Compulsory treatment order and rehospitalisation: A New Zealand study.

OBJECTIVE: The effectiveness of compulsory treatment orders (CTO) in psychiatric practice is an area in need of evidence. There are no recent New Zealand publications on outcomes for patients under CTOs. This study examined the association between CTOs and subsequent rehospitalisation for patients with schizophrenia or related disorders. METHOD: Two year outcome data for 326 consecutive patients discharged in 2013 and 2014 was obtained from the Programme for the Integration of Mental Health Data database. Regression analyses were performed with rehospitalisation as the main outcome. RESULTS: For the 54% of patients discharged under CTOs, rehospitalisation was 2-4 times more likely for the CTO group than for voluntary patients. Patients under CTOs also spent longer in hospital post index admission (IA). However, patients placed under CTOs during IA stayed longer than those under CTOs prior to IA. Ethnicity did not contribute significantly to any of the findings. CONCLUSION: This study did not show that patients under CTOs were associated with subsequent reduced resource use. The subgroup analysis suggested that studies with a longer follow-up period may provide better insight into the utility of CTOs.

Correlates of Presence and Remission of Post-trauma Stress Disorder in Incarcerated Women: A Case-Control Study Design.

Women in prison are vulnerable to post-trauma stress disorder (PTSD). However, little is known about the presence of PTSD in imprisoned women or of the natural course of that disorder. The purpose of this study was to assess the risk factors for PTSD in incarcerated women and document correlations of remission. We conducted a retrospective case-control study in the Female Prison of Hunan Province, China. Participants were screened for PTSD and depression using the Chinese version of the MINI International Neuropsychiatric Interview (MINI) 5.0. Of the 2,322 women screened, 220 met the criterion for PTSD on admission. Remission (N = 142) and non-remission PTSD (N = 78) were then separated depending on current PTSD status. History of drug use (OR = 0.43, 95% CI: 0.28-0.66, p < 0.001) and violent offense (OR = 1.56, 95% CI: 1.17-2.09, p < 0.001) were associated with the presence of PTSD. Positive associations with remission were found for longer length of sentence (61-120 vs. 13-60 months) (OR = 4.20, 95% CI: 1.50-11.75, p = 0.006), violent offense (OR = 2.50, 95% CI: 1.12-5.60, p = 0.03), and comorbid depression (OR = 29.69, 95% CI: 3.50-251.78, p = 0.002); while a negative correlate was identified for past depression (OR = 0.24, 95% CI: 0.11-0.53, p < 0.001). Although some incarcerated women with PTSD can spontaneously remit, this study suggested certain criminological and clinical risk factors are associated with the presence of PTSD and others with remission over time. Timely screening and effective intervention should be tailored for individuals with PTSD in prisons.

Sociodemographic and clinical variables associated with discharge under compulsory treatment orders.

OBJECTIVE: To document the sociodemographic and clinical variables associated with discharge under compulsory treatment orders in patients with schizophrenia or related disorders. METHOD: Information on various sociodemographic and clinical variables were extracted from the clinical files of 349 patients discharged from an adult (age 18-65) inpatient psychiatric unit with diagnoses of schizophrenia or related disorders. Univariate and multiple logistic regression analyses with legal compulsion (compulsory versus voluntary) as outcomes were applied. RESULTS: Two hundred of the 349 discharged patients were placed under compulsory treatment orders. In the univariate logistic regression analysis, unemployment, diagnosis of schizophrenia, forensic history, dosage of antipsychotics, prescription and frequency of injectable antipsychotics, polypharmacy and a hospital stay of more than 28 days were associated with compulsory status. Being married or in partnership and living with partner was associated with voluntary status. Multiple regression models respectively confirmed most of these relationships observed in the univariate analyses. CONCLUSION: Clarification of the apparent drivers for compulsory treatment may help thoughtful reductions in the use of compulsion.

Comparing legislation for involuntary admission and treatment of mental illness in four South Asian countries.

BACKGROUND: Involuntary admission or treatment for the management of mental illness is a relatively common practice worldwide. Enabling legislation exists in most developed and high-income countries. A few of these countries have attempted to align their legislation with the United Nations Convention on the Rights of Persons with Disabilities. This review examined legislation and associated issues from four diverse South Asian countries (Bangladesh, India, Pakistan and Sri Lanka) that all have a British colonial past and initially adopted the Lunacy Act of 1845. METHOD: A questionnaire based on two previous studies and the World Health Organization checklist for mental health legislation was developed requesting information on the criteria and process for involuntary detention of patients with mental illness for assessment and treatment. The questionnaire was completed by psychiatrists (key informants) from each of the four countries. The questionnaire also sought participants' comments or concerns regarding the legislation or related issues. RESULTS: The results showed that relevant legislation has evolved differently in each of the four countries. Each country has faced challenges when reforming or implementing their mental health laws. Barriers included legal safeguards, human rights protections, funding, resources, absence of a robust wider health system, political support and sub-optimal mental health literacy. CONCLUSION: Clinicians in these countries face dilemmas that are less frequently encountered by their counterparts in relatively more advantaged countries. These dilemmas require attention when implementing and reforming mental health legislation in South Asia.

Mental health service users' progression from illicit drug use to schizophrenia in New Zealand.

BACKGROUND: Recently, publications have hypothesised that the demonstrated increase in the incidence of schizophrenia in New Zealand is a side effect of the increased strength of available cannabis derivatives over the last 25+ years and the much more recent increase in the population's use of methamphetamine. AIM: To compare the rates of later schizophrenia between age-matched mental health service users with initial diagnoses as alcohol abusers or illicit drug users. METHOD: From the PRIMHD comprehensive national database, all users of the mental health services over a 5-year period who received an ICD-10 presenting diagnosis of alcohol or substance use/abuse were identified. For each person identified, the database was examined for the following 3 years to determine the numbers later diagnosed with schizophrenia. RESULTS: For the initial alcohol problem people in their twenties, 1.7% were diagnosed as suffering from schizophrenia in the subsequent 3 years. For the initial drug problem people, the rate was 10.9%. Within that drug-using population, the indigenous Maori developed schizophrenia at a higher rate than did the remainder of the population. CONCLUSION: These findings in New Zealand require further research into their generalisability, context and explanation.

Mental Health Problems, History of Drug Use, and Violent Offending Are Associated With Increased Suicide Risk in Imprisoned Females.

Background: In western countries, imprisoned females are at high risk for suicide, but the risk in Chinese imprisoned females has not been well established. The aim of this study was to clarify the suicide risk and its correlates among imprisoned females in China. Methods: In this cross-sectional study, subjects were recruited from the Female Prison of Hunan province, China. A standardized questionnaire was used to collect socio-demographic and criminological data. The Suicidality module of the Mini International Neuropsychiatric Interview (MINI) 5.0 and 12-item General Health Questionnaire (GHQ-12) were used to assess suicide risk and mental health problems, respectively. Ordinal logistic regressions were used to identify independent factors associated with increased suicide risk. Results: A total of 2,709 imprisoned females completed the survey questionnaire. Twenty percent were rated as presenting suicide risk. Mental health problems [odds ratio (OR) = 1.21, 95% confidence interval (CI) = 1.00-1.47], self-reported help-seeking for mental health problems (OR = 1.69, 95% CI = 1.11-2.56), violent offending (OR = 1.69, 95% CI = 1.37-2.09), history of drug use (OR = 1.46, 95% CI = 1.15-1.84), family history of mental disorders (OR = 1.57, 95% CI = 1.10-2.23), marital status (OR = 1.29, 95% CI = 1.05-1.58), and low educational level (OR = 1.36, 95% CI = 1.11-1.67) were independently associated with increased suicide risk. Conclusion: One fifth of the imprisoned females are at risk for suicide. This study highlights the importance of assessing mental health status for suicide prevention among female prisoners.

Gender differences among homicide offenders with schizophrenia in Hunan Province, China.

This study aimed to understand the demographic, clinical and criminological characteristics of Chinese homicide offenders with schizophrenia from a gender-based perspective. Information on all homicide offenders with schizophrenia who received forensic psychiatric assessment between 2010 and 2016 in Hunan Province, China, was systematically retrieved (n = 669). Gender differences in the above characteristics were analyzed, and independent correlates of homicide were explored. The male to female ratio of homicide offenders was about 4:1. Proportionally more males were single, unemployed and younger when committing their first crime than was apparent in females. Male perpetrators were more often influenced by delusions. Females were more likely to target their close family members. For males, living in rural areas and having a family history of mental disorder were positively associated with homicide, while having a criminal history and being unemployed were negatively associated. For females, younger age was positively, while being unmarried and unemployment were negatively associated with homicide. Our results indicate significant gender differences among Chinese homicide offenders with schizophrenia in demographic, clinical and criminological characteristics and in independent correlates of homicide. Further research in this field, especially aims at determining risk factors for crime in this population, should take the gender differences into account.

The rate of mental health service use in New Zealand as analysed by ethnicity.

OBJECTIVES: To compare by ethnicity the rates of apparent new referrals and admissions to mental health services for selected major diagnostic groupings. METHOD: Using a Ministry of Health database covering all referrals and admissions to New Zealand's Mental Health services in 2014 and who had not been patients in the preceding six years, population adjusted rates of presentation were calculated and compared across the two major New Zealand ethnic groupings. RESULTS: Population corrected rates of apparently new cases of schizophrenia are more than twice as common in Maori as in non-Maori. Major depression is also significantly more common in Maori. That same trend was not evident for bipolar patients. CONCLUSIONS: These ethnically associated apparent differences in the rates of schizophrenia and depression need both confirmation and explanation.

Drug driven psychoses and legal responsibility or insanity in six Western Pacific nations.

Prompted by four questions, forensic mental health clinicians from Russia, China, Japan, Hong Kong, Australia and New Zealand provided information on both the legislative basis and current practice concerning the relationship between legal insanity, intoxication and drug induced psychosis in their six Pacific Rim Countries which account for nearly 20% of the world's population. Details of the survey for each contributing nation are provided. While there are significant variations in practice that have been shaped by regional legal, clinical and cultural influences there is considerable similarity in the legislation underpinning how these issues are considered. Consequently there remain similar challenges for each nation. In none of the legislative bases was the issue of drug induced psychosis specifically addressed. The authors conclude that evolving pharmaco-neuropsychiatric knowledge, societal values and patterns of substance misuse require nations to consider developments in scientific and clinical knowledge to support their interpretations of the relationship between altered mental states as a result of substance use and the legal construct of insanity.

Correlates of rehospitalisation in schizophrenia.

OBJECTIVES: Schizophrenia typically has a fluctuating course; rehospitalisation is common. We studied associations between discharge variables and subsequent two-year rehospitalisation rates. METHOD: Using a New Zealand national database, we obtained rehospitalisation rates and bed days for 451 patients with schizophrenia discharged from three inpatient facilities between July 2009 and December 2011. RESULTS: Nearly half (44%) of the cohort were rehospitalised within two years. Patients over 50 were less likely [hazard ratio (HR) = 0.58, 95% confidence interval (CI) = 0.35-0.97, p = 0.04] to be rehospitalised. Patients whose index admission included compulsory treatment appeared more likely (HR = 1.3, 95% CI = 0.98-1.71, p = 0.06) to be rehospitalised and spent longer rehospitalised (p = 0.05). Those whose index admission was three weeks or longer were less likely (HR = 0.53, 95% CI = 0.39-0.72, p = 0.001) to be rehospitalised. Antipsychotic types, routes and dosages were not significantly associated with rehospitalisation rate, except for those prescribed clozapine (HR = 0.61, 95% CI = 0.41-0.89, p = 0.01). CONCLUSIONS: Rehospitalisation rates were higher for patients under the age of 50 and those with shorter index admissions; the latter finding requires further study. Other than the beneficial effect of clozapine, the type and route of prescribed antipsychotics did not significantly affect rehospitalisation rates.

Antipsychotic prescribing and its correlates in New Zealand.

OBJECTIVES: Antipsychotics are the cornerstone of schizophrenia management. There is substantial literature on their efficacy and optimal use. Doubts remain, however, regarding the translation of this knowledge into day-to-day practice. This study aimed to investigate antipsychotic prescribing in three New Zealand regions and its relationship to clinical guidelines and patient characteristics. METHODS: We studied 451 patients discharged from inpatient units with a diagnosis of schizophrenia or a related disorder (International Classification of Disease, version 10) between July 2009 and December 2011. Available information included patient demography, legal status, prescribed medications, duration of index admission and prescriber's country of postgraduate training and years of postgraduate experience. RESULTS: There was a high rate (33.7%) of multiple antipsychotic prescription, and lower than expected clozapine use (20%); Maori were prescribed clozapine more frequently than non-Maori (24% vs. 13%, respectively). Compulsory treatment was associated with more use of injectable medication and increased length of stay in hospital. Clinician characteristics did not significantly influence prescribing. CONCLUSIONS: Observed prescribing practice aligned with existing guidelines except for antipsychotic polypharmacy and clozapine under-utilisation.

Involuntary admission and treatment of patients with mental disorder.

Despite the efforts of the World Health Organization to internationally standardize strategies for mental-health care delivery, the rules and regulations for involuntary admission and treatment of patients with mental disorder still differ markedly across countries. This review was undertaken to describe the regulations and mental-health laws from diverse countries and districts of Europe (UK, Austria, Denmark, France, Germany, Italy, Ireland, and Norway), the Americas (Canada, USA, and Brazil), Australasia (Australia and New Zealand), and Asia (Japan and China). We outline the criteria and procedures for involuntary admission to psychiatric hospitals and to community services, illustrate the key features of laws related to these issues, and discuss their implications for contemporary psychiatric practice. This review may help to standardize the introduction of legislation that allows involuntary admission and treatment of patients with mental disorders in the mainland of China, and contribute to improved mental-health care. In this review, involuntary admission or treatment does not include the placement of mentally-ill offenders, or any other aspect of forensic psychiatry.

Stigmatization of psychiatrists and general practitioners: results of an international survey.

The stigma of mental illness affects psychiatry as a medical profession and psychiatrists. The present study aimed to compare the extent and correlation patterns of perceived stigma in psychiatrists and general practitioners. An international multicenter survey was conducted in psychiatrists and general practitioners from twelve countries. Responses were received from N = 1,893 psychiatrists and N = 1,238 general practitioners. Aspects of stigma assessed in the questionnaire included perceived stigma, self-stigma (stereotype agreement), attitudes toward the other profession, and experiences of discrimination. Psychiatrists reported significantly higher perceived stigma and discrimination experiences than general practitioners. Separate multiple regression analyses showed different predictor patterns of perceived stigma in the two groups. Hence, in the psychiatrists group, perceived stigma correlated best with discrimination experiences and self-stigma, while in the general practitioners group it correlated best with self-stigma. About 17% of the psychiatrists perceive stigma as a serious problem, with a higher rate in younger respondents. Against this background, psychiatry as a medical profession should set a high priority on improving the training of young graduates. Despite the number of existing antistigma interventions targeting mental health professionals and medical students, further measures to improve the image of psychiatry and psychiatrists are warranted, in particular improving the training of young graduates with respect to raising awareness of own stigmatizing attitudes and to develop a better profession-related self-assertiveness.

Review of psychiatric services to mentally disordered offenders around the Pacific Rim.

This article was commissioned to collate and review forensic psychiatric services provided in a number of key Pacific Rim locations in the hope that it will assist in future dialogue about service development. The Board of the Pacific Rim College of Psychiatrists identified experts in forensic psychiatry from Australia, Canada, China, Hong Kong, Japan, Russia, Singapore, Taiwan, and the US. Each contributor provided an account of issues in their jurisdiction, including mental health services to mentally disordered offenders in prison, competence or fitness to stand trial, legal insanity as a defense at trial, diminished responsibility, and special forensic services available, including forensic hospitals and community forensic mental health services. Responses have been collated and are presented topic by topic and country by country within the body of this review. The availability of mental health screening and psychiatric in-reach or forensic liaison services within prisons differed considerably between countries, as did provisioning of community forensic mental health and rehabilitation services. Diversion of mentally disordered offenders to forensic, state, or hybrid hospitals was common. Legal constructs of criminal responsibility (insanity defense) and fitness to stand trial ("disability") are almost universally recognized, although variably used. Disparities between unmet needs and resourcing available were common themes. The legislative differences between contributing countries with respect to the mental health law and criminal law relating to mentally disordered offenders are relatively subtle. The major differences lie in operationalizing and resourcing forensic services.