Benefits of the PRISM Shelter-Based Program for Attainment of Stable Housing and Functional Outcomes by People Experiencing Homelessness and Mental Illness: A Quantitative Analysis

OBJECTIVE

To explore the housing trajectory, personal recovery, functional level, and quality of life of clients at discharge and 1 year after completing Projet Réaffiliation Itinérance Santé Mentale (PRISM), a shelter-based mental health and rehabilitation program intended to provide individuals experiencing homelessness and severe mental illness with transition housing and to reconnect them with mental health and social services.

METHOD

Housing status, psychiatric follow-up trajectory, personal recovery (Canadian Personal Recovery Outcome Measure), functional level (Multnomah Community Ability Scale), and quality of life (Lehman Quality of Life Interview) were assessed at program entry, at program discharge and 1 year later.

RESULTS

Of the 50 clients who participated in the study from May 31, 2018, to December 31, 2019, 43 completed the program. Of these, 76.7% were discharged to housing modalities and 78% were engaged with psychiatric follow-up at the program's end. Housing stability, defined as residing at the same permanent address since discharge, was achieved for 62.5% of participants at 1-year follow-up. Functional level and quality of life scores improved significantly both at discharge and at 1-year follow-up from baseline.

CONCLUSIONS

Admission to PRISM helped clients secure long-term stable housing and appropriate psychiatric follow-up. Stable housing was maintained for most clients at 1-year follow-up, and they benefited from sustained functional and quality of life outcomes in long-term follow-up.

PRISM: A Shelter-Based Partnership for People Experiencing Homelessness and Severe Mental Illness

PRISM (Projet Réaffiliation Itinérance Santé Mentale [Homelessness Mental Health Reaffiliation Project]) is a clinical service developed through partnerships between shelters and the publicly funded Canadian health care system to address the needs of individuals experiencing homelessness and severe mental illness in Montreal. It provides inpatient treatment in a shelter setting for 2-3 months while helping clients find housing and appropriate longer-term support services. From program inception in November 2013 to May 2019, 52% of the 579 PRISM clients were in permanent housing after program discharge, 11% were in temporary housing, and 21% were not housed (homeless or incarcerated). In addition, 16% were transferred to inpatient treatment or rehabilitation services, and 85% were referred to and engaged in outpatient or community services.

Improving Transfer of Care Between Psychiatrists and Residents: Participants' Perspective on the Implementation of a Handover Protocol in a Psychiatric Emergency

OBJECTIVES

Handover refers to the transfer of information from one professional to another during transitions of care. I-PASS is a mnemonic tool which stands for Illness severity; Patient summary; Action list; Situation awareness and contingency planning; and Synthesis by receiver. It was developed to standardize the handover process. Psychiatrists, nurses, and residents at the Montreal Jewish General Hospital psychiatric emergency were trained and the I-PASS handover model was implemented.

METHODS

Thirty-one psychiatrists, nurses, and residents participated in this quality improvement project. Participants filled a pre-training questionnaire to examine the baseline status of handovers before attending a training session on I-PASS. Participants then filled a second questionnaire assessing the perceived quality of the handover training session, as well as anticipated benefits and challenges of I-PASS prior to its implementation. Finally, following implementation, two focus groups were held to collect feedback from participants.

RESULTS

Pre-training, most participants reported that information provided during handovers was incomplete. Training was overall much appreciated. The most significant anticipated obstacle for implementing I-PASS was lack of time to properly fill out the form. Post-implementation, participants unanimously reported an improvement in the handover process. Handovers were perceived as faster, providing all key information about patients, and the perceived quality of the information was better.

CONCLUSION

Overall, the implementation of the I-PASS handover model was much appreciated by participants, who perceived that handovers were more comprehensive, efficient, and of better quality.

When the law influences medical practice: Potential impact of the Bouchard-Lebrun ruling on the forensic unit of the Malartic Psychiatric Hospital in Northern Quebec, Canada

The attribution of criminal responsibility in the context of substance intoxication is a matter of controversy in forensic psychiatry. In 2011, the Supreme Court of Canada ruled that Tommy Bouchard-Lebrun was guilty in the straightforward case of a crime committed while in a state of substance-induced psychosis by an individual without a history of mental disorder. However, the ruling may since have served as a precedent also for settling cases where an offence is committed while in a certain state of intoxication and where there is much more diagnostic uncertainty. The goal of our research was to study the impact of the Bouchard-Lebrun Supreme Court decision on rates of criminal responsibility judgements and toxic psychosis diagnosis in the context of such cases. Applying a time-trend ecological study design, we conducted a chart review of every patient treated at the forensic unit of the Malartic Psychiatric Hospital in northern Quebec in the short periods pre- and post-ruling. We then determined the proportion of patients judged not criminally responsible and the proportion diagnosed with substance-induced psychosis. We ran chi-squared tests on the two sets of dichotomous variables. In the period following the Bouchard-Lebrun ruling, a statistically significant decrease was observed in the proportion of individuals judged not criminally responsible, as was a statistically significant increase in the proportion of individuals diagnosed with substance-induced psychosis. The findings suggest that the Bouchard-Lebrun ruling may have had an impact on subsequent forensic psychiatry decision-making and treatment at the Malartic Hospital.

Insights from homeless men about PRISM, an innovative shelter-based mental health service

PRISM (Projet Réaffiliation Itinérance Santé Mentale-mental health and homelessness reaffiliation project), is a new shelter-based mental health service in Montreal, Canada. It offers short-term residential services in a shelter with the aim of housing and connecting the person to the appropriate services in the community. This qualitative research project was designed to gain a rich understanding of service-user experience within this program, and to apply these impressions to a broader reflection concerning how to best serve the needs of homeless people living with severe mental illness. We conducted in-depth interviews with 20 clients from the all-male PRISM-Welcome Hall Mission at program intake and departure between May 2018 and March 2019. We used methods stemming from grounded theory to analyze themes emerging from the interviews. Analysis revealed three core aspects endorsed by PRISM clients as helpful to their recovery: first, the community-based and flexible PRISM structure allows for continuity in daily routine through the preservation and expansion of the client's existing informal resource network; second, the secure environment is conducive to improving one's physical and mental health; and third, the multimodal mental health and social service approach used at PRISM is appreciated and stands in contrast to what most have experienced during other inpatient experiences. This led us to reflect more broadly on the benefits of a shelter-based intervention, as a catalyst to the achievement of longer-term goals such as housing, as well as flexible care adapted to the specific needs of these individuals. Even though this study took place in a specific program in Quebec, it sheds light more broadly on how to best meet the needs of individuals with mental illness living in homeless situations and contributes to the growing literature on men's mental health.

Berkson's bias in biobank sampling in a specialised mental health care setting: a comparative cross-sectional study

OBJECTIVES

To determine whether studying aetiological pathways of depression, in particular the well-established determinant of childhood trauma, only in a specialised mental healthcare setting can yield biased estimates of the aetiological association, given that the majority of individuals are treated in primary care settings.

DESIGN AND SETTING

Two databanks were used in this study. The Canadian Community Health Survey (CCHS) on Mental Health and Well-Being 2012 is a national survey about mental health of adult Canadians. It measured common mental disorders and utilisation of services. The Signature mental health biobank includes adults from the Island of Montreal recruited at the emergency department of a major university mental health centre. After consent, participants filled standardised psychosocial questionnaires, gave blood samples, and their clinical diagnosis was recorded. We compared the cohort of depressed individuals from CCHS and Signature in contact with specialised services with those in contact with primary care or not in treatment.

PARTICIPANTS

There were 860 participants with depression in the CCHS and 207 participants with depression in the Signature Bank.

PRIMARY AND SECONDARY OUTCOMES

The Childhood Experiences of Violence Questionnaire was used to measure childhood trauma in both settings. Childhood trauma is associated with depression as with other common mental and physical disorders.

RESULTS

Individuals with depression in the CCHS who reported having been hospitalised for psychiatric treatment or having seen a psychiatrist or those from Signature were found to be more strongly associated with childhood abuse than individuals with depression who were treated in primary care settings or did not seek mental healthcare in the preceding year.

CONCLUSIONS

Berkson's bias limits the generalisability of aetiological associations observed in such university-hospital-based biobanks, but the problem can be remedied by broadening recruitment to primary care settings and the general population.

The meaning and experience of stress among supported employment clients with mental health problems

Many clinicians are concerned that competitive work may cause excessive stress for people with severe mental health problems. Individual Placement and Support (IPS) is acknowledged as the most effective model of supported employment for this population. The manner in which IPS clients define and experience employment-related stress is poorly understood. This qualitative study aims to explore how people with mental health problems receiving IPS services define and experience employment-related stress. We purposively sampled and interviewed 16 clients of an IPS programme, who had been competitively employed for more than 1 month. Data were collected between September 2014 and July 2015 in Montreal, Canada. Transcripts of semi-structured interviews were analysed using grounded theory methodology. IPS clients often defined stress similar to its common understanding: the result of experiencing prolonged or/and cumulative strains, or of an incongruence between efforts and rewards, hopes and reality. Stress experienced in this way could exacerbate psychiatric symptoms, especially depression or psychotic symptoms. However, when maintained at a more manageable level, stress stimulated learning and improved planning of tasks. Participants described different coping mechanisms, such as sharing their experiences and difficulties with others, focusing on problem resolution and avoidance. The first two of these helped IPS clients remain at work and bolstered their confidence. Work-related stress has potentially positive as well as negative consequences for IPS clients. In order to maximise the potential beneficial effects of stress, employment specialists can help clients anticipate potential stressors and plan how they might cope with them. Further research on the most effective ways of helping clients cope with stress is needed.

Can Geriatric Psychiatry Patients Complete Symptoms Self-Reports Using Tablets? A Randomized Study

BACKGROUND

With our aging population and limited number of geriatric psychiatrists, innovations must be made in order to meet the growing demands for geriatric psychiatry services. Emerging technologies could greatly improve access to care and systematic data collection.

METHODS

This randomized study compared completion rates and time to completion (primary outcomes) when using iPad technology vs. traditional paper forms to complete self-report psychiatric symptoms. Geriatric psychiatry outpatients (n = 72) and adult psychiatry inpatients (n = 50) were recruited to complete the Brief Symptom Inventory (BSI-53), the Activities of Daily Living (ADL), and Patient Health Questionnaire (PHQ-9) questionnaires.

RESULTS

Geriatric psychiatry outpatients completed the iPad and paper questionnaires at similar rates (91.7% vs. 97.2%, Fisher's Exact p = .61). In two-way ANOVA, including patients aged ≥ 60 (n = 85), outpatient status (F(1,81) = 4.48, p = .037) and iPad format (F (1,81) = 8.96, p = .04) were associated with a shorter time to completion. The effect of questionnaire formats was especially prominent in the inpatient group on time to completion.

CONCLUSIONS

Older adults with mental illness demonstrate a similar ability to complete self-report questionnaires whether iPads or paper forms. iPad questionnaires may even require less time to complete in geriatric psychiatry inpatients. Patients also found iPad questionnaires to be easy to use and read. Tablets could potentially be used for psychiatric symptom assessment for clinical, research, and population health purposes.

Changes in the nature and intensity of stress following employment among people with severe mental illness receiving individual placement and support services: an exploratory qualitative study

BACKGROUND

Most people with severe mental illness (SMI) want to work. Individual placement and support (IPS) programs have proven effective in helping them obtain and keep competitive jobs. Yet, practitioners often fear that competitive jobs might be too stressful.

AIMS

To explore how the nature and intensity of stress experienced by IPS clients changed after the transition from looking for work to being employed.

METHODS

Semi-structured interviews explored the experiences of 16 clients of an IPS program who had recently been competitively employed. Grounded theory was used to structure the analysis.

RESULTS

Most participants reported that their stress level decreased once they found work. Stress following work was associated with fear of failure, pressure to perform and uncertainty. The support that people perceived in their return-to-work project, and where they were on their recovery journey, modulated their perception of stress. Many cited IPS as a source of support.

CONCLUSIONS

Competitive work changed the nature of stress and was mostly associated with a decrease in stress level. Adjunctive interventions aiming to buffer self-stigma or help participants use more adaptive coping mechanisms may merit investigation.

Tolerability and suitability of brief group mindfulness-oriented interventions in psychiatric inpatients: a pilot study

OBJECTIVE

Mindfulness-oriented therapies have a positive impact on patients' overall well-being and alleviate many psychiatric conditions. However, little is known about their use in people with severe mental illness. We aimed to identify which clinical and sociodemographic factors are associated with suitability/tolerability of a brief group mindfulness-oriented therapy.

METHODS

This retrospective study examines pre-/post-data from 40 psychiatric inpatients who underwent one session of a 10-min mindfulness-oriented group intervention between January and March 2014. The main outcome was 'suitability for and tolerating the brief mindfulness-oriented group intervention'. We assessed potential correlates of the main outcome, including female gender, shorter hospitalisation, the absence of psychosis and good pre-morbid functioning.

RESULTS

The intervention was well tolerated (92.5%) and 50% of patients met both of our relatively stringent suitability and tolerability criteria. Sociodemographic and clinical variables were not associated with suitability/tolerability. Tai chi was the most suitable/tolerable compared to body scan and mindful eating (76.5% vs. 35.7% vs. 22.2%, Fisher's exact p = 0.01, Bonferroni p < 0.05).

CONCLUSIONS

Brief group mindfulness therapy interventions are very well tolerated and often suitable for acutely hospitalised psychiatric inpatients, including those with acute psychosis. Mindfulness-oriented intervention with an active component (e.g., tai chi, mindful walking) may potentially be best suited for this population.

Career Interests of Canadian Psychiatry Residents: What Makes Residents Choose a Research Career?

OBJECTIVES

Training future clinician-researchers remains a challenge faced by Canadian psychiatry departments. Our objectives were to determine the prevalence of residents interested in pursuing research and other career options as part of their practice, and to identify the factors associated with interest in research.

METHOD

Data from a national online survey of 207 Canadian psychiatry residents from a total of 853 (24.3% response rate) were examined. The main outcome was interest in research as part of residents' future psychiatrist practice. Bivariate and multivariate analyses were performed to identify demographic and vocational variables associated with research interest.

RESULTS

Interest in research decreases by 76% between the first and fifth year of psychiatry residency (OR 0.76 per year, 95% CI 0.60 to 0.97). Training in a department with a residency research track did not correlate with increased research interest (χ2 = 0.007, df = 1, P = 0.93).

CONCLUSIONS

Exposing and engaging psychiatry residents in research as early as possible in residency training appears key to promoting future research interest. Psychiatry residency programs and research tracks could consider emphasizing research training initiatives and protected research time early in residency.

What Makes Residents Interested in Geriatric Psychiatry? A Pan-Canadian Online Survey of Psychiatry Residents

OBJECTIVES

In spite of a rapidly increasing need, there remains a shortage of geriatric psychiatrists in North America. The factors associated with psychiatric residents' interest in geriatric psychiatry have not yet been examined in a nationally representative sample.

DESIGN

Cross-sectional study.

SETTING

Web-based online survey of Canadian psychiatry residents.

PARTICIPANTS

207 psychiatry residents (24.3% response rate).

MEASUREMENTS

The main outcome was interest in becoming a geriatric psychiatrist. Bivariate and multivariate analyses were performed to better understand what demographic, educational, and vocational variables were associated with interest in becoming a geriatric psychiatrist.

RESULTS

A number of respondents had an interest in becoming a geriatric psychiatrist (29.0%, N = 60); in doing a geriatric psychiatry fellowship (20.3%, N = 42); or an interest in doing geriatric psychiatry as a part of the clinical practice (60.0%, N = 124). Demographic characteristics (age, gender, ethnicity) did not correlate with interest in geriatric psychiatry. The variables most robustly associated with interest in geriatric psychiatry were: 1) completion of geriatric psychiatry rotation(s) before the third year of residency (OR: 5.13, 95% CI: 1.23-21.4); 2) comfort working with geriatric patients and their families (OR: 18.6, 95% CI: 2.09-165.3); 3) positive experiences caring for older adults prior to medical school (OR: 12.4, 95% CI: 1.07-144.5); and 4) the presence of annual conferences in the resident's field of interest (OR: 4.50, 95% CI: 1.12-18.2).

CONCLUSION

Exposing medical students and junior psychiatry residents to clinical geriatric psychiatry rotations that increase comfort in working with older adults may be potential future strategies to improve recruitment of geriatric psychiatrists.

A Bayesian Approach to Latent Class Modeling for Estimating the Prevalence of Schizophrenia Using Administrative Databases

Estimating the incidence and the prevalence of psychotic disorders in the province of Quebec has been the object of some interest in recent years as a contribution to the epidemiological study of the causes of psychotic disorders being carried out primarily in UK and Scandinavia. A number of studies have used administrative data from the Régie de l'assurance maladie du Québec (RAMQ) that includes nearly all Quebec citizens to obtain geographical and temporal prevalence estimates for the illness. However, there has been no investigation of the validity of RAMQ diagnoses for psychotic disorders, and without a measure of the sensitivity and the specificity of these diagnoses, it is impossible to be confident in the accuracy of the estimates obtained. This paper proposes the use of latent class analysis to ascertain the validity of a diagnosis of schizophrenia using RAMQ data.

Being a mindful clinical teacher: can mindfulness enhance education in a clinical setting?

Mindfulness may be viewed as a vehicle to promote the healer's role in medicine. This role addresses the way in which a medical practitioner interacts with patients. The aim of this article is to highlight how mindful qualities may also enhance teaching in clinical settings. Challenges to being a mindful clinical teacher are presented along with creative ways to accommodate them. Residents play an important role in training medical students. Examples of how mindfulness influenced a psychiatric resident's teaching experiences are presented to illustrate the concepts discussed herein. The dimension of "being" in medicine, based on the humanist philosophy of Dr Karl Jaspers, is provided as a framework for this article.