined among seriously mentally ill persons in an area with a well-funded community-based mental health system. METHODS: The sample consisted of 438 individuals referred between 1990 and 1992 to an extended acute care psychiatric hospital after a stay in a general hospital. Those experiencing an episode of homelessness, defined as an admission to a public shelter between 1990 and 1993, were compared with those who were residentially stable. Data from a longitudinal integrated database of public mental health and medical services were used to construct service utilization measures to test the mediating effect of outpatient mental health care on preventing homelessness. RESULTS: A homelessness rate of 24 percent was found among the 438 persons with serious mental illness. Those who experienced homelessness were more likely to be African American, receive general assistance, and have a comorbid substance abuse problem. They used significantly more inpatient psychiatric, emergency, and health care services than the subjects who did not become homeless. Forty to 50 percent of the homeless group received outpatient care during the year before and after their shelter episode. The number of persons who received intensive case management services increased after shelter admission. CONCLUSIONS: An enhanced community-based mental health system was not sufficient to prevent homelessness among high-risk persons with serious mental illness. Eleven percent of this group experienced homelessness after referral to an extended acute care facility. Strategies to prevent homelessness should be considered, perhaps at the time of discharge from the referring community hospital or extended acute care facility.     

Mothers with serious mental illness

Mental health services have generally ignored the parenting needs of women with serious mental illness. This chapter identifies the parenting risks and strengths that these women display, as well as the opportunities available to psychologists to play a key role in improving mother and child outcomes.