Why Does Employment Discrimination Persist against People with Mental Illness? Effects of Negative Stereotypes, Power, and Differential Discrimination

Mental illness affects a sizable minority of Americans at any given time, yet many people with mental illness (hereafter PWMI) remain unemployed or underemployed relative to the general population. Research has suggested that part of the reason for this is discrimination toward PWMI. This research investigated mechanisms that affect employment discrimination against PWMI. Drawing from theories on stigma and power, three studies assessed 1) the stereotyping of workers with mental illness as unfit for workplace success, 2) the impact of positive information on countering these negative stereotypes, and whether negatively-stereotyped conditions elicited discrimination; and 3) the effects of power on mental illness stigma components. I made a series of predictions related to theories on the Stereotype Content Model, illness attribution, the contact hypothesis, gender and mental health, and power. Studies tested predictions using, 1) an online vignette survey measuring attitudes, 2) an online survey measuring responses to fictitious applications for a middle management position, and 3) a laboratory experiment in which some participants were primed to feel powerful and some were not. Results of Study 1 demonstrated that PWMI were routinely stigmatized as incompetent, dangerous, and lacking valued employment attributes, relative to a control condition. This was especially evident for workers presented as having PTSD from wartime service and workers with schizophrenia, and when the worker was a woman. Study 2 showed that, although both war-related PTSD and schizophrenia evoke negative stereotypes, only schizophrenia evoked hiring discrimination. Finally, Study 3 found no effect of being primed to feel powerful on stigmatizing attitudes toward a person with symptoms of schizophrenia. Taken together, findings suggest that employment discrimination towards PWMI is driven by negative stereotypes; but, stereotypes might not lead to actual hiring discrimination for some labeled individuals.

Non-acute Transient Reversible Adrenal Insufficiency in a Survivor of Critical Illness: A Lesser-known Cause of Primary Adrenal Insufficiency

Objectives: Primary adrenal insufficiency AI is regarded as a progressive disease needing lifelong replacement therapy, but this may not always be the case. Material and methods: A non-acute presentation of AI following a hypotensive episode caused by blood loss was investigated. Results: Adrenal function fully recovered without treatment. Conclusions: There should be a high index of suspicion and a low threshold for performing tests of adrenal function in survivors of critical illness and severe hypotensive episodes.

A longitudinal qualitative exploration of healthcare and informal support needs among survivors of critical illness: the RELINQUISH protocol.

Introduction and background: Survival following critical illness is associated with a significant burden of physical, emotional and psychosocial morbidity. Recovery can be protracted and incomplete, with important and sustained effects upon everyday life, including family life, social participation and return to work. In stark contrast with other critically ill patient groups (eg, those following cardiothoracic surgery), there are comparatively few interventional studies of rehabilitation among the general intensive care unit patient population. This paper outlines the protocol for a sub study of the RECOVER study: a randomised controlled trial evaluating a complex intervention of enhanced ward-based rehabilitation for patients following discharge from intensive care. Methods and analysis: The RELINQUISH study is a nested longitudinal, qualitative study of family support and perceived healthcare needs among RECOVER participants at key stages of the recovery process and at up to 1 year following hospital discharge. Its central premise is that recovery is a dynamic process wherein patients’ needs evolve over time. RELINQUISH is novel in that we will incorporate two parallel strategies into our data analysis: (1) a pragmatic health services-oriented approach, using an a priori analytical construct, the ‘Timing it Right’ framework and (2) a constructivist grounded theory approach which allows the emergence of new themes and theoretical understandings from the data. We will subsequently use Qualitative Health Needs Assessment methodology to inform the development of timely and responsive healthcare interventions throughout the recovery process. Ethics and dissemination: The protocol has been approved by the Lothian Research Ethics Committee (protocol number HSRU011). The study has been added to the UK Clinical Research Network Database (study ID. 9986). The authors will disseminate the findings in peer reviewed publications and to relevant critical care stakeholder groups.

Identifying health inequalities in individuals with major mental illness (MMI) using routine data

Abstract and Summary of Thesis: Background: Individuals with Major Mental Illness (such as schizophrenia and bipolar disorder) experience increased rates of physical health comorbidity compared to the general population. They also experience inequalities in access to certain aspects of healthcare. This ultimately leads to premature mortality. Studies detailing patterns of physical health comorbidity are limited by their definitions of comorbidity, single disease approach to comorbidity and by the study of heterogeneous groups. To date the investigation of possible sources of healthcare inequalities experienced by individuals with Major Mental Illness (MMI) is relatively limited. Moreover studies detailing the extent of premature mortality experienced by individuals with MMI vary both in terms of the measure of premature mortality reported and age of the cohort investigated, limiting their generalisability to the wider population. Therefore local and national data can be used to describe patterns of physical health comorbidity, investigate possible reasons for health inequalities and describe mortality rates. These findings will extend existing work in this area. Aims and Objectives: To review the relevant literature regarding: patterns of physical health comorbidity, evidence for inequalities in physical healthcare and evidence for premature mortality for individuals with MMI. To examine the rates of physical health comorbidity in a large primary care database and to assess for evidence for inequalities in access to healthcare using both routine primary care prescribing data and incentivised national Quality and Outcome Framework (QOF) data. Finally to examine the rates of premature mortality in a local context with a particular focus on cause of death across the lifespan and effect of International Classification of Disease Version 10 (ICD 10) diagnosis and socioeconomic status on rates and cause of death. Methods: A narrative review of the literature surrounding patterns of physical health comorbidity, the evidence for inequalities in physical healthcare and premature mortality in MMI was undertaken. Rates of physical health comorbidity and multimorbidity in schizophrenia and bipolar disorder were examined using a large primary care dataset (Scottish Programme for Improving Clinical Effectiveness in Primary Care (SPICE)). Possible inequalities in access to healthcare were investigated by comparing patterns of prescribing in individuals with MMI and comorbid physical health conditions with prescribing rates in individuals with physical health conditions without MMI using SPICE data. Potential inequalities in access to health promotion advice (in the form of smoking cessation) and prescribing of Nicotine Replacement Therapy (NRT) were also investigated using SPICE data. Possible inequalities in access to incentivised primary healthcare were investigated using National Quality and Outcome Framework (QOF) data. Finally a pre-existing case register (Glasgow Psychosis Clinical Information System (PsyCIS)) was linked to Scottish Mortality data (available from the Scottish Government Website) to investigate rates and primary cause of death in individuals with MMI. Rate and primary cause of death were compared to the local population and impact of age, socioeconomic status and ICD 10 diagnosis (schizophrenia vs. bipolar disorder) were investigated. Results: Analysis of the SPICE data found that sixteen out of the thirty two common physical comorbidities assessed, occurred significantly more frequently in individuals with schizophrenia. In individuals with bipolar disorder fourteen occurred more frequently. The most prevalent chronic physical health conditions in individuals with schizophrenia and bipolar disorder were: viral hepatitis (Odds Ratios (OR) 3.99 95% Confidence Interval (CI) 2.82-5.64 and OR 5.90 95% CI 3.16-11.03 respectively), constipation (OR 3.24 95% CI 3.01-3.49 and OR 2.84 95% CI 2.47-3.26 respectively) and Parkinson’s disease (OR 3.07 95% CI 2.43-3.89 and OR 2.52 95% CI 1.60-3.97 respectively). Both groups had significantly increased rates of multimorbidity compared to controls: in the schizophrenia group OR for two comorbidities was 1.37 95% CI 1.29-1.45 and in the bipolar disorder group OR was 1.34 95% CI 1.20-1.49. In the studies investigating inequalities in access to healthcare there was evidence of: under-recording of cardiovascular-related conditions for example in individuals with schizophrenia: OR for Atrial Fibrillation (AF) was 0.62 95% CI 0.52 - 0.73, for hypertension 0.71 95% CI 0.67 - 0.76, for Coronary Heart Disease (CHD) 0.76 95% CI 0.69 - 0.83 and for peripheral vascular disease (PVD) 0.83 95% CI 0.72 - 0.97. Similarly in individuals with bipolar disorder OR for AF was 0.56 95% CI 0.41-0.78, for hypertension 0.69 95% CI 0.62 - 0.77 and for CHD 0.77 95% CI 0.66 - 0.91. There was also evidence of less intensive prescribing for individuals with schizophrenia and bipolar disorder who had comorbid hypertension and CHD compared to individuals with hypertension and CHD who did not have schizophrenia or bipolar disorder. Rate of prescribing of statins for individuals with schizophrenia and CHD occurred significantly less frequently than in individuals with CHD without MMI (OR 0.67 95% CI 0.56-0.80). Rates of prescribing of 2 or more anti-hypertensives were lower in individuals with CHD and schizophrenia and CHD and bipolar disorder compared to individuals with CHD without MMI (OR 0.66 95% CI 0.56-0.78 and OR 0.55 95% CI 0.46-0.67, respectively). Smoking was more common in individuals with MMI compared to individuals without MMI (OR 2.53 95% CI 2.44-2.63) and was particularly increased in men (OR 2.83 95% CI 2.68-2.98). Rates of ex-smoking and non-smoking were lower in individuals with MMI (OR 0.79 95% CI 0.75-0.83 and OR 0.50 95% CI 0.48-0.52 respectively). However recorded rates of smoking cessation advice in smokers with MMI were significantly lower than the recorded rates of smoking cessation advice in smokers with diabetes (88.7% vs. 98.0%, p<0.001), smokers with CHD (88.9% vs. 98.7%, p<0.001) and smokers with hypertension (88.3% vs. 98.5%, p<0.001) without MMI. The odds ratio of NRT prescription was also significantly lower in smokers with MMI without diabetes compared to smokers with diabetes without MMI (OR 0.75 95% CI 0.69-0.81). Similar findings were found for smokers with MMI without CHD compared to smokers with CHD without MMI (OR 0.34 95% CI 0.31-0.38) and smokers with MMI without hypertension compared to smokers with hypertension without MMI (OR 0.71 95% CI 0.66-0.76). At a national level, payment and population achievement rates for the recording of body mass index (BMI) in MMI was significantly lower than the payment and population achievement rates for BMI recording in diabetes throughout the whole of the UK combined: payment rate 92.7% (Inter Quartile Range (IQR) 89.3-95.8 vs. 95.5% IQR 93.3-97.2, p<0.001 and population achievement rate 84.0% IQR 76.3-90.0 vs. 92.5% IQR 89.7-94.9, p<0.001 and for each country individually: for example in Scotland payment rate was 94.0% IQR 91.4-97.2 vs. 96.3% IQR 94.3-97.8, p<0.001. Exception rate was significantly higher for the recording of BMI in MMI than the exception rate for BMI recording in diabetes for the UK combined: 7.4% IQR 3.3-15.9 vs. 2.3% IQR 0.9-4.7, p<0.001 and for each country individually. For example in Scotland exception rate in MMI was 11.8% IQR 5.4-19.3 compared to 3.5% IQR 1.9-6.1 in diabetes. Similar findings were found for Blood Pressure (BP) recording: across the whole of the UK payment and population achievement rates for BP recording in MMI were also significantly reduced compared to payment and population achievement rates for the recording of BP in chronic kidney disease (CKD): payment rate: 94.1% IQR 90.9-97.1 vs.97.8% IQR 96.3-98.9 and p<0.001 and population achievement rate 87.0% IQR 81.3-91.7 vs. 97.1% IQR 95.5-98.4, p<0.001. Exception rates again were significantly higher for the recording of BP in MMI compared to CKD (6.4% IQR 3.0-13.1 vs. 0.3% IQR 0.0-1.0, p<0.001). There was also evidence of differences in rates of recording of BMI and BP in MMI across the UK. BMI and BP recording in MMI were significantly lower in Scotland compared to England (BMI:-1.5% 99% CI -2.7 to -0.3%, p<0.001 and BP: -1.8% 99% CI -2.7 to -0.9%, p<0.001). While rates of BMI and BP recording in diabetes and CKD were similar in Scotland compared to England (BMI: -0.5 99% CI -1.0 to 0.05, p=0.004 and BP: 0.02 99% CI -0.2 to 0.3, p=0.797). Data from the PsyCIS cohort showed an increase in Standardised Mortality Ratios (SMR) across the lifespan for individuals with MMI compared to the local Glasgow and wider Scottish populations (Glasgow SMR 1.8 95% CI 1.6-2.0 and Scotland SMR 2.7 95% CI 2.4-3.1). Increasing socioeconomic deprivation was associated with an increased overall rate of death in MMI (350.3 deaths/10,000 population/5 years in the least deprived quintile compared to 794.6 deaths/10,000 population/5 years in the most deprived quintile). No significant difference in rate of death for individuals with schizophrenia compared with bipolar disorder was reported (6.3% vs. 4.9%, p=0.086), but primary cause of death varied: with higher rates of suicide in individuals with bipolar disorder (22.4% vs. 11.7%, p=0.04). Discussion: Local and national datasets can be used for epidemiological study to inform local practice and complement existing national and international studies. While the strengths of this thesis include the large data sets used and therefore their likely representativeness to the wider population, some limitations largely associated with using secondary data sources are acknowledged. While this thesis has confirmed evidence of increased physical health comorbidity and multimorbidity in individuals with MMI, it is likely that these findings represent a significant under reporting and likely under recognition of physical health comorbidity in this population. This is likely due to a combination of patient, health professional and healthcare system factors and requires further investigation. Moreover, evidence of inequality in access to healthcare in terms of: physical health promotion (namely smoking cessation advice), recording of physical health indices (BMI and BP), prescribing of medications for the treatment of physical illness and prescribing of NRT has been found at a national level. While significant premature mortality in individuals with MMI within a Scottish setting has been confirmed, more work is required to further detail and investigate the impact of socioeconomic deprivation on cause and rate of death in this population. It is clear that further education and training is required for all healthcare staff to improve the recognition, diagnosis and treatment of physical health problems in this population with the aim of addressing the significant premature mortality that is seen. Conclusions: Future work lies in the challenge of designing strategies to reduce health inequalities and narrow the gap in premature mortality reported in individuals with MMI. Models of care that allow a much more integrated approach to diagnosing, monitoring and treating both the physical and mental health of individuals with MMI, particularly in areas of social and economic deprivation may be helpful. Strategies to engage this “hard to reach” population also need to be developed. While greater integration of psychiatric services with primary care and with specialist medical services is clearly vital the evidence on how best to achieve this is limited. While the National Health Service (NHS) is currently undergoing major reform, attention needs to be paid to designing better ways to improve the current disconnect between primary and secondary care. This should then help to improve physical, psychological and social outcomes for individuals with MMI.

Psychiatric manifestations of sporadic Creutzfeldt-Jakob disease simulate depressive disorder with psychotic symptoms

Creutzfeldt–Jakob disease (CJD) is a rare and fatal neurodegenerative disorder with a broad spectrum of early clinical manifestations, comprising neurological and psychiatric symptoms. The authors report the case of a patient admitted with a diagnosis of depressive disorder with psychotic symptoms, with post-mortem confirmation of CJD and discuss how CJD’s clinical heterogeneity can lead to misdiagnosis of the disease. Despite CJD’s unique pathogenesis, its kaleidoscopic presentation justifies the integrated investigation of patients with psychiatric symptoms, avoiding restrictive diagnosis.

Portuguese health care costs related to asbestos exposure: a cost-of-illness study on mesothelioma hospital admission in the period 2000-2015

Background: Portugal has a temperate climate and low industrialization levels existing in the period after World War II, when asbestos materials were used worldwide, has contributed to the generalized belief of low usage of those materials. - Such supposition lacks confirmation; - There is no specific registry of asbestos-related diseases, workers asbestos exposure or asbestos industrial use; - Mesotheliomas are rare neoplasms strongly related to asbestos exposure so they can be used to understand the possible dimension of past exposure to asbestos; - It was estimated that professional diseases under notification was up to 90% for asbestos-related diseases, mainly mesotheliomas.

Exploring the potential role of allostatic load biomarkers in risk assessment of patients presenting with depressive symptoms

Background: Depression is a major health problem worldwide and the majority of patients presenting with depressive symptoms are managed in primary care. Current approaches for assessing depressive symptoms in primary care are not accurate in predicting future clinical outcomes, which may potentially lead to over or under treatment. The Allostatic Load (AL) theory suggests that by measuring multi-system biomarker levels as a proxy of measuring multi-system physiological dysregulation, it is possible to identify individuals at risk of having adverse health outcomes at a prodromal stage. Allostatic Index (AI) score, calculated by applying statistical formulations to different multi-system biomarkers, have been associated with depressive symptoms. Aims and Objectives: To test the hypothesis, that a combination of allostatic load (AL) biomarkers will form a predictive algorithm in defining clinically meaningful outcomes in a population of patients presenting with depressive symptoms. The key objectives were: 1. To explore the relationship between various allostatic load biomarkers and prevalence of depressive symptoms in patients, especially in patients diagnosed with three common cardiometabolic diseases (Coronary Heart Disease (CHD), Diabetes and Stroke). 2 To explore whether allostatic load biomarkers predict clinical outcomes in patients with depressive symptoms, especially in patients with three common cardiometabolic diseases (CHD, Diabetes and Stroke). 3 To develop a predictive tool to identify individuals with depressive symptoms at highest risk of adverse clinical outcomes. Methods: Datasets used: ‘DepChron’ was a dataset of 35,537 patients with existing cardiometabolic disease collected as a part of routine clinical practice. ‘Psobid’ was a research data source containing health related information from 666 participants recruited from the general population. The clinical outcomes for 3 both datasets were studied using electronic data linkage to hospital and mortality health records, undertaken by Information Services Division, Scotland. Cross-sectional associations between allostatic load biomarkers calculated at baseline, with clinical severity of depression assessed by a symptom score, were assessed using logistic and linear regression models in both datasets. Cox’s proportional hazards survival analysis models were used to assess the relationship of allostatic load biomarkers at baseline and the risk of adverse physical health outcomes at follow-up, in patients with depressive symptoms. The possibility of interaction between depressive symptoms and allostatic load biomarkers in risk prediction of adverse clinical outcomes was studied using the analysis of variance (ANOVA) test. Finally, the value of constructing a risk scoring scale using patient demographics and allostatic load biomarkers for predicting adverse outcomes in depressed patients was investigated using clinical risk prediction modelling and Area Under Curve (AUC) statistics. Key Results: Literature Review Findings. The literature review showed that twelve blood based peripheral biomarkers were statistically significant in predicting six different clinical outcomes in participants with depressive symptoms. Outcomes related to both mental health (depressive symptoms) and physical health were statistically associated with pre-treatment levels of peripheral biomarkers; however only two studies investigated outcomes related to physical health. Cross-sectional Analysis Findings: In DepChron, dysregulation of individual allostatic biomarkers (mainly cardiometabolic) were found to have a non-linear association with increased probability of co-morbid depressive symptoms (as assessed by Hospital Anxiety and Depression Score HADS-D≥8). A composite AI score constructed using five biomarkers did not lead to any improvement in the observed strength of the association. In Psobid, BMI was found to have a significant cross-sectional association with the probability of depressive symptoms (assessed by General Health Questionnaire GHQ-28≥5). BMI, triglycerides, highly sensitive C - reactive 4 protein (CRP) and High Density Lipoprotein-HDL cholesterol were found to have a significant cross-sectional relationship with the continuous measure of GHQ-28. A composite AI score constructed using 12 biomarkers did not show a significant association with depressive symptoms among Psobid participants. Longitudinal Analysis Findings: In DepChron, three clinical outcomes were studied over four years: all-cause death, all-cause hospital admissions and composite major adverse cardiovascular outcome-MACE (cardiovascular death or admission due to MI/stroke/HF). Presence of depressive symptoms and composite AI score calculated using mainly peripheral cardiometabolic biomarkers was found to have a significant association with all three clinical outcomes over the following four years in DepChron patients. There was no evidence of an interaction between AI score and presence of depressive symptoms in risk prediction of any of the three clinical outcomes. There was a statistically significant interaction noted between SBP and depressive symptoms in risk prediction of major adverse cardiovascular outcome, and also between HbA1c and depressive symptoms in risk prediction of all-cause mortality for patients with diabetes. In Psobid, depressive symptoms (assessed by GHQ-28≥5) did not have a statistically significant association with any of the four outcomes under study at seven years: all cause death, all cause hospital admission, MACE and incidence of new cancer. A composite AI score at baseline had a significant association with the risk of MACE at seven years, after adjusting for confounders. A continuous measure of IL-6 observed at baseline had a significant association with the risk of three clinical outcomes- all-cause mortality, all-cause hospital admissions and major adverse cardiovascular event. Raised total cholesterol at baseline was associated with lower risk of all-cause death at seven years while raised waist hip ratio- WHR at baseline was associated with higher risk of MACE at seven years among Psobid participants. There was no significant interaction between depressive symptoms and peripheral biomarkers (individual or combined) in risk prediction of any of the four clinical outcomes under consideration. Risk Scoring System Development: In the DepChron cohort, a scoring system was constructed based on eight baseline demographic and clinical variables to predict the risk of MACE over four years. The AUC value for the risk scoring system was modest at 56.7% (95% CI 55.6 to 57.5%). In Psobid, it was not possible to perform this analysis due to the low event rate observed for the clinical outcomes. Conclusion: Individual peripheral biomarkers were found to have a cross-sectional association with depressive symptoms both in patients with cardiometabolic disease and middle-aged participants recruited from the general population. AI score calculated with different statistical formulations was of no greater benefit in predicting concurrent depressive symptoms or clinical outcomes at follow-up, over and above its individual constituent biomarkers, in either patient cohort. SBP had a significant interaction with depressive symptoms in predicting cardiovascular events in patients with cardiometabolic disease; HbA1c had a significant interaction with depressive symptoms in predicting all-cause mortality in patients with diabetes. Peripheral biomarkers may have a role in predicting clinical outcomes in patients with depressive symptoms, especially for those with existing cardiometabolic disease, and this merits further investigation.

Using Needs Assessment to Understand Continuing Disability in Patients with Enduring Mental Illness. Implications for Considerations of Service Development

Particular strengths of the MRC Needs for Care Assessment Schedule have been used to investigate the treatment status of patients with persistent psychiatric disability in ways that other needs assessment tools are unable to. One hundred and seventy-nine such patients from three settings; a private sector psychiatric hospital, two public sector day hospitals situated in the same town, and a high security hospital, were found to have a high level of need. Although there were differences between settings, overall these needs were well met in all three. The high level of persistent disability found amongst these patients could not be attributed to failure on the part of those treating them to use the best available methods, or to failures to comply or engage with treatment on the patient's part. In some two thirds of instances persistent disability was best explained by the fact that even the most suitable available treatments have to be considered only partially effective.

Predictors of stress and depressive mood in portuguese middle-aged women

This cross-sectional study investigates the predictors of psychological symptoms-stress and depressive mood-in a sample of middle-aged women. A community sample of 1,003 women filled in the questionnaires and instruments, which included the Depression, Anxiety and Stress Scales and the Life Events Survey; sociodemographic, health, and menopause-related and lifestyle information was also collected. Structural equation modeling was used to build the model that had stress and depressive mood as dependent variables. Health status (both physical and psychological), recent life events, income and menopausal phase were significantly associated with the frequency of stress and depressive symptoms. Additionally, educational level and parity were also significant predictors of depressive mood. This study emphasizes that psychological symptoms occurrence in midlife depends not only on personal variables (such as health and menopausal status) but also on contextual ones (including recent stressful events) that can be a strong influence on how middle-aged women feel.

Study of depressive symptoms according to Zung's self-rating scale on men deprived of freedom in a city of Colombia

Objective: To assess depressive symptoms in men deprived from freedom in a prison in a Colombian intermediate city. Material and Method: A cross sectional study was performed on a sample of three hundred and three patients in the Medium Security penitentiary and Prison Facility of the city of Manizales between April and May 2014. The information was collected through the Zung self-rating depression scale (SDS), subsequently there were established the positive results for depression screening according to the final score of the scale. Results: 303 men deprived from freedom were evaluated, mean age of 32.96 years +/- 10.8 years, 43.5% were living in cohabitation, 38% were single and 10.2% married; 33.7% had a primary education, 58% had secondary or incomplete secondary education, 5.6% reported higher studies; 38.6% (95% CI: 35.8; 41.4) reported symptoms of depression, predominating in ages between 18 to 44 years, no statistically significant differences p> 0.05 between the variables analyzed were found. Conclusions: The results of this study give rise to clinical evaluation, by specialized staff in the area of psychiatry and his intervention, given the characteristics of self-reported depression for this population.

Age at the time of exposure to trauma modulates the psychopathological profile in early psychosis patients

Objective: To examine the potential differential impact of childhood trauma, according to the age at the time of exposure, on the psychopathological profile of patients with early psychosis treated in a specialized 3-year program during the early phase of the disease. Methods: 196 subjects with early psychosis aged 18-35 years were followed up prospectively over 36 months of treatment between 2004 and 2010. Patients who had faced at least 1 experience of abuse (physical, sexual, or emotional) or neglect (physical or emotional) were classified according to age at the time of the first exposure (early trauma: before 12 years of age; late trauma: from age 12 through 16 years) and then compared with unexposed patients (nontrauma). The level of symptoms was assessed using the Positive and Negative Syndrome Scale, the Young Mania Rating Scale, and the Montgomery-Asberg Depression Rating Scale. Results: Exposure to 1 or more forms of trauma before 16 years of age was present in 31.63% of patients. Comparisons over the 3 years of treatment with the nontrauma patients revealed that (1) patients with early trauma showed consistently higher levels of positive (P = .006), depressive (P = .001), manic (P = .006), and negative (P = .029) symptoms and (2) patients with late trauma showed only more negative symptoms (P = .029). Conclusions: These results suggest that the age at the time of exposure to trauma has a modulating effect on symptoms in patients with early psychosis. Various biological and psychological hypotheses can be proposed to explain this observation, and they need to be investigated in an experimental setting in order to develop therapeutic avenues.

CURB-65 and other markers of illness severity in community-acquired pneumonia among HIV-positive patients

Introduction: As the relative burden of community-acquired bacterial pneumonia among HIV-positive patients increases, adequate prediction of case severity on presentation is crucial. We sought to determine what characteristics measurable on presentation are predictive of worse outcomes. Methods: We studied all admissions for community-acquired bacterial pneumonia over 1 year at a tertiary centre. Patient demographics, comorbidities, HIV-specific markers and CURB-65 scores on Emergency Department presentation were reviewed. Outcomes of interest included mortality, bacteraemia, intensive care unit admission and orotracheal intubation. Results: A total of 396 patients were included, 49 HIV positive and 347 HIV negative. Mean CURB-65 score was 1.3 for HIV-positive and 2.2 for HIV-negative patients (p<0.0001), its predictive value for mortality being maintained in both groups (p¼0.03 and p<0.001, respectively). Adjusting for CURB-65 scores, HIV infection by itself was only associated with bacteraemia (adjusted odds ratio 7.1 CI 95% [2.6–19.5]). Patients with<200 CD4 cells/mL presented similar CURB- 65 adjusted mortality (adjusted odds ratio 1.7 CI 95% [0.2–15.2]), but higher risk of intensive care unit admission (adjusted odds ratio 5.7 CI 95% [1.5–22.0]) and orotracheal intubation (adjusted odds ratio 9.1 CI 95% [2.2–37.1]), compared to HIV-negative patients. These two associations were not observed in the>200 CD4 cells/mL subgroup (adjusted odds ratio 2.2 CI 95% [0.7–7.6] and adjusted odds ratio 0.8 CI 95% [0.1–6.5] respectively). Antiretroviral therapy and viral load suppression were not associated with different outcomes (p>0.05). Conclusions: High CURB-65 scores and CD4 counts<200 cells/mL were both associated with worse outcomes. Severity assessment scales and CD4 counts may both be helpful in predicting severity in HIV-positive patients presenting with community-acquired bacterial pneumonia.

Coherent childbearing

Background: Over the last 10 years, Australia's spontaneous vaginal birth rate has decreased approximately 1% each year and the caesarean section rate has increased approximately 1% each year. This trend has serious implications for the health of women and babies. As midwives we are the caretakers of normal birth and therefore partly responsible for its decline and the solution to its decline. Although antenatal education is in a potentially powerful position to promote normal birth, a structured review conducted as part of this thesis found that it does not realise that potential. Currently framed in pathogenesis, antenatal education in particular and maternity services in general, are in need of reframing. The theory of salutogenesis may offer a new lens as it focuses on health rather than illness. Sense of coherence is the cornerstone of salutogenesis and is a predictive indicator of health. What is unclear is the role pregnant women's sense of coherence plays in their birthing outcomes. This study explored associations between pregnant women's sense of coherence, their pregnancy choices, their anticipated labour choices, their labour and birthing outcomes as well as factors associated with modification to sense of coherence from the antenatal to postnatal periods. Methods: After a comprehensive review of the literature, questionnaire development and psychometric tool testing and modification, a longitudinal survey was conducted where eligible women completed a questionnaire before the 30th week of pregnancy (Phase One) and approximately 8 weeks after birth (Phase Two). Eligible women were less than 30 weeks pregnant with a single fetus, could read and write in English and lived in the Australian Capital Territory in Australia. Phase One provided information on women's sense of coherence scores, Edinburgh Postnatal Depression Scale (EPDS) scores, Support Behaviour Inventory (SBI) scores, pregnancy choices including care proVider, planned place of birth, planned birth type and anticipated epidural use and demographics. Phase Two provided information on women's sense of coherence scores, EPDS scores and their labour and birthing outcomes. Findings: 1074 women completed Phase One representing a 61.3% response rate. 753 women completed Phase Two representing a 70.1% retention rate between phases. Compared to women with low sense of coherence, women with high sense of coherence were older, reported fewer pregnancy conditions such as diabetes or hypertension, were less likely to have depressive symptoms, were more likely to feel well supported, were less likely to experience a caesarean section and more likely to experience an assisted vaginal birth. Sense of coherence was not associated with women's pregnancy choices. Higher EPDS scores, lower sense of coherence and greater satisfaction with birth were associated with an increase in women's sense of coherence from the antenatal to the postnatal period. Decreased birth satisfaction and experiencing epidural anaesthesia in labour and assisted vaginal birth were associated with a decrease in sense of coherence from the antenatal to the postnatal period. Conclusion: Strong sense of coherence in pregnant women halved the likelihood of experiencing caesarean section compared to women with low sense of coherence. Sense of coherence is a modifiable predictor of women's childbearing health and was found to be raised by birth satisfaction and lowered by birth dissatisfaction and labour interventions. These important findings add to the limited body of knowledge about sense of coherence and childbearing.