Accessing acute medical care to protect health: the utility of community treatment orders

Assessing the effectiveness of internet-based interventions for mental health outcomes: an umbrella review

Internet-based interventions (IBIs) for behavioural health have been prevalent for over two decades, and a growing proportion of individuals with mental health concerns prefer these emerging digital alternatives. However, the effectiveness and acceptability of IBIs for various mental health disorders continue to be subject to scholarly debate. We performed an umbrella review of meta-analyses (MAs), conducting literature searches in PubMed, Web of Science, Embase, Cochrane and Ovid Medline from their inception to 17 January 2023. A total of 87 MAs, reporting on 1683 randomised controlled trials and 295 589 patients, were included. The results indicated that IBIs had a moderate effect on anxiety disorder (standardised mean difference (SMD)=0.53, 95% CI 0.44 to 0.62) and post-traumatic stress disorder (PTSD) (SMD=0.63, 95% CI 0.38 to 0.89). In contrast, the efficacy on depression (SMD=0.45, 95% CI 0.39 to 0.52), addiction (SMD=0.23, 95% CI 0.16 to 0.31), suicidal ideation (SMD=0.23, 95% CI 0.16 to 0.30), stress (SMD=0.41, 95% CI 0.33 to 0.48) and obsessive-compulsive disorder (SMD=0.47, 95% CI 0.22 to 0.73) was relatively small. However, no significant effects were observed for personality disorders (SMD=0.07, 95% CI -0.13 to 0.26). Our findings suggest a significant association between IBIs and improved mental health outcomes, with particular effectiveness noted in treating anxiety disorders and PTSD. However, it is noteworthy that the effectiveness of IBIs was impacted by high dropout rates during treatment. Furthermore, our results indicated that guided IBIs proved to be more effective than unguided ones, playing a positive role in reducing dropout rates and enhancing patient adherence rates. PROSPERO registration number: CRD42023417366.

Quality of life for people with psychiatric disabilities employed in extended employment programs in two Arab towns in Israel: an exploratory study

Introduction

This study aims to examine the quality of life (QOL) for people with psychiatric disabilities who are engaged in extended employment programs (homogeneous versus heterogeneous) in the Arab-populated Triangle Area of Israel. The homogeneous program participants are exclusively Arab while the heterogeneous program includes both Arabs and Jews.

Methods

Quantitative research study of 104 adults with psychiatric disabilities engaged in two communal extended employment programs. Participants completed demographic (age (years), gender, marital status (married, widowed/separated, married, single), religion (Muslim, Jewish, Christian), dichotomous nationality variable (Jewish/Arab), and years of education) and employment questionnaires (length of time in the employment program, number of working days/h and salary satisfaction); SF 12 Scale; and The Personal Wellbeing Index questionnaire. Two-sample T-Test, exploratory factor analysis and multiple linear regressions were conducted for tracking the differences between participants in homogeneous and heterogeneous programs.

Results

A significant difference was found between the programs in two QOL components, insofar as satisfaction with the standard of living, together with health satisfaction were rated higher for participants in the heterogeneous program than for their homogeneous program counterparts. Furthermore, the results indicate that physical health and gender were the most important variables in explaining QOL in both programs, while the employment variables were not significant.

Discussion

Since the research findings show that the employment-related-items aren't significant in predicting the employees' QOL, the definition and suitability of extended employment environments as a mental health service must be reexamined. Cultural elements may also have an impact on QOL when the programs are located in a traditional town, with gender playing a key role. The family's role is pivotal in traditional societies, influencing an individual's ability to participate in employment programs and the support they receive. In patriarchal societies, there can be added pressure on men with psychiatric disabilities to conform to societal expectations. Given the general lack of health awareness in Arab communities, there is a need to develop additional projects or incorporate physical health improvement as a rehabilitation goal when working with individuals with psychiatric disabilities, regardless of the type of community rehabilitation program.

Crime and victimization outcomes following civil rights limits to the use of compulsory treatment

Community treatment orders (CTOs) have been associated with reduced crime/victimization-risk. Australia's ratification of the U.N. Convention on the Rights of Persons with Disabilities (CRPD) enabled patient-rights-advocacy to limit CTO-assignment to persons lacking decision-making-capacity. This effort was accompanied by a 15% reduction in CTO-utilization. Has this change affected crime/victimization-involvements of patients with schizophrenia-diagnoses? In Victoria Australia, the study considers crime/victimization-involvement among three patient-groups recruited with the same sampling-algorithm in the decade before (2000-2009, N = 14,711) and after (2010-2019, N = 10,702) CRPD-ratification. Each group is its own-control. Each group's positive-outcome across decades would be "no increase" in crime/victimization-involvement or in the ratio of the group's incident-rates to the State's. Following CRPD-ratification, first-hospitalized-patients with at least one CTO-assignment doubled their involvement in major crime-perpetrations (from 13% to 27%), non-CTO-hospitalized-patients almost doubled (from 10% to 18%), and 11% of outpatients were involved when none were before. Overall, a third (34%) were victimized-by-major-crime up from 28%, with 25% of outpatients experiencing victimization when none had before. Increases were most evident in major-crimes, led by assaults/abductions. Capacity-constraints on compulsory-treatment are associated with increases in crime/victimization-involvement, a transfer of responsibility for patients with schizophrenia-diagnoses from the mental-health-system to the criminal-justice-system, validation of dangerousness stereotypes, and growing negative family impact.

Mortality-Risk With "Capacity" Constraints On Community Treatment Order Utilization

BACKGROUND

Assignment to a community treatment order (CTO) has been associated with reduced mortality risk. In Victoria Australia civil-rights enhancements involving capacity to refuse involuntary treatment have contributed to a 15% reduction between 2010 and 2019 in CTO assignments among first hospitalized patients with Schizophrenia diagnoses. Has this change impacted patient mortality risk?

STUDY DESIGN

This study considered mortality-risk between 2010 and 2019 for 3 patient groups with schizophrenia diagnoses: All 4848 hospitalized patients who were assigned to a CTO for the first time in the period; 3988 matched and randomly selected patients, who were first hospitalized in the decade, without CTO assignment; and 1675 never hospitalized or CTO-assigned outpatients. Deaths of Schizophrenic patients in each group were evaluated against expected deaths given standardized mortality ratios for Victoria. Logistic regression was used to evaluate mortality risk for each treatment group while taking account of race, demographics, differential access to initial diagnoses of life-threatening physical illness, mental health service resources, and indicators of social disadvantage.

STUDY RESULTS

A total of 78% of the 777 deaths of schizophrenia patients in all 3 groups were premature. The 2 hospitalized groups did not differ in mortality risk. Among Victoria's 2010-2019 outpatients (inclusive of treatment refusers with a recorded service contact), 16.2% had a Schizophrenia diagnosis-up from 0.2% in 2000-2009, the prior decade. Outpatients with Schizophrenia were at 48% greater risk of death than individuals in the hospitalized groups, taking all the afore mentioned risk factors into account.

CONCLUSIONS

Reductions in CTO utilization associated with potential treatment refusals of involuntary community-treatment supervision, seem to have increased mortality risk for this vulnerable population. The line between civil-rights protection and abandonment has been blurred.