Steven Marwaha

Schizophrenia and employment

Abstract.Background:Little is known about the extent to which work contributes to the recovery of people with schizophrenia. There is increasing interest in the subject because of new service models and the economic cost of unemployment in people with severe mental illness.Methods:A literature search was carried out with the aim of investigating: a) employment rates in schizophrenia and first-episode psychosis and the extent to which they have changed over time; b) the barriers to work; c) the factors associated with being employed among people with schizophrenia; and d) whether employment influences other outcomes in schizophrenia.Results:There are wide variations in reported employment rates in schizophrenia. Most recent European studies report rates between 10 % and 20%, while the rate in the US is less clear. There is a higher level of employment among first-episode patients. The employment rate in schizophrenia appears to have declined over the last 50 years in the UK. Barriers to getting employment include stigma,discrimination, fear of loss of benefits and a lack of appropriate professional help. The most consistent predictor of employment is previous work history. Working is correlated with positive outcomes in social functioning, symptom levels, quality of life and self esteem, but a clear causal relationship has not been established.Conclusions:Very low employment rates are not intrinsic to schizophrenia, but appear to reflect an interplay between the social and economic pressures that patients face, the labour market and psychological and social barriers to working.

Views and Experiences of Employment among People with Psychosis: A Qualitative Descriptive Study

Background: Work is important for mental health but we are only just beginning to understand why so few people with psychosis in the UK work. Aims: To identify the opinions of a purposive sample of patients with psychosis on themes related to employment. Method: A thematic analysis of 15 semi-structured interviews with people with schizophrenia or bipolar affective disorder. Results: Participants identified a range of advantages to working but also expressed substantial doubts. Symptoms, medication and potential damage to health are the problems that people believe affect their ability to work. Most people would not tell their employers about their illness because they feared discrimination during the selection process, but believed it could help their chances of retaining a job if employers knew. A number reported a lack of encouragement to work from mental health professionals and not enough helpful employment services. Conclusions: Although most people want to work, given the pressures they face some may choose not to. Barriers that people face are both internal and external and these interact.

Stigma, racism or choice. Why do depressed ethnic elders avoid psychiatrists?

BACKGROUND Knowledge of mental health service users views is important in service planning, to ensure access for everyone and in particular for those in minority groups. Depression is common in older people and it has been suggested that ethnic elders may be more vulnerable to mental illness. This study therefore explored and compared the views of White British (WB) and Black African-Caribbean (BC) older people on depression as an illness, avenues of help and the place of mental health services. METHODS A qualitative analysis of semi-structured interviews using vignettes describing an older man with depression and a woman with psychosis. The purposive sample consisted of 40 WB and BC older people half of who had been depressed. RESULTS 21 WB (10 depressed and 11 not depressed) and 19 BC (10 depressed and 9 not depressed) were interviewed. Most people irrespective of ethnicity or depression recognised that there was something wrong with the man with depression. Most did not consider it an illness. Ethnicity but not depression effected the interpretation of the aetiology of the symptoms. A minority thought that consulting the GP would help but some BC specified that it would be inappropriate. BC who had not been depressed thought that spiritual help was appropriate. Both ethnic groups suggested that mental health services were for care, incarceration or dealing with violence. None of those who had been depressed thought that the mental health services were for dealing with violence. LIMITATIONS We interviewed established BC immigrants and our results might not apply to new BC immigrants or other immigrant groups. Descriptions within the vignettes of depression and psychosis were defined by us. CONCLUSIONS Most older people do not view depression as a mental illness. Older people, particularly BC therefore often do not see psychiatric services as appropriate and believe they are primarily for psychosis and violence. These views are amenable to change. Doctors should be explicit that services are for people with depression.

Mood Instability and Psychosis: Analyses of British National Survey Data

Background: We used British national survey data to test specific hypotheses that mood instability (1) is associated with psychosis and individual psychotic phenomena, (2) predicts the later emergence of auditory hallucinations and paranoid ideation, and (3) mediates the link between child sexual abuse and psychosis. Methods: We analyzed data from the 2000 and 2007 UK national surveys of psychiatric morbidity (N = 8580 and 7403, respectively). The 2000 survey included an 18-month follow-up of a subsample (N = 2406). Mood instability was assessed from the Structured Clinical Interview for DSM-IV Axis II (SCID-II) questionnaire. Our dependent variables comprised auditory hallucinations, paranoid ideation, the presence of psychosis overall, and a 15-item paranoia scale. Results: Mood instability was strongly associated in cross-sectional analyses with psychosis (2000: OR: 7.5; 95% CI: I 4.1–13.8; 2007: OR: 21.4; CI: 9.7–41.2), paranoid ideation (2000: OR: 4.7; CI: 4.1–5.4; 2007: OR: 5.7; CI: 4.9–6.7), auditory hallucinations (2000: OR: 3.4; CI: 2.6–4.4; 2007: OR 3.5; CI: 2.7–4.7), and paranoia total score (2000: Coefficient: 3.6; CI: 3.3–3.9), remaining so after adjustment for current mood state. Baseline mood instability significantly predicted 18-month inceptions of paranoid ideation (OR: 2.3; CI: 1.6–3.3) and of auditory hallucinations (OR: 2.6; CI: 1.5–4.4). Finally, it mediated a third of the total association of child sexual abuse with psychosis and persecutory ideation and a quarter of that with auditory hallucinations. Conclusions: Mood instability is a prominent feature of psychotic experience and may have a role in its genesis. Targeting mood instability could lead to innovative treatments for psychosis.

Cannabis use and mania symptoms : a systematic review and meta-analysis

BACKGROUND Whilst cannabis use appears to be a causal risk factor for the development of schizophrenia-related psychosis, associations with mania remain relatively unknown. This review aimed to examine the impact of cannabis use on the incidence of manic symptoms and on their occurrence in those with pre-existing bipolar disorder. METHODS A systematic review of the scientific literature using the PRISMA guidelines. PsychINFO, Cochrane, Scopus, Embase and MEDLINE databases were searched for prospective studies. RESULTS Six articles met inclusion criteria. These sampled 2391 individuals who had experienced mania symptoms. The mean length of follow up was 3.9 years. Studies support an association between cannabis use and the exacerbation of manic symptoms in those with previously diagnosed bipolar disorder. Furthermore, a meta-analysis of two studies suggests that cannabis use is associated with an approximately 3-fold (Odds Ratio: 2.97; 95% CI: 1.80-4.90) increased risk for the new onset of manic symptoms. LIMITATIONS We were only able to identify a small number of studies of variable quality, thus our conclusions remain preliminary. CONCLUSIONS Our findings whilst tentative, suggest that cannabis use may worsen the occurrence of manic symptoms in those diagnosed with bipolar disorder, and may also act as a causal risk factor in the incidence of manic symptoms. This underscores the importance of discouraging cannabis use among youth and those with bipolar disorder to help prevent chronic psychiatric morbidity. More high quality prospective studies are required to fully elucidate how cannabis use may contribute to the development of mania over time.

Clinicians' attitudes to the employment of people with psychosis

BackgroundNegative staff attitudes have been cited as a factor in explaining the low rates of employment in people with psychosis. We aimed to conduct the first systematic survey of staff attitudes in UK community mental health teams.MethodsA questionnaire survey of clinicians working in community mental health teams in North London, UK.ResultsClinicians believed that many more people with psychosis were capable of working than were actually doing so. Nevertheless they believed that about two thirds of their caseloads were either incapable of working or able only to do voluntary or sheltered work. The work roles they saw as suitable tended to be ones requiring lower levels of technical skills. Clinicians saw helping people get back to work as a core part of their role, but felt they had little relevant training and limited confidence in the vocational services currently available for their clients.ConclusionsIn this London catchment area, clinicians believed the majority of people with psychosis to be capable of some kind of work, albeit not always open market, but they had few resources available to them to facilitate this. They give priority to the development of place and support vocational services.

Side-effects of antipsychotic medication and health-related quality of life in schizophrenia

Objective:  This analysis used data from the large (n = 1208) European Schizophrenia Cohort to examine the association between subjective side‐effects of antipsychotic medication and the Mental and Physical Composite Scores (MCS; PCS) of the SF‐36 scale.

Correlates of subjective quality of life in people with schizophrenia: findings from the EuroSC study.

Quality of life (QOL) is an important outcome for people with schizophrenia, but most previous studies of its correlates have had small sample sizes or explored a limited number of variables. We conducted an analysis of the baseline data from the European Schizophrenia Cohort (EuroSC) study, a naturalistic investigation of people with schizophrenia living in France, Germany, and the United Kingdom (N = 1208). German participants had the highest subjective QOL. Country of residence, depression, accommodation status, and employment were the most important factors in explaining subjective QOL. Many correlates of subjective QOL in people with schizophrenia were similar to those in the general population. Many of the factors important in explaining subjective QOL in people with schizophrenia are not readily amenable to change. Differences in mental health service provision in the United Kingdom and Germany may in part explain variations in the QOL of people with schizophrenia resident there.

A systematic review and meta-regression analysis of aggression during the First Episode of Psychosis

The First Episode of Psychosis (FEP) represents a period of heightened risk for aggression. However, it is not known whether this risk is significantly altered following contact with mental health services.

Bullying victimisation and risk of psychotic phenomena: analyses of British national survey data

BACKGROUND Being bullied is an aversive experience with short-term and long-term consequences, and is incorporated in biopsychosocial models of psychosis. We used the 2000 and the 2007 British Adult Psychiatric Morbidity Surveys to test the hypothesis that bullying is associated with individual psychotic phenomena and with psychosis, and predicts the later emergence of persecutory ideation and hallucinations. METHODS We analysed two nationally representative surveys of individuals aged 16 years or older in Great Britain (2000) and England (2007). Respondents were presented with a card listing stressful events to identify experiences of bullying over the entire lifespan. We assessed associations with the dependent variables persecutory ideation, auditory and visual hallucinations, and diagnosis of probable psychosis. All analyses were controlled for sociodemographic confounders, intelligence quotient (IQ), and other traumas. FINDINGS We used data for 8580 respondents from 2000 and 7403 from 2007. Bullying was associated with presence of persecutory ideation and hallucinations, remaining so after adjustment for sociodemographic factors, IQ, other traumas, and childhood sexual abuse. Bullying was associated with a diagnosis of probable psychosis. If reported at baseline, bullying predicted emergence and maintenance of persecutory ideation and hallucinations during 18 months of follow-up in the 2000 survey. Controlling for other traumas and childhood sexual abuse did not affect the association between bullying and psychotic symptoms, but reduced the significance of the association with diagnosis of probable psychosis. Bullying was most strongly associated with the presence of concurrent persecutory ideation and hallucinations. INTERPRETATION Bullying victimisation increases the risk of individual psychotic symptoms and of a diagnosis of probable psychosis. Early detection of bullying and use of treatments oriented towards its psychological consequences might ameliorate the course of psychosis. FUNDING None.