'What difference does it make?' Finding evidence of the impact of mental health service user researchers on research into the experiences of detained psychiatric patients

Supporting movement and physical activity in people with psychosis: A qualitative exploration of the carer perspective

BACKGROUND

The need to increase exercise and decrease sedentary behaviour in people diagnosed with psychosis is well-recognised.

AIMS

We set out to explore caregivers' perspectives on what supports and prevents physical activity, and how to use carers' support most effectively.

METHOD

Fourteen caregivers of people diagnosed with psychosis were interviewed. Data were analysed using reflexive thematic analysis, in collaboration with caregivers.

RESULTS

Four themes were developed, the first flagging the importance of physical activity, then the others calling for action: (a) Physical inactivity matters: carers are keen to support efforts to increase physical activity in their family or friends because of the enormous impact physical inactivity has on patients, and consequently on carers themselves, such as social isolation and reduction in their own activity. (b) Tell us: without being well-informed about how to help, carers can feel like they are powerless to stop a 'slow suicide' or 'decline' in patients. (c) Listen to us: through knowing their family and friends well, carers are able to identify important changes in patients and identify successful motivators for them, but these insights can feel uninvited. (d) Ask us: being invited to support activity as a partner in a patients' care is desirable but having offers of help rejected can "demotivate the motivator."

CONCLUSIONS

Caregivers described strong motivation to help patients to be more physically active but can feel that their support is overlooked and under-used by services. Clinical recommendations for carer involvement in physical activity interventions are offered.

Protocol for a randomised controlled trial of ketamine versus ketamine and behavioural activation therapy for adults with treatment-resistant depression in the community

INTRODUCTION

Although short-term benefits follow parenteral ketamine for treatment-resistant major depressive disorder (TR-MDD), there are challenges that prevent routine use of ketamine by clinicians. These include acute dissociative effects of parenteral ketamine, high relapse rates following ketamine dosing and the uncertain role of psychotherapy. This randomised controlled trial (RCT) seeks to establish the feasibility of evaluating repeated oral doses of ketamine and behavioural activation therapy (BAT), compared with ketamine treatment alone, for TR-MDD. We also aim to compare relapse rates between treatment arms to determine the effect size of adding BAT to oral ketamine.

METHODS AND ANALYSIS

This is a prospectively registered, two-centre, single-blind RCT. We aim to recruit 60 participants with TR-MDD aged between 18 and 65 years. Participants will be randomised to 8 weeks of oral ketamine and BAT, or 8 weeks of oral ketamine alone. Feasibility will be assessed by tracking attendance for ketamine and BAT, acceptability of treatment measures and retention to the study follow-up protocol. The primary efficacy outcome measure is the Montgomery-Asberg Depression Rating Scale (MADRS) measured weekly during treatment and fortnightly during 12 weeks of follow-up. Other outcome measures will assess the tolerability of ketamine and BAT, cognition and activity (using actigraphy). Participants will be categorised as non-responders, responders, remitters and relapsed during follow-up. MADRS scores will be analysed using a linear mixed model. For a definitive follow-up RCT study to be recommended, the recruitment expectations will be met and efficacy outcomes consistent with a >20% reduction in relapse rates favouring the BAT and ketamine arm will be achieved.

ETHICS AND DISSEMINATION

Ethics approval was granted by the New Zealand Central Health and Disability Ethics Committee (reference: 2023 FULL18176). Study findings will be reported to participants, stakeholder groups, conferences and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

UTN: U1111-1294-9310, ACTRN12623000817640p.

Framework for understanding movement and physical activity in patients diagnosed with psychosis

BACKGROUND

Patients diagnosed with psychosis often spend less time than others engaged in exercise and more time sitting down, which likely contributes to poorer physical and mental health.

OBJECTIVE

The aim of this study was to develop a comprehensive framework from the perspective of patients, carers, and staff for understanding what promotes movement and physical activity.

METHODS

A critical realist approach was taken to design the study. Interviews (n=23) and focus groups (n=12) were conducted with (1) outpatients aged 16 years or older diagnosed with psychosis, and under the care of a mental health team, (2) carers and (3) mental health staff working in the community. Purposive sampling was used to maximise variation in participant characteristics. Data were analysed using reflexive thematic analysis.

FINDINGS

19 patients (9 women and 10 men, mean age=45·0 (SD=12·2) years, 15 White British, 2 Black African, 1 Pakistani and 1 other ethnic group), 14 carers (11 women and 3 men, mean age=59·9 (SD=12·7) years, 13 White British and 1 Asian) and 18 staff (14 women and 4 men, mean age=38·7 (SD=12·3) years, 15 White British, 1 White other, 1 Asian Bangladeshi and 1 other Asian) participated in the study. Five factors were found to promote movement and physical activity. Patients must be able to find a purpose to moving which is meaningful to them (Factor 1: Purpose). Patients need to have an expectation of the positive consequences of movement and physical activity, which can be influenced by others' expectations (Factor 2: Predictions). A patient's current physical (eg, pain) and emotional state (eg, distress about voices) needs to be addressed to allow movement and physical activity (Factor 3: Present state). Movement and physical activity can also be encouraged by the availability of effective and tailored support, provided by engaged and supported people (Factor 4: Provision). Finally, through the identification and interruption of vicious cycles (eg, between inactivity and mood states) more positive cycles can be put in place (Factor 5: Process).

CONCLUSIONS AND CLINICAL IMPLICATIONS

The 5 P (Purpose, Predictions, Present state, Provision and Process Physical Activity Framework) for understanding movement and physical activity for people diagnosed with psychosis has the potential to inform future research and guide interventions. A checklist is provided for clinicians to help foster change in activity levels.

Respect for the journey: a survivor-led investigation of undergoing psychotherapy assessment

PURPOSE

Psychotherapy assessments are key decision points for both clients and services, carrying considerable weight on both sides. Limited research indicates that assessments have immediate and long-term impacts on clients, particularly where trauma has been experienced, affecting engagement with therapy. Understanding assessments from clients' perspectives can inform service development and improve client experience.

METHODS

This is a survivor-led exploration of clients' experiences of undergoing assessment for talking therapies. Interviews were conducted with seven people who had undergone assessment for psychological therapies in third sector and NHS services. Interviews were recorded, transcribed and analysed thematically.

RESULTS

The core theme was 'respect for the journey' reflecting the need expressed by participants for their life experiences prior to the assessment to be given full respect and consideration. Six sub-themes were identified: trauma and desperation, fear of judgement, search for trust and safety, sharing and withholding (a balancing act), feeling deconstructed, and finding hope.

CONCLUSIONS

The findings highlight the heightened emotional power surrounding psychotherapy assessments, reflecting the journey participants had undertaken to reach this point. The dilemma facing clients at the heart of an assessment-how much to share and how much to withhold-demonstrates the importance for services and assessors of treating the journey a client has made to the assessment with care and respect. Findings indicate the value of services and practitioners undertaking a trauma-informed approach to assessment encounters.

A Safe Place to Learn: Peer Research Qualitative Investigation of gameChange Virtual Reality Therapy

BACKGROUND

Automated virtual reality (VR) therapy has the potential to substantially increase access to evidence-based psychological treatments. The results of a multicenter randomized controlled trial showed that gameChange VR cognitive therapy reduces the agoraphobic avoidance of people diagnosed with psychosis, especially for those with severe avoidance.

OBJECTIVE

We set out to use a peer research approach to explore participants' experiences with gameChange VR therapy. This in-depth experiential exploration of user experience may inform the implementation in clinical services and future VR therapy development.

METHODS

Peer-led semistructured remote interviews were conducted with 20 people with a diagnosis of psychosis who had received gameChange as part of the clinical trial (ISRCTN17308399). Data were analyzed using interpretative phenomenological analysis and template analyses. A multiperspectival approach was taken to explore subgroups. Credibility checks were conducted with the study Lived Experience Advisory Panel.

RESULTS

Participants reported the substantial impact of anxious avoidance on their lives before the VR intervention, leaving some of them housebound and isolated. Those who were struggling the most with agoraphobic avoidance expressed the most appreciation for, and gains from, the gameChange therapy. The VR scenarios provided "a place to practise." Immersion within the VR scenarios triggered anxiety, yet participants were able to observe this and respond in different ways than usual. The "security of knowing the VR scenarios are not real" created a safe place to learn about fears. The "balance of safety and anxiety" could be calibrated to the individual. The new learning made in VR was "taken into the real world" through practice and distilling key messages with support from the delivery staff member.

CONCLUSIONS

Automated VR can provide a therapeutic simulation that allows people diagnosed with psychosis to learn and embed new ways of responding to the situations that challenge them. An important process in anxiety reduction is enabling the presentation of stimuli that induce the original anxious fears yet allow for learning of safety. In gameChange, the interaction of anxiety and safety could be calibrated to provide a safe place to learn about fears and build confidence. This navigation of therapeutic learning can be successfully managed by patients themselves in an automated therapy, with staff support, that provides users with personalized control. The clinical improvements for people with severe anxious avoidance, the positive experience of VR, and the maintenance of a sense of control are likely to facilitate implementation.

Lessons learnt from delivering the public and patient involvement forums within a younger onset dementia project

Including the 'voices' of people living with dementia in a meaningful way is pivotal in shaping local, national and international health and social dementia care research. The Alzheimer's Society (United Kingdom) funded Angela Project (2016-19) was aimed at improving the diagnosis and post-diagnostic support for younger people living with dementia. From the outset, the Project Team ensured that the knowledge and expertise of people living with a younger onset dementia was integral to all decisions taken in respect to overall project design, implementation, and dissemination processes. This was achieved by establishing two project public and patient involvement (PPI) forums; a London PPI Forum and a Bradford-based local PPI Hub. This paper describes how the two groups were formed; the format of the meetings; and the key points learnt by the Project Team from involving people with dementia in all aspects of developing and delivering the Angela Project. Ultimately, the aim is to demonstrate to other researchers in the dementia field how the perspectives of those with a diagnosis can be included in research studies in an active and meaningful way.

Psychiatrization in mental health care: The emergency department

BACKGROUND

In the light of high incidences of diagnosed mental disorders and the growing utilization of mental healthcare services, a progressing psychiatrization of society has been hypothesized as the underlying dynamic of these developments. Mental healthcare institutions, such as psychiatric hospitals, may play a decisive role in this. However, there is a scarcity of research into how psychiatrization emerges in hospital settings. This paper explores whether the emergency department (ED) can be considered as a site where psychiatrization happens, becomes observable, and which factors in the context of the ED may be its potential drivers.

METHODS

Two cases as encountered in an interdisciplinary ED will be presented in the following in an anonymized way. Although the cases originate from individual consultations, they can be considered as prototypical. The cases were collected and discussed using the method of interactive interviewing. The results will be analyzed against the backdrop of current theoretic concepts of psychiatrization.

FINDINGS

The ED can be seen as an important area of contact between society and psychiatry. Decisions whether to label a certain condition as a "mental disorder" and to therefore initiate psychiatric treatment, or not, can be highly difficult, especially in cases where the (health) concerns are rather moderate, and clearly associated with common life problems. Psychiatrists' decisions may be largely influenced in favor of psychiatrization by a wide array of disciplinary, institutional, interpersonal, personal, cultural, and social factors.

CONCLUSIONS

The ED appears to be a promising field for research into the mechanisms and motives through which psychiatrization may emerge in mental healthcare settings. Psychiatrists in the ED work within a complex sphere of top-down and bottom-up drivers of psychiatrization. Encounters in the ED can be an important step toward adequate support for many individuals, but they also risk becoming the starting point of psychiatrization by interpreting certain problems through the psychiatric gaze, which may induce diagnoses of questionable validity and treatment of little use.

A qualitative study on the involvement of adolescents and young adults (AYAs) with cancer during multiple research phases: "plan, structure, and discuss"

BACKGROUND

Including the lived experience of patients in research is important to improve the quality and outcomes of cancer studies. It is challenging to include adolescents and young adults (AYAs) cancer patients in studies and this accounts even more for AYAs with an uncertain and/or poor prognosis (UPCP). Little is known about involving these AYAs in scientific research. However, by including their lived experiences during multiple phases of research, the quality of the study improves and therefore also the healthcare and quality of life of this unique patient group. We first aimed to document experiences of AYAs and researchers with AYA involvement initiatives using the Involvement Matrix and the nine phases of the research cycle. Second, we aimed to map the (expected) challenges and recommendations, according to patients and researchers, for AYA involvement in each research phase.

METHODS

Thirteen semi-structured qualitative interviews were conducted with AYAs and researchers from February 2020 to May 2020. A thematic analysis codebook with a critical realistic framework was used to analyze the data.

RESULTS

AYAs and researchers were predominantly positive about AYA involvement within six of the nine phases of research: identify and prioritize topics, develop study design, disseminate information, implement, and evaluate findings. Not all respondents were positive about AYA involvement in the following three phases: formulate research questions, conduct research, and analysis and interpretation. However, few respondents had experience with AYA-researcher collaborations in multiple phases of the research cycle. Last, the results indicate the importance of adding a role (practical support) and two phases (grant application and recruitment) to the Involvement Matrix.

CONCLUSION

Our results show the added value of AYA (with a UPCP) involvement within scientific research projects. We recommend researchers to actively think about the level and phase of collaboration prior to each research project, by involving and brainstorming with AYAs at the conception and throughout research projects. Besides, to enhance fruitful participation, we suggest thoroughly discussing the pros and cons of collaboration for each phase together with AYAs via the proposed Involvement Matrix to support transparency. We recommend to report experiences, choices, and results of AYA involvement.

The psychological journey of weight gain in psychosis

BACKGROUND

Rapid weight gain is common with antipsychotic medication. Lost confidence, low mood and medication non-adherence often follow. Yet, the dynamic interactions between the physical and psychological consequences of weight gain, and implications for intervention, are unknown.

OBJECTIVES

We examined first-person accounts of weight gain to identify preferences for weight change interventions.

DESIGN

A qualitative design was used to explore patients' experiences of weight change in the context of psychosis.

METHOD

Semi-structured interviews, analysed using grounded theory, were conducted with 10 patients with psychosis. Sample validation was conducted with peer researchers with lived experience of psychosis.

RESULTS

Patients described that initially the extent and speed of weight gain was overshadowed by psychotic experiences and their treatment. This led to a shocking realisation of weight gain. The psychological impact of weight gain, most strikingly on the self-concept, was profound. Loss of self-worth and changed appearance amplified a sense of vulnerability. There were further consequences on mood, activity and psychotic experiences, such as voices commenting on appearance, that were additional obstacles in the challenging process of weight loss. Sedative effects of medication also contributed. Unsuccessful weight loss left little hope and few preferences for interventions. Early information about common weight gain trajectories and working with experts-by-experience were valued. Rebuilding self-confidence, efficacy and worth may be a necessary first step.

CONCLUSIONS

The journey of weight gain in patients with psychosis is characterised by loss of self-worth, agency and hope. There are multiple stages in the journey, each with different psychological reactions, that may need different treatment responses.

Meaningful patient and public involvement in digital health innovation, implementation and evaluation: A systematic review

Introduction

The importance of meaningfully involving patients and the public in digital health innovation is widely acknowledged, but often poorly understood. This review, therefore, sought to explore how patients and the public are involved in digital health innovation and to identify factors that support and inhibit meaningful patient and public involvement (PPI) in digital health innovation, implementation and evaluation.

Methods

Searches were undertaken from 2010 to July 2020 in the electronic databases MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus and ACM Digital Library. Grey literature searches were also undertaken using the Patient Experience Library database and Google Scholar.

Results

Of the 10,540 articles identified, 433 were included. The majority of included articles were published in the United States, United Kingdom, Canada and Australia, with representation from 42 countries highlighting the international relevance of PPI in digital health. 112 topic areas where PPI had reportedly taken place were identified. Areas most often described included cancer (n = 50), mental health (n = 43), diabetes (n = 26) and long‐term conditions (n = 19). Interestingly, over 133 terms were used to describe PPI; few were explicitly defined. Patients were often most involved in the final, passive stages of an innovation journey, for example, usability testing, where the ability to proactively influence change was severely limited. Common barriers to achieving meaningful PPI included data privacy and security concerns, not involving patients early enough and lack of trust. Suggested enablers were often designed to counteract such challenges.

Conclusions

PPI is largely viewed as valuable and essential in digital health innovation, but rarely practised. Several barriers exist for both innovators and patients, which currently limits the quality, frequency and duration of PPI in digital health innovation, although improvements have been made in the past decade. Some reported barriers and enablers such as the importance of data privacy and security appear to be unique to PPI in digital innovation. Greater efforts should be made to support innovators and patients to become meaningfully involved in digital health innovations from the outset, given its reported benefits and impacts. Stakeholder consensus on the principles that underpin meaningful PPI in digital health innovation would be helpful in providing evidence‐based guidance on how to achieve this.

Patient or Public Contribution

This review has received extensive patient and public contributions with a representative from the Patient Experience Library involved throughout the review's conception, from design (including suggested revisions to the search strategy) through to article production and dissemination. Other areas of patient and public contributor involvement include contributing to the inductive thematic analysis process, refining the thematic framework and finalizing theme wording, helping to ensure relevance, value and meaning from a patient perspective. Findings from this review have also been presented to a variety of stakeholders including patients, patient advocates and clinicians through a series of focus groups and webinars. Given their extensive involvement, the representative from the Patient Experience Library is rightly included as an author of this review.

Patient and Public Involvement in Dermatology Research: A Review

Patient and public involvement (PPI) in research is defined as research being carried out 'with' or 'by' members of the public, patients, and carers, on both an individual and a group level, rather than simply 'about', or 'for' them. Within dermatology, PPI is increasingly recognised as a vital component of research as it helps to ensure that research remains relevant to the populations we intend to serve. Dermatology scholarship, with its rich psychosocial implications due to the stigma, physical disability, and mental health burdens these conditions may incur, is in a unique position to benefit from PPI to unlock previously inaccessible patient lived experiences or therapeutic consequences. Throughout the rapid growth of PPI, it has been infused throughout the research lifecycle, from design to dissemination and beyond. After first explaining the principles of PPI, we examine the existing evidence base at each research stage to explore whether our specialty has effectively harnessed this approach and to identify any subsequent impact of PPI. Finally, we scrutinise the challenges faced by those implementing PPI in dermatology research.

Recipients' experience with information provision for electroconvulsive therapy (ECT)

BACKGROUND

Despite improvements, studies continue to report unsatisfactory provision of information before, during and after electroconvulsive treatment (ECT).

AIMS

The study explores participants' experiences with information provision about ECT.

METHODS

In-depth interviews with 21 participants (21- 65 year-old) were conducted. Thematic analysis resulted in identification of four themes: pre-treatment knowledge, experience of informed consent, the need for information depth and life after ECT. The study includes user involvement.

RESULTS

Although some participants were satisfied with information provision, the majority experienced an education deficit throughout the treatment period. Their consent was based mostly on oral information, insufficient and unvaried information on official health websites and media. Further, patients reported a lack of follow-up services that can attend to (neuro) psychological concerns.

CONCLUSIONS

Better access to updated factual and narrative information should support patient education and autonomy. Active use of diary writing, better follow-up and more varied representations of experience with ECT in media and health information sites are necessary to educate, improve consent processes and reduce stigma.

The impact of Patient and Public Involvement in the SlowMo study: Reflections on peer innovation

BACKGROUND

The SlowMo study demonstrated the effects of SlowMo, an eight-session digitally supported reasoning intervention, on paranoia in a large-scale randomized-controlled trial with 362 participants with schizophrenia-spectrum psychosis.

AIM

The current evaluation aimed to investigate the impact of Patient and Public Involvement (PPI) in the SlowMo study.

METHOD

PPI members were six women and three men from Sussex, Oxford and London with experience of using mental health services for psychosis. They received training and met at least 3-monthly throughout the project. The impact of PPI was captured quantitatively and qualitatively through (i) a PPI log of recommendations and implementation; (ii) written subjective experiences of PPI members; (iii) meeting minutes; and (iv) outputs produced.

RESULTS

The PPI log revealed 107 recommendations arising from PPI meetings, of which 87 (81%) were implemented. Implementation was greater for recruitment-, data collection- and organization-related actions than for dissemination and emergent innovations. Qualitative feedback revealed impacts on study recruitment, data collection, PPI participants' confidence, knowledge, career aspirations and society more widely. Outputs produced included a film about psychosis that aired on BBC primetime television, novel webpages and journal articles. Barriers to PPI impact included geography, travel, funding, co-ordination and well-being.

DISCUSSION

A future challenge for PPI impact will be the extent to which peer innovation (innovative PPI-led ideas) can be supported within research study delivery.

PATIENT AND PUBLIC CONTRIBUTION

Planned Patient and Public Contribution in SlowMo comprised consultation and collaboration in (i) design, (ii) recruitment, (iii) qualitative interviews and analysis of service users' experiences of SlowMo therapy and (iv) dissemination.

Needs and Experiences in Psychiatric Treatment (NEPT)- Piloting a Collaboratively Generated, Initial Research Tool to Evaluate Cross-Sectoral Mental Health Services

BACKGROUND

Research tools to evaluate institutions or interventions in the field of mental health have rarely been constructed by researchers with personal experience of using the mental health system ("experiential expertise"). This paper presents a preliminary tool that has been developed within a participatory-collaborative process evaluation as part of a controlled, multi-center, prospective cohort study (PsychCare) to evaluate psychiatric flexible and integrative treatment, FIT for short, models in Germany.

METHOD

The collaborative research team consisting of researchers with and without experiential expertise developed 12 experiential program components of FIT models by an iterative research process based on the Grounded Theory Methodology. These components were transformed into a preliminary research tool that was evaluated by a participatory expert panel, and during a pilot and validation study, the latter using a random sample of 327 users from 14 mental health departments. Internal consistency of the tool was tested using Cronbach's alpha. Construct validity was evaluated using a Principal Components Analysis (PCA) and a Jonckheere Terpstra test in relation to different implementation levels of the FIT model. Concurrent validity was tested against a German version of the Client Satisfaction Questionnaire (ZUF-8) using correlation analysis and a linear regression model.

RESULTS

The evaluation of the expert panel reduced 29 initial items to 16 that were further reduced to 11 items during the pilot study, resulting into a research tool (Needs and Experiences in Psychiatric Treatment-NEPT) that demonstrated good internal consistency (Cronbach's alpha of 0.89). PCA yielded a 1-component structure, which accounted for 49% of the total variance supporting the unidimensional structure of the tool. The total NEPT score increased alongside the increasing implementation of the FIT model (p < 0.05). There was evidence (p < 0.001) for convergent validity assessed against the ZUF-8 as criterion measure.

CONCLUSIONS

The NEPT tool seems to be promising for further development to assess the experiences with and fulfillment of needs of psychiatric care models from the perspective of users. This paper demonstrates that it is possible to use a participatory-collaborative approach within the methodologically rigorous confines of a prospective, controlled research design.

Vocational rehabilitation via social firms: a qualitative investigation of the views and experiences of employees with mental health problems, social firm managers and clinicians

BACKGROUND

Employment within social firms in the UK is under-developed and under-researched, but a potentially beneficial route to vocational rehabilitation for people with mental health problems. This study explores the views and experiences of employees with mental ill-health, managers of social firms and mental health clinicians, in order to understand the potential value of social firms for the vocational rehabilitation, employment and well-being of people with mental health problems.

METHODS

Semi-structured interviews were conducted with 23 employees with mental health problems in 11 social firms in England. A focus group and individual interviews were conducted with 12 managers of social firms. Two focus groups were held with 16 mental health clinicians. Data were analysed using thematic analysis.

RESULTS

Most employees expressed very positive views about working in a social firm. In responses from both employees and social firm managers, an overarching theme regarding the supportive ethos of social firms encompassed several related features: openness about mental health issues; peer, team and management support; flexibility; and support to progress and develop skills over time. Managers identified benefits of employing people with mental health problems who were sufficiently recovered. Knowledge of social firms within clinician focus groups was very limited, although clinicians thought they could be a welcome additional vocational resource.

CONCLUSIONS

High levels of job satisfaction among social firm employees may be explained by the supportive ethos of these working environments. Social firms have potential to be a helpful addition to the range of vocational pathways available for people with mental ill-health. Further mixed methods investigations of experiences and outcomes in order to understand who engages with and benefits from this form of vocational rehabilitation would be valuable in informing decisions about scaling up the model.

Automated Virtual Reality Cognitive Therapy for People With Psychosis: Protocol for a Qualitative Investigation Using Peer Research Methods

Background

Many people with psychosis experience difficulties in everyday social situations. Anxiety can make life challenging, leading to withdrawal. Cognitive therapy, using active in vivo learning, enables people to overcome fears. These treatments are not readily available to people with psychosis. Automated virtual reality (VR) therapy is a potential route to increase accessibility. The gameChange automated VR cognitive therapy is designed to help people overcome anxious avoidance and build confidence in everyday social situations. A virtual coach guides the person through the treatment. Understanding user experience is key to facilitating future implementation. Peer research methods, in which people with lived experience of the issues being studied are involved in collecting and analyzing data, may be useful in developing this understanding. This encourages researchers to draw on their lived experience to explore participant perspectives and co-create knowledge.

Objective

The primary objective is to use a peer research approach to explore the participant experience of a novel automated VR therapy for anxious social avoidance. This includes understanding (1) the experience of anxious social avoidance in people with psychosis, (2) the experience of the gameChange automated VR cognitive therapy, and (3) any potential impact of the therapy in people’s lives. This will inform future implementation strategies. The secondary objective is to explore how peer research can be used to co-create knowledge.

Methods

Semistructured interviews will be conducted with approximately 25 people with psychosis participating in the gameChange trial (ISRCTN17308399). Participants will be recruited from the five trial centers based in National Health Service mental health trusts across England. Interviews will be conducted by two researchers. One is a peer researcher with similar lived experience to the trial participants. The other has lived experiences of mental health issues that do not directly overlap with those of the trial participants. Interview questions will focus on an individual’s experience of anxious social avoidance, experiences of participating in the gameChange VR therapy, and any changes or impact following therapy. The interview schedule was developed in collaboration with the gameChange Lived Experience Advisory Panel (LEAP), comprising 10 project advisors with lived experience of psychosis. Interpretative phenomenological analysis and template analysis will be used to explore individual accounts. The LEAP will contribute to the analysis.

Results

Data collection will be conducted from April to September 2021, and analysis will be conducted from June to October 2021. As of September 28, 2021, 20 participants had been interviewed, and coding is underway.

Conclusions

The study, employing a peer research approach, may provide a unique insight into the experiences of anxious social avoidance in people with psychosis and its treatment using automated VR therapy. This will inform potential future implementation of VR automated therapies in mental health services.

International Registered Report Identifier (IRRID)

DERR1-10.2196/31742

A rapid realist review of patient engagement in patient-oriented research and health care system impacts: part one

BACKGROUND

Patient-oriented research affords individuals with opportunities to genuinely contribute to health care research as members of research teams. While checklists and frameworks can support academic researchers' awareness of patient engagement methods, less guidance appears available to support their understanding of how to develop and maintain collaborative relationships with their patient partners. This knowledge is essential as patient partners report that the social atmospheres of research teams significantly impacts the quality of their experiences. This study sought to develop theory regarding how academic researchers support and sustain patient engagement in patient-oriented research.

METHODS

A six-step, rapid realist review was conducted: (1) research question development, (2) preliminary theory development, (3) search strategy development; (4) study selection and appraisal, (4) data extraction, analysis and synthesis (5) identification of relevant formal theories, and (6) theory refinement with stakeholders. Findings were additionally distilled by collective competence theory.

RESULTS

A program theory was developed from 62 international studies which illuminated mechanisms supporting academic researchers to engage patient partners, contexts supporting these mechanisms, and resources that enabled mechanism activation. Interaction between seven contexts (patient-oriented research belief, prior interaction with a healthcare system, prior interaction with a particular academic researcher, educational background of patient partner, prior experience with patient-oriented research, study type, and time lived in a rural-urban setting) and seven mechanisms (deciding to become involved in patient-oriented research, recognizing valuable experiential knowledge, cultural competence, reducing power differentials, respectful team environment, supporting patient partners to feel valued, and readiness to research) resulted in an intermediate outcome (sense of trust). Trust then acted as an eighth mechanism which triggered the final-level outcome (empowered patient-centred lens).

CONCLUSIONS

Our theory posits that if patient partners trust they are a member of a supportive team working alongside academic researchers who authentically want to incorporate their input, then they are empowered to draw upon their experiential knowledge of health care systems and contribute as researchers in patient-oriented research. Our theory extends conceptual thinking regarding the importance of trust on patient-oriented research teams, how patient partners' trust is shaped by team interactions, and the role that academic researchers have within those interactions.

A qualitative study of service users' experiences of mental health nurses' knowledge and skills in relation to medication

INTRODUCTION

The role of the mental health nurse in relation to medications remains complex. Despite an increasing focus on pharmacology within pre-registration nurse education, there is limited research exploring how mental health service users experience mental health nurses' knowledge and skills in relation to medication.

AIM

To explore the experiences of service users working with mental health nurses, in relation to the nurses' knowledge and skills associated with medicines management.

METHOD

The research prioritized the principles of co-production and was undertaken collaboratively with a researcher with lived experience. Data were collected via semi-structured interviews with individuals who have accessed UK mental health services. Interviews were audio-recorded, transcribed verbatim and subjected to thematic analysis.

RESULTS

Three themes were generated from the data: inconsistencies in knowledge and practice, holistic therapeutic engagement and dialogical approach to medicines.

DISCUSSION

Service users may have a sense of uncertainty around the role of the nurse, potentially resulting in frustration and anxiety. However, mental health nurses also possess unique skills in relation to medicines management.

IMPLICATIONS FOR PRACTICE

The findings emphasize that service users value not only pharmacological knowledge but also unique skills in facilitating dialogue, prioritising shared decision-making and practical support in medicines optimization.

Designed to Clash? Reflecting on the Practical, Personal, and Structural Challenges of Collaborative Research in Psychiatry

Background: In the field of mental health research, collaborative and participatory approaches in which mental health service users actively contribute to academic knowledge production are gaining momentum. However, concrete examples in scientific literature that would detail how collaborative research projects are actually organized, and how they deal with the inherent challenges are rare. This paper provides an in-depth description of a three-year collaborative project that took place in the wider context of a mixed-method process evaluation of innovative models of psychiatric care in Germany. Methods: The in-depth description we provide here draws on a vast body of notes and records that originated from numerous meetings and sessions. The research group continuously and systematically reflected on their collaboration itself using the interpretative method of "interactive interviewing," which included that also the personal memories of the researchers were collectively re-discussed before and during the process of writing. Our concrete experiences as a group were then contextualized with and analyzed in the light of more general challenges that are central to collaborative research in general. Results: Performing collaborative research requires unconventional thinking and improvisation in order to find creative solutions for practical problems and to overcome the structural obstacles inherent to the process of academic knowledge production. An atmosphere of mutual trust and respect within the group is crucial, and continuous self-reflection or supervision can be largely beneficial. Challenges mainly originate from the vast heterogeneity that characterizes the researchers, usually including large differences in economic, cultural, and social capital. Conclusion: Collaborative research in the field of psychiatry is designed to bring together researchers with widely diverse backgrounds. Emerging conflicts are important parts of knowledge production but also exceptional opportunities to negotiate research ethics, and potential vehicles for personal growth and transformation. Success or failure of collaborative research largely depends on how divergences and conflicts are articulated, mediated, and reflected. This also holds true in the light of the power asymmetries within the research team and the structural power inherent to the engines of academic knowledge production.

COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health

Most of the global population live in low-income and middle-income countries (LMICs), which have historically received a small fraction of global resources for mental health. The COVID-19 pandemic has spread rapidly in many of these countries. This Review examines the mental health implications of the COVID-19 pandemic in LMICs in four parts. First, we review the emerging literature on the impact of the pandemic on mental health, which shows high rates of psychological distress and early warning signs of an increase in mental health disorders. Second, we assess the responses in different countries, noting the swift and diverse responses to address mental health in some countries, particularly through the development of national COVID-19 response plans for mental health services, implementation of WHO guidance, and deployment of digital platforms, signifying a welcome recognition of the salience of mental health. Third, we consider the opportunity that the pandemic presents to reimagine global mental health, especially through shifting the balance of power from high-income countries to LMICs and from narrow biomedical approaches to community-oriented psychosocial perspectives, in setting priorities for interventions and research. Finally, we present a vision for the concept of building back better the mental health systems in LMICs with a focus on key strategies; notably, fully integrating mental health in plans for universal health coverage, enhancing access to psychosocial interventions through task sharing, leveraging digital technologies for various mental health tasks, eliminating coercion in mental health care, and addressing the needs of neglected populations, such as children and people with substance use disorders. Our recommendations are relevant for the mental health of populations and functioning of health systems in not only LMICs but also high-income countries impacted by the COVID-19 pandemic, with wide disparities in quality of and access to mental health care.

Mums Alone: Exploring the Role of Isolation and Loneliness in the Narratives of Women Diagnosed with Perinatal Depression

In this study, we explore the role that isolation and loneliness play in the narratives of women diagnosed with perinatal depression. Isolation and loneliness are increasingly seen as risk factors for depression, including in the perinatal period, but little is known about whether, and in what ways, women themselves associate isolation or loneliness with perinatal distress. Based on the thematic analysis of semi-structured interviews with fourteen mothers in England, we found that women often connected feelings of depression during and after pregnancy to feeling dislocated from their previous identities and relationships. Women felt lost, confined to their homes, and often unsupported by their partners and families. However, fears of being judged to be inadequate mothers made it difficult for women to make authentic connections with others or to express negative feelings, increasing isolation and depression. We drew on the intersectionality theory to illustrate how the intersect between motherhood and other aspects of women's identities (being young, single, deprived and/or from an ethnic minority) could leave some women particularly isolated and marginalised. Our conclusions emphasise the need to challenge social constructions of the good/bad mother, advocate for social change to lessen pressures on mothers, and develop support that addresses women's interpersonal contexts and social networks.

Measuring the impact of participatory research in psychiatry: How the search for epistemic justifications obscures ethical considerations

CONTEXT

Both within politics and practice, the field of psychiatry is undergoing a significant transformation, as increasing emphasis is placed on the importance of involving those with lived experience in research. In response to this participatory turn, a push towards measuring the impact of patient involvement is also growing, seeking to identify how participation can improve research.

OBJECTIVE

This paper examines the recent push towards measuring impact in relation to justifications underlying the democratization of research in psychiatry, revealing a disconnect between the two, and harms that could result from a singular focus on measuring impact.

DISCUSSION

While those promoting and regulating participatory research tend to focus on the epistemic benefits of such research, many have pointed to both epistemic and ethical justifications underlying participatory research. The ethical reasons for involving service users loom especially large in psychiatry, given its unique history of abuse, the ways diagnoses can be utilized as tools for oppression, and the prevalence of coercion. The current focus on measuring the impact of involvement can be harmful, in that it obscures ethical reasons in favour of epistemic ones, potentially exacerbating issues common to participatory research, such as role confusion and ineffective, tokenistic participatory efforts.

CONCLUSIONS

We argue that to take the ethical reasons behind involvement in mental health research seriously will involve looking beyond impact and towards sharing power. We suggest three ways this can be done: measuring more than impact, building service user capacities and sharing power in realms outside of research.

Multiperspective and Multimethod Evaluation of Flexible and Integrative Psychiatric Care Models in Germany: Study Protocol of a Prospective, Controlled Multicenter Observational Study (PsychCare)

Background: New cross-sectoral mental health care models have been initiated in Germany to overcome the fragmentation of the German health care system. Starting in 2013, flexible and integrative psychiatric care model projects according to §64b SGB V German Social Law (FIT64b) have been implemented. The study "PsychCare" combines quantitative and qualitative primary data with routine health insurance data for the evaluation of these models. Effects, costs and cost-effectiveness from the perspectives of patients, relatives and care providers are compared with standard care. Additionally, quality indicators for a modern, flexible and integrated care are developed. This article describes the rationale, design and methods of the project. Methods: "PsychCare" is built on a multiperspective and multimethod design. A controlled prospective multicenter cohort study is conducted with three data collection points (baseline assessment, follow-up after 9 and 15 months). A total of 18 hospitals (10 FIT64b model and 8 matched control hospitals) have consecutively recruited in- and outpatients with pre-specified common and/or severe psychiatric disorders. Primary endpoints are differences in change of health-related quality of life and treatment satisfaction. Sociodemographic and service receipt data of the primary data collection are linked with routine health insurance data. A cost-effectiveness analysis, a mixed method, participatory process evaluation by means of qualitative surveys and the development of quality indicators are further elements of "PsychCare." Discussion and Practical Implications: The results based on data from different methodological approaches will provide essential conclusions for the improvement of hospital based mental health care in Germany. This should result in the identification of key FIT64b elements that can be efficiently implemented into standard care in Germany and re-structure the care strongly aligned to patient needs. Clinical Trial Registration: German Clinical Trial Register, identifier DRKS 00022535.

An exercise intervention for people with serious mental illness: Findings from a qualitative data analysis using participatory theme elicitation

Background

People with severe mental illness (SMI) often have poorer physical health than the general population. A coproduced physical activity intervention to improve physical activity for people with SMI in Northern Ireland was evaluated by co‐researchers (researchers with lived experience of SMI) and academic researchers using a new approach to participatory data analysis called participatory theme elicitation (PTE).

Objective

Co‐researchers and academic researchers analysed the data from the pilot study using PTE. This paper aimed to compare these analyses to validate the findings of the study and explore the validity of the PTE method in the context of the evaluation of a physical activity intervention for individuals with SMI.

Results

There was alignment and congruence of some themes across groups. Important differences in the analyses across groups included the use of language, with the co‐researchers employing less academic and clinical language, and structure of themes generated, with the academic researchers including subthemes under some umbrella themes.

Conclusions

The comparison of analyses supports the validity of the PTE approach, which is a meaningful way of involving people with lived experience in research. PTE addresses the power imbalances that are often present in the analysis process and was found to be acceptable by co‐researchers and academic researchers alike.

Patient involvement in developing a patient-targeted feedback intervention after depression screening in primary care within the randomized controlled trial GET.FEEDBACK.GP

Background

Patient and public involvement (PPI) is increasingly required in mental health services research. To empower patients to actively address depression, the GET.FEEDBACK.GP study evaluates a patient‐targeted feedback intervention after depression screening using the Patient Health Questionnaire (PHQ‐9).

Objective

To refine the patient‐targeted feedback from a previous study within a participatory research team (PRT) by conducting workshops to investigate patients' needs and preferences for feedback. To evaluate the process and outcome of PPI.

Design

Patient and public involvement was carried out on the levels of collaboration and consultation. A PRT of patient partners and researchers planned and conducted three workshops with patients. Patients' needs were investigated using a focus group. Participants prioritized needs, discussed feedback drafts and evaluated two drafts using cognitive debriefings. Researchers of the PRT communicated the results at project level. PPI was evaluated using the Public and Patient Engagement Evaluation Tools (PPEET).

Setting and Participants

A purposeful sampling of N = 12 patients with experiences of depression participated in at least one workshop.

Results

Relevant content‐related needs about feedback (eg no distinction between severe and moderate symptoms), recommendations for action and patient‐relevant information were considered. Needs for comprehensible, valuing, nonstigmatizing language and design elements (eg dimensional bar) were implemented. Workshops and PRT were positively evaluated.

Discussion and Conclusions

Patient and public involvement influenced the content, wording and design of the feedback. Strengths include two levels of PPI, methodical diversity and purposeful sampling. Limitations include the lack of inclusion of patients who are unaware of their depression. The evaluated PPI concept can be useful for future studies.

'Dignity and respect': An example of service user leadership and co-production in mental health research

This paper explores the methodological aspects of a user‐led study investigating mental health service user experiences of targeted violence and abuse (often called 'hate crime'). 'Keeping Control' was a 16‐month qualitative study, undertaken in the context of adult safeguarding reforms in England. By collecting data on service user concepts and experiences, the research sought to address a gap in research and practice knowledge relating to targeted violence, abuse and hostility against people with mental health problems. In this paper, we discuss the significance of the design and methodology used for this study, with a particular focus on the interviews with service users. The research was both user‐led and carried out in collaboration with practitioners and academics, a form of research co‐production. Our aim is to inform researchers, practitioners and policymakers about the value of user leadership in co‐productive research with practitioners, particularly for a highly sensitive and potentially distressing topic.

Service user's actual involvement in mental health research practices: A scoping review

Service user involvement in mental health research is on the international political agenda, for example mirrored by an emphasis on user involvement in funding of research. The idea is that service users contribute with their lived experiences of mental distress to the research process and thereby heighten the quality and relevance of the research. The purpose of this scoping review was to identify and evaluate empirical research of how mental health service users actually partake in collaborative research processes and to summarize this research in dialogue with mental health user-researchers. The review included 32 studies. Main findings indicated that actual involvement of service user-researchers in research processes encompassed a complex set of precarious negotiation practices, where academics and service user-researchers were positioned and positioned themselves in alternative ways. The review accounts for how mental health service users were involved in collaborative research processes. The extracted themes concerned: (i) Expectations of research processes, (ii) Contribution to research processes, and (iii) Training and learning from research processes. The study reveals that collaborative research in mental health requires changes to traditional research practices to create and support genuine collaborative partnerships and thereby avoid tokenism and power inequalities.

Children’s Involvement in Research—A Review and Comparison with Service User Involvement in Health and Social Care

Changing conceptions of children and childhood have in the last three decades led to the increasing participation of children in social research and their involvement in active research roles. However, the benefits and challenges of this process are rarely discussed in relation to the wider literature on adult involvement, thus missing an opportunity to learn from potential commonalities or differences. In this paper, I argue for an explicit comparison between children’s involvement in research and (adult) service user involvement in health and social care research. The paper presents findings from a review of children’s involvement in research, first separately, and second, in comparison with themes from the literature on service user involvement. As the paper will illustrate, many of the themes manifest themselves in similar ways in the two areas of practice, leaving scope for the development of cross-disciplinary practice, reflection and conceptual development. Particular suggestions deriving from the paper are (a) a strengthening of organisational frameworks within Higher Education institutions to facilitate the involvement of diverse groups of children in research, (b) the development of a more systematic mechanism for reporting the involvement of children and young people in research and (c) cross-disciplinary and theoretical exploration of key concepts such as power and empowerment within the involvement context.

Australian Mental Health Consumer and Carer Perspectives on Ethics in Adult Mental Health Research

Barriers to research arise when national ethical guidelines governing the inclusion of consumers in mental health research are implemented at the local level. Equivalent guidelines for research involving carers are not available. A social science investigation of Australian mental health consumer and carer perspectives on research ethics procedures was conducted in two interlinked stages: (a) a discussion forum with consumers, carers, and lived-experience researchers and (b) in-depth interviews with consumers and carers. Data collection and analysis drew strongly on methodological features of grounded theory. Privacy, confidentiality, and stigmatizing ethics procedures were key issues for consumer and carer participants. Recommendations for research practice include the following: considering the impact of information sharing on participants' relationships and adopting individual-focused approaches to managing research risks.

Public involvement in health outcomes research: lessons learnt from the development of the recovering quality of life (ReQoL) measures

Background

To provide a model for Public involvement (PI) in instrument development and other research based on lessons learnt in the co-production of a recently developed mental health patient reported outcome measure called Recovering Quality of Life (ReQoL). While service users contributed to the project as research participants, this paper focuses on the role of expert service users as research partners, hence referred to as expert service users or PI.

Methods

At every stage of the development, service users influenced the design, content and face validity of the measure, collaborating with other researchers, clinicians and stakeholders who were central to this research. Expert service users were integral to the Scientific Group which was the main decision-making body, and also provided advice through the Expert Service User Group.

Results

During the theme and item generation phase (stage 1) expert service users affirmed the appropriateness of the seven domains of the Patient Reported Outcome Measure (activity, hope, belonging and relationships, self-perception, wellbeing, autonomy, and physical health). Expert service users added an extra 58 items to the pool of 180 items and commented on the results from the face and content validity testing (stage 2) of a refined pool of 88. In the item reduction and scale generation phase (stage 3), expert service users contributed to discussions concerning the ordering and clustering of the themes and items and finalised the measures. Expert service users were also involved in the implementation and dissemination of ReQoL (stage 4). Expert service users contributed to the interpretation of findings, provided inputs at every stage of the project and were key decision-makers. The challenges include additional work to make the technical materials accessible, extra time to the project timescales, including time to achieve consensus from different opinions, sometimes strongly held, and extra costs.

Conclusion

This study demonstrates a successful example of how PI can be embedded in research, namely in instrument development. The rewards of doing so cannot be emphasised enough but there are challenges, albeit surmountable ones. Researchers should anticipate and address those challenges during the planning stage of the project.

Longitudinal evaluation of a knowledge translation role in occupational therapy

BACKGROUND

In 2014, a large metropolitan mental health service in Australia developed a senior role (Lead Research Occupational Therapist) to address an identified need for greater research and knowledge translation, and associated capacity building. The aim of this study was to evaluate the impact, in the first 2.5 years, of this role across a range of variables.

METHODS

Multiple methods were used to gather a comprehensive range of data. Workforce surveys were completed both online and in hard copy in early 2014 (n = 42) and late 2016 (n = 44). Research key performance indicators (academic, research production and cultural) were also identified for measurement over time. The data from these surveys were analysed using descriptive and inductive analysis, and also with social network analysis.

RESULTS

This role has demonstrated positive outcomes across a range of variables. There was a medium effect on the quantity of participation in quality assurance and knowledge translation activities by the workforce. Most knowledge translation behaviours were occurring regularly, although several were absent. An improving trend in attitudes towards evidence-based practice was recorded, and perceptions of the knowledge translation role were generally positive. The Lead Research Occupational Therapist moved from the periphery to the centre of the evidence based practice social network. Improved awareness of other clinicians deploying evidence based practice was observed, and the frequency of interaction between clinicians increased. The role has met all key performance indicators, across the academic, research production and cultural domains.

CONCLUSIONS

The shift in focus of this role from research to knowledge translation has produced tangible outcomes for the occupational therapy workforce. These achievements have had a positive impact on the sustainability of the role, which will be continued for at least another two years. An ongoing challenge is to directly measure the impact of this role on outcomes for people with mental illness and their carers.

Patient involvement in improving the evidence base on mental health inpatient care: the PERCEIVE programme

Background

Despite the movement towards care in the community, 40% of the NHS budget on mental health care is still attributed to inpatient services. However, long before the Francis Report highlighted grave shortcomings in inpatient care, there were reports by service user groups on the poor quality of these services in mental health. The programme provides a particular focus on the inclusion of the patient’s perspective in the development and evaluation of evidence.

Objectives

To understand how changes to inpatient care affect the perceptions of the ward by service users and staff by using stakeholder participatory methods.

Design

The programme consisted of four work packages (WPs). (1) Lasting Improvements for Acute Inpatient SEttings (LIAISE): using participatory methods we developed two new scales [Views On Therapeutic Environment (VOTE) for staff and Views On Inpatient CarE (VOICE) for service users]. (2) Client Services Receipt Inventory – Inpatient (CITRINE): working with nurses and service users we developed a health economic measure of the amount of contact service users have with staff. The self-report measure records interactions with staff as well as the number of therapeutic activities attended. (3) Delivering Opportunities for Recovery (DOORWAYS): a stepped-wedge randomised controlled trial to test if training ward nurses to deliver therapeutic group activities would improve the perception of the ward by service users and staff. A total of 16 wards were progressively randomised and we compared the VOICE, VOTE and CITRINE measures before and after the intervention. A total of 1108 service users and 539 staff participated in this trial. (4) Bringing Emergency TreatmenT to Early Resolution (BETTER PATHWAYS) was an observational study comparing two service systems. The first was a ‘triage’ system in which service users were admitted to the triage ward and then either transferred to their locality wards or discharged back into the community within 7 days. The second system was routine care. We collected data from 454 service users and 284 nurses on their perceptions of the wards.

Main outcome measures

The main outcomes for the DOORWAYS and BETTER project were service user and staff perceptions of the ward (VOICE and VOTE, respectively) and the health economic measure was CITRINE. All were developed in WPs 1 and 2.

Results

We developed reliable and valid measures of (1) the perceptions of inpatient care from the perspectives of service users and nurses (VOICE and VOTE) and (2) costs of interactions that were valued by service users (CITRINE). In the DOORWAYS project, after adjusting for legal status, we found weak evidence for benefit (standardised effect of –0.18, 95% CI 0.38 improvement to 0.01 deterioration;p = 0.062). There was only a significant benefit for involuntary patients following the staff training (N582, standardised effect of –0.35, 95% CI –0.57 to –0.12;p = 0.002; interactionp-value 0.006). VOTE scores did not change over time (standardised effect size of 0.04, 95% CI –0.09 to 0.18;p = 0.54). We found no evidence of an improvement in cost-effectiveness (estimated effect of £33, 95% CI –£91 to £146;p = 0.602), but resource allocation did change towards patient-perceived meaningful contacts by an average of £12 (95% CI –£76 to £98;p = 0·774). There were no significant differences between the triage and routine models of admission in terms of better perceptions by service users (estimated effect 0.77-point improvement in VOICE score on the triage ward;p = 0.68) or nurses (estimated effect of 1.68-point deterioration in VOTE on the triage ward;p = 0.38) or in terms of the cost of the length of care provided (£391 higher on triage;p = 0.77).

Strengths and limitations

We have developed measures using methods involving both service users and staff from mental health services. The measures were developed specifically for acute inpatient services and, therefore, cannot be assumed to be useful for other services. For instance, extensions of the measures are under construction for use in mother and baby units. The strength of the BETTER PATHWAYS and DOORWAYS projects is the large-scale data collection. However, we were testing specific services based in inner city areas and stretching to inner urban areas. It may be that different effects would be found in more rural communities or in different types of inpatient care.

Future work

Our database will be used to develop an understanding of the mediating and moderating factors for improving care quality.

Trial registration

Current Controlled Trials ISRCTN06545047.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 7. See the NIHR Journals Library website for further project information.

'I-as-We' - Powerful boundaries within the field of mental health coproduction

To date, there is little research on personal crisis experiences of mental health professionals. The aim of this study was to explore some of the reasons for why self-disclosure is so difficult and how these difficulties may prevent productive forms of coproduction. These questions are addressed both from a psychiatrist's autoethnographic account and from the perspective of a peer worker who works in various coproductive relationships. It is shown that mental health professionals often revert to an "I-as-we", speaking of themselves as a collective and thereby reifying the boundaries between 'vulnerable users' and 'invulnerable professionals'. Ethnographic examples are given, of how these boundaries are produced by a continuous, often invisible, and powerful category work. It is discussed how the dichotomous logic of these boundaries can cause people on both sides to feel reduced to a representation of a certain species, which can take on an existential dimension. Ways out are identified for mental health professionals to self-reflexively engage with their own crisis experience in coproductive and other relationships.

Best practice framework for Patient and Public Involvement (PPI) in collaborative data analysis of qualitative mental health research: methodology development and refinement

BACKGROUND

Patient and Public Involvement (PPI) in mental health research is increasing, especially in early (pre-funding) stages. PPI is less consistent in later stages, including in analysing qualitative data. The aims of this study were to develop a methodology for involving PPI co-researchers in collaboratively analysing qualitative mental health research data with academic researchers, to pilot and refine this methodology, and to create a best practice framework for collaborative data analysis (CDA) of qualitative mental health research.

METHODS

In the context of the RECOLLECT Study of Recovery Colleges, a critical literature review of collaborative data analysis studies was conducted, to identify approaches and recommendations for successful CDA. A CDA methodology was developed and then piloted in RECOLLECT, followed by refinement and development of a best practice framework.

RESULTS

From 10 included publications, four CDA approaches were identified: (1) consultation, (2) development, (3) application and (4) development and application of coding framework. Four characteristics of successful CDA were found: CDA process is co-produced; CDA process is realistic regarding time and resources; demands of the CDA process are manageable for PPI co-researchers; and group expectations and dynamics are effectively managed. A four-meeting CDA process was piloted to co-produce a coding framework based on qualitative data collected in RECOLLECT and to create a mental health service user-defined change model relevant to Recovery Colleges. Formal and informal feedback demonstrated active involvement. The CDA process involved an extra 80 person-days of time (40 from PPI co-researchers, 40 from academic researchers). The process was refined into a best practice framework comprising Preparation, CDA and Application phases.

CONCLUSIONS

This study has developed a typology of approaches to collaborative analysis of qualitative data in mental health research, identified from available evidence the characteristics of successful involvement, and developed, piloted and refined the first best practice framework for collaborative analysis of qualitative data. This framework has the potential to support meaningful PPI in data analysis in the context of qualitative mental health research studies, a previously neglected yet central part of the research cycle.

Traditions of research in community mental health care planning and care coordination: A systematic meta-narrative review of the literature

CONTEXT

In response to political and social factors over the last sixty years mental health systems internationally have endeavoured to transfer the delivery of care from hospitals into community settings. As a result, there has been increased emphasis on the need for better quality care planning and care coordination between hospital services, community services and patients and their informal carers. The aim of this systematic review of international research is to explore which interventions have proved more or less effective in promoting personalized, recovery oriented care planning and coordination for community mental health service users.

METHODS

A systematic meta-narrative review of research from 1990 to the present was undertaken. From an initial return of 3940 papers a total of 50 research articles fulfilled the inclusion criteria, including research from the UK, Australia and the USA.

FINDINGS

Three research traditions are identified consisting of (a) research that evaluates the effects of government policies on the organization, management and delivery of services; (b) evaluations of attempts to improve organizational and service delivery efficiency; (c) service-users and carers experiences of community mental health care coordination and planning and their involvement in research. The review found no seminal papers in terms of high citation rates, or papers that were consistently cited over time. The traditions of research in this topic area have formed reactively in response to frequent and often unpredictable policy changes, rather than proactively as a result of intrinsic academic or intellectual activity. This may explain the absence of seminal literature within the subject field. As a result, the research tradition within this specific area of mental health service delivery has a relatively short history, with no one dominant researcher or researchers, tradition or seminal studies amongst or across the three traditions identified.

CONCLUSIONS

The research findings reviewed suggests a gap has existed internationally over several decades between policy aspirations and service level interventions aimed at improving personalised care planning and coordination and the realities of everyday practices and experiences of service users and carers. Substantial barriers to involvement are created through poor information exchange and insufficient opportunities for care negotiation.

Responding effectively to adult mental health patient feedback in an online environment: A coproduced framework

Background

Responding to online patient feedback is considered integral to patient safety and quality improvement. However, guidance on how to respond effectively is limited, with limited attention paid to patient perceptions and reactions.

Objectives

To identify factors considered potentially helpful in enhancing response quality; coproduce a best‐practice response framework; and quality‐appraise existing responses.

Design

A four‐stage mixed methodology: (i) systematic search of stories published on Care Opinion about adult mental health services in the South West of England; (ii) collaborative thematic analysis of responses to identify factors potentially helpful in enhancing response quality; (iii) validation of identified factors by a patient‐carer group (n = 12) leading to the coproduction of a best‐practice response framework; and (iv) quality appraisal of existing responses.

Results

A total of 245 stories were identified, with 183 (74.7%) receiving a response. Twenty‐four (9.8%) had been heard but not yet responded to. 1.6% (n = 4/245) may lead to a change. Nineteen factors were considered influential in response quality. These centred around seven subject areas: (i) introductions; (ii) explanations; (iii) speed of response; (iv) thanks and apologies; (v) response content; (vi) signposting; and (vii) response sign‐off that were developed into a conceptual framework (the Plymouth, Listen, Learn and Respond framework). Quality appraisal of existing responses highlighted areas for further improvement demonstrating the framework's utility.

Conclusion

This study advances existing understanding by providing previously unavailable guidance. It has clear practical and theoretical implications for those looking to improve health‐care services, patient safety and quality of care. Further validation of the conceptual framework is encouraged.

The impact of using peer interviewers in a study of patient empowerment amongst people in cancer follow-up

Background

A range of benefits have been reported from engaging peer interviewers in qualitative interviews, but little systematic evaluation exists to assess their impact on both process and outcomes of qualitative interviews in health research.

Objective

To investigate the impact of involving patient representatives as peer interviewers in a research project on patient empowerment.

Design

18 interviews were carried out as part of the wider study, seven by the academic researcher alone and eleven jointly with a peer interviewer. The interviews were analysed quantitatively and qualitatively to explore potential differences between interviews conducted by the researcher alone and interviews conducted jointly by the researcher and the peer interviewers. A phone evaluation of the peer interviews was carried out with the research participants, and notes were thematically analysed to understand their experiences.

Results

Differences were identified between the academic researcher and the peer interviewers in the types of questions they asked and the degree to which personal narrative was used in the interview. Peer interviewers varied significantly in their approach. Research participants were positive about the experience of being interviewed by a peer interviewer. No firm conclusions could be made about impact on outcomes.

Discussion and conclusions

The uniqueness and complexity of qualitative interviews made it difficult to provide any firm conclusions about the impact of having peer interviewers on the research outcomes, and the benefits identified from the analysis mostly related to the process of the interviews. Benefits from using peer interviewers need to be considered alongside relevant ethical considerations, and available resources for training and support.

Preferences for public involvement in health service decisions: a comparison between best-worst scaling and trio-wise stated preference elicitation techniques

Stated preference elicitation techniques, such as discrete choice experiments and best-worst scaling, are now widely used in health research to explore the public's choices and preferences. In this paper, we propose an alternative stated preference elicitation technique, which we refer to as 'trio-wise'. We explain this new technique, its relative advantages, modeling framework, and how it compares to the best-worst scaling method. To better illustrate the differences and similarities, we utilize best-worst scaling Case 2, where individuals make best and worst (most and least) choices for the attribute levels that describe a single profile. We demonstrate this new preference elicitation technique using an empirical case study that explores preferences among the general public for ways to involve them in decisions concerning the health care system. Our findings show that the best-worst scaling and trio-wise preference elicitation techniques both retrieve similar preferences. However, the capability of our trio-wise method to provide additional information on the strength of rank preferences and its ability to accommodate indifferent preferences lead us to prefer it over the standard best-worst scaling technique.

Patient perspectives on barriers and enablers to the use and effectiveness of de-escalation techniques for the management of violence and aggression in mental health settings

AIM

Investigate patient perspectives on barriers and enablers to the use and effectiveness of de-escalation techniques for aggression in mental health settings.

BACKGROUND

De-escalation techniques are the recommended first-line intervention for the management of aggression in mental health settings internationally, yet use of higher risk restrictive practices persists. This indicates de-escalation techniques are not used at optimum frequency and/or there are important factors limiting their use and effect.

DESIGN

Descriptive qualitative research using semi-structured interviews and Framework Analysis.

METHODS

Inpatient interviews (N = 26) exploring staff, patient and environmental factors influencing the use and effectiveness of staff de-escalation were conducted mid-2014. Three service user researchers led analysis.

RESULTS

Data were synthesized in three deductive themes relating to staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. The dominant view was that restrictive practices, rather than de-escalation techniques, are used in response to escalating patient behaviour. Under-use of de-escalation techniques was attributed to: lack of staff reflection on culture and practice and a need to retain control/dominance over patients. Ward rules, patient factors and a lack of staff respect for patients diluted their effectiveness. Participants identified a systematic process of de-escalation, rule subversion, reduced social distance and staff authenticity as enablers of effective de-escalation.

CONCLUSION

This study investigated patient perspectives on staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. Our framework of barriers and enablers provides indicators of organizational/behaviour change targets for interventions seeking to reduce violence and restrictive practices through enhanced de-escalation techniques.

Factors Supporting the Employment of Young Adult Peer Providers: Perspectives of Peers and Supervisors

Peer providers are a promising practice for transition-age youth community mental health treatment engagement and support, yet little is known about the experience of being a young adult peer provider or what helps to make an individual in this role successful. Utilizing a capital theory lens, this study uses data from focus groups (two with young adult peer providers and two with their supervisors) to examine facilitators of young adult peer provider success in community mental health treatment settings. Eight factors were identified as critical to young adult peer provider on-the-job success: persistence, job confidence, resilience, job training, skilled communications with colleagues, regular and individualized supervision, support from colleagues, and family support. Findings suggest that young adult peer providers may benefit immensely from an agency level focus on fostering social organizational capital as well as more individualized efforts to increase cultural, social, and psychological capital through training and supervision.

Service user involvement in the coproduction of a mental health nursing metric: The Therapeutic Engagement Questionnaire

Service users' involvement in mental health service research is increasingly acknowledged as important, yet, whilst involving users of mental health services as research participants is commonplace, seeking out their experience and indeed their "expertise" to facilitate the development of tools to be used within mental health services is in its infancy. This article describes the involvement and views of service users in the development of a nursing metric-the Therapeutic Engagement Questionnaire. It presents their role in the three stages of development: generation, statement reduction and authentication.

Service user involvement enhanced the research quality in a study using interpretative phenomenological analysis - the power of multiple perspectives

AIM

The aim of this study was to examine how service user involvement can contribute to the development of interpretative phenomenological analysis methodology and enhance research quality.

BACKGROUND

Interpretative phenomenological analysis is a qualitative methodology used in nursing research internationally to understand human experiences that are essential to the participants. Service user involvement is requested in nursing research.

DESIGN

We share experiences from 4 years of collaboration (2012-2015) on a mental health promotion project, which involved an advisory team.

METHODS

Five research advisors either with a diagnosis or related to a person with severe mental illness constituted the team. They collaborated with the research fellow throughout the entire research process and have co-authored this article. We examined the joint process of analysing the empirical data from interviews. Our analytical discussions were audiotaped, transcribed and subsequently interpreted following the guidelines for good qualitative analysis in interpretative phenomenological analysis studies.

RESULTS

The advisory team became 'the researcher's helping hand'. Multiple perspectives influenced the qualitative analysis, which gave more insightful interpretations of nuances, complexity, richness or ambiguity in the interviewed participants' accounts. The outcome of the service user involvement was increased breadth and depth in findings.

CONCLUSION

Service user involvement improved the research quality in a nursing research project on mental health promotion. The interpretative element of interpretative phenomenological analysis was enhanced by the emergence of multiple perspectives in the qualitative analysis of the empirical data. We argue that service user involvement and interpretative phenomenological analysis methodology can mutually reinforce each other and strengthen qualitative methodology.

Broadening public participation in systematic reviews: a case example involving young people in two configurative reviews

Background

Arguments supporting the involvement of users in research have even more weight when involving the public in systematic reviews of research. We aimed to explore the potential for public involvement in systematic reviews of observational and qualitative studies.

Methods

Two consultative workshops were carried out with a group of young people (YP) aged 12–17 years to examine two ongoing reviews about obesity: one about children's views and one on the link between obesity and educational attainment. YP were invited to comment on the credibility of themes, to propose elements of interventions, to suggest links between educational attainment and obesity and to comment on their plausibility.

Results

Researchers had more confidence in review findings, after checking that themes identified as important by YP were emphasised appropriately. Researchers were able to use factors linking obesity and attainment identified as important by YP to identify limitations in the scope of extant research.

Conclusion

Consultative workshops helped researchers draw on the perspectives of YP when interpreting and reflecting upon two systematic reviews. Involving users in judging synthesis credibility and identifying concepts was easier than involving them in interpreting findings. Involvement activities for reviews should be designed with review stage, purpose and group in mind. © 2015 The Authors. Research Synthesis Methods published by John Wiley & Sons, Ltd.

Cross-national comparative mixed-methods case study of recovery-focused mental health care planning and co-ordination: Collaborative Care Planning Project (COCAPP)

Background

Concerns about fragmented community mental health care have led to the development of the care programme approach in England and care and treatment planning in Wales. These systems require those people receiving mental health services to have a care co-ordinator, a written care plan and regular reviews of their care. Care planning and co-ordination should be recovery-focused and personalised, with people taking more control over their own support and treatment.

Objective(s)

We aimed to obtain the views and experiences of various stakeholders involved in community mental health care; to identify factors that facilitated, or acted as barriers to, personalised, collaborative and recovery-focused care planning and co-ordination; and to make suggestions for future research.

Design

A cross-national comparative mixed-methods study involving six NHS sites in England and Wales, including a meta-narrative synthesis of relevant policies and literature; a survey of recovery, empowerment and therapeutic relationships in service users (n = 449) and recovery in care co-ordinators (n = 201); embedded case studies involving interviews with service providers, service users and carers (n = 117); and a review of care plans (n = 33).

Review methods

A meta-narrative mapping method.

Results

Quantitative and qualitative data were analysed within and across sites using inferential statistics, correlations and the framework method. Our study found significant differences for scores on therapeutic relationships related to positive collaboration and clinician input. We also found significant differences between sites on recovery scores for care co-ordinators related to diversity of treatment options and life goals. This suggests that perceptions relating to how recovery-focused care planning works in practice are variable across sites. Interviews found great variance in the experiences of care planning and the understanding of recovery and personalisation within and across sites, with some differences between England and Wales. Care plans were seen as largely irrelevant by service users, who rarely consulted them. Care co-ordinators saw them as both useful records and also an inflexible administrative burden that restricted time with service users. Service users valued their relationships with care co-ordinators and saw this as being central to their recovery. Carers reported varying levels of involvement in care planning. Risk was a significant concern for workers but this appeared to be rarely discussed with service users, who were often unaware of the content of risk assessments.

Limitations

Limitations include a relatively low response rate of between 9% and 19% for the survey and a moderate level of missing data on one measure. For the interviews, there may have been an element of self-selection or inherent biases that were not immediately apparent to the researchers.

Conclusions

The administrative elements of care co-ordination reduce opportunities for recovery-focused and personalised work. There were few shared understandings of recovery, which may limit shared goals. Conversations on risk appeared to be neglected and assessments kept from service users. A reluctance to engage in dialogue about risk management may work against opportunities for positive risk-taking as part of recovery-focused work.

Future work

Research should be commissioned to investigate innovative approaches to maximising staff contact time with service users and carers; enabling shared decision-making in risk assessments; and promoting training designed to enable personalised, recovery-focused care co-ordination.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Bringing meaning to user involvement in mental health care planning: a qualitative exploration of service user perspectives

BACKGROUND

Service users wish to be involved in care planning but typically feel marginalized in this process. Qualitative explorations of the barriers and enablers of user involvement in mental health care planning are limited.

QUESTION

How is user involvement in care planning conceptualized by service users and how can meaningful involvement be instilled in the care planning process?

METHODS

In 2013, we conducted five focus groups (n = 27) and 23 individual interviews with current or recent adult users of secondary care mental health services (n = 27) in England. Eight users participated in both. Data were analysed using Framework Analysis. Results Ten themes emerged from the data: these themes encompassed procedural elements (connection; contribution; currency; care consolidation; and consequence), service user characteristics (capacity and confidence) and professional enablers (consultation; choice; and clarity of expression). Procedural elements were discussed most frequently in service user discourse.

DISCUSSION

The process of care planning, centred on the user-clinician relationship, is key to user involvement.

IMPLICATIONS FOR PRACTICE

Users describe a common model of meaningful involvement in care planning. Their requests, summarized through a 10C framework of care planning involvement, provide clear direction for improving service users satisfaction with care planning and enhancing the culture of services.

Lay involvement in the analysis of qualitative data in health services research: a descriptive study

PLAIN ENGLISH SUMMARY

There is a consensus that patients and the public should be involved in research in a meaningful way. However, to date, lay people have been mostly involved in developing research ideas and commenting on patient information.We previously published a paper describing our experience with lay partners conducting observations in a study of how patients in hospital are involved with their medicines. In a later part of the same study, lay partners were also involved in analysing interviews that a researcher had conducted with patients, carers and healthcare professionals about patient and carer involvement with medicines in hospital. We therefore wanted to build on our previous paper and report on our experiences with lay partners helping to conduct data analysis. We therefore interviewed the lay members and researchers involved in the analysis to find out their views.Both lay members and researchers reported that lay partners added value to the study by bringing their own perspectives and identifying further areas for the researcher to look for in the interviews. In this way researchers and lay partners were able to work together to produce a richer analysis than would have been possible from either alone.

ABSTRACT

Background It is recognised that involving lay people in research in a meaningful rather than tokenistic way is both important and challenging. In this paper, we contribute to this debate by describing our experiences of lay involvement in data analysis.Methods We conducted semi-structured interviews with the lay partners and researchers involved in qualitative data analysis in a wider study of inpatient involvement in medication safety. The interviews were transcribed verbatim and coded using open thematic analysis.Results We interviewed three lay partners and the three researchers involved. These interviews demonstrated that the lay members added value to the analysis by bringing their own perspectives; these were systematically integrated into the analysis by the lead researcher to create a synergistic output. Some challenges arose, including difficulties in recruiting a diverse range of members of the public to carry out the role; however there were generally fewer challenges in data analysis than there had been with our previous experience of lay partners' involvement in data collection.Conclusions Lay members can add value to health services research by being involved in qualitative data analysis.

Expectations of new treatment in rheumatoid arthritis: developing a patient-generated questionnaire

BACKGROUND

Service-user partnerships in research exist in mental health, but there have been few advances in other disciplines, apart from cancer.

OBJECTIVES

To develop a patient-generated expectancy measure for new treatments in rheumatoid arthritis (RA), using a participatory method.

METHOD

Stage 1: three repeated focus groups and two expert panels with patients with RA conducted by a patient researcher to generate items for the draft questionnaire. Stage 2: feasibility study of draft scale with consecutive outpatient attendees.

RESULTS

Patients identified 21 dimensions of new treatment expectations, grouped into (i) physical, (ii) psycho-social and (iii) expectations relating to the impact of treatment. This resulted in a draft instrument assessed in a feasibility study.

DISCUSSION AND CONCLUSION

The participatory research method was useful in involving patients actively in research and to produce collaboratively a feasible, valid and acceptable measure in RA. The scale will be included in a longitudinal observational study, with newly diagnosed patients, to assess (i) whether the new scale demonstrates sensitivity to change for expectations when receiving new treatment and (ii) participants' completion rate of the new scale compared with five instruments included in the future study.

Understanding recovery in the context of lived experience of personality disorders: a collaborative, qualitative research study

BACKGROUND

Concepts of recovery increasingly inform the development and delivery of mental health services internationally. In the UK recent policy advocates the application of recovery concepts to the treatment of personality disorders. However diagnosis and understanding of personality disorders remains contested, challenging any assumption that mainstream recovery thinking can be directly translated into personality disorders services.

METHODS

In a qualitative interview-based study understandings of recovery were explored in extended, in-depth interviews with six people purposively sampled from a specialist personality disorders' service in the UK. An interpretive, collaborative approach to research was adopted in which university-, clinical- and service user (consumer) researchers were jointly involved in carrying out interviews and analysing interview data.

RESULTS

Findings suggested that recovery cannot be conceptualised separately from an understanding of the lived experience of personality disorders. This experience was characterised by a complexity of ambiguous, interrelating and conflicting feelings, thoughts and actions as individuals tried to cope with tensions between internally and externally experienced worlds. Our analysis was suggestive of a process of recovering or, for some, discovering a sense of self that can safely coexist in both worlds.

CONCLUSIONS

We conclude that key facilitators of recovery - positive personal relationships and wider social interaction - are also where the core vulnerabilities of individuals with lived experience of personaility disorders can lie. There is a role for personality disorders services in providing a safe space in which to develop positive relationships. Through discursive practice within the research team understandings of recovery were co-produced that responded to the lived experience of personality disorders and were of applied relevance to practitioners.