Psychiatric readmissions and their association with physical comorbidity: a systematic literature review

Association of somatic comorbidity and treatment adherence in patients with psychotic disorder

BACKGROUND

Increased risk for somatic comorbidity in individuals with schizophrenia has been well established. In addition, psychiatric patients with somatic illnesses are more likely to have more psychiatric readmissions. Increased burden of treatment related to chronic somatic comorbidities may be associated with lower adherence to psychiatric medication.

METHODS

Cross-sectional study of 275 patients with schizophrenia spectrum disorder. A general practitioner performed a complete physical health checkup for all participants, including a complete medical examination and laboratory tests. Patients' adherence, attitudes, insight, and side-effects were evaluated using the Attitudes toward Neuroleptic Treatment Scale. Overall symptomatology was measured using the Brief Psychiatric Rating Scale. Regression analysis was used to investigate interactions and associations among health beliefs, disease burden, and treatment adherence. Separate regression models were utilized to account for the complexity of health behavior and treatment adherence pathways.

RESULTS

Patients' somatic comorbidity and health behavior were not associated with adherence or attitudes toward antipsychotic treatment. High dose of antipsychotics and obesity were related to the need for medical interventions, while a healthy diet reduced the risk. Higher BPRS score and older age were associated with having somatic symptoms. Somatic comorbidities had no negative effects on treatment adherence or attitudes.

CONCLUSION

This study focuses on exploring possible associations between health beliefs and treatment adherence pathways in patients with psychotic disorders. Contrary to our hypotheses, we found no evidence to support our health belief and diseases burden models and their associations.

Psychiatric disorders in childhood cancer survivors: A retrospective matched cohort study of inpatient hospitalisations and community-based mental health services utilisation in Western Australia

OBJECTIVE

We examined the impact of long-term mental health outcomes on healthcare services utilisation among childhood cancer survivors in Western Australia using linked hospitalisations and community-based mental healthcare records from 1987 to 2019.

METHOD

The study cohort included 2977 childhood cancer survivors diagnosed with cancer at age < 18 years in Western Australia from 1982 to 2014 and a matched non-cancer control group of 24,994 individuals. Adjusted hazard ratios of recurrent events were estimated using the Andersen-Gill model. The cumulative burden of events over time was assessed using the method of mean cumulative count. The annual percentage change in events was estimated using the negative binomial regression model.

RESULTS

The results showed higher community-based service contacts (rate/100 person-years: 30.2, 95% confidence interval = [29.7-30.7] vs 22.8, 95% confidence interval = [22.6-22.9]) and hospitalisations (rate/1000 person-years: 14.8, 95% confidence interval = [13.6-16.0] vs 12.7, 95% confidence interval = [12.3-13.1]) in childhood cancer survivors compared to the control group. Childhood cancer survivors had a significantly higher risk of any event (adjusted hazard ratio = 1.5, 95% confidence interval = [1.1-2.0]). The cumulative burden of events increased with time since diagnosis and across age groups. The annual percentage change for hospitalisations and service contacts significantly increased over time (p < 0.05). Substance abuse was the leading cause of hospitalisations, while mood/affective and anxiety disorders were common causes of service contacts. Risk factors associated with increased service events included cancer diagnosis at age < 5 years, leukaemia diagnosis, high socioeconomic deprivation, and an attained age of < 18 years.

CONCLUSIONS

The elevated utilisation of healthcare services observed among childhood cancer survivors emphasises the need for periodic assessment of psychiatric disorders, particularly in high-risk survivors, to facilitate early management and optimise healthcare resources.

Nurses' and patients' perceptions of physical health screening for patients with schizophrenia spectrum disorders: a qualitative study

BACKGROUND

Despite worldwide concern about the poor physical health of patients with schizophrenia spectrum disorders (SSD), physical health screening rates are low. This study reports nurses' and patients' experiences of physical health screening among people with SSD using the Finnish Health Improvement Profile (HIP-F) and their ideas for implementation improvements.

METHODS

A qualitative exploratory study design with five group interviews with nurses (n = 15) and individual interviews with patients with SSD (n = 8) who had experience using the HIP-F in psychiatric outpatient clinics. Inductive content analysis was conducted.

RESULTS

Two main categories were identified. First, the characteristics of the HIP-F were divided into the subcategories of comprehensive nature, facilitating engagement, interpretation and rating of some items and duration of screening. Second, suggestions for the implementation of physical health screening consisted of two subcategories: improvements in screening and ideas for practice. Physical health screening was felt to increase the discussion and awareness of physical health and supported health promotion. The HIP-F was found to be a structured, comprehensive screening tool that included several items that were not otherwise assessed in clinical practice. The HIP-F was also considered to facilitate engagement by promoting collaboration in an interactive way. Despite this, most of the nurses found the HIP-F to be arduous and too time consuming, while patients found the HIP-F easy to use. Nurses found some items unclear and infeasible, while patients found all items feasible. Based on the nurses' experiences, screening should be clear and easy to interpret, and condensation and revision of the HIP-F tool were suggested. The patients did not think that any improvements to the HIP-F were needed for implementation in clinical settings.

CONCLUSIONS

Patients with schizophrenia spectrum disorders are willing to participate in physical health screening. Physical health screening should be clear, easy to use and relatively quick. With this detailed knowledge of perceptions of screening, further research is needed to understand what factors affect the fidelity of implementing physical health screening in clinical mental health practice and to gain an overall understanding on how to improve such implementation.

Interventions promoting recovery from depression for patients transitioning from outpatient mental health services to primary care: A scoping review

INTRODUCTION

Major Depressive Disorder (MDD) is one of the most prevalent mental disorders worldwide with significant personal and public health consequences. After an episode of MDD, the likelihood of relapse is high. Therefore, there is a need for interventions that prevent relapse of depression when outpatient mental health care treatment has ended. This scoping review aimed to systematically map the evidence and identify knowledge gaps in interventions that aimed to promote recovery from MDD for patients transitioning from outpatient mental health services to primary care.

MATERIALS AND METHODS

We followed the guidance by Joanna Briggs Institute in tandem with the PRISMA extension for Scoping Reviews checklist. Four electronic databases were systematically searched using controlled index-or thesaurus terms and free text terms, as well as backward and forward citation tracking of included studies. The search strategy was based on the identification of any type of intervention, whether simple, multicomponent, or complex. Three authors independently screened for eligibility and extracted data.

RESULTS

18 studies were included for review. The studies had high heterogeneity in design, methods, sample size, recovery rating scales, and type of interventions. All studies used several elements in their interventions; however, the majority used cognitive behavioural therapy conducted in outpatient mental health services. No studies addressed the transitioning phase from outpatient mental health services to primary care. Most studies included patients during their outpatient mental health care treatment of MDD.

CONCLUSIONS

We identified several knowledge gaps. Recovery interventions for patients with MDD transitioning from outpatient mental health services to primary care are understudied. No studies addressed interventions in this transitioning phase or the patient's experience of the transitioning process. Research is needed to bridge this gap, both regarding interventions for patients transitioning from secondary to primary care, and patients' and health care professionals' experiences of the interventions and of what promotes recovery.

REGISTRATION

A protocol was prepared in advance and registered in Open Science Framework (https://osf.io/ah3sv), published in the medRxiv server (https://doi.org/10.1101/2022.10.06.22280499) and in PLOS ONE (https://doi.org/10.1371/journal.pone.0291559).

Integrating Electronic Health Records and Polygenic Risk to Identify Genetically Unrelated Comorbidities of Schizophrenia That May Be Modifiable

Background

Patients with schizophrenia have substantial comorbidity that contributes to reduced life expectancy of 10 to 20 years. Identifying modifiable comorbidities could improve rates of premature mortality. Conditions that frequently co-occur but lack shared genetic risk with schizophrenia are more likely to be products of treatment, behavior, or environmental factors and therefore are enriched for potentially modifiable associations.

Methods

Phenome-wide comorbidity was calculated from electronic health records of 250,000 patients across 2 independent health care institutions (Vanderbilt University Medical Center and Mass General Brigham); associations with schizophrenia polygenic risk scores were calculated across the same phenotypes in linked biobanks.

Results

Schizophrenia comorbidity was significantly correlated across institutions (r = 0.85), and the 77 identified comorbidities were consistent with prior literature. Overall, comorbidity and polygenic risk score associations were significantly correlated (r = 0.55, p = 1.29 × 10-118). However, directly testing for the absence of genetic effects identified 36 comorbidities that had significantly equivalent schizophrenia polygenic risk score distributions between cases and controls. This set included phenotypes known to be consequences of antipsychotic medications (e.g., movement disorders) or of the disease such as reduced hygiene (e.g., diseases of the nail), thereby validating the approach. It also highlighted phenotypes with less clear causal relationships and minimal genetic effects such as tobacco use disorder and diabetes.

Conclusions

This work demonstrates the consistency and robustness of electronic health record-based schizophrenia comorbidities across independent institutions and with the existing literature. It identifies known and novel comorbidities with an absence of shared genetic risk, indicating other causes that may be modifiable and where further study of causal pathways could improve outcomes for patients.

Length of hospital stay in involuntary admissions in Greece: a 10-year retrospective observational study

PURPOSE

The treatment of mental disorders has shifted from inpatient wards to community-based settings in recent years, but some patients may still have to be admitted to inpatient wards, sometimes involuntarily. It is important to maintain the length of hospital stay (LoS) as short as possible while still providing adequate care. The present study aimed to explore the factors associated with the LoS in involuntarily admitted psychiatric patients.

METHODS

A ten-year retrospective chart review of 332 patients admitted involuntarily to the inpatient psychiatric ward of the General University Hospital of Ioannina, Northwestern Greece, between 2008 and 2017 was conducted.

RESULTS

The mean LoS was 23.8 (SD = 33.7) days and was relatively stable over the years. Longer-stay hospitalization was associated with schizophrenia-spectrum disorder diagnosis, previous hospitalizations and the use of mechanical restraint, whereas patients in residential care experienced significantly longer LoS (52.6 days) than those living with a caregiver (23.5 days) or alone (19.4 days). Older age at disease onset was associated with shorter LoS, whereas no statistically significant differences were observed with regard to gender.

CONCLUSION

While some of our findings were in line with recent findings from other countries, others could not be replicated. It seems that multiple factors influence LoS and the identification of these factors could help clinicians and policy makers to design more targeted and cost-effective interventions. The optimization of LoS in involuntary admissions could improve patients' outcomes and lead to more efficient use of resources.

Comorbidity Burden and Health Care Utilization by Substance use Disorder Patterns among People with HIV in Florida

Substance use disorder (SUD), a common comorbidity among people with HIV (PWH), adversely affects HIV clinical outcomes and HIV-related comorbidities. However, less is known about the incidence of different chronic conditions, changes in overall comorbidity burden, and health care utilization by SUD status and patterns among PWH in Florida, an area disproportionately affected by the HIV epidemic. We used electronic health records (EHR) from a large southeastern US consortium, the OneFlorida + clinical research data network. We identified a cohort of PWH with 3 + years of EHRs after the first visit with HIV diagnosis. International Classification of Diseases (ICD) codes were used to identify SUD and comorbidity conditions listed in the Charlson comorbidity index (CCI). A total of 42,271 PWH were included (mean age 44.5, 52% Black, 45% female). The prevalence SUD among PWH was 45.1%. Having a SUD diagnosis among PWH was associated with a higher incidence for most of the conditions listed on the CCI and faster increase in CCI score overtime (rate ratio = 1.45, 95%CI 1.42, 1.49). SUD in PWH was associated with a higher mean number of any care visits (21.7 vs. 14.8) and more frequent emergency department (ED, 3.5 vs. 2.0) and inpatient (8.5 vs. 24.5) visits compared to those without SUD. SUD among PWH was associated with a higher comorbidity burden and more frequent ED and inpatient visits than PWH without a diagnosis of SUD. The high SUD prevalence and comorbidity burden call for improved SUD screening, treatment, and integrated care among PWH.

Classification of Schizophrenia, Bipolar Disorder and Major Depressive Disorder with Comorbid Traits and Deep Learning Algorithms

Recent GWASs have demonstrated that comorbid disorders share genetic liabilities. But whether and how these shared liabilities can be used for the classification and differentiation of comorbid disorders remains unclear. In this study, we use polygenic risk scores (PRSs) estimated from 42 comorbid traits and the deep neural networks (DNN) architecture to classify and differentiate schizophrenia (SCZ), bipolar disorder (BIP) and major depressive disorder (MDD). Multiple PRSs were obtained for individuals from the schizophrenia (SCZ) (cases = 6,317, controls = 7,240), bipolar disorder (BIP) (cases = 2,634, controls 4,425) and major depressive disorder (MDD) (cases = 1,704, controls = 3,357) datasets, and classification models were constructed with and without the inclusion of PRSs of the target (SCZ, BIP or MDD). Models with the inclusion of target PRSs performed well as expected. Surprisingly, we found that SCZ could be classified with only the PRSs from 35 comorbid traits (not including the target SCZ and directly related traits) (accuracy 0.760 ± 0.007, AUC 0.843 ± 0.005). Similar results were obtained for BIP (33 traits, accuracy 0.768 ± 0.007, AUC 0.848 ± 0.009), and MDD (36 traits, accuracy 0.794 ± 0.010, AUC 0.869 ± 0.004). Furthermore, these PRSs from comorbid traits alone could effectively differentiate unaffected controls, SCZ, BIP, and MDD patients (average categorical accuracy 0.861 ± 0.003, average AUC 0.961 ± 0.041). These results suggest that the shared liabilities from comorbid traits alone may be sufficient to classify SCZ, BIP and MDD. More importantly, these results imply that a data-driven and objective diagnosis and differentiation of SCZ, BIP and MDD may be feasible.

Shared and unique characteristics of metabolic syndrome in psychotic disorders: a review

Introduction

People with psychosis spectrum disorders (PSD) face an elevated risk of metabolic syndrome (MetS), which may reduce their life expectancy by nearly 20%. Pinpointing the shared and specific characteristics and clinical implications of MetS in PSD is crucial for designing interventions to reduce this risk, but an up-to-date review on MetS across the psychosis spectrum is lacking.

Methods

This narrative review fills this gap by examining the clinical literature on characteristics and implications of MetS in both distinct PSD and transdiagnostically, i.e., across traditional categorical diagnoses, with a focus on psychiatric and cardio-metabolic management.

Results

We discuss common and specific characteristics of MetS in PSD, as well as factors contributing to MetS development in PSD patients, including unhealthy lifestyle factors, genetic predisposition, pro-inflammatory state, drugs consumption, antipsychotic medication, and psychotic symptoms. We highlight the importance of early identification and management of cardio-metabolic risk in PSD patients, as well as the existing gaps in the literature, for instance in the screening for MetS in younger PSD patients. We compare hypotheses-generating clinical associations and characteristics of MetS in different PSD, concluding by reviewing the existing recommendations and challenges in screening, monitoring, and managing MetS in PSD.

Conclusion

Early identification and management of MetS are crucial to mitigate the long-term cardio-metabolic toll in PSD patients. Interventions should focus on healthy lifestyle and appropriate pharmacological and behavioral interventions. Further translational and clinical research is needed to develop targeted interventions and personalized treatment approaches for this vulnerable population, aiming at improving physical health and overall well-being.

The effect of neuroendocrine abnormalities on the risk of psychiatric readmission after hospitalization for bipolar disorder: A retrospective study

BACKGROUND

The correlation between the endocrine system and bipolar disorder(BD) has been well recognized, yet the influence of neuroendocrine hormones on readmission risk post-hospitalization for BD remains largely unexplored. This retrospective cohort study was to scrutinize the impact of neuroendocrine functionality on the readmission of patients with BD post-hospitalization for mental disorders.

METHODS

The dataset was derived from the electronic medical records of the First Affiliated Hospital of Jinan University in Guangzhou, China. Both univariate and multivariate logistic regression analysis were conducted on all patients hospitalized for BD, and from 1 January 2017 to October 2022.

RESULTS

Of the 1110 eligible patients, 83 and 141 patients experienced psychiatric readmissions within 90 and 180 days post-discharge, respectively. Multivariate analysis revealed that high serum TSH levels (aOR = 1.079; 95%CI = 1.003-1.160) and thyroid disease comorbidities (aOR = 2.899; 95%CI = 1.303-6.452) were independently correlated with the risk of 90-day readmission; while increased serum TSH levels (aOR = 1.179; 95%CI = 1.081-1.287) represented a risk factor for 180-day readmission. These results indicate that high serum TSH levels and thyroid disease comorbidities may contribute to an elevated readmission risk in patients with BD following hospitalization.

CONCLUSION

Routinely evaluating and intervening in thyroid function is crucial in the treatment of BD, as it may aid in preventing re-hospitalization.

"They had clothes on their back and they had food in their stomach, but they didn't have me": The contribution of parental mental health problems, substance use, and domestic violence and abuse on young people and parents

BACKGROUND

The parental risk factors of mental health problems, substance use, and domestic violence and abuse each individually negatively impacts children's health and developmental outcomes. Few studies have considered the lived experience and support needs of parents and children in the real-world situation where these common risks cluster.

OBJECTIVE

This study explores parents' and young people's lived experiences of the clustering of parental mental health problems, parental substance use, and domestic violence and abuse.

METHODS

Semi-structured interviews were conducted with 18 mothers, 6 fathers, and 7 young people with experiences of these parental risk factors. Transcribed interviews were analysed using reflexive thematic analysis.

RESULTS

Four themes were developed, 1) cumulative adversity, 2) the impact of syndemic risk, 3) families navigating risk, and 4) family support. Parents and young people described family situations of stress wherein they experienced cumulative impact of multiple parental risk factors. Parents sought to navigate stressors and parent in positive ways under challenging conditions, often impeded by their own childhood trauma and diminished confidence. Parents and young people spoke of the need for, and benefits of having, support; both as a family and as individuals, to successfully address this trio of parental risks and the related impact.

CONCLUSIONS

This study highlights the high level of stress families experience and the efforts they go to mitigate risk. Services and interventions need to reflect the complexity of multiple needs and consider both the whole family and individuals when providing support.

Metabolic disturbances are risk factors for readmission to psychiatric hospitals in non-smokers but not in smokers: results from a Swiss psychiatric cohort and in first-episode psychosis patients

Background

Psychiatric patients are at high risk of readmission, and a high body mass index has previously been shown as a risk factor. We sought to replicate this finding and 1) to prospectively assess the association of metabolic syndrome and its five components with readmission in psychiatric hospitals and 2) to identify other clinical and sociodemographic predictors of readmission.

Methods

Between 2007 and 2019, data on 16727 admissions of 7786 adult and elderly patients admitted to the Department of Psychiatry of the Lausanne University Hospital, were collected. Metabolic syndrome was defined according to the International Diabetes Federation definition. Cox frailty models were used to investigate the associations between readmission and metabolic disturbances.

Results

A total of 2697 (35%) patients were readmitted to our psychiatric hospital. Novel risk factors for readmission in non-smokers were identified, including being overweight (HR=1.26; 95%CI=[1.05; 1.51]) or obese (HR=1.33; 95%CI=[1.08; 1.62]), displaying hypertriglyceridemia (HR=1.21; 95%CI=[1.04; 1.40]) and metabolic syndrome (HR=1.26; 95%CI=[1.02; 1.55]). Central obesity and hyperglycemia increased the risk of readmission when considering the Health of the Nation Outcome Scales variable. In first-episode psychosis patients, obesity (HR=2.23; 95%CI=[1.14; 4.30]) and high-density lipoprotein hypocholesterolemia (HR=1.90; 95%CI=[1.14; 3.20]) doubled the risk of readmission.

Conclusion

The observed interaction between smoking and metabolic variables are compatible with a ceiling effect; metabolic variables increase the risk of readmission in non-smokers but not in smokers who are already at higher risk. Future studies should determine whether better metabolic monitoring and treatment can reduce readmission risk.

Psychiatric complications in Graves' disease

Background

Mood disorders are common in Graves' disease despite treatment. The pathogenic mechanisms involved are unknown and so is whether previous psychiatric disease influences these symptoms.

Methods

This is a longitudinal study conducted in Sweden on 65 women with newly diagnosed Graves' disease and 65 matched controls. Participants were examined during hyperthyroidism and after 15 months of treatment. Examinations included blood sampling, and psychiatric testing with the Comprehensive Psychopathological Rating Scale for Affective Syndromes and the Structured Clinical Interview for DSM-IV - Axis I Disorders. We also performed two analyses of a national population-based registry to determine previous psychiatric diagnoses and previous prescriptions of psychoactive drugs in (i) all patients we asked to participate and (ii) all Swedish women given a diagnosis of hyperthyroidism during 2013-2018, comparing them to matched controls.

Results

There was no increased previous psychiatric comorbidity in Graves' patients compared to controls. There was no higher prevalence of psychiatric diagnoses and prescriptions of psychoactive drugs between (i) included GD patients compared to those who declined participation and (ii) women with a hyperthyroidism diagnosis in 5 years prior to their diagnosis, compared to matched controls. Depression scores and anxiety scores were higher in patients compared to controls both during hyperthyroidism (depression (median (IQR): 7.5 (5.0-9.5) vs 1.0 (0.5-2.5) P < 0.001), anxiety: 7.7 (5.0-11) vs 2.5 (1.0-4.0) P < 0.001) and after treatment (depression: 2.5 (1.5-5.0) vs 1.5 (0.5-3.5) P < 0.05), anxiety: 4.0 (2.5-7.5) vs 3.0 (1.5-5.0) P < 0.05). Patients with a previous psychiatric condition, mild eye symptoms, and a younger age had more anxiety at 15 months compared to patients without these symptoms and a higher age (all p<0.05).

Conclusion

Graves' disease affects patients' mood despite treatment. A previous psychiatric condition, mild eye symptoms, and a younger age increase the vulnerability for long-lasting symptoms and require specific attention.

A file audit of gym usage in an Australian private inpatient psychiatric hospital

OBJECTIVE

This study aimed to determine the extent to which people admitted to a private psychiatric inpatient unit access and utilise the gymnasium and individualised coaching with an exercise physiologist (EP).

METHODS

An audit of the medical record of 100 consecutive discharges and 60 individuals referred to an EP during the audit period was undertaken. Selected demographic information, physical health status, psychiatric diagnosis and routinely collected outcome data were extracted from files.

RESULTS

Twenty-four percent of people discharged from the hospital had documentary evidence of having attended the gym. These people were noted to have used the gym regularly and had an exercise prescription documented on discharge. Those with substance use disorder were more likely to use the gym than those diagnosed with an affective disorder. There were no significant differences in outcomes between those who were noted to exercise and those who did not.

CONCLUSION

Those who may most benefit from coaching around exercise in the context of hospital admission are not presently the individuals most likely to be referred to an EP. Standardised procedures for assessment, referral, exercise prescription and ongoing monitoring of activity and outcomes are recommended across the care continuum.

[Mental disorders, social and demographic characteristics of patients with chronic and episodic migraine]

OBJECTIVE

To compare socio-demographic, clinical and psychological characteristics and comorbid mental disorders in patients with chronic migraine (CM) and episodic migraine (EM).

MATERIAL AND METHODS

Eighty patients with migraine (40 with CM (16 men and 24 women, mean age 33.5±6.1 years) and 40 with EM (9 men and 31 women, mean age 31.4±5.7 years) were examined. All patients were interviewed and tested with psychometric methods. Socio-demographic and clinical-psychological characteristics were determined in all patients. The psychiatrist assessed the mental status of patients and diagnosed comorbid mental disorders according to the ICD-10 criteria.

RESULTS

Symptoms of depression, high levels of trait and state anxiety, and a tendency to emotional inadequacy of response were more common in CM patients than in EM patients (p<0.05). Mental disorders, predominantly of the anxiety-depressive spectrum, were more common in CM patients than EM patients (OR (95% CI)=2.54 (2.03 to 2.98, p<0.001). Seventy-five percent of CM patients had more than one psychiatric diagnosis, almost a quarter of CM patients had schizotypal disorder, which is significantly higher than in EM patients (OR (95% CI)=1.99; 1.03 to 2.42, p<0.001). There were more unmarried, single (without constant partner), unemployed, high-education patients in the CM group than in the EM group. The negative impact of headache on the daily activity of patients was significantly higher in the CM group than in the EM group (p<0.05).

CONCLUSION

Mental disorders and psychological features (anxiety, depression symptoms, a tendency to emotional inadequacy of response) are more common in CM patients than in EM patients. The presence of these factors may contribute to the chronification of migraine.

Making meaning of multimorbidity and severe mental illness: A viewpoint

People living with severe mental illness, such as schizophrenia and bipolar affective disorder, frequently experience poorer physical health compared to those without mental illness. This issue has hitherto been approached through the disease-centred construct of comorbidity, where subsequent conditions are viewed as secondary to an 'index condition'. In contrast, this Viewpoint sets out to explain why multimorbidity, a patient-centred concept that instead refers to the coexistence of multiple chronic illnesses, is a more versatile and robust framework for tackling the issue of poor physical health in people with severe mental illness. In establishing this argument, this Viewpoint has sought to address three key areas. First, this article will discuss the epidemiology of both physical and psychiatric multimorbidity, with respect to how they manifest at greater frequency and at younger ages in people with severe mental illness. Second, the profound consequences of this multimorbidity burden will be explored, with respect to the 'three D's' of death (premature mortality), disability (functional impacts) and deficit (health-economic impacts). Finally, the utility of multimorbidity as a framework will be illustrated through a proposal for a three-dimensional multimorbidity construct composed of (1) quantity, (2) severity and (3) duration of an individual's chronic illnesses. Consequently, this Viewpoint aims to capture why it is necessary for modern psychiatry to grasp the concept of multimorbidity to facilitate holistic healthcare for people living with severe mental illness.

Status after Hospital Discharge: An Observational Study of the Progression of Patients' Mental Health Symptoms Six Weeks after Hospital Discharge

(1) Background: Transitioning from mental health inpatient care to community care is often a vulnerable time in the treatment process where additional risks and anxiety may arise. We collected data for this study as part of a pragmatic cluster-randomized, longitudinal approach in Alberta. As the first phase of the ongoing innovative supportive program, this paper assessed the progression of mental health symptoms in patients six weeks after hospital discharge. Factors that may contribute to the presence or absence of anxiety and depression symptoms, as well as well-being, following return to the community were investigated. This provides evidence and baseline data for future phases of the project. (2) Methods: An observational study design was adopted for this study. Data on a variety of sociodemographic and clinical factors were collected at discharge and six weeks after via REDCap. Anxiety, depression, and well-being symptoms were assessed using the Generalized Anxiety Disorder (GAD-7) questionnaire, the Patient Health Questionnaire-9 (PHQ-9), and the World Health Organization-Five Well-Being Index (WHO-5), respectively. Descriptive, chi-square, independent t-tests, and multivariate regression analyses were conducted. (3) Result: The survey was completed by 88 out of 306 participants (28.8% response rate). The chi-square/Fisher exact test and independent t-test revealed no significant change in the mental health conditions from baseline to six weeks after discharge. It was found that the only significant factor predicting symptoms six weeks after discharge from inpatient treatment was the baseline symptoms in all three logistic regression models. It was four times more likely for those who experienced anxiety and depression at baseline to experience anxiety and depression symptoms six weeks after discharge (OR = 4.27; 95% CI: 1.38-13.20) (OR = 4.04; 95% CI: 1.25-13.05). Those with poor baseline well-being were almost 12 times more likely to experience poor well-being six weeks after discharge (OR = 11.75; 95% CI: 3.21-42.99). (4) Conclusions: Study results found no significant change in mental health conditions in the short term following hospital discharge. It is essential that researchers and policymakers collaborate in order to implement effective interventions to support and maintain the mental health conditions of patients following discharge.

Reduction of Mental Health-Related Emergency Department Admissions for Youth and Young Adults Following a Remote Intensive Outpatient Program: Quality Improvement Analysis

BACKGROUND

Pediatric mental health emergency department (ED) visits are increasing at 6% to 10% per year, at substantial cost, while 13% of youth with psychiatric hospitalizations are readmitted in the following weeks. Hospitals do not have the resources to meet escalating youth's mental health needs. Intensive outpatient (IOP) programs, which provide multiple hours of care each week, have the power to reduce the number of patients in need of hospitalized care and provide a step-down option for patients discharging from ED's in order to prevent readmissions.

OBJECTIVE

The purpose of this program evaluation was to assess (1) whether youth and young adult ED admission rates decreased following participation in a remote IOP program and (2) whether there were differences in readmission rates between youth and young adults by gender identity, sexual orientation, race, or ethnicity.

METHODS

Data were collected from intake and 3-month postdischarge surveys for 735 clients who attended at least 6 sessions of a remote IOP program for youth and young adults. Patients reported if they had been admitted to an ED within the previous 30 days and the admission reason. Over half (407/707, 57.6%) of clients were adolescents and the rest were young adults (300/707, 42.4%; mean age 18.25, SD 4.94 years). The sample was diverse in gender identity (329/687, 47.9% female; 196/687, 28.5% male; and 65/669, 9.7% nonbinary) and sexual orientation (248/635, 39.1% heterosexual; 137/635, 21.6% bisexual; 80/635, 10.9% pansexual; and 170/635, 26.8% other sexual orientation) and represented several racial (9/481, 1.9% Asian; 48/481, 10% Black; 9/481, 1.9% Indigenous; 380/481, 79% White; and 35/481, 7.2% other) and ethnic identities (112/455, 24.6% Hispanic and 28/455, 6.2% other ethnic identity).

RESULTS

Mental health-related ED admissions significantly decreased between intake and 3 months after discharge, such that 94% (65/69) of clients with a recent history of mental health-related ED admissions at IOP intake reported no mental health-related ED admissions at 3 months after discharge from treatment (χ21=38.8, P<.001). There were no differences in ED admissions at intake or in improvement at 3 months after discharge by age, gender, sexuality, race, or ethnicity.

CONCLUSIONS

This study documents a decrease in ED admissions between intake and 3 months after discharge among both youth and young adults who engage in IOP care following ED visits. The similar outcomes across demographic groups indicate that youth and young adults experience similar decreases after the current tracks of programming. Future research could conduct a full return-on-investment analysis for intensive mental health services for youth and young adults.

Interventions promoting recovery from depression for patients transitioning from outpatient mental health services to primary care: Protocol for a scoping review

INTRODUCTION

Patients with severe Major Depressive Disorder (MDD) have an increasing risk of new psychiatric hospitalizations following each new episode of depression highlighting the recurrent nature of the disorder. Furthermore, patients are not fully recovered at the end of their treatment in outpatient mental health services, and residual symptoms of depression might explain why patients with MDD have a high risk of relapse. However, evidence of methods to promote recovery after discharge from outpatient mental health services is lacking. The proposed scoping review aims to systematically scope, map and identify the evidence and knowledge gaps on interventions that aims to promote recovery from MDD for patients transitioning from outpatient mental health services to primary care.

MATERIALS AND METHODS

The proposed scoping review will follow the latest methodological guidance by the Joanna Briggs Institute (JBI) in tandem with the Preferred Reporting Items for Systematic reviews and Meta-Analysis-extension for Scoping Reviews (PRISMA-ScR) checklist. The review is ongoing. Four electronic databases (Medline via PubMed, PsycINFO, CINAHL, and Sociological Abstracts) were systematically searched from 20 January 2022 till 29 March 2022 using keywords and text words. The review team consists of three independent screeners. Two screeners have completed the initial title and abstract screening for all studies retrieved by the search strategy. Currently, we are in the full text screening phase. Reference lists of included studies will be screened, and data will be independently extracted by the review team. Results will be analyzed qualitatively and quantitatively.

DISCUSSION

The chosen methodology is based on the use of publicly available information and does not require ethical approval. Results will be published in an international peer reviewed scientific journal, at national and international conferences and shared with relevant authorities.

REGISTRATION

A pre-print has been registered at the medRxiv preprint server for health sciences (doi.org/10.1101/2022.10.06.22280499).

'Auspicious liaisons'-evaluating the impact of a liaison geriatrician initiative on older adults psychiatric wards

BACKGROUND

Although liaison services in acute hospitals are now the norm, the reverse is not usually available for patients in mental health trusts. Following the introduction of support from geriatricians to older people's mental health inpatient wards, we wanted to see if this intervention was effective and acceptable to clinicians.

METHODS

We performed a retrospective cohort service evaluation on the impact of a liaison geriatrician, using routinely collected data, and assessed acceptability among medical staff by semi-structured interview.

INTERVENTION

Our service introduced regular sessions from consultant community geriatricians across older adults psychiatric wards including a mixture of video conference and face-to-face input.

RESULTS

There was no significant decrease in emergency transfers but there was a significant reduction in length of stay with an associated cost benefit for the service after the introduction of a liaison geriatrician. There was a significant increase in geriatrician consultations and a decrease in specialty consultations to other specialists. There was no change in discharge prescriptions or destination. There was a significant reduction in falls in the intervention arm but not in falls leading to emergency hospital admissions geriatricians gave confidence to psychiatrists of all grades to treat physical health care issues.

CONCLUSIONS

A liaison geriatrician service may be a component in reducing length of stay (although there are many others) and improving continuity of care, although it confers no impact on emergency transfers. The intervention was highly acceptable to clinicians.

The somatic care of patients with comorbid mental disorders: protocol of a mixed-methods study aiming to identify barriers to and enablers of utilization of somatic healthcare (SoKo)

BACKGROUND

Healthcare for people with somatic and comorbid mental diseases can pose a challenge to the healthcare system. The aim of the SoKo study (the Somatic care of patients with mental Comorbidity) is to assess the current state of care and the facilitators and barriers of somatic care of people with somatic disorders and comorbidity of a mental disorder.

METHODS

The study is conducted as a mixed-methods approach and will include (a) descriptive and inferential analysis of secondary claims data of persons insured by a German statutory health insurance company in North Rhine-Westphalia (Techniker Krankenkasse, TK-NRW), (b) qualitative individual interviews and group discussions, and (c) based on (a) and (b), quantitative surveys of both patients and physicians. We intend to analyse a sample of claims data of about 2.6 million persons insured by TK-NRW (group comparisons between TK-NRW insured persons with a diagnosis of a prevalent somatic disease [ICD-10-GM E01-E07, E11, E66, I10-I15, I20-I25, I60-I64] with and without comorbidity of a mental disorder [F00-F99]), in order to assess the uptake of somatic care by people with mental and somatic comorbidity. In addition, primary data from patients with the aforementioned somatic illnesses and a mental comorbidity as well as primary data from physicians (general practitioners and medical specialists) will be collected. The focus here will be on support factors and barriers in the somatic care of people with mental comorbidity.

DISCUSSION

Up to now, there have been no published results of a systematic collection of both secondary and primary data on the utilisation of different care services of somatically ill patients with mental comorbidity for Germany. The present mixed-methods study aims to address this gap.

TRIAL REGISTRATION

The trial is registered with the German Clinical Trials Register DRKS: DRKS00030513. The trial was registered on 3rd February 2023.

Advanced Biomarkers of Hepatotoxicity in Psychiatry: A Narrative Review and Recommendations for New Psychoactive Substances

One of the factors that increase the effectiveness of the pharmacotherapy used in patients abusing various types of new psychoactive substances (NPSs) is the proper functioning of the liver. However, the articles published to date on NPS hepatotoxicity only address non-specific hepatic parameters. The aim of this manuscript was to review three advanced markers of hepatotoxicity in psychiatry, namely, osteopontin (OPN), high-mobility group box 1 protein (HMGB1) and glutathione dehydrogenase (GDH, GLDH), and, on this basis, to identify recommendations that should be included in future studies in patients abusing NPSs. This will make it possible to determine whether NPSs do indeed have a hepatotoxic effect or whether other factors, such as additional substances taken or hepatitis C virus (HCV) infection, are responsible. NPS abusers are at particular risk of HCV infection, and for this reason, it is all the more important to determine what factors actually show a hepatotoxic effect in them.

Prevalence and characteristics of mental and physical disorders among female prisoners: a mixed-methods systematic review

PURPOSE

This study aims to provide an overview and quality appraisal of the current scientific evidence concerning the prevalence and characteristics of mental and physical disorders among sentenced female prisoners.

DESIGN/METHODOLOGY/APPROACH

A mixed-methods systematic literature review.

FINDINGS

A total of 4 reviews and 39 single studies met the inclusion criteria for the review. Mental disorders were the main area of investigation in the majority of single studies, with substance abuse, particularly drug abuse, as the most consistently gender biased disorder, with higher prevalence among women than men in prison. The review identified a lack of updated systematic evidence on the presence of multi-morbidity.

ORIGINALITY/VALUE

This study provides an up-to-date overview and quality appraisal of the current scientific evidence concerning the prevalence and characteristics of mental and physical disorders among female prisoners.

Perceived stigma, common mental disorders and associated factors among primary caregivers of adult patients with mental illness attending at public hospitals, Harari regional state, Eastern Ethiopia: A multicenter cross-sectional study

Background

Giving care to someone who is experiencing mental distress is a difficult and challenging task that could be detrimental to the caregiver's overall quality of life. Numerous studies show that caregivers frequently experience mental distress and feel stigmatized. However, there is limited study done on this topic in our country.

Objective

To determine the magnitude and associated factors of perceived stigma and common mental disorder among primary caregivers of adults with mental illness in public hospitals at Harari regional state, Eastern Ethiopia, 2022.

Methods

A cross-sectional study design was conducted. A total of 419 participants were recruited by a systematic random sampling technique. The data was collected by using a face-to-face interview and by reviewing patients' charts. Perceived stigma and common mental disorder were assessed by Family Interview Schedule and Self-Reporting Questionnaire, respectively. Epi-data version 4.6.2 was used to enter data, and SPSS version 20 was used to analyze. Bivariable and multivariable logistic regression were performed. P-values < 0.05 were considered statistically significant.

Result

The magnitude of perceived stigma and common mental disorder were 42.5% (95% CI, 37.7-47.3) and 39.4% (95% CI, 34.8-44.0) respectively. Age of caregiver between 26 and 33 [AOR = 3.13, 95% CI: (1.71-8.93)], no formal education [AOR = 3.85, 95% CI: (1.81-8.15)], illness duration ≥7 years [AOR = 1.93, 95% CI: (1.04-3.57)], family history of mental illness [AOR = 1.92, 95% CI: (1.09-3.39)] and poor social support [AOR = 4.87, 95% CI: (3.74-12.71)] were significantly associated with perceived stigma. Being female [AOR = 1.92, 95% CI: (1.31-3.34)], having no formal education [AOR = 4.04, 95% CI: (2.15-10.01)], having a family history of mental illness [AOR = 2.26, 95% CI: (1.29-4.00)], having comorbid other illness [AOR = 2.13, 95% CI: (1.15-3.94)], and having poor social support [AOR = 4.58, 95% CI: (2.53-8.28)] were significantly associated with common mental disorder.

Conclusion

The magnitude of perceived stigma and common mental disorder was high among primary caregivers of patients with mental illness compared with other studies. Age of caregiver between 26 and 33, no formal education, duration of illness ≥7 years, family history of mental illness and poor social support were associated with perceived stigma and being female, no formal education, family history of mental illness, comorbid other illness and poor social support were associated with common mental disorder.

Profiles, correlates, and risk of death among patients with mental disorders hospitalized for psychiatric reasons

This study identified profiles of hospitalized patients with mental disorders (MD) based on their 3-year hospitalization patterns and clinical characteristics and compared sociodemographic profiles and other service use correlates as well as risk of death within 12 months after hospitalization. Quebec (Canada) medical administrative databases were used to investigate a 5-year cohort of 4,400 patients hospitalized for psychiatric reasons. Latent class analysis, chi-square tests and survival analysis were produced. Three profiles of hospitalized patients were identified based on hospitalization patterns and other patient characteristics. Profile 3 patients had multiple hospitalizations and early readmissions, worst health and social conditions, and used the most outpatient services. Profiles 2 and 1 patients had only one hospitalization, of brief duration in the case of Profile 2 patients, who had mainly common MD and made least use of psychiatric care. All Profile 1 patients were hospitalized for serious MD but received least continuity of physician care and fewest biopsychosocial interventions. Risk of death was higher for Profiles 3 and 2 versus Profile 1 patients. Interventions like early follow-up care after hospitalization for Profile 3, collaborative care between general practitioners and psychiatrists for Profile 2, and continuous biopsychosocial care for Profile 1 could be greatly improved.

Physical, Psychiatric, and Social Comorbidities of Individuals with Schizophrenia Living in the Community in Japan

The physical, psychiatric, and social comorbidities interfere with the everyday activities of community-dwelling individuals with schizophrenia and increase the risk of their readmission. However, these comorbidities have not been investigated comprehensively in Japan. We conducted a self-reported internet survey in February 2022 to identify individuals aged 20-75 years with and without schizophrenia using a prevalence case-control study. The survey compared physical comorbidities such as being overweight, hypertension, and diabetes; psychiatric comorbidities such as depressive symptoms and sleep disturbances; social comorbidities such as employment status, household income, and social support between participants with and without schizophrenia. A total of 223 participants with schizophrenia and 1776 participants without schizophrenia were identified. Participants with schizophrenia were more likely to be overweight and had a higher prevalence of hypertension, diabetes, and dyslipidemia than participants without schizophrenia. Additionally, depressive symptoms, unemployment, and non-regular employment were more prevalent in participants with schizophrenia than those without schizophrenia. These results highlight the necessity of comprehensive support and interventions addressing physical, psychiatric, and social comorbidities in individuals with schizophrenia in the community. In conclusion, effective interventions for managing comorbidities in individuals with schizophrenia are necessary to enable them to continue to live in the community.

Schizophrenia as metabolic disease. What are the causes?

Schizophrenia (SZ) is a devastating neurodevelopmental disease with an accelerated ageing feature. The criteria of metabolic disease firmly fit with those of schizophrenia. Disturbances in energy and mitochondria are at the core of complex pathology. Genetic and environmental interaction creates changes in redox, inflammation, and apoptosis. All the factors behind schizophrenia interact in a cycle where it is difficult to discriminate between the cause and the effect. New technology and advances in the multi-dispensary fields could break this cycle in the future.

A digital patient-reported outcome (electronic patient-reported outcome) system for patients with severe psychiatric disorders: User-centered development study and study protocol of a multicenter-controlled trial

Background

The effective treatment of patients with severe psychiatric disorders primarily relies on subjective reporting of symptoms and side-effects. This information is crucial for a clinician's decision regarding medication adjustment. Treatment adjustment usually happens at a low frequency (∼4-8 weeks). In between points of care, patients are left alone with their symptoms and side-effects. This leads to uncertainty regarding the treatment, non-adherence, possible relapse, and rehospitalization.

Objectives

We aim to design a flexible electronic patient-reported outcome (ePRO) system, which allows patients with severe psychiatric disorders to: (a) record their symptoms using an app; (b) share the data with the clinical team at points of care; and (c) utilize the data to support therapy decisions.

Methods

In this article, we describe the development process which included the following steps: (a) formation of a co-design team; (b) stakeholder interviews with patients, practitioners, and digital health experts to access needs, requirements, and barriers; (c) prototype conceptualization and design; (d) user acceptance testing and refinement; and (e) finalization of the system for testing in a pilottrial.

Results

We included input from patients with lived experience of psychiatric disorders, clinical team members, software engineers, and researchers. A prototype system was refined, and iterative changes were made before finalization during a series of operational meetings. The system allows patients to digitally self-report their symptoms and provides longitudinal ePRO symptom data for export into the electronic health record.

Conclusions

Routine ePRO collection has the potential to improve outcomes and hereby also reduce health service costs. We have successfully developed a trial-ready ePRO system for severe psychiatric disorders. The findings were incorporated in the planning of a feasibility pilot trial. Assuming feasibility will be established, the system might be subjected to a certification process evaluation of safety and efficacy including a randomized controlled trial.

Long-Term Consequences of COVID-19 Disease Specific to Women: Exploratory Research

This study was designed to explore COVID-19 in a biopsychosocial model, taking into account the different mental and social consequences of the disease in women and men. A sociodemographic questionnaire containing anthropometric data, socioeconomic data, lifestyle data, health status before COVID-19, course of COVID-19, symptoms, and complications after COVID-19 was administered to 83 women and 64 men to investigate their mental health (MH) and quality of life (QoL). The Hospital Anxiety (HADS-A) and Depression (HADS-D) Scale, the Perceived Stress Scale (PSS-10) and the World Health Organization Quality of Life Scale Brief Version (WHOQOL-BREF) were adopted. Abnormal results in HADS-D and HADS-A were obtained in 33 (39.8%) women and 10 (15.6%) men and in 26 (31.3%) women and 14 (21.9%) men, respectively. Women experienced a lower level of QoL than men. The prolonged duration of COVID-19 symptoms was associated with increased anxiety in women during recovery. Good self-reported health before COVID-19 in women was associated with reduced QoL. Women had more symptoms of COVID-19 than men, and they experienced neurological complications more often. The presence of neurological complications in women appears to be associated with increased perceived anxiety and reduced QoL. This is an exploratory study whose results can influence future research with larger and more diverse samples.

Patterns of mortality risk among patients with substance use disorder: an opportunity for proactive patient safety?

BACKGROUND

Patients with substance use disorder (SUD) suffer from excess mortality compared to the overall population. This study aims to identify patterns in death rates among patients with SUD visiting a SUD emergency ward and to explore whether this knowledge can be used as input to identify patients at risk and increase patient safety.

METHODS

Hospital visit data to a SUD emergency ward were collected between 2010 and 2020 through medical records. Data included gender, age, SUD diagnosis, and the time of death. The Kruskal-Wallis rank sum test was used to test between ordinal variables, and risk ratio was used to quantify the difference in mortality risk. All statistical tests were two-sided, with a 95% confidence interval and a minimum significance level of 0.05.

RESULTS

The male patients in the study group had 1.41-1.59 higher mortality risk than the female patients. The study revealed an average death rate of 0.14 among all patients during the study period. Although patients with a diagnosed alcohol use disorder constituted 73.7% of the cohort, having an opioid use disorder or sedative hypnotics use disorder was associated with the highest death rates; 1.29-1.52 and 1.47-1.74 higher mortality risk than those without such diagnoses.

CONCLUSION

This study demonstrates that data from visits to SUD emergency wards can be used to identify mortality risk factors, such as gender, type of diagnosis, number of diagnoses, and number of visits to the SUD emergency ward. Knowledge about patterns of patient visits and mortality risk could be used to increase patient safety through a decision support tool integrated with the electronic medical records. An improved system for early detection of increased mortality risk offers an opportunity for an adaptive patient safety system.

The Impact of 90-day Physician Follow-up Care on the Risk of Readmission Following a Psychiatric Hospitalization

AIMS

This study measures the impact of 90-day physician follow-up care after psychiatric hospitalization among 3,311 adults and youth, with risk of subsequent readmission within six months.

METHODS

A 5-year investigation was conducted based on Quebec (Canada) medical administrative databases. Cox proportional-hazards regression was performed, with 90-day follow-up care as the main independent variable, controlling for various sociodemographic, clinical, and other service use variables.

RESULTS

Within the 90-day follow-up period after patient discharge, or in the first 30 days, receiving at least one consultation per month as opposed to no consultation was associated with a reduced risk of psychiatric readmission. Women showed an increased readmission risk compared to men, while those living in less materially deprived areas a decreased risk as opposed to more deprived areas. Patients hospitalized for suicide attempt or schizophrenia spectrum and other psychotic disorders, and those with co-occurring mental and substance-related disorders or chronic physical illnesses, especially illnesses high on the severity index, also presented a heightened risk of hospitalization. Patients hospitalized for personality disorders or receiving a high continuity of physician care showed a reduced risk of readmission.

CONCLUSION

This study demonstrates that follow-up care, if provided within the first 30 days of discharge or monthly during the 90-day follow-up period, decreased the risk of readmission, as did having a high continuity of physician care prior to and within the 90-day follow-up period. However, few patients in this study had received such high-quality care, indicating that the Quebec system needs to considerably improve its discharge planning processes.

Evaluation of Psychiatric Rehospitalization of Individuals Treated at a Federally Qualified Health Center

At a federally qualified health center which often receives discharge referrals from the local hospital, rehospitalization rates and reasons were unknown yet pertinent information for assuring timely follow-up appointments. This study examined psychiatric discharge and rehospitalization between August 2020 and January 2021. Between August and October 2020, all adult patients of the FQHC were investigated who presented to or were discharged from the hospital. Those who received a primary psychiatric diagnosis were then examined retrospectively (between November 2020 and January 2021) to determine readmission status. During the study period, 36 patients were hospitalized with primary psychiatric diagnoses, 81% of whom did not establish behavioral health care subsequent to their initial hospitalization. The overall 90-day readmission rate of the sample was 41.7% with 80% of these individuals returning within 30 days.

Internalizing-Externalizing Comorbidity and Impaired Functioning in Children

BACKGROUND

The comorbidity of mental illnesses is common in child and adolescent psychiatry. Children with internalizing-externalizing comorbidity often experience worse health outcomes compared to children with a single diagnosis. Greater knowledge of functioning among children with internalizing-externalizing comorbidity can help improve mental health care.

OBJECTIVE

The objective of this exploratory study was to examine whether internalizing-externalizing comorbidity was associated with impaired functioning in children currently receiving mental health services.

METHODS

The data came from a cross-sectional clinical sample of 100 children aged 4-17 with mental illness and their parents recruited from an academic pediatric hospital. The current mental illnesses in children were measured using the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID), and the level of functioning was measured using the World Health Organization Disability Assessment Schedule (WHODAS) 2.0. Linear regression was used to estimate the association between internalizing-externalizing comorbidity and level of functioning, adjusting for demographic, psychosocial, and geographic covariates.

RESULTS

Internalizing-externalizing comorbidity in children was associated with worse functioning compared to children with strictly internalizing comorbidities, β = 0.32 (p = 0.041). Among covariates, parent's psychological distress, β = 0.01 (p = 0.004), and distance to the pediatric hospital, β = 0.38 (p = 0.049) were associated with worse functioning in children.

CONCLUSIONS

Health professionals should be mindful that children with internalizing-externalizing comorbidity may experience worsening functioning that is disruptive to daily activities and should use this information when making decisions about care. Given the exploratory nature of this study, additional research with larger and more diverse samples of children is warranted.

Patient-, Hospital-, and System-Level Factors Associated With 30-Day Readmission After a Psychiatric Hospitalization

Readmission after inpatient care for a psychiatric condition is associated with a range of adverse events including suicide and all-cause mortality. This study estimated 30-day readmission rates in a large cohort of inpatient psychiatric admissions in New York State and examined how these rates varied by patient, hospital, and service system characteristics. Data were obtained from Medicaid claims records, and clinician, hospital, and region data, for individuals with a diagnosis of any mental disorder admitted to psychiatric inpatient units in New York State from 2012 to 2013. Psychiatric readmission was defined as any unplanned inpatient stay with a mental health diagnosis with an admission date within 30 days of being discharged. Unadjusted and adjusted odds ratios of being readmitted within 30 days were estimated using logistic regression analyses. Over 15% of individuals discharged from inpatient units between 2012 and 2013 were readmitted within 30 days. Patients who were readmitted were more likely to be homeless, have a schizoaffective disorder or schizophrenia, and have medical comorbidity. Readmission rates varied in this cohort mainly because of individual-level characteristics. Homeless patients were at the highest risk of being readmitted after discharge.

Severe psychiatric disorders and general medical comorbidities: inflammation-related mechanisms and therapeutic opportunities

Individuals with severe psychiatric disorders, such as mood disorders and schizophrenia, are at increased risk of developing other medical conditions, especially cardiovascular and metabolic diseases. These medical conditions are underdiagnosed and undertreated in these patients contributing to their increased morbidity and mortality. The basis for this increased comorbidity is not well understood, possibly reflecting shared risks factors (e.g. lifestyle risk factors), shared biological mechanisms and/or reciprocal interactions. Among overlapping pathophysiological mechanisms, inflammation and related factors, such as dysbiosis and insulin resistance, stand out. Besides underlying the association between psychiatric disorders and cardiometabolic diseases, these mechanisms provide several potential therapeutic targets.

Personality dysfunction in opiate addicts on opioid substitution treatment and the risk of HCV infection

Background

Impulsivity, affective instability, and neglect of oneself and other people's safety as symptoms of personality dysfunction are associated with risky behaviors regarding the transmission of infectious diseases either sexually or by intravenous drug abuse.

Objective

The aim of this study was to analyze the association between hepatitis C virus (HCV) infection and personality dysfunction in opiate addicts on opioid substitution treatment.

Methods

This was a cross-sectional, observational investigation of patients over 18 years of age who were actively participating in opioid substitution treatment at five centers in Bosnia and Herzegovina. The occurrence of HCV infection was the primary study outcome, and personality functioning, the main independent variable, was assessed using the Severity Indices of Personality Problems (SIPP-118) questionnaire. The association between scores of personality functioning domains items and HCV infection status was determined by binary logistic regression analysis.

Results

Patients on opioid substitution therapy with HCV infection more frequently had personality disorders (OR 2.168, 95% CI 1.161-4.05) and were treated longer than patients without HCV infection (OR 1.076, 95% CI 1.015-1.14). HCV infection was associated with lower self-respect (OR 0.946, 95% CI 0.906-0.988), decreased capacity to have enduring relationships with other people (OR 0.878, 95% CI 0.797-0.966), and lower capability to cooperate with others (OR 0.933, 95%CI 0.888-0.98). On the other hand, except for self-respect, other elements of the Identity Integration domain (enjoyment, purposefulness, stable self-image, and self-reflexive functioning), when more functional, increased the risk of HCV infection.

Conclusions

Our study demonstrates that opiate addicts on opioid substitution treatment have a higher risk of HCV infection if their personality is dysfunctional, especially in the aspects of self-respect, enduring relationships, and cooperativity. The risk is even higher in addicts who have an established diagnosis of any kind of personality disorder.

The impact of comorbid severe mental illness and common chronic physical health conditions on hospitalisation: A systematic review and meta-analysis

Background

People with severe mental illness (SMI) are at higher risk of physical health conditions compared to the general population, however, the impact of specific underlying health conditions on the use of secondary care by people with SMI is unknown. We investigated hospital use in people managed in the community with SMI and five common physical long-term conditions: cardiovascular diseases, COPD, cancers, diabetes and liver disease.

Methods

We performed a systematic review and meta-analysis (Prospero: CRD42020176251) using terms for SMI, physical health conditions and hospitalisation. We included observational studies in adults under the age of 75 with a diagnosis of SMI who were managed in the community and had one of the physical conditions of interest. The primary outcomes were hospital use for all causes, physical health causes and related to the physical condition under study. We performed random-effects meta-analyses, stratified by physical condition.

Results

We identified 5,129 studies, of which 50 were included: focusing on diabetes (n = 21), cardiovascular disease (n = 19), COPD (n = 4), cancer (n = 3), liver disease (n = 1), and multiple physical health conditions (n = 2). The pooled odds ratio (pOR) of any hospital use in patients with diabetes and SMI was 1.28 (95%CI:1.15–1.44) compared to patients with diabetes alone and pooled hazard ratio was 1.19 (95%CI:1.08–1.31). The risk of 30-day readmissions was raised in patients with SMI and diabetes (pOR: 1.18, 95%CI:1.08–1.29), SMI and cardiovascular disease (pOR: 1.27, 95%CI:1.06–1.53) and SMI and COPD (pOR:1.18, 95%CI: 1.14–1.22) compared to patients with those conditions but no SMI.

Conclusion

People with SMI and five physical conditions are at higher risk of hospitalisation compared to people with that physical condition alone. Further research is warranted into the combined effects of SMI and physical conditions on longer-term hospital use to better target interventions aimed at reducing inappropriate hospital use and improving disease management and outcomes.

Sex Differences in Comorbidity Combinations in the Swedish Population

High comorbidity rates, especially mental–physical comorbidity, constitute an increasing health care burden, with women and men being differentially affected. To gain an overview of comorbidity rates stratified by sex across a range of different conditions, this study examines comorbidity patterns within and between cardiovascular, pulmonary, skin, endocrine, digestive, urogenital, musculoskeletal, neurological diseases, and psychiatric conditions. Self-report data from the LifeGene cohort of 31,825 participants from the general Swedish population (62.5% female, 18–84 years) were analyzed. Pairwise comorbidity rates of 54 self-reported conditions in women and men and adjusted odds ratios (ORs) for their comparison were calculated. Overall, the rate of pairwise disease combinations with significant comorbidity was higher in women than men (14.36% vs. 9.40%). Among psychiatric conditions, this rate was considerably high, with 41.76% in women and 39.01% in men. The highest percentages of elevated mental–physical comorbidity in women were found for musculoskeletal diseases (21.43%), digestive diseases (20.71%), and skin diseases (13.39%); in men, for musculoskeletal diseases (14.29%), neurological diseases (11.22%), and digestive diseases (10%). Implications include the need for integrating mental and physical health care services and a shift from a disease-centered to an individualized, patient-centered focus in clinical care.

Follow-up Psychiatric Care and Risk of Readmission in Patients with Serious Mental Illness in State Funded or Operated Facilities

Receipt of outpatient treatment within 30 days of discharge from psychiatric hospitalization is an established quality indicator; however, there is scant, mixed evidence as to whether it reduces the risk of readmission. We evaluated this question in patients hospitalized for schizophrenic, bipolar or depressive disorders using the Mental Health Treatment Episode Data Set (MH-TEDS), comprising patients in state-funded or -operated facilities and programs. We performed a 6-month, retrospective longitudinal cohort study including 44,761 patients with schizophrenic disorders, 45,413 patients with bipolar disorders, and 74,995 patients with depressive disorders with an index hospitalization between 2014 and 2018, stratified by whether they had at least one outpatient treatment admission in the first 30 days post-discharge. We used multivariable logistic regression to assess risk of readmission during days 31-180. We found that less than 10 percent of patients in the three cohorts received the recommended follow-up outpatient care. Furthermore, we found that schizophrenic and bipolar patients who did receive such care were no less likely to be readmitted than those not receiving such care (AOR = 0.96, 95% CI 0.87-1.06; AOR 1.06, 955 CI 0.98-1.14), and patients with depressive disorders receiving such care were more likely to be readmitted (AOR = 1.14, 95% CI 1.07-1.22). Thus, few patients received follow-up outpatient care within 30 days of discharge. When it occurred, such outpatient care was either not linked to reduced readmissions or was associated with increased readmissions. These findings suggest the need for more effective care processes in state-funded or -operated facilities.

[5-Year Readmission Status and Risk Factors for Senile Dementia Patients: A Study Based on Chengdu Municipal Medical Insurance Database]

Objective

To study the status quo of the readmission of senile dementia patients in Chengdu, and to analyze the primary diagnosis, the economic burden and the influencing factors of readmission.

Methods

Dementia inpatients aged 60 and above in Chengdu were the subjects of this study. The subjects were diagnosed with dementia between 2013 and 2017. Their heath insurance coverage was either the basic medical insurance for urban employees in Chengdu or the basic medical insurance for urban and rural residents of Chengdu. The rank sum test and the chi-square test were conducted to analyze the differences in readmission rate and the economic burden of hospitalization among subjects with different characteristics. Logistic regression was done to analyze the factors affecting readmission.

Results

The total number of dementia inpatients over the 5-year period was 27881 patients (78820 admissions). The 30-day readmission rate was 25.14% (7011/27881) and the 5-year readmission rate was 45.79% (12767/27881). The primary diagnoses of 12767 readmitted patients mainly included dementia (28.57%), circulatory system diseases (24.26%), and respiratory system diseases (23.71%). The economic burden of hospitalization was higher for readmitted patients than that of patients who were not readmitted ( Z=33.777, P<0.001). The occurrence of readmission was correlated to the following factors, advanced age (compared to that of the 60-65 yr. group, the 70-75 yr. group: odds ratio [ OR]=1.123, 95% confidence interval [ CI]: 1.019-1.237, and the 75-80 yr. group: OR=1.123, 95% CI: 1.108-1.218), participation in the basic medical insurance for urban employees ( OR=1.674, 95% CI: 1.578-1.775), types of dementia (compared to unspecified dementia, Alzheimer's dementia group: OR=1.256, 95% CI: 1.163-1.357, Parkinson's disease dementia group: OR=1.774, 95% CI: 1.658-1.898, and mixed-type dementia group: OR=1.750, 95% CI: 1.457-2.103), disease condition (compared with patients with only dementia, those who have other diseases: OR=0.536，95% CI ：0.493-0.583), length of hospital stay ( OR=1.593, 95% CI: 1.552-1.635), and staying at a lower level hospital (compared to that of tertiary hospitals, secondary hospitals: OR=1.319, 95% CI: 1.248-1.395, primary hospitals: OR=1.744, 95% CI: 1.608-1.891, and other hospitals: OR=1.465, 95% CI: 1.311-1.537).

Conclusion

Senile dementia patients have a high 30-day readmission rate, and the readmission entails heavy economic burdens on the patients. For the populations covered by medical insurance, the following features are correlated to the occurrence of readmission: advanced age, coverage by the basic medical insurance for urban employees, Alzheimer's dementia, Parkinson's disease dementia, mixed-type dementia, dementia patients without other comorbidities, extended length of stay, and hospitalization at a lower level hospital. However, further research is needed for better understanding of the specific mechanisms so that readmission of senile dementia patients can be reduced and the economic burden of the disease can be minimized.

Advanced Brain-Age in Psychotic Psychopathology: Evidence for Transdiagnostic Neurodevelopmental Origins

Schizophrenia is characterized by abnormal brain structure such as global reductions in gray matter volume. Machine learning models trained to estimate the age of brains from structural neuroimaging data consistently show advanced brain-age to be associated with schizophrenia. Yet, it is unclear whether advanced brain-age is specific to schizophrenia compared to other psychotic disorders, and whether evidence that brain structure is "older" than chronological age actually reflects neurodevelopmental rather than atrophic processes. It is also unknown whether advanced brain-age is associated with genetic liability for psychosis carried by biological relatives of people with schizophrenia. We used the Brain-Age Regression Analysis and Computation Utility Software (BARACUS) prediction model and calculated the residualized brain-age gap of 332 adults (163 individuals with psychotic disorders: 105 schizophrenia, 17 schizoaffective disorder, 41 bipolar I disorder with psychotic features; 103 first-degree biological relatives; 66 controls). The model estimated advanced brain-ages for people with psychosis in comparison to controls and relatives, with no differences among psychotic disorders or between relatives and controls. Specifically, the model revealed an enlarged brain-age gap for schizophrenia and bipolar disorder with psychotic features. Advanced brain-age was associated with lower cognitive and general functioning in the full sample. Among relatives, cognitive performance and schizotypal symptoms were related to brain-age gap, suggesting that advanced brain-age is associated with the subtle expressions associated with psychosis. Exploratory longitudinal analyses suggested that brain aging was not accelerated in individuals with a psychotic disorder. In sum, we found that people with psychotic disorders, irrespective of specific diagnosis or illness severity, show indications of non-progressive, advanced brain-age. These findings support a transdiagnostic, neurodevelopmental formulation of structural brain abnormalities in psychotic psychopathology.

Clustering of physical health multimorbidity in people with severe mental illness: An accumulated prevalence analysis of United Kingdom primary care data

BACKGROUND

People with severe mental illness (SMI) have higher rates of a range of physical health conditions, yet little is known regarding the clustering of physical health conditions in this population. We aimed to investigate the prevalence and clustering of chronic physical health conditions in people with SMI, compared to people without SMI.

METHODS AND FINDINGS

We performed a cohort-nested accumulated prevalence study, using primary care data from the Clinical Practice Research Datalink (CPRD), which holds details of 39 million patients in the United Kingdom. We identified 68,783 adults with a primary care diagnosis of SMI (schizophrenia, bipolar disorder, or other psychoses) from 2000 to 2018, matched up to 1:4 to 274,684 patients without an SMI diagnosis, on age, sex, primary care practice, and year of registration at the practice. Patients had a median of 28.85 (IQR: 19.10 to 41.37) years of primary care observations. Patients with SMI had higher prevalence of smoking (27.65% versus 46.08%), obesity (24.91% versus 38.09%), alcohol misuse (3.66% versus 13.47%), and drug misuse (2.08% versus 12.84%) than comparators. We defined 24 physical health conditions derived from the Elixhauser and Charlson comorbidity indices and used logistic regression to investigate individual conditions and multimorbidity. We controlled for age, sex, region, and ethnicity and then additionally for health risk factors: smoking status, alcohol misuse, drug misuse, and body mass index (BMI). We defined multimorbidity clusters using multiple correspondence analysis (MCA) and K-means cluster analysis and described them based on the observed/expected ratio. Patients with SMI had higher odds of 19 of 24 conditions and a higher prevalence of multimorbidity (odds ratio (OR): 1.84; 95% confidence interval [CI]: 1.80 to 1.88, p < 0.001) compared to those without SMI, particularly in younger age groups (males aged 30 to 39: OR: 2.49; 95% CI: 2.27 to 2.73; p < 0.001; females aged 18 to 30: OR: 2.69; 95% CI: 2.36 to 3.07; p < 0.001). Adjusting for health risk factors reduced the OR of all conditions. We identified 7 multimorbidity clusters in those with SMI and 7 in those without SMI. A total of 4 clusters were common to those with and without SMI; while 1, heart disease, appeared as one cluster in those with SMI and 3 distinct clusters in comparators; and 2 small clusters were unique to the SMI cohort. Limitations to this study include missing data, which may have led to residual confounding, and an inability to investigate the temporal associations between SMI and physical health conditions.

CONCLUSIONS

In this study, we observed that physical health conditions cluster similarly in people with and without SMI, although patients with SMI had higher burden of multimorbidity, particularly in younger age groups. While interventions aimed at the general population may also be appropriate for those with SMI, there is a need for interventions aimed at better management of younger-age multimorbidity, and preventative measures focusing on diseases of younger age, and reduction of health risk factors.

Structured Interventions to Optimize Polypharmacy in Psychiatric Treatment and Nursing Homes: A Systematic Review

BACKGROUND

Polypharmacy is a common clinical issue. It increases in prevalence with older age and comorbidities of patients and has been recognized as a major cause for treatment complications. In psychiatry, polypharmacy is also commonly seen in younger patients and can lead to reduced treatment satisfaction and incompliance. A variety of structured polypharmacy interventions have been investigated. This systematic review provides a comprehensive overview of the field and identifies research gaps.

METHODS

We conducted a systematic review on structured interventions aimed at optimizing polypharmacy of psychotropic and somatic medication in psychiatric inpatient and outpatient settings as well as nursing homes. A search protocol was registered with PROSPERO (CRD42020187304). Data were synthesized narratively.

RESULTS

Fifty-eight studies with a total of 30,554 participants met the inclusion criteria. Interventions were most commonly guided by self-developed or national guidelines, drug assessment scores, and lists of potentially inappropriate medications. Tools to identify underprescribing were less commonly used. Most frequently reported outcomes were quantitative drug-related measures; clinical outcomes such as falls, hospital admission, cognitive status, and neuropsychiatric symptom severity were reported less commonly. Reduction of polypharmacy and improvement of medication appropriateness were shown by most studies.

CONCLUSIONS

Improvement of drug-related outcomes can be achieved by interventions such as individualized medication review and educational approaches in psychiatric settings and nursing homes. Changes in clinical outcomes, however, are often nonsubstantial and generally underreported. Patient selection and intervention procedures are highly heterogeneous. Future investigations should establish standards in intervention procedures, identify and assess patient-relevant outcome measures, and consider long-term follow-up assessments.

Impact of Antipsychotic Use on Readmission Rates in Children and Adolescents With Autism Spectrum Disorder and Irritability

Background

Risperidone and aripiprazole have been established as standard pharmacological treatments for irritability and associated aggressive behaviors in individuals with autism spectrum disorder (ASD), and are the only drugs approved by the United States Food and Drug Administration for those purposes. However, the rates of readmission with the use of these drugs in the pediatric population have not been studied, leaving a gap in the knowledge of antipsychotic effects. Readmission rates are a valuable metric of treatment efficacy that also reflect the financial burden, morbidity, and medical complications associated with multiple hospitalizations.

Methodology

A retrospective study was conducted in 65 Hospital Corporation of America Healthcare hospitals within the United States from 2016 to 2019. Patients aged 6-17 years with a diagnosis of ASD with irritability were included. The primary outcome was 30-, 60-, and 90-day readmission rates. Chi-square tests of independence and post-hoc analyses were used to assess the relatedness between readmission rate and antipsychotic use, as well as the type of antipsychotic medication if used. A binary regression analysis was used to analyze the relationship between demographic characteristics and readmission rate in this population. Patients on antidepressants, anxiolytics, or medications primarily used as mood stabilizers were excluded from the study to reduce confounding effects of such medications.

Results

A total of 2,375 patients aged 6-17 years were admitted for irritability and a diagnosis of ASD. In total 323 (13.8%) patients were readmitted from this group within 30 days of discharge. After controlling for age, sex, and gender, the use of antipsychotic medication was found to decrease 30- and 90-day readmission rates with an odds ratio of 1.2 to 1.4 times compared to no antipsychotic use (p < 0.04). In patients with autism not on antipsychotics, regression analysis revealed that older age (p = 0.0471) and White race (p = 0.0471) were associated with 30-day readmission (a = 0.05). For these patients, race was also significantly associated with 60-day (p = 0.0494) and 90-day (p = 0.0416) readmission rates. In patients with autism on either risperidone or aripiprazole, age (p = 0.0393) and race (p = 0.0316) were significantly associated with 30-day readmission rate.

Conclusions

Antipsychotic use reduced readmission rates within 30 days and 90 days in patients with irritability and ASD. Additionally, oral aripiprazole and oral risperidone were found to be equally effective in reducing the 30-day readmission rate, and neither was superior in comparison to the other in 30-, 60-, or 90-day readmission rates. The reduced 30- and 90-day readmission rates seen in our study with the use of antipsychotic medications emphasize the importance of antipsychotic use for individuals with ASD and irritability, even if the antipsychotic is not risperidone or aripiprazole. Groups who can particularly benefit from antipsychotic use include individuals who are refractory to first- and second-line therapies, such as behavioral interventions, or for those who present with persistent and serious risk of harm to themselves or others. Additionally, the use of antipsychotic medications in this scenario may reduce hospitalizations within 30 days of discharge, allowing reduction of the financial and emotional strain associated with these readmissions.

Association of cardiovascular metabolic risk factor measurements with psychiatric readmission among in-hospital patients with severe mental illness: a retrospective study

BACKGROUND

Patients with severe mental illness (SMI) and comorbid physical conditions were often associated with higher risks of mortality and hospital readmission. In this study, we aim to examine the association of cardiovascular metabolic risk factor measurements with risks of psychiatric readmissions among in-hospital patients with severe mental illness (SMI).

METHODS

We collected the longitudinal information of laboratory investigations, blood pressure and body mass index (BMI) among in-hospital patients who had been diagnosed with schizophrenia, major depression disorder or bipolar disorder and with comorbid diagnosis of hypertension, hyperlipidemia or diabetes from Jan 2014 to Jan 2019. The primary outcome was time to first psychiatric readmission. Cox proportional hazard model was utilized to calculate the hazard risks (HR) of cardiovascular metabolic risk factors with psychiatric readmission.

RESULTS

A total of 5,256 patients were included in the analysis. Compared to patients with normal blood parameters, patients with aberrant tests of high-density dyslipidemia (HDL) and diastolic blood pressure (DBP) during in-hospitalization period were associated with higher risks to first psychiatric readmission [ HR (Hazard Ratio), 1.37 95% Confidence interval (CI), 1.03-1.83 for HDL and HR, 1.32 (95% CI, 1.04-1.67])for DBP]. Compared to patients with optimal monitoring, patients with suboptimal monitoring of blood lipids and blood pressure during in-hospitalization period or recommended window period of cardiovascular disease (CVD) risk management were associated with higher risks to first psychiatric readmission.

CONCLUSIONS

Aberrant cardiovascular metabolic blood test and blood pressure and missing measurements among in-hospital patients with SMI were associated with increased risks of psychiatric readmissions. This calls for more active screening and monitoring of CVD risk factors for those in-hospital patients in need.

Comorbidity combinations in schizophrenia inpatients and their associations with service utilization: A medical record-based analysis using association rule mining

BACKGROUND

Comorbidities are common among patients with schizophrenia yet the prevalence of comorbidity combinations and their associations with inpatient service utilization and readmission have been scarcely explored.

METHODS

Data were extracted from discharge summaries of patients whose primary diagnosis was schizophrenia spectrum disorders (ICD-10: F20-F29). We identified 30 most frequent comorbidities in patients' secondary diagnoses and then used the association rule mining (ARM) method to derive comorbidity combinations associated with length of stay (LOS), daily expense and one-year readmission.

RESULTS

The study included data from 8252 patients. The top five most common comorbidities were extrapyramidal syndrome (EPS, 44.58%), constipation (31.63%), common cold (21.80%), hyperlipidemia (20.99%) and tachycardia (19.13%). Most comorbidity combinations identified by ARM were significantly associated with longer LOS (≥70 days), few were associated with higher daily expenses, and fewer with readmission. The 3-way combination of common cold, hyperlipidemia and fatty liver had the strongest association with longer LOS (adjusted OR (aOR): 3.38, 95% CI: 2.12-5.38). The combination of EPS and mild cognitive disorder was associated with higher daily expense (≥700 RMB) (aOR: 1.67, 95% CI: 1.20-2.31). The combination of constipation, tachycardia and fatty liver were associated with higher 1-year readmission (aOR: 2.05, 95% CI: 1.03-4.09).

CONCLUSION

EPS, constipation, and tachycardia were among the most commonly reported comorbidities in schizophrenia patients in Beijing, China. Specific groups of comorbidities may contribute to higher inpatient psychiatric service utilization and readmission. The mechanism behind the associations and potential interventions to optimize service use warrant further investigation.

Organization and Outcomes of Integrated Inpatient Medical and Psychiatric Care Units: A Systematic Review

OBJECTIVE

The goal of this review was to assess the relationships among aims, designs, and outcomes of integrated inpatient medical and psychiatric care units (IMPUs) and gather the evidence base on the effectiveness of these units.

METHODS

Using online searches of Embase, Medline, Web of Science, PsycINFO, Scopus, CINAHL, Cochrane, and Google Scholar, the authors identified and reviewed literature describing the aims and outcomes of specific IMPU designs.

RESULTS

The search yielded 55 studies, in which the authors identified 39 IMPUs that focused on patients with mood, psychotic, somatic symptom, substance use, organic, and personality disorders and a broad array of medical diagnoses. Most units were psychiatric-medical units and had medium medical and psychiatric acuity capabilities. The studies reviewed provided little information on the cost-effectiveness of various IMPU designs. Although some comparative studies indicated reductions in hospital length of stay (LOS), these studies were generally of low quality and rarely reported other intended outcomes.

CONCLUSIONS

IMPUs may help shorten LOS. IMPUs should focus care on patients with complex conditions and high acuity to maximize health system value. Implementing compulsory admission facilities; qualified psychiatric, medical, and nursing staff involvement; and cross-disciplinary training may improve IMPUs' capacity to treat high-acuity patients. Future research should relate IMPU designs to intended outcomes.

Physical-mental health comorbidity: A population-based cross-sectional study

Background

Multimorbidity is associated with physical-mental health comorbidity (PMHC). However, the scope of overlap between physical and mental conditions, associated factors, as well as types of mental illness involved are not well described in Eastern Europe. This study aims to assess the PMHC burden in the Estonian population.

Methods

In this population-based cross-sectional study we obtained health claims data for 55 chronic conditions from the Estonian Health Insurance Fund (EHIF) database, which captures data for all publicly insured individuals (n = 1 240 927 or 94.1% of the total population as of 31 December 2017). We assessed the period-prevalence (3 years) of chronic physical and mental health disorders, as well as associations between them, by age and sex.

Results

Half of the individuals (49.1% (95% CI 49.0–49.3)) had one or more chronic conditions. Mental health disorders (MHD) were present in 8.1% (8.1–8.2) of individuals, being higher among older age groups, women, and individuals with a higher number of physical conditions. PMHC was present in 6.2% (6.1–6.2) of the study population, and 13.1% (13.0–13.2) of the subjects with any chronic physical disorder also presented with at least one MHD. Dominating MHDs among PMHC patients were anxiety and depression. The prevalence of MHD was positively correlated with the number of physical disorders. We observed variation in the type of MHD as the number of physical comorbidities increased. The prevalence of anxiety, depression, and mental and behavioral disorders due to the misuse of alcohol and other psychoactive substances increased as physical comorbidities increased, but the prevalence of schizophrenia and dementia decreased with each additional physical disease. After adjusting for age and sex, this negative association changed the sign to a positive association in the case of dementia and mental and behavioral disorders due to psychoactive substance misuse.

Conclusions

The burden of physical-mental comorbidity in the Estonian population is relatively high. Further research is required to identify clusters of overlapping physical and mental disorders as well as the interactions between these conditions. Public health interventions may include structural changes to health care delivery, such as an increased emphasis on integrated care models that reduce barriers to mental health care.

Why Do People with Severe Mental Illness Have Poor Cardiovascular Health?-The Need for Implementing a Recovery-Based Self-Management Approach

People with severe mental illness (SMI) die significantly earlier than their well counterparts, mainly due to preventable chronic conditions such as cardiovascular disease (CVD). Based on the existing research, this perspective paper summarises the key contributors to CVD in people with SMI to better target the areas that require more attention to reduce, and ultimately resolve this health inequity. We discuss five broad factors that, according to current international evidence, are believed to be implicated in the development and maintenance of CVD in people with SMI: (1) bio-psychological and lifestyle-related factors; (2) socio-environmental factors; (3) health system-related factors; (4) service culture and practice-related factors; and (5) research-related gaps on how to improve the cardiovascular health of those with SMI. This perspective paper identifies that CVD in people with SMI is a multi-faceted problem involving a range of risk factors. Furthermore, existing chronic care or clinical recovery models alone are insufficient to address this complex problem, and none of these models have identified the significant roles that family caregivers play in improving a person’s self-management behaviours. A new framework is proposed to resolve this complex health issue that warrants a collaborative approach within and between different health and social care sectors.