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Suicides that occur while a patient is hospitalized are tragic events causing immense distress to relatives, peers, and professional caregivers. The prevalence of this infrequent occurrence is between 0.1% and 0.4% of all psychiatric admissions. This article reviews the literature to see if such events can be predicted and prevented; attempts to identify high-risk patients through demographics, diagnoses, medication treatments, and patient social situations; and examines the care-delivery environment such as length of stay and physical surroundings. This article also examines the means patients used to end their lives and when in their hospital course they did so. The authors ask if standard predictors are applicable to hospitalized patients, speculate on potential preventive measures, examine the effect on care providers, and explore what might ease the aftermath. Affective disorders or schizophrenia are most frequently associated with inpatient suicide. Most occur while patients are off the psychiatric unit. Suicides onward are usually accomplished by hanging; off-ward suicides are also often violent. Most patients denied suicidal ideation prior to the act. Factors associated with suicide in the general population are not consistently associated with inpatient suicides. Patient monitoring is not always effective. The first week of hospitalization and the days immediately after discharge are when patients are most vulnerable to end their lives. The authors conclude that the potential for suicide may be present from the initiation of hospitalization, but the ability to determine individuals at risk is, at best, poor.
Purpose – Psychological and epidemiological literature suggests that the built environment plays both causal and therapeutic roles in schizophrenia, but what are the implications for designers? The purpose of this paper is to focus on the role the built environment plays in psycho-environmental dynamics, in order that negative effects can be avoided and beneficial effects emphasised in architectural design. Design/methodology/approach – The approach taken is a translational exploration of the dynamics between the built environment and psychotic illness, using primary research from disciplines as diverse as epidemiology, neurology and psychology. Findings – The built environment is conceived as being both an agonist and as an antagonist for the underlying processes that present as psychosis. The built environment is implicated through several means, through the opportunities it provides. These may be physical, narrative, emotional, hedonic or personal. Some opportunities may be negative, and others positive. The built environment is also an important source of unexpected aesthetic stimulation, yet in psychotic illnesses, aesthetic sensibilities characteristically suffer from deterioration. Research limitations/implications – The findings presented are based on research that is largely translated from very different fields of enquiry. Whilst findings are cogent and logical, much of the support is correlational rather than empirical. Social implications – The WHO claims that schizophrenia destroys 24 million lives worldwide, with an exponential effect on human and financial capital. Because evidence implicates the built environment, architectural and urban designers may have a role to play in reducing the human costs wrought by the illness. Originality/value – Never before has architecture been so explicitly implicated as a cause of mental illness. This paper was presented to the Symposium of Mental Health Facility Design, and is essential reading for anyone involved in designing for improved mental health.
Purpose
The purpose of this paper is to report on the point of view of architecture of an interdisciplinary research on housing and social integration of people with severe mental disorder (SMD) in Brazil after deinstitutionalization. It first aims to present the need for a qualitative evaluation of the way people with SMD deal with their living spaces (house and city); then to describe the method adopted to approach people living under control – in therapeutic residential services (SRTs) proposed by the State as the only alternative model for those leaving psychiatric institutions – and people living alone – with little psychiatric assistance and no dwelling support provided by the State. It aims to conclude with a discussion of the observed dwellings pointing towards the need to accommodate differences in any housing model adopted by the State.
Design/methodology/approach
The qualitative evaluation enabled the focus of participant observation on the way people interact with each other and with their living space. The authors followed the routines of chosen people with SMD in three different cities in Brazil and provided reports for the whole group to analyze them.
Findings
It was found that those living in SRTs are much more obstructed by institutional control than those living alone. Despite the difficulties and fragilities of those living alone because of the lack of support, they end with more possibilities for autonomy and social integration.
Originality/value
Most research on the subject approaches objective housing issues focusing on statistical results. This research evaluates qualitative dwelling issues, summarizing little pointers for future health policy on housing for people with SMD.
Purpose
This paper aims to look into the significance of architectural design in psychiatric care facilities. There is a strong correlation between perceptual dysfunction and psychiatric illness, and also between the patient and his environment. As such, even minor design choices can be of great consequence in a psychiatric facility. It is of critical importance, therefore, that a psychiatric milieu is sympathetic and does not exacerbate the psychosis.
Design/methodology/approach
This paper analyses the architectural elements that may influence mental health, using an architectural extrapolation of Antonovsky's salutogenic theory, which states that better health results from a state of mind which has a fortified sense of coherence. According to the theory, a sense of coherence is fostered by a patient's ability to comprehend the environment (comprehensibility), to be effective in his actions (manageability) and to find meaning (meaningfullness).
Findings
Salutogenic theory can be extrapolated in an architectural context to inform design choices when designing for a stress‐sensitive client base.
Research limitations/implications
In the paper an architectural extrapolation of salutogenic theory is presented as a practical method for making design decisions (in praxis) when evidence is not available. As demonstrated, the results appear to reflect what evidence is available, but real evidence is always desirable over rationalist speculation. The method suggested here cannot prove the efficacy or appropriateness of design decisions and is not intended to do so.
Practical implications
The design of mental health facilities has long been dominated by unsubstantiated policy and normative opinions that do not always serve the client population. This method establishes a practical theoretical model for generating architectural design guidelines for mental health facilities.
Originality/value
The paper will prove to be helpful in several ways. First, salutogenic theory is a useful framework for improving health outcomes, but in the past the theory has never been applied in a methodological way. Second, there have been few insights into how the architecture itself can improve the functionality of a mental health facility other than improve the secondary functions of hospital services.
There’s abundant evidence that the dopamine system is dysfunctional in schizophrenia: specifically, the excitatory D2Low receptors (D1/D2 heteromers) of the frontal complex are depleted, while the subcortical areas that are rich in D2High (D2/D2 homomer) receptors, are over-stimulated. It is hypothesized that this imbalance may cause hallucinations because the dopamine pathways that appear to moderate selective attention - the leading edge of declarative perception become dysfunctional.
The dysfunctional distribution pattern effectively confines dopamine activity to the striatum and deeper subcortical regions. Exactly what this means is still speculative, but a tenable hypothesis is that the dopamine pathways process schemata: with the mesolimbic receptors processing well-learned and instinctive associations, and the frontal complex for processing perceptions that need declarative consideration and self-awareness.
It’s speculated that when dopamine is limited to the subcortical regions, the loss of activity in the frontal complex reduces the capacity to handle abstractions. The leap from symbols to meaning, the ability to reason and ability to critically question, will therefore be hampered. It will also reduce a capacity for self-awareness. This creates the opposite of the ‘flight of ideas,’ inflated ego, euphoria, dysphoria and other signs of expansiveness of a manic episode but still creates an event potential of sorts, although wholly within the striatum.
A surplus of striatal dopaminergic activation will stimulate automatic and the structural elements of thought: The striatum is well connected to manage the well-learned routines of lexica, grammar, schemata, and other procedural resources. Importantly for hallucinations, the striatum has bidirectional connections to the perceptual association cortex, which mediates the visuo-spatial sketchpad and phonological loop within working memory – meaning that striatal activations could reverse-trigger perceptual experience.
The prevailing model of psychiatric design (the world over) does not fulfil its potential in supporting the healing process. In order to design for future usability, design teams must have a vision beyond current paradigms and understand the direction healthcare is going. More importantly still, models of care that will actually improve mental health outcomes instead of just managing patient behaviour must be considered.
To create this vision, a methodological salutogenic approach can be employed for the project development and management phases – from design of the buildings through to the design of the models of care. This approach advocates taking an interdisciplinary and collaborative approach to actively improve a sense of coherence for all users including patients and staff. This can be done at every decision point by choosing to foster manageability, comprehensibility and most importantly meaning.
Introduction
The last half-century of epidemiological enquiry into schizophrenia can be characterized by the search for neurological imbalances and lesions, for genetic factors. The growing consensus that these directions have failed and there is now a growing interest in psycho-social and developmental models. Another area of recent interest is in epigenetics – the multiplication of genetic influences by environmental factors.
Methods
This integrative review comparatively maps current psychosocial, developmental and epigenetic models for schizophrenia epidemiology to identify crossover and theoretical gaps.
Results In the flood of data that is being produced around the schizophrenia epidemiology, one of the most consistent findings is that schizophrenia is an urban syndrome. Once demographic factors have been discounted, between a quarter and a third of all incidence is repeatedly traced back to urbanicity – potentially threatening more established models such as the psycho-social, genetic and developmental hypotheses.
Conclusion
Close analysis demonstrates how current models for schizophrenia epidemiology appear to miss the mark. Furthermore the built environment appears to be an inextricable factor in all current models and indeed may be a valid epidemiological factor on its own.
The reason the built environment hasn’t already become a de rigueur area of epidemiological research is possibly trivial – it just doesn’t attract enough science, and lacks a hero to promote it alongside other hypotheses.
Error prevention and mitigation is the primary goal in high-risk health care, particularly in areas such as surgery. There is growing consensus that significant improvement is hard to come by as a result of the vast complexity and inefficient processes of the health care system. Recommendations and innovations that focus on individual processes do not address the larger and often intangible systemic and cultural factors that create vulnerabilities throughout the entire system. This article introduces basic concepts of complexity and systems theory that are useful in redesigning the surgical work environment to create safety, quality, and reliability in surgical care.
The symptoms of psychiatric illness are diverse, as are the causes of the conditions that cause them. Yet, regardless of the heterogeneity of cause and presentation, a great deal of symptoms can be explained by the failure of a single perceptual function--the reprocessing of ecological perception. It is a central tenet of the ecological theory of perception that we perceive opportunities to act. It has also been found that perception automatically causes actions and thoughts to occur unless this primary action pathway is inhibited. Inhibition allows perceptions to be reprocessed into more appropriate alternative actions and thoughts. Reprocessing of this kind takes place over the entire frontal lobe and it renders action optional. Choice about what action to take (if any) is the basis for the feeling of autonomy and ultimately for the sense-of-self. When thoughts and actions occur automatically (without choice) they appear to originate outside of the self, thereby providing prima facie evidence for some of the bizarre delusions that define schizophrenia such as delusional misidentification, delusions of control and Cotard's delusion. Automatic actions and thoughts are triggered by residual stimulation whenever reprocessing is insufficient to balance automatic excitatory cues (for whatever reason). These may not be noticed if they are neutral and therefore unimportant or where actions and thoughts have a positive bias and are desirable. Responses to negative stimulus, on the other hand, are always unwelcome, because the actions that are triggered will carry the negative bias. Automatic thoughts may include spontaneous positive feelings of love and joy, but automatic negative thoughts and visualisations are experienced as hallucinations. Not only do these feel like they emerge from elsewhere but they carry a negative bias (they are most commonly critical, rude and are irrationally paranoid). Automatic positive actions may include laughter and smiling and these are welcome. Automatic behaviours that carry a negative bias, however, are unwelcome and like hallucinations, occur without a sense of choice. These include crying, stereotypies, perseveration, ataxia, utilization and imitation behaviours and catatonia.
This article systematically reviews studies of prevalence of schizophrenia in homeless persons.
Medline and PsychInfo were searched using the key words: homeless person, mental illness, psychosis, and schizophrenia. The bibliographies of identified articles were also reviewed.
Study designs varied considerably. The rate of schizophrenia in homeless persons reported in the 33 published reports, representing eight different countries, ranged from 2 to 45%. In the 10 methodologically superior studies, the prevalence range was 4-16% and the weighted average prevalence was 11%. In addition, rates were higher in younger persons, women and the chronically homeless. Slightly less than half of the homeless persons with schizophrenia were not currently receiving treatment.
Schizophrenia is much more prevalent among homeless persons than in the population at large. Future research should focus on better ways of meeting the mental health care needs of homeless people with schizophrenia.
Epidemiological studies have found that individuals who live in urban areas are at increased risk of developing psychosis. However it is unknown whether exposure to urban environments exacerbates psychotic symptoms in people who have a diagnosed psychotic disorder. The aim of the study was to examine the psychological and clinical effects of exposure to one specific deprived urban environment on individuals with persecutory delusions. It was predicted that the urban environment would affect emotional and reasoning processes highlighted in a cognitive model of persecutory delusions and would increase paranoia.
Thirty patients with persecutory delusions were randomised to exposure to a deprived urban environment or to a brief mindfulness relaxation task. After exposure, assessments of symptoms, reasoning, and affective processes were taken. Thirty matched non-clinical participants also completed the study measures to enable interpretation of the test scores.
In individuals with persecutory delusions, exposure to the urban environment, rather than participation in a mindfulness task, increased levels of anxiety, negative beliefs about others and jumping to conclusions. It also increased paranoia. The individuals with persecutory delusions scored significantly differently from the non-clinical group on all measures.
For individuals with psychosis, spending time in an urban environment makes them think more negatively about other people and increases anxiety and the jumping to conclusions reasoning bias. Their paranoia is also increased. A number of processes hypothesised in cognitive models to lead to paranoid thoughts are exacerbated by a deprived urban environment. Further research is needed to clarify which aspects of urban environments cause the negative effects. Methodological challenges in the research area are raised.
The inclination of M31 is too close to edge-on for a bar component to be easily recognised and is not sufficiently edge-on for a boxy/peanut bulge to protrude clearly out of the equatorial plane. Nevertheless, a sufficient number of clues allow us to argue that this galaxy is barred. We use fully self-consistent N-body simulations of barred galaxies and compare them with both photometric and kinematic observational data for M31. In particular, we rely on the near infrared photometry presented in a companion paper. We compare isodensity contours to isophotal contours and the light profile along cuts parallel to the galaxy major axis and offset towards the North, or the South, to mass profiles along similar cuts on the model. All these comparisons, as well as position velocity diagrams for the gaseous component, give us strong arguments that M31 is barred. We compare four fiducial N-body models to the data and thus set constraints on the parameters of the M31 bar, as its strength, length and orientation. Our `best' models, although not meant to be exact models of M31, reproduce in a very satisfactory way the main relevant observations. We present arguments that M31 has both a classical and a boxy/peanut bulge. Its pseudo-ring-like structure at roughly 50' is near the outer Lindblad resonance of the bar and could thus be an outer ring, as often observed in barred galaxies. The shape of the isophotes also argues that the vertically thin part of the M31 bar extends considerably further out than its boxy bulge, i.e. that the boxy bulge is only part of the bar, thus confirming predictions from orbital structure studies and from previous N-body simulations. Comment: 14 pages, 12 figures, minor corrections, accepted by MNRAS. Version with high resolution figures at http://www.oamp.fr/dynamique/pap/M31_th.pdf
Ronald Reagan and the commitment of the mentally ill: Capital, interest groups, and the eclipse of social policy
- Ar Thomas
Thomas AR. Ronald Reagan and the commitment of the mentally ill: Capital, interest groups, and the eclipse of social policy. Electronic Journal of
Sociology 1998; 3(4).