Compulsory treatment order and rehospitalisation: A New Zealand study.

OBJECTIVE: The effectiveness of compulsory treatment orders (CTO) in psychiatric practice is an area in need of evidence. There are no recent New Zealand publications on outcomes for patients under CTOs. This study examined the association between CTOs and subsequent rehospitalisation for patients with schizophrenia or related disorders. METHOD: Two year outcome data for 326 consecutive patients discharged in 2013 and 2014 was obtained from the Programme for the Integration of Mental Health Data database. Regression analyses were performed with rehospitalisation as the main outcome. RESULTS: For the 54% of patients discharged under CTOs, rehospitalisation was 2-4 times more likely for the CTO group than for voluntary patients. Patients under CTOs also spent longer in hospital post index admission (IA). However, patients placed under CTOs during IA stayed longer than those under CTOs prior to IA. Ethnicity did not contribute significantly to any of the findings. CONCLUSION: This study did not show that patients under CTOs were associated with subsequent reduced resource use. The subgroup analysis suggested that studies with a longer follow-up period may provide better insight into the utility of CTOs.

Sociodemographic and clinical variables associated with discharge under compulsory treatment orders.

OBJECTIVE: To document the sociodemographic and clinical variables associated with discharge under compulsory treatment orders in patients with schizophrenia or related disorders. METHOD: Information on various sociodemographic and clinical variables were extracted from the clinical files of 349 patients discharged from an adult (age 18-65) inpatient psychiatric unit with diagnoses of schizophrenia or related disorders. Univariate and multiple logistic regression analyses with legal compulsion (compulsory versus voluntary) as outcomes were applied. RESULTS: Two hundred of the 349 discharged patients were placed under compulsory treatment orders. In the univariate logistic regression analysis, unemployment, diagnosis of schizophrenia, forensic history, dosage of antipsychotics, prescription and frequency of injectable antipsychotics, polypharmacy and a hospital stay of more than 28 days were associated with compulsory status. Being married or in partnership and living with partner was associated with voluntary status. Multiple regression models respectively confirmed most of these relationships observed in the univariate analyses. CONCLUSION: Clarification of the apparent drivers for compulsory treatment may help thoughtful reductions in the use of compulsion.

The rate of mental health service use in New Zealand as analysed by ethnicity.

OBJECTIVES: To compare by ethnicity the rates of apparent new referrals and admissions to mental health services for selected major diagnostic groupings. METHOD: Using a Ministry of Health database covering all referrals and admissions to New Zealand's Mental Health services in 2014 and who had not been patients in the preceding six years, population adjusted rates of presentation were calculated and compared across the two major New Zealand ethnic groupings. RESULTS: Population corrected rates of apparently new cases of schizophrenia are more than twice as common in Maori as in non-Maori. Major depression is also significantly more common in Maori. That same trend was not evident for bipolar patients. CONCLUSIONS: These ethnically associated apparent differences in the rates of schizophrenia and depression need both confirmation and explanation.

Correlates of rehospitalisation in schizophrenia.

OBJECTIVES: Schizophrenia typically has a fluctuating course; rehospitalisation is common. We studied associations between discharge variables and subsequent two-year rehospitalisation rates. METHOD: Using a New Zealand national database, we obtained rehospitalisation rates and bed days for 451 patients with schizophrenia discharged from three inpatient facilities between July 2009 and December 2011. RESULTS: Nearly half (44%) of the cohort were rehospitalised within two years. Patients over 50 were less likely [hazard ratio (HR) = 0.58, 95% confidence interval (CI) = 0.35-0.97, p = 0.04] to be rehospitalised. Patients whose index admission included compulsory treatment appeared more likely (HR = 1.3, 95% CI = 0.98-1.71, p = 0.06) to be rehospitalised and spent longer rehospitalised (p = 0.05). Those whose index admission was three weeks or longer were less likely (HR = 0.53, 95% CI = 0.39-0.72, p = 0.001) to be rehospitalised. Antipsychotic types, routes and dosages were not significantly associated with rehospitalisation rate, except for those prescribed clozapine (HR = 0.61, 95% CI = 0.41-0.89, p = 0.01). CONCLUSIONS: Rehospitalisation rates were higher for patients under the age of 50 and those with shorter index admissions; the latter finding requires further study. Other than the beneficial effect of clozapine, the type and route of prescribed antipsychotics did not significantly affect rehospitalisation rates.

Antipsychotic prescribing and its correlates in New Zealand.

OBJECTIVES: Antipsychotics are the cornerstone of schizophrenia management. There is substantial literature on their efficacy and optimal use. Doubts remain, however, regarding the translation of this knowledge into day-to-day practice. This study aimed to investigate antipsychotic prescribing in three New Zealand regions and its relationship to clinical guidelines and patient characteristics. METHODS: We studied 451 patients discharged from inpatient units with a diagnosis of schizophrenia or a related disorder (International Classification of Disease, version 10) between July 2009 and December 2011. Available information included patient demography, legal status, prescribed medications, duration of index admission and prescriber's country of postgraduate training and years of postgraduate experience. RESULTS: There was a high rate (33.7%) of multiple antipsychotic prescription, and lower than expected clozapine use (20%); Maori were prescribed clozapine more frequently than non-Maori (24% vs. 13%, respectively). Compulsory treatment was associated with more use of injectable medication and increased length of stay in hospital. Clinician characteristics did not significantly influence prescribing. CONCLUSIONS: Observed prescribing practice aligned with existing guidelines except for antipsychotic polypharmacy and clozapine under-utilisation.

Stigmatization of psychiatrists and general practitioners: results of an international survey.

The stigma of mental illness affects psychiatry as a medical profession and psychiatrists. The present study aimed to compare the extent and correlation patterns of perceived stigma in psychiatrists and general practitioners. An international multicenter survey was conducted in psychiatrists and general practitioners from twelve countries. Responses were received from N = 1,893 psychiatrists and N = 1,238 general practitioners. Aspects of stigma assessed in the questionnaire included perceived stigma, self-stigma (stereotype agreement), attitudes toward the other profession, and experiences of discrimination. Psychiatrists reported significantly higher perceived stigma and discrimination experiences than general practitioners. Separate multiple regression analyses showed different predictor patterns of perceived stigma in the two groups. Hence, in the psychiatrists group, perceived stigma correlated best with discrimination experiences and self-stigma, while in the general practitioners group it correlated best with self-stigma. About 17% of the psychiatrists perceive stigma as a serious problem, with a higher rate in younger respondents. Against this background, psychiatry as a medical profession should set a high priority on improving the training of young graduates. Despite the number of existing antistigma interventions targeting mental health professionals and medical students, further measures to improve the image of psychiatry and psychiatrists are warranted, in particular improving the training of young graduates with respect to raising awareness of own stigmatizing attitudes and to develop a better profession-related self-assertiveness.

Which family--what therapy: Maori culture, families and family therapy in New Zealand.

New Zealand is a relatively young and small country which has seen steady migration for nearly seven centuries. Despite a long history of rivalry and hostility between Maori and European values, the country has also seen some significant synergism between the two cultures. For the last three decades Asians have also migrated at a significant pace. The country faces the challenge of delivering quality mental health services to such cultures which are bifurcated in being socio-centric (Maori, Pacific Islanders and Asian total 32% combined) or ego-centric (European total 68%). Significant progress has been made in including families of the mentally ill in their treatment and care planning. Legislative requirements have been introduced for the family to be consulted in the treatment of those who are being compelled to receive psychiatric care under the Mental Health Act. Models of family therapy developed through innovation meeting the unique local needs or adaptation of existing models from overseas are being used. An overview of such family therapy modalities is presented.

Patients' appraisal of psychiatric trainee interview skills.

OBJECTIVE: The aim of this pilot project was to explore the extent to which judgments made by psychiatrist examiners accord with those of patients in postgraduate clinical examinations, so as to inform further consideration of the role of patients in such assessments. METHOD: Senior psychiatrist examiners (N=8) and patients (N=30) rated 16 aspects of trainee psychiatrist interviewing style and performance during 30 observed clinical interviews (OCIs) conducted in the format of official examinations. RESULTS: Significant differences were apparent in the judgments of examiners and patients regarding 7 of 16 rated aspects of trainee performance. Differences were evident largely in domains in which patients could be expected to be "expert," reflecting their subjective experience of the interviewer. By contrast, there was little difference in the judgments of patients and examiners on the more technical criteria. CONCLUSION: These preliminary findings provide some challenge to the assumption that psychiatrists are the best judges of the "technical" skills and knowledge required by the profession. They support previous findings, with simulated patients, of the discrepancy between patient and examiner judgments of the more subjective elements of the examination. Psychiatric patients could contribute to clinical examinations as co-examiners, rather than merely constituting the substrate for the examination.

Clozapine use and outcomes among patients with treatment resistant schizophrenia.

OBJECTIVE: The phenomenology of patients with schizophrenia is similar world-wide, regardless of culture. However, the prognosis is variable both internationally and within national groups of patients. Furthermore, despite advances in pharmacological treatment, a significant proportion of patients with schizophrenia continue to show residual symptoms and disabilities due to poor response to antipsychotic medication. This study retrospectively assessed differences in outcome by gender, ethnicity and age among a group of treatment-resistant patients with schizophrenia. METHOD: Patients in the catchment (350,000 people) of a single New Zealand public mental health provider (Waikato) formed the study group. Information concerning demographic profiles, Health of the Nation Outcome Scales (HoNOS) ratings and details of Clozapine usage were extracted from clinical records and the data base. RESULTS: Gender, ethnicity and age did not emerge as significantly associated with any of the outcome variables except for the 30-40 year olds having more improvement on overactivity/aggression ratings than younger or older patients. CONCLUSIONS: Despite these negative results in the New Zealand context, there remain many unanswered questions about the higher rate of service use by Maori. Replication of this study on a larger cohort of patients may be indicated before discarding the idea of potential links between ethnicity, treatment choice and outcomes.

Psychiatric diagnoses in legal systems: an issue of validity.

When considering psychiatric evidence, justice systems from many countries are frequently presented with diagnostic labels from official psychiatric classificatory systems. A lack of validity in much of these classificatory systems is receiving increasing attention. Illustrative examples include post-traumatic stress disorder, various personality disorders and dissociative identity disorder. The courts and review bodies from many jurisdictions place tremendous faith in the present categorical classifications (e.g., DSMIV and ICD10). This paper questions whether the reliance on these classifications systems is appropriate in legal proceedings.

Correlates of Presence and Remission of Post-trauma Stress Disorder in Incarcerated Women: A Case-Control Study Design.

Women in prison are vulnerable to post-trauma stress disorder (PTSD). However, little is known about the presence of PTSD in imprisoned women or of the natural course of that disorder. The purpose of this study was to assess the risk factors for PTSD in incarcerated women and document correlations of remission. We conducted a retrospective case-control study in the Female Prison of Hunan Province, China. Participants were screened for PTSD and depression using the Chinese version of the MINI International Neuropsychiatric Interview (MINI) 5.0. Of the 2,322 women screened, 220 met the criterion for PTSD on admission. Remission (N = 142) and non-remission PTSD (N = 78) were then separated depending on current PTSD status. History of drug use (OR = 0.43, 95% CI: 0.28-0.66, p < 0.001) and violent offense (OR = 1.56, 95% CI: 1.17-2.09, p < 0.001) were associated with the presence of PTSD. Positive associations with remission were found for longer length of sentence (61-120 vs. 13-60 months) (OR = 4.20, 95% CI: 1.50-11.75, p = 0.006), violent offense (OR = 2.50, 95% CI: 1.12-5.60, p = 0.03), and comorbid depression (OR = 29.69, 95% CI: 3.50-251.78, p = 0.002); while a negative correlate was identified for past depression (OR = 0.24, 95% CI: 0.11-0.53, p < 0.001). Although some incarcerated women with PTSD can spontaneously remit, this study suggested certain criminological and clinical risk factors are associated with the presence of PTSD and others with remission over time. Timely screening and effective intervention should be tailored for individuals with PTSD in prisons.

Mental health service users' progression from illicit drug use to schizophrenia in New Zealand.

BACKGROUND: Recently, publications have hypothesised that the demonstrated increase in the incidence of schizophrenia in New Zealand is a side effect of the increased strength of available cannabis derivatives over the last 25+ years and the much more recent increase in the population's use of methamphetamine. AIM: To compare the rates of later schizophrenia between age-matched mental health service users with initial diagnoses as alcohol abusers or illicit drug users. METHOD: From the PRIMHD comprehensive national database, all users of the mental health services over a 5-year period who received an ICD-10 presenting diagnosis of alcohol or substance use/abuse were identified. For each person identified, the database was examined for the following 3 years to determine the numbers later diagnosed with schizophrenia. RESULTS: For the initial alcohol problem people in their twenties, 1.7% were diagnosed as suffering from schizophrenia in the subsequent 3 years. For the initial drug problem people, the rate was 10.9%. Within that drug-using population, the indigenous Maori developed schizophrenia at a higher rate than did the remainder of the population. CONCLUSION: These findings in New Zealand require further research into their generalisability, context and explanation.

Mental Health Problems, History of Drug Use, and Violent Offending Are Associated With Increased Suicide Risk in Imprisoned Females.

Background: In western countries, imprisoned females are at high risk for suicide, but the risk in Chinese imprisoned females has not been well established. The aim of this study was to clarify the suicide risk and its correlates among imprisoned females in China. Methods: In this cross-sectional study, subjects were recruited from the Female Prison of Hunan province, China. A standardized questionnaire was used to collect socio-demographic and criminological data. The Suicidality module of the Mini International Neuropsychiatric Interview (MINI) 5.0 and 12-item General Health Questionnaire (GHQ-12) were used to assess suicide risk and mental health problems, respectively. Ordinal logistic regressions were used to identify independent factors associated with increased suicide risk. Results: A total of 2,709 imprisoned females completed the survey questionnaire. Twenty percent were rated as presenting suicide risk. Mental health problems [odds ratio (OR) = 1.21, 95% confidence interval (CI) = 1.00-1.47], self-reported help-seeking for mental health problems (OR = 1.69, 95% CI = 1.11-2.56), violent offending (OR = 1.69, 95% CI = 1.37-2.09), history of drug use (OR = 1.46, 95% CI = 1.15-1.84), family history of mental disorders (OR = 1.57, 95% CI = 1.10-2.23), marital status (OR = 1.29, 95% CI = 1.05-1.58), and low educational level (OR = 1.36, 95% CI = 1.11-1.67) were independently associated with increased suicide risk. Conclusion: One fifth of the imprisoned females are at risk for suicide. This study highlights the importance of assessing mental health status for suicide prevention among female prisoners.

Gender differences among homicide offenders with schizophrenia in Hunan Province, China.

This study aimed to understand the demographic, clinical and criminological characteristics of Chinese homicide offenders with schizophrenia from a gender-based perspective. Information on all homicide offenders with schizophrenia who received forensic psychiatric assessment between 2010 and 2016 in Hunan Province, China, was systematically retrieved (n = 669). Gender differences in the above characteristics were analyzed, and independent correlates of homicide were explored. The male to female ratio of homicide offenders was about 4:1. Proportionally more males were single, unemployed and younger when committing their first crime than was apparent in females. Male perpetrators were more often influenced by delusions. Females were more likely to target their close family members. For males, living in rural areas and having a family history of mental disorder were positively associated with homicide, while having a criminal history and being unemployed were negatively associated. For females, younger age was positively, while being unmarried and unemployment were negatively associated with homicide. Our results indicate significant gender differences among Chinese homicide offenders with schizophrenia in demographic, clinical and criminological characteristics and in independent correlates of homicide. Further research in this field, especially aims at determining risk factors for crime in this population, should take the gender differences into account.

Comparing legislation for involuntary admission and treatment of mental illness in four South Asian countries.

BACKGROUND: Involuntary admission or treatment for the management of mental illness is a relatively common practice worldwide. Enabling legislation exists in most developed and high-income countries. A few of these countries have attempted to align their legislation with the United Nations Convention on the Rights of Persons with Disabilities. This review examined legislation and associated issues from four diverse South Asian countries (Bangladesh, India, Pakistan and Sri Lanka) that all have a British colonial past and initially adopted the Lunacy Act of 1845. METHOD: A questionnaire based on two previous studies and the World Health Organization checklist for mental health legislation was developed requesting information on the criteria and process for involuntary detention of patients with mental illness for assessment and treatment. The questionnaire was completed by psychiatrists (key informants) from each of the four countries. The questionnaire also sought participants' comments or concerns regarding the legislation or related issues. RESULTS: The results showed that relevant legislation has evolved differently in each of the four countries. Each country has faced challenges when reforming or implementing their mental health laws. Barriers included legal safeguards, human rights protections, funding, resources, absence of a robust wider health system, political support and sub-optimal mental health literacy. CONCLUSION: Clinicians in these countries face dilemmas that are less frequently encountered by their counterparts in relatively more advantaged countries. These dilemmas require attention when implementing and reforming mental health legislation in South Asia.

Patient and staff perspectives on the use of seclusion.

OBJECTIVES: This paper investigates the perceptions and experience of patients and staff on the use of seclusion in psychiatric services. METHOD: A purpose designed questionnaire was distributed to staff and patients in a general adult mental health service. RESULTS: Staff and patients both attributed more negative than positive feelings to patients' experience of seclusion. CONCLUSIONS: Monitoring and evaluation of the use of seclusion may be insufficient to prevent or ameliorate its emotional impact. More comfortable alternatives to seclusion need to be utilized whenever possible.