Suchergebnisse

IntroductionAdults released from incarceration experience complex physical and mental health problems, and are at markedly increased risk of preventable death. Despite this, not enough is known about the granular epidemiology of mortality in this population to inform development of targeted, evidence-based responses.
Objectives and ApproachWe created the Mortality After Release from Incarceration Consortium (MARIC), a multi-disciplinary collaboration from 12 countries representing 30 cohorts of adults with a history of incarceration. The combined sample size is 1,210,168, with 58,840 deaths recorded over 8,261,743 person-years of follow-up time. In this protocol paper, using a two-step, individual participant data meta-analysis (IPDM-A) methodology involving 22 MARIC cohorts, we calculated 1) a crude mortality rate (CMR; with 95% confidence intervals) for each individual cohort over the first 84 days (12 weeks) following release; and 2) a combined, meta-analysed CMR for the same period.
ResultsOf 1,704,208 individual releases, we observed 4,018 deaths over the first 84 days. The overall CMR over the first 84 days after release was 1610.97 deaths per 100,000 person-years (95% CI: 1263.4 - 1958.5). The rate was highest on the day of release (5768.0; 95% CI: 3296.5 - 8239.4), which was significantly higher than on days 4-84.
Conclusion/ImplicationsAdults released from incarceration were at an acutely increased risk of death on the day of release, and this risk remained elevated for at least the first 12 weeks. The MARIC study will provide decisive and empirical evidence to guide clinicians and policy makers in reducing mortality in this marginalized

IntroductionHigh rates of self-harm resulting in acute health service contact have been observed in adults released from prison. Contact with health services due to self-harm is a key intervention opportunity to prevent deleterious health outcomes. Little is known about subsequent mental health service contact after discharge from acute health services.
Objectives and ApproachWe aimed to describe mental health service contact after discharge from acute health service contacts following self-harm in a representative sample of adults released from prison. Ambulance, emergency department (ED), hospital inpatient and ambulatory mental health service records were probabilistically linked to pre-release interview data. Self-harm events after release were identified from ICD codes and coded from case notes in ambulance, ED, and hospital records. We calculated the time between discharge from ambulance, ED, or hospital after self-harm and subsequent contact with mental health services. Factors predicting the likelihood of mental health service contact were examined using multivariate logistic regression.
ResultsOf 1307 adults released from prison, 108 (8.3%) experienced 218 self-harm events resulting in acute health service use in the community. Of these presentations, 0%, 59%, and 50% of discharges from ambulance attendances, ED and hospital, respectively, had subsequent contact with a specialist mental health service within 7 days of that acute service contact. Mental health service contact within 7 days of acute service contact was positively associated with being female (adjusted odds ratio [AOR]: 3.27; 95%CI: 1.26-8.47) and being identified by prison staff as at risk for self-harm (AOR: 3.34; 95%CI: 1.29-8.62), and was negatively associated with dual diagnosis (AOR: 0.19: 95%CI: 0.06-0.61), substance use disorder only (AOR: 0.13; 95%CI: 0.04-0.48) and physical health functioning (AOR: 0.96; 95\%CI: 0.92-0.99).
Conclusion/ImplicationsAlmost half of adults with a recent history of incarceration discharged from acute health service after self-harm did not receive timely specialist mental health care. Improved integration of acute health services and ambulatory mental health services could improve outcomes for adults who present with self-harm.

The use of administrative health data for research, monitoring, and quality improvement has proliferated in recent decades, leading to improvements in health across many disease areas and across the life course. However, not all populations are equally visible in administrative health data, and those that are less visible may be excluded from the benefits of associated research.
Socially excluded populations -- including the homeless, people with substance dependence, people involved in sex work, migrants or asylum seekers, and people with a history of incarceration -- are typically characterised by health inequity. Yet people who experience social exclusion are often invisible within routinely collected administrative health data because information on their markers of social exclusion are not routinely recorded by healthcare providers. These circumstances make it difficult to understand the often complex health needs of socially excluded populations, evaluate and improve the quality of health services that they interact with, provide more accessible and appropriate health services, and develop effective and integrated responses to reduce health inequity.
In this commentary we discuss how linking data from multiple sectors with administrative health data, often called cross-sectoral data linkage, is a key method for systematically identifying socially excluded populations in administrative health data and addressing other issues related to data quality and representativeness. We discuss how cross-sectoral data linkage can improve the representation of socially excluded populations in research, monitoring, and quality improvement initiatives, which can in turn inform coordinated responses across multiple sectors of service delivery. Finally, we articulate key challenges and potential solutions for advancing the use of cross-sectoral data linkage to improve the health of socially excluded populations, using international examples.

ObjectivesPeople released from incarceration are at increased risk of death from diverse causes. We aimed to calculate the incidence of all-cause and cause-specific death after release from incarceration and identify individual-level risk factors for death.
ApproachWe conducted a series of individual participant data meta-analyses using data from >1.3 million adults released from incarceration in eight countries from 1980-2018. We used random effects meta-analysis to estimate the pooled all-cause and cause-specific crude mortality rates (CMRs), with 95% confidence intervals (CI) for the entire follow-up period, and for specific time periods after release from incarceration, overall and stratified by age, sex, and region.
ResultsWe included 1,395,318 people, 10,164,341 person-years of follow-up time, and 72,920 deaths in our analyses. The overall pooled CMR was 727 (95%CI: 623-840) per 100,000 person-years, with no difference between males and females. The risk of death was highest during the first week following release (all-cause CMR: 1,612, 95%CI: 1048-2,287, I2=91.5%), and the three most common causes of death across the entire follow-up period were 1) alcohol and other drug poisoning (CMR=144, 95%CI: 99-197); 2) cardiovascular disease (CMR: 102, 95%CI: 85-121); and 3) cancer and other neoplasms (CMR=74, 95%CI: 85-121). Leading causes of death varied across time periods following release from incarceration.
ConclusionOur findings indicate the need for routine monitoring of mortality following release from incarceration. The distribution of cause of death varies over time, such that clinical decision-making needs to be informed by the proximity to release from incarceration. The elevated risk of death in first 7 days following release highlights the urgent need for coordinated transitional care – including substance use and mental health treatment – and injury prevention initiatives.

IntroductionDespite an elevated prevalence of self-harm in the incarcerated adult population, little is known about patterns of self-harm following release from prison.
Objectives and ApproachBaseline self-report interviews with 1315 adults immediately prior to release from prison in Queensland, Australia, combined with interrogation of linked health data from >3750 post-release emergency department presentations, >2000 ambulance attendances, and corrections data during periods of re-incarceration.
ResultsApproximately 5% of all contacts with medical emergency services following release from prison resulted from self-harm. These were associated with being Indigenous, having a lifetime history of a mental disorder and having been identified by prison staff as being at risk of self-harm. Agreement between self-reported self-harm and medically-verified episodes of self-harm was poor.
Conclusion/ImplicationsEmergency services contacts resulting from self-harm following release from prison are common and represent an opportunity for tertiary intervention for self-harm. Our findings suggest that a self-reported history of self-harm should not be considered a reliable indicator of prior self-harm, or of future self-harm risk, in incarcerated adults.

IntroductionDrug-related death is substantially higher in formerly incarcerated adults compared to the general population. Despite this, remarkably little is known about the epidemiology of drug-related death among justice-involved adolescents. A richer understanding of drug-related mortality in justice-involved young people is essential for the development of effective, evidence-based interventions for this vulnerable group.
Objectives and ApproachIn a whole-population cohort of justice-involved young people in Queensland, Australia, we aimed to: 1) calculate the rate of drug-related death overall, and separately by intent and drug category; and 2) estimate the probability, and identify the predictors of, drug-related death. We probabilistically linked Youth Justice Queensland and National Death Index (NDI) records for every young person who came into contact with the youth justice system in Queensland between 1 January 1993 and 31 December 2014 (N=48,963). The NDI provided death data until 31 December 2017. Crude mortality rates (CMR) were calculatedoverall, separately by intent, and by prescribed versus illicit drug cause. Competing risk survival analysis will be conducted.
ResultsOf the 48,963 individuals, 1452 (3%) died by 31 December 2017. Of these, 204 (14%) deaths were due to drugs, yielding a CMR of 31 (95%CI:27-36) per 100,000 person-years. Most drug-related deaths were recorded as intentional (CMR=28; 95%CI:24-33 per 100,000 person-years) and deaths from prescribed medications were more common than illicit drugs (CMR=17; 95%CI:14-20 and CMR=11; 95%CI:9-14 per 100,000 person-years, respectively).
Conclusion / ImplicationsRates of drug-related deaths following contact with the youth justice system are disproportionately high and represent a major public health concern. Our findings highlight the importance of initiation of alcohol and other drug (AOD) treatment upon contact with the youth justice system and continuous engagement with community treatment after discharge from the youth justice system. Evidenced-base prevention strategies and efforts to improve the continuity of care are urgently needed.

IntroductionStudies of the health of prisoners have proliferated in the past decade. However, relatively few studies have examined health outcomes after release from custody. As such, although >30 million people are released from prison globally each year, the health and health service experiences of this population remain poorly understood.
Objectives and ApproachWell-powered longitudinal studies are essential for answering these questions but are expensive and difficult to conduct. Internationally, few such studies have been undertaken, and most suffer from either substantial and biased attrition, or recruitment bias. Cross-sectoral linkage of health and justice data circumvents some of these problems but presents its own ethical and methodological challenges. Large longitudinal studies, combining rich survey and clinical data with prospective data linkage, provide unique opportunities to examine and understand health outcomes for these highly marginalised individuals.
ResultsThis presentation will describe the process and challenges of establishing the world's largest (N=2,702) prospective study of adults released from prison: the Health After Release from Prison (HARP) cohort study. The cohort spans two Australian states and includes 538 women and 1,002 Indigenous Australians. An overview of the data collected through face-to-face surveys, medical record review, and prospective linkage with State-based health and correctional records, national Medicare and pharmaceutical records, and the National Death Index, will be provided. Some examples of how these data have been used to answer novel public health questions will be presented. The strengths and limitations of the cohort, and the applicability of this research design for other inclusion health populations, will be discussed.
Conclusion/ImplicationsGiven their extreme vulnerability, understanding the health of people who cycle through prisons is important to addressing health inequalities at the population level. Novel research designs that combine prospective data linkage with other data sources provide new opportunities to examine the health of socially excluded populations.

Abstract. Background: Rates of hospital admission for suicide-related thoughts and behaviors (SRTBs) are elevated in the Northern Territory (NT) of Australia, especially by Aboriginal people, but very little is known about emergency department (ED) presentations. Aim: We aimed to profile ED presentations in the NT involving SRTBs by Indigenous status and compare discharge arrangements. Method: Logistic regression analyses were performed on data from electronic patient records of consecutive ED presentations involving SRTBs. Results: During the study period, 167 presentations were observed. Aboriginal patients were more likely to present from remote areas and to report substance misuse and family conflict or violence compared with non-Aboriginal patients. In both groups, males were more likely than females to be admitted as were persons presenting with self-harm compared with those who had suicidal thoughts only. No differences in discharge arrangements were identified by Indigenous status. Limitations: The small scale of the study and use of administrative records points to the need for further research to improve the quality of the evidence. Conclusion: While presentations by high-risk groups are more likely to be admitted for further care, the assessment of psychosocial risks and needs in EDs is vital to informing decisions for aftercare that support recovery in the community for Aboriginal patients and patients discharged from EDs.

Trafficked people require timely and ongoing access to health services. Yet, many encounter difficulties accessing and utilising healthcare services both while in situations of exploitation and after their escape. This research investigated barriers that hinder healthcare providers from identifying, providing care and making necessary referrals for trafficked people in the United Kingdom. Semi-structured, face-to-face interviews were conducted with healthcare (n=23) and non-health (n=27) professionals with relevant policy or practical experience related to human trafficking in the UK. Topic guides covered identifying, referring, and providing care to trafficked people. Transcripts were analysed using thematic analysis. Four interconnected themes emerged: trafficked persons' entitlements to healthcare, availability of healthcare resources, providers' knowledge about trafficking, and the particular needs of trafficked individuals. Providers explained that policies limiting entitlements to healthcare created significant obstacles to care, as did the inadequate resourcing of interpreter services, trafficking support services, and specialist mental health services. Few healthcare professionals reported having received training on responses to trafficked people and most were unaware of support options and referral routes. Healthcare professionals will be better equipped to serve trafficked individuals if they are provided training to identify and respond to human trafficking, guidance on referral and support options and entitlements to care. Simultaneously, improving trafficked people's healthcare access and use will also require government interventions to ensure they are not unjustifiably denied health care.

Purpose Military populations may experience more severe forms of domestic violence than the general population. Although mental disorders are associated with domestic violence perpetration among the general population, it is not clear whether this is the case for military populations. This review aimed to establish the prevalence and odds of domestic violence perpetration among male and female military personnel with mental disorders. Methods Systematic review: searches of eleven electronic databases were supplemented by hand searches, reference screening, citation tracking and expert recommendations. Results Ten studies were included; nine reporting on partner violence and one on violence against an adult family member. Median prevalence estimates were calculated for partner violence perpetration among male military personnel with post-traumatic stress disorder (PTSD); estimates on other disorders were not possible due to lack of data. 27.5 % of men with PTSD reported past year physical violence perpetration against a partner and 91.0 % reported past year psychological violence perpetration against a partner. Due to limited data, no median estimates could be calculated for female military personnel. Data from individual papers indicate increased odds of past year partner violence perpetration among male and female military personnel with depression; inconsistent findings were reported for risk of partner violence perpetration among male and female military personnel with PTSD. Conclusions There is some evidence that mental disorders among military personnel are associated with past year domestic violence perpetration, though current data cannot confirm direction of causality. Research is needed to inform the development of interventions targeted to reduce domestic violence perpetration among military personnel.

PURPOSE: Military populations may experience more severe forms of domestic violence than the general population. Although mental disorders are associated with domestic violence perpetration among the general population, it is not clear whether this is the case for military populations. This review aimed to establish the prevalence and odds of domestic violence perpetration among male and female military personnel with mental disorders. METHODS: Systematic review: searches of eleven electronic databases were supplemented by hand searches, reference screening, citation tracking and expert recommendations. RESULTS: Ten studies were included; nine reporting on partner violence and one on violence against an adult family member. Median prevalence estimates were calculated for partner violence perpetration among male military personnel with post-traumatic stress disorder (PTSD); estimates on other disorders were not possible due to lack of data. 27.5 % of men with PTSD reported past year physical violence perpetration against a partner and 91.0 % reported past year psychological violence perpetration against a partner. Due to limited data, no median estimates could be calculated for female military personnel. Data from individual papers indicate increased odds of past year partner violence perpetration among male and female military personnel with depression; inconsistent findings were reported for risk of partner violence perpetration among male and female military personnel with PTSD. CONCLUSIONS: There is some evidence that mental disorders among military personnel are associated with past year domestic violence perpetration, though current data cannot confirm direction of causality. Research is needed to inform the development of interventions targeted to reduce domestic violence perpetration among military personnel.

Background Little is known about the long-term psychosocial outcomes associated with self-harm during adolescence. We aimed to determine whether adolescents who self-harm are at increased risk of adverse psychosocial outcomes in the fourth decade of life, using data from the Victorian Adolescent Health Cohort Study. Methods We recruited a stratified, random sample of 1943 adolescents from 44 schools across the state of Victoria, Australia. The study started on Aug 20, 1992, and finished on March 4, 2014. We obtained data relating to self-harm from questionnaires and telephone interviews at eight waves of follow-up, commencing at mean age 15·9 years (SD 0·5; waves 3–6 during adolescence, 6 months apart) and ending at mean age 35·1 years (SD 0·6; wave 10). The outcome measures at age 35 years were social disadvantage (divorced or separated, not in a relationship, not earning money, receipt of government welfare, and experiencing financial hardship), common mental disorders such as depression and anxiety, and substance use. We assessed the associations between self-harm during adolescence and the outcome measures at 35 years (wave 10) using logistic regression models, with progressive adjustment: (1) adjustment for sex and age; (2) further adjustment for background social factors; (3) additional adjustment for common mental disorder in adolescence; and (4) final additional adjustment for adolescent antisocial behaviour and substance use measures. Findings From the total cohort of 1943 participants, 1802 participants were assessed for self-harm during adolescence (between waves 3 and 6). Of these, 1671 were included in the analysis sample. 135 (8%) reported having self-harmed at least once during adolescence. At 35 years (wave 10), mental health problems, daily tobacco smoking, illicit drug use, and dependence were all more common in participants who had reported self-harm during the adolescent phase of the study (n=135) than in those who had not (n=1536): for social disadvantage odds ratios [ORs] ranged from 1·34 (95% CI 1·25–1·43) for unemployment to 1·88 (1·78–1·98) for financial hardship; for mental health they ranged from 1·61 (1·51–1·72) for depression to 1·92 (1·79–2·04) for anxiety; for illicit drug use they ranged from 1·36 (1·25–1·49) for any amphetamine use to 3·39 (3·12–3·67) for weekly cannabis use; for dependence syndrome they were 1·72 (1·57–1·87) for nicotine dependence, 2·67 (2·38–2·99) for cannabis dependence, and 1·74 (1·62–1·86) for any dependence; and the OR for daily smoking was 2·00 (1·89–2·12). Adjustment for socio-demographic factors made little difference to these associations but a further adjustment for adolescent common mental disorders substantially attenuated most associations, with the exception of daily tobacco smoking (adjusted OR 1·74, 95% CI 1·08–2·81), any illicit drug use (1·72, 1·07–2·79) and weekly cannabis use (3·18, 1·58–6·42). Further adjustment for adolescent risky substance use and antisocial behaviour attenuated the remaining associations, with the exception of weekly cannabis use at age 35 years, which remained independently associated with self-harm during adolescence (2·27, 1·09–4·69). Interpretation Adolescents who self-harm are more likely to experience a wide range of psychosocial problems later in life. With the notable exception of heavy cannabis use, these problems appear to be largely accounted for by concurrent adolescent mental health disorders and substance use. Complex interventions addressing the domains of mental state, behaviour, and substance use are likely to be most successful in helping this susceptible group adjust to adult life.