Persistent Illness Research Articles

Making a case for the inclusion of refractory and severe mental illness as a sole criterion for Canadians requesting medical assistance in dying (MAiD): a review

BackgroundFollowing several landmark rulings and increasing public support for physician-assisted death, in 2016, Canada became one of a handful of countries legalising medical assistance in dying (MAiD) with Bill C-14....

Impact of Interprofessional Care Conferences Across Primary Care and Mental Health Organizations on Family Medicine Resident Learning.

Patients with severe mental illness often lack care coordination between primary care and mental health providers which can negatively impact patient outcomes. Team-based care is integral in the effective management of patients with multiple comorbidities, with the family physician central in coordinating holistic care. Family medicine residency programs must provide models of effective interprofessional collaboration and mental health treatment to prepare residents to navigate an evolving health care landscape. The objective of this study was to evaluate family medicine residents' learning about providing holistic care with an interprofessional team and medication safety monitoring from the interprofessional cross-organizational care conference experience. To bridge care and cultivate the necessary skills, a family medicine clinic and mental health clinic implemented monthly interprofessional care conferences to coordinate care for their shared patients during 2019. Residents who participated in the care conference each (n=11) completed a retrospective pre/postsurvey (11/11=100% response rate) to gather perceptions of what they learned from the interprofessional care conference experience. After participating in the care conference, all residents agreed they understood the elements that must be considered to provide holistic patient care, were confident conducting medication safety monitoring for their patients taking second-generation antipsychotics (eg, lipids, A1C, ECG), and agreed the care conference helped them develop a more comprehensive patient-centered care plan. Additionally, they all intend to work collaboratively across professions in the future. Interprofessional and cross-organizational care conferences create an authentic learning environment that enhances family medicine residents' understanding and confidence in providing collaborative and holistic care for patients with severe and persistent mental illness.

Ethics of pad in mental disorders

Involuntary psychiatric hospitalization for suicide prevention and physician assistance in dying (PAD) for patients with severe and persistent mental illness (SPMI) combine to create a moral tension. Switzerland has the longest history of non-medicalized assistance in dying, considered as a civil right even beyond pathological situations. The debate in Switzerland centers on the notion of suffering in the context of PAD. In 2018, the Swiss Academy of Medical Sciences revised their end-of-life policy stipulating intolerable suffering due to severe illness or functional limitations and acknowledged as such by the physician as a core criterion for PAD. However, we argue that suffering is a necessary but insufficient condition for PAD, the other criteria being decision-making capacity (DMC) and refractoriness of the suffering. Moreover, we hold that suffering is a subjective experience that can only be quantified by the patient and cannot be compared between two persons in an objective way. According to this concept, however, some patients with SPMI, refractory suffering, and preserved DMC will meet the criteria for PAD. Therefore, we call for palliative care approaches in psychiatry which includes relief of suffering as much as possible, but also accepting PAD after a conscientious assessment of the criteria.DisclosureNo significant relationships.

Associations between baseline cortisol and trajectory of symptom improvement in depressed adolescents receiving psychological therapy

BackgroundCortisol hypersecretion in depressed adolescents and adults is associated with more persistent illness and may signal a lower response to psychological therapies. A meta-analysis of small and heterogenous studies demonstrated that higher pre-treatment basal cortisol levels were associated with poorer response specifically to psychological therapy for depression. The objective of this study was to investigate the relationship between both morning and evening salivary cortisol levels and response to psychological therapy in depressed adolescents participating in one large randomised controlled trial. MethodsWe tested the association between morning and evening salivary cortisol levels at baseline and improvement in depressive symptoms in response to psychological therapies in depressed adolescents at 6 time points: baseline, 6, 12, 36, 52- and 86-weeks post-randomisation, using the self-reported Mood and Feelings Questionnaire (MFQ). ResultsHigh evening cortisol was associated with a slower initial decline in depressive symptoms (cortisol x quadratic time p = .022); however it was not associated with total change in depressive symtoms over the whole course of the study. Morning cortisol was not associated with change in depressive symptoms. These effects were not significantly different across the three psychological therapies. LimitationsResults may not generalize to adolescents receiving other treatments (medication) or no treatment, and may not generalize to adults. Only a minority of eligible participants collected valid cortisol samples. ConclusionsHigher pretreatment evening cortisol may impair a depressed adolescent's ability to use psychological therapy.

Does the length of institutionalization matter? Longitudinal follow-up of persons with severe mental illness 65 years and older: shorter-stay versus longer-stay.

As part of the process of de-institutionalization in the Swedish mental healthcare system, a reform was implemented in 1995, moving the responsibility for services and social support for people with severe mental illness (SMI) from the regional level to the municipalities. In many ways, older people with SMI were neglected in this changing landscape of psychiatric care. The aim of this study is to investigate functional levels, living conditions, need of support in daily life, and how these aspects changed over time for older people with SMI. In this study we used data from surveys collected in 1996, 2001, 2006, and 2011 and data from national registers. A group of older adults with severe persistent mental illness (SMI-O:P) was identified and divided into those who experienced shorter stays (less than 3 years) in a mental hospital (N=118) and longer stays (N=117). After correcting for longitudinal changes with age, the longer-stay group was more likely than the shorter-stay group to experience functional difficulties and as a result, were more likely to have experienced 're-institutionalization' to another care setting, as opposed to living independently. The length of mental illness hospitalization has significant effects on the living conditions of older people with SMI and their ability to participate in social life.

Nurses' views on palliative care for those diagnosed with severe persistent mental illness: A Pilot Survey Study in Switzerland.

WHAT IS KNOWN ON THE SUBJECT?: In recent years, some have suggested that palliative care approaches be considered for patients diagnosed with severe, persistent mental illness. Palliative care aims to decrease the suffering related to illness rather than focusing on curing the illness. Palliative care approaches for patients diagnosed with severe, persistent mental illness are controversial: Some argue palliative care would improve quality of life while others argue it would negatively affect patients' well-being. A recent survey found that psychiatrists from Switzerland tended to support the idea of palliative care approaches for those diagnosed with severe, persistent mental illness, but little is known about nurses' attitudes or beliefs regarding palliative psychiatry. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Participating nurses tended to agree that palliative care approaches may be appropriate and even important in caring for those diagnosed with severe, persistent mental illness. Participating nurses tended to prioritize quality of life and respect for patient autonomy. Participating nurses tended to agree palliative sedation may be an appropriate intervention. WHAT THE IMPLICATIONS ARE FOR PRACTICE?: For those diagnosed with severe, persistent mental illness, care that aims to increase daily functioning and quality of life rather than care that looks to cure may be appropriate. Palliative psychiatry should be further explored and better defined. ABSTRACT: Introduction In recent years, palliative care approaches for patients diagnosed with severe, persistent mental illness have been proposed, but remain controversial. Aim/Question The central research question of the present study was whether nurses consider palliative psychiatry appropriate in general and for certain patient types in particular. This pilot study is designed to inform future research. Method A quantitative survey that explored attitudes and beliefs regarding palliative care for those with severe, persistent mental illness. Results The responding 38 nurses tended to agree that palliative care approaches are suitable (73%, n=24) and even important (62%, n=21) in treating patients diagnosed with severe, persistent mental illness, including interventions such as palliative sedation (73%, n=24). Discussion Widespread support among respondents regarding palliative care approaches for those diagnosed with severe, persistent mental illness might be an indication that palliative approaches are already implicitly understood and incorporated into patients' care. More research is needed to determine whether these findings represent nurses' views generally. Implications for practice These finding suggest that palliative psychiatry should be further explored and developed.

Consumer experiences of community-based residential mental health rehabilitation for severe and persistent mental illness: A pragmatic grounded theory analysis.

Semi-structured interviews were used to explore the consumer experience of community-based residential mental health rehabilitation support at Community Care Units in Australia. These clinical services provide recovery-oriented residential rehabilitation to people affected by severe and persistent mental illness. Typically, nurses occupy the majority of staff roles. However, two of the three sites in the study were trialling a novel integrated staffing model where the majority of staff were people with a lived experience of mental illness employed as peer support workers (PSWs). The interviews explored consumers' experiences of care 12-18months after admission. Fifteen interviews were completed with an independent interviewer. Most participants were diagnosed with schizophrenia or a related psychotic disorder. The analysis followed a pragmatic approach to grounded theory. Consumers viewed the CCU favourably, emphasizing the value of the relationships formed with staff and co-residents. No major differences in consumers' experience under the traditional versus integrated staffing models were identified; however, those from the integrated staffing model sites valued the contributions of the peer support workers. The understanding of the consumer experience emerging through this study aligned with their expectations of the service at the time of commencement.

Contribution of mental ill health during military service to postservice benefit claims in the UK

ObjectivesWhile most UK military personnel transition successfully into civilian life, some experience unemployment and disability, which may be partly attributable to in-service factors. This study aims to determine the degree...

Transcranial Photobiomodulation to Improve Cognition in Gulf War Illness.

Introduction: Approximately 25–30% of veterans deployed to Kuwait, 1990-91, report persistent multi-symptom Gulf War Illness (GWI) likely from neurotoxicant exposures. Photobiomodulation (PBM) in red/near-infrared (NIR) wavelengths is a safe, non-invasive modality shown to help repair hypoxic/stressed cells. Red/NIR wavelengths are absorbed by cytochrome C oxidase in mitochondria, releasing nitric oxide (increasing local vasodilation), and increasing adenosine tri-phosphate production. We investigated whether PBM applied transcranially could improve cognition, and health symptoms in GWI.Materials and Methods: Forty-eight (40 M) participants completed this blinded, randomized, sham-controlled trial using Sham or Real, red/NIR light-emitting diodes (LED) applied transcranially. Fifteen, half-hour transcranial LED (tLED) treatments were twice a week (7.5 weeks, in-office). Goggles worn by participant and assistant maintained blinding for visible red. Pre-/Post- testing was at Entry, 1 week and 1 month post- 15th treatment. Primary outcome measures were neuropsychological (NP) tests; secondary outcomes, Psychosocial Questionnaires, including PTSD.Results: Primary Analyses (all participants), showed improvement for Real vs. Sham, for Digit Span Forwards (p < 0.01); and a trend for Trails 4, Number/Letter Sequencing (p < 0.10). For secondary outcomes, Real group reported more improvement on the SF-36V Plus, Physical Component Score (p < 0.08). Secondary Analyses included only subjects scoring below norm (50%ile) at Entry, on specific NP test/s. Real and Sham improved at 1 week after 15th treatment; however, at 1 month, only those receiving Real improved further: Digit Span Total, Forwards and Backwards; Trails 4, Number/Letter Sequencing; California Verbal Learning Test-II, long delay free recall; Continuous Performance Test-II, False Alarm Rate; and Color-Word Interference, Stroop, Trial 3, Inhibition; Sham group worsened, toward Entry values. Only those with more post-traumatic stress disorder (PTSD) symptomatology at Entry, receiving Real, continued to have additional PTSD reduction at 1 month; Sham regressed.Conclusion: This study was underpowered (n = 48), with large heterogeneity at Entry. This likely contributed to significance or trend to significance, for only two of the NP tests (Digit Span Forwards; Trails 4, Number/Letter Sequencing) and only one general health measure, the SF-36V Plus, Physical Component Score. More subjects receiving Real, self-reported increased concentration, relaxation and sleep. Controlled studies with newer, transcranial LED home treatment devices are warranted; this is expected to increase enrollment.Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT01782378.

Graduate Education in Rehabilitation Counseling and the Stigma of Mental Illness: A Review of the Literature

The Rehabilitation Counseling profession has foundations in disability awareness and acknowledges disability stigma as a barrier to full participation. Graduate-level rehabilitation counseling programs assist students with self-evaluation and examination of attitudes toward individuals with disabilities. Effective service providers are seen as having knowledge of how social attitudes play a part in issue of inclusion and full participation. Mental health is an area that has historically drew considerable attention. However, barriers to effective service delivery still persist and may include the stigma toward individuals with mental illness. Attitude formation and the implications of stigma will be provided in this conceptual article. This literature review will include an overview of factors that may contribute to stigmatizing reactions. Recommendations for graduate educational programs are discussed including best practices. These include creating a learning environment that focuses on student's awareness, knowledge, and skills surrounding issues that affect individuals with severe and persistent mental illness.

Perceived Burdensomeness and the Wish for Hastened Death in Persons With Severe and Persistent Mental Illness.

Background: In several European countries, medical assistance in dying (MAID) is no longer confined to persons with a terminal prognosis but is also available to those suffering from persistent and unbearable mental illness. To date, scholarly discourse on MAID in this population has been dominated by issues such as decision-making capacity, uncertainty as to when a disease is incurable, stigmatization, isolation, and loneliness. However, the issue of perceived burdensomeness has received little attention.Objective: The study explores the possible impact of perceived burdensomeness on requests for MAID among persons with severe and persistent mental illness (SPMI).Method: Using the method of ethical argumentation, we discuss the issue of access to MAID for persons with SPMI and perceived burdensomeness.Conclusion: Perceived burdensomeness may be a contributing factor in the wish for hastened death among persons with SPMI. MAID is ethically unsupportable if SPMI causes the individual to make an unrealistic assessment of burdensomeness, indicating a lack of decision-making capacity in the context of that request. However, the possibility that some individuals with SPMI may perceive burdensomeness does not mean that they should be routinely excluded from MAID. For SPMI patients with intact decision-making capacity who feel their life is not worth living, perceived burdensomeness as a component of this intolerable suffering is not a sufficient reason to deny access to MAID.

Spirituality and Employment in Recovery from Severe and Persistent Mental Illness and Psychological Well-Being.

People diagnosed with severe and persistent mental illness (SPMI) face multiple vulnerabilities, including when seeking employment. Among SPMI patients, studies show that a stronger sense of spirituality can help to reduce psychotic symptoms, increase social integration, reduce the risk of suicide attempts and promote adherence to psychiatric treatment. This study examined how the variables spirituality and employment affect the recovery process and psychological well-being of people with SPMI who attend employment recovery services. The sample consisted of 64 women and men diagnosed with an SPMI. The assessment instruments included the Recovery Assessment Scale, Ryff Psychological Well-Being Scale, Work Motivation Questionnaire, Daily Spiritual Experience Scale, and Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being (FACIT-Sp12). Hierarchical regression analyses were performed to compare three different models for each dependent variable (recovery and psychological well-being). The findings showed that job skills predicted psychological well-being and recovery. When spiritual variables were included in the model, job skills dropped out and the dimension meaning/peace of the FACIT-Sp12 emerged as the only significant predictor variable. Integrating spirituality into recovery programs for people with SPMI may be a helpful complement to facilitate the recovery process and improve psychological well-being.

Understanding the Instruments of Proteinuria

An enormous assemblage of proof demonstrates that proteinuria is a solid indicator of dreariness, a reason for aggravation, oxidative pressure and movement of persistent kidney illness, and improvement of cardiovascular sickness. The cycles that lead to proteinuria are intricate and include factors like glomerular hemodynamic, cylindrical ingestion, and dissemination slopes. Modifications in different distinctive sub-atomic pathways and cooperations may prompt the indistinguishable clinical end points of proteinuria and persistent kidney illness. Glomerular illnesses incorporate a wide scope of resistant and nonimmune put-downs that may target and consequently harm a few parts of the glomerular filtration boundary. In a considerable lot of these conditions, the renal instinctive epithelial cell (podocyte) reacts to injury along characterized pathways, which may clarify the resultant clinical and histological changes. The new revelation of the atomic segments of the cut stomach, particular construction of podocyte-podocyte association, has been a significant leap forward in understanding the vital job of the epithelial layer of the glomerular boundary and the pathogenesis of proteinuria. This paper gives an outline and update on the design and capacity of the glomerular filtration hindrance and the pathogenesis of proteinuria, featuring the part of the podocyte in this setting. Likewise, current antiproteinuric restorative methodologies are momentarily remarked.

Applying futility in psychiatry: a concept whose time has come

Since its introduction in the 1980s, futility as a concept has held contested meaning and applications throughout medicine. There has been little discussion within the psychiatric literature about the use...

Adherence to treatment in collective multiprofessional activities and factors associated with adherence in a specialized center for psychosocial care.

IntroductionSpecialized psychosocial care centers (Centros de Atenção Psicossocial [CAPS]) are mental health services focused on social rehabilitation and reducing hospitalization of patients with severe and persistent mental illness. Collective multiprofessional activities (CMPA) are the main therapeutic tools used at CAPS. This study aimed to determine rates of adherence to CMPA and identify factors associated with adherence.MethodsThis is a cross-sectional study in which 111 CAPS users were evaluated using questionnaires covering patient characteristics, clinical status, and treatment and incorporating the Functioning Assessment Short Test (FAST), the Clinical Global Impression – Severity scale (CGI-S), and the Clinical Global Impression – Improvement scale (CGI-I). Adherence was defined as attendance at 50% or more CMPA during the previous 3 months. Data were analyzed using descriptive statistics, bivariate analysis, and Poisson logistic regression with robust variance to estimate prevalence ratios.ResultsCPMA adherence was 43%. Having children aged 14 years or younger was significantly associated with non-adherence (71%, p = 0.001). Poor or partial adherence to psychotropic drugs tended to be associated (p = 0.066) with poor adherence (33% higher risk), as was the number of psychiatric hospitalizations during CAPS (p = 0.076), with a cumulative association of 5% non-adherence per hospitalization.ConclusionsCMPA adherence was low in the study. It is necessary to consider the environment in which the individual lives and invest in support networks, providing patients and family members with explanations about the importance of CMPA to rehabilitation and attempting to tailor the care provided to each patient’s needs. There was an association between greater number of psychiatric hospitalizations and non-adherence, suggesting that CAPS are fulfilling a preventive role.

Nature and impact of in-hospital complications associated with persistent critical illness

Background: Persistent critical illness (PerCI) is defined as an intensive care unit (ICU) admission lasting ≥ 10 days. The in-hospital complications associated with its development are poorly understood. Aims: To test whether PerCI is associated with a greater prevalence, rate and specific types of in-hospital complications. Methods: Single-centre, retrospective, observational case-control study. Results: We studied 1200 patients admitted to a tertiary ICU from 2010 to 2015. Median ICU length of stay was 16 days (interquartile range [IQR], 12-23) for PerCI patients v 2.3 days (IQR, 1.1-3.7) for controls, and median hospital length of stay was 41 days (IQR, 22-75) v 8 days (IQR, 4-17) respectively. A greater proportion of PerCI patients received acute renal replacement therapy (37% v 6.8%) or underwent reintubation (17% v 1%) and/or tracheostomy (36% v 0.6%); P < 0.0001. Despite these complications, PerCI patients had similar hospital mortality (29% v 27%; P = 0.53). PerCI patients experienced a greater absolute number of complications (12.1 v 4.0 complications per patient; P < 0.0001) but had fewer exposure-adjusted complications (202 v 272 complications per 1000 hospital bed-days; P < 0.001) and a particularly high overall prevalence of specific complications. Conclusions: PerCI patients experience a higher prevalence, but not a higher rate, of exposure-adjusted complications. Some of these complications appear amenable to prevention, helping to define intervention targets in patients at risk of PerCI. Funding: Austin Hospital Intensive Care Trust Fund.

Metacognition and the clubhouse model in treating severe mental illness.

Clubhouses have demonstrated significant positive psychosocial outcomes, in addition to more enduring resiliencies for persons with histories of severe persistent mental illness (SPMI). However, there is a paucity of research investigating the recovery processes impacted by community-based interventions like clubhouse for SPMI. Research into metacognition and its relation to recovery trajectories in SPMI creates a compelling cognitive and intersubjective framework within which to understand the recovery impacts of the clubhouse intervention model of social practice. The present article examines significant areas of conceptual overlap between the clubhouse model of social practice, metacognition, and intersubjective recovery processes. A preliminary research project investigating the metacognitive impacts of community-based interventions for SPMI is presented. An overview of the theoretical and practical relevance of the clubhouse community-based treatment model of social practice to metacognitive recovery processes is presented through a discussion of the resilience observed in clubhouse settings as it relates to the enhancement of intersubjectivity. The clubhouse model of social practice is a unique therapeutic modality with outcomes that can be readily investigated and explained through metacognitive processes relevant to recovery in SPMI. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Lipid Mediators in Critically Ill Patients: A Step Towards Precision Medicine.

A dysregulated response to systemic inflammation is a common pathophysiological feature of most conditions encountered in the intensive care unit (ICU). Recent evidence indicates that a dysregulated inflammatory response is involved in the pathogenesis of various ICU-related disorders associated with high mortality, including sepsis, acute respiratory distress syndrome, cerebral and myocardial ischemia, and acute kidney injury. Moreover, persistent or non-resolving inflammation may lead to the syndrome of persistent critical illness, characterized by acquired immunosuppression, catabolism and poor long-term functional outcomes. Despite decades of research, management of many disorders in the ICU is mostly supportive, and current therapeutic strategies often do not take into account the heterogeneity of the patient population, underlying chronic conditions, nor the individual state of the immune response. Fatty acid-derived lipid mediators are recognized as key players in the generation and resolution of inflammation, and their signature provides specific information on patients’ inflammatory status and immune response. Lipidomics is increasingly recognized as a powerful tool to assess lipid metabolism and the interaction between metabolic changes and the immune system via profiling lipid mediators in clinical studies. Within the concept of precision medicine, understanding and characterizing the individual immune response may allow for better stratification of critically ill patients as well as identification of diagnostic and prognostic biomarkers. In this review, we provide an overview of the role of fatty acid-derived lipid mediators as endogenous regulators of the inflammatory, anti-inflammatory and pro-resolving response and future directions for use of clinical lipidomics to identify lipid mediators as diagnostic and prognostic markers in critical illness.

Cost-Savings Associated with Reductions in Public Service Utilization with Provision of Permanent Supported Housing in Midsized City in the United States.

Severe and persistent mental illnesses are frequently associated with homelessness and extensive use of public services. Cost savings after the provision of permanent supportive housing (PSH) have been examined in large metropolitan areas but not in medium-sized communities. Administrative and clinical data were collected to determine use of public services, such as use of emergency services, inpatient psychiatric and medical services, and correctional facilities, in the year preceding and the year subsequent to placement in PSH. Costs of the housing and the utilized services were also calculated. Ninety-one subjects were in housing first (HF) programs and 19 were in treatment first (TF) programs. Overall there was a net cost savings of over $1.2 million or $6134/consumer/year of PSH. Nearly all cost savings were in reduced service utilization which implies prevention of both medical and psychiatric morbidity. In HF the average per patient cost savings ($21,082.12) was not significantly greater than TF ($12,907.29; p= 0.33). Provision of PSH in a mid-sized city provides significant cost savings.

Regional Brain Correlates of Beta Bursts in Health and Psychosis: A Concurrent Electroencephalography and Functional Magnetic Resonance Imaging Study

BackgroundThere is emerging evidence for abnormal beta oscillations in psychosis. Beta oscillations are likely to play a key role in the coordination of sensorimotor information that is crucial to healthy mental function. Growing evidence suggests that beta oscillations typically manifest as transient beta bursts that increase in probability following a motor response, observable as post-movement beta rebound. Evidence indicates that post-movement beta rebound is attenuated in psychosis, with greater attenuation associated with greater symptom severity and impairment. Delineating the functional role of beta bursts therefore may be key to understanding the mechanisms underlying persistent psychotic illness. MethodsWe used concurrent electroencephalography and functional magnetic resonance imaging to identify blood oxygen level–dependent correlates of beta bursts during the n-back working memory task and intervening rest periods in healthy control participants (n = 30) and patients with psychosis (n = 48). ResultsDuring both task blocks and intervening rest periods, beta bursts phasically activated regions implicated in task-relevant content while suppressing currently tonically active regions. Patients showed attenuated post-movement beta rebound that was associated with persisting disorganization symptoms as well as impairments in cognition and role function. Patients also showed greater task-related reductions in overall beta burst rate and showed greater, more extensive, beta burst–related blood oxygen level–dependent activation. ConclusionsOur evidence supports a model in which beta bursts reactivate latently maintained sensorimotor information and are dysregulated and inefficient in psychosis. We propose that abnormalities in the mechanisms by which beta bursts coordinate reactivation of contextually appropriate content can manifest as disorganization, working memory deficits, and inaccurate forward models and may underlie a core deficit associated with persisting symptoms and impairment.