Service use and unmet needs in youth suicide: a study of trajectories.

OBJECTIVE: While 90% of suicide victims have suffered from mental health disorders, less than one-half are in contact with a mental health professional in the year preceding their death. Service use in the last year of life of young suicide victims and control subjects was studied in Quebec. We wanted to determine what kinds of health care services were needed and if they were actually received by suicide victims. METHOD: We recruited 67 consecutive suicide victims and 56 matched living control subjects (aged 25 years and younger). We evaluated subjects' psychopathological profile and determined which services would have been indicated by conducting a needs assessment. We then compared this with what services were actually received. RESULTS: Suicide victims were more likely than living control subjects to have a psychiatric diagnosis. They were most in need of services to address substance use disorder, depression, interpersonal distress, and suicide-related problems. There were significant deficits in the domains of coordination and continuity of care, mental health promotion and training, and governance. CONCLUSIONS: Our results show that we need to urgently take action to address these identified deficits to prevent further loss of life in our young people.

A patient with medication-resistant epilepsy featuring psychosensorial and psychotic symptoms presenting with significant functional improvement on psychotherapeutic treatment: a case report.

BACKGROUND: Partial complex epilepsy with psychosensorial and psychotic symptoms remains a relatively rare condition that can sometimes be mistaken for an axis I psychiatric disorder. There is no specific treatment for this particular type of epilepsy, anti-epileptic medication being the cornerstone of therapeutic intervention with the occasional addition of neuroleptics. Lack of response to anti-epileptic agents is often a sign of poor prognosis and requires risky and sometimes invasive interventions with high morbidity for patients. CASE PRESENTATION: We report the case of a 21-year-old right-handed Caucasian man of French-Canadian descent who was living with his mother immediately before being hospitalized in a psychiatric setting for the first time. He seemed obsessed with developing new concepts to reach a more 'perfect' existence. He also claimed feeling odd sensations in his mind and in his body that could be linked to some sort of 'evolutionary' process resulting from spiritual uplift. He reported non-specific visual hallucinations and what sounded like auditory hallucinations and telepathic powers. The first diagnosis was a possible schizophreniform disorder and our patient was hospitalized. Shortly afterwards, an electroencephalogram showed an important subcortical epileptic activity, compatible with partial complex epilepsy with psychosensorial and psychotic symptoms. Despite a negative response to medication, symptoms proper to this type of epilepsy were substantially alleviated using a psychotherapeutical treatment intended for patients with psychotic disorders, namely integrated psychological therapy (IPT). Significant functional improvement in our patient has been achieved since then. CONCLUSIONS: This case report illustrates that despite a negative response to medication, symptoms proper to this type of epilepsy could be substantially alleviated using psychotherapeutical treatment modalities. To the best of our knowledge, this is the first time such a finding has been reported in the scientific literature. This could open the way for new research themes and therapeutic interventions for such patients.

Staff perceptions and organizational factors as predictors of seclusion and restraint on psychiatric wards.

OBJECTIVE: Several factors have been shown to be involved in decisions to use seclusion and restraint in psychiatric inpatient settings. This study examined whether staff perceptions of factors related to the care team and violence on the ward predicted use of seclusion and restraint in psychiatric wards. METHODS: A total of 309 staff members (nurses, rehabilitation instructors, and nurse's aides) providing care to patients with serious mental disorders were recruited from eight university psychiatric hospitals and general-hospital psychiatric units in the province of Quebec. Factors assessed included sociodemographic characteristics, psychological distress, staff perceptions of aggression and of interaction between members of the psychiatric team (team climate), and organizational factors. RESULTS: Bivariate analyses showed that certain aspects of the team climate, staff perceptions of aggression, and organizational factors were associated with greater use of seclusion and restraint. The final multivariate model indicated that the following factors independently predicted greater use: type of hospital ward (emergency department and intensive care unit), staff perception of a higher level of expression of anger and aggression among team members, perception of the frequency of incidents of physical aggression against the self among patients, and perception of insufficient safety measures in the workplace. CONCLUSIONS: These findings represent the first stage of a research program aimed at reducing use of seclusion and restraint in psychiatric settings. They underscore the importance of evaluating a variety of factors, including perceptions of safety and violence, when examining reasons for use of these controversial interventions.

Contribution of the psychosocial work environment to psychological distress among health care professionals before and during a major organizational change.

The aim of this study was to investigate the relationships between 4 dimensions of the psychosocial work environment (psychological demands, decision latitude, social support, and effort-reward) among health care professionals as well as their psychological distress during a reorganization process. A correlational descriptive design was used for this quantitative study. A total of 159 health care professionals completed the questionnaire at T1, and 141 at T2. First, before the work reorganization, effort-reward imbalance was the sole variable of the psychological work environment that significantly predicted psychological distress. Second, the high overall level of psychological distress increased during the process of organizational change (from T1 to T2). Finally, effort-reward imbalance, high psychological demands, and low decision latitude were all significant predictors of psychological distress at T2, during the organizational change. In conclusion, to reduce the expected negative outcomes of restructuring on health care practitioners, managers could increase the number of opportunities for rewards, carefully explain the demands, and clarify the tasks to be performed by each of the employees to reduce their psychological burden and increase their perceptions of autonomy.

Development and validation of the RQC: a daily contact log for ACT and ICM teams.

AIM: Instruments to measure the process--the daily activities of home care workers--have received little attention and may impede research in refining the active ingredients, the clientele best served and continuous quality improvement. We developed a decade ago in Quebec, Canada, a new daily contact log (relevé quotidien des contacts or RQC) that has now reached in practice 1 million entries. METHODS: Three features distinguish the RQC development, namely, practical ergonomics, a clear logic, and response categories easy to understand and retain. The instrument is filled following any 10-minute or more contact with or about the client, and covers the location, time and actors of the episode of care, and the nature of the intervention (crisis, representing, accompanying, discussing) in 10 areas (i.e. medication, daily living activities, housing, relationships, substance abuse, legal, etc.). Inter-rater agreement for each RQC response category and rater agreement with a criterion measure (coded vignettes) were evaluated. RESULTS: Kappa coefficients and intra-class correlation coefficients yielded results ranging from at least moderate to generally substantial agreement for all 77 response categories. CONCLUSIONS: The new RQC may support international studies of the implementation and application of various forms of intensive home care, refining its indications, and serves as a clinical and managerial tool to ensure quality of the interventions.

The longitudinal association from obesity to depression: results from the 12-year National Population Health Survey.

Prior observational studies have investigated the association between obesity and depression but evidence remains weak and mixed. There has been a call for high-quality longitudinal studies to elucidate the etiologic relationship from obesity to depression. The main objective of this study was therefore to investigate whether obesity was a risk factor for depression in a nationally representative sample followed for 12 years. Seven waves of data collection (1994-1995 to 2006-2007) were obtained from the National Population Health Survey (NPHS). Our analyses included 10,545 adults without depression at baseline. Past-year major depression episode (MDE) was assessed from the Composite International Diagnostic Interview-Short Form for Major Depression (CIDI-SFMD). Obesity was estimated using baseline BMI from self-reported weight and height (obesity: BMI > or =30 kg/m(2)). Kaplan-Meier survival curves were generated and Cox proportional hazard regression modeling was used to estimate the risk of MDE by obesity status, controlling for sociodemographic and health and lifestyle variables. We found that obesity at baseline did not significantly predict subsequent MDE in women (adjusted hazard ratio (AHR): 1.03, 95% confidence interval (CI) 0.84-1.26) and negatively predicted MDE in men (HR: 0.71, CI 0.51-0.98), after adjusting for important confounders. In summary, our findings suggest that obesity is a significant (negative) predictor of depression in adult men but not in women. These results moderate prior evidence supporting a positive link from obesity to depression.

The psychosocial work environment and evidence utilization by health professionals.

The purpose of this study was to investigate the relationships between dimensions of the psychosocial work environment and health professionals' use of evidence in their practice. A correlational descriptive design was developed. Health professionals working in mental health units at 2 hospitals were asked to complete a questionnaire about their perceptions of the psychosocial work environment and their use of evidence. Correlations and regression analyses were performed. Use of evidence was found to be correlated with social support and decision latitude. Results of multiple regression analyses found perceived social support (beta = .27, p < .01) and perceived decision latitude (beta = .25,p < .01) to be significant predictors of the use of evidence. The authors conclude that good social support and decision latitude among interprofessional groups may promote use of evidence by health professions in their practice.

Is violent method of suicide a behavioral marker of lifetime aggression?

OBJECTIVE: The main purpose of this study was to investigate whether the method of suicide is a valid behavioral marker of a lifetime history of aggression. METHOD: The authors applied the psychological autopsy method to investigate 310 individuals who committed suicide. They used structured clinical assessments and personality trait scales in interviews with family members of the deceased. RESULTS: Violent method was associated with a higher level of lifetime aggression and a higher level of impulsivity. In addition, violent method was associated with lifetime substance abuse or dependence and psychotic disorders. Controlling for age, sex, substance disorders, and other major psychopathology, the authors found that lifetime aggression and the interaction between impulsivity and aggressive behavior remained associated with violent method. CONCLUSIONS: These results support the use of violent method of suicide as a behavioral marker of a higher level of lifetime impulsive-aggressive behaviors.

Familial aggregation of suicidal behavior: a family study of male suicide completers from the general population.

OBJECTIVE: This study compared suicidality in families of adult male suicide completers and community comparison subjects. METHOD: Two hundred forty-seven relatives of 25 male suicide completers and 171 relatives of 25 matched comparison subjects were assessed for recurrent risk of suicidal and related behaviors. Analyses were performed on a subgroup of relatives of suicide completers with cluster B personality disorders. RESULTS: Relatives of suicide completers were over 10 times more likely than relatives of comparison subjects to attempt or complete suicide after the authors controlled for psychopathology. Relatives of suicide completers were not more likely to exhibit suicidal ideation but had more severe suicidal ideation than relatives of comparison subjects. These findings were stronger for the suicide completers diagnosed with cluster B personality disorders. CONCLUSIONS: Suicide has a familial component independent of psychopathology that may be mediated by a combination of factors, including more severe suicidal ideation and aggressive behavior.

Psychiatric risk factors for motor vehicle fatalities in young men.

BACKGROUND: Motor vehicle accident (MVA) fatalities are an important cause of death in young men. Psychiatric disorders have been shown to be risk factors for MVA, but only a few studies have investigated MVA fatalities. METHOD: A case-control study was carried out comparing 61 young male MVA fatalities in which the subject was the driver with an equal number of living male subjects matched for age (case by case with no more than 1 year's difference between case subjects and control subjects) with the accident group. We assessed both groups, using structured interviews and psychological autopsies. RESULTS: Our results suggest that cluster B personality disorders (borderline and [or] antisocial) (OR 3.54; 95%CI, 1.38 to 16.01) and substance use disorders in the last 6 months (OR 4.33; 95%CI, 1.42 to 9.25) increased the risk of dying in MVAs. In addition, we observed an age effect, where differences in cluster B personality disorders and substance use disorders in the last 6 months were only significantly more prevalent in case subjects aged 26 years or over, compared with control subjects of the same age. Drivers under age 25 years appeared to be comparable with control subjects on all measures of psychopathology. Finally, this interaction between cluster B personality disorders and age over 26 years was the only significant predictor of car fatalities (adjusted OR 16.25; 95%CI, 1.67 to 158.10). CONCLUSION: Borderline and antisocial personality disorders in which impulsive-aggressive behaviours play a central role and substance use disorders appear to be risk factors for young male deaths in MVAs. Interestingly, this effect seems to be specific to MVA case subjects aged 26 years or over.

Seasonal differences in psychopathology of male suicide completers.

Suicide is known to vary according to season, with peaks in the spring and troughs in the winter. The presence of psychopathology is a significant predictor of suicidality, and it is possible that the seasonal variation of suicide completion may be related to seasonality in the manifestation of psychiatric disorders common to suicide completers. In the current study, we evaluated 115 French-Canadian male suicide completers from the Greater Montreal Area for DSM-IV psychiatric disorders using proxy-based diagnostic interviews. Subjects were assessed for seasonal differences in the prevalence of DSM-IV psychiatric diagnoses just before their deaths. Diagnoses of major depressive disorder (MDD) without comorbid cluster B personality disorders, and schizophrenia were differently distributed between seasons. Most (63.4%) subjects with MDD committed suicide in the spring/summer (P =.038). However, closer examination revealed that depressed suicides with comorbid cluster B personality disorders did not show seasonality, while 83.3% of depressed suicides without comorbid cluster B personality disorders committed suicide in the spring/summer (P =.019). 87.5% of those suicides with schizophrenia committed suicide in the fall/winter (P =.026), and the only suicide with schizophrenia who died in the spring/summer was also the only one without positive symptomology. Our study is limited to male suicide completers, and results should not be generalized to women. We conclude that seasonal variation in suicide manifests itself differently in patients with different psychopathology. These findings indicate that assessment of suicide risk may need to include consideration of possible seasonal effects, depending on psychopathology.

Toward benchmarks for tertiary care for adults with severe and persistent mental disorders.

BACKGROUND: Scarce attention has been paid to establishing benchmarks for tertiary care for adults with severe mental disorders. Yet, the availability and efficient utilization of residential resources partly determines the capacity of a comprehensive system of care to avoid clogging ever-shrinking acute care bed facilities. OBJECTIVES: To describe the actual utilization of and projected needs for residential resources, one part of tertiary care, in the catchment area of a psychiatric hospital in east-end Montreal. To compare results obtained against actual utilization and projected needs evaluated in other Canadian provinces and in other countries, with a view to establishing national benchmarks. METHODS: Two surveys were undertaken to establish the number of places in these facilities that were utilized and needed for adults aged 18 to 65 years with severe mental disorders, without a primary diagnosis of mental retardation or organic brain syndrome, and originally from the catchment area. A first survey ascertained the number of places utilized and of those needed for residential care among all long-stay inpatients and all adults in supervised residential facilities. A second survey identified the need for such long-stay hospitalization, nursing homes, and supervised facilities as an alternative or as a complement to hospitalization among acute care inpatients. RESULTS: The actual ratio of places in long-stay hospital units, nursing homes, and supervised residential facilities was 150:100,000 inhabitants. The ideal ratio, according to estimated needs, is 171:100,000. The figure breakdown is as follows: 20:100,000 for long-stay hospital units, 20:100,000 for nursing homes, 40:100,000 for group homes, 40:100,000 for private hostels or foster families, and 51:100,000 for supervised apartments. The needs of this urban, blue-collar population for supervised residential places hovered in the upper range of utilization and standards for European countries and within the proposed standards for Canadian provinces. DISCUSSION: Needs for long-stay hospitalization or for supervised residential facilities cannot be treated as absolute. For example, evaluation conducted in this hospital-led system of psychiatric care may produce higher estimates of institutional care. Comparing actual utilization and projected needs in this urban catchment area with current utilization in other jurisdictions in Canada and Europe should contribute to establishing sound national benchmarks within ranges. CONCLUSIONS: It is possible to establish benchmarks that guide the development of supervised residential settings to best meet the needs of the population of adults with severe and persistent mental disorders. The methods used here to assess needs should serve as guidelines for future research, because they were designed to contain the bias of over- or underprovision of care in the current utilization.

Factor structure of the Multnomah Community Ability Scale.

More and more, Intensive Community Treatment programs in Canada use questionnaires to evaluate the health and social functioning of individuals suffering from a severe mental illness. However, seldom are these tools subject to psychometric analyses to establish their validity on independent samples. This article presents the results of the validation of the French version of the Multnomah Community Ability Scale. Confirmatory factor analyses were carried out to assess the factorial structure. The factor structure, four dimensions with three items, emerging from a first sample was replicated with data from a different sample of clients. Moreover, these four dimensions respect the initial factor solution of the Multnomah Community Ability Scale, which are a) interference with functioning, b) adjustment to living, c) social competence, and d) behavior problems. The study shows the structural validity of this brief questionnaire, which could be useful both for clinical and research settings to evaluate the effectiveness of interventions.

Alternatives to acute hospital psychiatric care in east-end Montreal.

OBJECTIVE: As pressure mounts to reduce the number of costly acute care beds, governments and the literature propose top-down ratios. Is this reasonable and fair to the responsible medical officers who, as the key care providers, will need to admit patients and develop discharge plans in a reduced-beds environment? METHOD: Treating physicians of all acute care inpatients on a given day (n = 212) and all new acute care admissions over a 2-week period (n = 125) completed an adapted version of the Nottingham Acute Beds Use Survey (NABUS) Questionnaire. RESULTS: On a given day, only 62 of 212 inpatients were unsuited for any alternative to acute care hospitalization. A floor ratio of 18 acute care beds per 100,000 inhabitants seems adequate for the catchment area in question, provided that alternatives to hospitalization are fully and efficiently available. Alternatives essentially involve an array of the following: supervised residential settings, day hospitals, and intensive home care (2 to 6 hours weekly). The ratio of intensive home care workers required would be 25 per 100,000 inhabitants.

[Treating depression is an effective population suicide prevention strategy: recent evidence from Scandinavian studies.]. / Données récentes d'études scandinaves. Traiter la dépression : une stratégie efficace de prévention du suicide?

This article's objective is to signal to the Quebec and the francophone audience of public planners and decision makers, clinical and suicide prevention workers, staff, relatives as well as the public of these recent breakthrough findings that provides strong evidence now that increasing the treatment of depression is an effective suicide prevention strategy. The article summarizes the evidence published recently and then critically reviews the methods and if the evidence fits within a complete public health perspective demonstration of an effective suicide prevention strategy. It highlights that the treatment of depression may not only decrease suicide rates but have much more larger public health effects by decreasing the disability associated with depression and have impact on future generations at risk of depression and suicide. The obstacles to developing such nation-wide strategy of increasing the treatment of depression will be highlighted with specific reference to the situation in Quebec.