Impact of introducing capacity-based mental health legislation on the use of community treatment orders in Norway: case registry study

Background In 2017, a capacity-based criterion was added to the Norwegian Mental Health Act, stating that those with capacity to consent to treatment cannot be subjected to involuntary care unless there is risk to themselves or others. This was expected to reduce incidence and prevalence rates, and the duration of episodes of involuntary care, in particular regarding community treatment orders (CTOs). Aims The aim was to investigate whether the capacity-based criterion had the expected impact on the use of CTOs. Method This retrospective case register study included two catchment areas serving 16% of the Norwegian population (aged ≥18). In total, 760 patients subject to 921 CTOs between 1 January 2015 and 31 December 2019 were included to compare the use of CTOs 2 years before and 2 years after the legal reform. Results CTO incidence rates and duration did not change after the reform, whereas prevalence rates were significantly reduced. This was explained by a sharp increase in termination of CTOs in the year of the reform, after which it reduced and settled on a slightly higher leven than before the reform. We found an unexpected significant increase in the use of involuntary treatment orders for patients on CTOs after the reform. Conclusions The expected impact on CTO use of introducing a capacity-based criterion in the Norwegian Mental Health Act was not confirmed by our study. Given the existing challenges related to defining and assessing decision-making capacity, studies examining the validity of capacity assessments and their impact on the use of coercion in clinical practice are urgently needed.

518Trajectories of offending in people with psychotic illness and other mental disorders: a population study

Background Trajectory analysis has been used to study long-term patterns of offending and identify offending groups. Only few studies have explored patterns in people with psychotic illness and these were restricted to adult offenders. This study examines offending trajectories, and identifies risk factors, for people aged 10-26 with psychotic illness (PI) and other mental disorders (OMD) compared to those with no mental disorders (NMD). Methods This is a whole-population record-linkage study of 184,147 people born in Western Australia (WA) 1983-1991 using data from WA psychiatric case register, WA corrective services and other state-wide registers. Group-based trajectory modelling was used to identify offending trajectories. Results Four offender groups were identified for each mental health status (MHS) group: MHS groups had similar offending patterns, however PI had a lower proportion of individuals in the G1 group and later offending onset in the G3 group. Gender, indigenous status, substance use, childhood victimisation and parental offending were risk factors associated with group membership; for PI, childhood victimisation and parental offending were only significant in the G4 group. Conclusions Overall offending patterns and risk factors were similar for all MHS groups, however, some differences were observed for PI. Key messages To reduce offending in this population, interventions need to occur at an early age.

Impact of IRS: Four-years of entomological surveillance of the Indian Visceral Leishmaniases elimination programme

Background In 2005, Bangladesh, India and Nepal agreed to eliminate visceral leishmaniasis (VL) as a public health problem. The approach to this was through improved case detection and treatment, and controlling transmission by the sand fly vector Phlebotomus argentipes, with indoor residual spraying (IRS) of insecticide. Initially, India applied DDT with stirrup pumps for IRS, however, this did not reduce transmission. After 2015 onwards, the pyrethroid alpha-cypermethrin was applied with compression pumps, and entomological surveillance was initiated in 2016. Methods Eight sentinel sites were established in the Indian states of Bihar, Jharkhand and West Bengal. IRS coverage was monitored by household survey, quality of insecticide application was measured by HPLC, presence and abundance of the VL vector was monitored by CDC light traps, insecticide resistance was measured with WHO diagnostic assays and case incidence was determined from the VL case register KAMIS. Results Complete treatment of houses with IRS increased across all sites from 57% in 2016 to 70% of houses in 2019, rising to >80% if partial house IRS coverage is included (except West Bengal). The quality of insecticide application has improved compared to previous studies, average doses of insecticide on filters papers ranged from 1.52 times the target dose of 25mg/m2 alpha-cypermethrin in 2019 to 1.67 times in 2018. Resistance to DDT has continued to increase, but the vector was not resistant to carbamates, organophosphates or pyrethroids. The annual and seasonal abundance of P. argentipes declined between 2016 to 2019 with an overall infection rate of 0.03%. This was associated with a decline in VL incidence for the blocks represented by the sentinel sites from 1.16 per 10,000 population in 2016 to 0.51 per 10,000 in 2019. Conclusion Through effective case detection and management reducing the infection reservoirs for P. argentipes in the human population combined with IRS keeping P. argentipes abundance and infectivity low has reduced VL transmission. This combination of effective case management and vector control has now brought India within reach of the VL elimination targets.

Therapeutic inertia in proteinuria management among type 2 diabetes (T2DM) patients in primary care settings: prevalence and associated risk factors

Background Therapeutic inertia (TI), defined as physicians’ failure to increase therapy when treatment goals are unmet, is an impediment to chronic disease management. This study aimed to identify the prevalence of TI in proteinuria management among T2DM patients managed in primary care settings and to explore possible associating factors. Methods This was a cross-sectional study. T2DM patients with proteinuria (either microalbuminuria or macroalbuminuria) and had been followed up in 7 public primary care clinics of the Hospital Authority of Hong Kong from 1 Jan, 2014 to 31 Dec, 2015 were included. The prevalence of TI in proteinuria management and its association with patients’ demographic and clinical parameters and the working profile of the attending doctors were explored. Student’s t test and analysis of variance were used for analyzing continuous variables and Chi square test was used for categorical data. Multivariate stepwise logistic regression was used to determine the association between TI and the significant variables from patients' and doctors' characteristics. Results Among the 22,644 T2DM patients identified in the case register, 5163 (26.4%) patients were found to have proteinuria. Among the sampled 385 T2DM patients with proteinuria, TI was identified in 155 cases, with a prevalence rate of 40.3%. Male doctor, doctor with longer duration of clinical practice and have never received any form of Family Medicine training were found to have a higher TI. Patients with microalbuminuria range and lower systolic and diastolic blood pressure (BP) were also found to have higher TI. Logistic regression study revealed that patients’ systolic BP level and microalbuminuria range of proteinuria were negatively associated with the presence of TI, whereas doctor’s year of clinical practice being over 20 years and patients being treated with submaximal dose of medication were positively associated with the presence of TI. Conclusions TI is commonly present in proteinuria management among T2DM patients, with a prevalence of 40.3% in primary care. Systolic BP and microalbuminuria range of urine ACR were negatively associated with the presence of TI, whereas submaximal ACEI/ARB dose and doctors practicing over 20 years were positively associated with the presence of TI. Further studies exploring the strategies to combat TI are needed to improve the clinical outcome of T2DM patients.

Using a mobile application to improve pediatric presumptive TB identification in western Kenya

BACKGROUND: Early recognition of TB symptoms in children is critical in order to link children to appropriate testing and treatment. Healthcare workers (HCWs) in high TB burden countries are often overburdened with competing clinical priorities, leading to incomplete presumptive TB screening. We assessed if implementing a community health volunteer (CHV) led presumptive pediatric TB mobile android application (PPTBMAPP) in pediatric outpatient, primary care clinics in western Kenya would be feasible, appropriate, and effective.METHODS: We used a mixed-methods participatory, iterative approach to design and implement the PPTBMAPP during a 6-month period. We compared the proportion of children identified in presumptive TB and active TB disease registers out of all patients before and after the implementation of the intervention.RESULTS: Of the 1787 children aged ≤15 years screened using the PPTBMAPP, 376 (21%) met the criteria for presumptive TB. There was a statistically significant increase in the proportion of children to all patients in the presumptive TB registers (97/908, 10.7% vs. 160/989, 16.2%; P = 0.0005), and a trend towards an increase in the proportion of children to all patients in the TB case register (17/117, 14.5% vs. 15/83, 18.1%; P = 0.5). HCWs interviewed commented that the application sped up the presumptive TB screening process.CONCLUSION: Our CHV-led mobile screening intervention significantly increased presumptive TB notification. HCWs reported that the mobile screening intervention was feasible, appropriate, and effective.

Community Rehabilitation and Hospitalizations Among People With Chronic Psychotic Disorder: Is There a Differential Association by Co-occurring Substance Use Disorder?

Objective: Co-occurrence of chronic psychotic disorders and substance use disorder (SUD) is clinically challenging and increasingly prevalent. In 2000, legislation was passed in Israel to foster rehabilitation and integration in the community of persons with mental health disorders. In 2010, the need to allocate resources for patients with these co-occurring disorders (COD) was officially recognized. Yet, most rehabilitation services were not specifically designed for COD. This study examines the relationship between duration of community rehabilitation and number of psychiatric hospitalization days among persons with/without COD in Israel.Methods: Data from the National Psychiatric Case Register on 18,684 adults with schizophrenia/schizoaffective disorders hospitalized in 1963–2016, was merged with data from the Israel Mental Rehabilitation Register. Associations and interactions between COD-status (COD/non-COD), time-period (Period1: 2001–2009, Period2: 2010–2016), duration of housing or vocational rehabilitation on hospitalization days per year were analyzed using repeated-measures ANOVA.Results: The proportion of non-COD chronic psychotic patients who received rehabilitation services increased from 56% in Period1 to 63% in Period2, as it did among COD patients—from 30 to 35%. The proportion of non-COD patients who received longer-duration vocational rehabilitation (≥1 year) was significantly higher (43%) than among COD patients (28%) in both time periods. For housing rehabilitation, these proportions were 79 and 68%, respectively. Persons with COD experienced more hospitalization days annually than non-COD patients. Duration of rehabilitation (less/more than a year) was inversely associated with annual number of hospitalization days (p < 0.0001). This pattern was noted in both COD and non-COD groups and remained significant after controlling for age, sex, COD group, percent of hospitalizations with SUD, and age at first hospitalization.Conclusions: COD patients with prolonged rehabilitation seemingly achieve long-term clinical improvement similar to non-COD patients, despite most rehabilitation settings in Israel not being designed for COD patients. Yet, COD patients receive overall less rehabilitation services and for shorter periods than non-COD patients. Long-term rehabilitation services should be provided to COD patients, who may need more time to commit to treatment. To achieve better long-term mental health improvements, a continued expansion of community-based integrative treatment and rehabilitation services for COD patients is needed in Israel.