Assault experiences of 100 psychiatric inpatients: evidence of the need for routine inquiry

Health Care Costs of Individuals With Chronic Psychotic Disorders Who Experience Incarceration in Ontario

OBJECTIVE

Little is known about the health care costs of individuals with chronic psychotic disorders who experience incarceration. This study sought to address this knowledge gap.

METHODS

The authors analyzed linked 2007-2010 correctional and administrative health care data on sex- and age-matched individuals with chronic psychotic disorders with and without known incarceration in prison for up to 2 years in the Ontario correctional system. Mean 1-year health care costs (overall and by sex) in the year before incarceration (when release occurred in 2010) were estimated from third-party payer data and compared between the two groups. Costs were calculated in 2018 Canadian dollars.

RESULTS

Individuals who experienced incarceration (N=3,197) had mean 1-year costs of $15,728 in the year before incarceration, whereas those who did not (N=6,393) had 1-year costs of $11,588. This difference was mostly due to costs arising from psychiatric hospitalizations, emergency department visits, and physician services. The main factors associated with the difference were incarceration in the following year (increase of $4,827, p<0.001), being age 18-29 years compared with ages 30-39 or 40-49 (increase of $4,448 and $4,218, respectively, p<0.001), and chronic psychotic disorder duration of 1-2 years compared with ≤1 year duration (increase of $6,812, p=0.004). Women who experienced incarceration had higher costs than incarcerated men ($20,648 vs. $14,763).

CONCLUSIONS

Individuals with chronic psychotic disorders who experienced incarceration had higher health care costs than comparable individuals who did not. These higher health care costs may signal the need for interventions and policies that help individuals with psychotic disorders avoid criminal justice system involvement.

Posttraumatic stress disorder in outpatients with depression: Still a missed diagnosis

Comorbidity between major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) is a well-established fact but has been studied little among MDD patients and even less among outpatients. We assessed the prevalence and characteristics of comorbid MDD-PTSD patients in a sample of MDD outpatients in an effort to elucidate possible causes of MDD-PTSD comorbidity. A semistructured clinical interview was applied to 101 outpatients with MDD. Sociodemographic factors, psychiatric history, the presence of PTSD, and MDD-PTSD comorbidity were recorded. The prevalence of MDD-PTSD comorbidity was 38.6%, with 26.7% suffering currently from PTSD. The average duration of PTSD was 16 years, and in most cases (79.5%) PTSD started earlier than or simultaneously with MDD. Only 28.8% of patients with PTSD had a documented diagnosis in their medical record. The most significant factors predicting MDD-PTSD comorbidity were found to be chronic depression, a history of prolonged or repeated trauma, male gender, a younger age at onset of psychological symptoms, lower education, and a lower level of functioning. Our findings indicate that MDD-PTSD comorbidity still remains an overlooked fact. Prolonged trauma seems to be a major risk factor for MDD-PTSD comorbidity, predisposing subjects to PTSD and later on or simultaneously to comorbidity with MDD.

Early-Life Trauma in Hospitalized Patients With Mood Disorders and Its Association With Clinical Outcomes

BACKGROUND

The prevalence of childhood trauma and its impact on clinical outcomes in hospitalized patients with mood disorders is unknown. We studied the frequency of childhood trauma among inpatient adults with mood disorders and its association with clinical outcomes.

METHODS

Patients admitted to our hospital with a primary diagnosis of mood disorders completed the short form of the Early Trauma Inventory-Self-Report (ETISR-SF), the Sheehan Disability Scale, and the Clinician-Rated Dimensions of Psychosis Symptom Severity scale. A regression model adjusted for multiple comparisons was used to examine the association between scores on the ETISR-SF and clinical outcomes.

RESULTS

Subjects were 167 patients, all of whom reported ≥1 types of childhood trauma: 90% general trauma, 75% physical abuse, 71% emotional abuse, 50% sexual abuse, and 35% all 4 types of abuse. The subtypes of abuse did not differ by sex or race. Diagnoses in the sample were bipolar disorder 56%, major depressive disorder 24%, schizoaffective disorder 14%, and substance-induced mood disorder 5%. The mean age in the sample was 35±11.5 years, 53% were male, and 64% also had substance abuse disorders. Higher scores on the ETISR-SF were associated with longer hospital stays [odds ratio (OR)=1.13; 95% confidence interval (CI), 1.05-1.22], and greater disruption of work/school life (OR=1.12; 95% CI, 1.04-1.21). There was also a trend for higher ETISR-SF scores to be associated with more severe psychotic symptoms (OR=1.13; 95% CI, 1.01-1.27) and more disruption in social (OR=1.14; 95% CI, 1.06-1.22) and family life (OR=1.09; 95% CI, 1.02-1.17).

CONCLUSION

Childhood trauma was reported by all of the 167 patients, with general trauma the most common and approximately half reporting sexual abuse. Childhood trauma was associated with poor clinical outcomes. Early recognition of trauma and trauma-related therapeutic interventions may improve outcomes.

Sex-Related Differences in Health and Illness

Mortality and morbidity statistics which reflect the major health disorders in the nation have changed dramatically in this century. Infectious diseases have been largely controlled, and this country's citizens are now burdened with the chronic and disabling disorders of an aging population that are increasingly linked to environmental and behavioral factors. This article documents gender and sex differences among the major life-threatening disorders and chronic health problems and suggests implications for psychology as a health science and profession.

The Relationship between Interviewer Characteristics and Physical and Sexual Abuse Disclosures among Substance Users: A Multilevel Analysis

Data were collected at assessment for substance abuse treatment from 22 interviewers and 8,276 clients to assess the relationship between interviewer characteristics and disclosure of physical and sexual abuse. Characteristics examined were client and interviewer gender, race/ethnicity, and age. Multilevel regressions that adjusted for the clustering of clients within interviewers were compared to unadjusted logistic regressions to determine the effect of response similarity within clusters. Clustering accounted for only 2–5% of the unexplained variance; however, ignoring the clustering effect generated several misleading results. Adjusted models indicated that clients were more likely to disclose physical abuse to Caucasian interviewers than to African American interviewers and more likely to disclose sexual abuse to female interviewers than to male interviewers. Matching clients and interviewers on gender, race, and age did not increase disclosures of either physical or sexual abuse.

Family Violence As a Cause of Crime: Rethinking Our Priorities

Although we have known for some time that the victims of child abuse are more likely to grow up to be delinquent and more recently that even the bystanders to family violence have similar tendencies, there has been little attention paid to this fact in criminal justice policy making. Since these victims grow up to become the next generation's offenders, both inside the home and outside the home, there is good reason to develop policies based on a recognition that crime prevention policy requires immediate attention to the problems of woman abuse and child abuse.

Violence and Women With Disabilities

Women with disabilities typically occupy positions of extreme marginalization and exclusion that make them more vulnerable to violence and abuse than other women. There is a profound silence around the lived experiences of many women with disabilities that has meant that the violence in their lives is largely invisible and unknown. Further, many of our social practices involving women with disabilities appear to be based on contradictory assumptions that give rise to a series of paradoxes. Practices such as overprotection, segregation, the training of women with disabilities to comply with requests from staff, and a prevailing view that women with disabilities are simultaneously asexual and promiscuous all increase the incidence of abuse and violence rather than prevent it. This article examines experiences of a number of Australian women with disabilities, their mothers and other women who work with them, and official reports of several Australian inquiries into violence.

Assisting Women Victims of Violence Who Experience Multiple Barriers to Services

This study examines the extent to which programs for domestic violence and sexual assault gear services toward women facing multiple barriers (i.e., substance abuse disorders, mental health problems or learning disabilities, incarceration, and prostitution) and the unique problems such women encounter when accessing services. As part of a national evaluation, the authors interviewed staff from 20 programs focusing their service efforts on multibarriered women. Problems encountered by such women include lack of services dealing with multiple barriers, uneducated service providers, and batterers using women's barriers to further control or victimize them. This article describes the strategies programs use to meet these women's distinct needs.

Prevalence of abuse in mentally ill patients visiting outpatient setting in a tertiary care hospital in India

AIM

In a developing country such as India, the abuse of patients suffering from psychiatric disorders has been underreported. The aim of this study was to detect abuse in chronically ill psychiatric patients visiting a psychiatric outpatient setting in a tertiary care hospital in Delhi, India.

MATERIAL AND METHODS

A cross-sectional descriptive written survey was carried out on 406 patients. A self-administered questionnaire for patient abuse was developed in Hindi based on the World Health Organization's Domestic Violence Questionnaire that encompassed questions regarding physical, emotional and sexual abuse.

RESULTS

Of the 406 patients, 294 (72%) suffered from abuse, with 64% experiencing emotional abuse, 39% physical abuse and 21% sexual abuse. In chronically ill psychiatric patients, a significant association was found between education and abuse, with most abuse occurring among senior secondary pass outs (i.e. 11-12 years of education) and least among junior high school pass outs (6-8 years of education). A majority (74%) of these patients lived in urban areas (p = .020). A significant association was also found between abuse and the psychiatric diagnosis of the patient, with 53% suffering from depression, 66% anxiety disorder, 81% bipolar disorder, 94% psychotic disorder, 86% obsessive compulsive disorder, 44% sexual disorder and 12% other psychiatric disorders.

CONCLUSIONS

There is a need to create awareness in society in order to prevent abuse. Screening for abuse in routine psychiatric practice is of utmost importance so that timely interventions can be given, thereby preventing its deleterious health consequences.

Accessibility and Responsiveness Review Tool: community agency capacity to respond to survivors with disabilities

For persons with disabilities who have experienced trauma in the forms of abuse and violence, options for accessible and trauma-informed services are often limited. Using a self-assessment and planning process, disability service providers and victim/survivor service providers are able to strategize ways of addressing the needs of survivors with disabilities. The Accessibility and Responsiveness Review Tool (Review Tool) incorporates the principles of universal design and trauma-informed practices into an agency-wide discussion tool leading to increases in knowledge, reduction in barriers, and overall improved programs for survivors with disabilities. Results of agencies that participated in the Review Tool process are presented.

Comorbidity of PTSD in anxiety and depressive disorders: prevalence and shared risk factors

The present study aims to assess comorbidity of posttraumatic stress disorder (PTSD) in anxiety and depressive disorders and to determine whether childhood trauma types and other putative independent risk factors for comorbid PTSD are unique to PTSD or shared with anxiety and depressive disorders. The sample of 2402 adults aged 18-65 included healthy controls, persons with a prior history of affective disorders, and persons with a current affective disorder. These individuals were assessed at baseline (T0) and 2 (T2) and 4 years (T4) later. At each wave, DSM-IV-TR based anxiety and depressive disorder, neuroticism, extraversion, and symptom severity were assessed. Childhood trauma was measured at T0 with an interview and at T4 with a questionnaire, and PTSD was measured with a standardized interview at T4. Prevalence of 5-year recency PTSD among anxiety and depressive disorders was 9.2%, and comorbidity, in particular with major depression, was high (84.4%). Comorbidity was associated with female gender, all types of childhood trauma, neuroticism, (low) extraversion, and symptom severity. Multivariable significant risk factors (i.e., female gender and child sexual and physical abuse) were shared among anxiety and depressive disorders. Our results support a shared vulnerability model for comorbidity of anxiety and depressive disorders with PTSD. Routine assessment of PTSD in patients with anxiety and depressive disorders seems warranted.

The Effect of Violence on the Diagnoses and the Course of Illness Among Female Psychiatric Inpatients

INTRODUCTION

The aim of the study was to determine the rate of exposure to domestic violence among female inpatients at any period of their lives; to investigate the effect of different forms of violence on the diagnoses and the course of the illness.

METHOD

The study was conducted on 102 female inpatients treated at Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) was administered and socio-demographic and clinical data was collected. A form designed for the assessment of violence was used to evaluate domestic violence.

RESULTS

Ninety patients reported that they had been subjected to some kind of violence at some period of their lives. The parents or husbands were the most frequently reported persecutors. Seventy-three patients reported that they had been subjected to violence before the onset of their illness. Seventy-one had been subjected to physical, 79 to verbal, 42 to sexual, 52 to economic violence, and 49 to constraints on social relationship formation. Comorbid diagnosis of post traumatic stress disorder (PTSD) was related to all types of violence. The rate of suicide attempt was found to be significantly related to verbal-emotional violence. Only 12 patients had previously reported being subjected to domestic violence to their psychiatrist.

CONCLUSION

Domestic violence, an often overlooked phenomenon, is prevalent among women with psychiatric disorders. Subjection to domestic violence is found to be correlated with PTSD and suicidal attempt.

Victimization of the severely mentally ill in Greece: the extent of the problem

BACKGROUND

In contrast to extensive research on psychiatric patients' dangerousness, very few studies have examined their victimization.

AIM

The aim of our study is to record reported victimization of seriously mentally ill outpatients in Greece and compare them with healthy controls.

METHOD

We interviewed 150 severely mentally ill outpatients and a matched group of healthy controls using a semi-structured interview. This recorded incidents of victimization and perceived discrimination during the previous year. Logistic regression models were used to examine the influence of demographic parameters on both victimization and discrimination.

RESULTS

In this study 59.3% of patients and 46.0 % of controls (p = .02) reported being victims of a criminal act at least once and 52.0% of patients and 24.0 % of controls (p < .001) reported experiencing discrimination during the previous year. Patients, in comparison to controls, were more likely to report being victims of any kind of victimization (OR = 1.85, 95% CI = 1.07-3.21), of assault/threat (OR = 4.62, 95% CI = (2.32-9.19) and of discrimination (OR = 3.34, 95% CI = (2.1-5.62). In addition, patients reported experiencing higher distress in assault/threat crime compared to controls (p = .03).

CONCLUSIONS

Patients with serious mental illness are more likely than the general population to report being victims of criminal acts and experiencing discrimination.

Positive affect, childhood adversity, and psychopathology in psychiatric inpatients

BACKGROUND

Low positive affect is closely related to common pathological responses to childhood adversity, including posttraumatic stress disorder (PTSD) and depression, but little is known about how the characteristics of early adversity experiences might be related to positive affect in adulthood.

OBJECTIVE

This study aimed to explore whether low positive affect is related to specific childhood adversities, including abuse, neglect, caretaker dysfunction, and low childhood social support.

METHOD

Using structured interviews and self-report measure data collected from 173 adult psychiatric inpatients, this study examined the relationship between positive affect and symptoms of psychopathology, as well as how the number of types of abuse experienced, severity of adversity types (physical abuse and sexual abuse), childhood environment (childhood social support, neglect, and caretaker dysfunction), and number of non-abuse traumas related to positive affect.

RESULTS

Positive affect was significantly negatively related to several symptoms of psychopathology, including depression, dissociation, self-destructive behavior, PTSD, and global psychopathology. Individuals who experienced both physical and sexual abuse reported significantly less positive affect than those with only physical or no abuse experiences. Lower positive affect was predicted by lower childhood social support and greater severity of sexual abuse, with both factors accounting for unique variance in positive affect.

CONCLUSION

These results suggest that individuals who experience multiple types of early adversity, more severe sexual abuse experiences, and less social support are at risk of psychological difficulties. Given the relatively strong association between positive affect and childhood social support, interventions to foster social support may be a means of increasing positive affect among individuals exposed to childhood adversity.

Development and initial validation of the Structured Interview for Self-Destructive Behaviors

This article describes the initial validation of the Structured Interview for Self-Destructive Behaviors (SI-SDB), a brief interview assessing suicidality, self-injury, substance abuse, disordered eating, and risky sexual behaviors. Self-destructive behaviors present clinical and practical challenges for mental health treatment providers. Participants were 217 psychiatric inpatients with a wide variety of diagnoses who completed the SI-SDB and other measures of psychiatric symptoms, trauma exposure, and other childhood experiences. Internal validity analyses revealed an internally consistent measure with 2 major factors. External validity analyses indicated that the Substance Abuse and Disordered Eating scales were predictive of related psychiatric diagnoses. All scales except Substance Abuse were significantly correlated with psychiatric symptoms and childhood abuse. These findings indicate that the SI-SDB is a valid means of assessing 5 significant domains of dangerous behaviors in clinical and research settings. Further research on the reliability of reports over time, interrater consistency, and convergent validity with longer measures of the SI-SDB domains is needed.

Posttraumatic stress disorder comorbidity and clinical implications in patients with severe mental illness

Traumatic experiences and posttraumatic stress disorder (PTSD) are more frequent in patients with serious mental illness than in the general population. This study included 102 patients with schizophrenia, bipolar disorder, and schizoaffective disorder, according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. Epidemiological and clinical data were collected using the Brief Psychiatric Rating Scale and Traumatic Life Events and Distressing Event questionnaires. We found a high number of traumatic experiences, and 15.1% of the patients met all criteria for PTSD. We found no differences based on diagnosis or sex, although there was a nonsignificant trend toward greater PTSD comorbidity in women. Among patients with serious mental illness and PTSD, 64.3% had made some attempt at suicide at some point in life, compared with 37.4% of patients without PTSD.

Predicting long-term outcomes for women physically abused in childhood: contribution of abuse severity versus family environment

OBJECTIVE

Child physical abuse (CPA) has been associated with adverse adult psychosocial outcomes, although some reports describe minimal long-term effects. The search for the explanation for heterogeneous outcomes in women with CPA has led to an examination of a range of CPA-related factors, from the severity of CPA incidents to the childhood family environment. This study compares several models for predicting adult outcomes: a multidimensional CPA severity scale, the presence or absence of CPA, family environment, and childhood stresses.

METHODS

The effect of CPA on adult outcomes was examined among 290 community-dwelling women raised in 2-parent families. Standardized measures and a focused interview were used to collect data, with siblings as collateral informants.

RESULTS

Comparison of a multidimensional CPA severity scale to a dichotomous measure of the presence or absence of CPA showed that the severity scale did not have greater predictive value for adult outcomes than the dichotomous measure. Childhood family environment scales considerably attenuated the predictive value of the dichotomous measure of CPA, exerting a greater mediating effect on outcomes than did childhood stresses.

CONCLUSIONS

The specific characteristics of a CPA experience may be less important than the occurrence of CPA and the woman's childhood family environment for predicting long-term psychosocial outcomes.

PRACTICE IMPLICATIONS

The presence of child physical abuse is substantial and continues to increase, but the clinical significance of abuse on adult outcomes is unclear. The findings of the current study lend credence to the idea that family stresses and resources other than CPA may be crucial in understanding long-term effects in women. Hence treatment and support for victims of CPA might benefit from clinicians' exploration of the family environment.

Involvement in the US criminal justice system and cost implications for persons treated for schizophrenia

BACKGROUND

Individuals with schizophrenia may have a higher risk of encounters with the criminal justice system than the general population, but there are limited data on such encounters and their attendant costs. This study assessed the prevalence of encounters with the criminal justice system, encounter types, and the estimated cost attributable to these encounters in the one-year treatment of persons with schizophrenia.

METHODS

This post-hoc analysis used data from a prospective one-year cost-effectiveness study of persons treated with antipsychotics for schizophrenia and related disorders in the United States. Criminal justice system involvement was assessed using the Schizophrenia Patients Outcome Research Team (PORT) client survey and the victimization subscale of the Lehman Quality of Life Interview (QOLI). Direct cost of criminal justice system involvement was estimated using previously reported costs per type of encounter. Patients with and without involvement were compared on baseline characteristics and direct annual health care and criminal justice system-related costs.

RESULTS

Overall, 278 (46%) of 609 participants reported at least 1 criminal justice system encounter. They were more likely to be substance users and less adherent to antipsychotics compared to participants without involvement. The 2 most prevalent types of encounters were being a victim of a crime (67%) and being on parole or probation (26%). The mean annual per-patient cost of involvement was $1,429, translating to 6% of total annual direct health care costs for those with involvement (11% when excluding crime victims).

CONCLUSIONS

Criminal justice system involvement appears to be prevalent and costly for persons treated for schizophrenia in the United States. Findings highlight the need to better understand the interface between the mental health and the criminal justice systems and the related costs, in personal, societal, and economic terms.

Trauma and posttraumatic stress disorder (PTSD) in patients with schizophrenia or schizoaffective disorder

Trauma and posttraumatic stress disorder (PTSD) have high prevalence among individuals with severe mental illness, such as schizophrenia or schizoaffective disorder. This study examined whether trauma and PTSD are under-detected in this population, and whether the cognitive theory of PTSD is applicable to these individuals. Traumatic experiences, PTSD symptoms and negative posttraumatic cognitions were directly measured with questionnaires, and compared to information obtained via chart-review. Results showed clear evidence of under-report of trauma and under-diagnosis of PTSD in patients' charts. Furthermore, negative posttraumatic cognitions were positively related to PTSD symptom severity, supporting the cognitive model of PTSD. These findings underscore the importance of assessing trauma history as well as PTSD in the routine evaluation of patients with schizophrenia or schizoaffective disorder in outpatient clinical settings. Furthermore, the finding of negative posttraumatic cognitions suggests that the cognitive model of PTSD may be applicable to patients with schizophrenia or schizoaffective disorder.

Severe mental illness and criminal victimization: a systematic review

OBJECTIVE

To estimate the prevalence of criminal victimization among people with severe mental illness and to explore risk factors.

METHOD

Four databases (MEDLINE, ScienceDirect, ERIC, and AMED) were searched for articles published between January 1966 and August 2007, supplemented with hand-search of reference lists from retrieved papers. The author and a Medical Doctor independently abstracted data and assessed study quality. Disagreements were resolved by consensus after review of the article and the review protocol.

RESULTS

Nine studies, including 5195 patients, were identified. Prevalence estimates of criminal victimization ranged from 4.3% to 35.04%. Rates of victimization among severely mentally ill persons were 2.3-140.4 times higher than those in the general population. Criminal victimization was most frequently associated with alcohol and/or illicit drug use/abuse, homelessness, more severe symptomatology, and engagement in criminal activity.

CONCLUSION

Prevention and intervention programs should target high-risk groups and improve patients' mental health and quality of life.

Racial/ethnic variation in the relationship between physical limitation and fear of crime: An examination of mediating and moderating factors

This study has four objectives. First, we confirm the previously observed association between physical limitations and fear of crime. Second, we assess the role of age in this relationship. Third, we identify factors that mediate this relationship. Fourth, we assess whether this relationship is observed across racial/ethnic groups. Adjusting for perceptions of personal control and disability-related stigma reduces the magnitude of this relationship to non-significance for black and white respondents, but not for Hispanics. Also, we find that age is inversely related to fear of crime for blacks and whites.

Sibling agreement on retrospective reports of parental alcoholism and other childhood events

Studies have used siblings to verify subject reports of retrospective data and examined variables influencing subject-sibling agreement, but questions remain. From 1998 to 2000, we examined a community sample of women (N = 143) in a metropolitan area, aged 21-60, balanced by race, parental alcoholism, and social class, as well as their siblings, using standardized, self-administered questionnaires and an interview.

RESEARCH QUESTIONS

Do subject and sibling reports agree? Do reports vary by subject characteristics, or the type of childhood experience? Descriptive statistics showed that agreement was strong for measures of parental alcoholism and psychiatric problems, weaker for family environment, and varied little by subject characteristics. Study limitations and implications are noted, and future research suggested.

'Veiling sexualities': a grounded theory of mental health nurses responses to issues of sexuality

AIM

This paper is a report of a study to develop a grounded theory explaining how mental health nurses respond to issues of sexuality in clinical practice.

BACKGROUND

The history of sexuality and people with mental health problems has largely been a history shrouded in misunderstanding, stigma, myth and negativity. However, individuals with mental health problems may experience sexuality and relationship difficulties related to their life experiences, mental illness, or its treatment.

METHODS

Grounded theory was the methodology used for the study. Interviews were conducted in 2005-2006 with 27 mental health nurses working an urban area in the Republic of Ireland. Data were analysed using the concurrent processes of constant comparative analysis, data collection, theoretical sampling and memo writing.

FINDINGS

The core category to emerge from the data was 'veiling sexualities'. This refers to participants' accounts of how they responded to the sexuality dimension of clients' lives. Participants' main concerns about sexuality were related to feelings of personal and professional vulnerability, due to a lack of competence, comfort and confidence in this area. The theory highlights the manner in which nurses perpetuate practices that marginalize, discriminate and socially exclude clients as 'sexual citizens'.

CONCLUSION

The theory of Veiled Sexualities may facilitate acknowledgement of the presence of sexuality in all nurse-client encounters, and promote a discourse on the sexual rights of people experiencing mental distress among mental health nurses and all involved in the delivery of mental health services.

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.

The psychological consequences of combat exposure: the importance of appraisals and post-traumatic stress disorder symptomatology in the occurrence of delusional-like ideas

OBJECTIVE

The aim of the current study is to explore the association between combat experience and the occurrence of delusional-like beliefs. It is hypothesized that negative post-trauma appraisals and positive beliefs about paranoia will be associated with vulnerability to delusional ideas and that veterans who meet criteria for post-traumatic stress disorder (PTSD) will be more likely to hold delusional-like ideas.

DESIGN

A small-scale survey design was employed in order to ensure that detailed information was gathered concerning battle exposure.

METHODS

Forty-one British war veterans completed questionnaires relating to combat experience, delusional ideation, beliefs about paranoia, appraisals of combat trauma and PTSD symptomatology.

RESULTS

Negative post-trauma cognitions and positive and negative beliefs about paranoia were associated with increased predisposition to delusional beliefs; however, the severity of combat experience was not. It was also found that veterans who met criteria for PTSD were more likely to hold delusional-like ideas compared with those who did not. Furthermore, the PTSD group held more negative post-trauma cognitions and more positive beliefs about paranoia.

CONCLUSIONS

These findings suggest that PTSD symptoms may confer vulnerability to delusional beliefs and that this may be mediated by negative appraisals about the self, the world and dysfunctional beliefs about paranoia. However, it is possible that psychotic-like phenomena confer vulnerability to PTSD. The implications of these findings are discussed.

Childhood sexual abuse among Black women and White women from two-parent families

Differences in childhood sexual abuse (CSA) between Black women and White women are explored in a community sample of 290 women raised in two-parent families.A self-administered questionnaire and a face-to-face interview assessed CSA characteristics, aftermath, and prevalence as well as family structure and other childhood variables. Siblings served as collateral informants for the occurrence of CSA. Overall, comparisons of the nature, severity, and aftermath of CSA showed similarities by race; some differences, for example, in age of onset, are potentially relevant for the planning of prevention programs. Logistic regression models examined effects of childhood variables on CSA prevalence. Initial analyses showed a higher CSA prevalence among Black women (34.1% [45] of Black women vs. 22.8% [36] of White women) that was attenuated when family structure (e.g., living with two biological parents throughout childhood or not) and social class were considered. Of interest, differences in family structure remained important even among these two-parent families. Understanding the dynamics of abuse by race and family structure will facilitate the design of more targeted CSA prevention programs.

Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications

OBJECTIVE

To review the research addressing the relationship of childhood trauma to psychosis and schizophrenia, and to discuss the theoretical and clinical implications.

METHOD

Relevant studies and previous review papers were identified via computer literature searches.

RESULTS

Symptoms considered indicative of psychosis and schizophrenia, particularly hallucinations, are at least as strongly related to childhood abuse and neglect as many other mental health problems. Recent large-scale general population studies indicate the relationship is a causal one, with a dose-effect.

CONCLUSION

Several psychological and biological mechanisms by which childhood trauma increases risk for psychosis merit attention. Integration of these different levels of analysis may stimulate a more genuinely integrated bio-psycho-social model of psychosis than currently prevails. Clinical implications include the need for staff training in asking about abuse and the need to offer appropriate psychosocial treatments to patients who have been abused or neglected as children. Prevention issues are also identified.

Crime victimization in adults with severe mental illness: comparison with the National Crime Victimization Survey

CONTEXT

Since deinstitutionalization, most persons with severe mental illness (SMI) now live in the community, where they are at great risk for crime victimization.

OBJECTIVES

To determine the prevalence and incidence of crime victimization among persons with SMI by sex, race/ethnicity, and age, and to compare rates with general population data (the National Crime Victimization Survey), controlling for income and demographic differences between the samples.

DESIGN

Epidemiologic study of persons in treatment. Independent master's-level clinical research interviewers administered the National Crime Victimization Survey to randomly selected patients sampled from 16 randomly selected mental health agencies.

SETTING

Sixteen agencies providing outpatient, day, and residential treatment to persons with SMI in Chicago, Ill.

PARTICIPANTS

Randomly selected, stratified sample of 936 patients aged 18 or older (483 men, 453 women) who were African American (n = 329), non-Hispanic white (n = 321), Hispanic (n = 270), or other race/ethnicity (n = 22). The comparison group comprised 32 449 participants in the National Crime Victimization Survey.

MAIN OUTCOME MEASURE

National Crime Victimization Survey, developed by the Bureau of Justice Statistics.

RESULTS

More than one quarter of persons with SMI had been victims of a violent crime in the past year, a rate more than 11 times higher than the general population rates even after controlling for demographic differences between the 2 samples (P<.001). The annual incidence of violent crime in the SMI sample (168.2 incidents per 1000 persons) is more than 4 times higher than the general population rates (39.9 incidents per 1000 persons) (P<.001). Depending on the type of violent crime (rape/sexual assault, robbery, assault, and their subcategories), prevalence was 6 to 23 times greater among persons with SMI than among the general population.

CONCLUSIONS

Crime victimization is a major public health problem among persons with SMI who are treated in the community. We recommend directions for future research, propose modifications in public policy, and suggest how the mental health system can respond to reduce victimization and its consequences.

Posttraumatic stress disorder: an exploratory study examining rates of trauma and PTSD and its effect on client outcomes in community mental health

BACKGROUND

Rates of trauma and Posttraumatic Stress Disorder (PTSD) were examined in order to compare the profile in clients of an Australian Public Mental Health Service with that reported in the international literature for clients with major mental illness and to explore the effect of this on client health outcomes. Potential factors contributing to increased levels of trauma/PTSD in this group of clients and the issue of causality between PTSD and subsequent mental illness was also explored.

METHODS

A convenience sample of 29 clients was screened for trauma and PTSD using the Posttraumatic Stress Diagnostic Scale (PDS) and selected outcome measures. Paired and independent samples t-test and ANOVA were applied to the data.

RESULTS

High levels of undocumented trauma and PTSD were found. Twenty clients, (74%) reported exposure to multiple traumatic events; 33.3% (9) met DSM IV diagnostic criteria for PTSD. Significant difference was found for PTSD symptomatology, severity and impairment and for client and clinician-rated scores of Quality of Life (QOL) outcomes in the PTSD group. No effect for PTSD symptomatology on the Working Alliance (WA) was found. Factors that may influence higher rates of PTSD in this group were identified and included issues associated with the population studied, the predominance of assaultive violence found, and vulnerability and risks factors associated with re-traumatisation within the social and treating environments.

CONCLUSION

A similar trauma and PTSD profile to that reported in the international literature, including greater levels of trauma and PTSD and a poorer QOL, was found in this small sample of clients. It is postulated that the increased levels of trauma/PTSD as reported for persons with major mental illness, including those found in the current study, are primarily related to the characteristics of the population that access public mainstream psychiatric services and that these factors have specific implications for service delivery, and raise issues of efficiency and effectiveness of resource use in achieving successful outcomes in public mental health services for clients with co-morbid PTSD. Further research with a more rigorous design is needed to test these preliminary findings within Australian Community Mental Health Services.

Predicting long-term outcomes for women sexually abused in childhood: contribution of abuse severity versus family environment

OBJECTIVE

Child sexual abuse (CSA) has been associated with adverse adult psychosocial outcomes, although some reports describe minimal long-term effects. The search for explanations for the heterogeneous outcomes in women with CSA has led to an examination of a range of CSA-related factors, from the severity of individual CSA incidents to the childhood family environment. This study compares three factors for predicting adult outcomes: a multidimensional CSA Severity Scale, the presence or absence of CSA, and family environment.

METHODS

The effect of CSA on adult outcomes was examined among 290 community-dwelling women raised in intact families. Standardized measures and a focused interview were used to collect data, with siblings as collateral informants.

RESULTS

Comparison of a multidimensional CSA Severity Scale to a dichotomous measure of the presence or absence of CSA showed that the Severity Scale did not have greater predictive value for adult outcomes than the dichotomous measure, nor was it as parsimonious. Childhood family environment scales added significantly to the predictive ability of the dichotomous measure.

CONCLUSION

The specific characteristics of a CSA experience may be less important than the occurrence of CSA and the family environment of women for predicting long-term outcomes.

Women, Co-occurring Disorders, and Violence Study: Evaluation design and study population

The Women, Co-occurring Disorders, and Violence Study (WCDVS) was a multi-site cooperative study to evaluate new service models for women with co-occurring mental health and substance use disorders and a history of physical and/or sexual abuse. Despite common features in the service interventions and evaluation procedures, diversity across the nine sites plus differences introduced by non-random assignment led to numerous methodological challenges. This article describes the design, measurement, and analysis decisions behind the WCDVS and lays the foundation for understanding participant-level outcomes and service costs. This article also describes the study population, as recruited and following attrition at the 6-month follow-up, in order to address the threat of selection bias to inferences drawn from this multi-site study.

Establishing and running a trauma and dissociation unit: a contemporary experience

OBJECTIVE

To evaluate the functioning of a trauma and dissociation unit that has run for the past 8 years in a private hospital, with particular regard to operating philosophy, operating parameters, challenges encountered, research and educational initiatives, and the applicability of the treatment model to other settings.

CONCLUSIONS

Despite the challenges associated with significant difficulties in the corporate management of a private health-care system, it has been possible to operate an inpatient and day hospital programme tailored to the needs of patients in the dissociative spectrum, and the lessons learnt from this experience are valid considerations in the future planning of mental health services overall.

Negative and positive childhood experiences across developmental periods in psychiatric patients with different diagnoses - an explorative study

BACKGROUND

A high frequency of childhood abuse has often been reported in adult psychiatric patients. The present survey explores the relationship between psychiatric diagnoses and positive and negative life events during childhood and adulthood in psychiatric samples.

METHODS

A total of 192 patients with diagnoses of alcohol-related disorders (n = 45), schizophrenic disorders (n = 52), affective disorders (n = 54), and personality disorders (n = 41) completed a 42-item self-rating scale (Traumatic Antecedents Questionnaire, TAQ). The TAQ assesses personal positive experiences (competence and safety) and negative experiences (neglect, separation, secrets, emotional, physical and sexual abuse, trauma witnessing, other traumas, and alcohol and drugs abuse) during four developmental periods, beginning from early childhood to adulthood. Patients were recruited from four Psychiatric hospitals in Germany, Switzerland, and Romania; 63 subjects without any history of mental illness served as controls.

RESULTS

The amount of positive experiences did not differ significantly among groups, except for safety scores that were lower in patients with personality disorders as compared to the other groups. On the other side, negative experiences appeared more frequently in patients than in controls. Emotional neglect and abuse were reported in patients more frequently than physical and sexual abuse, with negative experiences encountered more often in late childhood and adolescence than in early childhood. The patients with alcohol-related and personality disorders reported more negative events than the ones with schizophrenic and affective disorders.

CONCLUSIONS

The present findings add evidence to the relationship between retrospectively reported childhood experiences and psychiatric diagnoses, and emphasize the fact that a) emotional neglect and abuse are the most prominent negative experiences, b) adolescence is a more 'sensitive' period for negative experiences as compared to early childhood, and c) a high amount of reported emotional and physical abuse occurs in patients with alcohol-related and personality disorders respectively.

The effects of trauma history, gender, and race on alcohol use and posttraumatic stress symptoms in a college student sample

The present study examined the extent to which different types of traumatic experiences interact with sex and race to effect alcohol use, posttraumatic stress symptomatology, and general psychological distress among a college student sample. Approximately 600 participants completed measures that assessed for a childhood sexual abuse (CSA) history, alcohol consumption, posttraumatic stress symptoms, and overall psychological functioning. Findings indicated that participants with a history of CSA reported greater psychological distress and posttraumatic stress symptoms compared to participants with a trauma history other than CSA and participants with no trauma history. Despite group differences in psychological distress and posttraumatic stress symptoms, no differences in alcohol use were detected across groups. Gender appeared to affect posttraumatic stress symptoms as a function of group. The implications of the results are discussed.

Mental health needs of crime victims: epidemiology and outcomes

This paper reviews epidemiological estimates of criminal victimization derived largely from nationally based studies in the United States. Origins of conflicting rates and prevalences are explained in terms of varying methodology. Risk factors for victimization, including age, race, gender, and disability, are also outlined, and derived from both national and geographically limited U.S.-based studies. Finally, mental health outcomes of violence are documented, with conclusions drawing on both national and regionally specific studies. These outcomes focus on posttraumatic stress disorder, but also include depression, substance abuse, and panic.

The incidence and influence of early traumatic life events in patients with panic disorder: a comparison with other psychiatric outpatients

Early traumatic life events, including childhood physical and sexual abuse, has been associated with increased risk for panic disorder in adulthood. We examined the incidence and influence of early traumatic life events in outpatients with panic disorder (n = 101), compared to outpatients with other anxiety disorders (n = 58), major depression (n = 19), or chronic schizophrenia (n = 22). Data were obtained by means of Structured Clinical Interviews and self-report questionnaires. The incidence of childhood physical abuse ranged from 16 to 40% and for childhood sexual abuse from 13 to 43% with no significant differences among the four diagnostic groups. Across all outpatient groups a history of childhood physical or sexual abuse was positively correlated to clinical severity. Patients with panic disorder who reported childhood physical abuse were more likely to be diagnosed with comorbid depression, to have more comorbid Axis I disorders, to score higher on symptom checklists as well as reporting a greater history of suicide attempts in the past year (5% vs. 0%); or lifetime (36% vs. 15%). Similar findings were noted, but not as robustly, for patients with panic disorder who reported childhood sexual abuse. There is a high rate of adverse early childhood events across diagnostic groups in psychiatric outpatients and these events are likely to influence the severity of the disorder but are unlikely to be a unique risk factor for any one type of disorder.

Gender-related concerns of rural women with severe and persistent mental illnesses

This study used focus groups to investigate the perceptions of rural women with severe and persistent mental illness (SPMI) about their gender-related health concerns. In a series of five focus groups conducted with 16 women at rural psychosocial clubhouses, women with SPMI discussed many gender-related issues, including unresolved grief over loss of children, isolation from family members, lack of sexual partners, diminished sexuality, and bodily changes secondary to medication side-effects. Women with mental illness felt like their roles as women was superseded by their role as mentally ill individuals. Rural women with SPMI have unmet needs for women's health. Psychiatric nurses have the optimal background for addressing gender-related concerns of rural women with SPMI.

A Cry from the Darkness: Women with Severe Mental Illness in India Reveal Their Experiences with Sexual Coercion

THIS STUDY used qualitative research methods to investigate the problem of sexual coercion among female psychiatric patients in India. Consecutive female admissions (n = 146) to the inpatient unit of a psychiatric hospital in southern India were screened regarding coercive sexual experiences. Women who reported coercion (n = 50; 34%) participated in a semi-structured interview to learn more about their experiences. Among these women, 24 (48%) reported that the perpetrator was their spouse, 13 (26%) identified a friend or acquaintance, and 10 (20%) identified a relative such as an uncle or cousin. Most experiences occurred in the women's homes. Thirty of the 50 coerced women (60%) reported that they had not disclosed their experience to anyone, and that they had not sought help. Women revealed a sense of helplessness, fear, and secrecy related to their experiences. The problem of sexual coercion is seldom addressed in mental health care in India; the prevalence and severity of such experiences warrant immediate clinical attention and continued research.

Sexual coercion and abuse among women with a severe mental illness in India: an exploratory investigation

Research from the west indicates that women living with a psychiatric disorder are particularly vulnerable to sexual coercion and abuse. However, there have been no published reports of sexual abuse among female psychiatric patients in India. This exploratory study sought (1) to determine the prevalence of sexual coercion in a representative sample of female psychiatric patients in India; (2) to identify clinical and sociodemographic correlates of sexual coercion; (3) to clarify the association between sexual coercion and human immunodeficiency virus (HIV)-related risk behavior; and (4) to determine whether self-report of sexual coercion from these patients was recorded in their medical charts. Consecutive female inpatient admissions (N = 146) to a large psychiatric hospital in southern India were assessed using a structured interview and standardized measures. During these structured clinical interviews, sexual coercion was reported by 30% of the 146 women. The most commonly reported experience was sexual intercourse involving threatened or actual physical force (reported by 14% of women), and the most commonly identified perpetrator was the woman's husband or intimate partner (15%), or a person in a position of authority in their community (10%). Women with a history of abuse were more likely to report HIV-related sexual behavior (P <.001). In contrast to the 30% of women who reported sexual coercion during interviews, only 3.5% of the medical records contained this information. Thus, sexual coercion is a serious and prevalent concern among female Indian psychiatric patients, but is rarely reported in medical charts. Increased screening and reporting are indicated, as are sexual abuse prevention and treatment programs.

The prevalence and management of trauma in the public domain: an agency and clinician perspective

This descriptive study surveyed the ways in which trauma survivor needs have been addressed within the public mental health system in one sector of Connecticut. Information was obtained about the prevalence of traumatic history among consumers, the existence of policy related to trauma, trauma screening and cross-referral mechanisms, and trauma-related supervision and education. The study maps current service system functioning related to the provision of trauma-specific services at both the agency and the clinician level. The study data indicate a need for service enhancement and increased service system collaboration and integration to permit access to a full range of trauma interventions. The data also indicate a need for increased clinician education and supervision specific to trauma both across agencies and among individual clinicians.

The social-environmental context of violent behavior in persons treated for severe mental illness

OBJECTIVES

This study examined the prevalence and correlates of violent behavior by individuals with severe mental illness.

METHODS

Participants (N = 802) were adults with psychotic or major mood disorders receiving inpatient or outpatient services in public mental health systems in 4 states.

RESULTS

The 1-year prevalence of serious assaultive behavior was 13%. Three variables-past violent victimization, violence in the surrounding environment, and substance abuse-showed a cumulative association with risk of violent behavior.

CONCLUSIONS

Violence among individuals with severe mental illness is related to multiple variables with compounded effects over the life span. Interventions to reduce the risk of violence need to be targeted to specific subgroups with different clusters of problems related to violent behavior.

Primary care and victims of domestic violence

Providing quality health care involves integrating routine inquiry about domestic violence into ongoing clinical practice. This means asking all women patients, and others who may be at risk, about abuse in their lives. Whether or not a woman chooses to use services or leave her partner, our intervention is very important. Some women return to violent partners several times before they feel safe enough to leave, feel they can survive on their own, or can accept that the person they love will not change. Make sure that she has follow-up for her medical problems and appropriate referrals for mental health and substance abuse problems when indicated.

Psychometric study of a brief screen for PTSD: assessing the impact of multiple traumatic events

Most measures of posttraumatic stress disorder (PTSD) symptoms are limited in that they focus on a single traumatic event and cannot be used to assess symptoms in persons who report no traumatic events. The utility of the brief PTSD measures that do not key to a single trauma is limited by lengthiness and high reading levels. The Screen for Posttraumatic Stress Symptoms (SPTSS) is a brief, self-report screening instrument for PTSD symptoms that overcomes these limitations by assessing PTSD symptoms using a low reading level and without keying them to a specific traumatic event. In a sample of 136 psychiatric inpatients, the SPTSS showed good internal consistency, a high sensitivity rate, and a moderate specificity rate. The concurrent and construct validity of the SPTSS were supported by strong correlations with symptom and trauma experience measures and by comparisons of SPTSS scores of groups with different trauma histories.

Multivariate prediction of posttraumatic symptoms in psychiatric inpatients

Based on a conceptual framework for the long-term effects of childhood abuse, this study examined the capacity of childhood family environment (caretaker dysfunction, neglect, perceived social support), violent abuse (physical and sexual), and individual variables (other abuse) to predict adult psychiatric symptoms of PTSD, dissociation, and depression. Complete interview data were obtained from 178 psychiatric in patients who varied greatly on abuse status and severity. Results of multiple regressions of predictor variables onto the three outcome variables showed that the predictor variables accounted for 15% (for depression) to 42% (for PTSD) of the variance in these symptoms and that violent abuse uniquely accounted for a significant proportion of the variance in outcomes for all three of the symptom groups studied.

Mothers with serious mental illness

Mental health services have generally ignored the parenting needs of women with serious mental illness. This chapter identifies the parenting risks and strengths that these women display, as well as the opportunities available to psychologists to play a key role in improving mother and child outcomes.