Community-based Psychiatric Services Research Articles

Substance Abuse Associated with Aggressive/Violent Behaviors in Psychiatric Outpatients and Related Psychotropic Prescription

Psychiatricdisorders with substance abuse are considered the leading causes of most violent and aggressive behaviors in the general population. This study was aimed to assess the impact of substance abuse and the therapeutic approaches adopted by psychiatrists in aggressive vs non-aggressive outpatients (n = 400) attending community-based psychiatric services and recruited over a 3-year period. Clinical and therapeutic variables were collected from medical records and the Modified Overt Aggression Scale (MOAS) was used to assess any aggressive/violent behavior. Violent behaviors were significantly higher in alcohol and substance abusers compared to non-abusers (p < 0.01), except for heroin abusers. Mean weighted MOAS score was significantly higher in patients taking antipsychotics (p < 0.005). The administration of Haloperidol, Zuclopenthixol, and Clozapine was more frequent in aggressive than in non-aggressive patients. The most frequently administered drug in these patients was Haloperidol (23.91%), with a higher mean daily dosage in violent vs non-violent patients. Our results confirm the well-established relationship between substance abuse and violent behaviors in psychiatric inpatients also within outpatient community services. Observed rates of most frequently prescribed antipsychotics to aggressive patients did not show any preference for newer generation compounds, with clinicians operating in the community setting likely being in need for further evidence and specific training to support their treatment choice.

Ten-year trends in depression care in Taiwan

The number of psychiatrists working in community clinics in Taiwan has increased dramatically in the recent decade. This study aimed to investigate the trend of prevalence and incidence of depressive disorders and assess the quality of depression care between 2007 and 2016 in Taiwan. We used the claims database derived from Taiwan's National Health Insurance (NHI) program, in which approximately 23.0 million individuals were enrolled, translating to a coverage rate of 99%. Patients with depressive disorders were identified based on International Classification of Diseases codes. The process indicators of depression care quality included visit, duration, and dose adequacy. The outcome indicators included the rate of psychiatric hospitalisation, emergency visit, self-harm hospitalisation, and suicide. The prevalence of treated depressive disorders increased from 1.61% in 2007 to 1.92% in 2016, i.e., a 25% increase, whereas the incidence of first-ever or recurrent depressive disorder did not change significantly. The number of patients treated by psychiatrists and in community clinics also increased. The quality of depression care improved, the proportion of patients receiving minimum psychiatric clinic follow-up and adequate medication increased, and the rate of emergency visits, psychiatric hospitalisation, and self-harm hospitalisation declined. The community-based psychiatric services increased and the quality indicators of depression care in Taiwan improved during 2007-2016. The causality warrants further investigations.

Community-Based Psychiatric Services in Sri Lanka: a Model by WHO in the Making

Sri Lanka is a lower middle-income, small island nation in the Indian Ocean, with a multi-ethnic population of 22 million. The healthcare system of the country is well established and relatively advanced, the delivery of which is free to the consumer. The health indicators of the country are impressive compared to regional figures. Psychiatric care in Sri Lanka has witnessed a rapid development over the last four decades, as the care model transformed from an asylum-based model, established during the British colonial times, to a district-wise hospital-based, care delivery model. Gradually, the teams that provided inpatient and outpatient services at the hospitals also started to provide community-based care. The newly added community-based services include outreach clinics, residential intermediate rehabilitation centres, home-based care, community resource/ support centres and telephone help lines. There is no or very little funding dedicated to community-based care services. The teams that deliver community services are funded, mostly indirectly, by the state health authorities. This is so, as these community teams are essentially the same psychiatry teams that are based at the hospitals, which are funded and run by the state health authorities. This lack of separation of the community and hospital teams without separate and dedicated funding is an impediment to service development, which needs to be addressed. However, paradoxically, this also constitutes an advantage, as the provision of care delivery from the hospital to the community is continuous, since the same team provides both hospital- and community-based care. In addition to the essential mental healthcare provision in the community with this basic infrastructure, each community service has improvised and adapted the utilization of other resources available to them, both formally as well as informally, to compensate for their financial and human resource limitations. These other resources are the community officials and the community services of the non-health sectors of the government, mainly the civil administration. Although sustainability may be questionable when services involve informal resources from the non-health sectors, these have so far proven useful and effective in a resource-poor environment, as they bring the community and various sectors together to facilitate services to support their own community.

Psychiatric patients' experience in receiving services provided by non-specialist community nurses, southern Thailand.

Psychiatric problems have been a growing and significant public health challenge. Community-based psychiatric services have been shown to contribute to the improvement of health and social-related outcomes, but with limited specialists in this field. Consequently, Thailand has integrated these services into the primary care system delivered by community nurses working in primary care units (PCUs). To describe the experiences of psychiatric patients in receiving services provided by non-specialist community nurses. A phenomenological approach was used. Eleven psychiatric patients with 10 major depressive disorders and 1 with schizophrenia were interviewed. The results were evaluated using thematic content analysis. The results revealed two main themes as barriers and facilitators experienced in receiving services from community nurses. Community-based services should be concerned about developing psychiatric nursing competency for community nurses to extend basic services to patients in communities and to assist family members.

Support for the social-cognitive model of internalized stigma in serious mental illness

One prominent social-cognitive model of internalized stigma by Corrigan and his colleagues (2012; 2002) proposes that individuals are exposed to societal stereotypes about mental illness, at least tacitly agree with them, and may apply them to oneself, engendering harmful self-beliefs. There is limited empirical support for this model in serious mental illness. Moreover, it is not clearly established how internalized stigma and its associated factors impact recovery in this population. The current study uses structural equation modeling (SEM) to assess the social-cognitive model's goodness of fit in a sample of Veterans with serious mental illness (Veteran sample, n = 248), and then validates the model in a second and independent sample of individuals receiving community-based psychiatric rehabilitation services (community sample, n = 267). Participants completed the Self-Stigma of Mental Illness Scale (SSMIS; Corrigan et al., 2006) and measures of self-esteem, self-efficacy, and recovery attitudes. Consistent with Corrigan and colleagues' formulation of internalized stigma, SEM analyses showed a significant indirect pathway from stereotype awareness, to stereotype agreement, to application to self, to self-esteem decrement, to poorer recovery attitudes. Additionally, there was a significant direct effect from stereotype awareness to self-esteem. This study shows that individuals with serious mental illness experience psychological harm from stigma in two ways: (1) through perceived public prejudice and bias, and (2) through internalizing these negative messages. In particular, stigma harms individuals' self-esteem, which then reduces their recovery attitudes.

Direct and Indirect Associations Between Loneliness and Thoughts of Self-Harm Among a Clinical Sample of Older Adults With Serious Mental Illness.

This cross-sectional study examines the relationships of loneliness and depressive symptoms to thoughts of self-harm among a clinical sample (n = 150) of older adults (M = 58.42 years, SD = 5.86 years; male, 55.3%; African American, 61.3%) with serious mental illness (SMI) receiving publicly funded, community-based psychiatric rehabilitation services. Participants completed the De Jong Gierveld Loneliness Scale, Multidimensional Scale of Perceived Social Support, Patient Health Questionnaire 9, and Geriatric Depression Scale-Short Form. Mediation analyses tested the association of loneliness with thoughts of self-harm through depressive symptoms and were adjusted for social support and demographic variables. The direct association of loneliness with thoughts of self-harm was mediated by depressive symptoms; indirect associations of overall and emotional loneliness to thoughts of self-harm were significant. Findings suggest the need for clinicians to reduce feelings of loneliness among older adults with SMI as a means of partially ameliorating depressive symptoms and thoughts of self-harm.

Determinants of Therapeutic Alliance With People With Psychotic Disorders: A Systematic Literature Review.

Therapeutic alliance determines medical treatment adherence, the success of psychotherapy, and the effectiveness of care. This systematic review aims at better understanding its determinants. The electronic databases Pubmed, Cochrane Library, and Web of Science were searched, using combinations of terms relating to psychosis and therapeutic alliance. Studies were selected and data were extracted using a PRISMA statement. Forty-one studies were selected, including 20 cross-sectional studies, 10 cohort studies, five randomized controlled trials, four literature reviews, and two retrospective studies. The quality of therapeutic alliance correlates with clinical symptoms, insight, social and family support, the therapist's qualities, the availability of shared therapeutic decision making, and the types of hospitalization. Although current evidence needs to be completed with further studies, it is already clear that group and family psychoeducation, cognitive remediation, community-based psychiatric services, and shared therapeutic decision making are essential approaches in the management of patients with psychosis.

The Relationship Between Hospital and Community Psychiatry: Complements, Not Substitutes?

Community-based psychiatric services are essential to mental health. For decades, researchers, advocates, and policy makers have presumed that expanding the supply of these services hinges on reducing the supply of hospital-based care. Cross-national data from the World Health Organization call this presumption into question. Community and hospital psychiatry appear to be complements, not substitutes.

Voluntary admissions for patients with schizophrenia: A systematic review and meta-analysis.

Voluntary admission rates of schizophrenia vary widely across studies. In order to make the topic be informed by evidence, it is important to have accurate estimates. This meta-analysis examined the worldwide prevalence of voluntary admissions for patients with schizophrenia. PubMed, EMBASE, PsycINFO, the Cochrane Library, Web of Science and Medline databases were systematically searched, from their commencement date until 19th November 2018. Meta-analysis of included studies was performed using the random-effects model. Thirty-five studies with 134,100 schizophrenia patients were included. The overall voluntary admission rate of schizophrenia was 61.9 % (95 %CI: 52.3 %-70.7 %), while the involuntary rate was 43.0 % (95 %CI: 34.8 %-51.7 %). Subgroup analyses revealed that patients in Europe had significantly higher voluntary admission rates, while their North American counterparts were more likely admitted involuntarily. Papers published prior to 2008 reported higher involuntary admission rates. Meta-regression analyses showed that higher male percentage and higher study quality were significantly associated with higher voluntary admission rate. Although the worldwide prevalence of voluntary admissions was higher than that of involuntary admissions, the latter was common for schizophrenia. With the continuing liberalization of mental health laws broadening community-based psychiatric services, the rate of voluntary psychiatric admissions is expected to further increase over time.

The Prevalence of Suicide Attempts and Independent Demographic and Clinical Correlates among Chronic Schizophrenia Patients in Agricultural Areas of China.

This study investigated the lifetime prevalence of suicide attempts (SA) and independent demographic and clinical correlates in stabilized schizophrenia inpatients. A cross-sectional study was conducted in three psychiatric hospitals in Anhui province, an agricultural province located in east China. Psychopathology and depressive symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS) and Hamilton Depression Rating Scale (HAMD), respectively. A total of 315 stable schizophrenia inpatients were interviewed prior to discharge. The lifetime prevalence of SA was 22.2%. Multiple logistic regression analysis revealed that female gender (P < 0.001, OR = 3.4, 95%CI: 1.9-6.0), being married (P = 0.02, OR = 2.2, 95%CI: 1.1-4.4) and having more severe depressive symptoms (P = 0.014, OR = 1.2, 95%CI: 1.01-1.3) were independently and significantly associated with higher risk of SA. Lifetime SA is common among hospitalized schizophrenia patients living in agricultural areas of China. For suicide prevention, regular assessments, appropriate interventions and clinical management should be integrated into a community-based psychiatric service model for this population.

Arts-based psychiatric rehabilitation programs in the community: Perceptions of healthcare professionals.

Despite the increase in arts-based programs in community rehabilitation services in many countries, little is known about how these programs are perceived by health professionals who can refer individuals with mental health conditions to community-based psychiatric rehabilitation services. This study examined how senior professionals with key positions in the public health system perceive the integration of the arts in community-based psychiatric rehabilitation services in Israel. Semistructured interviews were conducted with 10 professionals. The thematic analysis revealed 2 main themes. The first reflected "the perceived position of arts-based programs among other rehabilitation services," and had 2 subthemes: arts as a legitimate supplemental service, and arts as a motivating rehabilitation. The second theme reflected "the unique contribution of the arts to recovery processes," and had 3 subthemes: art-making facilitates self-expression and communication and bypasses resistance, art-making facilitates socialization, and art-making shapes and enhances personal identity. Because most of the professionals were exposed to the creative arts in their workplace, they valued their contribution to the rehabilitation process. Thus, direct contact can provide more information, more accurate perceptions, and a better understanding of the benefits of arts-based services, which may in turn encourage service managers and policymakers to include these services. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Police Response to People with Mental Illnesses in a Major U.S. City: The Boston Experience with the Co-Responder Model

ABSTRACTLike most major city police agencies, the Boston Police Department (BPD) serves a sizeable population of individuals with behavioral health challenges. In 2017, the BPD received a total of 681,546 calls for service; of those, 5,953 calls specifically involved people with mental illnesses. To better meet the needs of these individuals, the BPD has a strong history of working with the Boston Emergency Services Team (BEST) of the Boston Medical Center. This partnership resulted in the creation of the BPD’s co-response program, which was launched in January 2011 as a means to team Boston police officers with BEST clinicians. The goal of the program is to provide community-based psychiatric crisis services to stabilize nonviolent persons experiencing psychiatric emergencies, diverting these individuals from arrest and the criminal justice system when appropriate. In this article, we explore the development and implementation of the co-response model, both nationally and in Boston. Next, using quantitative co-responder data, we examine short-term outcomes of the BPD co-responder program. Finally, using qualitative data from officer interviews, we discuss the perspectives of police officers on the utility and effectiveness of the co-responder approach in Boston.

Effectiveness of Balancing Everyday Life (BEL) versus standard occupational therapy for activity engagement and functioning among people with mental illness \u2013 a cluster RCT study

BackgroundMany with a mental illness have an impoverished everyday life with few meaningful activities and a sedentary lifestyle. The study aim was to evaluate the effectiveness of the 16-week Balancing Everyday Life (BEL) program, compared to care as usual (CAU), for people with mental illness in specialized and community-based psychiatric services. The main outcomes concerned different aspects of subjectively evaluated everyday activities, in terms of the engagement and satisfaction they bring, balance among activities, and activity level. Secondary outcomes pertained to various facets of well-being and functioning. It was hypothesized that those who received the BEL intervention would improve more than the comparison group regarding activity, well-being and functioning outcomes.MethodsBEL is a group and activity-based lifestyle intervention. CAU entailed active support, mainly standard occupational therapy. The BEL group included 133 participants and the CAU group 93. They completed self-report questionnaires targeting activity and well-being on three occasions – at baseline, after completed intervention (at 16 weeks) and at a six-month follow-up. A research assistant rated the participants’ level of functioning and symptom severity on the same occasions. Non-parametric statistics were used since these instruments produced ordinal data.ResultsThe BEL group improved more than the CAU group from baseline to 16 weeks on primary outcomes in terms of activity engagement (p < 0.001), activity level (p = 0.036) and activity balance (p < 0.042). The BEL group also improved more on the secondary outcomes of symptom severity (p < 0.018) and level of functioning (p < 0.046) from baseline to 16 weeks, but not on well-being. High intra-class correlations (0.12–0.22) indicated clustering effects for symptom severity and level of functioning. The group differences on activity engagement (p = 0.001) and activity level (p = 0.007) remained at the follow-up. The BEL group also improved their well-being (quality of life) more than the CAU group from baseline to the follow-up (p = 0.049). No differences were found at that time for activity balance, level of functioning and symptom severity.ConclusionThe BEL program was effective compared to CAU in terms of activity engagement. Their improvements were not, however, greater concerning other subjective perceptions, such as satisfaction with daily activities and self-rated health, and clustering effects lowered the dependability regarding findings of improvements on symptoms and functioning. Although the CAU group had “caught up” at the follow-up, the BEL group had improved more on general quality of life. BEL appeared to be important in shortening the time required for participants to develop their engagement in activity and in attaining improved quality of life in a follow-up perspective.Trial registrationThe study was registered with ClinicalTrial.gov. Reg. No. NCT02619318.

Attualità di Goffman: quanto contribuisce alla carriera morale di malato mentale la psichiatria di comunità italiana contemporanea?

Erving Goffman revisited: How extensive is the contribution of today’s commu-nity mental health services in Italy to the moral career of the mental patient? In his 1961 book Asylums, Erving Goffman describes how the mental hospital promotes the career of the mental patient. Upon admission to the institution, the person is systematically, albeit often un-intentionally, mortified through a series of abasements, degradations and profanations of the self and is stripped of his individuality. In this way, the institution creates a population of inmates, reduced to obedience and standardized in their needs, that can be managed in large number in a reduced space and with few resources. This paper then investigates whether the present organization of Italian community-based psychiatric services presents similar detrimental effects and suggests possible scenarios for further developments of our model of community mental health.

A Pilot Initiative to Deliver Community-based Psychiatric Services in Rural Haiti After the 2010 Earthquake

BackgroundWorldwide, there is a gap between the burden of mental distress and disorder and access to mental health care. This gap is particularly large in low- and middle-income countries (LMICs). After the 2010 earthquake in Haiti, the international health care organizations Partners in Health and Zanmi Lasante worked to expand local mental health services in rural Haiti. ObjectiveThe aims of this study are to describe clinical characteristics of the patients served during a pilot project to deliver community-based psychiatric services in rural Haiti and to show how this experience complements the Mental Health Gap Action Programme (“mhGAP”), a tool developed by the World Health Organization to support mental health care delivery by nonspecialists in LMICs. MethodsThe pilot was conducted in March 2011. A visiting psychiatrist traveled to rural Haiti and paired with local clinicians to evaluate patients and to support quality improvement practices in psychiatric care. Patients received a standard neuropsychiatric evaluation. mhGAP was an important clinical reference. To assess the experience, we conducted a retrospective chart review of outpatient encounters. FindingsSixty-five patients presented with a wide range of common psychiatric, neurologic, and general medical conditions. Forty-nine of these patients (75%) reported primary problems subsumed by an mhGAP module. Fifteen patients (23%) reported headache as their chief complain, a condition that is not currently covered by mhGAP. Surprisingly, only 3 patients (5%), reported earthquake-related distress. ConclusionsOur clinical data reinforce the need for provision of standard psychiatric and neurologic services in LMICs. Such services ought to accompany interventions targeted specifically at disaster-related problems. Clinical situations falling outside existing mhGAP modules inspired the development of supplemental treatment protocols. These observations informed coordinated efforts at Zanmi Lasante to build a sustainable, integrated mental health system in Haiti that may be relevant to other resource-limited settings.

Clinical Features, Psychiatric Assessment, and Longitudinal Outcome of Suicide Attempters Admitted to a Tertiary Emergency Hospital

The objective of this study was to characterize admissions to an emergency hospital due to suicide attempts and verify outcomes in 2 years. Data were collected from medical records and were analyzed using descriptive statistics and logistic regression. The sample consisted of 412 patients (58.7% women; mean age = 32.6 years old, SD = 14.3). Self-poisoning was the most frequent method (84.0%), and they were diagnosed mainly as depressive (40.3%) and borderline personality disorders (19.1%). Previous suicide attempts and current psychiatric treatment were reported by, respectively, 32.0% and 28.4%. Fifteen patients (3.6%, 9 males) died during hospitalization. At discharge, 79.3% were referred to community-based psychiatric services. Being male (OR = 2.11; 95% CI = 1.25–3.55), using violent methods (i.e., hanging, firearms, and knives) (OR = 1.96; 95% CI = 1.02–3.75) and psychiatric treatment history (OR = 2.58; 95% CI = 1.53–4.36) were predictors for psychiatric hospitalization. Of 258 patients followed for 2 years, 10 (3.9%) died (3 suicide), and 24 (9.3%) undertook new suicide attempts. Patients with a history of psychiatric treatment had higher risks of new suicide attempts (OR = 2.46, 95% CI = 1.07–5.65). Suicide attempters admitted to emergency hospitals exhibit severe psychiatric disorders, and despite interventions, they continue to present high risks for suicide attempts and death.

The sociocultural conceptualisations of schizophrenia and patterns of help seeking in south-east Nigeria

Socioculturally influenced interpretations of mental illness play decisive roles on the time and choice of treatment. These often result in significant delays before patients present at the psychiatric services, with consequent worsening of the prognosis. The aim was to assess the association between sociocultural factors, choice of treatment and treatment delay among patients with schizophrenia. A cross-sectional study of 360 patients with schizophrenia, without previous contact with any statutory psychiatric services, was done. Of this, 75.8% of the participants had visited traditional/faith healers as the first treatment option and have attributed schizophrenia to magico-supernatural causation, despite 70.0% of the participants being educated, while 24.2% of them believed in the natural causation of the illness and presented early to psychiatric hospital. There is a need for community-based psychiatric services that would have mental health education as one of their core mandates; and collaborations with traditional and faith-based healers aimed to reduce delay in their facilities.

Cancer mortality among psychiatric patients treated in a community-based system of care: a 25-year case register study

Cancer mortality data allow assessing, at the same time, the risk of developing the disease and the quality of care provided to patients after the oncologic diagnosis. This study explores the risk of death caused by a single tumor site in a psychiatric population treated in a community-based psychiatric service. All patients with an ICD-10 psychiatric diagnosis, seeking care in 1982-2006 (25 years), were included. Data were drawn from the South Verona Psychiatric Case Register (PCR). Mortality and cause of death were ascertained using different procedures and sources. Standardized mortality ratios (SMRs) were used to compare the observed number of deaths with the expected number using as reference a population in the Veneto region. Having been admitted to the hospital (SMR = 1.32), having a short interval from registration (1.52), having a diagnosis of alcoholism (2.03), and being a middle-aged male (1.83) were factors showing an increased risk of death from cancer. Increased SMRs were found for cancer of the oral cavity (22.93), lymphoma, leukemias, Hodgkin's lymphoma (8.01), and central nervous system (CNS) and cranial nerve tumors (4.75). The SMR decreased for stomach tumors (0.49). Patients with alcoholism (5.90 for larynx), affective disorders (20.00 for lymphomas), and personality disorders (28.00 for SNC) were found to be exposed to a high risk of cancer death in specific sites. Psychiatric patients showed different patterns of site-specific cancer mortality when compared with the general population. The 20-fold higher risk of dying from hematological neoplasms needs further investigation. Chronic use of phenothiazines could be involved in the relative protection from stomach and prostate cancer found in psychiatric patients.

AMA’s Psychiatrist President Hails Involvement of APA

Jeremy Lazarus, M.D., says that the high profile of psychiatry within the AMA has helped to sharpen that organization’s focus on mental health issues.

New Law to Transform MH Services in China

New Law to Transform MH Services in China