Social exclusion of people with severe mental illness in Switzerland: results from the Swiss Health Survey

Interaction between mental disorders and social disconnectedness on mortality: a population-based cohort study

BACKGROUND

Despite the recognised importance of mental disorders and social disconnectedness for mortality, few studies have examined their co-occurrence.

AIMS

To examine the interaction between mental disorders and three distinct aspects of social disconnectedness on mortality, while taking into account sex, age and characteristics of the mental disorder.

METHOD

This cohort study included participants from the Danish National Health Survey in 2013 and 2017 who were followed until 2021. Survey data on social disconnectedness (loneliness, social isolation and low social support) were linked with register data on hospital-diagnosed mental disorders and mortality. Poisson regression was applied to estimate independent and joint associations with mortality, interaction contrasts and attributable proportions.

RESULTS

A total of 162 497 individuals were followed for 886 614 person-years, and 9047 individuals (5.6%) died during follow-up. Among men, interaction between mental disorders and loneliness, social isolation and low social support, respectively, accounted for 47% (95% CI: 21-74%), 24% (95% CI: -15 to 63%) and 61% (95% CI: 35-86%) of the excess mortality after adjustment for demographics, country of birth, somatic morbidity, educational level, income and wealth. In contrast, among women, no excess mortality could be attributed to interaction. No clear trends were identified according to age or characteristics of the mental disorder.

CONCLUSIONS

Mortality among men, but not women, with a co-occurring mental disorder and social disconnectedness was substantially elevated compared with what was expected. Awareness of elevated mortality rates among socially disconnected men with mental disorders could be of importance to qualify and guide prevention efforts in psychiatric services.

Preference for Competitive Employment in People with Mental Disorders: A Systematic Review and Meta-analysis of Proportions

PURPOSE

The inclusion of people with mental disorders (MD) into competitive employment has become an important political and therapeutic goal. The present paper investigates meta-analytically to which extent people with MD who were unemployed or on sick leave due to MD prefer to work in a competitive job environment.

METHODS

For this systematic review and meta-analysis of proportions, we searched Medline, PsycInfo, Cinahl, Google Scholar, and reference lists for peer-reviewed publications from 1990 to Dec 2023, which provided data on the job preferences of people with MD. Two authors independently conducted full-text screening and quality assessments. Pooled proportions of job preferences were calculated with a random-effects meta-analysis of single proportions, and subgroup analyses were performed to examine characteristics associated with job preferences.

RESULTS

We included 30 studies with a total of 11,029 participants in the meta-analysis. The overall proportion of participants who expressed a preference for competitive employment was 0.61 (95%-CI: 0.53-0.68; I2 = 99%). The subgroup analyses showed different preference proportions between world regions where the studies were conducted (p < 0.01), publication years (p = 0.03), and support settings (p = 0.03).

CONCLUSION

Most people with MD want to work competitively. More efforts should be given to preventive approaches such as support for job retention. Interventions should be initiated at the beginning of the psychiatric treatment when the motivation to work is still high, and barriers are lower.

TRAIL REGISTRATION

The protocol is published in the Open Science registry at https://osf.io/7dj9r.

1 plus 1 is more than 2: mental health problems, financial difficulties, and social exclusion in a cross-sectional study of 28,047 general-population adults

BACKGROUND

Mental health problems and financial difficulties each increase the risk of social exclusion. However, few large studies representing a broad age range have investigated the combined social effect of having both difficulties. The purpose of this cross-sectional study was to examine associations of mental health problems, financial difficulties, and the combination of both with social exclusion.

METHODS

This analysis was based on responses from 28,047 adults (age > 18 years) from the general population participating in The Norwegian Counties Public Health Survey 2019. Respondents answered questions about their financial situation, mental health problems, and social exclusion. Social exclusion was measured as a lack of social support, low participation in organized social activities, low participation in other activities, missing someone to be with, feeling excluded, and feeling isolated. Adjustments for sex and age were made in multivariable logistic regression analyses.

RESULTS

Having mental health problems or financial difficulties was associated with various measures of social exclusion (odds ratios [ORs] with 95% confidence intervals [CIs]: 1.33 [1.23-1.43] to 12.63 [10.90-14.64]). However, the odds of social exclusion strongly increased for respondents who reported a combination of mental health problems and financial difficulties compared with those who did not report either (ORs [CIs]: 2.08 [1.90-2.27] to 29.46 [25.32-34.27]).

CONCLUSIONS

Having the combination of mental health problems and financial difficulties is strongly associated with increased risk for social exclusion, far beyond the effect of either factor alone.

The risk of suicidal intention in severe mental illness: An ecological perspective

OBJECTIVE

Guided by the ecosystem theory model framework, we aimed to explore the influence of three ecological dimensions (social, family and psychological factors) on suicidal intention in people with severe mental illness (SMI). We hypothesized that three factors influence suicidal intention, and that psychological factors may play a mediating role in the influence of social and family factors on suicidal intention.

METHODS

We collected 994 patients with SMI aged 18 and above from May 2021 to March 2022 in the Fourth Hospital of Fuzhou City. We used logistic regression to analyse the association between social, family, psychological factors and suicidal intention. Furthermore, we explored the mediating effects among the influencing factors.

RESULTS

Younger male patients with schizophrenia were more likely to have suicidal intention due to psychosocial family factors (p < .05). Social factors (poor interpersonal relations, social retreat, social activities outside the home), family factors (parental functions, activities within the family, family functions), psychological factors (anxiety, depression, interest in the outside world, overt aggression, lack of accountability and planning) were all independent risk factors for suicidal intention in patients. Mediation analysis showed anxiety and depression mediated the role of social and family factors on suicidal intention (p < .05).

CONCLUSION

Social, family and psychological factors were important risk factors for suicidal intention, with anxiety and depression being partial mediators for suicidal intention. Therefore, interventions that enhance family and social functioning and reduce anxiety and depression may be effective in reducing suicidal intention in SMI.

An exploration of loneliness experienced by people living with mental illness and the impact on their recovery journey: An integrative review

WHAT IS KNOWN ON THE SUBJECT?: There is evidence that social isolation and loneliness is more prevalent in people living with mental illness than in the general population. People living with mental illness frequently experience stigma, discrimination, rejection, repeated psychiatric admissions, low self-esteem, low self-efficacy, and increased symptoms of paranoia, depression, and anxiety. There is evidence of common interventions that can be used to improve loneliness and social isolation such as psychosocial skills training and cognitive group therapy. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper offers a comprehensive assessment of the evidence between mental illness, loneliness, and recovery. The results suggest that people living with mental illness experience elevated levels of social isolation and loneliness leading to poor recovery and quality of life. Social deprivation, social integration and romantic loneliness are related to loneliness, poor recovery, and reduced quality of life. A sense of belonging, ability to trust and hope are important aspects of improved loneliness, quality of life and recovery. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The existing culture in mental health nursing practice needs to be examined to address loneliness in people living with mental illness and its impact on recovery. Existing tools to research loneliness do not consider dimensions in loneliness experience as reflected in the literature. Practice needs to demonstrate an integrated approach to recovery, optimal service delivery and augmentation of evidence-based clinical practice to improve individual's loneliness, social circumstances, and relationships. Practice needs to demonstrate nursing knowledge in caring for people living with mental illness experiencing loneliness. Further longitudinal research is required to clearly understand the relationship between loneliness, mental illness, and recovery.

ABSTRACT

INTRODUCTION: To our knowledge, there are no previous reviews on the impact of loneliness experienced by people aged 18-65, who are living with mental illness and their recovery experience.

AIM/QUESTION

To explore the experience and impact of loneliness in people living with mental illness during recovery.

METHOD

An integrative review.

RESULTS

A total of 17 papers met the inclusion criteria. The search was conducted using four electronic databases: MEDLINE, CINAHL, Scopus and PsycINFO. Across these 17 papers, participants were most commonly, diagnosed with schizophrenia or psychotic disorders and recruited from community mental health services.

DISCUSSION

The review revealed loneliness to be substantial in people living with mental illness and that loneliness affected their recovery, and their quality of life. The review identified many factors that contribute to loneliness including unemployment, financial strain, social deprivation, group housing, internalized stigma and mental illness symptoms. Individual factors such as social/community integration and social network size as well as an inability to trust, a sense of not belonging, hopelessness and lack of romance were also evident. Interventions targeting social functioning skills and social connectedness were found to improve social isolation and loneliness.

IMPLICATIONS FOR PRACTICE

It is vital for mental health nursing practice to employ an approach integrating physical health as well as social recovery needs, optimal service delivery and augmentation of evidence-based clinical practice to improve loneliness, recovery, and quality of life.

Inequities Gone or Enduring? Evaluating the Effects of a School-Based Antistigma Intervention on Race/Ethnic and Gender Intersectional Disparities in Mental Illness Stigma

While significant mental illness stigma disparities across race/ethnicity and gender exist, little is known about the efficacy of anti-stigma interventions in reducing these intersectional disparities. We examine the two-year effects of school-based anti-stigma interventions on race/ethnic and gender intersectional stigma disparities among adolescents. An ethnically and socioeconomically diverse sixth grade sample (N = 302) self-completed surveys assessing stigma before randomly receiving an anti-stigma curriculum and/or contact intervention versus no intervention. Surveys were also self-completed two-years post-intervention. Stigma measures assessed general mental illness knowledge/attitudes, awareness/action, and social distance. Stigma towards peers with specific mental illnesses were examined using vignettes-two adolescent characters were described as having bipolar (Julia) and social anxiety (David) disorder. Race/ethnicity and gender were cross-classified into six intersectional groups (Latina/o, Non-Latina/o Black, and Non-Latina/o White girls and boys). Linear regressions adjusting for poverty and mental illness familiarity examined anti-stigma intervention effects across intersectional groups in sixth and eighth grade. The school-based anti-stigma intervention reduced intersectional stigma disparities over the two-year study period. While Non-Latino Black boys and Latino boys/girls reported greater disparities in stigma at baseline compared to Non-Latina White girls, these disparities (14 total) were predominantly eliminated in the two-year follow-up following receipt of the curriculum and contact components to just one remaining disparity post-intervention among Non-Latino Black boys. By identifying differences in how school-based anti-stigma interventions reduce mental illness stigma for unique race/ethnic and gender intersectional groups, we can better understand how to shape future anti-stigma interventions for diverse intersectional populations.

Social exclusion in people with diabetes: cross-sectional and longitudinal results from the German Ageing Survey (DEAS)

As social exclusion can be linked to worse health and overall reduced quality of life, we describe social exclusion in people with diabetes and assess whether diabetes can be considered as a risk factor for social exclusion. We analyzed two waves (2014, 2017, N = 6604) from a survey of community-dwelling people aged > 40 using linear regression, group comparison and generalized estimating equations to explore the association between diabetes, social exclusion, socioeconomic, physical and psychosocial variables. In the entire cohort, diabetes was cross-sectionally associated with social exclusion after adjusting for covariates (p = 0.001). In people with diabetes, social exclusion was further associated with self-esteem (p < 0.001), loneliness (p =  < 0.001), income (p = 0.017), depression (p = 0.001), physical diseases (p = 0.04), and network size (p = 0.043). Longitudinal data revealed that higher levels of social exclusion were already present before the diagnosis of diabetes, and future social exclusion was predicted by self-esteem, loneliness, depression, and income, but not by diabetes (p = .221). We conclude that diabetes is not a driver of social exclusion. Instead, both seem to co-occur as a consequence of health-related and psychosocial variables.

Effects of social support on suicide-related behaviors in patients with severe mental illness: A systematic review and meta-analysis

OBJECTIVE

Patients with severe mental illness have a high risk of suicide and frequently living eliminated from mainstream society, but the effects of social support on suicide-related behaviors among this crowd is inconclusive. The present study aimed to explore such effects among patients with severe mental illness.

METHODS

We implemented a meta-analysis and a qualitative analysis of relevant studies published before February 6, 2023. Correlation coefficients (r) and 95 % CI were selected as the effect size index in meta-analysis. Studies that did not report correlation coefficients were employed for qualitative analysis.

RESULTS

Out of 4241 identified studies, 16 were identified in this review (6 for meta-analysis, 10 for qualitative analysis). The meta-analysis presented that the pooled correlation coefficients (r) were - 0.163 (95%CI = -0.243, -0.080, P < 0.001), suggesting a negative correlation between social support and suicidal ideation. The subgroup analysis showed that this effect works in all bipolar disorder, major depression, and schizophrenia. Concerning qualitative analysis, social support presented positive effects on reducing suicidal ideation, suicide attempts, and suicide death. The effects were consistently reported in female patients. However, there existed some unaffected results in males.

LIMITATIONS

The included studies were from middle- and high-income countries and used inconsistent measurement tools, our results may have some bias.

CONCLUSIONS

The effects of social support in reducing suicide-related behaviors were positive, but it showed better effects in both female patients and adults. Males and adolescents deserve more attention. Future research needs to pay more attention to the implementation methods and effects of personalized social support.

Suicide rates among people with serious mental illness: a systematic review and meta-analysis

BACKGROUND

People with serious mental illness are at great risk of suicide, but little is known about the suicide rates among this population. We aimed to quantify the suicide rates among people with serious mental illness (bipolar disorder, major depression, or schizophrenia).

METHODS

PubMed and Web of Science were searched to identify studies published from 1 January 1975 to 10 December 2020. We assessed English-language studies for the suicide rates among people with serious mental illness. Random-effects meta-analysis was used. Changes in follow-up time and the suicide rates were presented by a locally weighted scatter-plot smoothing (LOESS) curve. Suicide rate ratio was estimated for assessments of difference in suicide rate by sex.

RESULTS

Of 5014 identified studies, 41 were included in this analysis. The pooled suicide rate was 312.8 per 100 000 person-years (95% CI 230.3-406.8). Europe was reported to have the highest pooled suicide rate of 335.2 per 100 000 person-years (95% CI 261.5-417.6). Major depression had the highest suicide rate of 534.3 per 100 000 person-years (95% CI 30.4-1448.7). There is a downward trend in suicide rate estimates over follow-up time. Excess risk of suicide in males was found [1.90 (95% CI 1.60-2.25)]. The most common suicide method was poisoning [21.9 per 100 000 person-years (95% CI 3.7-50.4)].

CONCLUSIONS

The suicide rates among people with serious mental illness were high, highlighting the requirements for increasing psychological assessment and monitoring. Further study should focus on region and age differences in suicide among this population.

Job Retention and Reintegration in People with Mental Health Problems: A Descriptive Evaluation of Supported Employment Routine Programs

PURPOSE

Striking evidence supports the effectiveness of supported employment (SE) in achieving competitive employment in individuals with mental health problems. Yet, little is known whether SE is effective to maintain employment in individuals at risk of job loss. We aimed to descriptively compare SE for employed clients (SE-retention) and unemployed clients (SE-integration) regarding competitive employment.

METHODS

We used administrative data from January 2017 to October 2021 provided by a vocational rehabilitation center in Switzerland including all individuals (≥ 18yrs.) with mental health problems who participated either in SE-retention or SE-reintegration. The outcome was the proportion with competitive employment at discharge. Logistic regression was used to assess time trends and to descriptively compare SE-treatments. We used propensity score weighting, including personal, clinical and program-specific information to reduce group differences.

RESULTS

A total of 556 participants primarily diagnosed with mood/stress-related, schizophrenia and personality disorders were included (n = 297 SE-retention, n = 259 SE-reintegration) with median age 41 years and 57% female gender. The overall weighted comparison favored SE-retention over SE-reintegration OR 4.85 (95%-CI 3.10 to 7.58, p < 0.001) with predicted employment of 67.3% and 29.9% for SE-retention and SE-reintegration, respectively. While success for SE-reintegration remained stable over time, SE-retention showed an increase in more recent years.

CONCLUSION

SE-retention provides an approach for early work-related support that can prevent labor market exclusion. In contrast, reintegration is likely to require more efforts to achieve employment and may result in less favorable outcomes. It is therefore necessary that further research includes appropriate comparison groups to evaluate the effectiveness of SE-retention programs as well as the economic and individual benefits.

COVID-19 Vaccination Prioritization Strategies in Malaysia: A Retrospective Analysis of Early Evidence

The coronavirus disease 2019 (COVID-19) that can cause extreme acute respiratory syndrome has posed a catastrophic threat to public health. The vaccines had indeed restored optimism and, after more than two years of battling the pandemic, there is renewed hope for the transition to endemicity. At the start of vaccination efforts, when supply shortages of vaccines were inevitable, every nation determined the high-risk population groups to be given priority for the COVID-19 vaccines. In this paper, the characteristics of the initial COVID-19 vaccine recipients in Malaysia are described. In line with the policies of many other countries, Malaysia firstly inoculated frontline healthcare workers, and subsequently the list of front liners grew to include defense and security personnel and those involved in the provision of essential services. People with disabilities or those with special needs and several underlying medical conditions that increased their risk of developing severe COVID-related illnesses were included in the priority categories. These included patients with severe lung disease, chronic heart disease, chronic kidney disease, chronic liver disease, neurological disease, diabetes mellitus and obesity in adults, splenic dysfunction, and severe mental illness. With little information and under circumstances of great uncertainty, the Health Ministry of a middle-income country had developed a vaccination priority-list based on the disease's epidemiology and clinical data, vaccine type, operational considerations, and risk evaluation. Early evidence was presented and suggested that the full vaccination with any of the three predominant vaccines (AZD1222, BNT162b2, and CoronaVac) in the country had been highly effective in preventing COVID-19 infections, COVID-19-related ICU admissions, and death. As many SARS-CoV-2 variants of concern (VoC), such as the Omicron BA.2/4/5, are emerging, future vaccination strategies may necessitate the need to change the immunogen of the vaccine, as well as considerations for when to give high-risk groups booster injections. These considerations are valuable for future planning by policymakers and healthcare providers to make vaccination policy and decisions, especially for the inclusion of the COVID-19 vaccines into national immunization programs.

Factors of Parental Preparation of Children with Mental Illnesses for Their Independent Living after Their Own Death

Families of children with mental illnesses are often concerned about living in the community after their parents' death. The cross-sectional study aimed to examine the association between how parents prepare adult children with mental illnesses to live independently after the death of the parent(s). The participants were 1112 members of 46 family support groups for mental illnesses in Tokyo, Japan. The age of the people with mental illness was 40s, and that of their parents was 70s. Logistic regression analysis showed that mothers' support in daily living, no income or pension for disabled people, staying at home during free time, and parental livelihood being the same as the person with mental illness were factors that were negatively associated with the independent living of people with mental illness. In contrast, parental participation in the family group and creating a system for securing regular living expenses of the person with mental illness were positively associated with independent living. The results suggest that parents need to promote their children's recovery and prepare them financially by forecasting their independent living after their own death.

COVID-19 vaccine acceptance and perceived stigma in patients with depression: a network perspective

The association between coronavirus disease (COVID-19) vaccine acceptance and perceived stigma of having a mental illness is not clear. This study examined the association between COVID-19 vaccine acceptance and perceived stigma among patients with recurrent depressive disorder (depression hereafter) using network analysis. Participants were 1149 depressed patients (842 men, 307 women) who completed survey measures of perceived stigma and COVID-19 vaccine attitudes. T-tests, chi-square tests, and Kruskal-Wallis tests were used to compare differences in demographic and clinical characteristics between depressed patients who indented to accepted vaccines and those who were hesitant. Hierarchical multiple regression analyses assessed the unique association between COVID-19 vaccine acceptance and perceived stigma, independent of depression severity. Network analysis examined item-level relations between COVID-19 vaccine acceptance and perceived stigma after controlling for depressive symptoms. Altogether, 617 depressed patients (53.7%, 95 confidence intervals (CI) %: 50.82-56.58%) reported they would accept future COVID-19 vaccination. Hierarchical multiple regression analyses indicated higher perceived stigma scores predicted lower levels of COVID-19 vaccination acceptance (β = -0.125, P < 0.001), even after controlling for depression severity. In the network model of COVID-19 vaccination acceptance and perceived stigma nodes, "Feel others avoid me because of my illness", "Feel useless", and "Feel less competent than I did before" were the most influential symptoms. Furthermore, "COVID-19 vaccination acceptance" had the strongest connections with illness stigma items reflecting social rejection or social isolation concerns ("Employers/co-workers have discriminated", "Treated with less respect than usual", "Sense of being unequal in my relationships with others"). Given that a substantial proportion of depressed patients reported hesitancy with accepting COVID-19 vaccines and experiences of mental illness stigma related to social rejection and social isolation, providers working with this group should provide interventions to reduce stigma concerns toward addressing reluctance in receiving COVID-19 vaccines.

The Potential Impact of a Public Health Approach to Improving the Physical Health of People Living with Mental Illness

With already wide disparities in physical health and life expectancy, COVID-19 presents people with mental illness with additional threats to their health: decreased access to health services, increased social isolation, and increased socio-economic disadvantage. Each of these factors has exacerbated the risk of poor health and early death for people with mental illness post-COVID-19. Unless effective primary care and preventative health responses are implemented, the physical illness epidemic for this group will increase post the COVID-19 pandemic. This perspective paper briefly reviews the literature on the impact of COVID-19 on service access, social isolation, and social disadvantage and their combined impact on physical health, particularly cancer, respiratory diseases, heart disease, smoking, and infectious diseases. The much-overlooked role of poor physical health on suicidality is also discussed. The potential impact of public health interventions is modelled based on Australian incidence data and current research on the percentage of early deaths of people living with mental illnesses that are preventable. Building on the lessons arising from services' response to COVID-19, such as the importance of ensuring access to preventive, screening, and primary care services, priority recommendations for consideration by public health practitioners and policymakers are presented.

Social integration of people with non-psychotic mental illness over the last 2 decades: the widening gap in the adult population in Belgium

PURPOSE

Social integration is poor among people with mental illness (MI). In recent decades, many countries have developed policies to address this issue. It remains unclear, however, whether their social integration has improved over time. This study aimed to assess the evolution of the social integration of adults with moderate and severe non-psychotic MI compared to the general population without MI between 1997 and 2018 in Belgium.

METHODS

Data on the general adult population were retrieved from the Belgian Health Interview Survey in six cross-sectional waves from 1997 to 2018. Three degrees of non-psychotic MI severity were compared using the 12-items General Health Questionnaire: no MI, moderate MI, and severe MI (score < 4, 4-7, and > 7). Social integration was measured using indicators relating to employment, income, social contacts, and partnership.

RESULTS

Since 1997, the probability of being unemployed, having limited social contacts, and living on less than 60% of the median national income has been increasing among people with severe non-psychotic MI. Between 1997 and 2018, social integration increased among the general population without MI and among people with moderate non-psychotic MI, but decreased among people with severe non-psychotic MI.

CONCLUSION

The gap between the social integration of people with severe non-psychotic MI and people with moderate or no MI has widened over time, despite major reforms of mental health care and policies. Policymakers and clinical practitioners should pay more attention to supporting the social integration of people with more severe MI, particularly in relation to employability and social support.

Deinstitutionalization from the perspective of community-dwelling adults with a severe mental illness in Amsterdam: a cohort study protocol

Background

People with a severe mental illness (SMI) increasingly receive ambulatory forms of care and support. The trend of deinstitutionalization accelerated in the Netherlands from 2008 and onwards without sufficient understanding of its consequences. The study protocol herein focuses on deinstitutionalization from the perspective of adults with an SMI living within the community in Amsterdam and aims at delivering better insight into, amongst others, their recovery, quality of life, societal participation and needs for care and support.

Methods

A cohort design will be used. A representative sample of community-dwelling adults with an SMI, including those in care (n = 650) and not in care (n = 150), will be followed over time. During a two-year time period, participants will be interviewed twice using a wide-ranging set of validated instruments. Interview data will be matched with administrative data about the care process, as retrieved from their patient files. Primary outcomes are changes over time in recovery, societal participation and quality of life, controlled for the occurrence of adverse life-events during follow-up. Additionally, prevalence estimates of and associations between social functioning, safety and discrimination, substance use and health indicators will be investigated.

Discussion

The study protocol aims at delivering a comprehensive insight into the needs of community-dwelling adults with an SMI based on which ambulatory care and support can best be provided to optimally promote their social recovery and well-being.

COVID-19 hospitalisation, mortality, vaccination, and postvaccination trends among people with schizophrenia in Israel: a longitudinal cohort study

BACKGROUND

Individuals with schizophrenia have an increased risk of severe COVID-19 outcomes, nonetheless, no previous study has provided a year-long account of this risk, or assessed postvaccination trends in this population. This study assessed temporal trends in COVID-19 hospitalisation and mortality among people with schizophrenia during the first year of the pandemic, the predictors for COVID-19 vaccination, postvaccination infection, admission to hospital, and mortality.

METHODS

In this longitudinal cohort study, people with schizophrenia (n=25 539) and controls (n=25 539) were assessed for COVID-19 outcomes before and after vaccination, up to April 30, 2021. Cox proportional hazard regression models and Kaplan-Meier analyses were done to assess longitudinal trends. The study used the databases of Clalit Health Services, the largest health-care organisation in Israel.

FINDINGS

The sample included 51 078 participants, of which 31 141 (61·0%) male and 19 937 (39·0%) female participants, with a mean age of 51·94 years (SD 15·62). Most of the sample was from the general Jewish population (75·9%), followed by the Arab (19·1%) and Jewish Ultraorthodox population (5·1%). Overall of 51 078 individuals, 356 (0·7%) people had been hospitalised, 133 (0·3%) had died, and a total of 27 400 (53·6%) had been vaccinated. People with schizophrenia showed a higher risk for COVID-19 hospitalisation (HR 4·81, 95% CI 3·57-6·48, p<0·0001) and mortality (HR 2·52, 95% CI 1·64-3·85, p<0·0001), and showed a sharper decline in survival as time progressed. The control group showed a sharper incline in probability to vaccinate (log-rank=309·88, p<0·0001). Medical comorbidity of diabetes, hypertension, obesity, or ischaemic heart disease played a significant role in predicting vaccination rates in the schizophrenia group (all p<0·0001), but not in the control group. Hospitalisation and mortality disparities remained higher among people with schizophrenia who had not been vaccinated in comparison to controls (incidence rate difference of 6·2 and 3·2, respectively) but substantially declined in fully vaccinated groups (incidence rate difference of 1·1 and -0·9, respectively).

INTERPRETATION

People with schizophrenia have higher hospitalisation and mortality risk, yet have lower rates of vaccination than in the general population. Disparities in COVID-19 severe outcomes can be substantially reduced by national vaccination plans aimed at actively reaching out to people with schizophrenia.

FUNDING

No funding.

Social Processes Associated With Health and Health Behaviors Linked to Early Mortality in People With a Diagnosis of a Serious Mental Illness

Individuals with serious mental illness (SMI) experience a 10- to 25-year reduced life expectancy compared with the general population. Early mortality for people with SMI has mainly been attributed to unhealthy behaviors (e.g., poor diet, sedentary lifestyle), which has led to the development of health promotion and self-management interventions specifically for people with SMI to promote health behavior change. Yet after decades of research, the mortality gap between people with SMI and the general population is increasing. To address this early mortality disparity for individuals with SMI, a new paradigm must be explored. In this article, we present the social processes impacting early mortality in people with SMI paradigm, which highlights the powerful role of social processes in shaping the health and health behaviors of people with SMI. This paradigm explores how loneliness, stigma (social and self), trauma, social exclusion, social isolation, and social norms are related to early mortality in people with SMI. This new paradigm is an important step in understanding and potentially addressing early mortality in people with SMI.

COVID-19 vaccination for people with severe mental illness: why, what, and how?

Psychiatric disorders, and especially severe mental illness, are associated with an increased risk of severe acute respiratory syndrome coronavirus 2 infection and COVID-19-related morbidity and mortality. People with severe mental illness should therefore be prioritised in vaccine allocation strategies. Here, we discuss the risk for worse COVID-19 outcomes in this vulnerable group, the effect of severe mental illness and psychotropic medications on vaccination response, the attitudes of people with severe mental illness towards vaccination, and, the potential barriers to, and possible solutions for, an efficient vaccination programme in this population.

Poverty transitions in severe mental illness: longitudinal analysis of social drift in China, 1994-2015

BACKGROUND

Although poverty associated with severe mental illness (SMI) has been documented in many studies, little long-term evidence of social drift exists. This study aimed to unravel the poverty transitions among persons with SMI in a fast change community in China.

METHODS

Two mental health surveys, using the International Classification of Disease (ICD-10), were conducted in the same six townships of Xinjin county, Chengdu, China in 1994 and 2015. A total of 308 persons with SMI identified in 1994 were followed up in 2015. The profiles of poverty transitions were identified and regression modelling methods were applied to determine the predictive factors of poverty transitions.

RESULTS

The poverty rate of persons with SMI increased from 39.9% to 49.4% in 1994 and 2015. A larger proportion of them had fallen into poverty (27.3%) rather than moved out of it (17.8%). Those persons with SMI who had lost work ability, had physical illness and more severe mental disabilities in 1994, as well as those who had experienced negative changes on these factors were more likely to live in persistent poverty or fall into poverty. Higher education level and medical treatment were major protective factors of falling into poverty.

CONCLUSIONS

This study shows long-term evidence on the social drift of persons with SMI during the period of rapid social development in China. Further targeted poverty alleviation interventions should be crucial for improving treatment and mental recovery and alleviating poverty related to SMI.

"The biggest barrier is to inclusion itself": the experience of citizenship for adults with mental health problems

BACKGROUND

Citizenship has been promoted within mental health for several decades however, its application in the field of mental health policy and practice is relatively novel. The voices of people who experience mental health problems (MHPs) are often absent in ongoing discourses about citizenship.

AIMS

To explore how adults with experience of MHPs and other life disruptions identify potential barriers to citizenship.

METHOD

A community based participatory research approach was adopted with peer researchers. Six focus groups (N = 40) using semi-structured interviews were conducted, consisting of participants who had experience of MHPs and other life disruption(s) within the last 5 years. The focus groups were audio recorded, transcribed verbatim and analysed in NVIVO using a thematic approach.

RESULTS

Three major themes associated with participants lived experiences of barriers to citizenship were identified: 'stigmatisation (internal & external) creates further divide'; 'being socially excluded leads to isolation'; and 'a sense of difference (as perceived by the self and others)'.

CONCLUSIONS

Those who have experienced major life disruption(s) face multi-level barriers to citizenship. An awareness of such barriers has important implications for mental health research, policy and practice. Citizenship-oriented implementation strategies that aim to address multi-level barriers merit further investigation.

Independent Housing and Support for non-homeless individuals with severe mental illness: randomised controlled trial vs. observational study - study protocol

BACKGROUND

Social inclusion is essential for an adequate rehabilitation process for people with serious mental illness (SMI). Various supported housing settings aim to promote housing competencies and social inclusion in service users. Nevertheless, there is a strong preference in service users for independent living. We aim to evaluate the effectiveness and efficiency of Independent Housing and Support (IHS) compared to institutionalised residential care settings and other treatment as usual conditions (RCS/TAU) in two cities in Switzerland.

METHODS

This is a prospective multi-centre, four-arm, non-inferiority cohort study investigating the effectiveness and efficiency of IHS and RCS/TAU for people with SMI. Effectiveness will be measured by a standardised measure of social inclusion as primary outcome as well as by measures of functioning and well-being. Efficiency will be analysed on the basis of service usage and costs associated with the different housing settings. Participants will be consecutively recruited and subsequently enrolled between April 2019 and December 2020 and assessed at baseline and after six, twelve and after 24 months. At one study site, 56 participants will be randomly assigned to one of the conditions; the other study site will be conducted as an observational study investigating 112 admitted participants.

DISCUSSION

While the UN Convention of the Rights of People with Disabilities aims to promote the opportunity to choose one's place of residence, the limited supply of alternative forms of housing does not guarantee genuine freedom of choice. Increased diversification and flexibility of housing support is essential. If IHS shows non-inferiority in terms of their effectiveness and efficiency, users should be allowed to choose their kind of housing support.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03815604, December 04, 2019.

IPS in Supported Housing: Fidelity and Employment Outcomes Over a 4 Year Period

Background: People with severe mental illness have difficulties finding and maintaining competitive employment. This is particularly so for those living in supported housing who, by definition, have significant day-to-day support needs: in the Netherlands only 3 to 5% of people with serious mental health problems who live in supported housing are competitively employed. To support these people in finding and maintaining competitive employment, Individual Placement, and Support (IPS) was introduced within supported housing services in the Netherlands in 2015. As this is the first country that broadly implemented IPS in supported housing settings, this paper will focus on the first results regarding feasibility and effects on employment in clients of IPS in this sector. Methods: We investigated the feasibility and employment outcomes of delivering IPS in supported housing services using fidelity assessments and quarterly employment outcomes on IPS program level within eight supported housing organizations, and compared these with 21 mental health treatment organizations in the Netherlands over a 4 year period. We investigated possible reasons for our findings and their implications through qualitative evaluations of the IPS fidelity assessors' notes and additional focus groups with IPS specialists and coordinators from supported housing services and fidelity assessors. Results: The overall fidelity scores indicated reasonable implementation of the IPS model within both supported housing services and mental health services. However, there were differences between services with regard to specific fidelity items; mental health treatment organizations scored higher for team integration, whereas supported housing services scored higher for rapid job search and caseload size, diversity of jobs, and employers. Our qualitative data suggested that the difference in team integration between the two sectors was due to differences in their organizational and financial structures, as well as in the specific needs of their clients. Conversely, supported housing services had better connections with employers which facilitated more rapid job searching and greater diversity in employment opportunities. The average total client employment rate did not significantly differ; and was 25.8% per quarter in supported housing services and 29.6% in mental health treatment services. Conclusion: Implementing IPS in supported housing settings is both feasible and effective.

Mental Health Related Stigma as a 'Wicked Problem': The Need to Address Stigma and Consider the Consequences

Recent reviews on the evidence base for mental health related stigma reduction show that under certain conditions interpersonal contact is effective in promoting more positive attitudes, reduced desire for social distance, and increased stigma related knowledge (knowledge which disconfirms beliefs based on stereotypes). Short-term interventions may have effects that are attenuated over time; longer term programmes may support sustained improvements, but research following up long-term interventions is scarce. However, the effectiveness of these interventions should not obscure the nature of stigma as a social problem. In this article we describe stigma as a 'wicked problem' to highlight some implications for intervening against stigma and evaluating these efforts. These include the risks of unintended consequences and the need to continually reformulate the concept of stigma, to ensure that tackling stigma at the structural, interpersonal, and intrapersonal levels become part of the core business of stakeholder organisations. We compare the main targets of anti-stigma programmes with what is known about the sources of stigma and discrimination and their impacts to identify targets for future intervention. In some cases, interventions have been directed at the interpersonal level when structural level intervention is also needed; in others, systematic reviews have not so far identified any interventions.