The high burden of physical disease and delayed cancer diagnosis in those with psychotic disorders contributes to worse cancer survival in New Zealand psychiatric service users.

Four critical success factors were identified relating to disclosure, the employment relationship, freedom from discrimination and workplace flexibility.

The decision to disclose a mental illness is a dilemma throughout the employment process, not just a problem for the beginning of an employment relationship. Employees with experience of mental illnesses and their employers need to be able to access advice throughout this process on disclosure issues. Disclosure is irreversible; therefore, the decision to disclose, and its timing, must remain at the discretion of the employee.

ObjectiveTo determine whether contemporary sex-specific cardiovascular disease (CVD) risk prediction equations underestimate CVD risk in people with severe mental illness from the cohort in which the equations were derived.MethodsWe identified people with severe mental illness using information on prior specialist mental health treatment. This group were identified from the PREDICT study, a prospective cohort study of 495,388 primary care patients aged 30 to 74 years without prior CVD that was recently used to derive new CVD risk prediction equations. CVD risk was calculated in participants with and without severe mental illness using the new equations and the predicted CVD risk was compared with observed risk in the two participant groups using survival methods.Results28,734 people with a history of recent contact with specialist mental health services, including those without a diagnosis of a psychotic disorder, were identified in the PREDICT cohort. They had a higher observed rate of CVD events compared to those without such a history. The PREDICT equations underestimated the risk for this group, with a mean observed:predicted risk ratio of 1.29 in men and 1.64 in women. In contrast the PREDICT algorithm performed well for those without mental illness.ConclusionsClinicians using CVD risk assessment tools that do not include severe mental illness as a predictor could by underestimating CVD risk by about one-third in men and two-thirds in women in this patient group. All CVD risk prediction equations should be updated to include mental illness indicators.

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Aim To understand violence on acute mental health units according to staff and service user perspectives and experiences. Background The collateral damage of violence in acute inpatient mental health settings is wide-ranging, impacting on the health and wellbeing of staff and service users, and detrimental to public perceptions of people who are mentally unwell. Despite international research on the topic, few studies have examined psychiatric unit violence from both staff and service user perspectives. Methods We conducted in-depth interviews with 85 people (42 staff, 43 service users) in four adult acute mental health inpatient units in New Zealand. We undertook a thematic analysis of perspectives on the contributing factors and consequences of violence on the unit. Results Both staff and service users indicated violence was a frequent problem in acute inpatient units. Four themes regarding the causes of violence emerged: individual service user factors, the built environment, organisational factors, and the overall social milieu of the unit. Staff often highlighted complexities of the system as causal factors. These included the difficulties of managing diverse service user illnesses within an inadequate and unsafe built environment whilst having to contend with staffing issues and idiosyncrasies relating to rule enforcement. In contrast, service users talked of their needs for care and autonomy not being met in an atmosphere of paternalism, boredom due to restrictions and lack of meaningful activities, enforced medication, and physical confinement as precipitants to violence. Two broader themes also emerged, both relating to empathy. Both staff and service users exhibited ‘othering’ (characterised by a profound lack of empathy) in relation to acutely unwell individuals. Explanations for violent behaviour on the unit differed between groups, with service users being more likely to attribute unwanted behaviour to contextual factors and staff more likely to ‘blame’ mental illness. The consequences of violence included stress, physical injury, and a culture of fear and stigma. Conclusion Violence in acute inpatient mental health units in New Zealand is a significant, complex, and unresolved problem negatively impacting the therapeutic mission of these settings. Further in-depth qualitative investigations are urgently required into what is experienced as violence by service users, their view of how violence occurs, the role of fear and power relations, and the contributions of the built and organisational environment to all forms of violence to all unit users. A core function of the acute mental health unit is to offer a therapeutic environment for individuals at their most vulnerable. For this to happen, the unit must be a rewarding place to work, and a safe place to be.

Background People who smoke with serious mental illness carry disproportionate costs from smoking, including poor health and premature death from tobacco-related illnesses. Hospitals in New Zealand are ostensibly smoke-free; however, some mental health wards have resisted implementing this policy. Aim This study explored smoking in acute metal health wards using data emerging from a large sociological study on modern acute psychiatric units. Methods Eighty-five in-depth, semi-structured interviews were conducted with staff and service users from four units. Data were analysed using a social constructionist problem representation approach. Results Although high-level smoke-free policies were mandatory, most participants disregarded these policies and smoking occurred in internal courtyards. Staff reasoned that acute admissions were not the time to quit smoking, citing the sceptres of distress and possibly violence; further, they found smoking challenging to combat. Inconsistent enforcement of smoke-free policies was common and problematic. Many service users also rejected smoke-free policies; they considered smoking facilitated social connections, alleviated boredom, and helped them feel calm in a distressing environment – some started or increased smoking following admission. A minority viewed smoking as a problem; a fire hazard, or pollutant. No one mentioned its health risks. Conclusion Psychiatric wards remain overlooked corners where hospital smoke-free policies are inconsistently applied or ignored. Well-meaning staff hold strong but anachronistic views about smoking. To neglect smoking cessation support for people with serious mental illness is discriminatory and perpetuates health and socioeconomic inequities. However, blanket applications of generic policy are unlikely to succeed. Solutions may include myth-busting education for service users and staff, local champions, and strong managerial support and leadership, with additional resourcing during transition phases. Smoke-free policies need consistent application with non-judgemental NRT and, potentially, other treatments. Smoking cessation would be supported by better designed facilities with more options for alleviating boredom, expressing autonomy, facilitating social connections, and reducing distress.

Self-management of suicidality can encourage independence and resilience, a sense of citizenship, mutuality, and achievement.