Clozapine clinical toolkit optimizes inpatient clozapine monitoring.

Introduction: Clozapine is the most effective antipsychotic in the management of treatment-resistant schizophrenia; however, its use is challenging due to the risk of severe adverse effects. Despite the risks associated with clozapine, there is no mandatory monitoring in Canada beyond hematologic testing for agranulocytosis surveillance. This study focuses on the development, implementation, and evaluation of a clozapine clinical toolkit (CTK) targeted at optimizing inpatient clozapine use. Methods: A comprehensive literature review was conducted to identify clozapine best practices, experts were consulted, and a comprehensive clozapine CTK was developed and implemented at a large Canadian tertiary hospital in December 2018. To evaluate the CTK, a retrospective chart review was conducted to assess for change in guideline-concordant monitoring pre- and post- CTK implementation. Patients were included if they were > 18 years of age and received clozapine during inpatient admission. Results were analyzed using descriptive and inferential statistics. Results: Among the charts reviewed, 185 and 113 admissions met the pre- and post-CTK inclusion criteria, respectively. Staff used the CTK in the care of 96% of clozapine patients post implementation, and its use resulted in improvements in guideline-concordant monitoring for agranulocytosis and myocarditis. Discussion: Implementation of the clozapine CTK increased the concordance of clozapine monitoring with best practice recommendations. Future research is necessary to assess the impact of the CTK on clinical outcomes and patient satisfaction.

Developing consensus to enhance perinatal mental health through a model of integrated care: Delphi study.

Perinatal mental illness is an important public health issue, with one in five birthing persons experiencing clinically significant symptoms of anxiety and/or depression during pregnancy or the postpartum period. The purpose of this study was to develop a consensus-based model of integrated perinatal mental health care to enhance service delivery and improve parent and family outcomes. We conducted a three-round Delphi study using online surveys to reach consensus (≥75% agreement) on key domains and indicators of integrated perinatal mental health care. We invited modifications to indicators and domains during each round and shared a summary of results with participants following rounds one and two. Descriptive statistics were generated for quantitative data and a thematic analysis of qualitative data was undertaken. Study participants included professional experts in perinatal mental health (e.g., clinicians, researchers) (n = 36) and people with lived experience of perinatal mental illness within the past 5 years from across Canada (e.g., patients, family members) (n = 11). Consensus was reached and all nine domains of the proposed model for integrated perinatal mental health care were retained. Qualitative results informed the modification of indicators and development of an additional domain and indicators capturing the need for antiracist, culturally safe care. The development of an integrated model of perinatal mental health benefitted from diverse expertise to guide the focus of included domains and indicators. Engaging in a consensus-building process helps to create the conditions for change within health services.

Lack of Identity and Suicidality: The Mediating Role of Emotion Regulation Difficulties.

ABSTRACT: Identity disturbance has been connected to both psychological distress and suicidality, and associated with emotion dysregulation. However, despite empirical evidence of a relationship between lack of identity and poor psychiatric outcomes, the link between impaired identity and emotion dysregulation in suicide risk remains underexplored, particularly among individuals seeking outpatient mental health services. Using data from a large clinical sample (n = 246), the present study examined the association between lack of identity and suicidality and the role of emotion dysregulation within this process. Findings indicated that the mediation model was significant, with emotion regulation difficulties significantly mediating the association between lack of identity and future suicidal behavior. Furthermore, the indirect effect of lack of identity on anticipated suicidality remained significant beyond general distress and past suicide attempt. Our findings add to the literature examining the complex relationship among lack of identity, emotion regulation, and suicidality.

Association of homelessness and psychiatric hospital readmission-a retrospective cohort study 2016-2020.

BACKGROUND: A large proportion of adult psychiatric inpatients experience homelessness and are often discharged to unstable accommodation or the street. It is unclear whether homelessness impacts psychiatric hospital readmission. Our primary objective was to examine the association between homelessness and risk for 30-day and 90-day readmission following discharge from a psychiatric unit at a single urban hospital. METHODS: A retrospective cohort study involving health administrative data among individuals (n = 3907) in Vancouver, Canada with an acute psychiatric admission between January 2016 and December 2020. Participants were followed from the date of index admission until censoring (December 30, 2020). Homelessness was measured at index admission and treated as a time-varying exposure. Adjusted Hazard Ratios (aHRs) of acute readmission (30-day and 90-day) for psychiatric and substance use disorders were estimated using multivariable Cox proportional hazards regression. RESULTS: The cohort comprised 3907 individuals who were predominantly male (61.89%) with a severe mental illness (70.92%), substance use disorder (20.45%) and mean age of 40.66 (SD, 14.33). A total of 686 (17.56%) individuals were homeless at their index hospitalization averaging 19.13 (21.53) days in hospital. After adjusting for covariates, patients experiencing homelessness had a 2.04 (1.65, 2.51) increased rate of 30-day readmission and 1.65 (1.24, 2.19) increased rate of 90-day readmission during the observation period. CONCLUSIONS: Homelessness was significantly associated with increased 30-day and 90-day readmission rates in a large comprehensive sample of adults with mental illness and substance use disorders. Interventions to reduce homelessness are urgently needed. QUESTION: Is homelessness associated with risk for 30-day and 90-day psychiatric hospital readmission? FINDINGS: In this retrospective cohort study of 3907 individuals, homelessness at discharge was associated with increased 30-day and 90-day psychiatric readmission. MEANING: Housing status is an important risk factor for hospital readmission. High-quality interventions focused on housing supports have the potential to reduce psychiatric readmission.

Attitudes towards people who use substances: a survey of mental health clinicians from an urban hospital in British Columbia.

Stigma and other barriers limit harm reduction practice integration by clinicians within acute psychiatric settings. The objective of our study was to explore mental health clinician attitudes towards substance use and associations with clinical experience and education level. The Brief Substance Abuse Attitudes Survey was completed among a convenience sample of mental health clinicians in Vancouver, British Columbia. Five predefined attitude subgroups were evaluated. Respondents' attitudes towards substance use were associated with level of education on questions from two (non-stereotyping [p = 0.012] and treatment optimism [p = 0.008]) subscales. In pairwise comparisons, postgraduate education was associated with more positive attitudes towards relapse risk (p = 0.004) when compared to diploma-educated respondents. No significant associations were observed between years of clinical experience and participant responses. Our findings highlight important aspects of clinician attitudes that could improve harm reduction education and integration into clinical practice.

Association of Methadone Treatment With Substance-Related Hospital Admissions Among a Population in Canada With a History of Criminal Convictions.

Importance: People with criminal histories experience high rates of opioid dependence and are frequent users of acute health care services. It is unclear whether methadone adherence prevents hospitalizations. Objective: To compare hospital admissions during medicated and nonmedicated methadone periods. Design, Setting, and Participants: A retrospective cohort study involving linked population-level administrative data among individuals in British Columbia, Canada, with provincial justice contacts (n= 250 884) and who filled a methadone prescription between April 1, 2001, and March 31, 2015. Participants were followed from the date of first dispensed methadone prescription until censoring (date of death, or March 31, 2015). Data analysis was conducted from May 1 to August 31, 2018. Exposures: Methadone treatment was divided into medicated (methadone was dispensed) and nonmedicated (methadone was not dispensed) periods and analyzed as a time-varying exposure. Main Outcome and Measures: Adjusted hazard ratios (aHRs) of acute hospitalizations for any cause and cause-specific (substance use disorder [SUD], non-substance-related mental disorders [NSMDs], and medical diagnoses [MEDs]) were estimated using multivariable Cox proportional hazards regression. Results: A total of 11 401 people (mean [SD] age, 34.9 [9.4] years; 8230 [72.2%] men) met inclusion criteria and were followed up for a total of 69 279.3 person-years. During a median follow-up time of 5.5 years (interquartile range, 2.8-9.1 years), there were 19 160 acute hospital admissions. Dispensed methadone was associated with a 50% lower rate of hospitalization for any cause (aHR, 0.50; 95% CI, 0.46-0.53) during the first 2 years (≤2.0 years) following methadone initiation, demonstrating significantly lower rates of admission for SUD (aHR, 0.32; 95% CI, 0.27-0.38), NSMD (aHR, 0.41; 95% CI, 0.34-0.50), and MED (aHR, 0.57; 95% CI, 0.52-0.62). As duration of time increased (2.1 to ≤5.0 years; 5.1 to ≤10.0 years), methadone was associated with a significant but smaller magnitude of effect: SUD (aHR, 0.43; 95% CI, 0.36-0.52; aHR, 0.47; 95% CI, 0.37-0.61), NSMD (aHR, 0.51; 95% CI, 0.41-0.64; aHR, 0.60; 95% CI, 0.47-0.78), and MED (aHR, 0.71; 95% CI, 0.65-0.77; aHR, 0.85; 95% CI, 0.76-0.95). Conclusions and Relevance: In this study, methadone was associated with a lower rate of hospitalization among a large cohort of Canadian individuals with histories of convictions and prevalent concurrent health and social needs. Practices to improve methadone adherence are warranted.

Methadone maintenance treatment and mortality in people with criminal convictions: A population-based retrospective cohort study from Canada.

BACKGROUND: Individuals with criminal histories have high rates of opioid dependence and mortality. Excess mortality is largely attributable to overdose deaths. Methadone maintenance treatment (MMT) is one of the best evidence-based opioid substitution treatments (OSTs), but there is uncertainty about whether methadone treatment reduces the risk of mortality among convicted offenders over extended follow-up periods. The objective of this study was to investigate the association between adherence to MMT and overdose fatality as well as other causes of mortality. METHODS AND FINDINGS: We conducted a retrospective cohort study involving linked population-level administrative data among individuals in British Columbia (BC), Canada with a history of conviction and who filled a methadone prescription between January 1, 1998 and March 31, 2015. Participants were followed from the date of first-dispensed methadone prescription until censoring (date of death or March 31, 2015). Methadone was divided into medicated (methadone was dispensed) and nonmedicated (methadone was not dispensed) periods and analysed as a time-varying exposure. Hazard ratios (HRs) with 95% CIs were estimated using multivariable Cox regression to examine mortality during the study period. All-cause and cause-specific mortality rates were compared during medicated and nonmedicated methadone periods. Participants (n = 14,530) had a mean age of 34.5 years, were 71.4% male, and had a median follow-up of 6.9 years. A total of 1,275 participants died during the observation period. The overall all-cause mortality rate was 11.2 per 1,000 person-years (PYs). Participants were significantly less likely to die from both nonexternal (adjusted HR [AHR] 0.27 [95% CI 0.23-0.33]) and external (AHR 0.41 [95% CI 0.33-0.51]) causes during medicated periods, independent of sociodemographic, criminological, and health-related factors. Death due to infectious diseases was 5 times lower (AHR 0.20 [95% CI 0.13-0.30]), and accidental poisoning (overdose) deaths were nearly 3 times lower (AHR 0.39 [95% CI 0.30-0.50]) during medicated periods. A competing risk regression demonstrated a similar pattern of results. The use of a Canadian offender population may limit generalizability of results. Furthermore, our observation period represents community-based methadone prescribing and may omit prescriptions administered during hospital separations. Therefore, the magnitude of the protective effects of methadone from nonexternal causes of death should be interpreted with caution. CONCLUSIONS: Adherence to methadone was associated with significantly lower rates of death in a population-level cohort of Canadian convicted offenders. Achieving higher rates of adherence may reduce overdose deaths and other causes of mortality among offenders and similarly marginalized populations. Our findings warrant examination in other study centres in response to the crisis of opiate-involved deaths.

The effect of Housing First on adherence to methadone maintenance treatment.

BACKGROUND: Opioid overdose deaths have become a public health crisis in North America, and those who are homeless are particularly vulnerable. Methadone maintenance treatment (MMT) may prevent overdose and death among homeless people with opioid dependence, but suboptimal medication adherence is a common limitation. Previous research found that Housing First (HF) increases antipsychotic medication adherence among formerly homeless people. However, no experimental trials have examined whether HF has a significant impact on MMT adherence. We examined the intervention effect of HF on MMT adherence in a randomized sample of homeless adults experiencing mental illness and opioid dependence in Vancouver, Canada. METHODS: Comprehensive administrative and self-reported data from homeless adults living with serious mental illness recruited to the Vancouver At Home study were analyzed. Only methadone recipients were included (n = 97). The medication possession ratio (MPR) was utilized as the measure of adherence, and relevant data were obtained from provincial administrative pharmacy records. Study arms were HF and treatment as usual (TAU). Student t-tests were used to test for differences in MMT MPR between HF and TAU. RESULTS: No significant differences were observed in MMT MPR between participants in HF and TAU (0.52 vs. 0.57, p = 0.559) in the post-randomization period. CONCLUSION: HF was not associated with significantly different MMT MPR compared to TAU. Additional interventions are indicated as HF alone was insufficient to facilitate improved MMT adherence among formerly homeless adults experiencing concurrent opioid dependence and serious mental illness.

Associations between methadone maintenance treatment and crime: a 17-year longitudinal cohort study of Canadian provincial offenders.

AIMS: To estimate and test the difference in rates of violent and non-violent crime during medicated and non-medicated methadone treatment episodes. DESIGN, SETTING AND PARTICIPANTS: The study involved linkage of population level administrative data (health and justice) for all individuals (n = 14 530) in British Columbia, Canada with a history of conviction and who filled a methadone prescription between 1 January 1998 and 31 March 2015. Methadone maintenance treatment was the primary independent variable and was treated as a time-varying exposure. Each participant's follow-up (mean: 8 years) was divided into medicated (methadone was dispensed) and non-medicated (methadone was not dispensed) periods with mean durations of 3.3 and 4.6 years, respectively. MEASUREMENTS: Socio-demographics of participants were examined along with the main outcomes of violent and non-violent offences. FINDINGS: During the first 2 years of treatment (≤ 2.0 years), periods in which methadone was dispensed were associated with a 33% lower rate of violent crime [0.67 adjusted hazard ratio (AHR), 95% confidence intervals (CI) = 0.59, 0.76] and a 35% lower rate of non-violent crime (0.65 AHR, 95% CI = 0.62, 0.69) compared with non-medicated periods. This equates to a risk difference of 3.6 (95% CI = 2.6, 4.4) and 37.2 (95% CI = 33.0, 40.4) fewer violent and non-violent offences per 100 person-years, respectively. Significant but smaller protective effects of dispensed methadone were observed across longer treatment intervals (2.0 to ≤ 5.0 years, 5.0 to ≤ 10.0 years). CONCLUSIONS: Among a cohort of Canadian offenders, rates of violent and non-violent offending were lower during periods when individuals were dispensed methadone compared with periods in which they were not dispensed methadone.

Characteristics of adherence to methadone maintenance treatment over a 15-year period among homeless adults experiencing mental illness.

BACKGROUND: Methadone maintenance treatment (MMT) has important protective effects related to reduced illicit opioid use, infectious disease transmission, and overdose mortality. Adherence to MMT has not been examined among homeless people. We measured MMT adherence and reported relevant characteristics among homeless adults experiencing mental illness in Vancouver, British Columbia, Canada. MATERIAL AND METHODS: Homeless adults living with mental illness who had received MMT prior to the baseline interview of the Vancouver At Home study (n = 78) were included in analyses. The medication possession ratio (MPR) was used to estimate MMT adherence from retrospective administrative pharmacy and public health insurance data collected across 15 years. Independent sample t tests and one-way ANOVA were used to test for significant differences in MMT MPR by participant characteristics. RESULTS: Mean MMT MPR was 0.47. A large proportion of participants reported blood-borne infectious disease, three or more chronic physical health conditions, and substance use. Being single and never married was associated with significantly lower MMT MPR (0.40 vs. 0.55, p = 0.036), while living with schizophrenia, bipolar disorder, or a mood disorder with psychotic features was associated with significantly higher MMT MPR (0.54 vs. 0.37, p = 0.022). Daily drug use (excluding alcohol) was associated with significantly lower MMT MPR (0.39 vs. 0.54, p = 0.051). CONCLUSIONS: The level of adherence to MMT was very low among homeless adults experiencing mental illness. Efforts are needed to improve adherence to MMT as a means of reducing illicit substance use, preventing overdose deaths, and attenuating infectious disease transmission.

Food Insecurity among Homeless Adults with Mental Illness.

BACKGROUND: The prevalence of food insecurity and food insufficiency is high among homeless people. We investigated the prevalence and correlates of food insecurity among a cohort of homeless adults with mental illness in Vancouver, British Columbia, Canada. METHODS: Data collected from baseline questionnaires in the Vancouver At Home study were analysed to calculate the prevalence of food insecurity within the sample (n = 421). A modified version of the U.S. Department of Agriculture's Adult Food Security Survey Module was used to ascertain food insecurity. Univariable and multivariable logistic regression were used to examine potential correlates of food insecurity. RESULTS: The prevalence of food insecurity was 64%. In the multivariable model, food insecurity was significantly associated with age (adjusted odds ratio [aOR] = 0.97; 95% CI: 0.95-0.99), less than high school completion (aOR = 0.57; 95% CI: 0.35-0.93), needing health care but not receiving it (aOR = 1.65; 95% CI: 1.00-2.72), subjective mental health (aOR = 0.97; 95% CI: 0.96-0.99), having spent over $500 for drugs and alcohol in the past month (aOR = 2.25; 95% CI: 1.16-4.36), HIV/AIDS (aOR = 4.20; 95% CI: 1.36-12.96), heart disease (aOR = 0.39; 95% CI: 0.16-0.97) and having gone to a drop-in centre, community meal centre or program/food bank (aOR = 1.65; 95% CI: 1.01-2.68). CONCLUSIONS: The prevalence of food insecurity was extremely high in a cohort with longstanding homelessness and serious mental illness. Younger age, needing health care but not receiving it, poorer subjective mental health, having spent over $500 for drugs and alcohol in the past month, HIV/AIDS and having gone to a drop-in centre, community meal centre or program/food bank each increased odds of food insecurity, while less than high school completion and heart disease each decreased odds of food insecurity. Interventions to reduce food insecurity in this population are urgently needed.

Accuracy of reported service use in a cohort of people who are chronically homeless and seriously mentally ill.

BACKGROUND: Self-reported service use is an integral feature of interventional research with people who are homeless and mentally ill. The objective of this study was to investigate the accuracy of self-reported involvement with major categories of publicly funded services (health, justice, social welfare) within this sub-population. METHODS: Measures were administered pre-randomization in two randomized controlled trials, using timeline follow back with calendar aids for Health, Social, and Justice Service Use, compared to linked administrative data. Variables examined were: psychiatric admissions (both extended stays of more than 6 months and two or more stays within 5 years); emergency department visits, general hospitalization and jail in the past 6 months; and income assistance in the past 1 month. Participants (n = 433) met criteria for homelessness and a least one mental illness. RESULTS: Prevalence adjusted and bias adjusted kappa (PABAK) values ranged between moderate and almost perfect for extended psychiatric hospital separations (PABAK: 0.77; 95 % confidence interval (CI) = 0.71, 0.83), multiple psychiatric hospitalizations (PABAK = 0.50, 95 % CI = 0.41, 0.59), emergency department visits (PABAK: 0.77; 95 % CI = 0.71, 0.83), jail (PABAK: 0.74; 95 % CI = 0.68, 0.81), and income assistance (PABAK: 0.82; 95 % CI = 0.76, 0.87). Significant differences in under versus over reporting were also found. CONCLUSIONS: People who are homeless and mentally ill reliably reported their overall use of health, justice, and income assistance services. Evidence of under-reporting and over-reporting of certain variables has implications for specific research questions. ISRCTN registry: 57595077 (Vancouver at Home Study: Housing First plus Assertive Community Treatment versus congregate housing plus supports versus treatment as usual); and 66721740 (Vancouver at Home study: Housing First plus Intensive Case management versus treatment as usual).

A 10-year retrospective analysis of hospital admissions and length of stay among a cohort of homeless adults in Vancouver, Canada.

BACKGROUND: Homelessness is associated with a very high prevalence of substance use and mental disorders and elevated levels of acute health service use. Among the homeless, little is known regarding the relative impact of specific mental disorders on healthcare utilization. The aim of the present study was to examine the association between different categories of diagnosed mental disorders with hospital admission and length of stay (LOS) in a cohort of homeless adults in Vancouver, Canada. METHODS: Participants were recruited as part of an experimental trial in which participants met criteria for both homelessness and mental illness. Administrative data were obtained (with separate consent) including comprehensive records of acute hospitalizations during the 10 years prior to recruitment and while participants where experiencing homelessness. Generalized Estimating Equations were used to estimate the associations between outcome variables (acute hospital admissions and LOS) and predictor variables (specific disorders). RESULTS: Among the eligible sample (n = 433) 80 % were hospitalized, with an average of 6.0 hospital admissions and 71.4 days per person during the 10-year observation period. Of a combined total 2601 admissions to hospital, 1982 were psychiatric and 619 were non-psychiatric. Significant (p <0.001) independent predictors of hospital admission and LOS included a diagnosis of schizophrenia or bipolar disorder, as well as high (≥32 service contacts) non-psychiatric medical service use in the community. CONCLUSIONS: Our results demonstrate that specific mental disorders alongside high non-psychiatric service use were significantly associated with hospital admission and LOS. These findings suggest the importance of screening within the homeless population to identify individuals who may be at risk for acute illness and the implementation of services to promote recovery and prevent repeated hospitalization. TRIAL REGISTRATION: ISRCTN57595077 ; ISRCTN66721740.