Individuals in U.S. More Likely to Be Referred to Psychiatric EDs by Police Than in Other Countries

Nearly a quarter of referrals to psychiatric emergency departments (PEDs) in the United States are made by police, a rate dramatically higher than the global average, according to a report published today in Psychiatric Services.

Patients referred to PEDs by police tended to be homeless males with a diagnosis of substance use and/or psychotic disorders and were more likely to display aggressive behavior, according to the report.

“Because police-referred patients share many characteristics with incarcerated psychiatric patients, early psychiatric treatment may help reduce the risk for incarceration of police-referred patients,” wrote Thomas Goldschmidt, M.D., of the Frei Universität and Humboldt Universität, Berlin, and colleagues.

The researchers performed a literature search for articles reporting the proportion of adult psychiatric patients brought by police to PEDs in university or general hospitals or comparable settings (such as general medical-surgical hospitals that serve as psychiatric emergency receiving facilities). They included 34 study samples from 28 articles in their analysis, representing 542,143 psychiatric emergency admissions between 1986 and 2021 in 11 countries: the United States, Australia, Belgium, Canada, Croatia, Germany, Israel, Italy, Switzerland, Taiwan, and Turkey. Of the total admissions, 61,647 involved law enforcement.

On average, 13.7% of PED admissions globally were referred by police, compared with 22.8% in the United States. Compared with patients not referred by police, police-referred patients globally were more than four times as likely to show aggressive behavior, 1.84 times as likely to be homeless, and 1.33 times and 1.45 times as likely to have a diagnosis of a substance use or a psychotic disorder, respectively. Police-referred patients were also four times more likely to be involuntarily admitted to a hospital.

Goldschmidt and colleagues said that further research is needed on the effect of early intervention on referrals to PEDS. “Interventions to reduce homelessness among psychiatric patients and other preventive approaches might be especially useful to reduce police referrals,” they concluded.

For related information, see the Psychiatric News article “Stanford Team Examines Intersection of Homelessness, Mental Illness, Police Conduct.”

(Image: Getty Images/iStock/pablohart)

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Addressing Adults’ Social Anxiety, Depression May Boost Employment Success

Symptoms of social anxiety or depression may serve as a barrier to seeking or maintaining employment, according to a study issued by Psychiatric Research and Clinical Practice. However, working more hours may not by itself reduce depression or social anxiety symptoms.

“Social anxiety is associated with a lower likelihood of receiving and accepting job offers, poor job performance, increased work absences, and higher rates of terminations and resignations. However, bidirectional associations between social anxiety and unemployment are untested,” wrote Olivia M. Losiewicz, M.A., of the University of California, Los Angeles, and colleagues.

The researchers recruited 250 diverse adults with diagnoses of social anxiety disorder, more than half of whom were homeless or in transient housing, who were job-seeking at vocational centers in Detroit or Los Angeles. Depression and social anxiety were assessed at weeks four, 12, 26, and 52 using the eight‐item Patient Health Questionnaire (PHQ–8) and the Liebowitz Social anxiety scale.

Participants estimated the number of hours they worked for pay every two weeks by responding to a text-message prompt. The researchers averaged the number of hours participants worked for three time periods: weeks five to 12, 13 to 26, and 27 to 52. They also examined participants’ substance use, psychosis, homelessness, racial minority status, and household income.

After factoring in the above variables, the researchers reported that greater social anxiety and depression symptoms at one period predicted fewer subsequent hours worked for pay. However, contrary to their hypothesis, working more hours during a period was not significantly associated with reduced social anxiety or depression symptoms later.

“Findings suggest that clinicians should monitor employment‐related factors, such as work attendance and time spent working, when treating patients with depression or social anxiety, as symptoms may lead to significant functional impairment,” Losiewicz and colleagues wrote. “Furthermore, this study highlights the potential importance of mental health interventions to simultaneously address occupational concerns. Since symptoms of social anxiety or depression may serve as a barrier to seeking or maintaining employment, effective treatments, such as cognitive behavioral therapy, may indirectly help individuals obtain or maintain employment.”

For related information, see the Psychiatric News article “‘I Don’t Feel Like a Productive Member of Society.’”

(Image: Getty Images/iStock/SDI Productions)

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E. Fuller Torrey, M.D., Details Mistakes That Led to Today’s Public Mental Health Crisis

American psychiatry and the public mental health system must work to correct policy mistakes of the past that have led to today’s public health travesty: criminalization of people with mental illness by placing them in jails and prisons and the failure to treat homeless individuals with serious mental illness (SMI).

So said E. Fuller Torrey, M.D. (pictured above), the keynote speaker at yesterday’s Opening Session of APA’s IPS: The Mental Health Services Conference in New York. Torrey, the founder of the Treatment Advocacy Center and associate director for research at the Stanley Medical Research Institute, has been a fierce advocate for people with SMI for five decades.

During his address, he detailed a history of tragic public policy blunders that led to the current crisis: the emptying of state psychiatric hospitals, passage of the Community Mental Health Act (CMHA) with no mandated provisions for care after people with SMI were discharged from state hospitals, and federal financial incentives that encouraged states to abdicate responsibility for this population.

“In summary, we emptied the state hospitals and provided federal fiscal incentives to make sure it happened,” Torrey said. “We began a new program of community mental health centers that was targeted to prevent mental illness but ignored patients being discharged from the state hospitals. And we partially federalized what had been a state and county responsibility with no provisions for the most seriously mentally ill.”

Torrey drew attention to a grim irony: The founders of APA 175 years ago were concerned about and discussed the practice of locking up people with mental illness in jails and prisons. These discussions were instigated by Dorothea Dix, who had been outraged by what she saw when she toured the prisons of Massachusetts. This year, Torrey said, a detention center in Georgia became the first jail to be accredited as a mental health facility by the National Commission on Correctional Health Care.

Torrey wondered, “What would Dorothea Dix say of us today?”

He emphasized that the motives that led to deinstitutionalization were good. And he noted that the process of emptying the state hospitals did not begin with the CMHA but with the introduction of chlorpromazine (Thorazine). However, he said, the vast majority of community mental health centers created by the CMHA, having no mandates to treat discharged patients, operated as private psychiatric clinics focused on prevention rather than treatment.

Torrey said IPS is a crucial venue for addressing the problems created by the past and looked to young psychiatrists in the audience for solutions. “Rarely have so many well-meaning people been so wrong,” Torrey said. “My generation made major mistakes in emptying the state hospitals without thinking about how to treat the seriously mentally ill in the community. It is up to the next generation to solve those problems.”

For related information, see the Psychiatric News articles “Mental Illness in America’s Jails Also Made Headlines 50 Years Ago” and “Signs of Problems With Access: Homelessness and Incarceration.”

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Highlights From APA Annual Meeting: Day Five

The final day of APA’s Annual Meeting featured an animated, case-based session on ECT and a review of strategies to help prevent suicide in youth. Experts also offered practical guidance on how to treat pregnant women with psychiatric conditions and important insights on why migrant children face a long, slow recovery when they are separated from their families.

Look for future coverage of APA’s 2019 Annual Meeting in upcoming issues of Psychiatric News.

Expert Outlines Practical Tactics Parents, Practitioners Can Use to Help Teens Overcome Suicidal Urges

Increasing suicide rates among adolescents call for immediate approaches to reducing the risk. Michele Berk, Ph.D., offers seven practical tactics that parents and psychiatrists can use today.
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Panelists Discuss Difficult ECT Questions, From Patient Selection to Treatment Completion

In a lively, interactive session on Wednesday participants debated patients most likely to benefit from ECT, how to place electrodes, and whether to use lithium before and after treatment.  Read More >

Nine Tips for Managing Psychiatric Conditions Before, During, and After Pregnancy

Four perinatal psychiatry experts remind that treatment during pregnancy requires a risk-risk discussion with women: the risks of treating versus not treating.
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NIMH Research Seeks to Harness Power of Technology, says Gordon

Applying machine learning and other technologies to better understand risk factors for suicide were among the topics addressed by NIMH director Joshua Gordon, M.D., Ph.D., during the 175th History Track session.
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Considerations for Treating Migrant Children Separated From Parents

Building trust is an important first step to helping migrant children separated from parents begin a path to recovery, says child trauma expert Alicia Lieberman, M.D. Read More >

Panel Questions Evidence on Deep Brain Stimulation for Depression

While some studies show DBS to be effective, experts warn against “therapeutic enthusiasm,” saying the body of evidence does not sufficiently support the treatment. Read More >

From Patient to Inmate: Session Highlights Complex Interactions Between Social Policies and Mental Health Care Delivery

Experts explore how upstream social institutions and policies on homelessness and incarceration can drive downstream breakdowns in the delivery of public mental health services. Read More >

Join Us Next Year in Philadelphia

Be sure to save the date for next year's Annual Meeting, April 25 through 29, 2020, in Philadelphia, the city where APA was founded.

'Housing First' Model Key to Improving Lives of Homeless, Study Finds

Participation in a program that connects people who are homeless and have severe mental illness to housing quickly led to greater improvements in housing stability, quality of life, and community functioning one year later, according to a study in Psychiatric Services.

For the study, Sam Tsemberis, Ph.D. (pictured left), founder of Pathways to Housing and the “housing-first” model, and colleagues compared one-year outcomes in 950 high-need individuals participating in Housing First (a program that helps individuals establish stable housing within a year without requiring treatment or sobriety restrictions) with treatment-as-usual programs (including shelters, general medical health, addiction, social services, and more) across five Canadian cities. In-person interviews were conducted at the beginning of the study and at six and 12 months; participants’ housing history was documented every three months.

At the 12-month follow-up, 73 percent of Housing First participants and 31 percent of treatment-as-usual participants resided in stable housing. Participation in a Housing First program also produced improvements in overall quality of life compared with treatment-as-usual participants and greater improvements in community functioning compared with treatment-as-usual participants.

While the authors noted that “[i]t remains to be seen whether Housing First participants will show greater improvements than treatment-as-usual participants on clinical and other outcomes during the second year of this trial, [o]ur interim findings provide support for the redirection of programs and policies toward adopting Housing First to address chronic and episodic homelessness.”

The Washington Post recently featured a profile of Tsemberis, where it describes how the housing-first model is leading to gains in efforts to keep homeless people off of the streets across the country.

For more, see the Psychiatric News article “Housing Programs Effective, but Studies Plagued by Limitations.”

(Image: Sam Tsemberis, Ph.D.)