Social deprivation and psychiatric admission rates among different diagnostic groups

The Impact of the COVID-19 Pandemic and Socioeconomic Deprivation on Admissions to the Emergency Department for Psychiatric Illness: An Observational Study in a Province of Southern Italy

The restriction measures adopted to limit population movement in order to contain the COVID-19 pandemic contributed to a global public health system crisis. This retrospective study aimed at identifying changes in psychiatric admissions to Accident and Emergency Departments (A&Es) in a province in southern Italy during the first two years of the pandemic and was characterized by two different restriction levels (phases 2 and 3) compared to the pre-pandemic period (phase 1). We also investigated the role of socioeconomic deprivation (DI) on psychiatric admissions. The total number of patients admitted to the A&Es was 291,310. The incidence of admission for a psychiatric disorder (IPd) was 4.9 per 1000 admissions, with a significant younger median age of 42 [IQR 33–56] compared to non-psychiatric patients (54 [35–73]). The type of admission and type of discharge were factors related to the psychiatric admission to A&E, and their relationship was modified by the pandemic. In the first year of the pandemic, patients with psychomotor agitation increased compared to the pre-pandemic period (72.5% vs. 62.3%). In the period preceding the spread of SARS-CoV-2, the IPd was equal to 3.33 ± 0.19; after the pandemic started, there was an increase in the IPd: 4.74 ± 0.32 for phase 2 and 3.68 ± 0.25 for phase 3. The IPd was higher for psychiatric admissions from areas with a very low DI compared to areas with a low DI; however, during phase 2, this difference was reduced. In conclusion, an increase in admissions for psychiatric disease was observed during the initial spread of SARS-CoV-2. Patients who lived in the most deprived municipalities generally came to the A&Es less than others, probably because the patients and their families had less awareness of their mental health. Therefore, public health policies to address these issues are needed to reduce the pandemic’s impact on these conditions.

Use of psychiatric inpatient services by heavy users: Findings from a national survey in Italy

Purpose

To analyze factors associated with a patient's probability of being a Heavy User (HU) of inpatient psychiatric services and to compare the HU inpatient population with Non-Heavy Users (NHUs).

Patients and methods

The survey was conducted among inpatients enrolled in the PROGRES-Acute-project, an Italian nationwide survey of public and private inpatient facilities. Patients with three or more admissions over the last 12 months were considered HUs, and patients who had undergone one or two admissions during the same period made up the NHU group.

Results

Four hundred and thirty-five (40.5%) were HUs, and 640 (59.5%) NHUs. HUs were younger, more frequently unmarried, unemployed, receiving a disability-pension, and either homeless or living in a residential facility. HUs were more likely to have experienced conflicts with their partners or family members during the week prior to admission. A logistic regression analysis revealed that age, age at first admission, number of life-time admissions, and having been the victim of violence were the most important predictive factors for the HU phenomenon.

Conclusion

Our study suggests that specific attention should be given to patients’ family context, due to its crucial role in daily informal care and in the triggering of events leading to rehospitalization.

Understanding geographic variations in psychiatric inpatient admission rates: width of the variations and associations with the supply of health and social care in France

BACKGROUND

Inpatient care accounts for the majority of mental health care costs and is not always beneficial. It can indeed have detrimental consequences if not used appropriately, and is unpopular among patients. As a consequence, its reduction is supported by international recommendations. Varying rates of psychiatric inpatient admissions therefore deserve to draw attention of researchers, clinicians and policy makers alike as such variations can challenge quality, equity and efficiency of care. In this context, our objectives were first to describe variations in psychiatric inpatient admission rates across the whole territory of mainland France, and second to identify their association with characteristics of the supply of care, which can be targeted by dedicated health policies.

METHODS

Our study was carried out in French psychiatric sectors' catchment areas for the year 2012. Inpatient admission rates per 100,000 adult inhabitants were calculated using data from the national psychiatric discharge database. Their variations were described numerically and graphically. We then carried out a negative binomial regression to identify characteristics of the supply of care (public and private care, health and social care, hospital and community-based care, specialised and non-specialised care) which were associated with these variations while adjusting our analysis for other relevant factors, in particular epidemiological differences.

RESULTS

Considerable variations in inpatient admission rates were observed between psychiatric sectors' catchment areas and were widespread on the French territory. Institutional characteristics of the hospital to which each sector was linked (private non-profit status, specialisation in psychiatry and participation to teaching activities and to emergency care) were associated with inpatient admission rates. Similarly, an increase in the availability of community-based private psychiatrists was associated with a decrease in the inpatient admission rate while an increase in the capacity of housing institutions for disabled individuals was associated with an increase in this rate.

CONCLUSIONS

Our results advocate for a homogenous repartition of health and social care for mental disorders in lines with the health needs of the population served. This should apply particularly to community-based private psychiatrists, whose heterogeneity of repartition has often been underscored.

Admission to psychiatric hospital for mental illnesses 2 years prechildbirth and postchildbirth in Scotland: a health informatics approach to assessing mother and child outcomes

OBJECTIVE

To identify factors associated with: admission to a specialist mother and baby unit (MBU) and the impact of perinatal mental illness on early childhood development using a data linkage approach in the 2 years prechildbirth and postchildbirth.

METHODS

Scottish maternity records (SMR02) were linked to psychiatric hospital admissions (SMR04). 3290 pregnancy-related psychiatric admissions for 1730 women were assessed. To investigate factors associated with MBU admission, the group of mothers admitted to an MBU were compared with those admitted to general psychiatric wards. To assess the impact of perinatal mental illness on early child development, a pragmatic indicator for 'at potential risk of adversity', defined as a child who was recorded as requiring intensive treatment at any time under the health plan indicators (HPI) and/or who had no record of completing three doses of the 5-in-1 vaccine by 12 months was generated. Logistic regression models were used to describe the association between each variable and the risk of admission between those with a history of prior psychiatric admission and those without.

RESULTS

Women admitted to an MBU were significantly more likely to be admitted with non-affective psychosis (OR=1.97, 95% CI 1.22 to 3.18), affective psychosis (OR=2.44, 95% CI 1.37 to 4.33) and non-psychotic depressive episodes (OR=1.93, 95% CI 1.42 to 2.63). They were less likely to come from deprived areas (OR=0.68 95% CI 0.49 to 0.93). Women with a previous history of psychiatric admission were significantly more likely to be located in the two most deprived quintiles. Almost one-third (29%) of children born to mothers with a pregnancy-related psychiatric admission were assessed as 'at potential risk of adversity.'

CONCLUSIONS

A health informatics approach has potential for improving understanding of social and clinical factors, which contribute to the outcomes of perinatal mental illness, as well as potential adverse developmental outcomes for offspring.

The influence of social deprivation as measured by the CNI on psychiatric admissions

The purpose of this study was to examine the importance of social deprivation for psychiatric admissions and its correlation with two different deprivation scores. Care Need Index (CNI) and Townsend scores were calculated at the small area level in Malmö, a city in southern Sweden. Admission rates for all psychiatric inpatients from Malmö aged 20 - 79 years, admitted to the psychiatric and alcohol clinics from 1 January 1991 to 31 December 1994, were calculated. The relationship between the CNI and psychiatric admissions was analysed by applying a Poisson regression model. The results are shown as incidence density ratios (IDR) with 95% confidence intervals (CI). From the most deprived areas, the first psychiatric admission rate was more than four times higher than in the most affluent areas. The rates of second and third admission were even higher. Admissions to the alcohol clinic were similar to psychiatric admissions, but the most deprived areas had first admission rates about ten times higher than in the most affluent areas. About 27% of first admissions, including patients from both psychiatric and alcohol clinics, had a diagnosis of psychosis, and 43% were substance abusers. There were differences between the patients' diagnoses in different areas. The correlation between the CNI and Townsend scores was very high. The most important finding of this study is the strong correlation between social deprivation, based on different deprivation indices, and first admissions to psychiatric and alcohol clinics.

Examining the relationship between neighbourhood deprivation and mental health service use of immigrants in Ontario, Canada: a cross-sectional study

OBJECTIVE

While newcomers are often disproportionately concentrated in disadvantaged areas, little attention is given to the effects of immigrants' postimmigration context on their mental health and care use. Intersectionality theory suggests that understanding the full impact of disadvantage requires considering the effects of interacting factors. This study assessed the inter-relationship between recent immigration status, living in deprived areas and service use for non-psychotic mental health disorders.

STUDY DESIGN

Matched population-based cross-sectional study.

SETTING

Ontario, Canada, where healthcare use data for 1999-2012 were linked to immigration data and area-based material deprivation scores.

PARTICIPANTS

Immigrants in urban Ontario, and their age-matched and sex-matched long-term residents (a group of Canadian-born or long-term immigrants, n=501,417 pairs).

PRIMARY AND SECONDARY OUTCOME MEASURES

For immigrants and matched long-term residents, contact with primary care, psychiatric care and hospital care (emergency department visits or inpatient admissions) for non-psychotic mental health disorders was followed for 5 years and examined using conditional logistic regression models. Intersectionality was investigated by including a material deprivation quintile by immigrant status (immigrant vs long-term resident) interaction.

RESULTS

Recent immigrants in urban Ontario were more likely than long-term residents to live in most deprived quintiles (immigrants--males: 22.8%, females: 22.3%; long-term residents--both sexes: 13.1%, p<0.001). Living in more deprived circumstances was associated with greater use of mental health services, but increases were smaller for immigrants than for long-term residents. Immigrants used less mental health services than long-term residents.

CONCLUSIONS

This study adds to existing research by suggesting that immigrant status and deprivation have a combined effect on recent immigrants' care use for non-psychotic mental health disorders. In settings where immigrants are over-represented in deprived areas, policymakers focused on increasing immigrants' access of mental health services should broadly address the influence of structural and cultural factors beyond the disadvantage.

Identifying aspects of neighbourhood deprivation associated with increased incidence of schizophrenia

BACKGROUND

Several studies have found an association between area deprivation and incidence of schizophrenia. However, not all studies have concurred and definitions of deprivation have varied between studies. Relative deprivation and inequality seem to be particularly important, but which aspects of deprivation or how this effect might operate is not known.

METHODS

The Lambeth Early Onset case register is a database of all cases of first episode psychosis aged 16 to 35years from the London Borough of Lambeth, a highly urban area. We identified 405 people with first onset schizophrenia who presented between 2000 and 2007. We calculated the overall incidence of first onset schizophrenia and tested for an association with area-level deprivation, using a multi-domain index of deprivation (IMD 2004). Specific analyses into associations with individual sub-domains of deprivation were then undertaken.

RESULTS

Incidence rates, directly standardized for age and gender, were calculated for Lambeth at two geographical levels (small and large neighbourhood level). The Poisson regression model predicting incidence rate ratios for schizophrenia using overall deprivation score was statistically significant at both levels after adjusting for ethnicity, ethnic density, population density and population turnover. The incidence rate ratio for electoral ward deprivation was 1.03 (95% CI=1.004-1.04) and for the super output area deprivation was 1.04 (95% CI=1.02-1.06). The individual domains of crime, employment deprivation and educational deprivation were statistically significant predictors of incidence but, after adjusting for the other domains as well as age, gender, ethnicity and population density, only crime and educational deprivation, remained statistically significant. Low income, poor housing and deprived living environment did not predict incidence.

CONCLUSIONS

In a highly urban area, an association was found between area-level deprivation and incidence of schizophrenia, after controlling for age, gender, ethnicity and population density; high crime and low levels of education accounted for this. As both of these are potentially modifiable, this suggests a possible means to reduce the incidence of schizophrenia.

Urbanicity, social adversity and psychosis

In recent years, there has been increasing interest in research on geographical variation in the incidence of schizophrenia and other psychoses. In this paper, we review the evidence on variation in incidence of schizophrenia and other psychoses in terms of place, as well as the individual- and area-level factors that account for this variation. We further review findings on potential mechanisms that link adverse urban environment and psychosis. There is evidence from earlier and more recent studies that urbanicity is associated with an increased incidence of schizophrenia and non-affective psychosis. In addition, considerable variation in incidence across neighbourhoods has been observed for these disorders. Findings suggest it is unlikely that social drift alone can fully account for geographical variation in incidence. Evidence further suggests that the impact of adverse social contexts - indexed by area-level exposures such as population density, social fragmentation and deprivation - on risk of psychosis is explained (confounding) or modified (interaction) by environmental exposures at the individual level (i.e., cannabis use, social adversity, exclusion and discrimination). On a neurobiological level, several studies suggest a close link between social adversity, isolation and stress on the one hand, and monoamine dysfunction on the other, which resembles findings in schizophrenia patients. However, studies directly assessing correlations between urban stress or discrimination and neurobiological alterations in schizophrenia are lacking to date.

Non-clinical and extra-legal influences on decisions about compulsory admission to psychiatric hospital

BACKGROUND

On the eve of reform of the 1983 Mental Health Act (MHA), little is known about how decisions to admit people under its powers are made.

AIMS

To describe non-clinical and extra-legal influences on professionals' decisions about compulsory admission to psychiatric hospital.

METHOD

Participant-observation of MHA assessments, including informal and depth interviews with the practitioners involved, and follow-up interviews with the people who had been assessed.

RESULTS

A candidate patient's chance of being sectioned is likely to increase when there are no realistic alternatives to in-patient care. This typically occurs when staff have insufficient time to set such alternatives in place and are unsupported by other professionals in doing this. Outcomes may also be affected by local operational norms and the level of professional accountability for specific MHA decisions.

CONCLUSION

Non-clinical and extra-legal factors explain some of the geographical variation in MHA admission rates. If compulsion is to be used only in the 'last resort', administrators and policy makers should look beyond legislative change to matters of resource allocation and service organisation.

Social economic inequalities and mental health II. Methodological aspects and literature review

Summary

Objective - This study provides a framework for mental health inequalities beginners. It describes the methods used to measure socio economic inequalities and the inter-relations with different aspects of mental health: residence, mental health services organisation and main diagnostic categories. Method - Literature electronic-search on Medline, Psyclit, Econlit, Social Science Index and SocioSearch usingand relating the key-words inequalities, deprivation, poverty, socio-economic status, social class, occupational class, mental health for the period 1965-2002 (June). The articles selected were integrated with manual search (publications of the same authors, cross-references, working documents and reports of international andregional organisations). Results - Inequality is not an absolute concept and, mainly, it has been changing during the last years. For example, the integration and re-definition of variables that capture, in simple indices, a complex reality; the accent on social more than on economic aspects; the geo-validity and time-reference of the inequality's indices. Moreover, the inequalities could be the result of individual preferences, in this case, the social selectionand social causation issues will raise the suitability for a public intervention. Conclusions - Up to now, research has been mainly concentrated in describing and measuring health inequalities. For designing effective interventions, policy makers need to ground decisions on health-socioeconomic inequalities explanatory models.

Declaration of Interest

this work was partly funded by the Department of the Public Health Sciences “G. Sanarelli” of the University of Rome “La Sapienza” and the Department of Medicine and Public Health of the University of Verona.

Socio-economic status and geographies of psychiatric inpatient service use. Places, provision, power and wellbeing

This editorial briefly summarises some aspects of research on socio-economic status and use of mental health services that have particular relevance for the theme of this issue of Epidemiologia e Psichiatria Sociale. This discussion takes a view from the perspective of health geography, which examines how the relationships between individuals and their social and physical environment result in variations in health and health care use. Three particular issues are considered here. First, the geographical distribution and organisation of psychiatric services may interact with social and economic factors in ways that are important for service use. Second, increasingly sophisticated ecological modelling strategies have elucidated the associations between socio-economic factors and service use at the population level. Third, more intensive, qualitative research complements these statistical analyses and encouraged reflection on the socio-economic processes, within psychiatric care settings, as well as in wider society, which influence service use.

What is the impact of socio-economic inequalities on the use of mental health services?

Amartya Sen, who received the Nobel Prize for Economics, has demonstrated that the incidence of deprivation, in terms ofcapability, can be surprisingly high even in the most developed countries of the world. The study of socio-economic inequalities, in relation to the utilisation of health services, is a priority for epidemiological research. Socio-economic status (SES) has no universal definition. Within the international research literature, SES has been related to social class, social position, occupational status, educational attainment, income, wealth and standard of living. Existing research studies have shown that people from a more deprived social background, with a lower SES, are more likely to have a higher psychiatric morbidity. Many studies show that SES influences psychiatric services utilization, however the real factors linking SES and mental health services utilisation remain unclear. In this editorial we discuss what is currently known about the relationship between SES and the use of mental health services. We also make an argument for why we believe there is still much to uncover in this field, to understand fully how individuals are influenced by their personal socio-economic status, or the neighbourhood in which they live, in terms of their use of mental health services. Further research in this area will help clarify what interventions are required to provide greater equality in access to mental health services.

The epidemiology of schizophrenia: replacing dogma with knowledge

Major advances have been made in our understanding of the epidemiology of schizophrenia. We now know that the disorder is more common and severe in young men, and that the incidence varies geographically and temporally. Risk factors have been elucidated; biological risks include a family history of the disorder, advanced paternal age, obstetric complications, and abuse of drugs such as stimulants and cannabis. In addition, recent research has also identified social risk factors such as being born and brought up in a city, migration, and certain types of childhood adversity such as physical abuse and bullying, as well as social isolation and adverse events in adult life. Current research is focussing on the significance of minor psychotic symptoms in the general population, gene-environmental interaction, and how risk factors impact on pathogenesis; perhaps all risk factors ultimately impact on striatal dopamine as the final common pathway.

In-patient and residential alternatives to standard acute psychiatric wards in England

BACKGROUND

Acute psychiatric wards have been the focus of widespread dissatisfaction. Residential alternatives have attracted much interest, but little research, over the past 50 years.

AIMS

Our aims were to identify all in-patient and residential alternatives to standard acute psychiatric wards in England, to develop a typology of such services and to describe their distribution and clinical populations.

METHOD

National cross-sectional survey of alternatives to standard acute in-patient care.

RESULTS

We found 131 services intended as alternatives. Most were hospital-based and situated in deprived areas, and about half were established after 2000. Several clusters with distinctive characteristics were identified, ranging from general acute wards applying innovative therapeutic models, through clinical crisis houses that are highly integrated with local health systems, to more radical voluntary sector alternatives. Most people using the alternatives had a previous history of admission, but only a few community-based services accepted compulsory admissions.

CONCLUSIONS

Alternatives to standard acute psychiatric wards represent an important, but previously undocumented and unevaluated, sector of the mental health economy. Further evidence is needed to assess whether they can improve the quality of acute in-patient care.

Development and spatial representation of synthetic indexes of outpatient mental health care in Andalusia (Spain)

INTRODUCTION

There is a need to develop composite indicators to monitor mental health care in countries such as Spain, where there is wide variability of care systems in 17 different regions. The aim of this study is to generate and to test the usability of synthetic indexes in Andalusia (Southern Spain).

METHOD

Seven mental health indicators were selected by expert opinion from a previous list of simple indicators used to compare mental health care systems across Spain (Psicost-74). A Geographical Information Systems (GIS) was used to delineate 71 sectors based on the catchment areas of the mental health centers in Andalusia. Synthetic indexes were obtained through linear combinations of simple indicators via Principal Components Analysis (PCA), using activity data from the Mental Health Information System of Andalusia (SISMA). Maps of these indexes were drawn for 71 catchment areas.

RESULTS

Two synthetic indexes were obtained and showed high consistency in the PCA. The Care Load Index (component 1) related to population size and total outpatient care provided within the area. The Case Load Index (component 2) related to assisted morbidity in relation to the population size. The care load index was higher in populated urban areas, whereas the case load was higher in rural areas.

DISCUSSION

Care and case load indexes show a different pattern in urban and rural areas. This may be related to a different underlying model of care related to the degree of urbanisation. Geographical Information Systems (GIS) improved recognition and assessment of the spatial phenomena related to the mental health care system, and support policy decision making process in mental health.

Cumulative social disadvantage, ethnicity and first-episode psychosis: a case-control study

BACKGROUND

Numerous studies have reported high rates of psychosis in the Black Caribbean population in the UK. Recent speculation about the reasons for these high rates has focused on social factors. However, there have been few empirical studies. We sought to compare the prevalence of specific indicators of social disadvantage and isolation, and variations by ethnicity, in subjects with a first episode of psychosis and a series of healthy controls.

METHOD

All cases with a first episode of psychosis who made contact with psychiatric services in defined catchment areas in London and Nottingham, UK and a series of community controls were recruited over a 3-year period. Data relating to clinical and social variables were collected from cases and controls.

RESULTS

On all indicators, cases were more socially disadvantaged and isolated than controls, after controlling for potential confounders. These associations held when the sample was restricted to those with an affective diagnosis and to those with a short prodrome and short duration of untreated psychosis. There was a clear linear relationship between concentrated disadvantage and odds of psychosis. Similar patterns were evident in the two main ethnic groups, White British and Black Caribbean. However, indicators of social disadvantage and isolation were more common in Black Caribbean subjects than White British subjects.

CONCLUSIONS

We found strong associations between indicators of disadvantage and psychosis. If these variables index exposure to factors that increase risk of psychosis, their greater prevalence in the Black Caribbean population may contribute to the reported high rates of psychosis in this population.

Psychosis and place

One important line of epidemiologic inquiry implicating social context in the etiology of psychosis is the examination of spatial variation in the distribution of psychotic illness. The authors conducted a systematic review of evidence from urbanicity and neighborhood studies regarding spatial variation in the incidence of psychosis in developed countries since 1950. A total of 44 studies (20 of urbanicity and 24 of neighborhood) were culled from three databases with similar time frames: Medline (1950-2007), PsychInfo (1950-2007), and Sociological Abstracts (1952-2007). With a special emphasis on social factors potentially relevant to etiology, the authors elucidated contributions, limitations, and issues related to study design, measurement, and theory. Evidence from both arenas supports a possible etiologic role for social context. Studies of urbanicity indicate that early-life exposure may be important; dose-response relations, spatial patterning of schizophrenia, and interactions with other factors may exist. Neighborhood studies indicate heterogeneity in rates, hint at spatial patterning of schizophrenia, and offer intriguing evidence implying more proximal social (as opposed to physical) exposures. The authors encourage the exploration of social pathways engaging theory, methodological advances, and the life-course perspective. They also propose a conceptual shift from studies of spatial variation in outcomes to research addressing the etiologic effect of exposures shaped by place as a reservoir of risk or resilience.

Neighbourhood income and mental health: A multilevel follow-up study of psychiatric hospital admissions among 4.5 million women and men

This multilevel study followed 4.5 million Swedish women and men from 1 January 1998 until 31 December 1999 in order to examine the association between neighbourhood income (defined as proportions of individuals with low income) and psychiatric hospital admissions. Individuals living in the poorest neighbourhoods exhibited a statistically significantly higher risk of being hospitalised for mental disorder than individuals living in the richest neighbourhoods, after adjustment for individual demographic and socioeconomic characteristics. The neighbourhood variance indicated statistically significant differences in psychiatric hospital admissions between neighbourhoods. Both individuals and neighbourhoods need to be targeted in order to enhance mental health in low-income neighbourhoods.

Place and provision: mapping mental health advocacy services in London

The National Health Service (NHS) Executive for London carried out an investigation in 2002 as part of their wider mental health strategy to establish whether existing mental health advocacy provision in the city was meeting need. The project took a two-part approach, with an emphasis on, (a) mapping the provision of advocacy services and, (b) cartographic mapping of service location and catchments. Data were collected through a detailed questionnaire with service providers in collaboration with the Greater London Mental Health Advocacy Network (GLMHAN) and additional health and government sources. The service mapping identified some key statistics on funding, caseloads and models of service provision with an additional emphasis on coverage, capacity, and funding stability. The questionnaire was augmented by interviews and focus groups with commissioners, service providers and service users and identified differing perspectives and problems, which informed the different perspectives of each of these groups. The cartographic mapping exercise demonstrated a spatially-even provision of mental health advocacy services across the city with each borough being served by at least one local service as well as by London wide specialist schemes. However, at local level, no one borough had the full range of specialist provision to match local demographic need. Ultimately the research assisted the Advisory Group in providing commissioning agencies with clear information on the current status of city-wide mental health advocacy services, and on gaps in existing advocacy provision alongside previously unconsidered geographical and service dimensions of that provision.

[Social deprivation and mental health. Replicability and applicability in the Italian context of the resource allocation methods developed in the United Kingdom]

AIMS

Most of the available evidence on the relationship between socioeconomic indicators of social deprivation and patterns of use of mental health services has been produced in the United Kingdom, where the Ministry of Health has developed a resource allocation formula based upon the results of those studies. The main aim of the paper is to evaluate the replicability in the Italian context of such research, and of the resulting allocation strategies.

METHODS

Detailed description of the resource allocation method currently adopted in the United Kingdom, whose main purpose consists in reaching the best balance between available funding and patterns of need. Detailed description of resource allocation processes in Italy; discussion of the main methodological and statistical limitations restraining the replicability of the British formula in the Italian context.

CONCLUSIONS

There is a growing interest in Italy towards the introduction of evidence-based methods in health decision making, in order to correct the overwhelming influence of political issues. What is needed is a better understanding of the relationship between higher levels of equity in health services access, and their effects in terms of better outcomes.

Neighborhood socioeconomic environment and risk of postpartum psychosis

OBJECTIVE

To examine the hypothesized association between the neighborhood socioeconomic environment and postpartum psychosis, after adjustment for individual sociodemographic characteristics.

METHOD

All Swedish women aged 20-44 years who became first-time mothers from 1 January 1986 to 30 September 1998 (N = 485,199) were followed for first hospital admissions due to postpartum psychosis. Neighborhood income was divided into three groups according to the proportions of individuals with low income in the neighborhood. Cox regression was used to estimate hazard ratios for postpartum psychosis.

RESULTS

Women living in the poorest neighborhoods exhibited a significantly higher risk of first hospital admissions due to postpartum psychosis than women living in the richest neighborhoods, HR = 1.49 (95% CI = 1.15-2.91, p = 0.002).

CONCLUSION

Decision makers and health care workers should be aware that living in a poor neighborhood socioeconomic environment might contribute to the development of postpartum psychosis.

A census-based socio-economic status (SES) index as a tool to examine the relationship between mental health services use and deprivation

This paper discusses the development and application of a socio-economic status (SES) index, created to explore the relationship between socio-economic variables and psychiatric service use. The study was conducted in a community-based mental health service (CMHS) in Verona, Northern Italy, utilising service use data from 1996. An ecological SES index was constructed through a factor analysis from 1991 Census data, at census block level. Three factors reflected the following domains: the educational-employment sector (with four components), the relational network (with three components) and the material conditions (with three components). All service users were assigned a SES value, according to their place of residence in 1996. When these data were explored spatially, using ArcView 8.3, an association was observed between socio-economic deprivation and psychiatric service use. The SES index was then successfully validated using occupational status at the individual level. This study confirms the usefulness of developing and validating an ecological census-based SES index, for service planning and resource allocation in an area with a community-based system of mental health care.

Social fragmentation, deprivation and urbanicity: relation to first-admission rates for psychoses

BACKGROUND

Social disorganisation, fragmentation and isolation have long been posited as influencing the rate of psychoses at area level. Measuring such societal constructs is difficult. A census-based index measuring social fragmentation has been proposed.

AIMS

To investigate the association between first-admission rates for psychosis and area-based measures of social fragmentation, deprivation and urban/rural index.

METHOD

We used indirect standardisation methods and logistic regression models to examine associations of social fragmentation, deprivation and urban/rural categories with first admissions for psychoses in Scotland for the 5-year period 1989-1993.

RESULTS

Areas characterised by high social fragmentation had higher first-ever admission rates for psychosis independent of deprivation and urban/rural status. There was a dose-response relationship between social fragmentation category and first-ever admission rates for psychosis. There was no statistically significant interaction between social fragmentation, deprivation and urban/rural index.

CONCLUSIONS

First-admission rates are strongly associated with measures of social fragmentation, independent of material deprivation and urban/rural category.

Does socioeconomic status affect the use of community-based psychiatric services? A South Verona case register study

OBJECTIVE

To assess the effect of socioeconomic status (SES) on psychiatric service use in an Italian area with a well-developed community-based psychiatric service.

METHOD

An index of SES was calculated from nine census variables and grouped into four categories, ranging from SES-I-affluent to SES-IV-deprived, for each of 328 census blocks (CB). Fifteen indicators of psychiatric service use were collected using the psychiatric case register. All patients resident in the catchment area, who had at least one psychiatric contact in 1996 (n=989), were included in the study.

RESULTS

Indicators of in-patient, day-patient, out-patient and community service use showed an inverse association with SES. Only first-ever and long-term psychotic patients were equally distributed in the four SES groups.

CONCLUSION

The inverse association between SES and most indicators of psychiatric service use suggests that the planning of community-based services and resource allocation should take into account the SES of residents.

Patterns of mental health service utilisation in Italy and Spain--an investigation using the European Service Mapping Schedule

BACKGROUND

Methods for comparing local mental health service systems are needed to allow identification of different patterns of service provision and of inequities within and between countries.

AIM

The aim of this study was to describe and compare mental health service systems in 13 catchment areas in Spain and Italy. Within each country, a range of area characteristics was represented.

METHOD

The European Service Mapping Schedule (ESMS) and European Socio-Demographic Schedule (ESDS) were used to describe: (i) socio-demographic and geographical area characteristics; (ii) services provided; and (iii) service utilisation in each area.

RESULTS

Great differences emerged in patterns of service provision and use between and within countries. In contrast to Northern Europe, high unemployment rates were not associated with high service utilisation rates, but areas with large numbers of single-person households tended to have high service use. Most service utilisation rates were substantially below those reported from Northern European studies. Spanish centres tended to have low rates of hospital service utilisation despite limited development of community-based services. Trieste, where there has been a strong emphasis on developing innovative community services, showed a distinctive pattern with low hospital bed use and high rates of day service use and of contacts in the community.

CONCLUSION

This methodology yielded useful data, which raise significant questions regarding equity and the implementation of mental health policy. The very large variations indicate that underlying local patterns of service provision must be investigated and taken into account in the interpretation of research evaluations of interventions.

A needs index for mental health care in England based on updatable data

BACKGROUND

Mathematical models relating rates of mental health care use to population characteristics such as social deprivation are widely used in both planning and researching mental health services. The models currently in wide use in England are based on data mostly derived from the 10-yearly population censuses. These are perceived to be out of date many years before new census data are available for their replacement. A new set of government deprivation monitoring statistics based mainly on annually updatable data has recently been developed. This study set out to produce a mental illness needs index based on these new data.

METHODS

A series of regression models were tested using individual domain scores from the DETR Index of Multiple Deprivation and the Office of National Statistics area-type classification as independent variables to predict 1998/9 psychiatric admission rates for broad diagnostic groups for 8251 of the 8414 electoral wards in England as dependent variables.

RESULTS

The distribution of admission numbers in wards showed a pattern of over-dispersion with an excessive number of zero values for conventional regression approaches. A two-stage 'hurdle' model was, thus, adopted, predicting first the likelihood that wards would produce any admissions and second the probable number. This produced satisfactory predictive power, with residual variance showing strong geographical patterns associated with administrative areas, probably arising from differential resourcing or idiosyncratic clinical practice.

CONCLUSIONS

A website providing data on the various indicators has been provided and its uses are indicated.

Monitoring mental health reform in a Canadian inner city

This ecological study investigated whether the relationship between social disadvantage and hospitalization for psychoses changed during a time of social and economic stressors in an urban setting. Hospital separation rates were compared in the census years 1991 and 1996. Rates were 66% higher in the lowest income areas compared to the richest areas; but this relationship did not change over time. Instead, rates for psychoses increased by about 15% over time. These findings may be due to an increase in the need, a change in the level of resources or in coding practices. As hospital separation data are collected systematically in many countries, they can be used to monitor the progress of mental health reform. Variations in an area may signify that resources need to be redistributed more equitably and/or at a faster pace.

Systematic review of the role of gender as a health determinant of hospitalization for depression

Objectives:To conduct a systematic review of selected health determinants, including gender, and their impact on hospitalization rates for depression. Depression includes both depressive and bipolar disorders. Selected health determinants were gender, age, sex, family structure, education, and socioeconomic status.

Methods:Systematic search of conventional and fugitive literature sources. All reports of primary data, systematic reviews, and meta-analysis of primary data were included if they focused on hospitalization for depression and reported data by one or more of the selected health determinants. Two researchers independently evaluated each citation for inclusion and extracted data from the included studies.

Results:There is an important underreporting of health determinants data in studies of hospitalization for depression. No studies examined the role of gender. Age and sex were reported in 83 percent and 80 percent of the 110 included studies. Women showed a higher rate of hospitalization for depression than men (p<.05). Age and diagnosis had different effects in men and women. Adult women were significantly more likely than men to report a depressive disorder, whereas men were more likely to report a bipolar disorder (p<.05). Little can be concluded on the other health determinants.

Conclusions:The importance of reporting hospitalization data and conducting hospital utilization analysis by sex and health determinants, including gender, must be emphasized.

African-Caribbean interactions with mental health services in the UK: experiences and expectations of exclusion as (re)productive of health inequalities

In the context of current concerns about health inequalities among minority ethnic groups in the UK, this paper addresses perceptions of mental health services among members of an African-Caribbean community in a South England town. Efforts to reduce health inequalities must take account of the views of local community members on the sources of those inequalities and on local health services. The statistical existence of inequalities in diagnosis and treatment of African-Caribbeans in the UK is well-established, supported by sociological explanations of these inequalities which centre on social exclusion in a variety of forms: institutional, cultural and socio-economic. However, detailed studies of the perspectives of local communities on mental health issues and services have received less attention. In this case study of community perceptions of mental health services, we find that social exclusion comprises an explanatory framework which is repeatedly invoked by community members in describing their interaction with mental health services. Interviewees assert that experience and expectation of racist mis-treatment by mental health services are key factors discouraging early accessing of mental health services, and thereby perpetuating mental health inequalities. We conclude that participation and partnership are vital means by which to generate both the objective and subjective inclusion that are requirements for an accessible and appropriate health service.

Social deprivation and psychiatric service use for different diagnostic groups

Recent research has shown that the relationship between social deprivation and admission rates varies according to diagnosis. We have replicated a study of this kind. Furthermore, in addition to admission rates, we also look at variations in length of stay and the proportion of readmitted patients. Psychiatric admission data for the 79 Amsterdam neighbourhoods was obtained from the City Psychiatric Register. This data covered all the admissions between 1992 and 1995 of people from Amsterdam aged 19 and older, with the exception of short-term crisis admissions to the Crisis Centre. These admissions were divided into six diagnostic groups. The admission rates, the average length of stay and the proportion of patients readmitted were compared to the level of socio-economic deprivation in the area concerned, a factor which was determined using factor analysis. Admission rates for schizophrenia, other psychoses and neurosis disorders showed a significant relation with the level of socioeconomic deprivation. Admission rates for affective disorders, organic psychoses and personality disorders showed no significant relation with deprivation. The findings on average length of stay and proportion of readmitted patients showed no clear relation with deprivation according to diagnosis category. As was found in previous studies, the relationship with socio-economic deprivation varies according to diagnosis. The average length of stay and the risk of readmission, given the diagnosis, do not vary according to level of deprivation.

Clinical ethics revisited: responses

This series of responses was commissioned to accompany the article by Singer et al , which can be found at . If you would like to comment on the article by Singer et al or any of the responses, please email us on editorial@biomedcentral.com .

Individual and contextual effects on mental health status in São Paulo, Brazil

Objectives: There is evidence that mental health status is partly determined by socioeconomic status. Recent research in the U.K. has highlighted the importance of place or context as a health determinant. This study aimed to analyze both individual socioeconomic variables and area of residence as potential risk factors for mental ill health. The objectives were to determine whether the effects of key explanatory variables on mental health status varies by area of residence and whether area of residence has an independent effect on mental health status once other key variables have been controlled for. Methods: The study used data collected as part of the Brazilian Multicentric Study of Psychiatric Morbidity. Data from a cross-sectional survey carried out in three socioeconomically contrasting sub-districts in São Paulo, Brazil, was used. The main outcome measure was mental health status as measured by the Questionário de Morbidade Psiquiátrica de Adultos (QMPA). Results: The results demonstrate that, even after key individual socioeconomic variables were controlled for, area of residence had a statistically significant effect on mental health status. Discussion: A possible explanation for the effect of area of residence relates to the social and physical features of places and their subsequent impact on health. Conclusions: It is important for mental health research to acknowledge the potential importance of the effect of area of residence on health, particularly in relation to developing new mental health promotion initiatives.

Social deprivation and prevalence of epilepsy and associated health usage

OBJECTIVES

To examine the relation between social deprivation and the prevalence of epilepsy and associated morbidity using hospital activity data as a proxy.

METHODS

The study was conducted in the health district of South Glamorgan, United Kingdom (population 434 000). Routinely available hospital data (inpatient and outpatient), an epilepsy clinic database, and mortality data underwent a process of record linkage to identify records relating to the same patient and to identify patients with epilepsy. Each patient was allocated a Townsend index deprivation score on the basis of their ward of residence. Age standardised correlations were calculated between deprivation score and prevalence of epilepsy, inpatient admissions, and outpatient appointments. Standardised mortality ratios (SMR) were also calculated. All analyses were performed on two cohorts: (1) all patients with epilepsy and (2) those patients with epilepsy without any underlying psychiatric illness or learning disability.

RESULTS

The prevalence of epilepsy ranged between 2.0 and 13.4 per 1000 with a median of 6.7. There were positive correlations between social deprivation and prevalence in both populations: (1) r=0.75 (p<0.001) and (2) r=0.70 (p<0.001). After standardising for underlying prevalence there were also correlations for mean inpatient admissions: (1) r=0.62 (p<0.001), (2) r=0.59, (p<0.001) and for outpatient appointments: (1) r=0.53, (p=0.001) and (2) r=0. 51 (p=0.001). The SMR for those deprived was (1) 1.66 (95% confidence interval (95% CI) 1.27-2.05) and (2) 1.80 (95% CI 0.71-1. 67). For the population as a whole (with and without epilepsy) the SMR was 1.25 (95% CI 1.27-2.32).

CONCLUSION

This study shows a strong correlation between the prevalence of epilepsy and social deprivation and weaker correlations between social deprivation and mean hospital activity.

Variables associated with the hospitalization of psychiatric emergencies evaluated in the community

We investigated hospitalization factors in acutely ill patients visited by psychiatrists at home. A series of 100 consecutive calls for psychiatric emergencies of a community mental health centre were investigated with a structured evaluation of psychiatric symptoms and aggressiveness (IEF, GAS, and VSAS). First order interactions were tested, and selected variables were tested with logistic regression analysis. Admission was significantly associated with GAS scores (low scores were found in 92.6% of admitted patients vs. 43.8% of patients not admitted), paranoid delusions (66.7 vs. 39.7%), and lack of social support (70.4 vs. 30.1%). Multivariate analysis confirmed a significant independent effect only for low GAS score and lack of social support. The study replicated some findings from research on hospitalization in emergency wards, while other factors, such as 'diagnosis' and 'suicide risk', were not significant.

Characteristics of early- and late-diagnosed schizophrenia: implications for first-episode studies

First-episode studies of schizophrenia are being carried out in many places. However, previous work has suggested that only half of the patients with schizophrenia receive the diagnosis in the initial stages of the illness. We examined whether cases of early- and late-diagnosed schizophrenia differed with respect to key sociodemographic characteristics and indicators of service use that might bias first-episode studies. Individuals who (i) presented for the first time between 1983 and 1993 to psychiatric services in a defined urban area with a cumulative mental health case register; and (ii) received a diagnosis of schizophrenia at least once during their mental health career were identified (n = 186). This sample was divided into those who received the diagnosis of schizophrenia for the first time within the first year of service contact (early-diagnosed schizophrenia; EDS), and those who received it for the first time after the first year of service contact (late-diagnosed schizophrenia; LDS). The 10-year incidence of EDS and LDS were 10.4 and 7.0 per 100,000 person-years, respectively. EDS and LDS did not differ in their pattern of association with sex, single marital status and higher levels of neighbourhood socioeconomic deprivation. However, EDS was more incident in the higher age groups, and the level of service use was higher for EDS cases in the first years of contact with mental health services, with LDS cases gradually catching up and exceeding EDS service use later in the illness course. Although differences between EDS and LDS were few, studies of patients with schizophrenia in the 'first' episode are likely to be most representative if patients who receive the diagnosis for the first time after previous episodes of care for non-schizophrenic episodes are also included.

Severity of psychiatric disorder in day hospital and in-patient admissions

This study assessed whether severity of psychiatric disorder varies across day hospital and in-patient units according to local need, and whether severity of disorder predicts length of stay and therefore costs. Data were collected for a consecutive series of 2230 in-patients and 712 day patients using the Social Behaviour Scale (data completed by nurses) and diagnosis and Clinical Global Impression (CGI) (completed by doctors). Severity of illness of subjects admitted to in-patient units, but not to day hospitals, was associated with under-privileged area score (UPA). Length of in-patient stay is most accurately predicted by Clinical Global Impression and six other variables relating to diagnosis, demographic status and individual hospital. Improved resource allocation for mental health services could be achieved if severity of disorder was routinely collected.

Social deprivation and psychiatric admission rates in Amsterdam

The main subject of this study was the link between social indicators and the (re)admission rates for, and length of stay in, in-patient mental health care in Amsterdam. In a factor analysis of 15 sociodemographic variables, two principal components analysis factors were distinguished: housing quality and socioeconomic deprivation. The census variables and the factors almost all had high correlations with the crude admission rates as well as the rates standardised for age and sex. In general, the correlations with rates that were also standardised for marital status were significantly lower. This shows that many correlations between indicators and crude rates are determined to a significant extent by the marital status profile of an area. Socioeconomic deprivation is positively correlated with the proportion of readmissions and inversely correlated with average length of stay.

Social indicators and the prediction of psychiatric admission in different diagnostic groups

BACKGROUND

Recent findings indicate that the established association between social indicators of deprivation and psychiatric admission rates may not hold across all diagnoses.

METHOD

Admission rates in individuals aged 16-64 years for 71 electoral wards in North Staffordshire were calculated for six diagnostic groups using data from the Korner Episode System for 1987-1993. These were correlated with selected individual census variables, Townsend and Jarman indices. The ability of regression models to predict admission rates was tested.

RESULTS

The strongest correlations were found for total admissions (r 0.44-0.79). Strong correlations were found for neurotic disorders/depression (r 0.29-0.62), schizophrenia (r 0.24-0.59), all non-psychotic disorders combined (r 0.41-0.71) and all psychotic disorders combined (r 0.33-0.67). Predicted admission rates for total admissions, psychotic and non-psychotic admissions using regression models showed strong positive correlations with observed admission rates.

CONCLUSIONS

The strong correlations between social indicators of deprivation and total psychotic admission rates are consistent with the results of previous studies. The strong associations between social indicators and admissions for non-psychotic disorders is contrary to previous findings and may be partly explained by the relatively high admission rates for neurotic disorders.

Factors associated with multiple admissions to a public psychiatric hospital

The purpose of this study was to identify the psychiatric and social factors associated with multiple admissions, especially for psychotic patients. Demographic and diagnostic information (based on the DSM-III-R) was collected on a computerized database for all patients admitted to the only psychiatric hospital in Geneva, Switzerland. Patients who had had at least three admissions over a period of 1 year were compared with a control group drawn from the total clinic population. In 1994, a total of 1575 patients were hospitalized, and 18% of these patients were readmitted for the third or more time. The principal diagnoses were psychotic disorders (25%), affective disorders (35%) and substance-related disorders (24%). The predictors of multiple admissions for psychotic patients were a comorbidity of substance-related disorder, longer duration of illness, female sex, younger age and poorer psychosocial adjustment during the past year. These results highlight the usefulness of a computerized psychiatric database. Indeed, early identification of the types of psychiatric patient who are likely to be readmitted is necessary to enable the planning and implementation of specific programmes of ambulatory care to prevent rehospitalization.