The career of the mentally ill: an integration of psychiatric, labeling/social construction, and lay perspectives

Newcomers and Old Timers: An Erroneous Assumption in Mental Health Services Research

Based on the premise that treatment changes people in ways that are consequential for subsequent treatment-seeking, we question the validity of an unrecognized and apparently inadvertent assumption in mental health services research conducted within a psychiatric epidemiology paradigm. This homogeneity assumption statistically constrains the effects of potential determinants of recent treatment to be identical for former patients and previously untreated persons by omitting treatment history or modeling only main effects. We test this assumption with data from the 2001-2003 Collaborative Psychiatric Epidemiology Surveys; the weighted pooled sample is representative of noninstitutionalized U.S. adults (18+; analytic n = 19,227). Contrary to the homogeneity assumption, some associations with recent treatment are conditional on past treatment, including psychiatric disorder and race-ethnicity-measures of need and treatment disparities, respectively. We conclude that the widespread application of the homogeneity assumption probably masks differences in the determinants of recent use between previously untreated persons and former patients.

"I'm Not Mentally Ill": Identity Deflection as a Form of Stigma Resistance

Mental illness identity deflection refers to rebuffing the idea that one is mentally ill. Predictors of identity deflection and its consequences for well-being were examined for individuals with mental disorders in the National Comorbidity Study-Replication (N = 1,368). Respondents more often deflected a mental illness identity if they had a nonsevere disorder, had low impairment in functioning, had no treatment experience, viewed possible treatment as undesirable, and held multiple social roles, consistent with theory about stigma resistance. Persons who deflected a mental illness identity had lower distress and more positive affect than those who accepted it, even net of disorder severity, impairment level, and treatment experience. Among those who had ever been in treatment, deflection buffered the negative effects of serious impairment but exacerbated the effects of having a severe disorder on well-being, suggesting more complex consequences of formal labeling (greater stigma but helpful services), consistent with previous research.

Trajectory analyses of virologic outcomes reflecting community-based HIV treatment in Washington DC 1994-2012

BACKGROUND

Effective treatment of HIV since 1996 has reduced morbidity and mortality through virologic suppression. Combination antiretroviral therapy (cART) has been recognized as key to the prevention of drug resistance and the transmission of infection. We used eighteen years of virologic outcomes in a long-standing cohort of women to describe longitudinal viral load trajectories; and examine factors associated with sustained viremia and mortality.

METHODS

We analyzed data from DC WIHS women with > four semiannual visits using a group-based logistic trajectory analysis approach to identify patterns of HIV RNA detection (>80 copies/mL or lower assay limit, and >1000 copies/mL). We verified findings using cumulative viral load suppression-years, explored group characteristics using generalized linear modeling with generalized estimating equations for repeated measures, and examined survival using the Kaplan-Meier and Cox proportional hazard analyses.

RESULTS

329 women contributed 6633 visits between 1994 and 2012 and demonstrated high, moderate, and low probability patterns of HIV RNA detection (>80 copies/mL) in 40.7, 35.6, and 23.7% of participant visits, respectively. Analysis of cumulative years of viral load suppression supported these observations. Kaplan-Meier survival analysis demonstrated high mortality of 31.1% with sustained viremia, but no significant difference in mortality between intermittent viremia and non-viremia patterns, 6.9 and 4.9% respectively. Mortality was associated with higher age, lower CD4+ T lymphocyte count, and sustained viremia by Cox multivariate analysis.

CONCLUSIONS

This ecologic study demonstrates the effectiveness of viral suppression, and conversely the association between viremia and mortality. In community delivery of cART for HIV care, distinct patterns of sustained viremia, intermittent viremia, and non-viremia were identified over nearly 18 years in the DC WIHS, capturing the dynamics and complexity of sustaining long-term HIV care. Persistent viremia was associated with lower CD4s and mortality, but surprisingly mortality was not different between continuous suppression and intermittent viremia. Classification of long-term virologic patterns such as these observed HIV treatment "careers" may provide a suitable framework to identify modifiable factors associated with treatment resilience and failure. Both individual and population interventions are needed to reduce transmission, prevent the emergence of drug resistance, and improve outcomes of community ART programs.

Well, I'm healthy, but…--lay perspectives on health among people with musculoskeletal disorders

PURPOSE

The purpose was to investigate lay perspectives on health among people with musculoskeletal disorders.

METHOD

Semi-structured interviews were performed with 39 women and 30 men, (aged 22-63 years) with long-term, non-specific musculoskeletal disorders in the neck, shoulder and/or low back. Data was analysed using qualitative content analysis.

RESULTS

These people experienced health as "having resources and opportunities to lead the life one wants". Three categories, "a good enough physical and psychological functioning, freedom of action, and a positive state of emotion and an enriching life", illustrate the different resources and opportunities that the informants described as important for them to perceive themselves as healthy. The informants also reflected on "being ill" and "being well" and what makes the difference. Five aspects influenced the dynamics of their health experiences: "body and soul, prognosis, character of symptoms, physical and social activity, and emotional state". Consequently, the informants expressed a holistic view of health, where the focus lies on the opportunity and the ability to lead their lives the way they want.

CONCLUSIONS

This study points at the value of taking lay perspectives on health into account, as it might increase the opportunity to design effective, personalized rehabilitation strategies.

IMPLICATIONS FOR REHABILITATION

Musculoskeletal disorders (MSDs) are difficult to cure and actions to alleviate suffering are of most importance to increase wellbeing and thereby work ability. Research on lay perspectives can contribute towards a deepened understanding of the health experiences of the affected, and thereby the development of the goals and activities of rehabilitation. Our models, that present the view of health and aspects important for achieving wellness among people with MSDs, can contribute in the development of multimodal rehabilitation. The results can also be useful as a base in the evaluation of clinical practice.

What do people in forensic secure and community settings think of their personality disorder diagnosis? A qualitative study

PURPOSE

The aim of this study was to explore the experience of having a personality disorder diagnosis within the context of forensic secure and community services.

METHODS

We used an interpretative phenomenological analysis to analyse interviews with 10 service users purposively recruited from services in South London.

RESULTS

Participants described two facets of their lived experience: (1) the way they see themselves now, in light of their offending and social background and (2) the pejorative nature of the personality disorder label, its relationship to mental illness and their need to distance themselves from it.

CONCLUSIONS

Having a forensic identity affects participants' perceptions of their diagnosis and its treatment as well as their views about themselves.

The public stigma of mental illness: what do we think; what do we know; what can we prove?

By the 1990s, sociology faced a frustrating paradox. Classic work on mental illness stigma and labeling theory reinforced that the "mark" of mental illness created prejudice and discrimination for individuals and family members. Yet that foundation, coupled with deinstitutionalization of mental health care, produced contradictory responses. Claims that stigma was dissipating were made, while others argued that intervention efforts were needed to reduce stigma. While signaling the critical role of theory-based research in establishing the pervasive effects of stigma, both claims directed resources away from social science research. Yet the contemporary scientific foundation underlying both claims was weak. A reply came in a resurgence of research directed toward mental illness stigma nationally and internationally, bringing together researchers from different disciplines for the first time. I report on the general population's attitudes, beliefs, and behavioral dispositions that targeted public stigma and implications for the next decade of research and intervention efforts.

From Structural Chaos to a Model of Consumer Support: Understanding the Roles of Structure and Agency in Mental Health Recovery for the Formerly Homeless

Current understandings of the effect that mental health services on consumers' daily lives are still heavily informed by research conducted during the era of institutional treatment. This is problematic considering that changes to mental health care have shifted the locus of treatment to community settings for the majority of those living with serious and persistent mental illness (SPMI). With this shift there has been a greater focus on consumer-centered recovery in mental health care. In this paper I seek to develop a deeper understanding of the effect that the organization of mental health services offered in community settings has on the recovery process. I do this by presenting findings from the analysis of focus group and interview data collected from research informants (consumers and staff) at four Housing First programs located in a large Midwestern city. Housing First is based in a human rights approach to services that has been demonstrated to be more successful at housing chronically homeless consumers with dual diagnoses than traditional approaches to housing. My findings highlight the importance of understanding the connection that exists between social structure and personal agency and the recovery process.

Service users' views of moving on from early intervention services for psychosis: a longitudinal qualitative study in primary care

BACKGROUND

The role of primary care for young people with psychosis, and transitions between specialist mental health services and primary care, are underexplored areas, both clinically and in research terms.

AIM

To explore service users' perspectives of early intervention services and primary care, in-depth and over time.

DESIGN AND SETTING

Longitudinal qualitative methodology in five geographically diverse sites across England.

METHOD

Semi-structured interviews with 21 young people with first-episode psychosis at two time points.

RESULTS

Early intervention services are highly prized by service users; however, the 'gold standard' nature of the care is difficult to replicate in other services and may lead to unrealistic expectations. Flexibility in terms of the timing of discharge does appear to be happening in practice, but continuity is not always well established before discharge. Primary care seems to be under-utilised, both as a location of care during time with the early intervention service and as a skill set, particularly for physical health problems. Service users expected GPs to advocate for and navigate the health system, particularly at times of crisis or relapse.

CONCLUSION

Early intervention services should focus on actively establishing relationships between service users and either the community mental health team or the GP in the months leading up to discharge, and ensuring that service users' expectations about access and availability of care are 'realistic'. Primary care could be better utilised, even when service users are actively engaged with early intervention services, to help ensure physical health needs are met from the start of treatment.

Adolescent mental health, behavior problems, and academic achievement

Prior research on the association of mental health and behavior problems with academic achievement is limited because it does not consider multiple problems simultaneously, take co-occurring problems into account, and control for academic aptitude. We addressed these limitations using data from the National Longitudinal Study of Adolescent Health (N = 6,315). We estimated the associations of depression, attention problems, delinquency, and substance use with two indicators of academic achievement (high school GPA and highest degree received) with controls for academic aptitude. Attention problems, delinquency, and substance use were significantly associated with diminished achievement, but depression was not. Combinations of problems involving substance use were especially consequential. Our results demonstrate that the social consequences of mental health problems are not the inevitable result of diminished functional ability but, rather, reflect negative social responses. These results also encourage a broader perspective on mental health by demonstrating that behavior problems heighten the negative consequences of more traditional forms of distress.

Resisting the Stigma of Mental Illness

The relationship between stigmatization and the self-regard of patients/consumers with mental disorder is negative but only moderate in strength, probably because a subset of persons with mental illness resists devaluation and discrimination by others. Resistance has seldom been discussed in the stigma and labeling literatures, and thus conditions under which individuals are resistant have not been identified. I define resistance as opposition to the imposition of mental illness stereotypes by others and distinguish between deflecting (“that’s not me”) and challenging resistance strategies. Individuals should be more likely to employ resistance strategies when they have: past experience with stigma resistance; past familiarity with an ill family member or friend; symptoms that are non-severe or controlled; treatment experience in settings run by consumers; initially high levels of psychosocial coping resources; and multiple role-identities. Incorporating resistance into classic and modified labeling theories of mental illness highlights the personal agency of labeled individuals, missing especially in classic labeling theory.