Illness and drug modifiable factors associated with violent behavior in homeless people with severe mental illness: results from the French Housing First (FHF) program

Homeless people: a review of personality disorders

Personality disorders in homeless people pose a challenge to the medical community and society, requiring specialized approaches for these super-difficult patients. The prevalence of personality disorders is higher in homeless populations than in the general population. However, there is a knowledge gap regarding personality disorders among people experiencing homelessness, and the implications of this lack of recognition are substantial. This paper provides a brief narrative review of personality disorders among homeless individuals. The primary importance and specificity of these disorders in this population remain unexplored. We searched PubMed and Web of Science databases in February and November 2023 using the keywords 'homeless' and 'personality disorder', and selected fifty-eight studies to be included in this literature review. The main themes of the results were personality disorders in homeless individuals and comorbid psychiatric disorders; risk factors and other psychological and behavioral data; clinical and intervention outcomes; and challenges linked to assessment, treatment, and intervention. The homeless population experiences significant diagnostic variability and the diagnosis of personality disorders is still evolving, contributing to difficulties in diagnosis, assessment, and treatment. A future challenge is to raise clinical awareness and optimize research knowledge, assessment, and intervention in personality disorders among homeless individuals with comorbid psychiatric disorders.

Poverty and inequality in real-world schizophrenia: a national study

Background

Schizophrenia has high socioeconomic impact among severe psychiatric disorders.

Aims

To explore clinician-reported and patient-reported inequities between patients under the poverty threshold vs. the others.

Method

916 patients consecutively recruited in 10 national centers received a comprehensive standardized evaluation of illness severity, addictions and patient-reported outcomes.

Results

739 (80.7%) of the patients were classified in the poverty group. This group had poorer objective illness outcomes (lower positive, negative, cognitive, excitement/aggressive and self-neglect symptoms and lifetime history of planned suicide) in multivariate analyses. While they had similar access to treatments and psychotherapy, they had lower access to socially useful activities, couple's life, housing and parenthood. They had also more disturbed metabolic parameters. On the contrary, the poverty group reported better self-esteem. No significant difference for depression, risky health behavior including addictions and sedentary behavior was found.

Interpretation

The equity in access to care is attributed to the French social system. However, mental and physical health remain poorer in these patients, and they still experience poor access to social roles independently of illness severity and despite healthcare interventions. These patients may have paradoxically better self-esteem due to decreased contact with society and therefore lower stigma exposure (especially at work). Schizophrenia presents itself as a distinct impoverished population concerning health-related outcomes and social integration, warranting focus in public health initiatives and improved treatment, including tailored interventions, collaborative care models, accessible mental health services, housing support, vocational training and employment support, community integration, education and awareness, research and data collection, culturally competent approaches, and long-term support.

Personality and attachment in the homeless: A systematic review

BACKGROUND

Homeless people present high rates of psychopathology, including personality disorders. Given the link between personality disorders and attachment, and the potential importance of these two traits for understanding homeless populations.

AIMS

Our aim was to review all studies focusing on attachment and on the full assessment of personality disorders in the homeless.

METHOD

Overall, 213 studies were screened through title and abstract. Of these, 63 articles were chosen for full-text assessment.

RESULTS

A total of 14 articles met eligibility criteria and were included in the present review. Six studies evaluated personality disorders and eight studies assessed attachment in the homeless. In general, reports suggested that personality disorders are highly common in the homeless, with frequencies ranging between 64% and 79% for any personality disorder. The most common personality diagnoses were paranoid (14%-74%), borderline (6%-62%), avoidant (14%-63%), and antisocial (4%-57%) personality disorders. Attachment reports differed in the methods used and presented diverse results and correlates. Even so, insecure types of attachment dominated in the homeless, accounting for 62% to 100% of the samples.

CONCLUSIONS

The high prevalence of personality disorders and insecure types of attachment in the homeless may impact intervention strategies for these people. The available literature evaluating attachment and the full assessment of personality disorders in the homeless is scarce, which supports the need for more research on these two topics.

Clozapine Use for Bipolar Disorder: An Asian Psychotropic Prescription Patterns Consortium Study

BACKGROUND

Pharmacoepidemiological studies of clozapine use to treat bipolar disorder (BD), especially in Asia, are rare, although they can provide insights into associated clinical characteristics and support international comparisons of indications and drug dosing.

METHODS

We examined the prevalence and clinical correlates of clozapine treatment for BD in 13 Asian countries and regions (China, Hong Kong SAR, India, Indonesia, Japan, Korea, Malaysia, Myanmar, Pakistan, Singapore, Sri Lanka, Taiwan, and Thailand) within an Asian Prescription Patterns Research Consortium. We compared BD patients treated with clozapine or not in initial bivariate comparisons followed by multivariable logistic regression modeling.

RESULTS

Clozapine was given to 2.13% of BD patients overall, at a mean daily dose of 275 (confidence interval, 267-282) chlorpromazine-equivalent mg/day. Patients receiving clozapine were older, more likely males, hospitalized, currently manic, and given greater numbers of mood-stabilizing and antipsychotic drugs in addition to clozapine. Logistic regression revealed that older age, male sex, current mania, and greater number of other antipsychotics remained significantly associated with clozapine treatment. Clozapine use was not associated with depressed mood, remission of illness, suicidal risk, or electroconvulsive treatment within the previous 12 months.

CONCLUSIONS

The identified associations of clozapine use with particular clinical features call for vigilance in personalized clinical monitoring so as to optimize clinical outcomes of BD patients and to limit risks of adverse effects of polytherapy.

One-year results from the vaccination campaign against COVID-19 infection in 47 million individuals with severe mental disorders and other chronic diseases

Severe mental disorders have been associated with increased COVID-19 mortality. The aim of this study was to evaluate the results of the vaccination campaign against COVID-19 after 1 year using exhaustive population-based data. In this nationwide population-based study, we used data from the French national medico-administrative database (SNDS) and the COVID Vaccine teleservice from January 4, 2021 (date of activation of the teleservice) to January 30th, 2022. As of January 30th, 2022, the rate of first injection in France was 80.2% (54 million people) and the rate of booster vaccination was 78.3% (52.7 million people). Except for opioid use disorder, all individuals with chronic illnesses or risk factors for poor COVID-19 outcome (e.g., smoking and obesity) had higher rates of vaccination than the general population (from 83.4 to 94.5% vs. 78.3%). However, the four diseases ranking last for both initial and booster vaccinations were mental disorders: alcohol use disorders (86 and 84.3%), neurodevelopmental psychiatric disorders (85.3 and 83.7%), schizophrenia-spectrum disorder (85 and 83.4%) and opioid use disorders (72.9 and 69.4%). Except for opioid disorders, all patients with mental disorders had higher rates of vaccination compared to the general population. However, these rates were lower than other chronic diseases at risk of severe COVID-19 outcomes. Vaccination campaigns must redouble their efforts to improve vaccination penetration in patients with mental disorders.

End of life breast cancer care in women with severe mental illnesses

Little is known on the end-of-life (EOL) care of terminal breast cancer in women with severe psychiatric disorder (SPD). The objective was to determine if women with SPD and terminal breast cancer received the same palliative and high-intensity care during their end-of-life than women without SPD. Study design, setting, participants. This population-based cohort study included all women aged 15 and older who died from breast cancer in hospitals in France (2014–2018). Key measurements/outcomes. Indicators of palliative care and high-intensity EOL care. Multivariable models were performed, adjusted for age at death, year of death, social deprivation, duration between cancer diagnosis and death, metastases, comorbidity, smoking addiction and hospital category. The analysis included 1742 women with SPD (287 with bipolar disorder, 1075 with major depression and 380 with schizophrenia) and 36,870 women without SPD. In multivariate analyses, women with SPD had more palliative care (adjusted odd ratio aOR 1.320, 95%CI [1.153–1.511], p < 0.001), longer palliative care follow-up before death (adjusted beta = 1.456, 95%CI (1.357–1.555), p < 0.001), less chemotherapy, surgery, imaging/endoscopy, and admission in emergency department and intensive care unit. Among women with SPD, women with bipolar disorders and schizophrenia died 5 years younger than those with recurrent major depression. The survival time was also shortened in women with schizophrenia. Despite more palliative care and less high-intensity care in women with SPD, our findings also suggest the existence of health disparities in women with bipolar disorders and schizophrenia compared to women with recurrent major depression and without SPD. Targeted interventions may be needed for women with bipolar disorders and schizophrenia to prevent these health disparities.

Violent behavior by involuntarily committed female offenders with mental disorders: A population-based case series

The goal of the current study was to investigate the socio-demographic, psychiatric, and criminological characteristics of female violent offenders with mental disorders involuntarily committed to a forensic psychiatric hospital. The present study was a population-based retrospective case series including all female offenders with mental disorders found not guilty by reason of insanity by the criminal courts in the state of Rio de Janeiro, Brazil, and involuntarily committed to a forensic psychiatric facility (n = 27). Patients were assessed with Structured Clinical Interview for DSM-IV Axis I Disorders and the Positive and Negative Syndrome Scale. We found that most offenders were Afro-Brazilian, uneducated unmarried women. Schizophrenia with active psychotic symptoms was the most common clinical condition. Relatives were the frequent victims of aggressive behavior. Most patients had already been diagnosed with a mental disorder and placed under psychiatric treatment, but poor adherence and treatment dropout were common. Violent behavior in psychiatrically ill female patients is associated with a specific socio-demographic and clinical profile and is thus potentially amenable to prevention particularly if the mental health and social services are to provide the much-needed support for economically, socially, and psychologically vulnerable women.

End-of-Life Care Among Patients With Bipolar Disorder and Cancer: A Nationwide Cohort Study

OBJECTIVE

This study aimed to describe end-of-life (EOL) care in individuals with bipolar disorder (BD) who died of cancer compared with mentally healthy individuals.

METHODS

This was a nationwide cohort study of all adult individuals who died of cancer in hospitals in France between 2013 and 2016. Outcomes were compared between individuals with BD and mentally healthy individuals in the last month of life including palliative care and high-intensity EOL care (chemotherapy, artificial nutrition, and other interventions). A subanalysis explored differences between patients with BD and patients with schizophrenia.

RESULTS

The study included 2015 individuals with BD and 222,477 mentally healthy controls. Compared with the controls, individuals with BD died 5 years earlier, more often had comorbidities and thoracic cancer, and had fewer metastases, but did not have shorter delays from cancer diagnosis to death. After matching and adjustment for covariates, individuals with BD more often received palliative care in the last 3 days of life (25% versus 13%, p < .001) and less high-intensity care (e.g., chemotherapy 12% versus 15%, p = .004), but more artificial nutrition (6% versus 4.6%, p = .003). Compared with the schizophrenia comparison group, chemotherapy was received more by individuals with BD in the last 14 days of life (12.5% for BD versus 9.4%, p < .001).

CONCLUSIONS

Individuals with BD were more likely to receive palliative care and less likely to receive high-intensity EOL care, except for artificial nutrition. These results may not be specific to BD, as no difference was found between patients with BD and schizophrenia except for chemotherapy.

Pharmacological treatment of violence in schizophrenia

Chronic aggression and violence in schizophrenia are rare, but receive disproportionate negative media coverage. This contributes to the stigma of mental illness and reduces accessibility to mental health services. Substance Use Disorders (SUD), antisocial behavior, non-adherence and recidivism are known risk factors for violence. Treatment with antipsychotic medication can reduce violence. Aside from clozapine, long-acting injectable antipsychotics (LAI) appear to be superior to oral antipsychotics for preventing violence, addressing adherence and recidivism. LAI also facilitate the implementation of functional skills training. For the high-risk recidivist target population with schizophrenia, better life skills have the potential to also reduce the risk for contact with the legal system, including an improved ability to live independently in supported environments and interact appropriately with others. High-risk patients who are resistant to treatment with other antipsychotics should receive treatment with clozapine due to its direct positive effects on impulsive violence, along with a reduction in comorbid risk factors such as SUDs.

"Life Starts for Me Again." The Social Impact of Psychology on Programs for Homeless People: Solidarity Networks for the Effectiveness of Interventions

The role of psychology in the improvement of people’s lives is consistent, according to the scientific literature review. More and more studies within psychology, and other social sciences, are pointing out the importance of the quality of social interactions on physical and mental health and upon perceived wellbeing. When talking about homelessness, psychology has served these individuals mostly by informing intervention programs related to preventing and responding to substance abuse, healthcare, sexual risks, or mental illnesses, and these are key problems that psychology has also studied and found to be connected to homelessness. Such strategies, which were traditionally mostly centered on tackling the weaknesses that homeless people face, are now increasingly considering the role of the social support services. The aim of this study was, on the one hand, to identify evidence on the importance of solidarity as a key factor in the process of overcoming homelessness, and associated substance abuse situations, and the barriers and conditions to achieve it. On another hand, the aim was also to approach the impact of that solidarity on their general wellbeing from the perspective of homeless subjects themselves. To achieve this aim, 20 life stories of people aged 35 to 70 years old were conducted in the metropolitan area of Barcelona. The people interviewed had been homeless in a recent period of their lives and were currently dependent on different services. The communicative methodology allowed deepening into the life stories of these individuals via egalitarian dialogue between the researchers and the participants. The results of the qualitative analysis showed that a strong solidarity network was crucial in the process of overcoming the participants’ homelessness situation and to tackle related circumstances (alcoholism and drug abuse among others), and this has had an impact in their general wellbeing and in the development of more solidarity attitudes. These findings are discussed in light of psychological knowledge and other social sciences literature on the importance of quality social environments to support positive developmental trajectories and considering the potential social impact of the intervention programs that take into account the factor of solidarity during their implementation process.