Viewpoint: do antipsychotics protect against early death? A critical view

In the past 15 years, researchers utilizing prescription databases to assess medication usage have concluded that antipsychotics reduce mortality in patients diagnosed with schizophrenia and other psychotic disorders. These findings stand in contrast to studies in non-psychiatric patients that have found that antipsychotics, because of their adverse effects on physical health, increase the risk of early death. A critical review of the evidence reveals that the worry remains. There is reason to conclude that antipsychotics contribute to the ‘mortality gap’ between the seriously mentally ill and the general population and that the database studies are plagued with methodological and reporting issues. Most importantly, the database studies tell of mortality rates within a drug-centered paradigm of care, which confounds any comparison of mortality risks when patients are on or off antipsychotics.

Numbers and the Assembling of a Community Mental Health Infrastructure in Postsocialist China

This chapter shows how globally validated epidemiological estimates have constituted a population of seriously mentally ill patients in China. It talks about the target population of the 686 Program and compares the program's different visions. It also discusses how national and local interests translate estimates into program targets and evaluation standards. The chapter explains how the numbers' circulation in existing bureaucratic pathways can generate controversies of “quota apportioning.” It covers what the numerically guided community mental health infrastructure might include or exclude and when it might work or break down. The data for the chapter draw on ongoing ethnographic research on community mental health in China.

The Rise of Supermax Imprisonment in the United States

This chapter provides an overview of the history of supermax prisons: facilities built across the United States in the 1980s and 1990s in order to hold “problem” prisoners, like gang members, the seriously mentally ill, the extremely violent, and those sentenced to death, in solitary confinement for months and years at a time. Since nearly every state opened one of these facilities in the late twentieth century, prisoners have litigated the constitutionality of the harsh conditions: no human contact, 24-hour fluorescent lighting, limited time outdoors. In spite of these conditions, supermaxes were not just another popular tough-on-crime innovation; state (not federal) prison administrators designed the first supermaxes with little public knowledge or oversight, in response to organized protests in prisons in the 1970s and 1980s. Although prisoners have sought to challenge these facilities, litigation has, in many cases, played a legitimizing in the history of supermaxes.

HIGH ON SMI: QUALITY CONCERNS ABOUT NURSING HOMES SERVING HIGH PROPORTIONS OF SERIOUSLY MENTALLY ILL RESIDENTS

The proportion of nursing home (NH) residents that have serious mental illness (SMI) has increased over the least two decades. Residents with SMI tend be younger and have different medical needs than traditional residents. To better understand this population, our study examined the facility, staffing, and resident characteristics of NHs that were more likely to specialize in SMI. Utilizing the Certification and Survey Provider Enhanced Reports, low-SMI (N = 3,616) and high-SMI (N = 3,615) NHs were defined as the first and fourth quartile of the distribution of the proportion of SMI residents, respectively. We performed bivariate tests and multivariate logistic regression to compare facility, staffing, resident, and star-ratings characteristics between NHs. High-SMI NHs were less likely to be Not-For-Profit, have fewer beds, have more Medicaid-paying residents, lower registered nurse staffing, and lower certified nurse aide staffing levels (p’s<.001). Residents in high-SMI NHs were more likely to require behavioral healthcare (p<.001) and be treated with psychoactive medications (any psychoactive, antidepressants, antipsychotics, anxiolytics (p’s<.001), hypnotics (p<.01)). Finally, high-SMI facilities had lower overall quality, health inspection, quality measure, staffing, and registered nurse staffing star-ratings (p’s<.001). High-SMI NHs have characteristics that are associated with lower quality-of-care (e.g., For-Profit, more Medicaid), lower staffing, prescribe more psychoactive medications, and have lower star-ratings. As the SMI population grows, large numbers of SMI residents will concentrate in a few NHs. While further research is needed to understand the implications of these trends, policy-makers must be aware of this population when affecting the resources and staffing of NHs.

Analysis of Emergency Room Visits Reveals a Seriously Mentally Ill, Medically Fragile Population Requiring Strategic Management

OBJECTIVE: This practice improvement project evaluated the cost of health care services utilized by patients with comorbid mental and physical chronic conditions who were psychiatrically hospitalized but transported for health care services of physical symptoms that developed during their psychiatric hospitalization. METHOD: A retrospective review of invoices to a regional psychiatric hospital for non-psychiatric health services utilized by inpatients revealed high costs of emergency room (ER) visits from July 2016 to June 2017. Medical records for these seriously mentally ill inpatients who visited the ER for evaluation of sudden emergent physical symptoms were reviewed. The collected data were analyzed. RESULTS: ER invoices revealed that 41 visits had been made by 28 patients with a total cost of $308,466.67, of which $258,668.15 was judged to be for the treatment of patients with symptoms of preventable side effect syndromes. This chart review and analysis suggest a need for improved strategic medication management in an integrated model of care. CONCLUSIONS: Polypharmacy was found to be responsible for increased debilitating physical symptoms requiring ER visits for this seriously mentally ill, medically fragile population. An integration of care services for comorbid conditions by advanced practice registered nurses with protocols specifically designed for this population was recommended.