Not sick enough: Experiences of carers of people with mental illness negotiating care for their relatives with mental health services

Psychosocial Care Delivery in Intensive Home Treatment During a Mental Health Crisis: A Qualitative Thematic Analysis

Community-based intensive home treatment (IHT) is delivered as an alternative to psychiatric hospital admission as part of crisis resolution services. People receiving IHT present with complex mental health issues and are acutely distressed. Home treatment options are often preferred and there is evidence of service fidelity, although less is known about psychosocial care in this setting. Underpinned by a critical realist epistemology, this study aimed to explore psychosocial care in the context of home treatment from the perspectives of staff, service users and family carers. Data were collected using individual interviews and focus groups in two NHS organisations in England. An inductive qualitative thematic analysis resulted in five themes focused on (1) the staffing model and effective care provision, (2) the organisation of work and effective care provision, (3) skills and training and service user need, (4) opportunities for involvement and personal choice, and (5) effective communication. Findings suggest that co-production may improve congruence between IHT service design, what service users and carers want and staff ideals about optimal care. Service designs that optimise continuity of care and effective communication were advocated. Staff training in therapeutic interventions was limited by not being tailored to the home treatment context. Evidence gaps remain regarding the most effective psychosocial care and related training and supervision required. There is also a lack of clarity about how carers and family members ought to be supported given their often-crucial role in supporting the person between staff visits.

Implementation of guidelines on Family Involvement for persons with Psychotic disorders: a pragmatic cluster randomized trial. Effect on relatives' outcomes and family interventions received

Background

Family interventions (FI) are recommended as part of the treatment for psychotic disorders, but the implementation in mental health services is generally poor. Recently, The Implementation of guidelines on Family Involvement for persons with Psychotic disorders (IFIP) trial, demonstrated significant improvements in implementation outcomes at cluster-level. This sub-study aims to examine the effectiveness of the IFIP intervention on relatives' outcomes and received FI.

Methods

A cluster randomized controlled trial, was conducted in 15 Norwegian Community Mental Health Center (CMHC) units that were randomized to either the IFIP intervention, including implementation interventions and clinical interventions, or treatment as usual (TAU). The clinical interventions consisted of FI: basic family involvement and support (BFIS) to all patients and family psychoeducation (FPE) to as many as possible. Patients with psychotic disorders and their closest relative were invited to fill in questionnaires at inclusion and 6 months and 12 months follow-up. Received FI was reported by both relatives and clinicians. The relatives' primary outcome was satisfaction with health service support, measured by the Carer well-being and support questionnaire part B (CWS-B). The relatives' secondary outcomes were caregiver experiences, expressed emotions and quality of life. Patients' outcomes will be reported elsewhere.

Results

In total 231 patient/relative pairs from the CMHC units were included (135 intervention; 96 control).The relatives in the intervention arm received an increased level of BFIS (p=.007) and FPE (p < 0.05) compared to the relatives in the control arm, including involvement in crisis planning. The primary outcome for relatives' satisfaction with health service support, showed a non-significant improvement (Cohen's d = 0.22, p = 0.08). Relatives experienced a significant reduced level of patient dependency (Cohen's d = -0.23, p = 0.03).

Conclusion

The increased support from clinicians throughout FI reduced the relatives' perceived level of patient dependency, and may have relieved the experience of responsibility and caregiver burden. The COVID-19 pandemic and the complex and pioneering study design have weakened the effectiveness of the IFIP intervention, underscoring possible potentials for further improvement in relatives' outcomes.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT03869177.

Individual placement and support: A qualitative investigation of carers' experiences supporting someone experiencing mental illness into employment

BACKGROUND

Unemployment rates for people living with mental illness remain persistently high. Individual Placement Support (IPS) is an evidence-based employment model that supports people with severe mental illness to gain employment. Although carers provide emotional and instrumental support for people with mental illness, there is limited research exploring carers' perspectives of IPS.

AIMS

To explore carers' perspectives of their experience as caregivers of individuals living with mental illness who have participated in IPS.

METHODS

This qualitative descriptive study gained carers' perspectives through semi-structured interviews. A convenience sample of eight carers was recruited via a community mental health service in Adelaide. Data were analysed thematically.

FINDINGS

Three main themes were identified: (1) employment benefits, (2) factors that may impact on employment, and (3) knowledge and opinions of IPS. Within each theme, four sub-themes emerged.

CONCLUSIONS

This study addresses a gap in research and provides insights into carers' experiences of IPS. Increased communication and involvement of carers in IPS may benefit IPS participants and staff as carers provide invaluable additional insight into supporting individuals through their employment journey.

NegotiAge: Development and pilot testing of an artificial intelligence-based family caregiver negotiation program

BACKGROUND

Family caregivers of people with Alzheimer's disease experience conflicts as they navigate health care but lack training to resolve these disputes. We sought to develop and pilot test an artificial-intelligence negotiation training program, NegotiAge, for family caregivers.

METHODS

We convened negotiation experts, a geriatrician, a social worker, and community-based family caregivers. Content matter experts created short videos to teach negotiation skills. Caregivers generated dialogue surrounding conflicts. Computer scientists utilized the dialogue with the Interactive Arbitration Guide Online (IAGO) platform to develop avatar-based agents (e.g., sibling, older adult, physician) for caregivers to practice negotiating. Pilot testing was conducted with family caregivers to assess usability (USE) and satisfaction (open-ended questions with thematic analysis).

RESULTS

Development: With NegotiAge, caregivers progress through didactic material, then receive scenarios to negotiate (e.g., physician recommends gastric tube, sibling disagrees with home support, older adult refusing support). Caregivers negotiate in real-time with avatars who are designed to act like humans, including emotional tactics and irrational behaviors. Caregivers send/receive offers, using tactics until either mutual agreement or time expires. Immediate feedback is generated for the user to improve skills training. Pilot testing: Family caregivers (n = 12) completed the program and survey. USE questionnaire (Likert scale 1-7) subset scores revealed: (1) Useful-Mean 5.69 (SD 0.76); (2) Ease-Mean 5.24 (SD 0.96); (3) Learn-Mean 5.69 (SD 0.74); (4) Satisfy-Mean 5.62 (SD 1.10). Items that received over 80% agreements were: It helps me be more effective; It helps me be more productive; It is useful; It gives me more control over the activities in my life; It makes the things I want to accomplish easier to get done. Participants were highly satisfied and found NegotiAge fun to use (91.7%), with 100% who would recommend it to a friend.

CONCLUSION

NegotiAge is an Artificial-Intelligent Caregiver Negotiation Program, that is usable and feasible for family caregivers to become familiar with negotiating conflicts commonly seen in health care.

Understanding collaborative and coordinated care in a mental health and well-being context: Essential elements for effective service integration

Multiple system reforms in Australia, including the National Disability Insurance Scheme (NDIS), are changing mental health (MH) and disability-related service provision, whilst policy drivers continue to require service integration. This has necessitated service providers discovering new ways of working collaboratively to achieve an integrated model of care. This qualitative study examined what does and does not work to support collaborative and coordinated care (CCC), as essential components of service integration. The study sample (n = 59) included four cohorts: health and community service leaders (n = 16), staff (n = 23); MH service consumers with complex needs (n = 10), and MH carers (n = 10). Thematic analysis from interviews was applied to data from each cohort to identify overarching themes that described the lived experience of current CCC delivery. COREQ and EQUATOR guidelines were applied to reporting the findings. Themes emphasized CCC is enabled by the development and sustainability of positive working relationships, and depth of knowledge across health and community services. Unnavigable service systems, stigmatization, perceived power differentials, multiple and rapid service reforms and Fee-For-Service (FFS) models provide significant barriers to CCC. Recommendations include the need for accessible service navigation, consumer-friendly service environments, a stable workforce, standardization of knowledge across sectors, outcome measures and funding attached to CCC as part of a raft of potential changes.

How can healthcare providers involve with families in the care of patients with chronic mental illness? A mixed methods protocol study to adapt the clinical practice guideline

BACKGROUND

Chronic mental illnesses have long periods, are recurring, and require continuous care as well as an integrated and collaborative approach to organize the care. The purpose of this article is to summarize the most important steps necessary for adapting a clinical practice guideline for family-centered collaborative care of patients with chronic mental illnesses referring to the medical centers.

MATERIALS AND METHODS

As the study will be an exploratory mixed methods study, the design will be carried out as a sequential qualitative-quantitative study (QUAL quan), consisting of 3 phases, 9 modules, and 24 sequential steps, which is based on the Guidelines International Network to adapt the guideline manual. In the first phase, the prerequisites for adaptation of the clinical guideline were established. In the second phase, to collect evidence, a qualitative study (semi-structured interview) will be conducted to explore the dimensions and components of the care needs of patients with chronic mental disorders and their families from the perspectives of patients, caregivers, and healthcare providers. Additionally, a literature review to extract relevant clinical guidelines and articles will be done. A panel of experts will screen and evaluate potential clinical guidelines, and a draft guideline will be developed.

DISCUSSION

It is expected that these findings will meet the needs of patients with mental illness and their caregivers by providing integrated care and improving collaborative care within the sociocultural context of Iran.

Explaining context, mechanism and outcome in adult community mental health crisis care: A realist evidence synthesis

Mental health crises cause significant distress and disruption to the lives of individuals and their families. Community crisis care systems are complex, often hard to navigate and poorly understood. This realist evidence synthesis aimed to explain how, for whom and in what circumstances community mental health crisis services for adults work to resolve crises and is reported according to RAMESES guidelines. Using realist methodology, initial programme theories were identified and then tested through iterative evidence searching across 10 electronic databases, four expert stakeholder consultations and n = 20 individual interviews. 45 relevant records informed the three initial programme theories, and 77 documents, were included in programme theory testing. 39 context, mechanism, outcome configurations were meta-synthesized into three themes: (1) The gateway to urgent support; (2) Values based crisis interventions and (3) Leadership and organizational values. Fragmented cross-agency responses exacerbated staff stress and created barriers to access. Services should focus on evaluating interagency working to improve staff role clarity and ensure boundaries between services are planned for. Organizations experienced as compassionate contributed positively to perceived accessibility but relied on compassionate leadership. Attending to the support needs of staff and the proximity of leaders to the front line of crisis care are key. Designing interventions that are easy to navigate, prioritize shared decision-making and reduce the risk of re-traumatizing people is a priority.

Explanation of context, mechanisms and outcomes in adult community mental health crisis care: the MH-CREST realist evidence synthesis

Background

Mental health crises cause significant disruption to individuals and families and can be life-threatening. The large number of community crisis services operating in an inter-agency landscape complicates access to help. It is unclear which underpinning mechanisms of crisis care work, for whom and in which circumstances.

Aim

The aim was to identify mechanisms to explain how, for whom and in what circumstances adult community crisis services work.

Objectives

The objectives were to develop, test and synthesise programme theories via (1) stakeholder expertise and current evidence; (2) a context, intervention, mechanism and outcome framework; (3) consultation with experts; (4) development of pen portraits; (5) synthesis and refinement of programme theories, including mid-range theory; and (6) identification and dissemination of mechanisms needed to trigger desired context-specific crisis outcomes.

Design

This study is a realist evidence synthesis, comprising (1) identification of initial programme theories; (2) prioritisation, testing and refinement of programme theories; (3) focused realist reviews of prioritised initial programme theories; and (4) synthesis to mid-range theory.

Main outcome

The main outcome was to explain context, mechanisms and outcomes in adult community mental health crisis care.

Data sources

Data were sourced via academic and grey literature searches, expert stakeholder group consultations and 20 individual realist interviews with experts.

Review methods

A realist evidence synthesis with primary data was conducted to test and refine three initial programme theories: (1) urgent and accessible crisis care, (2) compassionate and therapeutic crisis care and (3) inter-agency working.

Results

Community crisis services operate best within an inter-agency system. This requires compassionate leadership and shared values that enable staff to be supported; retain their compassion; and, in turn, facilitate compassionate interventions for people in crisis. The complex interface between agencies is best managed through greater clarity at the boundaries of services, making referral and transition seamless and timely. This would facilitate ease of access and guaranteed responses that are trusted by the communities they serve.

Strengths and limitations

Strengths include the identification of mechanisms for effective inter-agency community crisis care and meaningful stakeholder consultation that grounded the theories in real-life experience. Limitations include the evidence being heavily weighted towards England and the review scope excluding full analysis of ethnic and cultural diversity.

Conclusions

Multiple interpretations of crises and diverse population needs present challenges for improving the complex pathways to help in a crisis. Inter-agency working requires clear policy guidance with local commissioning. Seamless transitions between services generate trust through guaranteed responses and ease of navigation. This is best achieved where there is inter-agency affiliation that supports co-production. Compassionate leaders engender staff trust, and outcomes for people in crisis improve when staff are supported to retain their compassion.

Future work

Further work might explore inter-agency models of crisis delivery, particularly in rural communities. Future work could focus on evaluating outcomes across crisis care provider agencies and include evaluation of individual, as well as service-level, outcomes. The implementation and effect of mental health triage could be explored further, including via telehealth. Barriers to access for marginalised populations warrant a specific focus in future research.

Study registration

The study is registered as PROSPERO CRD42019141680.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 15. See the NIHR Journals Library website for further project information.

Behavioral and psycho-social impairments among people living with dementia and their management by caregivers in South-Western Uganda: a qualitative study

OBJECTIVES

This study aimed to explore the behavioral and social impairments among people living with dementia (PLWD) in rural southwestern Uganda. It also explored the burden of caregivers for people living with dementia.

METHODS

This was a qualitative study among people living with dementia and their caregivers. We consecutively enrolled 30 people living with dementia with their caregivers from their homes. We conducted in-depth interviews using a semi-structured interview guide. We did a thematic content analysis.

RESULTS

The themes under-reported behavioral impairment were; difficulty in personal care, physical inactivity, and impaired judgment. Under the social and cognitive impairment theme, there was the failure to be in social gatherings like church, community groups, and markets. Under the caregivers' role, their burden included managing behavioral, social, and cognitive impairments of PLWD. Although caregivers were committed to caring for PLWDs, this required sacrificing time at the expense of income-generating activities.

CONCLUSIONS

Dementia hinders the behavioral and social aspects of the affected people. Caregivers are highly burdened to care for PLWD. Strategies to minimize caregivers' burden while caring for people living with dementia are recommended.

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

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

Family Functioning and Health-Related Quality of Life in Parents of Children with Mental Illness

Previous research suggests that family dysfunction may be related to lower health-related quality of life (HRQoL) in parent caregivers, but it is unknown if this association exists in the context of child mental illness. Therefore, the objectives of this study were to compare HRQoL between parent caregivers and Canadian population norms using the Short Form 36 Health Survey (SF-36); examine associations between family functioning and parental HRQoL; and investigate whether child and parental factors moderate associations between family functioning and parental HRQoL. Cross-sectional data were collected from children receiving mental healthcare at a pediatric hospital and their parents (n = 97). Sample mean SF-36 scores were compared to Canadian population norms using t-tests and effect sizes were calculated. Multiple regression was used to evaluate associations between family functioning and parental physical and mental HRQoL, adjusting for sociodemographic and clinical covariates. Proposed moderators, including child age, sex, and externalizing disorder, and parental psychological distress, were tested as product-term interactions. Parents had significantly lower physical and mental HRQoL versus Canadian norms in most domains of the SF-36, and in the physical and mental component summary scores. Family functioning was not associated with parental physical HRQoL. However, lower family functioning predicted lower parental mental HRQoL. Tested variables did not moderate associations between family functioning and parental HRQoL. These findings support the uptake of approaches that strive for collaboration among healthcare providers, children, and their families (i.e., family-centered care) in child psychiatry settings. Future research should explore possible mediators and moderators of these associations.

Behavioral and Psychological Symptoms of Dementia: Prevalence, Symptom Severity, and Caregiver Distress in South-Western Uganda-A Quantitative Cross-Sectional Study

The purpose of the study was to investigate behavioral and psychological symptoms (BPSD) prevalence, severity, and distress experienced by caregivers of people living with dementia (PLWD). A cross-sectional, population-based study was conducted in a rural area in southwestern Uganda. A Neuropsychiatric Inventory Questionnaire (NPI-Q) was used to determine the presence of BPSD as perceived by caregivers of PLWD. We carried out both descriptive and inferential data analysis. A total of 175 caregivers of PLWD were enrolled in this study. Among PLWD, 99% had presented BPSD in the past month. Hallucinations (75%) and dysphoria/depression (81%) were the two BPSD that occurred most frequently. Most participants (70%) stated that PLWD experienced hallucinations of significant severity. Aberrant motor activity was reported by 60% of the participants as the type of BPSD that caused severe distress. There was a high positive correlation (0.82) between the total severity score and total distress scores. Interventions aimed at addressing dysphoria and hallucinations may be essential for the reduction of caregiver distress. These findings point to the need for promoting early screening for BPSDs and the provision of support to caregivers.

Family-centered collaborative care for patients with chronic mental illness: A systematic review

Background

Chronic mental illnesses (CMI) are long lasting and reoccurring and require continuous care as well as an integrated and collaborative approach to organize the care. This study sought to examine whether family centered collaborative care is an acceptable treatment option for individuals with CMI.

Materials and Methods

From the years 2000 to 2021, ten electronic databases relating to family centered collaborative care for mental illness were searched adopting Preferred Reporting Items for Systematic Reviews and Meta Analysis checklist. Twenty seven relevant articles and a thesis from among 6956 studies retrieved, were assessed their quality appraisal through four standardized tools. The studies were rated as good, moderate, or poor. Studies were calibrated, different opinions were discussed, and extracted data were done.

Results

Evidence included 11 randomized controlled trials (from 19 articles), one randomized control trial, three mixed methods studies (from 3 articles and 1 thesis), and a qualitative study (from 4 articles). The quality of seven studies was good, 15 were moderate quality, and seven were poor quality. According to moderate to high quality qualitative research, family centered collaborative care was considered an acceptable intervention; though a few studies supported it.

Conclusion

The findings demonstrated that family involvement in the care of patients with CMI affects no recurrence of the disease, and no re hospitalization of patients with this disorder. As a result, engaging family members in the care process can have a positive impact on the health and well being of these patients.

Relatives’ experiences of an equine-assisted intervention for people with psychotic disorders

Purpose

The aim of this study was to describe relatives’ experiences of an equine-assisted intervention for people with psychotic disorders.

Methods

The study has a qualitative and descriptive design. Ten semi-structured interviews were performed with relatives of people with a psychotic disorder who had participated in an equine-assisted intervention. A conventional content analysis was used to analyse the data.

Result

The overall category “Being with the horses strengthens health capabilities” summarizes the four identified subcategories “The horses contribute to a context with a common focus”, “Interaction with the horses enhances self-confidence and motivation”, “The interplay with the horses nurtures positive emotions” and “Being with the horses encourages physical activity”.

Conclusions

The result of this study contributes to the growing body of research about the potential outcomes of equine-assisted interventions. The result also indicates that equine-assisted interventions may improve health capabilities among people with psychotic disorders. The generated knowledge may be useful in mental health services when developing equine-assisted interventions.

Perceived mental health and emotional trajectories of long-term family caregivers of persons with mental conditions: A mixed-methods study

AIMS AND OBJECTIVES

To explore the emotional experience and the perceived mental health of experienced family caregivers of people with mental disorders.

BACKGROUND

Family caregiving for individuals with mental disorders differs from other health conditions, as it implies a burden, deterioration in physical and mental health, stigma and a perceived lack of support from mental health services.

METHODS

A mixed-method study was undertaken with family caregivers of people diagnosed with mental disorders.

RESULTS

A total of 13 experienced family caregivers were included in the study. The qualitative data were classified into two major themes: emotions and perceived mental health. Emotions included five categories: irritability, painful emotions, pressure, emotions orientated towards coping, and positive emotions. The perceived mental health status embraced five categories: anxiety, burden and exhaustion, needing psychological or psychiatric treatment, insomnia and suicidal thoughts. An emotional path could be constructed from their discourses, starting with lack of control or irritation that evolved towards resignation, peace or satisfaction. The quantitative analysis partially replicated the qualitatively reported anxiety, depressive symptoms and insomnia.

CONCLUSION

Past and present emotions related to caregiving described by experienced family caregivers were identified. Their emotional trajectories converged in that negative emotions gave way to emotions towards coping, which in turn were followed by positive emotions. The participants' descriptions about their mental status were partially reflected through objective mental health measurements.

RELEVANCE TO CLINICAL PRACTICE

More support from mental health services could help caregivers to progress in their emotional trajectory towards coping, and improve their caregiving knowledge and skills. Mental health nurses have a role in patients and caregivers education and in the promotion of caregivers' psychological wellbeing.

Women's experiences when caring for relatives with mental illness in Northern Ireland: A qualitative study

Care in the Community policies has led to people with mental illness receiving treatment and care at home; however, few studies have examined the impact on carers of providing care to a person with mental illness. This was a qualitative study of the experiences of 11 women who are informal carers of people with a long-term mental illness. The study aimed to gain an understanding of the characteristics of this particular caregiving context that contributes to the stress of the role, and to identify the ways in which services could support women in these roles to promote their wellbeing and support the recovery of those they care for. Two groups of themes emerged: the first was the sources of stress, which included how they became a carer, family obligations and relationships and engaging with services. The second was the impact on health and wellbeing, including emotional and mental health, the need for, and absence of support, and coping with stress. The study highlighted a number of unique features of mental illness that lead to additional stress for the carer and render the usual support structures and delivery mechanisms inappropriate. The results pose challenges for those tasked with supporting carers in this context and developing interventions to promote recovery in the community.

Assessing the impact of caregiving on informal caregivers of adults with a mental disorder in OECD countries: A systematic literature review of concepts and their respective questionnaires

We conducted a systematic literature review to identify and review the concepts and questionnaires used to assess the impact of caregiving on caregivers for adults with a mental disorder. With our study, we aimed to provide an overview and categorize the conceptualization and operationalization of the impact of caregiving, with special attention for the complexity and multi-conceptualization of concepts. Embase, Medline, PsycInfo, Web of Science Core Collection, Cochrane Central Register of Trials, Cinahl Plus, Econlit and Google Scholar were systematically searched for articles from 1 January 2004 to 31 December 2019. Eligible articles were peer-reviewed studies that assessed the impact of caregiving for informal caregivers of adults with a reported mental disorder by means of a questionnaire. The complete study protocol can be found on PROSPERO (CRD42020157300). A total of 144 questionnaires were identified that assessed the impact of caregiving. Based on similarities in meaning, concepts were classified into 15 concept clusters. The most frequently assessed concept clusters were mental health, caregiving burden, other caregiving consequences, family impact, and overall health-related outcomes. The use of concept clusters differed per diagnosis group, with diagnoses, such as schizophrenia, using a wide range of caregiving impact concepts and other diagnoses, such as personality disorders, only using a limited range of concepts. This is the first study that identified and reviewed the concepts and questionnaires that are used to assess the impact of caregiving. Caregiving is researched from a broad array of perspectives, with the identification of a variety of concepts and dimensions and use of non-specific questionnaires. Despite increasing interest in this field of research, a high degree of variability remains abundant with limited consensus. This can partially be accredited to differences in the naming of concepts. Ultimately, this review can serve as a reference to researchers who wish to assess the impact of caregiving and require further insight into concepts and their respective questionnaires.

In their own words: An Australian community sample's priority concerns regarding mental health in the context of COVID-19

The COVID-19 pandemic has resulted in significant and unprecedented mental health impacts in Australia. However, there is a paucity of research directly asking Australian community members about their mental health experiences, and what they perceive to be the most important mental health issues in the context of the pandemic. This study utilises qualitative data from Alone Together, a longitudinal mixed-methods study investigating the effects of COVID-19 on mental health in an Australian community sample (N = 2,056). A total of 1,037 participants, ranging in sex (69.9% female), age (M = 40-49 years), state/territory of residence, and socioeconomic status, shared responses to two open-ended questions in the first follow up survey regarding their mental health experiences and priorities during COVID-19. Responses were analysed using thematic analysis. Participants described COVID-19 as primarily impacting their mental health through the disruption it posed to their social world and financial stability. A key concern for participants who reported having poor mental health was the existence of multiple competing barriers to accessing high quality mental health care. According to participant responses, the pandemic placed additional pressures on an already over-burdened mental health service system, leaving many without timely, appropriate support. Absent or stigmatising rhetoric around mental health, at both a political and community level, also prevented participants from seeking help. Insights gained from the present research provide opportunities for policymakers and health practitioners to draw on the expertise of Australians' lived experience and address priority issues through targeted policy planning. This could ultimately support a more responsive, integrated, and effective mental health system, during and beyond the COVID-19 pandemic.

Implications of Involuntary Psychiatric Admission: Health, Social, and Clinical Effects on Patients

Involuntary psychiatric admission is an increasing, widespread practice adopted throughout the world; however, its legal regulation and practice are still under debate, and it is subject to criticism from the human rights point of view. Only a few studies have strictly focused on the outcomes and subsequent treatment implications of this practice. To perform a scoping review of the literature on involuntary psychiatric admission and systematize and summarize its outcomes and implications for adult psychiatric inpatients.Four overarching issues emerged from the studies: a) symptomatological repercussions, b) impacts on treatment before discharge, c) impacts on treatment after discharge, and d) implications on patients' attitudes, behavior, and functioning. The overall evidence suggested correlations between involuntary psychiatric admission and several implications: length of stay, aggressive behavior, occurrence of psychopathologies, uses of coercive measures, psychiatric service activations after discharge, emotive reactions, and quality of life. The proposal presented here is the major involvement of the patient and of all the other actors involved during the entire treatment process to promote a shift from a delegation perspective to a negotiation perspective in the management of involuntary psychiatric admission.

Subjective experiences of the first response to mental health crises in the community: a qualitative systematic review

OBJECTIVE

To review and synthesise qualitative studies that have explored subjective experiences of people with lived experience of mental health-related illness/crisis (MHC), their families and first responders.

DESIGN

A systematic review of qualitative evidence was conducted. English-language articles exploring the content of interactions and participants' experiences were included.

DATA SOURCES

MEDLINE, PsycINFO, EMBASE, CINAHL; Google Scholar, SAGE journals, Science Direct and PubMed.

DATA EXTRACTION AND SYNTHESIS

Two reviewers read and systematically extracted data from the included papers. Papers were appraised for methodological rigour using the Critical Appraisal Skills Programme Qualitative Checklist. Data were thematically analysed.

RESULTS

We identified 3483 unique records, 404 full-texts were assessed against the inclusion criteria and 79 studies were included in the qualitative synthesis. First responders (FRs) identified in studies were police and ambulance staff. Main factors influencing response are persistent stigmatised attitudes among FRs, arbitrary training and the triadic interactions between FRs, people with mental illness and third parties present at the crisis. In addition, FR personal experience of mental illness and focused training can help create a more empathetic response, however lack of resources in mental health services continues to be a barrier where 'frequent attenders' are repeatedly let down by mental health services.

CONCLUSION

Lack of resources in mental healthcare and rise in mental illness suggest that FR response to MHC is inevitable. Inconsistent training, complexity of procedures and persistent stigmatisation make this a very challenging task. Improving communication with family carers and colleagues could make a difference. Broader issues of legitimacy and procedural barriers should be considered in order to reduce criminalisation and ensure an empathetic response.

Exploring the experience of being viewed as "not sick enough": a qualitative study of women recovered from anorexia nervosa or atypical anorexia nervosa

BACKGROUND

Despite common misconceptions, an individual may be seriously ill with a restrictive eating disorder without an outwardly recognizable physical sign of the illness. The aim of this qualitative study was to investigate the perspectives of individuals who have previously battled a restrictive eating disorder who were considered "not sick enough" by others (e.g., peers, families, healthcare professionals) at some point during their illness, and to understand the perceived impact on the illness and recovery. Such misconceptions are potentially damaging, and have been previously linked with delayed help-seeking and poorer clinical outcomes.

METHODS

Seven women who had recovered from anorexia nervosa or atypical anorexia nervosa participated in semi-structured interviews. Interviews were transcribed and interpretive phenomenological analysis was used.

RESULTS

Three main themes emerged: (1) dealing with the focus upon one's physical appearance while battling a mental illness, (2) "project perfect": feeling pressure to prove oneself, and (3) the importance of being seen and understood. Participants reported that their symptoms were occasionally met with trivialization or disbelief, leading to shame, confusion, despair, and for some, deterioration in eating disorder symptoms which drove further weight loss. In contrast, social support and being understood were viewed as essential for recovery.

CONCLUSION

To facilitate treatment seeking and engagement, and to optimize chances of recovery, greater awareness of diverse, non-stereotypical presentations of restrictive eating disorders is needed which challenge the myth that weight is the sole indicator of the presence or severity of illness.

Family perspectives of healthcare for relatives living with a mental illness

PURPOSE

This study explored how parents, partners or spouses, siblings, and adult children, who had a relative living with a mental illness, experienced interactions with mental healthcare providers and staff.

DESIGN AND METHODS

A descriptive qualitative research process guided interviews with 20 family members about their experiences with the mental healthcare system.

FINDINGS

Analysis yielded similar and different themes of experience for each family role. Although navigating the mental system presented challenges, positive experiences affirmed family members' contributions to caregiving.

PRACTICE IMPLICATIONS

Involvement of family members contributes to inclusive care and promotes family satisfaction with care provided to their relative.

The implementation of large-scale health system reform in identification, access and treatment of eating disorders in Australia

BACKGROUND

It seems to be a truth universally acknowledged that pathways to care for people with eating disorders are inconsistent and difficult to navigate. This may, in part, be a result of the complex nature of the illness comprising both mental and medical ill-health across a broad range of severity. Care therefore is distributed across all parts of the health system resulting in many doors into the system, distributed care responsibility, without well developed or integrated pathways from one part of the system to another. Efforts in many parts of the world to redesign health service delivery for this illness group are underway, each dependent upon the local system structures, geographies served, funding sources and workforce availability.

METHODS

In NSW-the largest populational jurisdiction in Australia, and over three times the size of the UK-the government embarked six years ago on a program of whole-of-health system reform to embed identification and treatment of people with eating disorders across the lifespan and across the health system, which is largely publicly funded. Prior to this, eating disorders had not been considered a 'core' part of service delivery within the health system, meaning many patients received no treatment or bounced in and out of 'doorways'. The program received initial funding of $17.6 million ($12.5 million USD) increasing to $29.5 million in phase 2 and the large-scale service and workforce development program has been implemented across 15 geographical districts spanning almost one million square kilometres servicing 7.75 million people.

CONCLUSIONS

In the first five years of implementation there has been positive effects of the policy change and reform on all three service targets-emergency departments presentations, hospital admissions and community occasions of service as well as client hours. This paper describes the strategic process of policy and practice change, utilising well documented service design and change strategies and principles with relevance for strategic change within health systems in general.

Implementing national mental health carer partnership standards in South Australia

Objective The aim of this study was to describe the current state of carer engagement and partnership in two mental health (MH) services in South Australia and the implementation of the six partnership standards in A Practical Guide to Working with Carers of People with a Mental Illness. Methods Anonymous surveys of carer experiences and clinician self-ratings of their own practice against the six partnership standards were completed by 94 staff and 58 carers within public and private MH in-patient units before and after exposure of clinicians to education about the partnership standards. Descriptive statistical analysis was performed and, where applicable, a comparative analysis used the two-sample Z-test of proportions. Qualitative data was analysed thematically. Results Considerable gaps were evident between carer experiences and clinician self-ratings of their own practice. Overall, the surveys point to the lack of a consistent approach by both public and private services, and suggest potential barriers to fostering carer participation and engagement. Confidentiality was a particularly noted barrier to partnership with carers. Conclusion Significant improvement is needed to meet the partnership standards. Brief exposure to the Guide is not, in itself, sufficient to effect change in the overall attitudes, skills and knowledge of clinical staff about engaging carers. Significantly more focus on staff education, clinical discussions and supervision is needed to meet the MH carer partnership standards. What is known about the topic? Partnership with MH consumers and carers is an established key principle within national MH policies and accreditation standards. Family carers play an important role in supporting consumers' recovery, yet many carers continue to report being excluded, particularly by in-patient clinical staff. What does this paper add? This is the first study to investigate the partnership standards in practice by comparing the perspectives of carers and in-patient MH clinical staff. What are the implications for practitioners? Improving partnership with carers of people with mental illness will require significant MH service leadership support shifts in current practice and culture. In addition, a more nuanced understanding of confidentiality is required to overcome the barriers to involving family carers more meaningfully in care.

The experience of parents faced with the admission of their adolescent to a child and adolescent psychiatric inpatient unit. A qualitative study with focus groups

The admission of an adolescent to a child and adolescent psychiatric inpatient unit has a serious impact on the entire family unit. The emotional experience of those primary caregivers has been scarcely studied qualitatively despite being recommended by previous research. This study aims to examine the experience of parents of adolescents with mental health needs that required psychiatric hospitalization in a child and adolescent unit. Qualitative cross-sectional research was carried out under the recommendations of Grounded Theory with three Focus Groups of parents (N = 22) of adolescents who required psychiatric hospitalization in a child and adolescent ward. The COREQ quality criteria were applied. The parental experience implies a high level of emotional suffering modulated by feelings of guilt, stigma, parental awareness of their child’s illness and the passage of time. The use of Prochaska’s and Diclemente’s trans-theoretical model of health behavior change is useful in understanding the parental experience.

Facilitators for improvement of psychiatric services and barriers in implementing changes: From the perspective of Finnish patients and family members

The need for psychiatric patients and their family members to have access to quality user-friendly services has been studied for decades, yet few improvements have been made in treatment services. This study aims to explain how patients and family members have experienced facilitators of improvements, and their thoughts about barriers in the implementation of changes. An explanatory qualitative design was adopted. Data were collected using semi-structured interviews with eight focus groups made up of a total of 35 participants from mental health associations in Finland. The Theoretical Domains Framework guided the deductive data analysis. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) was followed in the study. Participants in patient and family member associations had similar experiences and thoughts about facilitators of improvements in psychiatric services and barriers in the implementation of changes. For example, both participant groups experienced that promoting more positive roles of professionals could facilitate improvements in psychiatric care. On the other hand, a lack of theoretical competence and interpersonal skills of professionals could hinder change. We conclude that many of the facilitators that patients and families suggested could be addressed by enhancing collaboration and communication, having a more person-centred approach, focusing on recovery throughout the course of care, and acknowledging staff's well-being at work. Second, the barriers to implementing changes centre around the limited knowledge and skills of staff, and a paternalistic system that focuses on managing risk and administering treatment.

Pathways to care in children- perspectives from a child guidance clinic in South India

PURPOSE

In India the pathways to care in children with mental health problems remain relatively unexplored. Investigating the factors that drive the pathway will help determine interventions and also draft policies for a streamlined Child and adolescent mental health service.

METHOD

Children who attended the Child Guidance Clinic sampled by WHO Pathways Encounter questionnaire. Statistical tests applied to find key influencers like gatekeepers, intermediate points of care, symptoms initiating referral, duration of untreated illness, time to arrive at appropriate care and primary diagnosis.

RESULTS

The most common diagnostic category was externalizing disorder 51(37.5 %). The gatekeepers identified were 111(81.6 %) Parents/Relatives/Guardians and teachers 25 (18.3 %). Academic concerns identified by teachers took a mean of 72 months (30.271) to arrive at appropriate care versus 50.4 months (23.18) when identified by Parents/Relatives/Guardians group. Significant delays were observed with Neurodevelopmental disorders arriving to care with delays up to 130.2 (70.11) months (p < 0.001) and having 64.2 (33.7) months (p < 0.001) duration of untreated illness. Externalizing disorders took a duration of 94.08 (54.17) months (p < 0.001) to arrive to appropriate care and had 54.2 (36.33) months (p < 0.001) duration of untreated illness. Teachers took longer time in detecting the indicators and this caused duration of untreated illness of 73.44 (36.05) months (p < 0.001) and a delay of 128.08 (71.23) months (p < 0.001) to arrive to appropriate care.

CONCLUSIONS

The pathways to care in children are characterized by long duration of untreated illness and undue time to care. Gatekeepers like teachers and intermediary points of care were associated with inadvertent delays along the pathway.

An exploratory study of the experiences of being both a mental health professional and carer in mental health services in Norway

WHAT IS KNOWN ON THE SUBJECT?: Many carers report feeling unrecognized by professional healthcare teams. Carers often report difficulty accessing mental health services for relatives. Carers who are also mental health professionals may experience role conflict as found for General Practitioners. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Carers who are mental health professionals are often not recognized for their professional knowledge and face similar communication barriers as other carers. Difficulties for carers who are mental health professionals are concerned with information sharing, decision-making and continuity of care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Opportunity for services to learn from the experiences of mental health professional and carers to develop better communication and shared decision-making methods for carers Carers who are mental health professionals should be recognized by services for their dual role (and skills). Service development opportunity for training in supporting and engaging carers who are mental health professionals ABSTRACT: Introduction Around 60% of carers of relatives with mental health problems report feeling unrecognized by professional health care, and many report a lack of engagement, shared decision-making and information sharing. There is a paucity of research examining these issues for carers who are also mental health professionals. Aims This was an exploratory study to (a) explore the extent of this role among health service staff, (b) gather an indication of the issues faced by carers when interacting with the health system and (c) test the feasibility of conducting research. Methods Mental health professionals in mental health services completed an online survey that assessed the frequency, content and satisfaction of the experiences of carers. Results The sample comprised 453 mental health professionals (74% female), 52% being carers. Half of carers reported having therapist contact, and 25% were satisfied with the contact. Negative experiences were related to Information, Decision-making and Continuity of care. Discussion There was a high frequency of mental health professionals who were carers. The majority were dissatisfied, and this was primarily in relation to communication with services. Implications for practice Improving information sharing through training of staff and identification of the system barriers is likely to enhance experiences for service users and families.

Factors associated with family functioning among people with a diagnosis of schizophrenia and primary family caregivers

WHAT IS KNOWN ON THE SUBJECT?: Families act not only as the primary support for people with a diagnosis of schizophrenia but also as partners in the healthcare system. Families who have members with mental disorders, particularly schizophrenia, experience challenges in family functioning. Research on families in relation to schizophrenia primarily focuses on the determinants that affect family functioning from primary family caregivers' perspectives. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: This report provides evidence that there is a concordance between family functioning and inpatient psychiatric rehabilitation facilities for the patient-caregiver dyad; both care-receivers and primary family caregivers considered family functioning as poor. Care-receivers with lower education levels, increased number of previous hospitalizations and poor quality of family-centred care experienced unhealthy family functioning. Primary family caregivers and care-receivers with higher education levels, lower suicidality and greater quality of family-centred care experienced healthier family functioning. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Understanding the degree of family functioning, particularly its concordance and correlates as perceived by patients and primary family caregivers, may serve as a platform for inculcating assessment of family functioning to achieve holistic patient care. Open dialogue in family-focused care planning is essential to facilitate collaborative partnerships and improve family functioning among people with a diagnosis of schizophrenia and their primary family caregivers. Further research on culturally relevant, evidence-based family interventions to enhance the functioning of affected families is warranted, especially for families with members in inpatient psychiatric rehabilitation facilities. ABSTRACT: Introduction Families provide frontline caregiving support for people with a diagnosis of schizophrenia. However, research primarily addresses correlates of family functioning from primary family caregivers' perspectives. Aim To examine perceived family functioning, particularly its concordance within patient-caregiver dyads and associated factors in families of people living with schizophrenia. Methods A cross-sectional, descriptive correlational design was used. A total of 133 dyads of patients and primary family caregivers from inpatient psychiatric rehabilitation services participated. Descriptive statistics, independent-sample t test, one-way ANOVA, Pearson's correlation coefficients, intraclass correlation coefficient and stepwise multiple linear regression analyses were applied. Results Family functioning was perceived as impaired by patient-caregiver dyads, and there existed a concordance in this regard. Patients' and family caregivers' education levels, patients' suicidality, number of previous hospitalizations and quality of family-centred care correlated with patients' and primary family caregivers' family functioning. Discussion Findings highlight the importance of patient- and family-reported family functioning with implications to address individual and collective concerns. Implications for Practice Evidence-based family interventions are crucial for assisting vulnerable families in promoting family functioning. Mental health nurses should facilitate collaboration and open dialogue concerning perspectives of patients and families to improve delivery of comprehensive mental health care.

Nurses' attitudes facing the family involvment in caring for people with mental disorder

OBJECTIVE

To characterize the attitudes of Primary Health Care nurses, regarding the involvement of the family in the care for people with Mental Disorder.

METHODS

Correlational study with 257 nurses from the city of São Paulo. The scale "Importance of Families in Nursing Care- Nurses' Attitudes" was used. For the analysis, descriptive and inferential statistics were used.

RESULTS

The scale scores were high, with a mean value of 82.1 (SD=8.4) favorable to the families' involvement, and are related to being a nurse in the Family Health Strategy (p<0.001), having received education/training in family nursing (p<0.005), the workload of 40 hours/week (p<0.005), working in the West, East and Center Regions (p<0.005).

CONCLUSION

Most nurses have positive attitudes towards the involvement of families, a relevant indicator for their inclusion in the health-mental care process.

Exposure, Relaxation, and Rescripting Therapy for Trauma-Related Nightmares With Psychiatric Inpatients: A Case Series

Research has shown that posttraumatic stress disorder (PTSD) is a highly prevalent diagnosis for psychiatric patients, yet individualized care and treatment is limited in the inpatient acute care sector. Two case studies are presented which examine the use of Exposure, Relaxation, and Rescripting Therapy (ERRT) for chronic trauma-related nightmares, within a private acute care inpatient psychiatric hospital setting. ERRT is empirically supported with efficacy for veteran and civilian populations, however no research to date has been conducted with psychiatric inpatients. Two participants diagnosed with PTSD, suffering distressing trauma-related nightmares, completed ERRT over three sessions during their psychiatric hospital admission, with the aim of reducing the frequency and severity of nightmares and related psychological symptoms. PTSD, depression, sleep quality and quantity, and nightmare frequency and related distress, were measured pre-treatment, during treatment, and follow-up at one, 3 and 6 months. Only one participant reported ongoing nightmares by the third week of the intervention, with both participants reporting an absence of nightmares at the one and 3-month follow-ups, but mixed results by the 6-month follow-up. One participant also reported a reduction in PTSD symptoms and a mild improvement in depression. The results offer some preliminary support for the provision of ERRT for the treatment of trauma-related nightmares for psychiatric inpatients.

Conflicts Experienced by Caregivers of Older Adults With the Health-Care System

Background:

Family caregivers of older adults frequently navigate the health system for their loved ones. As older adults experience more medical issues, the interactions between caregivers and the health system can be fraught with conflicts.

Objective:

To characterize the conflicts that caregivers of older adults experience with the health-care system.

Methods:

A cross-sectional national online survey with open-ended questions was conducted among family caregivers ascertaining experiences with the health-care system. Qualitative thematic analysis was completed using constant comparative analysis and review by a third author.

Results:

Over a 2-month period, 97 caregivers completed the survey. Common themes where caregivers experienced conflicts were Difficulty With Accessing/Communicating With Providers, Delivery of Emergency Care, Disjointed Transitional Care, Unaddressed Clinical Concerns, and Financial. Caregivers reported needing to act as patient advocates in the conflicts with the health-care system.

Conclusion:

Understanding the conflicts that family caregivers encounter with the health system provides potential targets for future interventions to combat the challenges faced by caregivers of older adults and ultimately improve delivery of geriatric care.

From the service user association's perspective

Purpose

The aim of this study was to identify key components of integrated mental health and social care services that contribute to value for service users in Sweden.

Design/methodology/approach

An explorative research study design was used, based on data from four group interviews conducted in June and August 2017 with service user representatives.

Findings

The analysis resulted in eight subcategories reflecting components that were reported to contribute to value for service users. These subcategories were grouped into three main categories: (1) professionals who see and support the whole person, (2) organizational commitment to holistic care and (3) support for equal opportunities and active participation in society.

Research limitations/implications

The findings are primarily transferable to integrated mental health and social care services, as they emphasize key components that contribute to value for service users in these specific settings.

Practical implications

The complexity of integrated mental health and social care services requires coordination across the individual and organizational levels as well as ongoing dialogue and partnerships between service users, service user associations and health and social care organizations. In this integration, it is important that service users and service user associations not only are invited but also keen to participate in the design of care and support efforts.

Originality/value

Service User Associations (SUAs) can act as a bridge between county and municipal services through their participation in the development of local activities; at the regional and national levels, SUAs can help achieve more equitable integrated services. It is important that SUAs are not only invited but encouraged to actively participate in the design of such care and support efforts.

Experiences and satisfaction of children, young people and their parents with alternative mental health models to inpatient settings: a systematic review

Community-based mental health services for children and young people (CYP) can offer alternatives to inpatient settings and treat CYP in less restrictive environments. However, there has been limited implementation of such alternative models, and their efficacy is still inconclusive. Notably, little is known of the experiences of CYP and their parents with these alternative models and their level of satisfaction with the care provided. Therefore, the main aim of this review was to understand those experiences of the accessibility of alternative models to inpatient care, as well as overall CYP/parental satisfaction. A searching strategy of peer-reviewed articles was conducted from January 1990 to December 2018, with updated searches conducted in June 2019. The initial search resulted in 495 articles, of which 19 were included in this review. A narrative synthesis grouped the studies according to emerging themes: alternative models, tele-psychiatry and interventions applied to crisis, and experiences and satisfaction with crisis provision. The identified articles highlighted increased satisfaction in CYP with alternative models in comparison with care as usual. However, the parental experiential data identified high levels of parental burden and a range of complex emotional reactions associated with engagement with crisis services. Furthermore, we identified a number of interventions, telepsychiatric and mobile solutions that may be effective when applied to urgent and emergency care for CYP experiencing a mental health crisis. Lastly, both parental and CYP experiences highlighted a number of perceived barriers associated with help-seeking from crisis services.

Living with personality disorder and seeking mental health treatment: patients and family members reflect on their experiences

BACKGROUND

Despite effective treatments for personality disorders being developed, consumers and carers often report negative experiences of mental health services, including challenges accessing these treatments.

METHODS

This qualitative study used separate focus groups to compare the unique perspectives of consumer and carers, and to investigate how to improve services for individuals with personality disorders. Reflexive thematic analysis was used to analyze the data.

RESULTS

Both consumers and carers (N = 15) discussed the value of providing appropriate information to consumers when they are diagnosed with personality disorder. Consumers and carers described the importance of creating a safe environment for consumers when they present to the emergency department. Both groups discussed experiencing positive and negative treatment from mental health professionals, and suggested that professionals should be trained to understand personality disorder. Limited accessibility and quality of services, and offering peer support to consumers were also described by consumers and carers. Consumers and carers also had perspectives which were unique to their group. Consumers identified the importance of psychological treatment, having a strong therapeutic relationship with a mental health professional, and the benefit of long term psychotherapy with the same professional. Broadening the scope of psychotherapies including creative, animal-assisted, and physical therapies was recommended by consumers. Carers described the importance of assessing for personality disorder and intervening early. Involvement in the assessment, diagnosis, and intervention process was important to carers. The desire to be recognized and supported by mental health professionals was discussed by carers.

CONCLUSIONS

This research contributes to the concern that consumers with personality disorder and their carers experience stigma and low quality care within mental health services. In line with these findings, we recommend guidelines for health professionals who work with consumers with personality disorder.

Perspectives of patients, carers and mental health staff on early warning signs of relapse in psychosis: a qualitative investigation

BACKGROUND

Relapse prevention strategies based on monitoring of early warning signs (EWS) are advocated for the management of psychosis. However, there has been a lack of research exploring how staff, carers and patients make sense of the utility of EWS, or how these are implemented in context.

AIMS

To develop a multiperspective theory of how EWS are understood and used, which is grounded in the experiences of mental health staff, carers and patients.

METHOD

Twenty-five focus groups were held across Glasgow and Melbourne (EMPOWER Trial, ISRCTN: 99559262). Participants comprised 88 mental health staff, 21 patients and 40 carers from UK and Australia (total n = 149). Data were analysed using constructivist grounded theory.

RESULTS

All participants appeared to recognise EWS and acknowledged the importance of responding to EWS to support relapse prevention. However, recognition of and acting on EWS were constructed in a context of uncertainty, which appeared linked to risk appraisals that were dependent on distinct stakeholder roles and experiences. Within current relapse management, a process of weighted decision-making (where one factor was seen as more important than others) described how stakeholders weighed up the risks and consequences of relapse alongside the risks and consequences of intervention and help-seeking.

CONCLUSIONS

Mental health staff, carers and patients speak about using EWS within a weighted decision-making process, which is acted out in the context of relationships that exist in current relapse management, rather than an objective response to specific signs and symptoms.

Evaluation of a national training programme to support engagement in mental health services: Learning enablers and learning gains

WHAT IS KNOWN ON THE SUBJECT?: Patient and public involvement (PPI) is recognized as an increasingly important feature of healthcare research, education and public policy. In mental health, PPI is increasingly seen as evidence of the further democratization of services, which started with de-institutionalization in the 1960s and the recovery movement in the 1990s. While much is known about learning enablers and learning gains on generic community-based training programmes, less is known about PPI-specific programmes in mental health. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Participants at a national training programme to support the engagement of service users, their families and carers in mental health services identified training topics of greatest importance to them and reported on what they learnt and what helped their learning. Patient and public involvement training initiatives aimed at supporting the engagement of service users, their families and carers should emphasize individual needs and local contexts. Training programmes should not make artificial or actual distinctions between the programme participants who are health professionals and those who are non-professionals, such as service users. To our knowledge, this PPI initiative is the first time a national health service provider has sought to develop an engagement structure in mental health on a state-wide basis. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Participants in training programmes designed to support patient and public involvement believe that such programmes should include understanding how conflict is resolved, how committees work effectively and how to develop interpersonal and facilitation skills. Training programmes in mental health involving both professional and non-professional participants requires all the participants to work together in particular at commissioning and design stages to achieve their desired outcome. The evaluation of the training programme to support the roll-out of this initiative offers lessons to others who may wish to pursue similar structures in other jurisdictions. Abstract Introduction The Irish national mental health service provider commissioned a national training programme to support a patient and public involvement (PPI) initiative in mental health services. The programme evaluation afforded an opportunity to describe the learning gains and learning enablers and the factors that support PPI in mental health. Aim We aimed to evaluate a PPI training programme across nine regional administrative units in a national mental health service. Methods We conducted a participant exit survey, using the Student Assessment of Learning Gains (SALG) instrument. We analysed the survey responses using SPSS version 24 software and applied directed content analysis to the narrative comments provided in open-ended questions. Results A total of 54 participants returned the completed questionnaire, yielding a response rate of 60%. The overall mean SALG score yielded was 3.97 (SD 0.66; range 1-5), indicating that participants reported very good to excellent gains in their learning from the programme. Participants who offered narrative comments indicated an overall positive experience but suggested that all stakeholders should work together to co-produce the training. Discussion All the stakeholders in a PPI training initiative to support the engagement of service users, their families and carers in mental health should work together to achieve their desired outcome. This requires co-production in the design, delivery and evaluation of the training initiative, and co-production can impact at both individual and local levels. Implications for Practice PPI training initiatives in mental health should retain a focus on understanding conflict resolution, committee effectiveness, interpersonal and facilitation skills. Ensuring a shared understanding of key concepts, such as co-production, is a necessary prerequisite at the co-commissioning, co-design, co-planning, co-delivery and co-assessment stages of programme development, as is the need to avoid artificial or actual distinctions between health professionals and those who are non-professionals, such as service users. Relevance statement Mental health engagement and PPI are key principles underpinning modern mental health services and may increasingly impact on wider health service provision including policy and research imperatives. This paper discusses the evaluation of a PPI training programme and offers practical insights as to how such initiatives can be improved.

Developing an Evidence-Based Specialist Nursing Role to Improve the Physical Health Care of People with Mental Illness

The substantial physical health disadvantage experienced by people diagnosed with mental illness is now identified in a growing body of research evidence. The recent promulgation of improved physical health care as a goal of contemporary Australian Mental Health Policy should provide impetus for initiatives and strategies to address this inequity. To date increased knowledge of the problem has not resulted in obvious and sustained changes. The aim of this article is to introduce the role of the Physical Health Nurse Consultant as a potential strategy. The potential contribution and value of this role is considered by reviewing the evidence from the perspective of multiple stakeholders and considering the suitability of nursing to meet the complex needs involved in improving physical health. The requirement for a multi-faceted and comprehensive evaluation is also articulated. A robust, prospective and long-term evaluation plan includes physical health measures, changes in health behaviours, cost-benefit analysis and consumer acceptability to ensure the intervention is effective in the long term. This thorough approach is essential to provide the level of evidence required to facilitate changes at the practice and policy levels. The specialist nursing role presented in this article, subject to the comprehensive evaluation proposed, could become an integral component of a comprehensive approach to addressing physical health inequities in people with mental illness.

Caregivers' experiences of service transitions in adult mental health: An integrative qualitative synthesis

Approximately 5% of the UK population live with serious mental health problems. Data show that informal caregivers of people with mental illness provide care for the highest number of hours compared to other illness and the economic cost of this care is highest in the UK when compared internationally. People living with serious mental health problems make transitions between different intensities of service as their needs fluctuate, including referral, admission, transfer or discharge. Although caregiving is associated with both stress and positive reward, service transitions are particularly associated with increased stress. This review aimed to investigate what is known about the experiences of informal caregivers during mental health service transitions. An integrative qualitative synthesis was conducted following searches in six bibliographic databases and of the grey literature. Studies published in English between 2001 and 2017 were included if the study focus was on serious mental health problems, the experiences of caregivers and service transitions. Eleven studies were included, appraised using the Mixed Methods Appraisal Tool and synthesised, resulting in four themes: (a) Caregiver information, (b) Caregiver involvement in decisions about care and treatment, (c) Accessing services, (d) Being a caregiver. Caregivers' experiences were similar during transitions to their usual caregiving role but they faced more challenges and their experiences were amplified. Concerns about confidentiality created barriers to information sharing. Continuity of professionals across transitions was helpful. Caregivers struggled to deal with their own conflicting emotions and with the behaviours of the person yet rarely received help. The review findings point to a need for continuity of professionals across service transitions, co-designed and delivered training for professionals and caregivers about information sharing, greater understanding of barriers to implementation of family interventions and interventions that address emotional needs of caregivers.