Ethnic inequalities in the incidence of diagnosis of severe mental illness in England: a systematic review and new meta-analyses for non-affective and affective psychoses.

PURPOSE: Although excess risks particularly for a diagnosis of schizophrenia have been identified for ethnic minority people in England and other contexts, we sought to identify and synthesise up-to-date evidence (2018) for affective in addition to non-affective psychoses by specific ethnic groups in England. METHODS: Systematic review and meta-analysis of ethnic differences in diagnosed incidence of psychoses in England, searching nine databases for reviews (citing relevant studies up to 2009) and an updated search in three databases for studies between 2010 and 2018. Studies from both searches were combined in meta-analyses allowing coverage of more specific ethnic groups than previously. RESULTS: We included 28 primary studies. Relative to the majority population, significantly higher risks of diagnosed schizophrenia were found in Black African (Relative risk, RR 5.72, 95% CI 3.87-8.46, n = 9); Black Caribbean (RR 5.20, 95% CI 4.33-6.24, n = 21); South Asian (RR 2.27, 95% CI 1.63-3.16, n = 14); White Other (RR 2.24, 95% CI 1.59-3.14, n = 9); and Mixed Ethnicity people (RR 2.24, 95% CI 1.32-3.80, n = 4). Significantly higher risks for diagnosed affective psychoses were also revealed: Black African (RR 4.07, 95% CI 2.27-7.28, n = 5); Black Caribbean (RR 2.91, 95% CI 1.78-4.74, n = 16); South Asian (RR 1.71, 95% CI 1.07-2.72, n = 8); White Other (RR 1.55, 95% CI 1.32-1.83, n = 5); Mixed Ethnicity (RR 6.16, 95% CI 3.99-9.52, n = 4). CONCLUSIONS: The risk for a diagnosis of non-affective and affective psychoses is particularly elevated for Black ethnic groups, but is higher for all ethnic minority groups including those previously not assessed through meta-analyses (White Other, Mixed Ethnicity). This calls for further research on broader disadvantages affecting ethnic minority people.

The characteristics and health needs of pregnant women with schizophrenia compared with bipolar disorder and affective psychoses.

BACKGROUND: Most women with psychotic disorders and bipolar disorders have children but their pregnancies are at risk of adverse psychiatric and fetal outcome. The extent of modifiable risk factors - both clinical and socio-demographic - is unclear as most studies have used administrative data or recruited from specialist tertiary referral clinics. We therefore aimed to investigate the socio-demographic and clinical characteristics of an epidemiologically representative cohort of pregnant women with affective and non-affective severe mental illness. METHODS: Women with severe mental illness were identified from a large electronic mental health case register in south London, and a data linkage with national maternity Hospital Episode Statistics identified pregnancies in 2007-2011. Data were extracted using structured fields, text searching and natural language processing applications. RESULTS: Of 456 pregnant women identified, 236 (51.7%) had schizophrenia and related disorders, 220 (48.3%) had affective psychosis or bipolar disorder. Women with schizophrenia and related disorders were younger, less likely to have a partner in pregnancy, more likely to be black, to smoke or misuse substances and had significantly more time in the two years before pregnancy in acute care (inpatient or intensive home treatment) compared with women with affective disorders. Both groups had high levels of domestic abuse in pregnancy (recorded in 18.9%), were from relatively deprived backgrounds and had impaired functioning measured by the Health of the Nation Outcome Scale. Women in the affective group were more likely to stop medication in the first trimester (39% versus 25%) whereas women with non-affective psychoses were more likely to switch medication. CONCLUSIONS: A significant proportion of women, particularly those with non-affective psychoses, have modifiable risk factors requiring tailored care to optimize pregnancy outcomes. Mental health professionals need to be mindful of the possibility of pregnancy in women of childbearing age and prescribe and address modifiable risk factors accordingly.

Policy and service development implications of the second Australian National Survey of High Impact Psychosis (SHIP).

OBJECTIVE: We consider insights from the second Australian National Survey of High Impact Psychosis (2010) in order to identify the key policy and service development implications. METHOD: The Survey of High Impact Psychosis (SHIP) provides an updated description of the experiences of people living with psychosis in Australia. We discuss the SHIP survey participants' greatest challenges for the future in light of the strength of existing literature, highlighting prospective opportunities for policy and service planning. RESULTS: Targets for future policy development and service initiatives are informed by the survey participants' leading challenges: financial difficulties, social isolation, lack of employment, physical and mental ill health, accommodation, and access to services. CONCLUSIONS: Many of the areas of need identified by survey participants are supported by quality research that may be more widely translated into effective services. For areas of need where the evidence is lacking, more clinical research is urgently needed. A targeted approach is vital to secure necessary investment in the wider dissemination of efficacious interventions and their systematic evaluation in ordinary clinical practice, enabled by both research investment and active integration of the research effort within ordinary clinical settings.

The effect of community mental health services on hospitalization rates in Virginia.

OBJECTIVE: This study examined the relationship between the availability of mental health outpatient services provided by 40 publicly funded community service boards (CSBs) and the use of inpatient mental health treatment among Medicaid recipients. METHODS: Three-year data were obtained for Medicaid recipients aged 18-64 from the Medicaid claims database for the Commonwealth of Virginia. Medicaid recipients who had a mental disorder diagnosis and who had received at least one community mental health service were included in the sample. A multivariate regression model was used for the analyses. RESULTS: Of the 11,107 individuals included, 27% had schizophrenia-related disorders and 32% had affective psychoses; 60% were white and 37% were black; and the average age was 40.1±13.1 years. In this sample, greater use of outpatient mental health services, but not greater variety of services available, was correlated with fewer inpatient hospital days for mental health treatment (-1.0±.2 days of hospitalization). CONCLUSIONS: Virginia's CSBs provide a range of outpatient mental health services that are designed to enable individuals to remain in their community. The availability of community-based mental health services was correlated with lower rates of inpatient hospitalization for mental illness. More research, however, is needed to establish causality and to determine which services are most effective at reducing the need for inpatient care.

The association between cognitive functioning and occupational status in persons with a recent onset of psychosis.

The ability to engage in occupational activity is an important aspect of functioning in individuals with recent onset psychosis. We measured the determinants of occupational status in a sample of n = 86 adults with a recent onset of affective or nonaffective psychosis. Participants were evaluated with the Repeatable Battery of Neuropsychological Status, the Wisconsin Card Sorting Test, symptom rating scales, and other clinical and demographic measures. Results of a discriminant function analysis indicated that the most significant differences between those who worked or attended school and those who did not could be attributed to better immediate verbal memory (F = 13.16, p < .0005) and the absence of substance abuse (F = 5.17, p = .026). Occupational activity was not significantly associated with age, gender, race, or symptom severity in this population. Cognitive assessments may prove useful to identify recent onset patients who are most at risk for occupational impairment and who could most benefit from therapeutic interventions.

Elderly patient assaults: empirical data from the Assaulted Staff Action Program (ASAP) with risk management implications for EMS personnel.

Some elderly patients may become violent in the course of receiving health care services. This paper reviews the largely cross-sectional research on elder assaultive patients in health care settings and patient assaults, including those by the elderly, in EMS services. Data on the assault characteristics of elderly patients are presented from a 15-year, retrospective, longitudinal study of the Assaulted Staff Action Program (ASAP). The findings and their implications for the delivery of health care services are discussed and a detailed series of risk management strategies to reduce assaults in EMS services are presented.

Affective processes in the onset and persistence of psychosis.

OBJECTIVES: Cognitive models suggest that beliefs and appraisal processes are crucially important in the onset and persistence of psychosis. This study investigated whether (i) neuroticism increases the risk for development of psychotic symptoms, and (ii) a delusional interpretation and/or a depressed response to hallucinatory experiences predicts the onset of psychotic disorder. METHOD: A general population sample with no lifetime evidence of any psychotic disorder was interviewed with the Composite International Diagnostic Interview Schedule (CIDI) at baseline and 1 and 3 years later. At year 3, individuals with CIDI evidence of psychotic symptoms were interviewed by clinicians to identify onset of psychotic disorder. RESULTS: Baseline level of neuroticism increases the risk for incident psychotic symptoms. Given the presence of hallucinatory experiences at baseline, the increase in risk of having the psychosis outcome was much higher in the group with delusional ideation or depressed mood at year 1 than in those without delusional ideation or depressed mood. CONCLUSION: A cognitive style characterised by a tendency to worry increases the risk for newly developed psychotic symptoms. Individuals who report hallucinatory experiences and react to these with a delusional interpretation and/or negative emotional states have an increased risk for developing clinical psychosis.

Mefloquine increases the risk of serious psychiatric events during travel abroad: a nationwide case-control study in the Netherlands.

BACKGROUND: Psychiatric events during travel abroad account for a large percentage of medical repatriations arranged by insurance companies. Several risk factors have been proposed for such events, one of these being use of mefloquine. We investigated the risk of psychiatric events during use of mefloquine. METHOD: We performed a nationwide case control study using medical records from 4 large alarm centers in the Netherlands. Cases were patients contacting the alarm centers because of psychiatric events, according to International Code Primary Care code P (all psychiatric symptoms) or International Classification of Diseases, Ninth Edition, codes 290-319 (all psychiatric syndromes). To every case we matched up to 6 controls by alarm center, calendar time, and continent of travel. All controls had contacted the alarm centers because of nonpsychiatric medical reasons. Shortly after the anticipated day of return, cases and controls received a questionnaire regarding travel characteristics, gender, age, marital status, education, weight, height, general health, history of psychiatric diseases, use of medicines, smoking status, alcohol intake, coffee intake, and use of malaria prophylaxis. Dates of travel for the source population were between September 1, 1997, and June 1, 2000. RESULTS: The study population consisted of 111 cases and 453 controls. The risk of psychiatric events during the use of mefloquine was 3.5 (95% CI = 1.4 to 8.7). In females, the risk was strongly increased, with an odds ratio of 47.1 (95% CI = 3.8 to 578.6). Stratification for history of psychiatric diseases showed that the risk of psychiatric events during use of mefloquine in cases without a history of psychiatric diseases was 3.8 (95% CI = 1.4 to 10.1), whereas the risk in cases with a history of psychiatric diseases was 8.0 (95% CI = 1.8 to 35.8). CONCLUSION: The use of mefloquine is associated with an increased risk of psychiatric events in females and in patients with a history of psychiatric diseases.

Psychotic and mood disorders associated with the perimenopausal period: epidemiology, aetiology and management.

Contrary to widely held beliefs, menopause is not associated with an increase in psychiatric illness. Although just prior to menopause there is a slight increase in minor psychological symptoms, prevalence rates of depression fall postmenopause. Hypotheses for the occurrence of depression in some perimenopausal women include: a pre-existing sensitivity to the change in the gonadal hormones leading to decreases in neural transmitters; reactions to the physiological changes associated with menopause such as night sweats, or the influence of a multitude of negative attitudes and expectations concerning menopause. The loss of the protective effects of estrogen may be related to the slight increase in the incidence of schizophrenia in women at menopause. The role of hormone replacement therapy (HRT) in treating psychiatric symptoms remains poorly understood. In nondepressed women, HRT may improve well-being either as a direct effect or as a consequence of reduced physical symptoms and fear of aging. In women with moderate to severe depressions, HRT alone does not appear to be beneficial. HRT may have some beneficial effects on short term memory. More research is needed to assess the possible role of HRT in augmenting the effects of antidepressant and antipsychotic medications.

Incidence and consistency of antiretroviral use among HIV-infected medicaid beneficiaries with schizophrenia.

OBJECTIVE: To investigate the incidence and consistency of antiretroviral (ARV) treatment in the period before the introduction of protease inhibitors among Medicaid beneficiaries in New Jersey who had both the human immunodeficiency virus (HIV) and schizophrenia. METHOD: HIV-infected Medicaid beneficiaries were identified using the HIV and acquired immunodeficiency syndrome (AIDS) registries for New Jersey; claims histories were used to identify patients diagnosed with ICD-9-CM schizophrenia and affective psychoses and to examine use of ARV drugs. RESULTS: Bivariate and multivariate analysis found no difference in the likelihood of receiving ARV drugs between patients with HIV and schizophrenia and HIV-infected patients without schizophrenia. However, once the therapy was initiated, patients with schizophrenia were more consistent users of ARV drugs. CONCLUSION: Results do not indicate that HIV-seropositive (HIV+) patients with schizophrenia are less adherent to HIV therapies than HIV+ patients without schizophrenia. In our study population, consistency of use was actually higher among HIV+ patients with schizophrenia, perhaps because their multiple diagnoses place them under closer medical scrutiny.

Hospital downsizing and patients' assaults on staff.

Although the downsizing and closing of state mental hospitals is occurring with increasing frequency nationwide, there appears to be only one case study of the clinical impacts of downsizing state hospitals. In this study, Snyder reported a four-fold increase in frequency of assaults on staff as the hospital census decreased. The present paper is a second case study of state hospital downsizing and closing in which the frequency of assaults on staff decreased by 63%. Possible explanations for the two differing outcomes are considered, and some general guidelines for the downsizing and closing of state hospitals are proposed.

Socio-economic mobility among patients with schizophrenia or major affective disorder. A 17-year retrospective follow-up.

BACKGROUND: Social mobility among patients with schizophrenia or major affective disorder was compared with that among the general population. METHOD: Mobility was studied retrospectively from 1970 to 1987. Socio-economic status (SES) was defined by occupation as in the population census (upper white-collar, lower white-collar, blue-collar, entrepreneur, farmer, unemployed). All patients aged 30-60 years at discharge (2901 men and 3620 women) in 1987-88 in Finland were included in the study. The SES structure of the general population was used for comparisons. RESULTS: Among patients with schizophrenia there was a constant downward drift, commonly to unemployment. This risk was higher among men than women. In the youngest age group a marked decline from the parents' social status was observed. Among patients with major affective disorder the distribution of SES in 1970 was similar to that of the general population. By 1987, a downward drift was again observed, mainly to unemployment regardless of the initial SES group. The number of patients in occupational categories were usually 30-50% lower than expected. CONCLUSIONS: Schizophrenic patients had a high risk of social drop-out. Among patients with major affective disorder the downward drift was much less.

Changes in diagnostic case mix in psychiatric care in general hospitals, 1980-85.

The Hospital Discharge Survey of 1980 and 1985 was used to assess changes in diagnostic case mix of psychiatric inpatient care in short-term, nonfederal general hospitals. Information regarding presence of psychiatric and chemical dependency units was added to both surveys, and information regarding exemption from Medicare's PPS system was noted for 1985. The largest increase was in ICD-9 code 296 (affective disorder), which more than doubled in frequency, along with a similar decrease in Diagnosis-Related Group 426, depressive neurosis. One explanation for this sizable shift was "gaming the system." One cannot conclusively, however, distinguish between gaming the system and the effects of changing professional views of depression during this time period. Other variables potentially contributing to the effect are described as well.

[Clinico-epidemiological characteristics of the ambulatory group of elderly patients with endogenous affective psychoses]. / Kliniko-épidemiologicheskaia kharakteristika dispansernogo kontingenta bol'nykh éndogennymi affektivnymi psikhozami pozdnego vozrasta.

The studies were carried out on the basis of the Gerontopsychiatry Center servicing patients aged 60 and more years in one of the districts of Moscow. 163 persons suffering from endogenous affective diseases were identified. The disease prevalence was 3.75 per 1000 population and the incidence 32.2 per 100,000 population. The data were obtained, indicating the rise of the disease prevalence and incidence with age (mainly at the expense of women). In the majority of patients (71.8%), different psychopathological disturbances were detected. 37.4% manifested affective disorders within the structure of the successive disease attack. The number of inpatients was only 4.3%. These data point to the necessity of the development of outpatient specialized forms of gerontopsychiatric assistance.

Patterns of care among people with long-term functional psychosis in three different areas of Stockholm County.

This study of long-term functionally psychotic people in Stockholm County describes the psychiatric and somatic care provided as well as social welfare support and medication in a total cohort. This group included all non-organic cases of psychosis aged 18-64 years. The group was found still to be very dependent on institutional care, with an average of 75 d of psychiatric inpatient care. Males spent twice as long as females as inpatients, and people from the urban area spent a longer time than those from the other areas. Antipsychotic medication increased from the rural to the urban area. The diagnosis of schizophrenia and early age at onset were each per se associated with higher likelihood of inpatient treatment and depot medication. Contrary to expectations, medication with antipsychotic drugs was shown to increase with illness duration.

Social indicators and psychiatric admission rates: a case-register study in The Netherlands.

Environmental as well as individual socio-demographic and illness characteristics are related to the risk of admission. This paper addresses the problem of the interrelationships of these factors to admission rates. Using the Groningen Psychiatric Case Register, admission rates (during 1986 and 1987) from 34 administrative areas were calculated. Logit models were fitted in order to test the relationship between the relative risk of being admitted and sex, age, marital status, diagnosis, urbanization and distance from facilities. The effect of urbanization remains under the control of the other independent variables. The concept of 'need for care', related to 'true' and 'treated' incidence, is discussed.

Mentally ill chemical abusers discharged from VA inpatient treatment: 1976-1988.

Discharge abstracts were analyzed for all patients discharged from Department of Veterans Affairs (VA) medical centers with a primary non-substance abuse psychiatric diagnosis over a twelve year period (1976 to 1988). Patients were identified as Mentally Ill Chemical Abusers (MICAs) if they had a primary mental illness diagnosis and either a secondary substance abuse diagnosis or an admission for substance abuse treatment during the same fiscal year. The percentage of MICAs doubled, from 22.6% to 43.6%, during these twelve years. In 1988, MICAs were younger and more likely to be minorities than other VA psychiatric patients, and they spent only half as many days in the hospital per year.

Prevalence of benzodiazepine abuse and dependence in psychiatric in-patients with different nosology. An assessment of hospital-based drug surveillance data.

Frequencies of abuse and dependence assessed continuously within a drug surveillance system were analysed as a contribution to risk-benefit evaluations of benzodiazepines (BZDs). In 4.7% of 15,296 patients admitted to psychiatric hospitals between 1980 and 1985, BZDs had been involved in some kind of abuse or dependence. Primary BZD dependence, defined as physical dependence on BZDs in patients who had not been dependent before, was observed in about 1% of admitted patients. Linking these data with psychiatric diagnoses revealed a high risk of primary BZD dependence for in-patients (11.8%) with anxiety neurosis (ICD-9, 300.0), and a lower risk for neurotic (300.4) and for endogenous depressives (296.1) (risk 3.7% and 2.7% respectively). Older age was also related to primary BZD dependence. For depressive in-patients, the risk was twice as high in females as in males. Anecdotal observations advocate more systematic investigation of the emotional effects of long-term therapy with BZDs.