Juveria Zaheer

Assessment and Emergency Management of Suicidality in Personality Disorders

This article examines the association between suicidal behavior and personality disorders. It updates the review of epidemiological evidence for the association between suicidal behavior and suicide in individuals who have a personality disorder diagnosis, particularly in borderline personality disorder (BPD). The second part of the article presents new empirical evidence that characterizes suicidal behavior in patients who have BPD, specifically examining patient characteristics that differentiate patients who have BPD with a history of high versus low lethality suicide attempts. Finally, the article discusses the approach to a patient who has BPD and presents to the emergency department because of an increased risk of suicide.

Clinical outcome and memory function with maintenance electroconvulsive therapy: a retrospective study.

Abstract: Although maintenance electroconvulsive therapy (ECT) appears to be the logical choice for the prevention of relapses and recurrences in patients with refractory depression who have responded to a course of ECT, the perception of ECTs negative effect on memory continues to limit its wider use. This retrospective study of depressed patients maintained on ECT after an initial course revealed that maintenance ECT was effective in sustaining clinical improvement, particularly in patients who showed a satisfactory clinical response to the initial course of ECT, and that memory difficulties were limited and tolerable.

Ethnic Differences in Mental Illness Severity: A Population-Based Study of Chinese and South Asian Patients in Ontario, Canada.

OBJECTIVE Little is known about the sociocultural determinants of mental illness at hospital presentation. Our objective was to examine ethnic differences in illness severity at hospital admission among Chinese, South Asian, and the general population living in Ontario, Canada. METHODS We conducted a large, population-based, cross-sectional study of psychiatric inpatients aged from 19 to 105 years who were discharged between 2006 and 2014. A total of 133,588 patients were classified as Chinese (n = 2,582), South Asian (n = 2,452), or the reference group (n = 128,554) using a validated surnames algorithm (specificity: 99.7%). Diagnoses were based on DSM-IV criteria. We examined the association between ethnicity and 4 measures of disease severity: involuntary admissions, aggressive behaviors, and the number and frequency of positive symptoms (ie, hallucinations, command hallucinations, delusions, and abnormal thought process) (Positive Symptoms Scale, Resident Assessment Instrument-Mental Health [RAI-MH]). RESULTS After adjusting for sociodemographic characteristics, immigration status, and discharge diagnosis, Chinese patients had greater odds of involuntary admissions (odds ratio [OR] = 1.79; 95% CI, 1.64-1.95) and exhibiting severe aggressive behaviors (OR = 1.36; 95% CI, 1.23-1.51) and ≥ 3 positive symptoms (OR = 1.39; 95% CI, 1.24-1.56) compared to the general population. South Asian ethnicity was also an independent predictor of most illness severity measures. The association between Chinese ethnicity and illness severity was consistent across sex, diagnostic and immigrant categories, and first-episode hospitalization. CONCLUSIONS Chinese and South Asian ethnicities are independent predictors of illness severity at hospital presentation. Understanding the role of patient, family, and health system factors in determining the threshold for hospitalization is an important future step in informing culturally specific care for these large and growing populations worldwide.

Introducing psychiatry to rural physicians in China: an innovative education project.

A brief educational program for 10,000 rural physicians in China introduced them to psychiatric knowledge and skills, emphasizing suicide risk assessment and management. Six months after the program, the physicians reported positive changes in their attitudes toward psychiatry, applicability of their new knowledge, and more communication with specialists.

Bridging Cultural Psychiatry and Global Mental Health: A Resident-Led Initiative.

To the Editor: We describe the creation and implementation of a resident-led global mental health and cultural psychiatry discussion group at the University of Toronto, which is a revival and extension of a previous cultural psychiatry group recently described in this journal [1]. Global health is a growing area of interest among mental health practitioners. Given the significant contribution ofmental illness to the global burden of disease, there have been increasing calls for psychiatry to develop global health training programs [2]. Global health training in psychiatric programs promotes the development of leaders in mental health care interested in addressing health inequities, as significantly inequitable access to mental health care exists between high-, middle-, and low-income countries [2]. However, only 9 % of US psychiatric residency programs have global health training programs in place [3]. A survey of residency training directors suggested that, while they endorsed the value of international experiences, their availability and educational impact can be limited, and resources to support such endeavors were often scarce [4]. Furthermore, the benefit of international electives for host countries can be variable [3], which supports exploration of other means of global health education. Although the tension between global mental health and cultural psychiatry has been well documented [5], existing education initiatives teach cultural psychiatry [6] and global mental health [2–4] separately. While global mental health focuses on improving access to mental health care in lowand middle-income countries, critiques from cultural psychiatrists have sometimes viewed the movement as a form of cultural imperialism, with Western understandings of mental illness being used to export treatment to lower income countries without true collaboration [5]. Few if any residency education programs teach both subjects in one module or explore the possible tension between the two fields. In addition, limited opportunity for interdisciplinary discussion has been described. Thus, by inviting residents, staff physicians, community service providers, allied health professionals, advocates, consumers, and social scientists from related disciplines as both participants and speakers, we sought to create a forum for open, critical discussion of current issues in global mental health and cultural psychiatry, as a nuanced understanding of cultural psychiatry is thought crucial to good global mental health practice [2, 5]. We also sought to build a community of practitioners who could support each other in this stilldeveloping field. We named the initiative Mental Health on the Margins to capture the idea that both global mental health and cultural psychiatry work with marginalized populations and to highlight the group as a space to discuss marginalized topics in psychiatry. Group meetings occur monthly, with an invited expert speaker and a suggested reading distributed before the meeting. A period of community mingling over dinner is followed by our speaker introducing the topic briefly before moving into open, informal conversation pertaining to the topic. Meetings are held in group members’ homes to foster a non-institutional atmosphere conducive to freely airing of critical perspectives. Through formal and informal networks, our mailing list has around 100 members, with roughly half psychiatry residents and half comprised of researchers and other healthcare professionals. Topics alternate between different aspects of global mental health and cultural psychiatry, from practical “on-the-ground” * Juveria Zaheer Juveria.zaheer@camh.ca

“I Can’t Crack the Code”: What Suicide Notes Teach Us about Experiences with Mental Illness and Mental Health Care

Objective: While mental illness is a risk factor for suicidal behaviour and many suicide decedents receive mental health care prior to death, there is a comparative lack of research that explores their experiences of mental illness and care. Suicide notes offer unique insight into these subjective experiences. Our study explores the following questions: “How are mental illness and mental health care experienced by suicide decedents who leave suicide notes?” and “What role do these experiences play in their paths to suicide?” Method: We used a constructivist grounded theory framework to select a focus of qualitative analysis and engage in line-by-line open coding, axial coding, and theorizing of the data. Our sample is a set of 36 suicide notes that explicitly make mention of mental illness and/or mental health care, purposefully selected from a larger sample of 252 notes. Results: The primary themes from our sample were 1) negotiating personal agency in the context of mental illness, 2) conflict between self and illness, and 3) experiences of mental health treatment leading to hopelessness and self-blame. These experiences with mental illness and mental health care can give rise to exhaustion and a desire to exercise personal agency, contributing to suicidal behaviour. Conclusions and Relevance: This study highlights unique perspectives by suicide decedents, whose voices and experiences may not have been heard otherwise, addressing a critical deficit in existing literature. These insights can potentially enrich clinical care or strengthen existing suicide prevention programs.

Service utilization and suicide among people with schizophrenia spectrum disorders

OBJECTIVE To compare individuals with and without schizophrenia spectrum disorders (SSD) (schizophrenia, schizoaffective disorder, or psychotic disorder not otherwise specified) who die by suicide. METHOD This is a retrospective case control study which compared all individuals who died by suicide in Ontario, Canada with (cases) and without (controls) SSD between January 1, 2008 and December 31, 2012. Cases (individuals with SSD) were compared to controls on demographics, clinical characteristics, and health service utilization proximal to suicide. A secondary analysis compared the characteristics of those with SSD and those with severe mental illness (defined as those without SSD who have had a psychiatric hospitalization within the five-years before suicide (excluding the 30 days prior to death)). RESULTS Among 5650 suicides, 663 (11.7%) were by individuals with SSD. Compared to other suicides, SSD suicides were significantly more likely to be between the ages of 25-34. SSD suicide victims were significantly more likely to reside in the lowest income neighbourhoods and to reside in urban areas. SSD victims were also significantly more likely to have comorbid mood and personality disorders and all types of health service utilization, including outpatient mental health service contact in the 30 days prior to death, even when compared only with those who had a history of mental health hospitalization. CONCLUSIONS Individuals with schizophrenia spectrum disorder account for over 1 in 10 suicide deaths, tend to be younger, poorer, urban, more clinically complex, and have higher rates of mental health service contact prior to death. The demographic and service utilization differences persist even when the SSD group is compared with a population with severe mental illness that is not SSD. Suicide prevention strategies for people with schizophrenia spectrum disorder should emphasize the importance of clinical suicide risk assessment during clinical encounters, particularly early in the course of illness.

Assessing ‘Insight’, Determining Agency and Autonomy: Implicating Social Identities

In this chapter, we draw on a critical analysis of 120 inpatient charts from a large psychiatric institution in Toronto, Ontario to examine the concept of ‘insight’ as it is operationalized by psychiatrists in chart documentation. We argue that psychiatrists use insight as a discursive means to delegitimize patient perspectives that diverge from the medical model of mental illness, particularly those that are more likely to be held by marginalized people. Patients who expressed the logics and lived realities of white, middle class, male heteronormativity were often accorded more respect and were more likely to be perceived as insightful. The construct of ‘insight’ plays a fundamental role in the justification of coercive measures such as involuntary hospitalization or detention and compulsory treatment. Thus, the attribution of ‘insight’ and its associated discursive logic has serious implications for patient agency and bodily autonomy.

“We Went Out to Explore, But Gained Nothing But Illness”: Immigration Expectations, Reality, Risk and Resilience in Chinese-Canadian Women with a History of Suicide-Related Behaviour

Suicide is a complex and tragic outcome driven by biological, psychological, social and cultural factors. Women of Chinese descent and women who have immigrated to other countries have higher rates of suicidal ideation and behaviour, and immigration-related stress may contribute. To understand the experiences of immigration and their relationship with distress and suicide-related behaviour in Chinese women who have immigrated to Canada. 10 semi-structured qualitative interviews with Chinese women who have immigrated to Toronto, Canada and have a history of suicide-related behaviour were completed and analyzed using a constructivist grounded theory methodology. Immigration-related and acculturation stress stemmed from unmet expectations and harsh realities. These repeated experiences resulted in hopelessness, helplessness, and alienation, which are risk factors for suicide and suicide-related behaviour. However, immigration-related support can also increase hope, self-efficacy and connectedness to foster recovery and resilience. This is the first qualitative study focusing on immigration experiences and its relationship to suicide-related behaviour in Chinese immigrant women. Knowledge of immigration and acculturation stressors can a) help identify and support women at risk for suicide and b) form a target for social intervention for all immigrant women, regardless of suicide risk.

Postdischarge service utilisation and outcomes among Chinese and South Asian psychiatric inpatients in Ontario, Canada: a population-based cohort study

Objective We sought to examine the short-term and long-term impacts of psychiatric hospitalisations among patients of Chinese and South Asian origin. Design Retrospective population-based cohort study using linked health administrative data. Setting We examined all adult psychiatric inpatients discharged between 1 April 2006 and 31 March 2014 in Ontario, Canada, who were classified as Chinese, South Asian and all other ethnicities (ie, ‘general population’) using a validated algorithm. We identified 2552 Chinese, 2439 South Asian and 127 142 general population patients. Primary and secondary outcome measures We examined psychiatric severity measures at admission and discharge and performed multivariable logistic regression analyses to examine 30-day, 180-day and 365-day postdischarge service utilisation and outcomes, comparing each of the ethnic groups with the reference population, after adjustment for age, sex, income, education, marital status, immigration status, community size and discharge diagnosis. Results Despite presenting to hospital with greater illness severity, Asian psychiatric inpatients had shorter lengths of hospital stay and greater absolute improvements in mental health and functional status at discharge compared with other inpatients. After hospitalisation, Chinese patients were more likely to visit psychiatrists and South Asian patients were more likely to seek mental healthcare from general practitioners. They were also less likely to have a psychiatric readmission or die 1 year following hospitalisation (adjusted ORChinese=0.87; 95% CI 0.79 to 0.97; adjusted ORSouth Asian=0.82, 95% CI 0.73 to 0.91). Findings were consistent across genders, psychiatric diagnoses and immigrant groups. Conclusion Once hospitalised, patients of Chinese and South Asian origin fared as well as or better than general population patients at discharge and following discharge, and had a positive trajectory of psychiatric service utilisation.