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Drawing on the fields of human rights and public health, this research explores the covert administration of medication: the concealment of medication in food or drink so that it will be consumed undetected. Adopting a rights-based approach, it explores multiple understandings of the impact of the practice on inpatients' rights-experiences. Relying on critical approaches, it also explores the practice's underlying socio-political-legal structures. The common themes of policies, protocols or guidelines that govern its practice in Ontario are identified. Focus groups and individual interviews were held with three groups of stakeholders (nurses, legal experts and psychiatrists), relying on fictional clinical scenarios. Few policies, protocols or guidelines govern the practice in Ontario's psychiatric settings. The practice impairs access to knowledge by patients and substitute decision-makers. It also precludes healthcare practitioners' access to information about side effects and underlying reasons for medication refusal. It may interfere with therapeutic relationships and patients' meaningful recovery as they transfer from hospital without knowledge of the fact of the covert medication. It may be characterized as autonomy restoring since patients may become capable of making treatment decisions after having received the medication surreptitiously. Covert medication reflects an inflexible approach to capacity determination; it is distinguishable from approaches that imagine capacity as able to be fostered with support. It is primarily concerned with the management of "risky" inpatients in the short-term. The practice relies on a faith that medication will be effective, deferring to medical decision-making. While covert medication is understood to have "something to do" with rights, there is confusion about how those rights play out on the ground. Institutional silences underlie and reinforce the practice. This research will support the development of effective, safe and appropriate approaches to treatment non-adherence that maximize patient dignity. Most pressing, this research concludes that the covert administration of medication warrants an overt discussion.

This article examines the judicial treatment of complaints of discrimination from workers with mental health issues. Equality protections promise full inclusion in social, work and community life. The principle of inclusion is understood in three inter-related parts: inclusion in the workforce, inclusion in decision-making and, in the most broad and prospective sense, inclusion in Canadian society. The current framework of equality protections has not effectively addressed these core values of inclusion for workers with mental health issues. The workplace continues to be a site of discrimination and harassment. Barriers prevent workers with mental health issues from getting or keeping employment, discourage their participation in decision-making, and entrench the devaluation, isolation and exclusion of persons with mental health issues. Accommodative measures must be alive to the concrete and attitudinal barriers experienced by workers with mental health issues.

This article examines the judicial treatment of complaints of discrimination from workers with mental health issues. Equality protections promise full inclusion in social, work and community life. The principle of inclusion is understood in three inter-related parts: inclusion in the workforce, inclusion in decision-making and, in the most broad and prospective sense, inclusion in Canadian society. The current framework of equality protections has not effectively addressed these core values of inclusion for workers with mental health issues. The workplace continues to be a site of discrimination and harassment. Barriers prevent workers with mental health issues from getting or keeping employment, discourage their participation in decision-making, and entrench the devaluation, isolation and exclusion of persons with mental health issues. Accommodative measures must be alive.

Since the first publication of Medicine and Law thirty years ago, there have been significant international advances in patient rights and participant protections in clinical trials. Despite such advances, there are still alarming reports of actual or perceived breaches in ethical standards by Institutions, Investigators and Sponsors of pre-market drug clinical trials. This is particularly disturbing as these trials involve participants in the testing of an investigational drug before its full safety, effectiveness, and clinical outcomes are understood. Moreover, the study design may randomize participants (recruited because they have specific diseases or conditions) into a group receiving a placebo or comparator drug versus a group receiving the investigational drug. The proposed Charter of Participant Rights in Pre-Market Drug Trials reflects the growing trend towards a participant-centred approach to the implementation and enforcement of participant rights. The development and adoption of the Charter is the next natural step towards the guarantee of rights in pre-market clinical drug trials.

The following study evaluates the complex association between legal involvement and mental illness. It describes a population of consumers of community mental health programs, comparing those with legal involvement to those without legal involvement, on a number of demographic, clinical and social indicators. It is a secondary analysis of data collected in studies making up the Community Mental Health Evaluation Initiative (CMHEI) in the province of Ontario, Canada. Legal involvement was a significant issue among community mental health program consumers; about one in five consumers had at least some contact with the legal system in the preceding nine months. Legally involved consumers were more likely to be in receipt of social assistance and be unstably housed than those legally uninvolved. However, there were no significant differences between legally involved and uninvolved consumers with respect to severity of symptomatology, current medication use or number of hospitalization days in the past 9 months. A predictive model compared the differential impact of clinical and social determinants upon legal involvement. Analyses failed to uncover a significant relationship between severity of psychiatric symptomatology and legal involvement. Significant predictors of legal involvement included gender, race, drug use as well as housing instability, and receipt of social assistance. Legal involvement was attributable to factors other than the severity of mental illness; these results challenge assumptions that the most symptomatically severe consumers are most at risk of legal involvement. Accordingly, the rate of legal involvement in a sample of community mental health program users must be considered in a broad context, with particular emphasis on social disadvantage.

A multisite evaluation of community mental health services is used to answer two questions: (a) How do diagnosis, functioning, and self–assessments of consumer/survivor initiative (CSI) and assertive community treatment (ACT) participants compare?, and (b) What other supports/services are CSI and ACT participants using? The sample is from an Ontario evaluation of consumer/survivor peer initiatives in four communities (n = 73). The reference group is new (n = 48) and ongoing (n = 134) clients of four ACT teams. Self–help organizations are serving a broader population of individuals who include a significant subgroup of persons with severe mental illness along with others with a mixed picture of higher functioning and greater instability. There is little overlap in the use of these modes of service delivery, which suggests that maintaining options within systems of care is critical to ensuring coverage and access for the broader population.

Background: Separate lines of research have demonstrated strong associations linking alcohol misuse with major depression on the one hand, and anxiety disorders on the other. In the current study we examined the possible confounding and/or additive effects of co-morbid depression/anxiety in understanding these relationships. Methods: A total of 7195 individuals in Ontario, aged 15–64, were interviewed using the CIDI. Based on lifetime diagnoses, we compared rates of alcohol abuse/dependence in four groups consisting of normal controls, individuals with unipolar major depression but no anxiety disorders, individuals with one or more anxiety disorders without depression, and individuals with co-morbid major depression and anxiety. Age of onset of alcoholism in the four study groups was also compared. Results: In both genders, there were significantly higher rates of alcoholism in all three psychiatric groups relative to controls. In females only, there was also a significantly higher rate of alcoholism in the depressed/anxious group than in the pure anxious group. The age of onset of alcoholism was the same across all four study groups. Limitations: Due to limitations related to sample size, we combined subjects with various anxiety disorders into a single anxiety group and concurrent and sequential co-morbidity were not distinguished. Conclusions: Both gender effects and depression/anxiety co-morbidity may be important considerations in the design and interpretation of studies on alcohol misuse. This may be particularly relevant when considering the strength of the association between alcoholism and anxiety disorders in women. Depression and anxiety do not appear to influence the age of onset of alcoholism. Furthermore, no single temporal pattern of onset was identified in individuals with all three disorders, suggesting no obvious cause-effect relationship among them.

Data available from a recent planning project provided an opportunity to examine impairment and service needs of individuals with schizophrenia spectrum diagnoses living in a large board-and-care program. When first implemented, this minimum-support custodial program was assumed to be adequate for discharged long-term inpatients with schizophrenia and other chronic mental illnesses. However, the needs assessments indicated considerable heterogeneity in resident level of impairment. When a validated planning template was applied to assign residents to an appropriate level of care, almost one-quarter were assigned to independent living with minimal support, one-third to community living with intensive support, and 40 percent to residential or inpatient treatment. The authors conclude that this program is not able to meet the varying needs of residents. Despite a common diagnosis, many can function in more independent settings, while others need more treatment and rehabilitation than they are currently provided.

It has been well established that early adversity is a major risk factor for depression and for anxiety disorders in various populations and age groups. Few studies have considered the relative strength of these associations and the possible role of co-morbid depression/anxiety in understanding them. Using data from a large community sample of Ontario, Canada, we examined the relative strength of the associations between early physical abuse, sexual abuse, and/or parental strain with depression alone, anxiety alone, and co-morbid depression/anxiety. The current sample consisted of 6,597 individuals 15–64 years of age who were interviewed using the World Health Organization Composite International Diagnostic Interview (CIDI). Using a multivariate design, we compared early adversity scores across four diagnostic study groups including normal controls, individuals with major depression but no anxiety disorders, individuals with one or more anxiety disorders without major depression, and individuals with co-morbid major depression and anxiety. Individuals with past disorders were considered separately from those with current disorders. For both past and current disorders, highly significant differences in early adversity scores were found across the four study groups. A novel and robust finding, consistent across all analyses, was a marked association between early sexual abuse and co-morbid depression and anxiety but not the “pure” disorders. A strong association between early parental strain and major depression (independent of anxiety) was also found. The overall pattern of results suggest that there may be unique relationships linking particular adversities to particular manifestations of depression and anxiety disorders later in life. A particularly strong association between early sexual abuse and co-morbid depression/anxiety was found. Depression and Anxiety 17:34–42, 2003. © 2003 Wiley-Liss, Inc.

OBJECTIVE: Mental health care reform has brought an increasing emphasis on community care, with concomitant reductions in inpatient psychiatric resources. Hospitalization remains a necessary and integral component of the mental health care system, but it is taking on a more specialized role. Examining the circumstances in which hospitalization is indicated can help clarify emergency psychiatric practices and determine whether patients' needs are being met within this changing environment. This pilot study examined the impact of selected patient and contextual characteristics on the decision to admit patients to inpatient psychiatric units and assessed the utility of the Severity of Psychiatric Illness (SPI) scale for monitoring clinical practice in emergency psychiatric services. METHODS: Crisis workers in two emergency psychiatric services crisis teams in Toronto, Canada, used the SPI in the assessment of 205 visitors to the services during the winter of 1998-1999. Contextual characteristics, including bed availability, service site, and the admitting physician's level of training, were recorded. Multivariate logistic regression was used to assess the relative contribution of patient and contextual variables in the admission decision. RESULTS: The severity of axis I symptoms and difficulties with self-care were significantly associated with the decision to admit. Site, bed availability, and the admitting physician's level of training did not appear to be associated with clinical decisions. CONCLUSIONS: Patients with the most need are being admitted to inpatient units despite significant systemic pressures on inpatient services. The SPI is a useful and discriminating tool for evaluating clinical practice in emergency services.

The Pathways Into Homelessness project in Toronto interviewed 300 unaccompanied adult users of homeless shelters to identify characteristics of individuals who are homeless for the first time. The sample reflected the total population of homeless shelter users in terms of age, sex, level of use, and type of shelter. Two fifths of the sample were homeless for the first time. There were more similarities than differences between those who were homeless for the first time and those who had been homeless previously. The prevalence of psychiatric and substance use disorders and the rate of previous hospitalization did not differ between first-time homeless persons and those who had been homeless before. The two groups were distinguished by some childhood experiences related to housing. Both groups had multiple indicators of serious problems, suggesting that the need for intervention is as pressing for persons who are homeless for the first time as it is for the larger population of homeless persons.

The specificity of the association between 9 Axis I psychiatric disorders and quality of the relationship with spouse, relatives, and friends was evaluated for married participants who completed the Ontario Health Survey Mental Health Supplement (N = 4,933). When the authors controlled for the quality of other social relationships, not getting along with one's spouse was related to 6 disorders, with the strongest associations found for generalized anxiety disorder, major depression, panic, and alcohol problems; 4 associations remained significant when they controlled for comorbid disorders. Not getting along with relatives and friends was generally unrelated to psychiatric disorders when they controlled for the other social relationships. Results indicate that the association between marital quality and psychiatric disorders is not an artifact of general social dissatisfaction and that this association is significant for several disorders. (PsycInfo Database Record (c) 2022 APA, all rights reserved)