Longitudinal Mixed Modelling of Emergency Department Use Among a Sample of Homeless Participants in a Housing First Demonstration Trial.

The present Canadian study sought to identify predictors of emergency department (ED) use in a sample of adults who are homeless. Four hundred eighty-three participants were interviewed quarterly for two years, reporting their housing status, income, food security, physical/mental health, and other social determinants of health. Survey data were linked to administrative health and social services data. Predictors of ED visits were analyzed using negative binomial longitudinal mixed modelling. Emergency department visits were positively and reliably predicted by pre-baseline ED use, as well as by concurrent increased social assistance, primary care visits, ratings of physical health, substance use problems, and case management visits. Increased concurrent housing instability and food insecurity, and decreased homelessness history, positively predicted ED visits, but effect reliability was lower. Participant ill health appears to be a primary driver of ED utilization. The findings challenge misconceptions about the appropriateness of ED use among people who are homeless.

Older Adults' Narratives of Seeking Mental Health Treatment: Making Sense of Mental Health Challenges and "Muddling Through" to Care.

Older adults who experience challenges related to mental health are unlikely to seek professional help. The voices of older adults who have navigated through mental health issues and systems of care to arrive at psychological treatment are less well understood. We conducted individual interviews with 15 adults aged 61 to 86 who sought psychological treatment. Interviews were audio-recorded, transcribed, and analyzed using narrative methods. We identified several main storylines that describe the meaning-making and treatment-seeking journeys of older adults: resistance to being labeled with mental health problems (telling stories of resistance, defining mental health issues in mysterious and uncontrollable terms, and experiencing internal role conflict); muddling through the help-seeking process (manifestations of chaos and system-level barriers); and emotional reactions to psychological treatment (hope, fear, and mistrust). Findings add to the literature base in the area of narrative gerontology, and highlight the complex experiences that older adults face when seeking psychological treatment.

Conceptualizations of help-seeking for mental health concerns in First Nations communities in Canada: A comparison of fit with the Andersen Behavioral Model.

This qualitative study explored the fit between on-reserve First Nations community members' conceptualizations of help-seeking for mental health concerns and the Andersen Behavioral Model of Health Services Use. Youth, adults and elders (N = 115) living and or working in eight distinct First Nations communities within a tribal council area in Canada participated in focus groups or individual interviews that were transcribed, coded and then analyzed using a thematic analysis approach informed by grounded theory methodology. Resulting themes were then mapped onto the Andersen Behavioral Model of Health Services Use. Participants' conceptualizations of predisposing characteristics including social structures, health beliefs and mental illness, enabling and impeding resources had a high degree of fit with the model. While perspectives on perceived need for mental health care, and spirituality as a health and lifestyle practice had only moderate fit with the model, these domains could be modified to fit First Nations' interpretations of help-seeking. Participants' perceptions of avoidant strategies and non-use of mental health services, however did not map onto the model. These findings suggest conceptualizations of help-seeking for mental health issues in these First Nations communities are only partially characterized by the Andersen Behavioral Model, suggesting there are a number of considerations to Indigenize the model. Findings also highlight potential explanations for why some members of this population may not access or receive appropriate mental health treatment. Multi-pronged efforts are warranted to link culturally normed pathways of help-seeking with effective mental health supports for First Nations community members in Canada.

Fixed Nodes of Transience: Narratives of Homelessness and Emergency Department Use.

Discourse in popular media, public policy, and academic literature contends that people who are homeless frequently make inappropriate use of hospital emergency department (ED) services. Although researchers have investigated the ED experiences of people who are homeless, no previous studies have examined how this population understands the role of the ED in their health care and in their day-to-day lives. In the present study, 16 individuals participated in semistructured interviews regarding their ED experiences, and narrative analysis was applied to their responses. Within the context of narratives of disempowerment and discrimination, participants viewed the ED in differing ways, but they generally interpreted it as a public, accessible space where they could exert agency. ED narratives were also paradoxical, depicting it as a fixed place for transient care, or a place where they were isolated yet felt a sense of belonging. Implications for policy and practice are discussed.

Negotiating home base: Narratives of psychological well-being among female military members.

The current study aimed to understand how active duty service women with low levels of current psychological distress make sense of their military experiences in ways that might contribute to psychological well-being. Semi-structured interviews were conducted with active duty female members in the Canadian Forces and transcripts were analyzed using narrative analysis. A sense of belonging was found to be of utmost salience to the women, with several participants negotiating and constructing places that felt like home to them, and with different degrees of attachment to the military versus civilian world. The findings of this work are discussed within the context of focusing prevention and intervention efforts on increasing belongingness and a sense of home for female service members.

Mental health outcomes of burn: A longitudinal population-based study of adults hospitalized for burns.

PURPOSE: This study investigates the increased risk of mental health outcomes and health care utilization associated with burn with two year of follow-up using a longitudinal population-based matched cohort design. METHODS: Adult burn survivors (n=157) were identified from a provincial burn registry and matched 1:5 with non-burn control subjects from the general population (matching variables age and gender). The prevalence of mental health outcomes and the rates of health care utilization between the groups were compared for the 2years pre and post index date using anonymously linked population-based administrative health care data. Rates were adjusted for age, gender and sociodemographic characteristics. RESULTS: While the burn cohort had an increased prevalence of mental health problems after burn compared to the control cohort, the burn group also had an increased prevalence of pre-burn depression (16.6% vs 7.8%; p=0.0005) and substance use disorders (8.9% vs 3.2%; p=0.001) when compared to controls. Once the pre-existing prevalence of mental illness was taken into account there was no significant change in the prevalence of mental health problems when comparing the burn group to controls over time. CONCLUSIONS: Although burns may not increase rates of mental health issues and health care utilization, burn survivors are a vulnerable group who already demonstrate increased rates of psychopathology and need for care. The present study highlights the importance of assessment and treatment of mental health outcomes in this population.

Men, fire, and burns: Stories of fighting, healing, and emotions.

Burn recovery is a difficult process full of physical and psychological challenges. With increasing survival rates, there has been renewed interest in the psychological aspects of burn recovery. As men represent over 70% of all burn patients, it is particularly important to study how men experience and interpret this process. We interviewed a purposeful sample of ten adult male burn survivors from different age and cultural groups in the first 16 weeks of their recovery and asked them to discuss the problems they faced. Narrative analysis was used to interpret the interviews. In their narratives, the men tended to emphasize gains in their physical recovery; that is, they often used metaphors of "fighting" to demonstrate how committed they were to their healing. Further, they put less emphasis on the emotional aspects of their recovery. In our discussion, we compare these complex storylines to coping strategies identified in the literature and discuss why men may choose these strategies. Based on our findings we argue that it is important for health care providers to be aware of societal pressures which may influence burn survivors to minimize affective elements of burn recovery. Additionally, we encourage exploring and capitalizing on men's "fighting" stories during rehabilitation in order to foster an active role which men can take in their recovery.

Increased suicidal activity following major trauma: a population-based study.

BACKGROUND: Nonfatal injuries are a leading cause of morbidity and mortality. In 2008, 14,065 patients with major trauma were hospitalized across Canada. With individuals surviving trauma, the psychosocial sequelae of severe physical injury have become an important area of research. No previous studies have used a population-based sample to estimate the incidence of suicidality (suicide or suicide attempt) following physical injury. This study aimed to assess the odds ratio (OR) of suicidality among adults with major trauma compared with a matched cohort. METHODS: This retrospective study included persons older than 18 years who experienced an unintentional major traumatic injury (Injury Severity Score [ISS] > 12) at a regional academic trauma center between April 1, 2001, and March 31, 2011. Individuals who had no suicide attempts in the previous 5 years were identified from the trauma registry. These individuals were matched with data from provincial administrative databases. A cohort matched in terms of age, sex, and date of indexed injury was created from the general population with five controls for each trauma case, and the rate of suicidality was compared between groups. RESULTS: A total of 2,198 adults with major were matched to 10,990 individuals. Suicidality was increased in the trauma cohort (OR, 4.31). This increase persisted even if adjusted for anxiety/mood disorders and substance abuse (adjusted OR1, 3.65) as well as residence, physical comorbidities, income quintile and those factors in adjusted OR1 (adjusted OR2, 3.30). All ORs were significant with p < 0.05 CONCLUSION: Individuals who experience major traumatic injuries are at a greater risk for postinjury suicidality compared with those in a matched cohort. LEVEL OF EVIDENCE: Epidemiologic study, level IV.

Broken heart stories: understanding Aboriginal women's cardiac problems.

Many Aboriginal communities call heart problems, and in particular cardiovascular disease, "White man's sickness." At the same time, Aboriginal women present with some of the highest rates of this disease. Against this backdrop, we explored how women with cardiac problems understand their heart health and used narrative-discursive methods to analyze interviews conducted with women from two First Nations in North America. The women told stories that were riddled with contradictions, unfolding a complicated personal and cultural reality of living with cardiovascular disease. In many stories, heart disease was described as resulting from a "community imbalance" in the wake of colonialism whereby the women had to take over the traditional roles of men. Their ideas of heart disease risk and healing flowed from this understanding. They derived a sense of strength, however, from their ability to undertake both gender roles. Based on our findings, we provide some recommendations for cardiac care.

Protective factors for mental disorders and psychological distress in female, compared with male, service members in a representative sample.

OBJECTIVE: Although military interest in promoting psychological resilience is growing, resources protective against psychopathology have been understudied in female service members. Using a representative sample of Canadian Forces personnel, we investigated whether religious attendance, spirituality, coping, and social support were related to mental disorders and psychological distress in female service members, and whether sex differences occurred in these associations. METHOD: Religious attendance and spirituality were self-reported. Coping items were taken from 3 scales and produced 3 factors (active, avoidance, and self-medication). Social support was assessed with the Medical Outcomes Study Social Support Survey. Past-year mental disorders were diagnosed with the World Mental Health Composite International Diagnostic Interview. The Kessler Psychological Distress Scale assessed distress. Multivariate regression models investigated links between correlates and psychological outcomes within each sex. For associations that were statistically significant in only one sex, sex by correlate interactions were computed. RESULTS: In female service members, inverse relations were found between social support and MDD, any MDD or anxiety disorder, suicidal ideation, and distress. No associations were found between religious attendance and outcomes, and spirituality was associated with an increased likelihood of some outcomes. Active coping was related to less psychological distress, while avoidance coping and self-medication were linked to a higher likelihood of most outcomes. Although several statistically significant associations were found in only one sex, only one sex by correlate interaction was statistically significant. CONCLUSIONS: Social support was found to be inversely related to several negative mental health outcomes in female service members. Few differences between men and women reached statistical significance. Future research should identify additional helpful resources for female service members.

Objectif : Quoique l'intérêt militaire pour la promotion de la résilience psychologique va en grandissant, les ressources protectrices contre la psychopathologie ont été sous-étudiées chez les membres féminins des forces armées. À l'aide d'un échantillon représentatif du personnel des Forces canadiennes, nous avons recherché si la pratique religieuse, la spiritualité, l'adaptation, et le soutien social étaient liés aux troubles mentaux et à la détresse psychologique chez le personnel féminin des Forces, et si des différences selon le sexe survenaient dans ces associations. Méthode : La pratique religieuse et la spiritualité étaient auto-déclarées. Les items d'adaptation étaient tirés de 3 échelles et produisaient 3 facteurs (actif, évitement, et automédication). Le soutien social était évalué par le Medical Outcomes Study Social Support Survey. Les troubles mentaux de l'année précédente ont été diagnostiqués au moyen du World Mental Health Composite International Diagnostic Interview. L'Échelle de détresse psychologique de Kessler a évalué la détresse. Des modèles de régression multivariée ont servi à rechercher les liens entre les corrélats et les résultats psychologiques de chaque sexe. Pour les associations qui n'étaient statistiquement significatives que pour un sexe, les interactions des sexes par corrélat ont été calculées. Résultats : Chez les membres féminins des forces, des relations inverses ont été constatées entre le soutien social et le trouble dépressif majeur (TDM), tout TDM ou trouble anxieux, l'idéation suicidaire, et la détresse. Aucune association n'a été détectée entre la pratique religieuse et les résultats, et la spiritualité était associée à la probabilité accrue de certains résultats. L'adaptation active était liée à moins de détresse psychologique, tandis que l'adaptation par évitement et l'automédication étaient liées à la probabilité accrue de la plupart des résultats. Bien que plusieurs associations statisquement significatives n'aient été observées que chez un seul sexe, seulement une interaction des sexes par corrélat était statistiquement significative. Conclusions : Le soutien social s'est révélé être inversement lié à plusieurs résultats négatifs de santé mentale chez les membres féminins des forces armées. Peu de différences entre les hommes et les femmes ont atteint la signification statistique. La recherche future devrait identifier des ressources utiles additionnelles pour les membres féminins des forces armées.

"Put on your face to face the world": women's narratives of burn injury.

The survival rate of individuals with burn injury has significantly increased due to medical advances in burn care. This has led to a need to focus on psychological aspects of burn injury recovery, particularly on how people come to terms with their changed bodies. The literature suggests that burn size and severity are not directly associated with the degree of distress but that subjective perceptions and interpretations - of, for instance, body image - are pertinent. Body image appears to be particularly important for women and thus, in this study, we investigated women's experiences of their bodies following mild to moderate burns. We conducted in-depth interviews with 10 female burn survivors in the first year after injury, using methods of narrative analysis for the investigations of the transcripts. Thirteen consecutive women who met inclusion criterion were approached at regional burn care follow-up clinic. In their narratives, the women predominantly emphasized how well they were doing; however, counter-narratives emerged indicating dissatisfaction and distress. The tension between these two different kinds of narratives suggests an ambivalent relationship with the burn injury. We concluded that it is imperative for health care professionals to be cognizant of these conflicting experiences in order to adequately address burn survivors' needs in rehabilitation.

Risk factors for post-injury mental health problems.

Serious nonfatal physical injuries and burns are common occurrences that can have substantial implications for personal, social, and occupational functioning. Such injuries are frequently associated with significant mental health issues, and compromised quality of life and well-being. The purpose of this review is to summarize the current literature on physical, psychological, and social risk factors for mental health issues post-injury and to contextualize findings using Engel's biopsychosocial framework. We distinguish between pre-injury, injury-related, and post-injury risk factors for mental health problems. Female sex, history of mental health problems or trauma, type of injury, and level of pain are among the strong risk factors for mental health problems post-injury. We highlight inconsistent findings in the literature, identify directions for future research, and explore the implications of the risk factors identified for treatment and prevention.

Correlates of suicidality: investigation of a representative sample of Manitoba First Nations adolescents.

OBJECTIVES: We examined individual, friend or family, and community or tribe correlates of suicidality in a representative on-reserve sample of First Nations adolescents. METHODS: Data came from the 2002-2003 Manitoba First Nations Regional Longitudinal Health Survey of Youth. Interviews were conducted with adolescents aged 12 to 17 years (n=1125) from 23 First Nations communities in Manitoba. We used bivariate logistic regression analyses to examine the relationships between a range of factors and lifetime suicidality. We conducted sex-by-correlate interactions for each significant correlate at the bivariate level. A multivariate logistic regression analysis identified those correlates most strongly related to suicidality. RESULTS: We found several variables to be associated with an increased likelihood of suicidality in the multivariate model, including being female, depressed mood, abuse or fear of abuse, a hospital stay, and substance use (adjusted odds ratio range=2.43-11.73). Perceived community caring was protective against suicidality (adjusted odds ratio=0.93; 95% confidence interval=0.88, 0.97) in the same model. CONCLUSIONS: Results of this study may be important in informing First Nations and government policy related to the implementation of suicide prevention strategies in First Nations communities.

Stress and mental disorders in female military personnel: comparisons between the sexes in a male dominated profession.

The proportion of women in militaries is growing; however, many studies in the area of military mental health have been conducted with majority male samples. The present study examined sex differences in trauma exposure, work stress, and mental disorders in the Canadian Community Health Survey - Canadian Forces Supplement, a representative sample of 5155 regular force personnel and 3286 reservists ages 16-54. Past-year DSM-IV mental disorders (depression, generalized anxiety disorder, panic disorder, social phobia, PTSD, and alcohol dependence), lifetime exposure to 28 traumatic events, and work stress were assessed. Regular and reserve female personnel were less likely than males to experience deployment-related traumas, accidents, and several events involving violence (adjusted odds ratio [AOR] range 0.10-0.62). Women were more likely to endorse sexual trauma, partner abuse, and being stalked (AOR range 3.60-13.63). For work stress, regular force women reported higher levels of job demand and stress around social support than men, whereas regular and reserve force women reported less physical exertion. After adjusting for a range of covariates, regular female personnel were more likely than males to have PTSD (AOR 1.88, 99% CI 1.01-3.50), while reservist women were more likely than men to have depression, panic disorder, and any mood or anxiety disorder (AOR range 1.87-6.98). Both regular and reservist women had lower rates of alcohol dependence (AOR range 0.30-0.34). Clinicians working with female personnel should screen for trauma/stressors and mental disorders that are particularly common in this population.

Psychological distress and self-care engagement: healing after a cardiac intervention.

Silencing the self, a relational concept, occurs when individuals overvalue others' standards, self-sacrifice their needs for others, inhibit self-expression, and experience a sense of dividedness between their inner and outer self. Given the emerging literature highlighting the importance of relational beliefs and experiences in coronary heart disease, the contribution of a concept such as self-silencing to the cardiac healing process is valuable to consider. This study investigated self-silencing dimensions, psychological distress (anxiety and depressive symptoms), and self-care engagement after a serious cardiac event. Forty women and 80 men attending a rehabilitation program completed a series of questionnaires six months post-cardiac intervention. Multivariate regression analyses were performed to examine the role of self-silencing after the influence of cardiac health and sociodemographics were taken into account. Self-silencing was positively associated with anxiety and depressive symptoms for both sexes. For self-care engagement, sex interacted with some of the silencing dimensions. The findings were interpreted in the context of participants' attendance in a rehabilitation program. Women who are self-silencing may benefit from the self-care expectations associated with a cardiac program whereas for men, even engaging in cardiac self-care may be perceived as self-silencing.

Recovered or recovering: negotiating rehabilitation after stroke.

The role of narrative discourse has been increasingly recognized as crucial to all partners involved in the rehabilitation process after acquired brain injury. Particularly within the family, narrative offers an experiential space for meaning-making. To better understand this joint meaning-making process, a narrative-discursive methodology was used to analyze a family's conversation that took place 1 year after the mother had a stroke. In one narrative, a particular incident was used to illustrate that the mother has recovered; in another narrative, the same event was used to demonstrate that the mother was still recovering. The 2 narratives are associated with different rights, responsibilities, and rehabilitation trajectories. To holistically understand the rehabilitation process, health professionals need to be aware of the often hidden narrative meaning-making processes that take place within the family.

Heart stories: men and women after a cardiac incident.

In this study we explore the views and beliefs of men and women about cardiovascular disease and the emotions and social relations that are involved. Women and men attending a cardiovascular rehabilitation program participated in two in-depth interviews carried out with each individual six months after a first serious cardiac event. The transcribed interviews were analyzed using a narrative-discursive methodology. Although there were numerous differences between the men and women's stories, an outstanding commonality was that their narrative efforts to negotiate healing and rehabilitation were guided by gendered identities and societal roles.

Living with Parkinson's disease-managing identity together.

The specific aim of this paper is to discuss how individuals living with Parkinson's disease and their main family supports perceive communications with each other, with a focus on their roles related to care. The paper is based on individual interviews conducted with individuals and their main family support person. The transcripts were analyzed based on grounded theory and "managing identity together" emerged as the core category. This is discussed in terms of independence, a sense of self-sufficiency and an overall sense of personhood. Implications for other populations conclude the paper.

Continuity amid chaos: neurotrauma, loss of memory, and sense of self.

In serious illness or disability, individuals commonly say that their sense of self has dramatically changed. One might expect that the experience of a radically altered sense of self would be even more profound in individuals after neurotrauma because it is the brain itself that suddenly, and often literally, becomes "strange." The aim of this study was to investigate how people left with autobiographical memory impairments--impairments that also affect the capacity to organize complex linguistic productions such as autobiographical narratives--experience themselves and, specifically, their sense of self. Seven adults who had primarily anterograde memory impairments for 1 year were interviewed. Regardless of the profound changes in their everyday functioning and lives, the stories the participants told evoke a surprising sense of a continuous self. Employing several narrative and discursive techniques, they emphasized sameness and an unbroken connection between their pre- and post-morbid lives. We believe that most individuals felt they did not have to recover their former sense of self because they subjectively seemed to have never lost it.

Remembering without a past: individuals with anterograde memory impairment talk about their lives.

This paper describes the linguistic resources people with anterograde amnesia draw on in conversational narratives. Because of their problems in recollecting post-morbid memories, it is particularly challenging for such individuals to refer to personal experiences. Seven patients with anterograde memory impairments due to neurotrauma were interviewed one year post-event. Among other topics, they were asked to talk about their new lives and selves, which was expected to be a precarious affair given that they did not have many or any autobiographical memories. Microanalyses of their narratives identified three readily available linguistic resources that participants used to facilitate their storytelling. These were categorized as "memory importation" (transplanting a past memory into the present), "memory appropriation" (taking another's memory as one's own), and "memory compensation" (searching for memories). It is argued that although these resources were not always efficiently used by participants and their use often violated conversational expectations, these linguistic techniques provided a helpful means to sustain the production of personal narratives, even in the absence of autobiographical memory.