Cost Analysis of Psychiatric Care With and Without Supportive Housing for Patients With Severe Mental Illness in Canada: A Rapid Review

IntroductionMental health supportive housing aims to provide accommodation and support services to people with serious mental illness (SMI). Various supportive housing models have emerged in Canada post-deinstitutionalization, with heterogeneous and limited available information on congregate-based high support housing models (HSH) that provide 24/7 onsite supports. A registered scoping review was undertaken to identify the models and outcomes of HSH for people with SMI in Canada, including those exiting homelessness.MethodsFour academic databases (Medline, Embase, PsycINFO, CINAHL Plus) were searched, in addition to backward and forward citation searching and strategies for identifying grey literature. HSH configurations and outcomes (e.g., housing stability and preferences; physical and behavioral health; community integration, social support, and quality of life; costs) were investigated within the Canadian context.ResultsA total of 27,180 academic articles and 164 grey literature reports were initially screened. Following full-text review of 337 academic and 109 grey literature articles, and citation searching, a total of 58 academic articles and 31 grey literature reports were included in the review. The characteristics, objectives, and outcomes of HSH models were mixed. Three nonexclusive types of HSH were identified: [1] custodial HSH, [2] recovery-oriented HSH, and [3] alternatives to hospital programs and other institutions. Most studies were uncontrolled, though there was preliminary evidence to support improvements in HSH residents' health and functioning; gains in social support, quality of life, and community integration; reductions in housing and service costs, particularly when compared to the cost of inpatient hospitalization; and satisfaction with living arrangements, supports, and relationships. However, the findings were not unequivocal, and the diversity of methodologies and HSH models limited further comparisons of outcomes between the different types of HSH.ConclusionPeople with SMI experiencing complex and diverse needs can benefit from the services and supports provided by HSH. However, research on HSH is less developed compared to other, well-studied housing interventions. Further research on congregate housing settings, including their long-term outcomes and recovery-oriented practices, is warranted.

Cancer Risk Factors Among Adults with Serious Mental Illness

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. 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. 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. 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.

The meaning associated with the language used in health care undoubtedly has an impression on the way the individual and their condition is viewed. This is no more evident than in the mental health field where symptoms, risk factors, diagnosis, and the ‘expert’ interpretation of thoughts, feelings, and behaviours has a significant influence on people experiencing mental illness as well as clinicians and the wider public. Clearly, many people do encounter challenging, enduring, and at times debilitating states of mental illness; although we should not presume that all individuals ‘suffer’ from the experience of mental ill-health. Indeed, there are those who celebrate it (http://en.wikipedia.org/wiki/Mad_Pride). Much attention is currently focused on the physical health of people with mental illness and, consequently, a multitude of studies, reports, literature reviews, and discussion papers highlighting this issue have saturated nursing and medical journals. Included in this body of published work was a recent special edition of the International Journal of Mental Health Nursing published in 2012 which was devoted to ‘The physical health of patients with severe mental illness’. This cause is laudable, however, a definition of what constitutes ‘severe’ or ‘serious’ mental illness (SMI) is not forthcoming. It is assumed that everyone knows who this group is. These terms also appear to be used interchangeably, but are they the same thing? What is more, when such prefixes are used to describe a mental health condition, it implies that other degrees or even classes of mental illness exist, but one has to wonder where this ends. If there is such a thing as SMI, then conceivably there is ‘very serious’, or ‘extremely serious’, or perhaps even ‘not that serious’ mental illness. It does appear that only people with psychiatric diagnoses such as schizophrenia, bipolar disorder, or major depression are worthy of the labels serious or severe mental illness; but not those with anxiety, panic, or survivors of trauma, for example, which can also be debilitating and significantly impact on physical health. Additionally, what about those individuals with dieting and eating difficulties? This group also seems to be excluded from the SMI and physical health club. Being labelled with a mental illness is sufficiently challenging (and stigmatizing) without adjectives such as ‘serious’ or ‘severe’ being added to further consign the individual to a life of mental ill-health. Consider the message being conveyed: just when you thought that recovery from your mental illness was possible, here is an additional hurdle to overcome; now, try getting out of that one! Furthermore, the diagnostic systems used in mental health are already heavily laden with subjectivity, without more imprecision being added to the mix. We should always be mindful that psychiatric diagnoses are based on a consensus model and therefore represent merely one version of the truth. The problem-based and illness mentality that permeates mental health ‘care’ may be advantageous for a private practice business model, which relies on people remaining in longer-term ‘treatment’ for it to be sustainable. However, in the government-run health sector there is an ample number of individuals seeking support to keep these services busy and viable. Perhaps it is time to question whose interests are being served by this continued emphasis on risk, illness, and disorder, and consider the emancipatory quality of adopting a wellness focus, not only for people experiencing mental ill-health, but also for clinicians who work in this field. We may even find our workload decreases as a result.

Homeless and impaired: the burden of serious psychiatric illness.

Impact of Permanent Supportive Housing on the Use of Acute Care Health Services by Homeless Adults

Developed and produced at Toronto's Workman Theatre Project (WTP) in 1993, Terry Watada's play The Tale of a Mask weaves a Japanese folktale with a contemporary tragedy inspired by a double murder and suicide in Vancouver. Since 1991, the WTP has collaborated with playwrights to develop plays that educate audiences about mental illness and destabilize representations that perpetuate stigma. The Tale of a Mask was developed as part of a WTP initiative to investigate multiculturalism, immigration, and mental illness in Canada. The eponymous mask of the title, the author argues, acts as an enigmatic symbol for mental illness read differently by different cultures. Elabore et realise au Workman Theatre Project (WTP) de Toronto en 1993, The Tale of a Mask de Terry Watada est un conte japonais populaire entrelace avec une tragedie contemporaine inspiree par un double meurtre et suicide a Vancouver. Depuis 1991, le WTP a collabore avec des dramaturges pour elaborer des pieces de theâtre qui renseignent les auditoires sur les maladies mentales et destabilisent les representations qui perpetuent les stigmates. The Tale of a Mask a ete elabore dans le cadre d'une initiative du WTP pour examiner de plus pres le multiculturalisme, l'immigration et les maladies mentales au Canada. Le masque mentionne dans le titre represente, d'apres l'auteure, un symbole enigmatique de la sante mentale percu differemment par differentes cultures. How might mental illness be performed on a contemporary Canadian stage? This deceptively simple question lies at the heart of an innovative theatre company attached to the Centre for Addiction and Mental Health in Toronto. Since 1989, the Workman Theatre Project (WTP) has sought to produce plays about mental illness. Their more than 20 productions have had the dual aim of giving voice to artists who have experienced mental illness and educating the public in order to combat the stigma of mental illness. In The Last Taboo: A Survival Guide to Mental Health in Canada (2001), Scott Simmie and Julia Nunes argue that many people who have received mental health services in Canada cite stigma as worse than mental illness itself: social discrimination, stigma, and isolation may compound and exacerbate the suffering of people diagnosed with mental illness. Moreover, stigma may prevent people suffering with mental illness from seeking help, professional or otherwise. Left to cope with illness on their own, people may become vulnerable to a host of ill effects, a range of self-destructive behaviours, or suicide. For WTP members, such high stakes create a forceful need to combat stigma-a need that informs much of their creative work. The project's dramaturgical process involves collaboration between commissioned professional playwrights, actors and directors with an interest in mental illness issues, and project members.1 At its broadest level, the WTP seeks both to destabilize mental illness representations that perpetuate stigma and to highlight the impossibility of ever wholly fixing or knowing mental illness on stage. Terry Watada's The Tale of a Mask, staged at the WTP in 1993, was developed and performed as part of a broader WTP initiative to investigate multiculturalism, immigration, and mental illness in Canada. It is a tragedy based on the real life and death of Fumiyo Takabe, a Japanese immigrant who became profoundly isolated and depressed in her new home of Vancouver in 1990 and took her own life and that of her husband and sons.2 The Tale of a Mask tells a parallel story about a central character named Aiko Shinde, her husband Masato, and her son Kentaro, who experience isolation, stigma, and cultural misunderstanding when they immigrate to Toronto from Japan in 1992. In a state of extreme depression, Aiko kills Masato, Kentaro, and herself. While the play's broad narrative seems to posit a direct relationship between real and represented events, its formal structure aims to do the opposite. …

This research study portrays work initiatives for persons with serious mental illness in Canada. It considers 2 earlier papers on vocational programs and services to point out developments and current status in the field. Through a content analysis of documents collected from work initiatives across Canada, core values, models, and practices in the area of work integration are presented. Findings point to a consistent belief in the capacity of consumers to develop their work potential, to engage in the labour force, and to experience the many benefits of work. Results also reveal evidence of an increased emphasis on consumer initiatives, partnerships within the community, and negotiation of environmental factors, including workplace accommodations. Examples of work initiatives are provided, and suggestions for further research are offered.

Overweight and obesity disproportionally impact people with serious mental illness (SMI). Healthy lifestyle interventions can improve the health of people with SMI but may need to be adapted for this population. The aims of this study were: to (1) examine the feasibility and acceptability of delivering the Peer-based Group Lifestyle Balance (PGLB) intervention and (2) describe intervention adaptations for people with SMI in supportive housing. Peer specialists and social workers co-facilitated 12 weekly PGLB sessions for 14 supportive housing clients. We conducted structured interviews and collected qualitative data through field notes and two focus groups. Frequencies and measures of central tendencies were used to describe participant characteristics and PGLB feasibility and acceptability measures. Qualitative data was analyzed using directed content analysis. Participants on average attended 8 of 12 sessions, and reported that services were satisfactory and helpful. Intervention adaptations, ongoing throughout the study, focused on adding peer-specialists as co-facilitators, increasing individualized support and developing strategies to address socioeconomic barriers impacting participants' ability to engage in healthy lifestyle changes. Study findings suggest that participants with SMI in supportive housing perceived PGLB as feasible and acceptable. Expanding the relevance and reach of peer-based healthy lifestyle interventions in community settings serving people with SMI requires careful adaptations to the socioeconomic realities of this population and the complexities of living with co-morbid health and mental health conditions.

Overall, the retention of people with serious mental illness (SMI) in supportive housing is high. However, some supportive housing settings report average stays of only 15 months, and others report declines in housing retention over time. Many studies report variables associated with supportive housing stability and tenure, but there are few extensive, focused investigations on the subject.Hence, a literature review was conducted to investigate factors associated with supportive housing stability and tenure among people with SMI. The review of the included 28papers revealsthatthe factors associated with supportive housing stability and tenure fell into two general categories of individual factors (including psychiatric factors and prior homelessness), and contextual factors (including program characteristics and sense of community and social support). In conclusion, further focus on contextual factors, as well as a potential reframing of individual factors as contextual, may be helpful in addressing issues related to supportive housing stability and tenure for people with SMI.

People diagnosed with serious mental illness (SMI) experience significant health disparities, including high rates of premature mortality. Supportive housing may serve as a critical service setting for addressing physical health, but comprehensive health-related services within these programs remain an exception. This study sought to identify barriers, and potential solutions, to addressing the physical health needs of people with SMI within supportive housing. Semi-structured interviews and focus groups were conducted with multiple stakeholders(clients, peer specialists, non-peer staff, leadership) across three supportive housing agencies. There was general consensus regarding multiple barriers at the individual, organizational, policy/system, and community levels. Nevertheless, stakeholders also identified strategies in domains such as staffing, organizational culture, partnerships, communication, and infrastructure for addressing barriers. These findings can inform planning for implementation of health initiatives within supportive housing while also highlighting the need for broader community, systems, and policy change.Trial Registration Number: NCT02175641.

BackgroundCardiovascular disease (CVD) is a primary contributor to premature death among people with serious mental illness (SMI). This study examined the prevalence and correlates of the American Heart Association (AHA) metric of ideal cardiovascular health (ICVH) in racially and ethnically diverse people with serious mental illness living in supportive housing.MethodsOur study used baseline data from an NIMH-funded trial testing the effectiveness of a peer-led healthy lifestyle intervention, for overweight/obese participants with SMI in three supportive housing agencies. A total of 314 participants were enrolled in the trial and included in these analyses. Five ICVH metrics (BMI, smoking, diet, physical activity, and blood pressure [BP]) were measured and summed to create a composite ICVH score. Correlates were informed by findings from systematic literature reviews examining ICVH in the general population and studies examining correlates of CVD in people with SMI. Hierarchal regression analysis was used to examine the associations of sample correlates with the composite ICVH score.ResultsThe mean age of participants was 48.7 and 57.3% were male. The most common lifetime mental health diagnoses were depression (75.2%), schizophrenia/schizoaffective disorder (56.7%), and bipolar disorder (46.5%). Approximately 38.5% of participants reported lifetime substance abuse/dependence. The majority (62.7%) were taking an antipsychotic medication. Lifetime physical health diagnoses were high cholesterol (36.3%), diabetes (32.5%), cardiovascular disease (17.2%), and cancer (4.5%). Participants walked on average 318.4 meters during the six-minute walking test (6MWT), a measure of cardiorespiratory fitness (CRF). The prevalence of smoking (64.7%) and obesity (64%) were high, while the prevalence of ideal physical activity (37.6%), healthy diet status (2.2%), and ideal BP (23.6%) were low. The mean ICVH composite score was 3.15 (range 0 – 8). After controlling for all covariates, women, racial/ethnic minorities, use of antipsychotic medications, lifetime cancer diagnosis, and poor CRF were significantly (p < .05) related to low ICVH scores.DiscussionIn our racially/ethnically diverse sample of people with SMI in supportive housing, the prevalence of ICVH was low. Our findings suggest that there are specific subgroups that may benefit from targeted screening and interventions to improve cardiovascular health. The association between CRF and ICVH scores highlights the importance of increasing physical activity and reducing sedentary behavior. The AHA ICVH metric can be a useful tool for tracking and improving the cardiovascular health of people with SMI.

Patients With Serious Mental Illness Need Better Primary Care Integration, Health Advocacy

Serious Mental Illness in Post-Acute and Long-Term Care:Building Knowledge, Sharing Care

Healthcare leaders addressing homelessness and mental illness in Canada may find mental health laws challenging. This paper explores the limitations of the existing system, including insufficient hospital services, community resources and long-term housing solutions. It critiques proposals for forced treatment and confinement, arguing that they are costly, legally contentious and ineffective in providing sustainable care. Instead, it advocates for increased investment in community-based mental health services, stable housing and income support and coordinated care between hospitals and community programs. By shifting focus from detention to prevention and support, health leaders can create a more humane and effective system for individuals with mental illness and addiction.