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Critical Time Intervention (CTI) is designed to reduce the risk of homelessness and other adverse outcomes by providing support to individuals during challenging life course transitions. While several narrative reviews suggest the benefit of CTI, the evidence on the model’s effectiveness has not been systematically reviewed. This article systematically reviews studies of CTI applied to a variety of populations and transition types. Following the Preferred Reporting Items for Systematic Review and Meta-Analysis for protocols (PRISMA-P) guidelines, we reviewed 13 eligible experimental and quasi-experimental studies. Findings were summarized by individual outcome domains, including housing, service engagement use, hospitalization or emergency services, mental health, substance use, family and social support, and quality of life. CTI had a consistent positive impact on two primary outcomes—reduced homelessness and increased service engagement use—among different populations and contexts. Despite the effectiveness of CTI, the specific mechanisms of the model’s positive impacts remain unclear. Implications for practice, policy and research are addressed. more...

BackgroundIn 2005, Chile became the first country in Latin America to guarantee universal free access for the diagnosis and treatment of schizophrenia. A cluster randomized control trial utilizing the Dynamic Adaptation Process framework is underway to adapt and test the OnTrack coordinated specialty care model to provide recovery-oriented, person-centered care by a multidisciplinary team for individuals with first episode psychosis (FEP) in Chile.MethodsA qualitative formative research study was conducted to inform the initial adaptation of the OnTrack Chile (OTCH) program. We conducted key informant interviews (n = 17) with various stakeholders (policymakers; directors/managers of community mental health centers; mental health professionals) and focus group discussions (n = 6) with individuals with FEP and caregivers (n = 35 focus group participants total). Data was analyzed using thematic analysis, organized by participants' perspectives on the benefits, barriers, and recommendations for the key principles, multidisciplinary team, psychosocial components, and the training and supervision model of OnTrack.ResultsParticipants expressed enthusiasm and support for OnTrack's recovery-oriented and person-centered principles of care. While many participants lauded the emphasis on shared decision-making and family involvement, some reported reticence, citing that it is culturally normative for patients and families to adopt a passive role in treatment. Peer specialists, and the family psychoeducation and support and supported education and employment components were perceived as aspects that could encourage the promotion of personhood and autonomy development. However, implementation challenges, including the prevailing biomedical approach, professional hierarchy, and the lack of infrastructure, human, and financial resources necessitate some modifications to these aspects. Some mental health professionals further conveyed reservations regarding the perceived hierarchical structure of the supervision model.ConclusionOnTrack represents a shift from a biomedical model to a valued, aspirational, person-centered and culturally responsive model that focuses on recovery, shared decision-making and psychosocial care. With the appropriate governmental and agency-level provision of resources and modifications to some of the program components, particularly regarding the shared decision-making framework, peer specialist, family engagement, and the training supervision model, OTCH could be a transformative program for a more comprehensive, evidence-based care for individuals with FEP in Chile. more...

This pilot randomized controlled trial evaluated the effectiveness of critical time intervention-task shifting (CTI-TS) for people with psychosis in Santiago, Chile, and Rio de Janeiro. CTI-TS is a 9-month intervention involving peer support workers and is designed to maintain treatment effects up to 18 months.A total of 110 people with psychosis were recruited when they enrolled in community mental health clinics (Santiago, N=60; Rio de Janeiro, N=50). Participants within each city were randomly assigned to either CTI-TS or usual care for 9 months. Primary outcomes were quality of life, measured with the World Health Organization Quality of Life Assessment-Brief Version (WHOQOL-BREF), and unmet needs, measured with the Camberwell Assessment of Need (CAN), at 18-month follow-up. Results were analyzed according to intention-to-treat guidelines. Generalized estimating equations, with observations clustered within cities, and multiple imputation for missing data were used.At 18 months, both groups showed improved primary outcomes. In both unadjusted and fully adjusted analyses, no significant differences between CTI-TS and usual care (WHOQOL-BREF question on quality of life and CAN mean number of unmet needs) were found.Three factors might explain the lack of difference between CTI-TS and usual care: first-contact enrollment precluded rapport prior to randomization, a minority of patients were uncomfortable with peers being on the treatment team, and primary outcome measures may not have been sensitive enough to capture the effects of a recovery-oriented intervention. The results have implications for the design of transitional services for people with psychosis, especially in Latin America. more...

Purpose: To support future development and refinement of social work–led intervention programs among patients with firearm injuries and to demonstrate how a fidelity assessment can be used to adjust and refine intervention delivery in an ongoing trial. Method: We conducted a fidelity assessment of a randomized controlled trial of a social work–led intervention among patients with a firearm injury. Results: We found that our study intervention was well implemented, meeting 70% of the fidelity assessment score items, however, noted lower fidelity with client-based items. Discussion: As a result of fidelity assessment findings, we refined intervention delivery to improve implementation fidelity including beginning to review cases of all patients each month rather than focusing on patients in crisis. Our fidelity assessment process and findings offer insight into the challenges of implementing an intervention among patients with firearm injuries and highlight the value of monitoring intervention fidelity during an ongoing trial. more...

Background Substantial data from high-income countries support early interventions in the form of evidence-based Coordinated Specialty Care (CSC) for people experiencing First Episode Psychosis (FEP) to ameliorate symptoms and minimize disability. Chile is unique among Latin American countries in providing universal access to FEP services through a national FEP policy that mandates the identification of FEP individuals in primary care and guarantees delivery of community-based FEP treatments within a public health care system. Nonetheless, previous research has documented that FEP services currently provided at mental health clinics do not provide evidence-based approaches. This proposal aims to address this shortfall by first adapting OnTrackNY (OTNY), a CSC program currently being implemented across the USA, into OnTrackChile (OTCH), and then examine its effectiveness and implementation in Chile. Methods The Dynamic Adaptation Process will be used first to inform the adaptation and implementation of OTCH to the Chilean context. Then, a Hybrid Type 1 trial design will test its effectiveness and cost and evaluate its implementation using a cluster-randomized controlled trial (RCT) (N = 300 from 21 outpatient clinics). The OTCH program will be offered in half of these outpatient clinics to individuals ages 15-35. Usual care services will continue to be offered at the other clinics. Given the current COVID-19 pandemic, most research and intervention procedures will be conducted remotely. The study will engage participants over the course of 2 years, with assessments administered at enrollment, 12 months, and 24 months. Primary outcomes include implementation (fidelity, acceptability, and uptake) and service outcomes (person-centeredness, adherence, and retention). Secondary outcomes comprise participant-level outcomes such as symptoms, functioning, and recovery orientation. Over the course of the study, interviews and focus groups with stakeholders will be conducted to better understand the implementation of OTCH. Discussion Findings from this study will help determine the feasibility, effectiveness, and cost for delivering CSC services in Chile. Lessons learned about facilitators and barriers related to the implementation of the model could help inform the approach needed for these services to be further expanded throughout Latin America. Trial registration www.ClinicalTrials.govNCT04247711. Registered 30 January 2020. Trial status The OTCH trial is currently recruiting participants. Recruitment started on March 1, 2021, and is expected to be completed by December 1, 2022. This is the first version of this protocol (5/12/2021). more...

Background Few studies provide clear rationale for and the reception of adaptations of evidence-based interventions. To address this gap, we describe the context-dependent adaptations in critical time intervention-task shifting (CTI-TS), a manualized recovery program for individuals with psychosis in Rio de Janeiro, Brazil and Santiago, Chile. Implications of the adaptations – incorporating a task-shifting approach and modifying the mode of community-based service delivery – are examined from users' perspectives. Methods A secondary analysis of in-depth interviews with CTI-TS users (n = 9 in Brazil; n = 15 in Chile) was conducted. Using the framework method, we thematically compared how participants from each site perceived the main adapted components of CTI-TS. Results Users of both sites appreciated the task-shifting worker pair to provide personalized, flexible, and relatable support. They wanted CTI-TS to be longer and experienced difficulty maintaining intervention benefits in the long-term. In Chile, stigma and a perceived professional hierarchy toward the task-shifting providers were more profound than in Brazil. Engagement with community-based services delivery in homes and neighborhoods (Chile), and at community mental health centers (Brazil) were influenced by various personal, familial, financial, and social factors. Uniquely, community violence was a significant barrier to engagement in Brazil. Conclusion CTI-TS’ major adaptations were informed by the distinct mental health systems and social context of Santiago and Rio. Evaluation of user experiences with these adaptations provides insights into implementing and scaling-up task-shifting and community-oriented interventions in the region through the creation of specialized roles for the worker pair, targeting sustained intervention effects, and addressing socio-cultural barriers. more...

This study explores the beliefs and attitudes about the psychosocial mechanisms of peer support work among users who participated in Critical Time Intervention-Task Shifting (CTI-TS), which tested the acceptability and feasibility of a peer support work model to improve community-based mental health care for individuals with psychosis in Latin America. We conducted a secondary analysis of 15 in-depth interviews with CTI-TS participants in Chile, using the framework method and defined the framework domains based on five major mechanisms of peer support work identified by a recent literature review. The analysis revealed that users' perceptions of peer support work mechanisms were strongly shaped by personal motivations, beliefs about professional hierarchies, familial support, and the Chilean mental health system's incipient recovery orientation. The findings underscore the importance of adopting culturally tailored strategies to promote peer support work, such as involving mental health professionals and fostering equal-powered relationships between PSWs and users. more...

Hoarding disorder has significant health consequences, including the devastating threat of eviction. In this pilot study, critical time intervention (CTI), an evidence-based model of case management shown to be effective for vulnerable populations, was adapted for individuals with severe symptoms of hoarding disorder at risk for eviction (CTI-HD). Of the 14 adults who enrolled, 11 participants completed the 9-month intervention. Completers reported a modest decrease in hoarding severity, suggesting that, while helpful, CTI-HD alone is unlikely to eliminate the risk of eviction for individuals with severe symptoms of hoarding disorder. Clinicaltrials.gov Registry Numbers: NCT02367430 more...

Several Latin American countries have made remarkable strides towards offering community mental health care for people with psychoses. Nonetheless, mental health clinics generally have a very limited outreach in the community, tending to have weaker links to primary health care; rarely engaging patients in providing care; and usually not providing recovery-oriented services. This paper describes a pilot randomized controlled trial (RCT) of Critical Time Intervention-Task Shifting (CTI-TS) aimed at addressing such limitations. The pilot RCT was conducted in Santiago (Chile) and Rio de Janeiro (Brazil). We included 110 people with psychosis in the study, who were recruited at the time of entry into community mental health clinics. Trial participants were randomly divided into CTI-TS intervention and usual care. Those allocated to the intervention group received usual care and, in addition, CTI-TS services over a 9-month period. Primary outcomes include quality of life (WHO Quality of Life Scale - Brief Version) and unmet needs (Camberwell Assessment of Needs) at the 18-month follow-up. Primary outcomes at 18 months will be analyzed by Generalized Estimating Equations (GEE), with observations clustered within sites. We will use three-level multilevel models to examine time trends on the primary outcomes. Similar procedures will be used for analyzing secondary outcomes. Our hope is that this trial provides a foundation for planning a large-scale multi-site RCT to establish the efficacy of recovery-oriented interventions such as CTI-TS in Latin America. Diversos países latino-americanos já alcançaram avanços notáveis na oferta de assistência em saúde mental para pessoas com psicoses. No entanto, as clínicas de saúde mental geralmente realizam atividades de extensão muito limitadas dentro das comunidades, tendem a ter vínculos fracos com a assistência primária, raramente envolvem os próprios pacientes nos cuidados e poucas vezes prestam serviços orientados para a recuperação. O artigo descreve um estudo piloto randomizado e controlado sobre a Critical Time Intervention-Task Shifting (CTI-TS), que teve como objetivo analisar essas limitações. O estudo piloto foi realizado em Santiago (Chile) e no Rio de Janeiro (Brasil). Teve como meta a inclusão de 110 pessoas com psicose, recrutadas no momento da entrada em clínicas comunitárias de saúde mental. Os participantes foram randomizados para o CTI-TS ou para os cuidados usuais. Aqueles alocados ao grupo da intervenção receberam os cuidados usuais e os serviços de CTI-TS ao longo de 9 meses. Os desfechos primários incluíram a qualidade de vida (WHO Quality of Life Scale - Brief Version) e as necessidades não atendidas (Camberwell Assessment of Needs) no acompanhamento aos 18 meses. Os desfechos primários aos 18 meses serão analisados com a técnica de Equações de Estimação Generalizadas (GEE), com as observações agrupadas dentro dos locais do estudo. Serão utilizados modelos em três níveis para examinar as tendências temporais nos desfechos primários. Procedimentos semelhantes serão utilizados para analisar os resultados secundários. Espera-se que o estudo forneça uma base para planejar um estudo randomizado e controlado em grande escala e em múltiplos locais para estabelecer a eficácia da intervenção orientada para a recuperação, a exemplo da CTI-TS, na América Latina. resumen está disponible en el texto completo more...

Background: Latin America, and Chile in particular, has a rich tradition of community mental health services and programs. However, in vivo community-based psychosocial interventions, especially those with a recovery-oriented approach, remain scarce in the region. Between 2014 and 2015, a Critical Time Intervention-Task Shifting project (CTI-TS) was implemented in Santiago, Chile, as part of a larger pilot randomized control trial. CTI is a time-limited intervention delivered at a critical-time to users, is organized by phases, focuses on specific objectives and decreases in intensity over time. CTI-TS, which combines both the task-shifting strategy and the use of peers, introduces a novel approach to community mental health care that has not yet been tried in Chile. Aims: We aim to evaluate the feasibility, acceptability and applicability of such a community-based psychosocial intervention in urban settings in Latin America – specifically, in Santiago (Chile) from a user perspective. Method: We analyzed 15 in-depth interviews ( n = 15) with service users who participated in the intervention about their perceptions and experiences with CTI-TS through thematic analysis. Results: Three themes were revealed. The first was related to the structural characteristics of CTI-TS, especially regarding the timing, duration and phasic nature of the intervention. The second pertained to the acceptability of the in vivo community-based approach. The third theme dealt with the task-shifting aspect, that is, users’ perceptions of the peer support workers and the community mental health workers. Conclusions: CTI-TS was generally acceptable in this Latin American context. Users’ perspectives pointed to the need to make adjustments to some of the structural characteristics of the CTI model and to combine this type of intervention with others that can address stigma. Thus, future adaptations of CTI-TS or similar psychosocial interventions in Latin American contexts are feasible and can enhance community mental health in the region. more...

Release from prison is a vulnerable period, especially for people with severe mental illness. Critical Time Intervention (CTI) can be effective in improving service access and reducing negative outcomes. Nested within a randomised controlled trial of CTI, qualitative interviews were conducted with trial participants in both intervention (CTI) and treatment as usual (TAU) arms, CTI managers delivering the intervention and associated professionals. Data were analysed using a framework approach.Four themes were identified: uncertainty about post-release plans; inadequate housing provision; support during transition; and continuity of care.Interviewees shared common concerns about transition into the community but CTI participants felt less anxious about release and reported receiving more support with housing, access to services and community reintegration than during previous periods of incarceration. Professionals raised concerns about the time-limited nature of CTI and the impact of austerity measures on the availability of support following CTI. Implications for service delivery will be discussed. more...

Aim of the studyThe fidelity of an intervention can be defined as the degree to which a program implemented following the program model, i.e. the set of well-defined procedures for such intervention. This article aims to describe the steps taken to develop the assessment tool of fidelity to the original protocol of intervention for critical time intervention – task shifting (CTI-TS)Subject or material and methodsThe development of an instrument to assess the fidelity includes some key stages, as definition of the intervention model, definition of the key components of the intervention, preparation of a preliminary scale, development of assessment sheets fidelity, development of a manual application of scale fidelity, training assessor fidelity and test the preliminary scale carrying out a pilot studyResultsAccording the experts opinion, 18 key components of the intervention were defined. From these components, was built the fidelity scale which consists of 20 items, divided into three sections, each evaluating one of the types of fidelity: compliance, context and competence.DiscussionThe CTI-TS had its fidelity assessment method developed in accordance with the recommendations in the current literature.ConclusionsThe protocol compliance is essential for the results, whether positive or not, can be credited to the intervention itself. more...

The purpose of this paper is to describe the development and initial accomplishments of a training program of young leaders in community mental health research as part of a Latin American initiative known as RedeAmericas. RedeAmericas was one of five regional ‘Hubs’ funded by the National Institute of Mental Health (NIMH) to improve community mental health care and build mental health research capacity in low- and middle-income countries. It included investigators in six Latin American cities – Santiago, Chile; Medellín, Colombia; Rio de Janeiro, Brazil; and Córdoba, Neuquén, and Buenos Aires in Argentina – working together with a team affiliated with the Global Mental Health program at Columbia University in New York City. One component of RedeAmericas was a capacity-building effort that included an Awardee program for early career researchers in the mental health field. We review the aims of this component, how it developed, and what was learned that would be useful for future capacity-building efforts, and also comment on future prospects for maintaining this type of effort. more...

This study explores the experience of women with severe mental illness in transition from psychiatric hospital care to the community. Three focus groups were conducted among women with severe mental illness from transitional residences at two state psychiatric hospitals. Focus group transcripts and notes were coded according to women's perceived challenges and facilitators of transition. Participants described several challenges including fear of insufficient treatment support, safety concerns, social isolation, stigma, and lack of resources to meet daily needs. The supports that women described as important were an orientation to the neighborhood and residence, access to treatment support with flexibility, and connection to social supports. more...

Objective: Several studies have provided prevalence estimates of posttraumatic stress disorder (PTSD) related to the September 11, 2001 (9/11) attacks in broadly affected populations, although without sufficiently addressing qualifying exposures required for assessing PTSD and estimating its prevalence. A premise that people throughout the New York City area were exposed to the attacks on the World Trade Center (WTC) towers and are thus at risk for developing PTSD has important implications for both prevalence estimates and service provision. This premise has not, however, been tested with respect to DSM-IV-TR criteria for PTSD. This study examined associations between geographic distance from the 9/11 attacks on the WTC and reported 9/11 trauma exposures, and the role of specific trauma exposures in the development of PTSD.Methods: Approximately 3 years after the attacks, 379 surviving employees (102 with direct exposures, including 65 in the towers, and 277 with varied exposures) recruited from 8 affected organizations were interviewed using the Diagnostic Interview Schedule/Disaster Supplement and reassessed at 6 years. The estimated closest geographic distance from the WTC towers during the attacks and specific disaster exposures were compared with the development of 9/11–related PTSD as defined by the Diagnostic and Statistical Manual, Fourth Edition, Text Revision.Results: The direct exposure zone was largely concentrated within a radius of 0.1 mi and completely contained within 0.75 mi of the towers. PTSD symptom criteria at any time after the disaster were met by 35% of people directly exposed to danger, 20% of those exposed only through witnessed experiences, and 35% of those exposed only through a close associate’s direct exposure. Outside these exposure groups, few possible sources of exposure were evident among the few who were symptomatic, most of whom had preexisting psychiatric illness.Conclusions: Exposures deserve careful consideration among widely affected populations after large terrorist attacks when conducting clinical assessments, estimating the magnitude of population PTSD burdens, and projecting needs for specific mental health interventions.(Disaster Med Public Health Preparedness. 2011;5:S205-S213) more...

Objective:This study assessed the effectiveness of a previously tested model, critical time intervention (CTI), in producing an enduring reduction in the risk of homelessness for persons with severe mental illness who were discharged from inpatient psychiatric treatment facilities. Methods:A total of 150 previously homeless men and women with severe mental illness and who were discharged from inpatient psychiatric hospitalization to transitional residences on the hospital grounds were randomly assigned to receive usual care or usual care plus CTI at the point of discharge to the community. The nine-month intervention aims to gradually pass responsibility to community sources for providing ongoing support after the intervention ends, thereby leading to a durable reduction in risk of future homelessness. After participants were discharged from the transitional residence (length of stay six to 937 days), their housing status was assessed every six weeks for 18 months via participant self-report collected by ... more...

International dissemination of evidence-based interventions calls for rigorous evaluation. As part of an evaluation of critical time intervention (CTI) for homeless people and abused women leaving Dutch shelters, this study assessed fidelity in two service delivery systems and explored factors influencing model adherence. Data collection entailed chart review (n = 70) and two focus groups with CTI workers (n = 11). The intervention obtained an overall score of three out of five (fairly implemented) for compliance fidelity and chart quality combined. Fidelity did not differ significantly between service systems, supporting its suitability for a range of populations. The eight themes that emerged from the focus groups as affecting model adherence provide guidance for future implementation efforts. Electronic supplementary material The online version of this article (doi:10.1007/s10488-015-0699-9) contains supplementary material, which is available to authorized users. more...

Background: Data are limited that examine circumstances of initiation and risk for HIV infection among Latino injecting-drug users (IDUs) in the United States. Methods: Baseline data were obtained from a cohort study of young (aged 18–29 years) IDUs residing in Harlem, New York City, conducted during 1997–1999. Participants were administered standardized face-to-face interviews. Data collected included demographics, age and circumstances surrounding initiation of injecting-drug use, and lifetime and recent risk behaviors. Results: Of the 156 participants who self-identified as Latino, 145 (94%) were Puerto Rican, 112 (72%) were male, and 44 (28%) were female. The median number of years of injecting drug use was 3 for women and 5 for men (Wilcoxon ranks sums test p = .007). Significantly (p < .05) more women than men reported that at the first injection episode, they were injected by a sexual partner (26% versus 4%), were provided the syringe by their sexual partner (24% versus 4%), had sex with the initiator after being injected the first time (23% versus 5%), and were injected by a person ≥5 years older than themselves (50% versus 32%). Women were more likely than men to report having ever had unprotected sex with a person known to be HIV-positive (18% versus 4%, respectively; p = .006); however, women were just as likely as men to report having ever injected drugs with a person known to be HIV-positive (11% versus 10%). Conclusions: Latinas were more likely than their male counterparts to be initiated either directly (being injected) or indirectly (being provided a syringe) into injecting-drug use by their sexual partner. HIV and drug use prevention programs for Latinas in Harlem must address the interrelationship between drug use and sexual relations. more...

This report on the Chandigarh Acute Psychosis Study examines the early course of affective disorders of acute onset in a developing country setting. Forty-one cases of acute onset affective disorder (17 depressive and 24 manic subjects) were assessed at intake and evaluated at selected intervals up to 1 year. The rates of recovery and relapse and episode duration were determined for both the depressive and manic groups, and the relationship between possible predictors of outcome and the duration of the index episode was examined. All subjects experienced full recovery within the 1-year period. At 1-year follow-up, 71% of depressive patients and 75% of manic patients demonstrated no symptoms or social impairment. For depression and mania, respectively, the mean episode duration was 14.2 and 10.2 weeks, and the rate of relapse was 18% and 21%. Overall, these outcomes are considerably more favorable than in comparable studies of affective disorders in developed settings. Our findings suggest that acuteness of onset may be a major prognostic factor in predicting the course of affective disorders. more...

OBJECTIVES: This study examined a strategy to prevent homelessness among individuals with severe mental illness by providing a bridge between institutional and community care. METHODS: Ninety-six men with severe mental illness who were entering community housing from a shelter institution were randomized to receive 9 months of a "critical time" intervention plus usual services or usual services only. The primary analysis compared the mean number of homeless nights for the two groups during the 18-month follow-up period. To elucidate time trends, survival curves were used. RESULTS: Over the 18-month follow-up period, the average number of homeless nights was 30 for the critical time intervention group and 91 for the usual services group. Survival curves showed that after the 9-month period of active intervention, the difference between the two groups did not diminish. CONCLUSIONS: Strategies that focus on a critical time of transition may contribute to the prevention of recurrent homelessness among individuals with mental illness, even after the period of active intervention. more...

Objective: The authors investigated sexual behaviors related to HIV transmission among homeless mentally ill men in a New York City shelter. A previous study of a similar population found HIV prevalence to be 19%. Method: In standardized interviews with 122 men, data on sexual behaviors for the previous 6 months were collected. The frequency and nature of sexual episodes that may facilitate HIV transmission were examined. In addition, sexual risk behaviors among broadly defined diagnostic groups were compared. Results: Of the 122 men, 65 (53%) had sex, 56 with women and 20 with men (11 who had sex with both women and men are counted in each group). The sexually active men, in most cases, had only occasional sex (once per month or less). The majority of sexually active men-29 (52%) of those who had sex with women and 12 (60%) of those who had sex with men-had sex without a condom and with nonmonogamous partners. Comorbid cocaine abuse or dependence was significantly associated with high-risk sexual behaviors. Conclusions: The majority of these men had sex occasionally or not at all. Nonetheless, because many of them had unprotected sex with non-monogamous partners, the few sexual episodes may have carried an appreciable risk of HIV transmission. Moreover, men with a comorbid cocaine dependence may represent a group with an especially high risk for sexual HIV transmission. The authors propose that in this population, preventive interventions could modify the nature, if not the frequency, of sexual episodes more...

This study examined the relationship between childhood experience and homelessness in psychiatric patients.Three large and diverse samples of homeless patients (N = 512) were compared with a sample of patients who had never been homeless (N = 271), with respect to childhood experience of foster care, group home placement, and running away. One of the homeless samples and the never homeless sample were drawn from patients admitted to a state mental hospital. In this state hospital population, risk ratios for lifetime prevalence of homelessness could be derived.In the three homeless samples, over 15% had a history of foster care, over 10% had a history of group home placement, and over 20% had a history of running away. These figures compared with 2%, 1%, and 5%, respectively, in the never homeless sample. In the state hospital, the lifetime prevalence of homelessness in patients with any one of these childhood experiences was about threefold that of other patients. A history of homelessness was reported by the great majority of state hospital patients who had had one of these childhood experiences.These childhood experiences were strongly associated with adult homelessness in these psychiatric patients. It might be possible to prevent homelessness in some cases by interventions aimed at patients with such childhood histories. more...

We conducted a randomised clinical trial to test the efficacy of an enhanced version of an intervention previously shown to reduce HIV sexual risk behaviours among men with severe mental illness. One-hundred-and-forty-nine subjects aged 18-59 years were randomly assigned to the experimental or control conditions. Sexual risk behaviours were assessed every three months for 12-months. The primary analysis compared experimental and control groups with respect to sexual risk behaviours with casual partners as measured by the Vaginal Episodes Equivalent (VEE) score. Additional analyses included comparison of VEE scores of those men sexually active in the three months prior to baseline and the proportion of condom-protected sexual acts with casual partners. There were no significant differences in sexual risk behaviours with casual partners between experimental and control subjects. Additional analyses demonstrated a trend toward sexual risk reduction at six months post-intervention (p=0.06) but not at 12 months. These results may reflect a lack of efficacy or a true reduction in risk that the trial was underpowered to detect at the 0.05-level. If there was a true reduction in risk, it was not maintained after the initial six months. more...

We report on the inter-rater reliability of the Life Chart Schedule (LCS). The LCS is designed to assess the long-term course of schizophrenia in four key domains (symptoms, treatment, residence, and work) over two time periods (past two years, entire period of illness). The subjects were 27 consecutive admissions to a schizophrenia research unit. The LCS was filled out by pairs of raters, blinded to each others' ratings, using the same data (interview with subject and chart). Reliability was examined for 45 LCS ratings selected from all four domains and both time periods. Selected ratings pertained to the duration of specified experiences, the quality of these experiences, and the long-term time trend. The kappa statistic and the intra-class correlation coefficient (ICC) were used to determine inter-rater reliability for continuous and categorical ratings, respectively. LCS ratings proved reliable in all four key domains and both time periods. The reliability was fair to excellent for ratings of duration of experience (ICC ranged from 0.53 to 0.99), quality of experience (kappa ranged from 0.46 to 0. 92) and long-term time trends (kappa ranged from 0.66 to 0.94). The LCS can be used to obtain reliable ratings of the long-term course of schizophrenia in multiple domains. more...

Objective : The high seroprevalence of HIV that has been reported among homeless individuals with mental illness indicates an urgent need to examine HIV risk behavior in this population. Method : Injection drug use and sexual behavior were assessed in comprehensive interviews with 218 homeless mentally ill men in a New York City shelter. First, the proportion of men who had injected drugs was established. Then, among those who had injected drugs, the injection drug use behaviors associated with HIV transmission (i.e., whether they had ever engaged in high-risk behaviors and had ever engaged in risk-reduction behaviors) and their current sexual risk behaviors were examined. Results : Fifty (23%) of the 218 men had injected drugs. Among these 50, the great majority had engaged in high-risk behaviors, including sharing needles (66%) and using shooting galleries (64%). Few had engaged in risk-reduction behaviors, such as cleaning needles with bleach (22%) and using a needle exchange program (2%). In the past 6 months alone, the majority of the injection drug users had had unprotected sex with women (48%) or with men (10%). Conclusions : This study documents a high lifetime prevalence of injection drug use in a group of homeless men with mental illness. The men who had injected drugs reported injection drug use and sexual behaviors with high risk of HIV transmission and gave scant evidence of risk-reduction behaviors. These individuals may fall between service systems and may be difficult to reach but, nonetheless, must be included in efforts to prevent transmission of HIV infection. more...

BackgroundWe examined whether acute transient psychoses can be distinguished from schizophrenia and the affective disorders.MethodWe studied 46 cases of nonaffective acute psychosis in the Chandigarh Acute Psychosis Study. With respect to separation from schizophrenia, we examined the distribution of duration of the episode. With respect to separation from affective disorders, we assessed the frequency of affective symptoms.ResultsDuration was bimodal, suggesting the presence of two distinct conditions of short and long duration. Affective symptoms were minimal, suggesting that these were not atypical affective syndromes.ConclusionsAcute transient psychoses conform neither with schizophrenia of brief duration nor with atypical affective psychosis, and thus require separate classification as proposed in the ICD–10. more...

Epidemiologists all over the world have been good enough to express their concerns and worries about how we, and other friends and colleagues in New York, fared in the terror provoked on 11 September. This annotation responds to the editors' invitation that we convey something from our vantage point. We welcomed their interest. The experience is, so far, unique in history. Our account is personal, that of four individuals, all related (Sally married to Ezra, and Ezra born to Mervyn and Zena). We share the same house. Also, atypically for any institution, all are of the Department of Epidemiology in the Mailman School of Public Health of Columbia University. The themes we emphasise are common to many others among us in New York City. On the day of 11 September and after, much of what we saw and heard was televised, a source open to everyone else here and elsewhere. In some degree, then, much of the world was exposed to the New York experience. But in the Department of Epidemiology (the School and the Medical Center are on the north west outskirts of Manhattan) we were not only in propinquity to the events, we looked directly upon them from the south facing windows of the 18th floor of our own dwarfed tower. On the day of 11 September, only Sally and Ezra were in the city. Zena and Mervyn were in South Africa. We tell the story as it unfolded in both situations. In New York, immediately the first plane hit the South Tower of the World Trade Center, many of us, alerted to what seemed a tragic accident, went to our south looking windows. From there, horrified, we watched a second plane enter our view, veer toward and then disappear into the North Tower, becoming instantly enveloped, together … more...

We report on the prevalence of human immunodeficiency virus (HIV) infection among psychiatric patients in a New York City shelter for homeless men. We reviewed the records of all 90 men discharged from the shelter psychiatry program to community housing over a 2-year period. HIV serostatus was recorded for 62 of the 90 men. Of these 62, 12 (19.4%) were positive. There were 28 men whose serostatus was not recorded. Data on the HIV risk behaviors of these 28 men suggested that seroprevalence could have been similarly high among them. The results indicate an urgent need to develop and apply preventive interventions for HIV in this population. more...

Available evidence suggests that individuals with schizophrenia and other severe mental illnesses are at increased risk for homelessness in contemporary societies with diverse cultures and socioeconomic conditions. Yet the prevention of homelessness among individuals with mental illness has rarely been a focus of global health programs. We propose that it should be. In any given society, the overall risk of homelessness will reflect broad societal factors such as income inequality, housing, migration, economic conditions, and family ties. We strongly advocate for addressing these societal causes of homelessness. We also believe, however, that we need to develop special programs in parallel to prevent homelessness among individuals with severe mental illness. We use historical examples to draw attention to ways in which individuals with mental illness have been – and still are – explicitly excluded from societies. We suggest that this social exclusion requires us to take special measures to protect the rights of individuals with mental illness, and to develop programs to ensure they have access to basic necessities including a home. The form these measures take will of necessity vary widely according to local conditions. We describe mental health initiatives in two middle-income countries (Brazil and Argentina) which illustrate different approaches, and allude more briefly to efforts being made in other countries including low-income countries. Finally, we consider some of the efforts that are already being made by various international groups to further this agenda within the global health movement. more...

Background The spread of human immunodeficiency virus infection to impaired groups has intensified the challenge for its prevention; control of the epidemic now requires behavioral change among persons with limited ability to sustain attention and learn. In this randomized clinical trial, we tested an intervention to reduce sexual risk behaviors among homeless men with severe mental illness. Methods Men were recruited from a psychiatric program in a homeless shelter. Of 116 eligible men, 97 (83.6%) participated. Most were African American and had a chronic psychotic disorder and a comorbid substance use disorder. Participants were assigned to a 15-session experimental group intervention or to a 2-session control intervention and observed for 18 months. The 59 participants sexually active before the trial were the main target of the intervention. Sexual risk behavior was the primary outcome. Results Among the 59 sexually active men, follow-up data were obtained on 59 (100%) for the initial 6-month follow-up and on 56 (95%) for the remainder of the 18-month follow-up. The mean score on a sexual risk index for the experimental group was 3 times lower than for the control group (1.0 vs 3.1; P =.01) during the initial 6-month follow-up and 2 times lower during the remainder of the 18-month follow-up. Conclusions This intervention successfully reduced sexual risk behaviors of homeless men with mental illness. The effect diminished over 18 months but did not disappear. Similar approaches may be effective in other impaired high-risk groups. more...

The authors interviewed homeless men in New York City shelters about their childhood experiences. Childhood placement away from the family was frequent, especially among former psychiatric patients. Childhood problem behaviors were also frequent. more...

Because the problem of homelessness has generated such attention and controversy, findings from studies of homeless populations are often received eagerly without appreciation of the significant biases inherent in surveys. Drawing on surveys of the homeless made in the 1980s, the authors review problems in sampling and in measurement of mental disorder. They suggest that within any one study researchers employ alternative sampling strategies and measures of mental disorder to facilitate comparison of results within and across studies. more...

We assessed psychiatric states in 223 men at first entry to New York, NY, municipal men's shelters, overall and differentiated by prior experience of homelessness. Instruments included a diagnostic interview (Structured Clinical Interview for DSM-III-R: Psychotic Disorders), the Short Michigan Alcoholism Screening Test, and the Center for Epidemiologic Studies of Depression Scale. The use of a "first timer" sample, and of a clinical diagnostic interview, had not, to our knowledge, been previously attempted in studies of psychiatric problems in the homeless. The majority of men had a history of mental disorder or of heavy substance use. On diagnostic interview, 17% of the men had a definite or probable history of psychosis, and another 8% had a possible history of psychosis. A confident diagnosis of schizophrenia was made in 8%. A history of alcohol or other drug abuse was evident in 58%. Cocaine was already (in 1985) the drug of choice; 27% of the study sample had used it more than 50 times. One third of the men were in extreme distress, much of it apparently acute and associated with the transition to the shelter, and 7% reported suicidal thoughts at the time of the interview. The newly homeless, compared with those who had been homeless for much of the 5 years prior to shelter entry, were younger and had fewer psychiatric problems. more...

In the 20 years since the revolution, Cuba has gone from the health profile of an underdeveloped country to that of a developed one. Heart disease and cancer are the leading causes of death. Infant mortality has been drastically reduced. Maternal mortality is lower than any other Latin American country. Improvements have been accomplished through better nutrition, a medical system that is national, free, accessible, and well-organized, and health education and immunization programs. The health system is doctor-dominated. The nurse is subservient to the doctor, who has acquired technical skills and status comparable to his American counterparts. Curative, rather than preventive, medicine is emphasized. The diet is high in fat and sugar. Many in the population, including the medical profession, smoke cigarettes. The medical profession and the revolutionary leaders are in a struggle to shift emphasis from further improvements in curative medical care to an expansion of the role of mass organizations. Yielding to the idea that only doctors could deliver good health care, Cuba has created a generation of doctors who believe that they make the primary contribution to the people's health. Although most physicians support the ideals of the revolution, status is still accorded to those with diagnostic acumen, specialized qualifications, and academic credentials. more...

BackgroundThe transition from prison to community is difficult for prisoners with mental illness. Critical time intervention (CTI) is designed to provide intensive support to meet health, social care and resettlement needs through close working between client and key worker pre, and up to 6 weeks post, release.ObjectivesTo establish whether or not CTI is effective in (1) improving engagement of discharged male prisoners who have mental illness with community mental health teams (CMHTs) and (2) providing practical support with housing, finance and re-establishing social networks.Trial designA multicentre, parallel-group randomised controlled trial, with follow-up at 6 weeks and at 6 and 12 months. A subset of prisoners and case managers participated in a complementary qualitative study.SettingEight English prisons.ParticipantsOne hundred and fifty adult male prisoners, convicted or remanded, cared for by mental health in-reach teams and diagnosed with severe mental illness, with a discharge date within 6 months of the point of recruitment.InterventionParticipants were randomised to either the intervention or the control (treatment as usual). The intervention group was assigned a case manager who assessed mental and physical health before and following release, made appropriate links to health, housing and financial services and supported the re-establishment of family/peer contact.OutcomeThe primary outcome measure was engagement with a CMHT 6 weeks post discharge. Secondary outcomes included contact with mental health services at 6 and 12 months. A health economic evaluation was undertaken using service contact at the follow-up time points. We were unable to assess the intervention’s effect on reoffending and longer-term health-care use because of study delays.ResultsOne hundred and fifty prisoners were recruited: 72 were randomised to the intervention and 78 were randomised to the control. Engagement with teams at 6 weeks was 53% for the intervention group compared with 27% for the control group [95% confidence interval (CI) 0.13% to 0.78%;p = 0.012]. At 6 months’ follow-up, intervention participants showed continued increase in engagement with teams compared with control participants (95% CI 0.12% to 0.89%;p = 0.029); there were no significant differences at 12 months. Increased engagement resulted in higher levels of service use and costs for the intervention than for the control. Qualitative data showed the intervention group reporting better continuity of care and improved access to services.ConclusionThe intervention significantly improved contact with services at 6 weeks, although at a higher cost than the control. This is important as, in the days and weeks following release, recently released individuals are at a particularly high risk of suicide and drug overdose. Further research is required to establish how teams can better maintain contact with clients when the intervention ends.Future workFurther studies are indicated for groups with different needs, for example women, young prisoners and those in police custody, and at other transition points, for example following arrest and short-term custody, and at points of transition between different mental health services.Trial registrationCurrent Controlled Trials ISRCTN98067793.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 5, No. 8. See the NIHR Journals Library website for further project information. more...

This paper proposes community-based rehabilitation (CBR) as a potentially useful model for care of the mentally ill in developing countries and illustrates an application of CBR in such a setting. CBR is an approach to rehabilitation that makes use of local resources in order to meet the needs of a chronically disabled group. Our companion paper in this journal issue discusses the primary health-care system of one province in the Patagonia region of Argentina. This health-care system can be viewed as a valuable local resource that has been applied to the care of people with mental illness. The present paper describes a specific rehabilitation program for chronic psychiatric patients in the same province. At the Instituto Austral de Salud Mental, CBR principles are being adapted for this population. We emphasize this program's use of a plentiful local resource, the primary-care doctor, who plays a pivotal role in the long-term care and rehabilitation of the mentally ill. more...