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OBJECTIVE: The proportion of long-term care (LTC) residents being treated with antipsychotic medication is high, and these medications may exacerbate behavioral symptoms. We used propensity scores to investigate the effect of antipsychotic use on the worsening of behavioral symptoms among residents in LTC facilities. DESIGN: A retrospective study. SETTING AND PARTICIPANTS: Residents in LTC in 8 provinces and 1 territory in Canada, without severe aggressive behavior at baseline and reassessed at follow-up, between March 2000 and March 2022. METHODS: We used propensity score matching and weighting to balance baseline covariates and logistic regression to estimate the effect of antipsychotics on the worsening of behavioral symptoms in the original, matched, and weighted cohorts. The treatment variable was use of antipsychotic medication at baseline and the outcome was worsening of behavior at follow-up. RESULTS: A total of 494,215 participants were included (318,234 women and 175,981 men; mean age 82.8 years [SD 10.1; range 18-112]).130 558 (26.4%) used antipsychotics at baseline and 88,632 (17.9%) had worsening behavior in follow-up. In the matched cohort, there were 249,698 participants, and 124,849 were matched (1:1) in each treatment group. There was a significant association between antipsychotic use at baseline and worsening in behavior at follow-up in the adjusted regression models (OR 1.27 [95% CI 1.25-1.29], <0.0001) as well as in matched (OR 1.20 [95% CI 1.17-1.21], <0.0001) and weighted (OR 1.26 [95% CI 1.24-1.28], <0.0001) cohorts. CONCLUSIONS AND IMPLICATIONS: This study further evidence to support the cautious use of antipsychotics in LTC facilities. Future research in LTC facilities could include a more granular analyses of behavior change, including bidirectional analyses between different symptom severity classifications.
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Background: Numerous validation studies support the use of the interRAI Mental Health (MH) assessment system for inpatient mental health assessment, triage, treatment planning, and outcome measurement. However, there have been suggestions that the interRAI MH does not include sufficient content relevant to forensic mental health. We address this potential deficiency through the development of a Forensic Supplement (FS) to the interRAI MH system. Using three forensic risk assessment instruments (PCL-R; HCR-20; VRAG) that had a record of independent cross validation in the forensic literature, we identified forensic content domains that were missing in the interRAI MH. We then independently developed items to provide forensic coverage. The resulting FS is a single-page, 19-item supplementary document that can be scored along with the interRAI MH, adding approximately 10-15 min to administration time. We constructed the Problem Behavior Scale (PBS) using 11 items from the interRAI MH and FS. The Developmental Sample, 168 forensic mental health inpatients from two large mental health specialty hospitals, was assessed with both an earlier version of the interRAI MH and FS. This sample also provided us access to scores on the PCL-R, the HCR-20 and the VRAG. To validate our initial findings, we sought additional samples where scoring of the interRAI MH and the FS had been done. The first, the Forensic Sample (N = 587), consisted of forensic inpatients in other mental health units/hospitals. The second, the Correctional Sample (N = 618) was a random, representative sample of inmates in prisons, and the third, the Youth Sample (N = 90) comprised a group of youth in police custody. Results: The PBS ranged from 0 to 11, was positively skewed with most scores below 3, and had good internal consistency (Cronbach's Alpha = 0.80). In a test of concurrent validity, correlations between PBS scores and forensic risk scores were moderate to high (i.e., r with PCL-R Factor two of 0.317; with HCR-20 Clinical of 0.46; and with HCR-20 Risk of 0.39). In a test of convergent validity, we used Binary Logistic Regression to demonstrate that the PBS was related to three negative patient experiences (recent verbal abuse, use of a seclusion room, and failure to attain an unaccompanied leave). For each of these three samples, we conducted the same convergent validity statistical analyses as we had for the Developmental Sample and the earlier findings were replicated. Finally, we examined the relationship between PBS scores and care planning triggers, part of the interRAI systems Clinical Assessment Protocols (CAPs). In all three validity samples, the PBS was significantly related to the following CAPs being triggered: Harm to Others, Interpersonal Conflict, Traumatic Life Events, and Control Interventions. These additional validations generalize our findings across age groups (adult, youth) and across health care and correctional settings. Conclusions: The FS improves the interRAI MH's ability to identify risk for negative patient experiences and assess clinical needs in hospitalized/incarcerated forensic patients. These results generalize across age groups and across health care and correctional settings.
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Gender can have separate and interacting effects on mental health. Gender-based analysis provides insight into these effects on mental health, and it can provide evidence to inform policy and practice to meet these gender-specific needs among persons in forensic mental health settings. Both individual and facility-level characteristics play a role in restriction to room as a form of control intervention in forensic mental health. Understanding the gender differences associated with the factors that increase a person's risk of restriction to room can allow for more targeted interventions and provide insight into policies that will help reduce these types of control interventions.
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Clinical triggers from the Traumatic Life Events Clinical Assessment Protocol (CAP) identify individuals who might benefit from formal services or additional supports targeted towards trauma treatment. The Traumatic Life Events CAP identifies two groups who have experienced one or more potentially traumatic life events: (1) those who are in immediate danger due to current abuse/criminal victimization; (2) those who have experienced one or more traumatic events that evoked an intense sense of horror or fear. Descriptive analysis was conducted across psychiatric hospital and community-based mental health service settings to compare the two triggered groups to those without traumatic experiences (the not-triggered group). The Traumatic Life Events CAP identified subpopulations with unrecognized and untreated traumatic-stress-related symptoms, which are of great concern for those in community-based mental health services who are in immediate danger due to current abuse.