Great expectations: a systematic review of the literature on the role of family carers in severe mental illness, and their relationships and engagement with professionals

Interventions that support unpaid carers of adult mental health inpatients: a scoping review

BACKGROUND

Unpaid carers of adult mental health inpatients often lack support for their well-being and feel excluded from decisions about patient care.

AIMS

This scoping review aimed to: synthesise the peer-reviewed literature evaluating the outcomes of brief interventions for unpaid carers of adult mental health inpatients, identify transferable lessons for evidenced-informed practice, and establish future research priorities.

METHODS

PRISMA scoping review guidelines were followed to search 12 databases using predefined search terms. Two reviewers independently screened papers and applied exclusion/inclusion criteria. Studies were included if they evaluated the impact or outcomes of interventions. Two reviewers extracted data and assessed study quality. Data were synthesised to categorise types of interventions and evidence for their outcomes.

RESULTS

16 papers met the inclusion criteria, and five types of interventions were identified: those that aimed to (1) increase carer involvement in inpatient care; (2) facilitate organisational change to increase carer support and involvement; (3) provide carers with support; (4) deliver psychoeducation and offer support; and (5) reduce carer stress and improve coping skills.

CONCLUSIONS

Whilst evidence of intervention effectiveness was promising, the quality of studies was generally weak. More research is needed to develop an evidence-informed approach to supporting carers during inpatient stays.

Treatment Pressures and the Predicament of Family Care: A Grounded Theory Study With Relatives of People With a Serious Mental Health Condition

Relatives are increasingly recognized as important in the care of people with a serious mental health condition, such as major depressive disorder, bipolar disorder, or schizophrenia. Research indicates that in providing care, relatives use so-called treatment pressures, such as persuasion, interpersonal leverage, inducements, or threats, to promote the treatment compliance of their family member. This grounded theory study investigated why relatives use treatment pressures by analyzing the experiences of relatives of people with a serious mental health condition before, during, and after mental health crises of their family member. We conducted 11 semi-structured, problem-centered interviews with such relatives in Germany between October 2019 and January 2020. Our analysis showed that the key category of relatives' experiences is a predicament characterized by feeling responsible to take action while experiencing a limited range of action. Relatives' perceived responsibility to take action had three dimensions: relatives' worries about their family member and other members of the family, societal norms and expectations, and the transfer of responsibility from the mental healthcare system to relatives. The limitation of relatives' scope of action also had three dimensions: their family member's opposition to treatment, legal criteria for involuntary commitment or treatment, and their dependency on mental healthcare professionals and the mental healthcare system. We reconstructed three different ways in which relatives may deal with this predicament: assuming responsibility for their family member's treatment, which involved exerting treatment pressures, staying out of their family member's mental health-related matters, and focusing on their own well-being.

The experiences of living with a suicidal family member, and the impact on daily life: A systematic review and meta-aggregation

INTRODUCTION

Because of the pivotal role that family members play in caring for their suicidal relative, insight into their experiences is necessary to develop good support for them.

AIM

This systematic review aimed to aggregate qualitative research examining the experiences of family members living with their suicidal relative, and their impact on daily life.

METHODS

Systematic searches, covering the period 2000-2022, were conducted in Medline, Embase, PsycINFO, Ovid Nursing database and CINAHL. The JBI-QARI meta-aggregation approach and the PRISMA guidelines were followed.

RESULTS

Eleven studies met the inclusion criteria. Six themes were identified: The hard job of managing the risk of suicide; contributing to the relative's survival; struggling with professional care; being in a lonely position; pressure on relationships; and disruption of well-being.

DISCUSSION

The constant worry of losing their relative and ever-present vigilance dominates their lives in such a way that their well-being may be decreased. Professionals often overlook family members, which leads to feelings of powerlessness and loneliness.

IMPLICATIONS FOR PRACTICE

Collaborating with families in treatment, allowing them to share information and supporting them in the care at home may lead to better outcomes for both the family and their suicidal relative.

Family Involvement in Routine Services for Individuals With Severe Mental Illness: Scoping Review of Barriers and Strategies

OBJECTIVE

The authors investigated barriers to practices that promote family involvement in mental health services, focusing on individuals with severe mental illness, their families, and mental health providers. Additionally, the authors sought to identify strategies to facilitate family involvement in mental health provision to highlight the engagement process in routine practice and propose future directions for organizations to establish a family-friendly environment.

METHODS

Systematic searches for literature published from January 1990 to March 2023 were conducted in PsycInfo, PubMed, CINAHL, Sociological Abstracts, and Scopus databases. Gray literature searches and backward and forward snowballing strategies were also used.

RESULTS

Forty-six articles were reviewed, revealing contextual backgrounds and engagement practices that hindered family involvement. Inconsistencies in family involvement stemmed from organizational culture, societal attitudes, and providers' negating of family expertise. Uncertainty regarding confidentiality policies and the absence of practice guidelines posed challenges for providers. Negative experiences of families within the mental health system along with variable commitment also hampered involvement. Some service users declined family involvement because of privacy concerns and differing expectations regarding the extent of involvement. Promoting a shared culture of family work, integrating practice standards, and engaging in professional development activities emerged as key strategies.

CONCLUSIONS

A gap exists between implementing policies and practices for family involvement in mental health treatment. Without cultural and organizational shifts in support of working with families, the uptake of family involvement practices will remain inadequate. Each stakeholder has different perceptions of the barriers to family involvement, and family involvement will remain elusive without a shared agreement on its importance.

Strategies to promote treatment compliance: a grounded theory study with relatives of people with a serious mental health condition

BACKGROUND

Treatment pressures encompass communicative strategies that influence mental healthcare service users' decision-making to increase their compliance with recommended treatment. Persuasion, interpersonal leverage, inducements, and threats have been described as examples of treatment pressures. Research indicates that treatment pressures are exerted not only by mental healthcare professionals but also by relatives. While relatives play a crucial role in their family member's pathway to care, research on the use of treatment pressures by relatives is still scarce. Likewise, little is known about other strategies relatives may use to promote the treatment compliance of their family member with a serious mental health condition. In particular, no study to date has investigated this from the perspective of relatives of people with a serious mental health condition.

AIM

The aim of this study was to answer the following research questions: Which types of treatment pressures do relatives use? Which other strategies do relatives use to promote the treatment compliance of their family member with a serious mental health condition? How do treatment pressures relate to these other strategies?

METHODS

Eleven semi-structured interviews were conducted with relatives of people with a serious mental health condition in Germany. Participants were approached via relatives' self-help groups and flyers in a local psychiatric hospital. Inclusion criteria were having a family member with a psychiatric diagnosis and the family member having experienced formal coercion. The data were analyzed using grounded theory methodology.

RESULTS

Relatives use a variety of strategies to promote the treatment compliance of their family member with a serious mental health condition. These strategies can be categorized into three general approaches: influencing the decision-making of the family member; not leaving the family member with a choice; and changing the social or legal context of the decision-making process. Our results show that the strategies that relatives use to promote their family member's treatment compliance go beyond the treatment pressures thus far described in the literature.

CONCLUSION

This qualitative study supports and conceptually expands prior findings that treatment pressures are not only frequently used within mental healthcare services but also by relatives in the home setting. Mental healthcare professionals should acknowledge the difficulties faced and efforts undertaken by relatives in seeking treatment for their family member. At the same time, they should recognize that a service user's consent to treatment may be affected and limited by strategies to promote treatment compliance employed by relatives.

"Everyone means well but the one person who's really going to go to bat" - experiences and perspectives of substitute decision makers in caring for their loved ones with serious mental illness

In the era of on-going efforts to empower persons with mental illness to be independent decision makers as informed by the United Nations' Convention on the Rights of Persons with Disability (CRPD), family members acting as substitute decision makers (SDM) for people suffering from disabling serious mental illness (SMI) remain an integral part of the medical-legal system in psychiatric care in many parts of the world, including Canada; yet their experiences and perspectives are rarely studied. This explorative qualitative study examines the lived experiences and reflections of 14 family member SDMs in Toronto, Canada. Five key themes related to being SDM emerged: 1) Varied subjective understanding of the responsibility and authority of the SDM role; 2) Varied role demands and impact on SDMs' lives; 3) Challenges in dealing with the mental health system; 4) Leveraging decision making status to promote patient care; and 5) SDM role impact on family relationships. The need to improve SDM understanding of their role, acknowledging their value and care-taker burden, finding a balance for their involvement, and improving their support in efforts to enhance care for the patients are discussed.

Knowledge of mental health diagnosis among patients and their family members: an inpatient survey in China

BACKGROUND

Patient-oriented information disclosure has been advocated by the National Mental Health Law (NMHL) in China since 2012; however, reporting on diagnostic disclosure to patients with mental disorders after the NMHL is limited.

AMIS

This study aims to investigate and compare the knowledge of mental health diagnosis among patients and their family members in China.

METHODS

An inpatient survey was conducted among 205 patients with mental disorders and their family members. Group differences of the correctness of self-reported mental health diagnosis were compared, and logistic regression was performed to investigate correlates among both patients and their family members.

RESULTS

Overall, 76.7% patients and 80.6% of their family members reported a correct diagnosis. Only 46.2% patients with psychotic disorders correctly knew their diagnosis, significantly lower than their family members and patients with non-psychotic disorders. Multivariate regression analysis found that the diagnosis of psychotic disorders was a risk factor of patients' diagnostic knowledge (AOR = 0.137; 95% CI = 0.044-0.429), while family members' diagnostic knowledge was associated with their employment (AOR = 6.125, 95% CI = 1.942-19.323) and parent-child relationship with patients (AOR = 3.719; 95% CI = 1.057-13.086).

CONCLUSIONS

The majority of patients with non-psychotic disorders know their diagnosis correctly and informing family members of patients' diagnosis remains a common practice in psychiatric setting after the implementation of China's NMHL.

Caring for a Family Member with Psychosis or Bipolar Disorder Who Has Experienced Suicidal Behaviour: An Exploratory Qualitative Study of an Online Peer-Support Forum

BACKGROUND

The likelihood of suicidal behaviour is elevated amongst people with psychosis or bipolar disorder. This study aimed to understand how carers experience supporting family members with psychosis or bipolar disorder who have also experienced suicidal behaviour.

METHODS

A qualitative thematic analysis of online peer forum posts was carried out on the Relatives Education and Coping Toolkit (REACT) website, an online intervention for carers of people with psychosis and bipolar disorder. Analysis was based on 178 posts by 29 forum users. Posts were selected based on their relevance to suicidal behaviour.

RESULTS

Three themes were generated. "Suicide as the ultimate threat" highlights fears emerging from carers' difficulties with understanding and managing suicidal behaviour. "Bouncing from one crisis to another" reflects carers' experiences of recurring crises and the challenges of relying on emergency healthcare support. "It definitely needs to be easier to get help" emphasises carers' desires to be acknowledged by healthcare professionals and included in support offered to service users.

CONCLUSIONS

Digital platforms, including online forums, brief interventions such as safety planning, and interagency crisis models, hold the potential to meet carers' needs in this context. However, further research is required to investigate the effectiveness and implementation of these approaches.

Forced to move on: An interview study with survivors who have lost a relative to suicide

PURPOSE

To explore the loss of a relative due to suicide.

DESIGN AND METHODS

Ten survivors of relatives who had taken their lives were interviewed. Data was analyzed from a phenomenological perspective.

FINDINGS

The survivors described how they witnessed the darkness that took over their relative's lifeworld. During the time before and after the suicide, the survivor felt barred from having a role in the relative's care.

PRACTICE IMPLICATIONS

Understanding and exploring implicit dynamics, such as "a feeling of darkness taking over," "a sense of relief," or "putting on a mask" could be important for developing person-centered suicide care.

Patients' and family members' experiences of psychiatric inpatient services in China: a comparison based on a dyadic design

PURPOSE

Due to the family-oriented cultural and legal context in China, understanding the difference between patients' and family members' experiences of psychiatric services not only enriches perspectives of service quality assessment, but also promotes service utilization. This study aimed to compare experiences of psychiatric inpatient services between patients and their family members in China.

METHODS

The study included 126 dyads of patients and family members consecutively recruited from the psychiatric inpatient department in a large hospital in China. The responsiveness performance questionnaire was used to measure the experiences of psychiatric inpatient services after patient discharge. After adjusting reporting heterogeneity based on vignettes, dyad difference was examined by intraclass correlation coefficients (ICCs) and paired Wilcoxon signed-rank tests with Bonferroni correction in multigroup testing. Subgroup analyses were conducted within strata of four selected clinical and socio-demographic factors, to test their influence on difference pattern of experiences.

RESULTS

Poor consistency was found for all responsiveness items and the total scores among the 126 dyads and in most subgroup analyses (ICC < 0.6). Paired Wilcoxon signed-rank tests found that patients rated lower than their family members on the item of "asking user's opinions" in 126-dyad comparison (P < 0.05) and 3 subgroups related to severe mental disorders and income inequality after Bonferroni correction.

CONCLUSION

Results reveal inconsistent experiences of psychiatric inpatient services within families in China. Moreover, when making medical decisions, family members' opinions, rather than patients', are more frequently taken into consideration, especially on conditions where imbalanced decision-making power exists between patients and their family members. In the future, user experience improvement should pay equal attention to patients and family members, and the benefits of family involvement and patients' rights of shared decision-making should be carefully balanced.

Chinese adolescents' depression, anxiety, and family mutuality before and after COVID-19 lockdowns: Longitudinal cross-lagged relations

Objective

This study aimed to investigate the longitudinal cross-lagged association between family mutuality, depression, and anxiety among Chinese adolescents before and after the COVID-19 lockdown in 2020.

Background

Limited attention has been paid to the longitudinal links between family mutuality, depression, and anxiety in the context of the COVID-19 pandemic.

Method

We used self-administered questionnaires to collect data from three high schools and two middle schools in Chengdu City at two time points: Time 1 (T1), December 23, 2019-January 13, 2020; Time 2 (T2), June 16-July 8, 2020. The sample consisted of 7,958 participants who completed two wave surveys before and after the COVID-19 lockdown. We analyzed the data using cross-lagged structural equation modeling.

Results

The longitudinal cross-lagged model showed family mutuality at T1 significantly predicted depression, anxiety, and family mutuality at T2. We observed a decreasing prevalence of depression and anxiety after the COVID-19 lockdown.

Conclusion

Family mutuality plays an important role in mitigating long-term mental health disorders, such as depression and anxiety. More family-centered psychological interventions could be developed to alleviate mental health disorders during lockdowns.

Implications

Improving family mutuality (e.g., mutual support, interaction, and caring among family members) could be beneficial for reducing mental health disorders among Chinese adolescents during the COVID-19 pandemic.

Self-Report Measures Assessing Aspects of Personal Recovery in Relatives and Other Informal Carers of Those With Psychosis: A Systematic Review

Background

Providing long-term care for a family member with psychosis can cause significant distress for informal carers due to the trauma of seeing their loved one in crisis, dealing with the difficult symptoms of psychosis and the burden of providing care. An important aspect of carers' adjustment can be construed as their personal recovery in relation to having a relative affected by psychosis. Self-report measures are increasingly used to assess personal recovery in service users, but less is known about the utility of such tools for carers.

Aims

This review aimed to identify all self-report measures assessing aspects of carers' personal recovery, and to quality appraise them.

Methods

Academic Search Ultimate, CINAHL, MEDLINE, PsychINFO and PubMed were searched for articles that reported the development of self-report measures created for carers of those with psychosis. Studies were appraised using the Consensus-based Standards for the Selection of health status Measurement INstruments (COSMIN) checklist. A Levels of Evidence synthesis provided overall quality scores for each measure.

Results

The search identified 3,154 articles for initial screening. From a total of 322 full text articles, 95 self-report measures were identified with a final 10 measures included for the quality assessment showing varying levels of psychometric rigor.

Conclusions

The results show that no single self-report measure is currently available for use to comprehensively assess personal recovery for carers, highlighting the need for further research in this area and the development of a new measure.

Family Conundrums with Psychiatric Medication: An Inquiry into Experiences, Beliefs, and Desires

Research with families of people with serious mental illness consistently shows that the concerns and conundrums about their loved one's medication are among those most centrally voiced. The inquiry here relied on an anonymous cross-sectional survey of attitudes, beliefs, and experiences of family members (N = 339) specifically related to psychiatric medication use. A latent profile analysis yielded two categories of respondents: those "skeptical of the medical model," which represented 43% of the survey respondents, and those "supportive of the medical model," which represented 57% of the survey respondents. Data from open-ended questions suggests families crave inclusion and wish providers would more radically embrace both collaboration and balance in their approach to medication maintenance. The hope of this research is to help mental health providers be more responsive and compassionate in their work with families of people with serious mental illness, especially as it relates to psychiatric medication.

Family Caregiver and Provider Perspectives on Inclusive Care: Aligning Needs and Expectations

BACKGROUND

Home-based and community-based health care for individuals with complex medical conditions is often provided by family caregivers. Yet caregivers often are not meaningfully included in interactions with clinical health care teams. Inclusive care means inviting the caregiver to participate in shared decision-making and treatment planning. For aging or medically vulnerable adults, caregiver inclusion is an important facet of patient-centered care.

METHODS

We apply a mixed-methods approach using a survey (n=50) and semistructured interview data (n=13) from a national sample of caregivers of veterans and semistructured interview data from (n=24) providers from 3 Veterans Affairs regional networks. We elicited data from caregivers about their experiences with inclusive care and how providers communicate with them and assess their capacity. We juxtaposed these data with provider perspectives to see where there was alignment.

FINDINGS

We determined that caregivers play important roles in trust-building, communications management, implementation of care plans at home or in the community, and improving the care of care recipients-while maintaining a balance between competing tensions.

CONCLUSIONS

Our findings suggest that expanding inclusive care could improve care quality and health outcomes of individuals with complex health care needs. Further, our findings bolster recent policy efforts at the federal and state levels to increase recognition of caregivers as key members of the health care team.

Relatives' Experiences of Mental Health Care, Family Burden and Family Stigma: Does Participation in Patient-Appointed Resource Group Assertive Community Treatment (RACT) Make a Difference?

The aim of this exploratory cross-sectional study was to investigate the experiences of relatives of individuals with severe mental illness with and without participation in patient-appointed Resource Group Assertive Community Treatment (RACT). A total of 139 relatives (79 with and 60 without RACT) completed the Family Involvement and Alienation Questionnaire, the Burden Inventory for Relatives of Persons with Psychotic Disturbances, and the family version of the Inventory of Stigmatizing Experiences. We found that relatives participating in RACT experienced a more positive approach from the healthcare professionals, as well as a lower degree of alienation from the provision of care. Relatives who did not participate in RACT were more afraid that their ill next of kin would hurt someone. No other differences in family burden were found. Experiences of family stigmatization were similar in both groups. In conclusion, participating in patient-appointed RACT may contribute to a higher level of satisfaction for relatives in their encounter with healthcare professionals and a more positive alliance. Implementation of RACT in new settings would require adaptation to local conditions to facilitate cooperation between healthcare staff and other relevant services. Staff training focuses on the case manager function and needs assessment, as well as how to create an alliance with the patient and his/her relatives.

Deciding to discontinue prescribed psychotropic medication: A qualitative study of service users' experiences

Many mental health service users decide to discontinue their psychotropic medication at some stage in the treatment process; however, few studies have captured these experiences. This study aimed to explore people's experiences of coming off medication. A qualitative descriptive design and individual interviews with 23 people who experienced coming off medication were employed. COREQ checklist was used. Data were analysed using inductive and deductive approaches and six major themes were developed. Findings suggest that while medication was useful for many in the short-term, the adverse effects had significant impact and contributed to the decision to come off medication. Participants also reported being driven by a questioning of the biomedical model of treatment and the belief that there were other strategies to manage their distress. Mixed experiences of support from healthcare professionals for the medication cessation process were reported. The discontinuation process was often difficult resulting in changes in mood and behaviour which for many culminated in relapse of distress, rehospitalization and return to medication. To support the process of coming off and staying off medication, participants identified a range of useful strategies but particularly highlighted the importance of peer support. Findings from this study demonstrate the importance of mental health nurses having a collaborative discussion with service users which may support safer decision-making and lessen the risk of people discontinuing medication abruptly. Finding also indicates a need for robust studies that develop and test interventions to support people who wish to discontinue psychotropic medications.

Understanding the occupational identity of care-givers for people with mental health problems

Introduction

There is recognition within the literature that the role of care-giving can have a negative impact on care-givers’ general well-being. Less is understood about the role of care-giving on an individual’s occupational participation and in turn occupational identity. Occupational therapists have a unique understanding of the interplay between occupational participation and health, though this is an area that has been under researched in relation to mental health care-givers. Therefore, the current research aims to understand how the role of care-giving for an individual with a mental illness impacts on occupational participation and identity.

Method

A qualitative semi-structured interview the Occupational Performance and History Interview–Version 2 was utilised to understand life experiences. Six mental health care-givers were interviewed, and these interviews were transcribed for thematic analysis.

Findings

Three main themes were identified: being me, roles and responsibilities associated with care-giving and services.

Conclusion

The findings suggest being a mental health care-giver does have a detrimental impact on occupational participation and therefore occupational identity. As care-givers gained more experience in their role, they used occupational adaption as a positive coping mechanism that helped them achieve occupational balance. Using their unique understanding of occupational participation and occupational identity, occupational therapists are well placed to utilise their knowledge and skills to work in a systemic way supporting both the person with mental illness and their care-giver.

Quantifying the size of the informal care sector for Australian adults with mental illness: caring hours and replacement cost

PURPOSE

To quantify and value the total informal support provided by family and friends to Australian adults with mental illness in 2018.

METHODS

The number of mental health carers was drawn from the 2015 Survey of Disability, Ageing and Carers (SDAC), adjusted to the 2018 population. Annual caring hours by type of assistance were estimated using the SDAC, 2007 National Survey of Mental Health and Wellbeing and an online carer survey. Caring hours for each task were assigned an hourly replacement cost from the National Disability Insurance Scheme. Informal caring was valued as the sum of these costs minus expenditure on carer income support payments, estimating how much it would hypothetically cost governments to replace this care with formal support services.

RESULTS

An estimated 354,000 (95% uncertainty interval (UI): 327,000-383,000) Australian mental health carers provided 186 million (95% UI: 159-215) hours of support in 2018. The estimated replacement cost was AU$8.4 billion (95% UI: 7.0-10.0), excluding AU$1.3 billion in income support. Univariate sensitivity analyses demonstrated that results were robust to variation in model inputs, with total caring hours the most influential parameter. Using an alternative estimate of mean caring hours, the replacement cost could be as high as AU$13.2 billion (95% UI: 11.2-15.4).

CONCLUSION

Informal carers provide substantial support to people with mental illness, highlighting their important contribution to the mental health system and reinforcing the need for carer support services. Future valuation studies would benefit from refinement of available data collections, particularly on hours and types of care provided.

Perspectives of Veterans Affairs mental health providers on working with older adults with dementia and their caregivers

Continuing education directed at building providers' skills and knowledge in geriatrics represents a practical approach to addressing the geriatric mental health (MH) care workforce shortage. To inform the development of professional training curricula, we surveyed MH providers (N = 65) at a Veterans Affairs medical center on working with older persons with dementia (PwD) and informal caregivers. Providers rated service provision to PwD and caregivers as highly important but endorsed modest self-efficacy. Half of respondents were minimally confident in managing risk of harm to self or others in a PwD. Respondents believed PwD can benefit from MH treatments, yet identified several barriers to providing care, including inadequate time and staffing resources. Interest in geriatric training topics was high. Findings demonstrate that MH providers at this site value care provision to PwD and caregivers, and desire additional training to serve this population. System-level barriers to MH care for PwD should also be identified and addressed.

Experiences of involuntary psychiatric admission decision-making: a systematic review and meta-synthesis of the perspectives of service users, informal carers, and professionals

BACKGROUND

In involuntary psychiatric admission, used globally, professionals or caretakers decide upon hospitalization regardless of what the person with psychosocial disabilities decides. This raises clinical, ethical, legal, and human rights concerns, and it goes against Convention on the Rights of Persons with Disabilities (CRPD). CRPD mandates that member states respect the autonomy of people with disabilities. Through Article 12, it recognizes full enjoyment of legal capacity for persons with disabilities. Implementation of Article 12 is challenging in every country, and exploring all the stakeholders' experiences at admission decision-making will help us to understand the challenges that the current psychiatry system poses for service users to exercise their autonomy and identify the areas where service users need support to have their rights, will, and preferences respected.

AIM

To describe the experiences of service users, informal carers, and professionals in involuntary psychiatric admission decision-making and throughout the subsequent involuntary admission. We explored the support that the service users need to have their rights, will, and preferences respected.

METHOD

A search of twelve databases in medicine, sociology, and law in Danish, English, Japanese, Norwegian, Portuguese, Spanish, and Swedish was conducted in 2017 and 2018, limited to the past 10 years, using terms such as "involuntary," "admission," "mental illness," and "experience". The search identified 682 articles. Four researchers independently reviewed the articles to find those that completed original qualitative or mixed method studies exploring experiences of involuntary psychiatric admission among adults. We added seven publications from the articles' references, contacted experts in the field (no publications were added), and excluded two articles that were in German. Three researchers analyzed the articles' results using Thematic Analysis (PROSPERO registration number CRD42019072874).

RESULTS

Overall, 37 articles were included from 11 countries; they involved 731 service users, 100 informal carers, and 291 mental health professionals. We identified a lack of communication and a power imbalance among the stakeholders, which was exacerbated by the professionals' attitudes. At admission decision-making, the service users wanted to be heard and wanted to understand the situation. The families felt responsibility for the service users, they were careful not to ruin relationships, and they struggled to obtain support from the mental health system. Professionals believed that threats or harming others should lead to admission regardless of what the service users or their families felt. Professionals sometimes felt that it was not necessary to explain the information to the service users because they would not understand. Professionals were concerned and frustrated with difficulties in coordinating among themselves. During admission, service users struggled with the ward environment and relationship with staff; they most objected to coercion, such as forced medication. Families were frustrated that they were not involved in the treatment planning, especially as the service users moved toward discharge. The professionals often rationalized that coercion was necessary, and they believed that they knew what was best for the service users.

CONCLUSIONS

A lack of communication and a power imbalance among the stakeholders hindered respect for the service users' rights, will, and preferences. This was exacerbated by professionals rationalizing coercion and assuming that service users were incapable of understanding information. Services that encourage communication and overcome power imbalances (e.g. Crisis Plans, Family Group Conferencing) combined with stronger community mental health support will respect service users' rights, will, and preferences and avoid substituted decision-making on issues such as involuntary admission and forced medication.

Mastering the Art of Collaboration: Supporting Family Caregivers of Mental Health Patients by Service Providers in Iran

Responsive support systems, designed and promoted by policy makers, are critical in supporting family caregivers. The purpose of this study was to explore viewpoints of service providers in supporting family caregivers of mental health patients in Iran. In this qualitative study, a purposive sample of 29 service providers and policy makers consented to participate in semi-structured interviews. Data were analyzed through qualitative content analysis and three main categories and seven sub-categories were identified. The main categories were: interpersonal collaboration, intra-organization collaboration and inter-sectorial collaboration. A common theme in this study was that service providers play a key role in coordinating responsive support services for Iranian family caregivers of mental health patients across all levels. The increasing complexity of the health care system and resource limitations have created complex problems, which require the use of participatory approaches by the various specialties, disciplines and departments to provide complementary services and mutual support. This approach is the best way of ensuring that service users receive the most relevant services from the right service providers in the right place as and when needed.

Carers' experiences of involuntary admission under mental health legislation: systematic review and qualitative meta-synthesis

BACKGROUND

Carers are key providers of care and support to mental health patients and mental health policies consistently mandate carer involvement. Understanding carers' experiences of and views about assessment for involuntary admission and subsequent detention is crucial to efforts to improve policy and practice.

AIMS

We aimed to synthesise qualitative evidence of carers' experiences of the assessment and detention of their family and friends under mental health legislation.

METHOD

We searched five bibliographic databases, reference lists and citations. Studies were included if they collected data using qualitative methods and the patients were aged 18 or older; reported on carer experiences of assessment or detention under mental health legislation anywhere in the world; and were published in peer-reviewed journals. We used meta-synthesis.

RESULTS

The review included 23 papers. Themes were consistent across time and setting and related to the emotional impact of detention; the availability of support for carers; the extent to which carers felt involved in decision-making; relationships with patients and staff during detention; and the quality of care provided to patients. Carers often described conflicting feelings of relief coupled with distress and anxiety about how the patient might cope and respond. Carers also spoke about the need for timely and accessible information, supportive and trusting relationships with mental health professionals, and of involvement as partners in care.

CONCLUSIONS

Research is needed to explore whether and how health service and other interventions can improve the involvement and support of carers prior to, during and after the detention of family members and friends.

Mental health informed physical activity for first responders and their support partner: a protocol for a stepped-wedge evaluation of an online, codesigned intervention

BACKGROUND

First responders (police, fire and ambulance officers) are at a significantly increased risk of experiencing poor mental health, including depression and post-traumatic stress disorder. These conditions are associated with high rates of cardiovascular disease, in part due to low levels of physical activity (PA) and high levels of sedentary behaviour. Using a person's social support system may be an effective solution to help increase PA levels to improve mental and physical health outcomes. We will examine the efficacy of a group-based online intervention in increasing PA in first responders and their support partners, iteratively codesigned with advisors with lived experience of mental illness among first responders.

METHODS

This study will recruit a convenience sample of self-identified sedentary first responders and their self-selected support partners to a 10-week PA programme delivered through a private Facebook group. We will deliver education on predetermined topics related to PA and diet and provide participants with an activity tracker (Fitbit). A stepped-wedged design will be applied to compare multiple baselines to intervention and follow-up phases within subjects. Five cohorts of n=20 will be recruited, with each cohort randomised to a different baseline length. Our primary outcome will be psychological distress (Kessler-6). Secondary outcomes include feasibility, self-report and objective PA data (Simple Physical Activity Questionnaire and Fitbit accelerometry), depression and anxiety (Depression Anxiety and Stress Scale-21 items), post-traumatic stress disorder symptoms (PTSD Checklist for DSM-5), quality of life Assessment of Quality of Life-6 dimensions, sleep quality (The Pittsburgh Sleep Quality Index), suicidal ideation (Suicidal Ideation Attributes Scale) and social support for exercise. The mobile data collection platform MetricWire will be used.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of New South Wales, Deupty Vice-Chancellor Research, Human Research Ethics Committee on 3 June 2019, HC180561. Findings will be published in peer-reviewed journals and disseminated at national conferences.

TRIAL REGISTRATION NUMBER

ACTRN12619000877189.

Mental health presentations to the emergency department: A perspective on the involvement of social support networks

The involvement of families, carers and significant others (i.e. social support networks) has a positive corollary for a person experiencing mental health problems. Accordingly, in Australia involvement of social support networks within mental health services is endorsed in national health policy and service guidelines. Despite the endorsement, this is yet to be fully realised in all areas that provide mental health services, including emergency departments. Social support networks are integral in the provision of mental health consumers' care. Supporting the involvement of social support networks in the emergency department can provide healthcare services with opportunities for enhanced and cost-effective care, contributing to improved outcomes for consumers. An overview of some of the barriers and facilitators of social support network involvement is provided. The intention of this paper is to encourage reflection and dialogue on this important area of mental health service provision and support the evolution of a new paradigm of research into social support network involvement in the emergency department.

The treatment gap for mental disorders and associated factors in the Czech Republic

OBJECTIVES

To assess the extent of the treatment gap for mental disorders in the Czech Republic, determine factors associated with the utilization of mental health services and explore what influences willingness to seek mental health care.

METHODS

Data from the CZEch Mental health Study, a nationally representative study of community-dwelling adults in the Czech Republic were used. The Mini International Neuropsychiatric Interview assessed the presence of mental disorders. 659 participants with current affective, anxiety, alcohol use and substance use disorders were studied.

RESULTS

The treatment gap for mental disorders ranged from 61% for affective to 93% for alcohol use disorders. Mental health service use was associated with greater disability (OR 1.04; 95% CI 1.02-1.05; p < 0.001), female gender (OR 3.31; 95% CI 1.97-5.57; p < 0.001), urban residence (OR 1.84; 95% CI 1.12-3.04; p < 0.05) and a higher number of somatic diseases (OR 1.32; 95% CI 1.03-1.67; p < 0.05). Self-identification as having a mental illness was associated with greater willingness to seek a psychiatrist and a psychologist.

CONCLUSIONS

The treatment gap for mental disorders is alarmingly high in the Czech Republic. Interventions to decrease it should target in particular rural areas, men and people with low self-identification as having a mental illness.

Love and incomprehensibility: The hermeneutic labour of caring for and understanding a loved one with psychosis

Informal carers are increasingly involved in supporting people with severe and enduring mental health problems, and carers' perceptions impact the wellbeing of both parties. However, there is little research on how carers actually make sense of what their loved one is experiencing. Ten carers were interviewed about how they understood a loved one's psychosis. Data were analysed using a hermeneutic-phenomenological approach. Three themes described the carers' effortful quest to understand their loved one's experiences while maintaining their relational bonds. Carers described psychosis as incomprehensible, seeing their loved one as incompatible with the shared world. To overcome this, carers developed hermeneutic 'mooring points', making sense of their loved one's unusual experiences through novel accounts that drew on material or spiritual explanations. The findings suggest that informal carers resist biomedical narratives and develop idiosyncratic understandings of psychosis, in an attempt to maintain relational closeness. We suggest that this process is effortful - it is hermeneutic labour - done in the service of maintaining the caring relationship. Findings imply that services should better acknowledge the bond between carers and care-receivers, and that more relationally oriented approaches should be used to support carers of people experiencing severe mental health problems.

Family-focused recovery: Perspectives from individuals with a mental illness

Family members often provide significant support and care to their relative who has a mental illness. Nonetheless, how family members might be part of an individual's mental health recovery journey is rarely considered. The aim of this study was to investigate how those with a mental illness define 'family' and the role of family (if any) in their recovery journey. A qualitative approach was used. Purposive sampling and snowballing were used to recruit and conduct semi-structured interviews with 12 people who have been diagnosed with a severe mental illness. Participants defined family in various ways with some being very inclusive and others more selective. There was acknowledgement that family contributed to the individual's recovery in a myriad of ways, although the need for boundaries was stressed. While no participants suggested that their family might become active treatment facilitators, they did want clinicians to support them in talking to their family about their mental illness. A multifaceted approach is needed to promote family-focused recovery practice. The needs of different family members and the needs of the family as a group should be considered concurrently alongside the individual's needs in their recovery plan. Individual and relational components of recovery should be embedded in policy and clinical practice.

Caregivers experiences of nursing care for relatives hospitalized during manic episode: A phenomenological study

PURPOSE

To describe the experiences of informal caregivers with the nursing care received by relatives hospitalized for mania.

DESIGN AND METHODS

Multicenter phenomenological study using open interviews. Data were analyzed using the Stevick-Colaizzi-Keen method.

FINDINGS

The essence of the experiences was the importance of communication, about being informed and involved in treatment during hospitalization of their relative. The experiences depended on the nature of the relation between participant and relative.

PRACTICE IMPLICATIONS

Nurses should listen to caregivers' experiences, inquire about the expectations of caregivers regarding nursing care, and advise informal caregivers on how to take care of their relatives.

Parents and children suffering from mental distress: coping mechanisms, understanding and fear of the future

The aim of the study was to learn about the parents' coping experiences regarding the mental suffering of their children. This is an ethnographic study. Data was analyzed through content analysis. Three categories have been identified: 1. Coping with everyday situations 2. Understanding of mental suffering as a life situation; 3. Fear of the future, feeling of social and governmental helplessness. Mental suffering imposes situations that need to be quickly resolved on families and arrangements in an attempt to balance the family system; family members coexist with mental suffering in the perspective of a chronic illness, and seek coping mechanisms for day-to-day situations; lastly they fear the future of their sick relatives and feel helpless due to public policies. Research is needed in the area to assess the impact of this issue on the lives of families, institutions and public policies.

Considering axiological integrity: a methodological analysis of qualitative evidence syntheses, and its implications for health professions education

Qualitative evidence synthesis (QES) is a suite of methodologies that combine qualitative techniques with the synthesis of qualitative knowledge. They are particularly suited to medical education as these approaches pool findings from original qualitative studies, whilst paying attention to context and theoretical development. Although increasingly sophisticated use is being made of qualitative primary research methodologies in health professions education (HPE) the use of secondary qualitative reviews in HPE remains underdeveloped. This study examined QES methods applied to clinical humanism in healthcare as a way of advancing thinking around the use of QES in HPE in general. A systematic search strategy identified 49 reviews that fulfilled the inclusion criteria. Meta-study was used to develop an analytic summary of methodological characteristics, the role of theory, and the synthetic processes used in QES reviews. Fifteen reviews used a defined methodology, and 17 clearly explained the processes that led from data extraction to synthesis. Eight reviews adopted a specific theoretical perspective. Authors rarely described their reflexive relationship with their data. Epistemological positions tended to be implied rather than explicit. Twenty-five reviews included some form of quality appraisal, although it was often unclear how authors acted on its results. Reviewers under-reported qualitative approaches in their review methodologies, and tended to focus on elements such as systematicity and checklist quality appraisal that were more germane to quantitative evidence synthesis. A core concern was that the axiological (value) dimensions of the source materials were rarely considered let alone accommodated in the synthesis techniques used. QES can be used in HPE research but only with careful attention to maintaining axiological integrity.

'Between a rock and a hard place': family members' experiences of supporting a relative with bipolar disorder

PURPOSE

Clinical guidelines emphasise the central role of family members in supporting people with bipolar disorder. However, there has been little focus on the challenges family members face in supporting their relative. This qualitative study explored the challenges of providing support to a relative with bipolar disorder, and how family members attempted to meet these challenges. Factors that helped or hindered their efforts were also explored, including experiences of professional support.

METHODS

Semi-structured interviews were conducted with 18 family members (partners, parents, adult children, and siblings). Transcripts were analysed using the Framework approach.

RESULTS

Participants faced numerous challenges pertaining to the nature of the disorder and specific illness phases, their relative's responses to their attempts to help, and the limitations of support from healthcare professionals. Although participants were resourceful in managing these challenges, they strongly valued professional input. Six themes were identified: 'Not knowing: like being in a minefield', 'It's out of my control: sitting waiting for the next thing to happen', 'Treading on eggshells', 'Picking up on signs', 'Times of crisis: between a rock and a hard place', and 'I have to make my voice heard'.

CONCLUSIONS

Family members supporting a relative with bipolar disorder face significant challenges but show considerable resourcefulness in managing them. The findings underline the importance of input from healthcare professionals to help family members effectively support their relative and manage the challenges they face. Professional support should be strengths-based, and tailored to family members' needs.

Is India ready for mental health apps (MHApps)? A quantitative-qualitative exploration of caregivers' perspective on smartphone-based solutions for managing severe mental illnesses in low resource settings

Background

Mobile application based delivery of psycho-social interventions may help reduce the treatment gap for severe mental illnesses (SMIs) and decrease the burden on caregivers. Apps developed in high income settings show effectiveness, but they suffer from lack of applicability in low resource scenarios due to the difference in technology penetration, affordability, and acceptance.

Objective

This study aimed to understand health technology usage, perceived needs, and acceptability of app based interventions in patients with SMIs to improve illness management and reduce caregiver burden.

Methods

The study was conducted in inpatient and outpatient settings of a tertiary care center in North India. A cross-sectional survey assessed smartphone and health app usage. Further, three focus group discussions evaluated the needs and apprehensions in using apps in management of SMIs.

Results

A total of 176 participants including 88 patients and 88 caregivers completed the survey. Smartphone ownership was similar to the national average (30%) in both caregivers (38.6%) and in patients (31.8%). Although subjects regularly used a third party app, health app usage was very low. Cost, unfamiliarity, and language were significant barriers to adoption. The focus group discussions provided insight into the various apprehensions of caregivers in using and in allowing patients to use smartphones and such apps. Caregivers wanted mobile apps for accessing information regarding services and resources available for people with SMI, and they felt such apps can be helpful if they could automate some of their routine caregiving activities. However, the significant difficulty was perceived in regards to the cost of the device, language of the medium, and unfamiliarity in using technology. Apprehensions that SMI patients might misuse technology, or damage the device were also prevalent.

Conclusions

The study systematically looks into the scope, design considerations and limitations of implementing a mobile technology based intervention for low resource settings. With only one-third of the patients and caregivers having access to smartphones and internet, parallel outreach strategies like IVRS should be actively considered while designing interventions. The difficulty of understanding and searching in a non-native language needs to be addressed. Hand holding of caregivers and frequent encouragement from treating doctors might significantly help in technology adoption and in surmounting the apprehensions related to using technology. To make the solution acceptable and useful to the already over-burdened caregivers, developers need to work closely with patients’ family members and follow a ground-up collaborative approach to app development. The scope of delivering mental health services through technology is immense in resource constrained settings like India, provided we, researchers, appreciate and accept the fact that in the varied landscape of a divergent economic, educational, and cultural milieu, a single solution will never suffice for all, and intervention modality matching with end user capacity will be of paramount importance in determining the success of the endeavor.

Comparing Strategies for Providing Child and Youth Mental Health Care Services in Canada, the United States, and The Netherlands

This paper reviews how child and youth mental health care services in Canada, the United States, and the Netherlands are organized and financed in order to identify systems and individual-level factors that may inhibit or discourage access to treatment for youth with mental health problems, such as public or private health insurance coverage, out-of-pocket expenses, and referral requirements for specialized mental health care services. Pathways to care for treatment of mental health problems among children and youth are conceptualized and discussed in reference to health insurance coverage and access to specialty services. We outline reforms to the organization of health care that have been introduced in recent years, and the basket of services covered by public and private insurance schemes. We conclude with a discussion of country-level opportunities to enhance access to child and youth mental health services using existing health policy levers in Canada, the United States and the Netherlands.

Clinicians' Perspectives of Patient Engagement in Post-Acute Care: A Social Ecological Approach

Aims

To identify rehabilitation providers' perspectives on barriers and facilitators of patient engagement in hip fracture patients in skilled nursing facilities (SNFs) within the social ecological model.

Methods

We conducted 13 focus groups in SNFs throughout Los Angeles County comprised of rehabilitation staff (n=99). Focus groups were audio-recorded and transcribed. A secondary analysis of themes related to patient engagement were identified and organized within the social ecological model.

Results

Clinicians identified barriers and facilitators of patient engagement across all levels of the social ecological model: public policy (e.g., insurance), organizational (e.g., facility culture), interpersonal (e.g., clinicians fostering self-reflection), and intrapersonal (e.g., patients' anxiety).

Conclusions

Examining barriers and facilitators to patient engagement has highlighted areas which need to be sustained and improved. Thus, these findings future efforts to enhance patient engagement in order can to optimize patient healthcare decisions.

Barriers to Family Caregivers' Coping With Patients With Severe Mental Illness in Iran

The broad spectrum of problems caused by caring for a patient with mental illness imposes a high burden on family caregivers. This can affect how they cope with their mentally ill family members. Identifying caregivers' experiences of barriers to coping is necessary to develop a program to help them overcome these challenges. This qualitative content analysis study explored barriers impeding family caregivers' ability to cope with their relatives diagnosed with severe mental illness (defined here as schizophrenia, schizoaffective disorders, and bipolar affective disorders). Sixteen family caregivers were recruited using purposive sampling and interviewed using a semi-structured in-depth interview method. Data were analyzed by a conventional content analytic approach. Findings consisted of four major categories: the patient's isolation from everyday life, incomplete recovery, lack of support by the mental health care system, and stigmatization. Findings highlight the necessity of providing support for caregivers by the mental health care delivery service system.

Family Members' Existential and Moral Dilemmas With Coercion in Mental Healthcare

Coercion in mental healthcare does not only affect the patient, but also the patient's families. Using data from interviews with 36 family members of adult and adolescent people with mental health problems and coercion experiences, the present narrative study explores family members' existential and moral dilemmas regarding coercion and the factors influencing these dilemmas. Four major themes are identified: the ambiguity of coercion; struggling to stay connected and establishing collaboration; worries and distress regarding compulsory care; and dilemmas regarding initiating coercion. Subsequently, coercion can reduce, but also add burden for the family by creating strains on family relations, dilemmas, (moral) distress, and retrospective regrets; this is reinforced by the lack of information or involvement and low-quality care. Subsequently, it is a moral obligation to develop more responsive health services and professionals who provide more guidance and balanced information to increase the possibilities for voluntary alternatives and informed decision making.

Inpatient Psychiatric Care: Families' Expectations and Perceptions of Support Received From Health Professionals

PURPOSE

The purpose of this paper was to identify challenges of families caring for loved ones prior to inpatient psychiatric care, understand families' perceptions of support received from psychiatric health professionals, and identify ways for professionals to support families.

CONCLUSIONS

Families experienced many challenges prior to hospital admission. There was a large gap between families' expectations and perceptions of actual support received by psychiatric health professionals.

PRACTICE IMPLICATIONS

Nurses are well positioned to educate, advocate, and support overburdened families. Greater knowledge of families' challenges would enable nurses to anticipate and meet their needs.

Family inclusion in mental health services: Reality or rhetoric?

BACKGROUND

Contemporary mental health policies require family inclusion in the design, implementation and evaluation of services.

MATERIALS

This scoping review considers the factors in mental health practice which either mediate or promote family inclusion. A wide range of factors are reported to obstruct family inclusion, while a smaller number of studies report that meaningful family inclusion rests on a partnership approach which values the input of families and services users.

DISCUSSION

When it comes to family inclusion, there is a gap between policy and service delivery practice. Changes in service delivery attitudes, values and culture are necessary to meaningfully and systematically include families and service users.

Families' experiences of involvement in care planning in mental health services: an integrative literature review

WHAT IS KNOWN ON THE SUBJECT?: Current policy advocates for the participation of family carers in care planning. Caring for a person with a mental illness requires a significant commitment from families to support their relative's recovery. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The evidence of family involvement in care planning is generally fraught with conflicting experiences related to different requirements between mental health professionals, families and service users. Confidentiality remains contentious at a practice level in terms of information sharing and decision-making. There is a requirement and need for a shared understanding around care planning between families and mental health professionals. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The provision of written information pertaining to families regarding confidentiality is required at service level. Educational workshops concerning care planning and treatment options should be provided for service users, families and mental health professionals. Further research into effective service-wide strategies that explore with families how their engagement can be positively fostered in mental health services is warranted.

ABSTRACT

Introduction Mental health service policy stipulates that family carers be involved in care planning. Aim To identify families' experiences of care planning involvement in adult mental health services. Method An integrative review where electronic databases and grey literature were searched for papers published between 01 January 2005 and 10 February 2016. Results Fifteen papers met the inclusion criteria. Thematic analysis generated three themes: (1) families' experience of collaboration, (2) families' perceptions of professionals and (3) families' impressions of the care planning process. Collaborative decision-making is not regularly experienced by families with an 'us' and 'them' divide, perpetuated by a lack of communication, confidentiality constraints and a claim of 'insider knowledge' of service users. When involved, families perceive care planning to be uncoordinated and that their lived experiences are not always appreciated. Discussion Families need to be valued, empowered and engaged in care planning and the partnership distance be addressed. Accommodating the views of family, service user and professionals is preferable but not always possible. Our findings suggest that the key element for professionals is to value all 'insider knowledge' where possible. Implications for Practice Services should develop written information on confidentiality for families and facilitate open communication concerning their involvement in care planning.

Next of kin's experiences of involvement during involuntary hospitalisation and coercion

BACKGROUND

Norway has extensive and detailed legal requirements and guidelines concerning involvement of next of kin (NOK) during involuntary hospital treatment of seriously mentally ill patients. However, we have little knowledge about what happens in practice. This study explores NOK's views and experiences of involvement during involuntary hospitalisation in Norway.

METHODS

We performed qualitative interviews-focus groups and individual-with 36 adult NOK to adults and adolescents who had been involuntarily admitted once or several times. The semi-structured interview guide included questions on experiences with and views on involvement during serious mental illness and coercion.

RESULTS

Most of the NOK were heavily involved in the patient's life and illness. Their conceptions of involvement during mental illness and coercion, included many important aspects adding to the traditional focus on substitute decision-making. The overall impression was, with a few exceptions, that the NOK had experienced lack of involvement or had negative experiences as NOK in their encounters with the health services. Not being seen and acknowledged as important caregivers and co sufferers were experienced as offensive and could add to their feelings of guilt. Lack of involvement had as a consequence that vital patient information which the NOK possessed was not shared with the patient's therapists.

CONCLUSIONS

Despite public initiatives to improve the involvement of NOK, the NOK in our study felt neglected, unappreciated and dismissed. The paper discusses possible reasons for the gap between public policies and practice which deserve more attention: 1. A strong and not always correct focus on legal matters. 2. Little emphasis on the role of NOK in professional ethics. 3. The organisation of health services and resource constraints. 4. A conservative culture regarding the role of next of kin in mental health care. Acknowledging these reasons may be helpful to understand deficient involvement of the NOK in voluntary mental health services.

Redefining the patient-carer model at end of life

CONTEXT

While the patient-carer dyad has been broadly described, there is little exploration of patient-carer models in use.

AIM

To explore types of patient-carer models in use for those with advanced and progressive disease.

METHODS

Qualitative interviews were undertaken with patients at risk of dying in the next year and their carers across three sites (residential care home, medical assessment unit, general medical unit). Thematic analysis was undertaken.

RESULTS

Four patient-carer models were identified. In these, the provision of care and of coordination of care services were important areas and organised differently across the patient, the carer, and alternative sources of support.

CONCLUSION

A 'one size fits all' patient-carer model is outdated and a new understanding of different types of patient-carer models are required to fully inform care delivered at end of life.

The value of carers in mental health research

Purpose

– The purpose of this paper is to assess the impact of a mental health carers’ research reference group on mental health research in the Heart of England region.

Design/methodology/approach

– The methodology was a co-produced participatory evaluation, and the research was co-produced by the group. The design involved a literature review of carers’ involvement in UK mental health research, and collection of secondary data (group records) and primary data from researchers, group members, and facilitators. Analysis was initially thematic, then synthesised.

Findings

– The group’s work had a positive impact on researchers and group members, and to some extent on mental health research and networks more widely. No negative impact was identified.

Research limitations/implications

– The researchers were not able to contact or include everyone who had been involved with the group. Some of those who did not give input may have felt less positive about the group than those who did respond. Co-production does not signify equality. Evaluation inevitably involves bias.

Practical implications

– The conclusion is that mental health carers have a unique and positive contribution to make to mental health research, and have the right to be involved in such research in a non-tokenistic way. This has practical implications for mental health and mental health research services.

Originality/value

– This is the first mental health carer-controlled evaluation of a mental health carer research reference group. Mental health carers conducted the research and wrote this paper, giving a perspective rarely found in the literature. This has value for people working in, studying, and researching mental health, and for other mental health carers.

Relatives of Inpatients Suffering from Severe Depression: Their Burden and Encounters with the Psychiatric Health Services

The aim was to investigate relatives of inpatients with severe depression - their perceptions of encountering psychiatric specialist health services and their degree of burden. Sixty-eight relatives recruited via hospital wards and community specialist health centers responded to a questionnaire, with questions from the Quality from the Patients Perspective modified to relatives and the Burden Assessment Scale. Relatives recruited via community specialist health centers perceived less received information and support than those recruited via hospital wards. Higher burden was reported among relatives receiving less information and support than they needed from the psychiatric specialist health services. Healthcare professionals are recommended to give relatives the information and support according to their needs.

Physical health and mental illness: listening to the voice of carers

BACKGROUND

Shortened life expectancy of people with mental illness is now widely known and the focus of research and policy activity. To date, research has primarily reflected perspectives of health professionals with limited attention to the views and opinions of those most closely affected. The voice of carers is particularly minimal, despite policy stipulating carer participation is required for mental health services.

AIM

To present views and opinions of carers regarding physical health of the people they care for.

METHODS

Qualitative exploratory. Two focus groups and one individual interview were conducted with 13 people identifying as carers of a person with mental illness. Research was conducted in the Australian Capital Territory. Data analysis was based on the thematic framework of Braun and Clarke.

RESULTS

Two main themes were interaction between physical and mental health; and, carers' own physical and mental health. Participants described the impact of mental illness and its treatments on physical health, including their own.

CONCLUSIONS

Carers are acknowledged as crucial for the delivery of high quality mental health services. Therefore they have an important role to play in addressing the poor physical health of people with mental illness. Hearing their views and opinions is essential.

A qualitative analysis of relatives', health professionals' and service users' views on the involvement in care of relatives in Bipolar Disorder

BACKGROUND

Relatives of people with bipolar disorder report that services do not meet their own needs, despite clinical recommendations for the development of care plans for relatives, provision of information regarding their statutory entitlements, and formal involvement in decision making meetings. Further, there is now conclusive evidence highlighting the benefits of relatives' involvement in improving outcomes for service users, relatives, and the health system as a whole. This qualitative study explored the views of relatives of people with bipolar disorder, service users and healthcare professionals regarding the barriers and the facilitators to relatives' involvement in care.

METHODS

Thirty five people were interviewed (12 relatives, 11 service users and 12 healthcare professionals). Audio recordings were transcribed verbatim and common themes in participants' narratives emerged using framework analysis.

RESULTS

Participants' accounts confirmed the existence of opportunities for relatives to be involved. These, however, were limited and not always accessible. There were three factors identified that influenced accessibility namely: pre-existing worldviews, the quality of relationships and of communication between those involved, and specific structural impediments.

DISCUSSION

These themes are understood as intertwined and dependent on one another. People's thoughts, beliefs, attitudes, cultural identifications and worldviews often underlie the ways by which they communicate and the quality of their relationship. These, however, need to be conceptualised within operational frameworks and policy agendas in health settings that often limit bipolar relatives' accessibility to opportunities for being more formally involved.

CONCLUSIONS

Involving relatives leads to clear benefits for relatives, service users, healthcare professionals, and the health system as a whole. Successful involvement of relatives, however, depends on a complex network of processes and interactions among all those involved and requires strategic planning from policy makers, operational plans and allocation of resources.

Practical recommendations for improvement of the physical health care of patients with severe mental illness

OBJECTIVE

Health care for the physical health of patients with severe mental illness (SMI) needs to be improved. Therefore, we aimed to develop policy recommendations to improve this physical health care in the Netherlands based on consensus (general agreement) between the major stakeholders.

METHOD

A modified Delphi was used to explore barriers and subsequently establish policy recommendations with all key stakeholders. Consensus was sought between patients with SMI, their family carers, general practitioners, and mental healthcare professionals--all experts in the everyday practice of health care.

RESULTS

Consensus was reached on policy recommendations regarding (i) improvements in collaboration between healthcare professionals, (ii) the need for professional education on the specific medical risks of patients with SMI, and (iii) the distinguished responsibilities of general practitioners on the one hand and mental healthcare professionals on the other hand in taking care of patients' physical health.

CONCLUSION

This article provides a range of policy recommendations that could lead to considerable improvements in the physical health of SMI patients.