What are Canadian emergency physicians' attitudes and self-perceived competence toward patients who present with suicidal ideation?

INTRODUCTION: Suicide is the 9th leading cause of death in Canada, and a common reason for patients to present to Canadian emergency departments (ED). Little knowledge exists around Canadian emergency physicians (EPs) attitudes toward and understanding of individuals with suicidal ideation. METHODS: We developed a web-based survey on suicide knowledge, which was pilot tested by two EPs and one psychiatrist for clarity and content. The survey was distributed via email to attending physician members of the Canadian Association of Emergency Physicians. Data were described using counts, means, medians and interquartile ranges. The Understanding of Suicidal Patients (USP) Scale is an 11-point questionnaire to assess healthcare providers' attitudes toward individuals with suicidal ideation. Other questions pertaining to suicidal ideation, self-perceptions on ability to treat suicidal patients, and personal experiences with suicide were asked in Likert format. RESULTS: One hundred eighty-eight Canadian EPs responded to the survey (15% response rate), with a median age of 49 (IQR 39-55), academic practice reported by 55% of respondents, and 65% of respondents identified as male. The mean USP score was 21.8 (95% CI 21.1-22.5), which indicates a generally positive attitude and willingness to provide care for suicidal patients. Only 17% of respondents had participated in specific training for treatment of suicidal patients in the last five years, while the majority of respondents estimate treating 5-15 patients with suicidal ideation a month. Sixty four percent of respondents indicated they had the skills to screen patients for suicidal ideation, but less than one-third felt they could create a personalized safety plan for patients. CONCLUSIONS: Respondents have a generally positive attitude toward treating individuals with suicidal ideation. Respondents scored highly on the USP scale that measured willingness to provide care for and empathize with suicidal patients. Respondents felt they had the skills to adequately screen patients for suicidal ideation. Key gaps in knowledge were identified suggesting improved residency and ongoing medical education opportunities are needed to better improve care for this vulnerable population.

RéSUMé: INTRODUCTION: Le suicide est la 9e principale cause de décès au Canada et une raison courante pour laquelle les patients se présentent aux services d'urgence (SU) canadiens. Il existe peu de connaissances sur les attitudes et la compréhension des médecins d'urgence canadiens à l'égard des personnes ayant des idées suicidaires. MéTHODES: Nous avons développé une enquête en ligne sur la connaissance du suicide, qui a été testée par deux médecins d'urgence et un psychiatre pour en vérifier la clarté et le contenu. Le sondage a été distribué par courriel aux médecins traitants membres de l'Association canadienne des médecins d'urgence. Les données ont été décrites à l'aide de chiffres, de moyennes, de médianes et d'intervalles interquartiles. L'échelle de compréhension des patients suicidaires (USP) est un questionnaire en 11 points visant à évaluer l'attitude des prestataires de soins de santé envers les personnes ayant des idées suicidaires. D'autres questions portant sur les idées suicidaires, les perceptions de soi sur la capacité de traiter les patients suicidaires et les expériences personnelles de suicide ont été posées en format Likert. RéSULTATS: Cent quatre-vingt-huit médecins d'urgence canadiens ont répondu à l'enquête (taux de réponse de 15 %), avec un âge médian de 49 ans (IQR 39-55), une pratique universitaire déclarée par 55 % des répondants, et 65 % des répondants se sont identifiés comme des hommes. Le score USP moyen était de 21,8 (IC à 95 % 21,1-22,5), ce qui indique une attitude généralement positive et une volonté de fournir des soins aux patients suicidaires. Seuls 17 % des répondants ont participé à une formation spécifique pour le traitement des patients suicidaires au cours des cinq dernières années, tandis que la majorité des répondants estiment traiter 5 à 15 patients ayant des idées suicidaires par mois. Soixante-quatre pour cent des répondants ont indiqué qu'ils possédaient les compétences nécessaires pour dépister les idées suicidaires chez les patients, mais moins d'un tiers estimaient qu'ils pouvaient créer un plan de sécurité personnalisé pour les patients. CONCLUSIONS: Les répondants ont une attitude généralement positive à l'égard du traitement des personnes ayant des idées suicidaires. Les répondants ont obtenu un score élevé sur l'échelle USP qui mesurait la volonté de fournir des soins et de l'empathie envers les patients suicidaires. Les répondants estimaient avoir les compétences nécessaires pour dépister adéquatement les idées suicidaires chez les patients. Des lacunes importantes dans les connaissances ont été identifiées, ce qui suggère que de meilleures possibilités de formation en résidence et de formation médicale continue sont nécessaires pour améliorer les soins offerts à cette population vulnérable.

Quality of life and unmet need in people with psychosis in the London Borough of Haringey, UK.

OBJECTIVES: Deinstitutionalization of long-term psychiatric patients produced various community-based residential care facilities. However, inner-city areas have many patients with severe mental illness (SMI) as well as deprivation, unemployment, and crime. This makes meeting their community needs complex. We undertook a needs assessment of service provision and consonance between service users' evaluation of need and by care workers. DESIGN: Cross-sectional study with random sample of SMI service users in four housing settings: rehabilitation units; high-supported; medium-supported; low-supported housing. SETTING: London Borough of Haringey. OUTCOME MEASURES: 110 SMI service users and 110 keyworkers were interviewed, using Camberwell Assessment of Need; SF-36; Lancashire Quality-of-Life profile; demographic and clinical information. RESULTS: People in "low-support" and "high-support" housing had similar symptom scores, though low support had significantly lower quality of life. Quality of life was positively predicted by self-reported mental-health score and negatively predicted by unmet-need score in whole sample and in medium-support residents. Residents' and care-workers' assessments of need differed considerably. CONCLUSIONS: Although patients' housing needs were broadly met, those in low-supported housing fared least well. Attendance to self-reported mental health and unmet social needs to quality of life underpins planning of residential services for those with SMI. Social and personal needs of people in supported housing may be underestimated and overlooked; service providers need to prioritise these if concept of "recovery" is to advance.

Othello syndrome secondary to ropinirole: a case study.

This case report describes a forty-two-year-old man with no previous psychiatric history who developed delusional jealousy (Othello Syndrome) associated with ropinirole treatment. Ropinirole is a commonly used dopamine receptor agonist, which was being used to treat his Parkinson's disease, and his delusional symptoms resolved entirely with ropinirole dose reduction.

Prevalence of same-sex behavior and orientation in England: results from a national survey.

There are few data sources on the prevalence of same-sex sexual orientation in England.We aimed to measure the prevalence of same-sex orientation and behavior in the English general population and assess the impact of enquiry format on reporting. The Adult Psychiatric Morbidity Survey 2007 used a multi-stage, stratified probability-sampling design (n=7,403). Two questions addressed sexual orientation and sexual partnership and each had two versions. Version A of the sexual orientation question used "homosexual." Version B used "gay or lesbian." Version A of the sexual partnership question required participants who had male and female partners to say which was predominant, while Version B had a midpoint response option: "about equally with men and women." Participants were randomized between versions. Overall, 5.3% of men and 5.6%of women reported they were not entirely heterosexual. The question using "gay or lesbian" elicited higher (though not statistically significant) reporting of non-heterosexual orientation than the question using "homosexual." A significantly larger proportion of men and women (96.0 and 96.1%) reported entirely heterosexual partnerships in response to Version A of the partnership question than in response to Version B (94.0 and 92.9%) where Version B asked specifically about "kissing, touching, intercourse, or any other form of sex." These figures constitute the first national prevalence data on combined sexual orientation and sexual behavior in England, based on a random probability sample of the general population. They demonstrate that people are willing to report their sexual orientation in survey research, but reporting is sensitive to question wording.

A new model for quality improvement in acute inpatient psychiatry: observational data from an acute assessment unit.

OBJECTIVES: There is little research into the constituents of effective psychiatric inpatient care. The aim of this study was to assess the effectiveness of a newly adopted model of inpatient care; the acute assessment ward. DESIGN: Review of data collected over a year-long period. SETTING: Acute assessment ward in North London. PARTICIPANTS: All Admissions between 8 October 2009 and 7 October 2010. MAIN OUTCOME MEASURES: Duration of stay, need for readmission, patient satisfaction and frequency of conflict behaviours. RESULTS: A total of 485 admissions over the yearlong study period. The median stay to discharge from the assessment ward was 6 days, whereas in those transferred it was 19 days. Readmission within 28 days following discharge from the assessment ward was 13.9%, whereas those discharged from other wards was 9.2% (P = 0.1). Patient satisfaction was no lower, for all domains, than for other wards in the trust. Frequency of conflict behaviour was equal to previous studies,(1) but self harm was significantly less common (P = 0.01). CONCLUSIONS: Our data show that focusing on the 'point of entry' to inpatient services means that some admission times can be reduced without an increase in 28-day readmission rates or conflict behaviours. The acute assessment model attempts to address the need for the NHS to deliver more for less, whilst remaining focused on service-user and staff satisfaction. Research into which areas of this complex intervention are effective is challenging, but we would urge others who run services with novel structures to publish data about their functioning.

Mental health of the non-heterosexual population of England.

BACKGROUND: There has been little research into the prevalence of mental health problems in lesbian, gay and bisexual (LGB) people in the UK with most work conducted in the USA. AIMS: To relate the prevalence of mental disorder, self-harm and suicide attempts to sexual orientation in England, and to test whether psychiatric problems were associated with discrimination on grounds of sexuality. METHOD: The Adult Psychiatric Morbidity Survey 2007 (n = 7403) was representative of the population living in private UK households. Standardised questions provided demographic information. Neurotic symptoms, common mental disorders, probable psychosis, suicidality, alcohol and drug dependence and service utilisation were assessed. In addition, detailed information was obtained about aspects of sexual identity and perceived discrimination on these grounds. RESULTS: Self-reported identification as non-heterosexual (determined by both orientation and sexual partnership, separately) was associated with unhappiness, neurotic disorders overall, depressive episodes, generalised anxiety disorder, obsessive-compulsive disorder, phobic disorder, probable psychosis, suicidal thoughts and acts, self-harm and alcohol and drug dependence. Mental health-related general practitioner consultations and community care service use over the previous year were also elevated. In the non-heterosexual group, discrimination on the grounds of sexual orientation predicted certain neurotic disorder outcomes, even after adjustment for potentially confounding demographic variables. CONCLUSIONS: This study corroborates international findings that people of non-heterosexual orientation report elevated levels of mental health problems and service usage, and it lends further support to the suggestion that perceived discrimination may act as a social stressor in the genesis of mental health problems in this population.

Perceived racism, medication adherence, and hospital admission in African-Caribbean patients with psychosis in the United Kingdom.

BACKGROUND: Differences in outcome between African-Caribbean and white British patients with psychosis may be due to perceived racism and a difficulty in trusting services seen as discriminatory. METHOD: In 100 participants, racism was measured at baseline using the Perceived Racism Scale; with adherence, using the Drug Attitudes Inventory and Kemp Scale, and hospital admission data determined after 12 months. RESULTS: We found associations between total perceived racism for the previous year (b = -0.0074, P = 0.013), lifetime racism (b = -0.0068, P = 0.038), and everyday racism for the previous year (b = -0.051, P = 0.0046), with subsequent medication adherence. Shame felt about health system racism was associated with increased adherence (b = 0.20, P = 0.015), and powerlessness about it was associated with fewer subsequent hospital bed days (b = -14.49, P = 0.025). Finally, health system racism was associated with both the number of subsequent hospital bed days (b = 5.54, P = 0.010), and admission length (b = 4.92, P = 0.021). In addition, stratified analyses showed that both baseline adherence and 6-month estimated adherence appeared to mediate these effects. CONCLUSIONS: In this cohort of African-Caribbean patients with psychosis, perceived racism is a determinant of adherence over 12 months. We propose a model whereby perceived racism contributes to an individual rejecting mental health services (manifested by the mediating effect of poor adherence) which leads to a poorer outcome, evidenced by a longer hospital stay. Secondly, powerlessness about perceived health-service racism may represent a sense of resignation about the "system", leading paradoxically to greater adherence and better outcome.

Racism, mental illness and social support in the UK.

PURPOSE: The difference in risk of mental illness in UK ethnic minorities may be related to a balance between specific risk factors such as racial discrimination and mediating factors such as social support. We investigated whether social support from friends or relatives reduces the cross-sectional association between perceived racism and the risk of mental illness in an ethnic minority group. METHODS: We conducted secondary analyses of nationally representative community samples of five UK ethnic minority groups (EMPIRIC dataset; n = 4,281) using multiple regression techniques. RESULTS: We found that the associations between perceived racism, common mental disorder and potentially psychotic symptoms were mainly independent of social support as measured by the number of close persons and their proximity to the individual. CONCLUSION: Social support when measured in this way does not mediate the associations between perceived racism and mental ill health in this population-based sample.

Measuring perceived racism and psychosis in African-Caribbean patients in the United Kingdom: the modified perceived racism scale.

AIM: The increased rate of psychosis and poorer service-related outcomes in UK African-Caribbeans may in part be related to racism; racism as an aetiological factor remains comparatively under-investigated. We wanted to develop a measure of perceived racism in UK African-Caribbean patients with psychosis METHODS: We modified the Perceived Racism Scale (PRS) by substituting a mental-health-services' racism domain for the employment-racism domain and administered it to a sample of 150 individuals. RESULTS: 110 people completed the PRS with a total mean perceived racism score of 54.2 for the previous year and 71.3 for the lifetime. The modified instrument had good internal consistency, and both a similar factor-analytic structure and sampling adequacy to the original instrument. CLINICAL IMPLICATIONS: The modified PRS was acceptable to the sample, withstands statistical scrutiny and produced similar totals to those in previously-tested populations. Subjective measurement of perceived racism may improve understanding of psychosis in African-Caribbeans, improve engagement and, hopefully, outcome.