Effect of Community Treatment Orders on Mental Health Service Usage, Emergency Visits, and Violence: a Systematic Review and Meta-Analysis

INTRODUCTION

Community treatment orders (CTOs) enable patients to actively engage in mental health services while being supervised in the community outside the hospital setting. However, the efficacy of CTOs remains controversial in terms of mental health services usage or service contacts, emergency visits, and violence.

METHODS

The databases PsychINFO, Embase, and Medline were searched on 11 March 2022 by 2 independent reviewers through the Covidence website (www.covidence.org). Randomised or non-randomised case-control studies and pre-post studies were included if they examine the effect of CTOs on service contacts, emergency visits, and violence in individuals with mental illnesses by comparing with control groups or pre-CTO conditions. Conflicts were resolved by consultation of the third independent reviewer.

RESULTS

Sixteen studies provided sufficient data in the target outcome measures and were included in analysis. Variability in the risk of bias was high among studies. Meta-analyses were conducted separately for case-control studies and pre-post studies. For service contacts, a total of 11 studies with 66,192 patients reported changes in the number of service contacts under CTOs. In 6 case-control studies, a small non-significant increase in service contacts was observed in those under CTOs (Hedge's g = 0.241, z = 1.535, p = 0.13). In 5 pre-post studies, a large and significant increase in service contacts was noted after CTOs (Hedge's g = 0.830, z = 5.056, p < 0.001). For emergency visits, a total of 6 studies with 930 patients reported changes in the number of emergency visits under CTOs. In 2 case-control studies, a small non-significant increase in emergency visits was noted in those under CTOs (Hedge's g = -0.196, z = -1.567, p = 0.117). In 4 pre-post studies, a small significant decrease in emergency visits was noted after CTOs (Hedge's g = 0.553, z = 3.101, p = 0.002). For violence, a total of 2 pre-post studies reported a moderate significant reduction in violence after CTOs (Hedge's g = 0.482, z = 5.173, p < 0.001).

CONCLUSION

Case-control studies showed inconclusive evidence, but pre-post studies showed significant effects of CTOs in promoting service contacts and reducing emergency visits and violence. Future studies on cost-effectiveness analysis and qualitative analysis for specific populations with various cultures and backgrounds are warranted.

Advancement in the medicolegal requirement for testamentary capacity assessment in older adults: the dilemmas in Hong Kong

Medical and legal professionals are increasingly involved in probate disputes in which the validity of a will due to a lack of testamentary capacity in older adults is frequently challenged. The legal test for testamentary capacity under common-law jurisdiction was established in the famous case of Banks v Goodfellow (1870). The High Court of Hong Kong recently issued new practice guidance for legal professionals on the preparation of a will for older adults. This paper discusses the dilemmas and competing issues among different parties on this medicolegal interface based on recent literature and local examples. We recommend a risk-based pragmatic framework for legal and medical professionals to minimise potential disputes in testamentary capacity assessment.

Cognitive insight is correlated with cognitive impairments and contributes to medication adherence in schizophrenia patients

OBJECTIVE

Cognitive insight refers to the ability to distance oneself from and evaluate one's own beliefs and interpretations. Little is known about whether cognitive insight could influence medication adherence in schizophrenia patients. This study examined the role of cognitive insight in medication adherence and how it would interact with neuropsychological functions.

METHODS

Ninety clinically-stable schizophrenia patients completed the Beck's Cognitive Insight Scale (BCIS) and tasks measuring prospective (PM) and other neurocognitive functions. Medication adherence was estimated using a multi-axial method comprising interview, clinician-rating, pharmacy refill record and pill counting. Correlational and regression analyses were conducted to examine whether cognitive insight and PM would be associated with mediation adherence. Post-hoc mediational analysis was performed to examine the interplay between cognitive insight, PM and medication adherence.

RESULTS

Clinical insight and cognitive insight together significantly influenced participants' medication adherence, after neurocognitive functions and psychopathology were accounted for. Time-based PM, compared with other neurocognitive functions, affected medication adherence more strongly.

CONCLUSIONS

Cognitive insight complements clinical insight in affecting medication adherence in schizophrenia patients.

Depression prevalence based on the Edinburgh Postnatal Depression Scale compared to Structured Clinical Interview for DSM DIsorders classification: Systematic review and individual participant data meta-analysis

OBJECTIVES

Estimates of depression prevalence in pregnancy and postpartum are based on the Edinburgh Postnatal Depression Scale (EPDS) more than on any other method. We aimed to determine if any EPDS cutoff can accurately and consistently estimate depression prevalence in individual studies.

METHODS

We analyzed datasets that compared EPDS scores to Structured Clinical Interview for DSM (SCID) major depression status. Random-effects meta-analysis was used to compare prevalence with EPDS cutoffs versus the SCID.

RESULTS

Seven thousand three hundred and fifteen participants (1017 SCID major depression) from 29 primary studies were included. For EPDS cutoffs used to estimate prevalence in recent studies (≥9 to ≥14), pooled prevalence estimates ranged from 27.8% (95% CI: 22.0%-34.5%) for EPDS ≥ 9 to 9.0% (95% CI: 6.8%-11.9%) for EPDS ≥ 14; pooled SCID major depression prevalence was 9.0% (95% CI: 6.5%-12.3%). EPDS ≥14 provided pooled prevalence closest to SCID-based prevalence but differed from SCID prevalence in individual studies by a mean absolute difference of 5.1% (95% prediction interval: -13.7%, 12.3%).

CONCLUSION

EPDS ≥14 approximated SCID-based prevalence overall, but considerable heterogeneity in individual studies is a barrier to using it for prevalence estimation.

Elevated Clozapine Level Following Acute Infection in a Patient with Schizophrenia: a Case Report

We describe a 58-year-old Chinese man with schizophrenia who presented with an elevated clozapine level suspected to be related to acute infection.

A retrospective study on risk assessment and management of forensic psychiatric inpatients in Hong Kong

The Department of Forensic Psychiatry of Castle Peak Hospital is the only facility in Hong Kong that provides territory-wide forensic psychiatric services for patients with criminal involvement. This retrospective study aimed to explore whether the rehabilitation programs provided by the department could significantly reduce the risks of forensic psychiatric inpatients as measured by the Short-Term Assessment of Risk and Treatability (START). START ratings of inpatients who were hospitalized in the department for more than 3 months and were discharged to the community during the period from 11 April 2015 to 31 March 2019 were analyzed. A total of 79 patients were assessed, of whom 61 (77.2%) were males. Fifty-four (68.4%) patients suffered from schizophrenia. START scores upon admission (strength score = 5.67; vulnerability score = 17.43) and upon discharge (strength score = 6.87, vulnerability score = 11.18) indicated significant reduction of risks among inpatients (p < 0.05).

Comparison of major depression diagnostic classification probability using the SCID, CIDI, and MINI diagnostic interviews among women in pregnancy or postpartum: An individual participant data meta-analysis

OBJECTIVES

A previous individual participant data meta-analysis (IPDMA) identified differences in major depression classification rates between different diagnostic interviews, controlling for depressive symptoms on the basis of the Patient Health Questionnaire-9. We aimed to determine whether similar results would be seen in a different population, using studies that administered the Edinburgh Postnatal Depression Scale (EPDS) in pregnancy or postpartum.

METHODS

Data accrued for an EPDS diagnostic accuracy IPDMA were analysed. Binomial generalised linear mixed models were fit to compare depression classification odds for the Mini International Neuropsychiatric Interview (MINI), Composite International Diagnostic Interview (CIDI), and Structured Clinical Interview for DSM (SCID), controlling for EPDS scores and participant characteristics.

RESULTS

Among fully structured interviews, the MINI (15 studies, 2,532 participants, 342 major depression cases) classified depression more often than the CIDI (3 studies, 2,948 participants, 194 major depression cases; adjusted odds ratio [aOR] = 3.72, 95% confidence interval [CI] [1.21, 11.43]). Compared with the semistructured SCID (28 studies, 7,403 participants, 1,027 major depression cases), odds with the CIDI (interaction aOR = 0.88, 95% CI [0.85, 0.92]) and MINI (interaction aOR = 0.95, 95% CI [0.92, 0.99]) increased less as EPDS scores increased.

CONCLUSION

Different interviews may not classify major depression equivalently.

Validation of the "Security Needs Assessment Profile" for measuring the profiles of security needs of Chinese forensic psychiatric inpatients

Mapping forensic psychiatric services with the security needs of patients is a salient step in service planning, audit and review. A valid and reliable instrument for measuring the security needs of Chinese forensic psychiatric inpatients was not yet available. This study aimed to develop and validate the Chinese version of the Security Needs Assessment Profile for measuring the profiles of security needs of Chinese forensic psychiatric inpatients. The Security Needs Assessment Profile by Davis was translated into Chinese. Its face validity, content validity, construct validity and internal consistency reliability were assessed by measuring the security needs of 98 Chinese forensic psychiatric inpatients. Principal factor analysis for construct validity provided a six-factor security needs model explaining 68.7% of the variance. Based on the Cronbach's alpha coefficient, the internal consistency reliability was rated as acceptable for procedural security (0.73), and fair for both physical security (0.62) and relational security (0.58). A significant sex difference (p=0.002) in total security score was found. The Chinese version of the Security Needs Assessment Profile is a valid and reliable instrument for assessing the security needs of Chinese forensic psychiatric inpatients.

Antisocial Personality Disorder Subscale (Chinese Version) of the Structured Clinical Interview for the DSM-IV Axis II disorders: validation study in Cantonese-speaking Hong Kong Chinese

OBJECTIVE. Antisocial personality disorder (ASPD) is a risk factor for violence and is associated with poor treatment response when it is a co-morbid condition with substance abuse. It is an under-recognised clinical entity in the local Hong Kong setting, for which there are only a few available Chinese-language diagnostic instruments. None has been tested for its psychometric properties in the Cantonese-speaking population in Hong Kong. This study therefore aimed to assess the reliability and validity of the Chinese version of the ASPD subscale of the Structured Clinical Interview for the DSM-IV Axis II Disorders (SCID-II) in Hong Kong Chinese. METHODS. This assessment tool was modified according to dialectal differences between Mainland China and Hong Kong. Inpatients in Castle Peak Hospital, Hong Kong, who were designated for priority follow-up based on their assessed propensity for violence and who fulfilled the inclusion criteria for the study, were recruited. To assess the level of agreement, best-estimate diagnosis made by a multidisciplinary team was compared with diagnostic status determined by the SCID-II ASPD subscale. The internal consistency, sensitivity, and specificity of the subscale were also calculated. RESULTS. The internal consistency of the subscale was acceptable at 0.79, whereas the test-retest reliability and inter-rater reliability showed an excellent and good agreement of 0.90 and 0.86, respectively. Best-estimate clinical diagnosis-SCID diagnosis agreement was acceptable at 0.76. The sensitivity, specificity, positive and negative predictive values were 0.91, 0.86, 0.83, and 0.93, respectively. CONCLUSION. The Chinese version of the SCID-II ASPD subscale is reliable and valid for diagnosing ASPD in a Cantonese-speaking clinical population.

Mental health recovery for psychiatric inpatient services: perceived importance of the elements of recovery

OBJECTIVES. To develop a questionnaire for measuring the perceived importance of the elements of mental health recovery in psychiatric inpatients in Hong Kong and to test the psychometric properties of the questionnaire. METHODS. Thematic content analysis of identified literature on mental health recovery was performed to identify the elements related to mental health recovery. A questionnaire was developed to assess the perceived importance of the identified elements. An expert panel was set up to evaluate the content validity and patient focus group's face validity of the questionnaire. Participants were recruited from medium-stay and rehabilitation wards of Castle Peak Hospital. RESULTS. A total of 101 psychiatric inpatients completed the questionnaire, the majority of whom suffered from schizophrenia (75%). Having meaning in life was rated by 91% of the participants as an important element of recovery, followed by hope (86%) and general health and wellness (85%). Cronbach's alpha for internal consistency was 0.91. Explorative factor analysis yielded 7 factors and intraclass correlation coefficients revealed a fair-to-good test-retest reliability. CONCLUSIONS. The results supported the psychometric properties of the questionnaire for measurement of mental health recovery and serve as a basis for the future development of recovery-oriented services in the psychiatric inpatient settings in this locality.

A questionnaire survey on attitudes and understanding towards mental disorders

OBJECTIVES. To obtain information about basic knowledge towards mental disorders and to evaluate public attitudes towards mental disorders in the Hong Kong Chinese population. METHODS. Questionnaires which collected basic demographic information, opinions about potential stigmas and myths, and knowledge on case vignettes depicting fictional characters with symptoms of mental illness were delivered to subjects in a secondary school, 2 homes for the elderly, a private housing estate, and a public housing estate in Hong Kong. RESULTS. Completed questionnaires were collected from 1035 subjects. In general, the participants' acceptance of mental illness was good. Regular contacts with such patients were associated with better knowledge (t = -2.71, p < 0.01) and better acceptance (t = 2.77, p < 0.01) of mental illness. Younger participants aged 15 to 19 years had a lower level of knowledge about mental health problems compared with other age-groups (p < 0.001). CONCLUSIONS. Personal contact with people with mental illness may help to improve knowledge and acceptance. Younger people in secondary school should be the target and prioritised group for mental health education. Apart from the delivery of mental health knowledge, strategies to increase social contact of the public with people having mental illness could be considered in the design and implementation of anti-stigma programmes.

Pattern and determinants of burden in Chinese families of adults with obsessive-compulsive disorder

The burden on caregivers of patients with obsessive-compulsive disorder (OCD) is an important yet under-researched area in the Chinese population. This study aimed to assess the pattern and determinants of burden reported by caregivers of adults with OCD in Hong Kong. Seventy-seven OCD patient-caregiver dyads were recruited from a psychiatric out-patient clinic. Adults were assessed with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Global Assessment of Functioning (GAF) scale. Caregivers were interviewed with the Chinese version of the Family Burden Interview Schedule. Ninety-nine percent of the caregivers experienced objective burden. Mothers of patients with OCD experienced the greatest caregiver subjective burden. Multivariate analysis showed that GAF explained 41.5% and 49.8% of the variance of objective and subjective burden respectively. The functional level of OCD adults was an important determinant of both the objective and subjective burden on caregivers.

Systemic lupus erythematosus as a cause of first-episode psychosis in the second trimester of pregnancy

A Chinese woman had a first-episode of psychosis in the second trimester of pregnancy. The sudden onset of psychotic symptoms and fluctuating mental condition with visual hallucinations suggested an organic origin for the psychosis. Antipsychotic medication was started. Ultrasound investigation at 19 weeks of gestation revealed intrauterine growth retardation and she decided to terminate the pregnancy. Positive blood test results for antiphospholipid antibodies confirmed a diagnosis of systemic lupus erythematosus with antiphospholipid syndrome. Psychosis is one of the neuropsychiatric syndromes in systemic lupus erythematosus and can sometimes be the primary manifestation, antedating other evidence of the disease. Pregnancy can exacerbate systemic lupus erythematosus. This report highlights the importance of considering an organic cause for psychosis, including systemic lupus erythematosus, especially when it occurs for the first time during pregnancy in a previously healthy woman.