History Of Psychiatric Hospitalization Research Articles

Repetitive transcranial magnetic stimulation (rTMS) using different TMS instruments for major depressive disorder at a suburban tertiary clinic

Repetitive transcranial magnetic stimulation (rTMS) is a neurostimulatory technique used to modulate orbital frontal corticostriatal (OFC) activity and clinical symptomatology for psychiatric disorders involving OFC dysfunction. We examined the effectiveness of rTMS in the treatment of major depressive disorder in an applied clinical setting (Awakening KC CNI) to assess efficacy and optimize rTMS parameters within clinical practice. A retrospective review of medical records was carried out on patients with major depressive disorder undergoing rTMS therapy at Awakenings KC Clinical Neuroscience Institute (CNI), a suburban tertiary psychiatric clinic. A detailed de-identified data set of clinical outcomes was compiled. Patient Health Questionnaire 9 (PHQ-9) total score, clinical remission rate and week achieved were evaluated over 6 weeks of treatment to assess clinical response referencing two different rTMS instruments (MagVenture; NeuroStar). Our survey included 247 participants from males (N=98) and females (N=149) with average baseline PHQ-9 scores of 21.7±4, classified as severe depression. Clinically rated remission rates of 72% were achieved in 3.1±1.0 weeks and associated with prior history of psychiatric hospitalization, suicide attempts and substance use disorder. Average baseline PHQ-9 scores decreased significantly over time with proportionately greater remission rates achieved for patients treated using the MagVenture over NeuroStar instrument. rTMS in applied clinical practice is efficacious over a wide range of settings and patients. Clinical response was related to severity of depression symptoms (e.g., prior hospitalization; suicide attempts) validating efficacy in critically ill groups. Clinical response may be impacted by rTMS instrument, magnetic field parameters or individual factors.

Repetitive transcranial magnetic stimulation (rTMS) using different TMS instruments for major depressive disorder at a suburban tertiary clinic.

Repetitive transcranial magnetic stimulation (rTMS) is a neurostimulatory technique used to modulate orbital frontal corticostriatal (OFC) activity and clinical symptomatology for psychiatric disorders involving OFC dysfunction. We examined the effectiveness of rTMS in the treatment of major depressive disorder in an applied clinical setting (Awakening KC CNI) to assess efficacy and optimize rTMS parameters within clinical practice. A retrospective review of medical records was carried out on patients with major depressive disorder undergoing rTMS therapy at Awakenings KC Clinical Neuroscience Institute (CNI), a suburban tertiary psychiatric clinic. A detailed de-identified data set of clinical outcomes was compiled. Patient Health Questionnaire 9 (PHQ-9) total score, clinical remission rate and week achieved were evaluated over 6 weeks of treatment to assess clinical response referencing two different rTMS instruments (MagVenture; NeuroStar). Our survey included 247 participants from males (N=98) and females (N=149) with average baseline PHQ-9 scores of 21.7±4, classified as severe depression. Clinically rated remission rates of 72% were achieved in 3.1±1.0 weeks and associated with prior history of psychiatric hospitalization, suicide attempts and substance use disorder. Average baseline PHQ- 9 scores decreased significantly over time with proportionately greater remission rates achieved for patients treated using the MagVenture over NeuroStar instrument. rTMS in applied clinical practice is efficacious over a wide range of settings and patients. Clinical response was related to severity of depression symptoms (e.g., prior hospitalization; suicide attempts) validating efficacy in critically ill groups. Clinical response may be impacted by rTMS instrument, magnetic field parameters or individual factors.

Risk of manic switch with antidepressants use in patients with bipolar disorder in a Nigerian neuropsychiatric hospital.

BackgroundDepressive disorders are common among those with bipolar affective disorder (BAD) and may necessitate the use of antidepressants. This has been suggested to precipitate manic episodes in some patients.ObjectivesThis study aims to determine the prevalence of and factors associated with manic switch in patients with BAD being treated with antidepressants.MethodsCase notes of patients who were treated at a Nigerian neuropsychiatric hospital for a BAD from 2004 to 2015 were reviewed. BAD diagnosis was made using ICD-10 criteria. Treatment for bipolar depression included monotherapy (i.e. antidepressants, antipsychotics or mood stabilisers) or combination therapy (mood stabiliser with an antidepressant or a combination of mood stabilisers, antipsychotics and antidepressants). The primary outcome measure was a switch to mania or hypomania within 12 weeks of commencing an antidepressant.ResultsManic or hypomanic switch (MS) was observed in 109 (44.3%) of the participants. Female gender, younger age, number of previous episodes and a past history of psychiatric hospitalisation were all significantly associated with a risk of MS. There was no significant difference in the rate of MS in either those treated with adjunct antidepressants therapy with a mood stabiliser or an antipsychotic or those placed on a combination of antidepressants, antipsychotics and mood-stabilising agents.ConclusionA large proportion of patients with BAD on antidepressants experience medication-induced manic or hypomanic switch.

Executive Functioning Outcomes Among Adolescents Receiving Dialectical Behavior Therapy

Changes in the adolescent brain underlie the development of executive functions (EFs) after the onset of puberty; however, adolescents that engage in deliberate self-harm (DSH) have impaired EFs in the areas of inhibition, emotion regulation, shifting, and interpersonal functioning. On the other hand, dialectical behavior therapy (DBT) has been shown to be effective in treating adolescents with DSH. Moreover, the DBT skills of mindfulness, emotion regulation, distress tolerance, interpersonal effectiveness, and “walking the middle path” are suited to treat these adolescents with impaired EFs. This single group pre-post study examined changes in adolescents’ EFs who were enrolled in DBT. Ninety-three adolescents from a 16-week DBT program for DSH were administered the Behavior Rating Inventory of Executive Function-Self Report (BRIEF-SR) at pre-treatment and post-treatment. Adolescents improved from the elevated to non-clinical range on the Emotional Control, Shifting, and Monitor scales in addition to the Global Executive Composite of the BRIEF-SR. Significant effects for funding type on shifting, interpersonal functioning, and overall EF were observed while a significant effect for previous history of psychiatric hospitalizations was observed for emotion regulation. DBT appears to be effective for improving the EFs of adolescents with DSH and for specific subgroups of this population. Knowledge of these adolescents’ profile of EFs will assist clinicians in determining the type and level of intervention with DBT in order to shape positive behaviors during this important period of brain development.

Rapid and longer-term antidepressant effects of repeated-dose intravenous ketamine for patients with unipolar and bipolar depression

ObjectiveSingle-dose intravenous (IV) injection of ketamine has shown rapid but transient antidepressant effects. The strategy of repeated-dose ketamine infusions to maintain antidepressant effects has received little systematic study. This study was conducted to examine the efficacy and tolerability of six ketamine infusions in Chinese patients with unipolar and bipolar depression. MethodsNinety seven patients with unipolar (n = 77) and bipolar (n = 20) depression received repeated ketamine infusions (0.5 mg/kg over 40 min) with continuous vital sign monitoring. Depressive symptoms were measured by the Montgomery-Asberg Depression Rating Scale (MADRS). Suicidal ideation was assessed using the Scale for Suicidal Ideations (SSI)-part 1. Anxiety symptoms were evaluated with the 14-item Hamilton Anxiety Scale (HAMA). Adverse psychopathological and dissociative effects were assessed using the Brief Psychiatric Rating Scale (BPRS)-positive symptoms and Clinician Administered Dissociative States Scale (CADSS), respectively. Patients were assessed at baseline, 4 and 24 h, and 3, 4, 5, 6, 8, 9, 10, 11, 12, 13 and 26 days. ResultsAfter six ketamine infusions, the response and remission rates were 68.0% and 50.5%, respectively. There were significant decreases in MADRS, SSI-part 1, and HAMA scores within four hours following the first ketamine infusion, and the decreases were sustained over the subsequent infusion period. The nonresponder subgroup manifested rapid significant improvement in suicidal ideations throughout the course of treatment. After the six ketamine infusions, the response was positively associated with the response at 24 h after the first infusion (OR = 8.94), personal income ≥4000 yuan/month (OR = 3.04), and no history of psychiatric hospitalization (OR = 3.41). Only CADSS scores had a mild but marginally significant increase after the first infusion but with a significant BPRS score decrease. ConclusionSix ketamine infusions were safe and effective in patients with unipolar and bipolar depression. The rapid and robust antidepressant and antisuicidal effects of ketamine infusion within four hours were sustained following the subsequent infusions.

Evaluations of Urban Sovereign Citizens' Competency to Stand Trial.

There are few studies of sovereign citizens undergoing competency-to-stand-trial evaluations and little has been written about African-American or urban sovereign citizens. In this study, we examined competency-to-stand-trial reports of 36 New York City defendants who declared themselves to be sovereign citizens during their evaluations. All were men and 33 were African American. The majority denied recent or remote histories of psychiatric hospitalizations or substance use. Sixty-nine percent were deemed competent. Compared with those deemed competent, those deemed not competent were significantly more likely to have diagnosed psychotic disorders and to have reported histories of psychiatric hospitalizations. The 36 who declared themselves sovereign citizens were compared with 200 who did not, from a study conducted in the same forensic clinic. The sovereign citizens were significantly more likely to be male, African American, and high school graduates and were significantly less likely to report a history of psychiatric hospitalization or substance use. Compared with the nonsovereign citizens, they were less likely to receive a diagnosis of psychotic or mood disorders during the competency evaluation and were more likely to be deemed competent. Included are suggestions to assist forensic examiners conducting evaluations of these difficult cases.

Menthol cigarette use in young adult smokers with severe mental illnesses.

Smokers with severe mental illness (SMI) are more likely to start smoking and less likely to quit. Menthol may facilitate smoking progression, dependence, and maintenance by reducing harshness and irritation from smoking and providing a unique sensory experience during use. High rates of menthol use have been reported in smokers with SMI, but information on young adults with SMI has not been reported. This study provides a secondary analysis to assess the impact of menthol use in a pilot trial of brief tobacco interventions. Participants were assessed at baseline and again at a 3-month follow-up with structured interviews and breath carbon monoxide to confirm self-reported 7-day abstinence at follow-up. Participants included 81 young adult smokers with SMI, mean age of 24.2 years (SD = 3.6; range 18-30). Overall, 58% of the group reported that they recently used a menthol-flavored product. Menthol use was correlated with race (African American [18/21, 85.7%] vs. White [24/53, 45.3%] or other race [5/7, 71.4%]; χ2 = 10.7, p = .005) and more lifetime psychiatric hospitalizations (t = 2.39, p = .02), but not with cigarettes per day, nicotine dependence, quit attempts over the follow-up period, nor with achieving biologically confirmed abstinence at the follow-up assessment. The high prevalence of menthol-flavored cigarette use in this study group is consistent with previous reports of high rates of menthol use among young adults, Blacks, and middle-aged SMI smokers. This study supports existing evidence that policies to restrict menthol flavoring in combustible tobacco products could reduce smoking in young adults with SMI. High rates of menthol use have been reported in middle-aged smokers with SMI, but information on young adults with SMI has not been reported. In this study, more than half (58%) of 81 young adult smokers with SMI used a menthol-flavored product. Menthol use was associated with race and with history of psychiatric hospitalizations. The research supports existing evidence that policies to restrict menthol flavoring in combustible tobacco products could reduce smoking in young adults with SMI.

Effects of cumulative illness severity on hippocampal gray matter volume in major depression: a voxel-based morphometry study.

Patients with major depression show reduced hippocampal volume compared to healthy controls. However, the contribution of patients' cumulative illness severity to hippocampal volume has rarely been investigated. It was the aim of our study to find a composite score of cumulative illness severity that is associated with hippocampal volume in depression. We estimated hippocampal gray matter volume using 3-tesla brain magnetic resonance imaging in 213 inpatients with acute major depression according to DSM-IV criteria (employing the SCID interview) and 213 healthy controls. Patients' cumulative illness severity was ascertained by six clinical variables via structured clinical interviews. A principal component analysis was conducted to identify components reflecting cumulative illness severity. Regression analyses and a voxel-based morphometry approach were used to investigate the influence of patients' individual component scores on hippocampal volume. Principal component analysis yielded two main components of cumulative illness severity: Hospitalization and Duration of Illness. While the component Hospitalization incorporated information from the intensity of inpatient treatment, the component Duration of Illness was based on the duration and frequency of illness episodes. We could demonstrate a significant inverse association of patients' Hospitalization component scores with bilateral hippocampal gray matter volume. This relationship was not found for Duration of Illness component scores. Variables associated with patients' history of psychiatric hospitalization seem to be accurate predictors of hippocampal volume in major depression and reliable estimators of patients' cumulative illness severity. Future studies should pay attention to these measures when investigating hippocampal volume changes in major depression.

In psychotherapy with severe patients discouraging news may be worse than no news: The impact of providing feedback to therapists on psychotherapy outcome, session attendance, and the alliance.

Our objective was to assess low-cost and feasible feedback alternatives and compare them to Lambert's OQ feedback system. We also studied patient, therapist, and process characteristics that could moderate the effect of feedback on outcome, session attendance, and alliance. A total of 547 patients, 75% female, average age 41 (SD = 13), 95% Latino, treated in an outpatient individual psychotherapy setting in Chile were randomly assigned to five feedback conditions: no feedback, feedback on symptomatology, feedback on the alliance, feedback on both symptomatology and alliance, and Lambert's OQ progress feedback report. The measures included the Outcome Questionnaire and the Working Alliance Inventory. We also had follow-up interviews with therapists. We found through multilevel modeling that feedback had no effect on outcome, session attendance, and alliance. Contrary to previous findings, these results were maintained even when focusing only on patients "not-on-track." However, patients' former psychiatric hospitalization history and baseline severity, combined with lack of progress, significantly moderated the impact of feedback. For this more dysfunctional population, "positive feedback" (i.e., low symptomatology) to therapists had a positive impact on therapy outcome, while "negative feedback" (i.e., high symptomatology) had a negative impact. Providing feedback to therapists without offering them tools to improve treatment may be ineffective and even be detrimental. This may be especially the case for patients who suffer more severe mental health issues and whose therapists receive mostly discouraging news as feedback. (PsycINFO Database Record

Serious suicide attempts in outpatients with multiple substance use disorders

BackgroundSuicide is a major public health concern and suicide attempts (SA) are frequent and burdensome in people suffering from substance use disorders (SUDs). In particular, serious SAs are a preoccupying form of attempt, which remain largely overlooked in these populations, especially regarding basic risk factors such as gender, addictive comorbidity and substance use patterns. Thus, we undertook a gender-specific approach to identify the risk factors for serious SAs in outpatients with multiple SUDs. Material and methods433 Treatment-seeking outpatients were consecutively recruited in specialized care centers and reliably classified as serious, non-serious and non-suicide attempters. We also characterized lifetime exposure to SUDs, including tobacco smoking, with standardized instruments. Current medication, including psychotropic treatments were collected, which informed psychiatric diagnoses. Multinomial regression identified independent factors specifically associated with serious SAs in each gender, separately. Results32% Participants (N=139, 47% Women and 27% Men) reported lifetime SA. There were 82 serious attempters (59% of attempters), without significant gender difference. Sedative dependence was an independent risk factor for serious SA compared to non-SA in Women and compared to non-serious SA in Men, respectively. Other risk factors included later onset of daily tobacco smoking in Men and history of psychiatric hospitalizations in Women, whose serious SA risk was conversely lower when reporting opiate use disorder or mood disorder, probably because of treatment issues. ConclusionsDespite several study limitations, we identified subgroups for a better-tailored prevention of serious SAs among individuals with SUDs, notably highlighting the need to better prevent and treat sedative dependence.

Surgery type and psychosocial factors contribute to poorer weight loss outcomes in persons with a body mass index greater than 60 kg/m2

BackgroundThe current investigation aims to predict 3-year postoperative percent total weight loss among a sample of bariatric surgery patients with super-super obesity. ObjectivePrevious research implies that persons with presurgical super-super obesity (body mass index [BMI] ≥60 kg/m2) tend to have poorer loss outcomes compared with those with a lower presurgical BMI after bariatric surgery. SettingCleveland Clinic, Bariatric & Metabolic Institute, Cleveland, OH. MethodsBariatric surgery candidates (N = 1231; 71.9% female; 65.8% Caucasian) completed a presurgical psychological evaluation and the Minnesota Multiphasic Personality Inventory–2–Restructured Form. Participants with a baseline BMI ≥60 (n = 164) were compared with BMI<60 (n = 1067) on psychosocial and demographic factors, the Minnesota Multiphasic Personality Inventory–2–Restructured Form, and in the subset that had surgery (n = 870), percent total weight loss extending to the 3-year follow-up. ResultsPatients with a BMI ≥60 were younger, less educated, and more likely to be male compared with lower BMI patients. Patients with a BMI ≥60 had greater psychosocial sequelae as evidenced by being more likely to have a history of sexual abuse, history of psychiatric hospitalization, more binge eating episodes, and higher prevalence of major depression disorder and binge eating disorder. On the Minnesota Multiphasic Personality Inventory–2–Restructured Form, those with BMI ≥60 reported greater demoralization, low positive emotions, ideas of persecution, and dysfunctional negative emotions. After controlling for surgery type, weight loss for individuals with BMI ≥60 did not greatly differ from weight loss in patients with BMI<60. Variables predictive of less weight loss at 3 years regardless of presurgical BMI, included being older, having a sexual abuse history, and higher ideas of persecution scores. ConclusionAlthough patients with BMI ≥60 evidenced more psychopathology before surgery, findings suggest that the relationship between higher BMI and poorer outcome may better be explained by other co-morbid factors.

The Utility of Outpatient Commitment: II. Mortality Risk and Protecting Health, Safety, and Quality of Life.

This study assessed the contribution of a form of outpatient commitment-community treatment orders (CTOs)-to mortality risk and quality of life of patients with severe mental illness. Data (2000--2012) were obtained from the Australian National Death Index, Victoria Department of Health, Victoria police records, and National Outcomes and CaseMix Collection quality-of-life records for patients in the Victorian Psychiatric Case Register/RAPID with a history of psychiatric hospitalization: CTO cohort, N=11,424; non-CTO cohort, N=16,161. The contribution of CTOs to mortality risk associated with CTO facilitation of access to general medical care and prevention of criminal involvement was assessed with logistic regression models. Cohort differences in quality of life were also examined. A total of 2,727 patients (10%) in the overall sample died, and the sample had a higher mortality risk than the general population. Probability of death by any cause was 9% lower in the CTO cohort than in the non-CTO cohort. Facilitation of access to medical care accounted for a 20% reduction in risk of non-injury-related deaths in the CTO cohort, compared with the non-CTO cohort. Risk of death by self-harm was 32% higher, compared with the non-CTO cohort. CTO placement appeared to lead to a gain of 3.8 years of life among men and 2.4 years among women, compared with the non-CTO cohort. Quality-of-life scores were modestly less favorable for the non-CTO cohort. CTO placement was associated with lower mortality risk via facilitated access to medical care and with modest enhancement of quality of life.

Costs of services for homeless people with mental illness in 5 Canadian cities: a large prospective follow-up study.

Limited evidence on the costs of homelessness in Canada is available. We estimated the average annual costs, in total and by cost category, that homeless people with mental illness engender from the perspective of society. We also identified individual characteristics associated with higher costs. As part of the At Home/Chez Soi trial of Housing First for homeless people with mental illness, 990 participants were assigned to the usual-treatment (control) group in 5 Canadian cities (Vancouver, Winnipeg, Toronto, Montréal and Moncton) between October 2009 and June 2011. They were followed for up to 2 years. Questionnaires ascertained service use and income, and city-specific unit costs were estimated. We adjusted costs for site differences in sample characteristics. We used generalized linear models to identify individual-level characteristics associated with higher costs. Usable data were available for 937 participants (94.6%). Average annual costs (excluding medications) per person in Vancouver, Winnipeg, Toronto, Montréal and Moncton were $53 144 (95% confidence interval [CI] $46 297-$60 095), $45 565 (95% CI $41 039-$50 412), $58 972 (95% CI $52 237-$66 085), $56 406 (95% CI $50 654-$62 456) and $29 610 (95% CI $24 995-$34 480), respectively. Net costs ranged from $15 530 to $341 535. Distributions of costs across categories varied significantly across cities. Lower functioning and a history of psychiatric hospital stays were the most important predictors of higher costs. Homeless people with mental illness generate very high costs for society. Programs are needed to reorient this spending toward more effectively preventing homelessness and toward meeting the health, housing and social service needs of homeless people.

Gun Violence Following Inpatient Psychiatric Treatment: Offense Characteristics, Sources of Guns, and Number of Victims.

This study presents data on the relative contribution to gun violence by people with a history of inpatient psychiatric treatment and on federal efforts to deter presumptively dangerous persons from obtaining firearms, information useful for analyzing the potential public health benefits of gun policies targeting people with serious mental illness. The study also estimates the reduction in gun violence victims that would be expected if individuals with a previous psychiatric hospitalization were prohibited from purchasing firearms. Data from 838 violent gun offenders from a nationally representative sample of state prison inmates were analyzed. Those with and without a history of psychiatric hospitalization were compared on a range of offense characteristics, including relationship to the victim, number of victims, location of the offense, and source of firearms. Inmates with a history of hospitalization constituted 12% of all violent gun offenders and accounted for 13% of the sample's victims. They were less likely than those without a previous hospitalization to victimize strangers (odds ratio=.52) and were no more likely to commit gun violence in public or to have multiple victims. Among those with previous hospitalizations, 78% obtained guns from sources not subject to federal background checks. Of the total 1,041 victims of gun violence, only 3% were victimized by participants with a history of hospitalization who obtained guns from currently regulated sources. Prohibiting all individuals with a history of psychiatric hospitalization from purchasing firearms, absent expanded background checks, was estimated to reduce the number of gun violence victims by only 3%.

Bipolar disorder and the risk of fracture: A nationwide population-based cohort study

BackgroundThe co-primary aims are: 1) to compare the risk of fracture between adults with bipolar disorder and those without bipolar disorder; and 2) to assess whether lithium, anticonvulsants and antipsychotics reduce risk of fracture among individuals with bipolar disorder. MethodsThe analysis herein is a population-based retrospective cohort study, utilizing the National Health Insurance (NHI) medical claims data collected between 1997 and 2013 in Taiwan. We identified 3705 cases with incident diagnoses of bipolar disorder during study period and 37,050 matched controls without bipolar diagnoses. Incident diagnosis of fracture was operationalized as any bone fracture after the diagnosis of bipolar disorder or after the matched index date for controls. ResultsBipolar patients had significantly higher risk of facture when compared to matched controls (17.6% versus 11.7%, respectively p<0.001). The hazard ratio (HR) was 1.33 (95% confidence interval [CI]＝1.23–1.48, p<0.001) after adjusting for covariates. Persons with bipolar disorder and a prior history of psychiatric hospitalization were had higher risk for bone fracture than those without prior history of psychiatric hospitalization when compared to match controls. Higher cumulative dose of antipsychotics or mood stabilizers did not increase the risk of fracture. LimitationsThe diagnoses of bipolar disorder were not confirmed with structured clinical interview. Drug adherence, exact exposure dosage, smoking, lifestyle, nutrition and exercise habits were unable to be assessed in our dataset. ConclusionsBipolar disorder is associated with increased risk of fracture, and higher cumulative dose of mood stabilizers and antipsychotics did not further increase the risk of fracture.

Criminal insanity and psychiatric diagnoses in Greek penal cases

IntroductionTo our knowledge, few studies address the issue of criminal responsibility among psychiatric offenders. In Greece, articles 34 and 36 of the penal code regulate criminal insanity and diminished responsibility, respectively.ObjectivesThe objective of the present study was to provide psychiatric/legal data considering the appeal to articles 34/36 of the Greek penal code.MethodsLegal case files of 100 adult subjects, 90 male/10 female, 88 Greeks/12 foreigners were examined.ResultsAccording to the first degree court, one defendant was found criminally insane, 29 with partial responsibility, while the rest were regarded as fully capable. The decisions of the court of appeal/the supreme court of appeal were 2 criminally insane, 36 partially responsible and 62, fully criminally responsible. The decisions were unanimous in 78% of the cases.The most common diagnoses were schizophrenia spectrum psychosis (18%), antisocial/borderline/mixed personality disorder (15%) and substance use disorder (15%). Court decisions of criminal insanity/diminished responsibility were higher when the perpetrator had an Axis I diagnosis (47.5%), significantly lower in cases of personality disorder (22.2%) and even lower in cases of substance use disorder (16.7%). In patients with prior hospitalizations the percentage of criminal insanity/diminished responsibility was 55.6%, significantly higher than in cases without (24.4%).ConclusionsSchizophrenia is the most common mental disorder correlated with offenders criminally insane/partially responsible, while a history of psychiatric hospitalization is a very strong positive predictive factor for the successful appeal of the aforementioned articles.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Emergency Department Use in a Cohort of Older Homeless Adults: Results From the HOPE HOME Study.

The median age of single homeless adults is over 50, yet little is known about their emergency department (ED) use. We describe use of and factors associated with ED use in a sample of homeless adults 50 and older. We recruited 350 participants who were homeless and 50 or older in Oakland, California. We interviewed participants about residential history in the prior 6months, health status, health-related behaviors, and health services use and assessed cognition and mobility. Our primary outcome was the number of ED visits in the prior 6months based on medical record review. We used negative binomial regression to examine factors associated with ED use. In the 6months prior to enrollment, 46.3% of participants spent the majority of their time unsheltered; 25.1% cycled through multiple institutions including shelters, hospitals, and jails; 16.3% primarily stayed with family or friends; and 12.3% had become homeless recently after spending much of the prior 6 months housed. Half (49.7%) of participants made at least one ED visit in the past 6months; 6.6% of participants accounted for 49.9% of all visits. Most (71.8%) identified a regular non-ED source of healthcare; 7.3% of visits resulted in hospitalization. In multivariate models, study participants who used multiple institutions (incidence rate ratio [IRR]=2.27; 95% confidence interval [CI]=1.08 to 4.77) and who were unsheltered (IRR=2.29; 95% CI=1.17 to 4.48) had higher ED use rates than participants who had been housed for most of the prior 6months. In addition, having health insurance/coverage (IRR=2.6; CI=1.5 to 4.4), a history of psychiatric hospitalization (IRR=1.80; 95% CI=1.09 to 2.99), and severe pain (IRR=1.72; 95% CI=1.07 to 2.76) were associated with higher ED visit rates. A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior 6months than the general U.S. age-matched population. Within the sample, ED use rates varied based on individuals' residential histories, suggesting that individuals' ED use is related to exposure to homelessness.

Factors associated with substance use in older homeless adults: Results from the HOPE HOME study

ABSTRACTBackground: The median age of the single adult homeless population is 50 and rising. Although the prevalence of substance use decreases as individuals age, older adults now have a higher prevalence of substance use than older adults did 10 years ago. Homeless individuals have a higher prevalence of substance use disorders than the general population. However, little is known about substance use in older homeless adults. Methods: The objective of the study was to examine prevalence of and factors associated with substance use in a population-based sample (N = 350) of homeless individuals aged 50 and older in Oakland, California. Dependent variables included moderate or greater severity illicit drug symptoms (Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) score >3) and moderate or greater alcohol symptoms (Alcohol Use Disorders Identification Test (AUDIT) score >7). Independent variables included demographics, mental health problems, and negative life course events such as physical and sexual abuse, school expulsion, and onset of homelessness. Results: Almost two thirds of participants, 64.6%, had moderate or greater severity symptoms for at least 1 illicit drug; 25.8% had moderate or greater severity alcohol symptoms. History of psychiatric hospitalization was associated with moderate or greater illicit drug symptoms (adjusted odds ratio [AOR] = 1.9, 1.0–3.6). The presence of major depressive symptoms was associated with moderate or greater severity alcohol symptoms (AOR = 1.8, 1.1–3.0). Conclusions: In this sample of older homeless adults, substance use is common. There is a need for substance use treatment programs, integrated with mental health services, which are targeted towards the needs of older homeless adults.

Facteurs prédictifs d’hospitalisation à partir des lits de crise des urgences d’un hôpital général

IntroductionThe availability of short-stay beds for brief admission (less than 72hours) of crisis patients presenting to the emergency room is a model that has gained a growing interest because it allows time for developing alternatives to psychiatric hospitalization and favors a maintained functioning in the community. Still, the determinants influencing the disposition decision at discharge after crisis intervention remain largely unexplored. ObjectiveThe primary objective of this study was to determine the factors predicting aftercare dispositions at crisis unit discharge: transfer for further hospitalization or return to the community. Secondary objectives included the description of clinical and socio-demographic characteristics of patients admitted to the crisis unit upon presentation to the emergency room. MethodAll patients (n=255) admitted to the short-stay unit of the emergency department of Rambouillet General Hospital during a one-year period were included in the study. Patient characteristics were collected in a retrospective manner from medical records: patterns of referral, acute stressors, presenting symptoms, initial patient demand, Diagnostic and Statistical Manual, 5th edition (DSM-5) disorders, psychiatric history, and socio-demographic characteristics were inferred. Logistic regression analysis was used to determine the factors associated with hospitalization decision upon crisis intervention at discharge. ResultsFollowing crisis intervention at the short-stay unit, 100 patients (39.2%) required further hospitalization and were transferred. Statistically significant factors associated with a higher probability of hospitalization (P<0.05) included the patient's initial wish to be hospitalized (OR=4.28), the presence of a comorbid disorder (OR=3.43), a referral by family or friends (OR=2.89), a history of psychiatric hospitalization (OR=2.71) and suicidal ideation on arrival in the emergency room (OR=2.26). Conversely, significant factors associated with a lower probability of hospitalization were the presence of a personality disorder (OR=0.31), a precipitating conflict situation (OR=0.41), age between 20 and 39 years (OR=0.42), being employed (OR=0.49). ConclusionOur study confirms that clinical factors such as the presence of a personality disorder or the context of a precipitating conflict situation are predictive of a community return. Interestingly, it points out the importance of the patient's initial wish in the hospitalization decision.

P.3.b.018 - Longitudinal study (1 year) of influence of NGF and BDNF in functionality in first psychotic episode patients, with and without cannabis use

Suicide is a major public health concern and suicide attempts (SA) are frequent and burdensome in people suffering from substance use disorders (SUDs). In particular, serious SAs are a preoccupying form of attempt, which remain largely overlooked in these populations, especially regarding basic risk factors such as gender, addictive comorbidity and substance use patterns. Thus, we undertook a gender-specific approach to identify the risk factors for serious SAs in outpatients with multiple SUDs.433 Treatment-seeking outpatients were consecutively recruited in specialized care centers and reliably classified as serious, non-serious and non-suicide attempters. We also characterized lifetime exposure to SUDs, including tobacco smoking, with standardized instruments. Current medication, including psychotropic treatments were collected, which informed psychiatric diagnoses. Multinomial regression identified independent factors specifically associated with serious SAs in each gender, separately.32% Participants (N = 139, 47% Women and 27% Men) reported lifetime SA. There were 82 serious attempters (59% of attempters), without significant gender difference. Sedative dependence was an independent risk factor for serious SA compared to non-SA in Women and compared to non-serious SA in Men, respectively. Other risk factors included later onset of daily tobacco smoking in Men and history of psychiatric hospitalizations in Women, whose serious SA risk was conversely lower when reporting opiate use disorder or mood disorder, probably because of treatment issues.Despite several study limitations, we identified subgroups for a better-tailored prevention of serious SAs among individuals with SUDs, notably highlighting the need to better prevent and treat sedative dependence.