Severe mental illness diagnosis in English general hospitals 2006-2017: A registry linkage study.

BACKGROUND: The higher mortality rates in people with severe mental illness (SMI) may be partly due to inadequate integration of physical and mental healthcare. Accurate recording of SMI during hospital admissions has the potential to facilitate integrated care including tailoring of treatment to account for comorbidities. We therefore aimed to investigate the sensitivity of SMI recording within general hospitals, changes in diagnostic accuracy over time, and factors associated with accurate recording. METHODS AND FINDINGS: We undertook a cohort study of 13,786 adults with SMI diagnosed during 2006-2017, using data from a large secondary mental healthcare database as reference standard, linked to English national records for 45,706 emergency hospital admissions. We examined general hospital record sensitivity across patients' subsequent hospital records, for each subsequent emergency admission, and at different levels of diagnostic precision. We analyzed time trends during the study period and used logistic regression to examine sociodemographic and clinical factors associated with psychiatric recording accuracy, with multiple imputation for missing data. Sensitivity for recording of SMI as any mental health diagnosis was 76.7% (95% CI 76.0-77.4). Category-level sensitivity (e.g., proportion of individuals with schizophrenia spectrum disorders (F20-29) who received any F20-29 diagnosis in hospital records) was 56.4% (95% CI 55.4-57.4) for schizophrenia spectrum disorder and 49.7% (95% CI 48.1-51.3) for bipolar affective disorder. Sensitivity for SMI recording in emergency admissions increased from 47.8% (95% CI 43.1-52.5) in 2006 to 75.4% (95% CI 68.3-81.4) in 2017 (ptrend < 0.001). Minority ethnicity, being married, and having better mental and physical health were associated with less accurate diagnostic recording. The main limitation of our study is the potential for misclassification of diagnosis in the reference-standard mental healthcare data. CONCLUSIONS: Our findings suggest that there have been improvements in recording of SMI diagnoses, but concerning under-recording, especially in minority ethnic groups, persists. Training in culturally sensitive diagnosis, expansion of liaison psychiatry input in general hospitals, and improved data sharing between physical and mental health services may be required to reduce inequalities in diagnostic practice.

Equity trade-offs in conservation decision making.

Conservation decisions increasingly involve multiple environmental and social objectives, which result in complex decision contexts with high potential for trade-offs. Improving social equity is one such objective that is often considered an enabler of successful outcomes and a virtuous ideal in itself. Despite its idealized importance in conservation policy, social equity is often highly simplified or ill-defined and is applied uncritically. What constitutes equitable outcomes and processes is highly normative and subject to ethical deliberation. Different ethical frameworks may lead to different conceptions of equity through alternative perspectives of what is good or right. This can lead to different and potentially conflicting equity objectives in practice. We promote a more transparent, nuanced, and pluralistic conceptualization of equity in conservation decision making that particularly recognizes where multidimensional equity objectives may conflict. To help identify and mitigate ethical conflicts and avoid cases of good intentions producing bad outcomes, we encourage a more analytical incorporation of equity into conservation decision making particularly during mechanistic integration of equity objectives. We recommend that in conservation planning motivations and objectives for equity be made explicit within the problem context, methods used to incorporate equity objectives be applied with respect to stated objectives, and, should objectives dictate, evaluation of equity outcomes and adaptation of strategies be employed during policy implementation.

Accounting for enforcement costs in the spatial allocation of marine zones.

Marine fish stocks are in many cases extracted above sustainable levels, but they may be protected through restricted-use zoning systems. The effectiveness of these systems typically depends on support from coastal fishing communities. High management costs including those of enforcement may, however, deter fishers from supporting marine management. We incorporated enforcement costs into a spatial optimization model that identified how conservation targets can be met while maximizing fishers' revenue. Our model identified the optimal allocation of the study area among different zones: no-take, territorial user rights for fisheries (TURFs), or open access. The analysis demonstrated that enforcing no-take and TURF zones incurs a cost, but results in higher species abundance by preventing poaching and overfishing. We analyzed how different enforcement scenarios affected fishers' revenue. Fisher revenue was approximately 50% higher when territorial user rights were enforced than when they were not. The model preferentially allocated area to the enforced-TURF zone over other zones, demonstrating that the financial benefits of enforcement (derived from higher species abundance) exceeded the costs. These findings were robust to increases in enforcement costs but sensitive to changes in species' market price. We also found that revenue under the existing zoning regime in the study area was 13-30% lower than under an optimal solution. Our results highlight the importance of accounting for both the benefits and costs of enforcement in marine conservation, particularly when incurred by fishers.