Health Care Experiences of Patients with Nonbinary Gender Identities

Purpose

The primary purpose of this study was to characterize the health care experiences of diverse patients with nonbinary gender identities across a range of geographic locations. A secondary aim was to use the qualitative findings to inform recommendations for clinics and providers to create gender-affirming health care environments for nonbinary patients.

Methods

We conducted 3 focus group discussions with 7-9 participants, for a total of 24 unique participants. To be eligible, participants were required to be 18 years of age or older, live in the United States, speak English, have the ability to access Zoom in a private room, have a nonbinary gender identity, and be able to attend one of three scheduled focus groups.

Results

Participants reported frequent negative health care experiences, including misgendering, invalidation, and pathologization, even within clinics that signaled alliance with transgender communities. Participants described strategies they use to cope with negative experiences, including health care avoidance, identity concealment, and seeking out providers that are matched in terms of gender minority status and/or race.

Conclusion

Recommendations for the provision of gender-affirming health care for nonbinary patients include nonbinary-inclusive intake forms and electronic health records, having providers be proactive in eliciting preferred names and pronouns, and requiring education for providers and staff at all levels on the provision of nonbinary-inclusive gender-affirming health care.

Impact of a 10-week disability elective on health professions students' attitudes towards disabled persons

BACKGROUND AND PURPOSE

Disability is overlooked in health provider training despite the growing number of patients and providers with a disability. In-depth training on delivering outstanding care is provided as part of training for health professions, however little guidance is provided on how to interact with patients with disabilities.

EDUCATIONAL ACTIVITY AND SETTING

Students enrolled in a 10-week interdisciplinary elective at the University of California, San Francisco were asked to participate in the study. Students who consented to participate completed a pre-intervention assessment that incorporated the Interaction with Disabled Persons Scale (IDP) and Marlowe-Crowne Social Desirability Scale Short Form C (MC). At the conclusion of the elective, participating students retook both surveys as part of a post-intervention assessment.

FINDINGS

There was a significant difference in IDP score and non-significant difference in MC score following the elective. There was a positive but non-significant correlation between the paired results for the IDP and MC surveys.

SUMMARY

Following completion of a 10-week disability awareness curriculum, there was a significant improvement in health professions students' perceptions towards persons with disabilities.

Are depot antipsychotics more coercive than tablets? The patient's perspective

Some clinicians consider depot antipsychotics to be stigmatising, coercive and unacceptable to patients. This cross-sectional study investigated patients' perspectives of coercion for depot and oral antipsychotics. In all, 72 participants with chronic mental illness on voluntary maintenance antipsychotic medication were interviewed for their views on oral and depot medication and experiences of coercion. The MacArthur Admission Experience (short form) was adapted to explore coercion regarding medication. Mean total coercion levels were higher for those on depot (depot: mean 4.39; oral: 2.80, P = 0.027), as were perceived coercion (2.52 vs 1.73, P = 0.041) and negative pressures subscales (1.17 vs 0.33, P = 0.009). No significant differences were found for the 'voice' subscale and affective reactions. Specifically, more participants on depot felt that people try to force them to take medication (30% vs 2%, P< 0.001). Depots were perceived as more coercive than oral antipsychotics. Greater perceived coercion may explain why some consider depots to be a more stigmatising form of treatment. Although forced medication is sometimes required, the experience of coercion should be minimised by giving patients a fair say in treatment decisions, regardless of formulation.

Managing severe mental illness in the community using the Mental Health Act 1983: a comparison of Supervised Discharge and Guardianship in England

BACKGROUND

Two measures in the English Mental Health Act allow requirements to be imposed upon patients living in the community. These are Guardianship (Section 7) and Supervised Discharge (Section 25A).

AIMS

The paper aims to compare patients with mental illnesses, made subject to Guardianship or Supervised Discharge.

METHOD

Data on patient characteristics, impairment, needs and interventions were collected from keyworkers in a random national sample of Trusts and local authorities. Ratings were obtained on standardised measures of disability, impairment and needs.

RESULTS

Patients placed on Supervised Discharge were more likely to have problems of treatment compliance and drug misuse, whilst those on Guardianship were more likely to have problems of social welfare and higher ratings of disability and impairment. Supervised Discharge has a higher proportion of African-Caribbean patients. Interventions delivered are rated as effective for both measures.

CONCLUSIONS

Legal changes proposed in England include a single power for supervision in the community. This should not mean a focus on risk management to the neglect of social welfare interventions.

Persuading the persuadable: evaluating compulsory treatment in England using Supervised Discharge Orders

BACKGROUND

Supervised Discharge Orders (SDOs) were introduced in 1995, as an amendment to the Mental Health Act in England and Wales. They require patients to abide by specific conditions on discharge from hospital, but can not enforce medication compliance. On introduction, SDOs were received with scepticism by the psychiatric profession. The purpose of this study was to describe the use of SDOs in England and the characteristics of patients made subject to these orders, and to evaluate the effectiveness of the order in securing treatment compliance on discharge from hospital.

METHOD

A survey was conducted of 170 mental health provider Trusts in England. Interviews with senior managers in 12 Trusts and associated Local Authorities were subjected to qualitative analysis, and a cohort of patients subject to SDOs in 56 randomly sampled Trusts was described.

RESULTS

SDOs were being used for 596 patients (1.2 per 100,000 total population) at the survey date in 1999, and use had been increasing steadily since its introduction. The order is not systematically considered for all potential cases. The majority of the 182 patients in the cohort had complied, if sometimes intermittently, with conditions of the order.

CONCLUSIONS

For patients compliant with SDOs, the pressures necessary to treat effectively need not involve powers to enforce medication compliance.

Expenditure on mental health care by English health authorities: a potential cause of inequity

BACKGROUND

The York resource allocation formula includes a calculation of the amount needed to purchase mental health services equitably in each health authority in England. However, the amount which is actually spent on services is at the discretion of the authority.

AIMS

To compare expenditure on mental health services with allocation, and test the hypothesis that differences between them are to the disadvantage of services in deprived areas.

METHOD

A comparison of routine expenditure and allocation data, and linear regression modelling of the ratio of expenditure to allocation.

RESULTS

The ratio of expenditure to allocation varies widely. Relative underspending occurs more frequently in deprived areas, although not in the four inner-London health authorities.

CONCLUSIONS

The intentions of the York formula are not achieved in practice. The implications of the formula for mental health should be made explicit to health authorities, and shortfalls in mental health expenditure relative to allocation should be justified at a local level.

Psychiatric patients at greatest risk and in greatest need. Impact of the Supervision Register Policy

BACKGROUND

Mental health provider trusts in England were required in 1994 to establish local Supervision Registers of patients at risk.

AIMS

To identify the factors associated with registration, and obtain clinicians' views on its effectiveness.

METHOD

At a random sample of 14 trusts data were collected from case notes, key workers and responsible medical officers.

RESULTS

A sample of 133 registered patients were more disabled and had more extensive histories of violence and self-harm than 126 comparison patients on the upper tier of the Care Programme Approach (CPA). Those registered were a heterogeneous group. For some there was little evidence of risk. In most cases clinicians did not believe registration had improved care.

CONCLUSIONS

The Supervision Register policy has not resulted in the identification of a well-defined group. Its effectiveness is limited by the lack of operationalized measures of risk.

Continuity of care and clinical outcome: a prospective cohort study

BACKGROUND

Continuity of care is a central objective of community psychiatric services, but there is no consensus about its measurement.

AIMS

We developed measures of continuity of care suitable for routine use, and measured continuity and individual patient outcome over a period in which community services were developing.

METHOD

One hundred patients with severe mental illness receiving continuing care from two sectorised services were sampled and interviewed. Data were collected concerning their care over 20 months prior to interview. After 20 months prospective follow-up, they were re-interviewed. Continuity was defined as: perceived accessibility of services and knowledge about them, the number of keyworkers in a defined period of time, and the proportion of time out of contact with services.

RESULTS

Continuity of care improved significantly on all measures over the period of the study. Individual patient outcome also improved, but in multiple regression models including clinical and demographic variables, measures of continuity were not significant predictors of outcome. Continuity was similar for white and non-white patients.

CONCLUSION

Simple measures of continuity are useful in evaluating changes in the process of care, but they are not straightforwardly related to individual outcome.

Evaluating mental health policy in England. Care Programme Approach and supervision registers

BACKGROUND

The Care Programme Approach (CPA) and supervision register policies in England are intended to prioritize patients to receive specialist mental health care.

AIMS

To describe and evaluate the practical application of the policies.

METHOD

A questionnaire survey of key informants in mental health provider trusts and an analysis of aggregated data collected by health authorities using the Mental Illness Needs Index as a measure of population need.

RESULTS

On average, 1175 per 100,000 total population are subject to the CPA (95% CI = 1055-1309) and 8.6 per 100,000 (95% CI = 7.5-9.9) are on supervision registers. Wide local variations in the number of people subject to the CPA and supervision registers are not explained by variations in population need.

CONCLUSIONS

Prioritization to receive specialist mental health services is carried out inconsistently, and inequitable use of resources may result.

Routine clinical outcome measures for patients with severe mental illness: CANSAS and HoNOS

BACKGROUND

Two recently developed measures intended for clinical use are HoNOS (Health of the Nation Outcome Scales), measuring social functioning, and CANSAS (Camberwell Assessment of Need Short Appraisal Schedule), for measuring need.

AIMS

We investigated the association between CANSAS and HoNOS.

RESULTS

For some domains there were substantial associations, with high HoNOS rating correlated with CANSAS rating of the presence of a need. For other areas the agreement was less than might be expected. Seven factors were identified within the 22 CANSAS domains, and the presence of needs in the Drug/alcohol and Activities of daily living factors was associated with high scores in the related HoNOS domains.

CONCLUSIONS

CANSAS and HoNOS assessments differ. HoNOS can track changes in social functioning over time, but may be less useful for treatment planning, and should not be used to infer the level of morbidity in a case-load. CANSAS indicates when treatment should be commenced or continued. It can also be used as a case-load measure, but may be insufficiently sensitive to be used as an outcome measure at the individual level.

Substance misuse and risk of aggression and offending among the severely mentally ill

BACKGROUND

The aim of this study was to investigate whether 'dual diagnosis' (substance misuse and severe mental illness) is associated with aggression and offending.

METHOD

Twenty-seven people meeting the criteria for both psychotic illness and a substance use disorder and 65 people with psychosis only were interviewed. Case notes were also examined and keyworkers asked to rate substance misuse and aggression.

RESULTS

The severity of aggression and offending among this community treatment sample was low. Individuals with a dual diagnosis were significantly more likely than those with psychosis only to report any history of committing an offence (P = 0.001), or recent hostile behaviour (P = 0.001). Keyworkers were more likely to report recent aggression among the dually diagnosed (P = 0.01). Significant differences persisted when we used logistic regression to control for potentially confounding demographic and clinical variables.

CONCLUSIONS

Dual diagnosis may be an important factor in aggression and offending among severely mentally ill individuals in inner-city areas. Accurate risk assessment requires examination of substance use.

Can deinstitutionalised care be provided for those at risk of violent offending?

OBJECTIVE

The aim of this article is to explain the current status of deinstitutionalisation and of community care development in the UK.

DESIGN

Literature review of articles and reports on deinstitutionalisation.

SETTING

Articles included in the review related either to the whole of the UK, to England and Wales, or to a specific area such as London.

MAIN OUTCOME MEASURES

The review was carried out pertaining to the question of the extent to which community care can or should take over the functions of the asylum, with particular reference to those at risk of behaving violently. These functions include those that are manifest, or explicit, and those that are latent, or unintended but implicit (Bachrach, 1976).

RESULTS

The example of patients at risk of violent behaviour is-one that highlights the continuing relevance of both these sets of functions, which are argued to be exerting a powerful influence on the processes of asylum closure and community care development. This influence is seen in delayed asylum closure, transinstitutionalisation (the shift of some patients from asylums to other institutions), and the institutionalisation of aspects of community care.

CONCLUSIONS

Both the manifest and the latent functions of asylums must be acknowledged by those involved in planning community care; where it is felt desirable that community care does not take over certain functions, the consequences of this must be anticipated so that they can be prevented or dealt with in other ways.

Integration between primary and secondary services in the care of the severely mentally ill: patients' and general practitioners' views

BACKGROUND

Communication between secondary and primary care is an important aspect of continuity of care. We investigated communication between general practitioners (GPs) and psychiatric teams about a representative group of patients with severe mental illness (SMI). We also sought views on GP involvement in care from the patients and their GPs.

METHODS

One hundred patients with SMI were randomly selected from those under the care of two psychiatric sector teams in inner London. The patients and their GPs were interviewed.

RESULTS

GPs' knowledge about the care their patients received was limited. Most GPs perceived their role as providing physical care and prescribing. Few patients consulted GPs for mental health care. GPs perceived themselves as less involved in the care of Black Caribbean or Black African patients.

CONCLUSIONS

Considerable discontinuities of care between secondary and primary care were identified. GP involvement in the care of patients with SMI appears limited. Better communication is necessary if care is to be shared.

Continuity of care for the severely mentally ill: concepts and measures

Very few useful measures of service functioning are as yet available for the evaluation of mental health services. Continuity of care has been identified as "the strategic first choice" for the development of such process measures. The term "continuity" has been used to refer to a variety of important aspects of service functioning, including whether services maintain contact with patients, whether patients consistently see the same staff, success of transfer between services, degree to which plans for services are followed through, integration between service providers, and comprehensiveness in meeting patient's individual needs. In this paper, we reviewed the main theoretical definitions of continuity of care for the severely mentally ill, and discussed the work that has attempted to operationalise these definitions and to apply them in the study of mental health services. We concluded that whilst continuity of care has had a central place in theoretical discussions of community service planning, progress in developing and applying practical measures has so far been sporadic and limited. Obstacles to such research have included great diversity in definitions of continuity and the confounding influence of individual patient characteristics on the relationship between service process and outcome. Despite these limitations, research in this field has indicated that developing and applying measures of continuity of care may be feasible and produce useful results with findings of some of the studies suggesting a relationship between continuity of care and individual outcome.

Combination treatment with noradrenalin and serotonin reuptake inhibitors in resistant depression

Eight cases of resistant recurrent depression were treated with a combination of nortriptyline and a new serotonin reuptake inhibitor, with or without concurrent lithium therapy. Significant improvement was seen in all patients where other drug regimes and ECT had been ineffective. No adverse reactions occurred in any of our patients, seven of whom were elderly. The combination treatment was more effective than individual therapies alone.