An empirical literature review of definitions of severe and persistent mental illness

Case Managers' Attitudes Toward the Use of Homework for People Diagnosed With a Severe Psychiatric Disability

The study examined mental health case managers' attitudes toward the use of homework and explored the relationship between clinician attitudes and systematic homework administration practices. A survey examining attitudes toward the use of homework was completed by 122 Australian mental health case managers. Case managers who held more positive attitudes reported better client responses to homework. Systematic homework administration was predicted by the degree to which case managers felt that homework enhanced client outcomes and the importance that case managers placed on the use of homework for severe psychiatric disabilities. The use of training and supervision programs to promote systematic homework administration practice is discussed.

Development of the C4 inventory: a measure of common characteristics that complicate care in outpatient psychiatry

Background

Psychiatric syndromes are complicated by comorbidity and other factors that burden patients, making guideline-informed psychiatric care challenging, and negatively affecting outcome. A comprehensive intake tool could improve the quality of care. Existing tools to quantify these characteristics do not identify specific complications and may not be sensitive to phenomena that are common in psychiatric outpatients.

Objective

To develop a practical inventory to capture observations related to complex care in psychiatric outpatients and quantify the overall burden of complicating factors.

Design

We developed a checklist inventory through literature review and clinical experience. The inventory was tested and compared with related measures in a cross-sectional study of 410 consenting outpatients at the time of initial assessment.

Results

The summed score of inventory checklist items was significantly correlated with patient-assessed measures of distress (K10, r=0.36) and function (WHODAS 2.0, r=0.31), and physician-assessed measures of function (GAF, r=−0.42), number of psychiatric diagnoses [F(df3)=33.6], and most complex diagnosis [F(df3)=37.4]. In 53 patients whose assessment was observed by two clinicians, inter-rater reliability was acceptable for both total inventory score (intraclass correlation, single measures = 0.74) and agreement on specific items (mean agreement score = 90%).

Conclusions

The Psychiatric C4 Inventory is a reliable instrument for psychiatrists that captures information that may be useful for quality improvement and resource planning. It demonstrates convergent validity with measures of patient distress, function, and complexity. Further tests of validity and replication in other settings are warranted.

Smoking cessation advice for people with serious mental illness

BACKGROUND

People with a serious mental illness are more likely to smoke more and to be more dependent smokers than the general population. This may be due to a wide range of factors that could include a common aetiology to both smoking and the illness, self medication, smoking to alleviate adverse effects of medications, boredom in the existing environment, or a combination of these factors. It is important to undertake this review to facilitate improvements in both the health and safety of people with serious mental illness who smoke, and to reduce the overall burden of costs (both financial and health) to the smoker and, eventually, to the taxpayer.

OBJECTIVES

To review the effects of smoking cessation advice for people with serious mental illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Specialized Trials Register up to 2 April 2015, which is based on regular searches of CENTRAL, BIOSIS, PubMed, MEDLINE, EMBASE, CINAHL, PsycINFO, and trial registries. We also undertook unsystematic searches of a sample of the component databases (BNI, CINHAL, EMBASE, MEDLINE, and PsycINFO), up to 2 April 2015, and searched references of all identified studies

SELECTION CRITERIA

We planned to include all randomised controlled trials (RCTs) that focussed on smoking cessation advice versus standard care or comparing smoking cessation advice with other more focussed methods of delivering care or information.

DATA COLLECTION AND ANALYSIS

The review authors (PK, AC, and DB) independently screened search results but did not identify any trials that fulfilled the inclusion criteria of this review.

MAIN RESULTS

We did not identify any RCTs that evaluated advice regarding smoking cessation for people with serious mental illness. The excluded studies illustrate that randomisation of packages of care relevant to smokers with serious mental illness is possible.

AUTHORS' CONCLUSIONS

People with serious mental illness are more likely to smoke than the general population. Yet we could not find any high quality evidence to guide the smoking cessation advice healthcare professionals pass onto service users. This is an area where trials are possible and needed.

Complex and dynamic times of being chronically ill: Beyond disease trajectories of patients with ulcerative colitis

This article contributes to health research literature by problematizing the linear, sequential and intelligible understanding of time in the studies of illness. Drawing on the work of Martin Heidegger, it attempts to overcome the problem of considering the time of illness as either a framework controlling patients' experiences or a mind-dependent feature of their lives. The paper offers a conceptual analysis of the stories of ulcerative colitis patients from a recent clinical trial to present temporalities of illness as both objective and subjective, relational and dynamic. We attend to a combination of temporalities related to the ambiguous unfolding of illness and patients' relationships with such an unpredictable world of changing bodies, medical practices and temporal norms. Furthermore, our analysis reveals openness of times and considers ulcerative colitis patients as constantly evolving beings, with multiple possibilities brought about by illness. The paper highlights co-existence of times and considers patients' lives as incorporating a multiplicity of futures, presents and pasts. It concludes with conceptual observations about the consequences of developing complex approaches to illness in health research, which can better highlight the situatedness of patients and their multi-dimensional temporal foundations.

Psychoeducation (brief) for people with serious mental illness

BACKGROUND

Those with serious/severe mental illness, especially schizophrenia and schizophrenic-like disorders, often have little to no insight regarding the presence of their illness. Psychoeducation may be defined as the education of a person with a psychiatric disorder regarding the symptoms, treatments, and prognosis of that illness. Brief psychoeducation is a short period of psychoeducation; although what constitutes 'brief psychoeducation' can vary. A previous systematic review has shown that the median length of psychoeducation is around 12 weeks. In this current systematic review, we defined 'brief psychoeducation' as programmes of 10 sessions or less.

OBJECTIVES

To assess the efficacy of brief psychoeducational interventions as a means of helping severely mentally ill people when added to 'standard' care, compared with the efficacy of standard care alone.The secondary objective is to investigate whether there is evidence that a particular kind (individual/ family/group) of brief psychoeducational intervention is superior to others.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group register September 2013 using the phrase:[*Psychoeducat* in interventions of STUDY]. Reference lists of included studies were also inspected for further relevant studies. We also contacted authors of included study for further information regarding further data or details of any unpublished trials.

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs) comparing brief psychoeducation with any other intervention for treatment of people with severe mental illness. If a trial was described as 'double blind' but implied randomisation, we entered such trials in a sensitivity analysis.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently from included papers. We contacted authors of trials for additional and missing data. We calculated risk ratios (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data. For continuous data, we calculated the mean difference (MD), again with 95% CIs. We used a fixed-effect model for data synthesis, and also assessed data using a random-effects model in a sensitivity analysis. We assessed risk of bias for each included study and created 'Summary of findings' tables using GRADE (Grading of Recommendations Assessment, Development and Evaluation).

MAIN RESULTS

We included twenty studies with a total number of 2337 participants in this review. Nineteen studies compared brief psychoeducation with routine care or conventional delivery of information. One study compared brief psychoeducation with cognitive behavior therapy.Participants receiving brief psychoeducation were less likely to be non-compliant with medication than those receiving routine care in the short term (n = 448, 3 RCTs, RR 0.63 CI 0.41 to 0.96, moderate quality evidence) and medium term (n = 118, 1 RCT, RR 0.17 CI 0.05 to 0.54, low quality evidence).Compliance with follow-up was similar between the two groups in the short term (n = 30, 1 RCT, RR 1.00, CI 0.24 to 4.18), medium term (n = 322, 4 RCTs, RR 0.74 CI 0.50 to 1.09) and long term (n = 386, 2 RCTs, RR 1.19, CI 0.83 to 1.72).Relapse rates were significantly lower amongst participants receiving brief psychoeducation than those receiving routine care in the medium term (n = 406, RR 0.70 CI 0.52 to 0.93, moderate quality evidence), but not in the long term.Data from a few individual studies supported that brief psychoeducation: i) can improve the long-term global state (n = 59, 1 RCT, MD -6.70 CI -13.38 to -0.02, very low quality evidence); ii) promote improved mental state in short term (n = 60, 1 RCT, MD -2.70 CI -4.84 to -0.56,low quality evidence) and medium term; iii) can lower the incidence and severity of anxiety and depression.Social function such as rehabilitation status (n = 118, 1 RCT, MD -13.68 CI -14.85 to -12.51, low quality evidence) and social disability (n = 118, 1 RCT, MD -1.96 CI -2.09 to -1.83, low quality evidence) were also improved in the brief psychoeducation group. There was no difference found in quality of life as measured by GQOLI-74 in the short term (n = 62, 1 RCT, MD 0.63 CI -0.79 to 2.05, low quality evidence), nor the death rate in either groups (n = 154, 2 RCTs, RR 0.99, CI 0.15 to 6.65, low quality evidence).

AUTHORS' CONCLUSIONS

Based on mainly low to very low quality evidence from a limited number of studies, brief psychoeducation of any form appears to reduce relapse in the medium term, and promote medication compliance in the short term. A brief psychoeducational approach could potentially be effective, but further large, high-quality studies are needed to either confirm or refute the use of this approach.

Os signifıcados dos encaminhamentos feitos aos CAPS III de Santos: a visão dos profıssionais

Este trabalho teve como objetivo entender os significados dos encaminhamentos feitos aos CAPS III de Santos na visão dos profissionais de saúde que atuam nesses serviços, por meio de pesquisa de abordagem qualitativa, priorizando-se o método etnográfico. Para a obtenção das informações junto a esses profissionais, utilizou-se a técnica de entrevistas em profundidade, com roteiro semiestruturado. Foram entrevistados 12 profissionais (quatro psiquiatras e oito de outras especialidades) nos cinco CAPS III do município de Santos. Os significados dos encaminhamentos aos CAPS III, segundo os entrevistados, estão vinculados ao modo equivocado e “indevido” como ocorrem, com poucos dados e sem critérios específicos. Para eles, tais encaminhamentos, por profissionais de outros serviços, são decorrentes da falta de escuta; da pressa em encaminhar o paciente; do desconhecimento do que seja o CAPS III; o que acarreta uma demanda excessiva ou “voraz” para os CAPS III, sobrecarregando o serviço e impedindo que os profissionais possam se dedicar aos pacientes graves, prioritários nesses serviços. Observa-se uma contradição entre o discurso dos entrevistados e sua prática, pois as novas demandas, de casos leves, são atendidas. Ao se referirem aos CAPS III como um espaço de acolhimento, que oferece proteção e segurança, os entrevistados indicam de que maneira lidam em suas práticas com essa inversão de prioridades de demanda. Ao definirem o CAPS, seu local de trabalho e de experiência profissional, a partir da noção de acolhimento, uma “categoria nativa”, os entrevistados parecem explicar a contradição entre o discurso e a prática.

HIV prevention advice for people with serious mental illness

BACKGROUND

People with serious mental illness have rates of Human Immuno-deficiency Virus (HIV) infection higher than expected in the general population for the same demographic area. Despite this elevated prevalence, UK national strategies around sexual health and HIV prevention do not state that people with serious mental illness are a high risk group. However, a significant proportion in this group are sexually active and engage in HIV-risk behaviours including having multiple sexual partners, infrequent use of condoms and trading sex for money or drugs. Therefore we propose the provision of HIV prevention advice could enhance the physical and social well being of this population.

OBJECTIVES

To assess the effects of HIV prevention advice in reducing morbidity, mortality and preserving the quality of life in people with serious mental illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (24 January, 2012), which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. There is no language, date, document type, or publication status limitations for inclusion of records in the register.

SELECTION CRITERIA

We planned to include all randomised controlled trials focusing on HIV prevention advice versus standard care or comparing HIV prevention advice with other more focused methods of delivering care or information for people with serious mental illness.

DATA COLLECTION AND ANALYSIS

Review authors (NW, AC, AA, GT) independently screened search results and did not identify any studies that fulfilled the review's criteria.

MAIN RESULTS

We did not identify any randomised studies that evaluated advice regarding HIV for people with serious mental illness. The excluded studies illustrate that randomisation of packages of care relevant to both people with serious mental illness and HIV risk are possible.

AUTHORS' CONCLUSIONS

Policy makers, clinicians, researchers and service users need to collaborate to produce guidance on how best to provide advice for people with serious mental illness in preventing the spread of HIV infection. It is entirely feasible that this could be within the context of a well-designed simple large randomised study.

Social factors associated with mental disorders with risk situations in the primary health care

OBJECTIVE

To evaluate patients with mental disorders, with or without risk situations, treated at primary health care (PHC) units.

METHOD

A cross-sectional study was performed in samples of 240 patients living in a region of high social vulnerability in Belo Horizonte. The response variable was mental disorders with risk situations (MD-WR). The explanatory variables were gender, age, marital status, literacy, education, employment, social benefits and per capita income. Instruments from Berkman and Syme (social network), Sherbourne and Stewart (social support), adapted for Brazil, were applied. Pearson's χ2 test and binary logistic regression were used for the adjusted analyzes.

RESULTS

The factors associated with MD-WR were being male (OR = 3.62; 95%CI 1.84-7.09); having "up to one confident relative" only (OR = 2.53; 95%CI 1.18-5.42); being "not able to return home" when away from their living area (OR = 3.49; 95%CI 1.40-8.71). The reduction in the affective dimension of the Medical Outcomes Study (MOS) scale increases the chance of MD-WR.

CONCLUSION

The availability and access to social and support networks are lower for patients with MD-WR and need to be strengthened to promote autonomy and citizenship among its users. We conclude that there is the need of public policies to increase the availability of social networking equipment and social support projects, encouraging the participation of families.

Preliminary studies of the ICD-11 classification of personality disorder in practice

OBJECTIVE

This study aims to compare ICD-10 and putative ICD-11 classifications of personality disorder in different clinical populations.

DESIGN

Prospective recording of ICD-10 and ICD-11 personality disorder classifications was carried out in (1) an anxious medical population, (2) an acute psychiatric in-patient population and (3) a retrospective recording of a mixed anxiety depression cohort in which all baseline data were scored from baseline information using the ICD-11 classification and compared with the original ICD-10 assessments.

METHOD

Comparison of ICD-10 and ICD-11 prevalence of personality disorder in each population was carried out.

RESULTS

Data from 722 patients were recorded. Using the ICD-10 criteria, the prevalence of generic personality disorder was 33.8% compared with 40.4% using the ICD-11 ones (χ2  = 6.7; P < 0.01), with 103 (14.3%) discordant assessments. Using the severity definitions in ICD-11, 34.3% of patients had personality difficulty. Severity level varied greatly by population; severe personality disorder was five times more common in the inpatient group. The four domain traits originally denoted as qualifying severity in ICD-11, negative affective, dissocial, anankastic and detached, were linked to anxious, borderline, dissocial, anankastic and schizoid personality disorders in ICD-10. Many patients had pathology in two or more domains.

CONCLUSIONS

The ICD-11 classification of personality disorder yields somewhat higher levels of personality dysfunction than ICD-10, possibly because the age range for the onset of diagnosis is now flexible. The range of severity levels make the classification more useful than ICD-10 in clinical practice as it identifies the greater pathology necessary for intervention.

SMI life goals: description of a randomized trial of a collaborative care model to improve outcomes for persons with serious mental illness

BACKGROUND

Persons with serious mental illnesses (SMI) are more likely to die earlier than the general population, primarily due to increased medical burden, particularly from cardiovascular disease (CVD). Life Goals Collaborative Care (LG-CC) is designed to improve health outcomes in SMI through self-management, care management, and provider support. This single-blind randomized controlled effectiveness study will determine whether patients with SMI receiving LG-CC compared to usual care (UC) experience improved physical health in 12 months.

METHODS

Patients diagnosed with SMI and at least one CVD risk factor receiving care at a VA mental health clinic were randomized to LG-CC or UC. LG-CC included five self-management sessions covering mental health symptom management reinforced through health behavior change, care coordination and health monitoring via a registry, and provider feedback. The primary outcome is change in physical health-related quality of life score (VR-12) from baseline to 12 months. Secondary outcomes include changes in mental health-related quality of life, CVD risk factors (blood pressure, BMI), and physical activity from baseline to 12 months later.

RESULTS

Out of 304 enrolled, 139 were randomized to LG-CC and 145 to UC. Among patients completing baseline assessments (N = 284); the mean age was 55.2 (SD = 10.9; range 28-75 years), 15.6% were women, the majority (62%) were diagnosed with depression, and the majority (63%) were diagnosed with hypertension or were overweight (BMI mean ± SD = 33.3 ± 6.3). Baseline VR-12 physical health component score was below population norms (50.0 ± SD = 10) at 33.4 ± 11.0.

CONCLUSIONS

Findings from this trial may inform initiatives to improve physical health for SMI patient populations.

General physical health advice for people with serious mental illness

BACKGROUND

There is currently much focus on provision of general physical health advice to people with serious mental illness and there has been increasing pressure for services to take responsibility for providing this.

OBJECTIVES

To review the effects of general physical healthcare advice for people with serious mental illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (last update search October 2012) which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO and registries of Clinical Trials. There is no language, date, document type, or publication status limitations for inclusion of records in the register.

SELECTION CRITERIA

All randomised clinical trials focusing on general physical health advice for people with serious mental illness..

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We employed a fixed-effect model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE.

MAIN RESULTS

Seven studies are now included in this review. For the comparison of physical healthcare advice versus standard care we identified six studies (total n = 964) of limited quality. For measures of quality of life one trial found no difference (n = 54, 1 RCT, MD Lehman scale 0.20, CI -0.47 to 0.87, very low quality of evidence) but another two did for the Quality of Life Medical Outcomes Scale - mental component (n = 487, 2 RCTs, MD 3.70, CI 1.76 to 5.64). There was no difference between groups for the outcome of death (n = 487, 2 RCTs, RR 0.98, CI 0.27 to 3.56, low quality of evidence). For service use two studies presented favourable results for health advice, uptake of ill-health prevention services was significantly greater in the advice group (n = 363, 1 RCT, MD 36.90, CI 33.07 to 40.73) and service use: one or more primary care visit was significantly higher in the advice group (n = 80, 1 RCT, RR 1.77, CI 1.09 to 2.85). Economic data were equivocal. Attrition was large (> 30%) but similar for both groups (n = 964, 6 RCTs, RR 1.11, CI 0.92 to 1.35). Comparisons of one type of physical healthcare advice with another were grossly underpowered and equivocal.

AUTHORS' CONCLUSIONS

General physical health could lead to people with serious mental illness accessing more health services which, in turn, could mean they see longer-term benefits such as reduced mortality or morbidity. On the other hand, it is possible clinicians are expending much effort, time and financial resources on giving ineffective advice. The main results in this review are based on low or very low quality data. There is some limited and poor quality evidence that the provision of general physical healthcare advice can improve health-related quality of life in the mental component but not the physical component, but this evidence is based on data from one study only. This is an important area for good research reporting outcome of interest to carers and people with serious illnesses as well as researchers and fundholders.

Physical health care monitoring for people with serious mental illness

BACKGROUND

Current guidance suggests that we should monitor the physical health of people with serious mental illness, and there has been a significant financial investment over recent years to provide this.

OBJECTIVES

To assess the effectiveness of physical health monitoring, compared with standard care for people with serious mental illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (October 2009, update in October 2012), which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO.

SELECTION CRITERIA

All randomised clinical trials focusing on physical health monitoring versus standard care, or comparing i) self monitoring versus monitoring by a healthcare professional; ii) simple versus complex monitoring; iii) specific versus non-specific checks; iv) once only versus regular checks; or v) different guidance materials.

DATA COLLECTION AND ANALYSIS

Initially, review authors (GT, AC, SM) independently screened the search results and identified three studies as possibly fulfilling the review's criteria. On examination, however, all three were subsequently excluded. Forty-two additional citations were identified in October 2012 and screened by two review authors (JX and MW), 11 of which underwent full screening.

MAIN RESULTS

No relevant randomised trials which assess the effectiveness of physical health monitoring in people with serious mental illness have been completed. We identified one ongoing study.

AUTHORS' CONCLUSIONS

There is still no evidence from randomised trials to support or refute current guidance and practice. Guidance and practice are based on expert consensus, clinical experience and good intentions rather than high quality evidence.

Defining quality of life in the children of parents with severe mental illness: a preliminary stakeholder-led model

Severe parental mental illness poses a challenge to quality of life (QoL) in a substantial number of children and adolescents, and improving the lives of these children is of urgent political and public health concern. This study used a bottom-up qualitative approach to develop a new stakeholder-led model of quality of life relevant to this population. Qualitative data were collected from 19 individuals participating in focus groups or individual interviews. Participants comprised 8 clinical academics, health and social care professionals or voluntary agency representatives; 5 parents and 6 young people (aged 13–18 yrs) with lived experience of severe parental mental illness. Data underwent inductive thematic analysis for the purposes of informing a population-specific quality of life model. Fifty nine individual themes were identified and grouped into 11 key ‘meta-themes’. Mapping each meta-theme against existing child-centred quality of life concepts revealed a multi-dimensional model that endorsed, to a greater or lesser degree, the core domains of generic quality of life models. Three new population-specific priorities were also observed: i) the alleviation of parental mental health symptoms, ii) improved problem-based coping skills and iii) increased mental health literacy. The identification of these priorities raises questions regarding the validity of generic quality of life measures to monitor the effectiveness of services for families and children affected by severe mental illness. New, age-appropriate instruments that better reflect the life priorities and unique challenges faced by the children of parents with severe mental illness may need to be developed. Challenges then remain in augmenting and adapting service design and delivery mechanisms better to meet these needs. Future child and adult mental health services need to work seamlessly alongside statutory education and social care services and a growing number of relevant third sector providers to address fully the quality of life priorities of these vulnerable families.

Prevalence of interpersonal trauma exposure and trauma-related disorders in severe mental illness

BACKGROUND

Interpersonal trauma exposure and trauma-related disorders in people with severe mental illness (SMI) are often not recognized in clinical practice.

OBJECTIVE

To substantiate the prevalence of interpersonal trauma exposure and trauma-related disorders in people with SMI.

METHODS

We conducted a systematic review of four databases (1980-2010) and then described and analysed 33 studies in terms of primary diagnosis and instruments used to measure trauma exposure and trauma-related disorders.

RESULTS

Population-weighted mean prevalence rates in SMI were physical abuse 47% (range 25-72%), sexual abuse 37% (range 24-49%), and posttraumatic stress disorder (PTSD) 30% (range 20-47%). Compared to men, women showed a higher prevalence of sexual abuse in schizophrenia spectrum disorder, bipolar disorder, and mixed diagnosis groups labelled as having SMI.

CONCLUSIONS

Prevalence rates of interpersonal trauma and trauma-related disorders were significantly higher in SMI than in the general population. Emotional abuse and neglect, physical neglect, complex PTSD, and dissociative disorders have been scarcely examined in SMI.

Ethical issues raised in addressing the needs of people with serious mental disorders in complex emergencies

Recent manmade and natural disasters highlight weaknesses in the public health systems designed to protect populations from harm and minimize disruption of the social and built environments. Emergency planning and response efforts have, as a result, focused largely on ensuring populations' physical well-being during and after a disaster. Many public health authorities, including the World Health Organization, have recognized the importance of addressing both mental and physical health concerns in emergency plans. Individuals with mental disorders represent a notable proportion of the overall population, and anticipating their needs is critical to comprehensive emergency planning and response efforts. Because people with serious mental disorders historically have been stigmatized, and many individuals with mental disorders may be unable to care for themselves, ethical guidance may be of assistance to those engaged in emergency planning and response. This article considers several broad categories of ethical issues that arise during emergencies for people with serious mental disorders and offers recommendations for ways in which emergency planners and other stakeholders can begin to address these ethical challenges.

HIV risk behavior of psychiatric patients with mental illness: a sample of Brazilian patients

OBJECTIVE

The prevalence of HIV among psychiatric patients is higher than general population rates worldwide. Many risk behaviors have been identified in studies from both developing and developed countries, though sampling limitations restrict the generalizability of their results. The objective of this study was to report findings from the first national sample of psychiatric patients about lifetime practice of unsafe sex and associated factors.

METHOD

A national multicenter sample of adults with mental illness was randomly selected from 26 public mental health institutions throughout Brazil. Sociodemographic, sexual behavior and clinical data were obtained from person-to-person interviews and blood was collected for serology testing. Logistic regression was used for analysis.

RESULTS

The overall prevalence of lifetime unprotected sex was 80.3%. Married, older, female patients, those with multiple partners and living with children or partners only and those with less severe psychiatric diagnosis more often practised unsafe sex.

DISCUSSION

Risk behavior assessment is a critical tool for clinicians to be able to determine needed HIV-related services for their clients and ensure appropriate follow-through with care and prevention. Interventions that address situational risks in psychiatric patients' lives-institutional and individual- and increase their ability to make informed decisions about their sexual health are urgently needed.

Oral health advice for people with serious mental illness

BACKGROUND

People with serious mental illness experience an erosion of functioning in day-to-day life over a protracted period of time. There is also evidence to suggest that people with serious mental illness have a greater risk of experiencing oral disease and have greater oral treatment needs than the general population. However, oral health has never been seen as a priority in people suffering with serious mental illness. Poor oral health has a serious impact on quality of life, everyday functioning, social inclusion and self-esteem. We feel that oral healthcare advice could have a positive impact on this disadvantaged population.

OBJECTIVES

To assess the effectiveness of oral health advice in reducing morbidity, mortality and preserving the quality of life in people with serious mental illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (October 2009) which is based on regular searches of CENTRAL, MEDLINE, EMBASE, CINAHL and PsycINFO.

SELECTION CRITERIA

We planned to include all randomised clinical trials focusing on oral health advice versus standard care or comparing oral health advice with other more focused methods of delivering care or information.

DATA COLLECTION AND ANALYSIS

The review authors (GT, AC, WK) independently screened search results and did not identify any studies that fulfilled the review's criteria.

MAIN RESULTS

We did not identify any studies that met our inclusion criteria.

AUTHORS' CONCLUSIONS

Healthcare professionals should be more proactive in liaising with oral health professionals in developing novel ways to cater for the needs of people with serious mental illness.

The prevalence and correlates of sexual risk behaviors and sexually transmitted infections in outpatients with borderline personality disorder

This study examined the prevalence and correlates of sexual risk behaviors and sexually transmitted infections (STIs) in two samples of outpatients with borderline personality disorder (BPD), including suicidal BPD women (n = 99) and opiate-dependent BPD men and women (n = 125). High rates of sexual risk behaviors and STIs were found, particularly in the opiate-dependent BPD sample. Compared with suicidal BPD outpatients, opiate-dependent BPD outpatients reported higher rates of past-year sexual activity, commercial sex work, and lifetime hepatitis, as well as a greater number of lifetime sex partners. Substance use and demographic characteristics (age, sex, and marital status) were associated with higher rates of sexual risk behaviors and/or STIs, whereas cognitive-behavioral factors and indicators of psychiatric impairment were not. These findings point to a clear need for interventions aimed at decreasing sexual risk behaviors among individuals with BPD.

Classifying personality disorder according to severity

Current systems for classifying personality disorder according to specific categories are unsatisfactory because they do not take account of wide variations in levels of personality disturbance and associated impairment. We review previous attempts to classify personality disorder according to severity and place these findings in the context of work exploring the severity of other mental disorders. On the basis of these findings, we propose a new system for classifying personality-related problems based on severity defined by the extent of personality disturbance, the level of social dysfunctioning, and the impact of the disorder for individuals and society. We recognize that studies using these definitions will need piloting and testing in field trials, but believe that this simplified approach to classifying personality disorder would encourage greater use by clinicians and assist those involved in planning services for people with personality disorder.

Randomized Controlled Pilot Study of an Occupational Time-Use Intervention for People With Serious Mental Illness

OBJECTIVE. We assessed the efficacy and clinical utility of a new occupational time-use intervention, Action Over Inertia, designed to improve occupational balance and engagement among community-dwelling people with serious mental illness.

METHOD. Using a randomized controlled design, we assigned 24 participants to an intervention group or standard care group. Participants were community-dwelling people with serious mental illness receiving assertive community treatment services. Data on time use, occupational balance, and engagement were collected and compared at baseline and 12-wk posttest.

RESULTS. Eighteen participants completed the pilot study. Treatment group participants increased their occupational balance by spending an average of 47 min more per day in activity than the control group (p = .05). Differences in occupational engagement were not shown, but evidence of clinical utility was found.

CONCLUSION. This pilot study of Action Over Inertia has shown evidence of efficacy and clinical utility.

Cost-effectiveness of nidotherapy for comorbid personality disorder and severe mental illness: randomized controlled trial

Aims – Nidotherapy is the systematic modification of the environment to create a better fit for people. This is the first randomized controlled trial of its efficacy in an assertive community team. Methods – Patients in an assertive outreach team with continued management problems together with comorbid personality disturbance and severe mental illness were randomized to nidotherapy enhanced assertive treatment (up to 12 sessions) or to continued assertive outreach care. Use of psychiatric beds over one years (primary outcome) and change from base-line in other health service resources, psychiatric symptoms, social functioning and engagement with services were measured at 6 and 12 months (secondary outcomes). Results – 52 patients were recruited over 13 months, with 49 and 37 assessed at 6 and 12 months. Patients referred to nidotherapy had a 63% reduction in hospital bed use after one year compared with control assertive care (P=0.13) and showed non-significant improvement in psychiatric symptoms, social functioning and engagement than the control group. The mean cost savings for each patient allocated to nidotherapy was £4,112 per year, mainly as a consequence of reduced psychiatric bed use. Conclusion – Nidotherapy may be a cost-effective option in the management of comorbid serious mental illness and personality disorder, but larger confirmatory trials are necessary.

General physical health advice for people with serious mental illness

BACKGROUND

There is currently much focus on provision of general physical health advice to people with serious mental illness and there has been increasing pressure for services to take responsibility for providing this.

OBJECTIVES

To assess the effects of general physical health advice as a means of reducing morbidity, mortality and improving or maintaining quality of life in people with serious mental illness.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (November 2009) which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO.

SELECTION CRITERIA

All randomised clinical trials focusing on general physical health advice.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data we estimated mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses.

MAIN RESULTS

For the comparison of physical healthcare advice versus standard care we identified five studies (total n = 884) of limited quality. For measures of quality of life one trial found no difference (n = 54, 1 RCT, MD Lehman scale 0.00 CI -0.67 to 0.67) but another did (n = 407, 1 RCT, MD Quality of Life Medical Outcomes Scale - mental component 3.7 CI 1.7 to 5.6). There was no difference between groups for the outcome of death (n = 407, 1 RCT, RR 1.3 CI 0.3 to 6.0), for the outcome of uptake of ill-health prevention services, one study found percentages significantly greater in the advice group (n = 363, 1 RCT, MD 36.9 CI 33.1 to 40.7). Economic data were equivocal. Attrition was large (> 30%) but similar for both groups (n = 884, 5 RCTs, RR 1.18 CI 0.97 to 1.43). Comparisons of one type of physical healthcare advice with another were grossly underpowered and equivocal.

AUTHORS' CONCLUSIONS

General physical health could lead to people with serious mental illness accessing more health services which, in turn, could mean they see longer term benefits such as reduced mortality or morbidity. On the other hand it is possible clinicians are expending much effort, time and financial expenditure on giving ineffective advice. This is an important area for good research reporting outcome of interest to carers and people with serious illnesses as well as researchers and fundholders.

Intensive case management for severe mental illness

BACKGROUND

Intensive Case Management (ICM) is a community based package of care, aiming to provide long term care for severely mentally ill people who do not require immediate admission. ICM evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (less than 20) and high intensity input.

OBJECTIVES

To assess the effects of Intensive Case Management (caseload <20) in comparison with non-Intensive Case Management (caseload > 20) and with standard community care in people with severe mental illness. To evaluate whether the effect of ICM on hospitalisation depends on its fidelity to the ACT model and on the setting.

SEARCH STRATEGY

For the current update of this review we searched the Cochrane Schizophrenia Group Trials Register (February 2009), which is compiled by systematic searches of major databases, hand searches and conference proceedings.

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community-care setting, where Intensive Case Management, non-Intensive Case Management or standard care were compared. Outcomes such as service use, adverse effects, global state, social functioning, mental state, behaviour, quality of life, satisfaction and costs were sought.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes we calculated relative risk (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data we estimated mean difference (MD) between groups and its 95% confidence interval (CI). We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect.

MAIN RESULTS

We included 38 trials (7328 participants) in this review. The trials provided data for two comparisons: 1. ICM versus standard care, 2. ICM versus non-ICM.1. ICM versus standard care Twenty-four trials provided data on length of hospitalisation, and results favoured Intensive Case Management (n=3595, 24 RCTs, MD -0.86 CI -1.37 to -0.34). There was a high level of heterogeneity, but this significance still remained when the outlier studies were excluded from the analysis (n=3143, 20 RCTs, MD -0.62 CI -1.00 to -0.23). Nine studies found participants in the ICM group were less likely to be lost to psychiatric services (n=1633, 9 RCTs, RR 0.43 CI 0.30 to 0.61, I²=49%, p=0.05).One global state scale did show an Improvement in global state for those receiving ICM, the GAF scale (n=818, 5 RCTs, MD 3.41 CI 1.66 to 5.16). Results for mental state as measured through various rating scales, however, were equivocal, with no compelling evidence that ICM was really any better than standard care in improving mental state. No differences in mortality between ICM and standard care groups occurred, either due to 'all causes' (n=1456, 9 RCTs, RR 0.84 CI 0.48 to 1.47) or to 'suicide' (n=1456, 9 RCTs, RR 0.68 CI 0.31 to 1.51).Social functioning results varied, no differences were found in terms of contact with the legal system and with employment status, whereas significant improvement in accommodation status was found, as was the incidence of not living independently, which was lower in the ICM group (n=1185, 4 RCTs, RR 0.65 CI 0.49 to 0.88).Quality of life data found no significant difference between groups, but data were weak. CSQ scores showed a greater participant satisfaction in the ICM group (n=423, 2 RCTs, MD 3.23 CI 2.31 to 4.14).2. ICM versus non-ICM The included studies failed to show a significant advantage of ICM in reducing the average length of hospitalisation (n=2220, 21 RCTs, MD -0.08 CI -0.37 to 0.21). They did find ICM to be more advantageous than non-ICM in reducing rate of lost to follow-up (n=2195, 9 RCTs, RR 0.72 CI 0.52 to 0.99), although data showed a substantial level of heterogeneity (I²=59%, p=0.01). Overall, no significant differences were found in the effects of ICM compared to non-ICM for broad outcomes such as service use, mortality, social functioning, mental state, behaviour, quality of life, satisfaction and costs.3. Fidelity to ACT Within the meta-regression we found that i. the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36 CI -0.66 to -0.07); and ii. the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20 CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but 'baseline hospital use' result is still significantly influencing time in hospital (regression coefficient -0.18 CI -0.29 to -0.07, p=0.0027).

AUTHORS' CONCLUSIONS

ICM was found effective in ameliorating many outcomes relevant to people with severe mental illnesses. Compared to standard care ICM was shown to reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. ICM is of value at least to people with severe mental illnesses who are in the sub-group of those with a high level of hospitalisation (about 4 days/month in past 2 years) and the intervention should be performed close to the original model.It is not clear, however, what gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, but currently we know of no review comparing non-ICM with standard care and this should be undertaken.

Psychiatric rehabilitation interventions: a review

Psychiatric rehabilitation has become accepted by the mental health field as a legitimate field of study and practice. Over the last several decades various psychiatric rehabilitation programme models and procedures have been developed, evaluated and disseminated. At the same time the process of psychiatric rehabilitation has been specified and its underlying values and practitioner technology articulated. This review describes the psychiatric rehabilitation process and in so doing differentiates psychosocial interventions that can be classified as psychiatric rehabilitation interventions from other psychosocial interventions. Furthermore, the major psychiatric rehabilitation interventions are examined within a framework of the psychiatric rehabilitation process with a review of their evidence. The review concludes that psychiatric rehabilitation interventions are currently a mixture of evidence-based practices, promising practices and emerging methods that can be effectively tied together using the psychiatric rehabilitation process framework of helping individuals with serious mental illnesses choose, get and keep valued roles, and together with complementary treatment orientated psychosocial interventions, provide a broad strategy for facilitating recovery.

Physical health care monitoring for people with serious mental illness

BACKGROUND

Current guidance suggests that we should monitor the physical health of people with serious mental illness and there has been a significant financial investment over recent years to provide this.

OBJECTIVES

To assess the effectiveness of physical health monitoring as a means of reducing morbidity, mortality and reduction in quality of life in people with serious mental illness.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (October 2009) which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO.

SELECTION CRITERIA

All randomised or quasi-randomised clinical trials focusing on physical health monitoring versus standard care or comparing i) self monitoring vs monitoring by health care professional; ii) simple vs complex monitoring; iii) specific vs non-specific checks iv) once only vs regular checks or v) comparison of different guidance.

DATA COLLECTION AND ANALYSIS

The authors (GT, AC, SM) independently screened search results and identified three studies as possibly fulfilling the review's criteria. On examination, however, all three were subsequently excluded.

MAIN RESULTS

We did not identify any randomised trials which assessed the effectiveness of physical health monitoring in people with serious mental illness.

AUTHORS' CONCLUSIONS

There is no evidence from randomised trials to support current guidance and practice. Guidance and practice are based on expert consensus, clinical experience and good intentions rather than high quality evidence.

The temporality of "chronic" mental illness

Although multiple concepts of time can be found in psychiatric discourses and practices, the notion of time as an absolute category seems to predominate. In particular, the notion of "chronicity" implies the persistence of symptoms over the temporal course of a disease, thereby following a logic that conceptualizes time as an objective and universal measure. I argue that such a notion of time impedes the development of patients and the metrics by which to map change. This article, therefore, aims to present a different concept of time that should enable dealing with "chronic" mental illness in more flexible and creative ways. A case study of an everyday psychiatric routine is presented, followed by an in-depth analysis of its temporal implications. I conceptualize the notion of time as an extended field, being relationally and intersubjectively structured and linked to performed activities. Such a notion of time needs to be seen as a flexible and fluid matrix that possesses the character of an event-oriented and productive space. This conception favors an individualized temporality of change, suggesting concrete therapeutic procedures that can be implemented in clinical practice.

Recovering from recurrent mental health problems: giving up and fighting to get better

The purpose of this paper is to present selected findings of a grounded theory study that aims to explore individual processes and desired outcomes of recovery from recurrent health problems in order to build up a theoretical framework of recovery in an Irish context. Volunteers included mental health service users or participants of peer support groups who have experienced recurrent mental health problems for two or more years, consider themselves in improvement, and are willing to participate in individual interviews. The current paper is based on the analysis of 15 audiorecorded and transcribed interviews. We identified two open codes of 'giving up' and 'fighting to get better'. Giving up was associated with accepting a passive identity of a patient with a chronic mental illness and a lack of intrinsic motivation to get better. Fighting had both positive (fighting for) and negative (fighting against) dimensions, as well as internal and external ones. The fight for recovery entailed substantial and sometimes risky effort. Starting such a fight required strong, self-sustained motivation. Service providers might need to discuss internal and external motivators of fighting for recovery with service users, with a view to including such motivators in the care plans.

Prevalence of HIV, syphilis, hepatitis B and C among adults with mental illness: a multicenter study in Brazil

OBJECTIVE

There is evidence that patients with mental illness have increased prevalence of sexually transmitted infections, but data in Brazil are scarce. The objective of this study was to determine the prevalence of HIV, hepatitis C and B, and syphilis among patients with mental illness in Brazil.

METHOD

A multicenter representative sample of adults with mental illness was randomly selected from 26 mental health institutions throughout Brazil. Sociodemographic, sexual behavior and clinical data were obtained from person-to-person interviews and blood was collected for serology testing. Seroprevalence with 95% confidence limits were obtained correcting for sampling scheme.

RESULTS

Of the 2,475 patients interviewed, 2,238 had blood collected. Most participants were sexually active ever (88.8%) or in the last 6 months (61.6%), female (51.9%), and single (66.6%). Half of the sample had less than 5 years of schooling and the mean monthly individual income was low (US$ 210.00). Condom use was very low either during lifetime (8%) or in the last 6 months (16%). Overall seroprevalence were 1.12%, 0.80%, 1.64%, 14.7% and 2.63% for, respectively, syphilis, HIV, HBsAg, anti-HBc and anti-HCV.

CONCLUSIONS

Seroprevalences found were higher than other populations with representative studies in Brazil, with high rates of sexual risk behavior. This is of public health concern, and prevention and care strategies for sexually transmitted infections among psychiatric patients should urgently be implemented by health authorities.

Factors associated with substance use problem among Maryland Medicaid enrollees affected by serious mental illness

The objective of this study was to identify long-term factors associated with substance use problem among individuals affected by severe mental illness. Prospective data come from the 1994, 1998, and 2000 waves of the Maryland Mental Health Outcomes Survey conducted among a sub-cohort of adult Medicaid recipients affected by serious mental illness. We estimated factors associated with alcohol and drug problem, as well as a hierarchy of substance use problem severity constructed from the alcohol and drug problem outcomes. Drug problem was the strongest factor associated with alcohol problem, and vice versa. Conceptualizing alcohol and drug problem separately, and as a hierarchy of severity, revealed distinct profiles of significant factors. Further research is warranted to explore the utility of modeling substance use problem in terms of a hierarchy of severity.

Critérios de admissão e continuidade de cuidados em centros de atenção psicossocial, Rio de Janeiro, RJ

OBJETIVO: Analisar os critérios de admissão, encaminhamento e continuidade de cuidado a pacientes utilizados pelas equipes dos centros de atenção psicossocial. MÉTODOS: Pesquisa qualitativa com avaliação participativa realizada em três centros de atenção psicossocial do município do Rio de Janeiro (RJ) em 2006. Foram sorteados 15 casos admitidos e 15 casos encaminhados dentre os pacientes admitidos para tratamento nos seis meses anteriores ao início da pesquisa. Os critérios apontados pela equipe para a admissão do paciente para tratamento ou encaminhamento foram analisados a partir de um roteiro estruturado. A análise da continuidade de cuidados baseou-se em pesquisa em prontuário, informações da equipe e dos próprios pacientes e/ou familiares seis meses após a absorção ou encaminhamento do paciente. RESULTADOS: Os pacientes admitidos apresentavam diagnóstico de psicose (esquizofrenia), história de internações prévias, funcionamento social pobre e rede de apoio pequena e os pacientes encaminhados apresentavam transtornos ansiosos e depressivos, boa adesão a tratamento ambulatorial, bom funcionamento social e presença de rede social. Quanto à continuidade de cuidados, oito pacientes em 27 tiveram destino desconhecido. Quanto aos encaminhamentos, dos 13 pacientes encaminhados a ambulatórios da rede, sete permaneceram em tratamento, dois retornaram aos CAPS e quatro tiveram destino desconhecido. CONCLUSÕES: Os centros admitem pacientes que se encaixam na definição de um transtorno mental severo e persistente. A continuidade de cuidado foi apontada como problema, provavelmente devido à dificuldade de acompanhar os pacientes na comunidade.

Severely and persistently mentally ill - a changing group. Ten years after the 1995 Swedish mental health care reform

AIM

A mental health care reform was implemented in Sweden in 1995. The target group of the reform was persons considered severely and persistently mentally ill (SMI). The aim of this article was to study changes in the target group 10 years after the reform, i.e. changes in the group of persons defined as SMI.

METHODS

Inventories of persons considered SMI were made in a municipality of Sweden in 1995/96, 2000/2001 and 2006 based on the same definition. The invented persons were interviewed. The same interview procedures, questionnaires and need assessments were used on all three occasions. The results were based on comparing the new groups considered SMI in 2000/2001 and 2006.

RESULTS

In 2006, the group of persons considered SMI was younger. Fewer persons with a diagnosis of schizophrenia and more persons with a diagnosis of mood disorders or addictive problems were included. Problems concerning relations and physical health were more evident. A greater part had all their income from social security in 2006, and fewer persons were occupied in some kind of salaried employment, full-time or half-time, regular or sheltered.

CONCLUSION

The target group of the reform had changed and other groups of persons were considered SMI in 2006. These new groups require other strategies of care.

Benefits and changes for family to family graduates

Family members of people with serious mental illnesses (SMI) need information and support to cope with the considerable stresses they experience. The Family to Family Education Program (FtF) is a structured, peer-led, 12-week information and support self-help class for such individuals. Previous research by Dixon et al. (2004) shows reduced subjective burden and increased empowerment among graduates. The present study sought to understand what processes take place during FtF participation that might lead to these benefits, as a first step in building a conceptual model of how FtF causes its effects, using semi-structured interviews with 31 FtF graduates. Qualitative data analysis suggested that new factual and emotional information from FtF shifts interviewees' understanding of their situation and that skills acquired through FtF then allow participants to incorporate these new perspectives into more adaptive behaviors. These changes led to both proximal and distal benefits for the FtF participants interviewed. The results are discussed in the context of self-help, stress-and-coping, and trauma recovery theories.

Preliminary evidence for the integration of music into HIV prevention for severely mentally ill Latinas

BACKGROUND

Individuals with severe mental illness (SMI) may be at increased risk of HIV infection. Prevention programs designed specifically for SMI have relied primarily on principles of cognitive-behavior change theories delivered in a small group format and in venues and services utilized by SMI. Most intervention effects have not been shown to be sustainable over time. We report on our findings relating to the importance of music to Puerto Rican women with SMI and the implications for HIV prevention interventions with this population.

METHODS

We interviewed and shadowed over a 2-year period 53 women of Puerto Rican ethnicity between the ages of 18 and 50, residing in northeastern Ohio, who had been diagnosed with schizophrenia, bipolar disorder, or major depression.

RESULTS

Nearly one-half of the participants listened to music regularly. Some reported that music was essential to their lives. Participants reported that music improved their mental and social well-being by facilitating expression and reflection of their emotions and increasing their energy levels.

DISCUSSION

Music may affect the core negative symptoms and compensate for neuropsychological deficits in women with schizophrenia and related conditions by facilitating the articulation of emotion and allowing individuals to better attend to and potentially incorporate external activities into their lives. The use of music in HIV prevention efforts with SMI Latinas may facilitate their emotional expression and assist them in integrating the educative efforts into their life style choices.

HIV, syphilis, and hepatitis B and C prevalence among patients with mental illness: a review of the literature

A limited number of studies worldwide have investigated the prevalence of HIV, syphilis, and hepatitis B and C infection among psychiatric patients. However, prevalence of these infections in the population with chronic mental illness has not been clearly established. Most of the published papers are from developed countries and have derived from relatively small and non-representative samples. We performed a systematic review of the published literature to identify studies on these infectious diseases within psychiatric populations in Brazil and other developing countries. Overall, prevalence rates varied from 0% to 29% for HIV; 1.6% to 66% for HBV; 0.4% to 38% for HCV; and 1.1% to 7.6% for syphilis. Several risk factors were identified and discussed, although sampling limitations restrict the generalization of study findings. This review highlights the lack of information on the prevalence of sexually transmitted diseases and their associated factors among persons with chronic mental illness and identifies gaps in the knowledge base in both developing and developed countries.

A taxonomy for homework used by mental health case managers when working with individuals diagnosed with severe mental illness

A survey was completed by 122 case managers describing the types of homework assignments commonly used with individuals diagnosed with severe mental illness (SMI). Homework types were categorized using a 12-item homework description taxonomy and in relation to the 22 domains of the Camberwell Assessment of Need (CAN). Case managers predominately reported using behaviourally based homework tasks such as scheduling activities and the development of personal hygiene skills. Homework focused on CAN areas of need in relation to Company, Psychological Distress, Psychotic Symptoms and Daytime Activities. The applications of the taxonomy for both researchers and case managers are discussed.

Incidence and prevalence of intimate partner violence by and against women with severe mental illness

Although a significant body of research has focused on the victimization of severely mentally ill persons and their perpetration of violence against others, relatively little attention has specifically addressed partner violence inflicted against and committed by severely mentally ill women. We conducted a review of the existing research to examine these issues. The published literature suggests that severely mentally ill women are at increased risk of being victimized by their partners and that a high proportion of severely mentally ill individuals may assault their intimate partners. Directions for future research and suggestions for clinical practice are presented.

Psychiatric and psychosocial correlates of sexual risk behavior among adults with severe mental illness

Persons with severe mental illness (SMI) are disproportionately affected by HIV/AIDS. This study examined multivariate correlates of sexual risk among 152 adults with SMI receiving outpatient psychiatric treatment. Structured interviews assessed psychiatric, psychosocial, and behavioral risk factors. The majority was sexually active (65%), and many reported unprotected intercourse (73%), multiple partners (45%), and sex trading (21%) in the past year. Logistic regression models found that sexual behaviors were differentially associated with non-psychotic disorder, psychiatric symptoms, substance abuse, childhood sexual abuse, romantic partnership, and social support (all ps < .05). Findings underscore the need for targeted HIV prevention interventions that address psychiatric and psychosocial risk factors.

A study of polypharmacy with second generation antipsychotics in patients with severe and persistent mental illness

BACKGROUND

There is a paucity of empirical support for polypharmacy with second generation (atypical) antipsychotics (SGAs), especially in understudied populations.

OBJECTIVE

To investigate the frequency, effectiveness, and safety of this practice in patients with severe and persistent mental illness who are chronically hospitalized.

METHODS

A chart review was conducted at a state psychiatric hospital in Syracuse, NY. The study subjects (N=26) were chronically hospitalized individuals with DSM-IV diagnoses of schizophrenia or schizoaffective disorder who were initially prescribed at least one SGA and then received at least one other SGA during the study period. Demographic and clinical data were collected. Baseline and 6-month assessments were compared for statistical significance (p<0.05).

RESULTS

Of the 117 chronically hospitalized inpatients at the study center, 22.2% (N=26) received treatment regimens involving polypharmacy with SGAs. These patients as a group achieved statistically significant reductions on their scores on the Brief Psychiatric Rating Scale (34.2 +/- 11.0 compared with 25.3 +/- 11.8; p=0.016) and the Clinical Global Impressions-Improvement Scale (5.5 +/- 0.6 compared with. 5.0 +/- 0.8; p=0.016) at 6 months. There was a significant decrease in the use of prn medications (7.6 +/- 19.6 compared with 1.6 +/- 2.6; p<0.04). However, the number of patients receiving anticholinergic medications increased from 5 to 8 (p<0.04).

CONCLUSIONS

Polypharmacy with SGAs is quite frequent among chronic inpatients with severe and persistent mental illness despite a limited empirical database supporting its use. The results of our pilot study do not demonstrate the effectiveness and safety of this practice. However, methodological shortcomings may have contributed to our failure to detect a true, positive effect. Controlled studies are needed to accurately determine the risks and benefits of SGA polypharmacy.