Frank Sirotich

Predictors of Unmet Need for Medical Care Among Justice-Involved Persons With Mental Illness

OBJECTIVE This cross-sectional study examined factors associated with unmet need for care from primary care physicians or from psychiatrists among clients enrolled in mental health court support programs in Toronto, Ontario. METHODS The sample included adults admitted to these programs during 2009 (N=994). Both measures of unmet need were determined by mental health court workers at program intake. Predictors included client predisposing, clinical, and enabling variables. RESULTS Twelve percent had unmet need for care from primary care physicians and 34% from psychiatrists. Both measures of unmet need were associated with having an unknown diagnosis, having no income source or receiving welfare, homelessness, and not having a case manager. Unmet need for care from psychiatrists was associated with symptoms of serious mental illness and current hospitalization. CONCLUSIONS Obtaining care from psychiatrists appears to be a particular challenge for justice-involved persons with mental illness. Policies and practices that improve access warrant more attention.

Needs among persons with human immunodeficiency virus and intellectual and developmental disabilities in community mental health care: a cross‐sectional study

BACKGROUND The experience of having human immunodeficiency virus (HIV) is often associated with co-occurring mental health issues. Community mental health services are an important source of support for persons with HIV living in the community. Persons with intellectual disability (ID) are vulnerable to HIV and may have unique support needs beyond those without ID receiving community care. This study compared support needs of men with HIV in community mental health programmes, with and without ID. METHODS The sample was composed of 138 HIV-positive men with and without ID receiving mental health case management from one community organisation in Ontario, Canada, on 31 March 2013. Staff-rated needs across 16 domains grouped into four clusters were measured using the Camberwell Assessment of Need: Basic needs (accommodation, food, public transportation, money and benefits); self-care/functional needs (looking after the home, self-care and daytime activities); health/safety needs (physical health, psychological distress, psychotic symptoms, safety to self and safety to others); and social needs (company, intimate relationships and sexual expression). Adjusted logistic regression models examined the association between ID and each need domain. RESULTS One-quarter of the sample (n = 34/138, 24.6%) had co-occurring ID. Those with ID were more likely to have needs in the basic cluster [odds ratios: food 4.05 (1.14, 14.44), P:0.031; benefits 2.58 (1.05, 6.32), P:0.038)] and self-care/functional cluster [looking after the home (2.75 (1.17, 6.49), P:0.021); self-care (2.72 (1.18, 6.27), P:0.019)], but were less likely to have need for sexual expression: 0.35 (0.14,0.90), P:0.030) (social cluster). There were no differences in the domains in the health/safety cluster. CONCLUSION Despite elevated cognitive needs in the basic and self-care/functional clusters for the ID group, limited other differences suggest that with moderate additional targeting, community mental health programmes for persons with HIV may be appropriate for men with ID.

English Language Abilities and Unmet Needs in Community Mental Health Services: a Cross-Sectional Study

Language has been described as medicine’s most essential technology and its principle instrument. Even so, persons with limited English proficiency (LEP) often do not have access to providers who speak their language. In many jurisdictions in North America, many health services are provided in English without linguistic assistance. There is evidence that compared to clients with greater English proficiency, persons with LEP have less understanding of the care they receive, are less likely to follow recommendations for treatment and followup visits, are more likely to have delayed diagnoses, and are less satisfied with care. They are also more likely to rely on ad hoc interpreters (e.g., family, friends, nonclinical employees, or nonfluent health care professionals), which may transform the communication, leading to omission of questions, failure to mention medication side effects, and ignoring embarrassing issues. Given these challenges, it is not surprising that LEP individuals also have been shown to have more emergency department visits, more hospital admissions, and longer hospital stays for many medical and surgical conditions. For clients with mental illness, language barriers can be particularly problematic since mental health (MH) diagnostic and management processes rely more on communication than on objective tests. Similar to patterns of use for general health care, research has indicated that LEP persons have lower utilization of MH services than English-speaking patients even when they have greater MH need, although interventions conducted in clients’ native language can be much more effective in terms of symptom reduction and client satisfaction. Unmet need

Coercion in Outpatients under Community Treatment Orders: A Matched Comparison Study:

Objective: Since the deinstitutionalization of psychiatric services around the world, the scope of outpatient psychiatric care has also increased to better support treatment access and adherence. For those with serious mental illness who may lack insight into their own illness, available interventions include coercive community practices such as mandated community treatment orders (CTOs). This paper examines the perceptions of coercion among service users treated with a CTO. Method: We used a cross-sectional comparative design where service users treated under a CTO were matched to a comparison group of voluntary psychiatric outpatients. Both groups were receiving intensive community mental health services (n = 69 in each group). Participants were interviewed using a series of questionnaires aimed at evaluating their perceptions of coercion and other aspects of the psychiatric treatment. Results: The level of coercion reported by service users treated under a CTO was significantly higher than that in the comparison group. However, in adjusted analyses, service users’ perception of coercion, irrespective of their CTO status, was directly correlated with their previous experience with probation and inversely correlated with the sense of procedural justice in their treatment. Conclusions: Evaluation of psychiatric service users’ experiences of coercion should consider their past and current involvement with other types of coercive measures, particularly history of probation. Clinicians may be able to minimize these experiences of coercion by incorporating procedural justice principles into their practice.

Correlates of Mental Health Diversion Completion in a Canadian Consortium

ABSTRACT Mental health diversion is an important option for offenders with mental illness who do not pose a serious risk to public safety and who would otherwise be better served outside the criminal justice system. Predictors of complete vs. incomplete diversion were examined in a sample of 708 defendants seen in Torontos mental health diversion programs. Univariate analyses revealed that unsuccessfully diverted defendants were significantly more likely to be younger, homeless, and have more clinical and legal needs compared to those who were successfully diverted. In multivariate analyses, criminological factors (e.g., criminal history) had the strongest association with diversion completion, compared to clinical (e.g., primary diagnosis) and psychosocial (e.g., employment status) factors outside of marital status, which was strongly associated with completion. The results from this research add to previous research on mental health courts and diversion by giving guidance on how to select and prepare diversion candidates. These findings suggest that diversion programs may benefit from adaptations in order to better suit high need clients.