Peer support work for people experiencing mental distress attending the emergency department: Exploring the potential

'Everything would have gone a lot better if someone had listened to me': A nationwide study of emergency department contact by people with a psychosocial disability and a National Disability Insurance Scheme plan

Australians with a psychosocial disability (PSD) and a National Disability Insurance Scheme (NDIS) plan may at times require emergency care due to the fluctuating nature of their physical and mental health conditions or when their supports have become insufficient. This nationwide study investigated the experiences of people presenting to an emergency department (ED) who have a PSD and an NDIS plan. The objective was to understand current care and communication practices and to provide recommendations for service integration. Twenty-four interviews were conducted with people who had a PSD and an NDIS plan. Participants were asked semi-structured questions about their experiences when engaging with NDIS processes and when engaging with the ED as an NDIS recipient and how communication practices could be improved between the two services. A qualitative, descriptive thematic analysis approach was used. A lived experience advisory group participated in the research and provided commentary. The findings of this study indicate that the NDIS, as a personalised budget scheme, presents challenges for people with complex PSD and physical needs. ED clinicians appear to be unclear about what the NDIS provides and communication between the two systems is fragmented and inconsistent. The themes identified from the analysed transcripts are: (a) People with PSD experience distress when dealing with the NDIS; (b) There's a blame game between the ED and the NDIS; and (c) Inadequate service integration between the ED and NDIS. Recommendations to assist with service integration include building service capacity, providing overlapping care and bridging the diverse biomedical, psychosocial and disability care services.

Barriers and facilitators to the implementation of rapid HIV testing in Canadian Emergency Departments: a mixed methods study

OBJECTIVES

1 in 7 Canadians with Human Immunodeficiency Virus (HIV) do not know their status. Patients at increased risk of HIV routinely access the emergency department (ED), yet few are tested, representing a missed opportunity for diagnosis and linkage-to-care. Rapid HIV testing provides reliable results within the same ED encounter but is not routinely implemented. The objective of this study was to identify barriers and facilitators to rapid HIV testing in Ontario EDs.

METHODS

We employed a mixed-methods, convergent, parallel design study including online surveys and semi-structured interviews of physicians, nurses, and allied health across four hospitals in Toronto and Thunder Bay, Ontario. Data were analyzed in equal priority using descriptive statistics for quantitative data and thematic analysis for qualitative data guided by the Theoretical Domains framework and Capability, Opportunity, Motivation Behaviour change model.

RESULTS

Among 187 survey respondents, 150 (80%) felt implementing rapid HIV testing would be helpful in the ED. Facilitators included availability of resources to link patients to care after testing (71%), testing early in patient encounters (41%), and having dedicated staff with lived experience support testing (34%). Motivation to offer testing included opportunities to support an underserved population (66%). Challenges to implementation included limited time during ED patient encounters (51%) and a lack of knowledge around HIV testing (42%) including stigma. Interview themes confirmed education, and integration of people with lived experience being essential to provide rapid HIV testing and linkage-to-care in the ED.

CONCLUSIONS

Implementation of rapid HIV testing in the ED is perceived to be important irrespective of practice location or profession. Intrinsic motivations to support underserved populations and providing linkage-to-care are novel insights to facilitate testing in the ED. Streamlined implementation, including clear testing guidelines and improved access to follow-up care, is felt to be necessary for implementation.

Our Wished-for Responses: Recommendations for Creating a Lived and Embodied Sense of Safety During Mental Health Crisis

BACKGROUND

Medical interventions have a place in crisis support; however, narrow biomedical and risk-driven responses negatively impact people seeking crisis care. With increasing shifts towards involving people with lived experience (service users) in designing services, foregrounding people's desired responses is critical. Accordingly, the aim of the study was to explore the wished-for crisis responses from the perspective of people who have experienced crisis and accessed crisis care.

METHOD

Using a hermeneutical phenomenological approach, in-depth interviews were conducted to determine the desired crisis responses of 31 people who self-reported experiencing mental health crises and accessed crisis services at ED, phone lines and/or crisis alternatives.

RESULTS

The findings identified wished-for responses that gave a felt and embodied sense of their own safety influenced by a human-to-human response, emotional holding, a place of safety and choice within holistic care. For such responses to be possible, participants identified organising principles, including recognising crisis as meaningful and part of our shared human experience, understanding risk as fluid and a whole-of-community responsibility for responding to crises.

CONCLUSION

This paper proposes how insights from people who have experienced crises can be translated into more beneficial crisis care.

PATIENT OR CONSUMER CONTRIBUTION

Most authors are in identified lived experience roles. The first author engaged with participants during the recruitment and interviews and was explicit regarding their lived experience. Service users were involved as advisors, providing input throughout the study.

Evaluation of lived experience Peer Support intervention for mental health service consumers in Primary Care (PS-PC): study protocol for a stepped-wedge cluster randomised controlled trial

BACKGROUND

The demand for mental health services in Australia is substantial and has grown beyond the capacity of the current workforce. As a result, it is currently difficult for many to access secondary healthcare providers. Within the secondary healthcare sector, however, peer workers who have lived experience of managing mental health conditions have been increasingly employed to intentionally use their journey of recovery in supporting others living with mental health conditions and their communities. Currently, the presence of peer workers in primary care has been limited, despite the potential benefits of providing supports in conjunction with GPs and secondary healthcare providers.

METHODS

This stepped-wedge cluster randomised controlled trial (RCT) aims to evaluate a lived experience peer support intervention for accessing mental health care in primary care (PS-PC). Four medical practices across Australia will be randomly allocated to switch from control to intervention, until all practices are delivering the PS-PC intervention. The study will enrol 66 patients at each practice (total sample size of 264). Over a period of 3-4 months, 12 h of practical and emotional support provided by lived experience peer workers will be available to participants. Scale-based questionnaires will inform intervention efficacy in terms of mental health outcomes (e.g., self-efficacy) and other health outcomes (e.g., healthcare-related costs) over four time points. Other perspectives will be explored through scales completed by approximately 150 family members or carers (carer burden) and 16 peer workers (self-efficacy) pre- and post-intervention, and 20 medical practice staff members (attitudes toward peer workers) at the end of each study site's involvement in the intervention. Interviews (n = 60) and six focus groups held toward the end of each study site's involvement will further explore the views of participants, family members or carers, peer workers, and practice staff to better understand the efficacy and acceptability of the intervention.

DISCUSSION

This mixed-methods, multi-centre, stepped-wedge controlled study will be the first to evaluate the implementation of peer workers in the primary care mental health care sector.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12623001189617. Registered on 17 November 2023, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=386715.

Effectiveness of emergency department based interventions for frequent users with mental health issues: A systematic review

Frequent emergency department (ED) users with mental health issues are particularly vulnerable patients, who often receive insufficient or inadequate outpatient care. This systematic review identified and evaluated studies on ED-based interventions to reduce acute care use by this population, while improving outpatient service use and patient outcomes. Searches were conducted in five databases for studies published between January 1, 2000, and April 30, 2022. Eligibility criteria included: patients with mental health issues who made 2+ ED visits in the previous 6 months or were high ED users (3+ visits/year), and who received ED-based interventions to reduce ED use. The review included 12 studies of 11,082 articles screened. Four intervention groups were identified: care plan (n = 4), case management (n = 4), peer-support (n = 2) and brief interventions (n = 2). The definitions of frequent users varied considerably, while the quality assessment rated studies from moderate to good and risk of bias from low to high. Eight studies used pre-post design, and four were randomized controlled trials. Ten studies assessed outcomes related to use of other services than ED, mainly hospitalizations, while five assessed patients' clinical conditions and three, social conditions (e.g., housing status). This review revealed that case management and care plan interventions, based in ED, decrease ED use among frequent users, while case management also showed promising results for outpatient service use and clinical and social outcomes. Thus, the results support continued deployment of intensive ED-based interventions for frequent ED users with mental health issues although firm conclusions regarding the effectiveness of these interventions, particularly outcomes related to services other than ED, require further investigation.

Constructing recovery: A Lived Experience and post-structuralist exploration of how the meaning of personal recovery and rehabilitation has changed over time

OBJECTIVE

This article explores how the concept of 'recovery' has been much debated and often sits at odds with our notion of rehabilitation.

METHOD

This article provides a Lived Experience and post-structural commentary on the ever-changing meaning of recovery and rehabilitation.

RESULTS

Building on the contemporary Consumer Movement's use of the term recovery, this article explores how constructions of recovery try to create a boundary which stops people being invalidated based on their experience, or perceived experience, of mental distress. The concept of recovery has insufficiently influenced rehabilitation practices. Recovery is also frequently reappropriated, often with no or minimal consumer input, and reconstructed in line with notions of progress and improvement.

CONCLUSION

People with Lived Experience have challenged the concept of rehabilitation; however, rehabilitation may still have relevance if it is redefined according to Lived Experience values and recovery-oriented practice.

Research Directions for Leveraging and Supporting the Lived Experience of Mental Illness within Psychology

This paper explores the lived experience of mental illness within the field of psychology across higher education and the mental health workforce. There is a high prevalence of mental health issues among psychology students and practitioners, and it is critical not only to provide support for these populations, but also to acknowledge the value of leveraging their lived experience within their education and practice. There has been increased interest in and advocacy for the involvement of those with lived experience of mental illness within mental healthcare service provision to improve patient experiences and outcomes. However, there have been limited acknowledgement and research regarding the role of psychologists with personal lived experiences of mental illness, and how to leverage this experience. Further, there are challenges faced by both psychology students and practising psychologists with lived experience that act as barriers to leveraging their unique skills and experiences. Psychology students with lived experience face stigma, inadequate support, and incongruence between the course material and their personal experiences. Similarly, practising psychologists with lived experience encounter stigma and isolation, indicating the need for a culture change that promotes transparency and understanding. The paper calls for research in five key directions to provide evidence that can be used to support and leverage lived experience in psychology.

Coercive measures in psychiatry - When do they occur and who is at risk?

Coercive measures (CM) in psychiatry adversely affect patients and efforts to minimize CM are steadily increasing. One area that has not been a strong focus of preventative efforts to date is the time of use of CM during hospitalization although previous research indicates that the admission situation and early hospitalization are times of increased risk for CM. This study therefore aims to contribute to the body of research in this field by analyzing in detail the times of use of CM and identifying patient characteristics serving as predictors for CM during early hospitalization. Using a large sample (N = 1556) of all cases admitted in 2019 via the emergency room at the Charité Department of Psychiatry at St. Hedwig Hospital in Berlin, this study supports previous research showing that the risk of CM is highest within the first 24 h h of hospitalization. Of 261 cases who experienced CM, 71.6% (n = 187) experienced a CM within the first 24 h of hospitalization and 54.4% (n = 142) of cases only experienced CM within the first 24 h of hospitalization and did not receive any CM after. Furthermore, this study identified significant predictors for the early use of CM during hospitalization including acute intoxication (p < .01), aggression (p < .01), male gender (p < .001) and limited communication ability (p < .001). The results highlight the importance of directing preventative efforts to minimize the use of CM not only to psychiatric units but also to mental health crisis response and to develop interventions specifically tailored to this time and patient groups at highest risk.

Peer Workers in Co-production and Co-creation in Mental Health and Substance Use Services: A Scoping Review

People with lived experience of mental health challenges are extensively employed as peer workers within mental health and substance use services worldwide. Research shows that peer workers benefit individuals using such services and can have essential roles in developing recovery-oriented services. However, understanding how peer workers' contributions, by their role, functions, and input can be better used remains a critical challenge. Research on public sector innovation has focused on relevant actors collaborating to tackle complex demands. Co-production and co-creation are concepts used to describe this collaboration. Co-production refers to the collaboration between providers and users at the point of service delivery, whereas co-creation refers to collaboration starting in the early service cycle phases (e.g., in commissioning or design), including solution implementation. We overviewed research literature describing peer workers' involvement in mental health and substance use services. The research question is as follows: How are peer workers involved in co-production and co-creation in mental health and substance use services, and what are the described outcomes? A literature search was performed in 10 different databases, and 13,178 articles were screened, of which 172 research articles describing peer workers' roles or activities were included. The findings show that peer workers are involved in co-production and function as providers of pre-determined services or, most often, as providers of peer support. However, they are rarely engaged as partners in co-creation. We conclude that the identified peer worker roles have different potential to generate input and affect service delivery and development.

Peer Intervention following Suicide-Related Emergency Department Presentation: Evaluation of the PAUSE Pilot Program

The risk for future suicidal behaviours is elevated following suicide attempts, particularly for those with complex needs or those who are disconnected from healthcare systems. The PAUSE program was designed to address this gap using peer workers to provide continuity and coordination of care following suicide-related emergency presentations. This study aimed to evaluate the pilot program's effect on suicidal ideation and hope, and to explore the acceptability and participants' experiences. A mixed-methods design was employed with pre- and post-evaluation questionnaires, including the GHQ-28-SS (general health questionnaire suicide scale), AHS (adult hope scale), and K10 (Kessler psychological distress scale). Participant engagement rates and semi-structured interviews were used to explore program acceptability. In total, 142 people were engaged with the PAUSE pilot between 24 August 2017 and 11 January 2020. There were no significant gender differences in engagement. The suicidal ideation scores decreased, and the hope scores increased after participation in PAUSE. A thematic analysis revealed that participants identified that the key program mechanisms were holistic and responsive support, ongoing social connectedness, and having peer workers who understood their experiences and treated them like people rather than clients. The small number of participants and lack of a control group limited the result generalizability. The findings suggest that PAUSE was an effective and acceptable model for supporting people following suicide-related hospitalisations in this pilot sample.

Feasibility of Peer-Delivered Suicide Safety Planning in the Emergency Department: Results From a Pilot Trial

OBJECTIVE

The emergency department (ED) is an important site for suicide prevention efforts, and safety planning has been identified as a best practice for suicide prevention among ED patients at increased suicide risk. However, few ED clinicians are prepared to assess suicide risk or guide patients in the creation of safety plans. This study was a pilot randomized controlled trial of the feasibility, acceptability, and preliminary effects of safety planning by individuals with lived experience of suicide attempt or of severe suicidal ideation but without medical training (i.e., peers) in the ED.

METHODS

Patients at risk for suicide in a general ED were randomly assigned to receive peer-delivered or mental health provider–delivered safety planning. Intervention feasibility measures included ED length of stay, safety plan completeness, and safety plan quality. Acceptability measures included patient satisfaction. Preliminary effects were assessed as number of ED returns within the 3 months after the ED visit.

RESULTS

Data from 31 participants were available for analysis. Compared with participants with provider-delivered safety planning, participants with peer-delivered safety planning had similar ED lengths of stay, higher safety plan completeness, and higher safety plan quality. Acceptability of the safety planning process was similar for the two groups. Compared with participants receiving provider-delivered safety planning, participants receiving peer-delivered planning had significantly fewer ED visits during the subsequent 3 months than during the 3 months preceding the ED visit.

CONCLUSIONS

Peer-delivered safety planning is feasible and acceptable and may result in fewer return ED visits. These findings provide preliminary support for peer-delivered safety planning in the ED.

Exploring how to enhance care and pathways between the emergency department and integrated youth services for young people with mental health and substance use concerns

Background

Integrated youth services (IYS) provide multidisciplinary care (including mental, physical, and social) prioritizing the needs of young people and their families. Despite a significant rise in emergency department (ED) visits by young Canadians with mental health and substance use (MHSU) concerns over the last decade, there remains a profound disconnect between EDs and MHSU integrated youth services. The first objective of this study was to better understand the assessment, treatment, and referral of young people (ages 12–24 years) presenting to the ED with MHSU concerns. The second objective was to explore how to improve the transition from the ED to IYS for young people with MHSU concerns.

Methods

We conducted semi-structured one-on-one video and phone interviews with stakeholders in British Columbia, Canada in the summer of 2020. Snowball sampling was utilized, and participants (n = 26) were reached, including ED physicians (n = 6), social workers (n = 4), nurses (n = 2), an occupational therapist (n = 1); a counselor (n = 1); staff/leadership in IYS organizations (n = 4); mental health/family workers (n = 3); peer support workers (n = 2), and parents (n = 3). A thematic analysis (TA) was conducted using a deductive and inductive approach conceptually guided by the Social Ecological Model.

Results

We identified three overarching themes, and factors to consider at all levels of the Social Ecological Model. At the interpersonal level inadequate communication between ED staff and young people affected overall care and contributed to negative experiences. At the organizational level, we identified considerations for assessments and the ED and the hospital (wait times, staffing issues, and the physical space). At the community level, the environment of IYS and other community services were important including wait times and hours of operation. Policy level factors identified include inadequate communication between services (e.g., different charting systems and documentation).

Conclusions

This study provides insight into important long-term systemic issues and more immediate factors that need to be addressed to improve the delivery of care for young people with MHSU challenges. This research supports intervention development and implementation in the ED for young people with MHSU concerns.