Prevalence of bipolar disorder and schizophrenia in Houston Outreach Medicine, Education, and Social Services (HOMES) Clinic patients: implications for student-managed clinics for underserved populations

Improving kidney care for people with severe mental health difficulties: a thematic analysis of twenty-two healthcare providers' perspectives

Introduction

People with severe mental health difficulties (SMHDs) and concurrent kidney disease have less access to quality kidney care and worse clinical outcomes. Our research investigates the barriers and facilitators to effective kidney care for people with SMHDs, and how care might be improved for this underserved population.

Methods

We conducted semi-structured interviews with twenty-two physical (n = 14) and mental (n = 8) healthcare professionals with experience working with people with SMHDs and concurrent kidney disease. Interview data were analysed and interpreted using reflexive thematic analysis.

Results

Four themes were generated from the data: 1. "It's about understanding their limitations and challenges, without limiting their rights" describes how some people with SMHDs need additional support when accessing kidney care due to challenges with their mental state, motivation, cognitive difficulties, or mistrust of the healthcare system. 2. "There are people falling through the cracks" describes how the separation of physical and mental healthcare, combined with under-resourcing and understaffing, results in poorer outcomes for people with SMHDs. 3. "Psychiatry is a black spot in our continuing medical education" describes how many renal healthcare providers have limited confidence in their understanding of mental health and their ability to provide care for people with SMHDs. 4. "When they present to a busy emergency department with a problem, the staff tend to go '…psych patient"" describes how stigma towards people with SMHDs can negatively impact quality of care.

Conclusion

Healthcare professionals accounts' describe how people with SMHDs and kidney disease can have favourable outcomes if they have appropriate hospital, community and social supports. Findings indicate that effective management of kidney disease for people with SMHDs requires integrated physical and mental health care, which takes an individualised "whole person" approach to addressing the interaction between kidney disease and mental health.

Chronic kidney disease and severe mental illness: a scoping review

BACKGROUND

People who have severe mental illness experience higher rates of long-term conditions and die on average 15-20 years earlier than people who do not have severe mental illness, a phenomenon known as the mortality gap. Long-term conditions, such as diabetes, impact health outcomes for people who have severe mental illness, however there is limited recognition of the relationship between chronic kidney disease and severe mental illness. Therefore, the aim of this scoping review was to explore the available evidence on the relationship between chronic kidney disease and severe mental illness.

METHODS

Electronic databases, including MEDLINE, Embase, CINAHL, and PsycINFO were searched. The database searches were limited to articles published between January 2000-January 2022, due to significant progress that has been made in the detection, diagnosis and treatment of both SMI and CKD. Articles were eligible for inclusion if they explored the relationship between SMI and CKD (Stages 1-5) in terms of prevalence, risk factors, clinical outcomes, and access to treatment and services. Severe mental illness was defined as conditions that can present with psychosis, including schizophrenia, schizoaffective disorder, bipolar disorder, and other psychotic disorders. Thirty articles were included in the review.

RESULTS

The included studies illustrated that there is an increased risk of chronic kidney disease amongst people who have severe mental illness, compared to those who do not. However, people who have severe mental illness and chronic kidney disease are less likely to receive specialist nephrology care, are less likely to be evaluated for a transplant, and have higher rates of mortality.

CONCLUSION

In conclusion, there is a dearth of literature in this area, but the available literature suggests there are significant health inequalities in kidney care amongst people who have severe mental illness. Further research is needed to understand the factors that contribute to this relationship, and to develop strategies to improve both clinical outcomes and access to kidney care.

Shorter telomere length and suicidal ideation in familial bipolar disorder

Bipolar Disorder (BD) has recently been related to a process of accelerated aging, with shortened leukocyte telomere length (LTL) in this population. It has also been observed that the suicide rate in BD patients is higher than in the general population, and more recently the telomere length variation has been described as shorter in suicide completers compared with control subjects. Objectives The aim of the present study was to investigate if there is an association between LTL and BD in families where two or more members have BD including clinical symptomatology variables, along with suicide behavior. Methods Telomere length and single copy gene ratio (T/S ratio) was measured using quantitative polymerase chain reaction in a sample of 143 relatives from 22 families, of which 60 had BD. The statistical analysis was performed with a polygenic mixed model. Results LTL was associated with suicidal ideation (p = 0.02) as that there is an interaction between suicidal ideation and course of the disorder (p = 0.02). The estimated heritability for LTL in these families was 0.68. In addition, covariates that relate to severity of disease, i.e. suicidal ideation and course of the disorder, showed an association with shorter LTL in BD patients. No difference in LTL between BD patients and healthy relatives was observed. Conclusion LTL are shorter in subjects with familial BD suggesting that stress related sub-phenotypes possibly accelerate the process of cellular aging and correlate with disease severity and suicidal ideation.

Understanding Student-Run Health Initiatives in the Context of Community-Based Services: A Concept Analysis and Proposed Definitions

BACKGROUND

Student-run health initiatives in the community setting have been utilized to provide practical experience for undergraduate students to develop professional competencies, gain exposure to diverse populations, and to engage in activities of social accountability. There is much literature on student-run health initiatives; however, there is no consensus on a definition of this concept or a comprehensive synthesis of the literature that describes student-run health initiatives offered by students in pre-licensure healthcare education programs.

PURPOSE

To provide a concept analysis of, and propose a definition for, student-run health initiatives that provide community-based services for students during pre-licensure health discipline education.

METHODS

A systematic literature search and review process was used to identify and synthesize peer-reviewed articles from 7 academic databases covering a range of pre-licensure health disciplines and education. Walker and Avant's framework for concept analysis was used to guide exploration of attributes, antecedents and consequences of student-run initiatives, and to inform development of a definition for this concept.

RESULTS

The review yielded 222 articles for data extraction and represented 17 distinct pre-licensure health disciplines, 18 health-related disciplines, and a range of other baccalaureate and graduate programs. Our analysis revealed 16 definitions, 5 attributes, 6 antecedents, and consequences identified for student-run health initiatives. Attributes were Provision of Service, Service is Free, Target Clientele, Volunteerism, and Student Governance. Antecedents included Purpose/Rationale, Affiliation with Academic Unit, Location and Partnerships, Funding and Resources, Professional Oversight, and Preparation for Student Role. Consequences were improved access to services and outcomes for clients; competency development, personal gains and interprofessional learning for students; and positive outcomes for broader systems, such as decrease of service utilization and cost/benefit.

CONCLUSIONS

There was no clear conceptual definition for student-run health initiatives, but many defining characteristics and well-described exemplars in the literature. Given the variations in purpose and scope of these initiatives, particularly to distinguish degree of students' roles in operations and the involvement of academic institutions, we propose 3 distinct conceptual definitions: student-run, student-led, and student-infused health initiatives.

Improving the treatment and remission of major depression in homeless people with severe mental illness: The multicentric French Housing First (FHF) program

AIMS

The objectives of the present study were to determine the rates and associated factors of (i) MDD, (ii) antidepressant prescription and (iii) MDD non-remission in homeless subjects with bipolar disorder (BD) or schizophrenia (SZ).

METHODS

This multicenter study was conducted in 4 French cities. MDD was defined with the section L of the MINI. Unremitted MDD was defined by current antidepressant treatment and current MDD.

RESULTS

700 subjects, mean aged 38 years and 82.5% men were included: 55.4% were diagnosed with MDD but only 10.4% were administered antidepressants. Violent victimization in the past 6 months, alcohol use disorder and current substance abuse disorder were associated with increased rates of MDD. 71.2% antidepressant-treated subjects were unremitted. BD diagnosis and substance abuse disorder were found to be associated with increased risk of unremitted MDD. BD-MDD patients were found to be twice more frequently administered antidepressants than SZ-MDD ones, however the non-remission rates were higher in BD subjects compared to SZ. No antidepressant class and no specific antipsychotic or mood stabilizer has been associated with higher or lower rates of remitted MDD.

CONCLUSION

MDD seems to be highly prevalent, underdiagnosed and undertreated in BD and SZ homeless subjects. Beyond antidepressants, add-on strategies including complementary agents, lithium, lamotrigine/carbamazepine or anti-inflammatory drugs and the specific care of alcohol and substance use disorders may be recommended to improve the prognosis of this specific population in addition to other interventions including housing and resocialization. Violent victimization is also frequent and should be specifically prevented in this vulnerable population.

Prescription of potentially inappropriate psychotropic drugs in homeless people with schizophrenia and bipolar disorders. Results from the French Housing First (FHF) program

BACKGROUND

Guidelines have been edited for the treatment of schizophrenia (SZ) and bipolar disorders (BD). Background regimen is currently recommended for both illnesses (antipsychotic drug for SZ and mood stabilizer for BD). The recommendations are less clear for major depression in these disorders. Long-term anxiolytic and hypnotic prescriptions may have potential side effects and should be withdrawn as soon as possible.

OBJECTIVE

The aim of this study was to investigate the prevalence and associated factors of Potentially Inappropriate Psychotropic drugs (PIP) in a large multicenter sample of Homeless Schizophrenia (SZ) and Bipolar Disorder (BD) (HSB) patients.

METHODS

This multicenter study was conducted in 4 French cities: Lille, Marseille, Paris and Toulouse. PIP was defined by at least one item among: (i) absence of background regimen (antipsychotic for SZ or mood stabilizer for BD), (ii) absence of antidepressant for major depressive disorder and (iii) daily long-term anxiolytic or (iv) hypnotic prescription.

RESULTS

Overall, 703 HSB patients, mean aged 38 years and 82.9% men were included, 487 SZ (69.3%) and 216 BD (30.7%). 619 (88.4%) of the patients reported at least one PIP. 386 (54.9%) patients had an inappropriate background regimen prescription (209(43.4%) of SZ had no antipsychotic prescription and 177(81.9%) of BD no mood stabilizer), 336 (48%) had an inappropriate antidepressant prescription (with no significant difference between SZ and BD), 326 (46.4%) had an inappropriate prescription of anxiolytics and 107 (15.2%) had an inappropriate prescription of hypnotics. 388(55%) of the subjects were diagnosed with major depression but only 52(13%) of them were administered antidepressants. In multivariate analysis, PIP was associated with bipolar disorder diagnosis (aOR = 4.67 [1.84-11.89], p = 0.001), current major depressive disorder (aOR = 27.72 [9.53-80.69], p < 0.0001), lower rate of willingness to ask for help (aOR = 0.98[0.96-0.99], p = 0.001). Potentially inappropriate background regimen prescription was associated with bipolar disorder diagnosis (aOR = 6.35 [3.89-10.36], p < 0.0001), lower willingness to ask for help (aOR = 0.99[0.98-0.99], p = 0.01) and lack of lifetime history of psychiatric care (aOR = 0.30[0.12-0.78], p = 0.01). Inappropriate antidepressant prescription was associated with antisocial personality disorder (aOR = 1.58 [1.01-2.48], p = 0.04) and current substance use disorder (aOR = 2.18[1.48-3.20], p < 0.0001).

CONCLUSION

The present findings suggest that almost 9 on 10 HSB subjects may receive a PIP including inappropriate prescriptions or absence of appropriate prescription. Bipolar disorder and/or major depression should be targeted in priority and treated with mood stabilizers and/or antidepressants in this population, while anxiolytics and hypnotics should be withdrawn as much as possible. Major depression should be particularly explored in subjects with comorbid antisocial personality disorder and substance use disorder. The psychiatric care has been associated with better appropriate psychotropic prescriptions and should be reinforced in this population.

Exploring the experiences of violence among individuals who are homeless using a consumer-led approach

Homelessness increases vulnerability to violence victimization; however, the precise factors associated with victimization and injury are not clearly understood. Thus, this study explores the prevalence of and characteristics associated with violence victimization among homeless individuals by surveying approximately 500 individuals experiencing homelessness in 5 cities across the United States. Our findings reveal that nearly one-half of our sample reported experiencing violence and that prolonged duration of homelessness (greater than 2 years) and being older increased the risk of experiencing a violent attack. In addition, increased length of homelessness and female gender predicted experiencing rape. Women were also significantly more likely to know one's perpetrator and experience continued suffering after a violent attack. We conclude that certain subpopulations within the homeless population are at an increased risk for victimization and, subsequently, require added protective services; implications for health care and policy recommendations are also discussed.